2006, American Society of Heating, Refrigerating and Air-Conditioning Engineers, Inc. (www.ashrae.org).

Reprinted by permission from ASHRAE Transactions, Volume 112, Part 1. For personal use only. Additional distribution in either paper or digital form is not permitted without ASHRAEs permission.

CH-06-12-1

Control of Legionellae in the Environment: A Guide to the US Guidelines

Barry S. Fields, PhD Matthew R. Moore, MD

ABSTRACT The authors identified and reviewed 13 reference documents on Legionella and Legionnaires disease prevention that can be characterized as either guidelines, recommendations, standards, or position papers. These documents were produced by professional associations and government agencies at the federal, state, and local levels. This paper does not include reference documents produced by individual companies because of the number of these documents and the potential for bias, nor does this paper review international guidelines on Legionnaires disease. Rather, we compared US prevention guidelines on Legionella and Legionnaires disease to characterize the application of these documents. This review should help industry professionals navigate a diverse and potentially confusing collection of recommendations. INTRODUCTION Although the first recognized outbreak of Legionnaires disease occurred in 1976, guidelines for preventing the transmission of the disease did not appear for a number of years. The American Society of Heating, Refrigerating and AirConditioning Engineers, Inc. (ASHRAE), developed its first position statement on Legionnaires disease in 1981. Since that time, the number of guidelines and official recommendations has dramatically increased. A number of these publications have been modified over time, and some have undergone major changes, which leads to confusion over the best approaches and practices. Currently, there are multiple guidelines produced by the US federal, state, and local governments and industry and professional societies. In addition, there are numerous guidelines produced by other countries and international organizations. This paper provides a compendium of

current US guidelines. In addition, we have attempted to compare, contrast, and summarize some of the salient points of these documents. This paper offers a key to selecting appropriate approaches for the prevention of legionellosis and it highlights areas of controversy that require additional studies and data. We did not attempt to rank these documents in any particular order; rather, our goal was to synthesize existing information so that the most appropriate reference materials can be selected for specific situations. Methods We identified guidelines produced by government agencies and professional organizations using publicly available Web sites and the authors collections of previously published documents. To avoid any conflicts of interest, we excluded guidelines developed by groups with commercial interests, including private cooling tower manufacturers. For each guideline, we abstracted and tabulated information related to the intended audience of the document, the environmental source (e.g., cooling towers, potable water systems), and whether or not specific control parameters, such as temperature and biocide concentration, were included under routine or emergency conditions. If a guideline is available from the Web site of the organization that issued the document, that Web sites URL is included in the reference section. US FEDERAL GOVERNMENT GUIDELINES The following guidelines are covered in this section: (1) Centers for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, (2) CDC Guidelines for Preventing Health-Care-Associated Pneumonia, (3) CDC Guidelines for Preventing Opportunistic Infections Among Hematopoietic Stem Cell Transplant

Barry S. Fields and Matthew R. Moore are with the National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga.

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Recipients, (4) CDC National Center for Environmental Health Final Recommendations to Minimize Transmission of Legionnaires Disease from Whirlpool Spas on Cruise Ships, and (5) Occupational Safety and Health Administration (OSHA) Technical Manual, Section III, Chapter 7. The CDC has four guidelines that cover the prevention of legionellosis, but these are not limited to Legionella. Instead, these documents serve as recommendations for maintaining health-care environments, preventing health-care-acquired pneumonia, and preventing infection in transplant recipients. Therefore, the CDC guidelines include recommendations for preventing infection caused by a number of organisms, including Legionella. Because they are comprehensive, these guidelines are quite lengthy, and quickly identifying Legionella-specific information may be difficult. OSHA has a comprehensive guideline that applies to possible work site exposures to Legionella. CDCEnvironmental Infection Control The CDC Guidelines for Environmental Infection Control in Health-Care Facilities was published in June 2003. It covers recommendations for the prevention and control of infectious diseases that are associated with hospitals and other health-care environments. It is published jointly by CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). HICPAC is a committee of 14 external infection control experts that provides advice and guidance to the CDC. Members are appointed by the Secretary of Health and Human Services. The committees recommendations are classified on the basis of existing scientific evidence, theoretical rationale, applicability, and potential economic impact. In addition, recommendations may be based on existing national and state health regulations. Most of the strongly recommended practices are based on well-designed scientific studies. Other recommendations may reflect only an industry standard rather than an evidence-based conclusion. Appendix C of this CDC guideline includes a discussion of possible water sampling strategies as well as procedures for cleaning cooling towers and related equipment. It includes a comprehensive discussion of the background of the strategies for controlling Legionella, including a description of how different prevention strategies may be appropriate in facilities associated with cases versus those not associated with cases. The guideline also covers the special precautions for prevention among severely immunocompromised patients in healthcare facilities. Finally, this guideline recommends that shower heads and aerators be removed, cleaned, and disinfected in areas where patients are at risk, even if Legionella is not detectable in the water. The cleaning of shower heads and aerators is a controversial recommendation, as there are little or no data to support this procedure. CDCHealth-Care-Associated Pneumonia The Guidelines for Preventing Health-Care-Associated Pneumonia was issued jointly by CDC and HICPAC in 2003. It expanded and updated CDCs previously published Guide692

line for Prevention of Nosocomial Pneumonia. This earlier version of the guideline was issued in 1983 and included the first comprehensive recommendations to hospitals for using chlorine or increased temperature to control Legionella in potable water systems. It also included recommendations for decontaminating water sources during outbreaks. The 2003 guideline discusses the advantages and disadvantages of implementing a routine culturing for Legionella as part of a control strategy. It contains the same recommendations for solid organ transplant programs that are found in the guideline for bone marrow and blood transplant programs discussed below. CDCBone Marrow Transplant The Guidelines for Preventing Opportunistic Infections among Hematopoietic Stem Cell Transplant Recipients was issued by CDC, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation in October 2000. This guideline covers the prevention of infections by multiple organisms, including Legionella. Based on new data that identified an increased risk for severely immunocompromised patients, a statement was added to this document that routine culturing of potable water supplies for Legionella may be considered part of an overall prevention strategy at high-risk hospitals for bone marrow and blood transplant patients. The guideline also states that if environmental testing for Legionella is undertaken, the goal should be to maintain no detectable Legionella in the potable water systems, though the cost-effectiveness of this strategy has not been determined. The guideline does not include any remediation or disinfection strategies for potable water. It recommends sponge baths for patients using uncontaminated water in a facility that identifies Legionella in its water supply. There are also recommendations for use of sterile water for drinking and brushing teeth and restrictions on faucet use. This document does not offer a recommendation on showering of patients where Legionella has been detected in the potable water. CDCCruise Ship Spas CDC developed Final Recommendations to Minimize Transmission of Legionnaires Disease from Whirlpool Spas on Cruise Ships specifically for recreational spas on cruise ships following a highly publicized outbreak on a ship in 1994. CDC subsequently hosted a public forum that included the cruise ship industry, the spa and pool industry, academia, and the federal government. The resulting document was issued by the Vessel Sanitation Program in the CDC, National Center for Environmental Health. This guideline contains specific recommendations for the operation and maintenance of spas and states that the recommendations may or may not be appropriate for land-based recreational spas. The guideline puts a great deal of emphasis on maintenance of filtration systems. It also includes a recommendation that spas be shock treated every day after use.
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OSHA The Occupational Safety and Health Administration of the US Department of Labor published guidelines for preventing Legionnaires disease in Chapter 7 of its Technical Manual. This document was developed to provide assistance to industrial hygienists in assessing work sites for possible Legionnaires disease exposure. It includes information on identifying probable water sources of Legionella and control strategies. The appendices of this manual provide details on making employees aware of the disease, water sampling protocol, and water treatment strategies for situations where an outbreak has occurred. The guideline includes concentrations of Legionella in water that can be used to determine actions involving cleaning, disinfection, and employee exposure. However, the guideline goes on to state that the goal should be zero detectable Legionella in a water source. US PROFESSIONAL ORGANIZATION GUIDELINES The following guidelines are covered in this section: (1) ASHRAE Guideline 12, Minimizing the Risk of Legionellosis Associated with Building Water Systems; (2) American Society for Testing and Materials (ASTM) International, D 5952-02, Standard Guide for Inspecting Water Systems for Legionellae and Investigating Possible Outbreaks of Legionellosis (Legionnaires Disease or Pontiac Fever); (3) Association of Water Technologies (AWT), Legionella 2003: An Update and Statement by the Association of Water Technologies; (4) Cooling Technology Institute (CTI), Legionellosis Guideline: Best Practices for Control of Legionella; and (5) Joint Commission on Accreditation of Health Care Organizations (JCAHO), Standard EC.1.7, Utility Systems Management. These documents range from position papers primarily presenting background information to generalized industry standards to detailed recommendations for multiple disciplines. ASHRAE Guideline 12 was developed in 2000 by a Guideline Project Committee that includes equipment manufacturers, water treatment professionals, and experts from academia and public health. The document offers recommendations specific to a number of building water systems, including potable water systems, fountains, cooling towers, air washers, humidifiers, spas, and metalworking systems. It addresses routine maintenance for these systems and emergency decontamination procedures for some. This guideline primarily defers to CTIs Legionella guideline for emergency decontamination procedures for cooling towers. This document covers the use of a variety of decontamination techniques, including heat flush, chlorination, ionization, ozone, and chlorine dioxide. This guideline, currently undergoing revision, offers a relatively comprehensive set of recommendations in a succinct form, making it a very accessible document. ASTM This standard guide was developed by ASTM Committee D22 on air quality and published in 2003. The document is moderate in length but provides information on a variety of
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activities associated with detecting and preventing Legionnaires disease. These include background, microbiologic assays, diagnosis, environmental inspection, control measures, collection of samples, and an outline for conducting an epidemiological investigation. These are diverse areas of expertise, and the guide offers information from the disciplines of microbiology, risk assessment, epidemiology, engineering, and medical practice. Although detailed instruction for performing all of the roles cannot be provided in such a limited text, this document does provide an adequate overview of these processes. Recommendations for controlling Legionella in building water systems are limited to water delivery and storage conditions, or temperature, in what the document calls general measures to control Legionella. AWT Legionella 2003 is described as a statement by AWT and is designed as an aid for water treatment specialists. It provides a large amount of background information as well as some general treatment recommendations and a position statement. The document offers both an overview of approaches extracted from other guidelines and opinions on many of the controversial issues associated with these practices. Recommendations are offered for potable water and cooling towers, although these recommendations are not tailored to specific types of buildings or populations (i.e., domestic vs. commercial, health care vs. industry). This may be problematic since some of the recommendations, such as annual cleaning and inspection of hot water tanks and testing of cold water for the presence of legionellae, are not practical for some institutions and domestic users. The potable water recommendations include a comparison of the performance of six treatment technologies or disinfectants. It is not clear what the performance summaries are based upon, and no data or references are provided. The section on cooling towers provides more specific recommendations on emergency disinfection, design, and operational guidelines. The document contains a detailed discussion of the controversy surrounding the effectiveness of routinely sampling and testing for legionellae as a prevention strategy. The discussion is accompanied by a summary of action plans based upon legionellae counts. The document describes the use of legionellae concentration as determined by direct fluorescent antibody (DFA) as a guide for some actions. However, this test is not sensitive or specific enough for reliable detection of legionellae in the environment (Fields 2002). The final component of the document is the AWT Position Statement, which serves as the equivalent of the organizations official stance and recommendations. CTI The CTI document, Legionellosis Guideline: Best Practices for Control of Legionella, was published in 2000 and is described as a consensus document. The guideline is fairly brief and accessible. It contains a short introduction to Legionnaires disease and its symptoms and background information on the bacterias microbiology and ecology. There is a discussion on the utility of environmental testing for Legionella,
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which is not directly recommended except in the event of an outbreak. Of the 13 guidelines, this document provides the most definitive recommendations for routine and emergency treatment of cooling towers with halogens. These recommendations are adapted from a document that was originally produced by the Wisconsin Division of Health in 1987 and is no longer available. JCAHO JCAHOs Standard EC.7.1 does not specifically address Legionella, but it does state that an organization should maintain a systems management plan to reduce the potential for organizational-acquired illness. In addition, it states that the management plan should provide processes for managing pathogenic biological agents in cooling towers, domestic hot water, and other aerosolizing water systems. Legionella is not specifically mentioned, but it is covered by this broad description. This standard does not describe any specific control or prevention methods. The document simply requires that organizations have a management plan; it does not provide any details or a description of how to develop this plan. In an effort to offer a uniform strategy on management of waterborne pathogens, JCAHO collaborated with the American Society for Healthcare Engineering (ASHE) and drafted a Regulatory Advisory that provides guidance for controlling Legionella (Woodin 2000). This advisory provides a general description of a risk assessment plan, risk mitigation and management, and remediation. Engineering system controls are also described, including water storage temperatures, chlorine, copper-silver ionization, and chlorine dioxide use. There are also brief descriptions of remediation for potable water systems, including superheating of water and shock chlorination. In addition, there is a very brief section on cooling tower maintenance. US STATE AND LOCAL GUIDELINES We were able to identify only two state guidelines and one local guideline that specifically address controlling Legionella. Maryland and Texas have developed guidelines in response to recent outbreaks, and Allegheny County, Pennsylvania, is the only local government that was identified that has developed a guideline for prevention of legionellosis. State of Maryland Department of Health and Mental Hygiene (MD DHMH) During 1999, the state of Maryland experienced an increased number of health-care-associated cases of Legionnaires disease. These cases were of such concern to the state that the MD DHMH Secretary assembled a scientific working group to propose measures to prevent health-care-associated Legionnaires disease. The working group acknowledged that data are lacking and, thus, sought to develop an individualized risk management approach so that hospitals could implement preventive measures commensurate with their estimated risk. The document contains information and recommendations relating to surveillance for human disease and routine engineering measures that are similar to those of other
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guidelines. MD DHMH recommends that water distribution systems within acute-care hospitals should be routinely cultured and that the institution-specific risk assessment should drive the frequency of culturing. They define risk factors based on engineering characteristics, patient mix, and prior history of health-care-associated cases. In terms of secondary prevention, MD DHMH recommends enhancement of disease surveillance and remediation efforts. The goal of remediation appears to be a reduction in the number of colonized distal sites rather than the elimination of Legionella from all distal sites. It is unclear what magnitude of reduction is acceptable, but the intent is to use the risk profile of the facility, in combination with environmental culture results, to determine when remediation has been completed satisfactorily. Texas Department of State Health Services (TX DSHS) In 1999, TX DSHS convened a Legionnaires' Disease Task Force, partly in response to a health-care-associated outbreak in San Antonio in 1996. As part of its guideline development process, TX DSHS reviewed the guidelines then in existence from CDC, MD DHMH, and Allegheny County (see below). The recommendations, which are available on the TX DSHS Web site, are similar to the MD DHMH guidelines in that they emphasize the importance of hospitals having the capacity to diagnose community- and hospital-acquired cases of Legionnaires disease. The issues of temperature, biocide concentrations, and cooling tower siting are addressed briefly. TX DSHS took a unique position on the question of routine environmental sampling by recommending that all hospitals in Texas perform a risk assessment to determine whether or not baseline environmental cultures were warranted. They recommended that hospitals incorporate into their assessment environmental factors, engineering factors, patient mix, and prior history of health-care-associated Legionnaires disease. So, unlike MD DHMH and Allegheny County, TX DSHS does not recommend routine culturing in all health-care facilities. TX DSHS does, however, consider such cultures to be valuable if they are conducted in a setting where the risk of Legionnaires disease is considered to be high even in the absence of recognized cases of health-care-associated Legionnaires disease. The remainder of the TX DSHS guideline is similar to other guidelines, although it offers limited intervention procedures for cooling towers, potable water systems, and spas. Allegheny County, Pennsylvania This government agencys document addresses control measures for Legionella in potable water systems and states that cooling towers are not addressed because the guideline development committee is not convinced that they play a role in the transmission of Legionnaires disease associated with health-care facilities. The document does not mention other potential sources of transmission, such as spas or industrial water systems. The Allegheny County document provides detailed information on the use of water temperature to control Legionella, including maintenance, point of use, and return temperatures as well as an emergency heat flush procedure.
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The document provides a comparison of four disinfection approaches, including copper-silver ionization, chlorination, thermal eradication, and ultraviolet. It is not clear what the performance summaries are based upon, as supporting data and references are not provided. The Allegheny County guidelines are directive and specific in their recommendations regarding the testing of health-care facilities for the presence of Legionella. This document calls for annual culturing of a specified number of distal sites within hospitals; when the proportion of those sites positive for Legionella meets or exceeds 30%, remediation should be considered. If the proporTable 1.
H Not addressed % Addressed briefly G Addressed in detail

tion positive is less than 30%, then the situation should be investigated. While acknowledging that the 30% threshold is somewhat arbitrary, the authors cite a 1983 publication as the source of this figure (Best et al. 1983). DIFFERENCES IN THE GUIDELINES Potable Water Supplies A comparison of the potable water guidelines from the published sources discussed above is provided in Table 1. This

Comparison of Recommendations for Potable Water Systems

Temperature C (F) Hot Cold Emergency [flush duration, min] 71-77 (160-170) [5] 71-77 (160-170) [5] H H < 20 (68) < 20 (68) H H 20 (68) < 20 (68) Routine Shower Environmental Heads/ testing for Maintenance Emergency Faucet Legionella (following Aerators (addressed/ Shock outbreaks) Residual recommended) Dose 1-2 H 2 [5] Chlorine, ppm [flush duration, min]

Maintenance Storage > 60 (140) H H H > 60 (140) Point of Use Return

CDC Environmental Infection Control CDC Nosocomial Pneumonia CDC Bone Marrow Transplant CDC Cruise Ships OSHA

51
(124)

51
(124) H H H 50 (122)

%1

G/ Conditionally G/ Conditionally3

51
(124) H H

1-2

H H H 20 50 [60-120] H

%2
H H H

H H H

H H 1-2

%/ Conditionally3
H G/No

50
(122) H

70 (158)
[20] 71-77 (160-170)

60 (140)
ASHRAE 12-2000 [high risk] 49 (120) [other] >60 (140) H H H 60 (140) 60 (140)

514
(124)

2 [5]

%5

G/No

ASTM

50
(122) > 50 (122) H H 50 (122) 50 (122)

70 (158)
2-24hrs [5] 60-66 (140-151) [30] H H H H > 70 (158) [20-30]

20
(68) H H H H H < 20 (68)

10 (hot) 20 2 hr or 50 1 hr (cold) 20-50 H H H H H

%6

G/ Conditionally7 G/Yes H H G/Yes G/ Conditionally8 G/Yes

AWT JCAHO CTI Maryland Texas Allegheny County

1 2 3

H H H H H 50 (122)

H H H H H H

1-2 H H H H H

H H H H H

57.5-62.5 50-60 (135-145) (122-140)

%9

Remove, clean, and disinfect monthly (in areas with patients at risk). Remove aerators (in areas with immunocompromised patients). States that periodic routine culturing can be performed as part of an overall strategy for preventing Legionnaires disease in bone marrow transplant centers. 4 Or highest allowable by the state. 5 Remove and clean with bleach (high-risk applications). 6 Do not use materials known to support biofilm or Legionella colonization. 7 States that water system operators may identify undesirable situations by routine monitoring and may be able to implement control measures before the bacteria reach amounts sufficient to cause human illness. 8 Whenever one definite or two positive nosocomial Legionella cases occuring within a six month period are identified. 9 Avoid use of aerators.

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table is more complicated than those for cooling towers (Table 2) and heated spas (Table 3) because many of the documents contain detailed instructions for setting the temperature for cold water and hot water storage, point of use, and return. In addition, many of the recommended temperatures and duration times for emergency flushing of the building potable water systems are associated with outbreaks of legionellosis. Most of the guidelines agree on these temperatures, with recommendations differing by less than 1C. There are two minor differences. Although ASHRAE Guideline 12 recommends that hot water be stored at 60C, as most of the other documents do, it also states that hot water may be stored at 49C in buildings in which residents are not at high risk for acquiring Legionnaires disease. The other difference is that the Allegheny County document provides a more specific 5C range for storage and point-of-use water. Recommendations for emergency heat flushing of systems are similar for most of the guidelines. The guidelines vary on the length of the heat flush, with all documents recomTable 2. H Not addressed % Addressed briefly G Addressed in detail CDC Environmental Infection Control CDC Nosocomial Pneumonia CDC Bone Marrow Transplant CDC Cruise Ships OSHA ASHRAE 12-2000 ASTM AWT JCAHO CTI Maryland Texas Allegheny County
1

mending flushing for either 5 or 30 minutes. It is generally acknowledged that longer flushing is more beneficial, but some building water systems do not have enough capacity for a 30-minute flush. Therefore, several documents state that the flushing should last for at least 5 minutes. Finally, there are some minor differences in recommendations regarding the disinfection and use of shower heads and faucet aerators. There appears to be very little data to support most of the recommendations, although they may be of some value. Cooling Towers and Evaporative Condensers A comparison of the cooling tower and evaporative condenser guidelines from the previously discussed sources is provided in Table 2. The CTI and AWT guidelines are the only two that include specific biocide levels for routine maintenance of cooling towers and evaporative condensers. However, most of the guidelines recommend the use of

Comparison of Recommendations for Cooling Towers and Evaporative Condensers Routine Environmental testing for Legionella (addressed/ recommended) G/No G/No %/No H G/No G/No G/Conditionally2 G/No H G/No G/Yes G/No H

Maintenance Biocide Levels

Start-up and Shutdown Procedures

Drift Eliminators

Location Relative to Air Intake

Emergency Decontamination Procedures

% % %
H G G

H H H H

% % %
H

% % %
H

G H H H Shock with 50 ppm biocide, maintain 10 ppm 24 hrs

%1
4-5 ppm biocide H
3

% % % %
H

% % % %
H H

%
H H H 25-50 ppm, 10 ppm for 24 hrs H H H

% 1-2 ppm
H 1 ppm or 5 ppm for 6 hrs periodically G

H H H H H

% % %
H

% %
H

%
H

Clean and disinfect at least twice per year (e.g., at the beginning of the cooling season and after shutdown in the fall). 2 States that water system operators may identify undesirable situations by routine monitoring and may be able to implement control measures before the bacteria reach amounts sufficient to cause human illness. 3 Systems where Legionella risk and/or history are great (bad) (pp. 22).

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biocides to control the growth of Legionella. There are many different chemicals designed to provide water treatment for cooling towers and evaporative condensers. These chemicals are used to minimize microbial growth and scale, corrosion, sedimentation, and deposition of solids. There are both oxidizing and nonoxidizing biocides as well as corrosion inhibitors and surfactants. There is no consensus in the guidelines about the best water treatment strategy for controlling Legionella in cooling towers and evaporative condensers. The ASHRAE guideline includes comprehensive recommendations for start-up and shutdown procedures, and the OSHA and AWT guidelines also have some information on these procedures. Most of the guidelines that address cooling towers have recommendations for drift eliminators and for locating cooling towers and evaporative condensers away from fresh air intakes, although this information is not detailed or specific. Emergency decontamination procedures are discussed in the CDC environmental infection control document and in the OSHA, ASHRAE, and CTI guidelines. These recommendations are generally consistent and are adapted from a document that was originally produced by the Wisconsin Division of Health in 1987 entitled Control of Legionella Table 3.
H Not addressed % Addressed briefly G Addressed in detail CDC Environmental Infection Control CDC Nosocomial Pneumonia CDC Bone Marrow Transplant CDC Cruise Ships OSHA ASHRAE 12-2000 ASTM AWT JCAHO CTI Maryland Texas Allegheny County
1

in Cooling Towers. This document is no longer distributed by the Wisconsin Division of Health. Heated Spas and Hot Tubs A comparison of the guidelines for heated spas and hot tubs from the previously discussed sources is provided in Table 3. Only three of the 13 Legionella guidelines address recreational spas and hot tubs: the CDC cruise ship, ASHRAE, and ASTM documents. ASTM offers only a brief recommendation to change the filter periodically. Overall there is very little difference between the two remaining guidelines. ASHRAE Guideline 12 cites information found in other guidelines, including the CDC cruise ship guideline and those of the National Spa and Pool Institute. ASHRAE gives recommendations for filter surface loading rates and microbial monitoring and cites the recommendations from the CDC cruise ship guideline for chlorine, bromine, and pH values. Thus, the two guidelines with comprehensive guidance about maintaining spas and hot tubs for Legionella control are in general agreement. They both recommend keeping the chlorine residual between 3 and 10 ppm and the bromine between

Comparison of Recommendations for Heated Spas and Hot Tubs

pH Filtration Bather Load Bather Health Restrictions H H H

Halogen Residual, ppm (type) Maintenance 15 (Cl) 1, 2-5 (Cl) 2 H H 3-10 (Cl), 4-10 (Br) 3 H 3-10 (Cl), 4-10 (Br) 3 H H H H H H H Emergency H H H H H H H H H H H H H H H H 7.2-7.8 H H H H H H H H H H H H G4 H G6 H H H H H

%5
H

%7
H H H H H H H

%5
H H H H H H H

%8
H H H H H H

Small hydrotherapy pools (health care facilities only). 2 Whirlpools and whirlpool spas (health care facilities only). For larger hydrotherapy pools, follow state and local guidelines. 3 Spas should be drained, cleaned, and refilled at least daily. 4 Recommend media inspection and replacement. 5 Immunocompromised at increased risk. 6 High rate, diatomaceous earth (DE), and cartridge (maximum surface application rates for each category). 7 10 ft2 per bather. 8 Change periodically.

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4 and 10 ppm. Also, both recommend maintaining the pH between 7.2 and 7.8. The CDC Guidelines for Environmental Infection Control in Health-Care Facilities includes recommendations for cleaning and disinfecting hydrotherapy tanks and pools that are used to treat patients with certain medical conditions, such as burns. This information was not intended to apply to recreational spas and hot tubs but may provide additional insight on thorough cleaning and disinfecting procedures used in healthcare facilities. Legionella Testing and Action Plans It is generally accepted that culturing environmental samples for the presence of Legionella is necessary to establish the source of an outbreak of Legionnaires disease, to determine the efficacy of a disinfection program, and to evaluate the potential of a device to transmit the disease. However, recommendations concerning the routine culturing of water samples in the absence of documented legionellosis represent the greatest controversy for many of these guidelines. There is general agreement that such environmental sampling can be beneficial in institutions housing persons at extremely high risk for acquiring Legionnaires disease. However, there are no data to suggest the ideal frequency of such testing or the appropriate number of sites to test. As previously mentioned, there is a single study that suggests detecting Legionella in > 30% of sites tested may be an indicator of potential for disease in health care facilities (Best et al. 1983). However, more data are needed to substantiate this concept. Guidelines that recommend widespread use of culture for Legionella in the absence of disease acknowledge the arbitrary nature of recommendations regarding testing frequency. The OSHA and AWT guidelines offer action plans based upon the number of Legionella (colony forming units, CFU) detected by culturing cooling towers or potable water. Both of these numerical action plans are derived from a table published by Pathcon, Inc., a commercial testing lab (Morris and Shelton 1991). The guidelines acknowledge that these action plans do not apply to water systems used by immunocompromised individuals and that the selection of concentrations and their associated actions are somewhat arbitrary and should be viewed as a loose guide. A scientifically based number of Legionella acceptable in water systems would be valuable information and might be able to assist in controlling the disease. Unfortunately, this determination is not likely because of issues such as differences in building design and occupant susceptibility, differences in the virulence of various Legionella species and strains, and variations in aerosol mechanics. Also, there are the ethical hurdles of performing these studies whereby test populations cannot be exposed to certain levels of Legionella to establish that they are safe. However, continued scientific analysis should eventually be able to establish when and where testing for the presence of Legionella will be beneficial.
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BIBLIOGRAPHY Allegheny County Health Department. 1997. Approaches to the Prevention and Control of Legionella Infection in Allegheny County Health Care Facilities, 2d ed. Pittsburgh, PA: Allegheny County Health Department. ASHRAE. 2000. ASHRAE Guideline 12-2000, Minimizing the Risk of Legionellosis in Building Water Systems. Atlanta: American Society of Heating, Refrigerating and Air-Conditioning Engineers, Inc. Available at http:// www.ashrae.org/template/Index. ASTM. 2003. D 5952-02, Standard Guide for Inspecting Water Systems for Legionellae and Investigating Possible Outbreaks of Legionellosis (Legionnaires Disease or Pontiac Fever). West Conshohocken, PA: American Society for Testing Materials International. AWT. 2003. Legionella 2003: An Update and Statement by the Association of Water Technologies (AWT). McLean, VA: Association of Water Technologies. Available at http://awt.org/. Best, M., V.L. Yu, J.E. Stout, A. Goetz, R.R. Muder, and F. Taylor. 1983. Legionellae in the hospital water supply Epidemiologic link with disease and evaluation of a method of control of nosocomial Legionnaires disease and Pittsburgh pneumonia agent. Lancet 2(8345):307 310. CDC. 2003. Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR; 52 (RR-10): 1-249. Atlanta: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/ncidod/hip/enviro/ guide.htm. CDC. 2004. Guidelines for Preventing Health-Care-Associated Pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR; 53 (RR-3): 1-179. Atlanta: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/ncidod/hip/pneumonia/ default.htm. CDC. 2000. Guidelines for Preventing Opportunistic Infections Among Hematopoietic Stem Cell Transplant Recipients: Recommendations of CDC, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation. MMWR; 49 (RR-10):1-128. Atlanta: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/mmwr/ preview/mmwrhtml/rr4910a1.htm. CDC. 1997. Final recommendations to minimize transmission of legionnaires disease from whirlpool spas on cruise ships. Atlanta: Centers for Disease Control and Prevention. CTI. 2000. Legionellosis Guideline: Best Practices for Control of Legionella. Houston, TX: Cooling Technology Institute. Fields, B.S. 2002. Legionellae and legionnaires disease. In Manual of Environmental Microbiology, 2d ed., eds. C.J.
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Hurst, R.L. Crawford, G.R. Knudsen, M.J. McInerney, and L.D. Stetzenbach, p. 860870. Washington, D.C.: ASM Press. JCAHO. 2005. Comprehensive Accreditation Manual, Standard EC.7.1, Utility Systems Management. Oakbrook Terrace, IL: Joint Commission on Accreditation of Health Care Organizations. Morris, G.K., and B.G. Shelton. 1991. Pathcon Technical Bulletin 1.3, Legionella in environmental samples: Hazard analysis and suggested remedial actions. Norcross, GA: Pathcon Laboratories. OSHA. 1999. Technical Manual, Section III, Chapter 7. Occupational Safety and Health Administration. Available at http://www.osha-slc.gov/dts/osta/otm/otm_iii/ otm_iii_7.html. MD DHMH. 2000. Report of the Maryland Scientific Working Group to Study Legionella in Water Systems in Healthcare Institutions. Maryland: Department of

Health and Mental Hygiene. Available at http:// www.dhmh.state.md.us/html/legionella.htm. TX DSHS. 1999. Report of the Texas Legionnaires' Disease Task Force. Texas: Department of State Health Services. Available at http://www.tdh.state.tx.us/ideas/legionnaires/taskforce/report/. Woodin, D., D. Erickson, S. McLaughlin, D. Samet, G. Stevens, and T. Keane. 2000. Waterborne Pathogens Compliance with JCAHO Requirements. Chicago: The American Society for Healthcare Engineering. Available at http://www.ashe.org. DISCUSSION Erica Stewart, Kaiser Permanente National EH&S, Oakland, Calif: Please provide the specific citation for the OSHA reference. Barry S. Fields: It is in the paper.

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