by Roger P. Francoeur
We have been hearing about Legionnaires’ disease in our area lately; there was an outbreak stemming from a hot tub at a beach resort in New Hampshire. While scanning through the news on the web about outbreaks, I saw other recent occurrences of this illness: at a VA hospital in the Boston area, at a business in Upper Manhattan, at a nursing home in Rhode Island, at an apartment complex and at a homeless shelter in Baltimore, at a church in Illinois (from the baptismal font), and the list goes on.
The most disturbing thing is that some of the affected people have died from this disease. Then, among these articles, of course there are the inevitable lawyers advertising that they can get a lot of money for you if you or a loved one contracted Legionnaires’ disease from some form of negligence. I think how glad I am that it’s not me dealing with this at one of our offices, and how many others are probably thinking the same thing, especially those who are responsible for reducing the risk of it occurring. I ask myself, “Am I prepared to defend myself if there is a Legionnaire’s disease outbreak in any of our buildings?” Building owners and managers everywhere would do well to ask this too.
This article will provide an overview about legionellosis and help you understand the basics of how to prevent it in your building.
Legionellosis
Legionellosis includes two types of illnesses: Legionnaires’ disease, which results in lung infection (pneumonia), and Pontiac fever, which results in flu-like symptoms. Both are caused by different bacteria species in the Legionella family. About 98% of legionellosis results in Legionnaires’ disease; it can be deadly, and the severity of symptoms is worse than Pontiac fever, which is why there is more focus on Legionnaires’ disease. It was first identified in 1976 during a convention of the American Legion in Philadelphia. Pontiac fever, first reported in Pontiac, Michigan, is a big deal, too, for those who contract it and for the medical centers that are burdened by an outbreak.
Figure 1 Legionnaires’ disease is contracted by breathing in small droplets of water containing Legionella. Image from CDC.
Symptoms associated with Legionnaires’ disease include coughing, shortness of breath, muscular aches, fever, and headache. Most patients recover fully with treatment using antibiotics, although hospitalization is most times required. About one in 10 patients die.
People that are most susceptible to Legionnaires’ disease are aged more than 50 years, current or former smokers, those with lung diseases like emphysema or COPD, and those who have a weakened immune system from disease or medicines. Unfortunately, there are currently no vaccines for Legionnaires’ disease.
The bacteria occur naturally in fresh water, and only become a problem when they are amplified in man-made water systems that are not properly maintained. Legionella grows best in warm water that is not moving or that does not have enough disinfectant, and it is associated with biofilms (groups of bacteria and other microorganisms). Most outbreaks occur in buildings that have large water systems such as hot tubs, cold/hot water tanks and heaters, large plumbing systems, cooling towers (structures that contain water and a fan as part of air-cooling systems), and decorative water systems (e.g. fountains).
Legionnaires’ disease is contracted when a patient gets Legionella in their lungs by breathing in tiny droplets of contaminated water; it does not spread from person-to-person. Exposure to the droplets can occur from splashing around faucets, showers, or fountains; jets in hot tubs; or anywhere aerosolization occurs in an infected water system.
In 2016, the Center for Diseases Control (CDC) reported 6,100 cases in the United States and cautioned that it is likely underdiagnosed. The reported number of Legionnaires’ disease cases grew four-and-a-half times between 2000 and 2016 — it’s not clear if this is due to increased awareness and testing, increased Legionella in the environment, aging pipes in water systems, a larger population of susceptible people, or a combination of these factors. What is clear is that reported Legionnaires’ disease is on the rise.
CDC investigations showed that nine out of 10 Legionnaires’ disease outbreaks were caused by problems that were preventable with more effective water management systems. Often, there was human error (e.g. someone didn’t replace a filter as recommended by the manufacturer), there were equipment failures (e.g. a disinfection system didn’t work), or factors external to the building changed the water quality (e.g. nearby construction).
ASHRAE Standard 188
Figure 2 Legionnaires’ Disease is on the rise (image from the CDC)
In response to the rise in Legionnaires’ disease cases and the knowledge that better water management systems could help prevent outbreaks, The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) formed a team in 2005 to devise a standard for managing risk associated with building water systems. After five drafts were released for public review, the final standard was issued in June 2015, and was called Standard 188, “Legionellosis: Risk Management for Building Water Systems.”
Standard 188 is voluntary unless it is adopted by a government entity. For example, in 2015, New York City legislated building owners to follow part of Standard 188 after there was a Legionella outbreak that resulted in the death of 12 people. The standard addresses risk management of Legionella in building water systems throughout construction, operation, and maintenance phases of new building construction, renovations, modifications, or additions. Designers and building owners and their managers are the audience, and specific buildings types are targeted. These include nonresidential, human-occupied buildings only if there are multiple housing units with one or more centralized water systems, more than 10 stories, facilities with immunologically compromised patients that stay more than 24 hours, or facilities that house people more than 65 years of age.
All potable water systems, hot or cold, are included because of their delivery mechanisms — ice machines are included. It also applies to nonpotable water systems that have cooling towers or evaporative condensers, humidifiers, air washers, atomizers, misters, or any devices that result in water aerosols.
Healthcare facilities
Healthcare facilities, including long-term care, and their patients have conditions that cause elevated risk. In 2017, the CDC noted that people got Legionnaires’ disease from a healthcare facility in 76% of the locations that reported exposures, and that 25% of those died as a result. It is interesting to note that devices such as hydrotherapy equipment, respiratory machines, bronchoscopes, and CPAP machines offer ways in which Legionella can be spread.
The CDC encourages healthcare facility leaders to use CDC’s toolkit as a guide for developing their water management plan (which is based on ASHRAE’s Standard 188), to work with healthcare providers to identify Legionnaires’ disease cases early, report Legionnaires’ disease cases to local public health authorities quickly, and to investigate and prevent additional infections. The bonus here is that this will help control other water-related, healthcare associated infections.
There is a normative annex in the ASHRAE’s Standard 188 for healthcare facilities that meet certain qualifications. It calls for a water management program team member to be certified in infection prevention or to be an epidemiologist with a minimum of a master’s degree. It has other specifications such as criteria for the water system flow diagram, minimum requirements for the risk management plan, and types of building water systems to be included.
The risk of Legionnaires’ disease outbreaks at healthcare facilities is so high that The Centers for Medicare & Medicaid Services issued a memo in June of 2017 requiring certified healthcare facilities to have a water management program to reduce the growth and spread of Legionella. They referenced ASHRAE’s Standard 188 as a guide.
Some tips for preventing Legionnaires’ disease in your building
If you read through all the sections before this one, you will be able to guess that your best bet for helping to prevent Legionnaires’ disease in your building is to learn about and follow ASHRAE’s Standard 188. It is detailed, and it will take more than one read through to absorb it. You can access it online for free and buy a copy on www.ashrae.org/standards, if you go to the preview section. Also, the CDC created a helpful toolkit based on ASHRAE’s Standard 188, called “Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings,” with pointers on how to implement the program.
In general, the high-level steps of Standard 188 are as follows:
- Establish a water management program team to develop and implement a water management program according to the standard.
- Describe the potable and nonpotable water systems and provide schematics.
- Analyze the water systems to identify where Legionella may grow and spread.
- Decide what control measures are needed to stay within defined control limits, where in the system they need to be, and how to monitor them. Note that there is no safe level of Legionella
- Establish what interventions are necessary when control limits are not met.
- Make sure the program is effective and running as designed.
- Establish documentation and communication procedures.
Monitoring your water system is an important step:
- Monitor what is happening outside of your building; construction, water main breaks, and changes in municipal water quality can affect what is happening in your water system, including disinfectant levels.
- Keep cold water cold and hot water hot. Water temperature fluctuations can lead to Legionella growth, and it grows best between 95°F and 115° Follow antiscald regulations and consider engineering controls to mix hot and cold water near the delivery mechanism.
- Keep an eye on changes in water pressure. The flow of water is important; stagnation can be a contribution factor in biofilm growth where Legionella can prosper. It can also reduce water temperature and overall levels of disinfectant.
- Monitor disinfectant levels. Levels can become low through heating, storing, and filtering water. As well, outside factors such as a water main break can allow for unexpected depletion of disinfectants. Your building may need long-term supplemental disinfectants added.
- The American Industrial Hygiene Association (AIHA) issued a guideline in 2015, called “Recognition, Evaluation, and Control of Legionella in Building Water Systems.” It recommends proactively and routinely monitoring your water system by sampling for Legionella. Not only will it go towards reducing the risk of the bacteria’s growth and transmission, it will help you find out if your water management program is working as intended. There are specific methods for selecting locations and sampling methods, instructions for handling the materials, personal safety precautions to take, and considerations for interpretation of results. Let an expert handle this for you.
There is a lot to it, when taking steps to prevent Legionnaires’ disease in a building; we recommend relying on environmental health and safety professionals to help you. Hopefully, the next time you see an outbreak of Legionnaires’ disease in the news, you will be feeling confident that you have taken responsibility for preventing it in your own building.
Roger Francoeur, is president of RPF Environmental, Inc.
