Legionella 101

1. Legionella 101 The Organism The Illness The History The Legality Your Compliance STSWH009 Issue 1

2. Section 1:The Science behind the name

3. What is Legionella? Pathogenic ‘Gram Negative’ Bacteria with 56 known species & 70 known ‘sero groups’. Biological advantages include:- • Flagellum for motility • Simple structure • Asexual reproduction Prefers to invade other organisms (algae, protozoans etc…) to use as ‘hosts’.

4. COMMONLY FOUND LEGIONELLA SPECIES • Legionella pneumophila • Legionella longbeachae • Legionella micdadei • Legionella bozemanae • Legionella shakespearei

5. How would I catch the bug? Think about what you may already know about legionella:- • How does Legionella enter the body? • Where is the perfect environment for Legionella? • Draw a Legionella bacterium where you believe it will cause illness in the body… Group Activity: 1

6. How does my body try to fight it? Once Legionella has entered the lungs through aerosol transmission the organism is targeted by Macrophages which are part of the bodies defence system and live inside the Alveoli (small air sacks) of the lungs. The Macrophages engulf the Legionella in an attempt to destroy it, however as with the Protozoans and Algae found in nature the Legionella bacteria invades the Macrophage and reproduces itself eventually destroying the cell. This is what gives Legionella its description of an “Intracellular Pathogen”.

7. Why does it grow in my water system? • Temperatures in the range of 20°C to 45°C. • The presence of Sediments, Scale and Sludge. • The presence of Iron Oxide • The use of materials not approved by Water Fittings and Materials Directory

8. What part does biofilm play? How does biofilm contribute to the growth of Legionella and other organisms? Lets do a fun experiment to find out… Group Activity: 2

9. What have you discovered? In groups discuss and write down 5 environmental factors which encourage the growth of Legionella Group Activity: 3

10. section 2:the illness

11. Legionellosis – what is it? The many species of Legionella bacteria give rise to a number of serious health conditions with the collective name for the resulting diseases being Legionellosis. • The two main types of disease are… • Pneumonic Legionella pneumonia – Legionnaires disease • Non-pneumonic diseases – Pontiac fever and Lochgoilhead fever

12. What would my symptoms be? • Incubation period of roughly 2 – 10 days, however longer periods have been documented • Dry Unproductive cough • Muscle pains • Headache • High temperature, fever and chills • Pneumonia

13. How legionella affects the lungs? 1 • Healthy set of lungs prior to infection, notice how clear the lung tissue appears by the lack of cloudy patches. • Progress of infection after 4 days, notice the fluid appearing in the lung tissue indicated by the cloudy regions on the X-Ray. • Post treatment recovery over a period of six years, again notice the cloudy areas showing where permanent scarring has occurred. This leaves the patient with diminished lung capacity. 2 3

14. Who is most at risk? • Greater risk in Men • The age group of 40 to 70 • Smokers • Alcoholics • Diabetics • Patients with Heart, Kidney or Liver disorders • Patients with compromised immune response (Chemotherapy patients) • Approximately 12% of all cases are fatal even with medical care

15. Who keeps track of these cases? Data compiled by PHE and reports released regularly

16. What can be done? Legionella is resistant to most forms of classic antibiotics, however newer antibiotics such as macrolides (azithromyacin) or quinolones (ciprofloxin, leveofloxacin, gemifloxacinand moxiflaxacin) do penetrate host cells effectively killing Legionella bacteria.

17. section 3:the history

18. When and where did it first appear? • First recorded case was at the Bellevue Stratford Hotel in 1976. • 255 infected with 34 fatalities. • Year of investigation to identify the source of infection. • Source identified as evaporative cooling towers on the roof. • Named for the group of people affected by the outbreak. • Showed that infection can occur anywhere where water at the right temperature is aerosolized.

19. Well known UK OUTBREAKS 1988 2002 1985 Group Activity: 4 2012 2012 & 2014 2003

20. What CAN WE LEARN? All of these pieces of equipment have Legislation / Guidance that covers their maintenance and use so there was no need for any of the outbreaks to occur. All individuals need to do is follow the appropriate guidance for their type(s) of system.

21. Are any buildings more at risk? • Industrial settings:- cooling towers / evaporative condensers / spray booths etc… • Recreational / leisure settings:- spa pools / fountains etc… • Hotel settings:- large systems / occupancy levels / shower heads etc… • Healthcare settings:- immunocompromised individuals etc…

22. Do any other systems pose a risk? • Ultrasonic Humidifiers / Foggers and water misting systems • Spray Humidifiers, air washers and wet scrubbers • Water Softeners • Emergency showers and eye wash sprays • Sprinkler and Hose Reel systems • Lathe and machine coolant systems • Car / Bus washers • Horticultural misting systems • Dental systems • Spa Baths / Swimming Pools • Indoor fountains and water features

23. Section 4:the legality

24. Guidance and Legislation –any differences? Statutory documents refer to written law and as such, are legally enforceable. Therefore, failure to comply will be viewed as failure to comply with the law. Non statutory documents refer to guidance documents only, such as an approved code of practice. Therefore, failure to comply with a code of practice is not an offence, but it is rather what you would be measured against in order to comply with a statutory document.

25. Can you tell the difference? Non-Statutory Statutory Group Activity: 5

26. A clear management structure? Statutory Duty Holder ACOP L8 defines clear roles and responsibilities. From most senior to least senior, all have their part to play. Responsible Person Appointed Deputy

27. The duty holders responsibilities? Appoint a “Responsible Person” Responsible for ensuring communication lines are set Responsible for ensuring Risk Assessment is carried out by a competent person Must ensure competence of any outside contractor Must consult with employees on any Risks identified Responsible for Legionella training of all staff involved

28. The responsible persons responsibilities? Operational & Financial authority to carry out tasks effectively Ensuring all appropriate records are kept Reporting on condition of system to Duty Holder Must ensure competence of any outside contractor Knowledge of systems he / she is responsible for

29. Training, Competence or both? If the “Responsible Person” does not have the required expertise then competent assistance should be sought from outside the organisation, this is where water treatment providers come into the equation. However it is the Statutory Duty Holders responsibility to ensure that all staff involved in the Legionella control strategy are trained and competent.

30. Can we seek assistance from outside our organisation? Any subcontractors you employ must be competent to provide the services you require. The LCA scheme is not mandatory but demonstrates that appropriate systems are in place to manage the many and varied aspects of Legionella control. Details of the status of company's can be found at www.conduct.org.uk.

31. Key tasks of the responsible person? System monitoring is a vital part of the control regime and is the responsibility of the Responsible Person. Routine weekly monitoring should include… • Checking the performance of the system and its component parts. • Inspecting the system for signs of damage and contamination. • Monitoring to ensure the treatment regime continues to be effective.

32. An auditable paper trail In addition to the system monitoring the Responsible Person must ensure that appropriate records are kept, including… • The person(s) responsible for carrying out the Risk Assessment. • The person(s) responsible for managing and implementing the control scheme. • The significant findings of the Risk Assessment along with the written scheme and details of its implementation as required by the ACoP. • Results of any monitoring, tests, inspections or checks carried out citing dates and signatures. • Details of the state of operation of the system. All these records MUST be retained for a period of at least 5 years.

33. Support for the responsible person The Responsible Person is permitted to create deputies to act on his or her behalf during their absence or to assist in the day to day operation of the control scheme. These appointed deputies must have the necessary competence and knowledge to act effectively in their absence, this does not negate the overall charge of the Responsible Person. The Appointed Deputies must have regular refresher training to enable them to carry out their role and direct access to the Responsible Person to ensure they are kept informed as to the status of the systems under their control.

34. Do you know who they are? Statutory Duty Holder ______________ Group Activity: 6 Responsible Person ______________ Appointed Deputy ______________

35. Section 5:Your Compliance Control of a Domestic non-healthcare property to HSG274 Part 2

36. Where should I look for guidance? People who operate buildings and equipment which fall into these risk categories are defined as the “Statutory Duty Holder” and are ultimately responsible for the Legionella control program in operation in their buildings. The HSE released the 4th edition of ACOP L8 in 2013, followed by HSG274 part 2 in 2014 revised in 2015. HSG274 part 2 gives operators of Hot and Cold water systems guidance in the form of “Best Practice” on how to manage their water distribution systems to comply with ACOP L8.

37. Where do we begin? • Both ACOP L8 and HSG274 Part 2 recommend the ‘first step’ as being a system risk assessment. The Duty Holder may need access to competent help and advice when carrying out the Risk Assessment, in this case a competent organisation should be employed to carry out the risk assessment. The record of the assessment is a living document that must be reviewed to ensure it remains current. To this end the assessment must be reviewed regularly (no specified time period) and specifically where there is reason to suspect its no longer representative.

38. When should it be reviewed? The ACOP recommends reviewing more frequently in the following circumstances… • Changes to the Water System or its use. • Changes to the use of the building in which the water system is installed. • The availability of new information about risks or control measure. • The results of checks indicating that control measures are no longer effective. • Changes to key personnel. • A case of legionnaires disease / legionellosis associated with the system.

39. What should it cover? “Apply the Guidance” • The Plants design • The Systems design • The Storage Conditions • The Distribution temperatures • Water Quality • Potential for aerosol formation • Population exposure (at risk individuals)

40. a ‘sufficient’ schematic diagram? “Mains to Drains” • Filter packages • Strainers • Dosing Equipment • Pumps • Isolation Valves • Storage Tanks • Calorifiers • Thermostatic Mixing Valves (TMVs)

41. So now I’ve identified a riskwhat next? “Simple Pointers” • Reduce the spray produced. • Avoid temperature ranges that favour growth 20°C - 45°C. • Avoid stagnation in Calorifiers, CWSTs and pipework. • Avoid use of materials which harbour micro-organisms. • Avoid Sediment build-up in systems. • Ensure systems are well maintained and operated safely and correctly. • Ensure that any water treatment taking place is carried out correctly and is effective.

42. WHAT SHOULD A WRITTEN SCHEME INCLUDE? “Follow the ACOP” • An up-to-date schematic diagram of the system(s). • A written safe operating procedure. • The control measures utilised. • Checks to demonstrate the effectiveness of the control scheme. • Remedial actions to be taken should the system controls lapse out of specification.

43. What control options are available? “Which is right for your site” • Temperature Control • Chlorine Dioxide • Chlorine • Silver Peroxide • Ionisation • Ozone • Ultraviolet Radiation Domestic systems can be tricky to control as the water is ultimately intended for human consumption, so incredibly toxic biocides are not an option. HSG 274 Part 2 lists the available options of control, they are…

44. What tasks need to be done on a temperature regime? Consideration should be given to removing infrequently used showers, taps and any associated equipment that uses water. If removed, any redundant supply pipework should be cut back as far as possible to a common supply (eg to the recirculating pipework or the pipework supplying a more frequently used upstream fitting) but preferably by removing the feeding ‘T’ Infrequently used equipment within a water system (ie not used for a period equal to or greater than seven days) should be included on the flushing regime Flush the outlets until the temperature at the outlet stabilises and is comparable to supply water and purge to drain Regularly use the outlets to minimise the risk from microbial growth in the peripheral parts of the water system, sustain and log this procedure once started For high risk populations, eg healthcare and care homes, more frequent flushing may be required as indicated by the risk assessment . Weekly

45. What tasks need to be done on a temperature regime? • The flow temperature of the Hot water storage vessel should be at least 60°C, while the return temperature should be at least 50°C. • The temperatures of Sentinel outlets must be checked and recorded. • The Cold outlets should be less than 20°C within two minutes of running • The Hot outlets should be at least 50°C within one minute of running. “Make a Record” Monthly

46. What tasks need to be done on a temperature regime? Combination water heaters – check the water temperature at an outlet to confirm the heaters operates at 55°C - 60°C. POU water heaters (no greater than 15 litres) - check the water temperature to confirm the heaters operates at 50°C - 60°C – Monthly to six monthly as indicated by the risk assessment. Expansion vessels – flush through and purge to drain - Monthly to six monthly as indicated by the risk assessment. Monthly

47. What tasks need to be done on a temperature regime? Quarterly HSG 274 Part 2 recommends that at least on a quarterly basis if not more regularly all Shower Heads, hoses and spray taps should be completely dismantled, cleaned and de-scaled. This removes the potential for Legionella bacteria in areas of low flow within the shower head being caused by scale formation.

48. What tasks need to be done on a temperature regime? • The temperature of the cold water tank must be checked as follows:- • Remote from the ball valve and • The temperature of the cold water entering the tank at the ball valve. • Both should be below 20°C. “Preferably in Summer” If it is noted that the temperature of the incoming supply is greater than 20°C the water supplier may need to be contacted to investigate and rectify the cause. If however the cause cannot be rectified then the system risk assessment should be modified to reflect the increased risk. Annually

49. What tasks need to be done on a temperature regime? • The temperatures of a representative number of hot and cold outlets should be checked and recorded over a defined time period, using the same parameters as those for the Monthly checks. • A water sample should be taken from the from the hot water storage vessel drain valve and a determination made of its condition. (Is it clean or dirty?) • The internal surfaces of the hot water storage vessel should be assessed for the presence of sludge, scale and debris. If present remedial action should be carried out at once. Annually

50. What tasks need to be done on a temperature regime? Annually • The cold water storage tanks should be visually inspected for debris of any kind, if found adequate remedial action should be employed. • Water softeners should be serviced and disinfected on an annual basis. • Thermostatic Mixing Valves should be annually Inspected, cleaned, descaled, disinfected and serviced inline with manufacturer’s recommendations.