Legionnaires’ Disease

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Letter to Branches




No. 646/12
Ref P13
Date: 28 August 2012

To: All Branches

Dear Colleagues,
Legionnaires’ Disease
The recent Legionnaires' disease outbreak in Edinburgh which caused three deaths and 100 cases highlights a constant hazard associated with water systems. A cooling tower is suspected of causing the Edinburgh outbreak. Cooling towers tick all the risk-factor boxes and need to be managed carefully in order to ensure that dangerous conditions do not develop. The Health and Safety Executive (HSE) served three Improvement Notices on Edinburgh companies as part of its Legionella investigations. The Improvement Notices required thorough cleaning and disinfection of cooling towers and provision of access for inspection and maintenance of the cooling towers. It's a pity that it took so many deaths and illnesses to prompt a HSE Inspection blitz. Experts have warned that “plummeting” numbers of inspections carried out by the Health and Safety Executive are putting public health at risk. This is perhaps a prime example.

Legionella bacteria is a naturally occurring organism which can infect water systems. The risk to health arises where the bacteria are inhaled.
The risk factors are:
Stagnant or recirculated water;
Dirt and debris to provide ‘food’ for bacteria;
Warm temperatures (typically 20-50°C);
A means for the water to become air-borne;
Proximity of persons in the area (particularly those more vulnerable to infection).
Anywhere water is stored or used is a potential Legionella risk, but the hazards are greatest at locations such as cooling towers, showers, fountains and car-washes, where water forms droplets which can be inhaled.


The worst single Legionella outbreak in the UK occurred in Barrow-in-Furness in 2002 and was traced steam coming out of a badly maintained air conditioning unit which had been neglected for a number of months allowing the bacteria to build up to a dangerous level.


The system was located in the council-run arts centre with the vent emitting the disease over a busy alleyway in the town centre.

Ultimately seven people died and 172 cases were reported. The coroner criticised the council for its failings with regard to health and safety. Council employee Gillian Beckingham and employer Barrow Borough Council were cleared of seven charges of
manslaughter, but both admitted breaching the Health and Safety at Work Act. Beckingham, the council senior architect ultimately responsible for health and safety at the centre, was fined £15,000 and the authority £125,000. The borough council was the first public body in the country to have faced corporate manslaughter charges.

It is not just cooling towers which have the potential to transmit the infection. There have been examples of persons contracting Legionnaires' disease from all sorts of outlets including showers. In 2007, a health board was fined £80,000 following the death of a patient who had just recovered from leukaemia. The investigation found that an "inadequate" risk assessment had been carried out in March 2001 which identified
problem areas in the hospital's water system. However, due to lack of money, most of the recommendations were not carried out. Investigators found bacteria had been breeding in the shower head where the patient had taken a shower.

All organisations with responsibility for locations where there is a Legionella risk i.e. virtually anywhere where water is stored and used, have a legal duty to undertake a suitable and sufficient risk assessment and implement adequate controls. The outbreak of legionella in Edinburgh outlines the need for organisations to be vigilant in their management of their water systems. This incident serves as a timely reminder for
organisations to check upon the adequacy of their management arrangements for controlling legionella.

For your information see attached copy of the HSE's publication - "Legionnaires’ disease - The control of legionella bacteria in water systems"Approved Code of Practice and guidance.


Yours sincerely


Dave Joyce
National Health, Safety & Environment Officer
 

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