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ASHRAE SPC 188andand
What that means for Healthcare
South Carolina Society of H lth E iHealthcare Engineers
May 6, 2011
Confidential and proprietary to Garratt-Callahan Company
Who is Garratt Callahan?Who is Garratt Callahan?
Largest privately owned water treatment companyp y
Formed in 1904 family owned andFormed in 1904 – family owned and operated – 4th generation
USA, Mexico, Caribbean, Asia
Confidential and proprietary to Garratt-Callahan Company
ExperienceExperience
Ten years doing secondary disinfection – started in Wisconsin
Preferred vendor to national healthcare GPOs:healthcare GPOs:
Premier, Novation, Amerinet, Med Assets Catholic Health and moreAssets, Catholic Health and more
Confidential and proprietary to Garratt-Callahan Company
Member: National ASHE
PresentationPresentation
IntroductionLegionella, Biology, Mitosisg , gy,Sources of LegionellaRisksRisksCooling Water Domestic Water
Confidential and proprietary to Garratt-Callahan Company
PresentationPresentation
ASHRAEASHRAE HACCPIdentify an Ideal BiocideChoices for Domestic WaterRelative PerformanceEquipment Design / MethodEquipment Design / MethodQ & A
Confidential and proprietary to Garratt-Callahan Company
Legionella p. (gram-negative)Legionella p. (gram negative)
Confidential and proprietary to Garratt-Callahan Company
Legionella pneumophilaLegionella pneumophila
• Thin flagellated Gram-negativeThin, flagellated Gram-negativebacterium of the genus Legionella.
• L pneumophila is the primary• L. pneumophila is the primary human pathogenic bacterium in this group and is the causativethis group and is the causative agent of Legionellosis or Legionnaires' diseaseLegionnaires disease
Confidential and proprietary to Garratt-Callahan Company
Legionella pneumophilaLegionella pneumophila
• 54 genetic strains (serogroups)• 54 genetic strains (serogroups)• Legionella pneumophila
( 1) i th t l th l(serogroup 1) is the most lethal strain
• Protozoonotic - can live and reproduce within amoebae, paramecia (protective habitat)
Confidential and proprietary to Garratt-Callahan Company
Time for a Short Biology LessonTime for a Short Biology Lesson
Confidential and proprietary to Garratt-Callahan Company
But First…A Math Question: “Chess Board For Sale”Chess Board For Sale
64 SquaresPrice Increases in Geometric Progression (2X)g ( )$0.01 for the first square$0 02 for the second square$0.02 for the second square$0.04 for the third squareand so on…How Much for the Board?
Confidential and proprietary to Garratt-Callahan Company
Total Cost….Total Cost….
$184 467 440 737 095 000 00$184,467,440,737,095,000.00
$184 Trillion and Change
Confidential and proprietary to Garratt-Callahan Company
Legionella pneumophilaLegionella pneumophila
Confidential and proprietary to Garratt-Callahan Company
Bacteria CellBacteria Cell
Some bacterium can divide every 20 minutes, others 18 seconds,
Let’s say conditions are not idealLet s say conditions are not ideal
Mitosis takes place every hour…
Confidential and proprietary to Garratt-Callahan Company
Growth RateGrowth Rate
O ll t th St tOne cell at the Start
At end of the first hour 2 cellsAt end of the first hour – 2 cells
End of second hour – 4 cellsEnd of second hour 4 cells
At the end of six hours – 64 cells
Confidential and proprietary to Garratt-Callahan Company
Growth Continues…Growth Continues…
At 18hours – 262,144 Cells
In Only One Day…
16 777 216 Cells16,777,216 Cells
Confidential and proprietary to Garratt-Callahan Company
Bacteria Cells in WaterBacteria Cells in Water
Planktonic: free-floating
Sessile: attached, forming slime
Sli ll b i d i l h idSlime: cells buried in polysaccharide
Confidential and proprietary to Garratt-Callahan Company
Bacterial SlimesBacterial Slimes
Confidential and proprietary to Garratt-Callahan Company
Where is Legionella Found in a Typical Outbreak? USCDCTypical Outbreak? USCDC
100%
70%
80%
90%
80% from Domestic Water
(Potable)
40%
50%
60%
(Potable)
10%
20%
30%
40%
20% fromCooling Water
Confidential and proprietary to Garratt-Callahan Company
0%
10%
In which Facilities does Legionnaire's Disease appear?Legionnaire s Disease appear?
56% from all Others
21% Hotels
23% Healthcare
Confidential and proprietary to Garratt-Callahan Company
How does it enter the body?How does it enter the body?
Aerosol water droplets must be inhaled (aspirated)
Legionellosis develops as aLegionellosis develops as a pneumonia-like infection in the lungslungs
Confidential and proprietary to Garratt-Callahan Company
Areas of Highest RiskAreas of Highest Risk
• Hot and cold water systemsHot and cold water systems– Pipes, faucets, electronic faucets, shower heads, ice makers
• Nebulizers • Cooling towers and evaporative
condenserscondensers• Humidifiers and air washers
P l d• Pools and spas• Air conditioning
Confidential and proprietary to Garratt-Callahan Company
Medical Treatment?Medical Treatment?
Presents as pneumonia – treatment is penicillinp
Patient get worse doctors increasePatient get worse – doctors increase the penicillin dose
Patient can die…
Confidential and proprietary to Garratt-Callahan Company
Treatment for LegionellosisTreatment for Legionellosis
When the doctor knows it is Legionellosis:g
The treatment protocol changes to aThe treatment protocol changes to a “mycin”, penicillin doesn’t work
Confidential and proprietary to Garratt-Callahan Company
Medical Best Practice
Patient can die unless urinary antigen, culture, serology or DFA for Legionella was run and proper diagnosis and treatment is provided.
USCDC directs healthcare to:“maintain high index of suspicionmaintain high index of suspicionfor Legionellosis” where patients
t i kConfidential and proprietary to Garratt-Callahan Company
are at risk.
Legionella in Cooling WaterLegionella in Cooling Water
100%
60%
70%
80%
90%
30%
40%
50%
60%
20% from
0%
10%
20%
20% fromCooling Water
Confidential and proprietary to Garratt-Callahan Company
Cooling TowersCooling Towers
Confidential and proprietary to Garratt-Callahan Company
Cooling TowersCooling Towers
Confidential and proprietary to Garratt-Callahan Company
Cooling WaterCooling Water
Ideal Temperature for Growth –Ideal Temperature for Growth 68oF to 105oF
Lots of Food – air is washed
Biocide Choices are Important
M t P t t SliMust Penetrate Slimes
Confidential and proprietary to Garratt-Callahan Company
Cooling WaterCooling Water
Must KILL Before being dumped
Must Know the Wash Out Rate
Alternating Oxidizer with Non-Oxidizer is highly recommended (ASHRAE, ASHE, USCDC, CTI…)
Confidential and proprietary to Garratt-Callahan Company
Non-Oxidizing BiocidesNon Oxidizing Biocides
Alternate with Oxidizing Biocide
Must be USEPA RegisteredMust be USEPA Registered
Must be used per the LabelMust be used per the Label
Quaternary not effectiveQuaternary not effective
Confidential and proprietary to Garratt-Callahan Company
Non-Oxidizing BiocidesNon Oxidizing BiocidesIsothiazolone
Glutaraldehyde
Organo-sulfur
DBNPA
THPS
T b th l iConfidential and proprietary to Garratt-Callahan Company
Terbuthylazine
Oxidizing BiocidesOxidizing Biocides
Alternate with Non-Oxidizing BiocideBiocide
Must be USEPA RegisteredMust be USEPA Registered
Must be used per the Labelp
Confidential and proprietary to Garratt-Callahan Company
Oxidizing BiocidesOxidizing Biocides
Hypochlorous Acid (Bleach)Hypochlorous Acid (Bleach)OzoneBromine (activated by chlorine)Bromine (activated by chlorine)Bromine chlorideChlorine (gaseous)ChloraminesC o a esChlorine dioxide
Confidential and proprietary to Garratt-Callahan Company
Oxidizing Biocides - SelectionOxidizing Biocides SelectionHypochlorous Acid (Bleach) Not effective at pH
above 8.3, 30 minute kill timeOzone Not very soluble in waterBromine (activated) Good Choice, requires
t ll d i icontrolled mixingBromine chloride Very Good Choice in many
applicationsapplicationsChlorine (gaseous) Dangerous, requires
constant attentionChloramines Requires ammonia mixed with
chlorineChlorine dioxide Excellent but can be more
Confidential and proprietary to Garratt-Callahan Company
Chlorine dioxide Excellent but can be more costly, 99% kill in one minute
Legionella in Domestic WaterLegionella in Domestic Water
100%
60%
70%
80%
90% 80% from Domestic Water
(Potable)
30%
40%
50%
60%
0%
10%
20%
Confidential and proprietary to Garratt-Callahan Company
Domestic Water SystemsDomestic Water Systems
Confidential and proprietary to Garratt-Callahan Company
Domestic Water Pipe with Bacterial SlimeBacterial Slime
Confidential and proprietary to Garratt-Callahan Company
Bacterial SlimesBacterial Slimes
Confidential and proprietary to Garratt-Callahan Company
ASHRAE 12-2000ASHRAE 12 2000
• Recommendations for BestRecommendations for Best Practices
• Widely Ignored Due to Direct Costs ith littl i d b fitwith little perceived benefit
• No support from USCDC, ASHE, CTI, USEPA, Joint Commission
Confidential and proprietary to Garratt-Callahan Company
, ,
Why is Europe ahead of US?Why is Europe ahead of US?
Water Quality is Regulatedy gSpecific Enforcement DepartmentStrict LimitsStrict LimitsFines and Prison
In USA:Quality Measured, not Regulated
Confidential and proprietary to Garratt-Callahan Company
What is changing here in the USA?USA?
ASHRAE SPC 188ASHRAE SPC 188
Work started in 2008Work started in 2008
Due for publication later this year
June Meeting….
Confidential and proprietary to Garratt-Callahan Company
Organizations Supporting ASHRAE SPC 188ASHRAE SPC 188The following have been involved in
h i th St d d SPC188 d hshaping the Standard SPC188 and have indicated support:
1. ASHE2. USCDC - HICPAC3. USEPA4. Joint Commission
Confidential and proprietary to Garratt-Callahan Company
ASHRAE Standard 188ASHRAE Standard 188
• Covers Legionellosis as didCovers Legionellosis as did ASHRAE 12-2000
• No Longer Just a Suggestion• No Longer Just a Suggestion• Failure to Comply will be
id d N liconsidered Negligence• Expected to Require a HACCP be
formed
Confidential and proprietary to Garratt-Callahan Company
What is HACCP?What is HACCP?
• Hazard Analysis & Critical Control Points
• World Health Organization (1997)• Found in USEPA HACCP• Found in USEPA – HACCP
Strategies (2007)
Confidential and proprietary to Garratt-Callahan Company
HACCP PROCESS – initial stepsHACCP PROCESS initial steps
1. Assemble a Team – Operations, Consultants, Engineers, Vendors
2. Describe the end product3 Document the intended use3. Document the intended use4. Construct a Flow Diagram5 V lid t th Fl Di5. Validate the Flow Diagram
Confidential and proprietary to Garratt-Callahan Company
HACCP – Seven PrinciplesHACCP Seven Principles
1. Conduct Hazard Analysis2. Identify Critical Control Points3. Establish Critical Limits3. Establish Critical Limits4. Identify Monitoring Procedures5 E t bli h C ti A ti5. Establish Corrective Actions6. Validate/Verify the HACCP Plan7. Establish Documentation and
Record Keeping
Confidential and proprietary to Garratt-Callahan Company
p g
Next Step: Proactive ApproachNext Step: Proactive Approach1. Form a HACCP Team2 C ll f E i2. Cover all areas of Expertise3. Your Product is Water4. Produce a Flow Diagram5 Assess the Risks5. Assess the Risks6. Identify Control Points7 E t bli h C t l Li it7. Establish Control Limits8. Identify Monitoring Process
Confidential and proprietary to Garratt-Callahan Company
9. Establish Corrective Actions
What are your Products?What are your Products?
Water: used for drinking, showers, cooling water, cooking, ice making, medical treatments
Cooling Water for HVACCooling Water for HVAC
D ti C ld d H t W tDomestic Cold and Hot Water
Confidential and proprietary to Garratt-Callahan Company
Hazard Identified in Std 188Hazard Identified in Std 188
Presence of Legionella pneumophilaPresence of Legionella pneumophilaIn Potable Water
1. Domestic Cold Water2. Domestic Hot Water3 Cooling Water3. Cooling Water4. Water Features (fountains, etc.)
Confidential and proprietary to Garratt-Callahan Company
Your Goal should be PreventionYour Goal should be Prevention
Legionellosis as a Hospital Acquired Infection (HAI) can be actively ( ) yfought using secondary disinfection of potable water within pthe healthcare facility and a good biocide program in cooling waterp g g
Confidential and proprietary to Garratt-Callahan Company
Economic MotivatorsEconomic Motivators
Medicare and many Insurance Companies will not pay for HAIs
Bad Publicity sends potential patients elsewhere – loss ofpatients elsewhere loss of revenue
Lawsuits can cost millions - $$$
Confidential and proprietary to Garratt-Callahan Company
LawsuitsLawsuits
Simple Wrongful Death - $100,000 to $200,000 range
With Negligence - $1,000,000 to $2,000,000$2,000,000
With G N li $10 000 000With Gross Negligence - $10,000,000 to $600,000,000
Confidential and proprietary to Garratt-Callahan Company
Why Doesn’t the Water Authority Take Care of the Problem?Take Care of the Problem?
Most Public Water Authorities useMost Public Water Authorities useSodium hypochlorite (Bleach)
Biocidal Action comes from thef fformation of:
Hypochlorous Acid (HOCl)
Confidential and proprietary to Garratt-Callahan Company
THMs and HAAsTHMs and HAAs
Using bleach forms:
Tri-halomethanes (Chloroform) andTri halomethanes (Chloroform) and Haloacidic Acids by-products
These are identified as cancer i d li it d t 1 0 icausing and limited to 1.0 ppm in
drinking water by USEPA
Confidential and proprietary to Garratt-Callahan Company
Soft Water vs Hard WaterSoft Water vs Hard Water
Hard Water causes scale and under-deposit corrosioncomes from wellsincreased cooling water usagesofter water source is desirablesofter water source is desirable
Soft Water comes from lakes and i f trivers – surface waterscontains more organic pollutants
Confidential and proprietary to Garratt-Callahan Company
dirt and debris
Effect of pH on HOClEffect of pH on HOCl
At pH of 7.5 only 50% of Bleach forms HOCl ( 50% remainder is orders of magnitude less effective as biocide )
At pH of 7.5 a Double-Dose is required to get a Killrequired to get a Kill
HOCl 99% Kill Ti i 30 i tConfidential and proprietary to Garratt-Callahan Company
HOCl 99% Kill Time is 30 minutes
Criteria for an Ideal BiocideCriteria for an Ideal Biocide
High PerformanceEnvironmentally FriendlySafe to UseMake Economic Sense
Confidential and proprietary to Garratt-Callahan Company
Evaluate PerformanceEvaluate Performance
Speed of KillSelective – kills target organismsLow LC50 – lethal concentrationLow LC50 lethal concentrationPenetrates SlimesN t C d b M t i l fNot Consumed by Material of
ConstructionEffective over wide range of
Operating Conditions
Confidential and proprietary to Garratt-Callahan Company
Environmentally FriendlyEnvironmentally Friendly
Minimal by-products of reactionsResidues do not PersistResidues do not PersistBy-products do not PersistConsumables recyclable
Confidential and proprietary to Garratt-Callahan Company
Safe to HandleSafe to Handle
Manageable QuantitiesReleases non reportable (spills)Releases non-reportable (spills)Controllable FormNormal PPE for HandlingMinimized Storage Requiredg q
Confidential and proprietary to Garratt-Callahan Company
Economically FeasibleEconomically Feasible
A i t C t/B fitAppropriate Cost/BenefitEffective at Low DosageControlled ConsumptionMinimal Wasted ProductMinimal Wasted ProductReliable DeliveryO d /I t C t lOrder/Inventory Control
Confidential and proprietary to Garratt-Callahan Company
What are the Choices for Domestic Water Disinfection?Domestic Water Disinfection?
1. Superheat and Flush2. Periodic Hyper Chlorination3. Continuous Chlorination3. Continuous Chlorination4. Chloramines 5 O5. Ozone6. Copper-Silver Ionization7. Ultraviolet Light8. Chlorine Dioxide (ClO2)
Confidential and proprietary to Garratt-Callahan Company
8. Chlorine Dioxide (ClO2)
SUPER HEAT & FLUSH
• Proven effective, but…– Hot Water not available during disinfection– Risk of scalding (return at 124oF)– No residual effect once cooled– Rapid re-growth (not effective against
slimes)– Cold water mixes at point of use (>68oF)– Cold water carries the bacteria– Resource intensive - expensive
Confidential and proprietary to Garratt-Callahan Company
Biofilm vs CaCOBiofilm vs CaCO33 as an Insulatoras an Insulator
Water
BiofilmBiofilm ScaleScale5 mm
1 mm
5 mm
Heat Transfer Surface5 Times Equivalent Reduction in Heat5 Times Equivalent Reduction in Heat
Transfer Rate
CHLORINATION
• Hyper-chlorination is effective, but…– Resource intensive - labor– Does not penetrate slimes– Re-growth occurs quickly– High corrosion rates in copper pipesg pp p p– pH sensitive (50% wasted at 7.5 pH)– Taste and odorTaste and odor– THM’s and HAA’s (carcinogens)
Confidential and proprietary to Garratt-Callahan Company
Continuous ChlorinationContinuous Chlorination
• Requires feed and control system• Will not penetrate slimes• “Burns” the Polysaccharide slimeBurns the Polysaccharide slime• Consumed on non-living things
O idi thi i• Oxidizes anything – corrosive• Adds THMs and HAAs• Is depleted as it flows through
systems
Confidential and proprietary to Garratt-Callahan Company
y
ChloraminesChloramines
• Appears to work wellAppears to work well• Adds ammonia (NH4) to chlorine
R i i h d• Requires ammonia gas hazard on site
• Used in some city water plants• Not safe in a hospitalp
Confidential and proprietary to Garratt-Callahan Company
OZONE
• Effective against planktonic and sessile b t i (O )bacteria (O3, a gas)
• Sparingly soluble, difficult to control• Must be generated close to point of use• High maintenance – coronaHigh maintenance corona• High maintenance – molecular sieve
Hi h• High energy use• Works best at low pH
Confidential and proprietary to Garratt-Callahan Company
• EH&S issues (toxic gas)
Copper/Silver Ions
– 2006 EPA classified as biocide (toxic metals)Still t i t d ith USEPA– Still not registered with USEPA
– Show >40% users still have positives in t d f 16 h it l (J t St t Vi t Y )study of 16 hospitals (Janet Stout, Victor Yu)
– High capital costs ($90,000 average)S iti t H ( 7 6) d h d– Sensitive to pH (<7.6) and hardness
– Difficult to control desired residual– Sophisticated analytical techniques– High maintenance costs (cleaning)
Confidential and proprietary to Garratt-Callahan Company
– Source of corrosion in copper pipes
Ultra-Violet LIGHT
• Excellent disinfection technique when water is l (l NTU lt )clear (low NTUs - ultrapure)
• Effective over very short range when thin film (< 3 ) i d(< 3mm) is used
• Bulbs become coated, effectiveness lostF t b lb l t• Frequent bulb replacement
• No residual, localized disinfection only• Not effective on open-recirculating cooling
tower water
Confidential and proprietary to Garratt-Callahan Company
CHLORINE DIOXIDE
• EPA approved drinking water additive• OK to use on both hot and cold water• Effective regardless of water chemistry• Effective at very low levels 0 2 0 3 PPM• Effective at very low levels, 0.2 – 0.3 PPM• Controlled with Water Meter and ClO2 Analyzers (hot
or cold water)• Penetrates biofilm (polysaccharides) without reacting• Residual can be traced throughout facility• Low corrosion rates (very low affect on pH)• Low corrosion rates (very low affect on pH)• No THM’s or HAA’s, adds no taste or odor• Removed by normal Dialysis pre-filters
Confidential and proprietary to Garratt-Callahan Company
GC Selected This MoleculeGC Selected This Molecule
Chlorine Dioxide (ClO2)
5HCl + 5NaClO2 4ClO2 + HCl + 2H2O
Stoichiometric Reaction (equal volumes)
“Best Available Technology”
Confidential and proprietary to Garratt-Callahan Company
est a ab e ec o ogy
Water Pipe after Treatment with ClO2ClO2
Confidential and proprietary to Garratt-Callahan Company
Evaluate PerformanceEvaluate Performance
Speed of KillSelective – kills target organismsLow LC50 – lethal concentrationLow LC50 lethal concentrationPenetrates SlimesN t C d b M t i l fNot Consumed by Material of
ConstructionEffective over wide range of
Operating Conditions
Confidential and proprietary to Garratt-Callahan Company
ClO2 PerformanceClO2 Performance
99.999% Kill in 60 secondsVery low dosage
Polluted Water Study: 1 PPM ClO2
C t l t 40 PPM ClCompares to almost 40 PPM Cl2Selective OxidizerSame Kill Rate at pH 6.5-8.5LC50 = 293 ppm in air
Confidential and proprietary to Garratt-Callahan Company
LC50 293 ppm in air
ClO2 Environmental ImpactClO2 Environmental Impact
Not reg lated nder CERCLANot regulated under CERCLA (Comprehensive Environmental Response Compensation andResponse, Compensation and Liability Act of 1980)
Not regulated under SARA Title III, Section 304
Confidential and proprietary to Garratt-Callahan Company
ClO2 SafetyClO2 Safety
No Reportable Spill Quantity
USEPA Approved for Potable Water at 0.8 PPM
Normal PPE for Chemical H dliHandling
Confidential and proprietary to Garratt-Callahan Company
ClO2 EconomicsClO2 Economics
Low Dosage is Effective (0.1-0.3 ppm)
Made on site from PrecursorsSimple operationSimple operationMaintenance can be in-houseP di ti M i t kPredictive Maintenance makes
budgeting easyRange of Generator Capacities
Matched to Need
Confidential and proprietary to Garratt-Callahan Company
Grundfos EquipmentGrundfos Equipment
M th 30 i EMore than 30 years in EuropeWorld Class Pump ManufacturerSimplest Method – KISSEasy Set up and MaintenanceEasy Set up and MaintenanceNo membranes to scale or failSt i htf d t lStraightforward controlClO2 gas is always in solution
Confidential and proprietary to Garratt-Callahan Company
Grundfos MethodGrundfos Method
Add in WaterAdd in diluted hydrochloric acidyAdd in diluted sodium chloriteAdd in more dilution waterAdd in more dilution waterAllow to ReactGravity Feed to ReservoirPump to System on Demand
Confidential and proprietary to Garratt-Callahan Company
Data Collection and AlarmsData Collection and Alarms
Multiple Data PointsMultiple Data PointsAlarms with e-Mail OutT ki d T d A l iTracking and Trend AnalysisAutomatic Report GeneratorsVisible in Real Time from OffsiteDesigned to satisfy regulatorsDesigned to satisfy regulatorsReduces Labor Required
Confidential and proprietary to Garratt-Callahan Company
Operating Information NeededOperating Information Needed
Annual Water ThroughputAnnual Water ThroughputEstimate How Water UsageE ti t P k FlEstimate Peak FlowsWater QualityHot Water Temperature & FlowPipe SizesPipe SizesMaterials of Construction
Confidential and proprietary to Garratt-Callahan Company
ReviewReview
1 Legionellosis Can Kill1. Legionellosis Can Kill2. Form a HACCP Team3. Hire a Consultant Expert4. Identify Risksy5. Make a Plan6 If Secondary Disinfection is6. If Secondary Disinfection is
Needed, Choose Carefully
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Questions?Questions?
Thank You
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