In 1976, thousands of patriotic veterans of the American Legion gathered in Philadelphia for the nation’s Bicentennial Celebration. It should have been a festive occasion, but soon proved deadly. Nearly 300 attendees contracted an unfamiliar form of pneumonia that left them coughing, sneezing and in many cases, struggling to breathe.
In the end, nearly two dozen of those sufferers died in one of the worst infectious disease outbreaks in the city’s modern history.
An enterprising young Philadelphia Inquirer reporter was on hand to report on the outbreak but no one at the paper knew what to call the illness. After calls to local public health officials proved fruitless, the paper’s editor struck upon a name for the illness: “Legionnaires’ Disease.” It stuck.
Legionnaire’s Disease is said to be fairly rare, with less than 10,000 full-blown cases reported annually. But experts believe the real number may be closer to 70,000, or even higher.
That makes Legionnaire’s the leading waterborne-borne infectious disease in the country but you’d hardly know it from the dearth of attention it’s received.
While about 10% of those that contract the illness die from it, a large number only suffers moderate flu-like symptoms that do not require hospitalization.
That means the illness still exists largely under the radar.
Legionnaire’s is also unique – and seemingly less threatening — because it is not contagious from one person to the other. Individuals are exposed by inhaling bacteria that grows in stagnant water through the air or soil.
Hospitals, spas, gyms, and hotels – sometimes their hot tubs and showers, but just as often their HVAC systems — are the most common breeding grounds.
The incidence of Legionnaire’s Disease has grown five times between 2000 and 2017. Last year saw the highest number of Legionnaires cases in over two decades. Public health specialists are still trying to figure out why.
America’s decaying infrastructure coupled with its aging population is partly to blame. As older buildings continue to deteriorate, their piping systems become corrupted with large build-ups of water in temperature ranges that facilitate the growth of Legionella.
And those over 50 with weaker immune systems, including retirees living in congested facilities, are also much more likely to find themselves vulnerable to attack.
These conditions were clearly in play in 1976 when large numbers of seniors attending the same event and staying in the same hotels were struck with the disease.
There’s even a strong possibility that modern “green” buildings, which tend to conserve water at moderately warm temperatures that facilitate the growth of Legionella, are causing the numbers of cases to rise.
2019 witnessed a handful of severe outbreaks. Four fairgoers were killed and nearly 150 fell seriously ill at a hot tub exhibit at a North Carolina state fair two months ago. In August, more than 70 hotel guests became infected at a Sheraton Hotel in Atlanta.
One of the big problems with Legionnaires is the cost of “remediation.” Since the problem lies in defective water systems, these typically need to be flushed out – or replaced, which is time-consuming and expensive.
In 2012, before the current uptick, the cost of treating Legionnaires’ disease, based on hospitalization claims alone, was over $400 million nationwide. California spent $8.5 million in 2018 cleaning up an outbreak at a Stockton prison that killed a single inmate.
After years of foot-dragging, the CDC and other federal health authorities have begun to make Legionnaire’s prevention a top priority, but with mixed success. Since 2017, the Centers for Medicare & Medicaid Services (CMS) has mandated that health care facilities have water management plans in place to deter the growth of Legionella, the bacteria behind the disease.
But it turns out that even good water management plans are not necessarily effective.
In Missouri in 2017, a study of 61 hospitals, nursing homes, and hotels in the state found 7 to be infected with Legionella. But all 7 had water management plans in place.
“Legionella finds places within large complex water systems to hide,” says Jonathan Garoutte, administrator of the Missouri health department’s section for environmental public health.
Some observers note that the new CMS guidance, while useful in theory, also lacks enforcement teeth. In fact, many private health care providers have refused to comply, citing the exorbitant costs, and forcing CMS to back down.
Last year, the agency said it would not formally require health care facilities to test for Legionella or other waterborne pathogens.
“Testing protocols are at the discretion of the provider,” the directive said.
In response, some public health officials are pushing back and demanding even stronger guidelines.
In a report released in August 2019, the prestigious National Academies of Sciences, Engineering, and Medicine (NASEM) called for sweeping national protocols to reduce the threat from Legionnaire’s Disease. These included:
- Extending the scope and standards of the federal Safe Drinking Water Act (SDWA) beyond public water supplies to include all public and private buildings vulnerable to Legionella growth
- Requiring all public buildings to have a formal water management plan subject to regular inspections and fines for non-compliance.
- Mandatory monitoring of water temperatures in all buildings, public and private, including “green” buildings, to deter Legionella
- New recommended codes and guidelines for water heating and air cooling systems manufactured in the private industry.
- Expanding communications to private homeowners on the need to flush their shower and bathroom taps to prevent the build-up of stagnant water.
The NASEM report, the first of its kind, is suggestive of just how seriously federal health authorities take the potential threat from Legionnaire’s Disease.
Some sectors of private industry are likely to take new steps to comply with these recommended guidelines if only to reduce the threat of legal liability from a future outbreak.
But mandating a tougher enforcement regime may still be years away, analysts say.
The only good news? Effective treatment for Legionnaire’s Disease is readily available. The two most potent classes of antibiotic available are the macrolides (azithromycin), and the quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin).
But sufferers need to obtain the medicine quickly, or the risk of death, especially for those with pre-existing conditions, increases rapidly.