Water TreatmentDr Suliman AlJumaah

Director of Infection Control Dept, King Faisal Specialist Hospital & Research Centre

INFECTION PREVENTIONAND CONTROL 2018 CONFERENCE KSA

www.ipc2018ksa.com

#IPC2018KSA

WATER SAFETYSuliman Al -Jumaah, MD, MsC, CIC,FAAP

Director, Infection Control and Hospital Epidemiology Department

• 1.Review some important pathogen transmitted from water within HCF• 2. Review important aspects of HCF water systems• 3. Example of waterborne diseases and water contamination at HCF

Definitions

• utility water system: a building water distribution system that provides water intended for uses other than human consumption(e.gfire suppression)

• potable water system: a building water distribution system that provides hot or cold water intended for human consumption (e.g., drinking, bathing, showering, cooking, dishwashing, and maintaining oral hygiene

WATER SAFETY

• Water can be a vehicle for diseases in health care facilities (HCF)• Numerous outbreaks of diseases in HCF were associated with

contaminated water • Waterborne diseases could be the result of:• Inhalation of aerosol dispersed from water source: legionella, B. cepacia• Aspiration of contaminated water: legionella• Indirect contact transmission: improperly reprocessed devices: NTM• Direct contact with water: hydrotherapy

WATERBORNE INFECTIOUS DISEASES IN HEALTH CARE FACILITIES

• Common organisms found in hospital water system:• 1. Legionella• 2. Other gram negative bacteria as:

Pseudomonas aeruginosa•Serratia marcescens•Enterobacter spp•Acinetobacter spp

• 3. Infections and pseudo-infections due to non-tuberculousmycobacteria

• 4. Cryptosporidiosis

Case scenarioInfection control practitioner was informed about positive respiratory sample for legionella by PCR from an oncology

patient with worsening pneumoniaWhat is the next action?

Case review

• 38 years old with ALL, on chemotherapy, who is in hospital for 6 weeks then developed fever, cough and worsening respiratory distress that needed ICU admission. Cx-ray showed extensive infiltrates. BAL was done and multiplex PCR was positive for legionella pneumophila. Legionella culture from BAL and urine for legionella antigen were both negative.• Diagnosis: Legionella pneumonia

(Healthcare associated)

LEGIONELLA

• “Legionella causes two distinct clinical illnesses.• 1-Pneumonia, “Legionnaires’ disease” (LD). CDC estimates that each

year there are 8000 to 18,000 cases of LD in the USA, 10% of these cases are fatal. • 2-Influenza-like illness known as “Pontiac fever.” • Most cases of legionellosis are due to exposure to Legionella

associated with building water systems• Incubation period: 2-14 days

CDC legionella case definition

Case verification and outbreak investigation

• Case verified as “suspected LD” HAI, and outbreak confirmed after a second case noted and outbreak investigation initiated

• If one case of laboratory-confirmed, health-care--associated Legionnaires disease is identified, or if two or more cases of laboratory-suspected, health-care-associated Legionnaires disease occur during a 6-month period, certain activities should be initiated (181,189,191,193,199,200). Category IB Guidelines for Environmental Infection Control in Health-Care Facilities • Recommendations of CDC and the Healthcare Infection Control

Practices Advisory Committee (HICPAC)

MMWR, Recommendations and Reports

June 6, 2003 / 52(RR10);1-42

What is the source of this legionella?

LEGIONELLA COMES FROM WATER SYSTEM

• Are commonly found in nature or man-made aquatic environments• Can enter health-care facility water system in low or undetectable numbers• Cooling tower, evaporative condensers, heated potable water distribution

system, and locally produced distilled water can provide infected environments for multiplication of legionella• Factors that enhance colonization and amplification of legionella include:

• 1.Temperature of 25 C to 42 C• 2.Stagnation• 3.Scale and sediment• 4.Presence of certain free living aquatic amoebae that can support intracellular

growth of legionella

COOLING TOWER AND EVAPORATIVE CONDENSERS

• Contaminated aerosols from cooling towers can gain entry from an open window in the hospital or via air handling system intakes located near the tower equipment's

Factors contributing to legionellosis

• The presence of Legionella bacteria in building water systems is not sufficient to cause LD. Other necessary factors include:• 1- environmental conditions that promote the growth of Legionella• 2- Means of transmitting the bacteria to people in the building (e.g.,

aerosol generation)• 3- exposure of susceptible persons to colonized water that is inhaled or

aspirated into the lungs. • Legionella bacteria are not transmitted person-to-person or from normal

(nonaspirated) ingestion of contaminated water. Susceptible persons at high risk for legionellosis include the elderly, dialysis patients, smokers, and persons with underlying immunodeficiency

Environmental cultures

• 38 out of 69 water samples grew legionella (38%)• All air samples negative• Source of legionella is most likely HCF water system

How common is legionella in water?

• In Germany, 4482 samples from 718 buildings (including 12 hospitals) Legionella species found in 32% of samples

Acceptable Legionella limits in water

Country Public Water Health Care FacilitiesFrance General Public <1000(CFU/liter Prevention of nosocomial

infections <100(CFU/liter)Healthcare Facilities <50(CFU/liter)For High Risk Patients: Target level = not detectable

Germany General Public <1000(CFU/literNetherland General Public <100(CFU/literUK Public <100 Detection of legionella should be

investigated and, the system resampled to aid interpretation of the results in line with the monitoring strategy and risk assessment.”

USA (HOSPITAL WATER) Not Detectable (CDC)

Next stepRisk assessment of water system using Hazard Analysis Critical Control

Point (HACCP)systematic evaluation of potentially hazardous conditions associated

with each step in the process flow diagrams of water system.

HACCP

This approach to HACCP shall adhere to the seven principles:• 1. Conduct a hazard analysis.• 2. Determine the critical control points.• 3. Establish critical limits for each critical control point.• 4. Establish a system to monitor control of the critical control points.• 5. Establish the corrective action to be taken when monitoring indicates

that a particular critical control point is not under control.• 6. Establish procedures for verification to confirm that the HACCP system is

working effectively.• 7. Establish documentation concerning all procedures and records

appropriate to these principles and their application

Haccp-system maintenance• System Maintenance. The HACCP plan shall include:

• a) inspection frequencies for water containing vessels and system components

• b) maintenance procedures based on equipment manufacturers’ recommendations for

• 1) cleaning, disinfection and/or replacement of system components

• 2) flushing or mixing of stagnant or low flow areas

• 3) other treatments and any required monitoring that the HACCP team decides are necessary for

• i. hot and cold storage tanks

• ii. ice machines

• iii. water hammer arrestors

• iv. expansion tanks

• v. water filters

• vi. shower heads and hoses

• vii. electronic faucets

• viii. aerator and/or faucet flow restrictors

• ix. non-steam, aerosol generating humidifiers

• x. water heaters

• c) inspection notes and a corrective actions log

• d) regular updates of system component operating manuals

• e) identification of the responsible persons.

Best Practice

Ø Maintain cold water < 20°CØ Maintain hot water > 55°C – out at >60°C; return at

>55°CØ Avoid stagnation – maximum 12 hour tank retention

timeØ Avoid dead-legs / low flow areasØ Flushing in areas of low flow – or – remove from

serviceØ “Effective” water treatment regime

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ASHRAE-188P;management of legionella 2013• Water temperature recommendations for Legionella control are as

follows: water heater outlet temperature at or above 60°C (140°F); hot water temperature in any part of the system at or above 51°C (124°F); cold water temperature in any part of system at or below 25°C (77°F). If the HACCP team determines that these temperatures cannot be achieved, then it may find that additional hazard control measures are required.

POSSIBLE CAUSES OF WATER COLONIZATION

Ø Areas of stagnation and dead legsØ Ongoing construction causing vibration and release of pathogens

into the waterØ Ineffective water treatment regimesØ Poor temperature and chlorine levels

Actions done

• Increase chlorine level to maximum allowable level(0.5PPM)• Removal of dead ends• Patient in affected area advised not to use water for showering,

drinking and not to use sanitary hoses till legionella cleared• Shut off decorative water fountain, ice machines• Emergency water disinfection with hyperchlorination with chlorine at

30 PPM

Hot water System emergency disinfection

• 1-Thermal shock: water temperatures shall be maintained at 71-77°C (160-170°F) while progressively flushing each outlet in the system• d) a flush time of thirty minutes shall be attempted. • 2-hyper-halogenation (chlorine)level of free residual chlorine should be raised to 20-50 mg/L (ppm) of free residual oxidant, as chlorine and maintained at approximately 50 mg/L (ppm) for one hour or at approximately 20 mg/L (ppm) for two hours. The pH of the water should be maintained below pH 8.0. Water pH above 8.0 will significantly reduce chlorine disinfection efficacyclose all outlets and disinfect with halogen for a minimum of 2 hours (not to exceed 24 hours).

Cold water disinfection

• Halogenation procedure

close all outlets and disinfect with halogen for a minimum of 2 hours (not to exceed 24 hours)

One EPA approved halogen is chlorine. If using chlorine for disinfection, the level of free residual chlorine should be raised to 20-50 mg/L (ppm) of free residual oxidant, as chlorine and maintained at approximately 50 mg/L (ppm) for one hour or at approximately 20 mg/L (ppm) for two hours. The pH of the water should be maintained below pH 8.0. Water pH above 8.0 will significantly reduce chlorine disinfection efficacy. (Note: If chlorine dioxide is used, pH control is not required)

Legionella cases and environmental samples Epi curve

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2O MAY 22-May 23-May 26-May 28-May 29-May 30-May 1-Jun 2-Jun 3-Jun 3-Jun 4-Jun 6-Jun 19-Jun 9-Jul 17-Jul 2-Sep 9-Sep 12-Sep 13-SepNegative water samples positive water samples positive dr inking fountain negative drinking fountains negative air samples Water main hospital

Clinical cases1,2,3

Disinfection

Water for HCF (TREATED WATER FOR SPECIAL NEEDS)

§ Purified water required for:§ Dialysis§ CSSD§ Laboratory§ Endoscopy

COMPONENTS OF THE WATER TREATMENT SYSTEM

• 1. Pre filter or Sediment Filter: remove Particulate• 2. Carbon Filter: remove chlorine, chloramine, and organic material.• 3. Water Softening: exchange calcium and magnesium ions in incoming water for

sodium ions.• 4. Reverse Osmosis [RO]: capable of removing 90% to 99% of electrolytes and all

bacteria and endotoxin.• 5. Deionizers: contain resin beds, which remove cations and anions by binding

them to resin and releasing hydrogen and hydroxyl ions, respectively.• 6. Filters, Ultra filters, and/or Ultraviolet dialysis centers use filters and ultra

filters, with or without UV lights, to further reduce microbial or endotoxin contamination

WATER SYSTEMS IN HEALTH-CARE FACILITIESTYPES OF TREATED WATER

• 1.Permeate “Product water’’:Water that has passed through the RO membrane. Used for dialysis, endoscopy and other applications

• 2.Ultrapure dialysate (sterile and pyrogen-free):This is defined as dialysate with bacterial level negative or of maximum 0.1 CFU/mL and endotoxin level of 0.03 EU/mL

• 3.Deionized water: Purified water that has charged ions removed. Used for laboratory, dialysis and other applications

WATER SYSTEMS IN HEALTH-CARE FACILITIES

ANSI/AAMI 13959:2014 STANDARDS FOR DIALYSIS WATER

MICROBIOLOGICAL LEVEL STANDARD ACTION LEVEL

Colony forming units (CFU) ≤100 CFU/ml ≤50 CFU/ml

Endotoxin levels (EU/ml) ≤ 0.25 EU/ml ≤0.125/ml

ENDOSCOPY

• Water is used for:1.Preparation of detergent2.Preparation of disinfectant3.Final rinsing

• The water used must pass the RO process or higher • Weekly testing endoscopes is recommended for any source of

waterborne contamination

INFECTION DUE TO NON-TUBERCULOUS MYCOBACTERIA

• NTM are acid-fast bacilli commonly found in potable water.• The most common 4 forms of human disease associated with NTM

are:• 1.Pulmonary disease in adults • 2.Cervical lymph nodes in children• 3.Skin, soft tissue and bone infections• 4.Disseminated disease in immunocompromised patients• It can spread via all modes of transmission

PSEUDO-INFECTION DUE TO NON-TUBERCULOUS MYCOBACTERIA

• NTM pseudo outbreak of mycobacteria chelonae, M. gordonae and M. xenopi have been associated with both bronchoscopy and gastrointestinal endoscopy:• 1.When a tap water is used to provide irrigation to the site or to rinse off

viewing tip in situ • 2.When the instruments are inappropriately reprocessed with tap water in

the final steps

CONCLUSIONS

• HCF water system is important vehicle for disease transmission• ICP need to be proactive and familiar with risk assessment for water

systems and diseases associated with water colonization like legionella, gram negative bacteria and NTM

references

• ASHRAE Guideline 12-2000, Minimizing the Risk of Legionellosis Associated with Building Water Systems. ASHRAE, Atlanta, GA.

• BSR/ASHRAE Standard 188P Prevention of Legionellosis Associated with Building Water Systems. Third Public Review (January 2013)(Complete Draft for Full Review. ASHRAE, Atlanta, GA

• ANSI/ASHRAE Standard 188-2015,Legionellosis: Risk Management forBuilding Water Systems. ASHRAE, Atlanta, GA.• https://www.cdc.gov/legionella/index.html• http://legionella.org