National Academies Press: OpenBook

Management of Legionella in Water Systems (2019)

Chapter: Front Matter

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Management of Legionella in Water Systems. Washington, DC: The National Academies Press. doi: 10.17226/25474.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Management of Legionella in Water Systems. Washington, DC: The National Academies Press. doi: 10.17226/25474.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Management of Legionella in Water Systems. Washington, DC: The National Academies Press. doi: 10.17226/25474.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Management of Legionella in Water Systems. Washington, DC: The National Academies Press. doi: 10.17226/25474.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Management of Legionella in Water Systems. Washington, DC: The National Academies Press. doi: 10.17226/25474.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Management of Legionella in Water Systems. Washington, DC: The National Academies Press. doi: 10.17226/25474.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Management of Legionella in Water Systems. Washington, DC: The National Academies Press. doi: 10.17226/25474.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Management of Legionella in Water Systems Committee on Management of Legionella in Water Systems Water Science and Technology Board Board on Life Sciences Board on Population Health and Public Practice Division on Earth and Life Studies Health and Medicine Division A Consensus Study Report of Prepublication Version - Subject to further editorial revision

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by the Alfred P. Sloan Foundation under Grant No. G-2016- 7288; Centers for Disease Control and Prevention under Contract No. 200-2011-38807, TO# 59; Department of Veterans Affairs under Contract No. VA250-16-C-0012; and En- vironmental Protection Agency under Contract No. EP-C-14-005, TO# 22 and EP-C-14- 005/68HE0C18F0876. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organi- zations or agencies that provided support for the project. International Standard Book Number-13: International Standard Book Number-10: Digital Object Identifier: http://doi.org/10.17226/25474 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2019 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Cover credit: Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. Manan- agement of Legionella in Water Systems. Washington, DC: The National Academies Press. doi: http://doi.org/10.17226/25474 Prepublication Version - Subject to further editorial revision

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the char-ter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engi- neering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was estab- lished in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distin- guished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy deci- sions. The National Academies also encourage education and research, recognize out- standing contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. Prepublication Version - Subject to further editorial revision

Consensus Study Reports published by the National Academies of Sciences, Engineer- ing, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Acad- emies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Med- icine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opin-ions contained in proceedings are those of the participants and are not endorsed by other partici- pants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. Prepublication Version - Subject to further editorial revision

COMMITTEE ON MANAGEMENT OF LEGIONELLA IN WATER SYSTEMS JOAN B. ROSE, NAE, Chair, Michigan State University, East Lansing NICHOLAS J. ASHBOLT, University of Alberta, Edmonton, Canada RUTH L. BERKELMAN, NAM, Emory University, Atlanta, Georgia BRUCE J. GUTELIUS, New York City Department of Health and Mental Hygiene CHARLES N. HAAS, Drexel University, Philadelphia, Pennsylvania MARK W. LECHEVALLIER, Dr. Water Consulting, LLC, Morrison, Colorado JOHN T. LETSON, Memorial Sloan-Kettering Cancer Center, New York City, New York STEVEN A. PERGAM, Fred Hutchinson Cancer Research Center and the University of Washington, Seattle MICHÈLE PRÉVOST, Polytechnique Montréal, Canada AMY PRUDEN, Virginia Polytechnic and State University, Blacksburg MICHELE S. SWANSON, University of Michigan, Ann Arbor PAUL W. J. J. van der WIELEN, KWR Water Research Institute, Nieuwegein, The Netherlands LAN CHI NGUYEN WEEKES, La Cité, Ottawa, Canada National Academies Staff LAURA J. EHLERS, Study Director, Water Science and Technology Board ANDREA HODGSON, Program Officer, Board on Life Sciences KATHLEEN STRATTON, Scholar, Board on Population Health and Public Practice ERIC EDKIN, Program Coordinator, Board on Earth Sciences and Resources RAYMOND M. CHAPPETTA, Senior Program Assistant, Board on Earth Sciences and Resources v Prepublication Version - Subject to further editorial revision

WATER SCIENCE AND TECHNOLOGY BOARD CATHERINE L. KLING, Cornell University, Ithaca, New York NEWSHA AJAMI, Stanford University, Stanford, California JONATHAN D. ARTHUR, Florida Geological Survey, Tallahassee DAVID A. DZOMBAK, NAE, Carnegie Mellon University, Pittsburgh, Pennsylvania FRANCINA DOMINGUEZ, University of Illinois, Urbana-Champaign WENDY D. GRAHAM, University of Florida, Gainesville MARK W. LECHEVALLIER, Dr. Water Consulting, LLC, Morrison, Colorado MARGARET A. PALMER, SESYNC – University of Maryland, Annapolis DAVID L. SEDLAK, University of California, Berkeley DAVID L. WEGNER, Jacobs Engineering, Tucson, Arizona P. KAY WHITLOCK, Christopher B. Burke Engineering, Ltd., Rosemont, Illinois National Academies Staff ELIZABETH EIDE, Director LAURA J. EHLERS, Senior Staff Officer STEPHANIE E. JOHNSON, Senior Staff Officer M. JEANNE AQUILINO, Financial Business Partner/Administrative Associate ERIC J. EDKIN, Program Coordinator BRENDAN R. MCGOVERN, Research Assistant/Senior Program Assistant vi Prepublication Version - Subject to further editorial revision

Preface Legionnaires’ disease arrived on the scene in dramatic fashion during the 1976 Philadelphia out- break that included 182 cases of pneumonia and 29 deaths. Almost 40 years later, major outbreaks at a community level (Flint, Michigan), in healthcare facilities (such as the Quincy, Illinois veterans home), and due to cooling towers (New York City) have again catapulted Legionella into national headlines. Le- gionella is now the number one cause of reported waterborne disease in the United States, transmitted through contaminated water that is aerosolized and exposing those nearby via inhalation into the respi- ratory tract. The bacteria in the genus Legionella occur naturally in water but have optimal growth at warm temperatures. Wherever there are water and pipes eventually one can find Legionella including in many human-made building water systems. However, its exact niche and the factors influencing it to bloom are only now being elucidated. L. pneumophila is the species (among many) most often diagnosed as the cause of Legionnaires’ disease. For every case associated with an outbreak there are nine more sporadic cases. Are these patients exposed in hospitals, from cooling towers, or within residences or commercial buildings such as hotels? Who is responsible for monitoring and controlling the bacteria and the disease? These are complex issues and despite major gains in knowledge about the bacteria, its ecology, its trans- mission, and Legionnaires’ disease, there remains great uncertainty about how to control Legionella in water systems. The National Academies of Science, Engineering, and Medicine were asked by the U.S. Centers for Disease Control and Prevention (CDC), the U.S. Department of Veterans Affairs (DVA), the U.S. Environmental Protection Agency (EPA), and the Alfred P. Sloan Foundation to address the state of the science with regard to Legionella including its ecology, disease diagnosis, amplification within water sys- tems, quantification, prevention and control, policy and guidance, and all associated research needs. This study was established under the auspices of the Water Science and Technology Board (WSTB) of the National Academies. The WSTB convened a Committee to address the management of Legionella in water systems that included 13 individuals with various backgrounds and expertise in Legionella. Over the course of two years, the Committee conducted a scientific literature review on the state of the science, covering the biology, taxonomy, and ecology of the bacteria; outbreaks and disease surveillance; environ- mental data from all types of building water systems; control methods; and rules and guidelines for ad- dressing Legionella contamination. It conducted some original data analyses, and formulated conclusions and recommendations meant to improve management of Legionella contamination of water systems and consequently better control Legionnaires’ disease in the United States. vii Prepublication Version - Subject to further editorial revision

The Committee recognizes that Legionella is only one of a number of pathogens found in water distribution systems and in building premise plumbing. Some of these other pathogens may be as serious as Legionella, such as Mycobacterium avium (and other non-tuberculous mycobacteria). The control of Le- gionella may have unintended consequences on these other organisms, as discussed briefly in Chapter 4. However, it was not the purpose of this Report to consider organisms beyond Legionella. During its six committee meetings, the Committee heard from experts involved in characterizing, monitoring, and remediating Legionella as well as from those knowledgeable about Legionella control poli- cies from Australia, Canada, and Europe. I would like to thank the following individuals for giving formal presentations to the Committee including Sam Posner, Laura Cooley, Jason Kunz, and Brian Raphael, CDC; Shantini Gamage, Gary Roselle, and Oleh Kowalskyj, DVA; Eric Burneson, EPA; Paula Olsiewski, Sloan Foundation; Janet Stout, Special Pathogens Lab; Tim Keane, Legionella Risk Management, Inc.; Jen- nifer Clancy, ESPRI; Christopher Crawford, New York City Department of Health and Mental Hygiene; Jessica Evans, NSF International; David Krause, Forensic Analytical Consulting Services; Alvin Bartels, the Netherlands; David Cunliffe, Australia; Martin Exner, Germany; John V. Lee, England; and Gary Klein, Gary Klein and Associates. The Committee also thanks the many individuals that spoke during open-mic sessions or submitted written comments to the Committee during the course of the study. This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in mak- ing each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: Zia Bukhari, American Wa- ter; Anne Camper, Montana State University; Elizabeth Casman, Carnegie Mellon University; Jennifer Clancy, ESPRI; David Fisman, University of Toronto; Marian Heyman, Connecticut Department of Pub- lic Health; Sophie Jarraud, Lyon Medical School; Richard Miller, University of Louisville; Norman Pace, University of Colorado; and Caitlin Proctor, Purdue University. Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by Rhodes Trussell, Trussell Technologies, Inc., and Glen Daigger, One Water Solutions, LLC. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. Joan B. Rose, Chair Committee on Management of Legionella in Water System viii Prepublication Version - Subject to further editorial revision

Contents SUMMARY.........................................................................................................................................................1 1 INTRODUCTION........................................................................................................................... 11 2 DIAGNOSIS, ECOLOGY, AND EXPOSURE PATHWAYS.................................................. 31 3 QUANTIFICATION OF LEGIONNAIRES’ DISEASE AND LEGIONELLA................... 95 4 STRATEGIES FOR LEGIONELLA CONTROL AND THEIR APPLICATION IN BUILDING WATER SYSTEMS............................................................ 175 5 REGULATIONS AND GUIDELINES ON LEGIONELLA CONTROL IN WATER SYSTEMS.................................................................................................................. 245 ACRONYMS................................................................................................................................................. 285 APPENDIX Biographical Sketches of Committee Members and Staff........................................ 289 ix Prepublication Version - Subject to further editorial revision

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Legionnaires’ disease, a pneumonia caused by the Legionella bacterium, is the leading cause of reported waterborne disease outbreaks in the United States. Legionella occur naturally in water from many different environmental sources, but grow rapidly in the warm, stagnant conditions that can be found in engineered water systems such as cooling towers, building plumbing, and hot tubs. Humans are primarily exposed to Legionella through inhalation of contaminated aerosols into the respiratory system. Legionnaires’ disease can be fatal, with between 3 and 33 percent of Legionella infections leading to death, and studies show the incidence of Legionnaires’ disease in the United States increased five-fold from 2000 to 2017.

Management of Legionella in Water Systems reviews the state of science on Legionella contamination of water systems, specifically the ecology and diagnosis. This report explores the process of transmission via water systems, quantification, prevention and control, and policy and training issues that affect the incidence of Legionnaires’ disease. It also analyzes existing knowledge gaps and recommends research priorities moving forward.

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