Legionnaires Disease Outbreak

June 21 to July 4, 2011 6 cases of Legionnaires Disease reported Sent letters to guests who stayed at the Aria during this 2-week period High levels of Legionella bacteria detected in water supplying several guest rooms Follow-up testing did not detect the bacteria

should you be tested, did you develop symptom, who is at risk, could you be infected, could you transmit.

Legionnaires Disease

Epidemic of pneumonia at the Pennsylvania State American Legion convention 1976

221

people affected, 34 died An upscale hotel , the Bellevue-Stratford, closed due to the publicity

Causative mo not identified until 1977 (6 months later) fastidious gram-negative bacillus Prior outbreaks (1940s, 1950s, 1960s)
Unsolved

epidemic of nonpneumonic febrile illness in Pontiac, Michigan (1960s)

pontiac fever

2010 Selfridge Air National Guard Base Outbreak

July 12-24 at least 31 people with an URT illness 6 people diagnosed with Legionnaires disease

Legionella pneumophila
Gram negative aerobic bacillus Single polar flagellum, multiple pili Nutritionally fastidious

Medium:

charcoal yeast extract pH 6.9

Usually find as intracellular organisms

In

nature, found inside protozoa In vivo replicates inside macrophages

Ecology: Legionella pneumophila

Natural habitat: rivers, lakes, streams, thermally polluted waters Survives water treatment process

Chlorine

tolerant Proliferate in man-made habitats Cooling towers, water distribution systems

Transmission: Legionella pneumophila

Aerosolization Aspiration Instillation into lung

Not transmissible person to person

Diseases

Legionnaires disease
Non-specific

clinical presentation Early flu-like symptoms Mild cough early, slightly productive

Pontiac fever
Acute

self-limiting flu-like illness Common

Pontiac Fever
>90% exposed develop symptoms acute, self-limiting flu-like illness

IP

= 24-48 hrs malaise, myalgia, fever, chills, headache

only symptomatic tx necessary complete recovery within 1 week

Legionnaires Disease
Pneumonia is most prominent finding Spectrum of illness from mild cough to stupor with multi-system failure IP = 2-10 days L. pneumophila one of 3 most common etiologic agents of community-acquired pneumonia

Legionnaires Disease

Risk factors
Cigarette

smoking Chronic lung disease Advanced age Immunosuppression

Treatment: erythromycin, doxycycline, azithromycin

Outbreak of legionellosis in Wayne Co., Michigan in 1985

Early May of 1985 14 cases of pneumonia with high fever occurred in 380 persons who attended a church banquet at a hotel on April 27

cases fatal

Washings from the cooling coils of the A/C units supplying the banquet hall positive for Legionella pneumophila

Outbreak in Ohio automotive plant, 2001

March 12-15, 2001 4 cases of Legionnaires disease Exposure to aerosol-producing devices

Finishing

area

L. pneumophila and dentistry

Legionella associated with biofilms in dental unit water lines (DUWLs)

Also

Pseudomonas

DCWs shown to have an increased level of antibodies to Legionella DUWLs require treatment procedures to control biofilm and reduce #s of mos

Dental Unit Waterlines (DUWL)

Bacteria in DUWL first noted in 1963 by Dr. G.C. Blake Large numbers of bacteria present in water and aerosols associated with dental water systems. Biofilms form in DUWLs and can harbor a variety of microorganisms.

Most

of the microbes recovered from dental water systems are gram-negative noncoliform bacteria.

Safe Drinking Water Act

Sets standard for noncoliform bacteria in drinking and recreational water at 500 CFU/ml. DUWL contamination in untreated systems often exceeds 1000 CFU/ml

Range

of 10,000 to 100,000 CFU/ ml commonplace

ADA in 1996 established a goal for dental water to contain no more than 200 CFU/ml

Why the high numbers in DUWL?

Surface colonization
Materials

commonly used to deliver water to dental handpieces, etc., provide excellent substrates for colonization.
Minerals

in water, esp. calcium carbonate, deposited. Organic molecules attach & promote adhesion of bacteria suspended in water Individual cells multiply to form microcolonies Ultimately these coalesce and form a mature biofilm

Why the high numbers?

Laminar flow
Fluids

moving through narrow-bore tubing assume a hydrodynamic pattern known as laminar flow.
Frictional

forces slow the movement of fluids at the tubing surface, creating an environment conducive to formation of biofilm

Flushing

can eliminate suspended microbes but not biofilm.

Why the high numbers? continued

Surface:volume ratio
As

the diameter of a cylinder (waterline) decreases, an increasingly larger surface area becomes available for colonization. This is the biggest factor. Water moves from a 10 inch water main to a 0.5 inch pipe in the dental office to dental water system tubing that is 1/16 in. in diameter.

Water retraction

Older dental units designed to retract water (to prevent water dripping from handpieces and air/water syringes)
Could

also retract oral fluids

Anti-retraction valves installed to prevent retraction of oral fluids

What organisms present?

Biofilm is hospitable environment for fungi, protozoa, and other organisms Legionella pneumophila Pseudomonas aeruginosa Nontubercular Mycobacterium spp. Mostly noncoliform gram-negatives but coliforms have been isolatedespecially with careless handling of bottles and feeder tubes.

Improving the quality of dental water

Waterline flushing
Efficacy

not established as a stand alone tx Does not remove biofilm but can remove suspended organisms

Independent reservoirs
Allows

control of water quality Also best combined with chemical agents

Improving the quality of dental water

Chemical treatment no ideal agent

Intermittent
Intermittent

or continuous chemical release

usually uses biocidal concentrations of germicides that also remove biofilm

Active agent purged prior to patient care

Continuous

tx uses lower concentrations of

chemicals
Chlorine

cpds (sodium hypochlorite) Several dental unit manufacturers recommend weekly tx of DUWL with 1:10 dilution of household bleach

Improving the quality of dental water

Other chemical agents proposed or evaluated:

Chlorhexidine

gluconate Hydrogen peroxide Iodophors Commercial mouthrinses

Improving the quality of dental water

Automated treatment devices

Ozone

and silver germicide

Sterisil

straw/cartridge contains a cation exchange resin and silver (highest concentration 3 ppm) as a germicide

Periodic

treatment regimens

Several

of these including DentaPure iodinated resin cartridges which release 2-6 ppm free iodine into treatment water to control biofilm

Water source controls - reservoirs

Improving the quality of dental water

Filtration
Remove

suspended bacteria but no effect on biofilm formation in pretreatment areas of lines DentaPure filter includes 0.22 m filter

Bottom Line Infection control dilemma

Potential source of infection of immunocompromised patients CDC recommendations:

Sterile

irrigating solutions should be used when surgical procedures involve cutting of bone. All dental instruments that use water should be run 20-30 seconds after each patient and for several minutes before the start of each clinic day.

UDMSD Procedures 1

Before first patient:

Fill

water reservoir and attach to dental unit. Turn on master switch, wait a few seconds for system to pressurize. Flush waterlines for at least 1 minute.

Between patients:
Flush

lines 20-30 seconds.

UDMSD Procedures 2

At the end of the day:

Flush

lines for 30 seconds. Turn off master switch. Remove all handpieces. Remove and empty water bottle and place on bracket tray.