NYS Emergency Regulation PROTECTION AGAINST LEGIONELLA

10 NYCRR Part 4

2

Regulatory

Overview

3

Emergency Regulation

Effective August 17, 2015

Promulgated to protect the public from potential

exposure to Legionella associated with:

1. Inadequately maintained Cooling towers and

2. Water distribution systems in Article 28 facilities (i.e., Hospitals

and residential health care facilities)

4

Emergency Regulation:

PROTECTION AGAINST LEGIONELLA

Components: 1. Cooling Towers • Registration;

• Culture sample collection, cleaning, and disinfection; • Inspection and certification;

• Maintenance program and plan; • Recordkeeping;

• Discontinued use; • Enforcement;

• Electronic registration and reporting. 2. Healthcare facilities

5

Why do Legionella spp. Become a Problem?

Thermal modification Heat added -- but not enough to be lethal.

• Cooling Towers, by their function of exchanging heat, contain warm water and scrub nutrients out from the ambient air.

• Domestic hot water loops cooling down too much.

• Potable cold water loops warming up too much.

• Ornamental displays running at ‘tepid’ temperatures (about 68 F and higher).

6

You are familiar with the Modes of Transmission

• Airborne (aerosol)

– Most cases can be traced to human-made

aquatic environments where the water

temperature is higher than ambient temperature

• Other, in particular aspiration.

– Improper “gag” reflex resulting the inhalation of

water droplets/sputum.

• Not person-to-person

7

Regulation: Definitions

• Cooling Tower. The

term “cooling tower”

means a cooling tower,

evaporative condenser,

fluid cooler or other

“wet” cooling device

that is part of a

recirculated water

system incorporated

into a building’s

cooling, industrial

process, refrigeration

or energy production

system.

VAPOR and MIST*

Basin

air air

Fan

Chiller

Cool Cool

Hot - -

Typically

85 F - 95F

Hot

Cooling Loads within Building

Outdoors

Indoors

Fresh

Makeup

Water

<<<<<<<<<

Drift Eliminator

*Mist containing droplets less than 5 microns will leave the unit

The mist is what is referred to as “Drift”

8

What do Cooling Towers Look Like?

Pictures courtesy of Chem-Aqua

9

Regulation: What is Required?

• Registration of cooling towers (with initial sampling and inspection).

• Implementation of a maintenance program and plan according to ASHRAE 188-2015.

• Cleaning and disinfection as needed but especially after shut downs of 5 days or more.

• Quarterly inspections & bacteriological testing.

• Proper start-up and shut down procedures.

• Reporting and record keeping.

• An annual certification that verifies all of the steps above.

10

Regulation: Registration

• Owners must register existing towers with the Department; new towers

before operation; and whenever ownership changes

• Registration information includes:

• Building address

• Intended use

• Owner information

• Manufacturer name

• Model & serial number

• Cooling & basin capacity

• Commissioning date

11

Electronic Registration

• Registration through a statewide electronic system

• On NYSDOH website at http://ct.doh.ny.gov

12

Property Owner Page

13

Building Information Page

14

Equipment Details Page (first section)

15

Regulation: Routine culture sample collection and

testing

• Routine bacteriological culture testing at intervals not exceeding 90

days while in use, or pursuant to a Maintenance Program and

Plan. A Maintenance Program and Plan must be adopted by March

1, 2016.

• Routine bacteriological culture sample collection and analysis can

be dip slides or heterotrophic plate counts for routine analysis.

• Owners must take appropriate action immediately.

16

Regulation: Legionella culture sample collection and

testing

• Legionella culture testing in response to certain triggering events:

• power failure of sufficient duration to allow for the growth

• loss of biocide treatment sufficient to allow for the growth

• failure of conductivity control to maintain proper cycles of

concentration

• a determination by DOH Commissioner that one or more cases of

legionellosis may be associated with the cooling tower

• Interpretation of Legionella culture results (including appropriate action),

if any, as specified in Appendix 4-A.

17

Regulation: Cleaning and disinfection

Depending upon the type of culture and the culture

results: • Owners must take appropriate action immediately.

• Persons who perform disinfection: commercial pesticide

applicator or pesticide technician or a supervised pesticide

apprentice.

• Only biocide products registered by NYSDEC may be used.

• Owners must clean & disinfect towers when shut down for more

than five days.

18

Cleaning and Disinfection

Before

Before

After

After

Pictures courtesy of Chem-Aqua

19

Regulation: Maintenance program and plan

• By March 1, 2016 and thereafter prior to initial operation, owners must have a

maintenance program and plan developed in accordance with ANSI/ASHRAE

188-2015

• Program and plan also must include provisions for:

• Routine sample collection and culture testing of bacteriological samples

• Emergency sample testing collection and culture testing for Legionella: • Power failure sufficient to allow for the growth of bacteria

• Loss of biocide treatment or failure of conductivity control sufficient to allow for

the growth of bacteria

• Commissioner determines one or more legionellosis cases associated with tower

• Immediate action in response to culture testing results

• Copy of plan to be retained on site, and made available upon

request

20

21

Regulation: Inspection

• Owners were to inspect towers within 30 days, unless an inspection occurred in

prior 30 days; thereafter, inspections at intervals not exceeding every 90 days

while in use.

• Inspection components include:

– Presence of organic material, algae, etc.

– General condition of tower, basin, packing material, drift eliminator

– Water make-up connections and control

– Functioning of conductivity control and dosing equipment

• Deficiencies to be documented and corrective actions need to be taken.

• Findings, deficiencies, corrective actions to be recorded, retained, and reported

to the Department.

22

Regulation: Certification

• Owners must obtain annual certification from a qualified person as

described in the regulation.

• Certification components: – Tower has been inspected, cleaned, disinfected in compliance with

regulation;

– Tower condition is appropriate for intended use;

– Maintenance program and plan has been developed and implemented;

– Functioning of conductivity control and dosing equipment.

• This requirement is first effective November 1, 2016, and annually

on November 1 thereafter.

• Certification must be reported to Department

23

Regulation: Electronic registration and reporting

• Initially and thereafter within 10 days after any action, owner must

electronically report:

• Registration information

• Dates of sampling, sampling results, remedial actions

• Dates of last cleaning/disinfection

• Dates of shutdowns for more than 5 days

• Date of last certification and its due date

• Date of last inspection and its due date

• Date of discontinued use

24

Equipment Details Page (second section)

Air Conditioning, Refrigeration, Other

Manual, Time Injection, Continuous Delivery, Other

25

Vendor, Contractor, Other

<10000 CFU / ml >=10000 CFU / ml

Indeterminate Other

<10 CFU / ml >=10 but <1000 CFU/ml

>+1000 CFU/ml

26

Regulation: Recordkeeping

Owners must:

• Retain records of inspections, deficiencies, corrective actions,

cleaning, disinfection, testing, and certifications for 3 years.

• Maintain a copy of the maintenance program and plan at the

cooling tower premises.

• Have the records and the program and plan available upon

request (from Local Health Department, regulating authority, etc.)

27

Regulation: Discontinued use

• Owners must notify the Department and local health department

within 30 days of removing or permanently discontinuing use of a

tower

• Notice must include a statement that the tower has been

disinfected and drained in accordance with the shutdown plan as

specified in the maintenance and program plan

28

Regulation: Enforcement

• Officers, employees, or agents of the Department or local

health department are authorized to enter properties to conduct

compliance inspections

• The Department or local health department may determine that

failure to comply with the provisions of the regulation

constitutes a nuisance

• Violation of any provision of the regulation is subject to civil and

criminal penalties; each day a violation occurs constitutes a

separate and distinct violation

29

Regulation: Health care facilities

• All general hospitals and residential health care facilities, as defined

in Article 28 of the Public Health Law, shall, as the department may

determine appropriate:

• Adopt a Legionella sampling plan for its facilities’ potable water

distribution system;

• report the results of such sampling;

• take necessary responsive actions.

• The department shall determine if any requirements more stringent

than noted are warranted.

30

Health Advisory & Updated Guidance

31

Attachment #3

32

Implementation Status

33

34

35

Subject: Cooling Tower Registration Information – Action Required Dear Cooling Tower Registrant: This week the Department of Health launched an address validation tool in the Cooling Tower Registration database. Cooling

tower locations were passed through an address validation program and a significant number of cooling tower locations could not

be verified. We are requesting that all owners/property managers check the information submitted to date to ensure it is complete

and accurate. Please, before October 19, sign into your account at https://www.ny.gov/services/register-cooling-tower-and-

submit-reports to review and update your registration information if needed. In addition to invalid addresses, other common errors include missing or unexpected values in: Serial Number Basin Capacity Type of Disinfection Maintenance Performed by Last Inspection Date Last Routine Bacteriological Sample Collection Date Another common error involved multiple cooling towers being registered in the same record. Although multiple cooling towers

can be registered under a single owner, each piece of equipment should have its own entry. Thank you for your attention to this matter. If you have any questions concerning the registry, please do not hesitate to contact us

at (518) 402-7650 or by email at cooling.tower@health.ny.gov.

Data Validation: Addresses 4,249 out of 7,428 registrants have addresses that can be verified

36

37

Public Release of Cooling Tower Information

• In accordance with emergency regulation

• Release of “some” information submitted to the electronic database

• Anticipated to occur as early as October 19th

• Through Health Data NY website: www.health.data.ny

• Data to include:

• Cooling tower address

• Inspection date

• Culture sample collection dates

38

Registered Cooling Tower Map

with Fly Out further detailing

location

Users can click on a blue

point on the map to see a fly

out further detailing

location.

Health Data NY

39

Next Steps • Regulation implementation

• Roles and responsibilities of LHDs

• Providing “full” access to information in database

• Initial tasks

• Verifying and seeking input of missing elements including:

• Address

• Date of inspection

• Date of bacteriological sample collection

• Development and issuance of guidance (EHM)

• Training

40

Thank You