 For those of you that haven't seen the bio Alvin Bartels is a policy advisor and Works for the National Institute of Public Health in the environment He's got particular expertise in Legionella He's been involved in the implementation of prevention at buildings In Amsterdam, he's also written prevention guidelines and for community health services And he's a member of a number of committees and groups that meet To discuss Legionella prevention and so Alvin, we appreciate it very much if you can't Hear us you can ask after your presentation. We'll have some Q&A from the committee Okay, thank you and thank you for his nice introduction I will start my presentation and in the Netherlands we have Four regulations for Legionella prevention And these were all made after two outbreaks And the first outbreak we had in the Netherlands was in 1999 We had an outbreak during a flora event in both a gospel It's a small town approximately 60 kilometers north of Amsterdam And it was due to an hot tub on display And more than 200 people were diagnosed with Legionella's disease and 32 people died Of course, you can imagine it's got a lot of media coverage And also some political demands for regulations So we they added regulations to the drinking water act The hygiene and safety act for swimming and bathing facilities And also the safety at the work act for So workers weren't exposed anymore to Legionella But in 2006, we got another outbreak this time in Amsterdam near Central Station And this time it was a cooling tower A temporarily placed cooling tower And more than 30 people were diagnosed with Legionella's disease and three people died And they added Legionella regulations to the Environmental Protection Act Oddly enough, the regulation for hot tubs used at the fence is still lacking So the hot tub on display, we don't have any regulations for this at this moment All regulations are for Legionella's species And we have no similar regulations for other opportunistic pathogens in water systems Although in swimming pools, you have to monitor Pseudomonas And keep in mind we have no chlorination in the Dutch drinking water system First, the drinking water act And the legal owners of the drinking water system have to make a risk assessment And they have to make a management plan And they have to record all their action in the law book And they have to assess the risk If there are any aerosols present for the showers example Are there any risk for temperature between 25 and 55 degrees Celsius Is there any stagnation for more than one week? And also, is there a lack of proper maintenance? For example, dead legs or the showers that are not used anymore This is also part of our building regulations that is in the NEN 2006 And the owner of the drinking water system has to update the risk assessment If the drinking water system has changed significantly For example, more showers were added Now these regulations are only for priority premises And these are hospitals, healthcare facilities with overnight stay Hotels, vacation sites, bed and breakfast for more than five persons Swimming pools, harvest marinas with showering facilities Truck stops with showering facilities Asylum centers and prison And this list is based on our own list we make A list with water systems with increased risk for legionastasis And we based this classification on five criteria One is linked to cases of legionastasis The other one is travel accommodation Dispersion of aerosols to the environment And especially continuously Dispersion of aerosols like cooling towers Exposure of population from risk groups Like the elderly or people with weakened immune systems And temporarily used insulation for example at events And for this list we used peer refueled publications And Dutch matches and clusters And as mentioned these are the priority premises Mentioned in the drinking water act Then the management plan The control methods if you want to use the control methods They use a step metal in the drinking water act The first step is you can use temperature control and flushing And heat disinfection Or you can use an ultraviolet infiltration system And if the water management company can prove that This is not sufficient enough You can go to the second step That's electrochemical for example copper silvery ionization And in theory we can go to the third step The coronation of the drinking water But to my knowledge that has never been approved by the inspector You also have to monitor your control methods If you use the temperature control and flushing method You have to check your temperature The cold water needs to be 25 or lower And the warm water needs to be 60 degrees or higher And you have to sample every You have to take culture You have to sample every six months And you have to sample the taps that are most distant from the water meter Or the most distant from the boiler Or taps that are not used very often And you have to use the culture method The Dutch culture method The NEN 6265 And also recently we updated And you have to know the international standard It can also be used And next year it will only be the international standard 11731 The threshold is less than 100 colony forming units per liter And if you're above 100 You have to take action and lower your concentration And if the concentration is above 1000 Cv per liter You have to report to the inspectors And they will give a reply And you have to take action to get below the threshold And then if you got it below the threshold You have to notify the inspectors There are also certificates needed If you want to make a risk assessment or a management plan You have to have a certificate The BRL 6000 So only professional water consultancy firms Are making these risk assessment and management plans And if you want to use a control method Other than flushing You want to use ultrafital filtration You have to have a product certificate That's called the BRL 14010-1 If you want to use the electrochemical method You have to have a certificate BRL 14010-2 And to make a risk assessment And then a management plan You have technical guidelines available This one is called the ESO 55.1 The second act is the Hygiene and Safety Act For swimming and bathing facilities Or the Dutch abbreviation is the BHVBCIT And you only need to do like prevention measures If the location is built to be used As a swimming and bathing facility And one of the beds is at least two square meters wide And one and a half meter deep And at least one bath Dispersed as aerosols For example hot tub or play fountains Keep in mind this does not apply to hot tubs On display or in hotel rooms Or at the event Because it's not a swimming and bathing facility You also have to make a risk assessment You have to make a management plan And record all your action in the logbook You have to use an effective disinfection method Monitoring is needed The threshold is similar as drinking water systems Below 100 colony forming units per liter But no culture method is specified You only need to use an accredited laboratory And you have to report to the province authority If it's 100 CFU per liter or more But no certificates are needed To make a risk assessment or management plan So the swimming or bathing facility Can make their own risk assessment And also you don't need to update your risk assessment But the inspectorate can demand a new risk assessment Or an update To my knowledge there are no technical guidelines Available for making a risk assessment Or a management plan Third the Environmental Protection Act It's only for wet cooling towers Again you have to make a risk assessment You have to assess if there is biofilm Sediments, temperatures, stagnation And you have to make a management plan And record all your action in the logbook You have to use an effective water treatment It doesn't state what kind of treatment you have to use As long as it's effective And it's allowed to use in the Netherlands Then you have to monitor your cooling tower If it has to be clean Also the cooling water needs to be clean But there is no threshold And also no frequency specified But if it's mentioned in a management plan If a threshold and or frequency is mentioned In a management plan You have to use this threshold or frequency And you have to update your risk assessment When the cooling tower operation changes Or the surrounding steering For example there is another cooling tower placed On the location Or a hospital is going to be built next door And there are no certificates Required to make a risk assessment or management plan Or to use the water treatment But you do have to report placing a cooling tower If it's after January 2010 That's reported to the authority And for most cooling towers That's the municipality Some large industrial sites It can be the profits authority But if it's before January 2010 The authority has to find these cooling towers For themselves Then it's real hard to do And so at the moment Based on the water treatment industry numbers We have one third of the cooling towers registered And to make a risk assessment and management plan There are technical guidelines available This is called the ISO 55.3 and the AR32 And on the fourth one is the Safety at Work Act To protect workers from exposure To Legionella species during the work Again you have to make a risk assessment You also have to make some sort of a management plan This is part of the health and safety catalog But it's not specified what kind of preventive methods You have to use to protect workers from exposure To Legionella That is something for the company to decide for themselves And you have no certificates are required And the threshold is set at less than 100 cv per liter It's the same for the drinking water and the bathing facilities But no frequencies are specified Only that you need a standard culture method And there are no regular inspection from the national inspectorate They only check if you have a health and safety catalog And that's it And implementation and compliance is the responsibility Of the sector or the branch organization And to make this risk assessment There is a technical guideline available This is the AI32 again I made an overview of all the water systems and acts available The drinking water systems only priority premises It's the last update was in 2011 Legionella, Penovala and 20 other petrogenic species need to be monitored Well normally it's all species but because no lab is monitoring These 20 specific petrogenic species And the threshold is set at 100 cv per liter You have to use for now the Dutch 6265 But it will be the international standard 11731 And you have to sample every six months You have to notify the authority if it's above 1000 cv and for controllers you need to use the step model And flushing thermal disinfection is the most used control method in the Netherlands And you have to have certificates for making a management plan And to use other methods than flushing And the authority is the human environment and transport inspectorate And also for local inspections we have the water supply companies The embedding facilities since 2000 Since for all Legionella species threshold is set at 100 cv per liter Six months notification 100 or more You can use any effective methods as long as it's allowed in the Netherlands No certificates necessary and your authority is the professor authority Cooling tiles since 2010 for all Legionella species No threshold, no frequency, no notification necessary Only you have to report cooling towels that are placed After January 2010 And you can use any effective water treatment method As long as it's allowed in the Netherlands And you don't need any certificates And there are a number of authorities The most for most cooling towels It's the municipalities With some large industrial sites at the province authorities And local inspectors are done by environmental protection agencies And then the last one is the safety at work It's since 2007 for all Legionella species Threshold is set at 100 cv per liter No frequency specified, no notification You can use any effective method No certificates required And the national inspectorate only checks if there is a health and safety plan So it's the responsibility of your own branch organization I've got some numbers from the drinking water system Inspectorate ILT about implementation Unfortunately the numbers are in Dutch But it says in red there is no good compliance And Legionella increases likely there should be Legionella Green it means it's very good compliance And it's not likely to find Legionella in the water system Yellow it's slightly increased And orange it's a bit increased A bit more increased So on the bottom you see the number of hospitals That are inspected by this national inspectorate Every year it's our different hospitals Some maybe some are similar hospitals And you see the percentages change every year So there is still some room for improvement Implementation Same for healthcare centers It's a bit better The compliance And more than 50% is good We won't expect any Legionella in these drinking water systems But still there are 12% It's expected that there are Legionella in the drinking water system And data for swimming pools It's only for drinking water systems A little bit less than the healthcare centers Below 50% complete compliance And almost 20% bad compliance And likely to have Legionella in their drinking water system And keep in mind that the ILT doesn't take a sample themselves It's only on paper based on the management plan And the sauna and wellness of special interest to us Because we have a lot of patients in sauna and wellness And as you can see there is much room for improvement For these facilities Only, yeah, you see that last year in 2017 They visited the inspected 25 sauna and wellness centers In 2016-51 2016 was a better year And in 2017 it's again below 50% Complete compliance And 28% bad compliance And likely to have Legionella bacteria So much improvement for the implementation needed Hotels Similar numbers And this good compliance is very low Last year at 689 hotels were inspected And only 36.3% at complete compliance And about 90% is very bad compliance So also much improvement needed And the last one is the bad and breakfast for more than five persons Even worse numbers A third have good compliance And a third have very bad compliance In last year and 99 bad and breakfast locations were visited Now the implementation from cooling towers Unfortunately, we don't have any recent data available About the implementation and compliance Also the positive environmental samples are not registered And I have some old data from 2011 The government did a survey And asked all municipalities If they check for the presence of cooling towers They had a response of 84% It's about 350 municipalities And 88% of these municipalities Said they checked for the presence of cooling towers But 56% said they didn't have any cooling towers 53% inspected cooling towers And roughly 30% of the locations did not comply with the regulation Now keep in mind these are old numbers More municipalities have cooling towers than the 56% That's now that's noted here And in 2015 we did a small survey We asked 14 inspectors about their experience with Inspecting the management plans And registration And they say about 30% of all cooling towers are registered And two thirds of the interviewed inspectors Do not officially inspect the cooling towers So they do not check if the cooling tower is clean And the cooling model is clean Although it's mentioned in the regulations And that is because they have lack of time And lack of knowledge about the cooling tower And they hope to improve this knowledge in the coming years Implementation about bathing facilities There are no national registered numbers About how good the implementation is For bathing facilities I asked some province authorities And generally large rain pools facilities The compliance is generally good And small bathing facilities like vacation homes Or bed and breakfast Compliances it has to be improved And safety at work act I don't have any data available Because it's not registered by the national inspectors How enforceable is the regulation All regulations except the safety at work act Do regular inspections First they will give warnings If that doesn't help they can give fines Many thousands of years if necessary And in theory they can close the water system But it really depends on the health risk Well in the safety at work act again The inspector that only checks if a health and safety catalogue is present Unfortunately there are no regulations for risk systems According to our list for miss systems Decorative fountains, hot tubs at events And hotel rooms So they are also not enforceable Although municipality can impose local regulations Did the regulations have any effects? Unfortunately I don't have any data from environmental hits These samples are all done by the commercial labs Don't have their data I tried to get the notification data From the inspectors of the drinking water facilities And the bathing facilities But I don't have it available at this moment Maybe I can send you this information later Then if you look at the Legionnaire's disease notification in the Netherlands 2007-2017 And the red bars represent the domestic cases And the blue bars represent the travel abroad cases The travel abroad cases are similar over the years Around 140 cases in the Netherlands And domestic cases in the Netherlands rise Between 2017 and the highest number was in 2017 Around 400 cases And if you look at this figure You can conclude that all these regulations Do not have any impact Have any effect But unfortunately we can say Which regulations do have any effect Because at the moment we have insufficient data To compare Legionnaire's disease notifications With the effect of regulations There are limited sampling of potential sources And few clinical isolates available for comparison We only have a couple of matches each year And most matches are found at hospital and healthcare settings Wellness and spa pools A source of infection remains unknown For most notification And overall you can say that If you combine all regulations They do not have any effect on decreasing the LD rates We think there is an association with rainfall And so there might be other environmental sources That are not in the current regulations Are there any efforts in place to monitor the impact of regulations? Yeah, we need more data to monitor the impact of regulations Together with the municipal health service We try to improve the number of matches And we try to find new sources of infection For example, a couple of years ago We sampled bioscrapers at pig farms 36 bioscrapers Unfortunately we couldn't find any Legionnelle And unknown is if the national government Have plans to monitor the impact of regulations Not in this year or next year They don't have any plans And last we want to have a possible research We are current regulations for drinking water systems Effective compared to new insights In controlling Legionnelle growth Because the drinking water regulation Is already in effect since 2011 And of course there are new insights In controlling Legionnelle growth And we want to compare these data And hopefully your conclusions and recommendations Can help us answering this question Thank you for your attention This was my presentation Thank you very much That's very interesting in terms of the increased cases But we're seeing similar trends That you can't find the source In any case, domestically Let's start on this side of the room And then we'll go around Questions here now? Ruth, let's start with you Yeah, thank you very much for that It was really insightful You mentioned a lack of time and knowledge You made it to cooling towers And I wasn't sure what you meant By knowledge at cooling towers Was that knowledge of where they were Or registration or knowledge of what to do with them? Oh, sorry, yeah Now go ahead Yeah, go ahead Okay Now the technical knowledge Because the Environmental Protection Agency Did not inspect the cooling towers Before 2010 They didn't even know what cooling towers were So they really have to cooler themselves Okay, the second question is How do you assess the confidence In the environmental labs to culture for Legionella and quantify it? Would you repeat that because I can't hear Oh, I'm wondering about the environmental laboratories That culture for Legionella And how do you assess their competency Both for identifying it and for quantifying it Well, did you hear that, Alvin? That's just confidence in that Yeah, I think I Okay Yeah, we did some tests What I can remember Many years ago And you see differences between the All the commercial laboratories But I don't know what the quality is Of these labs, unfortunately I don't have any numbers Sorry, I can answer that For this moment But there is some differences in quality Steve A similar question I asked the last speaker Is how is Legionella testing happening in hospitals Within the Netherlands itself Because part of the question comes up is Are we seeing increasing rates Because of testing changes Because of better identification in communities Or is this truly an increase Or are we better at identifying Cases that we didn't Identify in the past Has that changed over these past few years? You're talking about environmental samples, right? No, in clinical samples Clinical samples Yeah, is the diagnosis getting better Or do you have sense that the cases are really increasing? Yeah, the cases really are increasing I don't think the diagnosis is better These couple of two years or three years Is similar compared to three or four years ago And what method are you using For clinical diagnosis now In sporadic cases that come into labs or in hospitals Are they different or Are they similar around the nation or Unfortunately, I don't have this detailed information But to my knowledge It's no different than five years ago Steve, did you have a follow-up question? No Okay Nick Yes, I want a point of clarification In your slide 20 Showing the increasing in domestic Just want clarity on what you define as domestic Because I assume You're not talking about individual households But you're talking about hospitals, institutions And the bed and breakfast hotels That you referred to under the act Is that what you were referring to Domestic I'm talking about a clear Can I go to the slides or a slide 20 is there Can you clean the cases? Thank you No No Course like that Yeah Because the title of the slide is Are regulations having an effect Now I'm just wanting clarity What your current regulations As I understand it do not address Household domestic To do with institutional No, no, no, don't do that Right No, and the number of cases We have some cases Domestic cases in households But a couple But as I mentioned We only have a few matches each year So and yes We have a couple of households Matches with households Maybe I think that was travel associated Or domestically acquired International So the figure that had domestically acquired cases That's all cases no matter what Yeah, no matter what It's all cases What? Yeah, all cases combined All notificates Okay Need to be notified to the RVM And these are all cases Hi Could you clarify There's a parent relationship with rainfall What actual data are you referring to? Yeah, there's data from my colleague Pietra Bransma And she found a correlation between Rayfall and the number of cases Rising in a certain period It's a warm period Followed by a wet period In a wet period You see a rise in the number of cases And if you want the numbers I can give you these numbers I have to contact my colleague Pietra Bransma Thank you So there's this association Yes Yeah Thank you Chuck and then we're going to go to Michelle Michelle You mentioned that one of the regulations on the I guess drinking water side Presumably for hospitals Is a hot water temperature of 50 degrees C Where is that measured? Yeah, that's the temperature of the hot water storage tank or the boiler And also the recycle line But of course they have the thermostatic valves that are set at Well, around 35 So it's not measured at the thermostatic valves It's measured at a couple of points But the hot water if they want to do Heat disinfection It has to reach 60 degrees Also on thermostatic valves is necessary The hot water return line has to be 60 Yes Yeah How do you get it? Keep it that hot I try to load the temperature And I think for If they don't have a return How you said Then it can be 55 But it has to be 60 In hospitals In hospitals specifically No, not only in hospitals In every drinking water system in Netherlands Basically Okay We have another question from a member online Michelle Prova Michelle, go ahead She's probably getting off mute right now Oh, I am off mute There you go I hear you now Okay Also a question of clarification For slide 20 So you responded that that includes Community acquired cases In all cases in Netherlands Is that correct? Yeah, that's all case Yes Go to number And would you Would you comment on whether the community Acquired cases are monitored with the same To the same extent as what you call sensitive Groups or installations or buildings Like hotels and hospitals Do you think that the current surveillance system Would pick up the community acquired cases As well Can you clarify your question because Yeah, you have a total number of cases And you mentioned that they include very few What you would call household or community acquired Type of cases in households Do you think that the Dutch surveillance Of sporadic cases from the community Would pick up these cases Yes, I think so Yeah, I don't have any doubt That would do the same level surveillance then Same, yeah, we have a surveillance team And we do a source finding And it doesn't matter where a patient If it's a household or a hospital Or whatever We try to find the source If it's if the patient only stayed in their house We don't do any source investigation But if it's there's lightly sourced outside of their house We do a source investigation Okay, that really helps I noticed the year and I was a very clear presentation On the different regulations that have been Armigated in the Netherlands Um, would you also comment on design Specifications for plumbing? I do believe that you have a few very progressive design Obligations that limit, for example, the number The length and the volumes of piping That does not have recirculation in hot water system Do you think those regulations and guidance are important? I do, um, I would say this Not all of them, I think We have a lot of, yeah, a lot of things That the plumbing system has to comply with I don't know, um, if all these measurements And all these, if it's one meter or a half a meter If that really will help to avoid the formation of biofilm To my personal opinion Okay, so you don't, in your opinion, you don't think that those Guidance contributed a lot to the levels that you see right now No, well, maybe some, but it's not How do you say it? A little bit, but I don't think it's really the key thing to avoid biofilm formation I also noticed that you mentioned the step approach for treatment Whenever levels are exceeded, reference levels So I have two questions for that The first one is how were the levels of a hundred and a thousand CFU per liter set Were they related to risk or were they operational levels? How did the Netherlands decide on these levels? Purely operation, purely, pure practical A hundred is seen as the detection limit for all laboratories And a thousand was only set because the inspector didn't want to have Too much of a notification So it's purely operation Practical Yeah, practical indeed And the second question is more about treatment Where is the part of the support I'll be working more on And I did notice that you rely on either UV filtration or Thermal disinfection Have you monitored how effective thermal shock treatment is for these infections in the Dutch systems? Well, I think Paul van der Wielen and KBR did some research But it's not from the government side, it's not monitored at this moment And and then a final sub question you did mention That you were not aware of any systems that had to go to step three, which is chemical disinfection, chlorine, actually So there are no, I was under the impression that Some hospitals did use on-site chlorination When things were difficult to handle Is that a can you confirm that in your To the best of your knowledge, there are no chemical treatment installed in Dutch systems Well, they are used if there are increased Increased concentration of Legionella present you can use chemical disinfection for shock treatment To eliminate the Legionella bacteria from your drinking water system But to my knowledge is not something that is continuously used as a control method But maybe there are some hospitals that I don't know of that use this this method And I have one last question. I just saw on my list. I was writing up as you were presenting I I see a much lesser focus on the obligations for cooling tower monitoring Uh, is that choice in the Dutch regulations? A based on the fact that your assessment of local sources is not really like cooling towers are not so important Or is it because you had so much regulations by the time you got to cooling towers that There was a push against too much monitoring regulations Well, you hit the nail the hat with the last one Because that's that's it. They want to have uh, it's it's a trend in the Netherlands to have less regulations uh, so they During that time they want to have less regulations than drinking And we would like to see a more strict regulation on cooling towers Sample mention a threshold mention a frequency so you can also inspect on this threshold and frequency But at the moment there are no plans to to change this Thank you Amy pruden has a question for you Hi, I actually have two questions. Um With the first I feel I have to address the elephant in the room of not adding secondary chlorine or chloramine disinfectant residual Right, so I mean are people frankly assessing whether that's playing A significant role in these increased cases. Is there any discussion about more of a role of disinfectant? No, there's no discussion about it because they're very strict Especially the drinking water supply companies. They don't want any chlorination in in the drinking water system So there is no discussion that To use this more often in drinking water system Okay, well, it seems it's a demonstrated control measure at many other locales. So this But then again, how long have the dutch systems been without chlorination? And they're never been I think they're never been chlorinated Not for at least 25 years. So the recent increases Um, I don't think can be related to the lack of chlorine I don't know and and and The the drinking water supply companies. They check their their distribution system and it's always below the 100th cfu per liter Um, so it's it's it's yeah the growth the legionella growth is within the drinking water systems and there are other alternatives to Eliminate the legionella bacteria. I think Don't mean what was your second mission so the second question was about The regulations related to bathing waters and I thought that was Was interesting and fairly unique the focus on that. Um, so I was wondering If it's largely reactionary since there was a large outbreak related to the the hot tub And if it's being found that those measures Are effective And what the future is and the focus in that area Um, it is a reaction on the outbreak, but uh, strangely enough The cause of the outbreak is not part of this bathing facilities act um I don't I try to get some numbers from the The province authority And they say that some provinces authorities They only see a couple of Positive samples, but there is another province. There's it has dozens of positive water samples Uh notifications And but I can't say if it's working or I like that data. I'm sorry Okay, uh nick asphal Uh, given the Dutch uptake of using cure marae Uh, work of jack shivan at rivm. I'm thinking of here And your use of water safety plans in the dutch version for managing drinking water systems my question is Are you or have you considered using qp cr legionella testing As a measure of change Given that we're less interested in absolute concentrations, but a trend up or down in water safety plan management Targeting I just wondering what the discussion has been in the Netherlands Yeah, um, there's a lot of discussion about this, uh, but um And the the the the the culture methods is only used as an indication of the control method is working And that that's it and also Um, if the levels are exceeded, uh, you get, uh, quite a big reaction Um, water systems are closed. Uh, you get press releases This all is happening and I'm afraid if you use qp cr the number of positive samples will increase And of course Is this a dead or alive? Are these bacteria dead or alive? So that's also a discussion Um, so we are a bit wary of Using qp cr as a monitoring methods monitoring tool for monitoring the control methods Okay, thank you So I have a question, um from um An individual in the health department. I think it's connecticut health department. Um from online And they want to know whether You're you've gone any reports or how much effort is being made to, um Match up isolates in the environment with the cases isolates from cases Yeah Well, uh We try to do that, of course, but the problem is we don't have much isolated clinical isolates We try to get more clinical isolate from the hospitals, but it's that's just the main problem Uh, and I hope to increase that and of course if we have both isolates, we try to match them Right, so it's it's pretty similar to what we're hearing with other Individuals who try to do those investigations um, you know, we didn't get um in your slides that you said we didn't get those bar graphs you um showed With the trend over time with um as you implemented the rules of compliance. I guess it was compliant Yes, yes. Yes. Yes. Yes compliance. Yeah, and that'd be quite interesting to get those graphs if you wouldn't mind sending that power point again to remy um But my question it was about where you're monitoring um as you're trying to assess Um implementation and compliance. Where where are they taking the samples? Is it from bathroom taps showers? um You know, or is it is it is it randomized? How how are they sampling? Well, the inspector doesn't sample anything. They just check if you're Following the regulations if your law book is is correct um and Only that the so the the legal owner of the drinker was the system has to sample every six months And they have to sample uh distant taps taps that are not used very often Basically the taps that you expect to have legionella Okay distal taps and like from sinks and right And uh, uh, I don't other members know more about this and maybe they can uh Ask the question uh more uh Succinctly than me, but I'm I'm wondering about I guess there's mixing valves and there's different kinds of taps um that um You might influence aerators all kinds of things that might influence what you find at the tap uh, is there any um approach that you use to try to understand that those differences in the plumbing or in the coating around Yeah Yeah, and it should be They should do it, but Uh, it's not in the regulations. Uh, I don't know I can speak of every left Taking in a fire mental sample, but uh, basically it can be done by a regular tap or a mixing valve They can uh Shower they can choose whatever Right. Okay. Very good. Thank you and and my understandings. They don't really have to report to you unless it's over that Threshold of cfu's then you get notification. Otherwise What do people do with the data? It just comes back to them from the lab and They store it in a notebook or something That's what I do and uh, if there is a threshold For drink waters and systems and bathing facilities They have to take action to get it below the threshold again So if they don't do it and there is an inspection by the national inspector And then they can get the warning Um Okay, Steve, uh, you had a follow-up question. Yeah the follow-up to that. Um, since you have a national health care system Are there the different regulations that, um We're testing The number of testing sites, etc in hospitals, or is that also sort of open to interpretation? If you have specific policies for how hospitals Have to do this in comparison to other community buildings where water is available um, well that the hospitals have Have to follow the regulation used the same Standard methods, but I do know that hospitals Use their own methods for environmental culture um, but yeah They They have to uh comply with the regulations that states you have to use the Dutch standard or the international standard Um, I hope that I don't know if that answers your question Yes, it sounds like it's a little bit varied per hospital. Yeah, maybe some basic guidelines. They have to follow but not Um, so a number of sites or Methodologies that they have to use specifically. Yeah, the the number of sites they have to sample Specified in in regulations. I don't have to accept numbers, but the larger the The drinking water system the more samples you have to take Okay. All right. Thank you And Elvis, so how is that? um How is compliance with any of these regulates regulations? monitored or checked or reported by any of the regulatory authorities um The the the figures I showed from before being the drinking water system Yes Um and the bar graphs you showed Yeah, yeah, yeah the the well the inspector at the uh visit on location Or the drinking water supply company visits on location and they check the management plan. They check the log notes um And uh, if it complies with the regulations and if it doesn't comply with the regulations They have to change this And uh, yeah, then they classify it in increased risk or very increased risk Just like I showed you in these in these figures And so the compliance is based on a self-reporting mechanism. It's not necessarily a In other words, if they don't self-report it to you, you guys don't check No, no, it's not uh, no, it's not so they've uh, the inspector at his visiting the location. So it's not only the the the Environmental samples above 1000 Uh, see if you have to be reported but not the compliance or anything like that That's that's the cluster inspections by the inspector You actually have people who are personally going out to the to the hospital Yeah, yeah More hotels I tried to follow a question with how often do they physically go to the site? well, um I don't know if you but uh, and in Below the bars to where this It stated how many locations they visit each year so, uh health care centers hundreds Uh hospitals around 70. So That's what I visit visit each year Great. Thank you I think so we're we're good. We really appreciate your time and this was very um Very useful and um And and thank you all and for for that presentation