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FEDECAI Conference. Legionella – A British Perspective Presented by David Handley of Healthy Buildings International On 24th October 2002 in Valencia. What is Legionnaires ’ Disease ?. Potentially fatal form of pneumonia Affects anybody, but some individuals are particularly susceptible
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FEDECAI Conference Legionella – A British Perspective Presented by David Handley of Healthy Buildings International On 24th October 2002 in Valencia
What is Legionnaires’ Disease ? • Potentially fatal form of pneumonia • Affects anybody, but some individuals are particularly susceptible • Contracted by inhalation of legionella bacteria from contaminated water • High fever, chills, headache & muscular pain • 200 –250 reported cases each year • Fatal in approximately 12% of cases • Legionellosis – range of illnesses cased by legionella bacteria
What are Legionella? • Types of bacteria • Found in water at temperatures 6°C to 55°C • Requires nutrients to multiply • 40 different types of legionella • Legionella pneumophila – 16 serogroups • Legionella pneumophila sg1 is the causative bacterium for 90% of Legionnaires’ Disease
Where are legionella found? • Found in environmental water sources • Colonises manufactured water systems • Cooling towers • Hot and cold water systems • Air handling plant • Other plant that uses or stores water
History of Legionnaires’ Disease • 1976 Philadelphia • Clinical samples pre 1930 • 1985 Staffordshire Hospital • 1986 BBC London • 2002 Barrow-in Furness
Legionella - Legislation • Health and Safety at Work Act 1988 • The Control of Substances Hazardous to Health 1994 (COSHH) • Approved Code of Practice (ACoP L8) • Launched 8th January 2001 • Replaced HS(G) 70, ACoP L8 (Rev) & MISC 150
Requirements of the ACoP • Identify & Assess Sources of Risk • Prepare a Scheme for Preventing or Controlling the Risk • Implement & Manage the Precautions • Keep Records of the Precautions Implemented • Appoint a Person to be Managerially Responsible
Changes in the New ACoP (1) • A New Title • Legionnaires’ Disease, The Control of Legionella Bacteria in Water Systems • Previously • The prevention or control of legionellosis (including legionnaires’ disease) • Aim • to directly identify the subject matter and avoid confusion
Changes in the New ACoP (2) • The New ACoP is Split (Part 1 and Part 2) • Part 1 – The ACoP • Part 2 – Guidance on Control • Includes Guidance in Part 1 • Aim • to make clear the Employers duty under the COSHH Regs to control legionella
Changes in the New ACoP (3) • Use of Risk Systems HAS TO BE AVOIDED in so far as is reasonably practicable • Previously SHOULD BE • Must assess practicality of removal of risk system • Now requires that you CONTROL the Risk • Previously MINIMISE the Risk
Changes in the New ACoP (4) • Now has a requirement to have access to competent help when conducting a risk assessment • Code of Conduct for organisations providing water treatment services • Water Management Society • British Association of Chemical Specialities
Changes in the New ACoP (5) • Greatly expanded section on Managing the Risk - gives advice on competence & training for those: • Developing, managing & conducting the risk assessment • Implementing controls • Managing external Contractors • Including detailed lines of communication
Changes in the New ACoP (6) • Emphasises the duty of suppliers of products and services to: • Carry out work effectively • Liase with Duty Holders about deficiencies • Clearly define limitations of work undertaken • Ensure staff have necessary ability, training, information, resources etc. • Code of Conduct
Design Requirements • Design requirements of L8 • Ensure that risk is reasonably avoided or, where not reasonably practicable; • Ensure that the plant or water system is so designed as to be safe and without risk when used • Provide on handover information as to safe usage. Such information should be updated as applicable.
Changes in the Part 2 Guidance (1) Cooling Towers • Much greater detail on regimes of control • Routine quarterly testing of cooling towers for the presence of Lp (records kept for 5 yrs) • Table 1 – details weekly, monthly & quarterly tests for make-up water and cooling water • Action levels for Lp & aerobic bacterial counts outlined in Table 2
Part 2 Guidance Cooling Towers • Must have regular programme of visual inspection • Particular attention is paid to: • Tower Pack
Part 2 Guidance Cooling Towers • Must have regular programme of visual inspection • Particular attention is paid to: • Tower Pack • Drift Reducers
Part 2 Guidance Cooling Towers • Must have a programme of water treatment effective against: • Corrosion • Scale formation • Fouling • Microbiological Activity
Part 2 Guidance (2) Cooling Towers • Weekly • Conductivity • Oxidising Biocide Reserve • pH • Microbiological Activity (Dip Slide)
Part 2 Guidance (2) Cooling Towers • Monthly • Hardness - Ca, Mg & Total !! • Oxidising Biocide Reserve • pH • Microbiological Activity (Dip Slide) • Chloride • Inhibitor Treatment Level • Concentration Factor
Part 2 Guidance (2) Cooling Towers • Quarterly • Legionella • Total Alkalinity & Sulphate • Suspended Solids • Soluble & Total Iron • Temperature
Part 2 Guidance (2) Cooling Towers • Cleaning & Disinfection • Before tower first commissioned • After shutdown of more than one month • If any mechanical work undertaken • If cleanliness is in doubt • If microbial test results show a problem • Temperature • Every six months
Changes in the Part 2 Guidance (2) Domestic Hot & Cold Water Systems • Removal of the limit of 300 litres for DHW • TMVs given recognition and procedures outlined • Table 3 & Checklist 2 introduced as guides to monitoring • Sentinel outlets introduced • Temperature measurement on DHW return • Annual tap temps reduced to “representative”
Changes in the Part 2 Guidance (3) Showers • Now included!! • Procedures outlined for showers served by TMVs (include hot supply as sentinel outlet) • Checklist 2 gives guide to monitoring • Shower heads – quarterly or as necessary • Flush little-used outlets weekly
Changes in the Part 2 Guidance (4) Other Risk Systems • Checklist 3 includes: • Water misting systems • Air washers & wet scrubbers • Dental equipment • Car/bus washes • Fountains & water features • Etc.
Part 2 Guidance Hot & Cold Water Systems • Monthly • Calorifier Temperatures – Flow & Return • Sentinel Taps (Nominal Nearest & Furthest) • Supplies to Thermostatic Mixing Valves
Part 2 Guidance Hot & Cold Water Systems • Annual • All Monthly Tests • Representative Number of Hot Water Outlets
Part 2 Guidance – Control Limits Hot & Cold Water Systems • Calorifier Temperatures • Flow >60°C & Return <50°C • Taps • Hot >50°C within 1 minute • Cold <20°C after 2 mins • Supplies to Thermostatic Mixing Valves • Same as Taps
Legionella Risk Assessment • Risk at Source • Condition • Accessibility • Cultivation Conditions • Temp & pH • Microbe Count & Water Change Rate • Exposure • Period and Type • Exposed Population
Precautions & Control Scheme • Prepare a Suitable System of Control • Manual • Details • Written Scheme • Regime of Maintenance & Control • Responsible Persons • Reporting Procedures • Risk Assessments
Lp High Risk Systems • Cooling Towers • Diligent Water Treatment Programme • Quarterly Lp Testing • Once or Twice Weekly Water Treatment Tests • Showers • Minimum Quarterly Clean/Descale of Shower Head • Weekly Flush Through of Low Usage Systems • Annual Lp Testing
Implement & Manage the Precautions • Log Book • Water Treatment Results • Lp Tests • Temperature Measurements • Cleanliness of systems • Disinfection certificates etc
Record Keeping • Keep Records • Manual (incl. Risk Assessments) • 2 Years • Log Book Records • 5 Years
Responsible Person • Manage the Control Scheme • Training • Regular Reviews • Communication
The Barrow Outbreak (1) • Britain’s Biggest Ever Outbreak of LD • 131 confirmed cases • Trawl of GPs nationwide shows 10 more suspected cases • 41 people still in hospital – 8 in intensive care • Majority of victims aged 55-75 - none <15yrs old • 4 Fatalities - 3 Women, 1 Man – all >50 yrs old • Mortality Rate 3.1%. Lower than norm - due to rapid diagnosis & more effective antibiotics
The Barrow Outbreak (2) • Identifying the Source • Epidemiological link to centre of Barrow-in-Furness • HSE checked 132 locations in immediate area • Most rapidly eliminated – just 4 cooling towers • 3 proved negative for legionella spp • Causative organism identified as Legionella pneumophila serogroup 1 – subtype Benidorm • Strain isolated from some patients and the Forum 28 Arts Centre cooling tower
The Barrow Outbreak The Forum 28 Arts Centre
The Barrow Outbreak (3) • The Arts Centre Cooling System • 30 yrs old and in poor condition • Local Council responsible for site maintenance • Biocide dosing system malfunctioning? • Discharging “discoloured steam” into alleyway • Part of system not used, but not decommissioned • 6-monthly disinfection being done for free! • System believed to have been operating badly for some time