Some attorneys still advise their hospital, hotel or industrial clients that a head-in-the-sand approach to Legionnaires' disease and other waterborne illness is the cost-effective way to manage related legal risk. But attorneys that have actually been involved in such litigation as well as the building owners, engineers and contractors that have been sued now know that doing nothing and pleading ignorance can lead to expensive lawsuits, emotional stress, wasted time and damaging press. Worse than that, it can result in debilitating illness and even death.
A number of government agencies and industry groups in the United States advocate a proactive approach to Legionnaires' disease, including the U.S. Environmental Protection Agency (EPA), the Occupational Safety and Health Administration (OSHA), the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) and some state and local health departments. Even the Centers for Disease Control and Prevention (CDC), which for years had defended a reactive approach ("don't worry about the water unless someone gets sick") to the disease, has recently released guidelines recommending "aggressive disinfection measures for cleaning and maintaining devices known to transmit legionellae" (U.S. Department of Health and Human Services, 2003).
In several foreign countries, the guidelines for reducing the risk of Legionnaires' disease are more extensive than in the United States, and are mandated. In Australia and the United Kingdom, violations that result in disease can carry stiff penalties and even prison terms.
What Should You Do?
Although industry groups, experts and government officials do not agree on all the details, most agree with the following overall strategy:
- 1. Form a team, appoint a leader and establish communication. In a hospital, the team should be headed by the facilities director and include members from infection control, risk management, administration and the medical staff. The team should meet periodically to ensure that the plan is being implemented, to review its effectiveness, and to consider revisions.
- 2. Identify high-risk building areas based on water exposure and occupant susceptibility.
- 3. In hospitals, establish patient surveillance, provide the laboratory tests required to diagnose Legionnaires' disease, and encourage clinician suspicion for it.
- 4. Conduct an environmental risk assessment. Have the cooling towers, domestic water system, manufacturing equipment and other aerosolizing devices evaluated with respect to conditions that promote growth or transmission of waterborne pathogens.
Don't rule out "closed" systems. For example, outbreaks of Legionnaires' disease have been attributed to water used for cooling plastic injection molding. Although these systems are technically closed, exposure to water spray can occur when changing molds or temperature control equipment. In 1997, OSHA fined a Cincinnati injection molding facility following an investigation of three Legionnaires' cases among its employees. OSHA cited Section 5(a)(1) of the 1970 Occupational Safety and Health Act, commonly referred to as the "General Duty Clause," which is a catch-all standard requiring employers to maintain a workplace free from recognized hazards that could cause death or serious physical harm. OSHA stated that the Cincinnati plant employees were exposed to excessive levels of Legionella bacteria (legionellae) during injection mold setting and changing, quality laboratory parts testing and equipment repair or maintenance, and that these exposures could have caused Legionellosis (Freije 2002).
- 5. Write and implement a management plan.
- 6. Document all risk reduction efforts: preventive maintenance, equipment changes, environmental sampling and disinfection procedures.
According to attorneys who have experience with Legionnaires' litigation, the above approach is prudent, not only for reducing health risk, but for reducing legal risk.
Writing Your Management Plan
Although management plans should cover several waterborne pathogens, most of the preventive measures will be based primarily on Legionella. Legionella has been studied more than other waterborne microbes, so there is an abundance of data on which to base an action plan. Also, because legionellae are tough to control, preventive measures that are effective against legionellae will also be effective against many other pathogens, especially bacteria.
The management plan should include the following:
Overview. List the members (if not by name, at least by job function) of your waterborne pathogen management team and outline your objectives, your plan for communication and review, and your high-risk occupant areas. Paint a clear picture of the overall strategy.
Preventive measures. Designing, operating and maintaining building water systems to minimize legionellae and other pathogens is crucial to reducing the risk of disease. Include preventive measures for the following:
- Domestic water system: List steps to take immediately based on the risk assessment measures that cost little or nothing and should thus be implemented out of good sense, as well as more costly measures that are required to solve high-risk problems. In a section that could be titled "future considerations," include measures that can be taken later, perhaps when equipment is replaced, or if contamination is identified. Also, write policies for regular maintenance and operation of systems, construction periods and special situations.
- Cooling towers: As with domestic water systems, list steps to take immediately, and future considerations. Establish policies for physical cleaning, water treatment, maintenance, conditions to avoid, water testing and tower location. Develop a checklist for regular inspections.
- HVAC equipment: Include policies for humidifiers, ductwork, air handling units and air filters.
- Manufactering equipment: List the aersolizing water devices in your plant, with policies and procedures that will be implemented to reduce risk.
- Other equipment: As applicable, list preventive measures for decorative fountains, whirlpool spas, misters, carpet cleaning equipment, ice makers, etc.
Environmental sampling. Although preventive measures will minimize conditions that provide a habitat for the bacteria, they will not guarantee a pathogen-free system. Even well maintained systems can harbor legionellae. The only way to know whether your preventive measures are working is to test the water for Legionella.
Since there is no specific action level for Legionella, one screening is not likely to give enough information to label your building as "safe" or "unsafe," but test results, especially after a few screenings, usually indicate specific changes in the operation or maintenance of water systems, helping facility managers make better decisions about maintenance.
Even if you decide not to sample routinely, your management plan should include a program for sampling in case Legionnaires' disease is identified. Outline the equipment to sample, number of samples per screening, supplies needed, and instructions for collecting samples and recording data.
Legionellae culture methodology is highly specialized. Few laboratorians are proficient, so finding a qualified laboratory is especially important. Take the time to thoroughly screen laboratories, and list two or three qualified ones in your management plan.
Disease response plan. Determine how you will respond to cases of disease. Outline steps for epidemiologic as well as environmental aspects of an investigation, and for emergency disinfection of cooling towers and the domestic water system.
Disinfection methods for plumbing systems. Since preventive measures alone, including high hot-water temperatures, do not always control legionellae in domestic water systems, it is sometimes necessary to install a continuous disinfection system. If test results indicate that legionellae are proliferating in the system, or if a case of Legionnaires' disease is identified, disinfection procedures should be implemented.
Technology is available at a reasonable cost to control legionellae and several other waterborne pathogens in domestic water systems. Your management plan should not dictate a particular method since better technology may become available. However, you should research available methods at the time of writing, and update periodically. Doing your homework now instead of rushing through it under a high-pressure outbreak situation could save you thousands of dollars and embarrasing blunders.
Don't let fear of cost keep you from getting started. Legionnaires' prevention is actually a pretty good bargain a modest investment yields a significant reduction in risk. An environmental quality head at one manufacturing plant even called their Legionella program "practical," in that it improved their facilities and protected their employees at a cost far less than anticipated.
Sidebar: References and Further Reading
Freije M and Burgoon S. "Responding to a Legionnaires' Disease Outbreak in an Industrial Plant: A Case Study." Legionella E-news, Jan. 17, 2002 (hcinfo.com/industrialoutbreak.htm).
Minimizing the Risk of Legionellosis Associated with Building Water Systems. Atlanta: American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2000.
U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention. "Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)." Morbidity and Mortality Weekly Report 52, June 6, 2003.
U.S. Department of Labor, Occupational Safety and Health Administration (OSHA). Technical Manual (1996); Section II, Chapter 7, 1996.
U.S. Environmental Protection Agency (EPA). Guidance Manual for the Compliance with the Filtration and Disinfection Requirements for Public Water Systems Using Surface Water Sources, March 1991 Edition, Parts One and Two, Appendix B, "Institutional Control of Legionella," 1991.
Matt Freije, a Purdue University mechanical engineering graduate, is president of HC Information Resources Inc. (hcinfo.com), a company that offers seminars, facility risk assessments, disinfection consulting, litigation support and publications pertaining to Legionella and other waterborne pathogens. His book Legionellae Control in Health Care Facilities: A Guide for Minimizing Risk, a 1997 award finalist, has been highlighted in professional journals worldwide and has sold in 30 countries. Freije can be reached at (760) 451-1050 or [email protected].