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04-10 SOW Attachment 10 - VHA Directive 1061.pdf

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T-1 Department of Veterans Affairs VHA Directive 1061 Veterans Health Administration Transmittal Sheet Washington, DC 20420 August 13, 2014 PREVENTION OF HEALTHCARE-ASSOCIATED LEGIONELLA DISEASE AND SCALD INJURY FROM POTABLE WATER DISTRIBUTION SYSTEMS 1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Directive addresses the prevention of healthcare-associated Legionella Disease and Scald Injury from Potable Water Distribution Systems in VHA buildings. 2. SUMMARY OF CONTENTS: This Directive establishes policy for the prevention and control of healthcare-associated Legionella disease in VHA-owned buildings in which patients, residents, or visitors stay overnight. 3. RELATED ISSUES: None. 4. RESPONSIBLE OFFICE: The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for the contents of this Directive. Questions related to the engineering aspects of this Directive are to be directed to the Office of Capital Asset Management, Engineering, and Support (10NA5) at 202-632-7900. Questions related to clinical aspects and validation processes in this Directive are to be directed to the National Infectious Diseases Service (10P4E) in the Office of Patient Care Services (10P4) at 513-246-0270. 5. RESCISSIONS: VHA Directive 2008-010, dated February 11, 2008, VHA Directive 2009-009, dated February 25, 2009, and Information Letter 10-2013-006, dated May 3, 2013 are rescinded. 6. RECERTIFICATION: This VHA Directive is scheduled for recertification on or before the last working day of August 2019. Carolyn M. Clancy, MD Interim Under Secretary for Health DISTRIBUTION: E-mailed to the VHA Publications Distribution List on 08/15/2014. August 13, 2014 VHA DIRECTIVE 1061 1 PREVENTION OF HEALTHCARE-ASSOCIATED LEGIONELLA DISEASE AND SCALD INJURY FROM POTABLE WATER DISTRIBUTION SYSTEMS 1. PURPOSE: This Veterans Health Administration (VHA) Directive establishes policy for the prevention and control of healthcare-associated Legionella disease in VHA-owned buildings in which patients, residents, or visitors stay overnight. These types of buildings include, but are not limited to, acute care facilities, Community Living Centers (CLCs), domiciliaries, and Fisher Houses and other temporary lodging facilities (e.g. “hoptels”). AUTHORITY: 38 U.S.C. 7301(b). NOTE: This Directive was developed to address areas in healthcare with a recognized higher risk for Legionella disease. It is anticipated that this Directive, and information gathered from its implementation, will serve as a template for further prevention policy in other VHA healthcare settings. Policy and guidance for full case investigations of confirmed or suspected healthcare-associated Legionella disease is not encompassed within the scope of this Directive. 2. BACKGROUND: a. Legionella is a Gram-negative bacterium, which causes respiratory diseases collectively referred to as legionellosis. Legionellosis includes Legionella pneumonia, traditionally known as Legionnaires’ disease and hereafter abbreviated as “LD” for “Legionella disease”, and Pontiac Fever, a self-limiting respiratory illness. Disease is primarily caused by Legionella pneumophila; however, other species of Legionella can be pathogenic, particularly in transplant and other immunocompromised or high risk patients. The bacteria, found naturally in water, have been associated with disease from building water distribution systems. LD occurs after inhalation or aspiration of contaminated water, followed by a general incubation period of 2 to 14 days. Legionella bacteria are not transmitted from person-to-person. b. Health care facilities are included in the types of buildings that have been associated with the transmission of Legionella to people. Cases of healthcare-associated LD (HCA LD) often arise from exposure to Legionella bacteria in hospital potable water distribution systems. The Centers for Disease Control and Prevention (CDC) guidance document on the prevention of healthcare-associated pneumonia defines laboratory-confirmed cases to be “definite” HCA LD if a patient has spent equal to or greater than 10 days continuously in a healthcare facility prior to the onset of LD, or “possible” HCA LD if a patient has spent 2 to 9 days in a healthcare facility prior to the onset of LD. NOTE: In January 2014, the CDC National Center for Immunization and Respiratory Diseases released an updated Legionellosis Case Report form, including guidance on determining if the case was definitely or possibly associated with a healthcare exposure. VHA Directive 1061 focuses on primary prevention activities for buildings where patients, residents or visitors stay overnight; in the event of a LD case suspected to be associated with any VHA building, case investigation and consideration of secondary prevention activities would be appropriate. c. Persons at increased risk for LD include the immunocompromised (due to, for example, transplant, malignancy, renal disease, or diabetes), those over 50 years of age, those with chronic lung disease, and smokers. However, LD cases reported in the medical literature indicate that the disease can also occur in seemingly healthy individuals. VHA DIRECTIVE 1061 August 13, 2014 2 d. Given the various factors and complexities associated with LD (e.g., host susceptibility, pathogen virulence, water distribution system configurations and conditions), 100% prevention of LD is likely not possible. However, prevention and control practices can be implemented to reduce the risk of exposing people to Legionella in building water distribution systems. The Legionella prevention activities in this Directive involve assessing risks, monitoring water quality and implementation of commensurate engineering controls to limit the growth of Legionella. Use of engineering controls to limit Legionella growth includes ongoing monitoring of implemented controls, validating that the control measures are effective at inhibiting Legionella growth, and modifying implementation or type(s), as necessary. By focusing on engineering controls, this Directive can be viewed as a horizontal intervention that can improve the overall microbiological quality of facility water, not just the inhibition of Legionella growth. e. Legionella growth in building potable water distribution systems is primarily suppressed by the implementation of engineering controls such as maintenance of appropriate water temperatures or biocide (e.g. residual oxidant) levels. Application of more than one control may be necessary for the successful inhibition of Legionella growth. (1) Maintenance of Appropriate Water Temperatures in Building Water Distribution Systems. (a) Water temperatures at 124 degrees Fahrenheit (°F) (51.1 degrees Celsius (°C)) or higher are necessary to inhibit Legionella growth in hot water systems. 1. For most adult individuals, 110°F at the water outlet (e.g., sink tap, showerhead) will minimize the risk of scalding and is consistent with the plumbing code adopted by the Department of Veterans Affairs (VA) for VHA buildings. At 117°F the risk of scalding increases significantly. At 140°F, second degree burns may occur after only 3 seconds of exposure. Some people, either due to illness, disabilities, extremes of age or side effects of medication, may be less sensitive to hot water temperatures or have impaired or reduced reactions and thus are at an increased risk for tissue damage caused by extended exposure to hot water. 2. It is not possible to maintain water temperatures at the outlet that kill Legionella bacteria and simultaneously eliminate the possibility of scald injury in persons partially or fully insensitive to hot water temperature or having delayed or impaired response capabilities. The water temperature and accompanying safety requirements in this Directive address the risk of inhalation or aspiration of live Legionella bacteria while minimizing the risk of scald injury from exposure to domestic hot water. (b) Cold water systems (temperature at 67°F (19.4°C) or lower) tend to be too cold to foster growth of Legionella. Cold water in piping and fixtures can reach ambient environmental temperatures exceeding 68°F (20°C) during prolonged periods of low flow or non-use. Use of piping system insulation, automatic drain devices, and recirculation to limit the rate and duration of an increase in cold water temperature in combination with appropriate biocide levels can be effective at preventing Legionella growth. August 13, 2014 VHA DIRECTIVE 1061 3 (2) Maintenance of Biocide at a Recommended Level for Legionella Control. (a) Minimum concentrations of various biocides (e.g. oxidizing agents such as chlorine) can inhibit the growth of Legionella in building potable water distribution systems. The use of one or more installed systemic water treatment system(s) may be necessary to supplement any residual disinfectant present in incoming water (from municipal or central plant sources). NOTE: The United States (U.S.) Environmental Protection Agency (EPA) regulates contaminant levels and disinfectant treatment for use under the Safe Drinking Water Act (42 U.S.C. §§300f, et seq.). U.S. EPA delegates primacy to States for the regulation and enforcement of the Act within individual State boundaries if the standards set by the State are at least as stringent as EPA’s. (b) The efficacy of biocides on suppressing or killing waterborne pathogens is dependent on multiple factors such as water quality, organic and inorganic contaminants, pH levels, water hardness, disinfectant concentrations, and contact time. Therefore, the minimum concentration of biocide necessary to suppress bacterial growth may vary from building to building and even within buildings. f. Installation of non-systemic systems or processes has been used in some buildings as mechanisms to provide further control of Legionella growth or delivery. g. This Directive was develope