Standard Guide for the Inspection of Water Systems for Legionella and the Investigation of Possible Outbreaks of Legionellosis (Legionnaires' Disease or Pontiac Fever)
5.1 Water systems may be inspected (see Section 7) and tested (see Section 8) for legionella under three circumstances (1) in the absence of reported legionellosis (see 5.2); (2) when a single legionellosis case has been reported (see 5.3); and (3) when two or more legionellosis cases are reported in a limited time period and geographic region (see 5.4). Following are factors building owners and operators need to understand when considering testing water systems for legionella in the absence of illness (see 5.2) and for single legionellosis cases (see 5.3). Refer also to the CDC 2003 Guidelines for Preventing Health-Care Associated Pneumonia, and the CDC 2000 Guidelines for Preventing Opportunistic Infections Among Hematopoietic Stem Cell Transplant Recipients, and the WHO Legionella and the Prevention of Legionellosis. Detection of legionella in a water system is not sufficient to identify the system as a health hazard. However, failure to detect legionella does not indicate, conclusively, that the bacterium is not present (see 6.2.4) or that the water system may not pose a potential health hazard. Methods to detect legionella vary in sensitivity and specificity (see 6.2), and laboratories vary in their skill and experience in the isolation and identification of legionella. Isolation of apparently identical legionellae from clinical and environmental samples (see 6.2.1, 184.108.40.206, and Section 8) may suggest that a water system was the source of the legionella responsible for a patient's infection (see 5.3.2). However, cases of Legionnaires' disease due to different legionella serogroups or species need not necessarily have different sources of exposure because a system may be contaminated by more than one legionella. Timely inspection, testing, and treatment of possible legionella sources may reduce legal liabilities for facility owners and operators. Refer also to the APHA Public Health Law Manual.
5.2 Environmental Testing for Legionella in the Absence of Illness:
5.2.1 Concerned employers, building owners and operators, facility managers, and others seek to prevent real and potential health hazards, if possible. Water system operators may identify undesirable situations by monitoring routinely for legionella and may be able to implement control measures before the bacterium reaches an amount sufficient to cause human illness (see 220.127.116.11). The CDC 2000 Guidelines for Preventing Opportunistic Infections Among Hematopoietic Stem Cell Transplant Recipients advises that because transplant recipients are at much higher risk for disease and death from legionellosis compared with other hospitalized persons, periodic culturing for legionella in water samples from a center's potable water supply could be regarded as part of an overall strategy for the prevention of Legionnaires' disease in transplant centers and other facilities housing persons at high risk of infection if exposed (see 6.4.2). There is some evidence that environmental legionella surveillance should be considered a proactive strategy for the prevention of hospital-acquired Legionnaires’ disease (1). However, the optimal methodology (that is, frequency or number of sites) for environmental surveillance cultures in transplant centers has not been determined, and the cost-effectiveness of such a strategy has not been evaluated for either transplant centers or other health-care settings nor for institutional, commercial, or residential buildings.
5.2.2 Some experts advise against testing water systems for legionella in the absence of illness, particularly in buildings other than hospitals or health-care facilities, given that absolute exclusion of this bacterium from water systems may not be necessary to prevent legionellosis nor may it be achievable without considerable expense. Microbiological water monitoring increases operational costs, and interpretation of test results may be difficult (see 6.2.4). Identification of legionella in environmental samples also may cause unwarranted alarm and unnecessary remediation. The WHO publication states that legionella testing cannot be considered a control measure, but does provide some evidence that the water safety plan is effective and that control measures are operating properly. Sampling for legionella cannot provide results sufficiently quickly to be useful in operational monitoring, which instead should be by measures that provide real-time results, for example, monitoring of the biocide concentration, temperature, and pH of the water.
5.3 Environmental Testing for Legionella for a Single (Sporadic) Legionellosis Case:
5.3.1 Testing potential legionella sources as soon as possible after confirmation of legionellosis may increase the likelihood of identifying the responsible source. Environmental conditions and equipment operation may change frequently, which may affect the likelihood of legionella detection. Inspectors may fail to identify the responsible source if they postpone sampling until an illness is confirmed as legionellosis (see 6.6 and 6.7) or until a search for other cases identifies common exposures (see Section 9).
5.3.2 Persons with legionellosis often have been exposed to more than one possible source during the disease's incubation period (see 6.4.3, 6.5.3) and may not recognize or recall all possible exposures. Isolation of apparently identical legionellae from clinical and environmental samples (see 6.2.1, 18.104.22.168, and Section 8) is suggestive, but does not identify a source absolutely as the site of a patient's exposure because the distribution of legionella species, serogroups, and subtypes (see 6.1.1 and 6.1.2) in the environment is not known, that is, the same legionella could colonize more than one water system. Identification of the environmental source responsible for legionella transmission may be difficult if no clinical isolate is available for comparison with environmental isolates (see 6.2.1, 22.214.171.124). Legionella has been found in a substantial proportion of water systems tested in prevalence surveys and outbreak investigations. Without a clinical isolate, identification of the probable source of legionella transmission must be based on environmental and epidemiological information (see Sections 7 – 9).
5.4 Environmental Testing for Legionella for Multiple Legionellosis Cases—Identification of multiple legionellosis cases in a circumscribed area and limited time period or that share a potential source warrants (1) environmental inspection of suspect sources to identify the water system responsible for legionella transmission to prevent further illness (see Sections 7 – 9); and (2) epidemiological investigation to identify common risk factors for cases (see 6.4.2, 6.5.2). Information from an epidemiological investigation (see Section 9) often facilitates identification of specific environments the legionellosis patients shared and on which inspectors should focus attention (see Sections 7 and 8). Environmental testing supplements, but does not replace, inspection and prompt correction of identified problems (see Section 10) at all possible legionella sources regardless of whether or not legionella is detected or the potential source is implicated in patient exposure.
1.1 This guide covers appropriate responses for employers, building owners and operators, facility managers, health and safety professionals, public health authorities, and others: (1) to a concern that a water system may be contaminated with the bacterium known as legionella (see 6.1); and (2) to the identification of one or more cases of Legionnaires' disease or Pontiac fever (see 6.3 – 6.5). Comprehensive and explicit recommendations to limit legionella multiplication in water systems, disinfect potential sources of human exposure to legionella, and prevent health-care associated infections are beyond this guide's scope.
1.2 The values stated in SI units are to be regarded as standard. No other units of measurement are included in this standard.
1.3 This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory limitations prior to use. See 7.3 and 8.5 for specific hazard statements.
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