Occurrence of Legionella in UK household showers

Too much ado about data: continuous remote monitoring of water temperatures, circulation and throughput can assist in the reduction of hospital-associated waterborne infections

BACKGROUND

National and international guidance provides advice on maintenance and management of water systems in healthcare buildings; however, healthcare-associated waterborne infections (HAWIs) are increasing.

AIM

To identify parameters critical to water quality in healthcare buildings and to assess whether remote sensor monitoring can deliver safe water systems, thus reducing HAWIs.

METHODS

A narrative review was performed using the following search terms: (1) consistent water temperature AND waterborne pathogen control OR nosocomial infection; (2) water throughput AND waterborne pathogen control OR nosocomial infection; (3) remote monitoring of in-premises water systems AND continuous surveillance for temperature OR throughput OR flow OR use. Databases employed were PubMed, CDSR (Clinical Study Data Request) and DARE (Database of Abstracts of Reviews of Effects) from January 2013 to March 2024.

FINDINGS

Single ensuite-patient rooms, expansion of handwash basins, widespread glove use, alcohol gel and wipes have increased water system stagnancy resulting in amplification of waterborne pathogens and transmission risk of legionella, pseudomonas, and non-tuberculous mycobacteria. Manual monitoring does not represent temperatures across large complex water systems. This review deems that multiple-point continuous remote sensor monitoring is effective at identifying redundant and low use outlets, hydraulic imbalance and inconsistent temperature delivery across in-premises water systems.

CONCLUSION

As remote monitoring becomes more common there will be greater recognition of failures in temperature control, hydraulics, and balancing in water systems, and there remains much to learn as we adopt this developing technology within our hospitals.

The impact of DNA extraction on the quantification of Legionella, with implications for ecological studies

Monitoring the levels of opportunistic pathogens in drinking water is important to plan interventions and understand the ecological niches that allow them to proliferate. Quantitative PCR is an established alternative to culture methods that can provide a faster, higher-throughput, and more precise enumeration of the bacteria in water samples. However, PCR-based methods are still not routinely applied for Legionella monitoring, and techniques, such as DNA extraction, differ notably between laboratories. Here, we quantify the impact that DNA extraction methods had on downstream PCR quantification and community sequencing. Through a community science campaign, we collected 50 water samples and corresponding shower hoses, and compared two commonly used DNA extraction methodologies to the same biofilm and water phase samples. The two methods showed clearly different extraction efficacies, which were reflected in both the quantity of DNA extracted and the concentrations of Legionella enumerated in both the matrices. Notably, one method resulted in higher enumeration in nearly all samples by about one order of magnitude and detected Legionella in 21 samples that remained undetected by the other method. 16S rRNA amplicon sequencing revealed that the relative abundance of individual taxa, including sequence variants of Legionella, significantly varied depending on the extraction method employed. Given the implications of these findings, we advocate for improvement in documentation of the performance of DNA extraction methods used in drinking water to detect and quantify Legionella, and characterize the associated microbial community.IMPORTANCEMonitoring for the presence of the waterborne opportunistic pathogen Legionella is important to assess the risk of infection and plan remediation actions. While monitoring is traditionally carried on through cultivation, there is an ever-increasing demand for rapid and high-throughput molecular-based approaches for Legionella detection. This paper provides valuable insights on how DNA extraction affects downstream molecular analysis such as the quantification of Legionella through droplet digital PCR and the characterization of natural microbial communities through sequencing analysis. We analyze the results from a risk-assessment, legislative, and ecological perspective, showing how initial DNA processing is an important step to take into account when shifting to molecular-based routine monitoring and discuss the central role of consistent and detailed reporting of the methods used.

A review of Legionella transmission risk in built environments: sources, regulations, sampling, and detection

The risk of Legionella transmission in built environments remains a significant concern. Legionella can spread within buildings through aerosol transmission, prompting the exploration of airborne transmission pathways and proposing corresponding prevention and control measures based on building characteristics. To this end, a comprehensive literature review on the transmission risk of Legionella in built environments was performed. Four electronic databases (PubMed, Web of Science, Google Scholar, and CNKI) were searched from inception to March 2024 for publications reporting the risk of Legionella transmission in built environments. Relevant articles and gray literature reports were hand-searched, and 96 studies were finally included. Legionella pollution comes from various sources, mainly originates in a variety of built environments in which human beings remain for extended periods. The sources, outbreaks, national standards, regulations, and monitoring techniques for Legionella in buildings are reviewed, in addition to increases in Legionella transmission risk due to poor maintenance of water systems and long-distance transmission events caused by aerosol characteristics. Air and water sampling using various analytical methods helps identify Legionella in the environment, recognize sources in the built environments, and control outbreaks. By comparing the standard regulations of national organizations globally, the authors further highlight gaps and deficiencies in Legionella surveillance in China. Such advancements offer essential insights and references for understanding and addressing Legionella transmission risk in the built environment, with the potential to contribute to safeguarding public health and building environment safety.

Immunomagnetic separation coupled with flow cytometry for the analysis of Legionella pneumophila in aerosols

Legionella pneumophila are pathogenic bacteria that can be found in high concentrations in artificial water systems like evaporative cooling towers, which have been the source of frequent outbreaks in recent years. Since inhaled L. pneumophila can lead to Legionnaires' disease, the development of suitable sampling and rapid analysis strategies for these bacteria in aerosols is therefore of great relevance. In this work, different concentrations of viable L. pneumophila Sg 1 were nebulized and sampled by the cyclone sampler Coriolis® µ under defined conditions in a bioaerosol chamber. To quantify intact Legionella cells, the collected bioaerosols were subsequently analyzed by immunomagnetic separation coupled with flow cytometry (IMS-FCM) on the platform rqmicro.COUNT. For analytical comparison, measurements with qPCR and cultivation were performed. Limits of detection (LOD) of 2.9 × 10³ intact cells m^-3 for IMS-FCM and 7.8 × 10² intact cells m^-3 for qPCR indicating a comparable sensitivity as in culture (LOD = 1.5 × 10³ culturable cells m^-3). Over a working range of 10³ - 10⁶ cells mL^-1, the analysis of nebulized and collected aerosol samples with IMS-FCM and qPCR provides higher recovery rates and more consistent results than by cultivation. Overall, IMS-FCM is a suitable culture-independent method for quantification of L. pneumophila in bioaerosols and is promising for field application due to its simplicity in sample preparation.

A Critical Review on the Factors that Influence Opportunistic Premise Plumbing Pathogens: From Building Entry to Fixtures in Residences

Residential buildings provide unique conditions for opportunistic premise plumbing pathogen (OPPP) exposure via aerosolized water droplets produced by showerheads, faucets, and tubs. The objective of this review was to critically evaluate the existing literature that assessed the impact of potentially enhancing conditions to OPPP occurrence associated with residential plumbing and to point out knowledge gaps. Comprehensive studies on the topic were found to be lacking. Major knowledge gaps identified include the assessment of OPPP growth in the residential plumbing, from building entry to fixtures, and evaluation of the extent of the impact of typical residential plumbing design (e.g., trunk and branch and manifold), components (e.g., valves and fixtures), water heater types and temperature setting of operation, and common pipe materials (copper, PEX, and PVC/CPVC). In addition, impacts of the current plumbing code requirements on OPPP responses have not been assessed by any study and a lack of guidelines for OPPP risk management in residences was identified. Finally, the research required to expand knowledge on OPPP amplification in residences was discussed.

Legionellosis risk-an overview of Legionella spp. habitats in Europe

An increase in the number of reports of legionellosis in the European Union and the European Economic Area have been recorded in recent years. The increase in cases is significant: from 6947 reports in 2015 to 11,298 in 2019. This is alarming as genus Legionella, which comprises a large group of bacteria inhabiting various aquatic systems, poses a serious threat to human health and life, since more than 20 species can cause legionellosis, with L. pneumophila being responsible for the majority of cases. The ability to colonize diverse ecosystems makes the eradication of these microorganisms difficult. A detailed understanding of the Legionella habitat may be helpful in the effective control of this pathogen. This paper provides an overview of Legionella environments in Europe: natural (lakes, groundwater, rivers, compost, soil) and anthropogenic (fountains, air humidifiers, water supply systems), and the role of Legionella spp. in nosocomial infections, which are potentially fatal for children, the elderly and immunocompromised patients.

Hot water plumbing in residences and office buildings have distinctive risk of Legionella pneumophila contamination

AIM

To observe how Legionella pneumophila, the causative agent for legionellosis, can transmit through the hot water plumbing of residences and office buildings.

METHOD AND RESULTS

Using qPCR, L. pneumophila and L. pneumophila Serogroup (Sg)1 were measured in hot water samples collected from 100 structures, consisting of 70 residences and 30 office buildings. The hot water samples collected from office buildings had a higher L. pneumophila detection frequency of 53% (16/30) than residences, with a 103 GU/L (median) concentration. An office building's age was not a statistically significant predictor of contamination, but its area (>100,000 sq. ft.) was, P = <0.001. Hot water samples collected at residences had a lower L. pneumophila detection frequency of 36% (25/70) than office buildings, with a 100 GU/L (median) concentration. A residence's age was a significant predictor of contamination, P = 0.009, but not its area. The water's secondary disinfectant type did not affect L. pneumophila detection frequency nor its concentration in residences, but the secondary disinfectant type did affect results in office buildings. Legionella pneumophila's highest detection frequencies were in samples collected in March-August for office buildings and in June-November for residences.

CONCLUSION

This study revealed that the built environment influences L. pneumophila transport and fate. Residential plumbing could be a potential "conduit" for L. pneumophila exposure from a source upstream of the hot water environment. Both old and newly built office buildings had an equal probability of L. pneumophila contamination. Legionella-related remediation efforts in office buildings (that contain commercial functions only) might not significantly improve a community's public health.

The Presence of Opportunistic Premise Plumbing Pathogens in Residential Buildings: A Literature Review

Opportunistic premise plumbing pathogens (OPPP) are microorganisms that are native to the plumbing environment and that present an emerging infectious disease problem. They share characteristics, such as disinfectant resistance, thermal tolerance, and biofilm formation. The colonisation of domestic water systems presents an elevated health risk for immune-compromised individuals who receive healthcare at home. The literature that has identified the previously described OPPPs (Aeromonas spp., Acinetobacter spp., Helicobacter spp., Legionella spp., Methylobacterium spp., Mycobacteria spp., Pseudomonas spp., and Stenotrophomonas spp.) in residential drinking water systems were systematically reviewed. By applying the Preferred reporting items for systematic reviews and meta-analyses guidelines, 214 studies were identified from the Scopus and Web of Science databases, which included 30 clinical case investigations. Tap components and showerheads were the most frequently identified sources of OPPPs. Sixty-four of these studies detected additional clinically relevant pathogens that are not classified as OPPPs in these reservoirs. There was considerable variation in the detection methods, which included traditional culturing and molecular approaches. These identified studies demonstrate that the current drinking water treatment methods are ineffective against many waterborne pathogens. It is critical that, as at-home healthcare services continue to be promoted, we understand the emergent risks that are posed by OPPPs in residential drinking water. Future research is needed in order to provide consistent data on the prevalence of OPPPs in residential water, and on the incidence of waterborne homecare-associated infections. This will enable the identification of the contributing risk factors, and the development of effective controls.

Direct-Read Fluorescence-Based Measurements of Bioaerosol Exposure in Home Healthcare

Home healthcare workers (HHCWs) are subjected to variable working environments which increase their risk of being exposed to numerous occupational hazards. One of the potential occupational hazards within the industry includes exposure to bioaerosols. This study aimed to characterize concentrations of three types of bioaerosols utilizing a novel fluorescence-based direct-reading instrument during seven activities that HHCWs typically encounter in patients’ homes. Bioaerosols were measured in an indoor residence throughout all seasons in Cincinnati, OH, USA. A fluorescence-based direct-reading instrument (InstaScope, DetectionTek, Boulder, CO, USA) was utilized for all data collection. Total particle counts and concentrations for each particle type, including fluorescent and non-fluorescent particles, were utilized to form the response variable, a normalized concentration calculated as a ratio of concentration during activity to the background concentration. Walking experiments produced a median concentration ratio of 52.45 and 2.77 for pollen and fungi, respectively. Fungi and bacteria produced the highest and lowest median concentration ratios of 17.81 and 1.90 for showering, respectively. Lastly, our current study showed that sleeping activity did not increase bioaerosol concentrations. We further conclude that utilizing direct-reading methods may save time and effort in bioaerosol-exposure assessment.

Risk Exposure to Legionella pneumophila during Showering: The Difference between a Classical and a Water Saving Shower System

The increase in legionellosis incidence in the general population in recent years calls for a better characterization of the sources of infection, such as showering. Water-efficient shower systems that use water-atomizing technology have been shown to emit slightly more inhalable particles in the range of bacterial sizes than the traditional systems; however, the actual rate of bacterial emission remains poorly documented. The aim of this study was to assess the aerosolisation rate of the opportunistic water pathogen Legionella pneumophila during showering with one shower system representative of each technology. To achieve this objective, we performed controlled experiments inside a glove box and determined the emitted dose and viability of airborne Legionella. The bioaerosols were sampled with a Coriolis^® Delta air sampler and the total number of viable (cultivable and noncultivable) Legionella was determined by flow cytometry and culture. We found that the rate of viable and cultivable Legionella aerosolized from the water jet was similar between the two showerheads: the viable fraction represents 0.02% of the overall bacteria present in water, while the cultivable fraction corresponds to only 0.0005%. The two showerhead models emitted a similar ratio of airborne Legionella viable and cultivable per volume of water used. Therefore, the risk of exposure to Legionella is not expected to increase significantly with the new generation of water-efficient showerheads.

Legionella: A Promising Supplementary Indicator of Microbial Drinking Water Quality in Municipal Engineered Water Systems

Opportunistic pathogens (OPs) are natural inhabitants and the predominant disease causative biotic agents in municipal engineered water systems (EWSs). In EWSs, OPs occur at high frequencies and concentrations, cause drinking-water-related disease outbreaks, and are a major factor threatening public health. Therefore, the prevalence of OPs in EWSs represents microbial drinking water quality. Closely or routinely monitoring the dynamics of OPs in municipal EWSs is thus critical to ensuring drinking water quality and protecting public health. Monitoring the dynamics of conventional (fecal) indicators (e.g., total coliforms, fecal coliforms, and Escherichia coli) is the customary or even exclusive means of assessing microbial drinking water quality. However, those indicators infer only fecal contamination due to treatment (e.g., disinfection within water utilities) failure and EWS infrastructure issues (e.g., water main breaks and infiltration), whereas OPs are not contaminants in drinking water. In addition, those indicators appear in EWSs at low concentrations (often absent in well-maintained EWSs) and are uncorrelated with OPs. For instance, conventional indicators decay, while OPs regrow with increasing hydraulic residence time. As a result, conventional indicators are poor indicators of OPs (the major aspect of microbial drinking water quality) in EWSs. An additional or supplementary indicator that can well infer the prevalence of OPs in EWSs is highly needed. This systematic review argues that Legionella as a dominant OP-containing genus and natural inhabitant in EWSs is a promising candidate for such a supplementary indicator. Through comprehensively comparing the behavior (i.e., occurrence, growth and regrowth, spatiotemporal variations in concentrations, resistance to disinfectant residuals, and responses to physicochemical water quality parameters) of major OPs (e.g., Legionella especially L. pneumophila, Mycobacterium, and Pseudomonas especially P. aeruginosa), this review proves that Legionella is a promising supplementary indicator for the prevalence of OPs in EWSs while other OPs lack this indication feature. Legionella as a dominant natural inhabitant in EWSs occurs frequently, has a high concentration, and correlates with more microbial and physicochemical water quality parameters than other common OPs. Legionella and OPs in EWSs share multiple key features such as high disinfectant resistance, biofilm formation, proliferation within amoebae, and significant spatiotemporal variations in concentrations. Therefore, the presence and concentration of Legionella well indicate the presence and concentrations of OPs (especially L. pneumophila) and microbial drinking water quality in EWSs. In addition, Legionella concentration indicates the efficacies of disinfectant residuals in EWSs. Furthermore, with the development of modern Legionella quantification methods (especially quantitative polymerase chain reactions), monitoring Legionella in ESWs is becoming easier, more affordable, and less labor-intensive. Those features make Legionella a proper supplementary indicator for microbial drinking water quality (especially the prevalence of OPs) in EWSs. Water authorities may use Legionella and conventional indicators in combination to more comprehensively assess microbial drinking water quality in municipal EWSs. Future work should further explore the indication role of Legionella in EWSs and propose drinking water Legionella concentration limits that indicate serious public health effects and require enhanced treatment (e.g., booster disinfection).

Quantification and modeling of the response of surface biofilm growth to continuous low intensity UVC irradiation

Though germicidal UV radiation is widely applied for disinfection of water and food, it may also be used to prevent bacterial growth and colonization on surfaces within engineered systems. Emerging UV source technologies, such as ultraviolet-C (UVC) LEDs, present new opportunities for deterring biofilms within certain devices, including medical equipment, food equipment, and potentially in plumbing fixtures for prevention of opportunistic respiratory pathogen infections. Rational design for incorporation of UVC sources into devices with complex internal geometries is currently hampered by the lack of an engineering framework for predicting reductions in biofilm growth rates in response to continuous low-intensity irradiation. Herein we have developed an experimental apparatus and method for growing biofilms under concurrent UV irradiation and quantifying the resulting suppression of surface growth. Under accelerated growth conditions over 48 h, E. coli surface biovolume was reduced by 95% compared to control biofilms (grown in the dark) by a UV intensity of 50.5 µW/cm² (254 nm). The required intensity for biofilm prevention was higher than expected, given the UV dose response of the bacteria employed and the cumulative doses delivered to the test surfaces. The results indicate that biofilms can establish even under irradiation conditions that would result in complete inactivation of planktonic cells, likely due to the shielding effects of colloidal material and microbial exudates. A pseudo-mechanistic model was also developed which correlated UV intensity to the resultant reduction in specific surface biovolume.

Can incorporation of UVC LEDs into showerheads prevent opportunistic respiratory pathogens? - Microbial behavior and device design considerations

Respiratory infections from opportunistic bacterial pathogens (OBPs) have heightened research interests in drinking water distribution systems, premise plumbing, and point-of-use technologies. In particular, biofilm growth in showerheads increases OBP content, and inhalation of shower aerosols is a major exposure route for Legionellae and Mycobacteria infections. Incorporation of UVC LEDs into showerheads has thus been proposed as a point-of-use option for healthcare facilities. Herein we have examined incongruities between the nature of OBP contamination in shower water and the hypothetical application of conventional UV disinfection engineering concepts. Effective UV dosing within showerheads must overcome significant shielding effects imparted by the biological matrices in which common OBPs reside, including biofilm particles and protozoan hosts. Furthermore, prevention of biofilm growth in showerhead interiors requires a different UV irradiation approach and is lacking in established design parameters. Development of showerhead devices is also likely to face a trade-off between bathing functionality and simpler form factors that are more conducive to internal UV irradiation.

Co-Occurrence of Free-Living Amoeba and Legionella in Drinking Water Supply Systems

Background and Objectives:Legionella is one of the most important water-related pathogens. Inside the water supply systems and the biofilms, Legionella interact with other bacteria and free-living amoeba (FLA). Several amoebas may serve as hosts for bacteria in aquatic systems. This study aimed to investigate the co-occurrence of Legionella spp. and FLA in drinking water supply systems. Materials and Methods: A total of 268 water samples were collected from apartment buildings, hotels, and public buildings. Detection of Legionella spp. was performed in accordance with ISO 11731:2017 standard. Three different polymerase chain reaction (PCR) protocols were used to identify FLA. Results: Occurrence of Legionella varied from an average of 12.5% in cold water samples with the most frequent occurrence observed in hot water, in areas receiving untreated groundwater, where 54.0% of the samples were Legionella positive. The occurrence of FLA was significantly higher. On average, 77.2% of samples contained at least one genus of FLA and, depending on the type of sample, the occurrence of FLA could reach 95%. In the samples collected during the study, Legionella was always isolated along with FLA, no samples containing Legionella in the absence of FLA were observed. Conclusions: The data obtained in our study can help to focus on the extensive distribution, close interaction, and long-term persistence of Legionella and FLA. Lack of Legionella risk management plans and control procedures may promote further spread of Legionella in water supply systems. In addition, the high incidence of Legionella-related FLA suggests that traditional monitoring methods may not be sufficient for Legionella control.

One-year survey of opportunistic premise plumbing pathogens and free-living amoebae in the tap-water of one northern city of China

In this study, qPCR was used to quantify opportunistic premise plumbing pathogens (OPPPs) and free-living amoebae in 11 tap water samples collected over four seasons from a city in northern China. Results demonstrated that the average numbers of gene copies of Legionella spp. and Mycobacterium spp. were significantly higher than those of Aeromonas spp. (p < 0.05). Legionella spp. and Mycobacterium spp. were 100% (44/44) positively detected while P. aeruginosa and Aeromonas spp. were 79.54% (35/44) and 77.27% (34/44) positively detected. Legionella pneumophila was only detected in 4 samples (4/44), demonstrating its occasional occurrence. No Mycobacterium avium or Naegleria fowleri was detected in any of the samples. The average gene copy numbers of target OPPPs were the highest in summer, suggesting seasonal prevalence of OPPPs. Average gene copy numbers of OPPPs in the taps of low-use-frequency were higher than in taps of high-use-frequency, but the difference was not significant for some OPPPs (p > 0.05). Moderate negative correlations between the chlorine concentration and the gene copy numbers of OPPPs were observed by Spearman analysis (r_s ranged from -0.311 to -0.710, p < 0.05). However, no significant correlations existed between OPPPs and AOC, BDOC, or turbidity. Moderate positive correlations were observed between the target microorganisms, especially for Acanthamoeba spp., through Spearman analysis (p < 0.05). Based on our studies, it is proposed that disinfectant concentration, season, taps with different-use frequency, OPPP species, and potential microbial correlations should be considered for control of OPPPs in tap water.

Factors Influencing Legionella Contamination of Domestic Household Showers

Legionnaires’ disease is a potentially fatal pneumonia like infection caused by inhalation or aspiration of water particles contaminated with pathogenic Legionella spp. Household showers have been identified as a potential source of sporadic, community-acquired Legionnaires’ disease. This study used qPCR to enumerate Legionella spp. and Legionella pneumophila in water samples collected from domestic showers across metropolitan Adelaide, South Australia. A survey was used to identify risk factors associated with contamination and to examine awareness of Legionella control in the home. The hot water temperature was also measured. A total of 74.6% (50/68) and 64.2% (43/68) showers were positive for Legionella spp. and L. pneumophila, respectively. Statistically significant associations were found between Legionella spp. concentration and maximum hot water temperature (p = 0.000), frequency of shower use (p = 0.000) and age of house (p = 0.037). Lower Legionella spp. concentrations were associated with higher hot water temperatures, showers used at least every week and houses less than 5 years old. However, examination of risk factors associated with L. pneumophila found that there were no statistically significant associations (p > 0.05) with L. pneumophila concentrations and temperature, type of hot water system, age of system, age of house or frequency of use. This study demonstrated that domestic showers were frequently colonized by Legionella spp. and L. pneumophila and should be considered a potential source of sporadic Legionnaires’ disease. Increasing hot water temperature and running showers every week to enable water sitting in pipes to be replenished by the municipal water supply were identified as strategies to reduce the risk of Legionella in showers. The lack of public awareness in this study identified the need for public health campaigns to inform vulnerable populations of the steps they can take to reduce the risk of Legionella contamination and exposure.

The influence of climate change on waterborne disease and Legionella: a review

Climate change is predicted to have a major impact on people's lives with the recent extreme weather events and varying abnormal temperature profiles across the world raising concerns. The impacts of global warming are already being observed, from rising sea levels and melting snow and ice to changing weather patterns. Scientists state unequivocally that these trends cannot be explained by natural variability in climate alone. Human activities, especially the burning of fossil fuels, have warmed the earth by dramatically increasing concentrations of heat-trapping gases in the atmosphere; as these concentrations increase, the more the earth will warm. Climate change and related extreme weather events are being exacerbated sooner than has previously been considered and are already adversely affecting ecosystems and human health by increasing the burden and type of disease at a local level. Changes to the marine environment and freshwater supplies already affect significant parts of the world's population and warmer temperatures, especially in more temperate regions, may see an increased spread and transmission of diseases usually associated with warmer climes including, for example, cholera and malaria; these impacts are likely to become more severe in a greater number of countries. This review discusses the impacts of climate change including changes in infectious disease transmission, patterns of waterborne diseases and the likely consequences of climate change due to warmer water, drought, higher rainfall, rising sea levels and flooding.

Prevalence of Legionella in retirement homes and group homes water distribution systems

BACKGROUND

Although historically the focus has been placed above all on hospital infections and travel-associated outbreaks, most of the cases of Legionella infection are sporadic and occur in community-dwellers.

OBJECTIVES

To evaluate the presence and load of Legionella in hot water systems of non-healthcare facilities that host closed communities. Furthermore, we tried to verify the association between Heterotrophic Plate Counts (HPCs) and presence of Legionella.

METHODS

We collected hot water and biofilm samples from the showerheads of retirement homes and group homes. Samples were tested by culture method for the presence of Legionella. Confirmation and identification were carried out through Latex test and PCR. We determined the HPCs at 22 and 37 °C by the pour plate method. Statistics performed through STATA.

RESULTS

We collected 140 hot water and biofilm samples, 95 from 26 retirement homes and 35 from 9 group homes. Legionella was found in 36.8% samples collected from retirement homes and only in 10.3% group homes' samples (p = 0.01). Legionella was identified more frequently in water than in biofilm (29.8% vs 16.9%); just in one case the pathogen was found in the biofilm only. L. pneumophila sg 1 was the pathogen more frequently isolated (65.8%), with an average load of 2720 CFU/L (SD = 8393 CFU/L). We have often noticed a high microbial contamination (67% of HPCs >200 CFU/mL) and identified a higher prevalence of Legionella for intermediate values of HPC 22 °C (p = 0.011). 32% of people hosted in retirement homes were exposed to Legionella.

CONCLUSIONS

Colonization of water-systems of retirement homes and group homes is anything but occasional, and in our survey it mainly affects the former, moreover often due to L. pneumophila sg 1. The search for the pathogen in the biofilm has proved to be of little use. The relationship between HPC and Legionella deserves further studies.

Environmental sources of community-acquired legionnaires' disease: A review

BACKGROUND

Most Legionnaires' disease in the US and abroad is community-acquired and believed to be sporadic, or non-outbreak associated. Most patients are exposed to numerous water sources, thus making it difficult to focus environmental investigations. Identifying known sources of sporadic community-acquired Legionnaires' disease will inform future sporadic Legionnaires' disease investigations as well as highlight directions for research. The objective is to summarize and rank sporadic Legionnaires' disease sources based on the level of linkage between the environmental source and cases.

METHODS

A PubMed search was conducted using the search terms legion* and (origins or source or transmission) and (sporadic or community-acquired). Studies of nosocomial and/or outbreak-associated disease were excluded from this review. Definite, probable, possible and suspect ranks were assigned to sources based on evidence of linkage to sporadic Legionnaires' disease.

RESULTS

The search yielded 196 articles and 47 articles were included in the final review after application of exclusion criteria. A total of 28 sources were identified. Of these, eight were assigned definite rank including residential potable water and car air-conditioner water leakage. Probable rank was assigned to five sources including solar-heated potable water and soil. Possible rank was assigned to nine sources including residential potable water and cooling towers. Suspect rank was assigned to 20 sources including large building water systems and cooling towers.

CONCLUSION

Residential potable water, large building water systems and car travel appear to contribute to a substantial proportion of sporadic Legionnaires' disease. Cooling towers are also a potentially significant source; however, definitive linkage to sporadic cases proves difficult. The sources of sporadic Legionnaires' disease cannot be definitively identified for most cases.

Microbial Community Composition of Tap Water and Biofilms Treated with or without Copper-Silver Ionization

Copper-silver ionization (CSI) is an in-house water disinfection method primarily installed to eradicate Legionella bacteria from drinking water distribution systems (DWDS). Its effect on the abundance of culturable Legionella and Legionella infections has been documented in several studies. However, the effect of CSI on other bacteria in DWDS is largely unknown. To investigate these effects, we characterized drinking water and biofilm communities in a hospital using CSI, in a neighboring building without CSI, and in treated drinking water at the local water treatment plant. We used 16S rDNA amplicon sequencing and Legionella culturing. The sequencing results revealed three distinct water groups: (1) cold-water samples (no CSI), (2) warm-water samples at the research institute (no CSI), and (3) warm-water samples at the hospital (after CSI; ANOSIM, p < 0.001). Differences between the biofilm communities exposed and not exposed to CSI were less clear (ANOSIM, p = 0.022). No Legionella were cultured, but limited numbers of Legionella sequences were recovered from all 25 water samples (0.2-1.4% relative abundance). The clustering pattern indicated local selection of Legionella types (Kruskal-Wallis, p < 0.001). Furthermore, one unclassified Betaproteobacteria OTU was highly enriched in CSI-treated warm water samples at the hospital (Kruskal-Wallis, p < 0.001).

Biofilms in shower hoses

Shower hoses offer an excellent bacterial growth environment in close proximity to a critical end-user exposure route within building drinking water plumbing. However, the health risks associated with and processes underlying the development of biofilms in shower hoses are poorly studied. In a global survey, biofilms from 78 shower hoses from 11 countries were characterized in terms of cell concentration (4.1 × 10⁴-5.8 × 10⁸ cells/cm²), metal accumulation (including iron, lead, and copper), and microbiome composition (including presence of potential opportunistic pathogens). In countries using disinfectant, biofilms had on average lower cell concentrations and diversity. Metal accumulation (up to 5 μg-Fe/cm², 75 ng-Pb/cm², and 460 ng-Cu/cm²) seemed to be partially responsible for discoloration in biofilms, and likely originated from other pipes upstream in the building. While some genera that may contain potential opportunistic pathogens (Legionella, detected in 21/78 shower hoses) were positively correlated with biofilm cell concentration, others (Mycobacterium, Pseudomonas) had surprisingly non-existent or negative correlations with biofilm cell concentrations. In a controlled study, 15 identical shower hoses were installed for the same time period in the same country, and both stagnant and flowing water samples were collected. Ecological theory of dispersal and selection helped to explain microbiome composition and diversity of different sample types. Shower hose age was related to metal accumulation but not biofilm cell concentration, while frequency of use appeared to influence biofilm cell concentration. This study shows that shower hose biofilms are clearly a critical element of building drinking water plumbing, and a potential target for building drinking water plumbing monitoring.

Evaluation of Exposure to Brevundimonas diminuta and Pseudomonas aeruginosa during Showering

This study experimentally assessed bacterial water-to-air partitioning coefficients resulting from showerhead aerosolization of water contaminated with Brevundimonas diminuta or Pseudomonas aeruginosa, and estimated human exposure through inhalation. Dechlorinated tap water was spiked with two cell densities (10⁹ and 10¹⁰ CFU l^-1) and cycled at three temperatures (10, 25, and 37 or 40ºC) through a full-scale shower system. For reproducibility, spiked water concentrations were intentionally higher than found in natural environments. Three types of samplers measured size distribution and viable concentrations throughout the system. Results indicate low levels of respirable bioaerosols were generated. The ratio of bacterial contaminant that was effectively aerosolized (bacterial water-to-air partitioning coefficient, PC _bwa ) was low - averaging 1.13×10^-5 L m^-3 for B. diminuta and 8.31×10^-6 L m^-3 for P. aeruginosa. However, the respirable fraction of aerosolized organisms was high, averaging above 94% (in shower) and above 99% (downstream) for both organisms. This study found no significant difference in bioaerosol load for a forward facing versus reverse facing individual. Further, for the average hot shower (33-43°C) the total number of respirable bioaerosols is higher, but the observed culturability of those aerosolized cells is lower when compared to lower temperatures. Bacterial water to air partitioning coefficients were calculated to predict microbial air concentration and these empirical parameters may be used for assessing inhalation as a route of exposure to pathogens in contaminated waters.