I spent years as the CEO of a company that provided infection surveillance software to hospitals – a sort of early warning system for outbreaks.
In that field, you see the impact of almost every hospital-acquired infection imaginable. I thought I had seen everything – until recently, when I ventured into the upside down world of Legionnaires' disease.
With outbreaks on the rise, including one across New York City that has killed 12 people and sickened more than 120, along with recent reports of Legionnaires' deaths in Cleveland, Denver and Detroit, and just last week in Illinois, and California, you would think national and state authorities would be springing into action, as they did when reports surfaced of deadly new superbugs such as MRSA or the Ebola scare. You'd be wrong.
While healthcare regulations now demand testing and the public reporting of data on MRSA, et al, there are no such regulations for Legionella, the bacteria that cause Legionnaires'.
This despite the fact that most cases can be prevented by routinely testing plumbing in buildings, along with fountains, hot tubs and cooling towers.
A short recap: Legionnaires' disease is a bacterial disease commonly associated with water-based aerosols that have originated from warm water sources. It is often associated with poorly maintained cooling towers and potable water systems. Medical experts estimate that each year 56,000 to 113,000 people are infected with the Legionella bacteria in the United States. Fatality rates vary from 15% to 30% of infections, depending on the health and age of those involved in the outbreak. With as many as 150 to 300 infections and 90 deaths per day, or up to 32,000 deaths per year, there is no doubt that this should be a priority for hospitals and public health. The incubation period can be from several days to two weeks, adding to the difficulty in tracing the source of the infection and its misdiagnoses as common pneumonia. Fortunately, Legionella bacteria are not transmitted from person to person. Due to the susceptibility of patients already compromised with illness, and the large water supply systems in hospitals, more than half of the reported Legionnaire's disease outbreaks are at healthcare facilities.
Although the CDC states that Legionnaire's disease is a "nationally reportable disease," only about 3,000 cases are reported. The implication is that the enforcement of the reporting requirements is inadequate. Further, the CDC states that keeping Legionella bacteria out of water is the key to preventing infection, yet it doesn't require routine testing for the bacteria.
That is an inexplicable stand when there are inexpensive tests available, not to mention simple and inexpensive technologies to control Legionella in potable water systems and cooling towers. For instance, there are copper silver ionization systems installed in hundreds of hospitals and commercial properties in the U.S., which are approved by the EPA to specifically eradicate Legionella. With proper monthly or quarterly water testing and a well-maintained system, the Legionella count in the facilities' water systems can typically be driven to near zero (below commonly available measurement sensitivity) for a cost of less than $100 per day. Most of these facilities learned the hard way that preventing an outbreak is far less expensive than incurring the human suffering, litigation and damages to reputation that an outbreak can cause.
It's particularly hard to imagine that the CDC does not support water testing in U.S. healthcare facilities. Patients and staff drink this water and shower in it, nurses wash their hands with it and rinse equipment in it, and surgeons rinse their hands with it before operating on patients.
In stark contrast, Europe has long-established, specific guidelines for Legionella testing and remediation. The recommendation is to test at least 35 samples at diverse location per facility at least quarterly, and remediation steps need to be taken if any samples exceed 1,000 CFU/L (colony forming units per liter).
In the absence of testing, public health agencies in this country need to act now to better educate environmental building engineers that warm, stagnant water is ideal for accelerating bacterial growth, especially Legionella. Agencies should also dispel the notion that cooling towers are the primary cause of Legionella infections. Many more infection reports originate from potable water systems in buildings, including showers, fountains, hot tubs, etc.
At long last this year, the American Society of Heating, Refrigerating and Air-Conditioning Engineers has stepped up and published ASHRAE 188, which establishes minimum Legionnaires' risk management requirements for building water systems. If adopted as local building code, as has been done in New York City, it is a step in the right direction. New York has also mandated water testing in all public buildings as part of this new law.
With two large outbreaks in New York in the past six months, perhaps there will finally be enough outrage to incite public health agencies in the U.S. to create standards for water testing and remediation. I hope I never have to read another headline such as one I saw recently on CBS News: "Baby Infected in Birthing Pool Dies of Legionnaire's Disease."
It is time for the U.S. to act to exercise due care in protecting its citizens from these avoidable Legionella outbreaks due to poor policy, poor education, poor surveillance and poor enforcement by public health.
Adam Boris is a healthcare and technology consultant and hospital board member. He was the former CEO of ICNet Systems, Inc., a leading clinical analytics software company focused on the detection and prevention of infection outbreaks in healthcare systems and the electronic reporting of infections to the CDC and other public health agencies.