By Gary Evans, Medical Writer
Federal health officials report a striking surge in healthcare-associated Legionnaires’ disease (LD), with the Centers for Medicare & Medicaid Services (CMS) underscoring the threat by ordering assessments of hospital water systems where the pathogen thrives.
“In a recent review of LD outbreaks in the United States occurring in 2000–2014, 19% of outbreaks were associated with long-term care facilities and 15% with hospitals,” CMS said in a June 2, 2017, memo to inspectors.1 “The rate of reported cases of legionellosis, which comprises both LD and Pontiac fever (a milder, self-limited, influenza-like illness) has increased 286% in the U.S. during 2000–2014, with approximately 5,000 cases reported to the Centers for Disease Control and Prevention (CDC) in 2014. The CMS expects Medicare-certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens building water systems.”
The regulatory move was supported by the CDC at a press conference, where the general consensus was that the threat of healthcare-associated LD warrants action beyond voluntary efforts like those recommended in a CDC toolkit2 on the issue.
“This [CMS memo] is essentially a warning to healthcare facilities that if you don’t have a good water management plan, this is the time to study up and develop one,” Anne Schuchat, MD, acting director of the CDC, noted at a June 6 press conference.
Asked why the CDC guidelines like the water management toolkit have not effectively reduced the problem, Schuchat gave infection preventionists a somewhat mixed review.
“This is a big culture change for infection control and hospital facilities,” she says. “We have had tremendous uptake on improving use of antibiotics and improvements in healthcare-associated infections through handwashing and other checklist kind of processes. We know we have a lot of opportunity to get the word out, and we know the infection control force in this country is a tremendous set of champions for patient safety. We think the CMS [action] is a very important way that the uptake will happen, because when hospitals are visited this will be one of many things that is checked consistently.”
An Inspector Calls
CMS surveyors were told in the memo to review policies, procedures, and reports documenting water management implementation results to verify that facilities:
- conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system;
- implement a water management program that considers industry standards and the CDC toolkit, and includes measures such as physical controls, temperature management, disinfectant levels, visual inspections, and environmental testing.
“Healthcare facilities are expected to comply with CMS requirements to protect the health and safety of patients,” CMS stated. “Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance with the CMS Conditions of Participation.”
At the press conference, the CDC released the findings of an analysis of 21 U.S. jurisdictions (20 states and New York City). Healthcare-associated LD was confirmed in 76% of the jurisdictions.
“People are getting LD from healthcare facilities in most parts of the country,” Schuchat says. “Most of these infections can be prevented with better water management programs. [We] have issued tools to help facilities with building water management, but this study suggests that more is needed to protect patients from contracting the deadly pneumonia from the facilities’ showers or other water exposures.”
With the CMS order as impetus, the CDC is hoping that hospital water management programs will be added to the list of bedrock infection control principles like hand hygiene and antibiotic stewardship.
“LD in healthcare facilities is widespread, deadly, and preventable,” Schuchat says. “About 10% of [all] people who get this infection die from it, but in this analysis we found that the death rate is higher in healthcare facilities — 25% of people die if they get sick with Legionnaires’ disease while in the hospital [or] long-term care.”
Numerous LD outbreaks over the years have been traced to the waterborne bug becoming aerosolized and inhaled in shower mist. Spas and baths, cooling towers, decorative fountains, and medical equipment have also been implicated in outbreaks.
To cite but one classic example of a healthcare outbreak, two patients died and eight others were infected in an outbreak in a cancer ward in an Alabama hospital reported in 2015.3 The hematology-oncology unit at the hospital had undergone recent construction, and infections began to appear right after the unit opened. Investigators discovered that a reservoir of standing water sat in the distal piping for the two months before shower heads and other fixtures were installed and the unit was opened. Environmental sampling revealed Legionella pneumophila serogroup 1 in the potable water at 50% (17/34) of hematology-oncology unit sites, including all patient rooms tested. Three clinical isolates were identical to environmental isolates from the unit. The exact exposure sources could not be determined, but all evidence tilted toward the individual shower units in each patient’s room.
While that case involved a renovation, old complex hospital plumbing systems in general can create areas conducive to Legionella growth and biofilm formation, but strategies that include heating water and using chemicals can effectively reduce the threat. The CDC currently recommends that infection preventionists should begin an outbreak investigation after one confirmed case of healthcare-associated LD or two probable cases.
In the analysis reported at the CDC press conference, a definite case of healthcare-associated LD was defined as a patient who had been in the hospital at least 10 days before the symptoms appeared.
“A possible healthcare-associated case [was defined as] when a patient was in a healthcare setting for some portion of the 10 days before developing LD symptoms,” Schuchat says. “Our study found 20 of 21 jurisdictions had possible healthcare-associated LD cases. Sixteen of 21 had definite healthcare-associated LD. In those 16 jurisdictions, cases occurred in 72 different facilities, with the number of cases ranging from one to six per facility.”
In percentage breakdowns of the confirmed cases, 80% were in long-term care facilities, 18% in hospitals, and 2% in some combination of both.
“In terms of the possible cases, the 20 jurisdictions had cases in about 415 different healthcare facilities,” she says. “Thirteen percent were associated with LTC facilities, 49% with hospitals, and 26% with outpatient facilities. These findings suggest that LD is a problem that can affect any state, and that all healthcare facilities can take action to protect patients.”
$38k a Case
Previous analysis shows insurers pay some $430 million in hospitalization claims for LD nationally. Total healthcare costs per patient averaged about $38,000, she says.
The aforementioned CDC water management tool includes a checklist to help identify common problems.
“It gives examples of where Legionella could grow and spread in a building, and it gives ways to reduce the risk of Legionella in water systems,” says Cynthia G. Whitney, MD, MPH, chief of the respiratory diseases branch in the CDC Division of Bacterial Diseases. “Because of the vulnerable population they serve, it is important for healthcare facilities to have a water management program and a dedicated team to correctly execute it.”
Healthcare providers on the frontline should “think Legionella,” having a high index of suspicion in patients with healthcare-associated pneumonia, she added at the press conference. Tests can detect Legionella to confirm or rule out suspicion, she says.
All 50 states and two large cities report basic LD data to the CDC, but not all report information on where transmission may have occurred. During 2015, approximately 6,000 cases of Legionnaires’ disease were reported to CDC, but only about half included exposure data.
A CDC Vital Signs4 report released at the press conference estimates that overall 3% of Legionnaires’ disease cases are definitely associated with a healthcare facility. Another 17% of LD cases are possibly associated with healthcare facility. There are at least 20 outbreaks reported each year.
“We know that LD is underreported,” Schuchat says. “The numbers we report each year are just the tip of the iceberg.”
- CMS. Center for Clinical Standards and Quality/Survey & Certification Group. Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD). Ref: S&C 17-30-ALL. June 02, 2017: http://go.cms.gov/2r3ue6B.
- CDC. Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A Practical Guide to Implementing Industry Standards. Version 1.1 June 5, 2017:
- Watkins FL, Harris AM, Toews, K, et al. Healthcare-Associated Outbreak of Legionnaires’ Disease on an Inpatient Hematology-Oncology Unit — Alabama, 2014. CDC 64th Annual EIS Conference. Atlanta: April 20-23, 2015.
- CDC. Legionnaires’ Disease. Vital Signs 2017: http://bit.ly/2r5Xg5K.