AIHA EMLAP Accredited Laboratory #162952 State of Virginia Department of Minority Business Enterprise: Certificate Number: 652931 State of Texas Department.

AIHA EMLAPAIHA EMLAP Accredited Laboratory #162952 Accredited Laboratory #162952State of Virginia Department of Minority Business EnterpriseState of Virginia Department of Minority Business Enterprise : Certificate Number: 652931: Certificate Number: 652931State of Texas Department of State Health ServicesState of Texas Department of State Health Services: License Number: LAB0166: License Number: LAB0166Consulting Member – Association of Water TechnologiesConsulting Member – Association of Water Technologies (AWT) (AWT)

LegionellaLegionella Analysis & Reporting Services Analysis & Reporting Services

Core ServicesCore Services

CUSTOM SAMPLING PROTOCOLS CUSTOM SAMPLING PROTOCOLS VIABLE AIR SAMPLE ANALYSIS VIABLE AIR SAMPLE ANALYSIS VIABLE, BULK/SWAB ANALYSISVIABLE, BULK/SWAB ANALYSIS LEGIONELLA ANALYSIS LEGIONELLA ANALYSIS NON-VIABLE AIR ANALYSIS NON-VIABLE AIR ANALYSIS DIRECT MICROSCOPY ANALYSISDIRECT MICROSCOPY ANALYSIS

SANAIR TECHNOLOGIES LABORATORYSANAIR TECHNOLOGIES LABORATORY operates a operates a state-of-the-art microbiological analysis laboratory, based in state-of-the-art microbiological analysis laboratory, based in Powhatan, Virginia, specializing in full service Powhatan, Virginia, specializing in full service environmental microbial analyses for indoor air quality (IAQ) environmental microbial analyses for indoor air quality (IAQ) investigations. investigations.

Major Market SegmentsMajor Market Segments

Segment 1 – Chemical Processing/Industrial PlantsSegment 1 – Chemical Processing/Industrial Plants

Segment 2 – Hospitals/HealthcareSegment 2 – Hospitals/Healthcare

Segment 3 – Commercial/Residential ComplexesSegment 3 – Commercial/Residential Complexes

Segment 4 - Hospitality IndustrySegment 4 - Hospitality Industry

Investigating the SourceInvestigating the SourceSegment 1Segment 1 - Chemical Processing/Industrial Plants - Chemical Processing/Industrial Plants

Cooling TowersCooling Towers Process Water SystemsProcess Water Systems Piping Dead LegsPiping Dead Legs Potable Water SystemsPotable Water Systems Air Conditioning SystemsAir Conditioning Systems Evaporative Cooling SystemsEvaporative Cooling Systems Other Aerosolizing Devices & EquipmentOther Aerosolizing Devices & Equipment

Investigating the SourceInvestigating the Source Segment 2Segment 2 - - Hospitals/HealthcareHospitals/Healthcare

Cooling TowersCooling Towers Air Conditioning SystemsAir Conditioning Systems Potable Water SystemsPotable Water Systems Decorative FountainsDecorative Fountains Ice MakersIce Makers Respiratory Care EquipmentRespiratory Care Equipment Dialysis EquipmentDialysis Equipment Whirlpool Bath Treatment SystemsWhirlpool Bath Treatment Systems Carpet Cleaning EquipmentCarpet Cleaning Equipment HumidifiersHumidifiers Cafeteria Water & Ice SystemsCafeteria Water & Ice Systems

Investigating the Source Investigating the Source Segment 3Segment 3 - Commercial/Residential Complexes - Commercial/Residential Complexes

Cooling TowersCooling Towers Potable Water SystemsPotable Water Systems Air Conditioning SystemsAir Conditioning Systems HumidifiersHumidifiers Whirlpool SpasWhirlpool Spas Decorative FountainsDecorative Fountains Ice MakersIce Makers Carpet Cleaning EquipmentCarpet Cleaning Equipment

Investigating the SourceInvestigating the SourceSegment 4 – Hospitality IndustrySegment 4 – Hospitality Industry

Cooling TowersCooling Towers Potable Water SystemsPotable Water Systems Air Conditioning SystemsAir Conditioning Systems HumidifiersHumidifiers Whirlpool SpasWhirlpool Spas Decorative FountainsDecorative Fountains Ice MakersIce Makers Carpet Cleaning EquipmentCarpet Cleaning Equipment

LegionellaLegionella: : Where is it commonly found?Where is it commonly found?

Cooling Towers: Evaporative Condensers / Heat-Transfer Cooling Towers: Evaporative Condensers / Heat-Transfer Associated Water Systems & Municipal/Potable/Process Water Associated Water Systems & Municipal/Potable/Process Water Systems.Systems.

LegionellaLegionella occurs naturally in aquatic habitats occurs naturally in aquatic habitats

Low levels occur in Municipal Water SystemsLow levels occur in Municipal Water SystemsThis occurrence may seed This occurrence may seed youryour Make-Up Water Make-Up Water

Legionella may colonize & amplify in hot water Legionella may colonize & amplify in hot water tanks, dead legs in distribution systems, etc…tanks, dead legs in distribution systems, etc…

LegionellaLegionella-Legionnaires Disease-Legionnaires Disease(Cause & Effect)(Cause & Effect)

Causative Agent: a bacterium named Legionella Causative Agent: a bacterium named Legionella pneumophila – pneumophila – an old bacteria that was finally recognized and an old bacteria that was finally recognized and named.named.

Forty-eight identified species currently - Forty-eight identified species currently - more than half being more than half being linked to human disease.linked to human disease.

LD is an acute bacterial infection of the lower LD is an acute bacterial infection of the lower respiratory tract - respiratory tract - bacterial pneumonia.bacterial pneumonia.

LD is potentially fatal - LD is potentially fatal - multi-system respiratory illness with an multi-system respiratory illness with an average mortality rate of 15-20%.average mortality rate of 15-20%.

Legionella dispersion can extend over a distance of 6 Legionella dispersion can extend over a distance of 6 kilometers, that’s more than 3.7 miles - kilometers, that’s more than 3.7 miles - Journal of Infectious Journal of Infectious DiseasesDiseases 193:102-11, 2006193:102-11, 2006   

Legionnaires’ DiseaseLegionnaires’ Disease … …aa common & serious illnesscommon & serious illness

American Society of Microbiology reports that 15-20% of American Society of Microbiology reports that 15-20% of patients admitted to intensive care units with pneumonia had patients admitted to intensive care units with pneumonia had LD.LD.

LegionellaLegionella bacteria are among the top three causes of bacteria are among the top three causes of sporadic, community acquired pneumonias.sporadic, community acquired pneumonias.

The CDC has estimated that the disease infects 8,000 – The CDC has estimated that the disease infects 8,000 – 18,000 persons annually in the US alone. 18,000 persons annually in the US alone.

OSHA estimates up to 50,000 cases of the illness occur each OSHA estimates up to 50,000 cases of the illness occur each year causing more than 4000 deaths.year causing more than 4000 deaths.

Sampling & Testing for Sampling & Testing for LegionellaLegionella: : A Proactive ApproachA Proactive Approach

Water Analysis for Water Analysis for LegionellaLegionella - - useful in useful in assessing risks and in determining whether assessing risks and in determining whether preventive and corrective measures are preventive and corrective measures are working.working.

An An Action PlanAction Plan based on Sampling Results - based on Sampling Results - will signal increased risks and trigger implementation of will signal increased risks and trigger implementation of disinfection procedures. disinfection procedures.

Without SamplingWithout Sampling – – First trigger First trigger → → a case of LDa case of LD..

Testing has been proven to save lives…Testing has been proven to save lives…According to Dr. Victor Yu, chief of the VA's Infectious Disease Section, “CDC CDC is failing Americans.” Between 1978 and 1998, Dr. Yu contends an estimated 35,000 people died needlessly from the disease. "They could have been cured. They didn't even have to have it."

Although its proven that testing saves lives, Yu said hospitals are reluctant to look for Legionnaires' and even more afraid to find it. "The perception is that it's a matter of national shame if you find it in your water supply. But it happens. And you can kill it," he said.

By 1993, Pittsburgh hospitals saw Legionnaires' disease more often than anywhere else in the country, but only because they were actively looking for it. In 1994, the county Health Department began advocating routine testing in hospital systems. According to Dr. Bruce Dixon, director of the Allegheny County Health Department, "It's been reduced in the hospital setting here to an extremely low number. People need to think about Legionella: test for it, find it, and then treat it."

LegionellaLegionella bacteria tend to be an unwanted occupant of the building environment. Their ability to contaminate domestic water systems, coupled with their potential to cause severe health complications, presents a very real concern to building owners and managers. Fortunately, there are methods readily available for both the detection of LegionellaLegionella and its control. Establishing a proactive approach of periodic periodic testingtesting, along with proper water treatment in both cooling towers and hot water systems, is the best way to avoid disease outbreaks and potential lawsuits.

Excerpt from an article in Engineered Systems Magazine by Excerpt from an article in Engineered Systems Magazine by Mr. Jack Springston, CIH, CSP…. Mr. Jack Springston, CIH, CSP….

It's been almost a quarter century since a then-mysterious disease killed 34 convention attendees. It's been almost a quarter century since a then-mysterious disease killed 34 convention attendees. Unfortunate its legacy is still going strong. Unfortunate its legacy is still going strong.

Complying with JCAHO EC 1.7 *Complying with JCAHO EC 1.7 *

Health Care Facilities accredited by the Joint Commission on Health Care Facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations (Accreditation of Healthcare Organizations (JCAHOJCAHO) must have a ) must have a management program to "reduce the potential for organizational-management program to "reduce the potential for organizational-acquired illness."acquired illness." The standard, EC 1.7, holds health care facilities The standard, EC 1.7, holds health care facilities responsible for "managing pathogenic biological agents in cooling responsible for "managing pathogenic biological agents in cooling towers, domestic hot water, and other aerosolizing water systems."towers, domestic hot water, and other aerosolizing water systems."

The American Society for Healthcare Engineering (The American Society for Healthcare Engineering (ASHEASHE), in ), in technical reports on managing waterborne pathogens per technical reports on managing waterborne pathogens per JCAHO EC 1.7JCAHO EC 1.7, , has recommended that health care facilities conduct a has recommended that health care facilities conduct a an assessment of potential sources of an assessment of potential sources of Legionella Legionella and develop a and develop a management plan for maintenance and operation of water systems.management plan for maintenance and operation of water systems.

*HC Information Resources Inc.*HC Information Resources Inc.

Waterborne Pathogens -Waterborne Pathogens - Compliance with JCAHO Requirements Compliance with JCAHO Requirements

Introduction Introduction The Joint Commission's accreditation manuals for 2001 The Joint Commission's accreditation manuals for 2001 includes a new standard that appears in the Environment of Care - Utility includes a new standard that appears in the Environment of Care - Utility Systems Management standards and require health care facilities to Systems Management standards and require health care facilities to develop programs that will reduce organization-acquired illness. Since develop programs that will reduce organization-acquired illness. Since its introduction the standard has been a source of frequent discussion its introduction the standard has been a source of frequent discussion among hospital engineers, facility managers, infection control among hospital engineers, facility managers, infection control practitioners, ASHE and JCAHO staff members. As a means to respond practitioners, ASHE and JCAHO staff members. As a means to respond to the questions regarding the expectations of these new standards to the questions regarding the expectations of these new standards (particularly the waterborne pathogen requirements) and to provide (particularly the waterborne pathogen requirements) and to provide clarification to the confusing and somewhat contradictory literature clarification to the confusing and somewhat contradictory literature ASHE provides information to develop a briefing to clearly state the ASHE provides information to develop a briefing to clearly state the issues and provide guidance for assessing the potential risk and dealing issues and provide guidance for assessing the potential risk and dealing with compliance issues. with compliance issues.

Visit our website for a complete copy of this article: Visit our website for a complete copy of this article: www.sanair.comwww.sanair.com

Who’s Ultimately Responsible…YOU?Who’s Ultimately Responsible…YOU?

YouYou can Detect can Detect

YouYou can Disinfect can Disinfect

YouYou can Control can Control

YouYou can Monitor can Monitor

YouYou can be Responsible can be Responsible

YouYou can also Ignore can also Ignore

YouYou can be held Accountable! can be held Accountable!

Case StudyCase Study Legionnaire's Disease Outbreak Legionnaire's Disease Outbreak

A A $600 million$600 million class action lawsuit was filed in October 2005 on behalf of class action lawsuit was filed in October 2005 on behalf of residents at a Toronto, Ontario nursing home as a result of a deadly outbreak of residents at a Toronto, Ontario nursing home as a result of a deadly outbreak of Legionnaires' disease (LD). Legionnaires' disease (LD).

At least 20 residents died and dozens were hospitalized after the residents of the At least 20 residents died and dozens were hospitalized after the residents of the nursing home became ill. The infection remained undiagnosed for a number of nursing home became ill. The infection remained undiagnosed for a number of days because of false-negative results. days because of false-negative results.

The defendants named in the action included the Public Health Department, the The defendants named in the action included the Public Health Department, the Board of Health, the Ontario Public Health Laboratory, the Homes for the Aged Board of Health, the Ontario Public Health Laboratory, the Homes for the Aged Division of Toronto Community and Neighborhood Services and the Seven Oaks Division of Toronto Community and Neighborhood Services and the Seven Oaks Home for the Aged. Home for the Aged.

The allegations stated that the defendants were The allegations stated that the defendants were negligent in the collection, negligent in the collection, sampling, testing, diagnosing and evaluating of the bacterium Legionella sampling, testing, diagnosing and evaluating of the bacterium Legionella Pneumophillia. Pneumophillia.

The Lab you chose is of the Greatest Concern… all labs are not equal.The Lab you chose is of the Greatest Concern… all labs are not equal.Choose Wisely… Choose Wisely…

Choose: SanAir Technologies LaboratoryChoose: SanAir Technologies Laboratory

Partnering Programs…Partnering Programs…

Water Hygiene Consulting ServicesWater Hygiene Consulting Services

Risk Management ProceduresRisk Management Procedures

Energy Efficiency Upgrade ProgramsEnergy Efficiency Upgrade Programs

LEED Credit Generation ProtocolsLEED Credit Generation Protocols

Water Hygiene Program ImplementationWater Hygiene Program Implementation

Autonomous Monitoring & ControlAutonomous Monitoring & Control

Solutions Guaranteed…Solutions Guaranteed…

SanAir Technologies Laboratory offers…SanAir Technologies Laboratory offers…

Industry Knowledge – Industry Knowledge – we know your needs we know your needs

Staff Engineer: 20 years in process/hospital industriesStaff Engineer: 20 years in process/hospital industries

Commitment to Excellence – Commitment to Excellence – we have the expertisewe have the expertise Lab Staff: all degreed and advanced degreed scientists Lab Staff: all degreed and advanced degreed scientists

Lab Equipment - Lab Equipment - utilize proven technologyutilize proven technology

State-of-the-art in Microbial AnalysisState-of-the-art in Microbial Analysis

Reporting Format – Reporting Format – offer quality, defensible reportsoffer quality, defensible reports

Web-based, remote access, near real timeWeb-based, remote access, near real time

Legionella Legionella Analysis…Analysis…

PCR-Polymerase Chain Reaction & DNA Sequencing TechnologyPCR-Polymerase Chain Reaction & DNA Sequencing Technology

Traditional Culture→ subculture to purify isolate Traditional Culture→ subculture to purify isolate [cfu/ml or [cfu/ml or cfu/L]→ cfu/L]→ DNA Acquisition DNA Acquisition with Polymerase Chain Reaction→ with Polymerase Chain Reaction→ DNA SequencingDNA Sequencing

Truly Quantitative – with Culture Based AccuracyTruly Quantitative – with Culture Based Accuracy Truly Qualitative - with Genomics Based AccuracyTruly Qualitative - with Genomics Based Accuracy Speciation of 45 Speciation of 45 LegionellaLegionella Species Species Serogroup ID for L. pneumophila (1 & 2/14)Serogroup ID for L. pneumophila (1 & 2/14)

97, 2489-2494, Vol 63, No. 7 Copyright © 1997, American Society for Microbiology

Development of a new seminested PCR method for detection of Legionella species and its application to surveillance of legionellae in hospital cooling tower water

H Miyamoto, H Yamamoto, K Arima, J Fujii, K Maruta, K Izu, T Shiomori and S Yoshida Department of Microbiology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan. [email protected]

The presence of PCR inhibitors in water samples is well known and contributes to the fact that a practical PCR assay has not been developed for legionella surveillance. In this study, we devised a new seminested PCR assay for detection of Legionella spp. in water samples as a means of overriding the PCR inhibitors without loss of sensitivity. The seminested PCR assay utilized primers to amplify the 16S rRNA gene (LEG primers) of 39 Legionella spp. The assay was specific to legionellae, and the sensitivity was 1 fg of extracted Legionella DNA in laboratory examination. To evaluate the feasibility and sensitivity of the PCR assay in identifying the presence of legionellae, it was used to survey Legionella contamination in the water of 49 cooling towers of 32 hospitals. A commercially available EnviroAmp Legionella kit and a culture method were also used in the survey for comparison with the seminested PCR assay. The detection rates of

legionellae in the samples were 91.8% (45 of 49) by the PCR assay and 79.5% (39 of 49) by the culture method. The EnviroAmp kit revealed that 30.6% of the water samples (15 of 49) contained inhibitors of the PCR amplification. However, the seminested PCR assay could produce the Legionella-specific DNA bands in 14 of the 15 samples. Although 8 of the 14 samples were positive in the first-step PCR, 6 of the 14 samples became positive in the second-step PCR. These results suggest that the effect of PCR inhibitors in samples, if any, can be reduced because of the dilution of the sample in the second-step PCR and that sensitivity of detection can be increased by the second- step PCR. Thus, the seminested PCR assay with LEG primers to amplify the 16S rRNA gene of 39 Legionella spp. was a practical and sensitive method to detect Legionella spp. in water samples.

SanAir’s Web Based Reporting FormatSanAir’s Web Based Reporting FormatReporting format to include:Reporting format to include:

Site specific cooling tower (ID) - Color coded indicating status of analysis.Site specific cooling tower (ID) - Color coded indicating status of analysis. Color Coding indicates numerical groupings of Colony Forming Units/liter (cfu/liter)Color Coding indicates numerical groupings of Colony Forming Units/liter (cfu/liter)Color Coding as indicated:GreenGreen:: no colonies detected – no action required no colonies detected – no action requiredBlueBlue: colonies detected - range: 1 – 9… Action Level : colonies detected - range: 1 – 9… Action Level OneOne Mandate MandateOrangeOrange:: colonies detected – range: 10 – 99… Action Level colonies detected – range: 10 – 99… Action Level TwoTwo Mandate MandateYellowYellow: colonies detected – range: 100 – 999… Action Level : colonies detected – range: 100 – 999… Action Level Three Three MandateMandateRedRed:: colonies detected – range: 1000 +… Action Level colonies detected – range: 1000 +… Action Level FourFour Mandate Mandate

Action Level Mandates per Client Corporate Standards… Action Level Mandates listed on Summary Page of Report.

Notes:Notes:

1.1. SanAir Technologies Laboratory will report each Cooling Tower’s actual number of SanAir Technologies Laboratory will report each Cooling Tower’s actual number of CFUs on Summary page.CFUs on Summary page.

2.2. SanAir Technologies Laboratory will report additional Bacterial Findings on SanAir Technologies Laboratory will report additional Bacterial Findings on Summary page.Summary page.

3.3. Client will have access code to view and download data from remote locations.Client will have access code to view and download data from remote locations.4.4. SanAir Technologies Laboratory will archive sample data for 5 yearsSanAir Technologies Laboratory will archive sample data for 5 years5.5. ISO standards require 1 liter sample/location.ISO standards require 1 liter sample/location.6.6. Samples should be received by mid-week in order to facilitate proper lab Samples should be received by mid-week in order to facilitate proper lab

proceduresprocedures7.7. All samples will follow strict Microbiology Chain of Custody protocols customized All samples will follow strict Microbiology Chain of Custody protocols customized

for Clientfor Client8.8. SanAir Technologies Laboratory’s QC, SOPs & C of C protocols are available via SanAir Technologies Laboratory’s QC, SOPs & C of C protocols are available via

websitewebsite9.9. SanAir Technologies Laboratory procedures based on ISO 1173.1 part 1: 1998SanAir Technologies Laboratory procedures based on ISO 1173.1 part 1: 1998 ..

Sample: Web Based Reporting FormatSample: Web Based Reporting Format

When to Sample for Bacteria ?When to Sample for Bacteria ?

Total Bacterial Sampling is not enough. Specific tests for Legionella is required for a good maintenance program. If there is a suspicion or presumption that water sources are contaminated or if a single case of Legionnaires’ disease exists, a thorough study of the water system is warranted. After the water systems have been systematically evaluated and control actions have been taken, water should be sampled. Water should be collected under the guidance of an accredited lab. The laboratory will analyze the bacteria under controlled conditions. Contamination is expressed in number of colony forming units per milliliter of water (CFU/ml). The limit of detection for this analysis is 200-1000 CFU/liter. The following table should be used to interpret lab results and develop action plans.

AACCTTIIOONN

CoolingCoolingTowerTower

DomesticDomesticWaterWater HumidifierHumidifier

11 100100 1010 11

22 1,0001,000 100100 1010

Action 1:Action 1: Prompt cleaning and/or biocide treatment of the system. Prompt cleaning and/or biocide treatment of the system.

Action 2:Action 2: Immediate cleaning and/or biocide treatment. Take prompt steps to prevent Immediate cleaning and/or biocide treatment. Take prompt steps to prevent employee exposureemployee exposure..

 Health and SafetyUAW members can draw upon the resources and expertise of the largest health and safety department of any American union. The UAW Health and Safety Department educates UAW members, local union leaders, and staff about ways to prevent and eliminate safety and health hazards.

Legionella pneumophila

Legionella sp. under UV illumination

Legionella Analytical Management Staff:Legionella Analytical Management Staff:

John H. KeeneJohn H. Keene, Dr. P.H., CBSP, , Dr. P.H., CBSP, Director of Technical DevelopmentDirector of Technical Development

Stephen N. HayesStephen N. Hayes, BSMT (ASCP), , BSMT (ASCP), VP, Technical OperationsVP, Technical Operations

L. Claire MacdonaldL. Claire Macdonald, BS, CMI, , BS, CMI, Laboratory DirectorLaboratory Director

William J. KokolisWilliam J. Kokolis, MS, (ASCP-M) , MS, (ASCP-M) Special Pathogens Technical Special Pathogens Technical ManagerManager

Legionella Sampling KitLegionella Sampling Kit

Shown: Kit – 1 # SA – LS – 4 – 2

Kit – 1 (4Pak) - # SA - LS – 4 – 2: 1 cooler, 4 sample bottles, 2 scoops, 4 swabs, ice pack Kit – 2 (6Pak) - # SA – LS – 6 – 2: 1 cooler, 6 sample bottles, 2 scoops, 4 swabs, ice pack Kit – 3 (8Pak) - # SA – LS – 8 – 2: 1 cooler, 8 sample bottles, 2 scoops, 4 swabs, ice pack

Custom kits per client need:

Summation:Summation:

Absence of Absence of LegionellaLegionella = no risk for Legionnaires’ Disease. = no risk for Legionnaires’ Disease.

Only practical way to determine the presence of Only practical way to determine the presence of Legionella Legionella →→ test for it.test for it.

Routine testing is a proven, logical, and proactive choice.Routine testing is a proven, logical, and proactive choice.

Detection is not the end of the world… Solutions are available.Detection is not the end of the world… Solutions are available.

When taking preventative measures to control When taking preventative measures to control LegionellaLegionella in water, then in water, then you should periodically test to insure the preventative measures are you should periodically test to insure the preventative measures are working.working.

Please, remember the results of sampling may provide life-saving Please, remember the results of sampling may provide life-saving information.information.

Additional Case Studies on Legionnaire's Disease are available on our website:

www.sanair.comwww.sanair.com