, CIC, FAPIC, is an infection prevention (IP) contractor in Western North Carolina. He trained in medical technology and transitioned to IP in 2008. Most of his experience is in acute care hospitals and ambulatory clinics. He is certified in infection control and is a fellow of APIC.

Ivan W. Gowe, MS, MLS(ASCP)CM, CIC, FAPIC 

Teacher with a spray bottle, gloves, and a rag, wiping, cleaning, and disinfecting school desks.

As students return to school from summer break, educators, administrators, and support staff ensure the learning environment is safe from infectious disease outbreaks. From kindergarten classrooms filled with tactile exploration to the close social interaction in high schools, where students share devices and meals during and after school, each grade presents its own opportunities. The following evidence‑based practices offer a strong foundation for actionable prevention.

Consistent, proper handwashing remains the most effective strategy for reducing gastrointestinal and respiratory illnesses in school settings. The CDC emphasizes teaching and reinforcing washing with soap and water for at least 20 seconds, building hygiene reminders directly into daily routines such as after bathroom breaks, before lunch, and after recess.

 Younger students and those with special needs will benefit from coaching and supervision to ensure thorough hand washing and complete drying, an often-overlooked step because germs spread more easily on wet surfaces.

 Hand sanitizer containing at least 60% alcohol should supplement, not replace, soap and water, especially when sinks are available.

Routine cleaning and disinfection of surfaces is essential for preventing the spread of infections. Daily cleaning of desks, chairs, doorknobs, faucets, electronics, and other frequently touched and shared items is recommended. Increase cleaning frequency during periods of elevated illness, like cold and flu season.

 Electronic devices are an area of particular concern in modern classrooms. They should be cleaned and disinfected using Environmental Protection Agency (EPA)-approved products compatible with keyboards, touchscreens, and tablets.

 Compatibility information can be obtained from the equipment manufacturer.

During cold and flu season, improving air quality can meaningfully reduce the risk of respiratory infection outbreaks; the goal is to dilute the room air with as much outside air as possible. Improve ventilation by optimizing HVAC function, opening classroom and bus windows when safe, and using fan‑assisted airflow. These practices dilute airborne particles and reduce the risk of respiratory transmission.

 Air ducts, intake, and exhaust grates must be kept clean and unobstructed.

Portable air cleaners and air sanitizing sprays can supplement the HVAC system when used according to the manufacturer’s instructions.

 However, their mechanisms of action have inherent shortcomings; many lack rigorous testing and validation metrics. They should not replace core strategies such as ventilation and surface cleaning.

The early detection of outbreaks relies on monitoring student (and staff) absenteeism. Research has shown that changes in absenteeism related to respiratory symptoms can correlate with community influenza trends.

 Schools should work closely with county health departments to interpret illness patterns when gastrointestinal or respiratory complaints are clustering.

CDC guidance recommends embedding an infectious disease section within the school’s Emergency Operations Plan. This section should outline protocols for monitoring illnesses, communicating with families, and activating enhanced preventive measures or temporary closure considerations during outbreaks.

It is challenging to balance public health priorities, educational needs, and parental satisfaction, particularly when deciding whether a student should be sent home. CDC recommends excluding students and staff who exhibit fever, repeated vomiting, significant diarrhea, draining wounds, or worsening respiratory symptoms not attributable to allergies.

 Schools can expect some level of mild illness throughout the year; however, symptoms that impair participation or present infection risk justify time at home. Return-to-school criteria should be clearly communicated to families and staff and enforced to maintain consistency and reduce confusion. Schools must be staffed to support families facing childcare challenges and to help students maintain educational continuity when illness keeps them at home. Without such programs in place, students will frequently show up sick, leading to transmission and outbreaks.

Vaccination remains one of the most powerful preventive tools in pediatric health. It reduces illness, decreases absenteeism, and lowers the likelihood of outbreak-related closures.

 State laws mandate vaccinations for K–12 students across public and private schools, with medical exemptions universally available and religious or philosophical exemptions permitted in some jurisdictions.

 Schools should ensure families understand these requirements and the process for submitting necessary documentation.

We are experiencing an ongoing decline in routine childhood vaccination, particularly after the COVID‑19 pandemic. Vaccine hesitancy is primarily driven by safety concerns/misinformation, philosophical beliefs, and lack of access in low-income, uninsured, or minority households. These factors have left students more vulnerable to a slew of vaccine‑preventable diseases.

 We see the effects of this drop in vaccine coverage in outbreaks of diseases like measles and whooping cough.

Food Safety in School Meals and Packed Lunches

Outbreak prevention extends to the realm of food safety. Millions of meals are served through school nutrition programs each year, creating opportunities for foodborne illness if proper controls are not followed.

 USDA guidance recommends building a food safety culture rooted in hazard analysis and critical control point principles. Schools must implement food safety programs covering every location where food is stored, prepared, or served.

Creating a culture of food safety requires engaging teachers, administrators, parents, and students

. Parents who send packed lunches should be reminded to use ice packs and insulated containers to maintain safe temperatures until mealtime. When possible, students may need access to microwave ovens to reheat food. School cafeterias, meanwhile, must ensure proper temperature control, safe storage, and adherence to hygiene protocols that prevent cross‑contamination.

Preventing outbreaks in K–12 schools relies on a comprehensive strategy grounded in evidence‑based health practices, consistent communication, and strong collaboration across the school community. Educators, administrators, and support staff should model the healthy behaviors they expect from students, reinforcing the value of cleanliness, personal responsibility, and empathy for peers’ health. Encouraging students not to share drinks or food, teaching proper cough etiquette, and reminding them to speak up when they feel unwell all contribute to a safer environment.

By prioritizing hand hygiene, maintaining clean environments, improving air quality, monitoring illnesses, enforcing vaccination requirements, supporting food safety, and fostering responsible student behavior, create healthier learning spaces where children can thrive academically and socially.

About Hand Hygiene in Schools and Early Care and Education Settings

. CDC. Published October 25, 2024. Accessed July 20, 2026. 

https://www.cdc.gov/clean-hands/prevention/about-hand-hygiene-in-schools-and-early-care-and-education-settings.html

Everyday Actions for Schools to Prevent and Control the Spread of Infections

. CDC. Published May 12, 2026. Accessed July 20, 2026. 

https://www.cdc.gov/children-and-school-preparedness/infection-prevention/actions.html

Cleaning and Disinfecting in School Classrooms

. Published August 7, 2020. CDC. Accessed July 2026. 

https://stacks.cdc.gov/view/cdc/91746/cdc_91746_DS1.pdf

Take Action to Improve Indoor Air Quality in Schools

. United States Environmental Protection Agency. Accessed July 20, 2026. 

https://www.epa.gov/iaq-schools/take-action-improve-indoor-air-quality-schools

EPA Registers Air Sanitizer for Residential and Commercial Use Against Influenza and Coronavirus

. United States Environmental Protection Agency. Updated March 23, 2026. Accessed July 20, 2026. 

https://www.epa.gov/pesticides/epa-registers-air-sanitizer-residential-and-commercial-use-against-influenza-and

Residential Air Cleaners: A Technical Summary, 3rd ed. United States Environmental Protection Agency. Published July 2018. Accessed July 20, 2026. 

https://www.epa.gov/sites/default/files/2018-07/documents/residential_air_cleaners_-_a_technical_summary_3rd_edition.pdf

Temte J, Barlow S; yenlik Zheteyeva, et al. Cause-Specific School Absenteeism Monitoring Identifies Community Influenza Outbreaks. 

. 2018;10(1):e103. Published 2018 May 30. Accessed July 20, 2026. doi:10.5210/ojphi.v10i1.8757

Preventing Spread of Infections in K‑12 Schools

https://www.cdc.gov/children-and-school-preparedness/infection-prevention/index.html

. CDC. Published October 28, 2024. Accessed July 20, 2026. 

https://www.cdc.gov/children-and-school-preparedness/php/interventions/when-students-or-staff-are-sick.html

https://www.cdc.gov/vaccines/partners/downloads/cta-school-health-partners.pdf

State School Immunization Requirements and Vaccine Exemption Laws

. CDC. Published February 2022. Accessed July 20, 2026. 

https://www.cdc.gov/phlp/docs/school-vaccinations.pdf

McKee C, Bohannon K. Exploring the Reasons Behind Parental Refusal of Vaccines. 

. 2016;21(2):104-109. doi:10.5863/1551-6776-21.2.104

Food Safe Schools: Creating a Culture of Food Safety

. Food and Nutrition Administration. Accessed July 2026. 

https://www.fna.usda.gov/fs/foodsafeschools

Guidelines on Developing a School Food Safety Program Based on HACCP Principles

. United States Department of Agriculture. Published June 2005. Accessed July 20, 2026. 

https://www.usda.gov/sites/default/files/guidance-documents/fns.foodsafety-HACCPguidance.pdf

Creating a Culture of Food Safety & Using the Action Guide

. Food and Nutrition Administration. Updated January 7, 2025. Accessed July 20, 2026. 

https://www.fna.usda.gov/fs/foodsafeschools/how

Articles

Evidence-based guidance outlines practical strategies for preventing infectious disease outbreaks in K–12 schools through hand hygiene, environmental cleaning, ventilation, illness monitoring, vaccination, and food safety.

Back-to-School Infection Prevention: Evidence-Based Strategies to Keep K–12 Students Healthy

Infection prevention is an essential health care domain. The pandemic put our work on the main stage for a while, and many people are looking for a way into this crucial career. Sadly, the professionals who help bedside staff safeguard patients from avoidable harm work in a landscape shaped by high regulatory expectations, performance pressure, and a shortage of human and other resources.

Where there is ruin, there is hope for a treasure

 captures the spirit of a new podcast dedicated to exploring staffing in infection control and patient safety, especially for professionals whose expertise is not defined by a nursing license.

 is the hopeful treasure borne of a phase of ruin in my life. I brought all my experience and credentials to bear on infection preventionist (IP) job openings, but I found myself wanting for a lack of nursing credentials. There could be many other reasons I was not selected; I know I am not a perfect candidate. However, the few who provided feedback preferred nurses.

In retrospect, I wish I could have asked why. I shared my pain with my friend. Her LinkedIn post and article were very well received by others in similar situations. There was a swell of conversation on the topic, and it sparked something in me.

Although nursing has historically shaped the infection prevention field, the modern IP team is intentionally multidisciplinary. According to the Centers for Medicare & Medicaid Services (CMS), facilities must designate 1 or more individuals as IPs responsible for the infection prevention and control program. CMS defines the IP as an individual with primary training in nursing, medical technology, microbiology, epidemiology, or another related field, who is qualified by education, training, experience, or certification, and has completed specialized training in infection prevention and control.

 The CDC uses a similar definition in their “Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings document,”

 another foundational document in IP practice. These definitions make it clear that infection prevention is not intended to be a discipline exclusively for nurses. Other backgrounds are admissible, especially if they have training in infection prevention and control. This CMS definition is adapted by The Joint Commission, Det Norske Veritas (DNV), Quad A, and other accreditation agencies.

However, the job market tells a very different story. Many IP job postings continue to require or prefer a nursing license, despite CMS’s multidisciplinary definition. This hiring pattern persists even as the field undergoes significant demographic and educational shifts. It is slow to change even in the face of staffing shortages, an increase in interest, and an increase in infection control-specific training and certification options.

The most comprehensive data on the IP workforce comes from the APIC MegaSurvey, published in the 

. The 2025 survey revealed that while 82% of IPs had a nursing background in both 2015 and 2020, that proportion dropped to 68% in 2025.

 This decline reflects a growing influx of professionals from microbiology, public health, epidemiology, and laboratory science—fields explicitly recognized by CMS as appropriate for the IP role.

At the same time, the field faces profound staffing challenges. APIC’s staffing research shows that nearly 80% of hospitals operate with lower-than-expected infection prevention staffing levels, creating vulnerabilities in prevention, surveillance, outbreak response, and staff education.

 When organizations restrict hiring to nurses alone, they worsen these shortages, especially when facilities are also struggling with nursing workforce constraints.

This is where the podcast enters the conversation. It is a space for discussion about IP staffing, nursing preference, and how people are working through that impediment. The 

 podcast elevates the full spectrum of infection prevention professionals - nurses, laboratorians, epidemiologists, microbiologists, public health practitioners, sterile processing staff, physicians, and others who contribute to patient safety every day. It explores the regulatory landscape, workforce challenges, and the lived experiences of IPs who entered the field through nontraditional pathways. It also examines how organizations can align their hiring practices with CMS’s multidisciplinary definition and expand the pipeline of qualified (or trainable) professionals.

Psychologist Viktor Frankl is attributed with the statement, 

What is to give light must endure burning.

 I think this resonates deeply with the infection prevention community. IPs endure the “burning” of surveillance, reporting, surveys, regulatory scrutiny, and the emotional weight of preventing harm in complex environments. Yet they continue to give light by showing up, desiring to protect patients, guide staff, and shape safer health care systems.

On a personal level, this quote represents my desire to improve our profession. The 

 podcast shines some light on the realities of IPs’ career paths and how we can make things better for the next generation. Episodes feature conversations about:

Innovations in training, onboarding, and professional development

How CMS regulations should shape hiring and staffing models

Why multidisciplinary expertise strengthens patient safety

The alignment of IP competencies and existing academic curricula

The human beings that work in infection prevention and quality and patient safety departments

Rumi’s reminder that treasure can be found in ruin speaks to the opportunity before us. The challenges in infection prevention, including staffing shortages, burnout, and regulatory complexity, are devastating. But within them lies the potential to rebuild the field into one that is more inclusive, more resilient, and better aligned with the diverse expertise required to collaborate with diverse health care facility departments to keep staff and patients safe.

 Translated by Barks, C. HarperCollins, 1995.

Michigan Safety Conference. Podcasts. Accessed May 12, 2026. 

https://www.healthcaresafetyspectrum.org/

42 CFR § 483.80—Infection control. Electronic Code of Federal Regulations. Centers for Medicare & Medicaid Services. Accessed May 12, 2026. 

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.80

Infection Prevention and Control: Core Practices.

 CDC. US Department of Health and Human Services; 2023.

Davis J, et al. A decade of change: Comparative findings from the 2015, 2020, and 2025 APIC MegaSurveys on the infection prevention workforce. 

Association for Professionals in Infection Control and Epidemiology. 

Infection Preventionist Staffing Challenges and Recommendations.

Occupational Outlook Handbook: Epidemiologists; Medical and Clinical Laboratory Technologists; Registered Nurses.

 US Department of Labor; 2024. Accessed April 20, 2026.

Frankl VE. “What is to give light must endure burning.” Commonly attributed quotation cited in logotherapy literature.

A new podcast, The Safety Spectrum, explores workforce challenges in infection prevention, particularly the barriers faced by qualified professionals without nursing credentials, despite CMS and other regulatory bodies recognizing infection prevention as a multidisciplinary field. The article highlights ongoing staffing shortages, evolving workforce demographics, and the need for more inclusive hiring practices to strengthen patient safety and rebuild the infection prevention profession.

 Where There Is Ruin, There Is Hope: Rebuilding Infection Prevention Staffing Based on Regulatory Definitions

Stylized hands colored purple with pathogens on them.

(Cover image by Chrissy Bolton/MJH Life Sciences using AI)

I had been in infection prevention and control (IPC) for close to a decade before I heard and recognized that health care personnel are not out to break our IPC rules. Sadly, this was my working assumption for years! A health care worker who misses a hand hygiene opportunity is not trying to hurt their patient or make trouble for the IPC department. It is either an honest oversight, they had something more pressing to attend to, or our process and set up is not conducive to them doing the right thing. I exaggerated on this epiphany in my new employee orientation by asking, "How many of you have ever woken up thinking, 'I really want to harm patients when I get to work'?" I would jokingly say that if anyone raised their hand, I would report them to Human Resources for being a Disney villain. We all laughed because that was a poor assumption.

Most health care workers cite a desire to help people as their reason for choosing this line of work.

 When I learned this, I was forced to take a second look at drivers of adherence. For a long time and in many facilities, infection preventionists have been dubbed hand-washing enforcers. We are greeted with phrases like, “What have we done this time?” Some staff go as far as hiding because of our well-earned reputation of auditing and chastising.

As behavioral science has progressed and we all recognize the need for psychological safety in our facilities, a growing body of evidence suggests that our methods do not drive long-term behavior change. A new paradigm is emerging—one that emphasizes psychological safety, peer coaching, and behavioral science to foster a culture of accountability and continuous improvement. As the adage goes, how we got here will not get us there. I want to go there, where staff do not hide from me when I come into their department, where I am greeted with the joy befitting a good partner and colleague, where frontline staff are equipped with the tools and reasons for them to follow their calling and take good care of people. Let us go there, shall we?

For decades, hand hygiene and other patient safety monitoring programs have followed this pattern: observing health care workers from a distance, recording, reporting, and correcting nonadherence. We rely on unfamiliar observers who are perceived as intruders within the department. This creates a culture of fear, mistrust, and eventually resistance. Staff feel scrutinized rather than supported. This leads to:

Underreporting of nonadherence and safety events to save face. “We did not tell you because we did not want to get in trouble.”

Adherence only while under surveillance (Hawthorne effect): “Everyone wash your hands; IPC is here!”

Gaming the system: “We recorded hand hygiene every time a team member left the bathroom.”

Disengagement from infection prevention efforts: “They will come and tell us when we do something wrong.”

Such methods yield short-lived gains. IPC staff know the frustration of returning to the same departments and addressing the same issues week after week, month after month, and year after year. We spend so much effort relaunching hand hygiene programs, injecting excitement and engagement into a practice as basic as wearing a seatbelt. As IPC staff review these results against our efforts, we may erroneously conclude that our teammates do not care about patient and staff safety.

Research has shown that such approaches are not sustainable. A systematic review by Erasmus et al. found that despite extensive monitoring, the median hand hygiene adherence rate in 96 empirical studies was 40%, and lower in intensive care units.

 Despite all this work, there is little evidence of sustained improvement over time.

There are also very few studies that look at behavioral determinants.

Psychological Safety as a Foundation for Change

Psychological safety, defined as the belief that one can speak up, ask questions, and admit mistakes without fear of punishment, is a cornerstone of high-performing health care teams. When staff feel safe, they are more likely to engage in open dialogue, seek feedback, and adopt new behaviors.

 Edmondson’s seminal work on psychological safety highlights its role in fostering learning and innovation in complex environments like health care.

 In the context of hand hygiene, psychological safety enables frontline workers to discuss errors and barriers without fear. This leads to sharing observations, cocreating solutions with other departments, and actual, intentional teamwork.

Moore and colleagues describe coaching as a method to “plant the seeds of change” by addressing the underlying reasons for nonadherence, such as workflow disruptions, forgetfulness, or unclear expectations.

 This approach aligns with behavioral science principles, including habit formation, social reinforcement, and intrinsic motivation.

Coaching offers a powerful alternative to traditional adherence enforcement. Rather than punishing nonadherence, coaching focuses on real-time, face-to-face, empathetic feedback that helps individuals reflect on their behavior and adjust. Peer-to-peer coaching leverages the influence of trusted colleagues to reinforce norms and build accountability.

Coaching works best when there is familiarity within and across teams. Familiarity builds trust and fosters psychological safety.

 In the field, this looks like auditors and observers being transparent about their tasks, being inquisitive about the processes they are observing, and providing positive and negative feedback.

The Hawthorne effect is the enemy of transparency in observations. We are concerned about behavioral changes when staff perceive they are being observed. This is important in study design, but in practice, most patient safety monitoring programs focus on improving patient outcomes rather than on study design. If leveraging the Hawthorne effect improves health care safety outcomes, then why not?

The Hawthorne effect is often cited, but I fear it is not well understood. When considering the Hawthorne effect, keep these characteristics in mind:

The size and type of behavioral change depend on how long the subject notices the observer.

Behavior change occurs only when individuals are aware of being observed.

Behavior change has a performance ceiling; even when observed, errors will still occur.

Behavior changes wane with time as subjects become accustomed to observers (habituation).

Several health care organizations have successfully implemented coaching-based hand hygiene interventions:

At UNC Medical Center, Sickbert-Bennett et al. piloted a peer observation program using a mobile app that allowed staff to provide real-time feedback on hand hygiene practices. Over 3 years, the program led to significant improvements in adherence and fostered a culture of mutual accountability.

 The strength of this approach is familiarity and its emphasis on providing positive feedback.

A London, England National Health Service Trust codesigned a behavioral intervention with frontline staff, emphasizing shared ownership of hand hygiene goals. The initiative resulted in improved adherence and greater staff engagement.

 The strength of this approach is intentional teamwork.

These case studies demonstrate that psychological safety can affect hand hygiene behavior, enhance team dynamics, and improve patient safety culture.

Many facilities are transitioning to electronic hand hygiene monitoring. Choose platforms with the closest-to-real-time feedback, eg, badge or dispenser alerts and messages, to impact behavior change. They provide the most opportunities for coaching. Platforms with aggregated or no feedback work best when the goal is data gathering and research. However, they can be integrated into a coaching program.

Transitioning to a coaching model requires planning and interdisciplinary leadership support. The approach hinges on psychological safety as an organizational and departmental characteristic. At the organizational level, safety and continuous improvement, as elements of organizational culture, are key drivers of psychological safety. At the team level, leadership integrity, status inclusiveness, change orientation, and leader and peer support are required.

 In the absence of these elements, the interventions will have limited effectiveness.

Aligning leadership messaging with the values of trust, learning, and shared responsibility.

Leveraging tools that facilitate data collection and real-time coaching.

Creating safe spaces for feedback and reflection, free from judgment or hierarchy.

Training peer coaches in effective communication, motivational interviewing, and feedback delivery.

Be transparent with the team about their process and outcome measures.

Cultural resistance, time constraints, and lack of resources will affect program success. Moreover, it requires a shift from measuring simple adherence metrics to more nuanced indicators of behavior change and team engagement. As mentioned earlier, all this hinges on psychological safety as a foundation for organizational change.

The future of hand hygiene lies not in surveillance tools but in programs that support team members. By focusing on behavioral change and psychological safety, health care organizations can move beyond burdensome programs and adherence metrics to a place where hand hygiene is a shared, valued, and sustained commitment.

Rosa WE, Roberts KE, Schlak AE, et al. The critical need for a meaning-centered team-level intervention to address health care provider distress now. 

. 2022;19(13):7801. doi:10.3390/ijerph19137801

Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on adherence with hand hygiene guidelines in hospital care. 

Gould DJ, Chudleigh JH, Moralejo D, Drey N. Interventions to improve hand hygiene adherence in patient care. 

. 2007;(2):CD005186. doi:10.1002/14651858.CD005186.pub2

O’Donovan R, McAuliffe E. A systematic review of factors that enable psychological safety in healthcare teams. 

. 2020;32(4):240-250. doi:10.1093/intqhc/mzaa025

Edmondson AC. Psychological safety and learning behavior in work teams. 

. 1999;44(2):350-383. doi:10.2307/2666999

Moore D. Plant the seeds of change with just-in-time coaching. 

. Published 2021. Accessed January 2026. 

https://www.infectioncontroltoday.com/view/plant-the-seeds-of-change-with-just-in-time-coaching

Chen LF, Vander Weg MW, Hofmann DA, Reisinger HS. The Hawthorne effect in infection prevention and epidemiology. 

. 2015;36(12):1444-1450. doi:10.1017/ice.2015.216

Sickbert-Bennett EE, DiBiase LM, Willis TM, et al. The holy grail of hand hygiene adherence: Just-in-time coaching. 

. 2019;47(5):531-536. doi:10.1016/j.ajic.2018.10.005

Price L, MacDonald J, Gozdzielewska L, et al. A helping hand: Co-designing hand hygiene interventions with healthcare workers. 

. 2024;19(1):e0287654. doi:10.1371/journal.pone.0287654

How IPC programs are shifting away from punitive audits toward human-centered coaching models. Include peer-to-peer observation, quiet feedback moments, and psychological safety as drivers of long-term adherence.

From Policing to Coaching: Rethinking Hand Hygiene Enforcement

Legionnaires’ disease bacteria illustration. Close-up view of bacteria under a microscope. Created by AI.

Legionnaire’s Disease (LD) is a potentially life-threatening pneumonia caused by the 

 bacteria. The infection is also known as Legionnaires’ pneumonia, legionellosis, or legion fever. The same microbe causes a milder, nonpneumonic infection called Pontiac fever or nonpneumonic legionellosis.

The disease was first identified after a July 1976 American Legion convention at the Bellevue-Stratford Hotel in Philadelphia, when over 200 attendees developed pneumonia and 34 died. The CDC launched an investigation, which led to the identification of 

LD is spread by inhalation of aerosolized droplets of water that are contaminated by 

 Sources include air conditioning systems, showers, nebulizers, hot tubs, and decorative water features. Infection requires the inhalation or aspiration of these droplets into the lungs.

People at increased risk of infection are adults over 50 years, current or former smokers, people with a weakened immune system, diabetics, and people with chronic lung or kidney diseases, characteristics that describe most residents of long-term care facilities. The average death rate in health care-associated cases is around 25%.

 Therefore, long-term care facilities must have adequate and effective prevention and control measures for LD for the safety of their residents.

In response to an increase in cases, most of them occurring in long-term care facilities, the American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) developed an industry standard for the development and implementation of water management programs in 2015. CDC and its partners developed a toolkit for the implementation of the ASHRAE standard in 2016, and in 2017, the Centers for Medicare & Medicaid Services (CMS) released a requirement for facilities to prevent Legionella infections by developing water management policies and procedures.

Many resources and toolkits are available to aid the development of a water management plan:

Water Management Program Toolkit, CDC | 

Water Management Program Template, 2018, NEHA | 

Standard 188 – Legionellosis Risk Management, ASHRAE | 

Water Management in Health Care Facilities, ASHE | 

Components of an effective Water Management Program (WMP)

The first piece of an effective water management program (WMP) is the development of a team. Infection preventionists are proficient at many things; however, we must engage other departments and show how infection prevention is everyone’s business. This team should be granted authority to intervene in any water-related issues that arise in the facility.

A water management team should include the following, when applicable: Infection prevention, facility or building management, maintenance, environmental services (EVS), safety officer, accreditation, risk and quality management, equipment suppliers, consultants (eg, water treatment and testing), industrial hygienist, microbiologist, and public health (state or local).

The team will develop, monitor, and document program requirements, performance metrics, and report to committees like the infection prevention and control committee and quality and performance improvement (QAPI). The team should meet at least annually to review and update the plan, but more frequently in response to incidents.

It is common to experience tension over the ownership of the WMP. It is infection-related, but most of the work is done by the maintenance or the environment of care team. Any of these departments' team members may lead the water management team. The responsibility does not lie with one department. An effective WMP requires collaboration between IP and various departments within the Environment of Care (ie, EVS, maintenance, building managers, etc.).

The WMP team must start by developing a description of the facility’s entire water system from initial supply, distribution, and heating, to the sewer. The description must include all buildings and equipment that aerosolize water droplets. This can be accomplished by prose, tables, or diagrams.

 thrives in water temperature ranges of 77°F to 113°F (25°C to 45°C); therefore, the next step is to identify where those temperatures can be attained, where the microbes can grow. Other hazards include water stagnation, aerosolization, and the absence of disinfection.

Legionnaires’ disease remains a deadly but preventable threat in health care, especially in long-term care. Every facility needs a strong, team-driven water management plan because prevention starts at the tap. This article explains what is needed to write one. 

Ivan W. Gowe, MS, MLS(ASCP)CM, CIC, FAPIC

Articles

Back-to-School Infection Prevention: Evidence-Based Strategies to Keep K–12 Students Healthy

Where There Is Ruin, There Is Hope: Rebuilding Infection Prevention Staffing Based on Regulatory Definitions

From Policing to Coaching: Rethinking Hand Hygiene Enforcement

Writing an effective Water Management Program for Long Term Care Facilities