SUPPLEMENTARY INFORMATION:

Background: CDC assists state and local health departments with Legionnaires disease response and prevention efforts by providing technical assistance and developing resources focused on preventing and investigating cases and outbreaks of Legionnaires disease ( https://www.cdc.gov/​legionella/​).

Legionnaires disease, a severe, sometimes fatal pneumonia, can occur in persons who inhale aerosolized droplets of water contaminated with the bacterium Legionella . The rate of reported cases of Legionnaires disease in the United States has increased more than four-fold since 2000.^[1] Legionella and other waterborne pathogens can multiply in large, complex building water systems where there are gaps in water system maintenance; thus, the most effective strategy for prevention of Legionnaires disease is through control of Legionella in building water systems. Water management programs (WMPs) identify hazardous conditions and take steps to minimize the growth and spread of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review.

In 2015, ASHRAE (formerly known as the American Society of Heating, Refrigerating, and Air-Conditioning Engineers) published a consensus standard for the primary prevention of Legionnaires disease,^[2] which calls for the development and implementation of WMPs in buildings with large or complex water systems and in buildings that house people who are particularly susceptible to Legionnaires disease. ASHRAE recommends WMPs for the following buildings and devices:

• Healthcare facilities where patients stay overnight
• Buildings that house or treat people who have chronic and acute medical problems or weakened immune systems
• Buildings that primarily house people older than 65 years (like a retirement home or assisted living facility)
• Buildings that have a centralized hot water system (like a hotel or high-rise apartment complex)
• Buildings 10 stories or more (including basement levels)

Devices that have been linked to transmission ofLegionella:

○ Cooling towers

○ Hot tubs (or spas) that are not drained between each use

○ Decorative fountains

○ Centrally-installed misters, atomizers, air washers, or humidifiers

Additionally, stakeholders can use CDC's toolkit, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to ( printed page 39440) Implementing Industry Standards. ^[3] This toolkit is dedicated to developing and implementing WMPs and can inform conversations with building owners and managers on how to reduce the risk of Legionella growth and transmission in their building water systems.

Information Needs

While a consensus standard and guidance exist regarding development and implementation of WMPs, there are gaps regarding the most effective methods to encourage WMP implementation. A variety of stakeholders ( e.g., public health partners, industry leaders, accreditation or licensing bodies) routinely work with building owners and managers on WMPs or on related policies. However, successful communication and implementation of WMPs can be challenging, and more information is needed on how implementation of WMPs can be improved. CDC seeks public comments in response to the following questions to guide best practices, especially regarding the dissemination and implementation of WMPs. The information gathered will be used to guide best practices regarding effective strategies to prevent Legionnaires disease in the United States. Information gathered can also inform efforts to prevent disease due to other waterborne pathogens.

Please feel free to respond to any or all of the questions. Possible domains to consider in answering these questions include (but are not limited to):

Local knowledge about Legionnaires disease,Legionella growth, and prevention strategies

• Stakeholder engagement (key supporters and opponents)
• Feasibility of WMP implementation
• Costs and benefits of WMP implementation
• Availability of effective communication strategies

Possible impact of proposed solutions including unintended consequences such as degradation of plumbing infrastructure or pathogen substitution (e.g., remediation directed at one pathogen, such as Legionella, leading to increases in a second pathogen, such as nontuberculous mycobacteria)

• Historical context in which a WMP was or was not adopted
• Influence of local regulations

Questions

(1) What existing standards or guidance does your organization use for the prevention of Legionella growth and transmission?

(2) Are there other standards or guidance for the prevention of Legionella growth and transmission that you would find useful but do not exist or are not currently available to you? If so, what information should those standards or guidance contain?

(3) What is your organization's role, and your role within the organization, in achieving implementation of WMPs by owners and managers of buildings at increased risk for Legionella growth and transmission?

(4) In your organization's experience, what are the principal barriers to implementation of WMPs by building owners and managers?

(5) Where there are barriers, what has your organization done to overcome these barriers?

(6) Where implementation of WMPs has gone smoothly, what factors ( e.g., resources, guidance, activities) contributed to this success?

(7) Has your organization had experience with approaches to WMP implementation that are specific to certain settings ( e.g., hotels, hospitals) or devices ( e.g., cooling towers, potable water)? If so, have you learned anything from these different approaches that could be used to improve WMP implementation? Have you looked for or experienced any unintended consequences related to a WMP?

(8) A limited number of jurisdictions have implemented regulations to reduce the risk of Legionella growth and transmission ( e.g., New York, New York City). In your state or local jurisdiction, should building codes or other types of public health regulation or legislation be used to help prevent Legionnaires' disease? Why or why not?

(9) Are there other approaches to reducing the risk of Legionnaires' disease that your organization has found to be useful besides implementation of WMPs?

(10) What additional considerations are relevant to developing guidance for preventing Legionnaires disease?

(11) Has your organization implemented specific approaches to reducing the risk of disease due to other opportunistic waterborne pathogens besides Legionella ? If so, please explain. Do these approaches conflict in any way with your approaches to reducing the risk of Legionnaires disease?

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