Why outbreaks of Legionnaires’ disease are still occurring and how they can be proactively avoided is shared by STUART ADCOCK, Legionella team leader for the Department of Health, Victoria.
In June 2000, one of the world’s largest outbreaks of Legionnaires’ disease occurred in Melbourne, Victoria, with 125 cases and four deaths. The source of the outbreak was a cooling tower at the Melbourne Aquarium.
And, a number of outbreaks investigated by the Victorian Department of Health that have occurred since the aquarium incident have been linked to cooling tower systems on commercial buildings managed by facilities managers. How can these outbreaks be avoided?
WHAT IS LEGIONNAIRES’ DISEASE?
Legionnaires’ disease is a form of pneumonia that can be fatal. Early treatment can prevent the disease from becoming severe. Legionella bacteria are found in natural water bodies such as rivers, lakes, creeks and hot springs, as well as in spas, potting mix, warm water systems and artificial systems that use water for cooling, heating or industrial processes, such as cooling towers. Early symptoms are similar to flu symptoms.
Not only do outbreaks of Legionnaires’ disease have a significant impact on human health, they also create a massive expense to the business operating the cooling tower system. There are the immediate costs associated with disinfecting and cleaning the cooling tower system, but, often, the business impacts associated with the publicity surrounding the outbreak are more significant. There is also the possibility of prosecution if there are breaches of the laws and the potential for civil litigation.
In 2001, following the Melbourne Aquarium outbreak, an expert panel was convened to provide a series of recommendations on a proposed Legionnaires’ disease prevention strategy. The cornerstone of the strategy was the registration of all cooling tower systems in Victoria, as well as the requirement to develop risk management plans that need to be audited annually. The legislation also included prescriptive requirements for the sampling and servicing of cooling tower systems and other warm water delivery systems.
The Victorian Legionella strategy represents one of the strictest programs in the world, with strong legislative provision for implementation and enforcement. The number of cases of Legionnaires’ disease in Victoria has decreased following the introduction of the legislation.
In addition, the aquarium outbreak highlighted to doctors treating patients with pneumonia that they should test them for Legionnaires’ disease. So it is likely that the number of cases of Legionnaires’ disease was underreported prior to the aquarium outbreak.
IRRESPONSIBLE SAMPLING AND SERVICING
The Department of Health’s Legionella Team conducts targeted inspection of sites where a lack of compliance with legislation is indicated, such as the non-renewal of their registration, lack of an annual audit or a non-compliant audit.
In 2011, during an investigation into a site that had not renewed the registration of a number of systems on the site, the samples collected detected Legionella in large numbers in almost all the systems on site. Service reports from the water treatment technician indicated that many of the dosing systems were faulty and needed to be replaced.
The facilities manager had not replaced the dosing equipment because the years of sampling by the water treatment technician had not detected Legionella. The problem with that decision was that it assumed that if Legionella had not been detected previously that it would not be found in the future, which is not the case.
It also did not consider the possibility that the sampling was not being conducted appropriately. For example, a water treatment technician could be concerned that their company would lose the account if they continually had to return to the site to undertake remedial actions. Under that pressure they might collect unrepresentative samples.
In this case, it appears that the sampling results were distorting the real story and the system had become heavily colonised with Legionella. It took months and tens of thousands of dollars to regain control of the system.
Sometimes, the department’s authorised officers visit facilities managers’ sites where all the paperwork is in order and records are complete and complying with the requirements; however, when they take a good look at the service records, they see reports of system failures and faults that require attention. Often no one has read the service reports or assessed the recommendations. This can lead to the costly failure of equipment that could have been avoided with preventative maintenance.
Often, contractual arrangements with the treatment providers mean that having to react to an adverse microbiological result will place a financial burden on the treatment provider. This encourages technicians to take unrepresentative samples.
It’s important to be on the lookout for small faults and problems before they develop into larger issues. Facilities managers need to be engaging with and questioning water treatment companies to ensure their clients are protected.
A common problem is not enough oversight and involvement with water treatment providers. It is important to work with treatment providers or to engage an independent consultant to develop a program to ensure the risks are being adequately managed. It is also important to identify the best way to manage the risks rather than comply with the legislation with the least cost.
IMPORTANCE OF REGISTRATION
According to the Public Health and Wellbeing Act 2008, the owner of any land on which a cooling tower system is in operation is required to ensure that the cooling tower system is registered with the Department of Health at all times it is in operation. The land owner must also take all reasonable steps to ensure that a risk management plan is prepared, reviewed and audited annually. Often the land owner will require the facilities manager to ensure these tasks are completed.
The department records the details of people to contact in relation to the registration of the system (the ‘registration holder’) and a person that can be contacted in relation to an investigation of Legionnaires’ disease (the ‘responsible person’).
If the department does not have the correct ‘responsible person’ details, it may delay the site being informed that they need to disinfect their system as a precaution, where the department has been notified of a person with Legionnaires’ disease who lives or works in the vicinity of the facility or has been to the facility.
If the department does not have the current ‘registration holder’ details, it may also result in the registration expiring in breach of the law. This can result in the department contacting the land owner directly after first conducting a title search. This may not reflect well on the facilities manager.
RISK MANAGEMENT PLANS
The Public Health and Wellbeing Regulations 2009 define the responsible person as “the person who owns, manages or controls a cooling tower system, water delivery system or aquatic facility”.
In many facilities, the facilities manager will be engaged to ensure the responsible person complies with the regulations, which are available from the Victorian Law Today Library. They set out the minimum maintenance, dosing, cleaning and testing requirements for a cooling tower system. All facilities managers that manage a facility with a cooling tower system are encouraged to be familiar with the regulations. Often the risk management plan will nominate higher levels of maintenance, dosing, cleaning and testing to manage the risks on a particular site.
A risk management plan is required for all cooling tower systems in Victoria. The plan must identify all the risks associated with the cooling tower system. Risk identification is usually undertaken by a number of individuals, including the water treatment service person, mechanical engineer, maintenance person and facilities manager. The plan must document how each risk will be managed. This process will drive operation and maintenance programs for the system and determine the frequency of servicing, cleaning and sampling.
FACILITIES NEEDING EXTRA PRECAUTION
The Public Health and Wellbeing Regulations 2009 also require that all premises supplying aged care, health services, health service establishments, registered funded agencies, correctional services and commercial vehicle washes must manage the risks of Legionella in any water delivery system.
Water delivery systems are defined as “any shower plumbing, bath, pipes, water heaters, bathing facilities, water storage tanks or vehicle washing equipment used to store, deliver, transmit, treat or mix water”.
The presence of warm water and a method of transmitting Legionella in fine droplets that could be inhaled creates the risk that Legionella will grow inside pipes and other parts of a system.
The focus for the majority of health and aged care facilities that are covered by this legislation is predominantly on the warm water shower systems. It is very important that these facilities ensure their patients are not scalded with hot water when showering. Managing the scalding risk, however, can mean that an environment that can encourage Legionella growth is created.
Other systems where Legionella has been detected in healthcare facilities are decorative fountains, ice and cool water dispensers, hydrotherapy pools and spa pools.
Depending on the facility and the risks involved, it may be important to regularly test the water delivery system for Legionella. The regulations require that if Legionella is detected in a water delivery system, that system must be disinfected.
Disinfection means “to carry out a process which is intended to kill or remove pathogenic micro-organisms”. Prior to sampling for Legionella, it is strongly recommend that a response plan is developed so the system can be disinfected if Legionella is detected in the system.