Healthcare Water Management Program Frequently Asked Questions
Legionnaires’ disease and other infections associated with building water systems
Why are healthcare facilities at higher risk for having Legionnaires’ disease cases and outbreaks than other types of buildings?
Healthcare facilities, such as hospitals and nursing homes, usually serve the populations at highest risk for Legionnaires’ disease. These include older people and those who have certain risk factors, such as being a current or former smoker, having a chronic disease, or having a weakened immune system. Also, healthcare facilities can have large complex water systems that promote Legionella (the bacterium that causes Legionnaires’ disease) growth if not properly maintained. For these reasons, the Centers for Medicare & Medicaid Services [4 pages] (CMS) and the Centers for Disease Control and Prevention (CDC) consider it essential that hospitals and nursing homes have a water management program that is effective in limiting Legionella and other opportunistic pathogens of premise plumbing (waterborne pathogens, for short) from growing and spreading in their facility.
What are “opportunistic pathogens of premise plumbing” and what are some examples other than Legionella?
Opportunistic pathogens of premise plumbing are germs that grow well in drinking water distribution systems and can cause disease in humans. Examples of these include Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, various species of fungi, and Naegleria fowleri. Many of the environmental factors that are conducive for Legionella growth also allow for growth of these other opportunistic pathogens.
How do Legionella and other opportunistic pathogens of premise plumbing get into building water systems?
Legionella and other waterborne pathogens occur naturally in the environment, in bodies of water like lakes, rivers, and streams. Although municipalities treat their water with disinfectants like chlorine that can kill these pathogens, a number of factors may allow these pathogens to enter a building’s water distribution system, such as
In addition, factors within building water systems can promote Legionella growth, including
- Biofilm, scale, and sediment
- Fluctuations in water temperature and pH
- Inadequate levels of disinfectant
- Changes in water pressure
- Water stagnation
Water Management / Sampling
What is a water management program?
Water management programs identify hazardous conditions and take steps to minimize the growth and spread of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key activities are routinely performed in a Legionella water management program:
In general, the principles of effective water management include
Members of a building water management program team work together to
Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions. Programs should include predetermined responses to correct hazardous conditions if the team detects them.
Is routine testing for Legionella recommended to validate a water management program at a healthcare facility?
Sometimes. The water management program team should regularly monitor water quality parameters, such as disinfectant and temperature levels. By monitoring these parameters, the team can ensure that building water systems are operating in a way to minimize hazardous conditions that could encourage Legionella and other waterborne pathogens to grow. However, it is up to the team to determine how to validate the efficacy of the program, based on the environmental assessment* and data supporting the overall performance of the water management program.
According to the CDC/Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for Environmental Infection Control in Health-Care Facilities [240 pages, 2.31 MB] and Guidelines for Preventing Health-care-associated Pneumonia [179 pages], as well as to ANSI/ASHRAE Standard 188–2015, one option for validating the efficacy of the program is to perform environmental testing for the hazard, which may be Legionella or other waterborne pathogens. Testing water samples for Legionella may be appropriate as a means to confirm that a water management program, when implemented as designed, effectively controls the hazardous conditions throughout the building water systems.
According to HICPAC guidelines, another option for validating the effectiveness of water management programs specifically in healthcare facilities is to perform clinical surveillance for infections due to Legionella (or other waterborne pathogens), which could indicate a problem with the facility’s water quality. This should be performed within the context of a comprehensive environmental assessment for ALL potential water system hazards plus an understanding of disease patterns due to Legionella (or other waterborne pathogens). Additional guidance for Legionella prevention for facilities with protective environments (i.e., transplant units) is included in the HICPAC guidelines.
If the team decides to perform validation using environmental testing for Legionella or other waterborne pathogens, it should not be performed in isolation but rather as part of a comprehensive water management program. Specific decisions about sampling frequency, location, and methodology are made by the team. Sampling plans are unique to each facility and are based on factors such as
*The environmental assessment enables the water management program team to gain a thorough understanding of a facility’s water systems and assists facility management with minimizing the risk of legionellosis. Guidance is available via CDC’s Legionella Environmental Assessment Form [15 pages].
What specific information is available regarding monitoring parameters and control measures (e.g., temperatures, disinfectant levels)?
Guidance on monitoring is available, but the specifics for each building will be defined by the water management program team, taking state and local regulations into consideration, as well as a variety of factors including the facility environmental assessment, manufacturer’s operating instructions, and the data supporting the overall performance of the water management program. ASHRAE Guideline 12 may be most helpful (note that it is currently under revision; the updated version is currently undergoing public review).
Can you provide an example of a water management program?
The CDC toolkit Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings [36 pages, 13.30 MB] walks through the key elements of a comprehensive water management program and describes the steps involved in creating and maintaining the program. Every building is different (depending on factors such as the structure, age, location, occupants of the building, or surrounding conditions), so each one needs a tailored program. The details will be defined by the water management program team, taking state and local regulations into consideration.
References and Resources
- Legionellosis: Risk Management for Building Water Systems. ANSI/ASHRAE Standard 188–2015. Atlanta, GA: ASHRAE; 2015.
- ASHRAE 188 Frequently Asked Questions
- Minimizing the Risk of Legionellosis Associated with Building Water Systems. ASHRAE Guideline 12-2000. Atlanta, GA: ASHRAE; 2000.
- Cooling Technology Institute, Legionellosis Guideline: Best Practices for Control of Legionella [12 pages]
- Model Aquatic Health Code
- Disinfection of Hot Tubs Contaminated with Legionella [2 pages]
Planning Guides and Toolkits
- Emergency Water Supply Planning Guide for Hospitals and Healthcare Facilities [95 pages, 2.07 MB]
- Drinking Water Advisory Communication Toolbox [166 pages, 4.78 MB]
- Centers for Disease Control and Prevention, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings
- Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-care Facilities [240 pages, 2.31 MB]. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR. 2003;52(RR-10):1–42.
- Centers for Disease Control and Prevention. Guidelines for Preventing Health-care-associated Pneumonia, 2003 [179 pages]: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR. 2004;53(RR-3):1–36.
- Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings, 2003 [76 pages, 1.22 MB]. MMWR. 2003;52(No. RR-17).
- Prevention of Healthcare-associated Legionella Disease and Scald Injury from Potable Water Distribution Systems
- Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults, 2007
- Management of Adults with Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society, 2016
- Centers for Disease Control and Prevention: Legionella (Legionnaires’ Disease and Pontiac Fever)
- European Centre for Disease Prevention and Control: European Legionnaires’ Disease Surveillance Network (ELDSNet)
- Environmental Protection Agency: Technologies for Legionella Control in Premise Plumbing [139 pages, 1.67 MB]
- Environmental Protection Agency: Legionella
- Environmental Protection Agency: Point-of-Use and Point-of Entry Treatment Devices
- Environmental Protection Agency: Mycobacteria Drinking Water Fact Sheet [4 pages]
- Environmental Protection Agency: Mycobacteria Health Advisory [35 pages]
- American Water Works Association: Distribution System Water Quality
- World Health Organization: Legionella and the Prevention of Legionellosis [276 pages, 1.71 MB]
- World Health Organization: Water Safety in Buildings [164 pages]
- Page last reviewed: September 14, 2017
- Page last updated: September 14, 2017
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