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Mike Wesenberg - Environmental Health Specialist, MDHHS
Bryce Spiker, MPH - Legionellosis Epidemiologist, MDHHS
The Communicable
Disease Division within the Michigan Department of Health and Human Services
(MDHHS) is pleased to announce a new Legionellosis Program. Michigan was recently awarded additional
funding from the Centers for Disease Control and Prevention (CDC) to increase state-level
capacity in conducting epidemiologic and laboratory surveillance of infections
caused by Legionella bacteria. This
funding will support more timely responses in the detection, investigation, and
implementation of control measures to reduce the incidence and prevalence of
legionellosis. Two individuals have been hired at the Communicable Disease
Division to roll out the Legionellosis Program: Bryce Spiker is the new
Legionellosis Epidemiologist and the Environmental Health Specialist is Mike
Wesenberg.
Legionellosis is associated with two clinically and epidemiologically distinct illnesses: Legionnaires' disease, which is characterized by fever, muscle pain, cough, and clinical or radiographic pneumonia, and Pontiac fever, a milder illness without pneumonia. Legionellosis occurs most frequently in susceptible persons, including individuals over the age of 50, current or former smokers, and those with chronic diseases or a weakened immune system. Legionellosis is caused by Legionella bacteria, a pathogen that is found naturally in fresh water environments such as lakes and streams. Legionella is considered a waterborne disease; it becomes a health concern when it survives and amplifies within man-made water systems. After Legionella grows and amplifies in a building water system, the contaminated water must then spread droplets small enough for people to breathe in. An estimated 8,000 to 18,000 of legionellosis cases are hospitalized each year in the United States, with a case fatality rate around 9%. The reported cases of Legionnaires' disease have been on the rise over the past decade, both globally and in the United States. Michigan has not been immune to these increases and is one of many states also experiencing an increase in reported cases.
The main goal of the MDHHS legionellosis program is to strengthen legionellosis surveillance by encouraging collaboration among epidemiologists, public health nurses, laboratorians, and environmental health specialists for primary prevention of legionellosis outbreak and response. Both Bryce and Mike will be working to address gaps in education related to public health investigations and legionellosis prevention in building water systems. A Legionella disease protocol and a hypothesis-generating supplemental questionnaire have been created to assist local health jurisdictions with completing case follow-up and conducting outbreak investigations; these guidance documents can be found on the MDHHS Communicable Disease Information and Resources webpage. Currently, the legionellosis team is developing training for state and local health department staff, which will provide general information about legionellosis and transmission, review of American Society of Refrigerating and Heating Engineers (ASHRAE) guidelines and the associated CDC Water Management Program Toolkit (see below), as well as information on environmental sampling. Specific trainings can be conducted throughout Michigan upon request.
MDHHS is actively working with some local health jurisdictions that are interested in piloting outreach activities to identify high-risk buildings within their jurisdiction. These buildings may include hospitals, hotels, acute and long-term care facilities, high-rise buildings, and buildings with cooling towers. According to the CDC, 85% of all Legionnaires' disease outbreaks during 2000-2014 were caused by contaminated water systems that could have been prevented if the facilities had in place an effective water management plan (WMP). In the future, the Legionellosis Program intends to work with local public health to identify high-risk buildings across the state and to educate building owners on how to create effective water management programs.
Water Management Plans and Centers for Medicare & Medicaid Services
In response to the national increases in legionellosis cases, the ASHRAE published Standard 188–2015 titled Legionellosis: Risk Management for Building Water Systems. This standard provides the framework necessary for a facility to create a WMP with the aim of reducing the risk of Legionella growth in their building water systems. One goal of ASHRAE 188 was for the WMP to be understandable to all WMP team members. With this goal in mind, the CDC crafted a document titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, A Practical Guide to Implementing Industry Standards. This guide further simplified ASHRAE 188 into a toolkit that could easily be understood and used by both technical and non-technical WMP team members alike.
On June 9, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum with the subject line statement of “Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)." This Memorandum escalated the need for hospitals, critical access hospitals, and long-term care facilities associated with CMS to create and implement water management plans to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.
In addition to CMS healthcare facilities, all building owners and operators should be surveying their building(s) to determine if a water management program should be implemented to reduce the risk of growth and spreading of Legionella bacteria. The CDC recommends establishing a water management program for a building’s hot and cold-water distribution system if it falls within the following criteria:
- The building is a healthcare facility where patients stay overnight and/or are treated for chronic and acute medical problems or have weakened immune systems (CMS Memorandum).
- The building houses people over the age of 65 years (e.g., retirement home or assisted-living facility).
- The building has multiple housing units that share a centralized hot water system (e.g., hotel or high-rise apartment complex).
- The building is more than 10 stories including basement levels.
Additional criteria pointing towards the need for a WMP are the presence of devices that can spread contaminated water droplets. Cooling towers; hot tubs; decorative fountains; and buildings with centrally installed misters, atomizers, air washers, and humidifiers are all devices that should have a water management program dedicated to them regardless of whether the building water distribution systems need a WMP. The newly created MDHHS Legionella program is well positioned to assist Michigan's local health departments and the building owner/operators of their jurisdictions, in the creation of functional water management plans.
For more information:
General Information on Legionella
Clinical Guidance
MDHHS Communicable Disease Information and Resources: (See Legionellosis)
Centers for Medicare & Medicaid Services Memorandum
CDC Water Management Program Toolkit
American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) 188-2015
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