Prevention Port Waterborne Disease Management in Healthcare Settings - Healthcare-associated Infections and Emerging Infectious Diseases Workshops ...
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Prevention Port Waterborne 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
“ 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 measures Legionella pneumophila and Pseudomonas aeruginosa Describe a Water Management Plan
Legionella pneumophila Gram-negative rod-shaped bacteria found naturally in the environment worldwide, usually in aquatic environments at least 60 different species, ~20 implicated in human disease
Natural Habitat Occurs worldwide Prefers 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 Disease
80% of reported cases are SPORADIC
Outbreaks in hospitals, cruise ships, hotels, and
other large buildings
complex water systems
Legionellosis
Disease 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 Factors Recenttravel 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 samplesDiagnosis
Nucleic Assay: detection of Legionella species by PCR
Seroconversion: Four-foldrise 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 ≥1:256Healthcare 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 areaPrevention 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 light
Nebulizer, respiratory therapy equipment: Use sterile
water, do not let water stand, clean regularlyPrevention 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
www.menti.com
Mentimeter Question #1 1. Go to www.menti.com on either
your mobile device or
computer’s web browser.
What is the threshold of healthcare acquired 2. Use the code shown on the
Legionellosis cases to be considered an outbreak? screen to participate in live
polling for this activity.
a) 1 presumptive healthcare acquired case 3. See results.
b) 2 presumptive healthcare acquired cases Enter Code
c) 2 possible healthcare acquired cases in 12
months
d) 4 possible healthcare acquired cases in 12
months
e) a&c
f) b&dPseudomonas Bacteria commonly found in soil and water Most common causing infection Pseudomonas aeruginosa Causes 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 In2017, 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 infections
Wash 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 settingWater 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 qualityWater 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
Identifywhere 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 unitsWater 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 Daily flushing of
floor both hot/cold
water
Increase frequency Documents all
of temperature and activities
chlorine monitoringWater 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 to Update 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, MPH Waterborne Disease Coordinator Raychel.Berkheimer@la.gov 504-568-8307
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