Legionnaires’ disease: ‘More Common & Deadlier Risk than Asbestos’

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Mark Ovcjak

I, like many people, thought Legionnaires’ disease was a thing of the past.  I couldn’t have been more wrong or grossly misinformed.  Legionella is alive and kicking – and having an exhaustive and life altering, if not devastating effect, on thousands upon thousands of people’s lives globally.

“In the United States, the reported incidence of Legionnaires’ disease increased more than five-fold from 2000 to 2017.  Worldwide, the actual burden of Legionnaires’ disease is generally acknowledged to be underreported, by as much as eight to tenfold,” states the US National Academy of Sciences, Engineering and Medicine.

“Experts estimate there are hundreds of thousands of Legionnaires’ cases each year, making Legionnaires’ disease a more common and deadlier risk to building occupants than asbestos,” says Dr. Paul Lem of Spartan Bioscience.

“The identified incidence of Legionnaires’ disease varies widely according to the level of surveillance and reporting,” says Carla Drysdale, Communications Officer for the World Health Organization.

"Since many countries lack appropriate methods of diagnosing the infection or sufficient surveillance systems, the rate of occurrence is unknown,” adds Drysdale.

Today Legionella is one of the top 5 pathogens leading to the most ‘Disability-Adjusted Life Years’  (DALYs) and only one of 4 considered to have both a high population and high individual burden of disease including HIV, tuberculosis and invasive pneumococcal disease.

Mark Ovčjak’s Story

Mark Ovcjak

Mark Ovčjak, Manager of Building Services for the Toronto Transit Commission (TTC), was diagnosed with Legionnaires’ disease at Mississauga Hospital, Trillium Health Partner on Tuesday, September 23rd, 2019.

One week prior, with a fever of 39.5 C (103.1 F), Ovčjak grew very tired and weak.  He took Tylenol to reduce his fever but his symptoms only grew worse.

“I could not eat anything, not even a bite of a cracker or a drink of water,” says Ovčjak. 

His family physician was not available, so Ovčjak went to a walk-in clinic where he was told “…well, it’s the start of the flu season so I think you have the flu.”  The doctor gave him a prescription for Tamiflu, did blood work and then asked him to come back the following Monday.   

During the next couple of days, Ovčjak experienced increased shortness of breath, tightness in the chest followed by extreme diarrhea and vomiting.  Having a fever of 40.5 C (104.9 F),  he was delusional and speaking gibberish, which created anxiety and worry with his family.

“I have never had a good sense of smell but while I was sick, there was this really horrible, putrid odour coming from my body…it made me want to vomit,” said Ovčjak. 

“My wife and children could not smell anything.  It was all in my head.”

Ovčjak returned to the clinic and saw another doctor who, after viewing his x-ray, told him he had “really bad pneumonia.”  The clinic sent him home with another prescription and told him, “…in a day or two you will feel a lot better.”

On Tuesday morning, Ovčjak’s symptoms were even worse and he saw Dr. Pilarski, his family physician, who told him to go to Trillium Emergency and Urgent Care immediately.

“As soon as I walked into Emerg, I received medical assistance.  They did more blood tests, put me on an IV and a short while later, a doctor told me that I have a high fever and pneumonia but that all my vitals were stable – although my heart rate was unusually low, in the mid 50s,” says Ovčjak.

“A couple of hours later the doctor came back to my room and apologized saying “…we did some more blood work and see something we don’t like.” 

Ovčjak was taken by ambulance to Mississauga Hospital and it was at this time that he started to cough and spit up blood and mucus.

"After a day or so of tests, Dr. Jeanne du Manoir, General Internist at Mississauga Hospital said I was the first Legionnaires disease case she has seen in her career,” said Ovčjak.

Ovčjak was administered the appropriate antibiotic and the following day was finally able to eat.

“I could smell sausages. Oh, it was wonderful. Mini sausages, eggs and toast!”

Ovčjak lost 16 lbs. since contracting Legionnaires’ disease.

Tracing his whereabouts for many days prior to contracting Legionnaires’ disease, he recalls being at a nursing home and a funeral home - as well as a few other public places.

“We [TTC] hired a contractor to clean out the storm water drainage systems and flush the lines at Finch West and at York University subway stations. I dropped by the sites shortly after the work was completed,” says Ovčjak.

He conducted a visual inspection of the area surrounding the storm water management pond at Highway 407 Station.

“Dr. Wu, a nephrologist, told me I had suffered acute kidney failure.  He went on to say that my test results confirmed I had Legionnaires’ disease and while he cannot be certain, I probably picked it up somewhere from work,” says Ovčjak.

Mark Ovcjak, his wife and 3 daughters

On September 28th, Ovčjak was released from hospital.  He returned to work the first week of November and just recently has been experiencing a little more energy although he says he lacks motivation.  He has a few follow-up medical appointments to assess his recovery, which physicians told him could take another year.

“I didn’t realize how serious this disease is and I feel pretty lucky that hospital staff diagnosed me as quickly as they did,” says Ovčjak. 

“I look back at how quickly Legionnaires’ disease started and how I kept returning to medical professionals seeking increased medical attention because I was not feeling better - I was feeling progressively worse regardless of the medications I was given.  If I didn’t insist that they diagnose me again and again, I don’t know where I would be now.  I could have died.”

Kristina, Mark Ovčjak’s daughter says, “At first, we thought he had a cold and then we thought he had a really bad flu, but we knew something serious was going on when my Dad’s thought process was all mixed up and he couldn’t put a sentence together.”

“When I saw my Dad in the hospital I was scared because I never heard of Legionnaires’ disease.”

“If I learned anything from this ordeal, it’s that when you know in your gut something is wrong, remain persistent and seek proper medical attention,” adds Kristina.

Ovčjak says, “When I was discharged from the hospital, I hugged Dr. du Manoir and thanked her for saving my life.”

“I hope this article makes a difference to someone’s life,” says Kristina.

Peel Public Health

Year

Number of cases

Crude rate per 100,000 population

2017

24

1.6

2018

51

3.3

2019

53

3.4

Source: integrated Public Health Information System (iPHIS), Ontario Ministry of Health Extracted on January 7, 2020 by Peel Public Health

“There was a high number of legionellosis cases in 2018 in Ontario," says Region of Peel - Public Health.

“The investigation of cases’ exposure locations, suggest the increase was comprised of sporadic cases.  Peel Public Health routinely monitors and analyzes Region of Peel data and monitors provincial rates. There have been no identified common source reasons for the overall increase.” 

Dr. Lisa Berger, Associate Medical Officer with Toronto Public Health states there were 67 cases (63 confirmed and 4 probable) in 2018, with a case fatality rate of 10% - which is consistent with the case fatality rate of previous years.  2018 presented an increase over the 5-year-mean from 2013 to 2017 of 36 cases per year.

Key Facts and Statistics

  • In 2016, there were 6,141 confirmed cases of Legionnaires’ disease in US; in 2017 over 7,000 confirmed cases and in 2018, the CDC reported over 10,000 confirmed cases – a record high since 1976. Medical experts state the actual number of cases in 2018 is considerably higher – as many as 70,000.
  • The Public Health Agency of Canada states that the average number of reported cases of Legionnaires’ disease is generally less than 100 per year; however, this number is considered to be much higher due to the fact that many people that present with pneumonia are not tested for Legionella.
  • In 2018, Public Health Ontario states there were 333 confirmed cases of Legionellosis of which 259 people were hospitalized and 22 died. This is the highest number of cases in the past six years, including the last peak activity year in 2013.  The majority of cases were observed in Toronto at 64 and Peel Region with 51.
  • Legionella is now the most common cause of reported drinking-water related outbreaks.
  • Most physicians treat symptoms, which present as pneumonia, but overlook and therefore fail to diagnose Legionnaires’ disease.
  • Many antibiotics, effective against other bacterial pneumonias, are ineffective against Legionella, because they do not penetrate the pulmonary cells where infectious Legionella thrive.
  • On a global scale, Legionnaires' disease is underreported and misdiagnosed by as much as 8 out of every 10 times.
  • Because Legionella is misdiagnosed, the true financial cost and human burden is greatly underestimated.
  • Legionella infected patients have the longest hospital stays and recovery times of all waterborne diseases.
  • Legionella occurs naturally in fresh water environments, i.e. lakes and streams, but it becomes a health concern when it grows and spreads in human-made building water systems.
  • Rapid detection and remediation are critical because sick and elderly people are at the highest risk of contracting Legionnaires.
  • At present, there are three active cases of Legionnaires’ disease in Canada: one in New Brunswick, one in Owen Sound and one in Toronto.

Legionnaires’ disease is often undiagnosed

Legionnaires’ disease is often undiagnosed because “…just a few medical laboratories use culture with biochemical confirmation in conjunction with antigen detection,” states the Government of Canada.                        

“To distinguish Legionnaires' disease from pneumonia from other causes, laboratory tests are needed that are not normally carried out on patients with fever and pneumonia.  The diagnosis is confirmed by laboratory examinations that isolate Legionella from respiratory secretions (sputum) or testing a patient's blood or urine,” says the Canadian Centre for Occupational Health and Safety (CCOHS).

While medical professionals are waiting for a diagnosis for their patients, people within the contaminated area of the building or facility don’t have a clue that the area they are visiting or working in, is at a potential outbreak level for Legionnaires’ disease.

This scenario has been going on for a very long time.  The medical field moved away from culture-based testing 15 years ago and yet ironically, and to the disadvantage of anyone infected with Legionella, it is still considered a ‘gold standard’ for the majority of diagnostic labs around the world.

Culture-based testing takes 10 to 14 days and is complicated and fraught with difficulties, i.e. isolating Legionella when other microorganisms are present.

An Innovative & Accurate Diagnostic Approach is Imperative

Legionella pathogen

Should a person present at a hospital with pneumonia, the patient would be administered antibiotics for pneumonia – not Legionella.  One or two days later, the patient would experience significant complications and only then, will medical staff realize there is something more serious going on that requires immediate attention and additional testing.

A study published by the Humber River Hospital in Toronto, Canada on January 3, 2020, acknowledged that 28% of pneumonia patients admitted to hospital tested positive for Legionnaires' disease. 

Spartan Bioscience, a biotechnology company, created a rapid DNA culture test for precision medicine.  They are able to analyze a person’s genetic makeup in real time and provide accurate diagnostics to the medical professionals, who in turn, can administer the appropriate medications to their patients.

Recent Outbreaks

October 2019 – Orillia, Ontario’s Rotary Place had 9 confirmed cases of Legionnaires’ disease and all required hospitalization with some in intensive care.  There was a higher than average presence of Legionella bacteria at the Rotary Place cooling centre.

September 2019 - At a state fair in South Carolina, 150 people contracted Legionnaires’ disease from an indoor hot tub exhibit.  4 people died.

September 2019 – At a retirement community in Batavia, Illinois, 13 residents were hospitalized with Legionnaires’ disease caused by the building’s water system.

September 2019 – 6 cases of Legionnaires’ disease caused by a cooling tower were diagnosed in a south-central London neighbourhood in Ontario.

August 2019 – Two guests staying at a hotel in Schaumburg, Illinois were diagnosed with Legionnaires’ disease.  Both reportedly used the hotel pool and spa.

July 2019 – At the Marriott Hotel in Atlanta, Georgia, 13 guests contracted Legionnaires’ disease and one person died.  The hotel was shut down for 30 days during testing and disinfection of their water system.

July 2019 – In Moncton, New Brunswick, 16 cases of Legionnaires’ disease were reported and all believed to be caused by a water source, although never identified.  Public health officials stated that the public would not benefit in knowing the source of the outbreak.

jacuzzi

June 2019 – At the Saltwater Hot Tub in Bournemouth, UK, 14 people were diagnosed with Legionnaires’ disease.  Another 39 visitors were reported to have the same symptoms although never tested.

May 2019 -16 patients at a hospital in Columbus, Ohio were diagnosed with Legionnaires’ disease and one patient died.

May 2019 – At the Ghent Paper Mill in Brussels, Belgium, 32 people were diagnosed with Legionnaires’ disease and two died due to contaminated cooling towers.

May 2019 – At a horse racetrack in West Virginia, 17 people were infected with Legionnaires’ disease due to a locker room hot tub and the mist that travelled to a 2nd floor office suite and hallway through the ventilation system.

March 2019 – At a resort in Wisconsin Dells, Wisconsin, 3 people contracted Legionnaires’ disease and one died due to the water system.

February 2019 – At a hotel in Casselton, North Dakota, two people were diagnosed with Legionnaires’ disease due to the whirlpool spa.

December 2018 – At the University of Wisconsin Hospital, 14 patients were diagnosed with Legionnaires’ disease and 3 died.

October 2018 – 29 cases of confirmed Legionnaires’ disease occurred in the Washington Heights neighbourhood in New York City.  One person died.

September 2018 – 405 people contracted Legionnaires’ disease in Lombardy, Italy.  42 of the cases were confirmed as Legionella including two people who died.  Officials confirmed that the cooling towers were the source.

To view the most up-to-date and complete global listing of Legionnaires’ disease outbreaks, click on HC Info – Legionella Assessment and Management Plan Support (LAMPS)

What Is Legionnaires' Disease?

The name ’Legionnaires’ disease’ was derived from an outbreak in 1976 that killed 29 people who attended the American Legion Convention at Bellevue-Stratford Hotel in Philadelphia, Pennsylvania.  The bacterium Legionella pneumophila, which causes severe pneumonia together with other devastating complications, spread from the hotel’s water system to the ventilation system.

There are approximately 60 different species of Legionella.

Legionella culture with script

The CDC states that:

  • Illness occurs most frequently with increasing age (most cases are at least 50 years of age).
  • People who smoke, have diabetes, lung or renal disease, malignancy and compromised immunity are at most risk of contracting Legionnaire’s disease.
  • Generally, more men than women contract Legionnaires’ disease.
  • It is rare in persons under 20 years-of-age.

A mild form of Legionnaires' disease is called Pontiac fever and can present with fever, chills, headache and muscle aches but does not infect your lungs.  Symptoms usually clear up within 2 to 5 days.

Where does Legionella exist?

Legionella thrive in warm and humid ventilation systems where they can multiply in the presence of algae and organic matter. 

  • HVAC Cooling towers in large buildings, specifically hotels, hospitals, long term care  and nursing homes
  • Plumbing systems including hot water tanks and heaters
  • Whirlpool spas, hot tubs and hot springs
  • Mist machines in supermarkets
  • Humidifiers
  • Decorative fountains
  • Swimming pools
  • Birthing pools
  • CPAP equipment
  • Sprinkling systems
  • Safety shower and eye wash stations
  • Nebulizers, hand powered resuscitators and breathing ventilators
  • Potting soil and compost
  • Ice machines

Symptoms

 

Incubation period for Legionnaires disease is 2 to 10 days – but can be as long as 16 days.  Legionnaires’ disease could cause the following symptoms:

upper body - lungs
  • Headache
  • muscle pain with a general feeling of malaise
  • high fever (up to 40-40.5°C or about 104-105°F) with shaking chills
  • on the 2nd or 3rd  day, dry coughing, chest pain and difficulty breathing
  • gastrointestinal symptoms including nausea, vomiting and diarrhea
  • pneumonia might involve both lungs and become so severe that hospitalization is required
  • confusion, disorientation, hallucination and loss of memory can occur

The Mayo Clinic acknowledges that Legionnaires’ disease:

  • primarily affects the lungs but occasionally can cause infections in wounds and other parts of the body including the heart
  • can lead to complications including respiratory failure, septic shock and acute kidney failure.

Prognosis

Legionnaires' disease is treated with antibiotics.  Early diagnosis and treatment helps reduce serious complications.

If the patient has a prior illness, is a transplant recipient or suffers from a compromised immune system, he/she could experience prolonged hospitalization, complications and death.

Patients are often admitted to intensive care units in hospitals and some patients suffer long-term impairment of health. 

  • 75% of outbreak survivors suffer from fatigue
  • 66% have neurological symptoms, and
  • 63% experience neuromuscular symptoms months after the onset of the disease

Legionnaires’ disease is not transmitted from person-to-person, although the CDC states it is aware of one case that occurred under rare circumstances.

Proficiency Studies of Legionella Culture Testing Labs

Science Direct published a study in October 2011 called, “Accuracy and precision of Legionella isolation by US laboratories in the ELITE program pilot study” where the CDC conducted a proficiency study of 20 ELITE-certified Legionella culture testing labs. 

Their findings showed that, on average, the culture labs undercounted the actual Legionella concentrations by 1.25 logs (17-fold) and values differed between labs by 0.78 logs (6-fold).

The Journal of Water & Health published a study in 2019 called, “Validation and in-field testing of a new on-site qPCR system for quantification of Legionella pneumophila according to ISO/TS 12869:2012 in HVAC cooling towers” and verified the following data:

  • 53 cooling towers were tested for 12 weeks by on-site qPCR and off-site lab culture.
  • On-site qPCR detected Legionella above the acceptable limit of 10 bacteria/mL in 21 towers at a rate of 40%.
  • In contrast, lab culture only detected Legionella above the limit in 8 towers (15%) and completely missed a tower with contamination of more than 100 times the limit.
  • The major reason for lab culture's poor performance was because bacteria degraded in 72% of water samples while being shipped to the lab.
  • Lab qPCR showed no correlation with lab culture and yet underwent the same bacterial degradation effect during shipping.
  • 11 cooling towers (21%) experienced rapid Legionella growth of 3 to 21 times over 7 days. 

Testing Water Delivery Systems

The Ministry of the Environment regulates the water delivery system in Ontario.  While “…licensed and eligible laboratories test hundreds of thousands of drinking water samples from the regulated systems to help ensure that drinking water quality meets Ontario’s health-based standards”, they do not routinely test for Legionella because it is ubiquitous to the environment – in the water, soil and sediment and can grow in a wide range of temperatures.

Microscope

Public Health Ontario (PHO) states they test the water for Legionella five times a week and any samples that show the presence of bacteria capable of causing illness are reported to the Medical Officer of Health as per the Ontario Health Protection and Promotion Act.

“If Legionella was isolated from an environmental sampling site in connection to an outbreak investigation and is a match to the clinical case, remediation is required and consultation with PHO Laboratory microbiologist is recommended,” states Public Health Ontario.

“The United States Environmental Protection Agency (EPA) declined to add Legionella tests to the water testing laboratory certification program in the early 1980s,” states GTS Legionella Testing Laboratory.

“Legionella on BCYE (buffered charcoal yeast extraction) agar media are often overgrown or inhibited by competing microbial flora that mask the presence of legionella colonies, particularly with water samples taken from warm water-containing mechanical equipment exposed to the environment such as fountains, cooling towers, and saunas,” states Dr Richard W Gilpin RBP CBSP, Director of GTS Legionella Testing Lab.

“Labs using the voluntary CDC Elite Culture Method, managed by the Wisconsin State Laboratory of Hygiene, often produce inaccurate test results,” adds Gilpin.

Spartan Bioscience

Spartan created the first on-site Legionella DNA test to prevent the risk of Legionnaires’ disease outbreaks in buildings.  It consists of the Spartan Cube and a single-use disposable test cartridge. 

For the first time, healthcare providers and their patients can receive DNA results on demand.

Spartan Bioscience is the leader in on-demand and on-site DNA testing in the world.  Spartan’s test provides highly accurate results in 45 minutes using a Nobel-Prize winning chemistry called quantitative Polymerase Chain Reaction (qPCR).  qPCR is commonly used for medical diagnostics because it is much faster and more accurate than culture.

The Spartan Cube, the world’s smallest DNA testing platform, enables unprecedented portability, convenience and efficiency in applications such as infectious diseases, pharmacogenetics and food and water safety testing.

Serving real estate; water treatment; data centres; healthcare; hotels and resorts; cruise ships; mining, oil and gas; food processing and distilleries; manufacturing and automotive industries, Spartan’s Legionella test is validated according to ISO/Technical Specification 12869:2012.  (4) For more information, visit https://environmental.spartanbio.com/

CDC Recommendations for Facilities and Buildings

Facilities and buildings may apply a “30% positivity action threshold” which means remediation of the water system is performed when Legionella is recovered from less than or equal to 30% of the samples tested.

After a source has been identified and remediated, CDC recommends re-testing for Legionella should be conducted every two weeks for three months, and then every three months, to ensure that the remediation has been effective.

Once Legionella has colonized a water system, eradication through disinfection is very difficult.

Long-term control (not eradication) of Legionella can only be achieved through proper treatment and management of water systems following strict guidelines towards the prevention of Legionella growth.

water tower with script

While the traditional method of thermal disinfection has been used to control Legionella, it is not effective.  The thermal mixing valves that blend hot and cold water to prevent scalding and the complexity of water systems, especially in healthcare facilities, proves difficult to maintain the required temperature in controlling Legionella. 

“Hot-water heater temperatures should be maintained above 140°F (60°C) and the hot-water temperature to distal points (the point of connection to a fixture such as a faucet, showerhead, or thermal mixing valve that blends hot and cold water right before they reach the tap) should exceed 131°F (55°C),” states the National Academies of Sciences, Engineering and Medicine.

Other water treatment technologies, such as copper-silver ionization, ultraviolet light radiation, ozone, monochloramine, point-of-use bacterial filters and chlorine dioxide (used by many hospitals), exhibit caveats and/or limitations.

Hydrogen peroxide looks to be a promising control method for decreasing Legionella colonization; however, further field studies are required to confirm its effectiveness in healthcare environments.

testing water from cooling towers for pathogens

The National Academies of Sciences, Engineering and Medicine (NASEM) published a news report last November 2019 called, ‘Stronger Policies Needed to Protect the Public from Legionnaires’ Disease’ wherein they stated,

“Studies worldwide have shown increasing incidence of Legionnaires’ disease.  In the United States, the reported incidence of Legionnaires’ disease increased more than fivefold from 2000 to 2017, likely due to multiple issues, including an increasing share of the population with health vulnerabilities (including the elderly and immunosuppressed), more people living in cities served by aging and centralized water systems that include cooling towers, and newer and easier ways to test for the disease, among other factors.

NASEM firmly advocates that all government buildings, hotels, hospitals, businesses, schools, apartment buildings and any other public buildings should be required to have a water management plan.  This requirement would be classified and managed by either local jurisdictions or state authorities and enforced by insurance companies, wherein if a building does not have a water management plan, then the building does not qualify for insurance.

Brilliant!

Undertaken by the Committee on Management of Legionella in Water Systems, this study was sponsored by the Centers for Disease Control and Prevention, U.S. Department of Veterans Affairs, U.S. Environmental Protection Agency, and the Alfred P. Sloan Foundation. 

Canada:  Primary Guidelines & Regulations for Water Systems

In Quebec, owners of cooling towers will be responsible for registering their facilities to the RBQ, establish a maintenance program, which needs to be certified by a cooling tower maintenance specialist and keep a record of interventions carried out on the cooling system and regular testing.

water cooler test for pathogens with script

Vancouver City Council stated in a policy report “…cooling towers are associated with the greatest number of confirmed Legionnaires’ disease cases in outbreaks between 2006 and 2017. With the strong support of health authorities, this report proposes mandatory operating permits for new and existing cooling towers, effective January 1, 2020.

In April 2010, the Health Protection Division of Public Health Services in Hamilton, Ontario declared a Cooling Tower Registration by-law “…to improve the scope and accuracy of the cooling tower inventory, expedite Legionella outbreak investigations, and diminish the potential of Legionella illnesses that could be related to exposure to cooling tower emissions.”

In July 2019, 16 cases of Legionnaires’ disease were reported in Moncton, New Brunswick.  Mayor Dawn Arnold proposed a cooling tower registry and compliance monitoring system to prevent future outbreaks.

United States

In 2018, The American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) amended Standard 188 (essential for anyone involved in the design, construction, installation, commissioning, operation, maintenance and service of centralized building water systems and components) by issuing minimum legionellosis risk management requirements for building water systems – and to date, does not mandate Legionella testing.

New York City implemented a registry in 2015 after an outbreak of Legionnaires’ disease.  Local Law No. 77. NYC LL77 requires registration, inspection, cleaning, disinfection, and testing of all New York City cooling towers.

United Kingdom

UK Approved Code of Practice L8 – is aimed at duty holders, including employers, those in control of premises and those with health and safety responsibilities for others, to help them comply with their legal duties in relation to Legionella.

Despite Legionella testing requirements, cases of Legionnaires’ disease are still on the rise.

The problem is that the traditional Legionella detection method involves culture testing in an off-site lab, which can take up to 14 days to provide a result. Legionella can grow to outbreak levels in as few as 7 days. 

Additionally, culture has been found to have a false negative rate of 62% because Legionella dies on the way to the lab. 

microscope-2

In comparison, Spartan Bioscience’s test provides highly accurate results in 45 minutes using quantitative Polymerase Chain Reaction (qPCR), which is commonly used for medical diagnostics because it is much faster and more accurate than culture.

Conclusion

The influx of Legionnaires’ disease cases is partially due to the disintegration of infrastructure systems, climate change, an aging population, and advanced medical technology that detects and characterizes the pathogen that causes the disease.

The CDC, WHO and NASEM affirm that outbreaks of Legionnaires' disease are preventable.  The maintenance of water management systems including cooling towers, drinking water systems, hot tubs and decorative fountains require regular monitoring, testing and cleaning.

While the CDC created a water management toolkit to reduce the number of Legionella cases and concurrently, assisted the Centers for Medicare and Medicaid Services (CMS) to integrate a 2017 ruling, especially for nursing homes, medical environments and institutions; officials from CMS issued a directive in 2018, which stated that testing protocols and the use of the toolkit is not compulsory and therefore, at the sole discretion of each company, organization and institution.

Since the discovery of Legionnaires in 1976, medical professionals have acquired substantial knowledge about the disease including effective medical treatments but the methods and guidelines of detecting pathogens and diagnosing patients is anything but adequate.  The word ‘antediluvian’ comes to mind.

Clearly, medical technological advancement and the procurement of innovative measures are required to detect pathogens in an accurate and timely manner.

While public health officials are aware of some of the contaminated locations where people are contracting Legionnaires’ disease, the information is privy and as well, there is concern about the conceivable, financial impact on the location.  The last statement reads like a regulatory response and not one that would serve, respect and protect its citizens. 

Health concerns are unobtrusively dismissed and once again, the almighty commercial dollar takes precedence.  That is, until you contract the disease - and then city staff and health officials will want to know everything about you.

People are just going about their days, accomplishing one thing after another on their ‘to do’ list, completely unaware that they are about to walk into a ‘hot zone’ where they could contract Legionnaires’ disease – a disease that will irrevocably change their lives and the livelihood of their family. 

Everything that I have read and researched tells me that this disease, if not detected and diagnosed in time, will kill you.

That the medical industry is aware of innovative technology that would expedite diagnosis for the benefit of the patient but is reluctant to use it – is beyond my capacity of acceptance or understanding.

That health officials know the locations of some of these ‘hot zones’ but can’t reveal their sources is something that just gets under my skin and makes me want to scream. 

Legionnaires’ disease is not something that people just get over; it is brutal and unrelenting - debilitating people’s lives for years after the initial diagnosis.  And for those less fortunate, who have succumbed to this insidious disease, I have only one question.  If they received the proper diagnosis and medical treatment, would they be alive today?

Withholding crucial information is not about being fair and just; it’s a governing voice that needs to be right.

“In any moment of decision, the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing.”  ~ Theodore Roosevelt

Resources

For additional information, Diligencia Investigative Reporting recommends the following websites:

HC Info – Legionella Assessment and Management Plan Support (LAMPS) – this website lists all the latest outbreaks globally

International Journal of Environmental Research and Public Health - Legionnaires’ disease Cases at a Large Community Hospital—Common and Underdiagnosed

The National Academies of Sciences, Engineering and Medicine – Management of Legionella in Water Systems (2019)

Public Services and Procurement Canada - Control of Legionella bacteria in the Public Services and Procurement Canada real property portfolio

Public Health Ontario – Legionella Investigations

Moncton calls for cooling tower regulations after legionnaires' outbreak – CBC News Report

Spartan:  Scientific Briefing – On-site Legionella DNA Testing

Spartan:  Understanding Legionella Testing

Health and Safety Executive – the control of Legionella bacteria in water systems

New York – Local Laws of the City of New York – 2015 – in relation to the regulation of cooling towers

Association of Water Technologies - a Position Statement and Guidance Document on Legionella in 2019

Public Works and Government Services Canada – MD 15161 – 2013 – Control of Legionella in Mechanical Systems

Government of Canada – Public Health Services

Public Health Ontario - Legionellosis

Legionella.org

Canadian Centre for Occupational Health and Safety

Legionellosis Outbreak Toolbox - WHO

CDC – Legionnaires’ disease Prevention

Additional Resources

Diligencia Investigative Reporting recommends the following articles:

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CDC – What Clinicians Need to Know about Legionnaires’ disease – contains valuable information on video format

CDC – Legionella – Prevention with Water Management Systems

CDC – Resources and Materials including fact sheets, videos, infographics, podcasts, public service announcements, blogs, toolkits and training.

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