Waterborne Pathogens Risk Assessment – Role of the IP

1. Waterborne Pathogens Risk Assessment – Role of the IP Presented by: Megan Canright, MPH, CIH Karen Trapane, MS, HEM March 9, 2016 (San Diego APIC meeting)

2. Meeting Objectives Understand what could be present in the hospital’s potable water systems that could contribute to HAIs. Understand what is your role on the water management team and identifying risks. Identify elements of the ASHRAE 188 standard for water management plan as it relates to hospitals.

3. Meeting Objectives Understand the risks associated with unmanaged water systems Learn about water management plan key elements and controlling risk Understand what actions can be taken to mitigate issues with water quality

4. The Infection Preventionist The link between patients and hospital water systems Under pressure to accomplish objectives surrounding insurance reimbursement and reducing HAIs May not always be included in engineering functions or water systems but should be Has great influence over processes and process changes

5. Waterborne Pathogens and Risk for HAIs

6. Waterborne Pathogens • Bacteria • Viruses • Protozoa • Helminths

7. Legionellaspecies • Gram-negative rod • Most motile – 1-3 flagellae • 50+ species, 70+ serogroups • 19+ pathogenic (pneumophila, longebeachae, bozemanii, micdadei, etc.) • Water (surface, ground) and soil • Commonly found in [low] in water systems

8. Legionella Growth Conditions • Water (potable, industrial, lakes, etc.) • Temperature 68-120°F (20-49°C) • Ideal growth range 96-115°F (35-46°C) • Commensal organisms (amoebae) • Biofilms • Sediment, scale, algae

9. Biofilms

10. Legionella – Associated Illness • Nosocomial v. community • Hotels, hospitals, long-term care, cruises... • Exposure: mists and aerosols, aspiration • Elderly, children, immunocompromisation • HAI susceptibility • recent surgery, assisted ventilation, NICU, immunosuppresion/therapy, transplant… • Agent: L. Pneumophilaserogroup 1??

11. Legionella – Associated Illness • Infectious dose unknown • Legionnaire’s Disease (pneumonia) • Pontiac Fever (not an infection) • Incubation period • 2-14 days: Legionnaire’s Disease • 1-2 days: Pontiac Fever • 1-2% of all pneumonia cases?

12. Diagnostic Tests • Legionnaire’s Disease diagnosis by: • Urinary antigen test • Blood, sputum culture • Chest x-ray • Lung biopsy • Pontiac Fever diagnosis by: • Urinary antigen test • Blood culture • False negative rate high

13. Diagnostic Tests

14. Hospital-Acquired Legionella Infections Statistics Reported by CDC: http://www.cdc.gov/legionella/index.html • Hospital-Acquired Pneumonia (HAP) accounts for 15-20% of all HAIs • Nosocomial Legionnaire’s Disease accounts for 20-30% of HAPs • 10 days hospitalization before onset = HAI • Mortality rate approaches 50% for HA Legionellosis

15. Hospital-Acquired Legionella Infections • First hospital-associated outbreak in 1965 • Psychiatric hospital in Washington, DC • 81 illnesses, 15 deaths • Antibody seroconversion – 85% patients • Largest hospital-associated outbreak 1977-1982 • VA hospital, Los Angeles • 218 confirmed cases

16. Hospital-Acquired Legionella Infections • Miami Valley Hospital, 2011 (new hospital) • 10 confirmed cases, 1 death • Within weeks of opening • Oxygen dehumidifier identified in 2009 outbreak (hospital not identified) • Known outbreaks worldwide: India, Turkey, Poland, Italy, Taiwan, etc.

17. Liability and Risks Increased length of stay Decreased or eliminated insurance reimbursement Increased level of care for patient Reporting requirements may lead to CMS inspection ASHRAE 188-2015 may establish a “duty of care” for use in litigation

18. Liability Considerations Two or more cases epidemiologically linked Often no “smoking gun”, multiple sources are common Difficult to “prove” patient and environmental sample match An implemented plan can help to prevent “negligence” or “at-will” claims

19. Financial Ramifications Preventable with Water Management Plan

20. What is ASHRAE 188-2015?

21. Who is ASHRAE? American Society of Heating, Refrigeration, and Air-Conditioning Engineers (ASHRAE) Published voluntary standards and guidelines Publications are peer-reviewed by panel of experts, public comment periods, iterations/revisions Not enforceable, but….

22. Purpose • Scope Establish minimumLegionellosis risk management requirements for building water systems. Applies to human-occupied commercial, institutional, multiunit residential, and industrial buildings. …intended for use by owners and managers of human-occupied buildings, excluding single-family residential buildings. … is also intended for those involved in the design, construction, installation, commissioning, operation, maintenance, and service of centralized building water systems and components. Annex: denotes special requirements for healthcare facilities

23. Anticipation, Recognition ASHRAE 188/IH Paradigm • Evaluation • Control • Prevention, Management

24. Key Standard Elements Requires a Team of Experts Risk Assessment Management Plans Contingency plans Verification Validation Courtesy of: ASHRAE

25. Key Elements – The Team Requires a Team of Experts Plumbing systems design expertise Facility Operations Expert Treatment and Control measures Expert Validation Expert Response Action Expert

26. Key Elements – Risk Assessment Risk Assessment • Health of Supply (Municipal, Wells) • Function of System • Occupants and users • Aerosolization potential • Control Measures • Chemistry, heat, flow • Impact to systems and existing biofilms • Short and long term

27. Key Elements – The Plans Management Plans • (Simple) Drawings • Control measures • Critical Control Points • Control values • Contingency plans • Verification & Validation • Establish “safe” range • Chemistry, temperature, bacteria

28. Key Elements – The Annex • Designated Team • Designated responsibility/leadership • Decision maker, Facilities, IP membership required • Water Diagrams • All key water service points • Water treatment, processing, control • Hazardous conditions (clinical support, patient care) • Water Management Plan • Documented risk assessment, assigned responsibility • Areas with higher risk of infection, likelihood assessment • Disease surveillance

29. Key Elements – The Annex • Risk Assessment • Repeated with changing processes, maintenance, or disruption • Proactive risk assessment with new construction/renovation • Commissioning plan, Legionella management plan • Water Systems Procedures • Systems start-up and shut-down • System maintenance • Water treatment • Cooling tower maintenance/disinfection • Backflow prevention

30. Risk Assessment & Management

31. Risk Assessment & Management

32. Water Systems with Potential Risk Domestic water and fixtures Industrial water Cooling towers Therapeutic spas Decorative features Emergency equipment

33. Common Conditions of Risk Low Occupancy Uncontrolled Dead Legs Construction Projects Unused/Unexercised Fixtures Inadequate Temperature, Flow Low Oxidant Residual

34. Common Areas of Risk • Potable Water Systems • Showers, sink fixtures (automatic) • Hoppers • Hot water tanks/boilers • Emergency showers/eyewashes • Historical dead legs • Ice machines • Emergency tanks • Thermal mixing valves

35. Areas of Risk - Hospitals • Non-Potable Water Systems • Cooling towers • Decorative water features • Humidification systems • Backflow/cross-connections • Low flow/use • Low occupancy wings • Future build outs • Unmanaged bypasses

36. Areas of Risk - Hospitals • Construction Projects • Water shut-offs • Stubbed piping • Tie-ins • Chlorination • Reliance on • Municipal treatment • Incoming treatment (e.g., UV)

37. System Control Plans • Control Gap Analysis • Residual Oxidant • Temperature Management • Flushing & Flow • Filtration • Dead Leg Prevention & Management • Preventive Maintenance • Water Treatment • Primary as needed • Secondary ongoing

38. Monitoring • Verification • Recordkeeping • Oversight • Validation/Environmental Assessment • Sample collection • Temperature, oxidant • Surrogates (HPC), specific pathogens • Response • Preventive action plan

39. Role of the Infection Preventionist • Integral part of Water Management Team • Provide feedback regarding patient risk • Patients at high risk • Departments with exposure risk • Assignment of qualitative risk (L, M, H) • Help determine need for sampling • Confirmation of risk areas • Validation of risk control • Feedback on specific testing locations

40. Role of the Infection Preventionist • Review sampling plan, provide feedback • Sampling objectives • Type of sampling (water, swabs, bulk) • Analytes • Analytical methods • Number of samples • Locations of samples • Frequency of sampling

41. Role of the Infection Preventionist • Review sampling data, provide feedback • Interpretation of data, “thresholds” • Historical context • Patient context • Assist with selection of controls • Feasibility of implementation • Specifications review • Evaluation and review of data

42. Role of the Infection Preventionist • Outbreak response support • Identification of HAI cases • Regulatory reporting • Collaborate with Public Health • Management of surveillance • Determine when to start/stop • Surveillance methods • Data management

43. Summary A water management plan is the best way to prevent waterborne HAIs You are an integral and very necessary stakeholder in the program Liability and Risks are too great for status quo It will compliment your TJC management plans

44. Selected References • Legionellosis: Risk Management for Building Water Systems. ANSI/ASHRAE 188-2015 • Evaluation, Recognition, and Control of Legionella in Building Water Systems. AIHA. 2015 • Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Centers for Disease Control. 2003. • Legionella and the prevention of legionellosis. World Health Organization. 2007.

45. Selected References Legionnaire’s disease, the control oflegionellabacteria in water systems: Approved Code of Practice and guidance. 3rd ed. Health and Safety Executive (HSE). 2000 OSHA Technical Manual (OTM) Section III: Chapter 7: Legionnaires’ Disease. Occupational Safety and Health Administration. 1999 CDC. [Increasing incidence of] Legionellosis in the United States, 2000-2009. MMWR 2011;60:1083-1086. Beer KD, Gargano JW, Roberts VA, et al. Surveillance for waterborne disease outbreaks associated with drinking water — United States, 2011–2012. MMWR. 2015;64(31):842–8

46. Questions? Megan Canright Director Scientific Operations mcanright@forensicanalytical.com 858-859-3322 Karen Trapane Director, San Diego ktrapane@forensicanalytical.com 858-247-1051

47. Thank You! Forensic Analytical Consulting Services, Inc. Right People. Right Perspective. Right Now.