Public Health Enemy - Research Paper Example

Legionella: Public Health Enemy US Water Systems Introduction Legionella has been termed as public health enemy number one in United States water systems due to the health risk associated with the outbreak of the disease. This research paper provides a describes health risk associated with water systems in the United States including the background history and early treatment methodology adopted during the earliest diagnosis of legionella as a pulmonary infection associated with water systems. The second section of the research paper presents a discussion of major factors, viewpoints and examples on legionella based on recent efforts to regulate issues related to the disease. This is followed by the third section, which is a summary and conclusion on the highlighted information about the growth and spread of Legionella bacteria. Part four of the paper address the root-cause of the problem highlighting reasons for the system to fall, people involved and the subsequent death and sickness associated with outbreak related to Legionella bacteria. The last section is about possible correctable solution that will increase the efficiency of water system therefore resulting in greater prevention against growth and spread of Legionella bacteria. 1. Describe the topic/problem Legionella is a bacterium that causes Legionnaires disease, which is an infection that results in severe pneumonia. Most of the infected groups of people contact Legionnaires disease from inhaling Legionella bacterium. Majority of the reported cases of Legionnaires disease have been found to be caused by Legionella pneumophila, although there are instances of other species of the bacterium, some also existing in soil. Additionally, some of the patients recording mild illnesses such as Pontiac fever have also been found to be infected by the Legionella bacterium (Hubbs, 2014; Bartram, 2007). It is now known that infection resulting from Legionella bacterium can result in two forms of illnesses whose early symptoms resembles that of flu. Some of those infected can proceed to develop pneumonia and systemic illness while others get Pontiac fever that is associated with mild illness. Research on the reason why the same bacterium can cause two different illness patterns remains inconclusive (Altman, 2006). Evidence show Legionella pneumophila exists in soil and natural water supplies, which has resulted in its presence in many re-circulating and water supply systems. Favorable environmental conditions for rapid breeding and breeding of the bacterium are temperatures degrees of around 35° C, pool of stagnant water and water with debris that act as foci for bacterial breeding. Due to its existence in water and soil, the bacterium is widely distributed in the environment in addition to high chances of breed in both natural and artificial water sources. Even with the increased risk of spreading when existing in water sources, the Legionella bacterium only becomes a public health risk when the environment provides conditions conducive for rapid multiplication. Cotruvo (2014a) notes the risk of contracting infection caused by Legionella bacterium is currently very low for Unites States residents although Legionnaires disease has become the most significant waterborne disease risk related to inhalation of water mist from municipal drinking water supplies. According to Cotruvo (2014a), data from the CDC had indicated that out of the 33 cases of waterborne diseases reported in the period between 2009 and 2010; about 19 or 58 percent were related to Legionella with the cases found to exist in drinking water distribution systems or plumbing systems. Further, the researcher reports that these outbreaks related to Legionnaires disease resulted in 105 cases of illnesses and 14 deaths in addition to the fact that these were the only cases of waterborne diseases that resulted in death for some of the affected individuals. Legionnaires’ disease, which has been a reportable disease from 2001, is not caused by ingestion of water but from inhalation of fumes resulting from showering or blown down fumes from heat exchangers or humidifiers. Among those facing high risks of Legionnaires disease infection are the elderly, with patients suffering from weakened immune systems present in hospital facilities and in extended care facilities having greater risk. However, Legionella bacterium exists in many other places in the community and is detectable in many plumbing systems in hotels, homes, and other buildings (Cotruvo, 2014b). The disease gets its name from the 1976 severe outbreak affecting those in attendance of the convention of the American Legion held in Philadelphia organized to commemorate the American 200th anniversary of United States independence. Out of the 182 legionnaires affected by the pulmonary infection, 29 individuals died (Hubbs, 2014; Altman, 2006). These infections and subsequent deaths led to diagnostic research on the infections leading to the determination that the causative organism was in fact Legionella pneumophila. Further, the bacterium was determined to exist in aquatic systems where its existence depends on formation of symbiotic relations with some amoebae species. Tracing the history of Legionella bacteria led to identification of a related infection in Pontiac, Michigan in 1968 with the outbreak determined to have been caused by Legionella bacterium although it did not result in lung infections. The outbreak of the disease in Philadelphia led to public outcry due to what many claimed was the failure of the CDC and its investigators to find quick and timely solutions for the outbreak. Since the outbreak happened at a time when there was widespread discussion regarding swine flu vaccine, there was speculation about its link with the CDC search for support of the vaccine program. There was also a congressional hearing that led to the conclusion that swine flu should not be eliminated as the possible cause of the outbreak leading to the 3 August 1977 approval of a vaccine manufacturers liability protection act by the US congressional subcommittee. There was also testing and proposed treatment of patients for nickel carbonyl poisoning as supported by an autopsy by toxicologists who believed that such poisoning was a strong possibility (Heuner and Swanson, 2008; Carney, 2006).  2. Discussion of Major Factors, Viewpoints, and Examples The risk of Legionnaires’ disease infection in the United States has led to increased focus on precautions needed to protect large sections of the population that face this risk. However, the United States lacks legislative framework for regulating testing or maintenance of a specified water systems level for facilities with higher risk factors of Legionella bacteria. Among the countries with examples of effective legislation aimed at preventing the spread of Legionella bacteria in water systems is the United Kingdom where the government has introduced effective measures to cover facilities attending to individual with greater risk of contracting the infection. There are a number of legislations and guidance for preventing the spread of Legionella bacteria through public water systems in the United Kingdom. Prevention and control of risk associated with exposure to Legionella bacteria is conducted under Control of Substances Hazardous to Health Regulation of 2002 where employees are required to introduce preventative measures to control exposure of any employee to substances that are harmful to their health. Existing measures to protect employees must also go through regular reviews at suitable intervals and when necessary conduct as revision set measures with records of the processes being maintained. Further regulation is provided under Approved Code of Practice (ACOP) with the regulation emphasizing that if the risk of exposure to Legionella bacteria has been proven, decisive efforts should be undertaken to ensure particular water systems with potential health risk are avoided to a reasonably practicable extend. When it is not reasonably practicable to avoid such water system, the management of property in question must introduce written scheme detailing control of associated risks with proper implementation and management framework also provided (HSE, 2014). While discussing legislation regulatory efforts to prevent Legionella infection, it is important to mention that role of United States Environmental Protection Agency (EPA) as an obstacle to such efforts. Provisions under EPA make it difficult for the management of many facilities to introduce water treatment measures aimed at preventing the growth and spread of Legionella bacteria at the outlet. EPA provisions governing the use of US water systems assert that any facility with more than 25 users having installation for treatment of public water entering the facility becomes by definition a public water supply. The disadvantage of this provision when applicable to facilities such as hospitals is that they are subjected to drinking water regulations and the related costs incurred in monitoring, management and reporting targeting public water supplies (Cotruvo, 2014b). Installation of water treatment services for these facilities means they become Non Transient Non Community Water Supply (NTNCWS) since they do not have permanent residents. The original guidelines restricting the installation of water treatment services is in line with the public health concern that allowing facilities serving more than 25 users to treat drinking water could potentially lead to contamination, which increases health risk for the consumers. 3. Summary and Conclusion(S) Based on the Information Found From the discussion about the Legionella bacteria and infection in the United States, there is need for effective framework for prevention of growth and spread of the bacteria both at the point of central treatment and in retribution pipelines. Lack of effective legislative framework to tackle the problem also increases chances of the outbreak affecting public facilities, as the management is not given the right incentive to undertake prevention measures. Although the EPA regulation on treatment of water supplies is important in preventing water contamination, there is need to increase responsibility of management of facilities such as hospitals and hotels to ensure they play a greater role in maintaining healthy standards of drinking water (Cotruvo, 2014b). A Country such as the United Kingdom provides important example on the role of effective legislation and regulation in preventing outbreak of Legionnaires’ disease when the management of targeted facilities are aware of their roles in the prevention efforts. It is also important to recognize the fact that the outbreak of Legionnaires’ disease was facilitated by a lack of knowledge on the part of officials managing facilities such as the hotel in Philadelphia and the medical facilities handling such outbreaks. Since by 1976 Legionella bacteria was unknown (Mara and Horan, 2003), the outcome would have been different if hotel management and doctors were aware of what they were dealing with. Therefore, existing scientific evidence on causes, prevention and treatment implies greater ability to prevent and deal with the disease by management of facilities and medical officers respectively. 4. Root-Cause of the Problem Effective prevention of Legionella bacteria requires strict measures to be taken both at the central treatment point and after water has gone through the distribution lines and building plumbing since the bacteria can easily colonize and contaminating water supplies after it has been centrally treated.  Existence of the bacteria beyond the central treatment point is because bio-films inside pipes can harbor them offering protection from disinfectants. Water infection is because of entry into the pipeline of a few Legionella bacteria that end up colonizing the whole water system. Additionally, providing hot and cold water systems at a temperature that supports the growth and spreading of Legionella bacteria is another reason for its spreading across the systems (Hubbs, 2014). The 1976 Philadelphia case of Legionella resulted from the entry of the bacteria into the hotel’s air conditioning system, which facilitated the transfer of water fumes to where the legionnaires were located. After investigations, it was determined that the designers of the hotel had vented its condenser close to its air intake system making it possible for the Legionella bacteria to grow in the large air conditioning system that had also been in use for a long time without being cleaned (Altman, 2014). Therefore, those in attendance of the convention inhaled the bacteria after it entered the air intake pipes as water fumes mixed with the incoming fresh air. This case was the first widely discussed outbreak of legionellosis although it was later determined that a number of cases had already taken place prior to the outbreak involving those in Philadelphia convention. According to medical records made available after the outbreak of Legionnaires’ disease in Philadelphia, there were 123 persons hospitalized in 1976 with various symptoms related to the disease. Manifestations of infection with Legionnaires’ disease included mild grippe to more severe pneumonia, which affected other organ systems of the patients. Constitutional symptoms were also observed with the patients demonstrating diarrhea, fever, malaise, headache and confusion (Tsai et al., 1979). An analysis of the number of people in attendance of the legionaries’ convention reveals out of the 182 legionnaires affected by the pulmonary infection, 29 individuals died from conditions related to the infection (Hubbs, 2014; Altman, 2006). 5. Correctable Solution Given that the EPA law on public water supplies hampers efforts by facilities serving more than 25 users from implementing measures to treat Legionella bacteria from water used in the facilities, correctable solution should begin with the removal of this requirement. Public facilities such as hospitals and large recreational facilities such as hotels should be exempted from the requirement under EPA through implementation of a special category exemption (Hubbs, 2014). The facilities can also be placed under a different oversight process that makes it possible to increase the level of protection targeting individuals seeking services from them. Removal of the requirements that puts these facilities under regulations governing public water supplies will increase their role in preventing the growth and spread of Legionella bacteria at both the water inlet and outlet. Application of the recommendations presented below will also have greater impact for the targeted facilities or individuals with higher risk of being infected. Safe and control measures related to prevention of Legionnaires disease focuses on hot and cold water used in facilities where water system is provided for individuals who are at high risk of being infected by the disease. The temperature control mechanism for preventing the growth and spread of Legionella bacteria is based on the fact that environment conducive for the pathogen is between 20 °C and 50 °C (WHO, 2014). Therefore, guidance on prevention of Legionnaires disease focuses on the role of management of premises in introduction of temperature control methods for existing hot and cold water systems. Under the temperature control strategy, cold water systems should remain below 20 °C in situations where applicable. Additionally, hot water systems for facilities where individuals are at an increased risk needs to be maintained at a high of 50 °C (but 55 °C in healthcare premises) one minute after exit from the outlet. However, while maintaining these temperature levels, the management should also assess risk of scalding, although the suggested temperatures for hot water systems might not be hot to such extent (HSE, 2014). While it is important to control water temperatures, the systems must also be properly maintained to ensure they are clean given that inorganic matter including scale can have negative effect on the efficacy of control measures introduced in any facility (HSE, 2014). Additionally, temperature control of Legionella for older can be difficult due to existence of complex water systems that might need overall overhaul for enhanced effectiveness. Therefore, temperature control as a preventative measure for Legionella can be a simple and effective strategy when hot and cold water systems are properly managed. However, the management must be careful to respond to complexities generated by parameters such as system design, size, age, and water chemistry that affect the possibility of attaining adequate control. Apart from control measures using temperature control for cold and hot water systems, chlorine dioxide is another alternative for preventing infection from Legionella (Mara and Horan, 2003). The use of chlorine dioxide responds to its chemical composition as an oxidizing biocide or disinfectant that can effectively control the growth and spreading of Legionella bacteria in hot and cold water systems. This is an alternative control measure for water systems where controlling temperature is difficult. In the appropriate application, it may be used to make possible Legionella bacteria control where maintaining a conventional temperature regime is difficult or impractical. However, the use of chlorine dioxide for preventing the growth of Legionella bacteria must be consistent with the national regulation on concentration of chlorine dioxide, chlorate and chlorite in drinking water supply. These regulations require chlorine dioxide content to be maintained at around 0.5 mg/l but labeling of water as not suitable for drinking must be done in circumstances where microbial control cannot be attained when without the average oxidant levels at the outlet going beyond 0.5 mg/l (Lin, Stout and Yu, 2011). Recent study by Lin, Stout and Yu (2011) highlighted the importance of copper and silver ions in preventing the spread of Legionella bacteria in water systems. Although the study was conducted for the purpose of application to water systems in hospitals, the simple application mechanism used in Copper-Silver Ionization provides an opportunity for application in other water systems used in other facilities. The use of Copper-Silver Ionization for preventing the growth and spread of Legionella bacteria exploits the fact that copper and silver are bactericidal in vitro against Legionella and other water borne pathogens. Lin, Stout and Yu (2011) determined that a copper ion concentration ranging from 0.20 mg/L to 0.80 mg/L and silver ion concentrations of 0.01 mg/L to 0.08 mg/L was adequate for elimination of Legionella bacteria in water systems. Existing evidence from studies on facilities that have implemented the use of Copper-Silver Ionization as the main method for preventing growth and spread of Legionella bacteria reported positive results of this application. Initial installation of Copper-Silver Ionization in hospital facilities indicated a positive result due to reported reduction of colonization from 75 percent to zero Legionella bacteria colonization with these results achieved after only three months. Water systems under study had copper ion concentration above 0.4 mg/L while a silver ion concentration was beyond the 0.04 mg/L (Lin, Stout and Yu, 2011). Conclusion The outbreak of Legionnaires’ disease in Philadelphia in 1976 was the first reported case of the disease due to the high number of individuals affected and the public limelight that followed the infection. Lack of knowledge about Legionella bacteria by the management of facilities such as hotels in addition to limited medical awareness contributed to the enhancement of the magnitude of the problem. It has also been established that existing legislative and regulatory frameworks such as EPA makes it difficult for the management of facilities to increase their Legionella bacteria preventative efforts as they attempt to avoid further obligations generated by such efforts. It is recommended that removal of restriction imposed by such regulatory frameworks will provide an opportunity for management of the facilities to increase preventative measures that ensures further reduction of risk for people visiting the facilities. References Altman, L. K. (2006). In Philadelphia 30 Years Ago, an Eruption of Illness and Fear. New York Times, Retrieved fromhttp://www.nytimes.com/2006/08/01/health/01docs.html?_r=2&oref=slogin&pagewanted=print& Bartram, J. (Ed.). (2007). Legionella and the prevention of legionellosis. Geneva: World Health Organization. Carney, J. K. (2006). Public health in action: Practicing in the real world. Sudbury, MA: Jones & Bartlett Learning. Cotruvo, J.A. (2014a). Facilitating supplemental disinfection for Legionella control in plumbing systems, Journal of the American Water Works Association, 106 (8), 74-82. Cotruvo, J. (2014b). Waterborne diseases. Water Technology. Retrieved from: http://www.watertechonline.com/articles/167968-professor-poupoe-may-2014 Heuner, K., & Swanson, M. (Eds.). (2008). Legionella: molecular microbiology. Norfolk: Horizon Scientific Press. Hubbs, S. (2014). Addressing Legionella: Public Health Enemy #1 in US Water Systems. Water quality and health. Retrieved from: http://www.waterandhealth.org/addressing-legionella-public-health-enemy-1-water-systems/ HSE. (2014). Legionnaires’ disease: Part 2: The control of legionella bacteria in hot and cold water Systems. Feltham: HSE Publications Lin, Y. E., Stout, J. E., & Yu, V. L. (2011). Controlling Legionella in hospital drinking water: an evidence-based review of disinfection methods. Infection control and hospital epidemiology, 32(2), 166-173. Mara, D., & Horan, N. J. (Eds.). (2003). Handbook of water and wastewater microbiology. Waltham, Massachusetts: Academic press. Tsai, T. F., Finn, D. R., Plikaytis, B. D., Mccauley, W., Martin, S. M., & Fraser, D. W. (1979). Legionnaires disease: clinical features of the epidemic in Philadelphia. Annals of internal medicine, 90(4), 509-517. WHO. (2014). Legionellosis. Retrieved from: http://www.who.int/mediacentre/factsheets/fs285/en/ Read More