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Monitoring Distribution Systems for Legionella Pneumophila Using Legiolert

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Received: 21 September 2018 Revised: 26 November 2018 Accepted: 17 December 2018 DOI: 10.1002/aws2.1122 ORIGINAL RESEARCH Monitoring distribution systems for Legionella pneumophila using Legiolert Mark W. LeChevallier Dr. Water Consulting, Morrison, Colorado This study implemented the Legiolert test (a culture-based assay for L. pneumo- Correspondence Mark W. LeChevallier, Dr. Water Consulting, phila based on the most probable number [MPN]) at 12 utilities to assess their Morrison, Colorado. experiences and to develop a baseline of Legionella pneumophila occurrence in Email: [email protected] drinking water distribution systems. A total of 679 samples were analyzed during Funding information the study: 53 source water, 50 from the plant effluent, and 576 from the distribution IDEXX Laboratories, Westbrook, ME system. L. pneumophila was detected in three of five source water samples at one utility but was not detected in any of the treated plant effluent samples. L. pneumophila was detected in only one distribution sample (0.17%) at a concen- tration of 1 MPN/100 mL in a sample that contained 0.72 mg/L free chlorine and was serotyped as belonging to the 2–14 serogroup. Four (0.7%) distribution sam- ples could not be confirmed by serotyping. Overall, the utilities found the test easy to learn and apply in their systems. This study provides a precedent for future mon- itoring of drinking water systems. KEYWORDS distribution, L. pneumophila, Legiolert, Legionella, microbiology 1 | INTRODUCTION L. pneumophila has become the most commonly identi- fied drinking water pathogen, responsible for about two-thirds Legionellosis is a respiratory infection caused by bacteria in of all potable water outbreaks and nearly all the fatalities asso- the genus Legionella. Currently, there are approximately ciated with drinking water outbreaks since 2000 (Benedict 50 species of Legionella consisting of 70 serogroups, but et al., 2017). Although outbreaks typically occur in building Legionella pneumophila serogroup 1 is responsible for about water systems and cooling towers, potable water utilities typi- 95% of the Legionnaires' disease cases in the United States cally do not monitor for this important pathogen. Legionella is (Fields, Benson, & Besser, 2002). The incidence of Legion- regulated under the Surface Water Treatment Rule (SWTR) naire's disease has increased over 550% since 2000 (Figure 1). with a maximum contaminant level goal (a nonenforceable It is not clear whether the increase is due to increased aware- guideline) of zero Legionella organisms for drinking water ness and testing, an aging population with increased suscepti- (U.S. Environmental Protection Agency [USEPA], 1989). The bility to the disease, increased Legionella in the environment, rule specifies a treatment technique for Legionella control or some combination of factors. Water is the natural reservoir for Legionellae, and the bacteria are found worldwide in many (e.g., filtration and maintenance of a detectable disinfectant different natural and manmade aquatic environments, such as residual), and therefore, monitoring for Legionella is not cooling towers; water systems in hotels, homes, ships, and fac- required. Although analytical methods existed for Legionella tories; respiratory therapy equipment; fountains; misting detection, the USEPA determined that testing was impractical devices; and spa pools (Fields et al., 2002). to implement, particularly for small systems. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2019 The Authors. AWWA Water Science published by Wiley Periodicals, Inc. on behalf of American Water Works Association AWWA Wat Sci. 2019;e1122. wileyonlinelibrary.com/journal/aws 1of11 https://doi.org/10.1002/aws2.1122 2of11 LECHEVALLIER Legionnaires’ disease is on the rise tower samples than the Centers for Disease Control and 2000—2016a 2.5 Prevention (CDC) culture method. The objective of this study was primarily to gain 2 U.S. utility experience with the Legiolert method and evalu- 1.5 ate the training and learning curve of the test for both pota- ble and nonpotable water samples. Testing was conducted 1 by 12 water utilities to collect data on the occurrence of 0.5 L. pneumophila in distribution systems. The study organizers worked with one state agency to develop guide- Incidence (cases/100,000 pop.) 0 lines for responding to positive potable water Legionella 2000 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2015 2016 2017 2007 2014 samples. Although this was a small study, it sets important Year precedents for future monitoring of drinking water systems. FIGURE 1 Increase in Legionnaires' disease in the United States. Source: Centers for Disease Control and Prevention. aNational Notifiable Disease Surveillance System 2 | MATERIALS AND METHODS Legiolert (IDEXX Laboratories Inc., Westbrook, ME) is 2.1 | Utility recruitment a culture-based assay for L. pneumophila based on the most A total of 45 water utilities initially expressed interest in partici- probable number (MPN) and similar to the Colilert test. Sar- pating in the study. Details of the study, the number of samples tory, Spies, Lange, Schneider, and Langer (2017) reported to be collected, a description of the analytical procedures, and that the Legiolert test resulted in significantly higher counts an anticipated quality assurance and quality control (QA/QC) of L. pneumophila than the standard International Organiza- training was provided (see Appendix S1, Supporting Informa- tion for Standardization (ISO) 11731-2 membrane filtration tion). In addition, each candidate was provided with a data col- method based on a multilaboratory study. They examined lection form and a draft memo that could be used to discuss the 290 paired counts for both the ISO and Legiolert methods, project with state regulators. Many of the prospective utilities with a mean of 132 MPN/100 mL for the Legiolert test expressed concerns about the possibility of detecting (range 0–2,273 MPN/100 mL) compared with a mean of L. pneumophila in their distribution system, and at least one 26 cfu/100 mL for the ISO 11731-2 method (range utility was told by their state regulator that a “do not use” order 0–368 cfu/100 mL). Of the 1,105 isolates examined, 96.7% would be issued if they detected L. pneumophila in their distri- were confirmed by serology to be L. pneumophila (Sartory bution system. That utility subsequently declined to participate. et al., 2017). The superior performance of the Legiolert Other utilities expressed concern about the laboratory workload method was attributed to the broth incubation (rather than or that other projects were currently underway. In the end, membrane filtration) and the extended counting range of the 12 utilities agreed to participate and represented a good geo- Quanti-Tray format. Spies et al. (2018) reported data from a graphic distribution, with five sites along the East coast and multilaboratory study that showed the 100 mL Legiolert four in the West as well as three sites within the center of the MPN method was equivalent to the highest result of either United States. Sites were also distributed equally, with six sites ISO 11731 or ISO 11731-2 regardless of whether nonpneu- both in the northern and southern parts of the United States. mophila species of Legionella were included in the evalua- Table 1 shows the characteristics of the systems. Ten of the tion. The Legiolert method had a specificity for systems used surface water, one used groundwater that was L. pneumophila of 97.9%, comparable to the 95.3% specific- recharged with surface water, and the other had a blend of sur- ity for the ISO 11731 method. The authors concluded that the face water and groundwater. Two systems were unfiltered, one Legiolert method represented a significant improvement in the used ultramembrane filtration, and the others used various enumeration of L. pneumophila from drinking water and forms of granular media filtration. For primary disinfection, related samples. Petrisek and Hall (2018) compared the Legio- two systems used ozone and ultraviolet (UV) disinfection, one lert test with method 9,260 J (Standard Methods, 2017) for the used UV alone, two used chlorine dioxide, six used prechlori- enumeration of L. pneumophila from potable and nonpotable nation, and one used prechloramination with sufficient contact waters and reported that Legiolert exhibited higher sensitivity time to meet the SWTR requirements (USEPA, 1989). Five of for the detection of L. pneumophila for potable water and the systems maintained a chloramine residual in the distribu- equivalent sensitivity for nonpotable water. For the Legiolert potable water samples, they reported a false positivity value of tion system, while the other seven sites used free chlorine. <0.5% and a specificity of 100%. Similarly, for the nonpotable 2.2 | Sampling sites water analysis, Legiolert had a false positivity value of <0.9% and a specificity of 100%. Similarly, Rech, Swalla, and The study plan included collecting four raw water, four plant Dobranic (2018) reported increased sensitivity, low false posi- effluent, and approximately 48 distribution system samples tive rates, and less interference for nonpotable water cooling from each utility. Some systems collected additional samples LECHEVALLIER 3of11 TABLE 1 Characteristics of participating systems Utility code Population
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