The year is 2015. It’s August. The setting is a 400-plus-person veterans home in Quincy, Illinois. Quincy lies in west-central Illinois on the banks of the Mississippi River, approximately 130 miles upriver from St. Louis in Adams County. It is home to around 40,000 hard-working, middle-class Americans.
Water had been in the news recently due to a major Legionnaires’ disease outbreak in the South Bronx in New York City. Just a little more than a month earlier, in July 2015, the Opera House Hotel in New York City was one of the sites considered to have contributed to 138 people becoming sick with Legionnaires’ disease and 16 fatalities. Cooling towers in the area were said to have been the source in the South Bronx outbreak.
A year earlier in Flint, Michigan, the infamous Flint water crisis began. Most people now know that when the city of Flint changed its water source, the water chemistry changed and approximately 140,000 people were exposed to dangerously high levels of lead in their drinking water. A side effect of this decision, which is not as well known, is that not only was lead leaching into the water, but iron corrosion also was happening at an alarming rate. This iron corrosion consumed the chlorine that was keeping bacteria levels low. Without proper levels of chlorine, Legionella bacteria thrived. During 2014 and 2015, 87 individuals contracted Legionnaires’ disease, with 12 of them dying from its effects.
Back to August 2015 in Quincy. On Aug. 6, the first case of legionellosis at the Quincy Veterans’ Home was identified. At this point, it was unfortunate, but not alarming. Adams county had had one confirmed case in 2013 but none in 2011, 2012 or 2014, and never at the Quincy Veterans’ Home. Fifteen days later, there was another one. Eyebrows began to raise. Both individuals lived in the same building. Staff at the Quincy Veterans’ Home, Illinois Department of Public Health and Illinois Department of Veterans’ Affairs began to jump into action. The following is a portion of the timeline that was published by the State of Illinois Office of the Auditor General following an investigation of the events surrounding the outbreak.
Author’s note: The following excerpt from the auditor general’s report shows only the rapid spread of the outbreak, not the actions taken — this is intentional. My intention here is not to make judgments on the decisions made at the time, but to highlight the terrifying nature of an outbreak such as this. The full report is available HERE.
For those involved, the first week must have been incredibly difficult to understand. How could anyone have been prepared for what was to come? Fifteen confirmed cases of a disease that they likely had just started hearing about in the news recently. Then people started dying. By the end of the second week, there were seven deaths and 48 confirmed cases. Terrifying! Within a month, 12 people had died, 55 people had confirmed cases of Legionnaires’ disease and countless lives were dramatically affected. One can only imagine the sense of helplessness that must’ve accompanied every new day while this outbreak continued.
So, what were the responses to the outbreak? This is likely a question on many of your minds at this point. In the earliest stages of the outbreak, much of the response focused on heightened awareness of people having respiratory distress, infection control practices and keeping windows closed due to concern that cooling tower drift was the source. There was also concern over a water heater that had been taken out of service due to repairs and then returned to service in early August. As the outbreak progressed, water sampling was conducted, water-use restrictions were put in place, and the cooling tower and ice machines were cleaned while use of outdoor decorative fountains was discontinued. As new information flowed in, focus was shifted away from the cooling towers and toward the potable water system, specifically the domestic hot water system. This facility sits on 210 acres and is comprised of over 25 buildings with central water heating for all residential buildings. To say this is a large, complex piping system would be an understatement. Bottled water was brought in for all patient care and services, the water heater that had been worked on was drained and swabbed for Legionella testing, a consultant was hired, and pointof-use filters were specified and ordered. The town of Quincy began operating at higher-than-normal levels of monochloramine in the municipal water chemistry. A disinfection plan for the domestic water system was developed and implemented using hyperchlorination (sodium hypochlorite). Point-of-use filters were installed and post-remediation monitoring plans were put into place.
Since the outbreak, much has been done at the Quincy Veterans’ Home to mitigate the possibility of this ever happening again. In November 2015, a new 12-inch water main was installed to the campus, which had previously been served by three smaller service lines, and a newly constructed on-site water treatment plant was commissioned, ensuring proper residual disinfectant levels could be attained. Every building was isolated from the supply by way of backflow prevention to make isolation from building to building more robust. Pointof-use mixing valves were installed across the campus to aid in raising the hot water distribution system temperatures. A dead-leg service pipe was removed from the system. In 2016, the hot water system was decentralized, placing water heating equipment in each building. Automatic hydrant flushing was implemented to avoid stagnation and to increase residual disinfectant levels. New therapy tubs and faucets that would better accommodate point-of-use filters were installed. Point-of-use filters were installed on all sinks, showers and ice machines campus-wide and point-of-entry filtration was installed in two of the residence buildings to improve the life of downstream microfilters. All this work was completed by the middle of 2018. Obviously, these improvements can’t bring back the 12 people who died because of this outbreak, but they can help us to view construction of new buildings in a different light than we had in the past. Implementing some of these measures at initial construction rather than as a response to a tragedy can save people’s lives.
“Those who cannot remember the past are condemned to repeat it.” – Philosopher George Santayana
There have been innumerable conversations, white papers, studies and conferences held about how to better prepare and respond to legionellosis outbreaks in the years since these outbreaks tore through the communities that endured them. So, what have we learned?
EARLY ISOLATION OF BUILDING OCCUPANTS FROM THE SUSPECTED SOURCE(S) IS IMPERATIVE.
Point-of-use filters on all system outlets allows for investigation while protecting the occupants.
MAINTAINING PROPER WATER DISTRIBUTION SYSTEM TEMPERATURE THROUGHOUT THE ENTIRE SYSTEM IS ESSENTIAL.
Earlier beliefs that a 120° F water heater setting is sufficient have been proved false. Holding water at a higher temperature of 140° F at the heater or storage tank, regulating it down a little with an ASSE 1017 mixing valve for distribution and cooling it for the consumer at the point-of-use with an ASSE 1070 mixing valve seems to be a much better method of controlling bacterial growth, especially when coupled with a properly designed hot water recirculation system.
“KEEP THE WATER YOUNG, KEEP IT HOT, AND KEEP IT MOVING.”
Minimizing water age within a distribution system has been a mindset since I first began learning about limiting pathogenic growth in a system.
HAVE AN ACTIVE, LEGITIMATE WATER MANAGEMENT PLAN IN PLACE!
Many of the experts I’ve spoken with cite not having a legitimate water management plan in place as being one of the biggest reasons that Legionella colonization occurs.
“Prevention Rather Than Cure” rings true in many of the discussions we have around ASSE; this example is one that rings the loudest for me. A qualified, educated workforce is the key — never stop learning.
