Legionnaires' disease at Promenade at University Place

The Enterprise — Michael Koff

Promenade Senior Living opened in December 2018, and since last week has been working to address a contamination with Legionella bacteria that has left one resident sick and another dead.

GUILDERLAND — Two residents of Promenade at University Place, a new assisted-living facility that opened in mid-December, have become sickened with Legionnaires’ disease, and one of them has died, according to a release last week from the Albany County Department of Health. Their names have not been released.

“No one else has gotten sick,” Mary Rozak, spokeswoman for the county executive, said on Wednesday.

The building was formerly a Best Western Sovereign Hotel; in 2010 and 2012, a number of cases of Legionnaires’ disease were linked to the hotel

“It’s a terrible thing that has happened,” said Paul Belitsis, Promenade Senior Living’s chief financial officer and chief operating officer. 

 “We’ve taken immediate and appropriate steps with the department of health to address the issue, and we will continue to,” he told The Enterprise. “We are committed to our residents’ safety.”

“We’re still happy to be in Albany, and we’re going to continue our mission,” he added. 

Promenade opened in December and currently has about 23 residents; it has a capacity of 200. Promenade at University Place is run by Promenade Senior Living, which is based in Tuxedo, New York and maintains five other facilities in Orange and Rockland counties as well as several day programs.

When the local Promenade was granted tax breaks by the Guilderland Industrial Development Agency in November 2017, it said that at least 40 percent of its beds would be reserved for “low-income seniors, thereby providing a much needed service to the Town’s lower income senior population.” 

Samples of water at Promenade have revealed preliminary positive results for Legionella, according to the county health department.

Legionnaires’ disease, or legionellosis, is spread by inhaling small droplets of water in the form of steam or vapor that contain the Legionella bacteria. The disease cannot be spread from one person to another. Exposure to Legionella can cause “severe disease including pneumonia, particularly in individuals who are elderly, have a weakened immune system or previous history of respiratory problems,” the release said.

The disease was first discovered after an outbreak among people who attended an American Legion Convention in Philadelphia, Pennsylvania in 1976, giving it its name.

Steps that Promenade has taken to minimize risk to other residents include, Belitsis said, installing new shower filters and providing all residents with bottled water.

After the outbreak nine years ago at the then-Best Western, the bacteria was found in the hotel’s water system. The health department had identified a cluster of six people across the state diagnosed with the disease, and the only connection among them was a stay at the Best Western. Those six people recovered. 

At that time, the hotel completed a process of “super-chlorinating” its water and showerheads. The hotel also installed a new hot-water tank.

Promenade Senior Living’s process of converting the former hotel involved an “extensive renovation that replaced every single fixture in the building, faucets as well as the hot-water heater,” Belitsis said, adding that all the piping was also replaced.

Belitsis said that Promenade’s management has been open and transparent in talking with residents and their families about the Legionnaires’ outbreak and will continue to give updates as it receives them.

Experts’ advice

Leonard A. Mermel, a doctor of osteopathy and a professor of medicine at the Warren Alpert Medical School of Brown University, has written that a period of water-main shutoff during construction, followed by re-pressurization when the water starts back up, can dislodge biofilm that has formed on the inside walls of pipes and that is contaminated with Legionella. 

Marmel said in an email answering Enterprise questions that, while he is not an engineer, he thinks it would be difficult to replace all of the piping in a building without tearing the building down. Even if all the pipes were replaced, he said, it is still possible that contaminated pipes leading to the facility or contaminated municipal water could have brought Legionella-laden water into the facility. 

Marmel, who is also medical director of the Department of Epidemiology and Infection Control at Rhode Island Hospital and adjunct clinical professor at the University of Rhode Island College of Pharmacy, gave some suggestions on what needs to be done, going forward: 

— Find the source of the Legionella (including testing of water entering the facility); 

— Test water in the new facility; 

— Make legionella testing mandatory “for a while” for any patient who develops pneumonia; and 

— Develop a remediation plan for each of these issues. 

Another expert, Janet Stout, president and director of Special Pathogens Laboratory, and research associate professor at the University of Pittsburgh Swanson School of Engineering, was the first person to demonstrate the link between Legionnaires’ disease and the presence of Legionella in hospital water systems.

She has written that the concentration of Legionella in water has not been shown to be predictive of risk for Legionnaires’ disease, because “Legionella infections are caused by the perfect storm of several factors.” She lists these factors as: 

— The virulence of Legionella species; 

— The mode of transmission (route and ability of the bacteria to enter the lungs); and 

— Health of the individual.

Stout also writes that tap water is not safe for use in patient care. She writes that healthcare personnel should be aware that Legionella and other waterborne pathogens can be transmitted when equipment is rinsed with tap water or when tap water is used for oral care. 

Stout has also written about construction as a possible factor. “Events like disruption of water flow caused by water main breaks, construction, and ward closures can impact the flow of disinfectant through the water supply,” she writes. “Many hospitals simply turn the water back on after renovation, not realizing that during this period, Legionella may have re-colonized in the plumbing system.”

Health departments’ approach

Efforts to address the issue are being led by the county department of health, although the state’s health department is also involved, said Jill Montag, a spokeswoman for the state’s department. 

Testing was done in 2012, after Legionella was detected, when the building was still a hotel, said Rozak. One of the remediation requirements at that time, she said, was that JH consulting group was to test for legionella biweekly, and then to test every month thereafter. 

The reporting requirement never ended, Rozak said, although it went from twice a month to monthly. Testing went on until the hotel closed, she said; the last sampling reported was in November 2017. The permit ended on Dec. 31, 2017. Information related to the assisted-living facility would need to come from the state’s health department, which has oversight over those facilities, said Rozak. 

Montag said that, in October 2018, because of the hotel’s history, the New York State Department of Health required Promenade to conduct water testing by a lab certified to do so. The test was negative for Legionella, she said. 

Health advice

According to the Centers for Disease Control and Prevention, many people being treated at health-care facilities, including long-term care facilities, have conditions that put them at greater risk of getting sick and dying from Legionnaires’ disease.

Predisposing conditions include, according to the CDC: being 50 or older, being a current or former smoker, and having a weakened immune system or a chronic disease.

The most common risk factor is heavy cigarette smoking, but chronic lung disease is also common, according to the website legionella.org. “The most intense risk factor is organ transplantation,” the website says; the medicines used to protect the new organ compromise the patient's defense system against infection. Patients who take corticosteroid medicines are also at high risk, the website adds. 

People who become sick with Legionnaires’ usually develop symptoms within two to 10 days after exposure, according to the National Institutes of Health. The first symptoms may include headache, chills, muscle pains, and a fever that can be 104 degrees Fahrenheit or higher.

Additional symptoms usually develop a day or two after the first symptoms and may include coughing, shortness of breath, chest pain, diarrhea, nausea and vomiting, and confusion.

The CDC says that contaminated water droplets can be spread by showerheads and sink faucets; hydrotherapy equipment such as jetted therapy baths; medical equipment such as respirator machines or bronchoscopes; ice machines; cooling towers (parts of large air-conditioning systems); and decorative fountains and water features. 

There is no known safe level Legionella in building water systems, according to the CDC, and cases of Legionnaires’ disease have been associated with very low levels of Legionella in building water systems; keeping it out of water systems in buildings is key to preventing infection. 

 Legionnaires’ disease is probably underdiagnosed in many places, Marmel told The Enterprise. He was one of the authors of a study that used computer software to look retrospectively at patients who were diagnosed with pneumonia or who had a bronchoscopic specimen sent for testing, to see if these patients were tested for Legionella.

The study found that 35 percent of patients with a discharge diagnosis of pneumonia were tested for Legionella. Forty-four percent of patients who had a bronchoscopic specimen tested had Legionella testing done on it.

Most people who are exposed to Legionella bacteria do not become sick, according to the National Institutes of Health. 

When people do become sick with Legionnaires’ disease, it is fatal in about one in 10 cases, according to the CDC. 

Ways to prevent the growth of Legionella include, the CDC says: 

— Keeping hot-water temperatures high enough; 

— Making sure disinfectant amounts are correct; 

— Keeping water flowing and preventing stagnation; 

— Operating and maintaining equipment to prevent slim, organic debris, and corrosion; 

— Monitoring factors outside buildings including construction, water-main breaks, and changes in municipal water quality. 

The CDC recommends creating a Legionella water management program at health-care facilities as a means of preventing the first case of the disease. This team would describe the building water systems in words and diagrams, identify areas where the bacteria could grow and spread, decide where to apply control measures and how to monitor them; establish ways to intervene when control limits are not; make sure the program is running as designed and is effective; and document all of its activities.

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