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An aging population, aging water and increased awareness are just a few possible reasons for a rise in Legionnaires’ disease.
If you weren’t thinking much about Legionnaires’ disease that certainly changed over the summer when the worst such outbreak in New York City history killed 12 people, sickened more than 120 people in the Bronx and commanded headlines throughout the country.
Since then, it seems there’s news of further outbreaks virtually by the week. In August, for example, approximately 100 cases of Legionnaires’ were reported among inmates in California’s San Quentin State Prison just as the Bronx outbreak was waning. Also that same month, 54 cases and 13 deaths occurred due to the disease at a veteran’s long-term care facility in Quincy, Ill. And then in September, 13 cases of Legionnaires’ and one death were reported in the Bronx again. However, officials deemed it unrelated to the earlier and deadlier outbreak.
Cases of Legionnaires’ have been increasing dramatically in the U.S., with reported cases in August alone more than doubling from expected levels for that period, according to U.S. health officials.
The recent figures from the Centers for Disease Control and Prevention represent a clear acceleration from the most recent overall national data available, which show the number of cases reported more than tripled between 2001 and 2012.
According to the CDC’s September 4 weekly report on death and disease, there were 404 cases of Legionellosis– Legionnaires’ and a related disease called Pontiac Fever — in the four weeks ended August 29. That is more than twice as many cases as would be expected for the same four-week period in the past five years.
And it’s not just happening in the United States. A quick scan on the web shows outbreaks this year in France, Portugal, Spain, Canada, New Zealand and the United Kingdom. What isn’t 100 percent clear is whether the numbers of cases have truly risen or whether our method of detection has actually improved. For some answers, we walked into a one-hour pathogen risk reduction seminar presented by Jorge Megias, from Viega, during the PHCC-National Association’s CONNECT 2015 last month in Florida.
“Legionella is going to be the new mold,” Megias said in an eye-opening presentation that his employer can and does take a full day to discuss.
While Megias talked about a few other nasty water-borne pathogens, such as Giradia and Shigella, much of the discussion centered on Legionella. As it turns out, Legionella couldn’t find a better breeding ground than inside us or inside piping.
Legionella’s ideal growth range is between 95°F and 115°F, which falls well within the range of the human body (98.6°F) and a temperate piping system (85°F to 110°F). Once the bacteria finds an imperfection in the pipe lining, out of the water flow, it settles down for the perfect place to grow. Once hidden away, the bacteria excretes biofilm that helps it propagate and which may offer some protection from disinfectants and thermal shock.
“A single simple organism would probably do no harm to a healthy or unhealthy individual,” Megias said. “But when given the right correct conditions — and when you think about it there are hundreds if not thousands of ‘right conditions’ nationwide — outbreaks will occur. A single organism can become 4,100 in 24 hours in the right conditions. Think about all the public buildings throughout the country, that are built with dead-legs, warm tepid water, temporarily shut down and waiting for the tap to be turned on.”
These are the kind of conditions, Megias said, engineers must prevent in design, but that also must be installed correctly and maintained properly.
“Everybody involved has to make sure the plumbing systems work,” Megias said. “And plumbing engineers not only have to design it properly, they have to design it economically. In my experience, builders always cut back on the plumbing. It’s a smaller percentage of the budget, but plumbing always gets beat up. The contractor has to install it correctly to code and in a way that it will function as the engineer designed it. And at the end of the responsibility chain, people maintaining the building and property have to take care of that water to make sure it’s good.”
Here are few reasons why we’re hearing more about Legionnaires’, and why we’re likely to hear even more in the future.
Theoretically, Legionnaires’ disease can strike us all. But, the people most likely to become ill are over age 50. And the risk becomes greater for people who suffer from debilitating health conditions such as cancer, diabetes and lung or kidney disease.
The odds of surviving the disease grow considerably worse with age, in particular when there are other underlying medical conditions present that hinder immune systems. For example, it should be no surprise that the average age of the people who died from Legionnaires’ at the Quincy retirement community was 88 and all suffered from other serious maladies.
As it turns out, America is growing older with a vast aging population in the years ahead. The older adult population has grown tremendously since the first of the baby boomers (born 1946–64) turned 50 in the mid-1990s. Between 1990 and 2010, the number of people age 50 or older jumped by 35 million, an increase of 55 percent, according to research done by the Joint Center for Housing Studies of Harvard University in September 2014.
With the oldest baby boomers reaching retirement age after 2010, the population aged 65 and over is projected to soar to 73 million by 2030, an increase of 33 million in just two decades. By 2040, the center says the aging baby boomers will also push up the population aged 80 and over to 28 million, more than three times the number in 2000.
In the meantime, the center says greater longevity has already helped to expand the population aged 75 and over. The number of individuals aged 75–84 rose from 10.1 million in 1990 to 13.1 million in 2010, a 30 percent increase, while that of individuals aged 85 and over jumped from 3.1 million to 5.5 million, a 78 percent increase.
Because older age groups will be growing more rapidly than younger age groups, their share of the overall population will also increase sharply. Today, one in seven persons is at least age 65; by 2030, that share will be one in five. At the same time, one in 16 people is now at least age 75; by 2040, the share will be one in eight.
What a single-cell organism like Legionella lacks in brain power, it more than makes up for in a will to live. These things are survivors to the nth degree.
“It waits for downtime in the system,” Megias said. “If you have a system that is down, you don’t have any flow. If you’ve got a hotel up in the mountains that is seasonal use, in the winter, they shut down. Like a Stephen King novel, they shut down the hotel the whole winter, and it’s dead. You have no use of the system. You have that down time. That’s the time for bacteria to grow.”
Not everything needs to be that horrifying, however, to produce a very real fright. Stagnation, for example, is only part of the problem.
“While water sits stagnant in a domestic hot water system what happens to the temperature?” Megias asked. “It drops. So not only do we have to take into consideration that the water should be continuously moving throughout the system, but we have to ensure that the temperature doesn’t decrease into a range that is the perfect breeding ground for Legionella.
Water also doesn’t have to be all that old to be considered “aging” either.
According to statistics Megias presented, 25 percent of annual Legionnaires’ outbreaks can be attributed to new construction or renovation. To Megias, who lives and works in South Florida, some of those instances are the result of an overbuilt real estate market that has 300-unit condo buildings with just a few owner-occupied units for the entire building. Other instances could be the result of lackluster inspection.
And while Megias mentioned a number of design ideas that would help the circulation of water, there are other instances of stagnation in plumbing that might further contribute to increases in Legionnaires’ in otherwise operable plumbing.
Take health care facilities. “Unused” water might also be a better way to describe the problems at hospitals and long-term care facilities that contribute 23 percent of annual outbreaks, according to Megias’ statistics.
Now, as a bad joke goes, if you aren’t sick when you enter a hospital, you’re going to be when you have to stay there. The point is you’re simply not in the best of health, and therefore, a prime target for everything bad.
Megias said the most used fixture in a hospital room is the hand sanitizer right inside the doors. As a result, the hand lav, patient lav, shower and toilet may not be used frequently, which can cause stagnation in the supply distribution systems for cold water lines. Megias related that when his first child was born, his wife was in a ward with four, maybe six, others in the room sharing the facilities.
“Nowadays, everybody’s got a personal suite or a room that looks like the Ritz,” he added. “It’s a beautiful room with nice plumbing that nobody uses. That’s a big problem.”
In fact, Megias said new hospitals have four times as many sinks as older hospitals.
Finally, Megias added another reason for what appears to be an increase in Legionnaires’ — the simple fact that doctors are diagnosing it. There was a time when pneumonia was referred to as “the old man’s friend,” meaning that if left untreated the sufferer often lapsed into a state of reduced consciousness and died peacefully in his sleep, giving a dignified end to a period of often considerable suffering.
At that time, pneumonia could have been caused by a number of conditions, none of which were that vital to sort out. Now, people do want to sort it out. If someone contracts pneumonia, doctors can test if it’s Legionnaires’. Or if someone succumbs to pneumonia, survivors are likely to want an autopsy.
“I think part of the problem is that Legionnaires’ may not have been identified properly,” Megias said. “Pneumonia, certainly, not the exact cause of the pneumonia. Now, I think people are more aware of the situation and will want answers.”
And as a result, we read more about outbreaks.