Educating Healthcare Facilities on Legionella Prevention Following Legionellosis Cluster Investigation in Kentucky

BACKGROUND: Legionella bacteria are found naturally in the environment, usually in warmer water. Legionellosis symptoms mimic common respiratory pathogens causing it to be an underdiagnosed illness. Most outbreaks are linked to exposure to contaminated aerosol originating from hot water supplies, air conditioning cooling towers and aerosol-producing devices. During July/August 2014, the Fivco Regional Epidemiologist with the Kentucky Department for Public Health (KDPH) and Centers for Disease Control and Prevention (CDC) investigated cases of Legionellosis linked to an acute care hospital (ACH) and long term care (LTC) facility.  These are uncommon findings in Kentucky and this region.

METHODS:  An outbreak investigation was initiated on July 3, 2014. Five confirmed cases were linked to the LTC facility and 3 confirmed cases to the ACH. In January/February 2014, this area experienced significant water disruptions from water line breaks due to extreme cold and a chemical spill in the Ohio River, the area’s primary water source. Both facilities experienced outages and were on boil water advisories. We learned during our investigation that both facilities had no plan in place or working knowledge of how to flush internal water sources after an outage.   Additionally, both facilities lacked knowledge of proper care for aerosol-producing devices such as nebulizers and no instructions were provided to their patients for home use. The Regional Epidemiologist, KDPH and CDC hypothesized that during the previous winter’s outages and subsequent restoration of the water supply, biofilm may have been introduced into the municipal water supply that feeds these facilities. The biofilm contamination could have flushed through the water supply and flourished in pipes during June 2014 when documented temperatures were well above average for 14 consecutive days.  While this hypothesis remains unproven, it did reveal an opportunity for improvement on the proper practices to protect the population from this source of potential contamination.

RESULTS:  An educational packet was developed and distributed by the Regional Epidemiologist to medical facilities, LTC centers and local physicians in January 2015. The materials outlined procedures for safely reinstating water supplies in healthcare facilities. It also provided take-home materials for patients for use and care of aerosol-producing devices in their homes.

CONCLUSIONS:  The Regional Epidemiologist identified a lack of knowledge, policy and procedure in healthcare facilities in her district that could be detrimental to the health of high-risk citizens.  This gap was addressed in educational materials and information for safe use of aerosol-producing devices in the home.