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  • Health Protection Surveillance Centre

    National Guidelines for the Control ofLegionellosis in Ireland, 2009

    Report of Legionnaires Disease Subcommittee of the Scientific Advisory Committee

    Health Protection Surveillance Centre

    25-27 Middle Gardiner StreetDublin 1, Ireland

    Ph +353 1 876 5300 Fx +353 1 856 1299 E hpsc@hse.ie

    www.hpsc.ie

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  • National Guidelines for the Control of Legionellosis in Ireland, 2009

    Report of Legionnaires Disease Subcommittee of the Scientific Advisory Committee

    Health Protection Surveillance Centre

    ISBN 978-0-9551236-4-1

  • National Guidelines for the Control of Legionellosis in Ireland, 2009 HSE/HPSC

    Published by Health Protection Surveillance Centre25-27 Middle Gardiner StreetDublin 1Tel: 01-8765300Fax: 01-8561299

    Health Protection Surveillance Centre 2009ISBN 978-0-9551236-4-1Date: July 2009

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    Important Note

    We wish to acknowledge that this document has been prepared and should be read with particular reference to the following documents:

    Health and Safety Commission. Legionnaires disease: the control of Legionella bacteria in water systems, approved code of practice and guidance. 3rd edition. UK Health and Safety Commission, 2000. ISBN 0 7176 1772 6. Available at www.hse.gov.uk/.

    EWGLI. European guidelines for control and prevention of travel-associated legionnaires disease. European Working Group for Legionella Infections, 2005. Available at www.ewgli.org/.

    World Health Organization. Legionella and the prevention of legionellosis. Geneva: World Health Organization; 2007. Available at www.who.int/water_sanitation_health/emerging/legionella/en/.

    Environment Agency, UK. The determination of Legionella bacteria in waters and other environmental samples (2005) Part 1 rationale of surveying and sampling. Bristol: Environment Agency; 2005. Available at www.environment-agency.gov.uk/static/documents/Research/book_200_1028650.pdf.

    Joint Health and Safety Executive and Health Protection Agency Spa Pools Working Group. Management of spa pools: controlling the risk of infection. London: Health Protection Agency; 2006. Available at www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1200471665170.

    Department of Health, UK, Estates and Facilities Division. The control of Legionella, hygiene, safe hot water, cold water and drinking water systems: Part B Operational management: Health Technical Memorandum 04-01 (ISBN 13 9780113227457). London: Stationery Office; 2006. Available at www.tsoshop.co.uk/.

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    Contents

    Membership of the Subcommittee 6

    Foreword 7

    Summary of Recommendations 8

    Chapter 1: Clinical Aspects of Legionellosis 121.1 Introduction

    1.2 Legionella - natural history of the organism

    1.3 Recognised and potential sources of Legionella infection

    1.4 Methods of transmission

    1.5 Risk of infection

    1.6 Treatment

    1.7 Definitions

    1.8 Epidemiology

    1.8.1 Legionnaires disease in Ireland

    1.8.2 Legionnaires disease in Europe

    1.8.3 Under-diagnosis and under-reporting

    Chapter 2: Laboratory Diagnosis 232.1 Introduction

    2.2 Clinical diagnostic tests

    2.3 Water and environmental samples

    2.3.1 Introduction

    2.3.2 Environmental laboratory testing methods

    2.3.3 Reference laboratory

    2.4 Application of PCR for the detection and enumeration of

    Legionella species

    Chapter 3: Legislation 283.1 Health and Safety at Work legislation

    3.1.1 Introduction

    3.1.2 Outline and description of legislation

    3.2 Infectious Diseases (Amendment) Regulations 1981 (S.I. No. 390 of 1981)

    3.2.1 Recommendations re Legionella-specific legislation

    Chapter 4: Risk Assessment 344.1 Introduction

    4.2 Risk assessment

    4.2.1 Responsibilities, training and competence

    4.2.2 Undertaking a risk assessment

    4.2.3 Process of risk assessment

    4.2.4 Written risk assessment

    4.2.5 Frequency of risk assessment

    4.2.6 Risk rating

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    Chapter 5: Legionella Prevention and Control 405.1 Implementing a control scheme

    5.1.1 Monitoring the control scheme

    5.1.2 Record keeping

    5.1.3 Audit

    5.1.4 Responsibilities of suppliers and service providers

    5.1.5 Reducing Legionella risk in new and refurbished buildings

    5.1.6 Material for construction of water distribution networks

    5.2 Technical guidelines for prevention and control

    5.2.1 Hot and cold water systems

    5.2.2 Cooling towers and evaporative condensers

    5.2.3 Other risk systems

    Chapter 6: Environmental Sampling 576.1 Introduction

    6.2 Sampling criteria

    6.3 Safety

    6.4 Site assessment

    6.5 Sample types

    6.5.1 Pre-flush sample

    6.5.2 Post-flush sample

    6.6 Additional information

    6.7 Sample transport and storage

    6.8 Laboratory analysis

    6.9 When to take an environmental water sample

    6.9.1 Hot and cold water systems

    6.9.2 Cooling towers

    6.9.3 Healthcare facilities

    6.9.4 Domestic premises when a case has possible domestic exposure

    6.9.5 Spa pools

    Chapter 7: Training 637.1 Introduction

    7.2 Competent person and assessment of competency

    7.3 Training matrix

    7.4 Personal protective equipment (PPE)

    7.4.1 PPE and Legionella

    7.4.2 Provision, training, use and maintenance of PPE

    Chapter 8: Legionella in Specific Risk Settings 678.1 Healthcare settings

    8.1.1 Recommendations for control of nosocomial legionellosis

    8.2 Travel-associated legionnaires disease

    8.2.1 Reducing the risk of legionnaires disease in hotels and other accommodation sites

    8.3 Dental chair unit waterlines

    8.3.1 Introduction

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    8.3.2 Risk to patients and dental healthcare personnel

    8.3.3 Control of Legionella bacteria in dental chair unit waterlines

    8.3.4 Portable ultrasonic scalers and mobile dental chair units

    8.3.5 Record keeping, equipment maintenance, quality-assurance and periodic review of

    procedures

    8.4 Decorative fountains, water features and planters

    8.4.1 Hospitals and healthcare institutions

    8.4.2 Hotels, restaurants and other commercial buildings

    8.4.3 Recommendations for maintenance of decorative

    fountains and water features

    8.5 Spa pools

    8.5.1 Definition

    8.5.2 Infection risk

    8.5.3 Duties of designers, manufacturers, importers and suppliers

    8.5.4 Identification and assessment of the risk associated with spa pools

    8.5.5 General factors to be considered in the risk assessment

    8.5.6 Specific factors to consider

    8.5.7 Managing the risk

    8.5.8 Records

    8.5.9 Monitoring

    8.5.10 Summary of spa pool checks (excluding domestic pools)

    8.5.11 Hydrotherapy pools

    8.6 Legionellosis aboard ships

    8.6.1 Risk factors associated with ships

    8.6.2 Controlling the risks

    8.6.3 Maintenance

    Chapter 9: Investigation of Legionellosis Cases 859.1 Introduction

    9.2 Response to a single (sporadic) case of legionnaires disease

    9.2.1 Community-acquired case single case

    9.2.2 Travel-associated cases

    9.2.3 Nosocomial infection

    9.2.4 Summary

    9.3 Investigating an outbreak of legionnaires disease

    9.3.1 Epidemiological investigation

    9.3.2 Microbiological investigation

    9.3.3 Environmental investigation

    9.3.4 Public relations

    9.3.5 Overview of the activities of the outbreak control team

    9.3.6 Investigation of sources

    9.3.7 Site survey

    9.4 Emergency control measures

    9.4.1 Thermal disinfection

    9.4.2 Chemical disinfection

    9.5 Outbreak report

    9.6 Post-outbreak routine monitoring

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    References 98

    Appendices 106Appendix A: European Working Group on Legionella Infection (EWGLI)

    Appendix B: Executive Summary of Survey of Laboratory Practices for

    Legionella Infection in Ireland, 2005

    Appendix C: Safety, Health and Welfare at Work Act 2005 (S.I. No. 10 of 2005)

    Appendix D: Safety, Health and Welfare at Work (Biological Agents)

    Regulations, 1994 as amended in 1998 (S.I. No. 146 of 1994

    and S.I. No. 248 of 1998)

    Appendix E: Safety, Health and Welfare at Work (General Application)

    Regulations 2007 (S.I. No. 299 of 2007)

    Appendix F: Safety, Health and Welfare at Work (Chemical Agents)

    Regulations, 2001 (S.I. No. 619 of 2001)

    Appendix G: Definition of a Competent Person

    Appendix H: Checklist for Hotels and other Accommodation Sites

    Appendix I: ISO 15223-1:2007(E) Medical Device Symbols

    Appendix J: Enhanced Surveillance Form for Legionnaires Disease

    Appendix K: List of Submissions and Acknowledgements

    Glossary of Terms: 122

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    Scien