What we've learned about Legionella in healthcare settings

JOSH MALBOGAT: [INAUDIBLE] sales team here at Brightly and have been working with the health care industry for about 20 years. The past three months for us here have been a really exciting time. Brightly is the first big change. Dude Solutions name has retired and we've evolved into Brightly Software. For some of you that might be still really new. I'm just getting used to it. Keep in mind, it's the same great software. Great people, great processes. Just a new name to take us into the future. We've also been expanding our presence in health care with the acquisition of Facility Health Inc. Really exciting expansion for us. Takes us into the strategic asset management space with [INAUDIBLE]. It's really the coolest thing I've seen for health care and capital planning. If you have trouble getting the c-suite to fund your capital planning or struggling to justify or defend operational and staffing budgets. It's a great tool for objective, data driven and risk based planning. So you'll see lots more info coming on that. Part of our mission to continue to expand the tools that we deliver to our clients. And in that vein we continue to deliver value just like this webinar here. So I'm really excited to be part of presenting Jack and Bill from IWC. It's a really great group of people who really understand the pains around water management and Legionnaires' in the health care space. They've been doing this as a team for 25 years. We've been working with them for about two years now and I've had the chance to present or to participate in a number of webinars with them, even having them present at our annual user conference. And I can say with confidence that the content you're about to get is going to be really valuable. Just before I pass it over to Jack and Bill for the meat of the presentation. A couple of housekeeping notes for you. Your audio is muted. There's enough people on here that we can all just chirp in. But you can, and we really want you to submit your questions through the Q&A. Down at the bottom of your screen in the middle there, there's a Q&A button, post your questions there. We've saved some time at the end to be able to share those answers with you. I find that can be the most valuable part of the presentations. There are going to be a few polling questions to make the session a little more interactive. So watch for those and please participate. And we are recording this session. So you're going to be able to listen again if you'd want. And for those of you who didn't make it live, welcome, thanks for listening to the recording. Now with that, I'm going to pass it over to Jack, who's going to run through the introductions for he and Bill. And I'm going to kind of fade to the background, watch with you all. Jack. JACK MURPHY: Thank you, Josh, and I appreciate the introduction. And what an exciting time to be here for the name change and the execution has been great. Love the new colors. They're awesome and it's pretty cool to see. So good morning and good afternoon, everyone, depending on where you are in the country, if not the globe right now. And welcome to our session titled, "What we have learned about Legionella in health care settings." So as Josh mentioned, my name is Jack Murphy. And joining me today is Bill Pearson. And we are ASSE 1280 certified Legionella specialists with extensive experience helping organizations be proactive when it comes to Legionella. So our star for the day is Bill Pearson. And Bill Pearson is first and foremost a water pathogen specialist. Bill has extensive experience in the industry and was the former Vise chair of the ASHRAE 188 committee. I myself, I work with many of our clients out in the marketplace and can be a resource for organizations when it comes to Legionella and helping develop solutions. So when we're speaking today we're coming from a very pragmatic experience. Very real life experience out in the industry and so really want to provide that context as we move forward. So before diving into the content for today I just want to give some background on who IWC innovations is. So on a global perspective, we're a full line provider of Legionella and water treatment solutions. So really anything that touches your potable and non-potable water system IWC can help with. But our specialty and our expertise goes deep into the world of Legionella. And it is such a hot button topic right now that we really are going to focus on that for today. But overall, we specialize in reducing risk, regulatory compliance, and implementing strategies to help your buildings be safer, and for your heating and cooling systems to run more efficiently. And our portfolio spans many different industries but we found a niche in the health care space, and really understand the needs that health care professionals have on a daily basis. So we're based out of Indianapolis, Indiana, but we operate nationwide with accounts in almost all 50 states right now. There's a couple of members of my team that are looking for some activity out in Hawaii. So if there's anyone from Hawaii right now, we would love to hear from you and see if we can conduct a site visit out there. But all in all we boast a full roster of ASSE 1280 certified Legionella specialists and are really here to help you with any challenge that you face today. So that's who IWC is. That's who Bill and I are. So with that, I'm going to pass the baton over to Bill who is going to take us through the first half of our continent-- content here today. BILL PEARSON: Well, thank you, Jack, both for the introduction. And I to extend a welcome to our listening audience, our attendees. Legionella has been my passion for many decades now. And Jack gave you some of the background. So we've done presentations in the past webinars where we have talked about Legionella 101. And we're going to just cover some basics here rather quickly. And we've also talked about the ASHRAE standard 188 that Jack mentioned. I was on that committee for the 10 long years it took to develop that standard, which was first released-- published in 2015. But more importantly, we do want to share it's been very active during the pandemic. I have another talk that says the COVID world and the Legionella world have collided. So we want to share what we have learned over the past three or four years, and in particular what we've encountered during the pandemic because it is very, very significant and impacts our-- I think our host audience for sure. The health care single living space. So Legionella bacteria. The basics. We primarily put this in the presentation just so you'll have the slides. We're not going to go into the details. They can certainly be asked during the Q&A and we encourage that. But I think we all know now that Legionella is a bacteria. It's a waterborne pathogen and it is responsible for Legionnaires' disease. Now, with that said I usually like to dismiss calling it Legionnaires' disease because that really still seems to be kind of tentative to some people. They don't quite understand what it is. It is pneumonia. This bacterium-- Legionella bacteria-- causes bacterial pneumonia. I think we're all very familiar with a lot of aspects of pneumonia. So Legionnaires' disease primarily is a bacterial pneumonia. There is a milder form, an illness that comes from Legionella bacteria. It will not be the focus of this because it's pretty insignificant. It's a mild flu like condition that resolves on its own. You don't need to go to the hospital and get antibiotics and it is not pneumonia. It's what they call Pontiac fever. But let's stick with Legionnaires' pneumonia, Legionella pneumonia, and with our background information. So I want to first and foremost say, if anything we've learned over the last several years is it is not a rare bacteria. It is a very, very commonly found bacterium in our fresh water bodies, lakes, rivers, streams, and it is even associated with some wet soils. So don't take the position that, oh, this must be some really rare disease or really rare-- caused by some rare organism. It is not. It's a very common bacterium. And it doesn't cause us problems in its natural environment. It's usually found in very, very low numbers. But it is when it enters into our premise plumbing, our building plumbing systems as well as some devices that it finds very favorable conditions to set up home, set up house in what we call biofilm-- a community of microorganisms that gives them some sort of protection. But it's where then with these favorable conditions they can grow and cause the problems they do upon exposure. There's a lot of different species in this Legionella genus. I just mention that because that becomes important when we do testing for Legionella to know what species we're dealing with. There's been more than 60 identified species but more than 90%-- some recent data says maybe up to 95% of the pneumonia is caused by one species that's called Legionella pneumophila. I usually say that pneumophila is Greek for lung loving. Of course, that's where infections-- bacterial infections, pneumonia infections occur. So Legionella pneumophila also has some smaller differentiated serogroups. But the one you'll see, the one you'll always hear talked about-- the red flag for us and as far as disease causing-- serious disease causing pneumonia is Legionella pneumophila Serogroup 1. I think we will also recognize, unfortunately when the outbreak occurred that got its name, Legionella, at a Legionnaires' convention in 1976 in Philadelphia. It was a cooling tower that was associated with that outbreak. And I think we all might recall in 2015, oddly, the year that the ASHRAE standard was published. That summer, New York City was experiencing a large outbreak of Legionnaires' disease. Said and done, 18 people died. 130 came down with the pneumonia. So it's very important. And that was also linked to a cooling tower. And so we often encounter people-- we've learned this over the past several years-- that think Legionnaires' disease, Legionella pneumonia, pretty much primarily comes from cooling towers and that is not the case. The most common source that causes this pneumonia is our building water systems, our potable water systems-- we have data, CDC, you'll see some other graphics-- About 56%. And now cooling towers are another vector, they are another reservoir but they're not as significant at all as the potable water systems. So cooling towers are roughly 22%. So here's where I said I wasn't going to get too much into the Legionella 101. We've got these slides but just a little bit more. People often ask, well, how do you get it? Do you get it by swimming in the water, or touching the water, or drinking the water. The exposure route or the transmission and catching Legionella pneumonia happens when these water systems that contain Legionella are also produced as an aerosol. We call it aerosolization or fine mist. Because to get a lung infection, to get a pneumonia infection into the lungs you've got to get the bacteria there. So it is aerosolization. Aspiration is another common means. If you were to aspirate while drinking water. We have a lot of residents in our senior living space that have swallowing issues and they-- choking issues, and that is the aspiration aspect of getting whatever you're drinking or eating pathway into the lungs. So three conditions must be met to contract the disease. You have to had that water source that contains the disease causing bacteria. And as I said earlier, there's a lot of species out there. But target one is Legionella pneumophila Serogroup 1. But there are some species that are less-- they're actually innocuous, haven't been associated with the disease. So you have to have the disease causing form of Legionella, let's say. And then you have to have exposure to that water source or the water enters the lungs. And then you have to have what we call an at risk host or a susceptible person. And healthy people contract or come in contact with Legionella and do not get sick. But unfortunately, our immunocompromised, our elderly, and now we're talking about the population that is a lot of our senior living spaces. And this is why the health care industry is very concerned about protecting those vulnerable people from any Legionella at all. So I mentioned, there are several devices. Just think about your building. You've got showers. You may have hot tubs. There are ice machines. There is a link between ice machines being able to actually have Legionella in there and end up being a route to patients or people that let's say sip on ice chips and all, and then maybe aspirate them into the lungs. If there's Legionella in that ice coming from the water that made the ice then that's how that route goes. We have water fountains and features. But think about all the water outlets in a facility. All your sinks. All your showers. These are all potential sources where the water gets aerosolized. When you turn that faucet on you are aerosolizing it. In fact, many of the minibar, these devices have aspirators and so that's a common source. I mentioned cooling towers, that is not part of the portable water system but that is a device where when Legionella is there-- a cooling tower by its action produces aerosols. You'll hear us talk about dead legs and hands, and hot water tanks because temperature is an important aspect. So I like looking at these four things that I've outlined here on this slide. It's actually-- I use the acronym STAR, S-T-A-R. That's the first letter of each of these. Sediment, this leads to forming biofilm in a community where bacteria, not only Legionella but other bacteria like to live. Temperature, very, very important. We say keep the hot water hot and keep the cold water cold. Please don't let them mix and be neutral. Don't let the hot water cool down. Don't let the cold water warm up to what's called an optimum temperature range. This causes problems for us and our health care facilities because the other issue with hot water is it presents a [? STAR ?] potential. And so we want to not have that condition so we reduce many times the temperature of the water and we get it into a temperature range where it can support Legionella growth. We may have a slide later on but. Don't think Legionella happens to be a very [INAUDIBLE] temperature tolerant bacteria. And its optimum temperature is actually up in the 105 108 degrees Fahrenheit range. And we see those temperatures many times in our health care facilities by not keeping the hot water hot and the cold water cold. Age of water. You're going to hear this term. Very important. This means how long is the water remaining in our building systems, particularly in low flow, no flow, dead zone, dead legs. In the unoccupied room, the seldom used outlet. These all become an issue because the water ages and by that it remains there. It loses what disinfectant it may have had coming from the municipal water supply. And so it's very important. You're going to see a lot of attention paid to what we call flushing programs. And paying attention to having the water come into the building when it's fresh with disinfectant getting used for whatever purpose, and then getting out of the building so fresh water can come in. And so that comes back also-- residual disinfection. We make the assumption if you get your water from a municipality that it comes in and it's all protected. We have a Safe Drinking Water Act that regulates that part of our potable water systems. But many times for various reasons you will encounter being on the end of the line, so to say, or having really low levels of chlorine, or [INAUDIBLE] disinfection process is and that becomes important. As well, there are interruptions in your water supply. Very, very important during construction, renovations, or just on their own. Water main breaks are very common and when that happens it really disrupts all that biofilm in the piping-- in the water mains and you can get slugs of bacteria water. I'm sure you're familiar with Brown water vents where they say don't drink the water, boil it, et cetera, until further notice. So that's a big introduction into the Legionella 101. And so going back, that it's not a rare occurrence. In fact, it's been on the increase. Significantly, data by the CDC has been showing us since 20-- 2001, we have a lot of data. And I'm going to show you these next slides in very quick action. Don't worry about them. This is actually just as you can see the United States. These are reported cases. Legionnaires' disease, Legionella pneumonia is a reportable disease in the US. So that data is handled by the CDC and the National Surveillance System. So this is what the map looked like in 2007. This is the cases per 100,000 population. Here it is 5 years later in 2012. Here it is 5 years later in 2017. And then we have one from 2018. I think this is our last data. The point I'm trying to make here is you're seeing that the light states where there were small incidents are getting darker. And the dark states are even getting more darker. So we do see Legionella on the increase in the US and it actually worsened a great deal during 2019 and 20-- even right now during the pandemic because we had a lot of idle systems. And the issues we just ran over a few minutes ago where we had water aging and supporting the growth of bacteria. So in order to keep this flowing where you don't just have to listen to me, Jack is going to-- I'm going to be handing off some slides to Jack and I'll ask him to take the next couple of slides when we talk about the business equation. JACK MURPHY: Thanks, Bill. Yeah. In working a lot with our customers obviously there is a joining of worlds between the science end of it and the risk management, and then even the business aspect and brand reputation of the world that we live in. So just in terms of prevention versus having a reactive case of Legionnaires' disease and we'll talk about it in a little bit. But a case of Legionnaires' disease can be extremely costly for an organization. In terms of just pure dollars spent, it can be up to 100 times more than it would take to prevent. So there really is a return on this investment and as we work with organizations we help them to understand that return. You also have brand image and we know how fast that news moves in this day and age with Twitter and 24 hour news cycles. If there is an easy story people will go out there and get it. And there is litigation around it. And there is an opportunity sometimes or there is a situation where you do have to shut down a building if you have an outbreak or situation where it is deemed not safe for the public. So there really is a return on the investment for prevention practices. Perfect and I will toss it back to Bill for this-- taking us through the ASHRAE 188 portion of what we've learned. BILL PEARSON: OK. Again, we've had a lot of presentations on this and what entertain anything in Q&A. But for the essence of moving into-- really wanting to talk about what we've learned, we'll just say, hopefully, we know now in 2022 the ASHRAE standard 188 came out in 2015. So it's seven years old now. It's not brand new news. But a compliant water management plan or program is the most effective way to prevent Legionnaires' disease by controlling the growth of Legionella in our building water systems. And you'll see up here I've highlighted the ANSI/ASHRAE 188-2021. The committee that first developed this standard in 2015 is still in existence as a Standing Standards Project Committee for constant maintenance and update of the standard. So in 2018, three years after the initial publishing, a revision came out. And then just this past year, three years later in 2021. So the most current document is the 188-2021. So we see that from the title legionellosis. I guess we can define that term. But that happens to be any disease caused by Legionella bacteria. Risk management for building water systems. And again, we'll leave the slides for you to look at but we're going to not dive into-- this is not going to be a ASHRAE 188 presentation other than to point out that's going to be your driving document that's going to help you control-- manage Legionella in your water systems. And will be a focus, if and when you have any problems. With the departments of health, in their case investigations, one of the first things they asked for, do you have a water management plan. We see from outbreak investigation data. As mentioned earlier, that health care is the largest sector. From these graphs, these will just be for your FYI. This is settings of recorded legionellosis outbreaks from 2001 to 2017. And it even dives a little bit deeper into senior assisted or senior living space. Kind of crossing over into health care. Travel associated [INAUDIBLE]. The CDC puts a great deal of data. Now this is more FYI because we'll be talking about their guidance documents. So water management plans. The CDC has told us 9 out of 10 cases of Legionnaires' disease-- actually their investigations may be prevented by proper water management practices. That's the crux of a water management plan. So having that water management plan and implementing it can help you avoid a lot of headaches as Jack said. When you get into the ASHRAE 188 Water Management Plan, you'll see that they talk about a team is going to be responsible for the oversight and implementing that management program. In some really small facilities it could actually be an individual or a two or three person team. We encourage our health care facilities though to really involve infectious control, someone from administration as well as in our maintenance facilities, engineering departments to be involved on that team. These documents are talking about something we've learned over the last several years. We're glad to see many water management plans coming out on their own within our health care facilities but many of them are lacking. They-- number 1, they're living documents. They're not one and done. And conditions may change in your facility. New construction, renovation, additions, where that need to be reflected in the management of those systems. So you may have something you think is a water management plan, particularly, if you put it together yourself or just looked at one document like ASHRAE 188. But most likely it's not going to be in complete alignment with the ASHRAE standard. We have encountered in many case investigations when it gets down to that unfortunate situation where there's a facility required case and the Department of Health is investigating it. When-- they're going to ask for your water management plan and it-- more often than not, they are deemed inadequate unless they have been put together usually with a consultant helping out to be inclusive of covering all aspects of the ASHRAE standard. So facilities as I mentioned, are constantly changing so your water management plans. In fact, the ASHRAE standard 188 to be compliant calls for a minimum of an annual audit of the plan to see that things haven't changed. So compliance with ASHRAE 188. Guess what, ASHRAE is not an authority having jurisdiction. They put out standards but it's when the standards get adopted into regulations, or code, where by an authority having jurisdiction where they're most powerful. And so we see the CDC, who was very prominent with the development of ASHRAE 188, they produced a lot of materials. They actually call them toolkits, Legionella Toolkits. And the most recent one was in 2021 but they came out starting in 2016 right after the ASHRAE standard did. So [INAUDIBLE] talk about that source. The Joint Commission in conjunction with the CMS. I know you're familiar with the Centers for Medicare and Medicaid Services. They have-- in fact, the Joint Commission most recently, made effective January of 2022 certain requirements that their inspectors are going to be looking for when they go to facilities that have a Joint Commission accreditation. And they call out as the CMS did. You must have policies and procedures in place, essentially a water management plan from ASHRAE 188 and the CDC Toolkit. So that's what they're going to be looking for. So challenges in implementing an ASHRAE 188 Water Management Plan. I'm going to ask Jack if he can keep it just to a few moments on the next few slides because I think we are running just a touch behind. I want to get to a little bit more of what the title is, what we have learned most recently. JACK MURPHY: Absolutely, Bill. I appreciate it. And I definitely speak quickly. It's always been one of my downfalls. So I'm going to keep it moving. But I do want to just make one comment on the previous section. All the time, as I said, we work with different clients around the country. And they're always looking for a silver bullet. What can I do? Is there a specific task? Is there something I can implement into my water system to just really take care of it? And it's really-- we go back to the best thing that you can do. And what we have learned is the best thing you can do is to implement that ASHRAE 188 compliant Water Management Plan. And the complexities around that are-- there are a few. ASHRAE tells you what to do but not exactly how to do it. It leaves it open. And so implementing a water management plan is challenging. And that's really what I want to highlight in these next few slides is the specific challenge. In working across every industry in the United States one of the top things, and especially what we're seeing right now in health care is staffing. And the people hours to be able to execute on a water management plan. And this is twofold. It comes from first and foremost, having the knowledge in-house on how to develop a proper ASHRAE 188 Compliant Water Management Plan is not something that is standard skill set when we're hiring facility staff. We're really good at HVAC plumbing. Knowledge of Legionella just doesn't exist until you get thrown into the fire in the health care industry. The other portion is the actual time to execute the control measure tasks within a water management plan. Now, I'm not saying it's hours and hours and hours or every single day. But when we have a backlog of work orders-- when there are patients that need to be taken care of and different things that need to happen within our facilities, the Water Management Plan sometimes gets left on the shelf. And so while the-- not silver bullet. But while-- the number one thing you can do is implement a Water Management Plan is the recommendation-- what I want to do is we acknowledge the fact that in a pragmatic standpoint, sometimes there just aren't the hours in the day. And so our recommendations and what we've learned is that there's new technology out there to help augment and help staff manage water management plans better from the creation side to the ongoing documentation piece, which is super important when it comes to a Water Management Plan. We acknowledge that you don't have hours and hours and hours every day to sit there and fill out logs of temperatures and things like that. And I know many of you have moved forward and found a solution for your day to day task management. And so utilize the tools that you're already using today because the hours aren't infinite, and we're down to doing more with less. And I know we've heard that for years. But that is so true today in our communities and facilities. And so the second part is utilizing third parties to help. So when it comes to the world of water and water management plans, leverage your water trader. Leverage your Legionella consultant. We are having more and more organizations come to us today and just say take this off of our hands. Help me out. And we utilize technology every day through this where we as IWC, we have our own water management plan app that helps you create an ASHRAE 188 Water Management Plan. And that was born out of the need for a cost effective solution that didn't take days and days and days. Give me an hour to walk around my community, or my facility. Fill in information. Give me a Water Management Plan that I can start executing on the same day. Then next slide. And then again, consultants. Like I said, leave it to the experts that do this every single day. I know there's an evolution in the industry just by being in there of relying more on consultants to help execute various parts of your Water Management Plan from the creation to-- if you have a water trader coming in to test your cooling tower, see if they can help on the Legionella side. It's about being creative with the resources that you have at your fingertips. You have somebody coming into your building already, rely on them to help execute for you. But from our perspective we're here to help with site assessments. We're here to help develop water management plans, leverage people that live and breathe this every day to give you tips and tricks to move that along. So we recognize there are challenges but there are some solutions. BILL PEARSON: Thank you, Jack. Thank you very much. And I appreciate you putting us back on time. So I think this is the one that I really want to share with the audience and it is dealing with Legionella case investigations and the corresponding Departments of Health. Sometimes they're called the Departments of Public Health, different names. Every state has a Department of Health and locally there are Departments of Health. And unfortunately, when it involves Legionella, particularly if there was a suspect or confirmed facility acquired case or more than one, which then becomes what they consider an outbreak. And CDC has told us that one out of four patients that contracts Legionella pneumonia in a health care setting succumb to that disease. So that's quite an alarming statistic. The fatality rate is 1 out of 4. In general, with outbreaks or with other catching Legionella pneumonia, it's 1 in 10. But when it's contracted in a health care setting it's 1 in 4. So the DOH just take it very seriously obviously. And this can be an extremely painful process. I maybe preaching to the choir so to say. If some of you attend these, have had to go down this road. But we want to get the word out and this is significant to what we have learned in the last several years. So nobody expects to get Legionella and that's why we continue to get the word out on it. Education is important. But it's not on your radar screen. We have found that out definitely. Unless they've had a case before, that first case is like, oh my gosh. We hadn't even thought about this. So we go back again to the CDC. They talk about the cases. A very important report came out by the National Academies of Science Engineering and Medicine, we'll call them NASEM. They estimate that a closer number of annual cases in the US is closer to 52,000 to 70,000. Some other authorities have even estimated that it is a six figure number, 100,000 cases a year. We know that a lot of cases go undiagnosed unless there is an outbreak involved. So there's a lot of sporadic community acquired but we're keeping our top counter to the senior living space, to health care facilities. This is an actual email and it's come from-- and I take to protect the innocent. I'm not going to talk about the facility or the state. So "Good morning. The DOH has been made aware of a case of Legionnaires' disease associated with your facility. You've been identified as a point of contact for additional questions. Based on the information available at this time, the DOH would request from you additional information to determine next actions including." And it goes on from here. The first thing they're going to want you to do is complete an environmental assessment form that is on the CDC website. They'll point you to it. And it can be daunting if you've never filled one of these environmental assessment forms out. In fact, the DOH usually says, get this form filled out by a member of the facility's water management team. Well, first question. Do you have a water management team? And it still is the rule rather than exception that most of our facilities don't actually have what we call compliant ASHRAE 188 plans or water management teams. So then they say with the support of the facilities consultant as appropriate. But you might say, well, we don't have any consultant for Legionella. They'll recommend that you get one during the case investigation. Look at number two. Let's have a copy of your current water management program and water quality monitoring the records pertinent to water systems connected to possible case exposures for the last six months. So when you have a facility acquired case, they want to do a retrospective study going back at least six months for any pneumonia case exposures and try and track down Legionella. Then they ask for copies of any environmental Legionella testing. Well, that bodes are you even doing testing. Again, the rule rather than exception is most of our health care facilities are not doing testing for Legionella until they get involved with a case investigation. We are seeing many more though become proactive and that's what we are trying to project. Become proactive, learn about ASHRAE 188, if you don't already know it, and get a water management plan in place. And the only way to validate that plan-- remember the plan is to control Legionella is to test for Legionella and see if you have it. Then they're going to-- they want identification of any response actions planned or taken to date. In other words, they've told you that you've had associated case at your facility. What are you going to do about it. So the DOH then says we request such information be available to their group, which is going to involve epidemiologists and many other people with the Department of Health as soon as possible, but no later than end of the day they'll give you a date. This is a daunting-- this is what we call going down a possible painful road to deal with the Department of H-- DOH when there's a case investigation. But the bottom line is their position, and ASHRAEs, and our major consultants is Legionella is controllable. It's a common bacteria where we've already pointed that out. What you need is compliant Water Management Plan. And when it's not controlled, that's when it becomes a public health hazard and can lead to serious illness and death. So the case investigations, as we talked about, the public health investigations, environmental assessment forms, this can start you down a journey. They're going to have you testing the bulk of them. And I will say this, we've been probably throughout-- I know of 45 or 46 states dealing with the Departments of Health both local and at the state level and they do vary. Their exposure or expertise with Legionella vary. Some of them have extensive backgrounds and we're finding out those that had the more extensive backgrounds are going to expect the most from you and your facility. They're not going to just ask you if you have a Water Management Plan, they will want to see it and they will pick it apart. They will critique it. So if you haven't done any testing they're going to put you on a testing regime. If you have done testing they'll want to see the results. And even if your results are not undetectable, because their investigation is of a facility required case, you will test every two weeks for three months, and then monthly for three months following. Look at how we [INAUDIBLE]. That's nine sets of tests. And I'm not talking about one sample. They're going to recommend to you how to develop a sampling plan. There's going to be a representative sampling of your facility. Not every single sink, not every single shower. But it's got to be represented. You can't just take one or two samples. They're going to want samples from your hot water heaters, in these storage tanks, ice machines as well as the incoming water. When this starts, if at any point during that testing timeline you receive let's just say bad results, several positives, you may have to restart the testing process all over again from the beginning. So you can start adding up. We see our average facilities, if it's just a single hot water system maybe a 50 or 100 bed facility, you're going to be taking somewhere between 20 and 25 samples. So do that 9 times within six months. Unfortunately, Legionella testing is not a simple test. It has to go to a special laboratory. They'll remind you of that. They'll want to know that the laboratory is CDC elite and as well as it's not inexpensive. I don't want to quote any numbers but you'll pay anywhere from $100 to $150 a sample, or more if it involves consultant ship going with it. So this is where the road gets very, very painful that Jack I did. So I like this graphic. We already went over what a case investigation testing is going to be like. Well, what if you had a Water Management Plan in place and you are already doing testing. That would be great. Most Water Management Plans, the recommendations are to do quarterly testing. So doing four tests in a year it's a heck of a lot better than doing nine tests in six months, and maybe doing nine more tests in the following six months. So let's be proactive. Make sure that you-- we use the word validation, that's actually from the ASHRAE standard 188. When you have a plan there's two things you must do. You must provide evidence that you are implementing the plan. You didn't get it and put it in file 13 or on the top of the shelf. Show me that you are doing what the plan says you should do. And then of course, is the plan effective. And that's where validation testing comes in. Yes, we have Legionella under control. So this takes us down-- I want to wrap up real quick. We're going to save this for a future presentation. But many times that road gets very painful because they're going to want you to do or remediation, come in and do a full facility hyper chlorination. That's not inexpensive and that is a big burden but you may not satisfy the Department of Health with the subsequent testing. They're going to want every single test non-detectable, zero Legionella. No such thing as zero because there is a level of detection. And so we have had to do multiple remediation's at facilities. And you reach a point where you go the only other recourse you have is for you to provide your own secondary disinfection. For you to set up a system on top of the incoming water to your building and add additional chlorine. There's other secondary disinfectants. That's another whole topic. Chlorine dioxide, copper silver, monochloramine. But this is where that road gets very difficult. So the key learnings we have here are the importance of a compliant ASHRAE 188 plan. To use technology and consulting third parties, unless you have that expertise available in your organization or at the facility to help, at least get it going. I envision down the road facilities will have what they need in-house. But again, the exception or the rule now is that they don't have it. And so dealing with Legionella case investigations and the Departments of Health can be extremely painful. Let's be proactive and hope that you don't have to deal with them because when you're in that loop it gets pretty difficult. So Jack, I think we've actually gotten to the Q&A. I kind of got right on the target of our time. But if you have anything to add let's just open it up and you take it from here. JACK MURPHY: Yeah, that was very well done. And I do believe we have some poll questions that are going to be popping up here through the Zoom feature. So I think that we have poll number one here in progress, which is we would love to know your current role. If you currently have a Water Management Plan and whether or not you're currently testing for Legionella. So as those are coming in what I will also say is that IWC, we do have a guide that our fantastic marketing team put together and they may or not be here in the room with me right now, but they put it together. What do you do if you've been contacted by a Department of Health? Again, it's not something that anyone is sitting there waiting for so it's really a nice thing to have in the background or you put it with your Water Management Plan and just say, OK, if the unthinkable happens what do I do. So it's really interesting to see we have a lot from the facilities world on this call right now. A lot from the other category as well. Facility administrators. A lot of the folks that are involved in the program team right now or that would be involved in the program team. So first and foremost props to everyone for being on this call right now. Whatever the impetus and willing to learn. Again, this is a topic that people-- we didn't grow up learning about Legionella. So this is a topic that we're having to learn. So the other poll as well about having a Water Management Plan is a lot were developed in house, utilize the third party. Some people are putting it together and that's what we're seeing a lot in the hospital space and the Joint Commission world. So again, also would you like a salesperson to reach out to you. A lot of no's but it would be great to get a Yes to help us have some conversations. Thank you for a yes. But we also do have some Q&As here. And I think this is very pertinent right now to start out with because the Joint Commission did just come out with their policies and procedures. And hospitals are very complex buildings and campuses sometimes. But Bill, I've got one that we actually haven't answered before and I'm interested to hear your thought on this. But the question is, "Hospitals are looking at alternative opportunities to reduce stress. Have you seen any Legionella cases or risks related to incense or essential oil diffusers used for aromatherapy?" BILL PEARSON: Boy, I thought I've heard all the difficult questions. That's a little bit beyond what I have heard anything about. There would have to be some knowledge of what the incense is. What the chemistry is of that. And would that be supportive of Legionella bacteria. It is a waterborne pathogen but it needs to have nutrients and it needs to be able to grow actually to be infectious. It's not an aerosolization but you would be taking that and breathing it in. And so it just comes a matter of trying to determine if Legionella growth is supported in that medium. I'm writing this one down, Jack because I've always learned that if you don't have the answer you better know somebody you can ask and I have a few colleagues that I'm going to ask that question to. JACK MURPHY: Excellent, yeah. It would be great to even pull a sample for our own edification on that and just understand and-- BILL PEARSON: You can start there but it's an interesting question. JACK MURPHY: Yeah, definitely. So yeah, I mean, as our buildings evolve as sort of the scope of what-- buildings are offering changes. There are new risk factors that get introduced every single day. And so we like when organizations keep us on our toes. So we'll look into that and keep an eye on our social media page. IWC Innovations on LinkedIn and-- BILL PEARSON: Jack, let me add. It's a follow up thought. When in doubt, any time you have aromatherapy or even respiratory therapy, always use a sterile water supply if there is a component of that therapy. Do not use tap water from your municipal supply. That will at least put you down the road of not introducing any bacteria to the process or device. JACK MURPHY: Absolutely, yeah. So that's a really good example there. It's kind of like with sea taps and some of the other equipment that's used out there as well. So OK, question number two. And this is one that we worked through all the time. And the CDC does have some pretty good resources on this that we can help pass along. But Bill, what is the recommended level of detection when testing for Legionella. And there's a second part to this question where-- and we deal with this all the time where some labs-- their limit of detection is 0.05 CFU per milliliter. We know that that is a certain level. But what is the action level that we look at when it comes to Legionella testing and results? BILL PEARSON: Yeah, a great subject. We encounter this all the time. So let's start with two scenarios because it is different. If you are involved with a Department of Health in a case investigation you're going to be asked to or asked/told to do two things. To collect one liter samples to submit to the lab. And what they're going to be looking for is non-detectable. So if that labs limit of detection is 0.05 that's going to be reported and the DOH is going to say that's a positive hit. To them that means there's Legionella there. Now, when it comes to-- and I do like this question. It's very important. Let me take you-- let me reference everybody. Look at the CDC most recent guideline in 2021 addressing this topic about Legionella testing. In the absence of an investigation or any previous outbreaks they consider Legionella to be controlled. When you find it below one colony forming units per milliliter. So the 0.1s, the 0.2s, the 0.3s, it's not their perfect control because that would be everything is non-undetectable. You'd never had a positive Legionella test. But the CDC says it's more important to look at it not just from one sampling set that's a picture in time but any trend. So if you've always had an outlier a 0.1, a 0.2, a 0.6, you might address that and say, is this an infrequently used outlet and tweak your Water Management Plan to flush more but they will consider that in control. And so if I answer that question, go get this CDC Legionella toolkit 2021. I think it's the very last page. It's got a table, and it talks about testing results, and making some recommendation or action based on those results. So I hope that answers the question. I will follow up and say as a practicing Legionellologist I do not like seeing labs continually equating the lower limit of detection as something that is useful without getting into what happens in a laboratory. At the end of the day, those very low detection's are a mathematical calculation after you filter concentrated the sample. So it makes it tough. That's the painful part of the case investigation. Don't worry about the [? level ?] of detection. If they're detecting it that's going to be considered positive. And I hope to see that change within the Department of Health and we can come to some pragmatic reasonality. JACK MURPHY: Yeah, definitely. We deal with that every day and in helping to explain fragments out there and the risk that those truly, truly represent. So this is-- yeah. JOSH MALBOGAT: I actually just-- I got a question texted not through here. But I got a question actually asking for IWC what can you guys help our client base with? What are the areas that you've stepped in? I know we've talked a lot about the background and some of the problems. But they're interested in knowing kind of where it is you guys have worked with other organizations. JACK MURPHY: Sure. And this is-- it's really the full gamut. So when I explain where our company can help it is from prevention strategies. So that is developing that ASHRAE 188 Compliant Water Management Plan. Whether it's one of our technicians coming out to your location and conducting that risk assessment or by providing the technology to develop that Water Management Plan. So we'll help you with that initial creation. We'll also help you with the testing aspect and that is designing a testing program and then providing the test kits as well as the follow up consulting and the so what. Exactly what Bill just did right there was explaining some of the questioning and some of the analysis that IWC provides as we are looking at test results. It is interpreting that data and understanding. So in our testing offering that is all that comes with it. It's not just bottles, and good luck, and call us when you need us. It's the full spectrum. And then we have the remediation and secondary disinfection end as well. So if there is a situation where you have a case or you-- and the Department of Health has asked you to do a remediation of your building, a hyper chlorination, IWC can help with that. If you have a situation where you've proactively tested and just to get ahead of the game you want to do a remediation, we can help as well. But some of the greatest things that we do are actually working with organizations through the case investigation process. We have active cases at all times. And that's really where we get folks like Bill. We have Brian Pickett who's our VP of Environmental Solutions. He gets involved as well. And we have relationships with Departments of Health around the country. And really act as the organization's advocate for helping them get through the process. Again, nobody's ever expecting for this to happen. So we get calls all the time to say, hey, can you help us through this but we love to be on the prevention end and how do we get out ahead of the problem. But we can really help from that. And we can also help in the treatment of your cooling towers as well. There's an overlap with the Legionella world in treating your non-potable water systems cooling towers and then keeping your closed loops and boilers functioning as they should. So if it touches water-- if you have a question about anything related to water that's really where IWC can get involved. JOSH MALBOGAT: Thanks, Jack. I mean, what I've really liked about what I've seen you guys do is you work kind of with your clients side by side and are really a supporting element. They've even come to us to talk about once they've completed a Water Management Plan, how do you then integrate that into your CMS? How do you trigger the kind of reminders for work that has to happen down the road to keep you protected? So we've done some [INAUDIBLE]. JACK MURPHY: That's really where-- that's really where the efficiency in doing more with less is. So the more time you have to take out of thinking about what do I need to do to execute my Water Management Plan and document all these activities. Work within the CMS program that you have. It's a really powerful solution that keeps you where you are every single day and integrating. We can help you do that is integrate the water management plan with that platform to help create that holistic solution. BILL PEARSON: Jack, let me jump in here. I know we're up against time. But there was a question I did want to respond to. The temperature question. They responded, "What is the temperature that will kill Legionella?" And I mentioned that the optimum temperature range when they are at the maximum growth is really in that one 105 108. But now it's growing very well in the 90s and the 100s. But to kill Legionella it will start slowly dying when you get temperatures at 140. Dies in a matter of 140 degrees Fahrenheit, minutes to hours. And then-- but the pasteurization temperature or the temperature it's used for these heat and flush remediation is 158. I always say 160 degrees. So you have to have water at 160 degrees Fahrenheit to essentially instantaneously or immediately kill living Legionella. The CDC gives you a guidance of keep the cold water below 78 degrees. It doesn't mean it's dead. It's just not really actively growing. And if-- the lower the temperature it will even go dormant. And the same thing happens on the upper end. It starts dying at 130 and 140. And it's going to quickly die at 160. JACK MURPHY: Right. And we do have one more if we've got a little bit of time. I think this is a really, really good question that a lot of people are facing right now. It is about drinking fountains. And many of those have been shut down during the pandemic. And Bill, what would you recommend to folks that have had drinking fountains that have been shut down. BILL PEARSON: Yeah. Good question. Excellent question. It's not just drinking fountains but even buildings being reoccupied after either being completely shut down or having a significant-- like a hotel it's only been operating at a 20% or 30% or 40% occupancy. They should have a robust flushing program. And this question on the drinking fountains. You will want to have-- in fact, a representative or someone, whoever does the maintenance on these, come in and change out any filters and do complete flushing. Do testing afterwards to see that you indeed are getting a residual disinfectant from your city water supply, which means you've gotten all of those lines clear. And then do some representative Legionella sampling especially if you know that you've ever detected Legionella in the incoming water supply. JACK MURPHY: Yeah, and we're doing a lot of that right now with a lot of areas easing up on the restrictions. That is a hot topic that we can absolutely help out with. And Bill, if you wouldn't mind flipping to the Contact US or the contact information part slide. That would be great just so people can take it down. Yeah, no problem. For those that are left. So feel free to reach out to myself. I'm available 24/7 365. The Legionella world does not sleep. So we're here to help at any point in time. And Josh is your Brightly contact to reach out to. And Josh is always a pleasure to interact with. So we're here to help and get you the information that you need. Again, we are your partners through this and can help answer any questions that you may have and solve your problems.