ASHRAE Standard 188 The New Face of Legionnaires’ Disease Prevention Richard D. Miller, Ph.D.
Part I • Anatomy of a Legionnaires’ disease outbreak Part II • Legionella biology • Explaining building colonization and disease
Part III • Preventing Legionnaires’ disease – Std 188
Part I • Anatomy of a Legionnaires’ disease outbreak
Legionnaires’ Disease Ocean City, MD (2011) Plim Plaza Hotel – on the Boardwalk in Ocean City, MD
Legionnaires’ Disease Ocean City, MD (2011) Cases in September 6 cases, 1 death
Legionnaires’ Disease Ocean City, MD (2011) Faucets and showerheads End of the season so the hotel was closed for remediation
Legionnaires’ Disease Ocean City, MD (2011) 2003 – 7 cases/0 deaths - Princess Royale Hotel, Ocean City, MD 2004 – 4 cases / 1 death - Braemar Towers, Ocean City, MD
Legionnaires’ Disease Las Vegas (2009-12) Luxor Aria (opened in 1993, 4,500 guest rooms) (opened in 2009, 4,000 guest rooms) 2011 – 1 case in March 1 case in April 1 case in December → died Env samples – June – negative Jan 2012 – positive hot water
Legionnaires’ Disease Las Vegas (2009-12) Luxor Aria (opened in 1993, 4,500 guest rooms) (opened in 2009, 4,000 guest rooms) 2011 – 1 case in March 2009 - 1 case in Dec (Grand Opening) 1 case in April 2010 - 1 case in May, 1 case in June 1 case in December → died 2011 - 2 cases in Feb (another suspected) - 2 case in April (another 2 suspected) Env samples – June 2010 - negative June 2011 - positive hot water
Legionnaires’ Disease Las Vegas (2001-08) Polo Towers - Time-share condominium 2001 - 3 cases 2007 - 2 cases in Oct/Nov 2008 - 4 cases in Aug/Sept Env samples – Oct 2008 - positive hot water - 300 guests re-located during remediation
Legionnaires’ Disease Ocean City / Las Vegas Learning Points Legionella colonize building potable water systems (especially hot loop) Faucets/showerheads (reservoir) Water containing Legionella gets into the air (aerosolization)
Legionnaires’ Disease Ocean City / Las Vegas Learning Points Legionella colonize building potable water systems (especially hot loop) Faucets/showerheads (reservoir) Water containing Legionella gets into the air (aerosolization) Inhale sufficient Legionella into lungs Growth in lungs Legionnaires’ Disease pneumonia
Legionnaires’ disease New Brunswick, NJ (2008) – hospital - potable water • St. Peters University Hospital • 8 cases, 3 deaths (38%) • Oncology ward patients, Aug-Sept • No cases in staff or visitors Env samples – 2008 - Extensive Legionella colonization - Throughout the hot water distribution system ?
Legionnaires’ Disease St Peters University Hospital Learning Points Legionella colonize building ? potable water systems showerheads (reservoir) Water containing Legionella gets into the air (aerosolization) Inhale sufficient Legionella into lungs ? Immunocompromised patients more susceptible Growth in lungs Legionnaires’ Disease pneumonia
Legionnaires’ Disease Many Hospital-Acquired Outbreaks Learning Points Legionella colonize potable water Faucets (reservoir) Drinking water containing Legionella gets into the URT Aerosolization Aspirate sufficient Legionella into lungs Immunocompromised patients more water susceptible to small numbers of Legionella Growth in lungs Legionnaires’ Disease pneumonia Liver transplant patient
Legionnaires’ Disease Netherlands (1999) Bovenkarspel West Frieslund Flora/Home Show
Legionnaires’ Disease Netherlands (1999) Bovenkarspel West Frieslund Flora/Home Show People were infected while walking by the whirlpool spas. Memorial service for the victims every year 252 cases 32 deaths 80,000 visitors
Legionnaires’ Disease Netherlands Floral/Home Show (1999) Learning Point Legionella colonize whirlpool spas (reservoir) Water containing Legionella gets into the air (aerosolization) – travel distances Inhale sufficient Legionella into lungs Growth in lungs Legionnaires’ disease Do not have to be sitting in the spa
Legionnaires’ Disease (Pontiac Fever) Los Angeles (2011) LA Times “Hugh Hefner’s lair of love is infected, but not with the diseases you’d expect!” 700 people from 30 countries attended a conference at the Playboy mansion (Feb 1-3) on Internet businesses called DOMAINfest Global
Legionnaires’ Disease (Pontiac Fever) Los Angeles (2011) 700 people from 30 countries attended a conference at the Playboy mansion (Feb 1-3) on Internet businesses called DOMAINfest Global
Legionnaires’ Disease (Pontiac Fever) Los Angeles (2011) Appears “smokey” from the use of a fog machine – culprit? 200 cases of Pontiac Fever - mild disease fever, chills, no pneumonia, no deaths
Legionnaires’ Disease (Pontiac Fever) Los Angeles (2011) Legionella cultured from the grotto whirlpool spa 200 cases of Pontiac Fever - mild disease fever, chills, no pneumonia, no deaths
Legionnaires’ Disease (Pontiac Fever) Los Angeles (2011) Legionella cultured from the grotto whirlpool spa People inhaled the aerosol while walking through the grotto – 200 were sick 200 cases of Pontiac Fever - mild disease fever, chills, no pneumonia, no deaths
Legionnaires’ Disease LA Playboy Mansion (2011) Learning Point Legionella colonize whirlpool spas (reservoir) Water containing Legionella gets into the air (aerosolization) – travel distances Inhale sufficient Legionella into respiratory tract? No pneumonia Pontiac Fever Do not have to be sitting in the spa Why?
Philadelphia – 1976 221 cases 34 deaths 10,000 attendees A snapshot from an American Legion convention in Philadelphia in July 1976. Within a month, an infectious disease killed two of these men.
Philadelphia – 1976 221 cases 34 deaths 10,000 attendees A snapshot from an American Legion convention in Philadelphia in July 1976. Within a month, an infectious disease killed two of these men.
Legionnaires’ Disease Transmission Cooling towers Aerosol can travel a mile or more and infect people!
Philadelphia – 1976 Risk – entering the lobby or walking on street in front of hotel 221 cases 34 deaths 10,000 attendees A snapshot from an American Legion convention in Philadelphia in July 1976. Within a month, an infectious disease killed two of these men.
Britain’s Worst Outbreak of Legionnaires’ Disease Barrow Arts Center- 2002 180 cases (perhaps 500 more), 7 deaths Cooling tower Gillian Beckingham Architect No contract for chemical treatment of cooling tower Head of Design Services for the Barrow Borough Council
Legionnaires’ Disease Barrow-in-Furnace (2002)
Legionnaires’ Disease Barrow-in-Furnace (2002)
Legionnaires’ Disease Barrow-in-Furnace (2002)
Legionnaires’ Disease Barrow-in-Furnace (2002) Forum 28 - Barrow Arts and Leisure Center • Total exposure unknown • Estimates of 2500 people with severe or mild disease (Pontiac fever) • 494 clinically diagnosed cases of severe LD-like disease • 180 confirmed cases of Legionnaires’ disease • 7 deaths
Legionnaires’ Disease Barrow-in-Furnace (2002) Forum 28 - Barrow Arts and Leisure Center • Total exposure unknown • Estimates of 2500 people with severe or mild disease (Pontiac fever) • 494 clinically diagnosed cases of severe LD-like disease • 180 confirmed cases of Legionnaires’ disease • 7 deaths
Legionnaires’ Disease Barrow-in-Furnace (2002) Forum 28 - Barrow Arts and Leisure Center • Total exposure unknown • Estimates of 2500 people with severe or mild disease (Pontiac fever) • 494 clinically diagnosed cases of severe LD-like disease • 180 confirmed cases of Legionnaires’ disease • 7 deaths
Legionnaires’ Disease Barrow-in-Furnace (2002)
Legionnaires’ Disease Barrow-in-Furnace (2002)
Britain’s Worst Outbreak of Legionnaires’ Disease Barrow Arts Center- 2002 179 cases (perhaps 500 more), 7 deaths 2000 Legal system considered LD to be a preventable disease Gillian Beckingham Architect Head of Design Services for the 40 Barrow Borough Council
Britain’s Worst Outbreak of Legionnaires’ Disease Barrow Arts Center- 2002 179 cases (perhaps 500 more), 7 deaths Tried on 7 counts of manslaughter for failing to have a contract for treating the Arts Centre cooling tower Acquitted by a jury, but fined £15,000 for breach of health and safety laws Barrow Borough Council was fined £125,000 Gillian Beckingham Architect Head of Design Services for the 41 Barrow Borough Council
Legionnaires’ Disease Philadelphia / Barrow-in-Furnace Learning Point Legionella colonize cooling towers (reservoir) Water containing Legionella gets into the air (aerosolization) – travel distances Inhale sufficient Legionella into lungs Growth in lungs Legionnaires’ disease
Legionnaires’ disease Toronto, Canada (2005) – nursing home - cooling tower • >110 cases, 20 deaths (patients only) (18%) • 71 patients, 23 staff, 14 visitors, 2 neighborhood residents
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