Legionella Guidelines, Standards, and Regulations

 

The Most Important Industry and Government Legionella Documents in the United States

 

American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE)

  • In 1998, ASHRAE published a position paper (ASHRAE 1998) warning, “Design and operation and maintenance procedures that prevent amplification and dissemination of Legionella should be formulated and implemented before systems are operated and continued rigidly thereafter.”

 

  • In 2000, it released Guideline 12, “Minimizing the Risk of Legionellosis Associated with Building Water Systems” (ASHRAE 2000) to “provide information and guidance in order to minimize Legionella contamination in building water systems. …to minimize the risk of occurrence of legionellosis.”

 

  • In June 2015, ASHRAE finalized and released ANSI/ASHRAE Standard 188, “Legionellosis: Risk Management for Building Water Systems” (ASHRAE 2015). ASHRAE 188, an ANSI standard, was a giant step for Legionella prevention in the United States in part because it represented agreement among government agencies and industry groups—not only about the need for Legionella prevention in building water systems—but also about the approach to it. To comply with ASHRAE 188, building operators must implement a water management program (WMP) for water systems that can harbor and transmit Legionella bacteria. The essential components ASHRAE 188 requires for a WMP are almost identical to those the World Health Organization outlined in 2007 (WHO 2007) and the United States Veterans Health Administration (VHA) has required since 2014 (VHA 2014). ANSI/ASHRAE Standard 188 has received widespread industry publicity and is currently recognized as the prominent Legionella risk management document in the United States. In 2018, ASHRAE updated Standard 188, making it more regulation-ready.

 

Centers for Disease Control and Prevention (CDC)

In 2002, the CDC clarified its agreement that building water systems should be managed to minimize Legionella bacteria:

  • “While opinions differ as to the role of routine periodic environmental monitoring, there is agreement that all health care facilities should have a control strategy in place” (Fields 2002).

 

  • “CDC recommends a strategy based on proper maintenance of water systems” (Besser 2002).

 

  • “Adoption of the ASHRAE guidelines [Guideline 12] could dramatically reduce the likelihood that legionellae will be amplified in a water system, thereby diminishing the risk of transmission” (Fields 2002).

 

In 2003, the CDC published “Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee” (CDC 2003). Recommendations for water systems and devices are pages 125-133 (139-147 of the PDF).

 

In June 2016, the CDC issued three publications on the importance and process of complying with ASHRAE 188:

 

 

  • A “toolkit,” Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards (CDC 2016-Toolkit), to help facility operators “develop and implement a water management program to reduce your building’s risk for growing and spreading Legionella.” Referencing ANSI/ASHRAE Standard 188, the CDC emphasized “Legionella water management programs are now an industry standard for large buildings in the United States.”

 

In 2017, the CDC released three more documents:

 

 

 

The CDC has also provided Legionella Environmental Investigation Tools.”

 

Centers for Medicare & Medicaid Services (CMS) Requirement to Reduce Legionella Risk

To avoid a citation for non-compliance, hospitals and nursing homes that receive Medicare or Medicaid reimbursements must “demonstrate measures to minimize the risk of LD” per the June 2, 2017 CMS “requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires’ disease (LD).”

CMS requires the facilities to “Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit” but leaves the details of the program up to each facility.

In July 2018, the CMS updated its requirement (QSO-17-30), clarifying expectations and specifically noting that environmental testing for pathogens is at the discretion of the facility.

 

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Guidelines Pertaining to Specific Water System Types

  • Cooling Towers: See “Legionellosis: Best practices for control of Legionella” at www.cti.org.
  • Decorative Fountains: Guidelines for Control of Legionella in Ornamental Water Features
  • Pools and Spas:
    • APSP/ANSI. 2009. American National Standard for Water Quality in Public Pools and Spas. Alexandria, VA: The Association of Pool and Spa Professionals. Available at www.apsp.org.
    • CDC. 2018. Model Aquatic Health Code, 3rd Edition. Atlanta: Centers for Disease Control and Prevention.
    • HSE. 2017. The control of Legionella and other infectious agents in spa-pool systems. Health and Safety Executive. Sudbury, UK: HSE Books. Available for purchase at HSE.gov.
    • WHO. 2006. Guidelines for Safe Recreational Water Environments. Vol. 2, Swimming pools and similar recreational-water environments. Geneva: World Health Organization. Available at WHO.int 
    • CDC. 2017. Disinfection of Hot Tubs Contaminated with Legionella. Atlanta: Centers for Disease Control and Prevention

Other Notable Legionella Documents

  • OSHA’s 1996 Technical Manual on Legionnaires’ disease (OSHA 1996) condensed many of the Legionella research findings to date into action steps building operators could implement to reduce risk. OSHA made it clear that managing water systems to minimize Legionella bacteria was the key to reducing the risk of Legionnaires’ disease: “The likelihood of contracting Legionnaires’ disease is related to the level of contamination in the water source. …An acceptable control strategy is to minimize the number of organisms present in a water source.”
  • US EPA Legionella: Human Health Criteria Document (EPA 1999)
  • US EPA Legionella: Drinking Water Health Advisory (EPA 2001). The 1999 and 2001 EPA documents provided an overview of Legionnaires’ disease and prevention strategy, agreeing with the OSHA document and other publications that building water management was needed to reduce risk: “Because there is little if any person-to-person transmission of Legionella and no vaccine is available to prevent infection, risk minimization efforts are focused on breaking the chain of transmission between environmental sources of Legionella and human hosts. …For hospitals and other health care settings, regular environmental surveys of both hot water systems and distal sites should be conducted; some health departments have issued mandates for such testing.”
  • US EPA Technologies for Legionella Control in Premise Plumbing Systems: Scientific Literature Review (EPA 2016)
  • World Health Organization’s Legionella and the prevention of legionellosis (WHO 2007).In this document, the World Health Organization introduced the water management program framework and essential elements that were later incorporated in VHA Directive 1061 and ASHRAE 188. It also emphasized that responsibility for Legionella risk management lies with the facility: “Fundamentally, the responsibility for managing the risk of legionellosis belongs to the facility owner or manager.”

List of Guidelines and References

ASHRAE. 1998. Legionellosis: Position Paper. Atlanta: American Society of Heating, Refrigerating and Air-Conditioning Engineers.

ASHRAE. 2000. Minimizing the Risk of Legionellosis Associated with Building Water Systems. Atlanta: American Society of Heating, Refrigerating and Air-Conditioning Engineers. Available at TechStreet.com.

ASHRAE. 2015. Legionellosis: Risk Management for Building Water Systems. Atlanta: American Society of Heating, Refrigerating and Air-Conditioning Engineers. Available at ASHRAE.org

ASHRAE. 2018. Legionellosis: Risk Management for Building Water Systems. Atlanta: American Society of Heating, Refrigerating and Air-Conditioning Engineers. Available for purchase at TechStreet.com

Australian Government. 2015. Guidelines for Legionella Control in the Operation and Maintenance of Water Distribution Systems in Health and Aged Care Facilities. enHealth, Canberra. Available at Health.gov.au

Besser RE. 2002. “Legionnaires’ disease in the Unites States: Opportunities for Prevention.” In: Marre R et al, eds. Legionella. Washington, D.C.: American Society for Microbiology, 391-397

CDC. 2003. Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. Atlanta: Centers for Disease Control and Prevention. Available at CDC.gov.

CDC. 2016. Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards. Atlanta: Centers for Disease Control and Prevention. Available at CDC.gov WMP toolkit

CDC. 2016. Legionnaires’ Disease: Use water management programs in buildings to help prevent outbreaks. Vital Signs, June. Atlanta: Centers for Disease Control and Prevention. Available at CDC 2016 Vital Signs.

CDC. 2017. Legionnaires’ Disease: A problem for health care facilities. Vital Signs, June. Atlanta: Centers for Disease Control and Prevention. Available at CDC 2017 Vital Signs.

CDC. 2017. Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards. Atlanta: Centers for Disease Control and Prevention. Available at CDC WMP Toolkit.

CMS. 2018. QSO-17-30-Hospitals/CAHs/NHs. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Available at CMS.gov Medicare Provider Enrollment and Certification.

CTI. 2008. Legionellosis Guideline: Best Practices for Control of Legionella. Houston, TX: Cooling Technology Institute.

EPA. 1999. Legionella: Human Health Criteria Document. Washington, DC: U.S. Environmental Protection Agency. EPA-822-R-99-001, November 1999.

EPA. 2001. Legionella: Drinking Water Health Advisory. Washington, DC: US Environmental Protection Agency. EPA-822-B-01-005, March. Available at EPA.gov Legionella Report.

EPA. 2016. Technologies for Legionella Control in Premise Plumbing Systems: Scientific Literature Review. EPA 810-R-16-001 September. Available at EPA.gov Legionella Document Master September 2016.

Fields B, Benson R, Besser R. 2002. Legionella and Legionnaires’ Disease: 25 Years of Investigation. Clinical Microbiology Reviews 15; 3; 506-526

Garrison L, Kunz J, Cooley L, et al. 2016. Vital Signs: Deficiencies in Environmental Control Identified in Outbreaks of Legionnaires’ Disease-North America, 2000–2014. Morbidity and Mortality Weekly Report (MMWR) 65(22);576-584. Available at CDC.gov.

HSC (Health and Safety Commission). 2013. Legionnaires’ disease: The control of Legionella bacteria in water systems. Approved Code of Practice and Guidance (L8, fourth edition). Sudbury, U.K: HSE Books. Available at HSE.gov.

HSC (Health and Safety Commission). 2013. Legionnaires’ disease: Technical guidance. Part 1: The control of legionella bacteria in evaporative cooling systems. Sudbury, U.K: HSE Books. Contains public sector information published by the Health and Safety Executive and licensed under the Open Government License. Available at HSE.gov.

HSC (Health and Safety Commission). 2013. Legionnaires’ disease: Part 2: The control of legionella bacteria in hot and cold water systems. Sudbury, U.K: HSE Books. Contains public sector information published by the Health and Safety Executive and licensed under the Open Government License. Available at HSE.gov.

HSC (Health and Safety Commission). 2013. Legionnaires’ disease: Technical guidance. Part 3: The control of legionella bacteria in other risk systems. Sudbury, U.K: HSE Books. Contains public sector information published by the Health and Safety Executive and licensed under the Open Government License. Available at HSE.gov.

OSHA. 1996. Technical Manual; Section II, Chapter 7. U.S. Department of Labor, Occupational Safety and Health Administration. Available at Available at OSHA.gov.

Soda E, Barskey A, Shah P, et al. 2017. Vital Signs: Health Care–Associated Legionnaires’ Disease Surveillance Data from 20 States and a Large Metropolitan Area — United States, 2015. Morbidity and Mortality Weekly Report. June 6. Available at CDC.gov.

VHA. 2014. Prevention Of Healthcare-Associated Legionella Disease and Scald Injury from Potable Water Distribution Systems. VHA Directive 1061. Washington, DC: Department of Veterans Affairs. Available at VA.gov.

WHO. 2007. Legionella and the prevention of legionellosis. Geneva: World Health Organization. Available at WHO.int