WATER HYGIENE & SAFETY
Person-to-person transmission Unlike Legionella, person-to-person transmission of P. aeruginosa is well documented. The areas designated for treating these patients should therefore be treated as ‘augmented care’, and extra measures should be implemented, including adherence to strict sink cleaning regimes, together with surveillance and monitoring taken to ensure that patients are adequately protected from waterborne infection. This is a real challenge for hospitals where there is a shortage of trained staff due to self- isolation or illness. Ongoing training to increase awareness is essential, even during the pandemic, as staff and patient support staff not familiar with working in such high-risk care settings may not understand the risks from drains, outlets, and water splashing leading to cross- contamination and patient infection. While access can be difficult to COVID- 19 wards, especially for non-medical staff, testing has already highlighted the risk of outlets colonised with high levels of P. aeruginosa (personal communication). A further difficulty I have been made aware of is the reluctance of testing laboratories to accept samples from COVID-19 treatment areas. This means that hospitals may need to carry out the testing ‘in house’. Methods are available which can be used which require little training and minimal equipment, such as the IDEXX Quantitray system, which can give some assurance of control.14
Be aware of the risks
Both the NHS and private healthcare sector need to be aware of the risks from building water systems and associated equipment which have been affected either directly or indirectly by the COVID-19 pandemic. Where water outlets have not been used, water quality can be adversely affected even after a few hours (see Fig. 1 ), and remedial measures – including the temporary fitting of point- of-use filters – should be considered to protect both patients and staff. Resources are required in terms of both finance and staffing to ensure that risk assessments and control measures are put in place to prevent outbreaks of waterborne infection such as Legionnaire’s disease and those caused by P. aeruginosa and other waterborne pathogens. This will avoid further unnecessary stresses on intensive care units, and help to ensure that the lives of patients and staff are not put at risk. In addition to the information on the ESGLI web pages, additional guidance is available from the Drinking Water Inspectorate.
References 1 Uldum LHK, Krogfelt KA, Albrechtsen HJ, Uldum SA. Cluster of Legionnaires’ disease in a newly built block of flats,
54 Health Estate Journal June 2020
Denmark, December 2008 – January 2009. Euro Surveill 2011; Jan 6; 16 (1): Pii. 19759.
2 BS 8680:2020 Water quality – Water safety plans – Code of practice. UK. BSI; 2020.
3 Zhou F, Yu T, Du R et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395 (10229): 1054-62.
4 Xing Q, Li G-j, Xing Y-h et al. Precautions are needed for COVID-19 patients with coinfection of common respiratory pathogens. BMJ Yale medRX [
https://tinyurl.com/y7xtrfku].
iv, 2020
5 European Centre for Disease Prevention and Control (ECDC). Surveillance report. Legionnaires’ disease – Annual Epidemiological report for 2015. Stockholm; 15 Nov 2017.
6 European Commission. Directive of the European Parliament and of the Council on the quality of water intended for human consumption (recast). 2018. Report No: COM(2017) 753 final.
7 European Centre for Disease Prevention and Control (ECDC). Legionnaires’ disease – Annual Epidemiological report for 2017. ECDC, Stockholm; Jan 17 2019.
8 Walker JT, Jhutty A, Parks S et al. Investigation of healthcare-acquired infections associated with Pseudomonas aeruginosa biofilms in taps in neonatal units in Northern Ireland. J Hosp Infect 2014; 86 (1): 16–23.
9 Breidenstein EB, de la Fuente-Nunez C,
Hancock RE. Pseudomonas aeruginosa: All roads lead to resistance. Trends in Microbiology 2011; 19 (8): 419-26.
10 Lalancette C, Charron D et al. Hospital drains as reservoirs of Pseudomonas aeruginosa: Multiple-locus variable- number of tandem repeats analysis genotypes recovered from faucets, sink surfaces and patients. Pathogens 2017; 6 (3): 36.
11 Breathnach AS, Cubbon MD, Karunaharan RN, Pope CF, Planche TD. Multidrug-resistant Pseudomonas aeruginosa outbreaks in two hospitals: Association with contaminated hospital waste-water systems. J Hosp Infect 2012; 82 (1): 19-24.
12 Salm F, Deja M, Gastmeier P et al. Prolonged outbreak of clonal MDR Pseudomonas aeruginosa on an intensive care unit: Contaminated sinks and contamination of ultra-filtrate bags as possible route of transmission? Antimicrobial Resistance & Infection Control 2016; 5: 53.
13 Hota S, Hirji Z, Stockton K et al. Outbreak of multidrug-resistant Pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room design. Infection Control and Hospital Epidemiology 2009; 30 (1): 25-33.
14 Sartory DP, Pauly D, Garrec N et al. Evaluation of an MPN test for the rapid enumeration of Pseudomonas aeruginosa in hospital waters. J Water Health 2015; 13 (2): 427-36.
Dr Susanne Surman-Lee
Dr Susanne Surman-Lee BSc, PHD, CBiol., FRSB, FRSPH, FIHEEM, FWMSoc, MPWTAG, is the chair of the BSI panel that drafted the BS 8680 Water Safety plans Code of Practice and BS 8580 part 2 Code of Practice for risk assessment of Pseudomonas aeruginosa and other waterborne pathogens. She is a long-standing member of both national and international standards committees producing standards relating to water microbiology. A State Registered Clinical Scientist (a Public Health Microbiologist) with over 45 years’ experience in
hej
clinical and public health microbiology, she is a former director of the HPA (now Public Health England) London Food, Water, and Environmental Microbiology Laboratory, and now director and co-owner of Leegionella Ltd – an independent public health consultancy recognised internationally and nationally for both training, and its expertise in the detection of waterborne pathogens and prevention of waterborne disease via the development and implementation of Water Safety Plans, especially in healthcare and the travel industry. She is the Programme director for the RSPH Water Webinar Series, and chair of the RSPH Water Special Interest Group. For almost 20 years she has been involved with the development of national and international guidelines, including the World Health Organization publications, Legionella and the Prevention of legionellosis and Water Safety in Buildings, HSG 274, HSG 282, and HTM 04-01, the PWTAG publications, Swimming Pool Water and Hot Tubs for Business, and Water Management Society guidance. She is the chair of the ESCMID Study group for Legionella Infections (ESGLI) working group, which produced the ESGLI Technical Guidelines for the prevention, control and investigation of infections caused by Legionella, and guidance for managing building water systems during the COVID-19 pandemic.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64