Prevention PortWaterborne Disease Management in Healthcare Settings

Healthcare-associated Infections and Emerging Infectious Diseases Workshops

January 28, 2020: Metairie

February 4, 2020: Bossier City

February 5, 2020: Lafayette

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The speaker does not have a financial or non-financial relationship with a commercial interest that would create a conflict of interest with this presentation.

Disclosure Statement

Objectives

By the end of this presentation, attendees will be able to:Describe transmission, burden, and prevention measuresLegionella pneumophila and Pseudomonas aeruginosa

Describe a Water Management Plan

Legionella pneumophila

Gram-negative rod-shaped bacteriafound naturally in the environment worldwide, usually

in aquatic environmentsat least 60 different species, ~20 implicated in human

disease

Natural Habitat

Occurs worldwidePrefers WARM WATERS with scale, sediment, metallic ions,

and commensal flora

Max multiplication from 25ºC to 45ºC (77-113F)

Reduction at >50ºC (122F)

No growth above 58.8ºC (138F)

Found in 1-30% of home hot water systems

Transmission

Generally is not present in sufficient numbers in environment to cause disease

Inhalation of water contaminated with Legionella

aerosols generated by cooling towers, showers, faucets, spas, respiratory therapy equipment, and fountains

Aspiration of contaminated potable water also proposed

NO Person-to-person transmission

Burden of Disease

CDC estimates:

8,000 –18,000 cases in the U.S. annually

130-300 in LA

Many infections not diagnosed or reported

~50 cases/year reported in Louisiana

Class B reportable; 1 Business Day

Reported Legionella Cases Louisiana, 1990-2017

Reported Legionella Cases and Incidence Rates per 100,000 Population Louisiana, 1990-2016

Burden of Disease80% of reported cases are SPORADIC

Outbreaks in hospitals, cruise ships, hotels, and other large buildings complex water systems

LegionellosisDisease occurs in 3 forms: Legionnaires’ Disease (LD)

Incubation 2-10 days Pneumonia illness accompanied by fever, cough, chills, myalgia, or

respiratory failure 10% of people who get sick with Legionnaires’ disease die; 25% of

healthcare associated cases

Pontiac Fever (PF) Incubation 1-2 days; lasts 2-5 days Flu-like illness (fever, chills, malaise) without pneumonia Self-limiting, does not benefit from abx

Extrapulmonary legionellosis (XPL) Disease outside the lungs (for example, associated with endocarditis,

wound infection, joint infection)

Risk FactorsRecent travel with an overnight stay outside of the home, including stay in a

healthcare facility

Exposure to hot tubs

Recent repairs or maintenance work on domestic plumbing

Renal or hepatic failure

Diabetes

Chronic lung disease

Systemic malignancy

Smoking (current or historical)

Immune system disorders

Age ≥50 years

Diagnosis Culture: Isolation of Legionella from respiratory secretions,

lung tissue, pleural fluid, or a normally sterile site

+Detects all species and serogroups+Clinical & environmental samples can be molecularly compared-Technically difficult & slow-May be affected by abx

Urinary Antigen: Detection L. pneumophila serogroup 1 antigens in the urine

+Rapid-Can only identify Lp1-Cannot molecularly compare to environmental samples

Diagnosis

Nucleic Assay: detection of Legionella species by PCR

Seroconversion: Four-fold rise in ab titer to Legionella by indirect immunoflourescent antibody assay (IFA)

+Less affected by abx-1 elevated ab titer does NOT confirm case of recent Legionellosis: 5-10% of population have single acute titers ≥1:256

Healthcare Associated Cases

Presumptive: Patient had 10 or more days of continuous stay at a healthcare facility during the 14 days before onset of symptoms.

Possible: Patient had exposure to a healthcare facility for a portion of the 14 days prior to onset.

Outbreak Definitions

Dependent on the circumstances behind the cases exposure Travel-associated: CDC defines travel-associated outbreaks as two or more

Legionnaires’ disease cases associated with the same travel accommodation in a 12-month period.

Healthcare-associated: ≥1 case of presumptive healthcare-associated Legionnaires’ disease at any time or ≥2 cases of possible healthcare-associated Legionnaires’ disease within 12 months of each other

Community-associated: You have identified one or more cases of Legionnaires’ disease at a correctional facility or other facility where people cannot leave the premises or you have analyzed available data and found an increase in Legionnaires’ disease in a certain geographic area

Prevention Measures Grows poorly at < 20°C (68°F) and > 50°C (122°F) Killed at temperatures > 58.8°C (138°F) Susceptible to chlorine and bromine disinfectants, ozone,

heavy metal ions, and UV lightNebulizer, respiratory therapy equipment: Use sterile

water, do not let water stand, clean regularly

Prevention Measures

Hot water systems:flushing for >5min at temp > 65°C

hyperchlorination but causes corrosion

May grow back unless hot water maintained at ≥ 50°C but risk of scalding users

cold water at ≤ 20°C

residual chlorine at ≥ 1-2 mg/L of free chlorine

remove scale and sediments

Mentimeter Question #1What is the threshold of healthcare acquired Legionellosis cases to be considered an outbreak?

a) 1 presumptive healthcare acquired case

b) 2 presumptive healthcare acquired cases

c) 2 possible healthcare acquired cases in 12 months

d) 4 possible healthcare acquired cases in 12 months

e) a&c

f) b&d

1. Go to www.menti.com on either your mobile device or computer’s web browser.

2. Use the code shown on the screen to participate in live polling for this activity.

3. See results.

www.menti.com

Enter Code

Pseudomonas

Bacteria commonly found in soil and waterMost common causing infection Pseudomonas aeruginosaCauses infections in the blood, lungs (pneumonia), or other parts of

the body after surgery

Transmission

Live in the environment and can be spread to people in healthcare settings when they are exposed to water or soil that is contaminated with these germs.

Person to person through: contaminated hands

Equipment

Surfaces

Burden of Disease

In 2017, multidrug-resistant Pseudomonas aeruginosa caused an estimated 32,600 infections among hospitalized patients and 2,700 estimated deaths in the United States

Cases Over Time

Who is at risk?

Those most at risk include patients in hospitals, especially those:on breathing machines (ventilators)

with devices such as catheters

with wounds from surgery or burns

Prevention Measures

Patients and caregivers should:Keep their hands clean to avoid getting sick and spreading germs

that can cause infectionsWash their hands with soap and water or use alcohol-based hand sanitizer,

particularly before and after caring for wounds or touching a medical device

Remind healthcare providers and caregivers to clean their hands before touching the patient or handling medical devices

Allow healthcare staff to clean their room daily when in a healthcare setting

Water Management Plan

Limits germ growth by:Keeping hot water temperatures high enough

Making sure disinfectant amounts are right

Keeping water flowing (preventing stagnation)

Operating and maintaining equipment to prevent slime (biofilm), organic debris, and corrosion

Monitoring factors external to buildings, such as construction, water main breaks, and changes in municipal water quality

Water Management Plan - Components

1. Establish a water management program team

Water Management Plan - Components

2. Describe the building water systems using flow diagrams and a written description

Include details like where the building connects to the municipal water supply, how water is distributed, and where hot tubs, water heaters or boilers, and cooling towers are located.

Water Management Plan - Components

3. Identify areas where Legionella could grow and spread

Identify where potentially hazardous conditions could occur in your building water systems, such as areas where water temperature could promote Legionella growth or where water flow might be low.

Healthcare facilities think about:Areas where medical procedures may expose patients to water

droplets, such as hydrotherapy

Areas where patients are more vulnerable to infection, such as bone marrow transplant units, oncology floors, or intensive care units

Water Management Plan - Components

4. Decide where you need to apply control measures and how to monitor them.

Establish control measures and limits for each hazardous condition, as well as plans for where and how to monitor them.Control measures are actions you take in your building water

systems to limit growth and spread of Legionella, such as heating, adding disinfectant, or cleaning.

Control limits are the maximum value, minimum value, or range of values that are acceptable for the control measures that you are monitoring to reduce the risk for Legionella growth and spread.

Water Management Plan - Components

5. Establish ways to intervene when control limits are not met.

Determine what corrective actions or contingency responses to take when control measures are outside of the control limits you established.

Construction on a floor

Documents all activities

Daily flushing of both hot/cold water

Increase frequency of temperature and chlorine monitoring

Water Management Plan - Components

6. Make sure the program is running as designed and is effective.

Verification: Are we doing what we said we would do?

Validation: Is our program actually working?

Update the program when necessary.

Water Management Plan - Components

7. Document and communicate all activities.

Document all the activities and communicate with building occupants, employees, and colleagues on a continual basis. If an event triggers you to review or update your water management program, remember toUpdate the flow diagrams, associated control points, control limits, and

corrective actions

Update the written description of your building water systems

Train those responsible for implementing and monitoring the updated program

Water Management Plan - Toolkit

https://www.cdc.gov/legionella/downloads/toolkit.pdf

Questions?Raychel Berkheimer, MPHWaterborne Disease CoordinatorRaychel.Berkheimer@la.gov504-568-8307