Christoph Lohr: Welcome to The Authority Podcast: Plumbing & Mechanical. When talking about the built environment, we would do well to remember: We shape our buildings, and afterwards, our buildings shape us. Therefore, on each episode, we’ll discuss the latest trends from IAPMO in plumbing and mechanical safety, sustainability and resiliency. Join me, your host, Christoph Lohr, and together we’ll explore the ways we can make our buildings shape us for the better.
And we’re back to The Authority Podcast: Plumbing & Mechanical. In this episode, we talk to Dr. Abraham Cullom, a microbiologist with expertise in plumbing systems. Dr. Cullom discusses the actions of various U.S. federal government agencies requiring water management plans to address the risk of Legionella and other waterborne pathogens in federal buildings and health care facilities.
Dr. Cullom explores the wider implications of these policies, why they are emerging now, required personal expertise and certifications, and how to set standards that ensure compliance with a variety of regulations. Dr. Cullom, or if I may call you Abraham, welcome to the show.
Dr. Abraham Cullom: Hey, yeah. Thanks so much for having me.
Christoph Lohr: And is it OK if I call you Abraham, or would you prefer Dr. Cullom?
Dr. Abraham Cullom: Abraham’s great. Most people call me Abe, but I’m not picky, honestly.
Christoph Lohr: Excellent. Excellent. Well, we’ll go with Abe. Let’s dive right into this. What is the significance that the General Services Administration, or GSA, and other federal government entities like the Center for Medicaid, or Medicare and Medicaid Services, are taking the risk of Legionella and water so seriously?
Maybe you want to provide some context for our listeners about Legionella in general.
Dr. Abraham Cullom: Yeah, thank you. It’s very significant because this is a serious issue and some efforts by industry organizations and federal entities like CMS and now GSA really are having a positive impact. What we’re talking about Legionnaires’ disease, it’s a type of pneumonia caused by that type of bacteria you mentioned, Legionella. A large majority of that’s caused by one species, Legionella pneumophila. Nailing down the risk of this, or talking about risk of this, is kind of tricky because these are bacteria that are naturally occurring in freshwater systems — lakes, rivers — very low levels, generally not a concern for human health. Can’t even be found in drinking water distribution systems and a well-maintained system again, pretty low levels, not really a concern.
But once they get into a building, that sort of manmade environment with water that may be warm, sitting stagnant for long periods like overnight, plenty of other bacteria to comingle with in that ecosystem, then they can really take off, start growing, start being found much more frequently. That’s where the risk of infection comes in.
It’s a very common bacteria. We think it’s present in roughly 50 percent of all large buildings, so many people listening to this have probably been exposed to Legionella in some way, and I suspect that millions of people are somewhat regularly exposed to Legionella without that leading to any sort of disease.
They typically only cause serious disease in elderly or immunocompromised people. But when they cause disease, the disease they cause called Legionnaires’ disease is very serious. Many people acquire it while they’re in a hospital, and in that context it has a fatality rate of 30%. What we’re talking about is something that can be very, very serious and historically it’s been something that’s been growing a lot.
Cases of Legionnaires’ disease since the mid-’90s have been growing exponentially. If you model this, it fits an exponential curve very, very well, growing by a factor of like nine in less than 20 years. So we have this bacteria, this issue, and this disease that seems to be growing. ASHRAE Standard 188, this is a voluntary standard to sort of minimize the risk of Legionella growing in those building water systems. That comes out in 2015, CMS sort of adopts it in 2017, and sort of a lot of other players step in to do the hard work of controlling this issue. COVID happens, there are changes in the official reporting and definition of cases.
There’s a bit of lag in these policies actually sort of manifesting, but if you look at data from 2021 on, it actually showed that not only have we arrested that exponential growth, but Legionnaires’ disease case numbers may actually be trending down, and I would attribute at least a portion of that to the growth in these water management practices being enshrined by CMS and now GSA policies.
It's a very serious disease. It’s very tricky to handle because we’re talking about a very common bacteria, but we have people and organizations stepping in to handle it and they’re getting results. That’s why it’s so significant.
Christoph Lohr: In your opinion then, what got us to this point where so many government agencies are mandating better water management plans for their facilities?
Dr. Abraham Cullom: These water management plans, that is basically what is described in that document I mentioned — ASHRAE Standard 188 — that is a document a building, a facility might have that lays out everything they got to do to keep their water system running in good condition to limit the growth of Legionella.
I think why we are here now is related to a lot of growth and awareness around the seriousness of this issue kind of analogous to what happened with lead. Until the D. C. lead water crisis in the mid-2000s, I think when people thought of lead poisoning, they thought of paint.
Treated drinking water was not really as much of a concern. Now when people think of lead contamination, water may be the first thing that comes to mind. Something similar kind of had to happen for drinking water for these sorts of infections, particularly in hospitals. We have prominent headline-making outbreaks of Legionella and other waterborne pathogens from clean drinking water, better tracking of the thousands of other cases that are not represented in those big stories, leading to awareness of infections from treated drinking water.
While these are rare, kind of letting us know these are something that we should at least have an eye on. That really, that trend started, since the Bellevue-Stratford Hotel, the outbreak of Legionella that put it on the map in 1976, but when the first standard for controlling Legionella — ASHRAE 188 — comes out and other guidance around it trickles out later, now, we as a society, we have something we can do about this.
And the fact that hospitals are such a large source of concern because they have more vulnerable populations — more elderly folks, more folks that might be immunocompromised in some way — they have very large; they’re big buildings, they have complicated water systems. I suspect that sort of explains the emergence of the CMS memorandum on Legionella water quality and how we get to this growth of water management practices in the health care industry generally. GSA is a little more interesting because the GSA is largely not health care. I think the development there is really driven by this growing acknowledgement that certain water quality issues are really a shared responsibility between utilities and building owners.
By that, I mean the utility can do a lot of things to ensure that issues like lead and Legionella definitely do occur, but they don’t necessarily have the control necessary to ensure that certain issues like Legionella never occur. A utility can provide you with the best, cleanest drinking water in the world, but if you do certain things, you let the water hang around sort of warm, nice bathwater temperatures like 100 degrees Fahrenheit stay really stagnant for long periods, days and days, Legionella is going to be able to grow in the building anyway, despite what the utility has delivered you.
Christoph Lohr: I was going to say, just for our listeners, one of the questions that I think just to kind of get some quick clarifications, kind of three quick items here: water management plans, what you’re talking about is basically a proactive plan and program that, it’s just something that the owner is doing to try to proactively manage the water and their facility, right, to try to prevent, and there’s any number of solutions to it, but they’re trying to do something active to prevent waterborne pathogens like Legionella to grow. Is that correct?
Dr. Abraham Cullom: Yeah, I think that’s the cleanest, briefest way to put it. You have a lot of folks within the building that, they understand the water systems.
They understand infections. You might have an infection preventionist, you have administrators that want to do something about Legionella. The water management plan describes everything those folks got to do to basically do the activities that are going to actually manage Legionella growth in the water system. That is going to be monitoring certain things in the plumbing; testing for Legionella, perhaps; everything those folks need to do to actually control the issue.
Christoph Lohr: That makes sense. And then CMS, so the Centers for Medicare & Medicaid Services for health care, correct me if I’m wrong here, Abe — they tied funding to having a water management program, so if you’re a health care facility and you get CMS funding, you have to have a water management program in place. Is that correct?
Dr. Abraham Cullom: Right. In 2015, ASHRAE Standard 188 comes out, which establishes, these are the core elements of what has to go in that water management program. Just two years later, 2017, which sounds long, but this emerged in 1976 — so something coming out only two years later in the grand scheme is pretty quick movement — two years later, CMS puts out a memorandum describing basically that you need to have some sort of water management practices in place for Legionella and makes reference to ASHRAE 188.
Everything that has come out since; or not every, most things that have come out since have made some reference to ASHRAE 188. It’s a very short document, but it’s very important within the grand scheme of Legionella control and regulations and guidelines; it’s really the backbone of a lot of this stuff.
Christoph Lohr: That makes sense. Now, the GSA requirement — going through some of our next questions here — the GSA requirement is different than the CMS one, because the GSA requirement said that, I guess it said about having water management practices, but then it even said that you needed a certain credential, an ASSC 12000 series-type credential, for one of the professionals working on your project.
Can you expand on that a little bit and then touch on how that GSA requirement strengthens water quality efforts in federal buildings and why that initiative is crucial to mitigate the risk of Legionella in water?
Dr. Abraham Cullom: Yeah, of course. That certification, ASSE 12080, it’s a certification for Legionella management in building a water system.
Essentially, it’s the basics of everything you need to know to start to mitigate Legionella risk in building water systems. It’s specified as a component, a sort of expert that needs to be brought in in certain stages to sort of help deal with Legionella issues or sampling within building water systems.
And I think it’s a good add there because it sort of ensures a minimum level of understanding for people who are going to be involved in this and people who are going to be tackling this important issue of Legionella being present in buildings, which is exactly the goal of that sort of certification. How this, their activities sort of strengthen water quality efforts, this is a big step, because basically everything I’ve talked about with water management has been relatively siloed within health care since the beginning. So the requirements mostly apply to health care. A lot of the guidance was developed within the context of health care. A lot of studies, or the large majority of studies of like Legionella growth within a building, are happening within health care.
A lot more surveys of hospitals than office buildings. The GSA, what they’re doing is implying water management practices and monitoring Legionella outside of health care at the biggest scale I think we’ve ever seen. It’s a big deal. I’m not a government employee, but I think anyone who is interested in Legionella is excited about that. Specifically, how this is strengthening things. By testing for Legionella in thousands of buildings, they’re going to identify what buildings are all good as is, what buildings need more effort on the water management side, engineering, temperature, sort of moving the water. This is very significant because we typically talk about Legionella with outbreaks, lots of people getting sick. But the large majority of cases or infections are sporadic, so they aren’t associated with some sort of cluster. This sort of dispersed monitoring, I suspect, is going to be very helpful for just getting a greater understanding of how to protect people in general, and my hope is that this will lead to engineering corrective actions, flushing water quality data, that can be leveraged to manage Legionella better at these sorts of facilities, these sort of non-health care facilities. They’re applying this at such a huge scale. They have the opportunity to develop best management practices for non-health care facilities, which are out there to some degree.
I think this will be a lot of rubber hitting the road. I think a lot of people are going to figure a lot of things out about managing Legionella risk in non-health care settings.
Christoph Lohr: That makes sense. Does the GSA requirement address other waterborne pathogens beyond Legionella or is it just focused right now on Legionella?
Dr. Abraham Cullom: Indirectly, yes; not explicitly. Other waterborne pathogens have so many cool differentiating things about them. Pseudomonas aeruginosa, they have these huge genomes, they’re very adaptable. Mycobacteria, another one we talk about a lot, it has this cell wall that’s 30% of their total cell mass.
They're like walking around in these suits of armor.
Christoph Lohr: Wow.
Dr. Abraham Cullom: Legionella have this very interesting amoeba life cycle that’s very unique to them. But for the large-scale factors that we look at for Legionella growth — stagnation, warm water, temperature, biofilms, lack of disinfectant residual — these organisms tend to operate pretty similarly.
Tackling these issues for Legionella is going to be beneficial for the control of these other pathogens just sort of by, not necessarily by accident, but not an explicit benefit that you get. There are some nuances there, but overall, if you integrate Legionella water management practices, that’s going to have a positive effect on the growth of other waterborne pathogens generally.
Christoph Lohr: Excellent. In your estimation, how do orders like this one from the GSA influence best practices for plumbing systems to protect building occupants from waterborne pathogens in general?
Dr. Abraham Cullom: I think a lot of that is going to be related to, again, the development of operations and best management practices that are applicable to non-health care facilities.
A big component of that feed into this thread of operational guidance gain a lot of momentum during and after the pandemic around minimizing stagnation. There are a lot of organizations that have guidance around this. There’s AWWA guidance — that’s what came around specifically to address the stagnation issues during the pandemic. This year, a Water Research Foundation project in this area I found very informative. I think GSA is going to generate quite a bit of data on what flushing practices are actually working very well. More broadly, I think this is going to spread some industry knowledge like ASHRAE Guideline 12, Cooling Technology Institute Guideline 159, into non-health care facilities. One possible pitfall here is simply taking what we’re doing in health care and throwing it at these other facilities; they don’t necessarily need that. The risk is much lower at a courthouse; that’s not an oncology ward, that’s not a transplant ward. I think part of the process here is going to involve finding how they can systematically evaluate Legionella results, apply best practices for response while dealing with the realities that this is a very common bacteria and these facilities are much lower risk. And then this is going to lead to expansion of that ASSE certification we talked about, which I think is going to be very beneficial in the long run because, as I talked about, those other pathogens operate very similarly to Legionella, and I think over the next decades they will see their own rise to prominence. So the more knowledge we have around Legionella and building water systems, the easier it will be as we start to manage these other pathogens more actively as well.
Christoph Lohr: That’s so interesting to hear you say, and it makes me think about the efforts we’ve had here at IAPMO. You mentioned the AWWA document about guidance for during the pandemic. IAPMO, we collaborated with AWWA on that and then we turn around and we created a manual, an IAPMO-led effort, for safe practices for closing and reopening buildings. And we also just recently released a construction practices for potable water, which is in one of our earlier podcast episodes with Tim Bartrand, Dr. Tim Bartrand, from ESPRI, and talking about some of that. It’s so interesting to hear that you see a similar trend that we’re seeing, which is water quality and flushing practices are on the rise and it seems like, as all these practices are being discussed along with ASSE 12000 Series education, this seems to be a really incredibly emerging consideration. As we’re getting here toward the end of our time together, as these federal requirements for water management are continuing to emerge as part of this overall growing awareness, in your opinion, how should local authorities — different cities or states outside of the federal government — how should they be proactive to set standards and building requirements, in your opinion?
If we can make you ruler for a day, you could do whatever you wanted to, how would you look at it?
Dr. Abraham Cullom: These all should be, in some way, particularized to the locality, to the region.
We know there’s a lot of variability from state to state of Legionnaires’ disease incidents; different states are going to face very different water quality challenges in the future. In the Southwest, they’re going to be doing more water reuse, which is great. It poses some challenges with Legionella and other opportunistic pathogen growth. That’s going to differ in sort of what they should be looking at compared to, I’m in Pennsylvania. I think over the next 30 years, we’re projected to get more water, which sort of causes its own, but different, issues with Legionella. I think, ideally, people should be somewhat focused on different things, but the fundamentals should be learn about Legionella, familiarize yourself with the relevant standards guidelines, look at how other locations are applying them for now. That learning, that could be the ASSE training we’ve been talking about. CDC offers Legionella training. There are a lot of really good free resources out there you can use to start to get an understanding of how Legionella operates.
And then I think understanding the key standards and guidelines that are going to be referenced in code or regulations are really important. That’s ASHRAE 188, Guideline 12, which gets into some more specifics and suggestions on Legionella; the Cooling Technology Institute Guideline 159 for cooling towers; and the CDC Legionella toolkit, which is also a very good evolving resource.
And then look at how this knowledge and these documents have been integrated into other state or local codes. Frankly, this is very small minority of places, but people have tried to take this on. Michigan, particularly New York and New York City are really the big ones, and then Virginia within the context of schools. These sorts of policies are very difficult to implement, so take a critical view of how it’s being done and what the results have been. If you are listening to this, you’re sort of interested in getting this started in sort of a policy or code way. That would be my suggestion, but the broadest point, just keep an eye on it. Keep an eye on Legionella. Do not panic in response to finding what is a common bacterium. That should be, I think, a big throughline in people’s responses to it. Something Dr. Janet Stout always likes to say; she’s got a lot of good lines, but this is probably my favorite: Our goal is zero cases of Legionnaires’ disease, not zero Legionella. If you are looking at policy around this, I think that phrase should be your guiding light.
Christoph Lohr: I love it, Abe. And honestly, I’m smiling over here because one of the things you said at the start of that answer, which was so well put.
But what I just have to smile about is your point about water quality differing from area to area. Solutions may be a little bit different from one spot of the country to the other, and this is something we at IAPMO believe. We dub actually the term for this kind of occurrence as plumbing resiliency, and we have a whole website — uniformcodes.org — that touches on this, and one of the things that we like to point out is that our code, the Uniform Plumbing Code, has, I think at this point we’re up to 21, 24 appendices in the back, which are opt-in provisions. So a jurisdiction adopts the Uniform Plumbing Code, they get the 17 first chapters and then they have a pick-and-choose approach, sort of like customization option. And the way we think about it is, water does differ, water needs do differ state by state. I’m smiling because what I’m hearing is we’re on the right path with this. Maybe there’s always room for improvement, but giving different options, as plumbing codes and general plumbing standards, plumbing manuals and guidance documents, giving that opportunity to customize and tailor it for a local need, that’s a key step in making a solution that’s really thought through and offering the best potential opportunity to prevent something that is preventable.
Dr. Abraham Cullom: Yeah. We are, I think, at 100% percent agreement. One of those contrasts that I keep bringing up, the difference between health care and non-health care facilities, they should have different standards. The risk is very different. The population is very different. They should have different goals that they’re trying to meet. And that same sort of principle applies to different cities, different regions, different states. Allowing people the sort of guidance they need when they are motivated and they have the right mindset to arrive at a correct solution is I think what we should be striving for.
Christoph Lohr: I love it, Abe. Well, to wrap things up, first off, I gotta say, I have just absolutely enjoyed having you on the podcast. I have learned so much from you today, and I think our listeners have as well. At some point, we’d love to have you come back. The next time we have you on the podcast — my last question here for you — the next time we have you on the podcast, what do you think we’re going to be talking about when it comes to Legionella and policy?
Dr. Abraham Cullom: If you had asked me that a year ago, I don’t think I would have said anything that we talked about today so I’m hesitant to offer a guess. I think one of the areas that’s, if I had to bet on growth in this sort of like water quality stock market, I would probably bet on the growth of non-Legionella pathogens getting more and more integrated into standards and awareness. These are briefly mentioned in the CMS 2017 memo, but they are not explicitly dealt with or tested nearly as much as Legionella. Legionella is really the poster child, but we have some understanding that other pathogens like pseudomonas aeruginosa, nontuberculosis mycobacteria, probably are as significant causes of concern for disease, so I feel confident that that will at least be sort of a relevant conversation.
Christoph Lohr: I love it. I think that’s very astute Abe. Well, on behalf of The Authority Podcast: Plumbing & Mechanical, I want to say it has been an absolute pleasure to have you here. Thank you so much for your time and sharing your expertise and knowledge with our listeners. And we really look forward to having you on again in the near future.
Dr. Abraham Cullom: That sounds great, yeah. Call me anytime.
Christoph Lohr: Excellent. Thanks for joining us on this week’s episode of The Authority Podcast: Plumbing & Mechanical. Love this episode of the podcast? Head over to iTunes to subscribe, rate and leave a review. Please follow us on Twitter @AuthorityPM; on Instagram @theauthoritypodcast; or email us at iapmo@iapmo.org. Join us next time for another episode of The Authority Podcast: Plumbing & Mechanical.
In the meantime, let’s work together to make our buildings more resilient and shape us for the better.
