Water Conditioning & Purification Magazine

The Nexus between Tap Water and Healthcare-Associated Infections

By Kelly A. Reynolds, MSPH, PhD

Healthcare Associated Infections (HAIs) claim the lives of tens of thousands in the US each year. Holistic approaches focus on four major pathogen transmission routes, or systems, as part of the overall healthcare setting: surfaces, person-to-person, water and air. After several outbreaks of Legionella and other waterborne bacteria, more emphasis is being placed on the importance of water quality during premise-plumbing distribution. Two upcoming conferences provide the opportunity for open discussion with a variety of stakeholders in the water treatment industry with the goal of developing practical solutions for the growing problem of emerging waterborne infections in hospitals.

Interdependent variables
If you had to pick the most significant public health advancement of all time, what would you choose? Usually hand hygiene, water disinfection or vaccine development are high on the list. In fact, interventions that have had the greatest impact on life expectancy are associated with environmental health controls (i.e., sanitation and hygiene). Environmental health controls are estimated to have added 25 years to the average life expectancy in the US, increasing from around 48 to nearly 78 years today. The additional five-year gain is often attributed to medications and drug interventions.

Advancements in public health rarely occur in a vacuum. Rather, there is an assumed interdependence among effect-variables that drive their success forward. The hospital environment is a great example of this interdependence effect, where the two primary infection prevention methods include hand hygiene and surface disinfection. One without the other, however, leads to a cycle of cross-contamination between surfaces and hands, diminishing the impact of any single intervention. Today’s complex problems require a systems approach. While waterborne infections are not the primary cause of HAIs, they are a part of the pathogen transmission system and may be the most easily monitored and controlled.

Water and the healthcare system
Worldwide and in the US, new diseases continue to emerge. The World Health Organization reports a rapid rate of emerging pathogens, with 40 new pathogens identified in the last four decades.1 Many pathogens have recently emerged as antibiotic-resistant strains, which make treatment difficult or impossible. Vulnerable populations, such as hospital patients, are at greatest risk for infection and adverse outcomes related to emerging and antibiotic-resistant organisms. According to the CDC, one in 31 hospital patients are burdened by at least one HAI on any given day. That equates to up to two million patients per year in the US, with direct cost burdens of between $28 billion to $45 billion per year.2 Experts estimate that about 72,000 of these patients will die from their HAI while in the hospital. Although surgical site HAIs are slowly trending downward in the US, documented waterborne disease related to common HAIs, such as Legionella, are increasing. While water is a component of the larger hospital systems targeted for controlling HAIs (i.e., hand hygiene, air and surface disinfection, food safety, quality care delivery and more), water is also a system with primary components, including source, distribution, processing (i.e., heating, cooling) and use.

The Healthcare Infection Transmission Systems (HITS) consortium
Recently, several initiatives have launched in an effort to bring together multiple disciplines to tackle the complex problem of HAIs. The HITS consortium is a not-for-profit organization serving the field of infection control and prevention. HITS takes a holistic perspective to targeting healthcare-associated infections by including multiple disciplines in the conversation, including infection prevention, environmental services, construction and renovation, facilities management and engineering, along with research scientists and industry experts. HITS focuses on the major avenues for pathogen transmission in hospitals: hands, surfaces, water and air, while providing the necessary, cross-disciplinary platform to share knowledge and engage in HAI prevention research.

HITS began in 2016 with a small group of volunteer experts from academia, industry and not-for-profit organizations who gather to strategize about best practices for HAI prevention using a systems approach. These stakeholders in HAI prevention promoted a ‘boots on the ground’ approach to improve current infection control solutions using a more holistic approach. Meeting goals included:

  • Communicating current infection control challenges
  • Gaining an understanding of barriers by incorporating the experiences of professionals across disciplines
  • Identifying research gaps that are needed for data-driven policy changes
  • Assembling task groups to address identified pressing needs for the healthcare ecosystem and initiate appropriate research

The first conference in 2017 was held at NSF International headquarters in Ann Arbor, MI, followed by a sold-out second year in Nashville, TN in 2018. Now in its third year, HITS is hosting a conference in Buffalo, NY, August 6-8 with a major focus on water quality, premise-plumbing risks and Legionella prevention. The HITS organizing committee has assembled world experts and key opinion leaders to share their knowledge and expertise. More information can be found at the website: https://hitsconsortium.org/

HITS 2019 offers a unique forum for the exchange of knowledge and experience in the prevention of healthcare-associated infections and promoting hospital health. Attendees work together to understand and prevent the transmission of pathogens throughout the hospital facility, through a collaborative effort that includes engaging in applied research. Poster sessions, workshop breakout sessions and new product forums are conference highlights.

After the conference, members have the opportunity to become involved in one of the many ongoing work groups conducting research around pathogen transmission in healthcare. This unique multimodal event provides a platform for multidisciplinary approaches to identifying research needs and translating research into practice using creative, innovative and holistic system approaches.

NSF International and NEHA host a Legionella conference
Another key conference in 2019 is being hosted by NSF International, in partnership with the National Environmental Health Association (NEHA). Now in its second year, this event continues to educate stakeholders and lead efforts in promoting a systems approach to managing Legionella and other pathogens in building water systems. In 2018, with support from the National Science Foundation, NSF International hosted the first meeting that brought together stakeholders from academia, government, facilities management, plumbing, healthcare, insurance and regulatory industries to plan how to utilize a collective, systems approach to reach targeted public health and sustainability goals and reduce waterborne illnesses.

The 2019 conference, titled Legionella 2019: Building water systems- sustainability and public health nexus, will take place September 11-13 in Los Angeles, CA. Topics include criminal liability perspectives for facilities, engineering gaps in water distribution, occurrence of contamination and the use of POU devices as part of a multifaceted strategy against waterborne HAIs, among other topics. The agenda of the NSF/NEHA conference clearly demonstrates a systems approach in addressing issues of water and energy conservation in balance with microbial controls and risk mitigation. More information can be found on NSF International’s website: http://www.nsf.org/newsroom/legionella-2019-building-water-systems-sustainability-public-health-nexus

Invitation to the POU industry
Both the HITS and NSF/NEHA conferences provide ample opportunities, through panel discussions, breakout groups and continuing work groups, for attendees to be a part of the conversation, offer new perspectives and drive future research, policy and educational objectives for the water treatment field.

The POU industry is invited to engage and promote their key role as part of a systems approach to controlling Legionella and other emerging waterborne pathogens. Few studies have been conducted validating the use, effectiveness or cost-benefit of POU devices in healthcare or other large facility (i.e., hotel) settings. More information is needed on commercial applications of POU systems but advocates for the industry are needed at events like the HITS and NSF/NEHA conferences to share their unique perspectives.


  1. WHO. “Global public health threats in the 21st century.” WHO. https://www.who.int/whr/2007/overview/en/index1.html. Published 2013. Accessed May 20, 2019.
  2. Stone, P.W. “Economic burden of healthcare-associated infections: an American perspective.” Expert Rev Pharmacoecon Outcomes Res. 2009;9(5):417-422. doi:10.1586/erp.09.53

About the author
Dr. Kelly A. Reynolds is a University of Arizona Professor at the College of Public Health; Chair of Community, Environment and Policy; Program Director of Environmental Health Sciences and Director of Environment, Exposure Science and Risk Assessment Center (ESRAC). She holds a Master of Science Degree in public health (MSPH) from the University of South Florida and a doctorate in microbiology from the University of Arizona. Reynolds is WC&P’s Public Health Editor and a former member of the Technical Review Committee. She can be reached via email at reynolds@u.arizona.edu

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