How to Prevent the Spread of Legionella in Hotels and Public Places - Term Paper Example

Table of Contents 1. Introduction 2 1.1 Objectives 3 Body 2. Legionella Description 3 2.1 Incubation 3 2.2 At-risk groups 3 2.3 Transmission 3 2.4 Diagnosis 3 2.5 Cases 4 3. Hotel Work Activities & Possible Infection Points 4 3.1 Staff 4 3.2 Guests 5 4. Where does it breed and multiply 5 5. Risk factors (based on personal qualities of individuals) 5 5.1 Smoking 5 5.2 Alcoholism 5 5.3 Diabetes 6 5.4 45 years and older 6 6. Legal Requirement Risk Assessment of Biological Hazards 6 6.1 Health and Safety at Work Act 1974 6 6.2 Management of Health and Safety at Work Regulations 6 6.3 Control of Substance Hazards to Health Regulations 7 7. Risk Factors & Risk Assessment Procedure 7 8. Tabulated Written Scheme 7, 8 9. Minimization of health risks 9 10. Risk Factors Reduction Methods 1 To 14 10 11. March 2006 Fact Sheet 10, 11 11. Eradication (or Elimination) 12 12.1 Isolation & Segregation 12 12.2 Containment 12 11. Conclusions 12 12. Recommendations in order of implementation importance 13, 14 13. Action Plan 15, 16 14. References & Further Reading 17 Introduction The outbreak of diseases in any part of the world is an imminent concern for most people. With our booming population and closer proximity with each other, the danger of being afflicted with a variety of diseases has become a higher possibility. The need to contain and control the spread of various communicable diseases is imperative for most managers in health industry and for those managing public business establishments like hotels, restaurants, movie houses, and schools. Legionella is one of these diseases which can spread rapidly without the proper safety precautions in place. The management and control of this disease is an important consideration for hotel managers and health coordinators because the lack of safety measures can result to a higher and faster spread in the general population. This paper shall discuss what an organization, which is concerned with the adequacy of preparations in the prevention of Legionella, can do in order to prevent its outbreak. This report shall identify and assess the risk exposure to Legionella bacteria from work activities and water systems in the workplace. It shall also propose a writing scheme for controlling the risk from exposure to Legionella bacteria and make recommendations for any required improvements in the organization. It shall also include an action plan for the implementation of recommendations. This paper is being prepared by the organization’s Health, Safety, and Environmental Advisor in response to the senior management’s worries that all reasonably practicable and foreseeable precautions against an outbreak of Legionella may not be in place at the London five stars Ribly Hotel. The Ribly hotel is a 200 hundred bed hotel in central London and employs over 100 personnel, both full and part time. Some employees and guests are more susceptible to Legionella by the simple fact that they frequently either come into contact with the water spray/mists or because they have a weak immune system. Some of them are smokers and drink alcohol for socialization purposes – sometimes until they are over the legal limit for alcohol intake. Three of them are diabetics. Most of the guests in the hotel use the spas, pools, and are exposed to the spray mists of the lobby fountain. About 35-40% of our hotel guests are smokers and some do take in alcohol during their stay. Some of them are also diabetics or are afflicted with cancer or kidney disease. These qualities make hotel staff and guests vulnerable to Legionella. Objectives: To ensure that the Control of Substances Hazardous to Health 2002 Regulations (as amended) (COSHH) will be studied; To guarantee that the contents of the L 8 Approved Code of Practice (ACOP) plus advice from the European Working Group for Legionella infections are implemented and adhered to Body Description of legionella Legionella or Legionnaires’ disease is a potentially fatal form of pneumonia which can affect anybody, but which principally affects those who are susceptible because of their age, illness, immunosuppression, smoking etc. It is 90% caused by the bacterium Legionella pneumophila and the rest of the 10% is caused by less serious illnesses which are not fatal or permanently debilitating (Pontiac fever, Lochgoilhead fever). Incubation period The incubation period of the disease is between 2-10 days (or in some cases, 3-6 days). Not everyone exposed will develop the symptoms of the disease and those who do not develop the ‘full blown’ disease may only present with a mild flu-like symptoms. At risk groups Certain groups of people are known to be at higher risk of contracting Legionnaires’ disease, with men appearing to be more susceptible than women, as well as those 45 years and older, and those who are smoking, are alcoholics, those who have diabetes, cancer, or kidney disease. Transmission It is normally contracted by inhaling Legionella bacteria, either in tiny droplets of water (sprays-mists), or in droplet nuclei (the particles left after the water has evaporated) contaminated with Legionella. Diagnosis The disease is usually diagnosed through a combination of tests. The organism may be cultured from the patient’s sputum, bronchial washings or lung tissue. Alternatively, tests are used to measure the presence of antibodies in the blood and, increasingly, tests are available to measure specific antigens in the patient’s urine. Cases Cases of Legionnaires’ disease have been seen among staff in workplaces (factories, offices, shops and hospitals); visitors (delivery drivers); and other members of the public (patients, hotel guests or passers-by). To date, approximately 40 species of the Legionella bacterium have been identified. L. pneumophila causes about 90% of cases. Sixteen different serogroups of L. pneumophila have been described however L. pneumophila serogroups 1 is most commonly associated with cases of Legionnaires’ disease in the UK. Hotel Work Activities and possible Infection Points Work activities that increase personnel’s and guests’ exposure to Legionella include: 1. Staff a. Front desk staff – due to proximity to decorative water feature/fountain. b. Swimming pool and Spa staff – due to pool water, spa water, showers, faucets, toilets and bidet’s. c. Plumbers/handy men/women – work with all manner of water features e.g. water coolers and air conditioning units, dead legs and design faults including open top boilers, any condensers internal or external. d. Cleaners – clean bath rooms, toilets, showers and taps. e. Contractors – work on roofs, rain water fittings “guttering holding stagnant water etc”. f. Hair dressers – sprays from sinks etc. 2. Guests – who use pools, spas, sinks, taps, toilets, water features and showers. Where does it Multiply and Breed 1. Hot and cold water tanks / cisterns 2. Warm water between 20°C and 45°C· 3. Pipes with little or no water flow (this includes unoccupied rooms) 4. Slime (biofilm) and dirt in pipes and tank surfaces 5. Rubber and natural fibres in washers and seals 6. Water heaters and hot water storage tanks 7. Scale in pipes, showers and taps. Poor hygiene standards/situations and conditions encourage the growth of Legionella bacteria and increase the risk of infection to hotel guests and staff. By removing the above incubation areas, Legionella bacteria proliferation can be controlled. Risk factors (based on personal qualities of individuals) 1. Smoking Smoking has been associated as a risk factor for legionella as supported by different studies which indicate “that nicotine and cigarette smoke condensate severely suppress the anti-Legionella resistance of alveolar macrophages” (Christidis, 2004, p. 301). In effect, smoking compromises the lung’s ability to resist infection caused by Legionella, making smokers highly vulnerable to the disease. 2. Alcoholism Alcoholism is also another risk factor for Legionella infection. Studies maintain that “chronic and even acute, moderate alcohol use can increase host susceptibility to infections caused by bacterial and viral pathogens” (Szabo, 1999, p. 830). These studies were able to establish that alcoholics had a lower inflammatory response, altered cytokine production, impaired cellular immunity, and functional abnormalities in their T & B lymphocytes, natural killer cells, and macrophages (Szabo, 1999). Consequently, exposure to the Legionella bacteria makes them alcoholics more susceptible to infection as compared to the general population. 3. Diabetes/kidney infection/cancer Diabetics have a higher risk of being infected by Legionella bacteria because of their compromised immune system. In a similar vein with patients who have kidney disease and cancer, these patients’ immune systems are compromised and is makes them vulnerable to a variety of opportunistic infections, like in this case, Legionella pneumophila. 4. Age 45 years and above Studies also reveal that aging is associated with increased vulnerability to bacterial infection. These studies set forth that aging is often synonymous with the following characteristics: aging of the gastrointestinal tract; higher prevalence of underlying medical disorders; malnutrition; and declining immune response levels which makes the host less able to defend himself against infectious agents (Clark, 2008). In this case, the older patients are more vulnerable to infected from the Legionella-causing bacteria. Legal Requirements Risk Assessment of Biological Hazards The requirement to carry out risk assessments on biological hazards is contained in the following legislation: 1. Health and Safety at Work Act 1974 (HASWA) General provisions SFARP, sections 2, 3, 4 and 6. 2. Management of Health and Safety at Work Regulations 1999 These Regulations contain a general requirement in the assessment of risks (reg 3 RA) to the health and safety of employees and others as a result of exposure at work. These regulations also caution women of child-bearing age; they must be given special consideration (reg 16). 3. Control of Substances Hazardous to Health Regulations 2002 (as amended) (COSHH) These Regulations specifically require a suitable and sufficient assessment of the risks to health from biological agents. Schedule 9 is specifically concerned with biological agents. Risk Factors and Assessment Procedure The legislation outlined above requires employers to carry out assessment of the risks which their employees have of any biological agents used or created by their work, and to carry out steps necessary for protecting workers and those affected by these activities. In the case of biological agents, the COSHH Regulations requires the classification of micro­organisms, of its ability to cause disease and hazards to employees, of its likelihood to spread disease, and of the availability of prophylaxis and treatment. Tabulated Written Scheme for the Ribly Service Task Frequency Ensure responsible persons identified to undertake the actions stated below; as per ACOP L8, page 15 sec 44. Ensure Diagrams are available thus eliminating the possibility of missing areas. Try to get CDM drawing if possible (These are Recommendation Issues) Hot water services Arrange for samples to be taken from hot water calorifiers, in order to note condition of drain water Annually Check temperatures in flow and return at calorifiers Monthly Check water temperature up to one minute to see if it has reached 50°C in the sentinel taps Monthly Visual check on internal surfaces of calorifiers for scale and sludge. Check representative taps for temperature as above on a rotational basis Annually Cold water services Check tank water temperature remote from ball valve and mains temperature at ball valve. Note maximum temperatures recorded by fixed max/min thermometers where fitted Every six months Check that temperature is below 20°C after running the water for up to two minutes in the sentinel taps Monthly Visually inspect cold water storage tanks and carry out remedial work where necessary. Check representative taps for temperature as above on a rotational basis Annually Shower heads Dismantle, clean and descale shower heads and hoses Quarterly or as necessary see recommendations Little-used outlets Flush through and purge to drain, or purge to drain immediately before use, without release of aerosols Weekly Sprinkler and hose reel systems When witnessing tests of sprinkler blow-down and hose reels ensure that there is minimum risk of exposure to aerosols As manufactures direct Spa baths Check filters – sand filters should be backwashed daily Daily Check water treatment – pools should be continuously treated with an oxidising biocide Three times daily Clean and disinfect entire system Weekly Indoor fountains and water features Clean and disinfect ponds, spray heads and make-up tanks including all wetted surfaces, descaling as necessary See manufacturers’ instructions Swimming pools As per the advice Swimming pool water: Treatment and quality standards Pool Water Treatment Advisory Group As manufactures direct Minimization of health risk factors In relation to the health risk factors inherent to the each individual, since the stay of the guests at the hotels are only for a short duration, the hotel can only impose certain limits in behaviour which can minimize their risks to infection. These programs can include: 1. Imposing a smoking ban within the hotel premises. This would help deter smoking among the staff and the guests. 2. Strictly implementing alcohol limits for hotel guests and staff. This would help limit the alcohol intake of the guests and staff. 3. Promoting and implementing healthy menus for the hotel cuisine. Such a menu should be high in fruits and vegetables and less in fat, sugar, and salt. This would help promote a healthy diet among guests and staff, and help ensure that the diabetics and those with co-morbid conditions (renal disease, cancer) are not vulnerable to bacterial infection while they are within the hotel’s care. 4. Imposing a healthy regimen for the staff. This would include healthy diet, exercise, and healthy habits for the staff. Gyms are recommended within the hotel premises – accessible to staff and guests. Regular physical and medical examinations are also recommended for staff in order to assess their health and ensure that their immune system is not compromised and that they are not vulnerable to bacterial infections. Risk Factor Reduction Methods (1 to 14) The following 1-14 advice was taken from, European Working Group for Legionella Infections and will be put into the Ribly hotels written scheme, items in red are recommendation issues. March 2006 Fact sheet – Information for Owners and Managers of Hotels. The risk of Legionnaires’ disease can be minimised. Any hotel that does not have an active programme to control the growth of Legionella bacteria is criminally negligent in ensuring the safety of their guests. The programme should include the following: 1. Have one named person responsible for Legionella control. (Maintenance Manager) 2. Ensure the named person is trained in control of Legionella and other staff are trained to be aware of the importance of their role in controlling Legionella. (Above Manager to undertake water management training; Legionella TBT to all employees) 3. Keep hot water hot and circulating at all times: 50°C - 60°C (too hot to put hands into for more than a few seconds) (temperature to be taken at frequency in scheme) 4. Keep cold water cold at all times. It should be maintained at temperatures below 25°C. (As above) 5. Run all taps and showers in guest rooms for several minutes at least once a week if they are unoccupied and always prior to occupation. (As per the scheme) 6. Keep shower heads and taps clean and free from scale. (As per the scheme) 7. Clean and disinfect cooling towers and associated pipes used in air conditioning systems regularly; once a year min (the Ribly Does this twice a year as per BS4485) 8. Clean and disinfect water heaters (calorifiers) once a year. (As per the scheme) 9. Disinfect the hot water system with high level (50mg/l) chlorine for 2-4 hours after work on water heaters and before the rooms are let. 10. Clean, disinfect all water filters regularly; every one to three months (depending on RA results). 11. Inspect water storage tanks, cooling towers and visible pipe work monthly. Ensure that all coverings are intact and firmly in place. (As per the scheme) 12. Inspect the inside of cold water tanks at least once a year and disinfect with 50mg/l chlorine and clean if containing a deposit or otherwise dirty. (As per the scheme) 13. Ensure that system modifications or new installations do not create pipework with intermittent or no water flow. (By complying with relevant British Standards or their European/International equivalents, if CDM required diagrams are available. 14. In the spa pool (also known as whirlpool spas, "Jacuzzis", spa baths) ensure that: It is continuously treated with 2-3mg/l chlorine or bromine and the levels are monitored at least three times a day, at least half of the water is replaced each day sand filters are backwashed daily, the whole system is cleaned and disinfected once a week, and daily records of all water treatment readings such as temperature and chlorine concentrations are kept. (Checked regularly by the manager). Eradication (or Elimination) The risk of Legionella contamination has been eliminated in a number of building air-conditioning systems by taking spray humidification equipment out of use, changing work methods, remove spray action from water feature in lobby area, and change to running brook type. Isolation and Segregation A common risk control method is to reduce individual exposure. In this context, work with Legionella needs to be segregated from less hazardous work, so only those whose work requires them to come into close contact could ever be exposed. Containment Engineering controls are available to prevent Legionella: 1. Enclose wet water systems that create mists/sprays 2. Place drift suction hoods on cooling towers. Specifics on cooling towers are in BS 4485; 1996/1998 part 3 and 4. 3. Other methods of water treatment include the electrolytic dissolution of metals such as copper and silver, thereby generating biocidal ions in solution. Another is the introduction of ozone, which produces an oxidising biocide in the water. Physical methods such as irradiation by ultraviolet (UV) light can also be used, although this is only effective when waters clear. Conclusions Legionella is a bacterial infection caused by Legionella Pneumophilia. It is highly risky for people who are older, for smokers, alcoholics, and for those who have diabetes, cancer, or kidney disease. Hotel establishments are often risky places for this disease because of spray mists and droplet nuclei in the water which can be contaminated with Legionella and which can later infect the guests and staff. In order to control the risks to staff and guests, the hotel can impose the legal mandates of the Health and Safety at Work, Management of Health and Safety at Work Regulations 1999, and the Control of Substances Hazardous to Health Regulations 2002. The hotel management can also impose the regular cleaning of the hotel water facilities in order to prevent spread and ensure control of the infection. Regular inspections of the water tanks and other water facilities of the hotel also help ensure that possible infection is controlled and prevented. These measures when set in place help ensure that the hotel is safe from Legionella and in case of infection control measures are in place to minimize the spread of the disease. Recommendations in order of implementation importance 1. The Legionella ACOP – L8 specifically identifies a responsible person to be in charge of what could be termed water management. At this time this issue rests with the Hotels manager. 2. Training has to be put in place so the maintenance manager and his deputies realise their duties under the COSHH regulation; the hotels safety manager to source suitable training ASAP. 3. Produce all the necessary pipe work and water course details required to ensure no areas are missed when the Ribly’s written scheme is put into action. If no diagrams are available then new ones will have to be made. 4. Maintenance manager to check sentinel hot water tap temperatures monthly and record findings in maintenance logs 5. Prior to rooms being made available, let the front desk staff have to check with the cleaning supervisor that all the rooms water features have been cleaned that day and showers, taps “hot and cold” bidets and toilets have run water as stated in the scheme. If any room has not been used for over a month, cleaning staff are required to wear P3 mask where the possibility of creating sprays/aerosols or mists is present. 6. Safety manager to produce and disseminate TBT to all staff on the controls to prevent Legionella out breaks, this will include when and how to use any necessary PPE. 7. Remove spray capability from front door lobby fountain and replace with babbling brook type action fountain 8. Maintenance manager must ensure the spa pools mechanical treatment mechanisms all work to deliver the right amount of chemicals, the identified control measures are in place, all tests carried out are logged and recorded (dated and timed), and any unexpected results to be reported to the hotel manager forthwith. ACTION PLAN COSTS TIMESCALES and RESPOSABILITIES TAKEN FROM RECOMMENDATIONS ACTION POINTS TAKEN FROM RECOMENDATIONS ACTIONS PRIORITISED AS NUMBERED, 1 FIRST COSTS LOW – UNDER £100 MEDIUM – UNDER £500 HIGH – OVER £500 TIME SCALES SHORT – 1 WEEK MEDIUM – 1 MONTH LONG – OVER 3 MONTHS RESPOSABILITY OF CLOSE OUT DATE 1. ENSURE MAINT/MANAGER IS NAMED R/P LOW SHORT HMM 2. H and S MANAGER TO PROVIDE TRAINING FOR ABOVE PERSON MEDIUM MEDIUM HSM 3. COMANDERE SUITABLE SYSTEM DIAGRAMS MEDIUM and HIGH LONG HTM 4. WATER TAPS TO CHECKED FOR 60% TEMP MEDIUM SHORT, MEDIUM, LONG HMM 5. ROOM LET PROCEDURE TO BE EMPLOYED MEDIUM and HIGH MEDIUM FRDS 6. TBT TO ALL STAFF and THIS REPORT PASS ON LOW and MEDIUM SHORT HSM 7. REPLACE LOBBY WATER SPRAY FOUNTAIN HIGH MEDIUM HTM/MTM 8. SPA CHEMICAL RELEASE CHECK and RECORD MEDIUM MEDIUM and LONG HMM 9. CHECK WATER TESTING IS BY UKAS LAB LOW SHORT HTM 10. KEEP RECORDS and ARCHIVE OTHERS TO COMPUTOR HARD DRIVE. MEDIUM MEDIUM HTM 11. REGULAR MEDICAL TESTS FOR HOTEL STAFF HIGH LONG HTM 12. HEALTHY HOTEL CUISINE MEDIUM MEDIUM HTM 13. REGULAR WORKOUT REGIME FOR HOTEL STAFF; OPEN TO INTERESTED GUESTS HIGH LONG HTM 14. POSTING NO SMOKING SIGNS AROUND THE HOTEL LOW SHORT HMM KEY: HTM-HOTEL MANAGER, HMM-HOTEL MAINTENANCE MANAGER, HSM- HOTEL SAFETY MANAGER,FDS-FRONT DESK References and Further Reading An introduction to local exhaust ventilation, HSG37, HSE Books A step by step guide to COSHH assessment, HSG97, HSE Books Biological monitoring in the workplace HSG167 ISBN 0 7176 1279 1 Breathe freely An employers’ leaflet on preventing occupational asthma INDG95 (rev2) (single copies free or priced packs of 15 ISBN 0 7176 0914 6) Guidance BS 4275:1997, Guide to implementing an effective respiratory protective device programme, British Standards Institution. Clark, M. (2008) The Significance of Age in Bacterial Infection, Marler Blog, viewed 12 July 2010 from http://www.marlerblog.com/2008/12/articles/lawyer-oped/the-significance-of-age-in-bacterial-infection/ COSHH Regulations 2002: Approved Code of Practice, L5, HSE Books COSHH essentials: Easy steps to control chemicals. Control of Substances Hazardous to Health Regulations HSG193 (Second edition) 2003 ISBN 0 7176 2737 It can also be freely accessed at www.coshh-essentials.org.uk Christidis, D., Liberpoulos, E., Tsiara, S., Drosos, A., & Elisaf, M. (2004) Legionella pneumophila Infection Possibly Related to Treatment With Infliximab, Infectious Diseases in Clinical Practice, volume 12(5), pp. 301-303 Health and Safety at Work etc. Act, 1974, The Management of Health and Safety at Work Regulations, 1999 and amendments, Control of Substances Hazardous to Health Regulations, 2002 and amendments, Personal Protective Equipment at Work Regulations, 1992 Health surveillance under COSHH: guidance for employers, ISBN 0 7176 0491 8, HSE Books Health surveillance at work HSG61 ISBN 0 7176 1705 X Breathe freely: A workers’ information card on respiratory sensitizers INDG172 (single copies free or priced packs of 25 ISBN 0 7176 0771 2) Respiratory sensitizers and COSHH: Isocyanates: Health hazards and precautionary measures Environmental Hygiene Guidance Note 16 (Fifth edition) 1999 ISBN 0 7176 1701 7 Maintenance examination testing of local exhaust ventilation HSG54 ISBN 0 7176 1485 9 Occupational Exposure Limits, EH40 (revised annually), HSE Books Organic Isocyanates in air MDHS25/3 (Third edition) ISBN 0 7176 1668 1 Personal Protective Equipment at Work Regulations - Guidance on regulations, HSE Books Preventing asthma at work; how to control respiratory sensitizers, L55, HSE Books Spraying of highly flammable liquids EH9, HSE Books Szabo, G. (1999) Consequences of alcohol consumption on host defence, Alcohol and Alcoholism, volume 34(6), pp. 830-841 The selection, use and maintenance of respiratory protective equipment HSG53 ISBN 07176 1537 5 The selection, use and maintenance of respiratory protective equipment - a practical guide, HSG53, HSE Books The Spraying of Flammable Liquids, HSG178, HSE Books Read More