Steps to Prevention

The World Health Organization says that every year more than 3.4 million people die as a result of

water related diseases, making it the leading cause of disease and death around the world

(WHO: Waterborne Disease is World’s Leading Killer, Jessica Berman, Voice of America, October 29, 2009)

Although the U.S. has one of the safest drinking water systems in the world, there are more than 4 million

cases of Acute Gastrointestinal Illness (AGI) per year from public drinking water systems(CDC website, Magnitude & Burden of Waterborne Disease in the U.S.)

Waterborne Illnesses

Public Water Supply and Waterborne Illness

• Aging infrastructure, funding challenges, and changes in public water treatment systems are overwhelming public officials

• Reports of waterborne illnesses are increasing• Although recently in the headlines, Legionella is

only one of the many waterborne threats• Legionella and other bacterial organisms live in

biofilm and can be released during disruptions to the public water system

Building Owners

• Public officials are attempting to transfer the responsibility for controlling these pathogens from the public water supply to building owners

• Costly new regulations are driving up liability, maintenance, and water treatment costs

• Lawyers and insurance carriers are layering additional costs on building owners

Consulting Engineers

• Understand how the drinking water supply interacts with the building water system

• Advise clients to request notifications for any changes or upset conditions related to their building’s drinking water supply

• Make clients aware of resources available from ASHRAE, Centers for Disease Control and Prevention (CDC), the Cooling Technology Institute (CTI), and the Alliance to Prevent Legionnaires’ Disease

Prevention Begins “Outside the Building”

• Legionella and other waterborne pathogens enter the building water system with the public drinking water supply

• Upset conditions and service disruptions increase the potential for waterborne pathogens to get into the building water system

• Increase building specific monitoring, testing, and treatment of water systems following notification of upset conditions affecting the public drinking water supply

Legionella Bacteria Basics

• Commonly found in nature and many source waters

• Numerous species and serogroups

• Most virulent strain associated with disease is Legionella pneumophilaSerogroup 1

Picture Source: CDC Toolkit 1.0 6/7/2016

Legionnaires’ Disease Basics

• Bacterial Pneumonia• Bacteria must be brought

deeply into the lungs by aspiration or inhalation to cause disease

• Environmental disease, not contagious

Legionella is found in source water and can MULTIPLY in the public drinking water distribution system

Bacteria ENTER buildings with the public drinking water and can amplify in building water systems (storage tanks and building water distribution system)

Legionella Bacteria Growth and Exposure

Bacteria can be DISSEMINATED from many water sources

Bacteria live in the biofilm and can be RELEASED when disrupted by maintenance, water main breaks, pressure surges, or fire hydrant use

Legionnaires’ Disease Beginning

“Nearly six months after the outbreak, the CDC announced that it had cracked the case… Although Legionella wasn’t found in the hotel’s cooling system because it had been cleaned by the time of its discovery, investigators surmised that the system’s powerful fans emitted a mist of contaminated water that fell on pedestrians on the sidewalk below and were sucked into the lobby through a ground-floor vent where victims breathed in the tiny, infected water droplets.”http://www.history.com/news/the-discovery-of-legionnaires-disease

Bias began based on inconclusive evidence…

Bias – Cooling Towers Take the Blame

• Public drinking water supply is ignored during outbreak investigations

• Potential sources are not sampled or tested• This investigation bias puts more people at risk

French cooling tower regulations require monthly testing for Legionella

Historical Cooling Tower Bias

0.0

0.5

1.0

1.5

2.0

2.5

3.0

2002 2004 2006 2008 2010 2012 2014

France

Regulations implemented 2004

French Regulations Focused on TowersC

ases

per

100

,000

Have not reduced disease!

NYC – Another Example of Bias

• NYC health officials repeatedly claimed that “the drinking water is unaffected”

• Water supplies in buildings linked to the initial Bronx outbreak were never tested

• “If you don’t test for it [Legionellabacteria in the drinking water], it’s ridiculous.”

Dr. Stephen Edberg, Yale University

NYC Reported Legionnaires’ Cases 2015

0

50

100

150

200

250

300

350

400

450

1-Jan 20-Feb 10-Apr 30-May 19-Jul 7-Sep 27-Oct 16-Dec

ALL Towers Cleaned and Disinfected

8/20/2015

Source: CDC MMWR

0

50

100

150

200

250

300

1-Jan 20-Feb 10-Apr 30-May 19-Jul 7-Sep 27-Oct 16-Dec

Legionellosis, Cum 2016 Average 2011-2015

NYC Reported Legionnaires’ Cases 2016

Source: CDC MMWR

“…it is the professional opinion of a CDC researcher that we should be able to apply lessons learned from outbreaks to help prevent disease, both sporadic and outbreaks…

However, to extrapolate the source of sporadic cased from outbreak root causes is not good practice because other, unknown variable are almost certainly in play.

I’m not sure if the majority of sporadic cases are due to potable sources, but I would feel quite comfortable opining that they are most likely NOT due to point sources like cooling towers.”

Dr. Claressa Lucas, CDC, August 2016 Organization Representative for CDC on ASHRAE SPC188.

The Scientific Community Agrees

Aging Public Water Supply Infrastructure

• In 2015, 562 water main breaks occurred in NYC alone

• Biofilm (slime) exists in drinking water pipes

• Maintenance of and disruptions to water mains can disturb biofilms and release bacteria into the water supply

Bacteria Multiply in Drinking Water System

Source: University of Montana Center for Biofilm Engineering

Typical Water Distribution System

The treatment plant is where Legionella is currently controlled

Storage tanks and water mains are where Legionella can multiply

Building water supply becomes point of exposure

Legionnaires’ Surged in Flint

EPA Surface Water Treatment Rules

…Require systems using surface water to…filter their water or meet criteria for avoiding filtration so that the following contaminants are controlled at the following levels:• Cryptosporidium: 99% removal/inactivation• Giardia lamblia: 99.9% removal/inactivation• Viruses: 99.99% removal/inactivation• Legionella: No testing requirement

“If you don’t test for it [Legionella bacteriain the drinking water], it’s ridiculous.”

Dr. Stephen Edberg, Yale University

Legionella Bacteria – Aspirated & Inhaled

Mitigating Risk – ‘Outside the Building’

• Increase awareness of water quality from the public water treatment plant through the distribution system

• Building notification for upsets to the drinking water supply, including maintenance, breaks, and malfunctions

• Investigate all cases of Legionnaires’ disease using CDC guidelines to identify the true source

1) Education2) Source Water3) Public Water System4) Building Water Systems5) Water Equipment

Management6) Investigative Protocols7) Research

http://preventlegionnaires.org

Steps of Risk Mitigation

Lines of Prevention

Steps of Risk Mitigation

Step 2 – Source Water Awareness• Major events can trigger release of Legionella

bacteria‒ Heavy Rains‒ Flooding‒ Nearby Construction‒ Changes to Reservoirs

• Public Water Treatment and Building Owners should be prepared to adjust their treatment in response

Steps of Risk Mitigation

Step 3 – Public Water System: Disinfectant• Encourage your Public Water Supplier to

consistently maintain disinfectant residual throughout the entire distribution system‒ Louisiana has shown high levels (0.5 ppm) of disinfectant

in the public water supply can lower the rate of Legionnaires’ disease

‒ More than 20 states support disinfectant levels of 0.2 ppm or higher

‒ Include routine monitoring of the disinfectant residual entering the building water system as part of the Water Management Program

Steps of Risk Mitigation

Step 3 – Public Water System: Monitoring• Include routine monitoring of the public drinking

water supply quality in your Water Management Program‒ Issue a written request to your Public Water Supplier for

notifications of any changes or upsets to the water distribution system

‒ Test incoming drinking water for disinfectant level and Legionella bacteria whenever an upset notification is received

Mitigating Risk – Areas of Focus

Steps of Risk Mitigation

Step 4 – Building Water Systems

Steps of Risk Mitigation

• Multi-story buildings are at greater risk of waterborne bacteria amplification than smaller buildings

• The complexity of their piping systems provides more areas for bacterial growth

Source: CDC Vital Signs 6/7/2016

Step 4 – Building Water Systems

Steps of Risk Mitigation

Proper selection, placement, maintenance, treatment, and monitoring of water-based equipment reduces amplification risk and pathways of exposure to waterborne Legionella bacteria

Develop a Water Management Program for equipment supplied with Public Drinking Water

Source: PreventLegionnaires.org

Step 5 – Water Equipment Management

Steps of Risk Mitigation

CDC’s Practical Guide provides

example Process Flow

Diagrams and Points of Exposure for water

based equipment

Step 5 – Water Equipment Management

Steps of Risk Mitigation

Step 5 – Water Equipment Management

• ASHRAE Guideline 12‒ Stagnant water‒ Dead legs‒ Hot water storage‒ Low flow faucets‒ Hands free faucets

Steps of Risk Mitigation

• Investigate all reported cases of Legionnaires’ disease using tools for single cases and outbreaks established by the CDC

• Imperative to investigate all possible points of exposure within a building to positively identify the source of Legionella bacteria and protect the public

Step 6 – Investigation Protocol

Key Points

Preventing Legionnaires’ Disease

Ensuring the water that flows into buildings is properly disinfected against

Legionella and other waterborne pathogens is the first and primary line of

defense to address Legionellaamplification and prevent disease

Building Owners’ Actions

• Understand how the water system impacts your building‒ Monitor incoming water quality as part of Water

Management Program as prescribed by Standard 188• Build a working relationship with your water utility

manager• Make a written request to your water utility manager

for notice of all upsets and maintenance related to the public water system

• Make a written request to your department of health for notice of all reported cases of waterborne illnesses

Normal Operation

Building Owners’ Actions

• Refer to Water Management Program action levels• Review maintenance records and test data• Collect the samples identified in your Water

Management Program for independent testing using an approved laboratory

• Make a written request to the health department and water utility manager for CDC involvement and the use of CDC investigation protocols

Following a Positive Test

Consulting Engineers’ Actions

• Be wary of marketing claims related to the eradication of Legionella bacteria

• Understand how the building’s water system interacts with the drinking water supply

• Make clients aware of resources available from ASHRAE, Centers for Disease Control and Prevention (CDC), Cooling Technology Institute (CTI), and the Alliance to Prevent Legionnaires’ Disease

General Guidelines

Consulting Engineers’ Actions

• ASHRAE Guideline 12‒ Stagnant water‒ Dead legs‒ Hot water storage temperature‒ Low flow faucets‒ Heated spas‒ Architectural fountains

Design Specifics

Education

Resources are available to learn more about Legionella Bacteria and Legionnaires’ Disease

• ASHRAE Standard 188-2015‒ Ashrae.org

• CDC Toolkit‒ cdc.gov/legionella/maintenance/wmp-toolkit.html

• Cooling Technology Institute‒ cti.org

• Alliance to Prevent Legionnaires’ Disease‒ Preventlegionnaires.org

Questions & Answers

Thank You!