VS Legionnaires’ Transcript

OPERATOR: Welcome and thank you for standing by. At this time all participants are in listen only mode. During the question and answer session, please press star one on your touchtone phone. Today’s conference is being recorded. If you have any objections, you may disconnect at this time. Now I would like to turn the meeting over to Kathy Harben.

KATHY HARBEN: Thank you Mary and thank you all for joining us today. This month’s vital signs is on health-care associated Legionnaires’ disease in 2015. We’re joined by the Acting Director, Dr. Anne Schuchat and Dr. Cynthia Whitney, who is chief of CDC’s respiratory diseases branch. I will turn the call over now to Dr. Schuchat.

ANNE SCHUCHAT: Thanks so much everyone. Thank you for joining us this afternoon. CDC works 24/7 to protect the health, safety and security of Americans. One of the ways we do this each month is by highlighting a critical public health issue in our vital signs publication and describing what can be done about the health threat. This month, we’re talking about Legionnaires’ disease, a potentially deadly pneumonia, and the extent to which people get this disease while at health-care facilities. Today’s news is that people are getting Legionnaires’ disease from health-care facilities in most parts of the country. Three-fourths of areas studies had patients who got infected with legionella when they were hospitalized or in long-term care facilities. Most of these infections can be prevented with better water management programs in these facilities. CDC has issued tools to help facilities improve their building water management. But this study suggests that more is needed to protect patients against contracting this deadly pneumonia from the facility’s showers or other water exposures. At CDC we take patient safety very seriously. We already focus on a number of strategies such as hand hygiene and antibiotic stewardship to protect patients from health-care associated infections. But having a water management program needs to be added to that list. Legionnaires’ disease in health-care facilities is widespread, deadly and preventable. It’s a type of serious lung infection with symptoms that include cough, shortness of breath, fever, muscle aches and headache. About 10 % of people who get this infection die from it. But in this analysis, we found in health-care facilities that the death rate is higher. Twenty-five percent of people die if they get sick with Legionnaires’ disease while in the hospital, long-term care or nursing home. In health-care facilities, people are most vulnerable because they are already sick. When legionella germs are present, patients can inhale them from small water droplets coming from showerheads, water therapy spas and baths, cooling towers, decorative fountains and certain medical equipment like respiratory therapy equipment. It’s important to note that most healthy people do not get Legionnaires’ disease after being exposed to legionella. People with greater risk are 50 years of age or older, current or former smokers and those with chronic diseases like COPD or Emphysema or weakened immune systems. Each year, state or city public health agencies report to CDC basic data on Legionnaires’ disease cases. Some states also provide information on where someone with Legionnaires’ disease might have been exposed to the bacteria legionella. In today’s vital signs, CDC examined the exposure data reported during 2015 from 20 states and one large city. We found that 76% of those areas had residents who definitely got Legionnaires’ disease from a stay at a health-care facility. Legionnaires’ disease cases were considered definitely health-care associated when a person stayed in the health-care setting for all ten days before developing Legionnaires’ disease symptoms. Or a possible health-care associated case when the person was in a health-care setting for some portion of the ten days before developing Legionnaires’ disease symptoms. Our study found 20 of 21 jurisdictions had possible health-care associated Legionnaires’ disease cases. 16 of 21 or 76% had definite health-care associated Legionnaires’ disease. In those 16 jurisdictions, cases occurred in 72 different facilities with a number of cases ranging from one to six per facility. 80% were associated with long-term care facilities, 18% with hospitals and 2% with both. In terms of the possible cases, the 20 jurisdictions had cases in about 415 different health-care facilities. 13% were associated with long-term care facilities, 49% with hospitals and 26% with outpatient clinics. We previously reported on outbreaks of Legionnaires’ disease in the U.S. which showed that effective water management could have prevented the problems leading to four out of five health-care associated outbreaks. These findings suggest that Legionnaires’ disease is a problem that can affect any state and that all health-care facilities can take action to protect their patients. Previous analysis showed that for one year alone, insurers paid an estimated $434 million in hospitalization claims for Legionnaires’ disease nationally. And total health-care costs per patient averaged about $38,000. Protecting patients’ safety from Legionnaires’ disease in health-care settings depended on keeping the water in health-care facilities safe. This means tending to the building’s water system infrastructure, especially with older facilities. The centers for Medicare and Medicaid services or CMS just announced that facilities are expected to develop and adhere to policies and procedures to reduce the risk of legionella and other pathogens in water. To describe more about how health-care facilities can prevent Legionnaires’ disease, Dr. Cynthia Whitney will now speak.

CYNTHIA WHITNEY: Thank you Dr. Schuchat and good afternoon, everyone. Ensuring patients, visitors and employees don’t become sick because they were in a health facility is important. Leaders of health-care facilities should create a team to develop and roll out an effective water management program to limit legionella and other water-borne germs from growing and spreading. This time last year, CDC released a tool kit for building owners and managers that explained how to create and run a water management program. You can find this document on the CDC website. This water management toolkit provides a checklist to help identify first of all if a building needs a water management program. It gives examples of where legionella could grow and spread in a building and it gives ways to reduce the risk of legionella contamination in water systems. The tool kit is based on ASHRAE 188, a document designed for building engineers that outlines how to reduce risk of legionella in building water systems. Because of the vulnerable population they serve, it’s important for health-care facilities to have a water management program and a dedicated team that correctly executes this program. Reducing the risk of Legionnaires’ disease in health-care facilities requires action from people inside and outside the facility. Health-care providers are the front line. They can think legionella, which means having a high clinical suspicion for Legionnaires’ disease as a possible diagnosis for certain patients with health-care associated pneumonia. They can also make sure to test patients with pneumonia using the right tests that can detect Legionnaires’ disease. Health-care facility leaders can maintain safe water in their building by creating a team and creating a water management program to limit legionella and other water-borne germs. Facility leaders can make sure that they alert local public health authorities quickly if a Legionnaires’ disease case is identified and then work with them to investigate and prevent additional infections. Finally, state and local public health officials can improve surveillance of Legionnaires’ disease in health-care facilities, including reviewing all cases they get to look for patterns and promptly responding to any that might be associated with health-care.

ANNE SCHUCHAT: Thanks so much, Dr. Whitney. The bottom line here is simple. Health-care associated Legionnaires’ disease is widespread, deadly and preventable. People are getting Legionnaires’ disease from health-care facilities in most parts of the country. Three-fourths of areas studied had patients who got infected whether they were hospitalized or in long-term care facilities. Most of these infections can be prevented with better water management programs in these facilities. We urge health-care facility leaders to use the practical guide for creating safe water management programs. We can work to together to lower this risk by reducing legionella growth in health-care facilities to protect the vulnerable patients in those settings. Thank you for listening today and I would like to turn things back over to the moderator.

KATHY HARBEN: Thank you Dr. Schuchat. Mary, we are now ready for questions.

OPERATOR: All right. We will now begin the question and answer session. If you would like to ask a question, please press star one. You will be prompted to record your name. One moment for the first question. Janine Interlandi, with Consumer Reports, you may go ahead with your question.

JENEEN INTERLANDI: Thanks so much. I have a couple of questions. The first being, given that the tool kit you created is about a year old now, can you speculate a bit about why more hospitals don’t seem to be using it? Is it a lack of awareness? Is it cost prohibitive? What are your thoughts on that? And then my follow-up is, if you can speak to the guidelines for patient notification in the event of a Legionnaires outbreak. Thank you.

ANNE SCHUCHAT: Thank you for those questions. Let me start and see if Dr. Whitney wants to add anything. You know, in terms of the uptake of the tool kit, the first thing I need to say is I don’t have data today about what percentage of hospitals have incorporated an effective water management plan into their work. But what I can say is this is a big culture change for infection control and hospital facilities. We have had tremendous uptake of improving our use of antibiotics and improvements in health-care associated infection prevention through handwashing and through other checklist kinds of processes. But most infection control practitioners haven’t even heard that Legionnaires’ disease can be a hospital-acquired infection. We know we have a lot of opportunity to get the word out. And we know that the infection control work force of the country is a tremendous set of champions for patient safety. So I hope in the future we will have statistics about the uptake of these — of the tool kit messages by health-care facilities. We think the CMS guidance is a very important way that that uptake will happen because when hospitals are visited, this will be one of many things that’s checked consistently. So this is essentially a warning to health-care facilities if you don’t have a good water management plan, this is the time to study up and develop one. Now in terms of patient notification issues, I can say that Legionnaires’ disease is nationally notifiable and that means that we are expecting to hear about the cases of Legionnaires’ disease when they occur. States have their own additional requirements for how detailed and what kind of information comes in with the reporting of cases. But we know that Legionnaires’ disease is underreported and that the numbers that we reported here are just the tip of the iceberg.

ANNE SCHUCHAT: I think we will see if Dr. Whitney wants to expand on that.

CYNTHIA WHITNEY: Just one thing to add. Legionnaires’ disease is a condition that prevents — that patients present with symptoms similar to other kinds of pneumonia. So you have fever, you have cough. So it’s very important that health-care providers order tests that are specific for diagnosing Legionnaires’ disease. If those tests aren’t ordered all the time, that’s why we think the cases go undetected and therefore unreported.

KATHY HARBEN: Next question, please.

OPERATOR: Maggie Fox with NBC News. You may go ahead with your question.

MAGGIE FOX: Thanks. I’m probably a little confused on this. But at first I misunderstood the way this report was presented to us as 76% of cases were acquired in hospitals. Once you read the report you realize 3% of the cases were reported in the hospital. Can you tell me why you are so concerned by your findings? Is it that perhaps this indicates that legionella is in a lot of hospitals even though a lot of cases aren’t being reported? I would like to characterize what the actual risk is to people when they go to the hospital.

ANNE SCHUCHAT: Yes. Thank you, Maggie, for those good questions. We think that the 3% is the tip of the iceberg. One in five Legionnaires cases in this report might have been health-care associated. The difference between a possible case and a definite case was the requirement that the entire 10 days before illness onset be occurring in the hospital. Most hospitalizations are shorter. So many people who are considered possible Legionnaires’ disease health-care associated cases probably got their disease in a health-care facility. The second thing to say is that this is a deadly infection. People who get Legionnaires’ disease when in a hospital or nursing home are much more likely to die than other people. They have underlying conditions that make them more vulnerable. This is a really nasty pathogen. The third thing to say is we can do something about this. For many Legionnaires cases that happen one at a time in a town or city, we don’t know where the person got infected. For health-care associated infections, we have a source. The critical thing is to try to prevent more cases from happening in that facility. Each single health-care associated case could be considered an outbreak waiting to happen. So we think that it’s very important that leaders in health-care facilities take notice of this and learn how they can protect the patients in their care. We also think for consumers it’s a great reminder that if someone you love is hospitalized or in a nursing home and develops pneumonia to ask about could this be Legionnaires’ disease, have you tested for that. Because it does take special tests. And we know those tests aren’t as widely used as they might be.

KATHY HARBEN: Next question.

OPERATOR: David Lewkowict, with Fox News, you may go ahead with your question.

DAVID LEWKOWICT: Dr. Schuchat, thank you so much for taking my call. I just had a quick question about regional differences. Do we see regional differences in where the cases are being diagnosed, number one? Number two, do we see differences between newer and older facilities, or is it statistically insignificant?

ANNE SCHUCHAT: Thanks. Those are both great questions. Our analysis isn’t the best way to get at that. But from other analysis and from our outbreak work, we know there are some areas of the country that are more frequently reporting outbreaks of Legionnaires’ disease. Some of the wetter New England or northeastern Mid-Atlantic States have frequently found Legionnaires outbreaks or investigated them. But we think that this can happen in any hospital or any health-care facility or any nursing home. And that’s a reason why every health-care leader needs to assess their hospital or their facility, its circumstances and make sure that if it does need to have a water management plan that there’s a good one in place. The other question that you asked was about the age of the building. That’s a terrific question. We have seen a 4 1/2-fold increase in Legionnaires reports since 2000. We wonder is that because our infrastructure is aging? Are some of the older buildings more at risk for overgrowth of bacteria? When you look at a typical hospital or a typical health-care facility, they have been expanded, renovated, and added on to. Their original plumping is hard to even figure out. So we know that those types of facilities lend themselves to poor circulation of water in some of the parts of the building. We think engineers who really work together with the facilities people to look at where the water is flowing and where it’s not flowing can help look for the vulnerabilities and help health-care facilities get a strong water management plan. I don’t have data that shows that older buildings are riskier than newer buildings. There are some things going on with newer buildings that make them potentially at risk. But what I would say is, the age of America’s health-care facilities infrastructure does put us at risk for more Legionnaires’ disease to be picked up in the hospitals. That’s one of the reasons we want people to pay attention to this problem.

KATHY HARBEN: Next question.

OPERATOR: Stephanie Souchery, with the University of Minnesota CIDRAP, your question is next.

STEPHANIE SOUCHERY: Yes. Hi. My question, you touched on it, but I’m trying to tease out what — what if any ascertainment bias might be at play. Healthy people in the community who get Legionnaires but don’t get sick enough to seek help or get tested.

ANNE SCHUCHAT: Thanks. The second part of your question got blurry. I think you are asking whether there’s some ascertainment bias in our statistics, would we be missing cases in healthy people or having selective reporting of Legionnaires’ disease. There’s several things to say. One thing is that people who are in long-term care facilities are likely to be there for ten days or longer. So it’s probably easier to confirm the source of health-care as a source of the Legionnaires’ disease in a person in a long-term care facility compared to a person in the hospital or who’s seeking care in an outpatient clinic. A second thing that you raise is whether people who are healthy might have Legionnaires’ disease and not know it. Legionnaires’ disease is pretty serious. We think that you are sick enough to need to seek care. If you develop pneumonia, you may or may not be diagnosed with Legionnaires’ disease. The healthy people are probably not tested for legionella the same way that people who are more infirm are. But we also know that healthy people can develop something called Pontiac fever, which is a different manifestation of exposure to the legionella bacteria, almost anyone can get Pontiac fever in the right circumstances. I think that our main problem, our main bias is the underreporting, the under diagnosis based on collecting the appropriate laboratory tests to make this diagnosis. Pneumonia is extremely common. Many people are treated without diagnostic tests being run. Even many people who are hospitalized and sick with severe pneumonia may not get tested for legionella.

KATHY HARBEN: Next question.

OPERATOR: Gary Evans, with Hospital Infection Control, you may go ahead with your question.

GARY EVANS: Hi. Thanks for taking my call. A couple things on infection control response in hospitals. First of all, could you just clarify what — how many cases of Legionnaires’ disease should prompt a hospital investigation? At one point, it was going to be moved to one. I’m not sure where it is right now. I would like to clarify that. The other thing is, is the CDC still relatively unfavorable or not recommending routine testing of legionella in the hospital water supply?

ANNE SCHUCHAT: Thanks for those great questions. Our current recommendations are that one case of definite healthcare-associated Legionnaires’ disease should prompt an investigation or two cases of probable health-care associated infection that occur within 12 months. Those are signals that there might be a bigger problem and that perhaps there’s some lapses in the water management plan. In terms of whether routine testing for legionella is recommended or not, we really updated our tool kit to be in line with the ASHRAE 188 guidance document. That is somewhat agnostic on the testing. The most important thing is to have a water management plan, some plans will include testing; some don’t. But most important thing is to get the team together to assess the building, to develop the management plan, to follow it and to make corrections when you have problems. So that’s really where we stand on that. The very important issue to make sure that we can protect patients in these settings.

KATHY HARBEN: Next question.

OPERATOR: Mike Stobbe with the Associated Press, you may go ahead with your question.

MIKE STOBBE: Thank you for taking the question. I just need a little clarification. I got confused, kind of following up Maggie Fox’s question about the 3%. The tip of the iceberg and one in five might be health-care associated. Dr. Schuchat, you talked about the ten days, but think you also said that 80% of the cases were long-term care facilities and 18% were hospitals. People in long-term care facilities would be there ten days or longer. I didn’t quite understand why — how much — to what extent you think one in five might be a strong number in giving people an idea. Also, is there anything else you can say about trend? Is this problem getting worse or better? Also, a little bit more about your response to the last question, about testing of the water supply. Why not call for regular testing of the water?

ANNE SCHUCHAT: Great. Thanks Mike for those terrific questions. We think that one in five cases may be healthcare associated is a stronger number than the 3%. The reality of under diagnosis, underreporting and the complexity of pinpointing a source of Legionnaires’ disease given the long incubation period makes it very likely that many people who get diagnosed with Legionnaires’ disease, after a hospital sta,y probably got that infection while they were in the hospital. I can’t prove that to you. But I think our experts feel that the one in five number is a lot closer to reality than the 3%. A second question is about trend. That’s quite difficult because we have had a few pretty big outbreaks in the past few years that have gotten a lot of attention. The single cases and two or three cases don’t get so much attention. We know that our surveillance has shown an increase of — a four and a half fold increase in routinely reported cases of Legionnaires’ disease since 2000. And we think part of that is better diagnosis because of the urine antigen test. It makes it simpler to diagnose this. Part of that is perhaps raised awareness. Part of that is probably real increases with more vulnerable patients, the elderly, people with chronic conditions, transplants and so forth, and also with aging infrastructure. Unfortunately, we don’t have perfect data to answer exactly how much of the increase is real versus better reporting and a more accurate impression of what’s really going on. We know that even with the better diagnosis, that that urine antigen test only picks up one type of legionella. And there’s many more types. We’re probably missing a lot of Legionnaires’ disease with the current way that diagnostic tests are run. In terms of testing of the water supply, this has been an issue of controversy for some time. Some hospitals and health-care facilities are finding very good results from routine testing. And others are quite challenged with it. We think the most important thing right now based on the data available is to develop a plan to implement it, to monitor it and to improve it. When you do find a problem with Legionnaires’ disease, the testing of the water for legionella is one component. There are other things that you need to check in the water, really the controls against legionella more than just the detection of that bacteria. Legionella is not the only water-borne germ that can cause problems in health-care facilities. So we think having a comprehensive water management plan is important. Dr. Whitney will expand a little on that.

CYNTHIA WHITNEY: Yeah, just a couple thoughts to add to what you said Dr. Schuchat. As you said, it’s very important to monitor how well your water management program is working and there is — it’s very important to water — excuse me, to monitor disinfectant levels as well as temperature to make sure things are moving in the right range. We for a long time have recommended testing for legionella in water where patients are really vulnerable, for example bone marrow transplant units, places where people may be receiving chemotherapy and not have much of an immune system. For larger hospitals, testing may make more sense because their systems are just very much more complicated than in smaller places. In smaller facilities, single story, long-term care facilities, for example, monitoring the temperature and the disinfectant levels may be enough to really know that your facility’s water management program is working. I think it really depends on the facility and facility leaders should be working with technical experts to understand what’s needed there.

KATHY HARBEN: Next question.

OPERATOR: Sean Hamill with Pittsburgh Post-Gazette, you may go ahead with your question.

SEAN HAMILL: Thank you. Dr. Schuchat, one of the most recent studies the CDC has done was about a health-care outbreak here in Pittsburgh in 2012 and 2013 at the Pittsburgh VA. We had a series of stories in December about e-mails exchanged between the people who were investigating that, including Dr. Whitney. There was a letter to the CDC in January from Senator Casey asking the CDC to investigate. I was wondering if you can tell us what has gone on with that investigation, where it stands now, whether you have confidence in how that investigation was carried out. It is important in understanding how these health-care facility outbreaks occur when they are investigated. In addition, I would like to ask Dr. Whitney about her comment where she said there would be poetic justice in investigating this case because the doctors had previously worked at this VA.

ANNE SCHUCHAT: You know, thanks for raising that. We will have to get back to you on that. Operator, could we get the next question, please?

OPERATOR: There are no other questions at this time.

KATHY HARBEN: Thanks, Mary. Thank you Dr. Schuchat and Dr. Whitney for joining us today. Also, thanks to all the reporters who joined us. If you have follow-up questions, we will be glad to get you connected. You can call the press office at 404-639-3286 or send an e-mail to media@cdc.gov. Thank you for joining us. This concludes our call.

OPERATOR: Thank you. This concludes the call. Please disconnect your lines

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES