Legionella concern as office buildings reopen

By Stacy Gittleman

Across the nation, schools, businesses, and office spaces are embroiled in what is known as “hygiene theater” to assure the public that indoor spaces are safe to return to work, learn, shop, exercise and dine in once the pandemic ebbs. Back at the office, workspace experts are trying their best to implement guidelines from the United States Centers for Disease Control and Prevention (CDC), repartitioning and reconfiguring layouts to maximize physical distancing of desks, installing plexiglass barriers and posting one-way foot traffic signs around workstations. Some schools and businesses have deployed high-tech devices for temperature checks as the world figures out how to get back to a new, post-pandemic normal.

But prolonged inactivity in all the buildings we normally occupy in day-to-day life has heightened the presence of another underlying hazard lurking in our man-made water systems that not even the CDC’s offices in Atlanta could evade: the presence of Legionella.

In August 2020, the CDC itself shuttered some of its office space because Legionella, a pathogen that exists naturally in surface waters but causes a deadly strain of pneumonia and other flu-like illnesses once it is allowed to grow in indoor water systems, was discovered due to a prolonged pandemic shutdown.

It is a warning to any building or facility manager that buildings were built to be used and run continually. Months of inactivity in office buildings have created an ideal environment for the growth of Legionella, which spreads in airborne water droplets that come from drinking fountains, hot tubs, sinks, toilets, sprinklers, showers, and air-conditioning systems.

Although there are plenty of guidelines on how to assess and manage the risk of Legionella in a building’s water system from professional standards associations and state and federal government agencies, they offer inconsistent advice. What's more, there are no government regulations mandating inspections to make sure building managers are properly putting these guidelines into action. Only New York has Legionella legislation that mandates regulations for healthcare buildings in their state.

Public health officials from the federal to the local level insist that practicing risk management to prevent Legionella is essentially a voluntary exercise for school districts, office buildings, gyms and the hospitality industry.

“Research shows that most office building owners do not test for Legionella, and the older the building, the likelier the bacteria is to show up, especially if buildings have been closed since the pandemic started,” said Jasen Kunz, commander of environmental health officer for the Water, Food, and Environmental Health Services Branch at CDC’s National Center for Environmental Health. “The temporary shutdown or reduced operation of schools and buildings, along with reductions in normal water use, can create hazards for returning students and staff.”

Kunz said that unless a cluster of cases arise, there is usually little to no testing in building settings for the pathogen. Sources from epidemiologists to environmental engineers agree that Legionella outbreaks and their numbers are even more challenging to pin down because Legionella is a form of pneumonia.

The name Legionnaire’s Disease (LD) was coined in 1976 when guests of the Philadelphia Stratford Hotel attending an American Legion conference contracted an unusual strain of pneumonia after being exposed to the Legionella bacteria, resulting in 34 deaths and 221 additional cases of the disease.

Pontiac fever, a non-fatal form of legionellosis, was discovered in 1968 in Pontiac, Michigan, when several Oakland Country health department workers were struck with a flu-like illness traced back to the pathogen.

According to the CDC, people older than 50 and those with underlying comorbidities, are most susceptible to infection, including current and former smokers, heavy drinkers, those with compromised immune systems, or with chronic lung disease. Most healthy people do not – or will not – get sick after being exposed to the pathogen.

The CDC estimates annual cases of the disease tally at 25,000, but only 5,000 cases are reported, because of its nonspecific signs and symptoms. Ten percent of those who become infected with Legionnaire's Disease will die from the infection. Legionnaire's Disease in children is not common and the disease is not transmitted from human to human. Domestic cases have grown ninefold since 2000, though the CDC states it is unclear if this growth is due to an aging, more susceptible population or other factors. To complicate matters, Legionnaire's Disease’s symptoms – cough, shortness of breath, fever, and chills – present the same way as COVID-19 and have a similar incubation period. While COVID-19 testing is determined with a nasal swab, Legionnaire's Disease is diagnosed through urinalysis.

At the state level, Michigan Department of Health and Human Services (MDHHS) Public Information Officer Lynn Sutfin said Legionnaire's Disease cases have been on a downward trend since the start of the pandemic. Before the 2020 shutdown, the state reported 52 cases as of March 31, 2020. The latest statistics show that as of March 2021, there have been 34 reported cases. In 2019, there were between 479 and 554 cases in the state, with 77 of those cases concentrated in Macomb County.

To understand the tricky nature of Legionella and why it is so difficult to remediate once it colonizes in a plumbing system, University of Michigan Microbiology and Immunology Professor Michele Swanson said the issue needs to be looked at from the molecular level.

Legionella exists in the natural world in bodies of water. Once it gets into manmade water systems like the plumbing of a large building, it favors stagnant water at tepid to lukewarm temperatures. Eventually, microbial colonies of Legionella adhere to another form of bacteria known as a biofilm, which forms a sticky mat that nestles inside pipes, especially ones that are corroding and leaching lead, copper, or iron.

Swanson said flushing a water system with biocides or extra chlorine may kill the Legionella floating in a water stream, but it is harder to rid pipes of Legionella clinging to the sticky biofilm, especially if it is in the pipes of a remote section of a complex, multistoried building. Water pumped at the necessary high temperatures (between 120-140 degrees F) may remediate the problem, but that may also be damaging to a building's plumbing and water heater. Also, pumping a water system with high levels of chlorine or other disinfectants cannot be done safely when the public is in a building.

Swanson said within a school setting, it is not young children who are vulnerable but any staff member who may have a compromised immune system. Though Legionella has an airborne nature, she said it does not grow in heating or air conditioning vents and is strictly found in waterworks.

In 2018, Swanson and eight mostly Michigan-based researchers authored a National Academy of Sciences (NAS) paper, Assessment of the Legionnaires’ Disease outbreak in Flint, Michigan (2018). The work chronicled an 18-month study that determined that the city drastically worsened its water quality and risk for Legionella.

Between 2014 and 2015, public health officials reported 90 Legionnaires' cases in Flint and at least a dozen people died of the illness. The bulk of the cases stemmed from McLaren Flint Hospital, which had been a hotbed of the disease for nearly a decade.

The NAS paper concluded that the risk of Legionella exposure in Flint jumped as much as 80 percent in some neighborhoods when water sourcing was switched from the Detroit system to the Flint River with reduced chlorine levels as a decontaminant in its water infrastructure.

Swanson also pointed to other examples of deadly Legionnaire's Disease outbreaks at the Quincy Veteran’s Center in Illinois between 2015-2018, as a reason why there should be more conversation, and then legislation, to regulate Legionella risk management practices.

“There are many guidelines from different levels of government but putting the practices into place the right way to prevent Legionella outbreaks is voluntary in all states,” said Swanson. “Only New York State has some limited regulations in place involving prevention of Legionella (in water cooling towers). One of the lessons we can learn from Flint is that we need to have more conversations about this in Congress. “

Shawn McElmurry, an associate professor of environmental engineering at Wayne State University, who also authored the NAS paper, said that Flint’s long-lasting water crisis is an example of the importance of understanding the intersection of water supply and public health and the need for transparency and reporting Legionella detection once it is found in a water system.

“The more that drinking health systems seamlessly interact with public health systems and infrastructure, the more resilient both can be in keeping the general public healthy,” said McElmurry.

McElmurry said he and other public health experts in academia viewed the stay-at-home orders of the pandemic as a major challenge to facility management. Buildings that ordinarily get a great deal of usage during the work and school week have their water systems flushed and moving with hot and cold water and disinfectants and anti-corrosive chemicals that keep both people and pipes healthy with daily use. When the flow came to a halt at the onset of the pandemic, McElmurry said building and facility managers should have been more proactive in establishing flushing routines and water maintenance plans as recommended by OSHA, the CDC, the EPA, and waterworks associations such as the American Water Works Association.

Wayne State University is no stranger to Legionella woes. In 2018, during a routine inspection, the microbe was detected in three water cooling towers and in three bathrooms at the WSU campus, and one employee was diagnosed with Legionnaire's Disease. In all, testing at WSU in 2018-2019 revealed significant Legionella blooms in the water systems of 25 buildings across campus, all of which were treated.

As a result, McElmurry said WSU took a “very aggressive” stance in Legionella monitoring and established its water safety program. Each week, campus building managers inspect, test, sample, and monitor the campus water system to ensure it is acting within federal, state, and local guidelines. The team works to monitor water quality and implement measures to ensure the safety of the Wayne State community. 

Soon after classes at WSU went online during COVID, McElmurry said the university’s water safety committee “stepped up its water flushing routine.” Building management staff went floor to floor flushing sinks and faucets in buildings and reminded students to do the same in dorm bathrooms.

“I cannot stress enough the importance of initiating a flushing routine as a preventative measure and this should have been happening before students, staff, and workers return to buildings,” said McElmurry. “There needs to be assessments of water systems before people return to in-person work and school. It is much more difficult to rid a system of Legionella and the whole point of having a water management plan with routine and regular flushing is to prevent it from happening in the first place.”

Most sources interviewed in this article pointed to standards written by the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) as the authority on Legionella risk management. ASHRAE standards document detailed prevention, testing, flushing requirements for building water systems and in detail describe environmental conditions that promote the growth of Legionella. Available for free online and specifically written to tackle COVID-19 questions, ASHRAE Standard 188 developed guidance for precautions building owners and operators should take before reopening buildings. Many of these precautions are specifically addressed toward the prevention of Legionella exposures.

In addition to establishing a flushing regimen that is customized to a building's specifications, ASHRAE advises that a building's water supply must be kept at an optimal temperature. Legionella favors tepid water (70-110 degrees), so the CDC and OSHA recommend buildings keep hot water tanks set at 140 degrees so hot water at this temperature can consistently reach all water fixtures. Any water in a looped water system must be kept at 120 degrees.

Among the associations providing detailed recommendations to its water authority clients, including the Oakland County Water Resources Commission and the Great Lakes Water Authority, is the American Water Works Association (AWWA).

Noting that it takes time, institutional support, funding, and personnel – things that may all be in short supply during a pandemic – to develop a water management plan – the AWWA for its members authored in October 2020, Responding to Water Stagnation in Buildings with Reduced or No Water Use. The free, 30-page paper is authored by national experts on waterborne illnesses and gives detailed instructions based on how buildings of different sizes and functions should properly maintain building water systems and respond to any detection of legionella – important advice for large and small commercial buildings where employees have been working virtually for over a year.

“Water is oftentimes the last thing people think about when returning to an office or school building,” said Bonnifer Ballard, head of the AWWA Michigan Section. “The AWWA provides guidance and resources to our members, many of them who are water authorities, but even individuals who own second or summer homes, if they have not been in those homes for a while, really need to be vigilant and flush their water lines thoroughly if they have not been used in a while.”

Ballard said when it comes to water management in interior environments, it is incumbent that commercial building managers have a direct partnership with health departments at all governmental levels, and hopes in the future that the Michigan state legislature will pay better attention to this issue by calling for requirements to test for the microbe.

Philadelphia-based Tim Keane is an environmental engineer and consultant for Legionella Risk Management. He was one of the authors of the 2020 AWWA response paper and an original author of ASHRAE 188 Standard. He has studied Legionnaire's Disease outbreaks all over the country, including Flint and Quincy, Illinois.

Keane said more can be done by municipalities to better flush main lines that feed into underutilized buildings.

“Michigan (and what happened in Flint), is a good example of what can happen to a building water system that has issues and is exposed to changing levels of disinfectant in a city water supply,” said Keane. “McLaren Hospital was the source of the outbreak in Flint, and the hospital was located in a part of the city’s water system with historically low disinfectant residuals.

If Legionella is detected, it is recommended – but not mandated by law – that the public be notified, according to the CDC. Once Legionella cases are diagnosed and identified, they are reported to the CDC, which publishes an ongoing database of case numbers of infectious diseases by state and updates it weekly.

Though guidelines are ample, officials in municipalities and school districts, as well as private building managers, say there is a lack of cohesion or guidance or a coordinated effort as to how to implement best practices to prevent the Legionella bacteria from growing. Because no two buildings are alike, creating a customized water management and Legionella prevention and mitigation plan requires hiring consultants and engineers that can be a cost private building managers or school districts may not want to take on.

City of Birmingham Engineer Jim Surhigh said the municipality hopes for a more cohesive plan from county and state officials as to how to take a proactive approach to prevent legionella cases as buildings once again become more populated.

“We should be getting better direction and advisories from public health agencies to advise us and a more proactive and coordinated, science-based response is needed,” said Surhigh. “It seems that each community is doing something different.”

Farmington Hills-based Friedman Real Estate manages 15 million square feet of commercial space in the metro Detroit area, including one million square feet in Southfield’s Galleria Office Centre. Scott Shefman, Friedman executive managing director, said the firm's janitorial costs since the pandemic has risen from $1 to $1.50 per square foot to properly maintain its buildings.

“Our clients have a constant concern about the spread of COVID,” said Shefman. “While we have doubled our efforts, we have had a few outbreaks, but we have never had an outbreak of Legionnaire's Disease in our properties. Through the pandemic, we have been vigilant in flushing the water systems in our properties and followed guidelines from ASHRAE, the CDC, and state health departments, as well. We never shut down any water system because shutting things down completely would not only be unhealthy but very costly."

Shefman said that even before the pandemic, Friedman would take precautions against Legionella by flushing biocides through the system and following ASHRAE guidelines for proper flushing and keeping hot water at 140 degrees.

When it comes to COVID-19 precautions, Shefman said in order to safeguard interior environments, the firm in its buildings is also following ASHRAE recommendations by switching air filters to a higher filtration rate – although he said that could cause problems down the line for a building's HVAC system, and will also increase freshly circulated air from 10 to 15 percent, though this may raise utility costs for heating and cooling the buildings.

Downtown newsmagazine also reached out to other real estate companies that manage large amounts of office space but they all declined to comment.

While there is concern about water quality once it enters a building’s water system, other experts caution that attention should also be paid to water leading to these buildings through municipal main lines, especially in downtown areas that went quiet during the pandemic.

Legionella Risk Management's Keane said while most building owners look to a building’s water-cooling tower as the most probable location for Legionella contamination, Keane disagrees.

“Eighty percent of Legionnaire's Disease outbreaks in buildings are caused by a building’s potable water system that is typically not being designed, treated or maintained to minimize the risk of Legionnaires' disease,” he explained.

He said risks arise when building designs become increasingly complex, or taller, making it harder for water flow to evenly distribute levels of biocides, disinfectants or anti-corrosive chemicals through a water system.

Keane added that inactivity in water main lines that have flowed to a trickle in the nation's downtowns because of the pandemic have presented a whole new problem.

"What happened in Flint is eerily similar to what's going to happen in many downtown areas that have come to a standstill because of COVID," said Keane. "You've got downtown offices and hotels running below 50 percent capacity, or are completely shuttered, and you've got all those water mains that supply those buildings with water just sitting there not moving the water. The water is not moving, and neither are the disinfectants that municipalities add to keep a building’s water systems risk of pathogen growth to a minimum. “

It's not only work spaces and schools that are of concern. The hospitality and fitness industries, both shut down for long periods, are equally vulnerable. Visit a Lifetime Fitness center, like the ones in Bloomfield Hills or Troy, and there is constant evidence on how staff is working to keep COVID-19 at bay through precautions such as temperature screenings, overnight deep cleanings and mask mandates.

Lifetime spokeswoman Amy Williams said that the company’s facility operations team is not concerned about an increase of Legionella in any of their facilities.

“We are following all CDC recommendations, including regularly flushing our systems during the time in which our clubs were closed to the public,” said Williams. “While our clubs were closed to the public, we maintained operations within the buildings to ensure the integrity of the asset. As a reminder, our indoor pools have also been in use since our clubs reopened in June 2020.”.

Mark Hansell, of the Oakland County Health Department, said as the state’s businesses and schools make strides to return to in-person work and school, there has not been an increase of reported Legionnaire's Disease cases, although inactivity in these buildings are a cause for concern.

“Oakland County, MDHHS and EGLE are taking this risk very seriously and we are collaborating across government agencies to provide as much communication and recommendations as possible for prevention and if necessary, remediation,” he said.

Hansell said the three agencies have placed a special focus on notifying school districts and reminding them of guidelines to establish water management plans. Under EGLE’s School Drinking Water Program, as stated on its website, the state environmental agency recommends – but cannot enforce – that all schools and childcare centers develop a drinking water quality maintenance plan.

“The state has had multiple meetings with superintendents of the school districts and we make sure we have as much guidance as possible available, but these guidelines are not enforceable,” said Hansell. “Keep in mind that these are guidelines and they are not enforceable by anyone though (risk management to prevent Legionella) is certainly the right thing to do. Some healthcare systems are mandated by federal regulations – especially if they participate in Medicaid or Medicare – to have water management programs in place. But across the board, outside of the health care systems, there are no mandated rules or testing requirements.”

Hansell said in responding to the Legionella outbreak at the school level, Birmingham Public School District’s response to remediating detected Legionella after it was discovered in some of its school buildings beginning in October 2020, has been “proactive and transparent.”

In December 2020, further samples collected by a contracted water testing consultant found unsafe legionella levels at Quarton and West Maple elementaries, and Groves and Seaholm high schools, among other schools.

Birmingham Schools spokeswoman Anne Cron said the district has been working to remediate detectable levels of Legionella and has shut the water supply to showers, water fountains, and water bottle filling stations.

An online report on the district’s website that offered details of discovered Legionella levels stated that because the school’s pools are regularly treated with chlorine, they are not considered a threat.

The district has installed specially designed shower heads in its locker rooms recognizable by their purple color. In another measure to remediate the problem, all pipes in all buildings are now flushed daily and water is being heated in boilers to the recommended 140 degrees.

Full remediation will take place beginning June 15, when students begin summer recess.

Elin Betanzo, founder of Safe Water Engineering, is one of the contractors working on the Birmingham Schools remediation process. She said one of the simplest ways to prevent growth of Legionella is to keep water moving by regular and routine flushing.

“My goal for Birmingham Schools, or any other school district, is to really be involved and proactive when it comes to regular flushing and monitoring of their water systems,” she said. “The older the school building is, the greater the risk there is of also finding lead levels in the water system’s plumbing. But at the same time, even the newest school buildings carry the same risk of Legionella if water is left to stagnate in the pipes.”

Betanzo said she is relieved that the CDC in February 2021 updated its water management guidelines in buildings and facilities to include information on how to best prevent a Legionella outbreak.

“Before this, there really was no clear guidance (from a federal level) of how to manage water systems to prevent an outbreak,” she said. “It’s like (building and water quality managers) have been making it up as they went along. As water management professionals, we are starting to get better guidance and are moving in the right direction with updated CDC resources, but overall, better management of water systems within buildings is needed to address many hazards, not just Legionella.”

To maintain water and air quality, Ken Vavruska, assistant director of physical plant services for Bloomfield Hills Schools, said the district participates in the School Drinking Water Quality Reimbursement Program administered by the Michigan Department of Education and EGLE.

This program, made possible by a $1.9 million grant from the U.S. Environmental Protection Agency (EPA) for lead testing of drinking water in schools and day care facilities, requires that schools submit proof of public notification of the number of fixtures providing water for drinking or food preparation, testing results, number of fixtures replaced, and other corrective action plans before reimbursement.

“As part of this program, we instituted a protocol of running water regularly, a practice set by EGLE, to avoid (Legionella) issues that other districts have had,” said Vavruska. “While many districts completely shut down in March and April 2020, BHS continued to have essential crews working throughout the district running water regularly and checking boilers. Since May 2020, we have had our full custodial staff working in all buildings.”

Vavruska added as a preventative practice against the spread of COVID-19, Bloomfield Hills Schools is following CDC recommendations to increase airflow and circulation within all buildings. The district changes air filters in all its schools three times per year and buildings exchange inside air with outside air up to four times per hour. The district has also purchased numerous air purifiers for all buildings as an extra precaution during the pandemic.

Unlike commercial properties or school districts in wealthier areas like Oakland County, not all public school districts can afford to fix problems such as Legionella or lead once they find them. Like everything else in public infrastructures, the pandemic has shone a harsh light on inequities and vulnerabilities in efforts to detect and mitigate against Legionella outbreaks and maintain school buildings.

Pamela Pugh, chief public health advisor for the city of Flint and vice president of the Michigan Board of Education, pointed once again to Flint as an example of how the priority of making sure safe water and building systems are available to the poorest and most vulnerable parts of Michigan’s population through adequate funding keeps getting put on the back burner.

“When we finally get to the other side of COVID-19, we will assess the lives lost, the lingering health impacts, but we will also examine the toll that this disease has taken on our children, especially our Black, Latino, and Indigenous children,” said Pugh. “Unfortunately, it looks like it will be at this late hour that policymakers will be forced to admit that a more urgent and overt push for adequate and equitable measures to mitigate risk exposures due to long-standing inadequate building maintenance and indoor air quality conditions should have been a primary response to this deadly and life-altering disease as well as in preparation for the next airborne diseases to come."

Pugh said in the summer of 2020, the Trump Administration and then-Secretary of Education Betsy DeVos pushed for the opening of schools with no thought to the conditions of the school buildings.

“You have to look at inequality and injustice,” said Pugh. “Not every school district can afford to have someone like (Elin Betanzo) come in and consult and remediate its water system, and many other school districts, with all the barriers to learning that are going on due to the pandemic, barely have the wherewithal to think about the physical health and upkeep of their facilities.”

Pugh explained that for many districts, discovering they had a lead or Legionella problem thanks to getting funds for testing was only half the battle. They also lacked funding to hire trained personnel or outside consultants, facility managers, and engineers to do the necessary repairs and remediation.

“In Flint, we learned that we need more than the manuals and guidelines to show us how to properly flush and test and monitor our water systems. We needed the personnel, the engineers, and the expertise of facility managers, so it becomes a human resources problem too,” said Pugh. “Now, engineers are investing their time in businesses, not schools. And while the Biden Administration is finally pushing funds our way, we have yet to receive the funding that was given to us by the Trump Administration.”

Pugh said that Michigan state House Bill 4048 forced schools to return to in-person learning by March 22, to receive certain funds at a time that could have been spent “implementing a more well thought-out water management plan.”

Pugh said there is still $841 million being held up by the state legislature that is meant to go towards helping schools with their reopening plans until Governor Whitmer turns over her executive powers to issue mandates like stay-at-home orders during the pandemic.

“Here we are in the most horrific health crisis that we have experienced collectively, and our state legislature lacks the humanity to appropriately address the problem or allocate funding so we can finally address the physical infrastructure of our schools,” said Pugh. “Unfortunately, the buildings where our children will be spending the most of their time once again comes in last priority.”