 Okay, so a little bit of Australian context. So Legionelosis is notifiable in every state and territory of Australia. We have about 340 cases per year, which equates to about 1.6 per 100,000 people. And they're equal with waterborne Legionella pneumophila. And we also quite commonly get Legionella long beachy from soil. And they're quite roughly to about 0.75 per 100,000 people. And that varies across the state. So in my state, South Australia, it's about 70-30 for long beachy. It's more common. It's the same the world over, I'm sure. In Australia, exposure is much, much greater than infection. And infection is much, much greater than disease. In Australia, cooling towers and spas are the most commonly identified cause of outbreaks. We know that building water systems are a source of infections, but they tend to be sporadic. We've only had two or three outbreaks associated with buildings. And one of those occurred in about 1979. So not very common. The last one about in 2013. We've had a few less common sources. About 2008, we had seven cases associated with a car wash. We've had occasional cases associated with ice machines and chilled water dispensers. In terms of regulation, the important point is that regulation is a state and territory issue. It's not a national issue. And that's the same with water in general. This is Legionelosis over the last 20 years in Australia. So the top line is total cases. And then the bottom line, Legionelonumophila. That was an outbreak in Melbourne, Melbourne Aquarium, over 120 cases. And then a smaller peak in 2013. That occurred because of an outbreak in a hospital in Queensland. Only a very small outbreak, two cases. But it led to a lot of increased testing. So we picked up some more cases. Again, for context, for Legionella, applied to building and manufactured device owners or operators. They don't apply to drinking water suppliers. We do not have Legionella guideline value in our drinking water. Therefore, our drinking water. The design is scope of regulations varies between jurisdictions. The regulations are generally administered by state health agencies in partnership with local government. But in some cases, safe work agencies play a role, particularly in regulating cooling towers. And that's not unheard of around the world. The focus of our regulations have been... Cutting in analysis. Sorry? You're cutting in and out a little bit every once in a while, but it's OK. Keep going. It's at a high risk, but generally regulated under recreational water legislation. There's been a recent birth due to risk-based assessments of potential sources of Legionella, particularly in hospital and aged care facilities. Our regulations are informed by national standards and guidance. And again, this is the same in Australia as per drinking water and recycled water. So we have the national documents from which we frame our regulations. So the most recent one is from N Health, which are guidelines for Legionella. Two standards that deal with testing, both by culture. One, just an old standard assay, not particularly sensitive, detection limit of one per 10 mil, and then a more recent one where we examine after concentration. And then finally, in Australia and New Zealand standard on air handling and water systems of buildings. Gives a little bit of information on water systems, but the focus is on cooling towers. So the general features of our regulations, and this is pretty common Australia-wide. So there's a general requirement for implementation of various management plans. Again, that's the same for drinking water and recycled. Monitoring for Legionella occurs, but it's not a focus of day-to-day management. And look, I think we all understand that the shortcomings of the long testing for Legionella. Our preference is to implement on-going operation or monitoring. So the chlorine residuals and temperatures in water distribution systems, cleanliness and biostyte dosing of cooling towers, all pretty standard stuff. The questions about the value of Legionella and heterotrophic colony testing are reflected by variable testing requirements across the state. So cooling towers. Generally, most jurisdictions, cooling towers, need to be registered. Typical requirements in the legislation include continuous biostyte dosing, fitting of drift eliminators, regular servicing, and regular cleaning programs. And all of these need to be documented in a risk management plan. In some states, we have mandatory inspections and audits required, and then reports have to go to the regulator. There are requirements for Legionella testing in a number of the jurisdictions, but these can range from monthly for high-risk systems to quarterly, six-monthly, or annual audit testing. All of these are by culture. Monitoring can be mandatory or, in a few cases, recommended. Some states also require or recommend monthly HCC testing. The regulatory limits for Legionella and HCC are set by the Australian standard, or the ones that are in the Australian standard are the ones that are adopted. So there are three levels, non-detected, which is then do more testing. Two consecutive non-detects. Clear tower, persistent detects can ramp up the disinfection and decontamination requirements. If you detected a greater than 1,000, then that leads to decontamination, which is a more severe tower, and persistent detects require further disinfection and decontamination. Heterotraffic colony counts, similar. Again, we got ranges much higher now, of course, less than 100,000. A similar program for Legionella, but just at much higher levels. Notifications are usually specified that need to go to the public health regulator, either the state health department or the local government. They're typically based on the upper limits specified in the Australian standard. So that is a greater than 1,000 Legionella per mil or greater than 500,000 HCC per mil. Some jurisdictions require notifications at lower levels. So, for example, 10 Legionella per mil or 100,000 HCC per mil. That's less common. Water distribution systems, hospitals and health care facilities. We've typically adopted two approaches. One is to regulate warm water systems. This is the older, more traditional approach. So these systems circulate water at no more than just the relatively higher risk for supporting Legionella growth. The newer approach is to regulate all water systems. So based on a risk assessment to identify potential sources of Legionella. With the newer approach, we're bringing in total building assessments. So we're looking at cold and hot water systems, warm water systems, fountains, ice machines, chilled water dispensers. And this all systems approaches is relatively new based on the in health guidelines. The warm water systems, clearly high risk due to the temperature profile. They were very popular at one stage. They were introduced in hospitals and aged care to reduce scalding risks while having minimal tempering control. Sorry. Can you still hear me? Can you? Yeah, sorry, David. That's so many online. Can you all mute your lines if you're not speaking? Thank you. Go ahead, David. Tempering control. So the idea was you'd have the tempering control basically at the inlet to the hot water system. You'd reduce the temperature to 45. The whole system would be operated at 45 degrees. It seemed easier and probably cheaper. But the popularity of those is waning a bit because of high Legionella control requirements. So we're seeing easy degrees and then have tempering devices on the individual bathrooms. Risk management for warm water systems based on maintaining and monitoring temperatures, monitoring disinfectant residuals, minimizing potential stagnation and dead legs and ensuring that water flows are maintained. Again, all standard methods. Other requirements. So in my state, we require six monthly high temperature or disinfectant decontamination. Our standards have now changed. We now talk about disinfectant decontamination. In the vast majority of cases, that means chlorine. So chlorine is very popular. Legionella monitoring is less frequent than it is for cooling towers. Again, most states require immediate notification when we trip the limit for Legionella, which in warm water systems is a detection. So if you detect Legionella in a warm water system, you have to tell the public health regulator. And you have to initiate immediate remedial responses. Generally take the form of disinfection or a 70 degree pasteurization with follow-up testing. And while all that's been done, exposure to contaminated aerosols is minimized until completion of decontamination. So what that means is a wing award, rooms that may be shut down from using their showers until the decontamination is complete. Okay, the general impact of regulations. The good side is that it's improved understanding of locations of high risk devices and systems. So we now have registers established for cooling towers. And in some cases, we have registers for warm water systems. So the health regulators know where these systems are. We've improved communication and reporting networks between operators, owners, and regulators. And as a result of all this, our investigation of outbreaks and clusters of cases have improved. That's all fairly qualitative. We don't have quantitative evidence on the impact of regulations. In Victoria, which were the first state to introduce regulations, they had shown that the... Since in 2001, there had been an increasing trend in Legionella pneumophila cases. And that peaked in 2000 due to the Melbourne Aquarium outbreak. In the first two to three years, the regulations produced a decrease in the number of cases. This level has since been maintained or plateaued. We haven't seen much reduction in recent years. They also showed greater than a 50% reduction in the proportion of cooling towers testing positive for Legionella following the introduction of regulations. The challenges of regulating... We've encountered is that regulating building owners and owners of devices can be difficult. Legionella control not always seen as core business. It should be, but it isn't. And this includes in hospitals, which can be frustrating. And skills are often lacking. It's common for building owners to engage maintenance and water treatment companies. And that can present a communication challenge because it adds additional management layers. I think one of the reasons that we've tended to steer away from Legionella testing is that there's been a tendency to default to testing at the expense of operational monitoring. So we recently had a case in a healthcare facility. They had a really nice chlorination system. When we went in, the first question was about the chlorinator. And the response was, yes, we've got this wonderful new system. It's got remote everything else. Unfortunately, when they went to check, it wasn't working properly. And they hadn't been monitoring residuals, even though their plan said that they would be doing this regularly. So that's been a difficulty. Future directions, several jurisdictions are reviewing or will review regulations in the next one to two years. I think we are, as I said, before going to move to a broader assessment of buildings, particularly in hospitals and aged care facilities. And we are considering increasing the monitoring for Legionella to get more information, to support what we're currently getting from our operational monitoring from our audits to improve our assessment of risk. And that's my presentation. I hope I answered the questions that you raised or at least attempted to answer them. Yeah, thank you, David. That was good. Well, I think we can open up for questions from all of us. I had a quick question for you to start with. This limit on the 10 to the third, was that evidence or science-based or was it methodologically driven? No, it was viewed as Are you thinking or did you cut out? A little bit of both. It was based on the evidence of what well-maintained cooling towers could produce and what we saw in poorly maintained towers. It wasn't based on risk of getting Legionella's disease. Okay, all right, very good, thank you. Yeah, it's got really high numbers. You've got a high risk. Right, got it. Okay, let's go around the table, start with Chuck. David, thank you. One of the things striking to me is it looks like your case rate for Legionellosis in Australia has been pretty flat, whereas in the US we show an increase. And I wonder if you have any thoughts about that. Yeah, it has been flat, great. And maybe that is one of the hidden successes of what we've been doing. I mean, it's hard to know. But if you take out those two peaks, yeah, the rate has been pretty steady for 20 years. Any questions, Nick? So, David, I think we've had this discussion a little bit before, but for the benefit of everyone here, is there an idea to move forward to initial testing by QPCR as a way of just having a better finger on the pulse rather than just relying on culture, or is that not seen happening in any of the states? A little wary about the QPCR. When we've done, there's been some experimental work done on QPCR, and of course we detect, we get a lot more hits. But we don't really know what they mean. I mean, to an extent, we don't completely know what the legionella detects mean. Our research at the moment is probably going more to being more exacting in that space. So, a couple of states are looking at programs for whole genome sequencing. We're getting some evidence that we can drill down into the legionella and pneumophilus a bit more. At one stage, we labeled all the pneumophilus serogroup ones as the potential nasties, but you will know that the evidence is showing that it's restricted strains, sequence types. So, we're probably moving more in that direction. It hasn't been a big move toward QPCR. Thank you. And I don't recall if there is an east-west differential in the sense of the dry west, the moisture east, or north-south on the east coast in the sense of prevalence of legionellosis. Sorry, I lost you. Can you nick the microphone? It's right there. Hopefully, this is better, David. The question is, is there any apparent east-west with the dry west versus generally the wetter east in the incidence rates of legionellosis or north-south on the east coast? Melbourne and Sydney have been traditionally our capitals of clusters anyway. And we think there's a bit of a climate issue, particularly in Melbourne. Division is probably more north-south with Long Beachy. So, Long Beachy is very common in South Australia and WA. Thank you. Ruth. Yeah, I want to follow up on an earlier question about the initial decrease of cases and then the flattening of cases, and I'm thinking particularly of mimoscellar now. And I wanted to know if there's any variation in the trends by state and by regulation? David, did you hear the question? Yeah, I did. I did. There have been variations in the states, so the states do go up and down a little bit. I've had a look at a couple of the states. Victoria is the one where they long-list, and I did mention that they did have an initial decrease and then it's flattened out. They've probably been amongst the more active. I'd have to go back and look at all the states, but my suspicion is that once we go into state by state, the numbers will get smaller, so we'll tend to see a bit more scatter. Yeah, what I'm trying to get to is whether the states that have been more active in regulation have seen more flattening or decrease in their curve. Is the trend a little different from those who have been less active? Again, I think you're right. The ones who are less active have fewer cases in the first place, but you still might be able to see trends if you lump some of those states together if you will. Pretty well all of our states now have regulations. They either have it in straight legislation or they'll have it in a code of practice that's linked to their Public Health Act. All by the Northern Territory have got some active regulation of mostly cooling towers, but now moving into the warm water systems. That tended to come second. So at least in the last 10 years, we've seen a reasonable amount of regulation increased slightly in Queensland more recently. I haven't looked closely at their figures. I can, I can get back to you. They moved into this risk assessment of buildings approach following an outbreak in a hospital in 2013. Victoria started in 2001. South Australia started in about 2008. As I said, pretty much all the states are on board now. Thank you. David, Michelle has a question for you and she's online. Go ahead, Michelle. Hi, David. Hi, Michelle. It's nice to hear you. I saw one of your slides with a 45 degree recycled temperature goal. I thought that was a bit higher in some of the guidance I've been looking at. Did I read that wrong? It's in the middle of your presentation. Yeah, 45 degrees. That's the temperature to be delivered in bathrooms where you've got vulnerable patients and young children. Now, the 45 degrees is right. In homes, it's higher. Okay, and it is in the recycle, not at the point of use with a thermostatic or mixing valve, right? Yeah, that's the warm water systems. It's predominantly most of the systems at 45, and that was cost cutting because they could put one tempering device on the start of the system, so they only had to have one tempering device and then circulate it all at 45. We prefer the five degrees and have a thermostatic mixing valve on each and every bathroom. There is a movement that way because there's a false economy in the 45 degree systems because they're a lot harder to maintain. What was the number you stated before, David? You cut out when you were. What was the temperature? It's 45 degrees in the warm water system, but we prefer that they operate at 55 to 60 and then have thermostatic mixing valves on the bathrooms, the individual bathrooms. I have two other questions for you. Do you have any idea of the community acquired burden in Australia with these hot water systems, also just this cold water that can reach 40 degrees in some households? Do you have any data on that for Australia? In houses. Legally, under the plumbing code, if they have a storage, they're meant to maintain the storage at 60 degrees. But all the storage has... The ones with permanent storages, they all just have a little dial and the householder can turn them up or down. But we haven't done a lot of work in that space. My third and last question. I really liked your bullet about the 50% reduction after the introduction of regulations in the state of Victoria for cooling towers. So the numbers of positive or high level Legionella positive towers went down. Do you have any reports or statistics for Victoria or other states that would help us understand that? Germany has statistics that we hope to acquire and it would be nice to have some from Australia. Yeah, I'll see if I can get it from our Victorian colleagues. They did publish some data in about 2008, 2009, which dealt with the first seven and so I can get that. And I can see if I can get an update. They used to publish it on their website every year, but they stopped doing it. But I should be able to get that for you. Thank you very much. Okay, Steve Danruth. Thanks for the nice presentation. Just a question about testing in the community. You know, Legionella urinary antigen is sort of available in some places and not others. Culture methodology is varied amongst different institutions. You have a sense of availability of more access to the culture versus standard treatment that's given in the communities. You guys have a sense of what that looks like because I would imagine that in Australia that's got to vary quite substantially. It might affect identification of cases. Did you hear that, David? You're asking about the diagnostics for the population as culture versus and then what they're doing about treatment in the general population. Testing of patients. Testing versus sort of empiric therapy. Testing versus empiric therapy. Okay. Testing is pretty standard. Antibody testing and culture when we can. We try to encourage testing of patients when it's community acquired pneumonia. It does vary a little and I alluded to that with the 2013 that you saw that was associated with the report from Queensland of cases in a hospital. So there is some evidence that testing did increase then. But certainly in my state in South Australia we're pretty keen when it's community acquired pneumonia to test. I think in major hospitals that's more likely. Less like there could be gaps once you move away from those. But I haven't looked at the stats in that one. So David, is there an underestimation of sporadic cases of pneumonia associated with Legionella because of the lack of testing if an individual comes in with respiratory disease or pneumonia? Is there an underestimation? Yeah, I think there's likely to have been underestimation. I'm going to ask everybody to pause just for one minute and ask all the committee members if they can turn off the Wi-Fi on their computers or their computer or phones. And anyone in the room is connected to the Wi-Fi if you can please disconnect because we think that this audio cutout is only affecting us. So if we can get all of us off the Wi-Fi and give those signals to the speaker I think we'll have less problems with audio. So if you were on the visitor network if you could just connect. Get off the network. Your phone might have automatically connected if you could take that off too. We're just trying this out, David because I don't think that anybody online is having problems hearing you, just us presumably because of the room we're in. So, okay. Carry on. All right. Ruth, you had a follow-up question. Yeah, you mentioned that you thought there was a lack of education or a lack of knowledge or ownership by the building owners and ownership devices. What is being done about education of people who building owners and people who own these devices? Anything? Yeah, so we talked to we talked to infection control teams we talked to hospital engineers we try and hold regular education sessions but it is a challenge. The hospital folk love to test because that's what the clinicians like to do. So if we talk to them about Legionnaires disease and Legionella they go off and do more testing for Legionella. The aged care facilities probably more challenging. We've got more of a mixture of public and private in those spaces. So we do continually try and put out educational material give presentations workshop seminars whatever we can do. Anything with hotels or other large buildings outside the healthcare system? We're not looking at hotels in much detail. We're moving to the health and aged care facility. That's probably more where we saw the warm water systems in the first place. Hotels get picked up if they've got a cooling tower. Great, thank you. David, what happened at the aquarium? How that outbreak happened? A cooling tower and really bad management. Amy has a question. I'm really intrigued by the long DTA and I think many folks in the scientific community are. I'm curious some insight into if there's more variation in that. Especially in the testing, has that open focus to broader testing beyond pneumophila or even within pneumophila, the different serogroups? You mentioned that you focus mainly on culture. I guess I'd like to hear a little bit of if you're looking broader at different serogroups and what's the general practice and what are the requirements? I'd also like to hear more about why you shied away from QPCR because you were cutting out on that part. Okay, so I mean standard testing is okay, yes. I heard all of that. Standard testing is for pneumophila serogroup 1 and 2-14 using the standard commercial kits. If we don't get a hit on those, then we do other speciation. We don't pick up a lot. We pick up the occasional McDaddi and of course we do pick up Long Beach because care of it and it's so common. So we pick that up. Yes, we are looking we do want to do more work on looking at sequence types. So we've started some work with whole genome testing and so we're going back to look at those. We want to have a better understanding of distributions of sequence types in environmental samples versus clinical samples. So we do more work in that space. I think in terms of QPCR there's a general reticence in Australia about QPCR because of the lack that we move further away from cultural ability, viability and I think there's a general there's a general lack of confidence and there's a concern about the increased uncertainty using PCR versus culture and that's not just the Legionella. But there's no study right now to compare you know in a building or seasonally the numbers between a QPCR method and a culture method that you know of in Australia. Hello We lost you David Yeah I think so. I'm back. Okay you're back. We thought after that question you just like sorry I got disconnected. No I'm just asking if you know of any study. No side by side that I'm aware of. People tend to use one or the other. Yeah so there is maybe it's an Australian thing we like culture and as I said before it's not just Legionella we generally like culture when we can. There is people feel less comfortable with the uncertainty associated with the PCR about the only place we are seeing increase in PCR where of course it works really well is in clinical samples. Right so you're moving to the PCR methodology in clinical samples and are you moving to the primer set that gives you serogroup1 specifically or are you just using just a genus based primer set? At the moment we're just doing with the PCR that isn't really so much a Legionella thing that's more with our cryptos we're using the standard for Legionella we're using the standard methodology of the serum antibodies, the urinary antigen and then culture and using standard methods and using PCR so much for clinical Legionella. Sorry I misled you on that. Thank you Now David I wanted to summarize because you said that you would get us access and you can either give us the links you can send it to me and Laura or just me I think the links to these reports that you mentioned or you can send the reports I think you mentioned a report or some of the data from was it New South Wales Victoria Victoria sorry Yeah and then are there other reports we're looking specifically for environmental monitoring during outbreaks in comparison to routine monitoring data sets and whether there's any reports that you have that during key outbreaks they went in and monitored it found certain numbers or certain percentage of samples positive. Okay we've certainly done quite a lot of investigations associated with clusters and some of those have been reported but not along those lines not in terms of a lot more our investigations tend to be to try and identify the source and and not characterize the source once you found it to less characterization and more just identification of what the source is yeah more identification more identification of the source and then nuking the source if we can we don't find the source in most of our investigations for your cases you don't find what the source is okay. No we don't most of our cases are sporadic we do have the occasional outbreaks we do occasionally detect the source the Wesley hospital the Melbourne Aquarium generally we don't find the source so we do a suite we'll find positives particularly cooling towers but but we generally don't find the source of the outbreak okay thank you rather yeah I can sorry I can get you some papers of I mean there have been some publications on source investigations so I can I'll see what I can find and send them to you. That'd be great that'd be terrific anytime yeah yeah I'm Ken Mortensen just so you know from the Alliance I'm here for Darren just so you know who it is my question was around a lot of the water systems since you're at a kind of a baseline level on cases are there chlorine residual regulations at all throughout Australia do they vary by state and are there any considerations for additional work there in terms of systems. David did you hear that question your question about chlorine residuals yeah chlorine residuals in water does it vary by state and what are the current thinking and the future thinking in that regard okay don't have that minimum required it does vary because one thing we do do is we chloraminate in three states including my own so you were cutting out a bit so if I understand you said it varies state to state and not all states require a chlorine residual in the potable water is that correct we don't have regulations for chlorine residuals at end of tap in any state but we do have chloramination in some states three states have chloramination one thing that does happen is a number of hospitals at their own chlorine so they have boost of chlorination and that's not just for Legionella it's also for other opportunistic as well so we do have examples of that occurring but we do not have a requirement that a minimum chlorine residual point two to point five for example would be introduced to the customer tap that is a goal that some of the utilities have set themselves but it is not regulated okay thank you Chuck do you have a follow up question yeah David when the hospitals at their own chlorine are they subject to the regulatory oversight of the state drinking water program again that varies but in my state yes so if you're a hospital in south Australia and you add chlorine you become a drinking water provider and I've had a discussion with Joker Truvo on this in the past we're very cognizant of not putting too many the hospital adds chlorine say again David you cut out David could you start over you cut out a little bit okay if a hospital adds chlorine they have to register with my department as a drinking water provider but their only requirements are that they register and that they monitor the residual and if they put in too much chlorine they notify us that's it okay so minimal burden in terms of the hospitals requirement that's right we wanted to keep it as small as possible to us it made sense for chlorine eddie you should measure chlorine residual other so what's the residual at which you have them notify you five are they required to have an engineer in the hospital that is overseeing that or what about the training of the personnel yes so most of the big hospitals hire contractors and they hire what a treatment professionals to do it okay okay other other comments or questions I think we grilled David David is it night time where you are is it time to go to sleep are you sitting there with a beer it's exactly 12 hours on there you go well we appreciate it this is very useful and very helpful and I will follow up with you on these links to these other reports okay and look I'm sorry about the crackly line if anybody's got any other questions please just send them to me and I'll try and answer them alright thank you thank you so much