Karla Peterson, P.E. | MDH DWP Protecting patients, protecting water: BMP for water conservation and Legionella Thank you for joining our webinar today. I am going to talk about who needs a water management plan to reduce the occurrence of legionella. I will run through the process of how to develop a management plan and describe where legionella and other pathogens may grow in your water distribution system. Karla Peterson, P.E. | MDH DWP April 25, 2019

Do you need a Legionella Management Plan? Who needs a Legionella Water Plan? Answer these questions: Is your building a healthcare facility? CMS directive Does your building primarily house people older than 65 years? Does your building have multiple housing units and a centralized hot water system? Does your building have more than 10 stories (including basement levels)? So, Who needs to develop a water management plan? The Center for Disease Control and ASHRAE have developed guidelines for buildings. Whether or not a plan is needed depends on the answer to the following questions: Is your building a healthcare facility where patients stay overnight or does your building house or treat people who have chronic and acute medical problems† or weakened immune systems? The Centers for Medicare and Medicaid Services or CMS , published a directive in June 2017 that requires all Medicare-certified nursing homes, hospitals and critical access hospitals to have water management policies and procedures to reduce the risk, growth and spread of legionella and other opportunistic pathogens in building water systems. 2.Does your building primarily house people older than 65 years or age (like a retirement home or assisted-living facility)? 3.Does your building have multiple housing units and a centralized hot water system , examples of these are hotels or high-rise apartment complexes)? 4.Does your building have more than 10 stories (including basement levels)?

Do you need a Legionella Management Plan? 5. Does your building have a cooling tower ? 6. Does your building have a hot tub that is not drained between each use? 7. Does your building have a decorative fountain? 8. Does your building have a centrally-installed mister, atomizer, air washer, or humidifier? If you answered YES to any of the above questions, a water management plan is needed. 5.Does your building have a cooling tower ? I will talk more about cooling towers and related facilities later in this presentataion 6.Does your building have a hot tub (also known as a spa) that is not drained between each use? 7.Does your building have a decorative fountain? 8.Does your building have a centrally-installed mister, atomizer, air washer, or humidifier? If the answer to any of the above questions is YES, you need a water management plan.

Water System Components Water system components that can potentially harbor and disperse legionella: Hot and cold water storage tanks Aerators Water heaters Faucet flow restrictors Water-hammer arrestors Showerheads and hoses Pipes, valves, and fittings Ice machines Expansion tanks Medical devices Water filters Nonsteam aerosol-generating humidifiers Electronic and manual faucets Eyewash stations This slide lists the types of water system fixtures or components that can potentially harbor, allow the growth of or disperse legionella: Legionella can be dispersed into the air with • Showerheads and hoses • Centrally-installed misters, atomizers, air washers, and humidifiers • Nonsteam type aerosol-generating humidifiers Certain Medical devices  Electronic and manual faucets

Additional Building Components Centrally-installed misters, atomizers and humidifiers Hot tubs and saunas Decorative fountains Cooling towers Additional building components that have particular maintenance requirements are: Hot tubs, spas and saunas - you should have a program in place to follow manufactures recommendations for maintenance. This includes training for all staff that monitors the spa, guarantee the maintenance of continuous chlorine or bromine levels, the correct ph and maintenance of the the filtration and recirculation system. • Decorative fountains – Regular maintenance including biocidal treatment will greatly reduce the risk of legionella growth. Ornamental water features that are in health care facilities ,include submerged lighting or contain water with temperatures exceeding 70 F required greater attention. There should never be a slimy layer on the fountain. • Cooling towers on the next slide

What is a cooling tower? Cooling Towers NSF P453: Cooling Tower Water Systems – Treatment, Operation, and Maintenance to Prevent Legionellosis What is a cooling tower- A cooling tower is a unit that recirculates water to make the inside of a building cooler. Cooling towers are often part of a building’s heating, ventilation and air conditioning (HVAC) system. Cooling towers may be found in or on top of large buildings. In commercial/industrial buildings, cooling towers may be part of a building's industrial process or energy production system and may be located outside the building. Units called evaporative coolers and fluid coolers are also considered cooling towers. Heat and evaporated water flow out the top of these towers in the form of a fine mist. This allows a considerable amount of water vapor and sometimes droplets to be introduced into the surroundings, despite the presence of drift eliminators that are designed to limit droplet release. Good maintenance is necessary, both to control Legionella growth and for effective operation. The NSF International P453 Plan- Cooling Tower Water Systems – Treatment, Operation, and Maintenance to Prevent Legionellosis is similar to the CDC Plan for Buildings. Some of OSHA’s top recommendations for keeping your facility’s cooling tower clean and free of Legionella> Use chemical biocides to control microorganisms. Keep sump water around 68°F or lower. Inspect the cooling tower equipment monthly. Clean and disinfect your facility’s cooling tower quarterly or twice a year if the unit is not in operation year-round. It’s important to clean it at the beginning of each cooling season and after it’s shut down in the fall. Systems with high levels of LDB may require more cleaning. Clean and disinfect systems any time they are out of service for more than 5 days Clean and disinfect new systems to remove any construction material residue. Keep detailed records showing all dates and details of operations and maintenance, Because of Legionella outbreaks in New York City they have passed city and state laws requiring registration of all cooling towers and maintenance and monitoring requirements. 5/11/2019

Internal Building Plumbing Internal factors that promote Legionella growth: Biofilm Low flow rates Scale and sediment Water temperature fluctuations Water pressure changes pH Inadequate disinfection Water stagnation Lets discuss factors in you building plumbing, or internal factors, that promote legionella and pathogen growth. These are issues that need to be controlled or monitored. Biofilm: Biofilm is a slimy layer in pipes in which pathogens can live; it can give pathogens including Legionella a safe harbor from heat and disinfectants; and provides food and shelter. Biofilms can grow on any surface that is constantly moist and can last for decades. Low flow rates: Lower water flow rates may be due to low system pressure or because of low flow water fixtures. The lower water use leads to greater water age in the internal plumbing. Scale and sediment: Uses up disinfectant and creates a protected home for Legionella and other pathogens Water temperature fluctuations: Provide conditions where Legionella grows best (77°F–108°F); Legionella can still grow outside this range. Many things can cause the hot water temperature to drop into the range where Legionella can grow, including low settings on water heaters, heat loss as water travels through long pipes away from the heat source, mixing cold and hot water within the plumbing system, heat transfer (when cold and hot water pipes are too close together), or heat loss due to water stagnation. In hot weather, cold water in pipes can heat up into this range. Water pressure changes: Can cause biofilm to dislodge, colonizing downstream devices pH: Disinfectants are most effective within a narrow range (approximately 6.5 to 8.5) Inadequate disinfectant: does not kill or inactivate Legionella. Even if the water entering your building is of high quality, it may contain Legionella. In some buildings, processes such as heating, storing, and filtering can degrade the quality of the water. These processes use up the disinfectant the water entered with, allowing the few Legionella that entered to grow into a large number if not controlled. Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant. Common causes of stagnation include renovations that lead to dead legs, reduced building occupancy or fixtures that are rarely used such as a shower in a hospital room.

External Factors External Factors to Building Plumbing: Construction that effects the public water supply Water main breaks Changes to municipal water quality External factors to the building plumbing that may introduce or dislodge legionella. These are things that happen outside your building or facility that may impact water quality coming into the building. Construction: Vibrations and changes in water pressure can dislodge biofilm and free Legionella and other pathogens to enter buildings. Water main breaks: Breaks normally result in changes in water pressure that can dislodge biofilm and free Legionella into the water, while dirt and other materials can be introduced into the water and use up disinfectant and later promote more growth. Changes in municipal water quality such as lower chlorine levels, increase in turbidity, changes in disinfectant type or the Ph.

Developing a Water Management Plan Center for Disease Control (CDC) Guidance recommends: A water management plant with the following elements: Establish your water management program team Describe the building water systems using flow diagrams and written description Identify areas where Legionella could grow and spread. Decide where you need to apply control measures and how to monitor them. The Center for Disease Control has created a tool kit to guide building owners through development of a water management plan. Developing and maintaining a water management program is a multi-step process that requires continuous review. This plan includes seven steps to building an effective Legionella water management program. Every building is different (depending on factors such as the structure, age, location, occupants of the building, or surrounding conditions), so each program needs to be tailored for that building water system. The 7 main elements include: 1 Establish a water management program team Your team will need members with certain skills to develop and implement your Legionella water management program. In some cases, you may need to train your in-house personnel or consider hiring professionals with specific environmental and Legionella experience.  Having a plumber on the team may be extremely helpful. 2 Describe the building water systems using flow diagrams and a written description Include details such as where the building connects to the municipal water supply, how water is distributed throughout the building, and where hot tubs, water heaters or boilers, and cooling towers are located. Include any dead end or under utilized areas. 3 Identify areas where Legionella could grow and spread These are areas where potentially hazardous conditions could occur in your building water systems, such as where water temperature is optimal to promote Legionella growth or where water flow might be low. 4 Decide where you need to apply control measures and how to monitor them Establish control measures and limits for each hazardous condition, as well as plans for where and how to monitor them. Control measures are actions you take in your building water systems to limit growth and spread of Legionella, such as heating the water to appropriate temperatures, adding disinfectant, or cleaning and flushing. Control limits are the range of values that are acceptable for the control measures that you are monitoring to reduce the risk for Legionella growth and spread. Control points are locations in the water systems where you can apply control measures. For example a control measure may be chlorine residual.

Developing a Water Management Plan Elements: 5. Establish ways to intervene when control limits are not met. 6. Make sure the program is running as designed and is effective. 7. Document and communicate all your activities. 5 Establish ways to intervene when control limits are not met  Determine what corrective actions or contingency responses to take when you control measures are outside of the control limits you established. Use the recorded information from your control limits to notice any changes in water quality and any significant variation from typical results. An example of this would be set limit for chlorine residual is not met. 6 Make sure the program is running as designed and is effective  Establish procedures to verify that your team is implementing the water management program as designed. This includes: validation that the program effectively controls the hazardous conditions throughout the building water systems. Updating the program when necessary. And making sure your team is following the program. 7 Document and communicate all activities Document all the activities and communicate with building occupants, employees, and colleagues on a continual basis. If an event triggers you to review or update your water management program, remember to Maintain records of any water quality parameters that are measured to evaluate deviations Update the flow diagrams as needed Update the written description of your building water systems Train those responsible for implementing and monitoring the updated program  

Other Legionella Control Options Adding treatment to the building entry point Considered an individual public water supply Alternatives to Legionella testing Sporadic testing for Legionella may not be useful If testing, must be on a regular basis Other daily monitoring – temperature, chlorine residuals, and pH - may be more useful Some other Legionella Control Options are: Treatment at the entry point to the building or at points of use. Treatment should be considered carefully as it may create other health risks, such as elevated lead and copper concentrations, disinfection by-products, and/or point of use maintenance failures. If treatment is added, the facility may be considered an individual public water system and subject to additional requirements under the federal Safe Drinking Water Act. Regular testing for Legionella. It’s important to note that sporadic testing for the Legionella bacteria may not be useful, as it can be found in any plumbing system. The variation from normal levels will be the indicator of growth and possible issues. Preliminary results take several days and confirmed results, a week or more depending on what kind or testing is used. As with all types of system monitoring, it is important to do and record on a routine basis to reveal any changes in results. Doing Consistent monitoring for temperature, chlorine residuals, and pH is a more useful general management tool.

Necessary control options that do affect water conservation Regularly flush plumbing system and cooling towers Regularly drain and clean plumbing components and cooling towers Have some plumbing components that are not low-flow, and/or remove aerators, to allow for adequate water velocity when flushing Consider automated flushing components (may include shower heads and faucets) Avoid water reuse where water can be aerosolized

Control options that don’t affect water conservation Remove dead legs in plumbing system Avoid rubber or plastic components or gaskets Insulate and/or tape hot water lines Use smaller water heaters Limit length of hot water recirculating lines Consider point of use water heaters for low-use lines Keep hot water > 140 degrees F and install anti-scald devices

Other Recommendations Communicate regularly with your public water system to be aware of: Nearby water main construction and repairs Nearby water main breaks Changes to CPWS water quality To assist building owners and managers in maintaining their internal water quality and reducing the introduction and growth of Legionella it is recommended that the PWS communicate when there is any: Construction that may impact the PWS distribution piping (including renovations and installation of new equipment): Vibrations and changes in water pressure can dislodge biofilm and release Legionella. Water main breaks: Changes in water pressure also can dislodge biofilm. In addition, water main breaks can introduce dirt and other materials into the water that use up all of the available disinfectant. Changes in municipal water quality: Changes in water quality can increase sediment, lower disinfectant levels, increase turbidity, or cause pH to be outside recommended ranges. Also, if a supplier changes the type of disinfectant it uses, this change can impact how the water management program team should monitor its building water systems.

References Center for Medicare and Medicaid Services (CMS) – Memorandum Requirement to Reduce Legionella ASHRAE Standard 188 - establishes minimum legionellosis risk management requirements for building water systems. Center for Disease Control (CDC) – Toolkit: Developing a Water management Program to Reduce Legionella Growth and Spread in Buildings NSF International – Cooling Towers Guidance Useful references for building owners and public water supplies include Center for Medicare and Medicaid Services – Legionnaires Disease Control ASHRAE Standard 188- which establishes minimum legionellosis risk management requirements for building water systems. This includes design and maintenance guidance Center for Disease Control (CDC) – If you do an online search for CDC -legionella you will find the Toolkit they have developed for building owners and managers that is an easy to use guideline for interpretation of the ASHRAE 188 standard. NSF Cooling Towers Guidance

Minnesota Department of Health Drinking Water Protection Thank you! Karla Peterson, P.E. Minnesota Department of Health Drinking Water Protection karla.peterson@state.mn.us