FAQs around Legionella, water hygiene and waterborne pathogens

There are estimated to be trillions of trillions of bacteria worldwide!  Many bacteria thrive in moist or wet environments, along with a range of other microorganisms and some of them can be harmful to us. The huge variety of organisms means it’s not practical to check for all the potentially pathogenic organisms in our water systems all of the time. That said, there are key indicator organisms that organisations are required to proactively monitor and manage.  The Water Supply [Water Quality] Regulations apply to companies that supply water to consumers and Schedules 1 and 2 of the Regulations contain maximum permissible concentrations for these indicator organisms.  The schedules detail:

• Coliform bacteria
• Aerobic colony counts [otherwise known as total viable cell [TVC] counts]
• Escherichia coli [commonly known as E.coli]
• Enterococci
• Clostridium perfringens

The Health & Safety Executive [HSE] provides specific guidance on how to manage the risk from Legionella bacteria in the Approved Code of Practice [ACOP] L8.  Further guidance on managing both Legionella bacteria and Pseudomonas aeruginosa within healthcare premises may be found in the Department of Health’s HTM04-01: Safe Water in Healthcare Premises: Parts A, B & C.

In the first instance, it is important to understand the reason for taking the sample.  In the section on 'Microbiological Monitoring, the HSE's Technical Guidance HSG274 Part 2 indicates the circumstances in which sampling for Legionella is appropriate.  Sampling should be a defined strategy and not a fishing exercise.

Secondly, the magnitude of the result, i.e the number of Legionella bacteria recovered from the sample will determine the action to be taken. HSG274 Part 2, Table 2.2 details the action levels following Legionella sampling in hot and cold-water systems.

For healthcare organisations there is additional guidance on what actions to take, this can be found in HTM04-01 Part B, Chapter 10, Figure 4 - Legionella sampling in hot and cold water systems.  This later guidance provides specific help on pre and post-flush samples for an expanded range of possible results.

Each organisation should have a written scheme of control [water safety plan] that details the action to take, these can be based on the published guidance.

Legionella is a bacterium that is common in natural water sources and, can also be found in man-made water systems within the built environment.  Such systems include cooling towers, evaporative condensers, spa pools and hot and cold water systems [to name a few].  Exposure to Legionella bacteria that have been allowed to multiply within a building water system can cause illness.  The collective name for illnesses caused by Legionella bacteria is ‘legionellosis’; the most serious form being Legionnaires’ disease. The risk of contracting Legionnaires’ disease increases with age [>50 years], heavy smoking, heavy drinking, underlying health conditions or an impaired immune system. New born babies are also at increased risk and data analysis shows that the disease affects three times more males than females.  Public Health England monitor reported cases of Legionnaires' disease and publish monthly reports; in 2018 there were 814 reported /notified cases. 

There is an average mortality rate of 15% but even survivors can be left severely affected as a result of Legionnaires' disease.

A Legionella risk assessment must be a suitable and sufficient assessment that identifies and evaluates the risk of exposure to Legionella bacteria from work activities and water systems on the premises, including any precautionary measures needed. Those persons who complete the risk assessment and provide advice on prevention and control measures must be competent to do so [as detailed in ACOP L8 Paragraph 29].  The risk assessor should be able to demonstrate experience of completing Legionella risk assessments and the precautionary measures, this maybe in the form of CV, training records and statement of qualification detailing the number of risk assessments completed. The Responsible Person [Water] and / or Authorised Person [Water] should request evidence of competence and experience and seek an interview with the risk assessor before commissioning the risk assessment. 

Others involved in conducting the Legionella risk assessment should include those who have knowledge of the building and water systems being assessed. This will include the Responsible Person [Water] and/or Authorised Person [Water] being available for interviews with the risk assessor as part of the process. They will also be able to facilitate the provision of information to aid the risk assessor [e.g. written scheme, monitoring records, previous risk assessments, schematics and risk minimisation schemes]. A competent person should also be available to assist the risk assessor with the building survey & inspection of water systems; they should know the building and be able to provide ‘insider’ knowledge. This level of input will assist the risk assessor with their final risk assessment report.

A risk assessment report is a living document that must be kept under review to ensure it does not become out of date.  The 2-year frequency for review of risk assessment is no longer applicable. As such those who have responsibility for actioning the risk assessment and the minimisation scheme need to routinely review the risk assessment. The frequency of reviewing is dependent on your organisation and the level of risk, for example an update on the status of the risk assessment and risk minimisation scheme maybe reported to the Water Safety Group.

The HSE ACOP L8 [Paragraph 47] provides an indication of when a review of the risk assessment, i.e. when it is time to revisit the actual risk assessment process for a building or system:

(a) changes to the water system or its use;

(b) changes to the use of the building in which the water system is installed;

(c) the availability of new information about risks or control measures;

(d) the results of checks indicating that control measures are no longer effective;

(e) changes to key personnel;

(f) a case of Legionnaires’ disease/legionellosis associated with the system.

We have previously published a blog asking  How often should a risk assessment be completed?

The risk can be defined as “the risk of exposing individuals to Legionella bacteria”. If your building has a water supply and processes associated with the water then you have a risk that needs to be assessed. The HSE ACOP L8[Paragraph  2] details there is a reasonably foreseeable Legionella risk in your water systems if:

• water is stored or re-circulated as part of your system;
• the water temperature in all or some part of the system may be between 20–45 °C;
• there are deposits that can support bacterial growth, such as rust, sludge, scale and organic matter;
• it is possible for water droplets to be produced and, if so, if they can be dispersed;
• it is likely that any of your employees, contractors, visitors etc could be exposed to any contaminated water droplets.

It is a requirement of the COSHH Regulations and HSE ACOP L8 to assess the risk.

The HSE's Technical Guidance HSG274 Part 2, Appendix 2.2, defines a ‘written scheme of control’ that should take the risk identified and valuated in the risk assessment, define the particular control strategy and detail the correct and safe operation of the water systems. 

The term  Water Safety Plan or WSP is taken from the Department of Health's guidance HTM04-01 Parts A, B & C and is a term used for healthcare organisations when it comes to the written scheme of control. 

The WSP is a risk management approach to the safety of water within an organisation. The WSP will outline:

• good practices for storage, distribution and supply of water;
• identify potential hazards;
• detail control measures required.

Before a WSP can be fully developed, a risk assessment is needed to identify all the associated water risk systems and to enable this information to be captured within the scope of the WSP. The WSP won’t necessarily be one document, it can be made of several documents with distinct purposes, e.g. the risk assessment element identifies the associated water risk systems, the standard operating procedures [SOPs] describe the correct and safe operation of the systems and the emergency action plans [EAPs] will provide the necessary information and protocols to guide an organisation through water-related safety incidents.

Little used outlets [LUO], as the name suggests, are those outlets that are not routinely used or that are not used at all. This lack of use can be due to a number of reasons, such as a change of use in a room / area, an outlet that is no longer required or an outlet that is broken.

The key element to the management of LUOs is knowledge of their existence. As such, awareness of what a LUO is and the risks created from them need to be shared with individuals who interact with outlets i.e. Competent Persons, Cleaners / Domestics, Building Managers etc. Their feedback on whether LUOs exist will help on the correct course of management. Those actions can include:

• where an outlet is no longer needed – remove and cut back all associated pipework to the main distribution runs;

• where an outlet can’t be removed - establish a flushing program. The frequency and duration of flushing needs to be assessed to determine the correct method for individuals to follow.

The management of water safety doesn’t necessarily fall to one person! The proactive management of water safety within an organisation will invariably rely on the combined efforts of several individuals who will collectively form the Water Safety Group [WSG]. The WSG:

• is a multidisciplinary group that undertakes the commissioning and development of the WSP;
• shall provide advice on remedial action required when water systems and outlets are found to be non-compliant or contaminated.