SECTION 10.4 LEGIONELLA

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1 SECTION 10.4 LEGIONELLA Introduction Legionella in Healthcare Settings Legionnaires Disease Appendix Management of Nebulisers Developed by Patricia Coughlan, Maire Flynn, Liz Forde, Niamh Mc Donnell In conjunction with Dr. Fiona Ryan Consultant Public Health Medicine Date developed August 2012 Approved by Cork and Kerry Infection Prevention and Control Committee Kerry Infection Prevention and Control Committee Reference number IPCG 10.4 Revision number 0 Revision date 2015 or sooner if new evidence becomes available Responsibility for Infection Prevention and Control Nurses review HSE South (Cork & Kerry) Page 1 of 6

2 Introduction The following document gives an outline of the National Guidelines for the Control of Legionellosis in Ireland (HPSC 2009), highlights the chapter specific to healthcare, provides information on and outlines some of the measures to control Legionellosis including an appendix on the management of nebulisers. National Guidelines National Guidelines for the Control of Legionellosis in Ireland were produced by the Health Protection Surveillance Centre in The document gives detailed recommendations for the control of Legionellosis including Surveillance and Diagnosis Legislation Risk Assessment Prevention and Control Training Legionella in specific risk setting including health care and dental settings. Investigation of Legionellosis cases. Legionella in Healthcare Settings Chapter 8 - Legionella in Specific Risk Settings provides recommendations for specific settings and the following sections are of specific relevance. Healthcare Setting (Section 8.1) Recommended measures to control nosocomial Legionellosis (Section 8.1.1) include Education of staff on measures to control nosocmial Legionellosis Prevention of the transmission of legionella by the correct use of respiratory equipment specifically nebulisers (see appendix to this document) Decorative Fountains; water features and planters (Section 8.4) It is recommended that healthcare institutions including day clinics and homes for care of the elderly should not contain decorative fountains or other water features that generate aerosols as the risk of disease to debilitated patients or residents outweighs the benefit. However where they are present they must be well maintained and disinfected appropriately. Spa Pool including whirlpool baths (Section 8.5) Whirlpool baths are not recommended for the healthcare facilities as the risk outweighs the benefit. HSE South (Cork & Kerry) Page 2 of 7

3 The control of Legionellosis for the Dental Setting is detailed in section 8.3. and includes but is not limited to the following flushing regiemes Dental Unit Waterlines Flush for a minimum of 2-3 minutes at the beginning of each working day AND Flush for a minimum of seconds after each patient. Dental hand pieces, ultra sonic scalers and air/water syringes Flush for a minimum of 30 seconds after each patient HSE South (Cork & Kerry) Page 3 of 7

4 Legionnaires Disease Introduction Legionnaires disease is a form of pneumonia with symptoms of fever, chills, headache and muscle pain. The causative organism is Legionella pneumophilia and other Legionella species Methods of Transmission Legionnaires disease is acquired through the respiratory tract when people inhale aerosols (tiny droplets of water) contaminated with Legionella bacteria. Aspiration of water contaminated with Legionella has also caused. This may occur in persons with swallowing disorders. Person to person transmission has never been documented. Risk Groups Legionnaires disease can affect anyone, however the following are recognised risk factors for Legionnaires disease include Older age group > 40years Males Smokers Those with excessive alcohol intake Immunocompromised - organ transplant patients, patients with HIV/AIDS and those receiving systemic steroids Patients with chronic underlying disease such as diabetes mellitus, congestive cardiac failure, chronic obstructive pulmonary disease and chronic liver failure. Source Legionella is a group of bacterium which may be commonly found in low, harmless numbers in water including tap water. Where water is stagnant it can multiply to high numbers. It grows best where there are deposits of sludge, slime, scale and organic matter such as can be found in water storage tanks and water fittings. Legionella bacteria grow at temperatures between 20 o c 45 o c. Therefore the highest risk occurs with water systems which lead to aerosolisation of water at these temperatures e.g. from: Shower Whirlpool Spa pools Fountain etc. Respiratory therapy equipment Legionella will not survive in temperatures above 60 o c HSE South (Cork & Kerry) Page 4 of 7

5 Legionella can multiply in: Hot and cold water tanks/cisterns Warm water between 20 o c 45 o c Pipes with little or no flow (e.g. unoccupied rooms or non used facilities and showers) Water heaters and hot water storage tanks. Slime and dirt on pipes and tank surfaces. Rubber and natural fibres in washers and seals. Scale in pipes, showers and taps. Control of Legionellosis Employers should ensure a risk assessment is carried out in relation to legionella prevention and control in the work place, where a risk is identified appropriate control measures should be put in place (Section 4.2) Details of risk assessment and control measures relevant to healthcare settings are available in the National Guidelines for the Control of Legionellosis in Ireland (2009) Controls include but are not limited to Keep hot water hot 50 o c to 60 o c, take care to avoid scalding use blending/ mix valve. Keep cold water cold below 20 o c. Avoid stagnation in any part of the system. Do not have any dead legs on the system. Showers and water outlets that are in daily use do not require flushing The frequency and duration of flushing will be based on a risk assessment. Only showers used intermittently (less then once a week) should be flushed. In healthcare facilities it is recommended that the following is carried out on a weekly basis as a minimum: Showers run for 6 minutes (run cold for 3 minutes and hot for 3 minutes) HSE South (Cork & Kerry) Page 5 of 7

6 Taps run individual taps, cold tap for three minutes, run hot tap (when hot) for three minutes Mixer taps run with the lever in the coldest position for 3 minutes, run with tap in the hottest position for three minutes Keep showerheads and taps clean and free of scale. Showers (excluding safety showers) should not be fitted where they are likely to be used less then once a week. Maintenance of the cleanliness of the water system including regular checking of the system, keep storage tanks covered and clean and use of water treatment where it is appropriate and safe to do so. Have one person who is trained, and responsible for above Legionella control and for keeping records of treatments and temperature. Have a trained deputy to act in that person s stead. Please note that employers are required to provide a safe work place for their employees under Safety Health and Welfare at Work Act Reference Health Protection and Surveillance Centre (HPSC) National Guidelines for the Control of Legionellosis in Ireland Report of the Legionnaires disease Subcommittee of the Scientific Advisory Committee. HPSC Dublin. HSE South (Cork & Kerry) Page 6 of 7

7 Appendix Management of Nebulisers The National Guidelines for the Control of Legionellosis (HPSC 2009) outlines that nebulisers have the potential to be a source of infection if used incorrectly, and recommends that in healthcare settings, single patient use nebulisers are cleaned in between each use to an exact standard as follows: Use a quality controlled standardized system Records of each cleaning should be maintained. Following cleaning, nebulisers should be rinsed with sterile water not tap water or distilled water. They should be thoroughly dried inside and out. After drying, store in a dust proof container Labeled with the patients details and date. A sink other then those designated for hand washing should be used. If the single patient use standard of cleaning in between each use is not feasible or can not be guaranteed single use disposable nebulisers should be used The following two approaches are available 1. Single use nebuliser sets comprising of mask, tubing and chamber. All items must be disposed of after one use. 2. Single use nebuliser chambers can be used with a single patient use mask and tubing. The single use chamber must be disposed of after each use. The mask and tubing can be cleaned between uses following manufacturers instructions. The symbol denotes the device to be single use and intends the device to be used once and then discarded i.e. DO NOT REUSE. Reference & Bibliography Health Protection and Surveillance Centre (HPSC) (2009) National Guidelines for the Control of Legionellosis in Ireland,2009. Report of the Legionnaires disease Subcommittee of the Scientific Advisory Committee. HPSC Dublin. HSE South (Cork & Kerry) Page 7 of 7

What is Legionnaires' disease?

What is Legionnaires' disease? Understanding Legionnaires disease: A Fact Sheet For Workers Organization(s): New York Committee for Occupational Safety and Health Other languages: Spanish Summary Statement: This NYCOSH fact sheet is