A spate of Legionnaires’ disease outbreaks in Sydney from February to May this year made front page news and caused NSW Health to react like never before. In total, five outbreaks occurred over a four month period, the most serious of which in Sydney’s CBD resulted in nine people catching the disease, one of whom died as a consequence.

As we come into the warmer months, the obvious question arises – what has the government and industry done to make sure this does not happen again?

Legionnaires’ disease is a serious form of pneumonia that is often caused via a cooling tower system that has not been properly designed, installed and/or maintained. Given that cooling tower systems are generally located in buildings that service large numbers of people, most outbreaks occur in highly populated areas, such CBDs, hospitals, shopping centres. Most importantly, the factors which can lead to an outbreak are usually avoidable.

To the end of September this year, 71 people have been diagnosed with Legionella (pneumophila) in NSW, compared to an average of 45 to end of September in the previous four years – a 58 per cent increase in infection rates.

In response to the series of outbreaks, NSW Health and local councils inspected hundreds of cooling tower systems across locations. No individual cooling tower system was identified as causing any of the outbreaks. However, numerous systems were identified as having positive Legionella detections – some of which were extremely high. There were also a number of systems identified as being unregistered or unregulated.

NSW Health and the City of Sydney also issued a notice under the Public Health Act requiring water treatment service providers and microbiological laboratories to provide all paperwork associated with certification, maintenance and testing for the previous six months in regard to all cooling towers within the postcodes 2000, 2001 and 2002. At this stage, no information has been released in relation to the analysis of data collected.

Where are we now?

In discussing this topic, we need to keep in mind that Legionnaires’ disease was only discovered in 1976. The first regulations were introduced in Australia in the mid-1980s. Much has been learnt in the intervening 30 years, both from a technical and a general risk management perspective.

The current framework requires owners and occupiers of buildings to comply with minimum prescribed standards. The Water Cooling System Compliance Survey 2010 – 2011 Report undertaken by NSW Health points out that “this form of legislation has been in existence in NSW since 1989, a period exceeding 20 years”. (See page 4 at NSW Health Report.)

Over time, regulations can become piecemeal as the technology and methodologies evolve. Under the existing framework there are numerous areas for improvement when compared to what has been achieved in other states and territories of Australia. The current situation is an opportunity to holistically review the regulatory approach.

NSW would benefit from implementing a risk based approach. The most obvious aspect of such an approach is that maintenance controls need to be most stringent where high numbers of people stand to be exposed, such as CBD, hospitals and shopping centres. It is these locations that by their nature can cause high numbers of cases in a short period of time.

A risk based method of regulation provides the input of more than one party to the minimisation of risk. When implemented together with some form of independent check to confirm compliance, this approach improves the standard of the approach – for the benefit of public health.

Who is Responsible?

Who is responsible for maintaining systems free of Legionnaires’ disease? This question needs to be answered at both the regulatory and the facility level.

The current regime has NSW Health providing the overarching regulatory authority and the local councils managing and implementing that authority.

At a facility level we also need clarity as to who is responsible for preventing outbreaks of Legionnaires’ disease. Large facilities often have numerous stakeholders: owners, facilities managers, tenants, mechanical contractors, consultants, water treatment providers and testing laboratories. The question is, from a regulatory perspective, which of those parties is primarily responsible for maintaining the cooling tower system free from Legionnaires’ disease.

Accurate Register of Cooling Tower Systems

One important aspect of regulating cooling tower systems is the maintenance of a registration system – which can be accessed in the event of an outbreak . In NSW, different councils manage their own registers in different ways – some only requiring a one off registration, not an annual registration, meaning that there is no consistent record of cooling tower systems.

When an outbreak occurs, the investigating authority needs to be able to quickly reference the cooling tower systems in the area of concern. For this to occur, an accurate register of cooling tower systems needs to be maintained. So a central authority for registration is the preferred option.

Redundant regulatory requirements

As a consequence of the evolution of the regulatory regime over a couple of decades, there are some required practices that have little or no real benefit in the current environment. An example is the requirement to issue an annual “Certificate of Disinfection” confirming that the system has effective process of disinfection.

This requirement is carried out by water treatment providers and, from my perspective, the fact that a certificate has been issued can lead to a false sense of security. Ongoing risk management is what provides an effective process, rather than a certified process or piece of equipment.

Recognition of Digital Reporting Systems

The existing framework and enforcement focuses on the presence of hard copy maintenance records close to the cooling tower systems.

From a practical perspective, this means that water samples need to be collected, delivered to the laboratory and then, four to 15 days later, hard-copy reports printed and delivered back to site for inclusion in the folder.

Many facilities managers no longer occupy an office within the building and so do not maintain hard copies of all records. Digital records are more common and these can be quickly and simply emailed to the environmental health officer conducting an inspection. In many cases, an electronic copy is more suitable to review than a hard-copy that has been exposed to the elements for 12 months or more.

NSW Health Legionella Expert Panel

NSW Health has convened an expert panel to review the existing regulations and procedures. The expert panel is expected to set minimum cleaning standards and regular testing requirements; and also introduce notification requirements. I understand that the panel’s recommendations will be released for public response in the coming weeks.

The way forward

The recent outbreaks and the data clearly show that we need to improve the way Legionnaires’ disease is controlled. The catalyst for change is to educate stakeholders on how best to avoid outbreaks. We can then work together with a unified approach.

I hope that government and industry take this opportunity of review to do more than just rework existing standards. Let’s move to a risk based approach that actually improves outcomes for public health.

Nick Duncan is chief executive officer, HydroChem

Legionella expert Clive Broadbent will deliver a series of technical briefings on Sydney’s summer of Legionella discontent on 15 to 21 November in both Sydney and Melbourne. For details see www.hydrochem.com.au/clive

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