Legionellosis Dean Bodager RS CFOI DAAS MPA Central

Legionellosis Dean Bodager, RS, CFOI, DAAS, MPA Central Florida Regional Environmental Epidemiologist Kimberly Stockdale, MSPH Southwest Florida Regional Environmental Epidemiologist July 27, 2018 FLORIDA DEPARTMENT OF HEALTH BUREAU OF EPIDEMIOLOGY FOOD AND WATERBORNE DISEASE PROGRAM DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Overview § Legionella Basics § Outbreaks § How Cases are Reported to the Florida Department of Health (Department) § Epi Data § Department Protocols § Facilities at Risk § CMS Memo § Sampling Plan and Protocols § Exercises § Questions DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Legionella Bacteria § Gram-negative § Fresh water and soil are its natural environment § 80 known species and 70 serogroups § Legionella pneumophila is only known species to cause human illness DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Biofilm Formation Process DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Biofilm DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

L. pneumophila Multiplying Image from http: //phil. cdc. gov/phil/home. asp DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Optimal Growth Conditions § Warm water temperatures between 68ºF to 122ºF (20ºC and 50ºC ) § Stagnant water § Low biocide levels § Bulk water p. H in the range of 5. 0 to 8. 5 § Sediment, scale, deposits, biofilm § Other microbes present including amoebae and other protozoa, algae and other bacteria DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Legionellosis Legionnaires’ Disease: §Pneumonia, cough, shortness of breath, fever §Usually requires hospitalization and antibiotics Pontiac Fever: §No pneumonia §Milder symptoms that clear on their own DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Route of Entry §Invisible water droplets less than 5 microns in size §Droplets must be inhaled deep into the lung and reach the alveoli Image from http: //phil. cdc. gov/phil/home. asp DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Outbreaks § 1976: Philadelphia, PA outbreak of pneumonia at American Legion Convention § 182 cases, 29 expired § Annual 3 day convention of the American Legion at the Bellevue -Stratford Hotel § Legionella bacterium was identified and isolated in hotel’s cooling tower Source: ww. cdc. gov/legionella/index. html DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Outbreaks § Bronx, NY 2015 ◦ 124 cases, 12 deaths ◦ Matched strain found in historic Opera House Hotel’s rooftop cooling tower with 25 patients ◦ NY City passed legislation requiring registration/inspection of all cooling towers DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Outbreaks § Flint, MI, June 2014 and May 2015 ◦ ◦ ◦ Previously switched from Detroit water to the nearby Flint River Switch a “likely trigger contributing to increase in LD incidence” City treatment plant did not control water’s corrosiveness – iron leaches Iron - micronutrient for the bacteria, inactivates chlorine Researchers from Virginia Tech tested water from homes and businesses ◦ (compared homes and hospitals with Flint River water to nearby businesses using Detroit water) Flint River water Detroit water Iron High levels, 51 ppb No iron Chlorine >1/2 of the homes had no detectable chlorine Legionella bacteria 7 x higher than baseline surveys None detected Source: Chemical & Engineering News https: //cen. acs. org/articles/94/web/2016/07/Legionnairesoutbreaks-Flint-linked-corrosive-tap. html DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Outbreaks § Venice, FL February 2018 § Sarasota CHD notified of 5 cases of legionellosis (positive urine antigen) of residents within a Venice community, at least two of which with exposure to community whirlpool spa § EH performed a routine environmental inspection of whirlpool spa and found adequate chlorine and p. H levels. Due to the investigation, EH did close the whirlpool spa. Once Sarasota CHD notified management of the cases within the community, the management chose to close the two community pools Ø 13 confirmed cases – all positive urine antigen tests for Legionella pneumophila serogroup 1 Ø 7 suspect cases § Ca. Co results show resort and whirlpool spa as significant exposures DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Legionellosis Reporting § Nationally notifiable disease since 1976 § Reportable disease in Florida since 1978 ◦ Florida Administrative Code Chapter 64 D-3. 029 – lists reportable conditions ◦ Florida Administrative Code Chapter 64 D-3. 030 – practitioner notification ◦ Florida Administrative Code Chapter 64 D-3. 031 – laboratory notification ◦ Florida Administrative Code Chapter 64 D-3. 030 – medical facility notification § The Department receives the positive laboratory results and investigation ensues to determine demographic information, severity of illness, exposures (identify potential source) and determine if individual is part of larger outbreak DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Travel-Related Cases § Travel 10 days prior to onset of symptoms ◦ Record accommodation name, address, room number and dates of stay § If travel outside of Florida ◦ Reported to CDC Travel group to help identify travel-related cases in other states § If travel within Florida ◦ Information is recorded in Florida-specific tracking system DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Legionellosis – National Data DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Cases of Legionellosis and Incidence Rates, Florida 2007 -2017 Florida Residents Cases Rate 500 2. 50 400 2. 00 300 1. 50 200 150 100 0. 50 50 0 2007 2008 2009 2010 2011 2012 Year 2013 2014 2015 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 2016 2017 0. 00 Rate per 100, 000 Number of Cases 350

Florida Legionellosis 2016 Data DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Number of Legionellosis Outbreaks, Cases, and Deaths, General Vehicle 2012 -2016, Florida Deaths Cases Outbreaks WATER-RECREATIONAL WATER-OTHER WATER-DRINKING 0 10 20 30 40 50 60 WATER-DRINKING WATER-OTHER WATER-RECREATIONAL Outbreaks 24 7 4 Cases 60 11 10 Deaths 2 1 0 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Number of Legionellosis Outbreaks, Cases, and Deaths Facility Site 2012 -2016, Florida Deaths Cases Outbreaks SPA PRISON OTHER NURSING HOME HOSPITAL 0 5 Outbreaks Cases Deaths HOSPITAL 10 NURSING 15 HOME 20 OTHER 25 PRISON 30 35 SPA 4 15 12 2 2 8 37 30 2 4 DIVISION OF DISEASE PROTECTION 0 3 CONTROL & HEALTH 0 0 0 40

Number of Legionellosis Outbreaks and Cases Other Facility Sites, 2012 -2016, Florida Cases Outbreaks RV RESORT HOTEL CONDO HOTEL CAMP APARTMENT COMPLEX 0 5 10 15 20 APARTMENT COMPLEX CAMP CONDO HOTEL RV RESORT Outbreaks 1 1 1 8 1 Cases 2 20 4 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Number of Legionellosis Outbreaks, Cases, and Deaths Vehicles by Facility Site, 2012 -2016, Florida Deaths Cases Outbreaks 8 7 6 5 4 3 2 1 0 5 10 15 20 25 30 35 1 2 3 4 5 6 7 8 Outbreaks 4 12 3 6 4 2 2 2 Cases 8 34 3 16 8 6 2 4 Deaths 0 2 1 0 0 0 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Number of Legionellosis Outbreaks and Cases Vehicles by Other Facility Site, 2012 -2016, Florida. Cases Outbreaks 6 5 4 3 2 1 0 2 4 6 8 10 12 1 2 3 4 5 6 Cases 2 2 2 12 8 4 Outbreaks 1 1 1 4 4 1 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Environmental Assessment §Two scenarios trigger a full environmental assessment of a facility: ◦ Single case of health care or other facilityassociated legionellosis if the case spent entire incubation period in that facility ◦ An outbreak: two or more cases that have an identified common place of exposure within the previous 12 months DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Requirement to Reduce Legionella § June 2, 2017 § Centers for Medicare and Medicaid Services DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Environmental Assessment §Objectives: ◦ Determine the most likely source(s) of Legionella bacteria ◦ Provide recommendations on the necessary steps to prevent biofilm development and Legionella colonization from occurring ◦ Provide guidance and resources regarding a water management program DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Gather Our Team §Epidemiologist §Pool/spa specialist §Regional environmental epidemiologist §Agency of jurisdiction inspector §Industrial hygienist §Engineer DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Prepare for the Assessment §Gather known epidemiologic data and determine the date of exposure period §Establish a detailed timeline in relation to possible exposure locations and activities §Create a working outbreak case definition that considers person, place, and time factors DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Check In @ Hotel A & sat in Spa Day -10 6/21/15 Day -10 6/2/15 Day -9 6/22/15 Day -9 6/3/15 Day -8 6/23/15 Day -8 6/4/15 Day -7 6/24/15 Day -7 6/5/15 Example Exposure Timeline Day -6 6/25/15 Day -5 6/26/15 Check In @ Hotel A Sat in Hotel A Spa Day -6 6/6/15 Day -5 6/7/15 Day -9 6/19/15 Day -8 6/20/15 Day -4 6/27/15 Day -3 6/28/15 Day -2 6/29/15 Day -1 6/30/15 Check Out Hotel A Day -4 6/8/15 Day -3 6/9/15 Day -2 6/10/15 Day -7 6/21/15 Day -6 6/22/15 Day -5 6/23/15 Day 0 7/1/15 Case # 616161 Symptom onset date Day -1 6/11/15 Sat in Spa & Check Out Hotel A Check In @ Hotel A Day -10 6/18/15 Symptom onset date Check Out Hotel A Day 0 6/12/15 Case # 565656 Symptom onset date Day -4 6/24/15 Day -3 6/25/15 Day -2 6/26/15 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION Day -1 6/27/15 Day 0 6/28/15 Case # 202020

Prepare for the Assessment • Review CDC materials • • Environmental Investigation Videos CDC Sampling Procedure and Potential Sampling Sites Legionella Environmental Assessment Form Sample Data Sheet www. cdc. gov/legionella/outbreak-toolkit Determine municipal water system disinfectant • • Chlorine or Monochloramine test kit DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Building Water Systems §Temperature §Disinfectant §Water recirculates §Biofilm layer of piping §Water heater/storage tank maintenance §Dead legs in plumbing design §Showers and faucet design and maintenance DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 52

Non-recirculated system – cold water supply DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 53

Recirculation System Design DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 54

Plumbing Design “ DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 55

Obvious Maintenance Problems DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Hot Water Heater DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 57

HVAC Systems and Air Sampling §Not normally amplification sites §Legionella cannot survive without water §Possible external or internal sources ◦ Water can be drawn into a system’s fresh-air intake ◦ Water can leak from pipes into HVAC ducts §There are no reliable methods to sample and test for nonviable Legionella in the air DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 58

HVAC Systems Conditions §Fresh-air intakes §Air handling unit ◦ Drain lines ◦ Drip pan buildup and standing water §Review maintenance procedures with facility staff DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 59

Cooling Tower §The smaller the water droplets, the more efficient the cooling §Maintenance §Location §Disinfectant §Water temperature DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 60

Cooling Tower Design DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Cooling Tower Drift DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 62

Spa/Whirlpool/Hot Tub §Jets aerosolize water droplets §Temperature §Disinfectant §Maintenance DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 63

Decorative Fountains DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 64

Other Possible Sources DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 65

Where to sample? §Develop a sampling plan as a team before any samples are collected. §Do not conduct random, undirected sampling of air, water, and environmental surfaces in suspected facilities. §Any and all environmental sampling, along with the environmental assessment, should be directed by the epidemiology case(s) exposure data. DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 66

Where to sample, continued? § Hot water systems/Cold water side-temperature ◦ Closest, middle, and farthest points in relation to the entry point and hot water heaters ◦ Unoccupied areas of the building ◦ Hot water heater drain or returning water line § Cooling towers ◦ Exit/overflow port or collection basin § Whirlpool spas ◦ Filter backflush, jets, or water line DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 67

What to test for? §Temperature §Disinfectant residual §p. H §Bacteria culture ◦ Legionella spp. ◦ Heterotrophic bacteria DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 68

Assessment Form § Legionella Environmental Assessment Form § https: //www. cdc. gov/legionella/downloads/legionellaenvironmental-assessment. pdf § Environmental Assessment Video DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Sampling Plan § https: //www. cdc. gov/legionella/downloads/legionella-environmentalassessment. pdf § https: //www. youtube. com/watch? v=xe. Fa 2 P 2 rdd. E § Use the team approach § Let Epi data be the guide § Include EH data DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Safety – Hazard Identification ◦ Potential Hazards: ◦ Exposure to Legionella bacteria ◦ Slips, Trips, and Falls ◦ Electrical ◦ Overhead ◦ Exposures to cleaning or water treatment chemicals stored around cooling towers DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Safety – Hazard Mitigation ◦ Mitigating Steps ◦ Exposure to Legionella bacteria ◦ Engineering Controls ◦ PPE ◦ Slips, Trips, and Falls ◦ Non-slip shoes, pay attention to wet areas ◦ Electrical ◦ LOTO ◦ Overhead ◦ Hard hat ◦ Exposures to cleaning or water treatment chemicals stored around cooling towers ◦ Goggles, gloves, Aware of Surroundings DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Water Quality Parameters § What can residual disinfectant tell us? § p. H? § Maximum temp? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Whirlpool Spa CDC Video Sampling Spa and Fountains DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Hot Water Heaters DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Points of Use Potable Water DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Cooling Towers § Cooling Towers DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Recommended Action Levels • The OSHA Technical Manual offers the following guidelines for interpreting Legionella results. • Action 1: Prompt cleaning and/or biocide treatment of the system. • Action 2: Immediate cleaning and/or biocide treatment. Take prompt steps to prevent employee exposure. Action Level Cooling Tower/Evap. C ondenser Domestic Water Humidifiers/ Misters 1 100 cfu/ml* 10 cfu/ml 1 cfu/ml 2 1, 000 cfu/ml 10 cfu/ml * cfu/ml = colony forming units of Legionella per milliliter DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Recommendations § Recommend a Water Management Plan ◦ Sample results do not guarantee that water system is free of Legionella ◦ Resources to provide Ø CDC: a new Practical Guide for Developing a Water Management Plan to Reduce Legionella Growth and Spread in Buildings Ø ASHRAE: Guideline 12 -2000 Minimizing the Risk of Legionellosis Associated with Building Water Systems Ø ASHRAE: Standard 188 -2015 framework for proactively managing building water systems and reducing the potential for Legionella colonization of these symptoms § Post environmental assessment ◦ Send recommendation letter Signed by appropriate person and CHD letterhead DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 1 • On October 7, 2015 the Epidemiology Program was notified of a positive lab of Legionella pneumophila serogroup 1 antigen in urine. • Interview revealed: • • The 70 -year-old female reported frequenting visiting Crisscross Fitness Center during the exposure period with no other reported relevant exposures. Exposures at the gym include the hot tub and shower in the women’s locker room. § What next? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Single Sporadic Case 1. Possible exposure facilities may be notified. 2. Facilities' regulatory agency may be notified. 3. If there was exposure to a spa, inspection can be conducted to ensure compliance. DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 1 • On October 22, 2015 the Epidemiology Program investigated another case. • A 33 -year-old female case who also visited Crisscross Fitness Center during the two weeks prior to her illness onset. • Exposures included the hot tub and shower facilities. • Now what? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Environmental Assessment Two scenarios trigger a full environmental assessment of a facility: 1. Single case of health care-associated legionellosis if the case spent entire incubation period in that facility 2. An outbreak: two or more cases that have an identified common place of exposure within the previous 12 months DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 1 • I’m the facility manager – what questions do you have? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 1 • Fitness club has: • • • 2, 014 -gallon hot tub with a cartridge filter. 51, 387 -gallon indoor swimming pool with a high rate sand filter. Male and female showers in locker rooms. No cooling towers associated with the air conditioning functions of this facility. No other water features or fountains are located on the property. DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 1 Testing Results Sample site Location in system Pre/Post flush Temp Chlorine p. H Hot tub 104 ˚F 1. 0 ppm 8. 2 Pool 85 ˚F 10. 0 ppm 8. 2 Women's shower Distal Pre flush 80 ˚F 0. 5 ppm 7. 2 Women’s shower Distal Post flush 120 ˚F 0. 2 ppm 7. 1 Heater Post flush 140 ˚F 0. 6 ppm 7. 1 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 2 • On March 27, 2014, the Epidemiology Program was notified of a positive lab of Legionella pneumophila serogroup 1 antigen in urine. • Interview revealed: • • An 87 -year-old female resides in an adult living facility (ALF) with an illness onset of March 16, 2014. Did not leave ALF 10 days prior to onset. Only exposure is showering in her room. What do you do? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Environmental Assessment Two scenarios trigger a full environmental assessment of a facility: 1. Single case of health care-associated legionellosis if the case spent entire incubation period in that facility 2. An outbreak: two or more cases that have an identified common place of exposure within the previous 12 months DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 2 • Our Time ALF consists of one building built in 2010, has four levels, and is over 200, 000 square-feet. • The total number of rooms that can be occupied overnight is 185 (total overnight capacity is 261). • Next steps? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 2 • I’m the facility manager – what questions do you have? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 2 • Room number of case • Floor plan • Recent construction • Maintenance plan • Hot water heater setting §Where do you want to take water samples? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 2 §Testing Results Sample site Location in system Pre/Post flush Temp Chlorine p. H Heater 1 Heater Post flush 120˚F 1. 0 ppm 7. 2 Room 102 Proximal room Pre flush 85 ˚F 0. 0 ppm 7. 1 Room 102 Proximal room Post flush 112 ˚F 0. 8 ppm 7. 2 Room 402 Distal room Pre flush 87 ˚F 0. 0 ppm 7. 1 Room 402 Distal room Post flush 104 ˚F 0. 6 ppm 7. 1 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 3 • On 12/13/2014, the Epidemiology Program received a travelassociated legionellosis notification from CDC. • 71 -year-old female resident of Pennsylvania who stayed in Vacation Villas, Building 502 from 11/18/2014 to 11/25/2014. • Onset of symptoms was 11/29/2014. • Used hot tub, swimming pool, and shower. • What do you do? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 3 • On 1/25/2015, the Epidemiology Program received a travelassociated legionellosis notification from CDC. • 61 -year-old female resident of Virginia who stayed in Vacation Villas, Building 502 from 11/18/2014 to 11/24/2014. • Onset of symptoms was 11/21/2014. • Used hot tub, swimming pool, and shower. DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 3 • Vacation Villas is a large resort located on the Gulf of Mexico • Five multi-story buildings each with a cooling tower and decorative fountain • One hot tub • One swimming pool • Where do we start!? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 3 • I’m the resorts facilities manager – what questions do you have? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 3 • Cooling towers and HVAC system • Decorative fountains • Pools and hot tub records • Hot and cold water systems DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Practice Exercise 3 §Testing Results Sample site Location in system Pre/Post flush Hot tub 502 Cooling tower Roof 502 Fountain Lobby Temp Chlorine p. H 102 ˚F 0. 5 ppm 8. 2 89 ˚F 0. 0 ppm 7. 1 85 ˚F 4. 0 ppm 7. 5 502 -Case 1 room Middle Pre flush 87 ˚F 0. 0 ppm 7. 1 502 -Case 1 room Middle Post flush 122 ˚F 1. 6 ppm 7. 1 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Sampling Plan Exercise § Known Information ◦ Six confirmed cases (urine antigen positive) in Skilled Nursing Facility § What would you ask facility? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Premise Plumbing DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Water Quality Parameters DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Fountain Water Quality Parameters DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Case/Visitor Patient Rooms DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Conclusions ØLobby Fountain ØEH assessment looked for contributors to Legionella growth ØLobby fountain contained incandescent lighting ØLobby fountain water was 93ºF, well within 68ºF-122ºF range in which Legionella can live and grow and close to the optimal growth range of 95ºF-113ºF ØDisinfected on 1/31 and removed from site 2/7 ØResident and visitor rooms ØAll within the same quadrant as lobby fountain ØFive on first floor and one on third ØMain Check-In and Out next to lobby fountain ØFour checked in in January except for two – one of which had checked in and out for a doctor’s apt in Jan. DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Recommendations ØRecommended a water management plan ØNo guarantee that water system is free of Legionella ØResources provided Ø CDC: a new Practical Guide for Developing a Water Management Plan to Reduce Legionella Growth and Spread in Buildings Ø ASHRAE: Guideline 12 -2000 Minimizing the Risk of Legionellosis Associated with Building Water Systems Ø ASHRAE: Standard 188 -2015 framework for proactively managing building water systems and reducing the potential for Legionella colonization of these symptoms ØFacility to continue with surveillance ØAny patients exhibiting symptoms should have a urine antigen test performed ØFL DOH-Lee should be notified of any patients undergoing Legionella tasting and of any positive results DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Prevention Key Steps § Develop water management program ◦ Trained and experienced consultant or personnel ◦ One plan will not fit all facilities § Follow water management program § Documentation, documentation ◦ Controls put in place ◦ Corrective actions taken when lapses occur § Make defensible decisions § DOH will conduct investigation and assessments when outbreaks are reported per our protocols DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Resources § Centers for Disease Control and Prevention: Legionnaire's Disease (LD) and Pontiac Fever Home: http: //www. cdc. gov/legionella/index. html § American Society of Heating, Refrigeration & Air-Conditioning Engineers Legionellosis: Position Document http: //www. ashrae. org/aboutus/page/335 § OSHA Technical Manual, Chapter 7 - Legionnaires' Disease: ◦ http: //www. osha. gov/dts/osta/otm_iii/otm_iii_7. html § US DOL, OSHA Safety and Health Topics - Legionnaires' Disease: http: //www. osha. gov/SLTC/legionnairesdisease/index. html § US EPA Legionella Drinking Water Fact Sheet: http: //www. epa. gov/waterscience/criteria/humanhealth/microbial/legionell afs. pdf § Florida Department of Health Legionellosis information: ◦ http: //www. floridahealth. gov/diseases-and-conditions/legionnairesdisease/index. html DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Dean Bodager, RS, CFOI, DAAS, MPA Kimberly Stockdale, MSPH Regional Environmental Epidemiologists Bureau of Epidemiology Florida Department of Health Dean. Bodager@flhealth. gov Kimberly. Stockdale@flhealth. gov DIVISION OF DISEASE CONTROL & HEALTH PROTECTION

Thank you for your attention and participation! Questions? DIVISION OF DISEASE CONTROL & HEALTH PROTECTION