Water Issues in Infection Control

Learning objectives

➢ Environmental sources of water-associated infectious agents

➢ Water system in health care facility

➢ Steps of water quality analysis in health care facility

➢ Strategies for Controlling Waterborne Microbial Contamination.

Key concepts

➢ Maintaining drinking water quality requires a high level of suspicion for infectious
agents associated with moisture and water-distribution systems.

➢ Bacterial and fungal contamination risks are associated with potable (drinking)
water and have potential for direct or indirect transmission.

➢ The overall risk is considered relatively low.

➢ P. aeruginosa spp., Atypical mycobacteria, and Legionella are the most commonly
reported pathogens.

➢ Water-associated disease has also been reported in the community- based personal
care services industry, highlighting the importance of infection prevention and
control in nontraditional industries.

Basic principles

➢ Environment (both animate e.g., patients & staff, and inanimate e.g., water, air,
food) is an important source of nosocomial infection.

➢ Environment may act as:

o Reservoir: place where microorganisms live and develop.

o Source: place from which a pathogen is transmitted to a host.

➢ Routs of transmission of a pathogen from inanimate environment to the patient:

o Air-born: (TB).
 o Vector: as water, food, blood, intravenous therapy.

o Contact

➢ Water Microbial Bio load

o EPA drinking water standard at <1 coliform/100ml.

o Not more than 500 cfu/ml of total bacteria count.

Modes of Transmission of Waterborne Diseases

➢ Direct contact (as in hydrotherapy).

➢ Ingestion of water (drinking water).

➢ Indirect-contact transmission [e.g., from an improperly reprocessed medical

device].

➢ Inhalation of aerosols dispersed from water sources.

➢ Aspiration of contaminated water.

Examples of microorganisms causing Waterborne Infection in Health-

Care Facilities

➢ Legionella spp.

➢ Other gram-negative bacteria include:

o Pseudomonas aeruginosa.

o Pseudomonas spp.

o Burkholderia cepacian.

o Sphingomonas spp.

➢ Non-tuberculous Mycobacteria

Environmental sources of water-associated infectious agents

➢ Potable water

➢ Sinks
 ➢ Showers

➢ Dialysis water

➢ Faucet aerators

➢ Cooling towers

➢ ICE & ICE MACHINS

➢ Flower vases decorative fountains

➢ Toilets & water bath

➢ Dental-unit water station & ear, eye washing stations

The primary goal of water treatment to produce water that is:

➢ Biologically, chemically safe

➢ Noncorrosive

➢ Nonscaling.

Maintenance of water quality depends on:

➢ Good design

➢ Preventive maintenance

➢ Surveillance for nosocomial infections that includes a high index of suspicion

for infectious agents associated with moisture and water-distribution systems.

Water system in health care facility

I. Components of water system & Building design considerations

➢ Designing the environment that is easy to keep clean and dry (e.g., use of non-
porous smooth material, design to avoid stagnation and aerosolization of fluid).

➢ Ensuring that water reservoirs are designed to enable proper maintenance.

➢ Basic components of water system in health care:

 a. Disruption system pipes

b. Valves.

c. Boiler systems, water heaters, and storage tanks.

d. Sewer water systems.

e. Point-of-use fixtures, sinks, toilets, showers, and faucets.

f. Decorative fountains.

II. Water supply surveillance

➢ Sanitary inspection

➢ Water quality analysis

Water quality analysis

What is water quality?

Water quality refers to the characteristics of a water supply that will influence its
suitability for a specific use. These characteristics include:

➢ Physico-chemical properties

➢ Biological properties

Physico-chemical properties

PH, color, odor, taste, temperature, turbidity and dissolved solids, salinity, and
hardness

1. Temperature:

Temperature affects the physical, chemical and biological process in water body
and therefore the concentration of many variables.

2. Color:

Natural water can range from <5 true color unit (TCU) in very clear water to
300 units in dark water; Normal 15 TCU.
3. Odor:

Presence of odor suggests higher biological activity than normal. It is a simple

test for suitability of drinking water.

4. PH:

➢ The preferable level is 7 – 8.

➢ PH below 7 may cause corrosion of the material of water distribution.

system

➢ PH above 8 results in decreased efficiency of chlorine disinfection process.

5. Total solids:

➢ Total solids is a measure of the suspended and dissolved solids in water

➢ Suspended solids are those that can be retained on a water filter (e.g., clay,
organic wastes). Its increase in water affects transparency and turbidity.

➢ Dissolved solids are the portion that passes through the filter (e.g., calcium,
magnesium, sodium, potassium, chloride and bicarbonate). TDS are a
measure of salinity.

➢ Both Dissolved & suspended solids are common tests of polluted water.

6. Hardness:

➢ Hardness of water depends mainly on dissolved calcium and magnesium

salts.

➢ The total content of these salts can be divided:

o Carbonate (temporary) hardness: determine by concentrations of

calcium and magnesium hydro carbonates.

o Non-carbonate (permanent) hardness: determine by calcium and

magnesium salts of strong acids.

➢ Hydro carbonates are transformed during the boiling of water into carbonates,
which usually precipitate
 ➢ The following is a measure of hardness (expressed in mg/l as CaCO3):

o Soft: 0 -75 mg/l as CaCO3

o Moderate: 75 -150 mg/l as CaCO3

o Hard: 150 -300 mg/l as CaCO3

o Very hard: 300 -500 mg/l as CaCO3

o Extremely hard: 500 -1,000 mg/l as CaCO3

Biological characteristics

➢ Ideally drinking water should not contain any microorganisms known to be

pathogenic.

➢ The primary bacterial indicator recommended for biological analysis of water is the
coliform group of microorganisms

A) Coliform micro-organisms group

➢ They include fecal (the majority) and non-fecal organisms

➢ There are several reasons why coliform group has been chosen as an indicator of
fecal pollution:

a. They present in huge amount on intestine & considered as foreign in

potable water.

b. Easily detected in culture as small as 1 bacterium in 100 ml water.

B) Fecal Streptococci

➢ Regularly present in feces but in much smaller number than E.coli.

➢ Its presence in water confirms recent water contamination.

C) Clostridium Perfringens

➢ Regularly present in feces but in much smaller number than E. coli.

➢ The spores are capable of survival in water for longer time than coliform organisms
& usually resist chlorination at the dose normally used for water disinfection
 ➢ Its presence in water in absence of coliform organisms indicate fecal contamination
that occurred at remote time

According to WHO, disinfection by chlorine is still the best guarantee of

microbiologically safe water.

Steps of water quality analysis in health care facility

A. Biological analysis

➢ Coliform bacteria are the most useful indicator when fecal contamination is
suspected.

➢ Ideally, chlorinated water should have <1 coliform bacterium / 100ml.

➢ Bacteriological analysis of water in health care facility should be performed at

least every month.

B. Analysis of residual chlorine in chlorine-treated water

➢ Testing of water supply for free residual chlorine (mg/l) is performed to assess
the effectiveness of disinfection.

➢ Free residual chlorine should be >0.2 & < 1.0 (mg/l) after at least 30 minutes
contact time (contact with water) at pH < 8.0. and NTU <1 unit (NTU,
nephelometric turbidity units or Jackson turbidity units).

C. Measuring pH of water

➢ PH of water can affect the efficiency of chlorine disinfection process.

➢ Chlorination of water is more effective at pH <8 & at higher temperature.

D. Testing for water turbidity

➢ Water turbidity is measured by calibrated turbidity tube.

➢ Ideally, drinking water should have turbidity < 1 TU (this is invisible by eye).

➢ At 5 NTU, turbidity can be seen by eye and water is not accepted for use.
Potable water

➢ Safe to drink

➢ Not necessarily esthetically pleasing

➢ Potability affected by:

o Microbials (e.g., Giardia, Cryptosporidium)

o Organic chemicals (e.g., chlordane, cis1,2-dichloroethylene, disinfection

byproducts)

o Inorganic chemicals (e.g., cadmium, copper, lead, mercury)

o Radionuclides

Palatable water

➢ Esthetically pleasing

➢ Presence of chemicals does not pose a threat to human health

➢ Includes chloride, color, corrosivity, iron, manganese, taste and odor, total dissolved
solids

The goal of municipal water treatment is to provide water that is both palatable and potable.

o Potability: Primary Maximum Contaminant Levels (MCLs)

o Palatability: Secondary Maximum Contaminant Levels (SMCLs)

Maximum Contaminant Levels (MCLs) are standards that are set by the United States
Environmental Protection Agency (EPA) for drinking water quality. An MCL is the legal
threshold limit on the amount of a substance that is allowed in drinking water systems
under the Safe Drinking Water Act (SDWA). The limit is usually expressed as a
concentration in milligrams or micrograms per liter of water.

Water treatment methods

1. Heat and flush (heat shock, short-term solution )

2. Super-chlorination

followed by continuous disinfection (corrosion and carcinogenic biproduct)

 Chlorination

➢ a chemical disinfection method that uses various types of chlorine or chlorine-

containing substances to disinfect water.

➢ Chlorination is the most popular method of disinfection and is used for water
treatment all over the world.

➢ A leading advantage of chlorination is that it has proven effective against

bacteria and viruses; however, some protozoan cysts are resistant to the effects
of chlorine.

➢ It is inexpensive and fairly easy to implement.

➢ Unlike some of the other disinfection methods like ozonation and ultraviolet
radiation, chlorination is able to provide a residual to reduce the chance of
pathogen regrowth in water storage tanks or within the water distribution system

➢ Chlorine act best at pH < 8, when pH exceeds 8, chlorine is unreliable as

disinfectant

➢ The minimum recommendation for free chlorine is 0.5 mg/l.

➢ The three most common types of chlorine used in water treatment are:

o Chlorine gas (best)

o Sodium hypochlorite

o Calcium hypochlorite.

3. Copper-silver ionization

➢ 0.4 ppm of copper and 0.04 of silver are best for killing legionella. This is below
the EPA drinking water maximum level of 1.3 ppm copper and o.1 silver.

➢ Advantage of copper-silver ionization:

a. Water temperature can be lowered safely.

b. Fully penetrate of the biofilm.

c. Control Legionella within 45 days.

 d. Distal point water flushing is not necessary

e. Treat all of the water systems including dead legs, and low flow ereas

f. Has a long residual effect up to 6 months.

g. The long residual effect and the way ions disarm bacteria and biofilm in
multiple ways, completely eradicates the contamination.

h. Non-corrosive to pipework.

i. Ease of installation and maintenance.

4. Ultraviolet radiation: Good for small portion of water system.

5. Ozonation: difficult to find performance report.

6. Chlorine Dioxide: currently being tested for efficacy in water distribution system.
7. Filtration: Additional filtration of potable water systems is not routinely necessary.
Filters are used in water lines in dialysis units, however, and may be inserted into
the lines for specific equipment (e.g., endoscope washers and disinfectors) for the
purpose of providing bacteria-free water for instrument reprocessing.

Strategies for Prevention of Waterborne Microbial Contamination

A. Proper water system design

B. Prevention of water stagnation

C. Periodic elevation of water temperature

D. Monitoring of chlorine level

E. Routine cleaning and maintenance of water storage tanks

System general design

➢ Systems should be designed to supply water at sufficient pressure to operate all

fixtures and equipment during maximum demand.

➢ Additionally, provision of two separate water lines from a looped municipal

water-supply system to a facility would minimize interruption of water services.

➢ Stop (isolation) valves should be provided for each fixture.

 ➢ Vacuum breakers should be installed on faucets. Approved backflow preventers
(i.e., antisiphon devices) protect water-supply systems from contamination in
high-risk such as dialysis units.

➢ Drainage piping should not be installed in ceilings or exposed in operating and

delivery rooms, nurseries, or other sensitive areas.

➢ Floor drains should be avoided as much as possible, and specifically should not
be in operating rooms or delivery rooms.

➢ Water-supply pipes with dead ends should be avoided.

Storge tanks

➢ Prevailing winds, dust, and foreign matter ingress

➢ Proximity of other discharges, exhausts and pollutants

➢ Lids should fit snugly

➢ Convenient maintenance access

➢ Minimal internal components to avoid sediments, algae growth, corrosion

➢ Internal liners inert to bacterial growth and disinfectant

➢ location away from sunlight and away from other heat sources

➢ Rapid draining and filling requirements

➢ Convenient water sampling facility

Water Temperature and Pressure in health care facility:

➢ The hot water temperature in hospital patient-care areas is within the range of
(40.6°C– 49°C), depending on the AIA guidance issued at the year in which the
facility was built.

➢ The hot water temperature requirements in certain service areas of the hospital
(e.g., the kitchen (49°C) or the laundry (71°C)).

➢ To minimize the growth and persistence of gram-negative waterborne bacteria

(e.g., thermophilic NTM and Legionella spp.), cold water in health-care facilities
 should be stored and distributed at temperatures below (20°C); hot water should
be stored above (60°C)

➢ If the return temperature setting of (51°C) is permitted, then installation of preset

thermostatic mixing valves near the point-of-use can help to prevent scalding.

Approaches to minimize the growth of Legionella spp. Include:

A. Periodically increasing the temperature to at least 66°C at the point of use [i.e.,
faucets]

B. Adding additional chlorine and flushing the water.

C. Systems should be inspected annually to ensure that thermostats are functioning

properly.

Water supply equipment consideration

1-Adequate and proper placement of hand washing facilities.

2-Equipment Design Issues Handwashing Stations.

3- Design Issues for Emptying Bedpans

4- Power interruptions or breaks in water line.

5- Environmental contamination

Adequate and proper placement of hand washing facilities is the major engineering and
infection control method for reducing risks.

➢ Sufficient numbers and proper placement of hand washing sinks.

➢ The AIA guidelines do not consider waterless agent dispensers as equivalent to
sinks, understanding soap and water is still required for washing hands
contaminated with visible soil.
Static (stagnant) water system

➢ Reservoirs of organisms.

➢ The residual chlorine or other water treatments can be overcome by microbial

growth.

➢ Leads to corrosion (scale and sediment) and development of biofilm that amplifies
the growth of microorganisms, particularly Legionella.

Hand washing stations

Faucets

▪ Non-touch faucets are preferred

Location

▪ Sinks need to be placed in convenient and accessible areas, prevent splashing of nearby
equipment and supplies.

▪ Nearby surfaces should be nonporous to resist fungal growth.

▪ Areas beneath sinks should not be used for storage.

Soap

▪ Built-in refillable soap dispensers should be avoided.

Drying

▪ Ideal designs dispense the towel without direct hand contact with the dispenser.

▪ If hot-air dryers are used, installation should preclude possible contamination by

recirculation of air.
Aerators

▪ Not recommended, though CDC guidelines indicate removal is an unresolved issue for
immunocompetent patients

▪ ASHRAE recommends cleaning and monthly disinfection of aerators in high-risk patient-

care areas as part of Legionella control measures.

Sink controls

▪ Faucets can be operated by hand, by elbow-, knee-, or foot-operated controls, or

automatically by electronic or other sensor-driven controls.

▪ Blade handles on clinical sinks should be at least 6 inches long for operation without
hands (i.e., elbow operated).

Design Issues for Emptying Bedpans

▪Bedpan-flushing devices should be provided in each inpatient toilet room.

▪There is no safe, aesthetic management of stool in bedpans; design of system should

provide for emptying bedpans without leaving patient room. or for minimal travel distance
to clinical/flushing rim sinks in treatment areas.

▪Bedpan flushing devices: Spray, arm, and disposable devices all create splashing; use of
personal protective equipment is essential.

Environmental contamination related to legionella spp

A. Mechanism of transmission.
B. Infection risks.
C. Primary control prevention.
D. Secondary control prevention.
Factors that enhance colonization & amplification of Legionella in water
environment

➢ Temperature of 25 - 42°C.

➢ Water stagnation

➢ Scales and sediments

➢ Presence of certain free-living aquatic amoebae that can support

intracellular growth of Legionella

Infection risk
➢ Presence of Legionella spp. in hospital water systems is not a predictor of disease.
➢ Routine culturing of the water as a control measure remains one of these
controversial and unresolved issues.
➢ The CDC does not recommend routine environmental surveillance for Legionella
➢ Surveillance is only recommended after 1 or 2 definitive cases of health care–
acquired Legionnaires’ disease.
➢ One exception for units housing hematopoietic stem cell transplant (HSCT) or
solid organ transplant recipients.
➢ ACHD??? See later

Mechanism of transmission

➢ Persons have breathed mists that come from water source contaminated with
Legionella spp.
➢ Aspiration of contaminated potable water.
➢ Aspiration of nasogastric tube-feeding contaminated solutions from tap water, but
not person to person.
Potential sources of Legionella

o Showerheads and sink faucets

o Cooling towers

o Water systems incorporating an evaporative condenser

o Spa pools

o Hot and cold-water systems

o Decorative fountains

o Hot water tanks and heaters

o HVAC humidifiers

o Nebulizers & other respiratory care equipment

Patient risk factors

➢ Severe immunosuppression from ➢ HIV

organ transplantation ➢ Elderly
➢ Chronic underlying illness ➢ Smoke cigarettes
➢ Hematological malignancy ➢ Chronic lung disease
➢ End-stage renal disease ➢ Non-hematological malignancy
➢ Diabetes mellitus
➢ Healthcare facility-associated Legionnaires’ disease may be underestimated in
facilities where clinicians do not perform routine specific diagnostic testing for the
disease.
➢ The disease is rare among children.
Primary Prevention of Legionnaires Disease

(No Cases Identified)

1- Education

➢ Physicians need to heighten their suspicion for cases of nosocomial

Legionnaires’ Disease.
➢ It is estimated that 3% of all pneumonias are caused by Legionella bacterium.

2-Surveillance

➢ Clinicians must have appropriate laboratory tests (testing sputum, urine and
blood) for the diagnosis of this disease.
➢ The diagnosis requires special tests not routinely performed on persons with
fever or pneumonia (e.g., culture, urine antigen, serology).

3-Nursing practice

➢ Using sterile water for rinsing nebulization devices and other semi critical
respiratory-care equipment after they have been cleaned and disinfected.
➢ Using sterile water to fill reservoirs and devices used for nebulization.

4- Primary preventive activities

➢ Ice machines

Should be cleaned and sanitized per current manufacturer’s recommendations.

➢ The PT Department to ensure whirlpool units and tubs are cleaned and disinfected
(2-5pp chlorine residual is maintained in the water) according to the manufacturer’s
instructions or CDC’s guidelines.
➢ Dentists should maintain the water quality of their units. Sterile water should be
used for sterile irrigations.
➢ Large Hydrotherapy pools

o Follow local requirement for chlorine disinfection.

o Patients who are feacally incontinent or who having draining wound

should refrain from pool using.
➢ Hydrotherapy tank

o Clean and disinfect between patients use.

o 15ppm chlorine residual in water prior to use.

➢ Cooling Towers and Evaporative Condensers

o Health-care facilities maintain indoor climate control during warm

weather by use of cooling towers (large facilities) or evaporative
condensers (smaller buildings). A cooling tower is a wet-type,
evaporative heat transfer device used to discharge to the atmosphere
waste heat from a building’s air conditioning condensers.

o Cooling towers and evaporative condensers provide ideal ecological

niches for Legionella spp.

o There should be regular cleaning and biocide treatment of these

devices.

o Because cooling towers and evaporative condensers can be shut down

during periods when air conditioning is not needed, this maintenance
cleaning and treatment should be performed before starting up the
system for the first time in the warm season.

o Conduct weekly inspection to identify & fix leaks, check for corrosion
& blockage, and ensure proper operation of the equipment.
Figure (1): Diagram of a typical air conditioning (induced draft) cooling tower

➢ Decorative fountains: should not be placed in patient care areas and regularly
disinfected.

➢ Eye wash stations & emergency showers: should be flushed weekly.

➢ Dialysis Water Quality and Dialysate:

o The water used to prepare neither the dialysate nor the dialysate itself
need to be sterile but tap water cannot be used without additional
treatment.

The bacterial standard for water used in dialysis unit is reviewed in the
following 2 tables
Table (1): Present standard*

Hemodialysis Maximum total Maximum endotoxin

fluid heterotrophs (CFU/mL) level (EU/mL) (endotoxin
(colony forming units per units per milliliter)
milliliter)

Product water – Used to 200 No standard

prepare dialysate

Product water – Used to 200 5

reprocess dialyzers

Dialysate 2000 No standard

Table (2): Present standard**

Hemodialysis fluid Maximum total Maximum endotoxin level

heterotrophs (CFU/mL) (EU/mL) (endotoxin units
(colony forming units per per milliliter)
milliliter)

Product water 200 2

Dialysate 200 2

** Dialysate for hemodialysis, RD 52, under development, American National Standards

Institute, Association for the Advancement of Medical Instrumentation (AAMI).

* The material in this table was compiled from references 789 and 791 (ANSI/AAMI
standards RD 5-1992 and ANSI/AAMI RD 47-1993).
Secondary Prevention of Legionnaires Disease

Interventions for an identified definite case of Legionella spp. (laboratory confirmed) or

two or more possible cases within 6 months.

o laboratory-confirmed cases of legionellosis:

Occur in patients who have been hospitalized continuously for >10 days before the
onset of illness)

o possible cases:

Laboratory confirmed infections that occur 2–9 days after hospital admission.

1- Epidemiological investigations for legionellosis

➢ Review medical and microbiologic records.

➢ Initiate active surveillance to identify all recent or ongoing cases.
➢ Determine the type of epidemiologic investigation needed for assessing risk factors:
Case-control study, Cohort study.
➢ Gather and analyze epidemiologic information.

➢ Evaluate risk factors associated with potential environmental exposures (e.g.,

showers, cooling towers, and respiratory-therapy equipment).

➢ Collect water samples:

- Sample environmental sources implicated by epidemiologic investigation

-Sample other potential source of water aerosols.

➢ Subtype strains of Legionella spp. cultured from both patients and environmental
sources.

2-Additional inf control measures to prevent exposure of high risk patients

➢ Restrict patients from taking showers if the water is contaminated with Legionella
spp.

➢ Provide sterile water for drinking, tooth brushing, or for flushing nasogastric tubes.
Perform supplemental treatment of the water for the unit.
 ➢ Consider periodic monitoring (i.e., culturing) of the unit water supply for Legionella
spp.

➢ Remove shower heads and faucet aerators monthly for cleaning.

➢ Use a 500–600 ppm (1:100 v/v dilution) solution of sodium hypochlorite to

disinfect shower heads and faucet aerators.

3- decontamination steps

➢ Superheating (flushing for at least 5 minutes each distal outlet of the system with
water ≥71-77° C) OR
➢ Hyper-chlorinating the system with water containing ≥10 mg/L free residual
chlorine).
➢ Post warning signs or install preset thermostatic valves in point of use to help
minimize the risk of scalding .
➢ Maintain potable water ≥50° C or ≤20° C or chlorinate heated water to achieve 1 to
2 mg/L free residual chlorine at the tap in hospitals housing patients who are at risk of
acquiring legionellosis (immunosuppressed patients).
➢ Clean hot-water storage tanks and water heaters to remove accumulated scale and
sediment.
➢ If cooling towers or evaporative condensers are implicated, decontaminate using
published protocols.

4- Follow up activities

Evaluate if control measures are working:

➢ Collect samples for culture at 2-week intervals for 3 months.

➢ If not detected, collect cultures monthly for another 3 months.
➢ If Legionella species are detected in one or more cultures, reassess control
measures, modify accordingly and repeat decontamination process.
➢ Keep records of all control measures and laboratory tests.