ANN ARBOR, MICH.—Environmental and public health experts agree that proactive water management plans, stronger policies, collaboration, communication and regulation are needed to stop the rapidly increasing number of Legionnaires’ disease cases and outbreaks.
Representatives from public health agencies, water utilities, water industry organizations, regulatory bodies and academia were among 360 international attendees at Legionella Conference 2019, Building Water Systems: The Sustainability and Public Health Nexus, co-hosted by NSF International and the National Environmental Health Association September 11 to 13 in Los Angeles.
The conference emphasized the importance of building water management plans and served as an important driver in thought leadership about surveillance and response to outbreaks.
“We are humbled by the enormity of the public health issue before us. Together, we can rise to the challenges and shape the approach to protect human health for decades to come,” said Chris Boyd, General Manager of Building Water Health at NSF Health Sciences, LLC.
Policies Need Attention
In his keynote address, Dr. Patrick Breysse of the U.S. Centers for Disease Control and Prevention (CDC) said policies need attention. Dr. Breysse, who is Director of the CDC’s National Center for Environmental Health/Agency for Toxic Substances and Disease Registry, presented grim statistics.
Legionnaires’ disease, a severe form of pneumonia caused by inhaling aerosolized water containing Legionella bacteria, is fatal for 25 percent of people who contract it in a health care setting and deadly to 10 percent of the general population, according to CDC data. About nine out of 10 outbreaks are caused by problems that could be prevented with more effective water management, Dr. Breysse said, adding that outbreaks are often due to environmental deficiencies related to process failure, human error, equipment repairs or unmanaged external events—such as a power outage.
“It will take a diverse set of stakeholders to truly move the needle. Everyone wins in the end when the outcome is preventing Legionnaires’ disease,” Dr. Breysse told a packed ballroom at the Westin Bonaventure Hotel in Los Angeles.
The first documented Legionella outbreak and name for the disease came after the 1976 American Legion convention in Philadelphia, when 221 people attending fell ill and 34 died. Since then outbreaks have continued to rise, and there has been a six-fold increase in reported cases between 2000 and 2018, according to the CDC.
Safe water is a strategic priority, and Legionella is one of the CDC’s main focus areas, Dr. Breysse said.
Legionella Toolkit Available
The CDC has published a Legionella toolkit based on ANSI/ASHRAE Standard 188-2015 detailing seven steps for a water management program. Other interagency efforts between the CDC, the Department of Veteran Affairs and the U.S. Environmental Protection Agency also address Legionnaires’ disease.
Nationally, water management programs are being implemented but aren’t yet widespread, according to Dr. Breysse, who added promising developments include the:
- Centers for Medicare & Medicaid Services June 2017 memo requiring water management plans in hospitals and long-term care facilities;
- Cooling tower registry and regulation in New York City and throughout New York state, as well as the potable water regulations in health care facilities in New York state; and
- Cooling tower and decorative fountain registry in Vancouver, Canada.
Deterrents in the long road to achieving widespread use of water management programs include cost and the lack of resources and expertise, as well as required policies still in their infancy, Dr. Breysse said.
Best Practices to Control Legionella
The CDC co-sponsored a study conducted by the National Academies of Sciences, Engineering, and Medicine (NASEM) that examined evidence and best practices to control Legionella in water systems.
Dr. Michèle Prévost, a NASEM Management of Legionella in Water Systems study committee member, presented the report in depth to Legionella Conference attendees. Dr. Prévost is Professor and Industrial Chair for Drinking Water of the Natural Sciences and Engineering Council of Canada and Civil Engineering Industrial Chair for Polytechnique Montréal.
The NASEM report, published August 14, 2019, conservatively estimates 52,000 to 70,000 people contract Legionnaires’ disease annually in the United States. The study made a number of recommendations and findings. Among them:
- Establish cooling tower registration systems and monitor cooling towers to improve the ability of public health departments to ensure these systems are operated safely, and to quickly investigate when prevention efforts fail;
- Expand the Centers for Medicare & Medicaid Services memo to require monitoring for Legionella in environmental water samples for all hospitals and long-term care facilities;
- Require water management plans in all public buildings, including hotels, businesses, schools, apartments and government buildings;
- Require a temperature of 60° C (140° F) at hot-water heaters and 55°C (131°F) to the distal points (the point of connection to fixtures including thermal mixing values);
- Require a minimum disinfectant residual throughout public water systems; and
- Develop better clinical tools for the urgent need to capture more cases of Legionnaires’ disease and identify pathogenic Legionella beyond the dominant species (Legionella pneumophila serogroup 1)
Additionally, the NASEM report says:
- Green buildings and water and energy conservation efforts have worsened many of the problems with Legionella.
- Low-flow fixtures should not be allowed in hospitals and long-term care facilities because of these buildings’ high-risk occupant populations.
- New designs are needed to help advance control of Legionella in cooling towers and humidifiers, in particular the use of temperature control in cooling towers.
- Regional centers of excellence could serve as a backbone to strengthen the capacity of state health departments to detect and investigate cases of Legionnaires’ disease.
“This is a significant report,” Dr. Prévost said. “Where are we 40 years after Philadelphia? Much has been learned, but much less progress has been made in preventing Legionnaires’ disease.”
Health Professionals Backbone of Public Health
Environmental health professionals are the backbone of public health, and local practitioners should be considered a foundational resource, Dr. David Dyjack, Executive Director of the National Environmental Health Association, emphasized. “Each state needs, as it manages its water resources, to align administrative, technical and political capital to nurture the relationships that make Legionella outbreaks much less likely. This begins with professional relationships grounded in trust and a common mission,” Dr. Dyjack said.
Water is a national security issue, Dr. Dyjack said, citing $1 trillion in water distribution infrastructure investments needed to ensure a healthy, sustainable and efficient supply. “We’ve entered an era where water management will present complexities sobering in scale…it is high time our nation gets our arms around this.”
View the Legionella Conference 2019 photo gallery at www.legionellaconference.org.