Legionella type bacteria in domestic distribution systems (house installations) Dr. Katrin Luden

1. Dr. K. Luden Legionella type bacteriain domestic distribution systems (house installations) Dr. Katrin Luden Warschau Nov. 2008 1

2. Dr. K. Luden Legionella type bacteria Legionella • are fresh water bacteria (~ 50 species, all of them potentially pathogenic to humans) • grow best in warm watere.g. in warm drinking water supply, pools (filter),air condition-systems or cooling towers • hardly grow <20°C and die at >60°C • infections are transmitted by inhalation of aerosols rarely by aspiration (90 % of infections caused by L. pneumophila) • cause Pontiac-fever and legionaires disease

3. Dr. K. Luden Pontiac-fever acute self-limiting influenza-like infection without pneumonia Incubation time: 2-3 daysCases ~800.000 – 1.5 billion / year (estimate of RKI) Legionaires disease Pneumonia (fever, chills, cough) sometimes fatalIncubation time: 2-10 daysCases: ~ 6.000 - 20.000 / year (estimate of RKI)Fatal cases: ~ 1.000 - 3.000 / year (estimate of RKI) Infections caused by Legionella

4. Dr. K. Luden Legionella not mentioned but General obligations (Article 4): Water shall be clean if it: is free from micro-organisms which in numbers or concentrations, constitute a potential danger to human health Article 5 (3) Quality standards “A Member State shall set values for additional parameters not included in Annex I where the protection of human health within its national territory or part of it so requires. The values set should, as a minimum, satisfy the requirements of Article 4(1)(a).” Drinking water directive 98/83/EC

5. Dr. K. Luden § 18 Monitoring by public health authorities (1) Public health authorities supervise the water supply ... from domestic distribution systems from which water is made available for the public, in particular in schools, kindergartens, hospitals, restaurants and other communal facilities, regarding the compliance to the requirements of the regulation by appropriate examinations. German Drinking water directive (DWD)

6. Dr. K. Luden Legionella mentioned twice: §20 order of the public health authorities public health authorities can order analysis of additional parameters considering the circumstances of the individiual case ... e.g. Legionella ... And Audit monitoring (Annex) Audit monitoring includes the investigation on Legionella in central drinking water warming systems as part of domestic distribution systems that supply water to the public. German Drinking water directive (DWD)

7. Dr. K. Luden Due to the considerable potential danger to human health connected to Legionella in warm water domestic distribution systems water from those systems has to be monitored for Legionella in facilities supplying water to the public. Rationale BUT

8. Dr. K. Luden Questions • What is the aim of the monitoring? Detection of systemic contamination or acute risk assessment? • What parametric values are to be used for assessment of results? • Sampling: where, how many samples, how, when?

9. Dr. K. Luden Aim of monitoring Recommendations by NLGA (2006) and FEA (2007): detection of systemic contamination The purpose in Lower Saxony is to gather information on systemic contamination with comparable results due to harmonized sampling techniques and sample identification using a coding system. The laboratory method for detection of Legionella was covered as well because ISO 11731 was not translated into a DIN.

10. Dr. K. Luden DIN 1988 (1988): technical standard for drinking water installations VDI*-Guide 6023 (2006): hygiene-conscious planning, construction, operation and maintenance of drinking water heating systems DVGW** W 551 (2004): Drinking water heating and distribution system, technical measures for limiting growth of legionella; planning, establishment, operation and redevelopment of drinking water installations DVGW** W 553 (1998): Dimensioning of central warm water circulation systems * VDI: Society of German Engineers**DVGW: German Technical and Scientific Association for Gas and Water Technical Standards

11. Dr. K. Luden Recommendation of the Federal Environmental Agency (FEA) Categories of facilities that have to be monitored • Hospitals and nursing facilities (geriatric homes, nursing homes, baby-nursery) • Facilities for ambulant surgery, dialysis, rehabilitation... • Schools, Kindergarten • Hotels, youth hostels • Other training facilities, homes, holiday camps etc. • Sports facilities • Community accommodations

12. Dr. K. Luden Recommendation of the Federal Environmental Agency (FEA) In addition to W551: • In Facilities of category 1 and 2 (Hospitals, nursing facilities) no orientating investigation but always extensive investigation • Additional sampling in units with high risk (e.g. intensive care units) • Facilities with many division ranks (Teilstränge) sampling has to be conducted in units were showers are used

13. Dr. K. Luden Parametric values No recommendation by authorities because: • Little or no data on the correlation between Legionella concentration in water and infection rates • Legionella are not normally distributed in water (biofilms, amoeba) ? Should a domestic warm water distribution system that is up to date not be free of Legionella?Detecting 500 CFU/100 ml one day can result in 5.000 or 500.000 the other day.

14. Dr. K. Luden Assessment of the results of a routine monitoring (orientating 1x a year) W551

15. Dr. K. Luden 1 2 i 2) LS1-LSi Steigstrang 1 2 i Verteiler 1) L1 Austritt Trinkwassererwärmer Zulauf 3) L3 Rücklauf Zirkulationsleitung Sampling point Water body to be checked during monitoring Lower Saxony Technical survey and inspection of the distribution system always first (checklist provided with the recommendation) Negative results of Legionella samples are no proof of a technically correct system

16. Dr. K. Luden Sampling Specifications: L1 sampling at maximum temperature, document sampling temperature LS run off exactly 1 liter of water, take sample, document sampling temperature, flush to maximum temperature, document temperature L3 flush shortly to sample circulating water, document temperature Follow instructions of ISO 19458 purpose b.

17. Dr. K. Luden Sampling - ISO 19458 Detection of systemic contamination: purpose b

18. Dr. K. Luden Sampling - ISO 19458 Risk assessment or case related investigation: purpose C

19. Dr. K. Luden Detection method - ISO 11731 optional

20. Dr. K. Luden Detection method - ISO 11731 • Range of measurement: • Plating of 2x 0.5 ml →< 100 to 40.000 CFU/100 mlwith a maximum of 200 colonies per plate in accordance with ISO 8199 • Membrane filtration of 20 ml →< 5 to 500 CFU/100 mlwith a maximum of 100 CFU/filter • Total of < 5 to 40.000 CFU/100 ml

21. Dr. K. Luden Results 2005

22. Dr. K. Luden Consequences • Facilities with samples that show extremely high contamination with Legionella might be asked to take action immediately. • Operators of house installations with medium contamination are asked to provide a mid term remediation plan. • Advice is offered and sometimes facilities are closed e.g. showers at a public swimming pool as a safety measure to public health. • NO concrete action is ordered by the public health services. The responsibility for providing safe water lies with the operator of the house installation.

23. Dr. K. Luden Concluding remarks • Sampling and evaluation of Legionella detection in house installations has been harmonized in Lower Saxony. • Consulting of Public health services and operators of house installations contaminated by Legionella has become easier. • Sampling techniques fit the purpose of the monitoring. • If the recommended protocol is used and all temperatures are documented a first step towards finding the cause of the problem often is taken. • Although technical standards have been existing for more than 20 years facilities prevail that are not at the state of the art.