Legionnaires’ Disease and the Hospitality Industry

by Andrew Carlson, and Mark Hodgson, LRSC
Packer Environmental Consultants

In 1976, the first recognized epidemic of Legionnaires’ disease was associated with the Bellvue Stratford Hotel in Philadelphia. Since that time, Hotels and Resorts continue to be associated with outbreaks, resulting in negative impact for the operators. The consequences of an establishment being implicated in cases of Legionnaires’ disease range from operational interference to lost business days and even permanent closure. Every operator wants the customer to enjoy a happy and healthy guest experience, free from actual or perceived health risk. Certainly no operator wants their establishment responsible for Legionnaires’ disease. Unfortunately Legionnaires’ disease catches too many operators unaware and unprepared.

Even a single case of Legionnaires’ disease (guest or employee) will have operational consequences. Many isolated cases of Legionnaires’ Disease occur where proving a definitive link to a specific circumstance or location is not possible, but a hotel or resort is implicated because of the timing of the symptoms. With guests traveling from widespread geography and varying the length of stay, the hospitality industry provides a unique challenge for investigators.

Legionnaires’ Disease is rapidly becoming a known health & safety and risk issue among governmental agencies, various industries, and the legal and insurance professions. Hotels typically have specific systems that have been repeatedly associated with endemic outbreak of Legionnaires’ Disease, including cooling towers, humidifiers, whirlpool spa baths, domestic and cold hot water systems, and decorative water features.

The estimated number of Legionellosis cases occurring each year make it statistically likely that a large resort or hotel chain will have to deal with a case of Legionnaires’ Disease, with the implication of responsibility regardless of whether the facility is at fault or not. A guest may arrive already infected, though not yet symptomatic, and become symptomatic during or after the stay. A unique risk factor of the lodging industry is the large de facto population in terms of the number of people that occupy a given facility, not just from occupation on a particular booking day, but also from guest turnover.

Legionella Overview
Legionella is a naturally-occurring bacteria that can find its way into a facility’s water systems and potentially infect occupants through inhalation of tiny, aerosol-sized water droplets that contain the bacterium resulting in a pneumonia type infection. Person-to-person transmission of the bacteria has not been demonstrated.

There are a number of factors that influence an individual’s susceptibility to the disease, and exposure to the bacteria does not automatically result in developing Legionellosis.

Of a general population, less than 1 to 5 percent of those exposed will become infected. The fatality rate is estimated to be between 10 and 15 percent of those infected, though falling as medical treatments improve. It is the responsibility of the diagnosing physician to report cases to the state Department of Health, which notifies the Centers for Disease Control and Prevention (CDC).

Risk Factors in the Hospitality Industry
Legionella risks in the hospitality industry include both the health and safety of a guest, but also potential business interruption or other significant fiscal impact. An understanding of the issues, whether during a single case or outbreak situation, is crucial at the onset. A case situation at an Arizona golf resort hotel resulted in a decision to go black for 3 days and conduct cleaning procedures only to subsequently determine that the case was not related to the facility. A New Jersey hotel experienced two separate outbreaks 2 years apart in the mid 90’s, resulting in 3 fatalities. Improper action in this case led to the permanent closure of the hotel.

With the 2-20 day period between exposure and onset of symptoms, a guest can arrive at your facility already infected (yet asymptomatic), leave your facility and be infected elsewhere, or be legitimately infected by your facility, subsequently attributing their illness to the hotel. In any event, you are challenged to evaluate your facility as possibly cause.

Recognizing an outbreak or potential outbreak situation can be challenging, for the travel industry due to the dispersed geography of potentially effected individuals. An outbreak is defined as two confirmed cases linked by time and location, but even a single case may bring scrutiny to your facility and require investigation. The CDC reports that 21% of Legionellosis cases are associated with travel, and one of the first questions asked by an investigator is, “Has the infected individual been traveling”?

Regulations & Guidelines
Sixteen countries have Legislation or guidelines in place. U.S. guidelines include the CDC, OSHA, ASHRAE and the EPA. OSHA requires employers to know the hazards caused by Legionella bacteria, and follow recognized good industry practices.

In the case of guests, hotels and resorts must look at their general fiduciary responsibility, along with risk and legal factors.

A number of professional societies and trade associations have produced standards and guidelines and are considered part of ‘industry standard’ and used with authority in industry and in litigious circumstances. The present ASHRAE guidelines that are proposed standards will essentially become the recognized industry practice that will require every property owner/manager to assess Legionella risk and act accordingly.

Facility Evaluation & Risk Assessment
Assessing risk at a given facility requires thorough evaluation of relevant water systems and looking at risk factors in given systems. Risk assessment generally considers the potential for growth of Legionella bacteria, and aerosol production and transmission. Many additional issues also need to be considered. Several types of systems with these risk characteristics are common to the hotel industry. This would include cooling towers, domestic hot and cold water systems, pools and whirlpool spa baths, decorative fountains, as well as other systems.

All of these systems, either by design and/or through improper maintenance, can be causal to Legionella exposure to guests or employees, as many hotel outbreaks have demonstrated. There are many factors and system complexities to consider when conducting an evaluation and risk assessment, and a facility owner should perform it in a thorough and defensible manner.

Conclusion—Risk Reduction
Risk can be limited through proactive evaluation and developing a thorough water quality management plan. It should include responsibilities, accountability, and understanding and buy-in at all levels. A good plan, with implementation, will not only assist in prevention, but, knowing that a case could be traced back to your facility when it is not causal, a quality program also acts in a manner of defensibility. Also include a plan to react properly to a case situation, or to positive water test results. Improper / untimely response can be to the detriment of a facility owner. Good communication plans will prevent unnecessary alarm among employees, and will prepare you to deal with the media, which frequently report on Legionella cases. Routine testing for Legionella is only recommended if you have a plan in place to deal with results.

A case situation, or worse, a potential outbreak at a given facility can result in significant business interruption, and even local market perception issues. The costs of a being reactive is very much larger, with a risk of litigation. Legionella risk prevention should be considered part of your risk reduction program, and addressing the issue now will put you ahead of the curve, helping to ensure that guest experience is all it should be.