ASHRAE Standard 188 The New Face of Legionnaires Disease Prevention - - PowerPoint PPT Presentation

ASHRAE Standard 188

Richard D. Miller, Ph.D.

The New Face of Legionnaires’ Disease Prevention

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

Plim Plaza Hotel – on the Boardwalk in Ocean City, MD

Legionnaires’ Disease

Ocean City, MD (2011)

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

2003 – 7 cases/0 deaths - Princess Royale Hotel, Ocean City, MD 2004 – 4 cases / 1 death - Braemar Towers, Ocean City, MD

Legionnaires’ Disease

Ocean City, MD (2011)

Legionnaires’ Disease

Las Vegas (2009-12)

Luxor

(opened in 1993, 4,500 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

Aria

(opened in 2009, 4,000 guest rooms)

Legionnaires’ Disease

Las Vegas (2009-12)

Luxor

(opened in 1993, 4,500 guest rooms)

2011 – 1 case in March 1 case in April 1 case in December→ died

Aria

(opened in 2009, 4,000 guest rooms)

2009 - 1 case in Dec (Grand Opening) 2010 - 1 case in May, 1 case in June 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) Water containing Legionella gets into the air (aerosolization) Faucets/showerheads (reservoir)

Legionnaires’ Disease

Ocean City / Las Vegas

Learning Points

Legionella colonize building potable water systems (especially hot loop) Water containing Legionella gets into the air (aerosolization) Inhale sufficient Legionella into lungs Growth in lungs Legionnaires’ Disease pneumonia Faucets/showerheads (reservoir)

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 Water containing Legionella gets into the air (aerosolization) Growth in lungs Legionnaires’ Disease pneumonia showerheads (reservoir) Inhale sufficient Legionella into lungs Immunocompromised patients more susceptible

?

?

Legionnaires’ Disease

Many Hospital-Acquired Outbreaks

Learning Points

Legionella colonize potable water Drinking water containing Legionella gets into the URT Growth in lungs Legionnaires’ Disease pneumonia Faucets (reservoir) Aspirate sufficient Legionella into lungs Immunocompromised patients more susceptible to small numbers of Legionella

Aerosolization water Liver transplant patient

Legionnaires’ Disease

Netherlands (1999)

Bovenkarspel West Frieslund Flora/Home Show

 252 cases  32 deaths  80,000 visitors

People were infected while walking by the whirlpool spas.

Legionnaires’ Disease

Netherlands (1999)

Bovenkarspel West Frieslund Flora/Home Show

Memorial service for the victims every year

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

“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)

LA Times

 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)

 200 cases of Pontiac Fever - mild disease  fever, chills, no pneumonia, no deaths

Appears “smokey” from the use of a fog machine – culprit?

Legionnaires’ Disease (Pontiac Fever)

Los Angeles (2011)

Legionella cultured from the grotto whirlpool spa

Legionnaires’ Disease (Pontiac Fever)

Los Angeles (2011)

 200 cases of Pontiac Fever - mild disease  fever, chills, no pneumonia, no deaths

Legionella cultured from the grotto whirlpool spa People inhaled the aerosol while walking through the grotto – 200 were sick

Legionnaires’ Disease (Pontiac Fever)

Los Angeles (2011)

 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

 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.

Risk – entering the lobby or walking on street in front of hotel

Gillian Beckingham Architect Head of Design Services for the Barrow Borough Council

Britain’s Worst Outbreak of Legionnaires’ Disease

Barrow Arts Center- 2002

180 cases (perhaps 500 more), 7 deaths

No contract for chemical treatment of cooling tower

Cooling tower

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)

Legionnaires’ Disease

Barrow-in-Furnace (2002)

40

Gillian Beckingham Architect Head of Design Services for the Barrow Borough Council

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

41

Gillian Beckingham Architect Head of Design Services for the Barrow Borough Council

 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

Britain’s Worst Outbreak of Legionnaires’ Disease

Barrow Arts Center- 2002

179 cases (perhaps 500 more), 7 deaths

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

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

Rooftop Cooling tower AHU and surroundings

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

Legionnaires’ disease

Significant pain, suffering, death $600 million class action lawsuit

 Toronto, Canada (2005) – nursing home - cooling tower

• >110 cases, 20 deaths (patients only) (18%)
• 71 patients, 23 staff, 14 visitors, 2 neighborhood residents

Legionnaires’ Disease

Toronto Nursing Home

Learning Point

Legionella colonize cooling towers

(reservoir)

Water containing Legionella gets into the air (aerosolization) – travel distances Inhale sufficient Legionella into lungs Immunocompromised patients more susceptible Growth in lungs

Legionnaires’ disease

$multi-million lawsuits

Legionnaires’ disease

 Rapid City, SD (2005) – restaurant – decorative fountain

• 18 cases (no deaths)
• June thru November, included the Mayor of Rapid City
• Small lobby fountain – positive for Legionella
• Without obvious aerosol-generating capability

Legionnaires’ Disease (2007-10)

• St. Luke's Aurora South Shore Hospital

2010 – 8 cases over 3.5 weeks no cases in admitted patients 6 cases in outpatients 2 cases in visitors Env samples - Legionella in water wall water

• Potable water negative

Lobby water wall Cudahy, WI Bethesda, MD

National Cancer Institute Hospital

2007 – 2 cases in cancer patients Env samples - Legionella in water wall water

• Potable water negative

Patient area water wall

Aerosolization?

Legionnaires’ Disease (2007-10)

Methodist Hospital Outpatient Center, Houston, TX

No cases – but are these a risk?

Lobby water wall

Legionnaires’ Disease

Restaurant / Hospital Outbreaks

Learning Point

Legionella colonize deocrative fountains / water walls

(reservoir)

Water containing Legionella gets into the air (aerosolization?) Inhale sufficient Legionella into lungs Growth in lungs

Legionnaires’ disease