Let’s be honest. Most people who work in facilities management, infection control, property management, safety, industrial hygiene, or engineering want to protect the people in their buildings from Legionella and other waterborne pathogens—not just in hospitals, but also in schools, hotels, nursing homes, apartment and condo properties, commercial buildings, and industrial facilities.
But, they have a plethora of other risks to manage, rules to follow, and maintenance tasks to perform — and their money, staff, and time are already like a rubber band stretched so far it’s fraying, about to snap.
Health officials are facing pressure, too. If building operators do not heed warnings and voluntarily follow and become compliant with the ASHRAE Standard 188, state agencies will be compelled to adopt and enforce regulations to protect public health. If they don’t, they could be accused of neglecting the public they are called to protect.
How did we get to this point?
Laws for Legionella prevention were established in the United Kingdom and Australia in 1991, relatively soon after the 1976 outbreak in Philadelphia that led to the discovery of Legionnaires’ disease. In the United States, however, pressure caused by insufficient action to reduce the risk of a preventable disease has been building for 40 years.
Inaction was not because of insufficient information. Legionella was studied more than any other waterborne pathogen after the 1976 outbreak and into the 1980s. Numerous scientific papers were published. In the late 1990s and into the new millennium, government and industry groups released Legionella position statements and guidance documents urging building operators to maintain and operate their water systems to minimize Legionella. Although the documents varied about specific preventive measures, they agreed that the best strategy for reducing the risk of Legionnaires’ disease is to manage to build water systems to minimize Legionella bacteria.
What changed with the June 2015 release of ASHRAE 188 was that it represented agreement among key parties—not only about the need for Legionella prevention in building water systems—but also about the approach to it (see “Unprecedented Agreement in the United States About the Approach to Legionella Prevention”). The essential components ASHRAE 188 requires in order to have companies meet compliance for a water management program are almost identical to those the World Health Organization recommended in 2007 and the United States Veterans Health Administration (VHA) has required since 2014.
ASHRAE 188 has received more attention and support than any government or industry Legionella document released in the United States to date:
- In July 2015, just a few days after the release of ASHRAE Standard 188, New York City and State responded to a major NYC outbreak of Legionnaires’ disease by adopting emergency ASHRAE 188-related regulations for minimizing Legionella risk associated with cooling towers. The regulations were updated and made permanent in 2016.
- In June 2016, the Centers for Disease Control and Prevention (CDC) report in Morbidity and Mortality Weekly Report (MMWR) about a rise in Legionnaires’ disease cases and the need for better building water management caught the attention of the mainstream media, which immediately published stories highlighting the responsibility of building owners and managers:
Washington Post: “Legionnaires’ outbreaks: Cases nearly quadrupled in 15 years.”
Wall Street Journal: “Almost all Legionnaires’ disease outbreaks are preventable with improvements in water systems management.”
USA Today: “Most outbreaks can be prevented through better water management, according to the CDC report.”
- The same month—June 2016—the CDC clarified its expectations in the Vital Signs article “Legionnaires’ Disease: Use water management programs in buildings to help prevent outbreaks,” telling building owners and managers to “develop and use a Legionella water management program” and state and local officials to “consider changing building and public health codes to include Legionella water management programs.”
- The CDC went even further by issuing “Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards” to help facility operators “develop and implement a water management program to reduce your building’s risk for growing and spreading Legionella.” Referencing ASHRAE Standard 188, the CDC wrote, “Legionella water management programs are now an industry standard for large buildings in the United States.”
- The Building Owners and Managers Association International (BOMA) posted an announcement on boma.org that the CDC “asks building owners and managers to adopt newly published standards that promote Legionella water management.”
Since the responsibility to manage water systems for Legionella control has never been more clearly defined and communicated, legal and brand damage risk is likely at an all-time high for US building operators that do not comply with ASHRAE 188 (see “Four Reasons CDC’s New Toolkit Could Impact Legionnaires’ Litigation“). Last July, law.com issued a report concluding, “Compliance with the new ASHRAE standard likely will be viewed by courts as the standard of care in personal injury lawsuits involving exposure to Legionella. …Adopting industry-standard practices and complying with applicable law is the best defense. Conversely, failure to follow such standards and legal requirements could expose building owners and operators to potentially significant liability.”
The pressure is therefore on building owners and managers to comply with ASHRAE 188 and on health officials to make sure they do.
What can be done to relieve pressure without neglecting the goal to drastically reduce Legionnaires’ disease? Let’s look at the roles of service providers, building operators, and health departments.
How can service providers help?
Most facility operators have neither the time nor expertise to establish and implement a good water management plan (WMP) on their own. Most need help from a combination of water treatment companies, engineering firms, industrial hygiene firms, and Legionella testing laboratories.
To meet the demand with high quality and reasonable prices, service providers need to become better educated and more proficient. Some companies have personnel that understands water systems but are not providing Legionella related services because of liability concerns or the time required to learn how to conduct site surveys or solves Legionella problems. Some are providing services but poorly (e.g., making Legionella remediation recommendations that are costly but ineffective). Others charge too much for WMPs because of inefficiency.
HC info has a responsibility here, too, because service providers (our WMP partners), as well as building operators, use our LAMPS cloud application. We need to improve LAMPS to further simplify and streamline the development and implementation of WMPs and develop new e-courses to cover unmet educational needs.
What should building owners and managers do?
The responsibility and opportunity to reduce the risk of Legionnaires’ disease ultimately lies with building operators. Legionnaires’ disease will continue to cause illness and death unless they implement effective WMPs. Fortunately, establishing and implementing a top-notch water management program does not take a burdensome amount of time and money if done intelligently and efficiently.
Many organizations with valuable brands have already established WMPs. They understand that implementing a good WMP is not only the right thing to do for the people who spend time in their buildings, it’s a smart investment for their organization to show good corporate citizenship and protect themselves against loss of business, brand damage, and legal risk.
For a quick evaluation of your organization’s water management program, see the January 2017 Buildings Magazine article, “6 Questions to Test Your Water Management Preparedness: Legionella threatens risk of disease, lawsuits and brand damage.”
What are the options for health departments?
Relying on voluntary prevention or enacting detailed regulations are not the only options for health departments. State health departments could issue an advisory echoing the CDC’s Vital Signs advice to building operators or adopt less restrictive principle-based regulations.
A health department advisory will not likely move the needle much, so let’s look at just three options – no regulations, detailed regulations, and principle-based regulations:
- No regulations
Although the number of facilities implementing Legionella WMPs has increased several-fold since ASHRAE 188 was finalized, the percentage is still low. Perhaps other facilities will do so eventually, simply out of concern for their legal risk and the health and life of the people in their buildings, but indications are that most need a nudge—maybe even a shove. Unless insurance companies begin requiring Legionella WMPs in the facilities they insure for liability, the nudge will likely need to come from health departments.
- Detailed regulations
Developing and enforcing regulations requiring specific control measures for the water systems that cause most cases of Legionnaires’ disease—domestic (potable) plumbing systems and cooling towers—would be difficult, time-consuming, and expensive. It could take years to enact such regulations. New York State and New York City tackled the challenge for cooling towers with impressive speed but setting rules that make sense for all domestic water systems would be far more complex.
Since regulations with detailed procedures must be one-size-fits-all, applying to many types of buildings and situations, they would end up overly burdensome for some buildings and inadequate for others. For facilities as well as governments, it would be the costliest and most burdensome path to prevention.
However, when considering healthcare costs and human suffering related to Legionnaires’ disease, regulated prevention is less expensive than inadequate prevention and will, therefore, be necessary if building operators ignore warnings to comply with ASHRAE 188. Health and life must take priority.
- Principle-based regulations
Instead of adopting regulations requiring a long list of water management procedures—and then inspecting properties or documentation to check compliance—health departments could establish principle-based regulations for Legionella water management programs.
The success of principle-based versus detailed regulations has been debated for manufacturing processes, financial services, safety and security in international trade, life insurance policy reserves, nursing homes, and other applications.
In a study of nursing homes, researchers were surprised to find that Australian principle-based (outcome-based) regulations produced better results than detailed standards required in the United States.
The researchers expected the US regulations to be superior since specific standards could be more easily inspected and enforced. What they found, however, was the detailed rules apparently encouraged checking boxes over caring for the elderly. The staff members in the US nursing homes—focused on meeting minimum requirements—used less creativity to find ways to offer better care. The Australian rules, by contrast, giving managers and staff flexibility to find ways to meet a principle-based outcome (e.g., to create “a home-like environment”) resulted in much better care and conditions. Inspections showed the detailed standards for the U.S. nursing homes were considerably less reliable than the broader Australian standards.
Pointing out some catastrophic failures of detailed regulations (e.g., the 2001 collapse of Enron), researchers contend detailed rules can even be risky since some will follow them to the letter but find ways to avoid the overall objective.
What does this have to do with managing building water systems for Legionella control? Perhaps principle-based regulations could be employed to “nudge” building operators to follow ASHRAE 188 soon, and at a relatively low cost to government agencies and building owners.
For example, a state health department could simply require WMP registration. In an online database, facilities would be required to answer some basic but telling questions about their WMP and then upload it in PDF. The online portal might look similar to the “Water Management Plan (WMP) Registration Example” shown in the figure below.
Health departments could add more specific questions that are shown in the sample, for example, “Does your WMP include cooling tower start-up and shut-down and water treatment control measures consistent with ASHRAE Guideline 12?” A simple algorithm could be employed to flag WMPs for review based on the data entered and question answers.
What are the likely outcomes of three regulatory options?
Consider three criteria to compare no regulations, detailed regulations, and WMP registration:
- Prevention: Percentage of facilities that will implement effective control measures in all water systems that can harbor and transmit Legionella bacteria
- The cost to government: Time, personnel, and financial burden to health departments or other government entities (taxpayers) to develop and enforce the regulation
- The cost to facilities: Time, personnel and financial burden
The percentage of facilities implementing effective Legionella control measures would likely remain low without regulations. Compared with WMP registration, detailed regulations with inspections might result in a slightly higher percentage of facilities complying but, based on studies of regulations, perhaps with less effective implementation and at a significantly higher cost.
Could facility operators cheat a simple WMP registration system, setting up an inadequate and ineffective WMP? Yes, but doing so would put them at risk for debilitating civil lawsuits and even criminal charges if their facility is implicated in a case of Legionnaires’ disease. Moreover, facilities that try to fudge WMP registration system would find a way to cheat detailed regulations as well.
Regulations aren’t needed for the organizations that have already established WMPs, or will soon, but that comprises a small percentage (5%?) of facilities. And regulations of any type will not bring effective prevention in the small percentage (5%?) of facilities that will do as little as possible to comply. The target group, then, is the 90% or so in the middle that wants to do the right thing but need to convince their managers to approve the money for it. They just need a nudge. If they are forced by principle-based regulations (e.g., WMP registration) to establish a WMP, they are likely to do it well. They don’t need regulations outlining details to follow.
WMP registration might yield even better prevention than detailed regulations since facility operators would be responsible for implementing defensible control measures. They would have to defend their WMP if questioned about its effectiveness. It’s easier to check boxes next to a list of regulated procedures than to defend what you have decided upon and created. Moreover, as happened with the nursing homes in Australia, building operators might take more interest and pride in a WMP for which they have ownership, using their creativity and intelligence to do it well.
Detailed regulations and inspections would be much costlier than WMP registration, with facilities as well as the regulating government agencies. WMP registration would likely result in significantly more risk reduction for the time and money spent and could be established much more quickly.
Where do we go from here?
The purpose of this article is not to propose a specific solution but to attempt to define the problem, discuss possible solutions, and invite your input. Perhaps agreement on the following three points can provide a foundation on which to begin a conversation:
- Nearly all cases of Legionnaires’ disease will be prevented by minimizing Legionella bacteria in domestic water systems, cooling towers, whirlpool spas, and decorative fountains.
- The ideal outcome is for a very high percentage of building operators to manage their water systems to effectively minimize Legionella—at the lowest possible cost to government agencies (taxpayers) and the facilities.
- Although implementing Legionella preventive measures is ultimately the responsibility of building operators, service providers, and health departments play an important role in maximizing prevention and minimizing costs.
Update: On 8/14/19, The National Academies of Sciences, Engineering, and Medicine released a report recommending all hospitals falling under the CMS memorandum routinely test for Legionella and that all public buildings — including hotels, businesses, schools, apartments, and government buildings — be required to implement water management programs (WMPs).
What do you think can be done to maximize prevention and minimize costs? Please leave a comment below.
There are many ways of treating and maintaining a building water system. No WMP is the same. There are also different levels of compliance to a site-specific plan. In many cases, it is important for the building owner to prove to regulatory bodies and insurance companies that all activities in the plan are being followed as designed. However, the main goal of implementing a WMP is to protect public health from waterborne hazards. Independent, third-party auditing can accomplish both objectives. This is critical to ensure that the plan is being followed and further improved upon.
Thanks Andrew. I agree that having a good WMP is not enough–only doing what’s in the plan will minimize Legionella and prevent disease.
I do agree that WMP registration is a good start, and that a simple Introduction to Legionella Prevention Notification to the Building Owners explaining the WMP Registration, in order to prevent enforcement and the additional cost of the State and Federal enforcement to the Building Owners, along with the risk of the Liability associated with not complying with the WMP Program for Legal cost and Law Suits by Personnel will get their attention!
I would also include some real case examples of other Building Owners who have actually been sued because of Legionella outbreaks in their facilities and the actual people who were affected, along with how the Building Owners could have prevented the outbreak by simply following and complying with a WMP Program. I think that they will get the message when you let them know they are either going to simply comply now at a minor cost and start the WMP, or pay dearly later when their Building Occupants are exposed and file lawsuits against them for not complying!
Thanks Neil! I appreciate your comments.
A web based WMP in conjunction with our water treatment provider has worked very well for us. Initially setting it up was a little confusing. But once all the information was entered it takes very little time to enter the most recent data to the site. Also working with the water treatment company there are additional reminders that the Legionella testing needs to be done.
Thanks for making the effort, David. You’re setting a good example for other property owners and managers.
Have already installed ClO2 on both hot and cold systems and have put recirculation on cold mains to improve distribution but without major refit will have to rely on a lot of flushing which is expensive in labor and material as well as hard to implement. We also need improvement in testing, it is too expensive now and takes too long to get results. With 3-14 day incubation time we need to be able to do testing often and economically.
For many facilities, flushing is the most difficult part of the program, as you apparently have found. Let’s hope less of it is required as plumbing designs and remediation technologies improve. How often do you think you need to test for Legionella?
The link below is to the VA”s Plumbing Design Manual were they speak of Legionella. The VA is very much aware of the issue and is in the process of puting in place monitoring stations in the hot and cold water systems. They are also requiring that the hot and cold water be recirculated to the fixture because no dead end are allowed.
Thanks for letting us know, Joseph, and for including the link.
I believe water treatment prevention is a good solution but it is costly, that is what we have done in our health care facility for many years. In the health care facility world its challenging to continue to meet more stringent regulatory requirements with less resources. I don’t believe there is a good prevention program that doesn’t come with a large cost adding more burden to an already over regulated health care facilities. If you have ideas or receive any on how to implementing a Legionella prevention program reasonably I’d be very interested. Thanks
I appreciate your candid comments, Steve. I’m focused on that very task, to make it easier to implement a high quality WMP using our LAMPS cloud application.
I think requiring registration at least indicates awareness. If the building owner is aware of the need to submit a plan, he becomes aware of the liability. There is no question that principle based approach is the best route. Very prescriptive regulations will be too costly. However, owners need to employ experienced expertise internally or as consultants to develop and implement the plan.
Most owners and/or operators of businesses with water systems that can harbor Legionella understand that there are risks associated with an outbreak in their facility. They just don’t want to believe that it will happen to them. The common thread I see in this article and in the comments is about taking care of the occupants in these facilities and understanding if you don’t, there will be consequences. It’s all about risk mitigation. It is very important for a business to provide a safe, and as much as possible risk-free environment for their employees and visitors.
As a company who actively encourages our customers to have WMP’s, we see the same numbers as presented here in this article. These customers are dealing with many significant issues and Legionella is just another one. Some enforcement of of these regulations will be required if we are ever to see them take hold. Not having any will lead us to the same place we are now. Detailed regulations will put another burden upon them, leaving them no option to comply or falsify their reports. Principle-Based regulations tailored to the particular industry seem to be the best fit. It will need to be something that is required now that can be continually strengthened over time. This allows time, money and resources to be set aside for this very important issue that these customers of water systems need to be dealing with for the health and safety of all who visit their facilities. It requires an action plan and an understanding of responsibility of the possible dangers of Legionella.
As mentioned in the article, service providers that become educated and proficient in site surveys, WMP configuration, and Legionella remediation play a key role in maximizing prevention at reasonable costs for facilities. Kudos to Garratt-Callahan for being a superstar role model! Thanks Jeff!
In your article dated Jan. 16, 2017, you offer 3 alternates to promote development of Water Management Program to reduce Legionella development in potable water systems:
a. No regulations.
b. Detailed regulaations
c. Principle -based regulations
Also, proposed methods discussed to destroy Legionella bacteria already admitted in the plumbing systems are limited to:
A. Recirculation in the interior plumbing piping of super hot water (160°F)
for 15-20 minutes, once or twice a week.
B. Recirculation in the interior plumbing piping of high concentration of
super chlorinated water (or other bactericide) for 15-20 minutes , once or
twice a week.
Unfortunatelly none of these methods are practical, since plumbing systems, as presently installed, contains many “dead ends”, and the super hot water or super chlorinated water will not reach them.
The solution is to provide an Ultraviolet (UV) generator to kill all bacteria at the point where the municipal water enters the building, and eliminate all “dead ends” in the plumbing piping systems.
These suggestions require a new approach of how plumbing is installed, to give the Owner and Maintenance personnel a practical method to fight Legionella.
Hi Haig. I agree that superheating or hyperchlorinating once or twice a week is impractical–even ridiculous. But there are other options. True that stagnation hinders the success of residual chemical disinfection but UV provides no residual at all, which has limited its success in large systems. I hope to see more research on UV or filtration at points of entry, used in conjunction with chemical treatment. Thanks very much for your comment
Very nice article that clearly defines the problem and explores possible outcomes. As noted in our Vital Signs, the vast majority of properties involved with Legionnaires’ disease outbreaks that were investigated by CDC were not managing their building water systems at all. Upon investigation we often noted obvious red flags in suboptimal temperature or chlorine residual that could have alerted building managers that something was off before anyone got sick if they had a water management program in place. Consequently, we would dearly like to devote more effort to prevention rather than outbreak response on a national level. The risk management approach to prevention, such as ASHRAE 188, that we at CDC promote should not be expensive or difficult, but should be a normal component of operations, positively contributing to the overall maintenance program. In short, we believe that most people can do a lot of good with very little effort.
At CDC we understand that developing and implementing water management programs from scratch can be a bit daunting and we would like to provide as much guidance as possible. However, the responsible parties – building owners and managers – are not a typical audience for us. Consequently, we appreciate feedback from those most closely involved in building operations and would be happy to receive questions and suggestions from the public. Comments may be submitted to email@example.com.
Thank you, Dr. Freije, for all you do!
Thank you for your comments, Claressa. And many thanks to you and others at the CDC who’ve worked hard to issue new publications and make presentations on Legionella prevention in the last year or so, in addition to your regular job tasks.
Thanks Matt for the opportunity. This is well defined information which is compacted into one page. However, I have noticed that there is little to no information given on the testing of Legionella. As per the WHO, there are at least 42 species of Legionella known. There are a number of waterborne bacteria that can be a good indicator of Legionella vulnerability in water systems. Although not all of the species are pathogenic or infectious to humans, it is still important to perform laboratory diagnostics because they can highlight the identification of the organism. This can lead to a meaningful remedial action, if needed, or to an overall better management of preventing water contamination from these infections agents.
Yes, WMPs must be validated to show they’re effective in controlling Legionella and testing water for Legionella provides the most direct feedback. Thanks Rajiv!
The hardest people to convert will be building managers who don’t have the usual risk factors: 1) occupants with compromised immune systems, or 2) high-risk systems like cooling towers, hot tubs, etc. They may be content to gamble that the cost of a WMP program outweighs the risk.
That’s what most are doing now. They just need a nudge. Thanks Thomas
i like the idea of simplification and streamlining of LAMPS. Continued education for both service providers and their customers will be KEY to more facilities committing to the process. I like the idea of employing principal based ideas to encourage building owners and facilities to follow ASHRAE 188 sooner than later.
What could be more costly than the cost of litigation due to negligence or lack of action to minimize the risk for Legionella? Putting this aside and to provide a more direct and practical answer to the question, I’d like to offer the following comments pertaining specifically to cooling towers:
Keep the fundamental approach of good housekeeping, good microbiological control program (proper biocide use), and good scale/corrosion control program. Remove dead legs if possible. Eliminate or minimize stagnation. Housekeeping (filtration, regular visual inspection and manual cleanings) is an important part of the program due to environmental contamination and airborne fouling debris. This fundamental approach is nothing different from what had been promoted and implemented in the industry and should not affect cost significantly unless the treatment has been historically under-dosed. Additionally, if a system is kept as clean as possible through good housekeeping, then the system biocide demand is significantly lowered, which will result to reduced treatment cost.
Thanks Rose. I couldn’t agree more. A clean and well maintained system likely increases inefficiency and reduces energy costs, too.
Being from California, I can attest to the burdens that facility personnel must face as they make efforts to comply with a plethora of state and local regulations. I believe that principle-based regulations would offer greater flexibility and would, therefore, encourage greater participation. Perhaps a state-managed centralized reporting system would be the best option. This model is used for other types of reporting concerning various regulations. Additionally, I believe three elements are important to drive a successful WMP.
1) Collaboration- a WMP has many internal and external stakeholders. Communication and continuous revision yields a top-notch WMP.
2) Education- there are individuals who believe water testing and remedial actions are enough to prevent Legionellosis. Often times, an effective WMP can seem intimidating. Promoting awareness and education, something the CDC is actively doing, allows individuals to truly understand the value and importance of an effective WMP.
3) Direction- directors in both private and public multi-campus organizations should take a proactive approach in supporting each facility/campus. As the old saying goes, change starts at the top.
Thanks Marco! I agree that collaboration, education, and management support are crucial to the success of a WMP.
Immunocompromised (IC) patients are susceptible to Legionnaire’s Disease (LD). To minimize LD, the first step is to communicate the risk of LD to IC patients.
Doctors should tell their IC patients to install 0.2 um filters on their taps and showers at home, and drink boiled tap water.
Most store bought beverages should be fine, however they may want to stay with Coke, Pepsi or Poland Springs water products since these beverages are highly purified.
When IC patients are away from home, they should stay away from taps, showers, pools, spas, and misters.
Building owners should post LD disclaimers near taps, showers, pools, spas and misters, similar to the LD disclaimer found in many municipal water quality reports.
Building owners should minimize LD risk in the building by developing a water management plan. The principle based regulations make sense.
Municipal drinking water organizations should inform drinking water customers when there are disturbances in the water source or water main system and notify them that LD risk may increase during these events. The building owner can then take appropriate measures.
Municipal drinking water organizations should test for Legionella in the water distribution system periodically to identify for any Legionella hot spots in the system.
These drinking water organizations have been testing the distribution system for coliform, e coli, Lead and THMs for years, there is no reason why they should not test for Legionella.
If the municipal drinking water organization find high levels of Legionella in drinking water distribution system, the drinking water customer should be notified immediately so they can take appropriate measures.
You make a good point in that, although building owners may have primary responsibility, many others have important roles in prevention. Thanks Daniel
This is a good article. We have seen local health districts respond to health complaints and not push or even suggest that the facilities prepare and follow WMPs. This has left it up to us to explain to the facilities the risks of not preparing and following a WMP.
We are also noticing that some facilities with WMPs are not following the control measures and are continuing to have issues. We find ourselves repeating “have you been following the control measures outlined in your WMP?” The work definitely continues after the WMP has been prepared. We have to continually educate and keep the discussions open with our facility managers so they do not stop thinking about their water systems and taking all the reasonable measures they can to help reduce their risk.
As always, good information from HC Info!
Excellent points, Teri. I’ve had the same experience with some local health departments. Many do a great job but others are not up to speed with CDC recommendations and Legionella education. Great job following up with your customers about implementing their WMPs. You’re providing a valuable service.
The cases of Legionellosis will continue to occur until we do a better job in making sure that a water management plan is in place wherever it is needed. Perhaps we need more leadership from water companies/providers. They can help by educating their customers. Obviously, more requirements for ensuring that an appropriate plan is followed cannot be avoided. Some kind of certification requirement in regards to Legionella for the operators of equipment such as hot tubs and wet heat rejection systems should accompany the installation and maintenance of equipment such as cooling towers and hot tubs. ASHRAE standard 188 is very applicable; however, there must be an understanding that any level of Legionella present should be addressed, and that killing the protozoa in which legionellae grow can be an important part of controlling Legionella populations. It all boils down to education, awareness, effective WMP’s, certification, and unfortunately some form of regulation that is reasonable. Proof of effective measures can only be obtained by using the proven standard laboratory procedures.
Thanks Jim. For those that don’t know you, I’ll mention there about 40 years of Legionella experience behind your comments, including significant research and heading the lab at the CDC. Thank you for years of public health service
There is no perfect solution for every building. Every building has its own specific problems and therefore its own specific solution. When in the design and build regulations are not strictly applied, it often results in a large, unmanageable maintenance plan. A good, practical and affordable maintenanceplan starts at the build. That takes awareness. Education is key. In the Netherlands we have strict rules for design, build and maintaining watersystems for buildings since 1993. Since then rules are intensified every five years or so. Rules for maintaining cooling towers are relatively new. We are getting there, but slow. We didn’t have any major outbreaks for years.
Hi Diny. I agree that prevention starts with design and construction. We include detailed measures for it in our LAMPS WMPs. If water systems were designed and built with Legionella prevention in mind, it would prevent a lot of problems from the start. Thank you for commenting
The WMP registration example is a good start because it’s not obtrusive. Perhaps the #2 section could include the response “Unsure” as well as “Yes” and “No.” Also, I agree that independent, third party verification should be included.
Here in the Uk & Scotland we have the same problem with compliance,the law we refer to is the health & safety executive update HSE274 part2 which is virtually same outline as your Ashrae 188 regulation, we have asked the government to implement registration for all that must comply, In Scotland all Landlords must register on the landlord registration list, so implementation would be easer,
Ignorance to the risk of Legionella is still the biggest problem we face,
we provide tenants of let property with the shower safe bag, this product increases their awareness and helps prevent the risk from the shower in a cost affective way , along with good simple guidance and a simpler testing methods is the way forward, cost is key even in the UK.
Hi Mario. I’m surprised to hear awareness is still low in the UK because I thought it was much higher than here in the US. Thank you for commenting.
Your article presents key points in this discussion on Legionella control and the importance of a water management plan (WMP). While regulations may provide the impetus for WMP development, they may come with added burdens that may not lower the risk, but add expense and time to the process. How can we motivate facilities to not just develop a water management plan, but to actually implement and follow it? We have to think of this as a safety issue and have the elements of a plan be as routine as safety measures. Documents exist for developing a WMP. ANSI/ASHRAE Standard 188-2015 provides the basis of a water management plan while allowing facilities flexibility to design their plan based on their specific systems. In addition, the CDC toolkit provides building managers an excellent guide to WMP development. I am not sure we need regulation or a third party certifying agency. Do we need motivation that comes through regulation or litigation? Do we need the building management community to truly recognize the importance of safe water management practices? Or do we recognize and address the problems that may be coming from our water infrastructure. These are all important questions that need building owner input.
Great questions! Thanks Helen!
It all starts today with effective plumbing design to help eliminate this problem in the future. Maximizing prevention and minimizing the costs associated with Legionella requires a proactive approach on the part of building owners and plumbing designers. From this point forward, with the ASHRAE 188 standard in mind, plumbing system designs MUST include measures to minimize the threat of Legionella. Plumbing system designs that do not address the potential for low flow, stagnant water, water temperature gains/losses and thermal balancing will lead to a reactionary posture by building managers and continue to prolong the problem and increase the costs associated with managing a building water system. It all starts with a system designed for minimizing the threat of waterborne pathogens.
Today, we have building managers and owners reacting to yesteryear’s flawed plumbing designs in an attempt to minimize the threat of Legionella. The available methods for effectively achieving this are well documented (chemical use, cutting out deadlegs, filtration, flushing, temperature control, etc.). The implementation of a WMP will be done only if the threat of loss outweighs the cost of execution.
Building owners therefore need to be educated and informed of the potential costs associated with a Legionella outbreak within their building (to the point of action). I think the WMP registration concept is a good start. I also feel that building owners should sign off on the document, personally. Additional, more pointed statements could also be included relating to the building owner’s ultimate responsibility for ensuring a safe building.
Questions such as the following:
* “Are you aware of the measures available today that can be implemented within your building in order to minimize the threat of Legionella. If so, please list them.”
* “Do you realize that the failure to implement an effective WMP to minimize the risk of Legionella could lead to fines and imprisonment”.
As we all know, water flows downhill so I believe we need to go to the top of the mountain to identify and deal with the source.
Thanks for commenting, Craig
Over the years, most facility owners/managers have utilized Standards of Operations (SOP) to provide maintenance for facility systems or to outline actions in response to a situation. Many SOPs are based on manufacturer’s recommendations for operation and maintenance. Over the years, these individual SOPs are combined into an Operation Manual that the facility or group of facilities uses as a guideline. Many maintenance dashboards have been developed to provide, schedule and regulate the requirements of each SOP. So the natural response is to attempt to meet the ASHRAE 188 standards utilizing the existing systems.
Is an SOP that addresses water safety a suitable response to the ASHRAE 188 standard? If not, what important elements are missing? How do you merge a water management plan into an existing maintenance dashboard?
Hi John. I think it’s easier and better to start with a good WMP template and insert the SOPs rather than trying to build a WMP from SOPs. I know you’ve been using our LAMPS WMPs. If you have suggestions for making LAMPS more easily integrated with your customers’ maintenance software, please let us know. Thank you for commenting
1) When folks believe a task to be onerous and costly they tend to defer it. We need to educate building owners of the “80/20” rule: 80% of the benefit can be achieved with 20% of the effort. Begin the WMP with only cooling towers and the building water system. It’ll be a living document so it can be refined over time. Just get started!
2) I prefer to tailor someone else’s work to my specific situation than to begin with a blank sheet of paper. So while one can successfully argue that each system is unique and there is no “cookie cutter”, I would argue that your 50-Ton open cooling tower has a lot in common with my 50-Ton tower. We need to provide simple templates and make it easier for them to get started.
“Get started” is a great word. Thanks Bill! And thank you for setting a good example for other facility operators.
Sadly all too often compliance will be driven by litigation and/or insurance coverage. We have seen that with mold and we will see it with Legionella. Merely having a WMP in place is no guarantee that it will be utilized but unlike mold, exposure to Legionella can have significant and even deadly impact. In the UK, criminal manslaughter penalties have been imposed upon building owners failure to maintain their water systems. As attorneys become more attuned to this potential action for negligence in the United States, litigation will likely grow which will force compliance if building owners and managers are not responsible enough to do this on their own. Similarly, insurance carriers are now starting to require both WMPs, risk exposure analysis and demonstrated compliance with plans prior to providing Legionella coverage. Perhaps lawyers and insurance companies will provide the incentive for everyone to do the right thing.
Thank you for sharing views based on your litigation and insurance expertise. I didn’t realize insurance companies are now requiring WMPs as a condition for Legionella coverage.
Thank you for your attention to the Legionella problem.
Many building maintenance personnel I speak to about this feel that Legionella minimization is the responsibility of the water treatment provider and will work on a WMP only when it is required by law or their employer.
Hi Bill. As you know, that’s false. ASHRAE 188 clearly places responsibility with the building owner. Moreover, a WMP with comprehensive control measures for domestic water (plumbing) systems could not practically be carried out by the water treatment provider–most of the measures must be performed by the facilities maintenance personnel. Thanks for commenting
The article provides a good explanation of the three possible ways to approach regulate (or not regulate) Legionella control in building systems. Unfortunately, NYC used the “Detailed Regulations” approach for cooling towers. Their top-down approach, while well-intentioned, directs a lot of resources (NYC resources and building management resources) toward regulatory compliance that may or may not actually improve Legionella control in cooling towers. I fear that NYC will take the same approach if/when they regulate Legionella control in potable water systems.
I’m looking forward to NYC publishing the review they are required to perform to show what the cooling tower regulations have accomplished after the first year. In my opinion, there is a lack of data that can help regulators create effective regulations that are also cost-effective.
As an aside, there was an article published in the Summer 2016 issue of the CTI Journal that questions whether the August 2015 outbreak was actually caused by a cooling tower. It’s an interesting read.
Thanks for commenting, Bryan
Building Facility Managment personnel are often already implementing many of the control measures required for “best practice” Legionella control in their water systems but may be unaware that their PM’s or daily checks also have an impact on lowering waterborn pathogen risk. The impact of implementing a WMP in these facilities is to bridge that gap between what is being done already and what should be done to meet the requirements of the Standard. In these instances, implementation of a site specific WMP actually then reduces redundancy, increases efficiency, and focuses efforts already being done in a way that better protects building occupants. I see this as falling within the category of Principle-Based Regulations and is more practical than adding detailed regulations that will certainly bog down FM’s and lower quality of work and results.
Excellent points, Jeremy. Thank you
I agree with the approach recommended, i.e. Principle-based regulations.
Here is a comment I sent to the NYC folks after their 9-3-2015 call in.
“In 2005 I chaired a NACE Panel discussion on Legionella which led to a full NACE symposium on Legionella in 2007, which I also chaired. The agenda for both is attached as well as some of the papers. Probably one of my favorites is the attached Power Point from the late Arthur Freedman. It shows only too well how a rote approach to Legionella control can fail, and what an experienced consultant and or water treatment professional can bring to the table. Again, my pitch for a blend of a descriptive, but performance based approach to prevent Legionella outbreaks.”
Thanks for your comment, Rich, and for your years of work in Legionella prevention
Hi Matt , you have posted an Informative article . While your 3 suggestions for implementing regulations have their independent merits , i find the outcome based option to be most practical. Having said that , please note that in some of the developing South Asian economies ( like the one where i happen to be based) , awareness of LB and LD is marginal at best and consequently, emphasis to have a sound WMP to comply with ASHRAE 188 is hardly a priority. I request you to please advise how any of these options can be incorporated /enforced in the SOPS of the global hospitality chains so that it actually percolates down to all their properties – more importantly mandating their franchises across the developing geographies to comply and be audited by tour operators and agencies with the wherewithal to do so . Today , what i notice is , unless there is a guest complaint or an outbreak threat , very few of even the branded players are taking cognisance of either developing or maintaining a WMP for Legionella Control .
Thank you for commenting, Mahesh. You’ve raised a good point. I’ve seen firsthand that operators of some international chains manage water systems in buildings in some countries (the UK) differently than in countries where there is lower awareness. About two years ago I provided Legionella training at a large South Asian property that was apparently the only one in the area implementing Legionella control measures. It was because the engineering director had come from a UK property and was familiar with Legionella risk.
Working in the UK we are used to a legislative approach to legionella management but that is how the UK approaches many things. The trick is not to think that legislation is burdensome but that if you comply you will be running your systems in a more efficient manner and hence are likely to save money in the long run. It is clear that well managed systems are less likely to have legionella present than those that are not well managed, in exactly the same way as a serviced car will last longer than one not.
Also there is a very important need for education of end users as can be seen from some of the comments made to this article. Legionella is very adept at hiding from everything we wish to do to remove it and so some of the ideas raised need to take this into account, for example low levels of legionella may enter the system within amoeba, which are neither tested for by the water provider nor the water treatment company and then the legionella can proliferate within the system, treated or not, by living in biofilms. The amoeba and biofilms show the need for flushing but this again does not need to be burdensome as correctly cleaning outlets on a regular basis can be enough flushing to manage static water without increasing costs of water use.
Many of the worst contributors to the problem are engineering issues such as deadlegs, the over-use of TMV’s, the use of flexible hoses, subordinate loops with poor flow etc. and by looking at the way the system is installed as well as looking at temperature profiles and the judicial use of water treatment, if required, then a more holistic approach to the problem can be created which in the long run will save money not increase costs.
This approach is perhaps why the UK has one of the lowest levels of Legionnaires’ disease cases in Europe, and hence the world.
As for the best approach to “legislating” I believe there is a large cultural issue involved and with a country the size of the USA with its myriad of contributing cultures, that will be a long argued and difficult to resolve issue. Educating the population is key, which includes the press, and then helping the end user understand how “easy” management can be and how cost effective and beneficial it is overall will minimise LD cases in the USA.
Thank you Nigel. It’s good to get your perspective since you’ve experienced years of Legionella regulations in the UK. What so many commenters seem to agree on is the importance of education. All the best to you
Max De Pree made a most important comment regarding leadership and leaders – “The first responsibility of a leader is to define reality.” And as leaders in the water treatment industry, it is incumbent upon us to clearly define the clear and present danger posed by not having a Water Management Program in place and keeping it up to date (ever evolving). In other words, the reality is that everyone will have a program . . . eventually. It’s the smart ones who will develop a one sooner rather than later.
Our customers must recognize that this process represents an INVESTMENT and not a cost to the owner/manager. Regardless of whether we are dealing with a hotel or a hospital, the health and safety of the occupants is everyone’s responsibility. As stated in the article, education is the key (isn’t it always) and as such the more we educate our customers and prospects the more they will understand the ramifications of not addressing this issue of Legionella (and other waterborne pathogens) head on. To wait until there’s an outbreak is to have waited too long. That’s the reality!
Hi Cal. Just yesterday I exchanged emails with Clive Broadbent, whose cooling tower Legionella research is the basis of many of our control measures today. Based on his experience, even with regulations in Australia, he agrees with you that “education, education, and education” is the key to prevention. Thanks for your insightful comments!
Great Job Matt
Looking forward to many more.
I see managers and operators of businesses falling into the ASHRAE 188 inclusion categories almost on a weekly basis. I’ve yet to visit a health care facility or manufacturing plant that doesn’t already have some awareness of Legionella and it’s risks. In fact, most have already decided on some good measures of testing, monitoring, circulating water, running faucets,etc. based on good practices suggested by staff members, and/or what their organization has advised them to do. While these may be good practices, will they ever be perceived as complete in the absence of a compliant Water Management Program? The answer is probably no, as the industry and the legal community look to ASHRAE 188 as the recognized standard. The reluctance of taking the final step of implementing the WMP often lies in the perceived cost and complexity of the task. The question often comes up, “When do I really have to have this completed, as I have so many other projects currently?” The simple answer is before someone gets sick in your facility. While it’s currently not regulated in most states, this brings to light that the cost of being compliant compared with the cost associated with the risk. I think most people are now realizing that. Safety seems to be the number one initiative in most organizations. Matt, thanks for all you’ve done to help raise awareness!
Thanks Vance. Your input is valuable because I know you and others at Garratt-Callahan talk with and help a lot of facilities. It’s encouraging to know awareness has increased. I think you’re correct in that the answer is “no” because what you described is not compliant with ASHRAE 188. There’s a big difference because 188’s requirement for control measure monitoring, limits, and corrective action — with documentation, verification, and validation of the WMP — is what helps to ensure that the control measures are actually implemented and are monitored and improved as necessary. Thanks again for your input.
As an engineer I look more to design solutions than implementation standards, although both are equally important, but I am in no control of the latter. I look forward to learning more about developments in design solutions in today’s webinar. One issue that confounds me is that in facilities with cylinder exchange water softening systems, I am convinced that the exchange cylinders are introducing Legionella into buildings that would otherwise be Legionella free. There is no control over this issue, and I think the water softening companies should be regulated to insure they are Legionella free.
Hi Tim. You’ve raised a good point about the softening cylinders. To my knowledge, as we may have discussed last spring, they have not been studied with respect to Legionella. Thanks for commenting
The Hospitality and Healthcare industries are at the forefront of the need for meaningful Legionella protection, given their exposure to the public. The beauty of implementing the WMP as described here is that it is voluntary and helps the facility managers prioritize those control measures which need to be taken in order to reduce potential for exposure.
This is an interesting and timely article. I take a stronger position than you about over-regulation, particularly with New York’s cooling tower regulations. The NYC and NYS regulations on cooling towers have had NO impact on the rate of Legionnaires’ disease. According to 2016 CDC MMWR statistics, reported cases in both NY state and NYC in 2016 were higher than their 5-year average. So while the state and city were speedy in setting rules, to be impressive the rules would need to be of at least some value to their citizens which these rules were not.
To prevent Legionnaires disease multiple defensive layers must be used starting with the potable water. The EPA knows this and has recently owned up to the fact that their current surface water treatment rules do not protect the drinking water from Legionella bacteria. The quote below is from the Federal Register dated 1/11/2017.
“REQUIREMENTS TO MAINTAIN A MINIMUM DISINFECTANT RESIDUAL IN THE DISTRIBUTION SYSTEM
EPA evaluated information related to the maintenance of a minimum disinfectant level in the distribution system and determined that there is an opportunity to reduce residual risk from pathogens (includes opportunistic pathogens such as Legionella) beyond the risk addressed by the SWTRs. The detectable concentration of disinfectant residual in the distribution system may not be adequately protective of microbial pathogens because of concerns about analytical methods and the potential for false positives (Wahman and Pressman, 2015; Westerhoff et al., 2010). Maintaining a disinfectant residual above a set numerical value in the distribution system may improve public health protection from a variety of pathogens.”
Until the drinking water is not randomly contaminating buildings and water-using equipment with Legionella bacteria this disease will not be controlled.
Hi John. Any regulation will need to cover all applicable water systems to have much of an impact on Legionnaires’ disease. I agree that, in some areas, the incoming water supply is a big problem, but disinfection byproduct risks and rules make it difficult to increase disinfectant levels. In any case, prevention will need to happen within the buildings. Thanks for commenting
Great article! Thank you very much for the information and progression of how this industry can better protect people.
Very good and timely article Matt. The comments to the article are very insightful as well, made by some very well respected names in the industry. I especially appreciate Richard Moll’s reference to my late father’s contributions, Dr. Arthur J. Freedman, Ph.D., to NACE on Legionella prevention. I also would like to note the important contributions that you have made Matt on this important topic, keep up the good work!
Thank you Pete!
This is great material.
In the spirit of focusing everyone’s resources on what is highest value for reducing the risk of Legionnaires’ disease, however, we need to focus building owners, service providers and health departments on ensuring they are controlling the primary causative agent of the disease, Legionella pneumophila. This can best be done by routine testing to determine whether the WMP is being effective, e.g. have they controlled the growth of Legionella pneumophila, and in the process, have very likely controlled the growth of all other Legionella species.
Thanks for your input, Kristin!
The UK probably takes about 4 -5 years to provide new regulations
Q: In my experience companies with multi state sites use the highest level and manage to that
Q: In the UK my experience shows that C-A is about 10 times the value of the water treatment industry value. So assuming USA spends $4-5bn on water treatment then it will cost $40-50bn per year.
Q: The presence or absence of legionella is not a verification as it only means it has not been found
Q: Verification could be by using an external independant consutant to verify WMP
Q: Buildings could be graded by complexity rather than size
Q: Try Tweeting Trump!
Q: Detailed regulations work in the UK with the lowest level of LD in Europe
Q: Not following rules makes it easy to prove causation
Hi Nigel. It looks like you’re responding to questions asked during the Q&A. Thanks for your input
Enjoyed the talk. Thanks for the invite.
Matt, your point about building owners w/ multi-state portfolios and the complications from the implementation of detailed regulations in each state is well made. I’ll submit that just having detailed regulations in one state is problematic. If one state has detailed regulations and the building owner follows those regulations, does the building owner not then establish their “standard of care” for the entire portfolio, forcing them to follow the regulations in their buildings in other states? If they didn’t, wouldn’t they leave themselves open to legal problems in the event of a law suit?
PS. Really good presentation. Thanks.
Hi Bryan. That’s a good question for an attorney with experience in litigating cases related to Legionnaires’ disease. Based on what I’ve seen in serving as an expert, I think it could be problematic for the defendant because the plaintiff’s attorney would likely demand (in discovery) documents related to other properties in the portfolio, and then ask why the one in question was managed differently than the others with respect to Legionella control measures. Thank you
You mentioned that there are other options to validate WMP other than Legionella testing in the webinar. Would you please explain what those other options are? Thanks.
Hi Zhe. Testing water for Legionella–if done properly–provides the most direct and useful validation. Hospitals have the option of validating also by testing patients for Legionella per CDC recommendations but I don’t think patient testing is a substitute for water testing. Total bacteria counts (HPC) provide pretty good Legionella validation for whirlpool spas but not for cooling towers, plumbing systems, or other water systems. Thanks
One of the questions presented during the webinar was what is the most appropriate mean to control Legionella and reduce the risks of transmitting Legionnaires’ Disease. In Quebec, Canada, a detailed regulation was adopted after an outbreak infected 181 persons killing 14 of them in 2012. The rule applies to cooling tower’s systems only. It was adopted in two phases. In brief, during the first year following the outbreak, cooling tower’s systems managers had to register their cooling towers and adopt a detailed maintenance program in compliance with the rule. After it, during the second year, they had to validate the program efficiency by Legionella tests as described in details in the regulation.
I never wondered before if something else would have been more appropriate. Looking back, it seems to me that a principle base regulation would have been a much better way to procede. First of all, we can wonder how a government agency which has little knowledge on Legionnaires Disease can write a detailed regulation while dedicated professionals took years to develop a standard? Plus, in having to write a detailed regulation, the government employees can be subject to pressures from lobbyists which it would be better to avoid…
So, to my view, the best mean to prevent the transmission of Legionnaires Disease within a country or area would be to force the building managers to register their systems at risk and issue a declaration that their systems comply to a standard like ASHRAE 188. A third party firm could then certify the compliance as performed by any quality program. However, a nationwide practical program of formation cannot be ignored in a sucessful strategy to prevent Legionnaires’ Disease. In the case of Quebec, while consulted during the adoption of the rule, I advocated the importance of a formation program like the ones concerning Health and Safety at work. It was never adopted. This simple point shows that even a regulation contains full of details it can always be completed and improved…
Hi Mario. You’ve made some good points. Thanks for commenting
I am wondering if any additional studies have been done on electronic biological remediation devices? I heard whispers of something happening in that regard in Seattle.
Hi Phil. I don’t know of any in particular but am interested in that subject, so let’s talk sometime.
For me there are three things that we should point out:
– 1) Legionella bacteria comes in the water supply, and then contaminates buildings and factories cooling tower systems, hot water lines…and others . So preassure should be first on water supply companies and authorities to avoid this to happen(the preassure should not only be on owners side)
whether contaminated water does not come in, final end customers through their installations, will not disperse the bacteria.
– 2) To eliminate or reduce the risk of Legionella on installations to less than 2-3% is franckly very expensive in terms of products, people and time. It is not only a question of developing a WMProgam. Its a question that some installations should be renewed and updated (for me is the key point in some installations), and this is costly aswell
– 3) Once Legionella comes into big hot water sytems, cooling towers…etc is quite difficult to be erradicated definitively. In fact Legionella cero is allmost imposible. This should be beared in mind by the authorities and owners. We should be ready to coexist whit it.
As you know we do have a very severe and detailed Legislation in SPain since 1998, and from my experience, and coming to the point, from the three alternatives you are suggesting, I think a Principle Based Regulation should be enough and better.
Detailed and complicated regulations have not erradicated Legionella in our country, neither in others. They have increased management costs to customers at crazy levels, and many installations have becomed damaged in middle-long term basis due to the massive use of chemicals in water treatment and disinfections, increasing the nutrients of Legionella bacteria to develop.
Furthermore, we work in other european countries were have less Legionella impact, even that there is no regulations at all.
Common sense is the key point. Nor doing nothing, neither promoting severe and complicated regulations (that as complicated, a big percentage of operators try somehow to avoid)
Hi Jose. Thank you for commenting based on what you’re seeing in Spain and other European countries. Treatment of public water supplies varies quite a bit among countries, and even among localities here in the US. Some chlorinate more heavily than others. There is somewhat of a trade-off between lowering risk of Legionella and other waterborne bacteria by applying higher disinfectant residuals in the distribution systems, and lowering the health risk of disinfection byproducts (DBPs) by minimizing disinfectants. Advances in water treatment will hopefully allow good pathogen control while minimizing DBPs, perhaps by reducing particulates and organic matter.
Thanks for the article, I was unsuccessful in logging in to the webinar when it was available. I’m glad to be able to reference the ideas in this article now. I like using the principle based regulations as a way to customize a WMP to specific needs of customers. I find that the most effective nudge to get my customers and prospects moving in the right direction is knowledge and I’m happy to be the source. Thanks again to you and HCInfo for sharing your expertise.
Excellent article and presentation, enhanced by the many thought-provoking comments above.
Thank you Dan!
Excellent overview of what is required vs what is currently regulated. Great template in LAMPS. Obviously your team has done the heavy lifting for compliance with an effective WMP.
Thank you, Jack!