LastNovember’s COP26 meeting in Glasgow put climate change into the spotlight asnever before, generating weeks of press coverage on an unprecedented scale inthe UK. This interest was not just down to our status as hosts: hopes andexpectations were running high for countries to make their strongestcommitments yet to fulfil the goals laid out at COP21 in Paris five years ago.This ‘Paris Agreement’ set targets for limiting the increase in globaltemperatures to well below 2°C above pre-industrial levels, ideally pursuingefforts towards an increase of no greater than 1.5°C.
But was thisachieved? By the end of the summit, the ‘Glasgow Climate Pact' that emerged“was welcomed by many for its commitment to doubling adaptation finance andrequesting countries to present more ambitious climate pledges next year.”However, although much was accomplished, it seems unlikely that there wasenough widespread agreement reached between countries to make the 1.5°C targetachievable.
Was watermuch discussed? WaterAid CEO Tim Wainwright thinks not, saying there was “notnearly enough” attention given despite the need for urgent action. “The waythat climate change affects human beings is almost entirely through water,either too much or too little,” he said. “So why aren’t we talking about waterall the time?” The health impacts of climate change do not seem to have beendiscussed enough. So, following the outcomes of this latest COP, what might theimplications look like for water safety in healthcare?
Warming water and infectious diseases
Dr GordonNichols, a Consultant Epidemiologist who has worked in public health settingsfor over 50 years, including for, the World Health Organisation (WHO), hasdescribed how climate change is likely to pose challenges to healthcare waterin the UK in two ways: rising temperatures may lead to higher watertemperatures, potentially leading to greater risks from infectious diseases(infectious disease control in hospitals); while unpredictable weather patternsthat could make water supplies erratic will harden the focus already in placeon more sustainable water use. In Europe, readings taken between 2000 and 2006estimated that 15% of the EU land area was already affected by drought.
Speaking ata webinar for the Royal Society for Public Health (RSPH) last summer, DrNichols described how despite 25 previous COP international meetings, readingsof atmospheric CO2 at the Mauna Loa Observatory on Hawaii have still steadilyincreased, from below 320 ppm in 1960 to over 400 in 2020. This has thepotential for change all around the world. Once ‘tipping points’ have beenreached “we will not be able to move backwards,” he said: Greenland ice sheetscould melt and/or there could be a huge release of methane from permafrosts orother sources.
In the UK, we will eventually see relatively high sea level rises, more extreme weather in the winter and more intense storms. Summer rainfall will decrease, but where it does fall may be heavier, while chances of summer heat waves could increase by 50% by 2050.
Looking at how weather can affect water-related disease outbreaks, Dr Nichols described how studies that comparedoutbreaks against rainfall between 1910 and 1999 indicated that 28% of drinkingwater-related outbreaks were preceded by lower than average rainfall in thethree weeks prior to the outbreak. Conversely, 15% of outbreaks were precededby heavy rainfall in the week before the outbreak. According to Dr Nichols,these results identified the importance of weather, which, he stressed, meansthat in future water companies will need to factor weather into their riskassessments.
The potential for warmer water in water systems could lead to a rise in incidence of healthcare-significant waterborne pathogens such as: legionellain water systems, pseudomonas in water systems / Pseudomonas spp and Mycobacteria.
Water supply changes
Talkingabout the significance of erratic rainfall, Darren Reynolds, Professor ofHealth and Environment at the University of the West of England (UWE) in Bristolnotes: “Historically [we know] civilisations thrive when they have access togood quality reliable sources of water....[but currently we] sometimes have toomuch, sometimes not enough. Where it falls really impacts our resilience.Moving forward...we may well get periods of very dry weather, followed byperiods of very wet weather, which is equally bad [because] we have‘catchments’ or reservoirs — no matter how much it rains you only ever have thesame ‘container’ to store the rainfall. The really big issue [is] howwe...manage our water supply.”
While it’shard to imagine that water supplies could be a problem in the UK, WRAS’s (WaterRegulations Approval Scheme) Managing Director Julie Spinks notes that only0.3% is available for human use. At the Water Management Society’s ‘Water; aprecious resource’ webinar in September 2021 she warned participants of theEnvironment Agency's prediction of a serious decline in availability of water —but also a significant increase in demand. Legionella and pseudomonas in watersupply can also be a danger.
Antimicrobial resistance (AMR)
Erraticrainfall leading to cycles of flooding and drought will also put another hugepressure on our water sources. Prof Reynolds highlights the crucial role ofwater bodies in the carbon cycle — the bacterial communities they containprocess and respire carbon. Pollution — including antibiotics that are excretedinto sewage and then find their way into ground water — that leaches into ourrivers is causing an actual change in their ecological function. And in the UK,“there isn’t one river in England and Wales that meets either good chemical orecological status.”
ProfReynolds highlights the resulting connection between polluted rivers and therise of antimicrobial resistance (AMR). Polluted rivers are a poorly recogniseddriver of AMR, he says, eventually leading to antimicrobial resistant organismsfinding their way into buildings’ water systems, in turn leading to biofilmgrowth.
Heemphasises: “We don't really have as much water available to us as we think —[and those] water sources are coming under increasing pressure in terms ofquality and that in turn is absolutely going to affect healthcare settings.”
“We need tounderstand that those healthcare settings are connected to the outside world...[and] what happens in the outside world matters a lot. If we're going to keepon top of antimicrobial resistance and if we're going to keep on top ofpreventing healthcare-acquired infections, [we] need to make sure that thewater we are supplying to those places is fit for purpose...”
Solutions for healthcare
Whilefacilities managers are already focused on keeping cold water temperaturesbelow 20°C to fend off bacterial growth, this may become more challenging; atthe same time pressures to reduce water usage are likely to require newengineering solutions. Everyone interviewed for this article agreed thatinnovation will be key, but Prof Reynolds also emphasised: “you do need thefinancial pull...industry can be a very powerful force for change if you getthe conditions right. You will also need encouragement from the government aswell to nudge those kinds of things in the right direction.”
Fixtures and fittings
According toone marketing executive of a leading sanitaryware company, solutions arealready in development (although currently too commercially sensitive todetail). “COP26 has given us an interesting — and critical — puzzle that wehave to take very seriously. I believe we have to find new ways of thinking andworking — and they’re not all obvious yet... [specifically] the materials weuse are going to have to change.”
Finding newmaterials for components will be a key challenge. Brass is widely used inhealthcare fittings because of its excellent anti-microbial properties,however, global supplies of copper and zinc, from which brass is composed, areshrinking. Increasing demand is leading to current reserves being exhausted,leading to escalating prices for both metals. Part of the demand for copper inparticular is being driven by its crucial role in sustainable technologies suchas wind turbines and solar panels — yet conversely new copper mines may havemajor negative environmental effects.
While brassis 100% recyclable and recycled brass from ‘retired’ taps is often used in newfittings, new designs are likely to reduce copper usage as other moresustainable anti-microbial materials are developed.
Fixturesmanufacturers will also need to develop designs that take into account changesin water temperatures and potentially reduced water supplies.
Somemanufacturers are reducing the scale of the problem by minimising the distanceof the water supply from the end of a tap’s spout, the water’s journey throughthe cartridge and spout. A smaller internal bore size allows water to flushthrough faster resulting in more ‘local’ pressure, which effectively keepsthose surfaces cleaner.
Warming temperatures
Warmingwater temperatures are already a major challenge in countries such as Australiawhere ambient ‘cold water’ temperatures of up to 27°C have been found in somebuildings. In future, hospitals may have to address rising temperatures byinstalling chillers — however, these in turn could have the disadvantage ofincreasing carbon consumption and facilities’ carbon footprints.
As warmerwater temperatures may adversely affect the operation of currently availablethermostatic mixing valves, fixtures manufacturers may also have to considerwarmer incoming water temperatures in new designs for thermostatic controls intaps.
Water usage
Theparticular need in healthcare for standard maintenance flushing to preventwater stagnation and consequent development of biofilm, with its potential toharbour pathogenic microorganisms, will mean that facilities will be hardpushed to reduce their water usage. If water usage in hospitals does have to becut there could be scope for reducing flushing in several ways:
- Utilisingblasts of high temperature water, an excellent method of removing biofilm — butwill require fixtures and fittings that are resilient against high watertemperatures
- Electronicprogrammes built into fixtures and fittings to run automatic periodic flushing:already available, although conversely seen as water wastage and not consideredbest practice by organisations such as WRAS, for example. These programmes mustnot be run as a default — the installer must make a conscious decision toswitch on the programme to allow periodic flushing. Yet these products must beflushed often enough to prevent biofilm build-up
- Toilets andurinals that reduce the volume of water needed for flushing. Some designsalready exist, for example ‘hybrid’ urinals that incorporate a sensor to detectthe concentration of salts in urine to determine the amount of water needed forflushing. However, while this technology meets sustainability requirements (andreduction of water bills in commercial premises), urinals are not likely to beinstalled in patient areas due to risks from aerosols
- Betterdesign of plumbing systems in new builds to eliminate scope for pockets ofstagnant water
- Alternativemethods of chemically treating pipe work, either incorporated into the pipematerial itself or added to the water. Fixtures and fittings will again need tobe resilient against chemical treatments. UV treatments are also available.
Biocides
As thepressure to reduce water usage increases, biocides are likely to play a greaterrole in keeping water safe. Prof Reynolds explains how the current tendency todisinfect water systems with chlorine-based products has a (desired) residualeffect after moving through lengthy pipe runs, but this can lead to the rise ofmore chlorine-resistant bacteria. Bacteria in hospital environments could beprevented by increased chemical use, which could require extra infrastructureto keep effluent within safe environmental levels exiting hospital premises.
A solutioncould be a move to ‘on-demand’ production of ‘green biocides’, in particularsignificantly less toxic alternatives such as hypochlorous acid (HOCl). In arecent study by Reynolds and his colleagues, HOCl was demonstrated to be aparticularly effective antimicrobial and anti-biofilm disinfectant in point ofuse (POU) drinking water applications.
Anotherlong-term strategy that could help prevent or reduce bacterial resistance wouldbe disinfection schedules that cycle different biocides.
Decentralised systems
The WHO’sSustainable Development Goals have greatly improved the provision of safedrinking water worldwide, yet centralised provision of safe water via largetreatment plants continue to represent a challenge for many lower incomecountries — as well as representing a potential vulnerability in all watersupplies. Prof Reynolds notes there is now a school of thought leaning towardsmore decentralised systems — or the ability to operate decentralised systems intandem with centralised systems. These could utilise technologies that producesafe or greener biocides on demand, thereby saving on use of other types ofantimicrobial or disinfectants that are often transported in plastic bottles.Decentralised (on premises) water waste treatment also opens up the possibilityof utilising ‘friendly’ bacteria to neutralise pathogens.
“If you lookat the cost to the environment of keeping hospitals clean, it's not great. [Weneed] an ability to think a little bit more localised and a little moredecentralised, [with less reliance] on complex supply chains, which we know are[currently] under a lot of pressure ...[and] maybe aren't as fit for purpose aswe were thinking.
“If youthink about what we do with water, we pump it around, we collect it, we treatit, we make it dirty, we throw it away and then we collect it again. Rainwaterharvesting in this country is not really as big as it could be. Grey water useis not as extensive as it could be. We've got to start thinking about water forwhat it is, which is quite a precious resource.
“I thinkthat's relevant for healthcare settings because at the end of the day ... weneed good quality water and we're trying to prevent healthcare-acquiredinfections that may emanate or originate from water supply systems."
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