Environmental Aspects of Legionnaires’ Disease

Legionnaires' disease in dental offices: Quantifying aerosol risks to dental workers and patients

Legionella pneumophila is an opportunistic bacterial respiratory pathogen that is one of the leading causes of drinking water outbreaks in the United States. Dental offices pose a potential risk for inhalation or aspiration of L. pneumophila due to the high surface area to volume ratio of dental unit water lines-a feature that is conducive to biofilm growth. This is coupled with the use of high-pressure water devices (e.g., ultrasonic scalers) that produce fine aerosols within the breathing zone. Prior research confirms that L. pneumophila occurs in dental unit water lines, but the associated human health risks have not been assessed. We aimed to: (1) synthesize the evidence for transmission and management of Legionnaires' disease in dental offices; (2) create a quantitative modeling framework for predicting associated L. pneumophila infection risk; and (3) highlight influential parameters and research gaps requiring further study. We reviewed outbreaks, management guidance, and exposure studies and used these data to parameterize a quantitative microbial risk assessment (QMRA) model for L. pneumophila in dental applications. Probabilities of infection for dental hygienists and patients were assessed on a per-exposure and annual basis. We also assessed the impact of varying ventilation rates and the use of personal protective equipment (PPE). Following an instrument purge (i.e., flush) and with a ventilation rate of 1.2 air changes per hour, the median per-exposure probability of infection for dental hygienists and patients exceeded a 1-in-10,000 infection risk benchmark. Per-exposure risks for workers during a purge and annual risks for workers wearing N95 masks did not exceed the benchmark. Increasing air change rates in the treatment room from 1.2 to 10 would achieve an ∼85% risk reduction, while utilization of N95 respirators would reduce risks by ∼95%. The concentration of L. pneumophila in dental unit water lines was a dominant parameter in the model and driver of risk. Future risk assessment efforts and refinement of microbiological control protocols would benefit from expanded occurrence datasets for L. pneumophila in dental applications.

Quantitative microbial risk assessment of Legionella pneumophila in a drinking water supply system in Israel

Legionella pneumophila cause human infections via inhalation of contaminated water aerosols, resulting in severe pneumonia. Legionella spp. prevalence was monitored in a drinking-water distribution system (DWDS) in Northern Israel. Five points (toilet faucets and showers) were sampled seasonally along a three years period. Toilet faucets and shower use, both generating aerosols, are known transmission routes for this pathogen and thus, present a potential health risk. Quantitative Microbial Risk Assessment (QMRA) was applied in order to assess the health risks posed by Legionella for these two exposure scenarios, while considering Legionella seasonality. The obtained results were compared with estimated tolerable risk levels of infection and of disease set by the USEPA and WHO. Both limits were expressed as Disability-Adjusted Life Years index (DALY) being 1 × 10^-4 and 1 × 10^-6, respectively. The QMRA revealed that the annual risk levels for both faucets and showers use exceeded the acceptable risk of infection with an average of 5.52 × 10^-4 and 2.37 × 10^-3 DALY'S per person per year, respectively. Annual risk levels were stable with no significant differences between the three years. Risk levels varied significantly between seasons by up to three orders of magnitude. Risk levels were highest during summer, autumn, and lowest during winter. The highest seasonal infection risk values were found in summer for both faucets and showers, which corresponded to 8.09 × 10^-4 and 2.75 × 10^-3 DALY'S per person per year, respectively. In conclusion, during summer and autumn there is a significant increase of the infection risk associated with exposure to Legionella-contaminated aerosols, in the studied water system. Public health assessment and prevention measures should focus on these seasons.

Greywater reuse - Assessment of the health risk induced by Legionella pneumophila

Greywater (GW), domestic wastewater excluding the streams generated by toilets and kitchens, can serve as an alternative water source. The main options for GW reuse are toilet flushing and garden irrigation, both generating aerosols. These may transmit inhalable pathogens like Legionella and present a potential health risk. This study quantified the health risk that may arise from inhalation of Legionella-contaminated aerosols due to non-potable GW reuse. Data on Legionella concentrations in potable water and GW was collected. Then, Quantitative Microbial Risk Assessment (QMRA) was performed for two possible exposure scenarios: garden irrigation and toilet flushing. This was performed while considering Legionella seasonality. In order to determine the safety of GW reuse regarding Legionella transmission, the obtained results were compared with estimated tolerable risk levels of infection and of disease. Both limits were expressed as Disability-Adjusted Life Years index (DALY) being 10^-4 and 10^-5, respectively. The QMRA revealed that the annual risk associated with reuse of treated and chlorinated GW for garden irrigation and toilet flushing was not significantly higher than the risk associated with using potable water for the same two purposes. In all studied scenarios, the health risk stemming from reusing treated and chlorinated GW was acceptable regarding Legionella infection. In contrast, reuse of untreated or treated but unchlorinated GW should not be practiced, as these are associated with significantly higher health risks.

Legionella pneumophila: From potable water to treated greywater; quantification and removal during treatment

Greywater is an alternative water source that can help alleviate stress on depleted water resources. The main options for greywater reuse are toilet flushing and garden irrigation, both producing aerosols. For that reason transmission of inhalable pathogens like Legionella present a potential risk. To improve the understanding about Legionella in greywater, we traced the pathogen seasonally from the potable water system to the final steps of the greywater treatment in four houses in northern Israel. Physicochemical and microbiological parameters were analyzed in order to assess background greywater quality and to establish possible associations with Legionella. The mean concentrations of Legionella pneumophila isolated from the potable water system were 6.4×10(2) and 5.9×10(3) cfu/l in cold and hot water respectively. By amending the ISO protocol for Legionella isolation from drinking water, we succeeded in quantifying Legionella in greywater. The mean Legionella concentrations that were found in raw, treated and treated chlorinated greywater were 1.2×10(5), 2.4×10(4) and 5.7×10(3) cfu/l respectively. While Legionella counts in potable water presented a seasonal pattern with high concentrations in summer, its counts in greywater presented an almost inversed pattern. Greywater treatment resulted in 95% decrease in Legionella counts. No significant difference was found between Legionella concentrations in potable water and the treated chlorinated greywater. These findings indicate that regarding Legionella, reusing treated chlorinated greywater would exhibit a risk that is very similar to the risk associated with using potable water for the same non-potable uses.

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.

Growth of Legionella and other heterotrophic bacteria in a circulating cooling water system exposed to ultraviolet irradiation

The effect of ultraviolet irradiation on the growth and occurrence of legionella and other heterotrophic bacteria in a circulating cooling water system was studied. Water of the reservoir was circulated once in 28 h through a side-stream open channel u.v. radiator consisting of two lamps. Viable counts of legionellas and heterotrophic bacteria in water immediately after the u.v. treatment were 0-12 and 0.7-1.2% of those in the reservoir, respectively. U.v. irradiation increased the concentration of easily assimilable organic carbon. In the u.v. irradiated water samples incubated in the laboratory the viable counts of heterotrophic bacteria reached the counts in reservoir water within 5 d. The increase in viable counts was mainly due to reactivation of bacterial cells damaged by u.v. light, not because of bacterial multiplication. Despite u.v. irradiation the bacterial numbers in the reservoir water, including legionellas, did not decrease during the experimental period of 33 d. The main growth of bacteria in the reservoir occurred in biofilm and sediment, which were never exposed to u.v. irradiation.

Inactivation of Legionella pneumophila by monochloramine

Chloramination which is used in South Australia to control the growth of Naegleria fowleri, was investigated to see if it would also control that of Legionella pneumophila. It was found that L. pneumophila was more sensitive than Escherichia coli to monochloramine. At 1.0 mg/l, a 99% kill of L. pneumophila was achieved in 15 min compared with 37 min for a 99% kill of E. coli. Combined with the stability of monochloramine, even at elevated temperatures, the results suggest that this disinfectant would control the growth of L. pneumophila in water distribution systems.

Efficacy of copper and silver ions and reduced levels of free chlorine in inactivation of Legionella pneumophila

Water disinfection systems utilizing electrolytically generated copper and silver ions (200 and 20, 400 and 40, or 800 and 80 micrograms/liter) and low levels of free chlorine (0.1 to 0.4 mg/liter) were evaluated at room (21 to 23 degrees C) and elevated (39 to 40 degrees C) temperatures in filtered well water (pH 7.3) for their efficacy in inactivating Legionella pneumophila (ATCC 33155). At room temperature, a contact time of at least 24 h was necessary for copper and silver (400 and 40 micrograms/liter) to achieve a 3-log10 reduction in bacterial numbers. As the copper and silver concentration increased to 800 and 80 micrograms/liter, the inactivation rate significantly (P less than or equal to 0.05) increased from K = 2.87 x 10(-3) to K = 7.50 x 10(-3) (log10 reduction per minute). In water systems with and without copper and silver (400 and 40 micrograms/liter), the inactivation rates significantly increased as the free chlorine concentration increased from 0.1 mg/liter (K = 0.397 log10 reduction per min) to 0.4 mg/liter (K = 1.047 log10 reduction per min). Compared to room temperature, no significant differences were observed when 0.2 mg of free chlorine per liter with and without 400 and 40 micrograms of copper and silver per liter was tested at 39 to 40 degrees C. All disinfection systems, regardless of temperature or free chlorine concentration, showed increase inactivation rates when 400 and 40 micrograms of copper and silver per liter was added; however, this trend was significant only at 0.4 mg of free chlorine per liter.