Presented on April 17, 2018 by: Jacob Persky, MPH, CIH

Transcription

1 Presented on April 17, 2018 by: Jacob Persky, MPH, CIH

2 Agenda 15 min 1 Legionella Overview 10 min 2 Standards and Guidelines 25 min 3 CDC Toolkit Implementation 10 min 4 Q&A

3 What is Legionella? Rod-shaped (bacillus) bacteria belonging to the genus Legionella Over 58 species 25 disease causing Legionella pneumophila serogroup 1 most virulent strain Naturally found in fresh water bodies

4 How does Legionella become problematic? Favorable conditions for growth F Present in environment Susceptible host Add text title Mode of transmission Add text title

5 Disease Vector Interruption Presence in environment. Ubiquitous Modes of transmission. Intrinsic to modern life Presence of susceptible host. Inevitable Favorable growth conditions Most controllable Primary focus area for regulations and standards

6 Historical Discovery Philadelphia, 1976 American Legion convention at Bellevue-Stratford hotel 182 cases; 29 deaths Investigated by CDC and Pennsylvania Health Department Linked to cooling tower of hotel air conditioning system

7 Legionellosis: 1 Bacteria, 2 Forms of Disease Legionnaires Disease vs. Pontiac Fever % Exposed that Develop Disease Morbidity 90% develop Pontiac Fever Mortality Death rate LD survival rate Legionnaires Disease Add title text Pontiac Fever Pneumonia Recovery requires antibiotic treatment 5-10% death rate Non-pneumonic Self limiting Acute flu-like symptoms Not lethal

8 Statistics About 6,100 cases reported to CDC in In the US from % of outbreaks associated with long-term care facilities 15% of outbreaks associated with hospitals. Number of reported Legionellosis cases has increased five-fold since 2000.

9 Disease Trends

10 Reputational Damage

11 Legal Implications & Tort Liability

12 Financial Risk

13 International Regulations and Standards WHO (2007) Legionella and the prevention of Legionellosis EWGLI (2011) European Guidelines for Control and Prevention of Travel Associated Legionnaires Disease UK (2013) Code of Practice L8 Hong Kong (2007) Code of Practice: Prevention of Legionnaires Disease Singapore (2001) Code of Practice for the Control of Legionella Bacteria in Cooling Towers Australia (2010) Code of Practice: Prevention and control of Legionnaire s

14 U.S. Regulations and Guidance Standards CDC Model Aquatic Health Code CDC Disinfection of hot tubs OSHA (1996) Technical Manual EPA (2001) Drinking Water Health Advisory Cooling Tower Institute (2008) Best Practices Guideline ASHRAE (2000) Guideline 12 Dept Veterans Affairs (2014) VHA Directive 1061 ANSI/ASHRAE (2015) Standard 188 EPA (2017) Toolkit for Developing a Water Management Program CMS (2017) S&C Memorandum

15 ASHRAE Standard 188 Add text title Guideline 12 (2000) 188P (2008) Proposed Standard 188P (2011) Numerous public review drafts 188P (2013) Approved Standard Addendums A-F ( ) Add text title Approved Standard 188 (2015)

16 ASHRAE Standard page technical document Available online for $69 at ASHRAE website Scope Provides minimum risk management requirements Applicability Voluntary best practices Human-occupied commercial, institutional, multiunit residential, and industrial buildings. Does not cover single family residential

17 CDC Toolkit Published in June 2017 User-friendly guide to implement ASHRAE 188 following a step-by-step process. Free and downloadable from:

18 CMS Memorandum S&C page memorandum Issued June 2, 2017 Requires certain facility types to take steps to reduce risk of Legionellosis. Applies to: 1. Hospitals 2. Critical Access Hospitals (CAHs) 3. Long-Term Care (LTC) facilities Provides general awareness for all healthcare organizations

19 CMS Memo: 3 Requirements 1 Conduct a facility risk assessment Identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. 2 Implement a water management program Consider ASHRAE 188 and CDC Toolkit Include control measures and environmental testing for pathogens 3 Specify testing protocols Define acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

20 7 Steps in the CDC Toolkit

21 Preliminary Qualification Step: Survey

22 STEP 1 Establish a water management team Who should be on the team and why

23 STEP 2 Describe your building water systems using text Describe the flow of water from entry to exit from the building and all the places visited in between. Develop a flow diagram Example 1 from CDC toolkit Example 2 from ASHRAE 188 Example 3 is a hybridized approach

24 Flow Diagram: CDC Toolkit Example

25 Flow Diagram: ASHRAE 188P Example

26 Hybrid Example

27 STEP 3 Identify Areas where Legionella could grow and spread Hazard identification

28 STEP 3 (continued) Develop Control Measures and Corrective Actions

29 STEP 4 Decide where and how Control Measures should be applied (risk management) Thermal management Hot water heater set points HW Loop temperatures Secondary disinfection Chemical, UV Point of Use filtration

30 STEP 4 (continued) Decide How to Monitor Control Measures What parameters? Temperature Analog thermometers vs. networked digital data-logging Disinfectant concentration Manual readings / periodicity vs. digital sensors Visual assessment Scale build-up, foaming, sediment, algae

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32 STEP 5 Establish Ways to Intervene When Control Limits Are Not Met CDC Toolkit provides example situations Out of control conditions 1. Biofilm growth in a decorative fountain 2. Unoccupied floor 3. Debris in a cooling tower Contingency responses for unexpected emergency events 4. Biofilm growth in a decorative fountain 5. Water main break 6. Broken chlorinator in the hot tub

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35 STEP 6 Make Sure the Program is Running as Designed & Is Effective Verification steps Are we doing what we said we would do? Monitoring temperatures, disinfectant levels Taking actions when called for by the WMP Validation actions Is our program actually working? Do water sampling results demonstrate in-control conditions? Any suspected Legionellosis cases?

36 STEP 7 Document & Communicate All the Activities of your Water Management Program Manual vs. data-logging of control points. Web-based tools for document management, archiving of water sampling results, and data trend analysis.

37 Recap and Key Takeaways Is your facility required to comply with the CMS memo directive? Yes Start building your WMP team. If not, are risk factors present which drive voluntary adherence for risk management purposes? Take the Toolkit survey.

38 Recap and Key Takeaways Build your team. Internal person knowledgeable of facility mechanicals (chief engineer) Infection control practitioner (if healthcare facility) Management (decision maker) Water treatment vendors (cooling towers, pool/spas, etc.) Program author (familiar with Toolkit and 188) or outsourced consultant Water sampling partner (internal or outside consultant) for sample collection and data interpretation. Ex. Certified Industrial Hygienist (CIH) Laboratory. CDC-ELITE accredited. CDC Guidance for selecting external partners:

39 Jacob Persky, MPH, CIH Principal, Co-Founder RHP Risk Management Inc W. Higgins Rd., Ste 320 Chicago, IL