LEGIONELLA

1. LEGIONELLA MANAGEMENT & CONTROL

2. IS IT WORTH WORRYING ABOUT?

4. LEGIONELLOSIS • Legionella = water-borne bacteria • Naturally widespread in the environment • Over 50 different species identified • 20 known to cause disease in man • Legionella pneumophila • Legionnaire’s Disease • Pontiac Fever / Lochgoilhead Fever

5. LEGIONELLA • Temperature range 20 - 50°C • Proliferates at 37 °C • Requires nutrients • Slow moving / stagnant water • Poorly managed water system = perfect environment

6. INCIDENCE RATES • 300+ cases/year - England & Wales • Steady rise in cases since 2002 • Studies show LP could be responsible for 2-3% of community acquired pneumonia (approx 83,000 cases of CAP) so 2,500? • Treatment is cheaper than testing • 10-12% mortality rate • Respiratory disease

7. CASES BY YEAR Barrow Outbreak

8. ‘AT RISK’ GROUPS

9. EU SURVEILLANCE

10. ENVIRONMENTAL FACTORS

11. WHERE IS IT ACQUIRED?

12. CHAIN OF EVENTS Bacteria present in water system Slow moving / stagnant water Adequate food source Temperature range 20-50°C Aerosol formed People present

13. OUTBREAKS

14. SHOWERS Operate at ideal temps Poor hygiene Infrequently used Prone to scaling Create aerosol

15. DEAD LEGS Stagnant water Ambient temps Breeding ground

16. STORAGE TANKS Over capacity Stagnation Out of sight Poor flow Ambient temps

19. CALORIFIERS Can run at critical temps Thermal stratification Sludge build up

20. COOLING TOWERS Run at ideal temps Open to elements Contamination via water supply Intermittent use Drift affects wide area

21. CASE HISTORY • Hospital outbreak - Glasgow 1992 • 1 patient died • Source = fire hose • ‘Deadleg’ • Need for awareness

22. THE LAW • Health & Safety at Work Act (1974) • COSHH Regulations (2002) • Notification of Cooling Towers Regulations (1992) • Approved Code of Practice (1992) • Revised ACOP January 2001

23. RESPONSIBILITY - ACOP • Identify & assess sources of risk • Prepare scheme to prevent/control the risk • Implement & manage control programme • Keep Records • Appoint a responsible person

24. RESPONSIBLE PERSON • Managerially responsible for implementation & supervision • Ensure all those involved are trained and competent • Manage contractors and suppliers • Maintain records • Ensure regular reviews are carried out

25. CAUSES OF OUTBREAKS

26. KEY FACTORS • Poor communication (internally) • Responsibilities not defined • Lack of training • Failure to record meetings / conversations • Insufficient contract documentation • Poor advice / management • Risk assessment not carried out

27. 2012 OUTBREAKS • Edinburgh – 101 cases, 3 deaths • North British Distillery Company – HSE Improvement Notice (failure to devise & implement a sustained & effective biocide control programme in one cooling tower) • Macfarlan Smith  – HSE Improvement Notices require thorough cleaning of one cooling tower & provision of access for inspection & maintenance. • All three notices have been complied with, and the HSE has stressed that the notices do not mean that the cooling towers have been identified as the source of the outbreak • Stoke on Trent – 21 cases, 2 deaths • JTF discount warehouse in King Street, Fenton, where a hot tub on display was singled out as the probable source of the bug

28. COST TO BUSINESS • Sick pay • Loss of production / skills • Cost of an investigation (FFI) • Prosecution & Civil Action • Bad publicity - loss of business • Employee de-motivation

29. RISK MANAGEMENT • Risk assessment • Regular monitoring • Temperature control • Water Treatment • Maintenance & Cleaning • Annual review • Awareness

30. RISK ASSESSMENT • ‘Suitable & Sufficient’ - all water systems • Reviewed regularly (bi-annually) and where: • change to plant / water system or its use • change to the use of the building • new information about risks / control measures • tests indicate control measure are ineffective • Carried out by competent person

31. BS8580 • Establish a standard approach to working • Encourage risk assessment rather than ‘surveys’ • Meet standards expected by the HSE / EHOs • More emphasis on • Appraisal of records and control measures • Incidents of persistent non-compliance • Training and competence of site personnel • Timely completion of recommended remedial work

32. SCHEME FOR CONTROL • Weekly flushing - infrequent use services • Monthly temperature monitoring - sentinel taps & calorifiers • Quarterly shower head disinfection / de-scaling • 6 monthly storage inspections • Annual review of scheme and risk level • Bi-annual review of the risk assessment document • Cleaning and disinfection as required

33. LEGIONELLA MONITORING • Programme for continual risk assessment • Early identification of problem areas • Demonstrate effective control • Visual inspection – cleanliness / operation • Compliance with current guidance

34. CONTRACT MANAGEMENT • Use registered suppliers – LCA • BS 8580 / BS 8558 • Check training records / CVs • Ask for references • Agree levels of service • Agree areas of responsibility • Review contract at quarterly intervals • Check log book records regularly

35. FUTURE TRENDS • Rise in susceptible individuals • Increased installation of TMVs • (new building regs – required on all baths / showers) • MRSA / Swine flu – increased use of alcohol gel • Office water coolers / boilers • IR no touch taps (low flow areas) • Increase in solar heating installations • Global warming

36. IS IT WORTH WORRYING ABOUT?