It is widely acknowledged that the healthcare sector – where patients by nature are at more risk of infection, is more susceptible than most to the dangers presented by Legionella bacteria. What may be less well known is that this risk is rising, as the number of healthcare-acquired cases of Legionnaires’ disease worldwide continues to increase. Greg Rankin, CEO at Legionella testing specialist, Hydrosense, explains how healthcare establishments can ‘go beyond compliance’ to better help protect the patients, residents, staff, and visitors, they serve.
In recent years, the importance of prioritising Legionella control as part of a robust water management plan in hospitals and other healthcare settings has been regularly highlighted by announcements on, and press coverage of, outbreaks. Earlier this year, for example, the discovery of Legionella bacteria led to a delayed opening of a new £41 m healthcare facility, Worthing Integrated Health Centre, in West Sussex.1 This follows myriad similar stories in recent years, with several hospitals and healthcare facilities across the country — including Lister Hospital, Stevenage, Western General Hospital, Edinburgh, and Victoria Hospital, Kirkcaldy, to name but a few — having reported Legionella bacteria detections, prompting urgent precautionary measures to protect patients and staff.
Worldwide, cases of hospital-acquired Legionnaires’ disease have been on the rise, with research showing that the potentially fatal bacterium is present in 12-85% of all hospital water systems too.2 Another high-profile study found that 19% of cases are associated with long-term care facilities, and 15% with hospitals.3
No sign of abating
The consensus is that this worrying upward trend shows no sign of abating anytime soon, with a range of complex factors — such as our changing weather, ageing infrastructure, and evolving water usage patterns, combining to promote favourable conditions for Legionella.
Not surprisingly then, hospitals and all other healthcare facilities are coming under increased pressure, both from the government and the public, to reduce infection count. To understand how this might be achieved, it’s important to first explore what Legionella is, and the full breadth of risks involved. As many healthcare providers will already know, Legionella is the bacterium that causes Legionnaires’ disease. It can colonise and grow in a range of man-made water systems found in healthcare settings, such as taps, showers, air-conditioning units, cooling towers, and even birthing pools. Although there are different species of Legionella, Legionella pneumophila is the most common pathogenic species, and responsible for most cases of Legionnaires’ disease.
Generally speaking, most healthy people exposed to Legionella will not fall ill. However, for those that do, Legionnaires’ disease is life-threatening unless treated quickly. This is especially true in healthcare facilities, where mortality rates are much higher due to the vulnerability of residents. Individuals with weakened immune systems, who have undergone recent surgery, and who are using respiratory equipment, are at a much higher risk of being infected with the disease. Smokers, the elderly, and newborn babies, are also more susceptible to infection.
Importantly too, it’s estimated that seven out of eight survivors of Legionnaires’ disease suffer with long-term impacts.4 These include fatigue, memory loss, insomnia, and PTSD; the upshot of which, for the already vulnerable healthcare patient, doesn’t bear thinking about. As a result it’s critical that healthcare establishments have the most robust measures possible in place to protect the people in their care from exposure to Legionella.
Complexities and challenges
Simultaneously, the reality is that there are a number of practical challenges which put healthcare establishments at greater risk of Legionella contamination. Foremost, hospitals and other healthcare buildings often have bigger and more intricate water systems than other premises, due to the number of residents and the components and services needed. Key contributing factors include the size and complexity of the estate and buildings on it, along with the scope for multiple washroom facilities, birthing pools, commercial grade catering facilities, and high rates of hot water consumption during periods of peak demand. These factors not only increase the potential for Legionella bacteria colonisation and spread, but equally make control more challenging.
Adding further complexity is the common use of aerosol-generating equipment such as humidifiers, respiratory therapy machines, nebulisers, and cooling towers, which can all produce tiny water droplets that, if contaminated, can carry Legionella directly into patients’ lungs. Many older healthcare establishments also have outdated plumbing systems, with deadlegs or incomplete schematics, complicating risk assessment and management. The scope for unoccupied rooms or infrequently used outlets brings further risk due to water stagnation, creating ideal conditions and breeding grounds for Legionella growth.
Temperature control
Temperature control can add to the complexity too. Most healthcare providers will use TMVs to enable water to be stored at 60 °C+, which is hot enough to kill Legionella, while being safely delivered at cooler temperatures to outlets. However, this can come as a double-edged sword — since while TMVs are essential for minimising the risk of scalding, they can inadvertently increase the risk of Legionella growth due to the scope for stagnant water and biofilm formation. In this way, TMVs require careful management and maintenance to avoid them becoming part of the Legionella problem. Couple all this with the challenges of constant and variable use, resource constraints, and extensive guidelines, and the result is a clearly arduous task for most healthcare providers.
So, what is to be done? Undoubtedly, more regular monitoring, testing, and disinfection of water systems offers healthcare providers the best possible chance of better detection and protection. However, in our experience most Water Safety Plans are often designed to meet bottom line regulations, rather than to reduce Legionella risks to the absolute minimum, and in some cases may not be comprehensive enough to completely avoid growth and spread of Legionella bacteria.
For example, most healthcare providers still rely solely on the standard lab-culture method — whereby water samples are collected from water systems on site and sent to a UKAS-accredited laboratory which will identify the presence or absence of Legionella — for Legionella testing. However, this approach is timely, cumbersome, and has limitations.
Foremost, most laboratory culture tests take 7-10 days to return results. Yet Legionella can double in a day. This large time lag means increased exposure and risk for healthcare providers and the people they serve. Water samples can also get damaged in the transportation process, potentially killing the Legionella inside, and increasing the risk of a false negative result. Lab culture testing is also unable to detect Viable but Non-Culturable (VBNC) Legionella — which, though a dormant form, can still be incredibly dangerous due to their ability to resuscitate and reinfect a water system — also being able to directly infect human cells, even in their dormant state. The result can be a false sense of security, with the potential for lab results to state a negative outcome when repeated subsequent tests confirm non-conformance.
Arguably then, as Legionella risk evolves, there is a clear case for healthcare establishments to consider including rapid testing as part of the Legionella testing process.
Latest generation of rapid testing kits
Designed to overcome the limitations of traditional Legionella detection, the latest generation of rapid testing kits enable detection in just 25 minutes, and are incredibly accurate at quickly detecting the most common and potentially fatal species of Legionella bacterium — Legionella pneumophila. To confirm its accuracy, we recently invested in an extensive third party study, conducted by California-based CDC ELITE laboratory Chemicals Incorporated (CHEM Inc.) The study, which saw Legionella samples tested using both the traditional lab-culture testing and the Hydrosense PRO rapid testing kit, revealed that our rapid test solution was 100% accurate in identifying both L. pneumophila serogroup 1 and serogroups 2-15 from blind samples, and gave comparable results to the traditional lab culture testing method, but in a much quicker time.
Enabling a rapid response
Detecting Legionella pneumophila so quickly empowers healthcare establishments to react promptly to contamination and take appropriate action, thereby significantly minimising the risk of exposure and human infection. Not only does using this method for routine testing help reduce risk, and minimise potential exposure for hospital patients and other healthcare facility users, but it also offers additional information during the required reviews of the risk assessment. In particularly high-risk environments, such as an intensive care unit or a surgical ward, the reality is that this advanced ability to rapidly detect Legionella could help to save lives.
Technology always moves faster than the law, and it is thus easy to see why — despite such significant growth in Legionella risk, the UK’s Legionella regulations and guidelines — such as The Health and Safety at Work Act 1974, The Control of Substances Hazardous to Health Regulations 2002, and HSE’s ACoP L8 — have remained largely unchanged, and continue to overlook the opportunity to advocate, if not mandate, the additional use of rapid testing technology. Added to this, of course, with the introduction of a new government tasked with tackling huge economic challenges and significant building regulation reforms, it’s unlikely that we will see the introduction of new legislation that specifically addresses the issue of rising Legionella risk any time soon.
For the time being then, the onus remains very much on high-risk environments — and especially healthcare establishments — to look beyond compliance and ensure that they go the extra mile to optimise safety for the people in their care. In most cases, it will always be those early adopters of any emerging trend that gain a marked advantage, and those healthcare providers who act now will be recognised for leading the trajectory toward a much more robust and thorough approach to combating Legionella in the long term.
Beyond regulatory compliance, Legionella control in healthcare is, of course, a moral imperative. Hospitals and other healthcare providers play a critical role in supporting some of society’s most vulnerable individuals, who have placed their trust in taking care of them. These providers thus have a moral duty to go above and beyond to provide a nurturing and safe environment. Failure to do so, and the potential consequences, include serious reputational ramifications, leading to loss of trust from families, employees, and the wider community, and regulatory scrutiny. Amid a growing Legionella risk, taking the opportunity to strengthen control measures demonstrates a commitment to protecting that trust and prioritising patient welfare.
Moreover, in the unfortunate event of a Legionella outbreak, it is important to note the profound impact that it can have on staff — not just in terms of physical stress, but also the emotional toil. At a time when many healthcare settings are facing staffing shortages, an outbreak can overwhelm team members tasked with complex disinfection procedures, medical interventions, and additional support. Elevating the approach to Legionella detection can help to prevent this, contributing to a deeper culture of safety and care.
Safer waters
Looking ahead, those who embrace this shift, at pace and to scale, will play a role in elevating healthcare standards, maintaining a solid reputation, supporting operational efficiency, and safeguarding reputation, all the while helping to render the healthcare experience a safer one for what can already prove an incredibly difficult time in anyone’s life.
Greg Rankin and Hydrosense
Greg Rankin, CEO at Hydrosense, is a seasoned technology product veteran with a deep passion for protecting public health from Legionella bacteria. Since joining Hydrosense as CEO in 2017, he has led its rapid growth, tripling revenue, and spearheading innovation in Legionella rapid testing solutions. Under his leadership, Hydrosense claims to have ‘revolutionised water safety’ – by providing the world’s fastest on-site test for Legionella bacteria.
With decades of technology, marketing, and business development experience, he has held key roles at companies including Oracle, Ingenico, and Metaforic, and at a number of start-ups.
Hydrosense says it is ‘on a mission to make Legionella detection easier, faster, and more effective’ with its rapid Legionella testing solutions. Its Hydrosense PRO range, for example, can detect the presence of Legionella pneumophila serogroups 1-15. It said: “Easy to use, accurate, and with results delivered in just 25 minutes, this means early detection of problems, speedy remedial action, and a reduction in potential exposure and the associated risks.”
References
1 Barlow P. Legionella bug delays £41 m health centre opening. BBC News, South East. 21 February 2025. https://www.bbc.co.uk/news/articles/cr5249pnvl8o
2 Stout J, Yu V. Hospital-acquired Legionnaires’ disease: new developments. Curr Opin Infect Dis 2003; 16(4):337-41.
3 What Types of Facilities Have Legionnaires’ Disease Outbreaks? Legionella Control Systems, Indianapolis. https://tinyurl.com/49cscd64
4 Lettinga KD, Verbon A, Nieuwkerk PT, Jonkers RE, Gersons BPR, Prins JM et al. Health-related quality of life and posttraumatic stress disorder among survivors of an outbreak of Legionnaires’ disease. Clin Infect Dis 2002; Jul 1;35(1):11-7.