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STARTING AT 12.30
Battles with the legion: What causes
Legionnaires’ disease and how the risks can be
managed
Please wear ...
Battles with the Legion
- What causes Legionnaires’ disease and how the
risks can be managed.
Presented by
Dr Colin Purnel...
3
SETTING THE
BATTLE SCENE
What are we up against?
4
Legionnaires’ Disease
• Named after an outbreak of
pneumonia in people attending a
convention of the American Legion
at ...
5
What is Legionnaires’ disease
Legionellosis - generic term - covers all
infections caused by legionella bacteria
Legio...
6
KNOW YOUR ENEMY
7
Legionnaires’ Disease
Caused by inhaling a virulent strain of
Legionella pneumophila contained in very
small water drop...
8
Legionnaires’ Disease
Infection Time On-set of symptoms in 2 - 10 days,
Symptoms Fever, chill, headaches, muscular
aches...
9
Legionnaires’ Disease
Infective dose not known, but likely to be low,
Infection occurs mainly in people aged 50+,
Som...
10
Where are Legionella bacteria found ?
In Nature
• Soil, ponds, lakes and rivers.
In Man-made water systems such as:-
• ...
11
Water systems
Cooling towers,
showers, spa pools,
etc.
Amoebae
Biocide
(if added)
Legionella in
supply water,
dirt or a...
12
How do Legionnaires’ disease outbreaks occur?
1. Legionella bacteria enters a water system,
2. Legionella bacteria are ...
13
EXAMPLES OF
BATTLES LOST
14
Headline ‘News of the World’
following outbreak Legionnaires’ disease
at Stafford District General Hospital in 1985
“KI...
15
How The Observer depicted Legionnaires’
disease at Stafford Hospital on 11 August 1985
16
Major Legionnaires’ Disease Outbreaks
in UK since 1985
 London (1988) - source - cooling tower
 Corby (1997) - source...
17
HSE INVESTIGATION OF PAST OUTBREAKS
• Make someone managerially responsible for
ensuring the requirements for control w...
18
FIGHTING THE BATTLE
BY MANAGING THE RISK
19
Replaced L8 (2000)
APPROVED CODE OF PRACTICE & GUIDANCE
Revisions to L8 intended to
simplify and clarify the text.
20
Removed the technical guidance from the
ACOP which is now published separately as
HSG274 - which has 3 parts.
Legionnai...
21
Control of legionella bacteria in water systems
Detailed guidance on spa pools
is currently provided in the 2006
HSE/PH...
22
OTHER CHANGES
 risk assessment - schematic now ACoP requirement,
 specific role of appointed competent "responsible"
...
23
ACOP - SCOPE AND APPLICATION
A “reasonably foreseeable risk” of exposure to
legionella bacteria exists for:-
(a) wet co...
24
PURPOSE OF THE RISK ASSESSMENT
To enable a decision to be made on: -
the risk to health, i.e. whether the
potential for...
25
Who should undertake the
risk assessment?
• The Duty Holder under ACoP L8 can select a
risk assessor – but retains resp...
26
“Suitable and Sufficient”
all the factors pertinent to the water
system’s use and operation have been
considered,
an in...
27
• Primary duty is to eliminate (prevent) the
risk of exposure to legionella bacteria.
• Secondary duty is to control th...
28
INDG 458 - A brief guide for dutyholders
Provides information on the how dutyholders
should comply with their legal dut...
29
PREVENTING OR CONTROLLING THE RISK
FROM EXPOSURE TO LEGIONELLA BACTERIA
• must be prepared where the risk assessment
sh...
30
THE WRITTEN SCHEME
The L8 ACoP Technical Guidance Parts 1,
2 and 3 provides detailed information of
the appropriate con...
31
 Arrangements in place - to ensure that the
responsible person (or their appointed deputy) can
be contacted at all tim...
32
The management of the water systems involves:-
a) checking the performance and operation of
the system and its componen...
33
Spa pool accessible parts
ACoP - inspect the “accessible” parts of the
system for damage and signs of contamination.
34
Spa pool “inaccessible” parts !
Any “retained” risks must be considered in the
written scheme pending corrective action.
35
• the responsible person(s) and their deputies,
• significant findings of the risk assessment,
• the written scheme and...
36
Review
Policy and
Procedures
Water
System
Surveys
Risk
Assessment
Written
Scheme
ACoP L8 (2013) –
THE WATER SYSTEM MANA...
37
ROLE OF CONSULTANTS AND
WATER TREATMENT CONTRACTORS
• Water treatment programmes,
• Water hygiene services (including w...
38
• Must ensure the control measures are designed and
implemented to be effective,
• Must provide adequate information on...
39
SOME FINAL COMMENTS
40
CONSEQUENCES OF AN OUTBREAK
• Adverse publicity - media, politicians, public
• Inspection of site facilities - by LA, H...
41
Sequence Based Typing (SBT)
DNA Profiling - Sequence Based Typing
(SBT) of Legionella pneumophila strains in
LD patien...
42
WHAT ARE THE IMPLICATIONS FOR THE
DUTYHOLDER IF THINGS GO WRONG?
If the ACoP L8 (2013) provisions are not complied
with...
43
THE FINAL COMMENT
An outbreak of Legionnaires’
disease has never been
caused by a clean and well
managed water system.
44
ANY QUESTIONS?
45
TECHNICAL GUIDANCE (HSG274)
PART 1 - EVAPORATIVE COOLING SYSTEMS
Considerably expanded covering:-
• Health and Safety L...
46
TECHNICAL GUIDANCE (HSG274)
PART 2 – HOT AND COLD WATER SYSTEMS
Considerably expanded covering:-
• Health and Safety La...
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Battles with the Legion - Colin Purnell - Safety & Health Expo 2014

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What causes Legionnaires’ disease and how the risks can be managed

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Battles with the Legion - Colin Purnell - Safety & Health Expo 2014

  1. 1. STARTING AT 12.30 Battles with the legion: What causes Legionnaires’ disease and how the risks can be managed Please wear the headphones to listen to presentation
  2. 2. Battles with the Legion - What causes Legionnaires’ disease and how the risks can be managed. Presented by Dr Colin Purnell of Cogent Risk Management Ltd on behalf of the BOHS 19th June 2014
  3. 3. 3 SETTING THE BATTLE SCENE What are we up against?
  4. 4. 4 Legionnaires’ Disease • Named after an outbreak of pneumonia in people attending a convention of the American Legion at a hotel in Philadelphia in 1976 • 179 people made ill and 34 died (including passers-by) • Causative agent eventually identified to be a previously unknown strain of bacteria, subsequently named Legionella pneumophila. Bellevue-Stratford Hotel
  5. 5. 5 What is Legionnaires’ disease Legionellosis - generic term - covers all infections caused by legionella bacteria Legionella bacteria cause two diseases:  Legionnaires’ disease – a rare, severe and potentially fatal form of pneumonia  Pontiac fever - mild ‘flu-like’ illness 90% of Legionnaires’ disease cases are caused by Legionella pneumophila.
  6. 6. 6 KNOW YOUR ENEMY
  7. 7. 7 Legionnaires’ Disease Caused by inhaling a virulent strain of Legionella pneumophila contained in very small water droplets (aerosols) Legionella bacteria penetrates deep into the lung (alveoli) Legionella bacteria invade alveolar macrophages in which they reproduce in large numbers.
  8. 8. 8 Legionnaires’ Disease Infection Time On-set of symptoms in 2 - 10 days, Symptoms Fever, chill, headaches, muscular aches, dry cough, breathlessness, diarrhoea, vomiting and delirium Incidence 250 - 350 confirmed cases a year (UK) Mortality Rate 10 - 15% for “healthy” people, 25 - 30% for hospital patients, >50% for the immuno-suppressed At Risk Groups 45 - 75+, alcohol drinker, smoker, (males > females) immuno-suppressed, existing respiratory or other disease, diabetes.
  9. 9. 9 Legionnaires’ Disease Infective dose not known, but likely to be low, Infection occurs mainly in people aged 50+, Some infected persons are exposed for very short periods and/or kilometres away from the source, Not everybody exposed develops Legionnaires’ disease.
  10. 10. 10 Where are Legionella bacteria found ? In Nature • Soil, ponds, lakes and rivers. In Man-made water systems such as:- • Hot and cold water systems and spa pools • Cooling tower water systems • Ultrasonic misting systems • Health and dental care equipment Any water system that is capable of supporting the growth of legionella bacteria.
  11. 11. 11 Water systems Cooling towers, showers, spa pools, etc. Amoebae Biocide (if added) Legionella in supply water, dirt or air Temperature 20 - 46°C Nutrients, + Iron salts, L-cysteine Other bacteria Sludge, scale, stagnation & biofilms Factors influencing the survival and growth of legionella in water systems pH 2 - 8.5
  12. 12. 12 How do Legionnaires’ disease outbreaks occur? 1. Legionella bacteria enters a water system, 2. Legionella bacteria are given suitable conditions to multiply to hazardous levels in the water, 3. Aerosols containing a virulent strain of Legionella bacteria are released into the air, 4. The aerosols are inhaled by susceptible persons who may then develop Legionnaires’ disease. All the above are required to cause an outbreak of Legionnaires’ disease.
  13. 13. 13 EXAMPLES OF BATTLES LOST
  14. 14. 14 Headline ‘News of the World’ following outbreak Legionnaires’ disease at Stafford District General Hospital in 1985 “KILLER CLOUD PROBE AS BUG’S TOLL REACHES 28” 175 people infected 28 people died Source of the outbreak was a cooling tower and its associated air conditioning system Legionella bacteria entered the air of the out-patients department of the hospital.
  15. 15. 15 How The Observer depicted Legionnaires’ disease at Stafford Hospital on 11 August 1985
  16. 16. 16 Major Legionnaires’ Disease Outbreaks in UK since 1985  London (1988) - source - cooling tower  Corby (1997) - source - not identified  Cardiff (2000) - source - ultrasonic mister  Barrow (2002) - source - cooling tower  Hereford (2005) - source - cooling tower  Wales (2010) - source – not identified Recent outbreaks (still under investigation) • Edinburgh (2012) - suspected source - cooling tower • Stoke (2012) - suspected source - spa pool.
  17. 17. 17 HSE INVESTIGATION OF PAST OUTBREAKS • Make someone managerially responsible for ensuring the requirements for control were properly carried out, • Prepare a “suitable and sufficient” risk assessment, • Implement a “robust” written scheme of precautionary measures, • Manage their water systems properly. The organisations involved failed to:-
  18. 18. 18 FIGHTING THE BATTLE BY MANAGING THE RISK
  19. 19. 19 Replaced L8 (2000) APPROVED CODE OF PRACTICE & GUIDANCE Revisions to L8 intended to simplify and clarify the text.
  20. 20. 20 Removed the technical guidance from the ACOP which is now published separately as HSG274 - which has 3 parts. Legionnaires’ disease – L8 (ACoP) 2013 MAIN CHANGE Part 1 - Evaporative cooling systems Part 2 - Hot & cold water systems Part 3 - Other risk systems (includes spa pools).
  21. 21. 21 Control of legionella bacteria in water systems Detailed guidance on spa pools is currently provided in the 2006 HSE/PHE publication ”The Management of spa pools: Controlling the risks of infection” Currently being updated.
  22. 22. 22 OTHER CHANGES  risk assessment - schematic now ACoP requirement,  specific role of appointed competent "responsible" person (and requirement for deputy),  written scheme and what it should include,  regular review of risk assessment and measures,  the duties and responsibilities of those involved in the design, manufacture & supply of water systems and services (consultancy & maintenance). The following issues now have ACOP status:
  23. 23. 23 ACOP - SCOPE AND APPLICATION A “reasonably foreseeable risk” of exposure to legionella bacteria exists for:- (a) wet cooling water systems (b) hot and cold water systems (c) spa pools (d) other risk systems All these systems require a Risk Assessment.
  24. 24. 24 PURPOSE OF THE RISK ASSESSMENT To enable a decision to be made on: - the risk to health, i.e. whether the potential for harm to health from exposure is reasonably foreseeable unless adequate measures are taken, the necessary measures to prevent, or adequately control, the risk from exposure to legionella bacteria.
  25. 25. 25 Who should undertake the risk assessment? • The Duty Holder under ACoP L8 can select a risk assessor – but retains responsibility for the quality of the risk assessment, • The risk assessment must be “suitable & sufficient”, • Must be completed by a “competent person”.
  26. 26. 26 “Suitable and Sufficient” all the factors pertinent to the water system’s use and operation have been considered, an informed and valid judgement has been reached about the risks and the steps which need to be taken to achieve and maintain adequate control of legionella in the water system. Dutyholder must be able to demonstrate that:-
  27. 27. 27 • Primary duty is to eliminate (prevent) the risk of exposure to legionella bacteria. • Secondary duty is to control the exposure risk by measures which do not allow proliferation of the legionella organism and reduce, SFARP, exposure of people to (inhalable) water droplets (aerosols). ACoP - Dutyholders
  28. 28. 28 INDG 458 - A brief guide for dutyholders Provides information on the how dutyholders should comply with their legal duties.
  29. 29. 29 PREVENTING OR CONTROLLING THE RISK FROM EXPOSURE TO LEGIONELLA BACTERIA • must be prepared where the risk assessment shows that there is a reasonably foreseeable (and unavoidable) risk, • should be properly implemented and managed, • should specify measures to be taken to ensure that it remains effective. THE WRITTEN SCHEME
  30. 30. 30 THE WRITTEN SCHEME The L8 ACoP Technical Guidance Parts 1, 2 and 3 provides detailed information of the appropriate control measures and water treatment regimes. The written scheme must include an up- to-date schematic of the water system.
  31. 31. 31  Arrangements in place - to ensure that the responsible person (or their appointed deputy) can be contacted at all times,  Emergency call-out procedures,  Clear lines of communication - unambiguous and regularly audited to ensure they are effective. This also applies to contractors and consultants who may be responsible for certain parts of the written scheme. IMPLEMENTATION OF THE WRITTEN SCHEME
  32. 32. 32 The management of the water systems involves:- a) checking the performance and operation of the system and its component parts, b) inspecting the “accessible” parts of the system for damage and signs of contamination, c) monitoring to ensure that the treatment regime continues to control to the required standard. Note: The above ACoP requirements were “guidance” in L8 (2000) ACoP - REVIEW OF CONTROL MEASURES: MONITORING AND ROUTINE INSPECTION
  33. 33. 33 Spa pool accessible parts ACoP - inspect the “accessible” parts of the system for damage and signs of contamination.
  34. 34. 34 Spa pool “inaccessible” parts ! Any “retained” risks must be considered in the written scheme pending corrective action.
  35. 35. 35 • the responsible person(s) and their deputies, • significant findings of the risk assessment, • the written scheme and its implementation, • details about the state of operation of the water system, • results of any monitoring, inspection, tests or checks. RECORD KEEPING Dutyholder must ensure records are kept including:- The L8 ACoP provides detailed guidance on exactly what records should be kept for each type of water system.
  36. 36. 36 Review Policy and Procedures Water System Surveys Risk Assessment Written Scheme ACoP L8 (2013) – THE WATER SYSTEM MANAGEMENT CYCLE Remedial Works Audit RECORDS
  37. 37. 37 ROLE OF CONSULTANTS AND WATER TREATMENT CONTRACTORS • Water treatment programmes, • Water hygiene services (including water sampling), • Preparation of schematics, risk assessments and written schemes, • Inspection, cleaning & disinfection of systems, • Provide training “Help and assistance” does not absolve the dutyholder from their responsibilities under ACoP L8 (2013).
  38. 38. 38 • Must ensure the control measures are designed and implemented to be effective, • Must provide adequate information on the correct and safe use of products in all circumstances of their use, • Must make the dutyholder or their responsible person(s):-  aware of any deficiencies in the risk assessment or written scheme and  aware of any limitations on their own expertise, products or services. SUPPLIERS OF PRODUCTS & SERVICES, INCLUDING CONSULTANCY & WATER TREATMENT
  39. 39. 39 SOME FINAL COMMENTS
  40. 40. 40 CONSEQUENCES OF AN OUTBREAK • Adverse publicity - media, politicians, public • Inspection of site facilities - by LA, HSE, PHE • Criminal proceedings • Public - nearly always affected - people die - possible manslaughter charges • Civil Action - award of damages • Financial costs - management time, legal fees, fines, insurance premiums, etc.
  41. 41. 41 Sequence Based Typing (SBT) DNA Profiling - Sequence Based Typing (SBT) of Legionella pneumophila strains in LD patients and environmental samples now a routine investigation procedure SBT can prove (unequivocally) that a particular strain of Legionella pneumophila bacteria in a water system was the same strain that infected the people with Legionnaires’ disease.
  42. 42. 42 WHAT ARE THE IMPLICATIONS FOR THE DUTYHOLDER IF THINGS GO WRONG? If the ACoP L8 (2013) provisions are not complied with then a Court of Law will view it as proof of contravention of legal requirements.
  43. 43. 43 THE FINAL COMMENT An outbreak of Legionnaires’ disease has never been caused by a clean and well managed water system.
  44. 44. 44 ANY QUESTIONS?
  45. 45. 45 TECHNICAL GUIDANCE (HSG274) PART 1 - EVAPORATIVE COOLING SYSTEMS Considerably expanded covering:- • Health and Safety Law and ACoP requirements • Types and Designs and Operation • Requirements of cooling water system treatment • Desired outcome in terms of water quality • Use of biocides and alternative treatments • Inspection, cleaning and disinfection procedures. • Monitoring water quality and understanding reports.
  46. 46. 46 TECHNICAL GUIDANCE (HSG274) PART 2 – HOT AND COLD WATER SYSTEMS Considerably expanded covering:- • Health and Safety Law and ACoP requirements • Types and Application of hot and cold water systems • System design and commissioning requirements • Checklists of inspection & maintenance requirements • Water treatment - thermal & biocides (Cl2, ClO2, etc) • Microbiological monitoring • Cleaning and disinfection (thermal & chemical) • Managing the duty: Shared premises & landlords • Special consideration for healthcare & care homes.

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