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6/29/2017
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OTHER WATERBORNE PATHOGENS
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Water as a Source and Vector of Infection (1)
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Anaissie et al, 2002Anaissie et al, 2003Cervia et al, 2010Exner et al, 2005Holmes et al, 2009Walker et al, 2013Crumby personal communication
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Multiple reports of infections linked to water Legionella pneumophila Pseudomonas aeruginosa Stenotrophomonas maltophila Acinetobacter baumannii Mycobacterium chelonae Aspergillus and Fusarium spp.
Literature citations of WHAIs Bone marrow transplant units Oncology wards Surgical ICUs Subacute care units Neonatal units Burn units
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74% of taps without temperature selection were contaminated with P. aeruginosa (2001)
In 15 of 45 patients, the genotypes of P. aeruginosainfections matched isolates from faucets in patient rooms
132 patient cases of P. aeruginosa were investigated In 42% of these cases, the DNA fingerprint of P. aeruginosa infections
from patients was identical to the DNA fingerprint of P. aeruginosafound in the inner part of faucets in an ICU
38 patient cases of P. aeruginosa were investigated 39% of water samples from electronic faucets in areas including hematology units and ICUs
nyielded P. aeruginosa.
Myers et al, 2014
Water as a Source and Vector of Infection (2)
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A 2009 study showed that NTMs are enriched > 100-fold above background water samples in showerhead biofilms
In 2010, a hospital-acquired outbreak of LD sickened 8 people. The source was identified as a decorative fountain in the hospital public area
A 2014 study showed that NTM was found in 106/183 (58%) of endpoint water samples over a three year surveillance period. Authors cited concern with risks of infection
A 2015 study showed the source of a postoperative breast infection by Mycobacterium fortuitum to be the hospital water supply
A pseudo-outbreak of Elizabethkingia meningoseptica infection in 30 patients over a 22 month period was epidemiologically linked to the hospital water system
Crago et al, 2014Feazel et al, 2009Haupt et al, 2102Jaubert et al, 2015Moore et al, 2016
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Water as a Source and Vector of Infection (3)
IMPLEMENTING A WATER SAFETY PLAN: A KEY STRATEGY TO REDUCE INFECTION RISKS FROM POTABLE AND UTILITY WATER
Ian Eisner – Water Safety Consulting Manager
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Managing The Risk of Water Safety
6/4/2015ASHRAE 188 Standard Establishes Risk Management Requirements for Building Water Systems
6/1/2016CDC June Vital Signs Publication Requests Building Owners Follow
ASHRAE 188 Standard.
A “Site Specific Legionella Water Management Program”
Follow ASHRAE Standard 188 7-Step Model
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TJC and DNV-GL are Auditing for WMP’s!
1/22/2017
TJC Audit indicating Water Management
Plan Non-Compliance
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Legionellosis Risk By Age Group 2000-2009
Age group (years) Number of cases
% of cases Incidence rate per 100,000 population
<9 79 0 0.02
10‐19 125 1 0.03
20‐29 516 2 0.13
30‐39 1473 7 0.36
40‐49 3622 16 0.81
50‐59 5401 24 1.44
60‐69 4658 21 1.94
70‐79 3672 16 2.29
>80 2864 13 2.66
6-fold
17-fold
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6032a3.htm
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Elements of a Water Management Plan to Reduce Riskper ASHRAE Standard 188
Program Team Development &Implementation
1
2
3
4
5
6
7
Describe Water Systems& Flow Diagrams
Analysis of BuildingWater Systems
Control Measures
Monitoring &Corrective Actions
Confirmation
Documentation
DO YOU HAVE A PLAN?
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System Assets & Risk Analysis
Reference Guides (Best Practices)
Program Manual
Elements of a Water Management Plan to Reduce Riskper ASHRAE Standard 188
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Organize a Team
Describe Your Systems
Define Control Measures & Monitor Them
Intervene When Control Limits are Not Met
Review & Confirm Program
Document, Communicate & Adjust
Analyze System Hazards
ASHRAE 7-Steps Description
1. Organize a Program Team Identifying persons (the “Team”) responsible for Program development, implementation and compliance.
2. Describe Water Systems & Flow Diagrams
Describing the potable and non-potable water systems during walk-thru. This will include simple process flow diagrams (not engineered drawings).
3. Analysis of Building Water Systems (“Risk Assessment”)
Completing an assessment during the on-site walkthrough to evaluate where hazardous conditions may occur in the water systems and determine where control measures can be applied.
4. Define Control Measures & Monitor Them
Determining locations where control measures must be applied, monitored, and maintained in order to stay within established control limits.
5. Intervene When Control Limits are Not Met
Providing guidance to Customer to establish control limits and to define corrective actions necessary to correct the condition when test results occur outside of the control limits.
6. Review & Confirmation Program
Program confirmation step… (1) to verify the program is being implemented as designed (are the control measures and monitoring/maintenance tasks being followed and is action being taken and documented), and (2) to validate the program is working to control the hazardous conditions based on scientific principles and monitoring evidence.
7. Document, Communicate & Adjust
The Program specifies documentation and communication procedures.
Completed On-site
Defined in Program Manual
Elements of a Water Management Plan to Reduce Riskper ASHRAE Standard 188
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PROGRAM VERIFICATION AND VALIDATION
Verify Program, Document Results & Activities in Logs Semi-Annual Team Review to Communicate & Adjust
Water Safety is aContinuous Process
Routine MonitoringPotable Water
SystemsCooling Water
SystemsOther At-Risk
Systems
Inspection & Maintenance
Water Temperatures
Oxidant Residual
Legionella Testing
Water Quality
Bacterial Dip slide
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Water Management Plan
PROPOSED PLAN TO BE FINALIZED
BY MANAGEMENT TEAM
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Planning To Successfully Reduce Risk:WMP Review Meetings
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Four (4) Program Reviews per year are RecommendedMonth 1 2 3 4 5 6 7 8 9 10 11 12
Year 1 Building the Program (Assess → Develop → Implement → Review) Review Annual
Year 2 Review Review Review Annual
Year 3 Review Review Review Annual **
.
Review = System Review ^^ | Annual = Program Review ^^
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Elements of a Water Management Plan per ASHRAE Standard 188:The Risk Assessment
Program Team Development &Implementation
1
2
3
4
5
6
7
Describe Water Systems& Flow Diagrams
Analysis of BuildingWater Systems
Control Measures
Monitoring &Corrective Actions
Confirmation
Documentation
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Managing Risks of Legionella
Riskof
ContractingLegionnaires’ Disease
SusceptiblePopulation
PathogenProliferation Transmission
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Managing Permissive Growth Conditions
<77°F
Return≥124°F
To Outlets≥124°F
Stored at ≥140°F
To Outlets<77°F
Keep it ColdKeep it HotKeep it MovingKeep it Clean Limit Water Age Maintain Water Temperature Maintain Oxidant Residual Remove Dead-legs
US-CDC
Domestic Water Treatment Strategy
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Waterborne microbes enter into the healthcare environment via:
Sources of Waterborne Pathogen Exposure
Direct contact
with water streams
Aerosols from
showers and faucets
Improperly reprocessed
medical devices
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Direct contact with ice
Utility Water?<100 cfu/ml
Sterile Water?Critical
Water?<10 cfu/ml
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DISINFECTANT RESIDUAL
TEMPERATURE
Oxidant and Temperature Mapping
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Growth Risk Potential
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How Residual is Impacted
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6/29/2017
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Disinfection Range158 - 176°F
Slowly Die122-158°F • 131°F ; die within 5-6 hrs• 140°F ; die within 32 min.• 151°F ; die within 2 min.
Growth Range77 - 122°F 95 - 115°F optimum
Do Not Grow Well68-77°F Below 68°F Dormant
Proliferation Risk
Utility & Domestic ServicesTemperature vs. Proliferation Risk
Tem
pe
ratu
re, °
F
Cold Water Tanks
Mains Cold Water
212
176
68
104
140
32
Cold Water Services
Hot Water Services
Spas & Bathing Showers
Hot Water Storage
Steam Humidification
Hot Water Boilers
Cooling Towers
Spray Humidifiers
HVAC Condensate
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General Issues that Contribute to Risk
Building 4 Penthouse 5402: Dead Legs
Sinks and Showers blocked off in Bio Medical Engineering Offices where 11 former patient rooms have been converted to offices.
Building 5 Room G869 Employee Shower. Note: Rarely Used
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Cooling Water Treatment Strategy
FROM
Performance-Based
Focused on
System Efficiency
Scale & Corrosion Control
Biofouling Control
TO INCLUDE
Health-Based
Focused on
Legionella Risk Management
Legionella Control & Monitoring
Cleaning & Disinfection
Confirmation of Risk Management
Fouling
Water Treatment Model
TheMicrobial
World
<100 CFU/mL (OSHA) Legionella
<10,000 CFU/mL Aerobic Bacteria
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General Issues that Contribute to Risk
Main Street Cooling Towers Bldg. 4 Penthouse Towers 58 Bldg. Cooling Towers
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Managing Risks of Legionella
Riskof
ContractingLegionnaires’ Disease
SusceptiblePopulation
PathogenProliferation Transmission
DW System Low Flow
DW System Dead legs
DW System/CW New Construction
DW System Lengthy Outages
DW System Temperatures
DW System Sequencing (Booster Pumps/Cross Connects)
DW Critical Equipment (HC Heater/Cooler)
DW Line Disturbances
DW Softeners/Heat Exchangers
DW/CW Pathogen Testing (Dip Slides)
CW Basin Accumulation/Fill Cleanliness
CW High Solids/Organics
CW System Higher Life Forms (DMA)
CW System Biofilms
CW System Deposits
CW Biocide(s) used (pH and dual)
CT C&D
Cooling Towers
CT Fill Cleanliness (DP)
Water Features (Spray, Pond, Cascade)
Sanitary Showers
Safety Showers
Aeration Ponds
Whirlpools/Jacuzzi’s
Hot Tubs
Faucets
Toilets
Irrigation Systems
Icemakers
Firewater Systems
Droplet Size
Distance
Age
Gender
Immunocompromised
• Critical Care
• Sick
• Other Complications (Asthma/HIV)
Smokers
DW = Domestic Water, CW = Cooling Water
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Contingencies to Regain Control in Building Water Systems
Hot & ColdHyperchlorination
Super Heat & Flush
Short Term Remediation Strategies
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Long-Term Continuous Control Strategies
Chlorine Dioxide
Chlorine Chloramine Copper-Silver Ions
Ozone UV light
What about these?What about these?
OZONE – NOT PRACTICAL
Cannot maintain residual due to volatility.
UV-Light – NOT PRACTICAL
Point-disinfection only.No Residual.
Contingencies to Maintain Control in Building Water Systems
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What’s the Optimal Solution?
Control, Monitoring,& Assurance Reporting
GenerationTechnique
PermittingRequirements
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• A Filtration Barrier for Waterborne Pathogens− Delivers sterilizing grade filtered water down to .2 micron
• For High Risk Healthcare Patients− Burn, BMT, Organ Transplantation, Hematology/Oncology, Intensive Care
• For Immediate Response − Confirmed outbreak− Suspected incident− Keeps the water moving
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Point Of Use Water FiltersA Point Control Strategy
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Reducing Risk of WHAIsA Comprehensive approach is vital to Reduce Risk
Legionella AnalyticalSelect a CDC ELITE
certified lab
POU disposable filters Wound care and shower unit
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Tower Cleaning & Disinfection
Risk AssessmentHazard analysis and full
service remediation
Secondary DisinfectionPotable water disinfection systems
with non-acid footprint toattain safest approach
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Key Takeaways
Water entering a hospital is not sterile
Design and use creates
biofilms
Pathogens may be
present in biofilms
Water can be a source and vector of infection
Infection risk can be
reduced
Water can be a source and vector of infection
Evidence showing infection risk, illness, and death on the rise
Legionella, Pseudomonas, NTMs and others can colonize water systems and subsequently cause WHAI’s
Strategies to reduce risk include Awareness, Water Management Plan, Secondary Disinfection, and POU Filters
6/29/2017
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Prevention or Emergency Response“Only you can prevent WHAI’s!”
73
Two Choices, Two Costs One Preferred Option!
Helmet $279
Mask $380
Axe $75
Gloves $150
Jacket $1,800
Boots $450
Cylinder $6,500
Hat$25
Jeans$16
Shovel$30
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Thank You
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QUESTIONS?