The following transcript is provided by YouTube. Mistakes are present. To hear the podcast episode, click HERE.
[Music]
welcome to scaling up sub podcast for water treatise by water treaters where
we’re scaling up on water treatment knowledge so we don’t scale up our systems hi everybody I’m trace Blackmore
the host of scaling up I am super excited about today’s show because
today’s show is something that most of us miss understand we don’t know how to
The L Word
talk to our customers about it and we simply don’t know what the right information is and where to go find it
we’re talking about the l word today yes I said it the l word I’m even going to
say the real word Legionella today’s show is all about Legionella we’re going
to get to the bottom of what Legionella is what we need to know about it how we explain it to our customers and how we
get everybody working together towards a common goal the reason I call it the l
word and the reason this show is entitled the l word is because I think the story where I got the l word really
explains the entire issue and why we’re talking about it today I had a client
that told me under no circumstances were I ever allowed to say the word
Legionella and her building I had to say
the l word because if somebody overheard us talking about Legionella they were
gonna come out of the woodwork and file a lawsuit on her miss understanding
Legionella is what is going on here folks and we are going to talk about it
today through education we can make better decisions about Legionella and
our customers can make better decisions about it so we’re going to make sure we understand the l word we’re gonna talk
about all topics around Legionella what’s a guideline versus a standard what are all these different documents
that are out there what do they mean what do they say that we have to do and who has to do them
how do we use all this information to educate our customers so they’re not
just simply pointing the finger at us and saying that’s your problem you take
care of it how do we all work together and take care of it as a team how do we
test what do we test what do we do when we get a positive test back how do we interpret all this stuff we’re going to
talk about that and more because we have the world renowned expert on Legionella
dr. Janet stout of special pathogens laboratory as our guest today folks she
literally wrote the book on Legionella and she’s gonna talk about everything
that we should know about Legionella and at the end of today’s show you’re gonna
be armed with knowledge to go out and educate on what people need to know and
do about Legionella we all know knowledge is power so let’s get started
with our interview with Janice Tao my lab partner today is dr. Janet stout and
Dr Janet Stout
I’m so privileged to have Jenna stout on the show today because as I said in the
intro she has literally written the book on Legionella Janet are you ready to let
the world the scaling-up nation know what Legionella is and what we should do
about it well I’m just thrilled to have the opportunity trace and I’d have you as a lab partner any day I love it thank
you very much well Jenn one of my favorite things that you have given me over the years besides all the great
information are the Legionella chill pills I just enjoyed a few before we
entered into this conversation and I think that is the coolest marketing theme I think it says take to Legionella
chill pills and they’re they’re minty fresh mints and call you in the morning after Legionella testing so my goal for
this show is at the end of this show we give everybody in the scaling-up nation
some audible chill pills because they now have knowledge to go out and understand the
l-word Legionella I think that’s a great goal and there is tremendous anxiety around
this both among the water treatment professionals as well as their clients in the general public so I think that’s
a fantastic goal all right I said you know you literally wrote the book on
Legionella but I can’t do justice to who you are in the Legionella community do
you mind sharing with our listeners basically who you are and what you do sure so I say that I’m I’m not old I’m
experienced and usually when I give lectures I’d like to introduce myself by showing the first publication that I had
on Legionnaires disease which was published in 1982 in the New England Journal of Medicine and that was the
result of my master’s thesis with dr. Victor U at the Pittsburgh VA hospital
so where Legionnaires disease was discovered after the Bellevue Stratford hotel outbreak and where the American
Legion convention was held in Philadelphia in 1976 and I started my
research in Legionnaires disease in 1980 so not too long after the discovery of
the organism did I actually begin my studies of Legionnaires disease and and I don’t know if I picked Legionella or
Legionella picked me but we’ve been together ever since and Legionella just celebrated its 40th
birthday last year so I’ve been studying it a long time and and that wealth of
information on the environmental side the the clinical diagnostic side and
understanding how the disease is transmitted and all that experience from over those years is what I like to share
with people like your audience because that’s who we are at special pathogens laboratory where the Legionella experts
and that expertise comes from studying the organism for a long time you know
sort of technically I have a masters and a PhD in infectious disease microbiology
from the Graduate School of Public Health here at the University of Pittsburgh and a bachelor’s degree from
Clarion University so lots of education but more most importantly I think is the
knowledge that I’ve gotten over all these years down there in the tank room or have my head in the cooling tower
that’s where you really learn the information that your audience is really interested in well great well let’s
let’s just get into it what the heck is Legionella well Legionella is a bacteria we talk
about Legionella generically you know just with that L word as you said Legionella but actually it’s part of a
pretty large family more than 58 members of that family or species and the
original outbreak that we all heard of in 76 was caused by one member of the Legionella bacterial family called
Legionella pneumophila zero group one and to this day that organism is
responsible for the majority of infections that we see that are caused by Legionella bacteria and the infection
is principally pneumonia so it’s bacterial pneumonia caused by Legionella
and what’s really kind of interesting is that the symptoms of Legionnaires disease are really no different than the
symptoms of other forms of bacterial pneumonia so when you let’s say you had Legionnaires disease and you went to see
your family physician and they listened to your chest and they say yeah I’ve got some fluid in there and they take your
temperature and yes you have a high fever usually about a hundred and two or 103 you’ve got pneumonia but unless that
physician thinks to test you specifically for Legionella usually with a urine antigen test they won’t know you
have Legionnaires disease and in fact many many cases of Legionnaires disease go undiagnosed because the physicians
not thinking about Legionella and the implications of that is the choice of
the antibiotic that you’re treated with because Legionella is not going to be killed by all types of antibiotics and
in fact some of the more common ones like penicillin or cephalosporins are completely ineffective in the treatment
of Legionnaires disease so you want that doctor to make the diagnosis test you for it and then treat you with either
levofloxacin or as a throme Ison so it’s a very very treatable form of bacterial
pneumonia if the diagnosis is made and if the antibiotic is effective and selected for treatment
so that’s what Legionnaires disease is well what are some of the signs when somebody contracts that well typically
it’s a very very high fever it’s not unusual for people with Legionnaires disease to have a hundred and two to 104
degree fever the cough is dry they may have diarrhea so that’s why these these
sort of symptoms are nonspecific and common to other forms of infection and that’s why it can be a cause of death
because if there’s a delay in treatment even of a few days it dramatically
increases the chance of death and compared to other bacterial infections people are more likely to die of this
infection particularly if they’re in the hospital so if you get Legionnaires disease out in the community the chance
of death is about 10 to 15 percent but if you’re unfortunate enough to get Legionnaires disease while you’re in the
hospital for something else the chance of death could be as high as 30% so it’s really really important for that
antibiotic treatment to start early can anybody give Legionella well that’s a
great question you know one of the reasons that a doctor might not think of Legionnaires disease when they’re
treating you with your pneumonia is because there’s an this idea that Legionnaires disease only happens in
people who are already sick with various diseases like diabetes or chronic lung
disease and and people might be on high doses of corticosteroids so there’s kind
of a preconceived notion that only sick people get Legionnaires disease but our studies and others have shown that about
25% of the cases of Legionnaires disease have none of those risk factors they’re
not a smoker they don’t have diabetes they don’t have chronic lung disease you know they’re not a transplant recipient
or otherwise immuno compromised so there’s there’s a wide spectrum of
individuals that get Legionnaires disease there is a tendency for older
people to get Legionnaires disease and the statistic is most cases are older
than 50 and I sort of took umbrage with that because I don’t think 50s that old what do you think Trey
I’m getting close so I agree so what can
a water tree to do about this well you know historically the water treatment
professional has only been asked to address general microbial fouling in a
cooling tower and they’ve attacked the cooling tower and the bio side program with that purpose in mind and their
clients have really only asked them to do that to improve heat exchange and and
efficiency so they’re not their clients the water treatment treaters clients have not historically been asking them
to provide a Legionella control and management program but that is changing
and there are a number of standards and and other requirements now that make the
client really be required in some instances to address Legionella in the
cooling tower so I think an important role of the water treatment professional is to make those clients aware of those
new requirements and to gently encourage them to follow them and I think most
people when when they understand the exposure they have I mean exposure in
two ways one exposing themselves or their patients or their workers to the
risk of Legionella in a cooling tower or water distribution system but I also mean exposure to litigation so in in
some ways that’s the other l word that’s applicable here litigation Legionnaires
disease is highly litigated lots of lawsuits so the chance if something
happens that the person will be sued is very very high and I find sadly
sometimes that’s a bigger motivator than public health so I think the water
treater in addition to applying water treatment that’s an effective program for overall microbial control as well as
Legionella their role is really education well I know that the conversation between the water treater
and the end-user building owner manager what have you is it could be better in most
cases and it’s probably not said in the best way that it could because nobody really knows what to inform the other
party to do in fact I actually received a bid specification a couple weeks ago
and it said that in order to comply with the specification the water treater had
to bring the entire building in compliance with ANSI ASHRAE 188 2015 or
higher so I think that just goes to show how you know the clients as well as the
water traders truly don’t understand what these documents are that state what
we’re supposed to do and how to deal with them and I say water treaters didn’t understand that because I know
water treaters actually bid on that not knowing what they were asking for so I
have a couple of questions built around that setup one what should we be saying
in that conversation with that owner or manager and then how do we lead that in
to the guidelines and standards that we have available to us today well those
are great questions I think what you say to the owner is things have changed
dramatically in terms of industry standard for management of building water systems and that’s both the
potable water water distribution system within the building as well as the utility water which is generally
speaking the cooling tower and what they need to understand about standard 188 which came out in 12 2015 and that’s the
title of that standard is legionellosis risk management for building water systems so it’s not just cooling towers
as you as that bid specification indicated it’s it’s both potable and utility water systems and so what you
want to be telling the end-user is that the standard is very specific about the
overall approach to implementing that risk management plan
and the responsible party for doing that assessment and implementing that plan is
the building owner and there are various steps in complying with standard 188 and
the first is really doing a survey of the building water systems do you have cooling towers and if you do
have cooling towers that checks a box that you need to have a risk management plan for the cooling tower do you have a
building that houses at-risk individuals for example a medical center that means
check that box you need to have a risk management plan for the building both
the potable water and the cooling tower because both of those present risks to
the building occupants so I think it’s really important to make clear who is responsible and I think for the water
treatment professional to convey that either they or in partnership with others can provide what is necessary to
meet those new industry standards I mentioned that it came out in June of
2015 and there’s been kind of a slow adoption and in part because it’s a
voluntary standard so that’s not yet been adopted into code except in
regulations in New York City in New York State because of the Bronx outbreak
which implicated a cooling tower and affected approximately 130 individuals
and and there were a number of deaths the outcome of that was regulations for
the state in New York and the city of New York so if any of your listeners are in New York they should pay particular
attention because New York is the first to have a law a regulation that requires
the building owner to do some very very specific things so the the point here is
really education informing the end-user kind of what they should be doing and
why they should be doing it both in terms of the health benefits in risk
mitigation for exposure to Legionella and risk of Legionnaires disease but also I think real
strongly emphasized that compliance is a safe harbor for the institution against
claims of negligence so compliance with ASHRAE 188 can be
looked at as a good thing for the institution to do and and spend their money on to protect the reputation and
also protect them from from liability so those those are the things I think the
reasons and the emphasis for the water treat are to be communicating to the
end-user I think it really also means that the water treatment professional
needs to be educated themselves and there are a number of places where they can get information you can in fact go
to the ASHRAE website and read the standard for free if you want to buy it and get a print copy or an electronic
copy they want some money but you can read it for free so you can educate yourself in that way
we here at special pathogens laboratory have a very very strong focus on education and so on our web-site special
pathogens lab comm and the resources tab is a treasure trove of information for
example there’s a table that has all of these guidelines and standards listed
there that you can click and look at them including the association of water technologies the AWT guideline the
cooling technology institute guideline some information from ourselves on
cooling tower control strategies so lots and lots of information there and also
after the standard came out from ASHRAE which for those of you that may not be familiar used to stand for the American
Society of heating refrigerating and air-conditioning engineers and now they just go by ASHRAE but that’s the
institution that created the standard 188 for Legionella management so there’s
there’s a tremendous amount of information available to you and and I think it’s really important to be
educated after ASHRAE came out in terms of Education the Centers for Disease
Control and Prevention CDC put together what they call a toolkit
and that’s also free and on the CDC website and really the purpose of that was kind of a simple way to introduce
people to the requirements that were being put out by ASHRAE standard 188 and
to help orient people in simple languages to the purpose of these standards in the risk management
approach so there’s a lot of good information there from CDC as well you spoke a lot about ASHRAE 188 and if
ASHRAE 188
somebody has not read the document in a nutshell what does it say well in a
nutshell what this standard is is a risk management approach to you know
controlling the risk that we have in built in building water systems to
exposure to Legionella if Legionella growth is unchecked and that risk is
where water is Legionella is a waterborne bacteria so you’re not going
to find Legionella on dry surfaces so within buildings there are certain water
features the presence of water particularly warm water distribution
systems that have historically been linked to cases of Legionnaires disease
so hot water distribution systems cooling towers decorative water features
humidification things that generate aerosols of bacteria so these these
devices in these water systems are the target for management in standard 188
and what you what you’ll find in standard 188 is kind of a high-level
approach it requires the organization to have a water management team so there’s
a number of individuals that have knowledge of the water systems as well as knowledge of Legionella and infection
prevention for example in a hospital they would be members of the team and sometimes that team includes the water
treatment professional as well the next step is to walk through the building
write down what happens to the water as it flows through the building and create
what’s called a flow diagram so it’s kind of a high-level box and line drawing of the water as it goes through
the building and then you evaluate conditions throughout the building that
may increase the probability of Legionella growing there and then you describe what kind of controls you can
put in place to make sure that that condition keeps Legionella under control
and then if by chance you would detect Legionella in that system you define
corrective actions so if you have something that’s not within the control limits what are you going to do
that’s all described in the water management plan and then most importantly is the piece called
confirmation so there’s two parts of confirmation one is that the plan itself
is being followed as it was designed but more importantly that the hazard of
Legionella has been controlled by implementing this plan and the only way
and I’m going to say that again the only way that you can confirm that Legionella is under control is to test specifically
for Legionella there are no surrogate substitutes you can’t use temperature
because the temperatures that control Legionella are above 140 degrees and
most systems aren’t operating that hot because you’d have scalding problems so temperature is not a surrogate pH isn’t
a surrogate heterotrophic plate count bacteria is not a surrogate so you cannot use those to inform yourself
about whether Legionella is present or absent and whether the risk is controlled so that piece of confirmation
is really really important and then finally it calls out the need for
documentation that you have measured these or monitored these control
locations you have addressed whether those that monitoring result is within the limits that you’ve specified and
then that corrective actions have been implemented and I think what I think
their listeners should really kind of get a feel for is that there’s a lot of freedom within standard
188 for you and the end user to make lots of decisions for example the water
management team decides where they’re gonna test for Legionella how often
they’re going to test and in fact whether they’re going to test there’s no requirement in standard 188 to test for
Legionella but you will find within the standard kind of a little bit of a warning like if these conditions exist
you probably really should be testing for Legionella and the reason there’s no you shall test for Legionella in
standard 188 is it was a big committee about 30 people and getting consensus
around a contentions contentious issue like that is very difficult but certainly I would recommend it for the
reasons that I’ve already stated so the good news I say is that there’s a lot of freedom for the people developing this
water management plan for the facility so you get to make lots of decisions and then I say the bad news is you get to
make lots of decisions so there’s a tremendous amount of responsibility there in part I think that’s why there’s
a team nobody wants that hot potato all to themselves now for some reason even
Cooling Tower
after all of that people just latch on to the cooling tower portion of that why
is that that’s a great point my after all these years my take on that is that
managing bacterial Legionella in a cooling tower is easier and it’s easier
in two ways so you’ve got this cooling tower basin of water and you can just
add more chemical or add a different biocide and there aren’t a lot of
restrictions on how much you can add so you can do a pretty good job of
controlling Legionella in that confined space of the basin when you’re talking
about a water distribution system there are a lot of rules about what you can
put in the water to control bacteria and how much and the the organization making
those rules is the Environmental Protection Agency they have maximum levels of biocides
that are allowable and that is described in the Safe Drinking Water Act so there
are it’s a little bit because there are so many rules about that it’s more complicated and then it’s also more
expensive so for example if a hospital test for Legionella finds Legionella
pneumophila Sur Group one in their water either hopefully before there is a case we want people to be proactive and
monitor before cases occur or unfortunately after an outbreak occurs well then what’s called secondary
disinfection these are systems that are placed on primarily the hot water is my
preference because I prefer not to add a lot of chemical to the drinking water and Legionella is growing almost
exclusively in the hot water system so when you put these systems on and it can be additional chlorine it can be
chlorine dioxide it can be monochloramine it can be copper silver ionization or you can you know elevate
the temperature and do a heat and flush these systems of additional chemical injection are not inexpensive so people
have a tendency to not want to look in or kind of peek into that box of is
Legionella in my water distribution system because they’re they’re afraid of the cost but I I always want to help
people to put that cost in perspective so for example if you’re a medical center and you have transplant patients
bone marrow transplantation or a solid organ transplant patient cost hundreds
of thousands of dollars well you don’t want to lose any of those patients to Legionnaires disease so when you put it
into perspective on the cost of these things it’s really not that much well I
know New York was the first municipality to actually make that part of law
ASHRAE 188 but they only chose the parts that dealt with the cooling tower I’ve
attended some of your talks before and there’s so much Legionella found in
potable water why didn’t they just go for the whole thing well there’s two
parts to this story so just with New York City they implemented the regulation in New York
City in response to the Bronx outbreak if you recall in the summer July August of 2015
that outbreak occurred and there was a tremendous amount of pressure on the
public health authorities in the city to get the situation under control one of
the impediments to doing that is they couldn’t find the cooling towers to test
them to see which one may have been the source they ultimately tested hundreds
of towers finally identified the source it was a small cooling tower on a hotel
in the Bronx but what would have helped them is if they had known where to find
them and so what they implemented in the regulation was a requirement for cooling
towers to be registered so that they could find them should an outbreak occur again a requirement for cleaning and
disinfection of cooling towers on a regular basis so that the problems that
occurred and resulted in the outbreak theoretically wouldn’t occur again and then also required Legionella testing
every 90 days so that there’s feedback both to the owner and the water treatment provider how well is the
treatment controlling Legionella so the reason New York City’s regulation focuses on cooling tower is a direct
result of that outbreak now the state of New York followed suit in terms of the regular
their regulation applying to cooling towers but they added health care
facilities so in New York State healthcare facilities are required to
have a water management plan for their water distribution system and to test for Legionella in their water
distribution system on a regular basis so so New York State did take it a step
further so in your opinion do you think other municipalities will follow well I
hope so actually and I do think that once there is
a regulation that people in other states can implement as well without recreating
the wheel it makes it easier for that to be done and I know in the state of Connecticut there at least part of the
state of Connecticut they’re they’re about to do something like that early you mentioned there there’s a lot of
Standards
different protocols their standards there’s guidelines what’s the difference between all of those well so for a long
long time there was only guidance documents and in fact ASHRAE guideline
12 was published in 2000 and it had kind of like you might think about doing this
and it was actually a very very good document on general education about the various water systems that were
implicated in Legionnaires disease and what to do to manage them but it was a
guideline you know and in fact you know next week all of us on the standard committee are going to put the final
touches I think on an update to guideline 12 so that’s a coming attractions kind of commercial for
ASHRAE on guideline 12 but you know for example when I mentioned the litigation
word and I always try to have a little lawyer on my shoulder when I’m advising
our clients on Legionella water management because when you follow a
guidance document it’s good to do that but it when you kind of get to that
litigation stage and and the other side saying well they didn’t follow the guideline it doesn’t have as much
strength as the standard now so now when lawsuits are brought and they bring the
standard out and they say you didn’t follow that standard that’s a little bit of a stronger argument and harder to
defend against so again ASHRAE standard 188 it has kind of your roadmap for
implementing and creating a water management approach and program the
other documents that are out there other than the state of New York and the city of New York are also voluntary so the
it’s still good information you know the association of Water Technologies position paper on Legionella the cooling
Technology Institute guideline on Legionella and and those documents are also under revision currently are very very good information
and they have kind of guidelines on for cooling towers what to do in response to
certain concentrations of Legionella and heterotrophic plate count bacteria so that’s good information there’s actually
a long-standing standard from Australia because lots of other countries have had
these standards a lot longer than the United States that I like very much and that’s what is on our website for the
cooling tower control strategy and essentially what was adopted by New York
City and what I like about that is it’s guidance incremental changes and water
treatment based on logarithmic or tenfold changes in Legionella concentration so it’s very reasonable
you know one of the mistakes that’s been made in the past is you find a little Legionella and they go oh my gosh we
have to pour 50 ppm a free residual chlorine in our cooling tower and that’s
just not necessary and it causes tremendous damage to the cooling tower of course but it’s like a knee-jerk
reaction that’s when they should take some of those doctors tout children’s and relax a little bit because you don’t
have to react like that and so both in New York City’s regulation and in that
Australia New Zealand standard its incremental changes in water treatment not that 50 ppm shock dose now in
response to concentrations of Legionella that would be detected when you do your testing well just recently a memo came
out for the Center for Medicare and Medicaid Services that speaks directly around ASHRAE 188 and water management
plans and Legionella what exactly does that document say well that was like a
lightning bolt that went across the United States and it came out on June
2nd and was slightly modified on June 9th so the Centers for Medicare and Medicaid
for me it was out of the blue I didn’t know that this was coming and I think for hospitals it was out of the blue
now it came out with this memorandum and the title of it is requirement to reduce
Legionella risk in health care facility water systems to prevent cases and
outbreaks of Legionnaires disease and I think what’s important for your listeners because they’re going well
who’s affected by this and the facilities that are affected by this or
hospitals critical access hospitals and long-term care facilities where we see
lots and lots of cases of Legionnaires disease and the the requirements in the
CMS memorandum and this would all is what also got people’s attention were effective immediately so of course that
really caused some anxiety and the requirements as stated in the memo is
that CMS expects Medicare certified healthcare facilities to have water management policies and procedures to
reduce the risk of growth and spread of Legionella and interestingly other water
other opportunistic waterborne pathogens in building water systems and they go on
to say that you these facilities need to conduct risk assessment to figure out
where Legionella and these other organisms may be growing and spreading in the facility water systems they need
a water management program and this is where ASHRAE comes in and it says that
considers the ASHRAE industry standard and the cdc toolkit includes control
measures and measurements and then finally specify testing protocols to
verify and determine that you know you’re under control and so when I was
just at last week the National infection control conference everyone was abuzz
about this CMS requirement and particularly because it said it’s effective immediately
so though all of those healthcare facilities that your listeners perhaps have been calling on and asking them to
do Legionella testing to implement ASHRAE 188
I think you will now have their ear and if they if those facilities haven’t
heard about the CMS memorandum then you need to provide it to them because the
CMS surveyors will be citing them if they are not in compliance and and and
that gets their attention too now in the in the memorandum it says those facilities unable to demonstrate
measures to minimize the risk of Legionnaires disease are at risk of citation for non-compliance that
certainly gets people’s attention sure I know there’s the rumor going around that if a doctor takes any money from
Testing
Medicaid or Medicare they now have to come in compliance with this document is that true I would say that probably is
not true because the the memorandum says that the memorandum applies to hospitals
critical access hospitals and long-term care facilities not to individuals well
thanks for clearing that up do you mind if we shift our focus a little bit and talk about testing I’d love to talk
about testing I thought you might like to talk about let me just say something
philosophically about testing because this has kind of been a hot potato issue many people not wanting to do it so your
end-users get pushed back to the water treaters when they bring it up and sometimes water treaters are afraid to
bring it up because they they think that it’ll upset the end user the reason to
do testing for Legionella as I said earlier is it’s the only way to assess
the risk truly and one of the things that I’ve learned in testing facilities
and cooling towers is that not all of them have Legionella in them and and
this is one of the myths that I take every opportunity to dispel because what
people say is how Legion L is everywhere its ubiquitous there’s no point in testing for it and in fact Legionella is
not everywhere and when we look at surveys of hospitals or large buildings
depending on the study that you cite anywhere from 20 to 70 percent will be positive
so the rule of thumb is about half so it’s important particularly for a
healthcare facility to find out which half they’re in are they in the half that have Legionella and then also as
important is what kind of Legionella is in the water because not all Legionella
are equal in terms of their ability to cause illness we talked earlier about Legionella pneumophila serogroup one
being the primary disease-causing agent so that’s the one that the majority 80%
of cases are caused by Legionella pneumophila Serie Group one so that’s the one we’re most concerned about and
when you test a hospital water distribution system you get information right away that has an implication for
the physicians in the facility because if you don’t have syrup one in the water
that urine test is not going to be any good at detecting hospital-acquired
Legionnaires disease because that test is specific for Legionella pneumophila syrup one so if you have seer group six
and they’re using that urine antigen tests they’re going to completely miss those cases so there’s a immediate
benefit to the hospital for doing that testing of their warm water distribution system and then similarly with cooling
towers only about thirty to fifty percent are positive for Legionella and
knowing that information and generally speaking for a tower that’s operating
year-round it would be a quarterly test and you want to get that test done because it gives you feedback about
whether or not the biocide program needs to be adjusted you know a little bit higher dose or greater frequency and as
you very very well know the operation of a cooling tower is very different
depending on the time of year so during the high heat loads in the peak of the summer the amount of biocide and the
frequency of addition that was good back in April or May may not be good enough
in the beginning of August so you need that feedback to make that adjustment so
you know Legionella is not everywhere but you learn really really good
information about risk of disease and about how to treat the water by doing that testing
well let me play a couple of scenarios out with you so I’m a water treat my
customer to do Legionella testing and A+ comes back what do I do now don’t panic
and there’s another opportunity for those chill pills again it’s the common theme through the show yes so one of the
advantages and ways to manage the anxiety the advantage of the water management plan or program is that you
define what the corrective actions are going to be should you find Legionella so that’s usually broken down into kind
of as I mentioned before logarithmic so ten hundred thousand Legionella per
milliliter and the corrective actions when you have those results so the water
management plan really helps mitigate the anxiety because people know what to do when that occurs the most important
thing is that you know we’re not trying to have well maybe there’s a goal to
have you know a non-detect for Legionella but in my experience it’s virtually impossible so you’re going to
have a positive so you might as well have that conversation with the end-user right away and I think it’s important to
have those conversations before the testing is done to kind of adjust expectations so you talk about what
could happen there might be a positive it doesn’t mean that it’s the fault of the water treat or it just means that
adjustments to the program need to be made and the results of that test help you to know what those adjustments need
need to be so the letting the client know the end user know that having a
positive is is going to happen you have a plan to address that and that it’s not
it’s not a reflection on the poor water treatment it’s just the dynamics change
and so you need that feedback to help people to adjust those programs so the
goal here whether it’s ASHRAE 188 or if you’re in New York and it’s the regulation
or or CMS is to prevent the disease you know our job in what we’re doing here is
to prevent Legionnaires disease that’s our mission here at special pathogens it’s we call it end LD that’s the goal
not to have zero Legionella from a water distribution system because it’s virtually impossible so I’m having a
conversation with one of my customers and I convinced them to do Legionella testing I then have the conversation
that you know this could come back positive so what are we going to do if
it comes back positive between one and a hundred and hundred and a thousand and over a thousand and they say I have no
idea I don’t have that plan now what do we do well you say well let’s create that plan and the plan can be simple it
could just be you know like we have on our website the strategy which lays out
on one column of the table it has the concentration of Legionella recovered
you know ten hundred thousand and then the other column it says what to do now
if it’s less than ten just carry on if it’s higher adjust the concentration of
the bias ID the dose or the frequency if it’s higher than you do a more aggressive disinfection protocol so the
information is there in terms of a simple kind of what do we do to react to
a positive and then the other thing you can say well you know ASHRAE standard
188 although it’s a voluntary standard requires a water management plan to be
developed to address the risk in the cooling tower and I’m happy to help you
to devise that plan either you the water treatment on treater on your own or in
consultation with other experts we do that all the time we offer our expertise to the water
treatment professional to help them deliver that service to their clients so
it sounds complicated and it certainly I understand is can be anxiety provoking
but you know all of this activity and the DMS the ASHRAE 188 CDC toolkit has
really brought Legionella into the conversation in a way that it’s not been before so it’s pretty tough to not know
about some of this either all of it or part of it and that helps you the water treatment
professional have that conversation because I think in the past you know they were kind of like I don’t know if I
want to have that conversation because the my end user is gonna get mad at me or maybe pick somebody else instead of
me but now it’s part of the conversation and so we’re all kind of on the same
page of prevention and I think it’ll be easier to have that conversation now than ever
well you mentioned earlier you always like to have a little lawyer on your shoulder so during this conversation the
water treaters going to have a lawyer on their shoulder and so is the building owner and they’re both thinking well if
I come up with this plan I’m gonna be liable so I want the other party to come up with this plan how do we get around
that well let me ask you just to clarify that what do you mean the other party you mean like the end users gonna say I
don’t want to do it you do it yes and that’s that that’s that’s what I’ve heard people say okay well ASHRAE standard 188 makes the
building owner responsible and so that means it’s not the water treatment
professional that’s responsible for developing and having the plan and and implementing the plan but you certainly
can help with that and you can certainly be part of the water management team so
the owner and your end user you know can’t put that on someone else but you can help
them to accomplish that so I think you know they have to sort of accept that
this is their responsibility but it’s not on them entirely in the sense of
getting the job done so you can tell them you know you can do this yourself
you can create your plan yourself or you can you can put it on someone else’s
plate to help develop that plan but ultimately they have to approve the plan
so it’s perfectly acceptable for the water tree you know like we do we do water
management plans and risk assessments for facilities all the time but then we
give it back to them and they have to approve it and it’s very collaborative you know we could we collaborate with
the water treatment provider and the end user to develop the best plan possible and one that works for them and again
with standard 188 there’s lots of room for the end user in their facility to
design that plan specifically and tailored to them and the decisions that
they make of course need to be what we call evidence-based there’s information upon which those decisions are made and
that you can produce that information if asked so you know they don’t have to
feel afraid or overburdened by this process there are many many of us
including yourself that are willing to help them with that compliance piece I
Water Testing
think 1,500 people just took a chill pill on that I think that that conned a lot of people you shared a lot of
insight around probably the biggest misconception around probably the second
l-word which is the the litigation so with testing what is the procedure on
the collection part of the test well that’s a great technical question and
and people make mistakes around this all the time so it’s not hard you know you take the the bottle the thing to do and
this may feel uncomfortable for some people but what you’re asking and doing
this testing is is the water treatment program controlling Legionella so what
you want to do is take the sample away from the point of injection of the
biocide and if it’s a intermittent application you do it right before the
next application of the biocide so essentially it’s kind of like the worst case scenario across the basin and away
from the point of injection of the biocide and right before the next dose that will tell you is the bio site
application the frequency of addition adequate to control the janela even at
that point in time and then you fill the bottle you put it in the box we provide
a thermal pouch and the Box you ship it back you ship it back next day delivery you don’t have to have ice or a cold
pack for Legionella testing because Legionella is a slow growing organism and the reason for the overnight is you
don’t want to take too long to get that to the laboratory because these other organisms that are in the water will
start to grow after several days making it a little challenge for us to isolate Legionella in the laboratory so it’s a
pretty simple straightforward procedure in the bottle there’s a neutralizer sodium thiosulfate if you were using an
oxidizing biocide the purpose of that is to neutralize that oxidizer so that it doesn’t continue to act on the organisms
in the specimen in transport so doesn’t that sound pretty simple it does when you say it I think a lot of people might
not have thought about does it really matter when I take my sample in reference to when the bias is coming on
so that’s a great point well now we ship it off you get it or another lab gets it
so does every lab do it the exact same way no they don’t and this is always a
big surprise to people and particularly water treatment professionals because they’re used to chemistry and you know
for example you might take a sample and test it for a metal and there’s one
method for testing metal and you should get the same answer every single time no
matter how you do it in what labs doing it in the case of Legionella culture
there is variation among Laboratories on how they do
Legionella culture and for a long long time there really was no what’s called
proficiency testing meaning there’s an external body that sends you a control
sample and sends that out to all these different laboratories to see if in fact they’re capable of growing Legionella if
Legionella is there now the CDC implemented what’s called the elite
program a number of years ago and stands for environmental Legionella
isolation techniques evaluation now thank goodness for acronym sometimes yes
that’s what it stands for and really the purpose of that was to gather information about how laboratories were
doing in terms of laboratory isolation so it wasn’t really a true proficiency program in that essentially everybody
that participated ended up being certified so it was not a good measuring stick to differentiate the capabilities
of the laboratory there is another proficiency program which is an international one through public health
England which is more rigorous we at special pathogens laboratory participate in both and so the thing you want to
look for in a laboratory is that they are accredited laboratory for environmental microbiology that they are
accredited for Legionella testing specifically and that they have a quality management program based on the
International Organization of standards or ISO 17025 so that makes sure that the
laboratory has quality standards so they’re like if I you mentioned a bid
spec earlier if I was going to make a bid spec that’s what I would include and the reason that they are different is
that there are different combinations of media and additives to the culture media
that helped to inhibit other bacteria and allowed Legionella to grow now for
example we developed our own media early on in our experience that is very good
it has dyes to differentiate certain species of Legionella it has antibiotics
polymyxin B and this of Meissen and glycine all intended to inhibit the
other bacteria and allow Legionella to grow and so there are different combinations of media there’s also
different combinations of pretreatment some laboratories don’t do the pretreatment and they’ll give you a
negative result you would never be the wiser but all of these steps the
antibiotic containing media the pretreatment with acid or heat are necessary in order to get the truest and
best result and and we do all of that here and then the pieces how is Legionella identified the
definitive identification is with something called the direct fluorescent antibody test which is specific to
different Syrah groups and species they the presumptive identification is done
with what’s called a slight agglutination and that’s where you get just you know is this Legionella
pneumophila or is it some other species so that’s an incomplete identification many labs will stop there and you know
charge you less for an incomplete identification but because we have been doing this so long and we know that
there are limitations to these steps we do a full identification with all of
those various treatment techniques so that’s how labs differ one from another so after all of that stun all the
results are going to be put on a report that report is going to be sent back to the person that sent you the test what’s
going to be on that report what you’ll see on the report should be both kind of
qualitative and quantitative results so it should give you a numeric colony forming units per milliliter result of
the type of Legionella that was isolated as well as defining what type of Legionella was there was at leisure
nella pneumophila is at Legionella Anisa or boesemani what was isolated so you should get both
the identification of the specific organisms in that sample as well as a quantitative estimate of the
concentration of the organisms alright so let’s go back to our scenario that we were talking about with our explanation
and conversation with our customer and we get a result back and it’s in a range
that we’ve already specified that we were going to make a change to the biocide program we do that we take
another sample we send it back and it went up what the heck’s going on there that does happen and it causes great
consternation both on the part of the water treatment professional as well as the interest rate word by the way
consternation yeah well what can happen is in response to the first result a
high dose of oxidizing by side is applied and as most water treatment
professionals know that can lift off the biofilm the scum and debris from the
bottom and kind of stir things up and then when you have a certain amount of
the oxidant in there it can’t really overcome all of that organic material even though you’ve got a certain level
there so you’ve stirred it all up you take another sample and it’s higher so
sometimes it takes multiple applications of that high dose of oxidant in order to
control it if it’s a pretty you know fouled system what would you recommend the next step be with that scenario
depending on the concentration that was isolated so let’s just say you started out with a hundred and now you’re over a
thousand well in that cooling tower control strategy when it’s over a thousand it’s a more aggressive higher
dose application of the oxidant and for longer so it’s it’s very clearly spelled
out there all right and we’re talking about biocide so are there more
Biocides
recognized biocides than others for controlling the growth of Legionella
bacteria there are and often times I use the analogy of the antibiotic that I
talked to you about earlier and and this was really driven home to me in an early outbreak that I was part of an
investigation where I was on site at this industrial site we’re going up to the roof to the cooling tower on the
roof and there’s these drums of chemical nice pumps and and ORP and all of all of
these things that are there and I’m thinking to myself you know this is a really well managed cooling tower is
probably not a problem and then I open the the latch and I look inside and it’s crystal clear you know it would be the
the poster child of a quote-unquote well-maintained cooling tower well when
I took a sample of that water it was over 3,000 colony forming units of
Legionella pneumophila Surrey Group one and was the source of the outbreak so
what I learned was that they were using biocides that
were intended to control algae like carbamate and not oxidants like bromine
or chlorine or combinations thereof so it’s really important that the bio side
selection have efficacy against Legionella so you often hear people
talking about dual by sides you know using an oxidant and a non oxidizing bio
side and that usually works pretty well the non oxidizers being glutaraldehyde
and iso thiazole and in combination and alternating with the the oxidant the one
caveat that I would share in in using bromine which is commonly used one of
the things that happens sometimes is the dose is not high enough so for example
you might have good efficacy at 1/2 a part per million of free chlorine but
you need higher doses of bromine to get the same effect and we learned that in
some of the experiments that we had done here and at the University of Pittsburgh when comparing the efficacy of various
biocides against Legionella so one of the mistakes that gets made is assuming
that that 1/2 a part per million of bromine is going to be effective and so that’s another reason to test
periodically for Legionella just to confirm that is there a document that actually states you know what’s better
than other and what dosage rates they should be applied at I’m not aware of one particular document there’s lots of
information that’s been published but that’s actually a good idea I don’t know if that is under
consideration at AWT or CTI but that would be a really good suggestion and
makes it easy for people to see typical dosing patterns and I think that the
tricky part is is having evidence of the efficacy of those programs let’s do a
recap you’re looking at a water treatment company you’re doing a survey
they’re doing everything right what are they doing with respect to a cooling tower sure well just as
said using biocides with known efficacy against Legionella one of the things I
think that’s important for a water treaty to emphasize to the end-user is that you know sometimes that means
possibly a more expensive biocide or more frequent addition and that’s where
the periodic testing for Legionella helps demonstrate that the program is
working effectively and provides evidence of that water management so I
think ideally and certainly in the context of CMS and ASHRAE you want to
have a water management program around the cooling tower that defines these
things so that’s something that’s going to be new to most of the end-users what
you want to have is that adequate biocide program with documented evidence
of efficacy now the one thing I did want to touch on that’s i’m reminded i’ve
been talking about this best program is the use of heterotrophic plate count as
a monitor of the efficacy of the by side either HPC or ATP people sometimes think
that you can use that result to predict the presence or absence of Legionella
and our studies and others have shown that not to be true but it doesn’t mean you don’t keep using that because that’s
a good measure of how well the buy-side is doing in general against the bacteria
that are detected by the hpc test so you want to continue to use that as sort of
your your kind of high level measure of efficacy but don’t rely entirely on that
with respect to knowing whether Legionella is controlled or not so you want to be doing both of those on a
regular basis and the other thing I might encourage water treatment professionals to do is involve the
end-user or try to anyway in in between those service calls so most water
treatment professionals are on-site once a month and one of the things that I like to see and put into our water
management programs is that the user manually check the oxidant level in
between those service visits there’s nothing like the element of gathering data and getting
feedback to help them understand the value of this information and what you know it’s not just an air conditioning
system they’re actually preventing disease and and the more that they can work with you and together the more
important I think they see what you the water traders are doing what Jena let me ask if we’re testing for chlorine do we
test for free do we test for total and what should those numbers be well so
you’re the you’re the water treatment chemist and so you’re setting me up for a question I think you know the answer
to but you want to be looking at free residual chlorine or free oxidant
because that tells you that you’ve got enough to kill now measuring total
because these oxidants can combined with things is not going to give you as much good information about the buy-side
activity as the free residual will and actually that’s a mistake
– that’s made by just testing for total you can kind of be lulled into
complacency by thinking you’re good when in fact you don’t have active free
residual available for killing so I think you want to be looking for free and you want to be doing it you know
frequently enough – for that information to be of use and obviously we’d all like
to see automatic dosing and ORP monitoring at all of the installations
but that’s not possible so sometimes those manual checks are very valuable well let me further that question so
let’s say we do have o RP feed and it’s constantly being fed in what’s an
acceptable free chlorine that we should be maintaining I think an acceptable free chlorine when chlorine is the bias
I’d people have had success at 0.5 or higher you know you know that’s that fine line you’re walking corrosion
control versus biocidal activity but there’s lots of those anti corrosives
now that are are stable in the presence of higher doses of free chlorine and so I think if you can bump that up a little
bit above a half a part per million you’d be well served okay now what about a system where we don’t have
the luxury of ORP and we’ve got to slug that in every so often one how often
should it be slugged in and what should the residual be once it’s in there well with manual Edition or slug dosing it’s
a little trickier because you what you’re trying to achieve is a certain residual for a sufficient amount of time
to keep things under control so with a with a bromine as I said I’d prefer to
see it at 1 or higher there’s so many variables you know how much how dirty
the tower is I’m sure you’ve seen a dirty tower – haven’t you trace maybe
one or two so so the so I think you know
the every cooling tower is a little different but the you know the professionals and water treatment are
trying to get that sweet spot between concentration and contact time as you
know the efficacy of any biocide is a combination of those two you have to have a sufficient concentration long
enough to get the desired reduction if you have a lower concentration of the
biocide you need a longer exposure period if you have a higher concentration of the buy-side you need a
shorter period of exposure to get the same effect so I think I’m not an expert
in in the duration of of how long you should keep that biocide in the cooling
tower but you want to maintain that high enough concentration long enough to have
that effect and I think with slug dosing it’s hard and so the preference and I think what
the industry would like to see is more of that automated dosing to keep those residuals high all the time and when the
building owner wants to save a few bucks and not clean the cooling tower on a regular basis they should probably look
for other areas to save that money wouldn’t you agree absolutely and and
you know those dirty towers you know we want to advocate for sidestream filtration anything to keep the dirt and
debris at a minimum you know those sweepers on the bottom of the larger cooling towers help in that regard
so anytime you can minimize all that material that accumulates that provides
material for growth of organisms including Legionella as well as interfering with demand of your oxidant
you want to do that so I know that oftentimes end-users don’t see the value in it but hopefully Legionella will
change that conversation dramatically well I know we’ve educated a lot of
people here around Legionella and I have no doubt that we’re gonna have several water treatment professionals go out and
talk with their customers and say hey this is something that you need to be doing and they’re gonna be met with
somebody saying something like hey this is law in New York not here down in Georgia so when somebody makes me do
this I’ll do it until then ignorant is bliss what would you advise them to say well you know that that’s
playing Russian roulette with the lives of others and I know probably be very
uncomfortable for a water treaty to say that but I think what she I’m always a glass half-full person so what you want
to emphasize are the positive things that having these programs can bring you
know having a better water treatment program increases energy efficiency protecting their their job and the
reputation of the facility and keeping them out of harm’s way in terms of disease causation and litigation is a
wonderful thing and I can’t imagine why anybody would say no to that but then of
course you know the final thing is is that even though it may not be required
having this ASHRAE standard 188 is the industry standard now and you would have
a hard time defending yourself and your institution if you willfully neglected
to follow that industry standard I’ve heard you say several times that the
goal is to take negligence off the table would you speak around that yes I you know I’m a microbiologist not a lawyer
and so I went to a lawyer and one that I had worked with on some Legionella cases
so when standard 188 came out I said to him what in your opinion
does this change about litigation and liability for those that would follow
standard 188 and it was his position that following standard 188 represented
and these were his words a safe harbor for any facility following and having a
water management plan as described in standard 188 because that is the
industry standard and if you are not following that then that opens you up to
well why not and what are you doing and is it sufficient and so another caveat here is it’s a
safe harbor if you follow your plan so it’s very very important that when you
walk down this this path with your end-user to develop the water management plan that you make sure that they follow
the plan because you can get yourself in a lot of hot water legally speaking
whether it’s a Legionella water management plan or another policy that if you have the policy and you don’t
follow it so you want to make sure that they understand that as they develop this plan that they can do it and so
that’s part of the give-and-take and the and the customization of the plan that
standard 188 allows the water management team to decide how they’re going to
mitigate this risk the section in standard 188 that deals specifically with cooling towers is pretty
prescriptive but the section on potable water there’s quite a wide berth there on how you can approach it you know how
frequently to monitor what the endpoints are going to be so you just want to make sure that you have the plan and that you
follow the plan on my show I do a segment every now and then for my personal therapy called the boiling
point and it’s things I see out in the field other water traders do that just
ticks me off and they shouldn’t do it anymore so I’m going to give you this therapy opportunity what do you see out there
around the subject of Legionella that you just want people to stop those just
so terrific tres well you know I the the one thing that comes to my mind is that
that business about the heterotrophic plate count bacteria or ATP tests as
being sufficient to monitor the performance of the of the water treatment program whether it’s a cooling
tower or a water distribution system and I don’t think the water treater is
serving themselves or the end-user very well and kind of letting the end-user go
along without testing for Legionella specifically and I hope that there aren’t any of your listeners that tell
the end-user that that’s going to tell them whether Legionella is controlled or not because it’s it’s while it satisfies
the user because it’s a inexpensive test compared to a Legionella test it doesn’t
serve them well in the long run and and and doesn’t serve the water treat or
well either because water treaters are getting sued with cases of Legionnaires disease and so you want to promote the
best possible program let the end-user refuse and one of the things that some
water treaters are doing is having a document that says you have been informed and advised to test for
Legionella and have declined that service and they have the end-user sign it I think that’s a wonderful thing to
do it helps protect the water treater then it also helps the end-user to
understand the seriousness of what you’re proposing well Janet is there anything we missed
what should we have talked about I think we’ve covered an awful lot trace and I think all of your listeners are thanking
you for all of these programs that you have on scaling up it sounds like a
tremendous amount of practical knowledge gets conveyed and you know thank you for doing it oh it’s absolutely a pleasure
and thank you for allowing me to have such wonderful guests if somebody wanted
to learn more where can they go well I would really love to give any one of
your users some of my doctor stouts Legionella chill pills and so all they have to do is email me
at Jays and Janet Stout sto UT at special pathogens with an s lab comm J
Stout at special pathogens lab comm I’d like to do that because sometimes the
having those chill pills helps begin that conversation with your end user in a humorous way and kind of takes the
edge off that conversation a little bit and I’m certainly happy to answer any other questions that your listeners
might have well I will definitely put that information on my show notes page and you have that treasure trove of
information on just about everything that’s ever been written as far as a standard guideline or recommendation on
Legionella so if it’s okay with you I’m gonna link that as well now I’d be happy and and again there’s tremendous
resources on our website special pathogens lab comm well Janet you’re a
trusted partner with me and my company and I can’t thank you enough for coming
up on the scaling-up nation and sharing all your knowledge about Legionella I know we did a lot of good today and I
know we created a lot of knowledge and knowledge is power thank you so much for the opportunity my pleasure what a great
interview I hope you learned something today honestly I can’t see how you could
not learn something today we started out talking about the l word and we were
scared to even call it Legionella we didn’t know what it was we didn’t know what to do about it well now we know all
those things and more and I know Janet threw out some resources for us to go online and find
out more about Legionella and what we can do don’t worry I know you’re driving
around I’ve got all that information on my show notes page so
WWC a lien up h2o comm go to the show notes page and all of that will be there
for you I hope you enjoy today’s show I hope you want to use this information to
empower yourself to be a better water treated tomorrow
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