When it comes to Legionnaires’ disease, the real issue is a lack of effective public health policy and competent oversight. Ronald Reagan once said, “The nine most terrifying words in the English language are, ‘I’m from the government and I’m here to help.’”
When it comes to control of Legionella in building water systems, this Reagan quip is all too often the case.
Last month the state of Illinois’ Office of Auditor General published a report titled “Performance Audit of Legionnaires’ disease at the Quincy Veterans’ Home.” This report is about the four Legionnaires’ disease outbreaks that occurred at this long-term care facility in 2015, 2016, 2017 and 2018.
Each one of these outbreaks was followed up by an audit and subsequent written report by CDC Epi-Aid teams, four in all. In addition to Centers for Disease Control and Prevention audits, there were multiple audits by Veterans Affairs audit teams and Illinois Department of Public Health. After these many audits by public health experts failed year after year to identify and resolve the ongoing building water system Legionella issue. This was after tens of millions in costs, including over $1 million in lab testing fees. The CDC concluded in 2017 the water management plan in place was effective and in 2018 the water management plan was optimal.
The CDC Legionella Environmental Health group may have some confusion on the definition of effective public health policy. The best type of effective public health policy should be the greatest public good at the lowest public cost, not the opposite. An effective risk management plan will not eliminate illness but will effectively control risk.
For example, you may have one automobile accident every five years, but with effective signage you will not have multiple automobile accidents in the same place year after year. The CDC’s 2018 report, after finding the water management plan was optimal, also suggested a next step to resolving ongoing Legionella issues was to demolish buildings.
Even worse for the building owner, the Illinois report concluded ongoing illness at the Quincy home in 2016, 2017 and 2018 wasn’t the fault of the ‘experts’ from CDC, VA and IDPH that failed to identify root causes, but the fault of Quincy Veterans’ home staff. To me, that’s baffling.
Could this happen in a non-government facility? The answer is yes. I’ve seen all the issues that occurred at Quincy, repeatedly, however, never to this extent! If an outbreak lasted three years at a private nursing home, Medicaid and private insurance reimbursements could have been cut and new admissions would be put on hold.
The Quincy Veterans’ home had access to tens of millions of dollars in an endless stream of public funding, but a private nursing home would possibly have been put in bankruptcy had the Legionnaires’ disease outbreak not been addressed in a timely manner.
Health departments with the best of intentions too often don’t have the expertise to resolve building water system issues. Building owners will place their complete trust in these ‘we’re here to help’ health departments.
To make matters worse these health departments are now getting training from CDC on how to resolve building water system issues to address Legionella problems.
What should a facility manager do in the case of an outbreak?
- Response to even a single suspected case should be thorough, quick and well documented.
Not addressing the problem quickly and effectively can result in additional illness and huge consequential costs as discussed above. When one case turns into an outbreak, costs escalate quickly, and residents become sicker.
- Immediately hire a Legionella building water system engineering expert.
Check the CV or resume of the consultant you hire and make sure the person (not the company) coming to audit your water system has background and expertise in 1) design, operation and maintenance of building water systems, 2) Legionella control and remediation 3) effective engineering solutions to building water system issues and 4) development and implementation of Legionella risk management plans.
If you hire someone selling water treatment services, then most likely that suppliers’ conclusion will be to buy their water treatment. Others are selling lab testing services, HACCP process control and cloud data management. As the Quincy home found out, take any building water system recommendations from CDC, including contractors, with a grain of salt.
- If the health department makes any recommendations, ask for it in writing.
If you rely on health departments alone, in many, if not most, cases you will spend more money solving the problem. It will take longer to get water restrictions lifted and the toll on employees and residents will be much more than it should have been. Health departments will often give advice but will only put in writing what they are very confident about. If the health department refuses to put recommendations in writing, that says a lot.
Many in public health are excellent to work with, have tremendous interest in the issue and have become very knowledgeable of building water system Legionella issues and typically everyone in public health wants to help.
Unfortunately, too often, health departments don’t have a clue what to recommend and all too often will portray themselves as experts and will pull an Urkel, “did I do that?” when their advice fails.
In my next column, I’ll discuss what nursing home administrators should do to comply with CMS and how to implement a cost-effective Legionella Risk Management Plan.
Tim Keane is a consultant for Legionella Risk Management Inc.