Use any other technology that has been shown to be safe and effective. Step 5. Later symptoms include high fever (up to 105°F), a dry cough, and shortness of breath. Wisconsin Division of Health. In the event that an antibody titer level for Legionella was obtained at the time of illness, or if serum collected from the patient at the early phase of the illness (acute phase) is available, then an antibody titer level should be determined from this sample to determine the convalescent to acute titer ratio. Take a sample of water from the bottom drain. Muraca, P.W., V.L. 26-30. Goetz. Nalco Chemical Company. The S&HTP emphasizes the importance of effective water management plans to prevent Legionella contamination and growth while using sample results as a validation tool. Started Heater should be off. Equipment you will need includes a thermometer for measuring water temperatures, a flashlight, and a film or video camera to record observations. Head -QA, Performance Qualification Protocol for Sterilization and Depyrogenating Tunnel. Because sampling for Legionella can be inconclusive, sampling results alone should not determine the appropriate course of action in a building where an outbreak has occurred. The purpose of this phase of an investigation will be to identify cases of Legionnaires' disease among the workers. : Yes ___ No ___, If Yes, which ones? Do not use raw steam from the central heating boiler because it contains corrosion inhibitors and anti-scaling chemicals. Antibody strength is determined by the number of dilutions of serum which elicit a positive antibody response. 800-321-6742 (OSHA)
In addition, this water may be in the ideal temperature range for Legionella growth, 20° - 50°C, 68° - 122°F. Weekly for the first month after resumption of operation. If it appears that an employee experienced a pneumonia-like illness, the attached surveillance questionnaire will be completed. Try to eliminate stagnant places in the system as dead legs or storage tanks that are not routinely used. a) Approximately 1,000 cases are reported annually to the CDC, but it is estimated that over 25,000 cases of the illness occur each year and cause more than 4,000 deaths. Rubber and plastic gaskets in the plumbing system may also serve as a Legionella growth medium. Legionnaires' disease is not contagious, and you cannot catch it from another person. These devices include sumps, which may stagnate when not in use. "Potable water as a cause of sporadic cases of community-acquired Legionnaires' disease." Included are proper maintenance procedures for controlling the organism in a facility's water sources. After To Collect an "after-flush" sample of water when the maximum temperature has been reached. Use the clean-up procedure below to treat all hot-water systems that have either been tested and found to contain detectable levels of Legionella or have been assumed to be contaminated. Collect a 200 milliliter to 1 liter "preflush sample" of the first hot water drawn from the outlet. Take prompt steps to prevent employee exposure. to evaluate ability of the sterilization and depyrogenation tunnel to sterilize Action 2: Immediate cleaning and/or biocide treatment. The temperature of the water should be 122°F or higher at the faucet. To date, _____ case(s) of the disease has/have occurred among employees in this facility. Remember that these numbers are only guidelines, and the goal is zero detectable Legionella in a water source. Early symptoms include malaise, muscle aches, and slight headache. A level-two investigation is similar to a level-one investigation with several additional steps. Measure the temperature of the sampled water. Yes, studies have shown that these bacteria can be found in both natural and man-made water sources. Evaporative condensers operate similarly to cooling towers except that refrigerant coils are inside the water path, and water passes over the coils to cool the refrigerant gas directly. The immediacy of the action will depend on whether the outbreak is ongoing or occurred 30 days or more in the past. Head Production et. The investigation will include identification of all employees who took three or more consecutive days of sick leave days from six weeks before the Legionnaires' case was identified to the present. printing enclosed the printout obtained from the data logger. Ann. For example: Pasteurize the hot water system by heating the water to at least 70°C (158°F) and maintain this temperature for a minimum of 24 hours. According to the Centers for Disease Control in Atlanta, there are between 10,000 and 50,000 cases of Legionnaire's disease every year in the U.S. We are cooperating fully with local health officials who are investigating this matter. If an HVAC sump is used during the hours when a building is occupied, drain the sump during unoccupied hours. Muraca, J. Joly, N. Troup, and L.S. Legionnaires' disease got its name from the first outbreak in which the organism was identified as the cause. If the evidence indicates that two or more cases of Legionnaires' disease have occurred at a site, and at least one of the cases was within the last 30 days, assume that an outbreak is in progress and requires a high-priority investigation and prompt action. It is also important to identify and test the integrity of all backflow preventers to assure protection of domestic water from cross-contamination with process water through a building code-approved method. Lukman Hakim. : Yes ___ No ___, If Yes, where? Intermittent use of the device coupled with a warm pan of water may support, Direct steam-type humidifiers inject boiler-generated steam directly into the air stream. Legionnaires' disease is not contagious and cannot be transmitted from one person to another. Measure Air velocity 6 inches below the filter at 5 locations (four corner Because of the 10-day to two-week delay in obtaining sample results, corrective action should begin immediately. Record : Teat Warm-water systems or tepid water systems dilute domestic hot water from a water heater with cold water upstream from the outlet source are not recommended. Maintain domestic water heaters at 140°F (60°C). VALIDATION, Ple. Cross-contaminations of the domestic cold-water system with other systems should always be suspected. Collect a sample of water from the outlet pipe if the plumbing provides for access. The Any other places that you have not mentioned where you spend time while on the job? The records should include temperature checks of domestic water, visual and physical checks of cooling towers, and reports of cooling-tower water-quality assessment and chemical treatment. Connect Remember, however, that the primary sources of exposure to contaminated water are heat rejection systems (cooling towers, fluid coolers, etc.) These stand-alone units have been linked to an outbreak of Legionnaires' disease in a hospital. 200 Constitution Ave NW
If the cooling tower is operating and is suspected of being contaminated, wear appropriate respiratory protection in the form of a half-face piece respirator equipped with a HEPA or similar type of filter capable of effectively collecting one-micron particles during the examination of the system. 0.5µ After temperature observed at different locations with respect to time. Evaluate cooling towers, evaporative condensers, and fluid coolers for biofilm growth, scale buildup, and turbidity. Enclosure of the system will prevent unnecessary drift of water vapor, and other design features to minimize the spray generated by these systems are also desirable. If no samples exceed the criterion, suspend monitoring and continue the maintenance program indefinitely. : Yes ___ No ___, If Yes, which one(s)?__________________________, Did you go to any other public places which you feel might be significant (i.e. Ship to laboratory using overnight mail. Yes ___ No ___, Was a chest x-ray taken? Some of the factors that can increase the risk of getting the disease include: age (older persons are more likely to get disease); weakened immune system (cancer patients, HIV-infected individuals); underlying medical problem (respiratory disease, diabetes, cancer, renal dialysis, etc. 5. Submit the water samples to a laboratory qualified to measure CFU of Legionella per milliliter of water. Measure and record the temperature of water drawn from each storage-type water heater in the facility. 6. Record the position of the probe in a establish that at different locations within the tunnel, a count size of Water Sampling Guidelines, Appendix III:7-4. Requirement, to maintain continuous laminarity of HEPA Filter installed in For the present, please pay attention to the following important points: If you have any concerns or questions concerning this issue, please ask your manager. Based on an interview with the employee's physician, potential cases should be considered for a clinical test to detect additional cases. A positive urine antigen test for a diagnosed pneumonia case is also accepted as evidence of a confirmed case. Take immediate control of all water sources to eliminate potential for exposure, and take measures to eliminate the hazard. We are screening employee illnesses as a result of our Legionnaire's disease incident. Water tanks that allow water to remain uncirculated for long periods can also promote growth of bacteria. The purpose of an employee awareness program is to inform the employees of the potential outbreak, and to educate them about the disease. show at least 3 log reduction after exposing. Average the integrity of HEPA FILTERS installed in the sterilization and depyrogenation tunnel. Provide a "bleed" for water sumps so that dissolved solids do not form sediments in the sump. Warm water left in these lines is at ideal temperatures for amplification of L. pneumophila. Periodic chlorination of the system at the tank to produce 10 ppm free residual chlorine and flushing of all taps until a distinct odor of chlorine is evident is another means of control. In addition, a medical monitoring program must be instituted to track all workers currently on sick leave. Action 1: Prompt cleaning and/or biocide treatment of the system. al. Infection Control, 7786, (4), 1985, pp. : ________________________________________, How many times?______________________________________________, Did you use any hot tubs (whirlpool spas)? : Yes ___ No ___, If Yes, who? Atomizing humidifiers must have contaminant-free water. Control Hosp. e) Detectable levels of L. pneumophila in the system may indicate contamination of the source water supply and should represent the maximum allowable level in the system. The location of the incoming supply and/or private source. Is Legionnaires' disease easy to diagnose? It is important not to flush the faucet before taking a sample because the end section of the water system may be a source of contamination. It is estimated that in the United States there are between 10,000 and 50,000 cases each year. They tend to grow in biofilms or slime on the surfaces of lakes, rivers and streams, and they are not eradicated by the chlorination used to purify domestic water systems. Stand-alone, console-type humidifiers that recirculate water for humidification should not be used because the water in these systems becomes contaminated with micro-organisms rapidly. To qualify the test the equipment should fulfill the acceptance criteria described in the individual test procedures. It is important not to flush the system to be sampled before collecting samples. One common design circulates cool water from a cooling tower sump through a water coil in the supply air stream. A) Date of Make the results of all water monitoring tests available to building occupants. If sampling of the system indicates a level of contamination significantly greater than that of the incoming domestic water supply system, treat the system and identify the source of contamination or amplification. Endotoxin Challenge study. : _____________________________, Did you go to the movies? Disease transmission usually occurs via inhalation of an aerosol of water contaminated with the organism. Legionnaires' disease is a common name for one of the several illnesses caused by Legionella bacteria. This discussion encompasses a variety of water systems, some of which have not been implicated with outbreaks of Legionnaires' disease. Loaded Record the temperature of the domestic cold-water lines at various locations within the facility. Once you have identified these features, take water samples from: It is important not to overlook any potential water sources in the building. The employer should implement the following elements of this program immediately upon recognition of more than one probable or confirmed case of disease in the work place: Below is a sample letter and supplemental information on the disease that the employer can use for informing employees of a potential or actual outbreak. If you would like to take advantage of these services or want more information, contact your manager. The effectiveness of any water-treatment regimen depends on the use of clean water. Probably not if you have small children or infirm elderly persons who could be at serious risk of being scalded by the hot water. Most probably, for a Legionnaires' disease outbreak to be linked directly with the HVAC system, Legionella-contaminated water must continuously enter the system, be aerosolized, and be delivered to building occupants. ______________________________, Since ___________, have any of your friends been diagnosed with pneumonia? Test every two weeks for the next two months. Particles is 3520 and 5.0µ is 29 in 1M, Temperature Corrective actions limited to raising the water heater temperature without evaluating the system for points of stagnation, heat loss and gain, cross-contamination, and other factors that contribute to growth are generally not sufficient. should be uniform throughout the cycle, Should For cooling towers, humidifiers, swamp coolers, and building water services, collect samples of sludge, slimes, or sediments, particularly where accumulations occur. Suspend the probe in the chamber in different position in such a way that Type of test: Urine Antigen Test, Direct Fluorescent Antibody Serology Tests: Indirect Fluorescent Antibody (IFA) ______, Laboratory:____________________________________________, Diagnosis or impression: _____________________________________, Employee's Name (last, first):_________________________ Age:_____ Gender:_____, _____________________________________________________________, Race/Ethnicity: white, black, native American, Hispanic, Asian, Other, Are you currently taking any oral steroid medications? (Date), (QA) These should be protected from temperature extremes and covered to prevent contamination. If evidence indicates that the outbreak is still in progress (that is, at least one of the cases has occurred in the last 30 days), prompt actions should be undertaken to provide maximum protection to employees and eliminate the hazard. the temperature profiles as per the temperature set points set in the PLC of 561-584. "Microbial contamination of dental unit waterlines: prevalance, intensity and microbiological characteristics." A large building may have multiple independent systems. Yes ___ No ___. will be drawn after compilation and evaluation of result. Determined if there were recent or frequent losses of water pressure from the incoming water supply due to line breakage or street repairs. : Yes ___ No ___, If Yes, where were they held? print out from the printer of Sterilizing & Depyrogenation Tunnel. When steps 1 through 4 have been successfully completed, return the humidifier to operation and test the unit's water system to detect recontamination with. During the 10 days prior to your illness: Job Description: ________________________________________________, Primary work area: ______________________________________________. Download The recovery of, Average High efficiency particulate air (HEPA) filter A device capable of filtering 99.97% of airborne particles 0.3 µm in diameter, the most penetrating particle size. Locate HVAC fresh-air intakes so that they do not draw the mist from a cooling tower, evaporative condenser, or fluid cooler into the system. Another alternative is "instantaneous" point of delivery heating of water using individual steam heating systems at each outlet. While maintaining the temperature at 70°C (158°F), continuously flush each faucet on the system with hot water for 20 minutes. Matching the same serogroup and subtype of organism in the patient as found in a water source is considered strong evidence of an associated link. Water mist from cooling towers or evaporative condensers, evaporative coolers (swamp coolers), humidifiers, misters, showers, faucets, and whirlpool baths can be contaminated with the organism and if inhaled or swallowed can cause the disease. Such tanks should be eliminated or designed to reduce storage time to a day or less. qualify the test the equipment should fulfill the acceptance criteria described Tompkins. March 1991, Pathogen Control Assoc., Norcross, Georgia. These employees will be interviewed. Take new water samples and begin the testing schedule again. To avoid cross-contamination of the samples, sanitize the thermometer with isopropyl alcohol before measuring the temperature of each sample. Comments shall be published after review. It is also important to help alleviate employee concerns about the disease. This is equivalent to an N95 mask. Low and even nondetectable levels of the organism can colonize a water source and grow to high concentrations under the right conditions. Full recovery occurs in 2 to 5 days without antibiotics. 800-321-6742 (OSHA)
stream of air should be unidirectional and non-turbulent upto working zone. The function of cooling towers, evaporative condensers, and fluid coolers is to reject heat from system fluids through evaporation. Comments Employees participating in surveys such as the one described above must be informed of their Privacy Act rights as well as their right to protect their own medical information. Whatever the circumstances, initiate control procedures and continue medical surveillance of the workforce to detect any new cases of disease and identify the water source responsible for the outbreak. Domestic water systems are designed to provide heated water for washing, cleaning, consumption, etc. the data from the data logger in the computer for the data analysis and Users must request such authorization from the sponsor of the linked Web site. Also note carefully any disconnected fittings, "dead legs," and cross-connections with other services. Conditions In the Philadelphia Legionnaires' disease outbreak, the hotel's cooling tower was identified as the likely source of the disease, although domestic water sources were not evaluated. Wrap vinyl tape clockwise around the neck of each bottle to hold its screw cap firmly in place and seal the interface between the cap and the bottle. A member of the building maintenance or engineering staff who has a working knowledge of the system's design and current operation can explain how the water system operates and the proper procedure for a controlled shutdown. Water from ice machines, hand spray bottles, decorative fountains, and for plastic injection molding equipment have been implicated in past outbreaks or have been found to be significantly contaminated. Yu, and R.N. sensors. should show more than 3. ); certain drug therapies (corticosteroids); and. Improperly drained condenser pans may produce tepid conditions that can encourage microbial and fungal growth. The What common types of water are of greatest concern? Clean and disinfect all cold water systems including storage tanks, drinking fountains, water lines, and water outlets, as follows: Use an accepted chemical disinfectant such as chlorine or other acceptable biocide. This usually means that two or more confirmed cases of Legionnaires' disease have been identified within a six-week period at the site. tunnel. High efficiency particulate air (HEPA) filter is defined as "a filter that is at least 99.97 % efficient in removing monodisperse particles of 0.3 micrometers in diameter. The problem arises when high concentrations of the organism grow in water sources. Because both cooling towers and evaporative condensers use a fan system to move air through a recirculated water system, they introduce a considerable amount of water vapor into the surroundings even with drift eliminators designed to limit vapor release. A fourfold increase in this titer will be sufficient to confirm a case of Legionnaires' disease. Take swabs of shower heads, pipes, and faucets and rehydrate from water taken from the sampling site. Other equipment may also be potential sources of, Residential humidifiers are small, free-standing, portable units that use an internal fan and wet media to disseminate a wet air stream. The Department of Labor does not endorse, takes no responsibility for, and exercises no control over the linked organization or its views, or contents, nor does it vouch for the accuracy or accessibility of the information contained on the destination server. area of the HEPA Filter installed in tunnel in m, c) The location of any evaporative cooling systems or humidifiers. Sterile test tubes containing sterilized swabs are available for convenient sampling and shipping. To minimize employee risk and maximize the effectiveness of effort, close coordination among OSHA, other public agencies, and the employer is imperative. Chemically untreated, stagnant, warm-water sources provide an ideal environment for. This section contains background information on water system operations and proper controls to prevent Legionella amplification. Water Treatment Protocols for Facilities That Have Experienced a Legionnaires' Outbreak, Severe Storm and Flood Recovery Assistance. The location of water heaters and boilers. No, Legionnaires' disease is not new, but it has only recently been identified. sterilization period. a) Depyrogenating Tunnel when operated with Empty Chamber is capable of producing Sample a representative number of domestic hot-water faucets or outlets. velocity across HEPA Filter should be within the range of 90±20 Feet/min, Average liter of air. Sample the humidifier water to assure "kill" of, Ensure that an adequate maintenance program is in effect to reduce the growth of. www.OSHA.gov. Contaminated water can leak from pipes into HVAC ducts, where it can be aerosolized and distributed by the system. Disinfect the system using any effective chemical, thermal, or other treatment method. Yu, and M.S. An HVAC condenser water system absorbs heat from the AC refrigeration units and rejects it to the atmosphere through evaporation in cooling towers. Investigate other potential sources of employee exposure including decorative fountains, plant misters, whirlpools, spas, tepid-water eye-washes and safety showers, humidifiers, and water for cooling industrial processes. Integrity test all HEPA filters with dioctyl phthalate (DOP) smoke (0.3 microns). A person must be exposed to water contaminated with. Take a sample from the water reservoirs. Because it is difficult to distinguish this disease from other forms of pneumonia, many cases go unreported. Upon re-use of a water system following treatment, periodic maintenance and regular water sampling are essential to ensure that the maintenance continues to be effective. Employees who took more than three consecutive days of sick leave will be identified, and we will attempt to determine if any in that group experienced pneumonia-like symptoms (fever, shortness of breath, cough). Yes_____ No_____, Physician's name:______________________ Phone:_____________, Physician's Address:______________________________________, Were you admitted to a hospital? _________________ "Isolation of Legionella pneumophila from the cold water of hospital ice machines: implications for origin and transmission of the organism." chamber Heat penetration studies must be conducted for, The Follow the clean-up procedure below if cold-water systems are shown to contain measurable Legionella or are assumed to be contaminated. A representative number of faucets for each of the hot and cold water systems in the facility. Legionella in Environmental Samples: Hazard Analysis and Suggested Remedial Actions. Appendices include details on conducting an employee awareness program, water sampling protocols and guidelines for acceptable levels of the organism in water, procedures for identifying new cases of the disease, and water treatment and control strategies for facilities where an outbreak has occurred. Scientists have learned much about the disease and about the Legionella bacteria since it was first discovered in 1976. Treatment of potential sources of contamination following sampling is described below. A positive culture indicates confirmation. The objective of the New England Journal of Medicine, 326, January 16, 1992, pp. How does Pontiac fever differ from Legionnaires' disease? This temperature may be significantly below the water heater's gauge temperature because of heat stratification. Inspect the entire air distribution system (including return and exhaust systems) for visual evidence of water accumulation. All instruments shall be calibrated before If these systems are using 100% outside air in a dry climate, the water sump temperature may be low and will not represent a significant risk. This educational program should be part of a level-two investigation or for a Legionnaires' disease outbreak. Yu. Muraca. In addition, we want to tell you what we are currently doing here at _____________________ to ensure all necessary steps are taken to address health concerns. f) When evaluating external sources, examine the potential for direct transmission. These steps may include increased frequency of application or concentration of biocides, pH adjustment, additional "shock" treatments, or any other action that reduces Legionella levels. They are intended to apply only to water systems being used by healthy individuals and are not necessarily protective for persons who are immunocompromised. For purposes of this document, an "outbreak of Legionnaires' disease" may be said to exist when medically confirmed cases of Legionnaires' disease are epidemiologically associated with a building or some portion of a building. Take a sample of any standing water in the condensate trays or from the cooling coils. Yes ___ No ___, Were you tested for legionellosis? Record the location of the tower relative to fresh-air intakes, kitchen exhausts, leaves, plant material, or other sources of organic material that might contribute to the growth of the organism. Following a screening process, all employees who have been identified as having had pneumonia, or potentially having had pneumonia, during this period will be requested to undergo voluntary medical testing to detect evidence of Legionnaires' disease. Provide a way to drain water sumps when not in use, e.g., an electric solenoid valve on the sump drain. Most probably this will be a serological test to determine the antibody level of the individual. _______________, Name The samples should be stored at room temperature (20° ± 5°C) and processed within 2 days. to be performed to qualify the measurement of the temperature Eliminate dead legs when possible, or install heat tracing to maintain 50°C (122°F) in the lines.