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Legionnaires’ disease in LTC facilities: A hidden threat

June 11, 2014
by By Yusen E. Lin, PhD, MBA, and Victor L. Yu, MD
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Proposed standard recommends stronger safeguards
Legionella pneumophila; Click on image to see photos of authors.

In the summer of 2013, the Wesley Ridge Retirement Community in Reynoldsburg, Ohio, experienced the largest and deadliest Legionnaires’ disease outbreak in state history. The assisted- and independent-living facility saw six people die and another 33 become seriously ill. The victims ranged in age from 63 to 99 and included residents, visitors and one employee.

For most people, Legionnaires’ disease is something from the history books, a vague memory of Philadelphia conventioneers falling ill in the 1970s. In fact, outbreaks of this often-fatal form of pneumonia, including in long-term-care (LTC) facilities, have been increasing for several years in the United States. In just the past three years, nursing home and senior living outbreaks have occurred in Baltimore; Pittsburgh; Cleveland; Clearwater, Fla.; Jacksonville, Fla.; and Florence, Ala. The worst outbreak in an LTC facility in North America occurred in 2005 at the Seven Oaks Home for the Aged in Toronto, Ontario, where 23 residents died and 112 other people fell ill.

A little background

Legionnaires’ disease—clinically known as legionellosis—is a form of pneumonia caused by waterborne bacteria of the genus Legionella. It carries a mortality rate of 40 percent when acquired in hospitals.

More than 50 species and subspecies of Legionella exist, several of which can infect people. By far the most common is Legionella pneumophila serogroup 1. The bacteria are ubiquitous and usually harmless in the environment, but they easily can grow in warm, stagnant water. In certain circumstances, especially in institutions housing the elderly or in those with chronic illness, Legionella can multiply and cause pneumonia when people aspirate tiny particles while drinking water or showering.

Since 2001, Centers for Disease Control and Prevention (CDC) surveillance reports have stated that Legionella is the single most commonly reported pathogen associated with drinking water outbreaks in the United States. Voluntarily reported cases of Legionnaires’ disease tripled from 2000 to 2009, to 3,522 annually. This amount, however, is now known to be a vast underestimate, and some estimates of incidence exceed 10,000 cases per year. As many as 70 percent of all water systems in buildings taller than three stories are contaminated with Legionella. Because it takes specialized laboratory testing to diagnose it, the disease is severely underdiagnosed in long-term care.

Special concerns for senior living

The increase in cases of Legionnaires’ disease is of particular concern for owners and managers of LTC facilities. Although anyone can become infected under certain circumstances, Legionnaires’ disease principally affects those who are susceptible due to age, illness or compromised immune systems.

Outbreaks usually are followed by lengthy, costly litigation. The aforementioned Toronto outbreak, for instance, resulted in a $600 million class action lawsuit. Under the right circumstances—detectable contamination of the water source, the right species of Legionella, a susceptible individual and sufficient intensity of exposure—victims of Legionnaires’ disease easily can establish the basis for a valid claim, according to Russell Nassof, JD, founder of RiskNomics, a Scottsdale, Ariz.-based risk management assessment firm and an expert in Legionella litigation. Negligence can be alleged if a responsible party “knew or should have known” that a problem existed with the water and failed to maintain and clean up the system, resulting in punitive damages, Nassof says.

The need to take action likely is soon to be a part of building codes. In mid-May, ASHRAE (formerly the American Society of Heating, Refrigerating and Air-Conditioning Engineers) announced the impending fourth public review of a draft of ASHRAE Standard 188P, Legionellosis: Risk Management for Building Water Systems. The organization says 188P would be the first set of standardized requirements specific to the building industry for management of the risks associated with amplified growth of and exposure to Legionella. The latest draft, which is expected to be approved and made available this summer, will recommend that nursing home facility managers implement stronger safeguards through risk assessment and risk management practices. ASHRAE is not indicating when it will finalize the standard, but finalized ASHRAE standards are the basis for many municipal building codes.

Central to the process that may be required by the standard will be assembling a team to be responsible and accountable for building water system safety. This team will conduct a complete survey of potential problems in the water system, such as dead legs where water has sat for a long period of time. If significant risk factors exist, then the team will need to prepare a plan that identifies and establishes control measures at critical points, verifies the control measures are implemented within specific performance limits and validates that the plan is effective in preventing Legionnaires’ disease.

The CDC doesn’t yet recommend routine environmental cultures for hospitals and nursing homes. In contrast, the World Health Organization and many public health agencies in Europe and Asia do recommend routine environmental surveillance for Legionella.