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PURPOSE OF STUDY:
The recommended minimum level of free chlorine for disinfection of
public swimming pools is 1 mg/liter (1 ppm). This level is
difficult to maintain due to the chlorine-demanding organic material
introduced by bathers themselves as well as the environment. Eye and
skin irritation may also occur at the minimum chlorine level needed
for effective disinfection. Electrolytically generated
copper/silver ions are also microbiocidal and are much less subject
to degradation but are slower acting than chlorine. Therefore, the
authors tested the hypothesis that using the two methods together
would accomplish effective disinfection while reducing the level of
free chlorine required.
MATERIALS AND METHODS:
Two 32-gallon plastic containers, one indoors (temperature range 22
to 25) and the second outdoors exposed to sunlight (temperature
range 18 to 36) were filled with tap water. After chemical analysis
and adjustment of pH and test levels of disinfectants, bath water
and urine were added to stimulate typical swimming conditions. Four
treatment regimens were tested: (1) No added disinfectants (2) Free
chlorine alone at the generally recommended level of 1 mg/liter (3)
Free chlorine at 0.3 mg/liter combined with copper and silver ions
at a ration of 400 ug/liter of copper to 40 ug/liter of silver (4)
Copper and silver ions alone at the same ratio as above. An isolate
of Staphylococcus sp was employed for bacterial challenge testing
since previous work had shown that staphylococci are more resistant
to disinfection than are coliform bacteria. The experiment was
continued for 12 weeks.
RESULTS:
In the test of free chlorine alone, location proved to be critical.
In the outdoor setting subject to strong sunlight and high
temperatures, no residual chlorine could be detected 3 to 4 hours
after optimization. Indoor, where environmental factors were much
less extreme, a residual level of 0.1 to 0.3 mg/liter was found
after 24 hours.
Bacterial counts were kept within drinking water standards (as
recommended for swimming pools) by either high levels of chlorine
alone or by the combination regimen of copper and silver ions with
low levels of chlorine: the difference in total bacterial numbers
was not significant. Hen challenged with Staphylococcus sp isolate,
the combination of copper and silver ions with low levels of
chlorine achieved a 2.4 log 10 reduction in bacterial numbers within
2 minutes, while the single-agent regimes (free chlorine alone, or
copper/silver alone) showed only 1.5 & 0.03 log 10 reductions
respectively. Under Staphylococcus sp challenge, the combined
copper/silver and free chlorine had a faster log 10 reduction of
microbial numbers than did treatment with a high level of chlorine
alone.
CONCLUSIONS:
The addition of electrolytically generated copper/silver ions in the
radio tested (400 ug/liter copper (0.4 ppm) to 40 ug/liter silver
(0.04 ppm)) allowed reduction in the concentration of free chlorine
to one third of the level customarily recommended. The use of
copper/silver may provide resisting protection in swimming pools
after chlorine has been rendered ineffective due to contamination
from swimmers and the natural environment.
|
Efficacy of Copper /
Silver Ions & Reduced Levels of Free Chlorine in
Inactivation of Legionella pneumophilia.
AUTHORS: Landeen LK, Yahya
MT, and Gerba CP
PUBLICATION REF: Applied & Enviromental Microbiology 55:
3045-3050,1989 |
|
PURPOSE OF STUDY:
Relatively high levels of chlorination are known to be
effective in inactivating Legionella pneumophilia in drinking
water. However, high levels of free chlorine may degrade
rapidly, especially at high temperatures, producing only
temporary suppression rather than continuous disinfection.
Also, high chlorine levels may lead to the development of
resistant strains and be corrosive to plumbing fixtures.
Therefore, the authors investigated the effectiveness of
electrolytically generated copper and silver ions together
with low concentrations as an alternative disinfection
treatment.
MATERIALS AND METHODS:
Pellets of Legionella pneumophilia were suspended in samples
of filtered well water and bacterial inactivation rates were
determined using chlorination alone at low concentrations of
0.1, 0.2, 0.32, & 0.4 mg/liter. Then electrolytically
generated copper & silver ions at copper to silver ratio
of 200 and 20, 400 and 40, and 800 and 80 ug/liter were tested
both separately and in combination with chlorination to
evaluate any incremental bactericidal effect. The majority of
experiments were conducted at room temperature with some tests
performed at elevated temperatures (39 to 40). Inactivation
rates for each experimental regimen were calculated by linear
regression analysis. Buffering was avoided because phosphate
buffer had been found to interfere with the disinfection
efficacy of copper in previous test using Escherichia Coli.
RESULTS:
Bacterial inactivation with chlorination alone was
progressively greater as concentrations were increased from
0.1 to 0.4 mg/liter. Although the rates were relatively
slower, a similar inactivating effect was demonstrated in
tests of copper and silver ions alone: the ratio of 800
(copper) to 80 (silver) ug/liter was significantly faster than
ratios of either 200 and 20 or 499 and 40 ug/liter.
When the chlorination and copper/silver disinfection methods
were combined, inactivation rates and amounts of bacterial
reduction were enhanced. The 400 to 40 copper and silver
regimen augments the measure rate of bacterial inactivation at
all tested chlorine levels; the difference was statistically
significant at a chlorine concentration of 0.4 mg/liter.
Although reported by other investigators, significantly
increased inactivation rates at high temperatures were not
observed in this study.
CONCLUSIONS:
Electronically generated copper & silver ions increased
the level of inactivation of Legionella pneumophilia achieved
in filtered well water above the levels observed with free
chlorine alone. This effect was consistent at all copper &
silver ratios tested and at various low concentrations of
chlorine. The improvement was statistically significant when
400 ug/liter of silver were added to a chlorine concentration
of 0.4 mg/liter. Thus copper/silver ion treatment was shown to
provide effective disinfection against Legionella pneumophilia
while maintaining free chlorine levels sufficiently low to
avoid the known disadvantages of relatively high
concentrations
|
Links:
Very
useful information on Legionnaires' disease: FAQ from HC
Information Resources Inc
at http://hcinfo.com/ldfaq.htm
http://www.legionella.org/
Experiences
of the First 16 Hospitals Using Copper-Silver Ionization for Legionella
Control: Implications for the Evaluation of Other Disinfection
Modalities
by Janet E. Stout and
Victor L. Yu (Infection Control and Hospital Epidemiology,
24: 563-568, 2003.)
Hospital-acquired Legionniares' disease can be prevented by
disinfection of hospital water systems. The experience of the
first 16 hospitals (the Sweet 16) that used copper-silver
ionization for Legionella control from 5-11 years is
reported. No cases of hospital-acquired Legionnaires' disease
have occurred in any of these hospitals since 1995. This study
represents the final step in a proposed 4-step evaluation process of
disinfection methods that includes (1) demonstrated efficacy in
vitro (laboratory assays), (2) anecdotal experiences in individual
hospitals, (3) controlled studies in individual hospitals, and (4)
validation in confirmatory reports from multiple hospitals during a
prolonged period (years). Copper-silver ionization is now the
only disinfection modality to fulfill all four evaluation
criteria.
Click to
Download
A
proactive approach to prevention of health care–acquired
Legionnaires’ disease: The Allegheny County (Pittsburgh)
experience
by
Cheryl L. Squier, Janet E. Stout, Sharon Krsytofiak, Joan McMahon,
Marilyn M. Wagener, Bruce Dixon, and Victor L. Yu (American
Journal of Infection Control, 2005)
Click
to Download
Legionella
surveillance: political and social implications--a little knowledge
is a dangerous thing.
by
Victor L. Yu (Journal of Infectious Diseases 185:259-261,
2002, University of Chicago Press)
Fear of adverse publicity and litigation are obstacles to a rational
scientific approach to Legionnaires’ disease prevention.
“Surveillance should be complemented by education of the public
and lay media. The public must be informed that Legionella are
common colonizers (as are Pseudomonas species) of man-made
water distribution systems that are rarely pathogenic for
immunocompetent hosts and that Legionnaires’ disease is not a
contagious disease. Ignorance leads to panic and panic leads to
irrational actions. We have observed the implementation of emergency
measures that are expensive, logistically tedious, and have little
impact on the risk of acquiring Legionnaires’ disease.”
Click
to Download
Legionnaries'
Disease Contracted from Patient Homes: The Coming of the Third
Plague?
by M.L.
Pedro-Botet, Janet E. Stout and Victor L. Yu
Eur
J Clin Microbiol Infect Dis, 21:699-705, 2002, Springer-Verlag
Click
to Download
Hospital
-acquired Legionellosis: Solution for a preventable infection
by
Miguel Sabria and Victor L. Yu
The
Lancet Infectious Diseases, 2:368-373, June 2002
Although cooling towers were linked to the cases of Legionnaires'
disease in the years after its discovery, potable water has been the
environmental source for almost all reported hospital outbreaks.
Microaspiration is the major mode of transmission in
hospital-acquired Legionnaires' disease; showering is not a mode of
transmission. Since the clinical manifestations are non-specific,
and specialized laboratory testing is required, hospital-acquired
legionellosis is easily underdiagnosed. Discovery of a single case
of hospital-acquired Legionnaires' disease is an important sentinel
of additional undiscovered cases. Routine environmental culture of
the hospital water supply for Legionella has proven to be an
important strategy in prevention..
Click
to Download
Prevention
of Legionnaires' disease in transplant recipients: recommendations
for a standardized approach
by
N. Singh, J.E. Stout, V.L. Yu
Transplant
Infectious Diseases 6:58-62, 2004
Click
to Download
Approaches
to Prevention and Control of Legionella Infection
- Allegheny
County Health Department Guidelines
Allegheny County Health Department, Pennsylvania. 2nd Edition,
January, 1997.
Culture
Your Water System for Legionella or Not?
Yu,
V.L., " Resolving the Controversy on Environmental Cultures for
Legionella: A Modest Proposal, Infection Control and
Hospital Epidemiology, 19, pp. 893-897, 1998
This editorial reviews the proactive position of Pittsburgh
investigators in prevention of hospital-acquired Legionnaires’
disease. Pittsburgh investigators document that knowledge that the
hospital water is colonized is a scientifically-based method that
effectively prevents cases of hospital-acquired Legionnaires’
disease. In contrast, U.S. CDC does not favor culturing the hospital
water supply unless one or more hospitalized patients contract
Legionnaires’ disease. The scientific evidence and effectiveness
of both positions is reviewed.
Report
of the Maryland Scientific Working Group to Study Legionella
in Water Systems in Healthcare Institutions
June
14, 2000, Baltimore, Maryland
In
October, 1999, Georges Benjamin, MD, Secretary, Maryland Department
of Health and Mental Hygiene (DHMH), formed a Scientific Working
Group to review scientific and technical data and gather information
from experts on the current status of prevention and management of
water system-related Legionella bacteria. These
guidelines are the most comprehensive guidelines on Legionella
prevention for hospitals.
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Prevention: "Hospital water should be cultured and,
if contaminated, should be disinfected with one of two
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prospective study. Infect. Control 1987;8:357-363.
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Burbridge, S. Legionellaceae in the potable water of Nova
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McClure, J., Kominos, S. Nosocomial legionnaires’ disease
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D., Butler, J.C., et al. Hospital characterisitics associated
with colonization of water systems by Legionella and risk of
nosocomial legionnaires’ disease: a cohort study of 15
hospitals. Infect. Control Hosp. Epidemiol. 1999;20:798-805.
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controversy on environmental cultures for Legionella: A modest
proposal. Infect. Control Hosp. Epidemiol. 1998;19:893-7.
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Yu, V.L. Susceptibility of Members of the family
Legionellaceae to thermal stress: Implications for heat
eradication methods in water distribution systems. Appl.
Environ. Microbiol. 1986;52:396-399.
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G., Bornstein, D., et al. Control of nosocomial
Legionnaire’s disease through hot water flushing and
supplemental chlorination of potable water. J. Infect. Dis.
1991;163:413.
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Wireman, J., et al. Reduction in Legionella pneumophila
through heat flushing followed by continuous supplemental
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1990;162:127-132.
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Pfaller, M., and Helms, C. Continuous hyperchlorination for
control of nosocomial Legionella pneumophila: a ten year
follow-up of efficacy, environmental effects, and costs. In:
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J.M., Breiman, R.F. and Dufour, A.P., Eds. Washington, D.C.
American Society for Microbiology; 1993.
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and Gerba, C.P. Efficacy of copper and silver ions and reduced
levels of free chlorine in inactivation of Legionella
pneumophila. Appl. Environ. Microbiol. 1989;55:3045-3050.
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Tedesco, L., et al. Controlled evaluation of copper-silver
ionization in eradicating Legionella pneumophila from a
hospital water distribution system. J. Infect. Dis.
1994;169:919-922.
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M., et al. Intermittent use of copper-silver ionization for
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infection. Clin. Infect. Dis. 1998;26:138-140.
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Goetz, A.M., and Muder, R.R. Controlling Legionella in
hospital water systems: experience with the
superheat-and-flush method and copper-silver ionization.
Infect. Control Hosp. Epidemiol. 1998;19:911-914.
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Farley, A., et al. Efficacy of thermal treatment and
copper-silver ionization for controlling Legionella
pneumophila in high-volume hot water plumbing systems in
hospitals. Am. J. Infect. Control 1997;25:452-457.
- 53. Biurrun, A., Caballero, L.,
Pelaz, C., et al. Treatment of a Legionella pneumophila-colonized
water distribution system using copper-silver ionization and
continuous chlorination. Infect. Control Hosp. Epidemiol.
1999;20:426-428.
- 54. Rohr, U, Senger, M., Selenda,
F., Turley, R., Wilhelm, M. Four years of experience with
silver-copper ionization for control of legionella in a German
university hospital hot water plumbing system. Clin. Infect.
Dis. 1999;29:1507-11.
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Yu, V.L. Comparative assessment of chlorine, heat, ozone, and
UV light for killing Legionella pneumophila within a model
plumbing system. Appl. Environ. Microbiol. 1987;53:447-453.
- 56. Farr, B.M., et al.
Evaluation of UV light for disinfection of hospital works
contaminated with Legionella. Lancet 1988;2:669.
57. Cunliffe, D.A.
Inactivation of Legionella pneumophila by monochloramine. J. Appl.
Bacteriol. 1990;68:453-459.
- 58. Kool, J.L., Carpenter, J.C.,
and Fields, B.S. Effect of monochloramine disinfection of
municipal drinking water on risk of nosocomial Legionnaire’s
disease. Lancet 1999;353:272-277.
- 59. Pic-Albas, L., Donegan,
N.E., Witherell, L.E., et al. Short trial of monochloramine
for legionella disinfection in a hospital setting. Abstract, 4th
Decennial international Conference on Nosocomial and
Healthcare-Associated Infections. Atlanta, GA, March 5-9,
2000.
- 60. ASHRAE Guideline 12-2000.
Minimizing the risk of legionellosis associated with building
water systems. American Society of Heating, Refrigerating and
Air-Conditioning Engineers, Atlanta, GA., 1999. (available
through the ASHRAE web site: www.ASHRAE.org)
- 61. Best, M., Yu, V.L., Stout,
J.E., et al. Legionellaceae in the hospital water supply-
epidemiological link with disease and evaluation of a method
of control of nosocomial legionnaires’ disease and
Pittsburgh pneumonia. Lancet 1983;2:307-310.
- 62. Allegheny County Health
Department. Approaches to prevention and control of Legionella
infection in Allegheny county health care facilities. 2nd
ed. Pittsburgh, PA: Allegheny County Health Department.
1997:1-15.
- 63. Dixon, Bruce; statement to
Time/CNN, broadcast Nov. 21, 1999
The following three notes were excerpted from
Legionella E-news, a free newsletter available at
http://hcinfo.com."
1. Three Cases and One Death at Rochester,
N.Y. Hospital
Three patients at a hospital in Rochester, N.Y. contracted
Legionnaires' disease within the last four weeks. One has died. The
first case was diagnosed on Jan. 27, 2006 in a patient who was
admitted mid-January with advanced cancer. The second patient, who
had been suffering from hepatitis, died Sunday, Feb. 19, 2006. The
third patient, who was admitted Feb. 2 and receiving chemotherapy
treatment for leukemia, was in satisfactory condition as of Tuesday,
Feb. 21. After Legionella bacteria was found in the hospital's water
system on Feb. 13, all patients were given bottled water, showering
was restricted, and the water system was chlorinated. Source: News
reports
2. THREE CASES AND ONE DEATH AMONG GUESTS OF FLORIDA HOTEL
A 144-room hotel in Daytona Beach, Florida was voluntarily
closed by the owner on Feb 3, 2006 following confirmed cases of
Legionnaires' disease in three people who stayed there in January
2006. A county health official said the hotel is the only known
connection among the three cases, one of whom has died. The first
two cases occurred in early January, both in men over the age of 60.
Source: Orlando Sentinel
3. TEN WAYS TO MINIMIZE STAGNATION IN PLUMBING SYSTEMS
"Ebb & Flow: Ten Ways to Minimize Stagnation in
Domestic Water Systems," by Matt Freije (Health Facilities
Management, January 2006), is posted at http://www.hospitalconnect.com/hfmmagazine/jsp/articledisplay.jsp?dcrpath=HFMMAGAZINE/PubsNewsArticleGen/data/0601HFM_FEA_Infrastructure&domain=HFMMAGAZINE
Legionella E-news is a free monthly
international e-newsletter that covers recent outbreaks, new
publications, and new technology. To subscribe, go to http://hcinfo.com
Contact:
Biophysica Inc., Toronto, Ont, Canada
Technical Support Hotline,
Phone: (905) 827-9448 (10am to 10pm EST)
e-mail:
info@biophysica.com
This page last updated on February
27, 2006
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