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 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, Florida; Jacksonville, Florida; and Florence, Alaska. The worst outbreak in a long-term care facility in North America occurred in 2005 at the Seven Oaks Home for the Aged in Toronto, Ontario, where 23 residents died and 112 others 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 pneumonia serogroup 1. The bacteria are ubiquitous and usually harmless in the environment, but they can quickly grow in warm, stagnant water. In certain circumstances, especially in institutions housing the elderly or in those with chronic illnesses, Legionella can multiply and cause pneumonia when people aspirate tiny particles while drinking water or showering.
Since 2001, CDC surveillance reports have stated that Legionella is the single most 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 over three stories are contaminated with Legionella. Because it takes specialized laboratory testing to diagnose it, the disease is severely underdiagnosed in long-term care facilities.
Particular concerns for senior living
The increase in cases of Legionnaires’ disease is of particular concern for owners and managers of long-term care facilities. Although anyone can become infected under certain circumstances, Legionnaires’ disease principally affects those 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 correct species of Legionella, a susceptible individual, and sufficient intensity of exposure—victims of Legionnaires’ disease can quickly 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 act will likely 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 managing the risks associated with amplified growth and exposure to Legionella. The latest draft, expected to be approved and made available this summer, will recommend that nursing home facility managers implement more robust safeguards through risk assessment and 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 the standard may require 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 an extended period. If significant risk factors exist, the team will need to prepare a plan that identifies and establishes control measures at critical points, verifies that the control measures are implemented within specific performance limits, and validates that the program effectively prevents Legionnaires’ disease. Read the full article.