LEGIONNAIRES’ DISEASE From Philly to Flint and Beyond

transcript

Janet E. Stout, PhDDirector, Special Pathogens LaboratoryResearch Associate ProfessorUniversity of Pittsburgh

LEGIONNAIRES’ DISEASEFrom Philly to Flint and Beyond

40th Anniversary: 1976 to 2016

1976 Happenings in Philadelphia

The Bellevue-Stratford Hotel

1976 Philadelphia (Philly)

• 58th convention of the American Legion held July 21-24

• Mysterious illness effects 221 and kills 34

• Causative agent of pneumonia would not be identified until 1977

Legionella pneumophila• CDC microbiologist

Joseph McDade sees bacteria for the first time over Christmas 1976

• Bacteria does not grow on standard culture media –new media developed (BCYE) in 1977

• First diagnostic test developed – Direct Fluorescent Antibody (DFA) test

1980: Research Begins in Pittsburgh

• More than 30 years studying Legionnaires’ disease I’m a

Legionellologist

• Mission: What I’ve learned can help you

How?Microbiologist with a Minor in Plumbing!

MY HISTORY WITH LEGIONELLA IN BUILDING WATER SYSTEMS

First – A History Lesson

Research Pioneers in 1982

• Over 100 nosocomial cases identified in 5 years in one hospital

• An epidemic redefined - endemic disease and the source was the hospital water system – not a cooling tower!Janet E. Stout and Victor L. Yu

• Not a common source for sporadic and hospital-acquired cases

• More commonly associated with large community outbreaks

Paradigm Shift: Not Cooling Towers

Paradigm Shift

Potable water especially in hospitals (and other buildings)

with complex hot water systems, is the most important

source of Legionella transmission.

Today’s Topics

• The continued challenge of Legionnaires' disease

• Understanding Legionella in the built environment

• Role of Legionella testing in disease prevention

• Approaches to prevention

THE CHALLENGE OF LEGIONNAIRES’ DISEASE

The Disease

• Is Legionella reallyan opportunistic pathogen?

What Is Legionellosis?

• Legionnaires’ disease is pneumonia, caused by bacteria in the family Legionellaceae.

• Most often caused by Legionella pneumophila, serogroup 1

Are You At Risk?

• Elderly (>50)• Smokers• Immunocompromised Transplant patients High-dose steroids for lung disease Diabetes Cancer

• Approx. 25% cases no known risk factors

Legionnaires’ Disease

• Most cases in people with health conditions that increase risk

Early treatment with effective antibiotics reduces mortality

Mortality as high as 30% for healthcare acquired cases

TRANSMISSION AND HEALTHCARE-ACQUIRED CASES

Epidemiology and Infection Prevention

Legionellain water (reservoir)

+Transmission to the host(exposure)

+Susceptible Host

Risk of Acquiring Disease

Exposure Alone Doesn’t = Disease Acquisition

Modes of Transmission for Legionnaires’ disease

• Aerosolization

• Aspiration

• Direct instillation into the patient (tap water rinsing of nasogastric tubes, respiratory tubing, etc)

IS LEGIONNAIRES’DISEASECONTAGIOUS?

Cooling Tower 300km Away

• Outbreak cluster Portugal• Patient 1 was a 48 yr old male

worked at cooling tower complex where outbreak occurred

• Travels home 300km where 74 yomother provides care and also becomes ill

• Same sequence type

No Person-to-Person Transmission

Cases and Outbreaks

• Majority of cases are sporadic and not outbreak-associated = no investigation

• Outbreak is defined as two or more cases related in time & location = investigation

PREVENTING LEGIONNAIRES’ DISEASE

How are we doing?

Legionella Is Winning

• Legionnaires’disease is increasing

• Legionella proves to be a difficult opponent!

Increasing U.S. Cases 1998–2014

Consider This…

• Legionellosis cases have increased substantially more than

200% in last 10 years

Why Increase in Reported Cases?

• Increase in diagnostic testing = more cases identified

• Environmental factors?

Wet Weather & Legionnaires’ Disease?

Morbidity Mortality Weekly Report (MMWR). August 14, 2015/64 (31); 842-848. Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water — United States, 2011–2012

Many Cases Linked to Drinking Water

Legionella in Water

Centers for Disease Control and Prevention (CDC) reported:

• Legionella accounted for 66% of reported drinking water–associated outbreaks

• Legionella in building plumbing systemslead to drinking water-associated outbreaks.

How does Legionellaget into our water?

Legionella in Source Water (1987)

• “Public water supplies may contaminate the plumbing systems of hospitals and other large buildings.”

From: States, SJ, Conley LF, Kuchta JM, et al. Survival and multiplication of L. pneumophila in municipal drinking water systems. Appl. Environ. Microbiol. 1987; 53: 979-986.

Ground, Surface, and Potable Waters and Legionella (1997)

• “Results of this study confirm the ubiquity of Legionella in aquatic environments, even ground water.”

Lye, D, Fout S, Crout S. et al. Survey of ground, surface, and potable waters for the presence of Legionella species by PCR, culture, and immunofluorescent staining. Water Res. 1997; 31: 287-293.

Origins of Legionella in Building Water Systems?

Origins of Legionella

• Incoming potable water (undetectable or very low conc.)

• Systems with warm water, such as water distributions systems and air cooling systems (provide growth factors)

• Biofilms within these systems provide growth-promoting conditions

Pressure Change Increased Legionella

• Isolation of Legionella pneumophila from the hospital water supply

• Upsurge in cases following a pressure drop caused by a pump failure

• Documentation of a 30-fold increase in concentration of Legionella in the water when this “pressure shock” was artificially recreated.

Pressure Change Increased Legionella

150 CFU/mL 1140 CFU/mL 5370 CFU/mL

Community Water System Outbreak: Senior Apartment Complex

• Legionnaires’ disease case-finding algorithm, attack rates, and risk factors during a residential outbreak among older adults: an environmental and cohort study

Benjamin J Silk, Jennifer L Foltz, Kompan Ngamsnga, Ellen Brown et al. BMC Infectious Diseases 2013, 13:291

Probable Causes

1. Elderly population with comorbidity 2. Water heaters had low temperatures

at the bottom of tanks (range: 70–100°F/21.1–37.8°C)

3. Low or no chlorine4. Interruptions in water service

Interruption In Water Service = Brown Water Event

Interruption in Water Service

1. Three-quarters (75%) of residents who were interviewed noted at least one interruption in water service since August 1st.

2. More than half of residents (56%) reported changes in the taste, odor, or color of their water during the same period.

Why Do Outbreaks Continue?

Legionella-Related Anxiety

Five Stages Of Coping with Legionella

1. Denial2. Bargaining3. Depression4. Acceptance5. Medication

1. Denial

Denial

Most wait to address

the problem until after

a case of Legionnaires’

disease is diagnosed.

Approaches to Disease Prevention

• REACTIVE After 1 transplant

patient or 2+ cases within 6 months• Combined

epidemiologic and environmental investigation

• Legionellasource identified = decontaminate

• PROACTIVE Perform

environmental surveillance before cases Perform clinical

surveillance to identify unrecognized cases

• Legionella source identified = decontaminate

Proactive Approach Reduced Legionnaires’ Disease

Am. J. Infection Control 2005; 33(6):360-367

Our Study Results of 48 Hospitals

• Proportion of hospitals performing environmental surveillance = 65%

• Proportion of cases hospital-acquired: Pre-guideline = 33% Post-guideline = 9%

• Proportion that started water treatment (disinfection) = 44%

2 . Bargaining

Bargaining

• Legionella is everywhere

• There’s hardly any cases

• It is too costly to control/monitor

• If I don’t know, I’m not responsible

Myth: Legionella Is Everywhere

• Published studies find: 20–70% of

buildings and 30-50% of

cooling towers colonizedwith Legionella

• Legionella is not ubiquitous (everywhere)!

Many Cases of This Disease

• In the U.S. approximately 600,000 adults are diagnosed with community-acquired pneumonia requiring hospitalization

• A minimum of 2-5% are caused by Legionella, as many as 30,000 cases/year

Under ReportingDue to Missed Diagnosis

Results for 37 Cases

41% of Legionella cases were missed when following current

Infectious Disease Society recommendations for

Legionella testing

Many Cases Still Missed

• Diagnostic tests for Legionella not routine – often not done

• Many studies have demonstrated under reporting/missed diagnosis

PREVENTING LEGIONNAIRES’ DISEASE OUTBREAKS

How are we doing?

Legionellosis in the U.S.

Outbreaks continue to occur (building warm water systems, cooling towers, fountains)

Outbreaks 2000 to 2014

Hospitals at Significant Risk According to Recent

CDC Report

Legionella in hospitals –accounted for 57% of all cases and 85% of deaths

Outbreaks in Nursing Homes & Assisted Living Facilities

HOSPITAL OUTBREAK LINKED TO NEW CONSTRUCTION

Hospital Construction

• New $135M 12-story cardiac care patient tower

• 11 cases & one death shortly after opening

• 74% of distal outlets positive for Legionella within one month of opening

Legionnaires' Cases in Quebec City

TOTAL=180

Outbreak

• Canada’s biggest and deadliest in 25 years

• 89 cooling towers disinfected

• Source=Cooling Tower

2013 Outbreak in Germany

• Warstein, Germany 165 cases, 12 ICU, 2 deaths caused by

Legionella pneumophila, serogroup 1

Outbreak strain found in 2 cooling towers + other sources – including wastewater from a brewery!

Public health communication

Public Safety Announcement

“Whether or not the Warsteiner brewery is found to be the breeding ground for the Legionella bacteria, officials have been making it clear that …

the beer is completely safe to drink.”

DRINKING WATERWhat Ben Franklin said

with water comes bacteria Legionella.”

“With wine comes wisdom,

with beer comes freedom,

Water Quality & LD in Flint, Mich.

Outbreak Flint, Michigan91 cases and 12 Deaths

• April 2014 switch source water from Lake Huron to Flint River

• 45 cases from June 2014 to 2015

• 46 cases from May to October 2015

• October 2015 switch source back to Lake Huron

Flint Legionnaires’ Disease Outbreak

2015: Summer of Legionella

South Bronx Outbreak

• 130 cases, 12 deaths

• Declared over August 20, 2015

Outbreak Linked to Hotel Cooling Tower

NEW YORK STATE EMERGENCY REGULATIONS

Emergency Regulation

• Cooling towers must be registered

• Legionella testing every 90 days

• Inspection• Certification• Maintenance

program

PREVENTING LEGIONNAIRES’ DISEASE

Is It Worth the Effort (Money)?

U.S. Healthcare Costs Associated with Legionnaires’ Disease

Total hospitalizationcosts

$101 - $321 millionper year

Collier s.A., L. J. Stockman, l.A. Hicks, l. E. Garrison, f. J. Zhou and m. J. Beach. Epidemiol. Infect. (2012), 140, 2003–2013.

Legionella Outbreaks Are Costly

Costly Outbreaks

• Even a single case can dramatically affect an organization

$700,000

$ 10 Million

Outbreak Response:Pittsburgh VA Hospital

Outbreak Response:Illinois Vets Home

3. Depression

The Times They Are a-Changin’

New Paradigm

for Prevention

ASHRAE Proposes a Standard to Prevent Legionnaires’ Disease

American Society of Heating, Refrigerating and Air-conditioning Engineers

4. Acceptance

• First Legionellastandard in the United States.

• ApprovedJune 26, 2015

Purpose of ASHRAE Standard 188

Establish minimum Legionellosis risk management requirements for building water systems.

The Real Purpose of ASHRAE Standard 188

To help engineers and infection preventionistscommunicate more effectively

ASHRAE 188

Water Safety and Management Plans

New Responsibilities

BUILDING OWNERS & FACILITY MANAGERS

• Responsible for implementing ASHRAE 188 requirements and safeguards to protect against Legionella

• Assist building owners with Program development and review, monitoring water systems and results interpretation

WATERMANAGEMENT TEAM

New Responsibilities &

Liabilities

Building Operating Management (Facilitiesnet.com) ASHRAE 188

Compliance

The building shall be surveyed to determine whether it has one or more of the listed

water systems and/or the factors described that relate to

risk for Legionellosis.

Does ASHRAE 188 Apply to Me?

• Section 5: Building Survey Building owners must survey all existing

buildings for the following:oNon-potable Systems

oBuilding Characteristics

Water Systems Covered by 188

• Potable and non-potable water systems, in the building or on the site Includes building water distribution systems

(including centralized potable water heater systems) Cooling towers, evaporative condensers Whirlpools or spas Ornamental fountains, misters, atomizers, air

washes, humidifiers or other non-potable water systems or devices that release water aerosols in the building or on the site

Section 5.2: Building Characteristics

• Multiple housing units• > 10 stories high (including below grade)• Patient stays exceed 24 hours• One or more areas for purpose of housing

or treating occupants receiving treatment for burns, chemotherapy, organ transplantation or bone marrow transplantation

Section 5.2: Building Characteristics

• One or more areas for the purpose of housing or treating occupants that are immuno-compromised, at-risk, taking drugs that weaken immune system, have renal disease, have diabetes, or chronic lung disease

• Housing occupants over the age of 65.

Elements of Water Management Program

Program Team – Persons responsible for Program development and implementation.

Water Systems/Flow Diagrams – Describe potable and non-potable water systems and develop water system-schematics.

Water System Analysis/Control Measures – Evaluate where hazardous conditions may occur and decide where control measures should be applied.

Monitoring/Corrective Actions – Establish procedure for monitoring whether control measures are within operating limits and, if not, take corrective actions.

Confirmation – Establish procedure to confirm Program is being implemented as designed (verification) and the Program effectively controls the hazardous conditions (validation).

Documentation – Establish documentation and communication procedures for all activities of the Program.

ASHRAE 188 ComplianceGood News, Bad News

• Standard is not prescriptive – Good News - You get to make lots of

decisions

Bad News - You get to make lots of decisions

ASHRAE 188: Mind the Gaps

Testing for Legionella

• Legionella testing isn’t required to validate that the risk management program is working.

• The ProgramTeam decides whether to test for Legionella.

• BUT testing is the only way to validate efficacy of your control measures and assess threat from Legionella.

Control Measures

• Control measures are also at the discretion of the Program Team

• Example – hot water temperatures The standard refers back to the ASHRAE

guideline which recommends temperatures• Hot water generation 60oC (140oF) and 51oC

(124oF) upon return in healthcare facilities • All other facilities are to generate hot water at 49oC

(120oF) or above.

Elements of Water Management Program

Program Team – Persons responsible for Program development and implementation.

Water Systems/Flow Diagrams – Describe potable and non-potable water systems and develop water system-schematics.

Water System Analysis/Control Measures – Evaluate where hazardous conditions may occur and decide where control measures should be applied.

Monitoring/Corrective Actions – Establish procedure for monitoring whether control measures are within operating limits and, if not, take corrective actions.

Confirmation – Establish procedure to confirm Program is being implemented as designed (verification) and the Program effectively controls the hazardous conditions (validation).

Documentation – Establish documentation and communication procedures for all activities of the Program.

Knowledge

The program team shall have knowledge of

the building water system design and water management as it relates to Legionellosis

Test Your Knowledge: True or False?

• Legionella is ubiquitous (everywhere).• If chlorine levels at or above 0.5 mg/L in the

supply water, Legionella is controlled.• Only old buildings have Legionella problems.• If total bacteria are controlled, Legionella is

controlled.• Water and energy conservation approaches

minimize Legionella risk.

Water-Saving Low Flow Faucets

Manual Faucet Sensor Faucet

Disturbing Findings

WHY TEST?

Environmental Monitoring for Legionella: Key to Prevention

Testing Can Be Revealing

• Hospitals performing Legionellaenvironmental testing are more likely to prevent cases of hospital-acquired Legionnaires’ disease

Squier CL, Stout JE, Krystofiak S, McMahon J, Wagener MM, Dixon B. Yu VL. Am. J. Infect. Control 2005; 33(6): 360-367.

Approach to Environmental Sampling

• Select a minimum of 10 distal sites (faucets or showers) that roughly represent the water distribution system, plus hot water tanks or recirc. line.

• Include sites on multiple floors and wings, high risk areas like oncology, transplant units, medical surgical units.

Calculating Percent Positivity

• Number of outlets positive for Legionella of 10 distal sites (faucets or showers) that were tested

• Estimating the probability of a patient “bumping into” Legionella (percent positive)

• If >30% risk increases, especially if L. pneumophila, serogroup 1 is present

Risk – Building Potable Water

Risk of Legionnaires’ disease was better predicted by the

proportionof water system sites

testing positive for Legionellathan by the

concentration of Legionella bacteria.

Kool J L, et al. Infect. Control Hosp. Epid. 1999 20:797-805

High (>30%) Legionella Distal Site Positivity And Cases Prior to Treatment

Distal Site Positivity

No Cases after Treatment (NH2Cl)Cases

Monitoring of Cooling Towers

Can You Tell by Looking?

>3000 CFU/mL Legionella pneumophila serogroup 1

Automated dosing ofchemical biocides and clean clear water

Microbiological Testing: HPC (Total) Bacteria

What Can We Learn about Legionella from an HPC Test?

Heterotrophic Plate Count (HPC) Bacteria Testing

• HPC method does not detect Legionella

• HPC cannot be used to predict presence or absence of Legionella

• HPC counts can be low when Legionellais high

Heterotrophic Plate Count (HPC) Bacteria Testing

Effective Use of HPC or ATP Test:• Use as a biocide performance

indicator for general microbiological fouling

• An inexpensive early warning of a process or biocide application upset

• Not a substitute for Legionella culture

2015 Publication

Is the Sky Falling?

If I Find Some Legionella?

What is an acceptable amount

of Legionella?

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IS ZERONECESSARY?

Zero Legionella is virtually impossible to achieve in complex

water systems

Don’t Chase Zero

Not All Legionella Are Dangerous

• Zero Legionella is nearly impossible in complex water systems

• Many species of Legionella can be present at any given time

• Of 58 species only half pose risk; Legionella pneumophila serogroup 1 causes majority of cases of Legionellosis

Don’t Chase Zero

Risk Criteria Based on Environmental Monitoring Results

• Concentration-based thresholds that establish target values in CFU per liter or milliliter

OK for cooling towers as a performance-based target (not health-based)

• Colonization rate or proportion of distal sites in the water system that are positive for Legionella

Best for hospitals and building water systems

Meaning for You

• Sampling the water system of a building can give you a meaningful “snapshot” of the colonization status.

• Methods for Legionella detection and quantitation Standard culture – validated/gold

standard Non-culture based molecular methods

• Quantitative Polymerase Chain Reaction (qPCR)

• Next Generation Sequencing (NGS)

Detection of Legionella

“Apples To Apples”or

“Apples To Oranges”?

Laboratory Testing

Did you know that labs differ in

their methods for Legionella

testing & identification?

Standard Culture Method

• Processing Methods Pretreatment (heat and/or acid) Filtration (yes/no or how much) Culture media (types and how many)

• Identification (ID) Methods Only presumptive agglutination test? Definitive ID with DFA or sequencing for

unusual species?

Culture for Legionella

Sometimes it’s like finding Waldo

This Is Waldo

Found Waldo (Legionella)

Acid Pretreatment

Heat Pretreatment

Selective Antibiotic-containing

Culture Media

Use of Molecular Methods for Detection of Legionella

What is Quantitative Polymerase Chain Reaction (qPCR)?

• Relies on highly specific amplification of the target gene sequence

• Fluorescent reporter molecules that allow quantification of PCR products

• qPCR allows many samples to be processed in a short amount of time

qPCR Methodology

• Allows for the simultaneous detection and identification of L. pneumophila and L. pneumophila serogroup 1 Detects gene for LPS

Advance: qPCR for LP1

Merault, et al. APPLIED AND ENVIRONMENTAL MICROBIOLOGY, Mar. 2011, p. 1708–1717

Molecular Testing: Quantitative PCR (qPCR)

• Limitations Cannot

discriminate between live and dead cells Genomic units

(GU) do not directly correlate to CFU

• Benefits Rapid Genus and species

specific probes Good agreement

with culture with Legionella pneumophila and L. pneumophila, serogroup 1 probes

DISINFECTION APPROACHES

I Have Legionella…Now What?

DISINFECTION OPTIONS

Secondary Disinfection Methods

• Thermal shock treatment(heat & flush)

• Shock chlorination (>10 mg/L residual), may require water tanks to be 20-50 mg/L

• Continuous supplemental chlorination (2-4 mg/L)

• Copper-silver ionization (continuous)

• Chlorine Dioxide (ClO2)• Monochloramine• Point-of-use filtration

Multiple Approaches

BUILDING 1• High percentage of

outlets positive with cases;

• monochloramine system installed

BUILDING 2• High percentage of

outlets positive no cases;

• copper-silver ionization system installed

Building 1 - Legionella Distal Site Positivity Reduction With Monochloramine

Distal Site Positivity

Monochloramine Start Date

Conclusions

• Both disinfection approaches were effective in reducing Legionella positivity

• Monochloramine was used in the building housing the highest risk group and to achieve the fastest reduction

• Legionella remediation - not “one size fits all”

Monochloramine Field Evaluation

PROTECTING TRANSPLANT, HIGH RISK PATIENTS, NEONATES

We Filter the Air…But Let Them Drink Tap Water?

Pediatric Legionnaires’ Disease

• CDC study showed 72% pediatric cases had healthcare exposure

• Mortality rate 22%

Protect Vulnerable Populations with Point Of Use Filters

My First Field Evaluation

American Journal of Infection Control 2005; 33:S20-25.

History of Point-of-Use Filters

• Bacterial exclusion at 0.2 micro

• Use duration has gone from 15 days, to 31 to 62 and beyond

• Depending on water quality (particulates), filters may clog

• Seen significant improvement

2013 Study Using POU Filters

• Newer Products – up to 62 days of use• Test Location – Cancer Center• Sampling – five control faucets (no filter)

and five test faucets (with filters)• Sampling Frequency– Weekly• Duration – 14 weeks

POU Filters Eliminate Legionella

Evaluation Published in AJIC

American Journal of Infection Control 2014: 42; 1193-6.

Aqua-Tools: Point-of-Use Filters

• Our evaluation of 62 day filters Study No. 1 performed at a 1,157 bed

healthcare facility (faucet filters) - completed Study No. 2 at a 200 bed community

healthcare center (faucet and shower filters) –ongoing Results presented separately today…

Study Design for POU Filters

• Test Location – Hospital• Sampling – five control outlets (no filter)

and five test outlets (with filters)• Sampling Frequency– Weekly• Duration – at least 12 weeks

Point-of-Use Filters: Conclusions

• System-wide disinfection not always the best answer

• Next generation filters last longer—more than 60 days

• High risk areas may require long-term use for maximum risk reduction

• Extend protection to home for high risk patients?

Journal Am Water Works Assoc 2014; 106(10): 24-32

Disinfection Method Review

EPA Issues Review of LegionellaControl & Disinfection Methods

U.S. Regulatory Agencies: New Focus

on Legionella Prevention

CDC Focus:Effective water management

for Legionnaires’ disease prevention

Conclusions• Missed prevention opportunities leads to

outbreaks

• Making water management programs a routine part of building ownership and management will require education and enforcement

NSF International & ASHRAE Collaborate

NSF 444: Prevention of Injury

and Disease Associated with Building Water Systems

Klebsiella oxytoca, Enterobacter cloacae, Pseudomonas aeruginosa

Water From MICU faucet!

What Culture Shows

Not Just Legionella in Our Water Faucets

Acinetobacter

P. aeruginosa

S. maltophilia

Amoeba Resistant Microorganisms ( NTM’s )

Nontuberculous Mycobacteria

Clinical Infectious Diseases 2015;61(1):67–75

Sorin 3T Heater Cooler Unit

Our Testing of Sorin Instruments

• We tested 92 Sorin instruments from 20 hospitals in 13 states

• 42.2% were colonized with M. chimaera

• Some instruments were colonized with as many as 4 NTM species

• HPC values on some instruments were as high as 5,200,000 cfu/mL

Positive Sorin Culture

M. chimaera

Experience

Learn From Other’s Mistakes

• Outbreaks, water service disruption and construction Don’t risk it – test now! Renovation and construction conditions

favor LegionellaoInstallation of low flow/electronic sensor

faucetsoLong dormant periods before occupying

Summary

• Legionnaires’ disease is increasing• Potable Water systems, especially in

hospitals (and other buildings) with complex hot water systems, are the most important source of Legionellatransmission.

• Proactive prevention = ASHRAE 188 Water Management Programs and Risk Assessments

• Environmental testing for Legionella is a key indicator for disease risk

Legionella Anxiety?

MEDICATION

Dr. Stout’s Legionella Chill Pills

• For treatment of Legionella-related anxiety.

• Take 2 tablets 1 hour before Legionella testing or as needed.

Mission: End Legionnaires’ Disease

• No one should die from a preventable disease caused by a bacteria in water.

• Legionnaires’ disease can and should be prevented.

Let’s End LD Together

THANK YOUDr. Janet E. StoutPresident, Microbiologist

info@specialpathogenslab.com