In July 1976 the American Legion held its annual three-day convention at the Bellevue-Stratford Hotel, Philadelphia and approximately 2000 Legionnaires’ attended. Within a few days of the convention closing a number of Legionnaires who’d attended were suffering from symptoms of tiredness, chest pains, lung congestion and fever. A few weeks after the convention there were 182 people suffering from these symptoms and 29 people died. During the course of the outbreak, a total of 211 cases were identified among the Legionnaires’ who attended the convention or were associated with the hotel in some way.
Given the number of cases and deaths the U.S. Centre for Disease Control and Prevention started an investigation which eventually focused on the hotel environment. In January 1977, the causative agent was found in the cooling tower of the hotel. This being a previously unidentified bacterium that was later named Legionella pneumophila.
This was the first identified outbreak in a hotel, legionella has since continued to cause issues within the internal environment of buildings; be it schools, hospitals, care homes, offices or hotels…
The objective of this paper is to highlight the risk associated with hotels and Legionnaires’ disease, starting with understanding if there is really a risk to hotels, resorts, guest accommodation i.e. the hospitality industry. The focus will be on understanding where within a hotel legionella bacteria might be found and the reasons for it being there. Finally, it will look at the duties of those responsible for the management of hotels [including other hospitality accommodation] and what options and resources are available to assist with managing the risk of Legionnaires’ disease.
Water supplied by the water undertaker is delivered through the mains cold water network to buildings/properties for individuals to use and consume. The law does not require that the water is free from all bacteria, only that it is fit for consumption, hence public water supplies are disinfected to reduce microbiological activity to a safe level at which no infections occur when the water is used for domestic purposes. As a result, naturally occurring bacteria may be found throughout both natural and man-made aquatic environments including water distribution systems within buildings. Many of these bacteria are entirely harmless but others, such as Legionella pneumophila, have the capacity to cause illness in humans.
It is the conditions within the building water system that determine whether bacteria remain at a safe level or multiply and become a threat to health. Considering that hotels will have hot and cold water distribution systems i.e. a supply of water to the guest rooms, the water supplied to the rooms may contain the legionella bacteria and as such airborne dispersal of the bacteria can occur when aerosols or droplet nuclei are created i.e. water is run from an outlet, shower, a flushed toilet.
Already one can appreciate that legionella risk in hotels is a real threat. The following cases may help to demonstrate how much of a threat…
In 2008 a former guest of a holiday resort died from Legionnaires’ disease, an investigation found the same strain of legionella bacteria which had caused the death was the same strain found in the showers and hot tub in the lodge where the guest stayed.
More recently, the Ludlow legionella incident involved a reported case of Legionnaires’ disease associated with The Feathers Hotel in Ludlow in September 2017 where a guest died after suffering a stroke because of Legionnaires’ disease.
These are two examples that have received media coverage, although several years apart, the time between them is no reflection of how frequently a legionella risk in hotels may occur. As an insight into the cases of Legionnaires’ disease, Public Health England publishes a monthly report on the number of reported cases and confirmed cases of Legionnaires’ disease in England & Wales, the report for December 2018 details there were 812 reported cases of which 532 were confirmed cases.
On a personal note, travelling the UK supporting clients I tend to stay in a lot of hotels. On one occasion, having checked into my hotel for the week, I started to run a bath for a long hot soak. On return to the bath a few minutes later I was greeted with brown jelly string pouring out of the taps! Yes, biofilm, the perfect environment for legionella to develop! Reporting this to reception I was informed work had been completed on the hotel water system that day and this was the result of the work. I really don’t think the staff on reception had a clue about what I was reporting or the implications of this either! I was moved to another room in another part of the hotel on a different supply of water.
Hotels [and hospitality accommodation] can come in many shapes, sizes, complexity, and differing ages! Despite these considerations, there are several commonalities:
These commonalities can include many known and unknown issues that are dangerous in hotels.
Let’s explore what these dangers in hotels can look like…
Water temperature is seen as the traditional strategy for controlling legionella growth. To this end, hot water should be stored at 60°C with hot water flow around the entire distribution system achieving at least 50°C. When a hotel is designed and built the water system within the hotel is sized on the intended occupancy of the hotel. Over time the water system and its usage can change. For example, if the hotel is extended and more facilities are added, there will be a corresponding increase in demand on the existing hot water system. Where additional services are added with no additional capacity to generate or store the hot water needed to meet this increase, the existing system may struggle to achieve the required storage, flow and return temperatures and the temperature control strategy will fail.
With time, hotels go through updates and refurbishments; this can see alterations being made to the bathrooms which could result in cut off ends / blind ends being created. These sections of redundant pipework trap water that turns stagnant and creates the ideal environment for legionella to become established.
Equally, with time, some hotels fall into disrepair. In one example, a hotel with seven floors only used the 1st, 2nd and 3rd floors. The remaining floors had not been used for over 40 years but all the outlets in these unoccupied floors were still live and connected to the same water system which served those areas that were still in use.
As with all things that become older they become outdated, start to fail and require more maintenance. A good example being old inefficient domestic hot water generators that maybe scaled up inside and can no longer achieve the minimum storage temperature of 60°C… let alone the return temperature of 50°C!
Occupation, there are times when not all the rooms are occupied continuously e.g. seasonal variation. Water services in rooms that are not used during these periods of lesser demand create little used outlets. The flow of water to these outlets can be very much reduced, allowing stagnation and the favorable conditions for colonisation by legionella bacteria. Furthermore, there may be periods of shut down for low season or perhaps for refurbishment. When parts of the hotel or the entire hotel are closed the water systems within becoming stagnant; which again allows legionella to establish.
There is also the routine monitoring and maintenance required on water systems, an example being the quarterly clean and descale of shower heads, roses and hoses. The shower head or rose is an ideal surface area for scale and biofilm to establish which allows legionella to develop [hence the need for the quarterly task]. The awareness of the need for this one task alone is important and isn’t always understood or in some cases, the task is simply not done [possibly as a cost-saving exercise]. In such cases, it means that decisions affecting public safety are being made without the prerequisite competence and knowledge on the importance of the task.
These examples are not an exhaustive list of dangers in hotels when it comes to legionella. If you can imagine a combination of all these examples existing within your hotel then the danger for guests starts to become more realistic and a serious safety consideration!!
RCHT have identified an improved method for the way in which legionella assessments are determined after the two-year risk assessment review frequency was removed from guidance in 2013.
Included in this case study:
The Health and Safety Executive [HSE] states:
It is an employer's duty to protect the health, safety and welfare of their employees and other people who might be affected by their business. Employers must do whatever is reasonably practicable to achieve this.
This means making sure that workers and others are protected from anything that may cause harm, effectively controlling any risks to injury or health that could arise in the workplace.
Note ‘other people’ and ‘others’ will cover a multitude of people but principally within a hotel that will be the paying guests. As such water safety and legionella control in hotels definitely falls into the above statement, as one piece of the ‘health and safety jigsaw’.
It is necessary to have an appreciation of what is required by the regulations and guidance documents to improve your hotel water safety.
The key regulations being:
The main guidance documents being:
ACoP L8 and the supporting HSG274 documents are not compulsory [unless specifically stated] other action can be taken. If you follow the guidance, you will normally be doing enough to comply with the law. ACoP L8 fourth edition provides advice on how to comply with the Health and Safety at Work etc Act 1974 [HSWA] and Control of Substances Hazardous to Health Regulations 2002 [COSHH] with respect to the risk from exposure to legionella bacteria. The ACoP L8 are approved by the HSE with the consent of the Secretary of State. It details recommended methods and advice on how to achieve compliance.
The broad requirements of the ACoP L8:
The starting point to improve legionella control in hotels is ‘management’
As detailed in the previous section, one of the requirements of the ACoP L8 is the need to complete a risk assessment.
Risk assessments are the ‘cornerstone’ of health and safety. The HSE state:
“it is a legal requirement for every employer and self-employed person to make an assessment of the health and safety risk arising out of their work. The purpose of the assessment is to identify what needs to be done to control health and safety risks”
This legal requirement to complete the risk assessment means if you don’t have a risk assessment in place for your hotel, then you need to get one completed!
The risk assessment needs to be completed by someone who is competent to do so. ACoP L8 tells us that this person should have the ability, experience, instruction, information, training and resources to be able to carry out the work and should know:
As such the person who is responsible for legionella risk management in the hotel is unlikely to be the risk assessor.
The risk assessor will need to be someone with specialist knowledge and understanding of the risk associated with dangers in hotel water systems, invariably this will be an independent consultant. When sourcing external support for legionella [whether for risk assessments, monitoring, remedial works, etc] the person responsible in the hotel for legionella risk management will need to make sufficient enquiries to satisfy themselves of the competency of the person/organization in the area before entering into a contract. The Legionella Control Association is a membership scheme where such external support organisation/consultants etc have a Code of Conduct to adhere to.
Previous versions of the ACoP L8 used to include a 2-year minimum frequency for the review of the risk assessment. This 2-year minimum review frequency no longer exists. This places a duty on those responsible for managing the risk of legionella in hotels to review the risk assessments frequently to ensure that it remains current and up to date in response to changes that may affect the risk. For E.g. following the completion of remedial works, if additional rooms are added to the hotel, replacement of cold-water tanks or a failure in the temperature control strategy is identified as a result of monitoring.
As part of the risk assessment process, the risk assessor will need support to complete the assessment; this will include the need to interview those responsible for managing the risk, provision of records, including the previous risk assessments, action plans, schematics, site log books/site monitoring records, sampling data, evidence of remedial work.
The risk assessment should take into account the entire property. Access to all parts of the building and water system will be required to allow an assessment of all risk systems i.e. hot water generators, cold water storage tanks, outlets, valves, blender valves, strainers – to name a few. As such the risk assessor may need assistance from site staff to ensure that all relevant water systems, plant, equipment and components are included in the survey.
As well as the domestic water systems previously detailed, the dangers in hotels from legionella can be found in other types of water systems, namely hot tubs and spa pools! More and more of these devices are in use and are accessible to the public.
The risk associated with a hotel hot tub or spa pool is the fact they are small volumes of water heated to 32-42°C [the ideal temperature range for legionella], individuals can introduce nutrients into the water from their bodies and if the pool water is not adequately treated, e.g. filtered and dosed with a chemical disinfectant, or if water treatment is absent then ideal conditions prevail for legionella to establish. Couple this with water & air jets that ‘bubble’ the water and users are then directly exposed and breathe in the tiny water droplets created whilst enjoying the spa effect of the pool!
A human soup that is a recipe for disaster! In the last few years, cases of Legionnaires’ disease where the source has been traced to a hot tub/spa pool have increased from 3% to 5% - not a huge increase admittedly, but the increase demonstrates more people using them and possibly the management of hot tubs and spa pools is failing.
When one hotel manager received a complaint that the water in the hotel spa pool was stinging a guest’s eyes, they turned the chemical dosing unit off. Within a matter of days, guests were reported feeling unwell and one died of Legionnaires’ disease. Had the hotel manager had legionella training or training in relation to the operation of the hotel spa pool? No.
All those persons involved in the control of legionella and the safe operation of the water systems need to have suitable and sufficient training. As an analogy, a person wouldn’t drive a car without having had driving lessons and passing their driving test, some might argue that there are drivers who have not had lessons. Just like the Hotel Manager who’d not had training in legionella or spa pool management yet turned the chemical dosing off to appease a guest. The dosing being the means of controlling the legionella bacteria from establishing in the pool.
It is a statutory requirement [as detailed earlier] that employees should have adequate information, instruction, and training regarding health and safety risks and their duties. This training needs to be appropriate to the role i.e. the hotel manager who may be responsible for legionella control in the hotel but isn’t the plumber, so the manager shouldn’t be sent on a plumbing course. Equally those people who are monitoring the water systems i.e. measuring water temperatures, checking chemical levels or flushing little used outlets need to attend training specific to their duties.
Legionella training for hotel employees needs to be appropriate to the role of the person and needs to be recorded and periodically updated.
To conclude, the dangers in hotels resulting from legionella are real! We’ve seen in this paper that legionella control in hotels is not only for hotels in hot sunny countries but hotels here in the UK too. Hotel water systems have been a source of bacteria that have caused Legionnaires’ disease and subsequently the death of some of those unfortunate to have been exposed. Given the detailed guidance and resources available to manage legionella bacteria in hotels the risk of people contracting the disease is preventable; yet it is not always prevented. A lack of knowledge or understanding of the risks associated with legionella control in hotel water and the management requirements of HSE ACoP L8 and the HSG274 Technical Guidance is not a defense if there were to be a case of Legionnaires’ disease with a hotel.
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