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WATER HYGIENE & SAFETY 2 μm ‘‘ Figure 2: Legionella, shown via atomic force microscopy.


Water Safety Plans, to ensure that water systems are designed constructed, commissioned, and managed safely to avoid what are essentially preventable infections. It highlights the importance of the specification stage to ensure that there is adequate time built into tenders for consultation with stakeholders, and that the whole process is risk assessed and agreed by the Hospital Water Safety Group (WSG) at each stage. It also identifies the need for a high-level gap analysis to ensure that there is the appropriate governance at corporate level, and that the WSG has the necessary training and support, and is empowered to ensure that water safety is managed effectively.


ESGLI is concerned that because there are many similarities between the symptoms and at-risk groups of both Legionnaire’s disease and COVID-19, there is an increased likelihood that Legionnaires’ disease will be


underdiagnosed, resulting in unnecessary deaths. As with COVID-19, those most at risk are the elderly, and those with underlying illness such as heart disease, diabetes, and other respiratory conditions. For both infections, men are more at risk than women. Ensuring that both COVID-19 patients and hospital staff are protected from waterborne infections should not be overlooked.


Evidence from China Early evidence from China3


is that


COVID-19 patients admitted to hospital could fall into the group at increased risk of waterborne infection, with half of the patients who died having a secondary bacterial infection. While ventilator- associated pneumonia is to be expected


52 Health Estate Journal June 2020


in up to 40% of ventilated patients, preliminary findings from a small recent study by Xing et al.,4


indicated that 20%


(6/30) were IgM positive for Legionella pneumophila. Infection by Legionella is usually by inhalation of aerosols derived from contaminated water sources, but in healthcare, infection by aspiration should also be considered.


There is a real risk that water systems which have been extended, altered, or had a reduction in use, could pose a significant risk to highly susceptible patients, both now and in the future, unless immediate action is taken. Legionella colonisation and growth present the greatest risk, as it can affect patients, staff, and visitors. Worldwide we are seeing an increase in the number of cases, and in Europe the European Centre for Disease Prevention and Control report from 20155


resulted in the World Health About ESGLI


The European Society for Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Legionella Infections (ESGLI) is a multidisciplinary group of like-minded professionals with the aim of improving the clinical diagnosis, treatment, control, and prevention of legionellosis. The forerunner of ESGLI, the European Working Group for Legionella Infections (EWGLI), and members of the associated European surveillance network (ELSNET), which was set up to detect travel-associated Legionnaires’ disease, have a long history of developing guidance to prevent outbreaks of legionellosis from building water systems. The first EWGLI guidelines were developed almost 20 years ago, and were formally endorsed in 2003 by the Network Committee for the Epidemiological Surveillance and Control of Communicable diseases in the EC. They were developed to be of use both by regulators and epidemiologists investigating cases and outbreaks, and also by the owners/ managers of accommodation sites, to improve the recognition and reduce the risk of Travel Associated Legionnaires Disease (TALD). In 2017 these were expanded and updated to be applicable to all public buildings.


A huge challenge, which is going to require some innovative


management, is the large number of buildings that have been lying empty or have been only partially occupied


Organization identifying Legionella as causing the highest health burden of all waterborne illness in Europe,6


with a


mortality rate of around 25% in healthcare-acquired cases.7


Adequate control measures The need for Legionella risk assessments, and for adequate control measures to be put in place, are required under health and safety legislation, and the current crisis does not absolve those accountable for health and safety from ensuring that these are carried out and implemented. It is important that these risk assessments cover all potential sources, including where additional provisions have been made, e.g. mobile washhand stations – especially if these have been stored with water inside them, and mobile units for additional changing facilities, as well as staff showers etc.


The need for huge numbers of beds for COVID-19 patients has necessitated other patients either being sent home or relocated to residential, nursing, and care homes. It is inevitable that some of these patients will fall into the category of those at higher risk of waterborne infections than the normal population. In an ideal world, these premises would have been


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