Occurrence of Legionella in hot water systems of single-family residences in suburbs of two German cities with special reference to solar and district heating

Distribution System Water Quality Affects Responses of Opportunistic Pathogen Gene Markers in Household Water Heaters

Illustrative distribution system operation and management practices shaped the occurrence and persistence of Legionella spp., nontuberculous mycobacteria (NTM), Pseudomonas aeruginosa, and two amoebae host (Acanthamoeba spp., Vermamoeba vermiformis) gene markers in the effluent of standardized simulated household water heaters (SWHs). The interplay between disinfectant type (chlorine or chloramine), water age (2.3-5.7 days) and materials (polyvinyl chloride (PVC), cement or iron) in upstream simulated distribution systems (SDSs) profoundly influenced levels of pathogen gene markers in corresponding SWH bulk waters. For example, Legionella spp. were 3-4 log higher in SWHs receiving water from chloraminated vs chlorinated SDSs, because of disinfectant decay from nitrification. By contrast, SWHs fed with chlorinated PVC SDS water not only harbored the lowest levels of all pathogen markers, but effluent from the chlorinated SWHs were even lower than influent levels in several instances (e.g., 2 log less Legionella spp. and NTM for PVC and 3-5 log less P. aeruginosa for cement). However, pathogen gene marker influent levels correlated positively to effluent levels in the SWHs (P < 0.05). Likewise, microbial community structures were similar between SWHs and the corresponding SDS feed waters. This study highlights the importance and challenges of distribution system management/operation to help control opportunistic pathogens.

Field testing hot water temperature reduction as an energy-saving measure--does the Legionella presence change in a clinic's plumbing system?

Legionella spp. represent a significant health risk for humans. To ensure hygienically safe drinking water, technical guidelines recommend a central potable water hot (PWH) supply temperature of at least 60°C at the calorifier. In a clinic building we monitored whether slightly lowered temperatures in the PWH system led to a systemic change in the growth of these pathogens. In four separate phases we tested different scenarios concerning PWH supply temperatures and disinfection with chlorine dioxide (ClO2). In each phase, we took 5 sets of samples at 17 representative sampling points in the building's drinking water plumbing system. In total we collected 476 samples from the PWH system. All samples were tested (culture-based) for Legionella spp. and serogroups. Additionally, quantitative parameters at each sampling point were collected, which could possibly be associated with the presence of Legionella spp. (Pseudomonas aeruginsoa, heterotrophic plate count at 20°C and 36°C, temperatures, time until constant temperatures were reached, and chlorine dioxide concentration). The presence of Legionella spp. showed no significant reactions after reducing the PWH supply temperature from 63°C to 60°C and 57°C, as long as disinfection with ClO2 was maintained. After omitting the disinfectant, the PWH system showed statistically significant growth rates at 57°C. PWH temperatures which are permanently lowered to less than recommended values should be carefully accompanied by frequent testing, a thorough evaluation of the building's drinking water plumbing system, and hygiene expertise.

Relationship between Organic Carbon and Opportunistic Pathogens in Simulated Glass Water Heaters

Controlling organic carbon levels in municipal water has been hypothesized to limit downstream growth of bacteria and opportunistic pathogens in premise plumbing (OPPPs). Here, the relationships between influent organic carbon (0–15,000 µg ozonated fulvic acid /L) and the number of total bacteria [16S rRNA genes and heterotrophic plate counts (HPCs)] and a wide range of OPPPs (gene copy numbers of Acanthamoeba polyphaga, Vermamoeba vermiformis, Legionella pneumophila, and Mycobacterium avium) were examined in the bulk water of 120-mL simulated glass water heaters (SGWHs). The SGWHs were operated at 32–37 °C, which is representative of conditions encountered at the bottom of electric water heaters, with water changes of 80% three times per week to simulate low use. This design presented advantages of controlled and replicated (triplicate) conditions and avoided other potential limitations to OPPP growth in order to isolate the variable of organic carbon. Over seventeen months, strong correlations were observed between total organic carbon (TOC) and both 16S rRNA gene copy numbers and HPC counts (avg. R² > 0.89). Although M. avium gene copies were occasionally correlated with TOC (avg. R² = 0.82 to 0.97, for 2 out of 4 time points) and over a limited TOC range (0–1000 µg/L), no other correlations were identified between other OPPPs and added TOC. These results suggest that reducing organic carbon in distributed water is not adequate as a sole strategy for controlling OPPPs, although it may have promise in conjunction with other approaches.

Lesser-known or hidden reservoirs of infection and implications for adequate prevention strategies: Where to look and what to look for

In developing hygiene strategies, in recent years, the major focus has been on the hands as the key route of infection transmission. However, there is a multitude of lesser-known and underestimated reservoirs for microorganisms which are the triggering sources and vehicles for outbreaks or sporadic cases of infection. Among those are water reservoirs such as sink drains, fixtures, decorative water fountains and waste-water treatment plants, frequently touched textile surfaces such as private curtains in hospitals and laundry, but also transvaginal ultrasound probes, parenteral drug products, and disinfectant wipe dispensers. The review of outbreak reports also reveals Gram-negative and multiple-drug resistant microorganisms to have become an increasingly frequent and severe threat in medical settings. In some instances, the causative organisms are particularly difficult to identify because they are concealed in biofilms or in a state referred to as viable but nonculturable, which eludes conventional culture media-based detection methods. There is an enormous preventative potential in these insights, which has not been fully tapped. New and emerging pathogens, novel pathogen detection methods, and hidden reservoirs of infection should hence be given special consideration when designing the layout of buildings and medical devices, but also when defining the core competencies for medical staff, establishing programmes for patient empowerment and education of the general public, and when implementing protocols for the prevention and control of infections in medical, community and domestic settings.

Current and emerging Legionella diagnostics for laboratory and outbreak investigations

Legionnaires' disease (LD) is an often severe and potentially fatal form of bacterial pneumonia caused by an extensive list of Legionella species. These ubiquitous freshwater and soil inhabitants cause human respiratory disease when amplified in man-made water or cooling systems and their aerosols expose a susceptible population. Treatment of sporadic cases and rapid control of LD outbreaks benefit from swift diagnosis in concert with discriminatory bacterial typing for immediate epidemiological responses. Traditional culture and serology were instrumental in describing disease incidence early in its history; currently, diagnosis of LD relies almost solely on the urinary antigen test, which captures only the dominant species and serogroup, Legionella pneumophila serogroup 1 (Lp1). This has created a diagnostic "blind spot" for LD caused by non-Lp1 strains. This review focuses on historic, current, and emerging technologies that hold promise for increasing LD diagnostic efficiency and detection rates as part of a coherent testing regimen. The importance of cooperation between epidemiologists and laboratorians for a rapid outbreak response is also illustrated in field investigations conducted by the CDC with state and local authorities. Finally, challenges facing health care professionals, building managers, and the public health community in combating LD are highlighted, and potential solutions are discussed.

Mycobacterium avium complex in day care hot water systems, and persistence of live cells and DNA in hot water pipes

The Mycobacterium avium complex (MAC) is a group of opportunistic human pathogens that may thrive in engineered water systems. MAC has been shown to occur in drinking water supplies based on surface water, but less is known about the occurrence and persistence of live cells and DNA in public hot water systems based on groundwater. In this study, we examined the occurrence of MAC in hot water systems of public day care centers and determined the persistence of live and dead M. avium cells and naked DNA in model systems with the modern plumbing material cross-linked polyethylene (PEX). The occurrence of MAC and co-occurrence of Legionella spp. and Legionella pneumophila were determined using cultivation and qPCR. Co-occurrences of MAC and Legionella were detected in water and/or biofilms in all hot water systems at temperatures between 40 and 54 °C. Moderate correlations were observed between abundance of culturable MAC and that of MAC genome copies, and between MAC and total eubacterial genome copies. No quantitative relationship was observed between occurrence of Legionella and that of MAC. Persistence in hot water of live and dead M. avium cells and naked DNA was studied using PEX laboratory model systems at 44 °C. Naked DNA and DNA in dead M. avium cells persisted for weeks. Live M. avium increased tenfold in water and biofilms on PEX. The results suggest that water and biofilms in groundwater-based hot water systems can constitute reservoirs of MAC, and that amplifiable naked DNA is relatively short-lived, whereas PEX plumbing material supports persistence and proliferation of M. avium.

First report of a Chinese PFOS alternative overlooked for 30 years: its toxicity, persistence, and presence in the environment

This is the first report on the environmental occurrence of a chlorinated polyfluorinated ether sulfonate (locally called F-53B, C8ClF16O4SK). It has been widely applied as a mist suppressant by the chrome plating industry in China for decades but has evaded the attention of environmental research and regulation. In this study, F-53B was found in high concentrations (43-78 and 65-112 μg/L for the effluent and influent, respectively) in wastewater from the chrome plating industry in the city of Wenzhou, China. F-53B was not successfully removed by the wastewater treatments in place. Consequently, it was detected in surface water that receives the treated wastewater at similar levels to PFOS (ca. 10-50 ng/L) and the concentration decreased with the increasing distance from the wastewater discharge point along the river. Initial data presented here suggest that F-53B is moderately toxic (Zebrafish LC50-96 h 15.5 mg/L) and is as resistant to degradation as PFOS. While current usage is limited to the chrome plating industry, the increasing demand for PFOS alternatives in other sectors may result in expanded usage. Collectively, the results of this work call for future assessments on the effects of this overlooked contaminant and its presence and fate in the environment.

Identification and quantitative detection of Legionella spp. in various aquatic environments by real-time PCR assay

In this study, a SYBR green quantitative real-time PCR was developed to quantify and detect the Legionella spp. in various environmental water samples. The water samples were taken from watershed, water treatment plant, and thermal spring area in Taiwan. Legionella was detected in 13.6 % (24/176), and the detection rate for river water, raw drinking water, and thermal spring water was 10, 21.4, and 16.6 %, respectively. Using real-time PCR, concentration of Legionella spp. in detected samples ranged between 9.75 × 10(4) and 3.47 × 10(5) cells/L in river water, 6.92 × 10(4) and 4.29 × 10(5) cells/L in raw drinking water, and 5.71 × 10(4) and 2.12 × 10(6) cells/L for thermal spring water samples. The identified species included Legionella pneumophila (20.8 %), Legionella jordanis (4.2 %), Legionella nautarum (4.2 %), Legionella sp. (4.2 %), and uncultured Legionella sp. (66.6 %). The presence of L. pneumophila in aquatic environments suggested a potential public health threat that must be further examined.

Microbial and physicochemical parameters associated with Legionella contamination in hot water recirculation systems

Hot water recirculation systems (HWRS) in hotels and nursing homes, which are common in countries such as Spain, have been related to outbreaks of legionellosis. To establish the relationships of microbial and physicochemical parameters, especially protozoa, with the occurrence of Legionella in HWRS, 231 samples from hotels and nursing homes were analysed for Legionella, protozoa, heterotrophic plate counts (HPC) at 22 and 37 °C, Pseudomonas, metals, temperature and others. Legionella pneumophila was the dominant species isolated, and 22 % were sg. 1. The sampling method became particularly important in order to define which factors were involved on the occurrence of Legionella. Results showed that the bacteria and the accompanying microbiota were more abundant in the first flush water whose temperature was lower. The bacteria occurred in those samples with high HPC and were inversely correlated with high temperatures. Multivariate regression showed that a concentration above 1 × 10(5) CFU/100 mL of HPC at 37 °C, Fe above 0.095 ppm and the presence of protozoa increased significantly the risk of Legionella colonization, while univariant regression showed that the presence of Cu above 0.76 ppm and temperature above 55 °C diminished it. Therefore, to reduce the risk associated with Legionella occurrence in HWRS these parameters should be taken into consideration.

Molecular survey of the occurrence of Legionella spp., Mycobacterium spp., Pseudomonas aeruginosa, and amoeba hosts in two chloraminated drinking water distribution systems

The spread of opportunistic pathogens via public water systems is of growing concern. The purpose of this study was to identify patterns of occurrence among three opportunistic pathogens (Legionella pneumophila, Mycobacterium avium, and Pseudomonas aeruginosa) relative to biotic and abiotic factors in two representative chloraminated drinking water distribution systems using culture-independent methods. Generally, a high occurrence of Legionella (≥69.0%) and mycobacteria (100%), lower occurrence of L. pneumophila (≤20%) and M. avium (≤33.3%), and rare detection of Pseudomonas aeruginosa (≤13.3%) were observed in both systems according to quantitative PCR. Also, Hartmanella vermiformis was more prevalent than Acanthamoeba, both of which are known hosts for opportunistic pathogen amplification, the latter itself containing pathogenic members. Three-minute flushing served to distinguish distribution system water from plumbing in buildings (i.e., premise plumbing water) and resulted in reduced numbers of copies of Legionella, mycobacteria, H. vermiformis, and 16S rRNA genes (P < 0.05) while yielding distinct terminal restriction fragment polymorphism (T-RFLP) profiles of 16S rRNA genes. Within certain subgroups of samples, some positive correlations, including correlations of numbers of mycobacteria and total bacteria (16S rRNA genes), H. vermiformis and total bacteria, mycobacteria and H. vermiformis, and Legionella and H. vermiformis, were noted, emphasizing potential microbial ecological relationships. Overall, the results provide insight into factors that may aid in controlling opportunistic pathogen proliferation in real-world water systems.

Legionellae in engineered systems and use of quantitative microbial risk assessment to predict exposure

While it is well-established that Legionella are able to colonize engineered water systems, the number of interacting factors contributing to their occurrence, proliferation, and persistence are unclear. This review summarizes current methods used to detect and quantify legionellae as well as the current knowledge of engineered water system characteristics that both favour and promote legionellae growth. Furthermore, the use of quantitative microbial risk assessment (QMRA) models to predict potentially critical human exposures to legionellae are also discussed. Understanding the conditions favouring Legionella occurrence in engineered systems and their overall ecology (growth in these systems/biofilms, biotic interactions and release) will aid in developing new treatment technologies and/or systems that minimize or eliminate human exposure to potentially pathogenic legionellae.

Prevalence of Legionella spp. in water systems of hospitals and hotels in South Western Greece

The aim of the present study was to determine the prevalence of Legionella spp. in water systems of hospitals and hotels located in South Western Greece, to study the molecular epidemiology of the isolated strains and their possible association with bacterial contamination (total count and Pseudomonas aeruginosa), the water pH, and temperature. A prevalence survey for Legionella spp. by culturing techniques in water distribution systems of eight hospitals and nine hotels occurred in South Western Greece. Water sampling and microbiological analysis were carried out following the ISO methods. Legionella pneumophila was detected in 33% and 36% of the distribution systems of hospitals and hotels, respectively. Our survey results suggest a frequent prevalence of elevated concentrations of Legionella spp. in water systems of hospitals and hotels. Our investigation has confirmed the need to regularly monitor the microbiological condition of water systems in hospitals and hotels.

An in-premise model for Legionella exposure during showering events

An exposure model was constructed to predict the critical Legionella densities in an engineered water system that result in infection from inhalation of aerosols containing the pathogen while showering. The model predicted the Legionella densities in the shower air, water and in-premise plumbing biofilm that might result in a deposited dose of Legionella in the alveolar region of the lungs associated with infection for a routine showering event. Processes modeled included the detachment of biofilm-associated Legionella from the in-premise plumbing biofilm during a showering event, the partitioning of the pathogen from the shower water to the air, and the inhalation and deposition of particles in the lungs. The range of predicted critical Legionella densities in the air and water was compared to the available literature. The predictions were generally within the limited set of observations for air and water, with the exception of Legionella density within in-premise plumbing biofilms, for which there remains a lack of observations for comparison. Sensitivity analysis of the predicted results to possible changes in the uncertain input parameters identified the target deposited dose associated with infections, the pathogen air-water partitioning coefficient, and the quantity of detached biofilm from in-premise pluming surfaces as important parameters for additional data collection. In addition, the critical density of free-living protozoan hosts in the biofilm required to propagate the infectious Legionella was estimated. Together, this evidence can help to identify critical conditions that might lead to infection derived from pathogens within the biofilms of any plumbing system from which humans may be exposed to aerosols.

[Generally accepted engineering standards and Legionella in drinking water : findings from Frankfurt am Main]

To investigate the association between the engineering standards of drinking water systems and the extent of the Legionella colonization, we subjected our 2006 published data of the drinking water monitoring of the city's public health services for Frankfurt on Main, Germany, to closer analysis. A total of 413 records were available, with both technical data and results of the Legionella colonization. When comparing the classes of technical deficiencies of the drinking water installations with the Legionella colonization results, 93% of the Legionella data "not dedectable in 100 ml" were found in the group of drinking water installations that were technically assessed as "free of deficiencies". Thus, "good" technical engineering is associated with low or lack of Legionella colonization with a high probability even with hints for a dose-effect phenomenon-the more engineering deficiencies that exist, the higher the Legionella contamination.

High-resolution in situ genotyping of Legionella pneumophila populations in drinking water by multiple-locus variable-number tandem-repeat analysis using environmental DNA

Central to the understanding of infections by the waterborne pathogen Legionella pneumophila is its detection at the clonal level. Currently, multiple-locus variable-number tandem-repeat (VNTR) analysis (MLVA) of L. pneumophila isolates can be used as a tool for high-resolution genotyping. Since L. pneumophila is difficult to isolate, the isolation of outbreak strains often fails due to a viable but nonculturable (VBNC) state of the respective environmental population. Therefore, we developed a cultivation-independent approach to detect single clones in drinking water. This approach is based on the extraction of DNA from drinking water followed by PCR using a set of eight VNTR primer pairs necessary for MLVA genotyping of L. pneumophila. The PCR amplicons were analyzed by single-strand conformation polymorphism (SSCP) and capillary electrophoresis to obtain the respective MLVA profiles. Parallel to the high-resolution analysis, we used the same environmental DNA to quantify the number of L. pneumophila cells in drinking water using real-time PCR with 16S rRNA gene-targeted primers. We used a set of drinking water samples from a small-scale drinking water network to test our approach. With these samples we demonstrated that the developed approach was directly applicable to DNA obtained from drinking water. We were able to detect more L. pneumophila MLVA genotypes in drinking water than we could detect by isolation. Our approach could be a valuable tool to identify outbreak strains even after the outbreak has occurred and has the potential to be applied directly to clinical material.

Drinking water quality in household supply infrastructure--A survey of the current situation in Germany

As a result of the amendment to the German Drinking Water Ordinance in 2001, local public health authorities are obliged to monitor the water supply in installations providing water for public use (Section 18 German Drinking Water Ordinance). With a systematic and nationwide survey of locally available data relating to hygienic drinking water quality and the existing drinking water infrastructure in buildings, the extent of microbial contamination of in-building distribution systems in Germany is intended to be assessed. To gain an overview of the microbial contamination of drinking water in public buildings all 419 local public health authorities in Germany were contacted in 2007. In a detailed study with a representative cooperation level of 5% of these local public health authorities, the available data relating to microbiological, chemical, physical and technical parameters gained from in-building distribution systems were collected. Drinking water parameters were combined with regard to the total number of analyses and the absolute number as well as the percentage of limit compliance failures (n=108,288). Limits exceeded were classified as the failure to comply with the German Drinking Water Ordinance, DVGW technical regulations and Federal Environment Agency recommended limits. The highest rates of samples exceeding these limits were found for the parameter Legionella sp. which contaminated 12.8% of all samples (n=22,786; limit: 100 CFU/100ml), followed by heterotrophic plate count at 36 degrees C (3.5%, n=10,928; limit: 100 CFU/1 ml) and Pseudomonas sp. (2.9%, n=3468; limit: 0 CFU/100ml). Legionella sp. and Pseudomonas sp. pose a direct health risk to immunosuppressed users. Additionally, for some chemical parameters, such as nickel, iron and lead, a potential risk for the health of consumers was detected. Further data analysis may reveal whether this contamination is related to stagnation where there is only sporadic use or whether other factors are involved in the process of microbial growth in installation systems.