Unveiling the Truth About Legionnaires Disease and Water Safety

[00:00:00] You might not realize it, but we are exposed to dozens of hazards every day. Can any of these hazards negatively impact your health? Definitely this is the Exposure Scientist podcast.

[00:00:13] My name is Alex LeBeau and here we answer your questions and concerns on what you may be exposed to every day. Welcome to the Exposure Scientist podcast. I would like to welcome you today's episode of the Exposure Scientist podcast.

[00:00:30] Today I think I'd like to discuss a little bit more about Legionella and Legionnaires disease. I do a lot of work in the Legionella and Waterborne Pathogen Water Quality area. And I think it's an important area that continually misses the attention that it so desperately needs.

[00:00:48] If you look at news articles right now and go search for news and Legionnaires disease, or Legionella, there are a lot of articles including some involving a federal building that's in Michigan.

[00:01:00] Where a lot of the people don't want to go back because they've identified Legionella in the building water system. I think it's important to understand what the risks are, who the Exposure population could be and what you should do about it.

[00:01:13] And one of those ways is to view what's in the news. And that's what I like to do. See what people are seeing and one of those areas is a nursing home that actually had a recent outbreak or a recent case of Legionnaires disease.

[00:01:29] And there was Legionella detect in the water. And today I'd like to kind of discuss the article that I've seen and understood from reporters and how the public is perceiving it. The views expressed in this podcast may not be those of the host or management.

[00:01:45] This podcast is for informational purposes only and should not be considered health advice. It is recommended that you consult the exposure scientist to discuss the particulars of your exposure scenario. Now I do a lot of work in the Legionella realm dealing with Legionella bacteria,

[00:02:02] dealing with facility water quality, addressing harms from general waterborne pathogens. It could be anything from pseudomonas, it could be Legionella, it could be non-micobacterium tuberculosis that is growing within the facility water system for whatever reason, whatever impacts it has. One recent news article got my attention for Legionella.

[00:02:29] I was a little bit disappointed in my LinkedIn. I just like to have a discussion with you and I always like to bring up news articles. It's what people are seeing in the public.

[00:02:38] It's in their mind, it's on their phone in front of them formatted very nicely for them to see and understand. But when the reporting or even what are identified as people who are dealing with the issue are giving information that doesn't make a lot of sense.

[00:02:57] It is important to point that out. So this is a nursing home in the title. I'll just make it general, it says the nursing home investigates rare case of Legionnaires disease. Well first of all, Legionnaires disease is not rare.

[00:03:15] In fact, the Legionnaires disease has been increasing in identification. It's a reportable disease, CBC reportable disease and has been increasing over the last 20 years. And in fact, I've recently done an analysis to show that the under reporting.

[00:03:30] There's a lot of under reporting, you know, the idea that, you know, let's just, I don't have, let's just say, you know, last year there may have been 12,000 report cases of Legionnaires disease. That number is likely much higher. Some sources say it's eight to 10 times higher.

[00:03:48] Some sources say it's two to four times higher. I've done an analysis to show that under reporting is definitely occurring week by week. And the disease is being missed to say this was rare disease for people who are knowledgeable in this area,

[00:04:03] would say Legionnaires, Legionnaires disease is not a rare disease. And to say that it is minimalized, minimizes it, it trivializes the disease impacts, especially for those that are a higher risk for developing Legionnaires disease from exposure to the Legionella bacteria. So very generally, for Legionella and exposure,

[00:04:25] again, we're expung exposure scientist on the exposure scientist podcast. You have to be exposed to Legionella in such a way that it can impact your body. What is the primary way for exposure to Legionella bacteria?

[00:04:40] Well, it would be inhalation of aerosolize water, water droplets or potentially desiccated or dried water. It would be inhaled or dried water, aerosolized into the air that we inhale in our lungs. And once it's inside our lungs from a water source that has Legionella growing in it,

[00:04:59] it's not only the presence of it but has to be growing in such a way that it can infect someone. Once it's inside our lungs from the release of a source that had Legionella growing, it can in certain scenarios and people with risk factors develop into Legionnaires disease.

[00:05:20] Our host immune system could be such that it is not strong enough to combat the bacteria. Many times healthy individuals can fight it with no problem. You may have some issues from it, but our host immune system is pretty good. Some people may have those risk factors.

[00:05:38] What are some of those risk factors? For over 50 years of age, your former current smoker. You have some autoimmune issues or some kind of a compromise immune system. Looking at those and taking those in consideration are mean may be the higher risk that your body cannot fight.

[00:06:00] Use its host defenses to protect you from exposure, protect you from the growth of the bacteria within your lungs. And that is going to develop in pneumonia and once that in the morning presents,

[00:06:16] it may be difficult to get rid of using bacteria when you go into the emergency room or go into a hospital. There has to be certain antibiotics to treat that disease to Legionnaires disease. There is lots of ways it gets from the water system within the facility.

[00:06:34] Grows inside that water system, aerosolizes into the air from shower heads, from faucets, from anything that's going to make aerosols. Think about a faucet and it has an aerosolizer on there. It kind of makes it a little bubbly. Well those aerosols will go up into the air.

[00:06:54] Those can float around. Those can exist inside the indoor environment. So to say that and when we have data that shows that this happens more often than you may think it does. And to say that Legionnaires disease is a rare occurrence, we definitely know it's not.

[00:07:16] Centers for Medicaid Medicare Services have put out memos saying we need to have facility protection plans against Legionella, who grow the Legionella within your facility and have water management. There have been ash ray 188 talked about facility water management.

[00:07:34] There's a new ash ray 514 out there for dealing with other waterborne half of the ginsenged issues inside of a facility's water system. It's known that there are issues. CMS has talked about it. Joint commission has talked about it.

[00:07:50] The fact that this article says that it is a rare case of Legionnaires disease just boggles my mind because it's not rare. So let me get into it a little more. So we talked about the exposure.

[00:08:04] We've talked about how people could be exposing that they are risk factors. It says one person at the nursing home has been infected, but they're being treated like minimizing it. They're working with Iowa Department of Public Health regarding precautions and treatment

[00:08:22] and bottled water is being provided to residents. Now, I talked about the major route for exposure being inhalation air source. What are some other potential minor routes? Well, water has to get the air solve. The water containing the Legionella bacteria has to get into your lungs.

[00:08:42] So I can breathe it in, whether it have been instances of reports where people have ingested water and aspirated the water and inhale that aspirated water into the lungs. Those are very, very minor instances. Passing out bottled water to the residents, I don't know what they're doing.

[00:09:04] That just makes it seem like there's water that has other issues. Maybe they're not reporting other issues that are in the water system or they just don't really understand the problems going on here. Let's just say, it says no action,

[00:09:22] the Department of Health says no action is necessary as the case appears to be specific to the individual facility. Exposure science covers a broad subject area, including toxicology and duster of hygiene and risk assessment. From occupational, community, or environmental exposure, scientists apply scientific methodologies to understand exposure risks

[00:09:49] and apply controls when necessary. We at Exposure Assessment Consulting have this expertise. Please reach out to us at info at exposuresconsulting.com for a free 15-minute consultation to discuss the specifics of your exposure scenario. That is interesting because if you have identified,

[00:10:15] it doesn't say whether there is bacteria in the facility, or whether there is any other indication that I may be, says water samples from the distribution system in the area showed no bacteria presence. Typically, local water utilities do not test for Legionella bacteria.

[00:10:31] I don't know if that was done here. Many times they rely on surrogate measurements of Legionella, or in monocloramine disinfectant, PH, other measures of water quality to indicate physical call form units. Total call forms, heterotrophic bacteria, to surrogate to indicate whether or not Legionella is present.

[00:10:57] Many, many times local water utilities do not test for the presence of Legionella in their systems. If they do that here, I don't know because it typically don't. Talks about CDC, whether they can grow on a system of water,

[00:11:11] whether they can grow on a system of water's found in fresh water systems. It is interesting the way they say, they say this or bring it up, is one of, I'll just say, a health department representative said, is rare to see a Legionella disease case,

[00:11:37] but they do pop up from time to time. They pop up many times. Many times they can be overlooked, especially during COVID because COVID people with COVID or people with Legionnaires disease will present with the same symptoms.

[00:11:55] At a doctor, they'll observe the same signs as a doctor amount of physician, but I understand pneumonia increased fever, difficult to breathing, et cetera. It's not rare to see Legionella disease and that's important to understand. And this just goes on to show the lack of knowledge here.

[00:12:20] It says, the disease is spread by aerosolidropis getting the person's lung perfect, often in wet areas or in air conditioning systems. That is very much, I'll say, the air conditioning system is very much a misnomer. It will be in certain types of cooling systems, like a cooling tower,

[00:12:40] but typically those will be closed, systems. Individualysis says bacteria can be deadly, but it's usually treatable with antibiotics. They're only certain antibiotics that were going to treat Legionella, and Legionella infection and the individual legionalosis. So there's lots of information that's out here that's being presented in the story.

[00:13:01] That makes me question that they actually know what's going on here. This is interesting also, I love this quote. And says, I don't want to say avoid hot tubs and world pools because it's a really nice thing at the end of the day

[00:13:15] to be able to sit in there. But if you do have compromised lungs, that may not be in your best interest. It's trivializing the disease. It's the, and again, I'm not privy to the whole interview. Maybe they just grab snippets.

[00:13:34] But the way that they are flippantly talking about Legionella and Legionella, and Legionella, is insulting to exposure scientists because we understand these risks. We understand when you may need to mitigate the exposures when you may need to avoid the exposures.

[00:13:52] There are things you need to do to ensure that you are protecting the individuals within the facility. A facility like this that had someone that says they have Legionella or Legionnaires disease, have the individual has not left the facility.

[00:14:09] Does that, does that individual go to other doctors visits outside the facility? Have they been doing emergency room lately or they go out with their family or whatever, or they isolate it to the facility? All right, understand of their isolation. Evaluate the facility.

[00:14:26] Does facility have a facility of water management plan? How about they do in their routine testing? Do they have data to show that they have or do not have detectable levels of Legionella or showing that Legionella is not growing in there. Do they have water quality per man.

[00:14:40] Are they, are they deferring all this information out to outside vendors? Are they doing it in house? Do they even have it at all? There's so many factors that go into this. And the response by the health department workers or the coach in here really worrying me that

[00:14:59] someone may not have the expertise to address these unique exposures that they're so rare. I've seen this before. If they're so rare and they do not happen that often, and how do you know that you're dealing with it correctly if you deal with it very seldomly?

[00:15:20] I deal with it often. I understand what goes along with it. I understand what you need to be looking for, where you need to be looking. But if you don't deal with that much, it's okay to ask for help.

[00:15:33] Exposure science covers a broad subject area including tax ecology and industrial hygiene and risk assessment. From occupational community or environmental exposure, exposure scientists apply scientific methodologies to understand exposure risks in applied controls when necessary. We at exposure assessment consulting have this expertise.

[00:15:54] Please reach out to us at info at exposuresconsulting.com for a free 15 minute consultation to discuss the specifics of your exposure scenario. It's okay to say, maybe this is not my area expertise.

[00:16:10] Maybe I need to have somebody come in here and assist me with this or kind of give me some pointers. Because the comments again that are included in this story show me that there is a little lack of complete understanding of the exposures and the risks.

[00:16:32] What about the other industry home residents? Has a comprehensive review been done? What do they think only this one person is going to be impacted if there's impacts in the facility? This one person have particular risk factors for it.

[00:16:47] Again, over 50 that's a risk factor is an nursing home. There are requirements for nursing homes to address water quality. As has been done, I've seen, I've spoken and seen nursing homes and I've gone in there and they say, Oh, everything's fine.

[00:17:04] We were defaulting this out to the other side of the other side. Vendors to come in and address for us. I go in there and I say, well, your vendor is not doing US service because I walking in the door just walking down the hall.

[00:17:18] I've seen four or five things that would make me question whether or not they are doing things in your best interest or they are doing things to check a box. Because there's a difference between doing the basic minimum.

[00:17:31] So you're doing what something may call for an actual versus actually using the data and the information or making informed decisions and evaluating risk. The way that some of these facilities are addressing their water quality. And again, I'm putting this in the scope of Legionella.

[00:17:55] But it's all kinds of water quality or waterborne pathogen issues. Health care facilities should be highly aware and a lot of these issues. Again, some of them are not. But some of them are not. But you think about other non health care facilities that people go too often.

[00:18:16] There's lots of different types of facilities and have Legionella issues hotels have Legionella issues. We've seen it restaurants. We've seen it occasionally. We'll see it at a residence, but that's a whole other story and discussion. See it at Businesses multi-family residences.

[00:18:37] There's lots of places where Legionella can impact, but there's lots of people who are not managing their water as it is called for. And I always like to say it's people who are playing the Legionella Lottery.

[00:18:49] At some point, you're going to win that lottery for better or for worse. What does that mean? Are you going to have the data that is required in the water management plan to back up any claims that are made about your facility?

[00:19:05] If you have the Health Department knocking on your door saying, We have a reported case of Legionella as disease that came from your facility. Do you have the data say, we do quarterly testing, we do semi-annual testing, we do monthly or weekly water quality testing.

[00:19:23] All this here is our companion of data on our water quality or facility water management plans. It is not our facility. Or do you not have much? That is a vaccine in a lot of times.

[00:19:41] There are people, I mean, there are people who are going to sue and say we got it at your facility. You're not following the standard of care that is out there for this.

[00:19:55] And those kind of claims are low-hanging fruit or anyone who wants to go after it because if you have a facility, that is monitoring, oh well for example, I'll give this example down here in Florida.

[00:20:09] There's a requirement says you have to monitor your water quality and your pool or spa or whatever everyday. It can be every 24 hours every day. It has to be recorded on a log sheet. The state provides a log sheet for you to fill out.

[00:20:25] Many times outside vendor will come in and say, This is the cost for us doing it in varying costs and there'll be a determination where we will have the outside vendor come three days a week. We just need that form fill that three days a week.

[00:20:42] This is low hanging fruit. All it takes to someone to come and say, well what about the other four days a week where there's no recording on that log? Some facilities will do it in house they'll say, okay, on the days those vendors are not coming.

[00:20:57] We will take the water quality measurements record them on the log. Other places just say, I don't really need that. I'm doing something. Well, but it comes down to it and someone gets lead generes disease.

[00:21:12] They claim it's your facility and either the individual gets very sick or dies. They're going to get a knock on their door and there are insurance companies going to have to get involved.

[00:21:23] There's going to be a claim that it came from your facility. Are you going to have the data to support that? And that's what's important. You know, Ash Ray, 188, which is a consensus standard of care for a legionalosis facility water management and surface facilities.

[00:21:39] Came out in 2015 and I recall a research article that was done in 2017 or 2018 it was published. That was a evaluation of healthcare facilities. I think it was in Minnesota and they pulled them said, do you have facility water management plans?

[00:22:00] I think it was something like half of the facilities didn't even have those plans. In 2017, 2018 CMS came out with memos about discussion for legionalosis and facility water management plans.

[00:22:14] I'm sure that's a lot higher now. I haven't seen any current data on healthcare facilities on what they may be doing for their facility water management. I think and you'll see this in the CDC data and I have done this evaluation.

[00:22:31] And illustrated it is that during COVID, other reportable diseases like legionnaires disease took a back seat.

[00:22:43] So the data from 2019 to 2020 drastically different. The way it looks, the way it presents the way it reads, just the way it was reported because of a variety of reasons things shut down.

[00:22:58] Facility shutdown, health departments are focused on COVID, not Legionnaires disease healthcare facilities were focused on COVID, not Legionnaires disease reporting for thus 2020 is very strange and usually there's supposed to be annual numbers other presented by CDC those annual numbers haven't come out in the few years.

[00:23:18] We can use some weekly reporting data for that evaluation to determine a current incidence of legionnaires disease over a certain period time.

[00:23:30] But the way that it was been evaluated, the way legionnaires disease has been looked at has somewhat again taken to back seat. I think it's on the upswing again.

[00:23:44] I've heard people may comments even in our profession even amongst industrial hygienists or other exposure scientists will say these these issues are settled.

[00:23:53] But they're not settled there can tenial issues facility water management and water quality are continual issues that need to be addressed by the facility you cannot rely on the local water utility to do that for you.

[00:24:09] They are responsible for the water that they are treating what comes into your tap what comes out there. It's in distal spots we could be many miles from where water quality or water enters the facility is treated.

[00:24:28] So you need to take it upon yourself to understand the quality of the water entering your facility. Quality of the water that your occupants are using the quality of the water that's a distal points within your facility.

[00:24:42] You know, they're staying the risk factors of those individuals that are either patronizing or occupying or visiting your facility or what have you because you need to have a robust plan one place I worked with. I remember this they you know.

[00:25:00] They had an outbreak and they didn't want to a for a facility water management plan we don't we don't need to spend the money.

[00:25:09] They had an outbreak and they ended up paying on the other end it cost a lot more once there was an outbreak and people were up in arms about it.

[00:25:21] And then being proactive approach reactive always costs a lot more than being proactive and it's hard to help people understand that because they see stories like this. They say, oh, we need you there as disease it says it's a rare I don't need that.

[00:25:37] I mean, it's not going to happen to me but it will happen at some point whether you own multiple health care facilities whether you own multiple hotels restaurants what have you. The chances that someone will claim that they got it at your facility is in greasy because.

[00:26:04] Whether or not someone thinks is rare it is not I think that's very important understand that minimizing the impact of any water quality issue again here talking about Legionnaires is is.

[00:26:21] It's hard to get over that hill we saw it during COVID we saw we see it now we will continue to see it one on I'll say public health. Is the inability to effectively communicate risk.

[00:26:45] One of our jobs as exposure scientists is to effectively have risk communication from people that are knowledgeable and have the expertise to those who may not have that expertise in the effect of about it you scientifically back to value back.

[00:27:05] You know, I think that's the reason why we're making decisions. I can use data to see that Legionnaires disease is not rare but communicating it the way they did of well it's rare we're passing out bottle water it's fine.

[00:27:21] I want to go in the spot relax you have to wait it gets you know whether or not you may want to get it then having these kind of comments is not helpful I'll be honest and someone as a practitioner in this area it.

[00:27:40] It makes it a hill higher and it makes it seem like we are lower on the hill to get over for making people understand what the issues are.

[00:27:50] I always been like this it will always be like this and I think as exposure scientists we're going to continue to help and aid and understand and get this in the forefront.

[00:28:03] I think that is a very important thing to have a new product like this is is detrimental to our efforts. I think establishing good communications with people and the media or with health departments is is vital for us to.

[00:28:21] I think that is a very important thing to do with the health department or the facility or we're having that. You are not familiar with this okay to ask for help.

[00:28:36] No shame in saying you know what this is not my area let me go find someone who is because it's better to address it now when come in later on when you've had someone try to address it and then someone else has to clean it up because.

[00:28:53] If you're not effectively all this maybe you say evaluating the facility taking the correct type of samples understanding the water quality for you know. Even this little small thing.

[00:29:07] When you're evaluating incoming water quality of facility you have to understand what the local utility uses for their disinfectant I've seen at many times where. And then they say oh look there's zero zero parts per million of chlorine.

[00:29:24] And you go back and look and you say well of course there's your chlorine machine is going to probably be recording zero because the facility the local water utility uses a lot of chlorine the different type of.

[00:29:37] Instrumentation for evaluation is going to show up differently you have to make sure you're evaluating the correct thing to get the right numbers it takes a lot of time coming back to explain why things are wrong and yours are right.

[00:29:51] And it's better to get us in early then it is late because there's a lot of catch up has to be done. You know, you have to get a lot of information and you have to get a lot of information.

[00:30:07] So I want you to take this information that presented today is just a little bit again for Legion Ellen and it was all prompted by this article I saw minimizing the impact of it Legion Ellen is not a small issue. I think it's a big question for you.

[00:30:21] Because it's statements like those are included in this article make it seem like someone doesn't know what they're doing or talking about and.

[00:30:33] For those who are reading this article to say well, why do I have to worry about doing this or doing that when that's not the correct risk communication that we should be having for those impacted. I hope today's podcast was helpful to you.

[00:30:46] Be having any questions please feel free to reach out. I'm happy to have this discussion. I love talking about this stuff. I'm happy to and again ask for help. It's never a problem never an issue and you it will benefit things in long run hope everyone takes care.

[00:31:02] Thank you.