 Okay, I try to give you an overview on Legionella regulations and the impact in Germany. And I'd like also to mention the sentence of Churchill, you must look at the facts because they look at you. And you have put a lot of questions. I try to answer now these questions which you know. And just some remarks on Legionellosis in Germany. In 2016, we had 992 notified Legionellosis at the Robert Koch Institute in Berlin. It's our National Public Health Department. And 96% of them were hospitalized. We have a fatality rate from the notified cases of 4.7%. We had surdine outbreaks. The biggest outbreak was in 2007 surdine in Warstein with 159 cases. I was engaged also in the outbreak management. But according to the Competence Network of Community Acquired Pneumonia, it's a big research project done a lot of years. It is estimated in Germany that we have in Germany between 15 to 30,000 cases of Legionellosis occurring each year. And it's increasing. We think it has something to do with the mobility of older population now in Germany and other countries. This means that the numbers of notified cases are a significant underestimation of the true rate of Legionellosis in Germany. The CUTNETS research was a very big research project supported by Ministry of Health and Ministry of Research. Now, just this slide. When you look on the mortality from selected diseases that can be transmitted by water in the United States, it's very interesting to see that in this study, we have more das water transmitted by water-associated pathogens, which are coming from aquatic microorganisms like Pseudomonas, anti-M and Legionella, non-turbaculosis mycobacteria, that grow in water system bioforms. Now, the impact of infectious diseases on population health in Europe is researched by this article, which was published some weeks ago by the ECDC, and they were dealing on the impact of infectious diseases on population health using incidence-based disability-adjusted life years, results from the burden of communicable diseases in Europe. And the next slide shows you that they divided infections with a low population burden and a high individual burden like rabies and diphtheria. Those infectious diseases with a low population burden and low individual burden like mumps, Croptosporidia or GRDSS. And on the other side, infections with high population burden, but low individual burden like influenza, and then infectious diseases with high population burden and high individual burden. And there are HIV, tuberculosis, invasive pneumonia and legionary disease. And this means from a public health impact, we have a high population burden and high individual burden by Legionellosis. Legionellosis is seen in Europe as an important public health risk and judged resulting exclusively transmitted from the environment as a preventable disease. And therefore, there is a strong public health reason to regulate this risk to change the situation and achieve better public health protection. When we try to assess the risk, we must... We have also modified from Duncan and Edward, which the risk of an infection is determined by the concentration of pathogens, by the environments, by the antibiotic resistance, by tenacity. In Legionella, also environmental factors like inversion, climate factors, modulate also the risk. And on the other side, the infection predisposition of the host. And therefore, we must take into account, and what I personally have learned that it is, as I said also in the conference in Rome last year, it's a long way to tip a rary. We have the Philadelphia Legionellosis outbreak in 1976, and from the detection of risk to risk regulation, it took up to my experience 20 to 30 years. Now, what is in the German regulation? In Germany, we have some specifics which I have to mention. We have the proportionary principle. It is codified in the Protection Against Infection Act. We have the concentration principle that means water must be free from any microorganism which constitute a potential danger to human health. We have a minimizing principle for disinfectants like chlorine that we have not to use if it's not necessary, distant chemical disinfectants. And we have a principle of risk transparency as obligation to inform responsible authorities and consumers in case of deviation from regulation. Now, in the case of water supplied from a distribution work, we have to fulfill not only the risk regulation at the water meter, but in the European regulation and in Germany, we must fulfill this regulation also at the water tap and shower head. Now, the systematic regulation begins or began in 1987 by our Federal Public Health Department, and they said in this publication, Legionella sea are a part of the aquatic flora. Eradication of water systems seems unrealistic, but drastic reduction in technical systems is necessary to reduce infection risks. It is the ALLARA principle as low as reasonably achievable, and this is the discussion between quantitative microbial risk assessment versus ALLARA as low as reasonably achievable. Now, we made in 1987, we made a roadmap where we put the discussed, in this year, the discussed infection reservoirs, plumbing systems in buildings, hot water pools, cooling towers, and also natural cooling towers. And we have now seen there is another very important reservoir. It is wastewater plants. I will mention it in detail. Now, the regulations are based on acts. The water for human consumption is based on the Federal Protection Against Infection Act. Also, swimming, pool, and bathing water are based on the Protection Against Infection Act. Water for cooling and other aerosol producing technical systems are based on the Federal German Emission Control Act. And for wastewater treatment plants, we have also a paragraph in the Federal Protection Against Infection Act. The legal basis is for regulation for water for human consumption is on the one side, as I mentioned, the Protection Against Infection Act, then the EU drinking water directive from 1998 on the Quality for Human Consumption. Then we have an own audience on the quality of water intended for human consumption. And we have proposals of the German Federal Environmental Protection Agency. And in the Protection Against Infection Act, it is mentioned in one paragraph, water for human use must be of such quality that there is no reason to fare any damage to human health, particularly through pathogens being involved in its consumption or use. It means this is the precautionary principle, which we have based on a legal basis. And then we have also in this paragraph also regulated swimming pools and bathing pools, no reason to fare any damage to human health. And this is based on a whole holistic overview from water catchment to water taps. It means as the conference named in Atlanta in 1916 from Watershed to Shower Hand. It is based also in the Infection Protection Act. In the Council directive of the EU from 1989, it's mentioned that water intended for human consumption shall be wholesome and clean if it is free from any microorganism and parasites from any substance in numbers or concentrations constitute a potential danger to human health. It means we have an obligation that we should say what is the concentration which could be a potential danger to human health. It is regulated in the Council directive of the EU. And then it is mentioned that in case of water supplied from a distribution network, it must be fulfilled these rules within premises or an establishment at which it emerges from the taps that are normally used for human consumption. This is also mentioned in the German drinking water ordinance. I will not go in detail. And then we have also technical standards, which were done by the German Technical and Scientific Association for Gas and Watery and the Association of German Engineers. And there we have codes of practices. The WE 551, a very important technical rule, which was first published in 1993 and then in 2004, which is also translated in English. You can read it in English. It is called drinking water heating and drinking water piping systems, technical measures to reduce legionella growth, design, construction, operation and rehabilitation of drinking water installations. And then we have a technical rule 556, which is called hygienic microbial irregularities in drinking water installation, what is to be done. A further rule, how can I clean and disinfect if it is necessary, plumbing systems. And then the rules from the Association of German Engineers to hygiene and drinking water supply system as an analysis. Now, for cooling towers, we have since 2017 the German Federal Emission Control Act. And we have also guidance, technical guidance for open recooler systems, secure hygienically sound operation of evaporative cooling systems. You see here again, these two technical rules are based also on control acts, acts which give the legal basis for all of them. And then we have also an act in the Protection Against Infection Act concerning sewage. And there is, it's mentioned, those of Leech to dispose of sewage are of Leech. That sewage is disposed of in a way that does not give rise to any assets to human health due to pathogens. It was a long time before published, and people were thinking of Vibrio Cholera and Shigella and things like that. But today we see, because we have the biggest outbreak of Legionella in 2013, and there we could show that in this outbreak, by a sewage plant, which took sewage also from a brewery, the river where Vester was contaminated with very high concentrations of Legionella, which were increasing also in the sewage plant, and we could show that in a brewery, they had also a radiation ponds to diminish the concentrations of nitrogen and things like that. And this big a radiation pond has had temperatures of 38 degrees Celsius. We found there in up to 100 million Legionella, including the infectious Legionella, and this strain was responsible, and this sewage was brought to the wastewater treatment plant of the community, and from this point the river was contaminated on a distance of up to 12 kilometers with concentrations of between 20,000 Legionella per 100 milliliters, and at 12 kilometers below, they found up to 12,000 Legionella per milliliters, and industries were taking just the river water without any treatment to use it also for cooling tanks, and therefore I would be very interested to see what's happening in Flint if they have also had very high concentrations of Legionella in the river Flint, and therefore in only one German federal state, it's in North Rhine-Westphalia, we have a decree, sewage treatment systems must be monitored for Legionella by cultural methods, and in the radiation ponds of breweries, paper mills, and sugar industries, we found very high concentrations of Legionella, up to 10 to the 8 colony forming units per 100 milliliters. Here you see the details on it, I will spare you a little bit more time for it. What water systems building types there are a bit of cable to every sink cooling towers, water supplies at ETC, for water systems building times, water for human consumption, every public and private big building must be monitored when they have hot water storage volume for more than 400 liter or more of three liter hot water volume between each, and the last step at the end of pipe, they must be monitored, and the cooling towers, every open recooler system and natural the draw cooling tower must also be monitored. And therefore you have now an overview on the slide, on the first slide which I give, we have regulations for buildings and the piping system including for hospitals, hotels, all the big buildings, we have a technical rule for whirlpools, we have technical rules and now acts for cooling towers and now we have also for natural cooling towers and now one state in Germany has now also for wastewater treatment regulation. What organisms are addressed mainly Legionella, environmental monitoring of Legionella is regulated by audiences, the concentrations must be below 100 CFU Legionella species, not Legionella pnomophila per 100 milliliter, I prefer to have Legionella pnomophila and the environmental monitoring of pseudomonas aeruginosa is regulated in hospitals by the hospital ordinance and now we say lower than one CFU pseudomonas aeruginosa per 100 milliliter. Non-tuvaculosis mycobacteria are for the moment not regulated but we have now an outbreak worldwide, outbreak for heater cooler in cardiac surgery by non-tuvaculosis mycobacteria and therefore in hospitals they have to look for those. Do they recommend required environmental monitoring? Yes, if so by what methods? We have only cultural methods, it's the ISO 11731 2017 which is prescribed in Germany and I go through it, I have mentioned you see here the German drinking water ordinance, you see here Legionella species and we have a so-called technical action level, technical measure and I will just say where we have to sample in a building we have to sample for Legionella in the central parts, water coming back to the boiler and water going to the building and then in the peripheral area and we are looking not showers but we are looking for taps at sinks, then there we have to take samples. Do the regulations specify levels of Legionella above which certain actions should be taken and who has to be informed when results came back above the thresholds? We have the so-called technical action value and this is the value that when exceeded gives reason to fear an avoidable health alert related to the drinking water installation and leads to measures to check the sanitary and technical condition of the drinking water installation being taken in the form of a risk analysis and this comes from the precautionary principle, we know that a well-maintained plumbing system in a water installation system can have concentrations lower than 100 CFU of Legionella species per 100 ml and now what's the explanatory statement for the technical level? Concerning the parameter Legionella species, no science-based threshold value can be fixed below by which any human health risk can be excluded with reasonable certainty. Therefore a technical measure is implemented also in the Infection Prevention Act and in case of reaching this technical measure value a human health risk cannot be excluded with a certainty. The formulation reaching or exceeding the technical measure value serves for technical clarification and legal security for public health departments but also for owners of these systems and the technical measure value is an appearing derived value which in case of fulfilling the approved technical rules and best care and attention by the owner of the plumbing system will not be reached or not exceeded. Now we have a lot of technical rules, I just go quickly through them. You see we have the code of practice, the WH-551 which I mentioned, it's also written in English. You have their chapters on planning and construction, operation, maintenance and inspection, rehabilitation and the hygienic microbiological examination and assessment and the main rules are keep the stored volume of hot water small, keep the hot water hot, the cold water cold, keep the non-circulating parts of the pipeline short and avoid stagnation, have a maintenance and inspection and have rehabilitation. And then we have as I mentioned hygienic microbiological monitoring and assessment and we have an orientation examination and more detailed examination. You see here again the sampling points which are mentioned and then we have the assessment. What have you to do if you have Legionella in your system and it's important that it means if you have a systemic contamination. It means also in the central part, if the concentrations are below 100 then you have nothing to do and you should re-monitor after one year and then without in hospitals after three years if there are no significant alterations. In hospitals you must look even each year for the Legionella contamination and if you have very high concentrations in the systemic parts then it means it is an extremely high contamination and you have something to do immediately and you have a follow-up examination one week after disinfection. And there are also the same rules for the more detailed examination. Then we have this technical rule also translated in English. What is to do if you have higher concentration, if you have pseudomonas, if you have Legionella, if you have coliforms or other pathogens or indicators in your system, what can you do? As you can see here are the algorithms, what you can do and I don't go now into the detail. Perhaps you can look for the slides in detail and I can answer also the questions. Then I go through it because I let it there but all these technical rules are translated also in English. Now we have also a guideline for plumbing systems by our engineers. It's the guideline 6023 which is also always translated in English and there are rules for requirements for planning, construction, operation and maintenance, completion and expansion of the WV551 in technical terms, implementation of qualification and training of the operational staff. They must be trained. There are rules, rules also for formation and therefore we want that in Germany every owner has a special responsible person which is trained. Also what he has to do for the plumbing system. You see there are details on health expect from problematic areas, measurements, procedures and things like that. Then we have also technical guidelines for cooling towers. It's the cooling tower code of practice. Also this is translated in English. You see here the contents and in the same way we have actions which have to be taken when you have an exceeding of the technical value. You see here if you have concentrations between 100 up to 1,000 per 100 milliliter, not milliliter, repeated examination if concentrations confirmed before and microbala examination at monthly intervals and they have also to do a risk analysis. How is it similar to different than other regulations? The European technical guidelines from the ECDC has similar action levels and who has to comply with it? No one, certain hospitals, federal buildings, a whole country in Germany, a whole country. Not only specified buildings which have a population with a higher risk. Is the management plan required for those who have to comply? Yes. A management plan is required for drinking water installation system and for cooling towers and we have also their technical rules. If so, how are these plans prepared and kept up to date? We have an obligation based on acts and ordinances and technical rules and it must be prepared by the owner or entrepreneur or responsible person of the system in a dynamic way taken into account also new regulations. Is it difficult to get compliance? In case of exceeding, this is a must. They have to look and therefore we have no discussion because it is regulated. They must because they can be punished especially if there are infections, diseases or if there are death. We are now in a transition phase but we have a widespread regulation implementation. We have the implementation for environmental monitoring everywhere and drinking water installation systems. Now, since 2017, also in industrial cooling towers and until now, here and there in small cooling towers, we have problems but now they are obliged to notify their cooling tower and in North Rhine with failure, we have now since two years experience with sewage monitoring. Since, excuse me, how enforceable is it? It is very enforceable these rules because it's regulated. What has been the outcome if you in this guidance policy regulation have the regulations been in place long enough to have a demonstratable effect? We are in a transition phase and we see that we have a reduction of the technical action value and did the regulation lower the number of positive hits from environmental samples? Yes, if so, how much? In the 19s, we had about 70% of all large buildings were systematically contaminated with Legionella and after the establishment of the technical rules today we have only about 10% of buildings who have a systematically contaminated plumbing system and after the regulations had an impact on the number of clinical cases until today, no reduction of the notified cases. We have even an increase but we are in a transition phase and we have to take into account better diagnostics but in outbreak clusters, we can show that we have no recurring of Legionella infections when we fulfill these rules. I can show it at this example. This is a hospital where I was integrated in the outbreak management. They had half a year after the opening of this hospital for 11 Legionellosis and for death and we could show that they have a lot of mistakes in their plumbing systems and until today, they have an obligation to diagnose every pneumonia which is occurring therein and since the sanitation of this system in 1991 there are no new Legionella. It means we can show in outbreaks that by implementing these rules which are mentioned, we can show also in other buildings that these were successful. But we must have a shared responsibility. Risk regulation can only guarantee low concentration in the central parts of the plumbing system but the consumer must guarantee that they flush their showers or water taps after periods of stagnation. This cannot be regulated and therefore it is a challenge for risk communication also for the consumers. What are the open questions? We see that we have also in some areas in cold drinking water installation contaminations and we must have a good flushing procedure and should environmental monitoring be supplemented by temperature profiles? I think yes, because temperature for Legionella is very, very important and Legionella species, we have now a discussion in Germany, perhaps in Europe what should we monitor, Legionella species or better Legionella pneumophila? When you look to the clinical diagnosis, they are just looking for Legionella pneumophila and with the urinary anti-gene, they are looking just for Legionella pneumophila Sirbubwan and we are looking for the moment for all Legionella species and therefore for the moment I am convinced that we should concentrate on Legionella pneumophila because our rules implemented in the beginning of the 19th were based on Legionella pneumophila. So my presentation, I hope I could answer a little bit your questions. Thank you, thank you Martin and I realize, I apologize, I didn't introduce you the committee has your bio in our books but I would like to just take a moment and introduce Martin to the rest of the online participants and others in the room because you do have so much experience. So Martin is a professor of hygiene and public health and manages the Institute for Hygiene and Public Health at the University of Bonn and he's been involved with drinking water commission in Germany, he chairs the commission there and he's also been involved with the German Society of Hospital Hygiene. I think you're the current president there and a past president of the Society of Hygiene and Environment and Preventive Medicine. So he has a lot of experience with environmental issues and especially hospital and hospital acquired diseases that's connected to the drinking water and he's now in a working group looking at plumbing systems with the German Technical and Scientific Association so we're really pleased to have so many of your calibers here helping us understand what's going on in Europe. So Martin I'm going to open it up for some questions from the committee and we'll just carry on with the discussion for 10 to 15 more minutes. Okay, Jack Koss. Yeah, one of your slides you had a survey of 70% of buildings being positive for Legionella. Was that a representative or a systematic survey? It was a survey which we made with some institutes and these are also the data which we hold it in our institute and it's published in some German publications. It's not internationally published in English but it was important to convince that by such rules we can lower the concentrations. I think that would be interesting to copy of even if it's in German. Yeah, Martin you cannot send anything a link or you can send the paper directly to Laura or to me or to both of us or to Remy and we're happy to take it from there for the rest of the committee. So we would appreciate that. That's the survey that you did in the 1990s. Yeah, very good. We have now a lot of data because in Germany it's regulated and there is a must to monitor these buildings and therefore we have a lot of experience from a lot of other institutes and laboratories. And those monitoring data there compiled or it's compiled by special studies. Where does the monitoring data go when it's in compliance? In other words when there's not a problem where does the monitoring data go? Does it just go on a report with the institution or is it compiled at the national level? It is for the former data from institutes but we have now a national study which called L'étriva which is done by the Federal Ministry of Health and supported by the Federal Ministry of Health to gather with our national Robert Koch Institute and the Federal Institute of Environmental Protection Agency where these data are compiled. That's what he was talking about where the 70s and the first 10. So there's a publication we could go to Martin that shows the... I will try to send it to you, yeah. He said to say the 10% so that must be the national survey. Amy Pruse. So it's a very impressive, comprehensive monitoring and mitigation plan. So I'm curious about the risk communication side of that both in terms of the folks that have to implement these plans but also the general public. Especially it's interesting that you communicate with households about things like water stagnation. So I'd like to know about risk communication and I'd also like to know a little bit more about what you were recommending in households and how that's been implemented and if there's any benefit. Every public health department which have the regional communication task for their people in every community have an information site on their homepage where you can click on Legionella. And in this information site you can also find these informations and our Environmental Protection Agency has also given out informations. But I think that now by the obligation to monitor then there is a better sensibilization also for consumers to have there these informations. Long time they were not interested but now they see there is something and if a responsible person of a plumbing system of a private big building when they have an exceeding of the technical value he must inform people who are living in these houses and then they have questions and they ask also public health departments what can I do. And therefore there is also the communication which is activated. It's the same when a woman is pregnant. A long time she's not interested in informations on little child but then if she comes in such a situation she has more sensibilization. It's the same effect which we see also for these communications. Is there any special communication to susceptible or immunocompromised groups? And also is there any pushback from an enforcement standpoint? It's one thing to say you have to do this. Is there vocal pushback or is it more quiet dissonance or just a high level of compliance? Yeah, we made from the Robert Koch Institute we have there an hospital hygiene committee I'm a member also of this and we have an own guideline for immunosuppressed people and there are the risk factors and the risk management what they can do and we have also there in also an information what they can do in their households hand disinfection and things like that and there is also a chapter on water and water associated risks that they can use for example in these situations when they have a long time immunosuppressive of more than 10 days that and are lower granulocytes of 1,000 millilitre than they should do more for example like filtration of their tap water and shower hands and this is also written in this guideline and we have also published these information in a very simple way that people can understand especially those who are at very high risk for also for Legionella infections Nick? Hi Martin interested in following up on your German statistics of the prevalence of Legionella so my question really relates to what are the sequence of events that lead to the identification of Legionella in your statistics in other words do you first look at urinary antibody and then follow up with a culture and then follow up with an identification of that culture or is there a direct say molecular approach to look at clinical samples to make that identification we have in Germany an obligation to notify Legionelosis most as in every country most of the diagnosis are done by urinary antigen in urine it's a little bit of pity because we see that by PCR of sputum and Ronchella avage you have a better outcome of the diagnosis and therefore this must be notified to the public health local public health department this has to notify to the federal states and the federal states have to notify the Robert Koch Institute where these statistics are collected and they have to notify also to the ECDC the European Center for Disease Prevention and Control in Stockholm when we have an increase of Pneumonia and Legionelosis then we try to go to the homes and to the occupational areas of the persons who are infected and to look if we can find in the plumbing systems or in other areas the same Legionella which we are looking by cultural methods because cultural methods have the advantage that we can compare the clinical and the environmental sample we try also to use in outbreaks PCR to have a quicker information if there are reservoirs in one or two of the cooling towers as it's mentioned also by a lot of outbreak cases but for the moment the golden rule for environmental monitoring is the culture you can use also PCR but we have no consent and technical value our action values and it is for the moment an add to the cultural methods in environmental monitoring Answer this question, Nick Yes, I have one follow-up for clarity for at least my side I'm interested in when you've gone directly by PCR of clinical say Lavaage or sputum sample and compare that to culture what the relative difference was both in prevalence and in diversity of Legionella I have to look for it I can't answer this question directly for the moment I have to look to clarify it but you may have that data available perhaps? Yes, I have to look Thank you Thank you, Martin Steve? My comment is more it would be great to get those guidelines for what patients Oh, the patient guidelines so we can get a copy of the patient guidelines Yeah, Martin, if you send us a link or the PDF directly then we'll get it to Kaveny The patient guidelines Is that only in Germany? In German? The patient guidelines? It's a pity it's only published in German Also, rules for Pneumonia diagnostic which is very important, long time they were not looking they were not a bleach to look also for Legionella when they have severe Pneumonia now it's recommended that in severe Pneumonia you must or you should look also for Legionella because in the Wastain outbreak it was the biggest outbreak with 159 cases long time in the beginning of the outbreak they didn't look for any they didn't do any Legionella diagnostics and it was overseen and therefore it's so important if you have an increase in Pneumonia in your hospital you should take into account that there could be also a Legionella outbreak and if you have a severe Pneumonia you should also look in your intensive care unit or in your hospital you should look also for Legionella and it's paid by state this diagnostic Okay, so there's some heterogeneity and how the states would do things Okay, we have a question from Michelle Pueblo she's online Michelle, go ahead Yes, that was an excellent overview of the regulations and what works in us now is more difficult and I really appreciated that you put answers to the questions that the committee was very useful Now, I'm going to go back to the Letriwa study because I think the committee would benefit from information from that study especially I know the group working on this study is just about to present in Lyon I believe would there be any preliminary results from that study Dr. Exner that could be shared with the committee because it really would shed a lot of light on many of our questions regarding the efficacy of regulation and the cost return of regulations as well Yeah, the Letriwa project is under the... it's led by the Robert Koch Institute and they had published also some preliminary results excuse me, it's a little bit difficult I must ask them that they could send to me the publications and then I will send it to you It's okay if it's in German we have a few German students Wonderful Yeah, we could work on that It makes sense and I'm sure with the academies capacity we can figure it out but one of the questions that I think Nick asked or somebody else is the positivity was 70% before the regulation and it's gone down to 10% now this Letriwa study will cover the impact of regulation on positivity extensively, will it? Yeah, it will Yeah, the combination between the clinical case and what they find in the environment and they try to bring it together I don't know if it will be successful because it's a very difficult thing but on the other side if you look for outbreaks with these recommendations you can be very successful successfully control on a sustainable way outbreak that we can mention now for example in Wastain since 2013 we have no no Legionella infection with this same sequence time One last question with Germany is quite unique and having the study that led to the estimation of community acquired pneumonia the numbers are much higher than the reported case you made that point in one of your first slides What do you think are the approaches or regulations that would be most efficient in diminishing these numbers and do you think that some of the regulations you have now in Germany are already contributing to lowering those numbers? I think we can say we have done a good we have done the best what we can to regulate this especially we have a notification also now for a cooling task if you have outbreaks with cooling tasks like in Wastain and I was engaged in the management with my co-workers and we have to look every cooling task no one knows who is a cooling task and to look then it is very you use much of time and it's a waste of time and now we can push on the knob to look and we have also information of it and therefore I think perhaps in some years we can see that we have no big increase because on the other side our population is going older and older and there is also the risks will increase for the population and it is also the same for sporadic for example by plumbing systems Thank you Ruth Brooklyn Hi, thank you very much and that was perfect I want to clarify do you believe that some of the increase in regenerative cases in recent years is due to improved awareness and increased clinical testing of pneumonia cases I'll repeat it because I'm close to the microphone the recent increase in clinical cases is that due to more testing and better testing of pneumonia cases more testing Do you believe that that's the reason for the increase There are some factors which influence this a better diagnostic a better awareness of Legionella infections from the clinical colleagues and then on the other side we have as I mentioned an increase in a vulnerable population more older population will have more risk factors or have more risks to have Legionella infections I can't say that there is one risk but all these factors have influence One other question is what about education of engineers formal education in training in terms of the engineers and the building owner Is anything going on there I can give you an example I had a problem with my eating and then a young a technique man was coming, he was perhaps 25 years and he told me something for Legionella in a very detailed way and I was very proud to listen to him that it is now implemented in the awareness of also young technical installation specialists and this is part of the success of good formation in this area Just as a clarification on that is there a do the German government provide generalized education you said that everyone has to be trained but is there a specific training program or is this sort of passed down information or is there a defined program that Germany has put together We have it not regulated in acts and also not in ordinance but in technical rules in the technical rule for engineers it is proposed that they must be trained in it they must for reasons on qualification they must send responsible persons to be trained in it because if you have no trained people for installations then it could be that they are pursued Martin I have a question from an individual who is online they want to know if you had to ramp up your regulatory field staff to ensure compliance with the regs how does that affect not you yourself but the state or national program and how do staff do the field inspections do they visit or is it self-reporting colleagues from the public health departments are also trained they must be trained because in case of notification they must have a field inspection and also if there are now higher concentrations than the technical action value then they must be informed and therefore there is also motivation for the public health departments to look for it as I was in Baltimore to the conference which was organized by Jerker Truvo there were colleagues from public health departments and they asked what can we do and I can just say in Germany we have a regulation which is transposed by the public health department people so the last thing one of your slides you said regulations have impacted the prevalence that is how often you find it but you said until now there is no reduction notified cases so but there has been a reduction in outbreaks and especially recurring outbreaks if I understand did I get that correctly in terms of your presentation Joa a decrease in prevalence of occurrence but not a decrease in notified cases but a decrease in recurring outbreaks in the same facility that's right if we have it's my own experience because I was integrated in some of the outbreaks which I could personally look for over a long time and I could say that in these outbreaks with these regulations and the fulfillment of the technical rules you have a high security that will have a sustainable effect I read an article now which is in preparation and they looked for the reoccurrence of Legionellosis in travel associated infections in hotels and in up to 55% in Europe countries you have a reoccurrence of new infections and our aim is that if we have an infection and we can say this is associated with a building or with a cooling tower we must bring it in such a way under control that no further infection associated with it this is for me a very important ascertainment that rules are effective very very good the new hour real quick on the wastewater treatment plant case what would you say was the primary remediating action Martin on the wastewater case that you presented, what was the primary remediation approach? we covered the aeration point we said that we should not have an open ventilation and we know now that some industries with some risk factors like breweries paper mills where you have a high content of yeast and they have high temperatures and they must aerate the sewage then you have factors which can increase your system and it was covering the aeration point the ventilation system must be in the wastewater not above the wastewater to bring a zone there and then we had good experience with UV treatment of clean sewage water before it was lead into the rivers I think that we really appreciate this comprehensive presentation and appreciate you joining us thank you Martin