The Center for Disease Control has released a report indicating that the recent outbreak of Legionnaire’s Disease in an Illinois veterans home was most likely caused by an antiquated and poorly managed water system. Numerous residents and staff members at the facility were infected, 12 of whom died. The outbreak occurred in Illinois’ largest and oldest veterans home facility located in Quincy.
The state is in the process of initiating a $4.8 million project to replace the 129 year old water system and conform to the recommendations of the CDC. Inspectors spent 2 weeks at the facility during the investigation and carefully documented all of the pertinent information regarding the outbreak. Some of the most notable excerpts from the report are below:
- Based on Illinois Veterans Home (IVH) resident medical charts and staff files, 186 individuals were tested for Legionella between August 21 and October 1 with 57 (31%) positive.
- As of October 13, 2015, 56 cases of legionellosis were identified with 45 confirmed as Legionnaire’s disease and 12 confirmed as Pontiac Fever. Of the 45 Legionnaire’s Disease cases, 35 were IVH residents, 6 were IVH staff, and 4 were community cases.
- 3 potable water system issues were highlighted as most likely to be associated with potential Legionella amplification and dissemination: 1) sub-optimal hot-water holding temperature due to lack of thermostatic mixing valves facility wide, 2) inadequate disinfectant levels in facility potable water system, and 3) an extensive and poorly understood water distribution system with dead-legs, stagnation, and irregular flow.
- An initial inspection and decontamination of the cooling tower was performed prior to our arrival on August 27. At that time, operation and maintenance record keeping was largely absent and excessive biofilm formation was observed inside and outside of the cooling tower.
- Initial environmental sampling (Aug 21 and 31) included A total of 39 samples with 21 (54%) positive for L. pneumophilia serogroup 1 (Lp1) – the most prevalent disease-causing species and serogroup of Legionella.
- This outbreak occurred in a setting with no formal water management plan, no Legionella specific prevention plan, limited previous Legionella testing both clinically and environmentally, and limited monitoring of water treatment parameters.
- The age of facility water infrastructure likely contributed to this outbreak through the natural biofilms which tend to grow within older plumbing systems. This process is worsened in situations of low chlorination, decreased water flow, and dead legs – all of which were likely issues at the facility.
The Center for Disease Control’s full report can be read here: CDC Report
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