Document name: Maintenance & Operational Procedures for the control of Legionella, water hygiene, ‘safe’ hot water, cold water, drinking water and non-drinking water. Document type

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2.10 Emergency and Outbreak Actions

The contact details, both during office hours and out-of-hours, of the Authorised Person [Water], the Senior Operations Manager, Authorised Person [Water] and the Infection Control Officer [Water] are kept on the main switchboard and the major incident control room.

An outbreak is defined by the Health Protection Agency [HPA] as 2 or more confirmed cases of legionellosis occurring in the same locality within a six month period.

The Trust will follow the guidance presented in Appendix 1 of the “Operational Management” volume of HTM.04-01.
The Authorised Person [Water] will be informed of a suspected case of legionnaires’ disease by the Infection Control Officer [Water]. An investigation will be carried out in association with the Health Protection Agency and the local Consultant in Communicable Disease Control [CsCDC].
It is essential that systems are not drained or disinfected before samples have been taken.
The investigation will concentrate upon all potential sources of Legionella contamination, including:-
[a] cooling towers

[b] domestic hot and cold water storage and distribution systems;

[c] showers or spray washing equipment;

[d] drainage systems and traps;

[e] whirlpool baths or hydrotherapy pools;

[f] condensate trays and traps from air conditioning cooling coils;

[g] humidification equipment;

[h] ice-making machines and water coolers.

NOTE: South West Yorkshire Partnership NHS Foundation Trust & Wakefield PCT have no evaporative cooling towers.
The Authorised Person [Water] will be required to:-
[a] provide details of all pipe layouts and associated equipment;

[b] provide adequate documentation detailing operation and maintenance procedures;

[c] assist the investigation team by locating outlets from which samples can be taken. Easy access to these sampling points is essential;

[d] identify water supplies to medical equipment such as orthodontics, renal dialysis, respiratory therapy;

[e] provide any off-site information e.g. local excavation or earthmoving works, alterations to water supply or drainage systems.
If any relevant legislation has been infringed then the Trust may be subject to a formal investigation by the Police and/or Health and Safety Executive. Once the samples have been taken and the cause of infection identified, it is the responsibility of the Infection Control Officer [Water] and the Authorised Person [Water] to carry out disinfection procedures and implement any remedial action.

2.10.1 Guidelines for Investigating Single Hospital Cases of Legionnaires’ Disease

These guidelines have been developed from “Guidelines for investigating single cases of legionnaires’ disease” published in Communicable Disease & Public Health journal Vol. 5 No. 2 June 2002. Authors - JV Lee and C Joseph of the Health Protection Agency [HPA].
These guidelines are produced for Consultants in Communicable Disease Control [CsCDC], microbiologists, clinicians, environmental health officers [EHOs] and other public health specialists involved in the control and prevention of legionnaires’ disease. It will be the responsibility of the hospital’s Infection Control Officer [Water] to lead the investigation into a single case in a hospital, it is essential that the local CsCDC is informed as soon as possible. The hospital’s Infection Control Officer [Water] will be Authorised for updating this procedure.
Local management of the investigation:

Local Memorandum of Understanding [MoU] – this must be agreed between all relevant agencies [HSE, CsCDC, HPA laboratory, Environmental Health Departments].
Clinical diagnosis of legionnaires’ disease must be supported by confirmed or presumptive microbiological evidence.
As soon as a laboratory diagnosis has been made by a microbiologist the case should be reported to the local CsCDC and local infectious diseases clerk.
Investigation to be commenced following the pre-defined MoU. Investigations for Legionella infections may take place outside the residential area of the patient. If this is the case the suspected / confirmed diagnosis result should be immediately sent to the public health department in whose area the patient resides, the local CsCDC can commence follow up procedures.
The CsCDC to obtain the patient’s movements for the two weeks prior to onset of illness. This will include full address and postcode of place residences, place of work, travel details, accommodation details [overnight stays]. This should also include details of possible hospitals visited and other potential common sites and exposure to Legionella.
All cases should be reported to CsDSC in confidence, via telephone or encrypted fax to a named person. Once clinical, microbiological and exposure histories have been obtained for the case these should be detailed on the standard CsDSC reporting form.
Investigations specific to hospitals will require reviewing the risk assessment for controlling Legionella and maintenance records by the incident control team in conjunction with the Authorised Person [Water].
The review of the risk assessment & maintenance records should identify if there are any deficiencies in controls as detailed by the HSE and NHS guidance. If any such deficiencies in the control are found these should remedied as soon as possible. Any precautionary disinfection of any part of the water system should only be completed after sampling. This sampling will be under the direction of the incident control team and carried out in accordance with BS7592:2008.
A case search for other confirmed or presumptive cases of legionnaires’ disease associated with the hospital or community should be conducted.

2.11 Operation of domestic water systems

System/Service	Task	Frequency	File
Domestic cold water pressurisation pumps	Switch over pumps automatically, Or, manually.	Daily Weekly	N/A PPM
Domestic water tanks	Where multiple tanks, operate in parallel. Where one or more tanks are drained, ensure that all interconnecting pipework and mains cold feed are drained and vented. Check tank temperatures and visually inspect and carry out remedial [where necessary].	Start-up At changeover Biannually	PPM B C
DHW Generator	Where multiple, operate in parallel. Where one or more DHW generators are drained, ensure that all interconnecting pipework and cold feed are drained and vented. Thermostat set to achieve minimum flow temperature of 60^oC and a return temperature of at least 50^oC. In premises with high vulnerability occupants, DHW generator to operate 24 hrs per day, 7 days per week. In other premises operate by time clock, to achieve full temperature one hour before occupation and one hour after each day.	Start-up At changeover Start-up Start-up	PPM B C PPM
DHW generator shunt pumps	Control by time clock. Alternatively, if data plot for one week shows that DHW generator performance criteria are met under continuous pump operation.	1 hr / night	N/A
DHW generator shunt pumps		Continuously	C
DHW distribution pumps	In premises with high vulnerability occupants, distribution pumps to operate 24 hrs per day, 7 days per week. In other premises operate by time clock, to achieve full temperature one hour before occupation and one hour after each day. Manual check that the distribution pump[s] are operating effectively [by temperature checks].	Start-up	N/A
		Monthly	C
Air conditioning plant - humidifier	Set the fan to operate for 30 minutes before the humidifier starts up. Set the humidistat to a maximum of 70% relative humidity.	Start-up Start-up	C C

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