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5 Regulations and Guidelines on Legionella Control in Water Systems
Pages 233-270

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From page 233...
... Contributing to this widespread inconsistency in approaches to managing Legionella is the lack of any federal law that targets Legionella contamination of water supplies and building water systems as sources to be controlled. This chapter begins by describing why the Safe Drinking Water Act does not provide any substantial control of Legionella in water systems.
From page 234...
... using quantitative polymerase chain reaction (qPCR) in two chloraminated drinking water distribution systems: Legionella pneumophila was detected in 5.6 percent of samples and Legionella spp.
From page 235...
... Some have claimed that such an interpretation of the SDWA would make implementation of building water treatment systems untenable, as there would be hundreds of thousands of water systems to regulate. For many systems, the disinfectant boost would be only on the hot-water system
From page 236...
... Department of Veterans Affairs and the Centers for Medicare & Medicaid Services (CMS) , as well as New York City and State regulations for Legionella control in cooling towers and in certain healthcare facilities.
From page 237...
... Although this tradeoff complicates Legionella control in the VHA system, it was thought necessary because of its elderly and vulnerable patient population. The cold-water system is not thought to support Legionella growth, but it could if piped water temperatures remain greater than 25°C for several weeks.
From page 238...
... If samples are positive, then additional testing of that outlet and nearby outlets and remediation are required. Depending on where positive hits occur, the entire building water system may require remediation.
From page 239...
... (vi) for critical access hospitals states that policies must include "a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel." On June 2, 2017, CMS wrote a directive that requires Medicare-certified healthcare facilities to have water management policies and procedures to reduce the risk in building water systems of growth and spread of Legionella and other pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, fungi)
From page 240...
... The state's regulations apply statewide, including in NYC, such that there is overlap between the city and state regulations. The NYC and New York State regulations require cooling tower owners to take the following actions: 1.
From page 241...
... New York State Healthcare Facility Requirements for Legionella As of July 2016, all general hospitals and residential healthcare facilities in New York State are required to perform an environmental assessment, prepare and implement a sampling and management plan to sample their potable water systems for Legionella, and institute control measures in the event of a Legionella exceedance. The New York State regulations apply to buildings of general hospitals that provide in-patient services or buildings of residential healthcare facilities that provide a "health-related service," such as lodging, board, and physical care.
From page 242...
... Building owners have to be in compliance with plumbing codes when a building is being built or renovated; hence, codes are mainly enforceable prior to a certificate of occupancy being signed. Some plumbing codes can be used to partially manage Legionella in building water systems, and those codes are the focus of this section.
From page 243...
... Historically, plumbing codes were not written with the goal of managing building water systems for Legionella. In fact, some codes (unintentionally)
From page 244...
... In general, like the VHA Directive, the major guidance documents take a risk-based approach to managing Legionella in building water systems. To a greater or lesser extent, they each follow the general principles of risk management and require development of a plan or program to mitigate the risk (variously called water safety plans, water management programs, and other terms)
From page 245...
... Finally, unlike the other guidance documents, this guidance includes a section on managing Legionnaires' disease in patients. The Allegheny County Health Department guidance documents are the basis for the 30 percent positivity rule that has permeated many other guidance documents as well as the previously described New York State regulations for healthcare facilities.
From page 246...
... was created to help building owners and managers d ­ evelop and implement a water management program to reduce a building's risk for growing and spreading Legionella. The tool kit both simplifies and explains ASHRAE 188, and it applies the principles to healthcare facilities.
From page 247...
... provides minimum practices for treating, operating, and maintaining cooling towers to avoid Legionella growth. The standard uses the terms program (all the conducted activities)
From page 248...
... A new European Drinking Water Directive was developed in 2018 (European Commission, 2018) , which makes risk assessment in domestic building water systems obligatory.
From page 249...
... The Drinking Water Act regulations apply only to buildings labeled "priority premises" such as hospitals and other healthcare facilities with overnight stays, hotels and other accommodations that house more than five people, truck stops with showers, harbors, and marinas with showers, asylum centers, and prisons. The Act requires that a risk management plan for the building be created, and include such risks as water stagnation, tepid temperature, formation of aerosols, presence of high-risk individuals, past cases of Legionnaires' disease, whether the building accommodates travelers, whether it is used for temporary events, and lack of proper maintenance.
From page 250...
... In 1987, the German Federal Health Department said that drastic reduction in Legionella concentrations was necessary to reduce infections, further emphasizing that the goal should be "as low as reasonably achievable." The country's federal Protection Against Infection Act regulates water for consumption as well as swimming pools and bathing water and all wastewater treatment plants. For drinking water in particular, there is not only the Protection Against Infection Act, but also the EU Drinking Water Directive (discussed previously)
From page 251...
... Implementation of the regulations in large cooling towers and most building water systems is now broad, although the implementation is not as widespread for small cooling towers. The sewage regulations are only being enforced in North Rhine Westphalia.
From page 252...
... . The monitoring requirements for cooling towers are quarterly sampling for Legionella spp.
From page 253...
... Unlike other European countries, the French regulations are mainly based on environmental monitoring and specify what should be done by the facility manager in case of Legionella contamination or legionellosis cases, with less emphasis on a water management plan. Regional health and environmental agencies are the enforcement agencies for these regulations.
From page 254...
... A hospital outbreak in 2013 led to increased testing at healthcare facilities. The regulations now focus on cooling towers and hot-water systems in buildings such as hospitals and other healthcare facilities.
From page 255...
... MD-15161 mandates minimum design, installation, opera tion, maintenance, and validation testing requirements to reduce the risks associated with Legionella. There are specific requirements for cooling towers; open water systems (e.g., ornamental water features)
From page 256...
... PSPC started implementing MD-15161 in its portfolio in 2013 and started monitoring compliance in 2014, which has led to increased awareness of Legionella control from project inception to building operation and maintenance. There has also been a concomitant reduction in the number of positive results in cooling towers, as shown in Table 5-2, which provides data on the number of times unscheduled cleaning and disinfection of a cooling tower system was triggered by the Legionella testing required by MD-15161.
From page 257...
... pneumophila control was most effective in systems using halogen-based biocides and on-line control of dosage. The study suggests that a regular review of the cooling tower treatment program and monitoring results, including L
From page 258...
... For most of the countries, it is too early to make conclusions about the impact of regulations on rates of legionellosis, although there is evidence that the regulations are leading to declines in environmental detection of Legionella. Both the German building water system and Canadian government and Quebec cooling tower regulations have coincided with declines in the frequency of detection of Legionella.
From page 259...
... (2008) systems >1,000 CFU/L, alarm bell 3.  Notification of Cooling Towers 2.  Healthcare facilities and Evaporative Condensers 3.  ooling tower registration C Regulations (1992)
From page 260...
... . Thus, all VHA facilities along with cooling towers and healthcare facilities in New York State are currently required to implement water management plans and monitor for Legionella.
From page 261...
... into building water systems not covered by the CMS memo. The recommendation here is to make water management plans a requirement for all public buildings.
From page 262...
... Derivative products that provide details for specific building types and devices, much like the CDC Toolkit has done for healthcare facilities, would be useful to help implement this recommendation. The team developing and implementing the water management plan would outline the operation, monitoring, and maintenance of building water treatment systems using licensed and trained individuals to collect and retain appropriate records and monitoring data.
From page 263...
... In fact, monitoring for Legionella in the absence of any cases of Legionnaires' disease has not been recommended by the CDC.10 ASHRAE 188 does not require Legionella monitoring as part of the building water management plan. Yet, three of the five recommendations above incorporate monitoring of Legionella in building water systems, which will require a framework in order to interpret the data.
From page 264...
... This education should also include sufficient aspects of water management to effectively educate patients on inherent risks within their homes that may require attention when they are released from the hospital. Education and training are also needed for those designing water systems, for those overseeing municipal water supplies, for those developing and implementing plumbing codes, and for those in government responsible for the safety of buildings, cooling towers, and the potable water supply.
From page 265...
... The program is designed for professionals involved in water management programs including public health professionals, infection preventionists, building managers, maintenance and engineering staff, safety officers, and equipment and water treatment suppliers, as well as consultants. The training is relevant to building water systems in hospitals, retirement homes and long-term care facilities, hotels, apartments, and other buildings, as well as other devices that may need a water management program even if the building does not, such as cooling towers, decorative water features, hot tubs, and misters.
From page 266...
... In many instances, barriers to success can be associated with a general lack of understanding about water management plans by other professionals represented across the paradigm of building construction -- engineers and architects who design the building, construction managers and general contractors who hire and manage the trades, and the trade groups that build the building. Although building commissioning professionals add to oversight on behalf of the owner and the operators, unless these individuals are specifically educated and understand the relevance of water safety, their value in preventing waterborne pathogens via effective design and plans is negligible.
From page 267...
... However, if the temperature requirement was codified in the CMS memo, then much more rapid risk reduction, based on elevating building water temperatures, could occur. And finally, water utilities will be responsible for managing, monitoring, and addressing disinfectant residuals and new requirements for Legionella monitoring in drinking water distribution systems (Recommendation #5)
From page 268...
... 2017. Developing a water management program to reduce Legionella growth and spread in buildings: A practical guide to implementing industry standards.
From page 269...
... 2015. Molecular survey of occurrence and quantity of Legionella spp., Mycobacterium spp., Pseudomonas aeruginosa and amoeba hosts in municipal drinking water storage tank sediments.
From page 270...
... 2012. Molecular survey of the occurrence of Legionella spp., Mycobacterium spp., Pseudomonas aeruginosa, and amoeba hosts in two chloraminated drinking water distribution systems.


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