Not-so-fun fact, the bacterial infection known as Legionella was discovered and given its name after the 1976 outbreak that occurred at the American Legion convention in Philadelphia. Conference goers became ill with pneumonia-like symptoms that included cough, fever, achy muscles, and more. By the end of the outbreak, more than 200 became ill, and 34 died.1 Since its discovery in 1976, Legionella can be found worldwide. In Australia, Europe, and the United States, the incidence of occurrence is 10 to 15 cases per million people, according to World Health Organization (WHO).2
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Unfamiliar with Legionella? Read on!
What Exactly is Legionella, and How Does Wind Up in Public Spaces?
The bacteria Legionella pneumophila is found naturally in freshwater environments, such as lakes and streams, but it becomes a health concern, according to Atlanta-based Centers for Disease Control (CDC), “when it grows and spreads in human-made building water systems, like3:
Legionella’s ability to grow and spread is especially a concern where “building water systems that are not managed adequately and where disinfectant levels are low, water is stagnant, or water temperatures are ideal for growth of bacteria,”4 notes the CDC. It’s important to note that, because home and car air-conditioning units do not use water to cool the air, they are not a risk for Legionella growth.
Once Legionella grows and multiplies in large, complex water systems that are not adequately maintained, it has the potential to spread. This happens when water containing the bacteria is dispersed in droplets that are small enough to be breathed in. People contract Legionnaires’ disease when they breathe in the mist or aspirate (swallow water into the lungs) water containing Legionella.3
Additionally, Legionella can grow and spread in internal and external areas. Internal areas include cold water distribution to locations such as cooling towers, ice machines, decorative fountains, sinks/showers, hot tubs and pools; heating locations such as water heaters and hot water storage; hot water distribution areas such as sinks/showers and kitchen appliances; and the sanitary sewer. External areas include nearby construction projects and water main breaks.6
Why Is Legionella a Problem?
Legionella is a growing concern for three reasons. First, it’s found in common public places. “About 5,000 people are diagnosed with Legionnaires’ disease, and there are at least 20 outbreaks reported each year,” according to the CDC. “Most identified outbreaks are in buildings with large water systems, such as hotels, long-term care facilities, and hospitals.”5 Second, there are no vaccines to prevent the disease. Third, specific subsets of the population are at greater risk of getting sick, including:
- People 50 years or older
- Current or former smokers
- People with a chronic lung disease (like chronic obstructive pulmonary disease or emphysema)
- People with weak immune systems or who take drugs that weaken the immune system (like after a transplant operation or chemotherapy)
- People with cancer
- People with underlying illnesses such as diabetes, kidney failure, or liver failure3
How Can We Prevent the Spread of Legionella?
One way to prevent the growth and spread is to reduce the amount of stagnant water in the water system. Moving water is less likely to develop biofilm and pathogen contaminants. Dead legs—outlets that are either unused or lengths of pipe that are closed at one end to prevent water flow—can result in water stagnation. Removing them or addressing them with pipe flushing or recirculation eliminates potential issues. Additionally, the development of a routine schedule to flush shower systems should be considered.
To thoroughly limit the growth and spread of Legionella, building owners should employ a comprehensive water management program in each of their buildings, especially health care, education, and commercial facilities.
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In the United States, ANSI/ASHRAE Standard 188-2018, Legionellosis: Risk Management for Building Water Systems, establishes minimum Legionellosis risk management requirements for building water systems.7 To help building owners comply with these standards, CDC has developed a toolkit called Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings: A Practical Guide to Implementing Industry Standards. It is designed to “help people understand which buildings and devices need a Legionella water management program to reduce the risk for Legionnaires’ disease, what makes a good program, and how to develop it.”6
Specifically, the CDC’s water management program recommends the following steps to prevent the growth and spread of Legionella:
1. Establish a water management program team
2. Describe the building water systems using text and flow diagram
3. Identify areas where Legionella could grow and spread
4. Decide where control systems should be applied and how to monitor them
5. Establish ways to intervene when control limits are not met
6. Make sure the program is running as designed and is effective
7. Document and communicate all the activities”6
Revised in June 2021, the 36-page guide is available free at https://www.cdc.gov/legionella/
Because Legionella is caused by the bacteria Legionella pneumophila, which is found in potable and non-potable water systems, it is not contagious, like SARS and influenza. However, it is severe and can be lethal, especially to the at-risk populations mentioned above. In fact, 56,000 to 113,000 people are infected with the bacteria every year in the United States, according to Legionella.org, a nonprofit organization that provides educational resources to those affected by the disease, including those who are living with it, clinicians, and water treatment professionals. Moreover, according to CDC, in the United States, “the rate of reported cases of Legionnaires’ disease has grown by nearly nine times since 2000,” although it is unclear whether that’s because of increased awareness and testing, increased susceptibility, increased Legionella in the environment or a combination of those factors.8 CDC officials also believe that the disease is underdiagnosed and that these numbers, therefore, underestimate its true incidence.
The Benefits of a Water Management Program
So, the bottom line is that a thoroughly implemented water management program can prevent the growth and spread of Legionella. Following ANSI/ASHRAE Standard 188-2018, implementing a well-documented risk management program and monitoring the program serves to keep this deadly (there’s one death per 10 diagnoses9) bacteria out of building water systems, thereby preventing infection and death rates, and reducing building owners’ culpability.
Resources
1. Klein, C. (July 21, 2016). Remembering the Legionnaires outbreak. Retrieved August 2023, from https://www.history.com/news/the-discovery-of-legionnaires-disease
2. Legionnaires’. (December 2016). Retrieved August 2023, from https://www.who.int/features/qa/legionnaires/en/
3. Causes, how it spreads, and people at increased risk. (n.d.) Retrieved August 2023, from https://www.cdc.gov/legionella/about/causes-transmission.html
4. Patients in health care facilities at risk for Legionnaires’ disease. (June 6, 2017). Retrieved August 2023, from https://www.cdc.gov/media/releases/2017/p0606-legionnaire-disease-risk.html
5. Legionnaires’ disease: Use water management programs in buildings to help prevent outbreaks. (n.d.). Retrieved August 2023, from https://www.cdc.gov/vitalsigns/pdf/2016-06-vitalsigns.pdf
6. Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings: A Practical Guide to Implementing Industry Standards. (June 24, 2021). Retrieved August, 2023, from https://www.cdc.gov/legionella/downloads/toolkit.pdf
7. ANSI/ASHRAE Standard 188-2018: Legionellosis: Risk management for building water systems. (n.d.). Retrieved August 2023, from https://www.ashrae.org/technical-resources/bookstore/ansi-ashrae-standard-188-2018-legionellosis-risk-management-for-building-water-systems
8. History, burden and trends. (n.d.). Retrieved August 2023, from https://www.cdc.gov/legionella/about/history.html
9. Diagnosis, treatment, and complications. (n.d.) Retrieved August 2023, from https://www.cdc.gov/legionella/about/diagnosis.html
