1. W I N T E R 2 0 1 5 - 1 6 event report
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The IBBS is an international, multi-disciplinary organisation formally established
in 1969 with the aim of promoting the science and technology concerning the
biodeterioration, biodegradation and bioremediation of commercially important
materials.
The specific focus for the Winchester meeting was ‘safety of water as a product
in healthcare’.The meeting was chaired by IBBS president John Gillatt of Thor
Specialities (UK) Ltd and the main speakers were prominent microbiologists
concerned with water usage in healthcare, analytical scientists specialising in
microbial testing and disinfection specialists involved in water supply and microbial
control.
There were four themed sessions with very high standard of presentations.The
first morning dealing with legislation and guidance and Legionella and first up
was Marcus Rink, the newly appointed Chief Inspector of the Drinking Water
Inspectorate, who introduced himself to the water microbiology world with an
outline of the role current role of the DWI.
The DWI sits within Defra but is able to act autonomously in respect of regulatory
power and has a number of enforcement options. Mr Rink emphasised the
importance of regulation by noting the continuing improvement of standards: in
2014, only 0.05% of tests of public water supplies failed to meet standards against
compared to 1.6% in 1991.
John Newbold, Principal Specialist Inspector of the Health and Safety Executive’s
Biological Agents Unit, discussed the HSE’s proposed ill health strategy, particularly
in the context of HSE’s role in tackling work-related ill-health.
Over 1.2 million people suffer each year through illness resulting from exposure at
work to harmful substances including pathogens, such as Legionella (See Figure 1).
HSE’s proposed work place ill-health strategy will help to tackle and raise awareness
around work-related illness from substances hazardous to health, Mr Newbold said.
He stressed that HSE’s regulatory role goes beyond simply policing compliance and
imposing sanctions. It also has an enabling function: sharing lessons learnt from
investigations, providing improvement advice, disseminating knowledge, publishing
guidance and providing policy advice to government and industry.
But Mr Newbold emphasised that the biggest challenge currently lies in tackling
occupational disease and ill-health, issues that are much harder to recognise and
tackle than safety.
A recent Government review recommended HSE review its health and safety
guidance, with particular focus on its Approved Codes of Practice with the aim of
producing simple, clear guidance that is easy to understand to help compliance with
health and safety law.The L8 Approved Code of Practice on the control of Legionella
in water systems, published in November 2013, was part of this review.
HSE will continue to focus on developing different ways of integrating and
interacting with those that create the risks, for example by influencing through
industrial forums, Mr Newbold said. As an example, HSE has carried out research to
identify key issues around the management and control of Legionella, and undertook
a detailed analysis to underpin a targeted intervention programme.
Public Health England statistics show that the organism is not going away. Numerous
outbreak investigations reveal that compliance with health and safety guidance and
legislation has been mixed - requiring further reinforcement of key messages for
those that create the risks.
Based on research of outbreaks of Legionnaires’ disease from 2002 to 2012 (see
HEX 12/07, available on the HSE website), HSE developed several measures
which, combined, were aimed at encouraging industry to take ownership for risk
management and lead work to bring about sustained improvements in standards.
These interventions included a targeted inspection programme in 2013/14 to assess
the risk potential of around 1500 cooling towers; promoting key messages using the
revised L8 ACOP and HSG274 guidance to raise awareness and help compliance; and
an extensive stakeholder engagement programme to promote sustained compliance.
HSE are currently working collaboratively with other Government departments
including PHE and the Department of Health in reviewing key guidance including the
management of spa pools and DH’s HTM 04-01.
City of London Environmental Health Officer (EHO) Toby Thorp outlined the
complex challenges faced during outbreak investigations.
He highlighted the point that “Legionella knows no boundaries” – so the origin of
an outbreak may lie in a neighbouring local authority.The City of London covers
just a square mile, but in the context of its surrounding area, an outbreak inside its
boundaries is within range of around 90 cooling towers, any of which could be the
source.
Each outbreak is different and will require its own investigation strategy, he said.
Points to be considered include decisions on which premises to visit, and where to
go first, what resources are available and therefore what speed inspections can take
place, and the expertise of available officers.
7-8 September 2015, University of Winchester
The International Biodeterioration and Biodegradation Society (IBBS) has held a number of successful water-related meetings over the
past few years and its two-day conference held in collaboration with Public Health England (PHE) at the University of Winchester in
September was no exception.
by Susan Pearson
Water Microbiology
Current and Emerging Issues in Healthcare
Figure 1: Work-related ill health: 2013/14
• 1.2 million working people suffering a work related illness
and ½ million new cases each year
• 23.5 million working days lost
• Estimated 13,000 deaths from occupational lung disease,
cancer and respiratory disease
• Wide spread of diseases and industries
• Costs to Britain - £double figure billions
Image: City of London - density of potential sources of outbreaks

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event report waterline | THE JOURNAL OF THE WATER MANAGEMENT SOCIETY
A sampling strategy is essential, he said, to assist with identification of potential
sources, to compare results with clinical samples, to assess effectiveness of any
remedial action and to provide evidence for formal enforcement action. But this
is not without its challenges, such as establishing a methodology and protocol,
agreeing competence of those undertaking sampling, and deciding on numbers of
samples and what information should be collected.
But one of the biggest challenges for field officers, Mr Thorp stressed, is to manage
the expectation of the public that the spread will be controlled, future incidents will
be prevented and the culprits will be found and prosecuted.
However, since carrying out emergency decontamination and obtaining samples
cannot be carried out at the same time,“how do you prioritise?”
He also emphasised that outbreaks are resource intensive – yet resources are
continually being stretched and there are now fewer officers available who have the
required skills and competence to manage an incident.
Discussing laboratory investigations of Legionella outbreaks, Dr Heather Aird, Unit
Head of the PHE Food,Water and Environmental Microbiology Laboratory in York,
highlighted problems with home birthing pools.The FW&E laboratory provides water
microbiology services to local authorities, NHS trusts and commercial organisations,
In June 2014, a health
protection team in the
North East found a baby
on a neonatal unit infected
with Legionella. Legionella in
newborns is very rare and this
baby subsequently died.The
infant had been born at home
in a hired birthing pool that the
company instructed be set up
and filled with water around
two weeks before the birth.
The heater/circulating pump
associated with the pool was
to be switched on and the water allowed to circulate in the pool at around 28-40°C
(the ideal growth temperature for Legionella). Disinfectant provided by the supplier
was to be added and a complex regime followed during this two week period. It
seemed likely, later confirmed by the coroner, that aspiration of contaminated water
into the baby’s lungs had occurred during birth.
By the time of the investigation, the pool had been cleaned, dried and re-packed
flat. However, samples were taken from debris found in the outlet pipe and the tiny
amount of residual water in the pump and residual moisture on the pool covers. A
10-day culture and confirmation using selective media was carried out.
These tests found heavy bacterial contamination, but no Legionella. However,
quantitative PCR at PHE Porton detected Legionella from the inlet and outlet pipes,
the pump and the pool covers. Further DNA analysis found one of the samples to be
the same strain as that isolated from the baby.
Testing of a further ten pools found Legionella in three more, and Pseudomonas and
various other opportunistic bacteria in all of the pools.
PHE now recommends that these heating/circulation pools should not be used and
are working with the coroner and the Medicines and Healthcare Products Regulatory
Agency on regulation. However, birthing pools can still be used at home provided
they are filled during labour.1
An afternoon session on Pseudomonas saw two particular messages emerge: that
the guidance document for Pseudomonas aeruginosa in augmented care units,
the Addendum to Health Memorandum 04-01 on the control of Legionella, is an
excellent document but there are challenges with compliance on a day-to-day basis;
and that understanding of the science on which the current guidance is based is
continually moving on as new information emerges.
Published in 2014, HTM 04-01 has been a landmark, the first guidance to be written
for P. aeruginosa based on the formation of multidisciplinary Water Safety Groups
(WSGs) and detailed Water Safety Plans (WSPs).
Dr Robin Smith, a consultant microbiologist and infection control doctor at the
Royal Free Hospital outlined the details of water safety groups’ remit.WSGs are
multi-disciplinary groups that undertake the commissioning and development of
a water safety plan (Figure 2), advise on remedial actions for contaminated water
outlets and look at risks to susceptible patients.
Dr Smith’s examples of how HTM 04-01 can be difficult to comply with included:
• Sampling: Lack of clarity over the definition of ‘augmented care’ has led to the
decision to test water in day care units as well as certain wards at the Royal Free –
a challenging testing routine including over 600 outlets every month.
• Sensor taps: Can be problematic: often do not flush for very long. Internal
solenoids have also been found colonised with Pseudomonas.
• Sinks: Some immuno-compromised patients may have as many as four water
outlets in their vicinity, leading to stagnation from under-use.
• Staff shortages: “One of the bigger problems”: Some London Trusts are running
on a 40% shortage in nursing staff, meaning that nurses do not have time to
attend water safety groups.Appropriate clinical practice and training can suffer.
• Persistent contamination: Outlets found to be persistently positive for
Pseudomonas are on the increase, even after sinks and taps are changed.
Dr Beryl Oppenheim, Consultant Microbiologist and Joint Theme Lead of the Surgical
Reconstruction and Microbiology Research Centre, University Hospitals Birmingham
NHS Foundation Trust also emphasised the Addendum’s excellence – and some of
the difficulties with compliance.“How (do you) do the surveillance on patients when
you’re talking about adults in augmented care? What constitutes a new case? How
do you count it? How do you say where that person might have acquired it?”
She went on to discuss new findings from a major new study to look further into
whether water really is an important source of acquisition of P. aeruginosa in adults
in a non-outbreak setting.
Carried out at the University Hospitals Birmingham (UHB) NHS Foundation Trust, a
major burns centre, the study focused on patients with severe burns, for which
P. aeruginosa is a major pathogen.Water plays a critical part in burns treatment and
reports of links between water and P. aeruginosa infections in burns patients go back
to the 1990s. However, Pseudomonas sequence types found in water in healthcare
environments are very widespread internationally, so patients presenting with the
same sequence type as the water may not be significant.
Dr Oppenheims’s team utilised next generation whole genome sequencing to acquire
the “forensic” detail (such as any differences between any bacterial nucleotide in a
bacterial genome) needed to confirm links between bacterial strains from different
samples.
An initial audit of burns
patients at UHB found around
30% developed P. aeruginosa
colonisation.The study’s results
from environmental sampling
– i.e.,‘dry’ sites – were negative
for Pseudomonas, while half of
all samples from ‘wet’ sites (taps,
showers etc.) were positive.
Given the initial 30% figure, the
researchers expected to identify
at least ten colonised patients
during the study, however only
five were identified.
Correlating these results with a plan of the burns unit revealed that all the positive
sample strains from environmental wet sites were mostly very closely related. But
significantly, the wound swabs from the two patients who had acquired identical
strains were also identical to the both the water and environmental isolates from
one room – in which they had both been treated.
Dr Oppenheim concluded that there is definitely a transmission and that
Pseudomonas travelled from water to the patient.
But the research also demonstrated that the majority of patients admitted to the
burns unit do not carry detectable levels of P. aeruginosa, so water “is not the only
source... Can we make any leap to say water is also an important source in other
patients?
“For the moment we don’t have a final engineering solution,” she said,“we currently
have POU filters on the highest risk water outlets in that unit.”
Figure 2: Water Safety Plan
• Assist with understanding and mitigating contamination
risks from water distribution and supply systems and all
associated equipment.
• Provide a risk management approach to the
microbiological safety of water.
• Establish good practices in local water usage,
distribution and supply.

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Dr Jimmy Walker of PHE’s Biosafety Group at Porton Down, one of the conference
organisers, discussed findings from a test rig that also provided some new
information on Pseudomonas.
Analysis of data from numerous outlet components of the 27 tap rig demonstrated
that the outlets themselves may not always be the source of Pseudomonas
contamination in hand washbasins.
Following inoculation of the rig with P. aeruginosa, many months of water sampling
established that the majority of the outlets became contaminated. However, after
one year, no Pseudomonas was recovered from the outlet components – despite the
presence of scale deposits on the components. Instead, extensive build-up of biofilm
on the EPDM material inside the solenoid valves was found.When new solenoids
were put in place, they did not become colonised. Removal of flow straighteners
made no impact on those results.
Flushing analysis also indicated that flushing does have a role in reducing
proliferation of microorganisms but does not “ does not control contamination as
such,” Dr Walker concluded.
George McCracken, Head of Risk and Environment at the Belfast Health and Social
Care Trust explored innovative approaches to asset management.
“We are ‘whirling’ in data.. (which) is mostly used.. to show compliance,” Mr
McCracken said, but questioned whether compliance data on its own is always a true
indication that patients are actually safe. For example, on a neurology ward at the
Belfast Trust, where additional water sampling had indicated a Legionella problem,
compliance data, such as water temperatures and biocide levels, had indicated that
patients were safe. In fact they were actually at risk.
“We want to create a safe environment – not just a compliant environment,” Mr
McCracken emphasised.
One of Mr McCracken’s solutions has been to exploit the Government’s ‘efficiency’
pressure to improve risk reduction: re-direction of budget saved from ‘efficiencies’
brought in by the Trust’s energy team have been used to set up a dedicated water
sampling team to provide data on top of that required for compliance.
And in his quest to utilise data more effectively to improve and demonstrate
patient safety, McCracken has replaced laborious spreadsheets by tapping into the
‘internet of things’ concept to develop, in partnership with Spidex Ltd and MICAD
Ltd, software that aligns data in variety of forms. For example, when there is an
incident, a floor plan and the location of the patients involved can be overlain
with appropriate temperature and water sampling data from specific outlets.This
new database ‘talks’ to the old database and for the first time allows a graphical
representation of the last set of results in addition to the ability to easily examine
trends within the data.The estates team can now easily demonstrate the relationship
between water sample results and a specific patient and share this information with
other teams such as microbiology and infection control.
This approach allows for the creation of optimum level of risk management in water
hygiene. If other Trusts could be encouraged to contribute to the same database,
McCracken says, it will become easier to share good practice between hospitals and
to determine the effectiveness of the interpretation and application of guidance.
Senior PHE microbiologist Dr Sam Collins discussed emerging technologies for the
detection of waterborne pathogens, all of which are ‘rapid’ techniques producing
faster results than the current ’gold standard’ culture test.This tried and tested
technique is still the best tool for matching patients to infection sources, Collins
said, but is slow, taking 2-4 days for Pseudomonas and up to 28 days for some
environmental bacteria. It has poor recovery and reproducibility and some organisms
will not grow in culture.
These rapid methods are already in use in clinical testing.They can be automated to
allow a more efficient work flow, allow large sample volumes to be processed, are
generally more sensitive, more specific, have better reproducibility and can detect
microorganism groups that culture methods cannot.
Rapid tests also have the potential to detect ‘viable but not culture able’ (VBNC)
cells.These are dormant but still live cells that may retain their infectious potential
and cannot be detected by culture.
Many of these methods can be used as stand-alone tests or supplementary to
culture, and some of them can be brought into the field at the point of use without
having to send a sample to the laboratory – providing the ability to perform more
frequent trend analysis and better risk management, Dr Collins said.
First up for discussion was real time polymerase chain reaction (RT PCR) a molecular
technique that detects, in real time, a small fragment of the DNA of an organism of
interest.
PCR is very fast, producing results within 3-4 hours, is highly specific and can be
designed to identify groups of organisms, for example all 60 or more species of
Legionella, or just one strain.The test can be adapted to any organism and is highly
reproducible.
Collins commented that the demand for this application in the water testing world
will lie in Legionella testing and guidance documents are already available, for
example ISO TS 12821:2012.
But PCR also has downsides. Results tend to be higher than those from culture and
the difference in results compared to culture (genomic units v. colony forming units)
are hard to interpret. However, an international study published in 20112
has shown
it is possible to come up with algorithms to interpret PCR data compared with
culture results.At least one hospital trust is already using PCR exclusively for testing
Legionella.
Another approach is immuno-magnetic separation (IMS), which selectively draws
out the organism of interest using magnetic beads coated in antibodies.This can
be bolted on to rapid enumeration methods, can provide same day results and only
detects viable cells.A kit is now on the market for the detection of Legionella. It is
particularly useful for samples with a high bioburden, such as from cooling towers
and dirty spa pools.
Other tests Dr Collins outlined included:
• Enzyme based kits: already in use for Pseudomonas. Combine culture with
molecular detection and only detect viable cells. Easy to perform and interpret,
does not require any specialist equipment or skills and up to 24 hours faster than
traditional culture.3
• Point-of-use kits: now widely used in the industry, especially for Legionella.
Work in a similar way to pregnancy tests to produce a visible line for positive
results. Easy to perform.
• MALDI-TOF based protein mass fingerprinting: matrix assisted laser desorption
and ionisation time-applied mass spectrometry provides a very fast real-time
identification for organisms grown in culture.Works very well for identifying
Legionella.
• Biosensors: up and coming test using minute amounts of water. Several designed
to be powered by mobile phone devices. Likely to be used in the field.
References
[1] Collins, S. et al,‘Heated Birthing Pools as a Source of Legionnaires’ Disease’,
Epidemiology and Infection, on-line, 20 August, 2015.
[2] Lee J. et al, J Appl Microbiol, 110: 1032-44, 2011.
[3] Sartory, David P., J Water Health, Jun; 13(2):427-36, 2015.
The Department of Health will be reviewing the content of HTM 04-01 in due course
to align it with the HSE Approved Code of Practice for the Control of Legionella in
Water Systems.
The IBBS will hold another water microbiology workshop during its next Triennial
Conference in Manchester in 2017. For further information see: www.ibbsonline.org
Susan Pearson BSc (susan@wordways.co.uk) is a freelance journalist and
communications consultant specialising in medicine and the environment.
W I N T E R 2 0 1 5 - 1 6 IBBS event report
Image: PHE Porton - test rig
Figure 3: Emerging rapid technologies: Choosing a test -
points to consider
• Validation?
• Peer-reviewed evidence?
• Sensitivity/specificity compared to reference method.
• Units - will the end user understand them?
• Suitable for your laboratory or need?
• Cost.
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