Hostname: page-component-586b7cd67f-t8hqh Total loading time: 0 Render date: 2024-11-20T07:15:26.650Z Has data issue: false hasContentIssue false
  • English
  • Français

Disinfection of Water Distribution Systems for Legionella: A Review of Application Procedures and Methodologies

Published online by Cambridge University Press:  21 June 2016

Paul W. Muraca ,
Victor L. Yu  and
Angella Goetz
Paul W. Muraca
Affiliation:
USA Environmental Protection Agency, Drinking Water Section (Region III), Pennsylvania
Victor L. Yu*
Affiliation:
Special Pathogens Laboratory and Infectious Disease Section, VA Medical Center and, University of Pittsburgh, Pennsylvania
Angella Goetz
Affiliation:
Special Pathogens Laboratory and Infectious Disease Section, VA Medical Center and, University of Pittsburgh, Pennsylvania
*
VA Medical Center, Infectious Disease Section, University Dr. C, Pittsburgh, PA 15240
Get access Rights & Permissions [Opens in a new window]

Abstract

Hospital-acquired legionella pneumonia is emerging as a major problem; potable water distribution systems have been shown to be the primary reservoirs for the legionella organisms. As a result, disinfection measures have been developed to eradicate the organism from the hospital water supply. Each disinfection modality differs in its design and application such that choosing an appropriate cost-effective control measure requires careful analysis and planning.

We assess in comparative fashion the disinfection modalities of thermal eradication (“heat-and-flush”), instantaneous steam-heating system, chlorination, ultraviolet light irradiation, ozonation and metal ionization. The theoretical bases, the actual procedure or system, the logistics of implementation, the costs and personnel requirements and the advantages and disadvantages are presented for each modality. Criteria for selection of a method, the use of combinations of methods, parameters for installation, pitfalls in implementation and a plan for subsequent environmental surveillance are discussed in detail.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 11 , Issue 2 , February 1990 , pp. 79 - 88
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1990

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Muder, RR, Yu, VL, Woo, AH. Mode of transmission of Legionella pneumophila: a critical review. Arch intern Med. 1986;146:1607–1612.CrossRefGoogle ScholarPubMed
2. Fraser, DW, Tsai, T, Orenstein, W, et al. Legionnaires' disease: description of an epidemic of pneumonia. N Engl J Med. 1977;297:1189–1196.10.1056/NEJM197712012972201CrossRefGoogle ScholarPubMed
3. Rosmini, F, Castellani-Pastoris, M, Mazzotti, MG, et al. Febrile illness in successive cohorts of tourists at a hotel on the Italian adriatic coast: evidence for a persistent focus of Legionella infection. Amer J Epidemiol. 1984;119:124–134.10.1093/oxfordjournals.aje.a113713Google Scholar
4. Grist, NR, Reid, D, Najera, R. Legionnaires disease and the traveler. Ann Intern Med. 1979;90:563–564.10.7326/0003-4819-90-4-563Google Scholar
5. Meenhorst, PL, Reingold, AL, Groothuis, DG, et al. Water-related nosocomial pneumonia caused by Legionella pneumophila serogroups 1 and 20. J Inf Dis. 1985;152:356–364.10.1093/infdis/152.2.356CrossRefGoogle Scholar
6. Stout, JE, Yu, VL, Vickers, RM, et al. Ubiquitousness of Legionella pneumophila in the water supply of a hospital with endemic Legionnaires' disease. N Engl J Med. 1982;306:466–468.CrossRefGoogle ScholarPubMed
7. Wilczek, H, Kalllings, I, Nystrom, B, Tyden, G, Groth, CG. Experience with 5 cases of Legionnaires' disease at the Department of Transplantation Surgery, Huddinge Hospital, Stockholm, Sweden. Scand J Urol Nephrol. 1985;92(supp1):67–69.Google Scholar
8. Brennen, C, Vickers, RM, Yu, VL, Puntereri, A, et al. Discovery of occult legionella pneumonia in a long-term care facility. Brit Med J. 1987;295:306–307.Google Scholar
9. Muraca, PW, Stout, JE, Yu, VL, et al. Legionnaires' disease in the work environment: implications for environmental health. Am Ind Hyg Assoc J. 1988;584–590.Google Scholar
10. Stout, J, Yu, VL, Muraca, I? Legionnaires' disease acquired from the water supply within the homes of two patients. JAMA. 1987;257:1215–1217.10.1001/jama.1987.03390090087029CrossRefGoogle ScholarPubMed
11. Stout, JE, Yu, VL, Muraca, F! Isolation of Legionella pneumophila from the cold water of hospital ice machines: implications for origin and transmission of the organism. Infect Control. 1984;6:141–146.10.1017/S0195941700062937CrossRefGoogle Scholar
12. Stout, JE, Yu, VL, Best, M. Ecology of Legionella pneumophila within water distribution systems. Appl Environ Microbiol. 1985;49:221–228.10.1128/aem.49.1.221-228.1985CrossRefGoogle ScholarPubMed
13. Wadowsky, RM, Yee, RB, Mezmar, L, et al. Hot water systems as sources of Legionella pneumophila in hospital and nonhospital plumbing fixtures. Appl Environ Microbiol. 1982;43:1104–1110.CrossRefGoogle ScholarPubMed
14. Plouffe, JF, Webster, LR, Hackman, B. Relationship between colonization of hospital buildings with Legionella pneumophila and hot water temperatures. Appl Environ Microbiol. 1983;46:769–770.10.1128/aem.46.3.769-770.1983Google Scholar
15. Vickers, RM, Yu, VL, Hanna, S, Muraca, P, et al. Determinants of L pneumophila contamination of water distribution systems: 15-hospital prospective study. Infect Control. 1987;8:357–363.10.1017/S0195941700067412CrossRefGoogle ScholarPubMed
16. Wadowsky, RM, Yee, RB. Effect of non-Legionellaceae bacteria on the multiplication of Legionella pneumophila in potable water. Appl Environ Microbiol. 1985;49:1206–1210.10.1128/aem.49.5.1206-1210.1985CrossRefGoogle ScholarPubMed
17. Muraca, PW, Yu, VL, Stout, JE. Environmental aspects of Legionnaires' disease. J Amer Water Works Assoc. 1988;80:78–86.10.1002/j.1551-8833.1988.tb02996.xGoogle Scholar
18. Fields, BS, Shotts, EB, Feeley, JC, et al. Proliferation of Legionella pneumophila as an intracellular parasite of the ciliated protozoan tetrahymena pyriformis. Appl Environ Microbiol. 1984;47:467–471.10.1128/aem.47.3.467-471.1984CrossRefGoogle ScholarPubMed
19. King, CH, Shotts, EB, Wooley, RE. Survival of coliforms and bacterial pathogens within protozoa during chlorination. Appl Environ Microbiol. 1988;54:3023–3033.CrossRefGoogle ScholarPubMed
20. Skaliy, P, Thompson, TA, Gorman, GW, et al. Laboratory studies of disinfectants against Legionella pneumophila . Appl Environ Microbiol. 1980;40:697–700.CrossRefGoogle ScholarPubMed
21. Muraca, P, Stout, JE, Yu, VL. Comparative assessment of chlorine, heat, ozone, and UV light for killing Legionella pneumophila within a model plumbing system. Appl Environ Microbiol. 1987;53:447–453.10.1128/aem.53.2.447-453.1987CrossRefGoogle ScholarPubMed
22. Kuchta, JM, States, SJ, McNamara, AM, et al. Susceptibility of Legionella pneumophila to chlorine in tap water. Appl Environ Microbiol. 1983;46:1134–1139.10.1128/aem.46.5.1134-1139.1983CrossRefGoogle ScholarPubMed
23. Kuchta, JM, States, SJ, McGlaughlin, JE, et al. Enhanced chlorine resistance of tap water—adapted Legionella pneumophila is compared with agar medium-passaged strains. J Appl Microbiol. 1985;50:21–26.10.1128/aem.50.1.21-26.1985CrossRefGoogle ScholarPubMed
24. Wang, WLL, Blaser, M, Cravens, J, Johnson, M. Growth, survival and resistance of Legionnaires' disease bacterium. Ann Int Med. 1979;90:614–618.10.7326/0003-4819-90-4-614CrossRefGoogle ScholarPubMed
25. Helms, CM, Massanari, M, Wenzel, RP, et al. Legionnaires' Disease associated with a hospital water system (A five year progress report on continuous hyperchlorination). JAMA. 1988;259:2423–2427.10.1001/jama.1988.03720160043028CrossRefGoogle ScholarPubMed
26. US EPA Office of Drinking Water. Microorganism removal for small water systems. Washington, DC: 1983:(Chapter VI) 1–11.Google Scholar
27. Mead, P, Lawson, JM. Chlorination of water supplies to control Legionella may corrode the pipes. JAMA. 1988;260:2216. Letter,10.1001/jama.1988.03410150064019CrossRefGoogle ScholarPubMed
28. Stout, J, Best, M, Yu, VL. Susceptibility of members of the family Legionellaceae to thermal stress: implications for heat eradication methods in water distribution systems. Appl Environ Microbiol. 1986;52:396–399.CrossRefGoogle ScholarPubMed
29. Best, MG, Goetz, A, Yu, VL. Heat eradication measures for control of nosocomial Legionnaires' disease: implementation, education, and cost analysis. Am J Infect Control. 1984;12:26–30.10.1016/0196-6553(84)90069-5CrossRefGoogle ScholarPubMed
30. Edelstein, P, Whittaker, R, Kreiling, R, Howell, C. Efficacy of ozone in eradication of Legionella pneumophila from hospital plumbing fixtures. Appl Environ Microbiol. 1982;44:1330–1334.10.1128/aem.44.6.1330-1333.1982Google Scholar
31. Knudson, G. Photoreactivation of UV-irradiated Legionella pneumophila and other Legionella species. Appl Environ Microbiol. 1985;49:975–980.10.1128/aem.49.4.975-980.1985CrossRefGoogle ScholarPubMed
32. Gilpin, RW. Laboratory and field applications of UV light disinfection on six species of Legionella and other bacteria in water. In: Thornsberry, C., et al, eds. Legionalla-Proceedings of the 2nd international symposium. Washington, DC: American Society of Microbiology: 1984:337–339.Google Scholar
33. Antopol, SC, Ellner, PD. Susceptibility of Legionella pneumophila to ultraviolet radiation. Appl Environ Microbiol. 1979;30:347.10.1128/aem.38.2.347-348.1979Google Scholar
34. Farr, BM, Gratz, J, Tartaglino, J, Gretchel-White, S, Groschel, D. Evaluation of ultraviolet light for disinfection of hospital water contaminated with legionella. Lancet. 1988;2:669–672.10.1016/S0140-6736(88)90478-3Google Scholar
35. Weber, WJ. Physicochemical processes for water quality control. New York: Wiley; 1972:450.Google Scholar
36. Landeen, KL, Yahya, M, Gerba, CP. Efficacy of copper and silver ions and reduced levels of free chlorine in inactivation of Legionella pneumophila . Appl Environ Micribiol. 1989; 55:3045–3050.10.1128/aem.55.12.3045-3050.1989CrossRefGoogle ScholarPubMed
37. Dournon, E, Bibb, WF, Rajagopalan, P, et al. Monoclonal antibody reactivity as a virulence marker for Legionella pneumophila serogroup 1 strains. J Infect Dis. 1988;157:496–501.10.1093/infdis/157.3.496Google Scholar
38. Stout, JE, Joly, J, Para, M, et al. Comparison of molecular methods for subtyping patients and epidemiologically-linked environmental isolates of L pneumophila . J Infect Dis. 1988;157:486–494.10.1093/infdis/157.3.486CrossRefGoogle Scholar
39. Tompkins, LS, Troup, N, Wood, ST, et al. Molecular epidemiology of Legionella species by restriction endonuclease and alloenzyme analysis. J Clin Microbiol. 1987;25:1875–1880.10.1128/jcm.25.10.1875-1880.1987CrossRefGoogle ScholarPubMed
40. Technical Publications Committee. Technical Memoranda 13, Minimizing the risk of Legionnaires' disease. London: Chartered Institution of Building Service Engineers; 1987.Google Scholar
41. Baird, I, Potts, W, Smiley, J, Click, N, et al. Control of endemic nosocomial legionellosis by hyperchlorination of potable water. In: Thornsberry, C, et al., eds. Legionella—Proceedings of the 2nd International Symposium. American Society of Microbiology: Washington, DC; 1984:333.Google Scholar
42. Witherell, LE, Orciari, LA, Duncan, RW, et al. Disinfection of hospital hot water systems containing Legionella pneumophila . In Thornsberry, C., et al, eds. Legionella-Proceedings of the 2nd international Symposium. American Society of Microbiology: Washington, DC; 1984:336–337.Google Scholar
43. Hanrahan, JP, Morse, D, Scharf, V, et al. Community hospital legionellosis outbreak linked to hot water showers. In: Thornsberry, C., eds. Legionella—Proceedings of the 2nd International Symposium, American Society of Microbiology: Washington, DC; 1984:236–237.Google Scholar
44. Shands, K, Ho, J, Meyer, R, Gorman, G, et al. Potable water as a source of Legionnaires' disease. JAMA. 1985;253:1412–1416.10.1001/jama.1985.03350340064018CrossRefGoogle ScholarPubMed
45. Johnson, JT, Yu, VL, Best, M, Vickers, RM, et al. Nosocomial legionellosis uncovered in surgical patients with head and neck cancer: implications for epidemiologic reservoir and mode of transmission Lancet. 1985;2:298–300.CrossRefGoogle Scholar
46. Johnston, JM, Latham, RH, Meier, FA, et al. Nosocomial outbreak of Legionnaires' disease: molecular epidemiology and disease control measures. Inf Control. 1987;8:53–58.10.1017/S0195941700067072CrossRefGoogle ScholarPubMed
47. Best, M, Yu, VL, Stout, J, Goetz, A, Muder, RR, Taylor, F. Legionellaceae in the hospital water supply—epidemiological link with disease and evaluation of a method of control of nosocomial Legionnaires' disease and Pittsburgh pneumonia. Lancet. 1983;2:307–310.CrossRefGoogle ScholarPubMed
48. Peel, M, Calwell, J, Christopher, P, Harkness, J, Rouch, G. Legionella pneumophila and water temperature in Australian hospitals. Aust NZ J Med. 1985;15:38–41.10.1111/j.1445-5994.1985.tb02729.xCrossRefGoogle ScholarPubMed
49. Rudin, J, Wing, E, Yee, R. An ongoing outbreak of Legionella micdadei . In: Thornsberry, C, et al, eds. Legionella—Proceedings of the 2nd International Symposium. American Society of Microbiology: Washington, DC; 1984:227–229.Google Scholar
50. Neill, MA, Gorman, G, Gibert, C, et al. Nosocomial legionellosis, Paris, France; evidence for transmission by potable water. Am J Med. 1985;78:581–588.Google Scholar
51. Strulens, M, Rost, F, Maas, A, Maes, N, MacIntyre, M, Serruys, E. Nosocomial outbreak of Legionnaires' disease linked to a contaminated water distribution system: epidemiology and control. Interscience Conference of Antimicrobial Agents and Chemotherapy. (abstract); 1988:675.Google Scholar
52. Tobin, JO'H, Beare, J, Dunnill, M, et al. Legionnaires' disease in a transplant unit: Isolation of the causative agent from shower baths. Lancet. 1980;2:118–121.10.1016/S0140-6736(80)90005-7CrossRefGoogle Scholar
53. Fisher-Hoch, SP, Smith, M, Harper, D, Colbourne, J. Source of Legionella pneumophila in a hospital hot water system. In: Thornsberry, C, et al, eds. Legionella—Proceedings of the 2nd International Symposium. American Society of Microbiology: Washington, DC; 1984:302–304.Google Scholar
54. Beam, T, Moreton, D, Heaslip, W, Montes, M, et al. Epidemiology and control of Legionellaceae in state developmental centers. In: Thornsberry, C, et al, eds. Legionella—Proceedings of the 2nd International Symposium, American Society of Microbiology: Washington, DC; 1984236237.Google Scholar
55. Parry, MF, Stampleman, L, Hutchinson, J, et al. Waterborne Legionella bozemanii and nosocomial pneumonia in immunosuppressed patients. Ann Int Med. 1985;103:205–210.10.7326/0003-4819-103-2-205CrossRefGoogle ScholarPubMed
56. Lane, T, Cocke, J, Falk, P, Hansen, C. Four hour superheating of hot water storage tanks to control legionella contamination. 28th Inters cience Conference on Antimicrobial Agents and Chemotherapy (abstract); 1988:676.Google Scholar
57. Snyder, M, Siwicki, M, Wireman, J, Pohlod, D, Riney, S, Grimes, L. Reduction of Legionella pneumophila with continuous supplemental chlorination in a hospital hot water system. 28th Interscience Conference on Antimicrobial Agents and Chemotherapy (abstract); 1988:677.Google Scholar