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Water Management Program

2017 Sacramento Health and Safety SummitOctober 3, 2017

∗ Legionellosis Prevention

∗ANSI/ASHRAE 188-2015 Standard

Water Management Program

Presenter Name: Bill Jones Date: 10/3/17e-mail : [email protected] Phone : 909.460.8351Master of Public Health University of Oklahoma, Bachelor of Science in Chemistry University of Central Oklahoma, Bachelor of Science in Biology Oklahoma State University.

Certifications:

Certified Industrial Hygienist ABIH, 2117 CP;

Certified Safety Professional BSCP, Comprehensive Practice 12190;

Certified Professional Ergonomist BCPE 1295.

Title:

Vice President of Industrial Hygiene, Clark Seif Clark, Inc. (retired)

Years of experience: 40

Presenter

∗ Introduction

∗ Why is a WMP is necessary

∗ Case Study 1 Prison

∗ What ANSI/ASHRAE 188-2015 does

∗ The 8 Elements of a WMP

∗ Case Study 2 Assisted Living Home

∗ Developing the Program and Controls

∗ Questions

∗ Handouts

Agenda

∗ Philadelphia July 4, 1776 – Declaration of Independence

∗ 200 Years Later, 2,000 American Legionnaires met at the Belleview Stratford Hotel in Philadelphia

∗ 130 of the 2,000 contracted a mysterious disease and 25 died

∗ Etiologic agent not identified for a year

IntroductionNation’s Birthplace

Introduction

August 16, 1976

Bellevue-Stratford Hotel.

Closed in November, 1976, four months after the outbreak

Ecology of L. pneumophila

1. Gram negative bacteria2. Its hosts are fresh water

protozoa in ponds and domestic water supplies

3. Protozoa can colonize on plumbing surfaces and scale

4. Survives up to 120o F. Amplifies (multiplies) from 77o to 108o F -That is, it amplifies in elevated temperatures of building water systems

5. It becomes hazardous when the water with the bacteria becomes an aerosol

Life Cycle

Case Study 1San Quintin 2015

San Quentin Correctional FacilityLegionella Outbreak

Case Study

Just In Case Some of You Have Ideas

1. Legionaire’s Disease and Pontiac Fever2. Facility Information3. Outbreak Background4. Epidemiological & Age Distribution Data5. Preliminary Action(s)6. Laboratory Data7. Conclusions

Content

∗ Legionellosis is a common name for two illnessescaused by Legionella bacteria. Legionnaires’ disease(LD) and Pontiac Fever (PF). LD is an infection of thelungs that causes a form of pneumonia. PF is a milderinfection with symptoms similar to those of LD,usually lasting from 2 to 5 days, but without thepneumonia. A person can develop Legionellosis byinhaling water mist contaminated with viableLegionella bacteria.

Background(Legionellosis)

∗ According to OSHA, Legionella pneumophila bacteria are widely distributed in water systems. They tend to grow in biofilms or slime on the surfaces of lakes, rivers, and streams and somewhat resistant to the chlorination used to purify domestic water systems. Low and even non-detectable levels of the organism can colonize a water source.

Legionella Background

∗ Examples of water sources that frequently provide optimal conditions for growth of the organisms include, but are not limited to:

∗ Cooling towers, evaporative condensers, and fluid coolers that use evaporation to reject heat. These include many industrial processes that use water to remove excess heat;

∗ Domestic hot-water systems with water heaters that operate below 60°C (140°F) and deliver water to taps below 50°C (122°F);


∗ Humidifiers and decorative fountains (Chicago Marriott) that create a water spray and use water at temperatures favorable to growth;

∗ Spas and whirlpools; ∗ Dental water lines, which are frequently maintained at

temperature above 20°C (68°F) and sometimes as warm as 37°C (98.6°F) for patient comfort; and

∗ Other sources including stagnant water in fire sprinkler systems and warm water used for eye washes and safety showers.


San Quentin Prison Information

San Quentin State Prison is California’s oldest and best known correctional institution, established on Point San Quentin, in July of 1852, as an answer to the rampant lawlessness in California at the time. During construction, inmates slept on the prison ship, the Waban, and labored to build the new prison during the day. San Quentin housed both male and female inmates until 1933 when the women’s prison at Tehachapi was built. The prison overlooks the bay on 432 acres, and is located just 12 miles north of the Golden Gate Bridge in the county of Marin. The walled prison is made up of four (4) large cell blocks (West, South, North, and East Block), one (1) maximum security cell block (the Adjustment Center), Central Health Care Service Building, a medium security dorm setting and a minimum security firehouse. It has the state's only gas chamber.

1. August 27, 2015 confirmed case of Legionnaire’s Disease and increased number of pneumonia cases

2. August 28, 2015 CDCR Environmental Compliance Section collected water samples from cooling towers and water tank that supplied water to the facility

3. Subsequently, additional Legionnaire’s cases were reported and the epidemiological chart reflected an outbreak

4. September 1, 2015 CSC was retained to assist in the assessment

5. CSC retained the services of Dr. Richard Wade

Outbreak Background

∗ September 1, 2015 conference call meeting to setup scope∗ September 2, 2015, Franco Seif & Dr. Wade attend a

meeting at San Quentin∗ September 2, 2015, Dr. Wade collects limited surface and

water samples, mainly from cooling towers ∗ September 3 CSC industrial hygienists collect water and

surface samples throughout the facility∗ September 11 CSC collects water samples from the

decontaminated cooling towers

Outbreak Background

∗ As of September 2, 2015, based on the then availableepidemiological data combined with the lack of anyrecords of HVAC water chiller Legionellacontrol/cleaning and disinfection, an informedassumption was made that the most likely source ofthe outbreak was from the cooling towers on top ofBuilding 22, the healthcare facility

Outbreak Background

Cooling Towers

Just in Case You are Still Wondering

∗ According to CCHCS there were 81 cases of radio-graphically confirmed pneumonia or lab confirmed Legionellosis (n=13) with onsets from August 10 through September 15, 2015.

∗ The median age was 56 years old (range 25 to 83 years old); 13 patients were hospitalized with no fatalities reported. Among staff, there were 3 confirmed cases of Legionellosis, 12 reported cases, and 1 case of pneumonia.

Epidemiological Data

Epidemiological Chart

Age Distribution

Legionellosis cases were distributed throughout facility!

∗ Shut off and stop the use of water throughout facility.

∗ Transfer potable and shower water to inmates.

∗ Provide trucked in food to inmates.

∗ Shut off cooling system to healthcare facility and kitchen.

Preliminary Action PlanCDCR

∗ Install point of use bacteria filters on shower headsand kitchen water outlets.

∗ Attain the services of a contractor to decontaminatethe cooling towers on the Health Services buildingand kitchen.

∗ Activate the cooling towers after thedecontamination is complete.

∗ Allow dental operation to proceed.

Preliminary Action PlanCSC

∗ Collect water samples for legionella bacteria from the3 Bldg. 22/Healthcare facility cooling towers and themain kitchen cooling tower.

∗ Collect water samples throughout facility. Thelocations of the samples were pre-determined by Dr.Wade.

Preliminary Action PlanCSC

Location Volume (mL) Identification Results (CFU/mL)Water Reservoir at Supply 750 ND ND

Water Reservoir at Supply 800 ND ND

Main kitchen, cooling tower 950 ND ND

Adjustment Center, Cell sink 900 ND ND

Adjustment 1st tier, S shower 1000 ND ND

Bldg. 22, AC-1-2 (North) 700 Legionella Pneumophila, (sero 1)

1200

Bldg. 22, AC -2-1 (center) 1000 Legionella Pneumophila, (sero 1)

880

Bldg. 22, AC-1-1 (South) 1000 Direct plating ND

CDCR Sample ResultsAugust 28, 2015

Water

Location Volume (mL) Identification Results (CFU/S)Bldg.22 AC-1-2, Water Pan,

sludge5 Legionella Pneumophila

(sero 1)24,000

Bldg. 22 AC-1-2, Exhaust 5 ND ND

Bldg. 22, AC-2-1 Exhaust 5 ND ND

Bldg. 22, AC-2-1, sludge 5 Legionella Pneumophila(sero 1)

16,800

Bldg. 22, AC-1-1 Vent 5 ND ND

Bldg. 22, AC-1-1 , Bottom 5 ND ND

Central Kitchen, cooling tower, interior

5 ND ND

Central Kitchen Cooling tower, drain

5 ND ND

CSC Sample ResultsSeptember 2, 2015

Swabs

Location Weight (g)

Identification Results (CFU/g)

Bldg. 22, AC-1-1, Water Pan, Dry Sludge

10 LegionellaPneumophila, (sero 1)

96,000

Bldg. 22, AC-2-1, Water Pan, Moist Sludge


33,600

Bldg. 22, AC-2-1, Water Pan, Moist `Sludge


400,000



200,000



420,000


Sludge

∗ In summary, CSC collected over 100 water and surface samples throughout the facility.

∗ Samples were collected from showers, kitchen faucets and sculleries, inmate sinks and faucets, and drinking fountains.

∗ Laboratory results were non-detect for all samples.


∗ Outbreak was related to warm temperatures in theBay Area.

∗ Lack of maintenance of the cooling towerscontributed to the growth of bacteria.

∗ Wind acted as a fan to spread the bacteria over theprison population.

∗ CDCR develops and CSC approves an Operations &Maintenance procedures for cooling towers.

Conclusions

WMPWMP With Case Study 2

∗ Confirmed case of LD summer 2015 in an assisted living facility

∗ CSC monitored, assessed and advised∗ As the investigation/response actions proceeded it

became apparent that a WMP was needed

Case 2 Assisted Living Case

∗ Client contacted us with the concern∗ CSC deployed VP of IAQ and an IH∗ Immediate actions included:

∗ Advised client to bring in bottled drinking water∗ Have most vulnerable residents only get sponge baths∗ Ask medical personnel to request antigen testing for any

residents with pneumonia symptoms∗ Install point of use filters∗ Brought in plumber and with the building Facilities rep, walked

the facility and reviewed drawings to identify hazards such as plumbing dead legs, expansion tanks and more

∗ Collected water and swab samples throughout the facility

Case Study 2 CSC Response

∗ Six months into the project, CSC had me come into the picture to develop a WMP

Investigation and Responsive Actions Underway

∗ Legionella growth (amplification) can start anytime.

Even with shock chlorination, plumbing fixture cleaning and eliminating areas conducive to growth, Legionella “hits” can persist

Why Is A WMP Needed?

∗ Water from public utilities can bring in this naturally occurring bacteria

Why Is A WMP Needed?

The Program

8 Elements

Plus Management of Change

∗ Happy Fall!

The WMP

Here’s the Meat But it Could Be a Little Dry

∗ 2 Minutes:∗ In groups of 2 or 3 discuss who should be on the team

ASHRAE 188 – 2015 Element 1: Program Team

∗ What kind of facility∗ Different roles and

various expertise are needed to identify necessary actions, authorize and implement actions


People with Knowledge of:The water systemAHJ requirementsMedical managementControlsHazardsMonitoringTreatmentPrecautionsAuthorized to act

∗ Executive Director ∗ Operations staff members, including Medical,

Facilities and others ∗ Service Providers and Suppliers∗ Consultants (CSC)∗ Others who have been delegated authority by the

building owner to take actions∗ Must be knowledgeable of the building water

systems


∗ 2 Minutes∗ In groups of 2 or 3 discuss how you might approach

describing and analyzing the water system

ASHRAE 188 – 2015 Elements 2 and 3: Water Systems Descriptions and Analysis

∗ A contract plumber responded in August and September 2015 and reviewed drawings and documented observations and identified hazards

∗ Identified hazards such as “dead-legs” were removed or dealt with

∗ CSC and local management and maintenance personnel gathered data on the system

∗ Drawings are now digitized for easier access and record keeping

∗ A second plumbing contractor was brought in to look for additional hazards

∗ Water systems are now fairly well defined


∗ The process of reviewing the flow diagrams (Attachment A of the WMP), sampling and consulting with AHJs and other sub-consultants regarding areas of higher legionella risk, the building water system has been analyzed

∗ For example, there are no:∗ Cooling towers∗ Ornamental fountains

∗ There are:∗ Showers∗ Spa tubs∗ Vanity and kitchen sinks∗ Expansion tanks


∗ 2 Minutes∗ In groups of 2 or 3 discuss possible control measures

ASHRAE 188 – 2015 Element 4: Control Measures

∗ Control Measures are spelled out in the plan, including:∗ Flushing∗ Descaling∗ Removal of biofilm∗ Shock chlorination∗ Temporarily using bottled water∗ Sending suspect cases for clinical testing

∗ Attachment B and C∗ Attachment B Summarizes hazards and actions∗ Attachment C has an action guideline taken from: AIHA

Guidance Document – 2015, Recognition, Evaluation, and Control of Legionella in Building Water Systems


Location Risk Factor Control MeasureAll apartments Scale deposits on sink aerators

and shower heads could provide an environment for Legionella amplification

Place routine (i.e. semi-annual) scale removal in the TELS maintenance system

All apartments PTAC HVAC units

Some units have biofilm build-up. Legionella could amplify in unit condensation trays

Scrub and disinfect PTAC condensation trays. Place on TELS system for routine maintenance (e.g. semiannual)

Glass filler station Possible dispensing of Legionella containing water

Install and replace Eco-Lab filters on a scheduled basis

Ice Machine Possible dispensing of Legionella containing water

Install and replace Eco-Lab filters on a scheduled basis


Attachment BIdentified Risk Factors and Control Measures

Sample Source NonDetectable(UnitsCFU/ml)

AcceptabilityLow* (UnitsCFU/ml)

Action Possible Amplification(Units CFU/ml)

Action IndicatesAmplification (UnitsCFU/ml)

Action

Humidifiers &Misters <1 <1 1 1-10 2 >10 3

DecorativeFountains andWater Features <1 <1 1 1-10 2 >10 3

Shower heads,kitchen andbathroomfaucets

<1 <1 1 1-10 2 >10 3


Attachment CLegionella Control Limits and Corrective Action Guide*

Action Level

Typical Actions as Recommended By AIHA Publication “Recognition, Evaluation and Control of Legionella in Building Water Systems”

1Continue monitoring based upon WMP Monitoring Plan (see Attachment E). Continue system maintenance and adjust plan as necessary to prevent Legionella colonization.

2

If no Legionellosis is suspected:• Immediately clean and implement shock chlorination or other biocide treatment• Take action promptly to eliminate exposures (remove aerators, bottled water, sponge baths,

end point filters, etc.)• Review and modify maintenance and treatment protocols as appropriate• Implement remedial cleaning or disinfectant protocols• Review current sampling frequency and look at other parameters such as pH, residual chlorine

levels, temperatureIf Legoinellosis cases are suspected:• Send affected resident for clinical testing • Immediately eliminate exposures (remove aerators, bottled water, sponge baths, end point

filters etc.)• Notify management and public health authorities• Review and modify maintenance and treatment protocols as appropriate• Implement remedial cleaning or disinfectant protocols• Review current sampling frequency and look at other parameters such as pH, residual chlorine

levels, temperature• Investigate for amplification sites and correct identified causes• Perform re-testing after implementation of remedial actions


Attachment CLegionella Control Limits and Corrective Action Guide

∗ This is discussed in the body of the WMP but is addressed in the following Attachments C, D and E

ASHRAE 188 – 2015 Element 5: Monitoring and Corrective Actions

Location Component/Fixture Monitoring Frequency Parameter (Values)

All Apartments Shower Heads Weekly Hot Water Temperature (110o F – 115o F)

All Apartments Kitchenette Faucets Weekly Hot Water Temperature (110o F – 115o F)

All Apartments Bathroom Vanity Faucets Weekly Hot Water Temperature

(110o F – 115o F)

Kitchen Ice Machine Annually Legionella (<0.1 CFU/ml)

ASHRAE 188 – 2015Element 5: Monitoring and Corrective Actions

Attachment D Monitoring Frequency and Parameters

Location Component/Fixture Frequency TaskAll Apartments Shower Heads Daily Flush hot water for 5 minutes

All Apartments Shower Heads Quarterly Remove, Soak in 10% Chlorine Solution with Agitation

All Apartments Kitchenette Faucets Daily Flush hot water for 5 minutes

All Apartments Kitchenette Faucets Quarterly Remove, Soak in 10% Chlorine Solution with Agitation

ASHRAE 188 – 2015Element 5: Monitoring and Corrective Actions

Attachment EMaintenance Frequency and Task

∗ Verification that the program has been implemented and

∗ Validation that it is effective∗ Both verification and validation will be accomplished

through sampling schedules found in Attachment D of the WMP and in an annual audit/survey/update

ASHRAE 188 – 2015Element 6: Confirmation

∗ The body of the WMP describes the communications and record keeping requirements∗ Includes a call down list to ensure the right people on

the Program Team, AHJ and in management are easily found

∗ Finally, the body includes our change management section, not a part of the ANSI/ASHRAE 188-2015 Standard

ASHRAE 188 – 2015Elements 7 and 8: Documentation and Communication/

Management of Change

∗ Since August 2015 – nearly 650 ISO (CDC) samples∗ Because, we still had random “hits”, we worked with

our client and potential vendors to find a secondary disinfectant system for the facility’s hot water system.

ASHRAE 188 – 2015Case Study 2 Update

∗ Brief discussion of choices.∗ After reviewing costs and documentation of relative

effectiveness of various systems, our client selected a chlorine dioxide generating system. There have been eight sampling events since the installation of the secondary disinfectant system. The system’s history is summarized on the next slides.

Secondary Water Treatment Update

∗ Prior to installation, monthly sampling had revealed random “hits”, sometimes in excess of 100 cfu/ml.

∗ The system was installed 8/3/16∗ First sampling event 8/24/16 (30 locations). Results N.D. in 28

and 0.35 cfu/ml in one and 0.1 cfu/ml in another – deemed acceptable

∗ Second event 9/22/16 (30 locations). Results – All N.D.∗ Third event 10/26/16 (30 locations). Results N.D. in 28 and 0.05

cfu/ml in one and 1.5 cfu/ml in another – since the species was not L. pneumophila, results deemed acceptable

∗ Fourth and Fifth events 11/16/16 and 12/19/16 respectively (30 locations each). Results – All N.D.


∗ Sixth event 1/26/17 (30 locations). Results N.D. in 28 and 0.05 cfu/ml in one and 0.6 cfu/ml in another – deemed acceptable. With six successful sampling events, the sampling frequency was changed to quarterly.

∗ Seventh event 5/22/17 (30 locations) Results – All N.D.∗ Eighth event 8/21/17 (30 locations) Results – N.D. in 27 locations,

0.05 cfu/ml in kitchenette and bathroom faucets of one apartment and 0.05 cfu/ml at the shower head of another apartment. The species was not L. pneumophila and results were deemed acceptable.

∗ The secondary treatment system appears effective and the WMP needs to be adjusted to incorporate/document the results.


∗ ANSI/ASHRAE Standard 188 – 2015, Legionellosis: Risk Management for Building Water Systems

∗ ANSI/ASHRAE Guideline 12-2000, Minimizing the Risk of Legionellosis Associated with Building Water Systems

∗ Veterans Health Affairs VHA Directive 1061, August 13, 2014, Appendix C, Clinical and Environmental Validation of Engineering Controls for Prevention of Legionella Growth

References

∗ AIHA Guidance Document – 2015, Recognition, Evaluation, and Control of Legionella in Building Water Systems

∗ CTI Guidelines WTB-148 (08) – July 2008, Legionellosis Guideline: Best Practice for Control of Legionella

∗ OSHA Technical Manual, Appendix III:7-3 Water Sampling Guidelines

∗ “Legionella and Legionnaires’ Disease: 25 Years of Investigation”, Clinical Microbiology Reviews, July 2002

∗ “Existence and control of Legionella bacteria inbuilding water systems: A review”, Journal Of Occupational And Environmental Hygiene – 2017, Vol. 14, No. 2, 124-134

References

∗ http://www.cdc.gov/vitalsigns/topics.html∗ www.cdc.gov/legionella/health-depts/inv-tools-

cluster/environmental-inv-tools.html∗ https://www.cdc.gov/legionella/index.html

A Few Links

http://www.cdc.gov/vitalsigns/topics.html

http://www.cdc.gov/legionella/health-depts/inv-tools-cluster/environmental-inv-tools.html

∗ Mr. Franco Seif, P.E., CAC, Principal Clark Seif Clark, Inc. (CSC)

∗ Mr. Derrick Denis, CIAQP, CAC, CIEC, V.P. Indoor Environmental Quality CSC

∗ Mr. Les Puvathingal, Industrial Hygiene Consultant∗ Mr. Paul Anderson, Industrial Hygienist∗ Dr. Richard Wade, PhD, MPH, Principal Scientist,

Adjunct Professor UCI

Acknowledgements

∗ QUESTIONS?

FIN

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