WATER HYGIENE AND SAFETY


Their findings were as follows: C. difficile was recoverable from air sampled at heights up to 25 cm above the toilet seat. The highest numbers of C. difficile were recovered from air sampled immediately following flushing, and then declined eight-fold after 60 minutes, and a further three-fold after 90 minutes. Surface contamination with C. difficile occurred within 90 minutes after flushing, demonstrating that relatively large droplets are released, which then contaminate the immediate environment. The mean numbers of droplets emitted upon flushing by the lidless toilets in clinical areas were 15-47, depending on design. C. difficile aerosolisation and surrounding environmental contamination occur when a lidless toilet is flushed. The researchers concluded that lidless conventional toilets increase the risk of C. difficile environmental contamination, and they went onto suggest that their use should be discouraged, particularly in settings where C. difficile is common. Unfortunately, despite these findings, it is still common practice in UK healthcare settings for toilets within clinical areas to have no lid.


into an outbreak of Legionnaires’ disease, associated with a decorative water wall fountain in a hospital, laboratory-confirmed Legionnaires’ disease was diagnosed in eight patients, all of whom were present at the same hospital during the 10 days prior to their illness onsets. Six patients had known exposure to a water wall-type decorative fountain near the main hospital entrance. Although the decorative fountain underwent routine cleaning and maintenance, high counts of Legionella pneumophila serogroup 1 were isolated from cultures of a foam material found above the fountain trough. This led to a conclusion that the outbreak of Legionnaires’ disease was associated with exposure to the bio-aerosol emitted from the decorative fountain, and that routine cleaning and maintenance of fountains did not eliminate the risk of bacterial contamination.


Decorative water features An additional area of risk which thankfully is now more well-known is decorative water features (both indoor and outdoor). In a study conducted by Thomas E. Haupt et al18


Jonathan Waggott


During a 30-year career, Jonathan Waggott Dipm, MCIM, FRSPH, MWMSoc, MHIS (Ass), RIBA (Aff), has developed many innovative healthcare products. He studied design and engineering, and is an affiliate member of The Royal Institute of British Architects, an associate member and council member of The Healthcare Infection Society, and chairs two sub-committees of the Water Management Society. He has travelled worldwide visiting many hospitals to better understand how products can be improved and made safer for patients. Last year he was made a Fellow of the Royal Society for Public Health, and has been given the Freedom of the City of London, as well as being inducted into the Worshipful Company of Plumbers. He now runs a consultancy, Jonathan Waggott & Associates, and has become a leading expert in sanitary infection control issues.


there should be very careful consideration of when and where to site sanitary apparatus, while decorative water features should ideally not be used in healthcare premises.


References: 1 ASHRAE Position Document on Airborne Infectious Diseases. 19 January 2014.


2 Barker J, Jones MV. The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet. J Appl Microbiol 2005; 99 (2): 339-47.


3 Seto WH, Conly JM, Pessoa-Silva CL, Malik M, Eremin S. Infection prevention and control measures for acute respiratory infections in healthcare settings: an update. WHO IRIS. 2013: 39-47.


4 Szymanska J. Dental bioaerosol as an occupational hazard in a dentist’s workplace. Ann Agric Environ Med 2007; 14 (2): 203-7.


5 Laheij AM, Kistler JO, Belibasakis GN, Valimaa H, de Soet JJ; European Oral Microbiology Workshop (EOMW) 2011. Healthcare-associated viral and bacterial infections in dentistry. J Oral Microbiol 2012; 4.


6 Brankston G, Gitterman L, Hirji Z, Lemieux C, Gardam M. Transmission of influenza A in human beings. Lancet Infect Dis 2007; 7 (4): 257-65.


To conclude, it is clear that bio-aerosols containing harmful pathogens can come from a number of apparatuses within healthcare premises – including showers, taps, washbasins, sinks, toilets, and decorative water features. I believe that in order to reduce the instances of people becoming sick, and sometimes dying, due to healthcare-acquired infections caused by such bio-aerosols, manufacturers should continue to design better products that reduce aerosol risk. In addition,


7 Tellier R. Aerosol transmission of influenza A virus: a review of new studies. JR Soc Interface 2009; 6 (Suppl 6): S783-90


8 Gralton J, Tovey E, McLaws ML, Rawlinson WD. The role of particle size in aerosolised pathogen transmission: a review. J Infect 2011; 62 (1): 1-13.


9 Tuttlebee CM, O’Donnell MJ, Keane CT et al. Effective control of dental chair unit waterline biofilm and marked reduction of bacterial contamination of output


water using two peroxide-based disinfectants. J Hosp Infect 2002; 52 (3): 192–205.


hej


10 Roberts K, Smith CF, Snelling AM et al. Aerial dissemination of Clostridium difficile spores. BMC Infect Dis 2008; 8: 7.


11 Cordes LG, Wiesenthal AM, Gorman GW. Isolation of Legionella pneumophila from hospital shower heads. Ann Intern Med 1981; 94 (2): 195-7.


12 Meenhorst PL, Reingold AL, Gorman GW et al. Legionella pneumonia in guinea pigs exposed to aerosols of concentrated potable water from a hospital with nosocomial Legionnaires’ disease. J Infect Dis 1983; 147 (1): 129-32.


13 Bollin GE, Plouffe JF, Para MF, Hackman B. Aerosols containing Legionella pneumophila generated by shower heads and hot-water faucets. Appl Environ Microbiol 1985; 50 (5): 1128-31.


14 De Geyter D, Blommaert L, Verbraeken N et al. The sink as a potential source of transmission of carbapenemase- producing Enterobacteriaceae in the intensive care unit. Antimicrob Resist Infect Control 2017; 6: 24.


15 Jessen CU. Airborne microorganisms: occurrence and control. GEC Gad Forlag, Copenhagen, 1955.


16 Barker J, Jones MV. The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet. J Appl Microbiol 2005; 99 (2): 339-47.


17 Best EL, Sandoe JA, Wilcox MH. Potential for aerosolization of Clostridium difficile after flushing toilets: the role of toilet lids in reducing environmental contamination risk. J Hosp Infect 2012; 80 (1): 1-5.


18 Haupt TE, Heffernan RT, Kazmierczak JJ et al. An outbreak of Legionnaires’ disease associated with a decorative water wall fountain in a hospital. Infect Control Hosp Epidemiol 2012; 33 (2): 185-91.


February 2019 Health Estate Journal 41


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