NEHA March 2019 Journal of Environmental Health

8 '85=6/ • =6,/: ' % ! % SCIENCE Sana S. Ahmed, MD National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention Candis M. Hunter, MSPH National Center for Environmental Health, Centers for Disease Control and Prevention Jeffrey W. Mercante, PhD Laurel E. Garrison, MPH National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention George Turabelidze, MD, PhD Missouri Department of Health and Senior Services Jasen Kunz, MPH National Center for Environmental Health, Centers for Disease Control and Prevention Laura A. Cooley, MPHTM, MD National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention Introduction Legionnaires’ disease (LD) is a severe pneu- monia caused by the bacterium Legionella . Approximately 9% of cases are fatal (Dool- ing et al., 2015). The rate of reported LD cases in the U.S. rose nearly 300% from 2000–2014, likely due to a number of fac- tors (e.g., an increase in susceptible popu- lations, aging infrastructure leading to in- creased opportunities for Legionella growth, increased awareness with improved testing and reporting) (Garrison et al., 2016). Le- gionella is found in freshwater sources. It amplifies in manmade water systems (e.g., spas, potable water systems, cooling towers) and disseminates via aerosolized droplets (Fields, 1996). In a review of LD outbreaks reported to the Centers for Disease Control and Prevention (CDC) during 2000–2014, 85% of outbreaks were caused by problems that effective water management could have prevented. Hotels and resorts accounted for 44% of outbreaks in this analysis (Garrison et al., 2016). In- adequate water system maintenance creates conditions favorable for Legionella amplifi- cation, including tepid water temperatures (77–108 °F), low residual disinfectant levels, water stagnation, and the presence of free-living protozoa, biofilm, scale, and sediment (Centers for Disease Control and Prevention [CDC], 2017). Changes in wa- ter pressure and water quality due to exter- nal factors, such as construction or water main breaks, have also been associated with amplification of Legionella in building wa- ter systems (Mermel, Josephson, Giorgio, Dempsey, & Parenteau, 1995). An industry standard published in 2015 described mea- sures to reduce the risk of Legionella ampli- fication and transmission in building water systems through use of water management programs (ASHRAE, 2015). In-depth knowledge of facility water sys- tems is critical for LD prevention and out- break response. Key components of facility water systems include source water (i.e., from a municipal water treatment plant, private well, or other source), cold water distribu- tion, heating, hot water distribution, waste- water elimination, and disinfectant treatment (CDC, 2017). An environmental assessment, ,; < : +- < During a Legionnaires’ disease outbreak at a Missouri hotel in 2015, the Centers for Disease Control and Prevention assisted state and local health departments to identify possible sources and transmission factors and to recommend improvements to water management. We performed an environmental assessment to understand the hotel’s water systems and identify areas of risk for Legionella amplification and transmission. We obtained samples from the pool, spa, and potable water systems for Legionella culture. In the potable water system, we noted temperatures ideal for Legionella amplification and areas of water stagnation. Additionally, we found inadequate documentation of pool and spa disinfection and maintenance. Of 40 water samples, Legionella pneumophila serogroup 1 that matched the sequence type of one available clinical isolate was recovered from five sink and shower fixtures. A comprehensive environmental assessment proved crucial to identifying maintenance issues in the hotel’s water systems and underscored the need for a water management program to reduce Legionnaires’ disease risk. Legionnaires’ Disease at a Hotel in Missouri, 2015: The Importance of Environmental Health Expertise in Understanding Water Systems  S P E C I A L R E P O R T

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