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What is Legionella?

Legionella are bacteria. There are many disease-causing (pathogenic) species of Legionella bacteria. The pathogenic species most associated with outbreaks of disease is L. pneumophilaIt was named after an outbreak at the 1976 American Legion convention in Philadelphia, PA. L. pneumophila is the Legionella species that causes legionellosis including Legionnaires’ disease. People can get Legionnaires’ disease when they breathe in small droplets of water in the air that contain Legionella. One out of 10 people who get sick from Legionnaires’ disease will die. Keeping Legionella out of water systems is key to preventing Legionnaires’ disease.

Part 1: How does Legionella form?

Dr. William McCoy, Phigenics CTO and Legionella consultant and expert explains the life cycle of Legionella and how it forms.

Part 2: Where does Legionella grow (biofilm)?

Dr. William McCoy, Phigenics' CTO & Legionella consultant and expert explains where in building water systems Legionella are found.

Part 3: How does Legionella grow?

Dr. William McCoy, Phigenics' CTO & Legionella consultant and expert explains how Legionella bacteria thrive and survive in building water systems.

Part 4: How does Legionella spread (lysis)?

Dr. William McCoy, Phigenics' CTO & Legionella consultant and expert explains what lysis is and how it impacts the spread of Legionella bacteria.

Part 5: What is Legionella's impact on health (Legionnaires' Disease and Pontiac Fever)?

Dr. William McCoy, Phigenics' CTO & Legionella consultant and expert explains what is Legionella's impact on health (Legionnaires' Disease and Pontiac Fever)?

Part 6: What is the long-term impact of Legionnaires' Disease (Legionellosis)?

Dr. William McCoy, Phigenics' CTO & Legionella consultant and expert explains the long term impact of Legionnaries' disease (Legionellosis).

What are the standards and guidelines for Legionella Prevention and Risk Management (ASHRAE 188 and CMS Requirement S&C 17-30)?

The safe management of water in the built environment is a dynamic process that includes stakeholders with varying water management objectives. This is important, as according to the CDC, 6,100 people in in the U.S. were diagnosed with Legionnaires’ disease. CDC investigations show that 9 in 10 of these outbreaks were caused by problems that were preventable with more effective water management https://www.cdc.gov/vitalsigns/pdf/2016-06-vitalsigns.pdf.

The table below represents the major guidance and industry directives for the development and implementation of water safety and Legionella risk management programs. In many cases, they were developed by a committee of experts, and represent the best knowledge and guidance available.

Published Guidelines & Directives for Water Safety Management Programs - UPDATED 2018

What is ANSI/ASHRAE Standard 188?

ANSI/ASHRAE Standard 188:2015, “Legionellosis: Risk Management for Building Water Systems” was originally approved and published in June 2015. More than 5 million buildings in the U.S. are within scope of the standard’s requirements.

Minimum Standard Requirements:

The Standard requires at a minimum that building owners establish and practice a Water Management Program for facilities with any of the following:

    • Cooling towers or evaporative condensers
    • Whirlpool spas
    • Ornamental fountains
    • Misters, atomizers, air washers, humidifiers
    • Other devices that release water droplets

For potable (domestic) plumbing systems with any of the following, the Standard also applies:

    • Multiple housing units with a centralized hot water system
    • More than 10 stories
    • Housing for occupants over age 65
    • Patients staying longer than 24 hours
    • An area housing or treating people with certain health factors

Requirements for implementing an ongoing Water Management Program:

      1. A list of Water Management Program team members
      2. A brief description of building water systems, with floor diagrams, listing salient information about all the water systems and showing, in simple line diagrams, where water is received, processed, and used.
      3. A (Legionella) Hazard Analysis for building water systems that briefly explains why each water processing step does or does not present significant potential for Legionella growth and transmission and, for those processing steps that do, whether it is a location at which Legionella control measures can be applied.
      4. Application of (Legionella) hazard control measures to actually reduce the risk of Legionnaires’ disease. For most control measures, options are available; selecting the appropriate one for your facility is critical.
      5. Ongoing documented confirmation that the Water Management Program is being implemented as designed (verification) and that control is effective (validation).

Water Management Programs require continuous, ongoing implementation and maintenance. Like all other facility management programs, it takes time, expertise, resources, and independent confirmation to establish defensibility.

Below is a list ASHRAE 188 Frequently Asked Questions answered by Phigenics CTO and ASHRAE 188 Committee Member, Dr. William McCoy. Click on each question to view an answer.

What is the CMS (Centers for Medicare and Medicaid Services) Requirement Survey and Certification (S&C) 17-30?

The Centers For Medicare & Medicaid Services (CMS) Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD) was published on 2 June 2017. All Medicare and Medicaid certified healthcare facilities are within scope of the new requirement.

The CMS Requirement states that healthcare facilities must have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens such as Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria (NTM) and fungi in facility water systems.

CMS Surveyors for Medicare and Medicaid eligibility certification will expect facility managers to implement water management programs based on ANSI/ASHRAE Standard 188:2018 and the CDC Toolkit for Development and Implementation of Water Management Programs.

Water management programs must consider control measures such as:

    • physical controls
    • temperature management
    • disinfectant level control
    • visual inspections
    • environmental testing for pathogens

Water management programs must specify testing protocols and acceptable ranges for control measures and corrective actions taken when control limits are not maintained. Results from monitoring and testing must be documented.

Below is a video that provides independent guidance on how to achieve compliance with the CMS Requirement S&C 17-30.

 

 

What are the 7 Steps for developing a defensible Legionella Prevention and Risk Management Program?

Having a water management program is the most defensible action to prevent Legionella in building water systems. A good water management program must be sustainable and comprehensive.

The purpose of a program is to make sure it is documented and that when implemented properly, optimizes the total cost of building water systems by improving safety and efficiency.

7 steps for developing a program are depicted in the infographic below. For the purposes of preventing Legionella, the following will focus on water safety.

 

7 Steps NOPHIGENICS LOGO

Step 1: Form a Team

Establishing the Water Management Team is the critical first step in developing a Legionella Prevention and Risk Management Program. The Water Management Program Team (called the Program Team in the ASHRAE Standard 188) is responsible for all aspects of developing and implementing the program.

The Water Management Program Team is required to have one or more individuals selected from the following: the building owner or designee, employees, suppliers, consultants, other individual(s) to whom the building owner has delegated authority and responsibility for the actions required by the Program.  Teams:

      • Must have more than one person
      • Are committed to regular meetings
      • Have AUTHORITY and RESPONSIBILITY for designing and implementing the program
      • Understand the facility owner and manager are responsible and liable for all decisions and take ownership of decisions

While specific make up of each team will vary, there are certain areas to consider when recommending selection of team members. These include:

      • Executive Management/Sponsor
      • Facility Management
      • Infection Control/Prevention
      • Nursing/Clinical
      • Environmental Services
      • Engineering
      • Plumbing
      • Sustainability
      • Environmental Health and Safety

Table of Professionals with Chat Boxes 2

Step 2: Develop Program Goals

The team then should develop high-level program goals and can document them in an Executive Summary. While an Executive Summary is not part of a standard or regulation, it is a useful tool to support the program, especially with higher level management. It should also be viewed as a dynamic, living document. It helps to develop consensus and get the team members on the same page at the beginning of the process.

Examples of goals and objectives for a Comprehensive Water Management Program:

    • To improve human health and safety by achieving compliance with ANSI/ASHRAE Standard 188.
    • To achieve a water use intensity metric, e.g. gallons/sq ft.
    • To achieve an energy use intensity metric, e.g. kBtu/sq ft
    • To achieving desired life expectancy for capital assets, e.g. 20 yrs/cooling tower and 25 yrs/boilers
    • To optimize chemical treatment costs, e.g. $ to treat 1000 gallons of makeup water for a cooling tower.

Step 3: Describe Water Systems

The third step in developing a Legionella Prevention and Risk Management program is to describe the water system.

There are two parts to describing the system: a system description in words, and a schematic of the system in a process flow diagram.

Process flow diagrams and system descriptions must describe how the water is received and processed, i.e. conditioned, stored, heated, cooled, re-circulated, treated, and delivered to end-point uses.

There should be separate process flow diagrams and system descriptions for potable water and utility water. All potable water systems and utility water systems must be identified.

flow diagram

The Water Management Team must confirm that the process flow diagrams and system descriptions accurately represent the water systems as built. This confirmation must be done with a site visit.

Step 4: Analyze Water Systems for Safety & Efficiency

Once the process flow documents have been confirmed with a site visit and approved by the Water Management Team, the next step is to analyze the system. Most community water utilities produce and distribute safe, high-quality water that complies with EPA regulations and is safe for intended use. However, the water provided by public water utilities is not sterile. Once the water is delivered to buildings it goes through building water systems that have may have one or all of the following characteristics:

    • Complex network
    • Small diameter pipes
    • Tepid water temperature
    • Stagnant/excessive water age
    • Cross connections/backflow
    • Dead Legs
    • Nutrients

The water may also go through one or more of the processing steps:

    • Filtering
    • Heating
    • Chilling
    • Softening
    • Storing
    • Distributing

Water quality can be changed by each processing step!

Building water systems consist of potable and utility water systems. Potable water consists of fixtures such as sinks, showers and fountains. Utility water is primarily boilers and cooling towers.

The system analysis should encompass both a safety analysis and an efficiency analysis for potable and utility water. These steps are done simultaneously but are noted separately because the terminology used to describe the process is different.  When doing a safety/hazard analysis, the team is looking for hazard or compromised safety. When doing an efficiency analysis, the team is identifying opportunities for optimizing water, energy, and asset use. For the purposes of this topic “Legionella Prevention and Risk Management”, the focus will be on safety.

The safety analysis is also commonly known as a “hazard analysis” as the system is being evaluated for hazards that would compromise safety. The first step in conducting a hazard analysis is to answer the question “What are the hazards or potential hazards at each processing steps?

Building water system hazards are physical, chemical, or microbial agents with the potential to cause harm under certain conditions.  

An example of a physical hazard is water. Scalding is a very serious problem. Injuries to the elderly, the very young and to people with disabilities such as diabetes can be horribly severe. Water temperatures above 130 F can scald in less than a minute.  The very old and very young are highly susceptible to scalding. It is important to control the temperature of hot water exiting the heater with a tempering valve. Do not control hot water temperature by the water heater temperature setting. If you use anti-scald valves, they must be maintained.

water temperature

Lead is an example of a chemical hazard. Where testing shows elevated levels of lead, you should:

    • Maintain pH greater than 8.5
    • Flush tap before each use
    • Flush system frequently (up to 4 times per day)

sources of lead in drinking water

Disinfectants and disinfection by-products are also chemical hazards:

    • Bromate
    • Chloramines
    • Chlorine
    • Chlorine dioxide
    • Chlorite
    • Trihalomethanes
    • Haloacetic acids
    • Nitrate
    • Nitrosodimethylamine (NDMA)
    • Other Nitrosoamines

One of the most important reasons for this regulation is that disinfection by-products (listed) can be toxic and/or carcinogenic. For example, nitrosamines and nitrosodimethylamine (NDMA) are known carcinogens that are associated with water that has been disinfected. Therefore, when supplemental disinfection is used, care must be taken to ensure that chemical hazards that may result from the treatment are well controlled.)

The following are examples of microbial hazards in the built environment.

    • Bacteria
      • Acinetobacter, Burkholderia, Elizabethkingia, Klebsiella, Legionella, Pseudomonas, Non-Tubercular Mycobacteria (NTM), Stenotrophomonas, coliform bacteria
    • Protozoa (Protists)
      • Acanthamoeba, Hartmannella (renamed Vermamoeba)
    • Fungi
      • Aspergillus, Fusarium
    • Viruses
      • Norovirus, Hepatitis A

Below is an example of the system analysis and the format it could be structured in. You’ll identify the hazard or potential hazard, determine if the risk is significant, and what the basis is for the team to determine if the risk is significant.  Under the risk basis, you will need to provide defensible documentation as to why the decision was made that the risk was or wasn’t significant. This can include industry best practices, data, or other information used to determine risk basis.

Then, the controls for that hazard are documented. If the controls must be applied in order to reduce the hazard, then this becomes a control location, or in HACCP terminology a critical control point (CCP).  We will discuss control locations in much more detail in the next section, as this will carry over to the next step of the process. The last column of this table indicates a cost impact.  It is useful for water management teams to identify the financial impact of the changes they’re making.

Processing Step Description

Potential Safety Hazard

B = Biological
C = Chemical
P = Physical

2. Cold water filtering (potable)

B - Growth of microorganisms on filter surfaces

4. Hot water distribution (potable)

B - The temperature of the water delivered throughout the facility and to the points of use is between 105 and 120 F, which is conducive to microorganism growth.

P - The presence of copper, lead and other heavy metals as a result of pipe corrosion

The next step in analyzing the water system is to answer the question, “Is the risk of harm from the identified hazards significant?” The team must make a defensible decision about the risk of harm from identified hazards.  

It is important to note that hazard does not equal risk. Risk equals probability x severity. Initially, the risk is identified is significant or not. It is then classified as “high, medium, low”. The basis for determining the risk level must be documented. For example, there is a high probability that a baby will fall when first learning to walk but the severity of injury is a very low risk; whereas, there is a moderate probability that an elderly person may fall and the risk of injury is very high so this is labeled as high risk. For hospitals, patient risk characterization must be taken into consideration. Below is an example of a matrix developed by a hospital Water Management Team. It is appropriate to note that this type of risk characterization can only be done in healthcare facilities, which have separated floors and wings for specific procedures and patient types. This cannot be done in a hotel, casino, university, or any other setting where the population can vary at any moment in time. In this particular example, the team decided to rank the risk in 4 levels, as you can see on the left. The highest risk area represented the most at risk for illness if exposed to water-related hazards. Again, this is an example provided for context. It is up to the individual Water Management Teams to determine how to appropriately characterize risk at their healthcare facilities.

risk characterization of areas in the facilities

From: Mayo Clinic published in Infection Control and Hospital Epidemiology 2014, 35, 556-563.

For other buildings, it is not feasible to take population risk into consideration because there are no designated spaces for specific individuals.

The following is what the table should look like after answering question 2.

Processing Step Description Potential Safety Hazard
B = Biological
C = Chemical
P = Physical
Risk Significant?
Yes/No
Basis for Risk Characterization
2. Cold water filtering (potable) B - Growth of microorganisms on filter surfaces No Improperly maintained filters can increase microbiological growth, however cold water temperatures could reduce the risk of growth. Water is also chlorinated by the city.
4. Hot water distribution (potable) B - The temperature of the water delivered throughout the facility and to the points of use is between 105 and 120 F, which is conducive to microorganism growth. P - The presence of copper, lead and other heavy metals as a result of pipe corrosion Yes Hot water distribution systems have has been associated with severe cases of disease. The water distribution system is complex throughout the building. Along with favorable temperatures for growth, there is a high potential for disinfectant residuals to dissipate as a result of the heating process, which directly reduces the ability to control hazards. These factors in conjunction with the potential for water to be aerosolized present a high risk at this processing step.

 

The third and final step is to answer the question, “What controls are being applied or could be applied at the processing step to reduce or eliminate the hazards?” Control options:

    • Water age
    • Heat
    • Disinfection
    • Filtration
    • Maintenance

Combinations of these controllable parameters are the basis for all hazard control approaches in water management of the built environment.

Water management teams should always insist on the hazard control option that is the:

    • Simplest
    • Safest
    • Least expensive
    • Has the least regulatory burden

Microbial hazard control options for utility water include:

    • Water preconditioning
      • Filtration
      • Softening
    • Scale and Corrosion inhibition
    • EPA registered biocides
      • Oxidizing biocides
      • Non-oxidizing biocides
    • Dispersants

Microbial hazard control options for potable water include:

    • Thermal disinfection
    • Flushing (reduce water age)
    • EPA approved supplemental disinfection
      • Chlorine
      • Chloramine
      • Chlorine dioxide
    • Other treatments
      • Point-of-use filtration
      • Cu/Ag ionization
      • UV disinfection

By the time all 3 questions are answered, the table should look like the following.

Processing Step Description Potential Safety Hazard
B = Biological
C = Chemical
P = Physical
Risk Significant?
Yes/No
Basis for Risk Characterization Controls Applied or Could be Applied CCP (Control Location)
Yes/No
Cost Impacts
A = Avoidance
O = OPEX
C = CAPEX
2. Cold water filtering (potable) B - Growth of microorganisms on filter surfaces No Improperly maintained filters can increase microbiological growth, however cold water temperatures could reduce the risk of growth. Water is also chlorinated by the city. 1.Maintain filters according to manufacturer's recommendations
2. Change filters when pressure drop occurs
No O - Could result in higher costs if filter changes are increases
C - Maintaining filters properly would reduce/eliminate replacement
4. Hot water distribution (potable) B - The temperature of the water delivered throughout the facility and to the points of use is between 105 and 120 F, which is conducive to microorganism growth. P - The presence of copper, lead and other heavy metals as a result of pipe corrosion Yes Hot water distribution systems have has been associated with severe cases of disease. The water distribution system is complex throughout the building. Along with favorable temperatures for growth, there is a high potential for disinfectant residuals to dissipate as a result of the heating process, which directly reduces the ability to control hazards. These factors in conjunction with the potential for water to be aerosolized present a high risk at this processing step. 1 - Flushing of the system is performed per the guidelines developed by the WMT 2 - Emphasis will be placed on the identification, removal, or mitigation of potential dead-legs that may exist within the distribution system 3 - Filtration at critical locations can be applied if necessary. 4 – Monitor oxidant levels at distal locations Yes O - Increased flushing will increase water usage and costs
O - Manpower to identify and remove deadlegs
C - Cost of potential filtration equipment
A - Decreased likelihood of negligence lawsuit

 

Step 5: Specify Control Locations, Control Limits, Monitoring, and Corrective Actions

When the potential hazard is indicated as a “significant risk”, a control must be applied to the location in the process step. This location is designated as a control location.

For each control location that was established in the System Analysis, the team must decide:

    • The control limit(s)
    • The control monitoring method(s)
    • The frequency of control monitoring
    • The corrective actions to be taken if control limits are violated

Control location (also called a critical control point in HACCP terminology) is the location at which control must be applied to control the hazard. Examples could include:

    • Location (point) at which disinfection is added
    • Location (point) where routine flushing is initiated
    • Location (point) at which cooling water treatment chemicals are added

A control limit (also called a critical limit in HACCP terminology) is the range of the applied control measure. It must be:

    • Quantitative
    • Measurable
    • Physical or chemical parameter

For example:

    • 0.5 – 1.0 ppm applied continuously is a control limit for free residual oxidant used to control microbial hazards in a potable water system
    • 4 – 5 ppm applied continuously is a control limit for phosphonate used to inhibit mineral scale deposits in order to reduce water use in a cooling tower

Monitoring and Frequency

The purpose of monitoring is to determine if control applied at the control location is within the control limits. The means, method, and frequency of monitoring must be established by the team.

Corrective Actions

A corrective action is a predetermined procedure to be followed if there is a deviation from the control limit. Corrective actions are NOT responses to detections of Legionella (or any other hazard) from analyses of water samples.

      1. Identify the processing step and critical control point from the system analysis
      2. For each control location, identify the type of control that will be applied
      3. For each control location, identify the control limits that the control must be kept within to control the hazard
      4. Identify a monitoring requirements for the control (means, method, and frequency)
      5. Develop a corrective action process for when monitoring indicates the control at the control location is outside of the control limits
      6. Determine where the records for monitoring are to be maintained
      7. Establish verification procedure for each control location. This is to verify that the monitoring was done as planned, and also to verify that corrective actions were taken  if monitoring indicated a control at a control location was outside of the control limits

For practical guidance click: Ask A Legionella Consultant: Common Mistakes With Control Locations, Control Limits, Monitoring, and Corrective Actions

Once the team has specified control locations, control limits, monitoring, and corrective actions, they are documented in a Systems Control Summary.

Processing Step Safety Hazard or Efficiency Opportunity Control Point Control Limits Monitoring Frequency Corrective Action Verification Procedure
4. Cold water distribution (potable) Safety Supplemental disinfection 0.5 - 4.0 ppm as Cl2 free residual oxidant (FRO) Perform free chlorine test on colorimeter instrument; perform disinfection by-products via certified lab Daily during startup, monthly after start-up Check product feed; call vendor if not operating properly; consider increased product feed after consultation with WMT Quarterly review of data log sheets
6. Cooling towers (utility) Efficiency - water and energy use reduction Chemical addition 4 ppm phosphate
2 ppm polymer
3.0 cycles of concentration
Phosphate test kit
Polymer test kit
Conductivity meter
Once per week
Once per week
Continuous
Consider increase / decrease feed
Consider increase / decrease feed
Increase / decrease blowdown
Contact chemical vendor
Check incoming water quality
Completion of utility verification form / service report
Quarterly review

 

Step 6: Develop Verification Strategy

As defined in ANSI/ASHRAE 188-2015, verification is initial and ongoing confirmation that the WMP is being implemented as designed. Verification is:

    • Confirmation that conditions at control locations meet control limits
    • Confirmation that all operations and maintenance activities are being carried out as specified, by designated personnel
    • A Quality Assurance (QA) function
    • Always documented

Verification is done to:

    • Prove that the System Controls Summary is being implemented as designed
    • Provide defensible documentation that the program is being implemented as designed
    • Confirm that conditions at control locations meet control limits
    • Prove that corrective actions are carried out when control limits are not met

If verification is not done, or if it is done but not documented, then it’s just as if no control was applied to the system.

Documents used as verification records:

    • Control limit monitoring data at control locations
    • Corrective action logs
    • Equipment service and maintenance records
    • Housekeeping records
    • Service reports from water treatment vendors

Step 7: Develop Validation Strategy

As defined in ANSI/ASHRAE 188-2015, validation is initial and ongoing confirmation that the WMP, when implemented as designed, effectively controls the hazardous conditions through the building water systems. Validation is a Quality Control (QC) function. Validation evidence must include confirmation that conditions at sentinel points fall within sentinel points targets (parametric validation).

Validation evidence may include:

    • Environmental testing and sampling that indicate that microbial counts are within acceptable levels
    • Clinical testing and observation that indicates the absence of injury or illness associated with identified hazards

Environmental Validation Responses per the VHA Directive 1061

 

Overview of Hazard Control Options for potable Water Systems

Chlorination of Building Water Systems

Chlorine disinfection is the most sensible, simplest, safest, least hazardous and least expensive means to control microbial hazards in building water systems. Application issues are often overstated as objections by vendors selling more complex and expensive alternatives.

Click here to see full whitepaper of chlorination of Building Water Systems

chloration of building water systems

Chloramination of Building Water Systems as an Alternative to Chlorination

Monochloramine is increasingly promoted for direct on-site addition to premise plumbing for supplemental disinfection. Notwithstanding the claimed advantages, monochloramine compares unfavorably to the use of chlorine for supplemental disinfection. Compared to supplemental chlorination of building water systems, the alternative use of chloramine is not preferred because:

1) Microbial control is inadequate

2) It results in higher proportions of Mycobacterium, Pseudomonas, Acinetobacter and nitrifying bacteria in biofilms

3) It induces the viable-but-nonculturable (VBNC) state in Legionella

4) Higher concentrations of nitrite and nitrate (regulated drinking water contaminants) can occur

5) It degrades to ammonium ion in premise plumbing treatments which can lead to nitrification

6) Corrosivity of elastomers and other construction materials is significant

7) Volatility is very high

8) The application is more complex due to instability of chloramines

9) The application is more expensive because the cost of chlorine is very low

10) N-Nitrosodimethylamine (NDMA), a potent carcinogen, in chloraminated drinking water is an emerging issue of great concern Therefore, supplemental chlorination of building water systems is more effective, simpler, safer and less expensive compared to chloramination. Additionally, in cases where the water supply is chloraminated, supplemental chlorination of the building water is a very effective control strategy.

Click here to see full whitepaper of Chloramination of Building Water Systems as an Alternative to Chlorination

chloration of building water systems as an alternative

Ask a Legionella Consultant: Why is it important to comply with SDWA?

Megan Cochran, Phigenics Regional Manager answering "Why is it Important to Comply with the SDWA?"

Ask a Legionella Consultant: Will my hospital become a Public Water System if I treat the water?

Dr. William McCoy, Phigenics CTO, Legionella consultant and expert answers "will my hospital become a Public Water System if I treat the water?"

Overview of Supplemental (Secondary) Disinfection Technologies for Legionella Prevention

Dr. William McCoy, Phigenics CTO, Legionella consultant and expert with Missy Cain, Phigenics Regional Manager discuss an overview of supplemental (secondary) disinfection technologies for Legionella prevention.

What is Legionella testing?

Legionella testing is the process of obtaining a water sample and analyzing it to detect the presence of the bacteria.

Why are water systems tested for Legionella?

Legionella testing done to confirm effectiveness is defined as validation. Testing for Legionella is done to confirm that a Water Management Program is effective at controlling Legionella, which is defined as a hazard. It is also done to discover the source of exposure after a disease case is reported.

What are the types of Legionella tests?

There are two general types of Legionella tests: Microbial culture tests (spread plates and field sampler “dipslides”) and molecular tests (Polymerase Chain Reaction, PCR). For microbial culture, L. pneumophila serogroup 1, serogroups 2-14 and Legionella spp. should always be determined for every isolate.

Why should my testing service be independent?

An independent, third-party testing service provides improved defensibility by removing real or perceived commercial conflict of interest or bias toward proprietary water treatment solutions.

Where should I test for Legionella?

Sampling locations are decided by the Water Management Team. Locations may include incoming water, showers, misters, ice machines, faucets, cooling towers and decorative water features. Phigenics recommends collecting post-flush samples from plumbing fixtures, when Legionella testing is done as part of routine validation to confirm WMP effectiveness. Call us to learn why.

When should I test for Legionella?

Testing should be undertaken after a Water Management Team has confirmed that a program has been implemented as designed (verification). The frequency of testing is determined by the Water Management Team and is often monthly, quarterly or semi-annually.

How should I respond to a positive Legionella test?

Any response should be predetermined and documented as a “contingency response” in the Water Management Program. Contingency responses should include a review of the verification data and may include activities such as flushing or hyperchlorinating the water system. Call us to learn more.

What is the CDC’s guidance for laboratory selection?

The CDC has five considerations for laboratory expertise: ELITE accreditation, the performance of culture method, level of identification, willingness to save samples and experience with environmental risk assessment and sampling. Click here to see how Phigenics meets the CDC’s criteria.

To learn more about Phigenics Legionella Testing Services please visit: www.phigenics.com/testing

Mayo Clinic: Proactive Water and Legionella Risk Management at one of the World’s Most Prestigious Clinics

Mayo Clinic partnered with Phigenics to develop and operationalize a comprehensive Water and Legionella Risk Management Program (ref: CMS S&C (17-30) and ASHRAE Standard 188). The program includes quarterly independent verification and validation (Legionella testing) of its performance.

Click here to download case study

Mayo Clinic Case Study-2

Walmart: Pioneering a Portfolio Approach to Water Management with Walmart

Walmart's adoption of a portfolio approach to cooling water management program is one way companies can make meaningful impacts in reducing water consumption and improving energy efficiency and safety.

Click here for additional details

Walmart Case Study Graphic 1-01

2018 Smart Water Leadership Summit Videos including Florida Hospital, Mandalay Bay, Atrium Health, Universal Health Services, Royal Carribbean Cruises and many more.

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smart water youtube

Visit the 2019 Smart Water Leadership Summit website by clicking here.

Chlorination of Building Water Systems

Chlorine disinfection is the most sensible, simplest, safest, least hazardous and least expensive means to control microbial hazards in building water systems. Application issues are often overstated as objections by vendors selling more complex and expensive alternatives.

Click here to see full whitepaper

chloration of building water systems

Chloramination of Building Water Systems as an Alternative to Chlorination 

Monochloramine is increasingly promoted for direct on-site addition to premise plumbing for supplemental disinfection. Notwithstanding the claimed advantages, monochloramine compares unfavorably to the use of chlorine for supplemental disinfection.

Click here to see full whitepaper

chloration of building water systems as an alternative

A Comprehensive Water Management Program for Multicampus Healthcare Facilities. Journal: Infection Control and Hospital Epidemiology Authors: Mayo Clinic and Phigenics 

Application of the HACCP process for long-term building water systems management was practical and effective. The need for critical control point management of temperature, flow, and oxidant (chlorine) residual concentration was emphasized. The process resulted in discovery of water system components requiring additional hazard control.

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HACCP-Based Programs for Preventing Disease and Injury from Premise Plumbing: A Building Consensus Journal: Pathogens Authors: Phigenics and Gordon and Rosenblatt

Thousands of preventable injuries and deaths are annually caused by microbial, chemical and physical hazards from building water systems. Water is processed in buildings before use; this can degrade the quality of the water. Processing steps undertaken on-site in buildings often include conditioning, filtering, storing, heating, cooling, pressure regulation and distribution through fixtures that restrict flow and temperature. Therefore, prevention of disease and injury requires process management. A process management framework for buildings is the hazard analysis and critical control point (HACCP) adaptation of failure mode effects analysis (FMEA). It has been proven effective for building water system management. Validation is proof that hazards have been controlled under operating conditions and may include many kinds of evidence including cultures of building water samples to detect and enumerate potentially pathogenic microorganisms. However, results from culture tests are often inappropriately used because the accuracy and precision are not sufficient to support specifications for control limit or action triggers. A reliable negative screen is based on genus-level Polymerase Chain Reaction (PCR) for Legionella in building water systems; however, building water samples with positive results from this test require further analysis by culture methods.

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Environmental Validation of Legionella Control in a VHA Facility Journal: Infection Control and Hospital Epidemiology Authors: Central Texas Veterans Health Administration and Phigenics

We conducted this study to determine what sample volume, concentration, and limit of detection (LOD) are adequate for environmental validation of Legionella control.

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Sustainable Comprehensive Water Management Program Training Course

The purpose of the Phigenics course is to enable learners to improve facility water system safety and efficiency.

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Ask a Legionella Consultant: Why should I invest in a Water Management Program?

Marty Detmer, Phigenics Regional Manager answers "Why should I invest in a Water Management Program?"

Considerations when choosing a Legionella Consultant

If your building needs a Legionella water management program or remediation services, you may consider working with one or more Legionella consultants. Deciding whether to work with consultants at all, and if so, the exact type and number of consultants you decide to use, will depend on your situation and the consultant’s area of expertise.

We didn’t write the previous paragraph—it’s straight from the Centers for Disease Control and Prevention (CDC). Our credentials as Phigenics Legionella consultants match the CDC standards so closely, they might as well have been written with us in mind. In this blog post, we’ve placed the CDC’s guidelines on the left and our credentials on the right:

Level of experience:

  • For example, what kind of Legionella-specific experience do the employees of this company have?
  • Do the employees have appropriate training in critical fields (e.g., engineering, environmental health or industrial hygiene, water treatment, plumbing, microbiology)?
  • Does the company have Legionella-specific experience with a facility of your size/type?
  • Does the company have experience with water system remediation, implementation of water management programs to prevent Legionnaires’ disease, or both?

Phigenics has developed comprehensive water management programs to combat Legionella in 50 states and multiple foreign countries.

We have Legionella-specific experience from the best known healthcare and retail facilities (like the Mayo Clinic, the VA, and Walmart), all the way down to the smallest hotels and university buildings.

We have extensive expertise with both remediation and implementation of comprehensive water management programs that prevent Legionnaires’ disease.

Laboratory expertise:

  • For example, is the laboratory used accredited for environmental testing?
  • Does it participate in a proficiency testing program for Legionella?
  • Does the laboratory perform culture for Legionella (which is particularly important following remediation to ensure adequacy of the remediation process)?
  • What level of identification (species/serogroup) can the laboratory perform?
  • Is the laboratory willing to save samples and isolates and share them with public health laboratories if requested during an outbreak investigation?

We are certified as proficient in the Environmental Legionella Isolation Techniques Evaluation (ELITE) program administered by the CDC. In fact, we have passed every proficiency test since the beginning of the CDC ELITE program with 100% correct scores. We are also EPA-NELAP certified for the analysis of drinking water.

Phigenics analytical services laboratories are certified as proficient in the Environmental Legionella Isolation Techniques Evaluation (ELITE) program administered by the Centers for Disease Control and Prevention (CDC) for using the Phigenics patented PVT Test and the ISO 11731 spread plate method.

Phigenics delivers the fastest and most accurate Legionella testing service for water systems found in commercial, institutional, and industrial facilities. We provide independent confirmation that water treatment products and services have been applied correctly (verification) and that the water treatment applied is effective (validation). We perform comprehensive testing, including Legionella pneumophila (serogroup 1 and 2-14), non-pneumophila Legionella species, and Total Heterotrophic Aerobic Bacteria (THAB), and fully comply with investigations during outbreaks.

Environmental risk assessment expertise:

For example, how much experience does the company have with environmental risk assessments and/or sampling for Legionella? Can they describe situations where they performed an environmental risk assessment and/or Legionella sampling in a facility of your size/type?

Phigenics is an EPA-NELAP certified laboratory for the analysis of drinking water and provides a wide range of testing services for biohazards. Phigenics also provides complete testing services required by the Safe Drinking Water Act. As a Legionella testing company, we have performed environmental risk assessments and samplings for facilities of all sizes and types.

Remediation expertise

For example, how frequently does the company provide remediation services and can they describe situations where they remediated Legionella from a building water system in a facility of your size/type? Can the company discuss the benefits and challenges associated with multiple approaches to remediation?

Phigenics assists hundreds of building owners, from a myriad of industries, to effectively manage their water systems. Phigenics' clients include over 70 Veterans Health Administration facilities, Mayo Clinic, Walmart, the National Security Agency, Pernod Ricard, and multiple state and private universities. We are familiar with the benefits and challenges associated with different approaches to remediation and have written numerous white papers on the subject.

Water management expertise:

For example, how much experience does the company have creating water management programs compliant with industry standards for a facility of your size/type?What level of support does the company provide with creation and implementation of water management programs? What is the spectrum of services they offer once the water management program is established?

We have created hundreds of sustainable, comprehensive water management programs for facilities of every size and type. Phigenics ensures that every water management program is implemented as designed (verification) and that the program effectively controls the hazardous conditions throughout the building water systems (validation). All team members have access to phiMetrics, a web-­based platform developed by Phigenics, to bring data front and center with charting and alerting capabilities. Water management team members can analyze real­-time data and respond appropriately in any situation.

Knowledge of codes, standards, and regulations:

For example, does the company have previous experience working in your state and/or jurisdiction? How familiar is the company with state and local building codes in your jurisdiction, water treatment regulations, healthcare accreditation and survey requirements, and public health reporting requirements? Local building code officials or your health department may be good resources for knowledge about existing codes, standards, and regulations.

After working in all 50 states, Phigenics’ independent, expert representatives are knowledgeable in the SDWA compliance process and individual state requirements for additional testing. Our Legionella consultants are well-versed in state and local building codes, water treatment regulations, healthcare accreditation and survey requirements, and public health reporting requirements.

Potential conflicts of interest:

For example, does the company have interest in promoting specific services or products?

As an independent Legionella company, Phigenics does not sell water treatment products. Instead, we provide independent guidance on improving safety and efficiency.

Whether you’re looking for an independent Legionella testing company, a Legionella consultant, or a comprehensive water management program to improve both safety and efficiency, Phigenics can help.