Show me the evidence! Water can cause infection and illness if hospital water systems are not properly engineered and managed 6/29/2017

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Key Takeaways can May 5, 2017 HEALTHCARE PLUMBING SYSTEMS: PUBLIC HEALTH RISKS ASSOCIATED WITH LEGIONNAIRES DISEASE AND OTHER HEALTHCARE-ASSOCIATED INFECTIONS JOHN HANLIN AND IAN EISNER NALCO WATER A

linked to HAIs (whais) Strategies to reduce risk include awareness, risk assessment, secondary disinfection and POU filters Design and use creates can Infection risk can be reduced A Growing Concern,

water Anaissie et al, 2002 Arch Intern Med 162: 1483-92 Legal Financial Regulatory Rising Tide of Prevention, Prevention, Prevention can cause infection and illness if hospital water systems are not

1 Key Takeaways can May 5, 2017 HEALTHCARE PLUMBING SYSTEMS: PUBLIC HEALTH RISKS ASSOCIATED WITH LEGIONNAIRES DISEASE AND OTHER HEALTHCARE-ASSOCIATED INFECTIONS JOHN HANLIN AND IAN EISNER NALCO WATER A DIVISION OF ECOLAB Evidence showing infection risk, illness and death Legionella, Pseudomonas, NTMs and others can colonize water systems and subsequently cause infection These organisms have been linked to HAIs (whais) Strategies to reduce risk include awareness, risk assessment, secondary disinfection and POU filters Design and use creates can Infection risk can be reduced A Growing Concern, The Connection of Healthcare Associated Infections to A Series of Interconnecting s Public Health Public Image Perhaps the most overlooked and controllable source of nosocomial pathogens is hospital water Anaissie et al, 2002 Arch Intern Med 162: Legal Financial Regulatory Rising Tide of Prevention, Prevention, Prevention can cause infection and illness if hospital water systems are not properly engineered and managed Design and use creates can Infection risk can be reduced Show me the evidence! 2015 Ecolab USA Inc. All rights reserved Ecolab USA Inc. All rights reserved Ecolab USA Inc. All rights reserved. 1

Part II Legionella and other bacteria naturally occur in fresh water

water is water as it may contain up to 500 heterotrophic plate count

gallons of fresh water each day Millions of bacteria could be

Calculation Assumption: each ml of water contains 10 10 10 HPC

= ~ 3.8X10 9 HPCB 9 1. http://water.epa.gov/drink/contaminants/index.

8 billion bacteria including some opportunistic pathogens be entering

So what happens once they enter your hospital?

2 How Do Bacteria get into our Systems? Part I How Do Bacteria get in our Systems? Part II Legionella and other bacteria naturally occur in fresh water and in soil An aging infrastructure 7 8 Drinking Supply Chain Fresh water is water as it may contain up to 500 heterotrophic plate count (bacteria) per ml 1 A 200 bed hospital could easily use 100,000 gallons of fresh water each day Millions of bacteria could be hospital s water system every day Let s Explore this Further: Quick Calculation Assumption: each ml of water contains HPC bacteria (HPCB) 10 X 3,785 = 37,850 HPCB per gallon 37,850 X 100,000 = ~ 3.8X10 9 HPCB Ecolab USA Inc. All rights reserved. Could ~ 3.8 billion bacteria including some opportunistic pathogens be entering your hospital s water system daily? So what happens once they enter your hospital? 10 Ecology of borne Are these bacteria and fungi really different from us? To survive and thrive, they need to find food, water, shelter and a place to raise their families. Here s What Happens Next They find themselves in a nutrient-poor environment Thus, they search for a new home They build or find one A microbial biofilm develops in your premise plumbing system They have food, water, shelter and a place to raise their families There are few bad actors among the 3.8 Billion

Design and use creates can Infection risk

Point-of-Use Point-of-Entry 15 16 Phase 1:

are adsorbed to the inner surface of water

Bacteria attach to the conditioned surface.

3 Design and use creates can Infection risk can be reduced can 2017 Ecolab 2015 USA Ecolab Inc. USA All Inc. rights All Rights reserved. Reserved Building Systems Can Support Growth Biofilm Develops in Several Phases Biofilm can develop in pipes and at outlets Drinking water supply chain Point-of-Use Point-of-Entry Phase 1: Conditioning Phase 2: Attachment Particles are adsorbed to the inner surface of water pipes. Bacteria attach to the conditioned surface Ecolab Ecolab USA USA Inc. Inc. All All rights rights reserved Ecolab USA Inc. All All rights reserved. 3

Phase 3: Slime Formation Phase 4: Biofilm Growth Bacteria produce a sticky extracellular matrix & reproduce quickly.

reserved. Biofilm increases in size and protects microorganisms within. 20 2017 2015 Ecolab Ecolab USA USA Inc.

-C. Flemming, Univ. Duisburg Biofilm particles shear off under the force of water flow.

reserved. 22 2017 2015 Ecolab USA Inc. All All rights reserved.

4 Phase 3: Slime Formation Phase 4: Biofilm Growth Bacteria produce a sticky extracellular matrix & reproduce quickly Ecolab Ecolab USA USA Inc. Inc. All All rights rights reserved. reserved. Biofilm increases in size and protects microorganisms within Ecolab Ecolab USA USA Inc. Inc. All All rights rights reserved. reserved. Phase 5: Release Phase 5: Release With kind permission of M. Exner, Univ. Bonn and H.-C. Flemming, Univ. Duisburg Biofilm particles shear off under the force of water flow. Biofilm particles shear off under the force of water flow Ecolab Ecolab USA USA Inc. Inc. All All rights rights reserved. reserved Ecolab USA Inc. All All rights reserved. A Few of the Bad Actors Source CDC; Margaret Williams, Claressa Lucas, Tatiana Travis LEGIONNAIRES DISEASE (LD) Perhaps the most granular example of how a hospital s water system can be the source Biofilm particles shear off under the force of water flow Ecolab Ecolab USA USA Inc. Inc. All All rights rights reserved. 4

Serious neurological and renal sequelae can result Milder form of legionellosis infection called Pontiac fever, named after an outbreak of pneumonia in Pontiac, MI borne pathogen that can thrive in

5 Legionnaires Disease Primer What is it? A serious, potentially deadly form of bacterial pneumonia caused by Legionella pneumophila Legionnaires Disease (LD) presents as: pneumonia: cough, fever, chest pain. Serious neurological and renal sequelae can result Milder form of legionellosis infection called Pontiac fever, named after an outbreak of pneumonia in Pontiac, MI borne pathogen that can thrive in building water systems and can become pathogenic when aerosolized and inhaled by susceptible individuals Public Health Insights About 5,000 people are diagnosed with Legionnaires disease annually in the U.S. Average hospital stay is 10.2 days at an average cost of $30,000 The number of people diagnosed with Legionnaires disease grew by nearly four-fold between 2000 and 2014 Under-recognized, under-diagnosed and under-reported Average fatality rate is about 10% People who are most susceptible to infection are Over the age of 50 Those with risk factors related to smoking, chronic lung disease or a weakened immune system There are approximately 20 outbreaks of Legionnaires disease annually in the U.S. mm6235a3.htm?s_cid=mm6235a3_e m?s_cid=mm6522e1_w 26 Legionellosis By Age Group CDC Comprehensive LD Report June 7, 2016 Age group (years) Number of cases % of cases Incidence rate per 100,000 population < fold > fold /mmwrhtml/mm6032a3.htm _cid=mm6522e1_w Legionnaires disease is on the rise 29 Possible Reasons for Rise Urine antigen test availability Increased surveillance Increased awareness and testing Increase in susceptible population More Legionella in the environment Warmer temperatures Aging infrastructure -saving building modifications Source: 2015 U.S. Ecolab CDC USA Inc. (with All rights thanks) reserved. CDC Legionnaires Disease Investigations 27 outbreaks investigated over a 15 year period Hotels and resorts accounted for 44% of outbreaks and 6% of deaths Healthcare facilities accounted for 34% of outbreaks, 57% of illnesses and 85% of deaths Outbreaks Hotels/Resorts LTC Centers Senior Living Hospitals others Source: CDC MMWR June 7,

Key Insights CDC Insights: Observed Deficiencies CDC investigated 27 outbreaks of Legionnaires disease Leading sources (in order of prevalence) from showers and faucets Cooling towers Hot tubs

water safety management plan Human error, such as a hot tub filter not being cleaned or replaced Inadequate levels of disinfectant 31 http://www.cdc.gov/vitalsigns/pdf/2016-06-vitalsigns.

s_cid=mm6522e1_w Process failures such as not having a water safety management plan Inadequate disinfection in potable water Inadequate disinfection in cooling tower Inadequate disinfection in hot

6 Key Insights CDC Insights: Observed Deficiencies CDC investigated 27 outbreaks of Legionnaires disease Leading sources (in order of prevalence) from showers and faucets Cooling towers Hot tubs Industrial equipment Decorative fountains and water features 90% of the LD outbreaks could have been prevented through improved water safety management plans Process failures such as not having a water safety management plan Human error, such as a hot tub filter not being cleaned or replaced Inadequate levels of disinfectant m?s_cid=mm6522e1_w Process failures such as not having a water safety management plan Inadequate disinfection in potable water Inadequate disinfection in cooling tower Inadequate disinfection in hot tub Disinfectant not routinely added to decorative fountain Stagnation closed wing with unused potable water system Use of tap water in personal respiratory device Insufficient clinical testing for Legionella among patients with healthcare-acquired pneumonia 32 m?s_cid=mm6522e1_w Hospital and LTC-Associated Outbreaks of LD Building Type Source Year Illnesses and Deaths Long Term Care Center Potable water illnesses, 2 deaths Long Term Care Center Cooling towers illnesses, 23 deaths Hospital Potable water illnesses, 3 deaths Senior Living Facility Potable water illnesses, 0 deaths Senior Living Facility Potable water illnesses, 1 deaths Hospital Decorative Fountain illnesses, 0 deaths Hospital Potable water illnesses, 1 deaths Long term Care Center Potable water illnesses, 8 deaths Hospital Potable water illnesses, 5 deaths Long Term Care Center Unknown illnesses, 5 deaths Long Term Care Center Cooling tower cases, 6 deaths Veterans Home Unknown cases, 11 deaths Legionnaires Disease South Bronx July/August 2015 Community-acquired outbreak 124 confirmed or suspected cases of Legionnaires disease 12 deaths All deceased individuals were adults with underlying medical conditions Health departments used DNA fingerprinting to match the Legionella strain found in the cooling tower of a hotel with the strain found in patients Officials attributed the outbreak to inadequate maintenance and inadequate levels of biocide Sources: U.S. CDC and Haupt et al, Ecolab USA Inc. All rights 34 reserved. LD Outbreak in South Bronx Epidemiological Curve Legionnaires Disease South Bronx July/August 2015 Hotel cooling tower

Legionellosis Water Management and Investigation Case Study

Legionellosis Water Management and Investigation Case Study Michigan Department of Health and Human Services Bryce Spiker, MPH Legionellosis Epidemiologist Mike Wesenberg Environmental Health Specialist