1. How to Control Legionella and
Pseudomonas Species and Remain
Legal
2. Legionella
• Legionnaires' disease is a form of pneumonia caused by the legionella
bacterium. The majority of cases are reported as single (isolated) cases
but outbreaks can occur. All ages can be affected but the disease mainly
affects people over 50 years of age, and generally men more than women.
Smokers and the immunocompromised are at a higher risk.
• The bacteria are widely distributed in the environment. They can live in all
types of water including both natural sources such as rivers and streams,
and artificial water sources such as water towers associated with cooling
systems, hot and cold water systems and spa pools.
4. Legionnaires’ disease medical
profile
Most people will not develop Legionnaires’ disease
and may only show flu-like symptoms
Statistically approximately 12% of identified cases
are fatal
There are high risk groups that are more likely to
become infected and less likely to recover
Smokers, alcoholics, diabetics, immune suppressed
people
5. Pseudomonas Species
• Pseudomonas species are Gram-negative rod shaped bacterium
commonly found in soil and ground water and often associated with
biofilm.
• P. aeruginosa is increasingly important clinically as it is a major cause of
both healthcare-associated infections and chronic lung infections in
people with cystic fibrosis.
6. Method of Infection
• P. aeruginosa is one of the more common causes of healthcare-
associated infections and is increasingly resistant to many antibiotics. In
hospitals the organism contaminates moist/wet reservoirs such as
respiratory equipment and indwelling catheters and infections can occur
in almost every body site but are particularly serious in the bloodstream
(bacteraemia).
• If it enters lung tissue, for example in a cystic fibrosis patient, it can cause
a form of pneumonia.
• Infection of a skin wound or burn can lead to extensive tissue damage or
even septic shock.
• If the bacterium infects the gastro-intestinal system of a vulnerable
patient, then a condition called "necrotising enterocolitis" can follow,
which again causes severe tissue damage.
7. Pseudomonas infections medical
profile
• Latest figures suggest that the number of Pseudomonas infections is fairly
steady, with between 3,700 and 4,000 cases reported to the Health
Protection Agency each year.
• Nine out of 10 of these were the P. aeruginosa strain.
• Rates were highest in the London region, and the majority of cases were
in the elderly and babies under one year old.
• The bacterium appears to have an inbuilt resistance to antibiotics, as well
as the ability to mutate into new, even more resistant forms.
8. Controlling the risk
• Control and prevention of the disease is through treatment of the source
of the infection, i.e. by treating the contaminated water systems, and
good design and maintenance to prevent growth in the first place
9. Preventative measures
• System Design, materials, installation and testing
• Procedures and best practice
• Training, responsibility and awareness
• Monitoring and recording
• Treatment and control
• Maintenance
• Environmental considerations
• Guidance Documents and legislation
• Identify and assess the risk and apply appropriate actions
10. Managing the risk
• Are conditions suitable for multiplication of the organisms (for example
temperatures between 20°C and 45°C and stagnant water)
• Is the presence of Legionella in sufficient numbers
• Is there a source of nutrients (for example sludge, scale, rust, protozoa,
algae and other organic matter);
• Is there a means of creating and disseminating fine droplets (for example
cooling towers, showers and most other water draw-offs that are capable
of creating a spray or causing splashing)
• Is there the presence of people who may be exposed to contaminated
aerosols, especially those who are vulnerable to Legionella infection (for
example those with compromised immune or respiratory systems, and
transplant patients
11. What does the Approved Code of
Practice & Guidance L8 cover
The control of legionella bacteria in
water systems
Issued by The Health and Safety
Commission and came into force 8th
January 2001
It has legal status under:
Health and Safety at Work Act.
Control of Substances Hazardous
Health Regulations
12. HTM-04
• The Health Technical Memorandum
(HTM) outlines the principles
involved in the design, installation
and testing of hot and cold-water
supply, storage and distribution
systems in healthcare premises.
• It is applicable to new and existing
premises
13. Training Academy Courses
• Level 3 endorsed Award in Legionella Control for Responsible Persons
suitable for Statutory Duty Holders, Responsible People, and managers
involved in legionella control. The focus being on why legionella presents
a risk, legislation, Approved Code of Practice L8, HTM04:01, roles of
individuals, record keeping, and appointment of competent staff.
• Level 2 accredited Award in Principles of Legionella Awareness
suitable for Statutory Duty Holders, Responsible People, Managers,
Deputies and all staff involved in legionella control on site. This course
covers the topics above also but it’s main focus is on the actions required
to control legionella in specific systems.
14. Regulatory Factors
• Biocidal Products Directive/Regulations (BPD/R)
• Registration, Evaluation, Authorisation and Restriction of Chemicals
(REACH)
• Regulation 31(4)A of the Water Supply (Water Quality) Regulations 2000
• Water Regulations Advisory Scheme (WRAS)
• World Health Organisation (WHO)
15. What are Biocidal Products?
Biocidal products contain or generate active substances and are used against
harmful organisms such as pests and bacteria.
They are used both to protect human and animal health. They include
household products such as disinfectants, rodenticides, repellents, and
insecticides.
Others are used in more industrial applications as wood and material
preservatives, anti-fouling paints, and embalming products to avoid damage
to natural or manufactured products.
16. What is the Objective of the
Biocidal Products Regulations?
Due to their intrinsic properties and uses, biocidal products may themselves
pose health risks and be harmful to the environment.
It is vital therefore to ensure that only biocidal products safe for use are
placed on the market
The EU Biocidal Products Regulations provide the legal framework to regulate
biocidal products on the market
In the UK the HSE is the Competent Authority
17. How will this impact the market?
• Only those actives which have been notified for a particular product type
(application) can be used legally within the EEC
• If an active is not supported then it must be withdrawn from the market,
for example copper was not supported so for biocidal use a withdrawal
notice was published on 1st Feb 2012 in order to enable removal of copper
electrodes by 1st February 2013
• This means the use of copper as a biocide will be illegal within the EEC
from 1st Feb 2013
18. What if my site still has a Copper
Silver Generator?
• The HSE is taking a pragmatic response as organisations have a
responsibility to manage the risks from legionella and it is essential that
these duties continue to be met and that legionella control is not
compromised.
• The HSE encourages users of silver/copper ionisation water treatment
systems to contact the manufacturer/maintainer of their system to
discuss how to achieve this.
• A wide range of supported alternative treatments are available
19. WHO Guidelines
• Copper is included in the plan of work of the rolling revision of the WHO
Guidelines for Drinking-water Quality.
• Recent studies in rabbits have suggested a link between copper in
drinking-water and Alzheimer disease. Levels in the rabbits’ drinking-
water were well below the current WHO guideline of 2 mg/litre, based on
acute gastrointestinal effects; however, it has not been established
whether rabbits are an appropriate model. In addition, a communication
received by WHO Headquarters suggested the need to review the
guideline value and text on copper with regard to toxicity in the
preparation of formula for bottle-fed infants.
20. What Products are Legal to Use?
• Many active manufactures have notified their actives for the relevant
product types which are PT5 for (Drinking Water Disinfectants ) and PT11
for Process Water (Preservatives for Liquid Cooling)
• There are over 20 Actives notified for PT5 however not all are being
supported for drinking water for human consumption as PT5 also covers
drinking water for animals
• Use of such actives must also comply with EU Drinking water legislation
such as Council Directive 98/83/EC of 3 November 1998 on the quality of
water intended for human consumption and meet national requirements
21. Actives Supported for PT5 Human
Consumption
• Chlorine Dioxide
• Active Chlorine
• Calcium Hypochlorite
• Sodium Hypochlorite
• Chlorine
22. Chlorine Dioxide
• At ambient temperature and pressure Chlorine dioxide is a yellowish-
green gas that is readily soluble in water and is an excellent oxidising
biocide.
• It has more than 2.5 times the oxidising capability than chlorine and
requires a lower contact time than chlorine.
• Chlorine dioxide is effective in alkaline conditions (pH <10) whereas
biocide such as sodium hypochlorite lose activity quickly as the pH rises
and are not suitable for use at pH >8.
• Chlorine dioxide does not generally react with other water treatment
chemicals or with nitrogen compounds including ammonia and naturally
occurring organic materials such as organic acids.
23. Chlorine Dioxide
• Chlorine dioxide is a gas that explosively decomposes into chlorine and
oxygen so for this reason it should always be used as a dissolved gas in
water at relatively low concentrations.
• Chlorine dioxide is therefore generated situ. Precursor chemicals react
inside the generator to produce a solution of chlorine dioxide
• For potable water the application of Chlorine Dioxide is limited to 0.5 ppm
as ClO2,Chlorite and Chlorate at the point of application, this can result in
inadequate control in large systems
24. Chlorine
• Chlorine has been used as a disinfectant for over 200 years and remains
one of the most effective treatments for microbial control.
• Within water the principle species are Hypochlorous Acid (HOCl) and
Hypochlorite. The HOCl is the most efficacious species as its neutral
electrochemical charge and small molecular size enables rapid
penetration through the negatively charged cell walls and slime layers of
microbes.
• Chlorine is less effective in alkali conditions as they favour hypochlorite
species over HOCl
• Chlorine has wide regulatory approvals and is supported by an extensive
toxicological package via the Euro Chlor Consortium
25. Non Chemical
• UV light at certain wavelengths is mutagenic towards bacteria as it breaks
the molecular bonds of microbial DNA. Efficacy depends on the power,
exposure time, particles which can protect the microbes and ability to
withstand exposure. Also there is no residual effect
• Filtration via point of use filters can be an effective solution especially in
high risk areas. There are concerns that this is a short term fix and low
pressure, tap design, cost and disposal are further issues.
• Flushing and water movement reduce the opportunity for microbes to
multiply however dead legs can harbour microbes
• Temperature control is effective as water temperatures in the range 20°C
to 45°C seem to favour growth. Legionella do not appear to multiply
below 20°C and will not survive above 60°C.
26. Latest Developments?
• HTM - 04 Addendum (March 2013)
• Biocidal Products Regulations (September 2013)
• L8 update (Late 2013)
• Greater public awareness via multimedia
• Evaluating a new products
27. What is the Ideal Biocide?
• Excellent efficacy against all microbes
• Low use concentrations
• Easy to apply
• Simple to measure electronically/test kits
• Low hazard classification
• Cost effective product and equipment
• Wide range of regulatory approvals
• Broad in use compatibility
• Single dose system
• Good environmental profile
28. Stable Active Halogen
High performance stable active halogen solutions which are
extremely efficacious against planktonic and sessile
microorganisms at very low concentrations
29. Stable Active Halogens
• Infection Control
• Water Treatment
• Wound Care
• Animal Health
• Surface Sanitisation
• High Level Disinfection
• Laundry Treatment
• Fruit and Vegetable washing
• Seed Priming
• Pool and Spa
30. NHS Healthcare Case Study
• Building only 4 years old
• B & V took over in 2008 -site not fully occupied
• Several hundred outlets, with some low/no usage, and low turnover of
water
• Legionella problems from day 1
• Flushing and high temperature pasteurisation did not eliminate the
problem
• Cold – TVCs and Pseudomonas species problems
• Hot – Legionella (~1/3), TVC and Pseudomonas species problems
31. The Trial
• Dosing equipment installed
• Shock dosed for 2 days
• Down to maintenance dose after 48 hrs
• Technical team regularly visited for 3 months – chemical monitoring
and samples carried out on 4 CW and 6 HW points
• Quarterly positive outlets added to sampling (total=18)
37. Outcome
• All Legionella eliminated from trial points
• 1 rogue outlet picked up on additional sampling– GP49
• Requires more than chemical solution -working with site to find an
engineering/scheduling solution
• All Pseudomonas species and TVCs reduced to zero
• Abulox has brought the micro problems under control and has been
adopted
38. Food Company Case Study
• Recirculating hot water system
• Continuous Legionella issues
• Numerous chlorinations with Chlorine Dioxide, SuPerSil and
Chlorine with little effect
• Abulox trialled at maintenance dose of 0.5 – 1.0 ppm
• Initial shock of 5 ppm for 3 days
39. Case Study – Legionella Results
Legionella
Results Removal of Biofilm
5
4.5
4
3.5
Mens 4th floor hot
3 Ladies Ground floor hot
Log
2.5 Reduced Visitors hot
to Zero Mens cloakroom hot
2
Ladies cloakroom hot
1.5
Ladies 2nd floor hot
1
Ladies 2nd floor hot
0.5 Ladies cloakroom hot
Mens cloakroom hot
0
Visitors hot
01.04.11 Ladies Ground floor hot
04.04.11
05.04.11
06.04.11 Mens 4th floor hot
08.04.11
13.04.11
Sample Date 15.04.11
19.04.11
40. Case Study – TVC Results
TVC
Results
6
5
Mens 4th floor hot
4 Ladies Ground floor hot
Visitors hot
Mens cloakroom hot
Log
3
Ladies cloakroom hot
Ladies 2nd floor hot
2
L Cloakroom shower LHF hot
L Cloakroom shower RHF hot L Cloakroom shower RHF hot
1 L Cloakroom shower LHF hot
Ladies 2nd floor hot
Ladies cloakroom hot
Mens cloakroom hot
0 Visitors hot
01.04.11 Ladies Ground floor hot
04.04.11
05.04.11
06.04.11 Mens 4th floor hot
08.04.11
13.04.11
15.04.11
Sample Date 19.04.11
41. Case Study – Pseudomonas Species Results
Pseudomonas
Results
3.5
3
2.5
Mens 4th floor hot
2 Ladies Ground floor hot
Log
Visitors hot
1.5 Mens cloakroom hot
Ladies cloakroom hot
1 Ladies 2nd floor hot
0.5 Ladies 2nd floor hot
Ladies cloakroom hot
Mens cloakroom hot
0
Visitors hot
01.04.11 Ladies Ground floor hot
04.04.11
05.04.11
06.04.11 Mens 4th floor hot
08.04.11
13.04.11
15.04.11
Sample Date 19.04.11
42. Government Organisation Case Study
• Under capacity building with poor quality incoming mains
• Traditional liquid and dual powder pack chlorine dioxide treatment &
chlorinations were not able to solve the problem
• System shock dosed for 48hrs and chemical maintained at 1.5ppm
Cl2
43. Case Study – TVC 22 Results
TVC 22
1400
1200
1000
800
600 GF Quiet/First Aid Room CWS
400
Zero
200
0
Incoming Mains Chlorine Chlorine Abulox
Dioxide 1 Dioxide 2
44. Case Study – Pseudomonas Results
Pseudomonas
1400
1200
1000
800
GF Accessible Shower
600
400
Zero
200
0
Incoming Mains Chlorine Dioxide 1Chlorine Dioxide 2 Abulox
45. Case Study – Legionella Results
Legionella
12000
10000
8000
6000
GF Accessible Toilet CWS
4000
2000
Zero
0
Chlorine Dioxide 1 Chlorine Dioxide 2 Abulox
46. NHS Hospital
• Legionella concerns at up to 8000 cfu/litre in the pre and post flush
samples at various points within the hospital
• Shock dosed Abulox for 3 days followed by a maintenance dose at 0.5 to
1.0 ppm Cl2
• Pre and Post Flushing samples taken at 5 key points defined by the NHS
Trust
• Samples tested by external UKAS accredited laboratory
49. NHS Hospital
• Legionella completely eliminated by day 2 of treatment in all post flush
samples and virtually eliminated in all pre flush samples
• Pseudomonas eliminated in post flush samples
• Trial continuing to form part of a technical paper
50. Performance Summary
• High level of microbial control and biofilm removal
• Fast rate of kill and no resistance
• Low use concentration
• Simple to apply and measure
• Long term stable solutions
• Good safety and Environmental Profile
• Wide range of packs
• Regulatory Approvals
• Cost effective
51. Regulatory
• Drinking Water Inspectorate Approval (Number DWI 56.4.1074) under
Regulation 31(4)A of the Water Supply (Water Quality) Regulations 2000
SI No 3184 & The Water Supply (Water Quality) Regulations 2010 SI No
994 (W.99)
• WRAS approved dosing components
• All chemical constituents are BS EN Listed
• Active ingredient notified for PT5 Drinking Water for Human consumption
plus PT’s 2, 3, 4 and 11
• WHO recommended limit of 5 ppm Cl2 for potable water
• Use in accordance with Council Directive 98/83/EC
• Manufactured under ISO13485, ISO 9001 and ISO14001
