The Legionella Standard 188 proposed by the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) can have a widespread affect on not only how healthcare operations run but also the overall safety of employees and patients alike. Below are a few facts that organizations should know about this pending Standard.

1. LEGIONELLA & ASHRAE
STANDARD 188
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2. BIO
AMI Environmental
 AMI Environmental is a full-service environmental consulting and remediation firm,
specializing in facility-based environmental problems affecting facility operations,
renovation and demolition activities. Established in 1986 and headquartered in
Omaha, Nebraska, AMI services clients nationally and internationally.
Jamie Hilger
Industrial Hygiene Professional
A.S Liberal/Health Sciences (2008)
B.S. Environmental Studies –University of Nebraska (2011)
Member – American Society for Healthcare Engineering
ASHE Infection Control Training (2012)
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3. OBJECTIVES
 Introduction
 Legionella
 ASHRAE Standard 188P
 Summary
 Q&A
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4. WHAT IS LEGIONELLA?
• Pathogenic gram negative bacterium common in many environments
• Primarily warm water environments
• Approx. 50 species 70
serogroups
• Include species that
cause Legionellosis
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5. LEGIONELLOSIS
• Legionellosis: any illness caused by exposure to legionellae.
Legionnaires 'disease and Pontiac fever most common types.
• Legionnaires’ disease: multisystem illness
including deadly type of pneumonia.
• Pontiac fever: flulike illness, without
pneumonia
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6. LEGIONELLOSIS (CONT.)
• 80 - 90% of all cases of legionellosis are caused by a single species:
Legionella pneumophila
– 65 – 70% serotype 1
• One of the top three
causes of community-
acquired pneumonia
• Transmission is not person
to person
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7. DISCOVERY OF LEGIONELLA
• July 1976
• American Legion Convention
• Bellevue Stratford Hotel in Philadelphia
• 221 fell ill, 34 died
• 1965 St. Elizabeth Hospital
• 81 patients developed pneumonia,14 died
• Frozen specimens confirm Legionella 12 yrs later
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8. LEGIONELLOSIS (CONT.)
• 8,000 – 18,000 US
(cases/year)
• Death rate: 5 – 30%
• Many infections are not diagnosed or reported
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9. LEGIONELLOSIS (CONT.)
 Risk Factors
 Age
 Highest risk in elderly >65
 Not common in people <50
 Very rare in people <20
 Smoking
 Pre –existing COPD, or diabetes
 Compromised immune system
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10. HEALTHCARE COSTS
 Waterborne diseases cost over $500 million annually in the U.S.
 Legionnaire’s disease $101 – 321 million
 $34,000 per case
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11. LEGIONNAIRES’ DISEASE OUTBREAKS
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12. HOW IS LEGIONELLA TRANSMITTED?
• Inhalation: Airborne water droplets containing legionellae are inhaled.
• Aspiration: contaminated water or liquid enter the lungs.
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13. HOW IS LEGIONELLA TRANSMITTED? (CONT.)
Contaminated Source
Transmission
Susceptible Host
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14. COMMON SOURCES OF LEGIONELLA
Typical manmade water sources:
• Plumbing systems
• Cooling towers
• Humidifiers
• Showers
• Hot tubs
• Decorative fountains
• Evaporative condensers
• Misters, air washers
Environmental Sources include freshwater ponds, rivers, and creeks
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15. LEGIONELLA GUIDELINES
• ASHRAE 2000
• CDC 2003
• AIA 2001
• EPA 1991
• WHO 2007
• OSHA 1996
• JCAHO 2001
• UK L8 2000
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16. WHAT IS ASHRAE STANDARD 188P?
• A standard that presents methods for the prevention of legionellosis
associated with building water systems.
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17. WHY IS ASHRAE 188P DIFFERENT?
• Standard vs. Guideline
Law
• Consensus
Standard
Guideline
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18. ASHRAE STANDARD 188P
• “Prevention of Legionellosis associated with building water systems”
• Purpose: identify specific practices in prevention of Legionellosis
• Scope: it provides methods of risk management for the prevention of
legionellosis associated with centralized industrial and commercial
building water systems.
• Intended for: facility owners/manager
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19. STANDARD 188 REQUIRES HACCP WATER PLAN
FOR BUILDING WITH ANY OF THESE FACTORS:
• Centralized hot water heater
• More than 10 stories high
• Inpatient healthcare facility
• Occupants over age >65
• Whirlpool/spa
• It has one or more water features
• Free chlorine <0.5 ppm
• Cooling towers and or evaporative condensers
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20. WHAT TO DO?
Does your building have any of the risk factors
No Yes
Resurvey Establish a
annually HACCP water plan
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21. HACCP PRINCIPLES
- risk management method that prevents hazards form harming
people.
1. Conduct hazard analysis
2. Identify critical control points
3. Establish critical limits for each ccp
4. Establish critical control point monitoring
5. Establish corrective action
6. Verify and validate
7. Document the plan
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22. ACTIONS INVOLVED IN DEVELOPING AN HACCP
WATER PLAN:
1. Form a water management team
– One who understands HACCP
– Building water system
– Employees
– Suppliers
– Consultants
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23. 2. DEVELOP FLOW DIAGRAMS
Objectives:
• Identify end-point uses and processing steps in the water systems
• Construct at least two flow diagrams
• Confirm accuracy
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24. PROCESS FLOW DIAGRAMS
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25. 3. HAZARD ANALYSIS SUMMARIES
 HACCP requires hazard analysis summaries that identify the chemical,
physical, or biological hazards. For each of the water systems.
Chemical
Biological Physical
Hazard
Analysis
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26. HAZARD ANALYSIS SUMMARIES EXAMPLE
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27. 4. ESTABLISH CRITICAL CONTROL POINTS
(CCP’S)
 CCP’s are points at which legionella control measures can and should be
applied.
 Use process flow diagrams and hazard
analysis summaries to identify points
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28. 5. CONTROL MEASURES
• Monitoring frequency, critical limits, and corrective actions at the ccp’s.
• Measures must be
– Evidence based
– Up to date
– Reasonable in cost
– Simple and practical
– Clearly written
Include measures for: routine maintenance of applicable water
systems, design/construction, and incidents.
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29. 6. DEVELOP VALIDATION, VERIFICATION, AND
DOCUMENTATION PROCEDURES
 Validate
 Verify
 Document
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30. ASHRAE STANDARD 188P 2ND PUBLIC REVIEW
DRAFT
 https://osr.ashrae.org/Public%20Review%20Draft%20Standards%20Lib/St
d-188P-PPR2%20Final%206%2010%202011.pdf
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31. RECAP
 Legionella
 Steps to ASHRAE Standard I88 Compliance
 Water management team
 Process flow diagrams
 Hazard analysis summaries
 Critical Control Points
 Control measures
 Validate, Verify, and Document
 How AMI can help
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32. REFERENCES
 ASHRAE Guideline 12-2000, “Minimizing the Risk of Legionellosis Associated
with Building Water Systems”, American Society of heating, Refrigerating
and Air-Conditioning Engineers, Inc.
 Center for Disease Control and Prevention. “Legionellosis Resource Site”
July 23rd 2012. http://www.cdc.gov/legionella/
 American Society for Healthcare Engineering. “Prevention of Legionellosis
Associated with Building Water Systems” , February 23, 2012
http://www.ashe.org/resources/pdfs/HACCP_Plan_Legionellosis_Building_
Water_Systems.pdf
 Freije, Matthew .“Legionella Control in Healthcare Facilities” A Guide for
Minimizing Risk. 1997
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