1. ©2006 Armstrong International, Inc. www.armstronginternational.com Legionella. What is it and how do we treat it?

2. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 2 Legionella – What is it? Type of bacteria found in bodies of water At least 39 species have been identified More than 60 serogroups have been identified Some serogroups have several subtypes

3. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 3 Legionella Pneumophila Most common species of all 15 serogroups Serogroup 1 has at least 50 subtypes Causes 85 to 90 percent of all cases

4. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 4 What is Legionaires’ Disease? A multisystem illness with a deadly type of pneumonia Named by the press to identify the unknown bacterium

5. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 5 Legionaires’ Disease First identified – Bellevue-Stratford Hotel – Philadelphia, July of 1976 Illness struck 221 people 72 who did not attend the convention 34 died

6. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 6 Did you know? 2.4 million cases of pneumonia each year in the U.S. 10,000 to 100,000 are cases of Legionaires’ disease Only 1,000 to 3,000 are reported to CDC

7. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 7 Legionaires’ Disease Cases go undetected due to lack of testing Other cases missed because test procedures are not sensitive enough Deaths from undetected cases classified as pneumonia with an unknown cause

8. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 8 Legionaires’ Disease Most cases occur one or two cases at a time and not an outbreak Sporadic cases generally not reported to the public Overall opinion is that the problem is not that great

9. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 9 Legionaires’ Disease Considered an environmental disease – water to people. Not communicable. Transmission occurs when airborne water droplets containing Legionella are inhaled

10. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 10 The Risk of Infection is Based on Two Key Factors 1.The number of bacteria reaching the body 2.The resistance of the individual

11. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 11 Legionella – Where does it come from? Poorly treated water Poorly designed plumbing systems Poorly treated plumbing systems

12. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 12 Primary Sources of Legionellae Bacteria Domestic Hot Water Systems Cooling Towers Evaporative Condensers Respiratory Care Equipment Showers

13. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 13 Primary Sources of Legionellae Bacteria Faucets Whirlpool Baths Humidifiers Fountains Grocery Store Produce Mister

14. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 14 Legionella – Where does it live? Bacterial amplifiers Biofilm within plumbing systems

15. Storage Tank Feed-Back System Heated Water Safety Relief Valve Recirculated Water Make Up Water Storage Tank Liquid or Gas Filled Bulb Condensate Return V.B. F&T Trap Temperature Reg Valve Steam Supply P Thermo- meter Temperature signal is “fed back” through capillary tube Recirculatin Pump

16. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 16 Legionellae and Temperature Below 68°F legionellae can survive but are dormant Legionellae growth range (68°F – 122°F) Ideal growth range (95°F – 115°F) Above 122°F legionellae can survive but do not multiply At 131°F legionellae die within 5 to 6 hours At 140°F legionellae die within 32 minutes At 151°F legionellae die within 2 minutes Disinfection range (158°F - 176°F)

17. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 17 Preventive Measures Maintain mechanical and plumbing systems for the control of Legionella If you are high risk for Legionella consider more costly measures to fix your systems and reduce the risks Document all preventive measures to show you took responsible action

18. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 18 Environmental Samplings CDC does not recommend regular water sampling Negative results may create a false sense of security and positive results a false alarm Sampling results, though sometime inconclusive, provide lifesaving information

19. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 19 Samplings – Yes or No? Weigh value of information provided against the cost Weigh the risk of misleading sampling against the risk of not sampling Consider risk management DO NOT use as a substitute for preventive measures

20. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 20 Methods of System Treatment Superheat and Flush (thermal) Feed-Forward Instantaneous Water Heaters (thermal) Hyperchlorination (biocide) Ultra Violet Rays (biocide) Ozone (biocide) Chlorine Dioxide (biocide) Copper/Silver Ionization (biocide)

21. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 21 Superheat & Flush Positives Inexpensive Proven effective irrespective of water quality Non aggressive to pipe work and fittings Non toxic/consumable No professionally qualified personnel required to administer treatment

22. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 22 Superheat & Flush Negatives Potential scald risk Non-effective unless sterilization temperature is achieved (biofilm) Dead-legs may not permit adequate flushing

23. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 23 Temperature/Time Burn Chart Temperature in F° 111.2 116.6 118.4 122.0 131.0 140.0 149.0 158.0 Time for 1 st degree burn 5 hours 35 minutes 10 minutes 1 minute 5 seconds 2 seconds 1 second ------

24. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 24 What types of Water Heaters are on the market today? Feed-Back Units: Operate on a differential of water TEMPERATURE Feed-Forward Units: Operate on a differential of water PRESSURE

25. Storage Tank Feed-Back System Heated Water Safety Relief Valve Recirculated Water Make Up Water Storage Tank Liquid or Gas Filled Bulb Condensate Return V.B. F&T Trap Temperature Reg Valve Steam Supply P Thermo- meter Temperature signal is “fed back” through capillary tube Recirculatin Pump

26. Feed-Forward Instantaneous Water Heater Control Valve Schematic TubeBundle Mixing Chamber Valve #1 Valve #2 Valve #3 Supply Water In @ P1 Blended Water Out @ P2 P1 P2 “Over-heated” Water from tube bundle

27. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 27 Feed-Forward Instantaneous Water Heater Positives Sterilizes water in the heat exchanger as a function of making hot water

28. Feed-Forward Instantaneous Water Heater Control Valve Schematic TubeBundle Mixing Chamber Valve #1 Valve #2 Valve #3 Supply Water In @ P1 Blended Water Out @ P2 P1 P2 “Over-heated” Water from tube bundle

29. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 29 Feed-Forward Instantaneous Water Heater Positives Sterilizes water in the heat exchanger as a function of making hot water Non aggressive to pipe work and fittings Non toxic/consumable No scald risk

30. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 30 Feed-Forward Instantaneous Water Heater Negatives Water which bypasses the heat exchanger is not sanitized Does not kill bacteria in the system biofilm

31. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 31 Hyperchlorination Positives Inexpensive Effectively kills bacteria in the water

32. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 32 Hyperchlorination Negatives Hazardous material which requires trained operators in order to handle The chemical is a carcinogen Aggressive to pipe work and fittings Does not kill bacteria in the biofilm

33. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 33 Ultra Violet Positives Harmless and non-toxic Effectively kills bacteria in the water

34. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 34 Ultra Violet Negatives Expensive Only effective at point of treatment High maintenance cost – lamps wear out and are fragile and need replacement Micro organisms can become resistant and repair UV damage Does not kill the bacteria in the biofilm

35. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 35 Ozone Positives Effectively kills bacteria in the water

36. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 36 Ozone Negatives Difficult to maintain effective levels of ozone in the system – decomposes into water High ozone levels may damage pipe Not tested in facilities – its use would be pioneering Does not kill the bacteria in the biofilm

37. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 37 Chlorine Dioxide Positives Effectively kills bacteria in the water Early indications show potential of killing bacteria in the biofilm as well as removal of biofilm

38. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 38 Chlorine Dioxide Negatives Expensive Concentration levels required often exceed health standards – health & safety issues Aggressive to copper piping Needs special storage – hazardous material Chemical (Potassium, Chlorate and Hydrochloric Acid) is unstable – may explode Professionally qualified personnel required

39. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 39 Copper/Silver Ionization Positives Use of sacrificial anodes produce ions that kill Legionellae bacterial in the water Ions also kill bacteria in the biofilm

40. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 40 Copper/Silver Ionization Negatives Expensive Constant monitoring of ion levels Sacrificial anodes need regular replacement Ion levels can become toxic if they accumulate Professionally qualified personnel required

41. “Expect many enjoyable experiences!” David M. Armstrong “Expect many enjoyable experiences!” David M. Armstrong 41 Questions?Questions?