A Growing Public Health Threat. Research shows there has been a marked increase in recent years of Legionnaires’ Disease (LD) in the U.S. and around the world. To address this growing threat, government agencies, healthcare experts, and code officials have been developing several strategies — the most prominent of which include ANSI/ASHRAE Standard 188-2021, Legionellosis: Risk Management for Building Water Systems (ASHRAE 188).
Application of ASHRAE 188 often results in the development and implementation of comprehensive Water Management Programs (WMPs) to identify, eliminate, and prevent conditions that give rise to outbreaks of LD in building water systems (also known as premise piping systems), which is where most cases arise. [1] A key resource in this area is the Legionella Toolkit from the Centers for Disease Control and Prevention (CDC), Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, which recommends that the best method for combatting LD is for building owners to develop a comprehensive WMP (Water Management Programs) designed in accordance with the policies and procedures set forth in ASHRAE 188.
Under any conditions, deployment of effective diagnostic and treatment measures is vital to protecting public safety. Moreover, this work can be particularly difficult in certain technically advanced water systems, such as those in healthcare facilities. For these reasons, implementation of ASHRAE 188 and WMPs generally involves challenging and extraordinarily complex work. It is, therefore, essential that the companies and individuals performing this work have the appropriate skills, training, and qualifications. These factors were the driving force behind the development of ASSE/IAPMO/ANSI Series 12000-2021 (ASSE Series 12000), Professional Qualifications Standard for Water Management and Infection Control Risk Assessment for Building Systems, which is specifically designed to establish appropriate skill and qualifications standards, and certifications needed to implement ASHRAE 188 and WMPs correctly.
Nature of Legionnaires Disease. While drinking water in America has been relatively safe for several decades, recent developments are giving rise to new threats of contaminants, including Legionella.
The U.S. Safe Drinking Water Act (SDWA), passed in 1974, propelled progress by requiring water suppliers to meet national standards for monitoring contaminants and managing them through filtration, disinfection, and other processes. The U.S. now has one of the world’s safest drinking water supplies. Yet, many microorganisms still slip through the cracks of U.S. drinking water systems, sickening up to an estimated 4 million to 32 million people every year. [2]
LD presents some of the greatest risks to public safety in this regard, which is why leading public health authorities, such CDC and key code bodies such as ASHRAE, have focused their attention in this area.
Legionella, which is a bacterium that exists naturally in the environment and is not-threatening, can lead to outbreaks of LD when Legionella interacts with certain conditions in building water systems, including stagnant water, inadequate circulation, and high-water temperatures. Many of these conditions involve unintended consequences that have been caused by recent changes in federal energy policy that result in the use of lower temperatures and lower water pressure in building water systems. While such changes are beneficial in saving energy and water, they also create conditions that can cause Legionella to spike to dangerous levels. As explained in ASHRAE 12, the guideline that is the companion piece to ASHRAE 188:
The presence of Legionella bacteria in building water systems is not by itself sufficient to cause LD. Other factors necessary for LD to occur include environmental conditions that promote the growth of Legionella; a means of transmitting the bacteria to people in the building, such as aerosol generation; and exposure of susceptible persons to water colonized by Legionella that is inhaled or aspirated into the lungs. [3]
LD, a serious type of pneumonia, is a health risk that can result in major illness or death. Specifically, “Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires’ disease.” [4] Legionella bacteria can also cause Pontiac fever, a less serious illness. LD can be found in various areas of a building’s water system.
The most common source of building-associated Legionnaires’ disease outbreaks was drinkable water (56 percent), such as water used for showering, followed by cooling towers (22 percent), and hot tubs (7 percent), says the report. Other sources included industrial equipment (4 percent) and a decorative fountain/water feature (4 percent). [5]
Acute, Persistent Rise in LD Cases. In 2018, the “rate of Legionnaires’ cases reported to the U.S. Centers for Disease Control and Prevention [CDC] increased four and a half times since 2000.” [6] As the following CDC chart shows, this surge in LC cases has been building for several years: [7]
Since 2018, outbreaks of LD have continued to occur in various states across the country, promoting public health agencies to work with key stakeholders to address this threat.
Leading Tools for Combatting LD. As noted, Legionella WMPs, particularly those designed in accordance with ASHRAE 188, are emerging as the leading strategy for combatting LD.[8] In this regard, the CDC Toolkit recommends that building owners seeking to address this risk develop a WMP to identify areas or devices in buildings “where Legionella might grow,” and stresses that such WMPs designed in accordance with ASHRAE 188 “are now an industry standard for large buildings in the United States.” [9] State legislatures have also been adopting this approach by incorporating ASHRAE 188 WMPs into a growing number of new laws and bills. [10]
WMPs designed to meet ASHRAE 188 can be highly effective in eliminating Legionella and preventing outbreaks of LD due to the intensive, rigorous assessment, control and remediation requirements established under this standard. Although this is highly complex work and it is critically important because of its impact on public safety, ASHRAE 188 does not include any training or other qualification standards to ensure that this work is done correctly. Moreover, although the ASHRAE 12 Guide includes several references to the need to have companies and personnel administering WMPs to have adequate training to ensure this work is done properly, it does not specify the source or type of training that should be used.
ASSE/IAPMO/ANSI Series 12000: A Key Component to Water Quality Management. Fortunately, a related standard has been developed to specifically address this need. ASSE Series 12000was carefully designed to establish necessary training and certification criteria precisely to ensure that companies and individuals engaged in the design and administration of WMPs generally and ASHRAE 188 specifically have the professional qualifications to perform this work.
ASSE Series 12000 — an American Standard for Professional Qualifications Standard for Water Management and Infection Control Risk Assessment for Building Systems — offers an effective solution to fill the gap left in ASHRAE documents. Indeed, ASSE Series 12000 is the only industry standard developed for this purpose. This series is pointedly comprehensive as it includes the following:
- Standard #12010 for Environment of Care, Infection Control, and Construction Risk Assessment
- Standard #12020 for Environment of Care, Infection Control, and Construction Risk Assessment for Construction and Maintenance Employers
- Standard #12060 for Employers and Designated Representatives of Water Quality Programs
- Standard #12061-12063 for Water Quality Program Plumbers, Pipefitters and HVAC Technicians, and Sprinkler Fitters
- Standard #12080 for Legionella Water Safety and Management Specialists
Using companies and individuals certified pursuant to these standards is a critical quality control step in ensuring safe water quality. Implementation of WMPs under ASHRAE 188 often involves complex operations, particularly in industries like healthcare with sophisticated water systems. In other words, while WMPs may have the most advanced policies and procedures for water quality treatment, indeed because they do—building owners will not be able to trust them to work effectively unless they are designed and administered by qualified entities and individuals.
Specifically, the development of reliable WMPs requires in-depth knowledge of water structures and systems, and the ability to understand and interpret the complicated specifications of ASHRAE 188. In addition, persons responsible for these programs must have sufficient training and specialized skills to identify, assess, and prioritize water quality risks wherever they may exist in each system. They must also possess prerequisite expertise for implementing corrective actions and control measures when hazardous conditions are found, and have the capabilities to modify piping, fixtures, or other system components to prevent hazardous conditions from occurring in the first place.
For these reasons, ASSE Series 1200 standards are a vital component in water quality management. Unless effective training and certifications are used for this work, WMPs could easily fail or have only marginal impact — results which are unacceptable when battling a fatal disease — especially one whose threat is growing exponentially in our state and nationally.
[1] Center for Disease Control and Prevention (CDC), Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide To Implementing Industry Standards, p. 2 (2021)(CDC Toolkit), Legionella Toolkit-Version 1.1-June 24, 2021 (cdc.gov).
[2] Lynne Peeples Ensia, Smithsonian Magazine, Why Reports of Legionnaires’ Disease Are on the Rise in the United States
Why Reports of Legionnaires’ Disease Are on the Rise in the United States | Science| Smithsonian Magazine (last visited June 12, 2023; emphasis added).
[3] ASHRAE 12-2020, Managing the Risk of Legionellosis Associated with Building Water Systems (2020)
[4] CDC, Legionella (Legionnaires’ Disease and Pontiac Fever: Fact Sheet, Legionnaires Disease and Pontiac Fever | CDC (last visited June 12, 2023)(CDC Legionella Fact Sheet)
[5] Naomi Millán, FacilitiesNet, Legionella Toolkit From CDC Based on ASHRAE Legionella Standard (2016), Legionella Toolkit From CDC Based on ASHRAE Legionella Standard – Facility Management HVAC Quick Read (facilitiesnet.com)
[6] Brett Walton, Circle of Blue, Water News, Deadly Legionnaires’ Disease Outbreaks Persist in the U.S (2018) Deadly Legionnaires’ Disease Outbreaks Persist in the U.S. – Circle of Blue (last visited June 12, 2023; emphasis added).
[7] CDC Toolkit p. ii.
[8] CDC Legionella Fact Sheet
[9] CDC Toolkit p. ii.
[10] See e.g., Maryland, SB 0302, Nevada, AB 263, New Jersey, S1006.
