Legionella Investigations

in Colorado

Tori Burket, MS, CPO

Nisha Alden, MPH

Introductions

Tori Burket, MS, CPO

Waterborne Disease Epidemiologist

Colorado Department of Public Health & Environment

tori.burket@state.co.us

Nisha Alden, MPH

Active Bacterial Core & Influenza Surveillance Manager

Colorado Department of Public Health & Environment

nisha.alden@state.co.us

1. Legionella background

2. Case and Outbreak Investigation protocol

3. Prevention in healthcare facilities

4. Example Outbreaks

5. Conclusions & Questions

Agenda

Legionella

• Bacterium

• Naturally found in many sources of fresh water

Reservoirs, ponds, pools, hot springs,

municipal water systems, ice machines,

cooling towers, and more

• Causes Legionnaires’ disease

Spread through inhalation of contaminated

aerosolized water droplets

• Shown to survive between ~32o F - 158

oF

Grows and multiplies between ~68oF - 128

oF

1

Legionnaires’ Disease

• Severe form of pneumonia

• Not spread from person to person

• Symptoms usually appear 2-10 days after exposure

Shortness of breath, cough, fever,

headache, muscle ache, altered mental

status

• People most at-risk

Over the age of 50, immunocompromised,

history of smoking, pre-existing respiratory

illness

• In Colorado, between 2007-2016

~92% hospitalization rate

~8% fatality rate

2

Legionellosis Disease

Investigation

1. Legionellosis case is reported to CDPHE within 4

days of positive laboratory results

2. Case patient is typically interviewed within 7 days

of received report (aim for within 3 days)

3. Environmental exposures are noted and cross-

checked against other cases within the last year

Routine Steps

When is an environmental

investigation conducted?

1. One case likely associated with a healthcare facility

• Case spent the majority or entirety of their

exposure period in a healthcare facility

2. Two or more cases associated with the same

exposure within 1 year

• Examples include hotels, pools/hot tubs, gyms, hot springs,

retirement homes, and healthcare facilities

Environmental Investigation

Protocol

1. Water and/or HVAC restrictions

2. Environmental investigation

3. Mitigation recommendations

4. Retrospective and prospective surveillance

Water Restrictions

1. Discontinue use of non-vital water features that the

public has access to, such as:

Water fountains, sinks, ice machines, hydrotherapy

tubs, pools/hot tubs, saunas…etc

2. Avoid using showers if possible

Recommend utilization of bed/sponge baths

3. Bottled water usage

Dependent upon level of risk

To reduce further risk of illness until mitigation can be completed

Environmental Investigation

Environmental Assessment

• Facility wide assessment to identify:

Water/HVAC features and sources

Building and water/HVAC system design

Current water management plan practices

Previous or current disruptions/maintenance

to the water/HVAC system

Infection control practices

Environmental Investigation

Environmental Sampling

• Water samples and swabs analyzed from identified sources

• Water chemistry levels analyzed from identified sources

What is a Biofilm?

A group of microorganisms in which cells stick to

each other and produce an slimy protective surface

Mitigation Strategies:

Potable Water Systems

Immediate Remediation Methods

• Drain and flush water heaters to

reduce sediment accumulation

• Flush water entire water system,

including each outlet (showers and

sinks), to eliminate stagnant water

• Clean and disinfect water features

with chlorine bleach solution (50

mg/L) to remove biofilm

Mitigation Strategies

Water System Disinfection

• Superheating: Raise

temperature of water heaters

to 160o-170

oF and flush each

outlet for a minimum of 5

minutes

• Hyperchlorination: Raise level

of chlorine to a minimum of

2ppm and leave in system for a

minimum of 2 hours followed by

a system flushing

Mitigation Strategies:

Pool/Hot Tub

1. Drain hot tub (can drain pool if able to)

2. Scrub all hot tub and pool surfaces, skimming devices,

jets, and circulation components with disinfectant

3. Replace filter media and service filter unit(s)

4. Inspect for and fix broken or poorly functioning

components

5. Refill and superhalogenate water in hot tub and pool

Follow-Up Testing6 month re-testing schedule

• Sampling every 2 weeks for 3 months and then

• Sampling once a month for 3 months

Conditions for re-opening/lifting restrictions

• Completion of mitigation requirements

• Negative Legionella culture test results

• Pass inspection (for pools/hot tubs)

Conditions for closure

• Any positive Legionella culture test results

• Fail inspection (for pools/hot tubs)

9

Surveillance Recommendations

for Healthcare Facilities

Retrospective Surveillance

1. Review records of patients from the last 6-12 months to find

those diagnosed with pneumonia while in or within 10 days of

leaving the facility

2. Identify if these patients were tested for Legionella

Prospective Surveillance

1. For the 3 months following remediation, patients that develop

pneumonia should be tested for Legionella using a sputum

culture and UAT

2. Clinicians ordering diagnostic testing will need to be notified of

this recommendation

Prevention of legionella

in the water system

Implement and utilize a water management plan!

CMS Regulation Goal:

Reduce the Risk of Growth & Spread

of Pathogens Requirement

CMS Regulation Requirements

1. Conduct facility risk assessment to identify where Legionella

could grow and spread in the facility water system

2. Implement a water management plan that considers ASHRAE

industry standard and the CDC toolkit, and includes control

measures such as physical controls, temperature

management, disinfectant level control, visual inspections,

and environmental testing for pathogens

3. Specify testing protocols and acceptable ranges for control

measures, and document the results of testing and corrective

actions taken when control limits are not maintained

Colorado Outbreaks

10

Outbreak: LTCF A

• Single case of legionellosis in a skilled nursing facility in

metro-area

• Testing conducted in potable water system

• PCR positives during initial sampling

• Legionella pneumophila- hot water return, water

feature, patient room shower swab

• Legionella spp- patient room shower water, patient

room shower swab, water fountain, lobby sink

• 10 days between initial sampling and repeat sampling

• Superheating occurred very quickly

• All follow-up sampling was negative

Outbreak: Hotel B

Locally owned franchise hotel in southeastern Colorado

• Five cases of unexplained pneumonia in guests who

attended a wedding at the hotel at the end of July

Three of the five cases were hospitalized and developed

severe manifestations of their illness

15

Hotel B Sampling

Potable Water System (16)

• Water heaters (3)

1 liter samples

• Guest room showers (6)

1 liter samples

Swabs

• Guest room sinks (6)

1 liter samples

Swabs

• Ice machine (1)

Swabs

Pool/Hot Tub (10)

• Pool (7)

Water, water line,

filter baskets,

pump, filter

• Hot tub (3)

Jets, filter, pump

Swamp Coolers (2)

• 1 liter samples (2)

16

Hotel B Findings

Swamp Coolers

Dead bird inside one of the chillers

Rough shape; leaks, cracks, sediment…etc

Detected dead Legionella

Pool/Hot Tub

Pool hadn’t been drained in 5 years

Chemical levels were way off

Filter media hadn’t been replaced in quite a while

No CPO on staff

No records being kept

Detected both live and dead Legionella

Potable Water System

Problems with water heaters and water temperature

Brown water came out of one of the showers

Detected dead Legionella

17

Conclusions

1. Investigations are lengthy, frustrating, and expensive

2. Hotels & LTCFs pose unique risks to public health, so

extra measures are needed to ensure safety

3. Prevention is cheaper and easier than responding to an

outbreak

17

Questions?