Legionella bacteria are found naturally in freshwater envi- ronments but can also exist in water supply systems. Certain risks increase the likelihood of Legionella exposure, such as stagnant water in long-term care (LTC) facility plumbing sys- tems, hot tub use, decorative fountains, and different water features. Legionella live and grow in water systems at tem- peratures of 68 degrees Fahrenheit (20 degrees Celsius) to 122 F (50 C), with 95 F the optimal temperature for growth. They survive and grow within biofilms which develop in water sys- tems.1,2,3 It’s important to note that any system or equipment containing nonsterile water can grow Legionella. Legionella can lie dormant at temperatures below 68 F (20 C), making ice machines conducive to harboring the bacteria.
Legionellosis is a respiratory infection caused by expo- sure to Legionella bacteria. It manifests in two ways: Pontiac fever, a mild flu-like illness (e.g., fever, chills, headache, muscle aches) that lasts two to five days, or Legionnaires’ disease, a serious, sometimes fatal pneumonia with symptoms including dry cough, fever, muscle aches, and pulmonary infiltrates.
Risk factors for developing Legionellosis include:4
- Elderly
- Immunocompromised
- Recent surgery
- End-stage chronic kidney disease
- Chronic obstructive pulmonary disease (COPD)
- Malignancy
- Smoking
The mortality rate for Legionnaires’ disease ranges from 13% to 33%. Legionellosis is acquired by inhaling aerosols that contain the bacteria or aspirating contaminated drinking water. There are no vaccines available to prevent this disease.1,3,4 Legionellosis must be managed with preventative measures— particularly inhibiting Legionella growth. In 2015, ASHRAE (the American Society of Heating, Refrigerating and Air-Conditioning Engineers) approved a new industry standard to control and prevent building-associated Legionnaires’ disease. This risk man- agement approach applies to buildings with any of the following:5
- Multiple rooms served by a centralized water heater
- Ten or more stories
- Healthcare facility where the patient stays exceed 24 hours
- Housing immunocompromised individuals
- Cooling towers, ornamental fountains, and/or whirlpools
- Housing occupants over 65 years of age
The Centers for Medicare & Medicaid Services (CMS) issued a policy memorandum in June 2017 for hospitals and LTC facili- ties to raise awareness about facility requirements to prevent Legionella infections. Facilities are expected to comply with the new requirements to protect the health and safety of their resi- dents/patients.6
Healthcare facilities participating in Medicare are required to develop and adhere to policies and procedures that reduce the risk of growth and spread of Legionella and other opportunis- tic pathogens in building water systems. Facilities not able to demonstrate measures to minimize the risk of Legionnaires’ disease may be cited under regulation 42 CFR §483.80.6.
Water Treatment Plan
- Allegheny County Health Department
- Updated Guidelines for the Control of Legionella in Western Pennsylvania (PDF) Centers for Disease Control and Prevention (CDC)
- ASHRAE 188: Legionellosis: Risk Management for Building Water Systems
- Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings
- Legionnaires’ Disease Fact Sheet for Patients Council of State and Territorial Epidemiologists (CSTE)
- Legionnaires’ Disease Risk Communication Toolkit New York State Department of Health
- Sampling and Management Plan for Healthcare Facilities: Guidance and Template Tennessee Department of Health
- Water Management Program Template (Word doc)
Everyone Deserves a Clean, Safe Environment
Exposure to germs in the environment can lead to illness in both residents and healthcare workers. Environmental clean- ing is a fundamental principle of infection prevention. The resident environment can facilitate transmission of bacteria and viruses through communal living, high-touch areas, and shared equipment. Decreasing the number of germs in the environment decreases the risk of transmitting disease.
Contact with contaminated surfaces easily leads to crosstrans mission of microorganisms between staff and the environ ment. Residents spread their flora throughout their room, con- taminating the environment. If the surfaces are not cleaned properly, subsequent staff, residents, and visitors may touch the contaminated surfaces, acquire the germs, and pass them on to others, contaminating more surfaces. Bedrails, overbed tables, intravenous (IV) poles, curtains, computer keyboards, and telephones are often contaminated with bacteria.7
When thinking about bacterial transfer, it is important to remember the ability of the microorganism to survive on vari-ous common surfaces.
Surfaces must be cleaned first to remove visible soil and or ganic contamination, such as blood and/or other potentially infectious material prior to disinfecting, as residual debris can reduce the effectiveness of disinfection. Always use a detergent first to remove dirt and debris, followed by disinfection with an Environmental Protection Agency (EPA)–registered dis- infectant labeled for healthcare use, fol- lowing all manufacturer instructions. This can be either two separate prod- ucts: a detergent followed by an EPA-registered disinfectant or an EPA-registered combined detergent and disinfectant.8
CDC recommends standardizing cleaning from cleaner to dirtier areas and high to low with a focus on high-touch areas. Using tools such as checklists and cleaning logs will help improve clean- ing in your facility by helping make sure that all steps are completed and guiding staff in daily workflow.8
How Clean Is Your Linen?
Laundry in a facility includes a variety of items, such as sheets and blankets, towels, and residents’ personal cloth- ing. Contaminated linen often contains high numbers of microorganisms from skin and body fluids and may cause transmission of disease when handled inappropriately. Bacteria, viruses, fungi, and scabies can be transmitted from contaminated linen to staff by direct contact or by aero- solization of lint from shaking, sorting, or handling the linen inappropriately.9
Hygienically clean laundry, laundry considered free from pathogens that could cause illness, is processed with a combination of soil and pathogen removal and pathogen inactivation. It poses a minimal risk of transmitting pathogens to staff and residents if it is not contaminated before use.9
Transporting, processing, and storing linen is important to prevent transmission. Handling dirty linen with a minimum of agitation may help prevent the generation of lint aerosols in resident-care areas. Sorting or rinsing contaminated laundry at the location where contamination occurred is prohibited by Occupational Safety and Health Administration (OSHA) regulation standard 29 CFR 1910.1030(d)(4)(iv)(A)(1).10 Staff should use personal protective equipment (PPE) when handling contaminated linen. Never carry contaminated linen against your body or down the hallway. It should be placed in a laundry bag or hamper at the point of use. All linen (clean and dirty) is covered during transport and when stored on the unit.9
Resources for Environmental Cleaning
CDC
- Best Practices for Environmental Cleaning in Healthcare Facilities: in Resource-Limited Settings
- Options for Evaluating Environmental Cleaning
Statewide Program for Infection Control & Epidemiology (SPICE) Environmental Rounds Worksheet for Infection Prevention in LTC
Resources for Linen Management
American Healthcare Association (AHCA)
Tips for Meeting the Linen Requirements in Skilled Nursing Facilities
CDC
- Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings: Observation Form - Healthcare Laundry
- Laundry and Bedding
The Joint Commission
Laundry Practices Infection Control Assessment Checklis
