Healthy building initiatives that have in recent years been emphasized in the United States and Europe are important since so many people spend a large part of their lives indoors. What seems out of sync with health data, though, is that the term “healthy building” has focused mostly on air contaminants which, compared with water, cause a relatively small percentage of hospitalizations and deaths (see figures below).

“Healthy building” initiatives have focused on air. Many buildings have sensors installed in ducts to measure particulate matter (PM 2.5), carbon dioxide, carbon monoxide, total volatile organic compounds (TVOC), and humidity. Periodic onsite testing is performed to detect radon, mold, formaldehyde, carbon monoxide, asbestos, and other contaminants. Specifications require minimum air exchange rates, turnover rates for air filtration and humidity must be controlled.

Water, by contrast, is almost an afterthought. Several aspirational documents recommend providing safe water and establishing water management programs to control Legionella and other opportunistic premise plumbing pathogens, but few building owners are required by regulations or insurance carriers to implement such measures, and few do.

Water is processed by municipalities in batches and sent through hundreds or thousands of miles of pipes, creating its own flora and fauna and picking up trace amounts of various contaminants along the journey. When the water enters a building, it finds an environment even more favorable for pathogen growth–smaller pipe sizes with more surface area for biofilm formation, warmer temperatures, and cozy crevices in which to hide from disinfectants–and efficient pathways to people (e.g., faucets, showers, hot tubs). COVID has likely made the problem worse because of water stagnation in underused buildings.

Pathogens are not the only water-related cause of illness in buildings. VOCs from disinfectants and disinfection byproducts can be expelled each time a faucet or shower is opened.

Water-related illness is expensive, too. According to the Centers for Disease Control and Prevention (CDC), the estimated direct healthcare cost of biofilm-associated waterborne pathogens such as nontuberculous mycobacteria, Pseudomonas, and Legionella is $2.39 billion yearly in the United States.


Figure 1. Average hospitalizations from carbon monoxide (1,3) or fire (4) in buildings compared with opportunistic premise plumbing pathogens (2). Note: Air contaminants (e.g.,PM2.5, VOCs, humidity etc.) are typically not a direct cause of hospitalization or death. 


Figure 2. Average deaths from carbon monoxide(1,3) or fire (4) in buildings compared with opportunistic premise plumbing pathogens.(2)

Think about how far buildings have come with fire safety. Countless lives have been saved because of codes, regulations, technologies, and inspections. Illness and death from waterborne pathogens can be prevented, too.

Momentum for better building water management is gaining steam. Hospitals and nursing homes are already required by the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission to have water management programs that satisfy ASHRAE Standard 188. Recently, some states have adopted regulations that would require Legionella water management programs in other types of large buildings–hotels, commercial buildings, apartment and condo towers, and industrial facilities

Everything building owners need to get started is available–technologies, advanced data analytics, and training. If buildings are managed to control water hazards as well as air hazards, they could become healthy indeed. In addition to protecting health and life, a truly healthy building also protects profits and brand equity by attracting tenants and guests and limiting legal risk.

David Swiderski is the Senior Technical Strategist at HC Info.


  1. CDC. Carbon Monoxide Poisoning.
  2. Collier S, Deng L, Adam E, et al. 2021. Estimate of Burden and Direct Healthcare Cost of Infectious Waterborne Disease in the United States. Emerging Infectious Diseases.
  3. Sircar K, Clower, J, Shin M, et al. 2015. Carbon monoxide poisoning deaths in the United States, 1999 to 2012. The American Journal of Emergency Medicine 33, 9.
  4. Nonresidential Building Fire Trends (2010-2019). National Fire Data Center (FEMA).
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