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CDC Report: Legionnaires' Disease Risk At Quincy Veterans’ Home ‘Cannot Be Eliminated’

The entrance to the Illinois Veterans Home in Quincy, seat of Adams County along the Mississippi River north of Hannibal, Mo.

The water system at a state-run veterans’ home in Quincy where 13 people have died of Legionnaires’ disease may never be fully cleansed of the bacteria that causes the sometimes fatal illness, and more cases could be inevitable, federal public health authorities warned Thursday.

This arch acknowledges the original name of the Illinois Veterans Home in Quincy. The name was changed in 1974.
Credit Andrew Gill/WBEZ

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In a new report, the Centers for Disease Control and Prevention encouraged the state to undertake a series of new precautions aimed at curtailing the threat of more Legionnaires’ cases at the 132-year-old Illinois Veterans Home, but conceded that none of its recommendations represent an ironclad safeguard for the facility’s nearly 400 residents.

“While adoption of these recommendations should further reduce risk, the possibility of future cases of disease associated with the [Quincy veterans’ home] cannot be eliminated,” the CDC said in a report released by Illinois public health authorities. “How much further our recommended changes will reduce risk is unclear,” the agency said, noting the “probability” that the Legionella bacteria will continue to live in the water there.

The latest report from the CDC was released after an investigation by WBEZ that focused on the state’s handling of a 2015 outbreak that claimed a dozen lives. The story has prompted questions from public officials about why residents at the home keep getting sick -- with the thirteenth death in October -- despite the state’s investment of nearly $6.4 million in water-system upgrades and a 2016 pledge by Gov. Bruce Rauner that the state was “really on top of the situation.”

WBEZ also offered a first-time public glimpse into some of the 11 negligence cases against the state arising from the fatal 2015 outbreak.

The CDC report released Thursday focused on a half-dozen Legionnaires’ cases in 2017 -- the third outbreak at the home in three years. It offered an ominous outlook for the state’s largest veterans’ home and coincided with a surprise move by Rauner to move into the facility with First Lady Diana Rauner for “several days” to “gain a more thorough understanding” of the operations and water-treatment plan there, according to a spokeswoman.

The governor’s office would not provide details about the Rauners’ living arrangements at the facility, including whether they planned to drink tap water, use unfiltered sink faucets, or take showers at the complex.

In late December, the state touted CDC test results that showed no Legionella was detected in 47 of 48 samples, with the lone outlier turning up behind a shower head that had been outfitted with a special filter.

But in Thursday’s report, the CDC noted the strain of bacteria found in that shower head was the same type associated with the fatal outbreak in 2015 that claimed 12 lives and with another outbreak in 2016 that sickened five residents.

Some of the most unsettling new recommendations from the CDC focus on the many unprotected sinks in the facility that have been identified as potential sources of Legionella, the bacteria that can cause the sometimes deadly form of pneumonia.

The agency advised the state to outfit every sink faucet with special filters designed to capture Legionella, like those now on shower heads, though it cautioned that could cause other problems.

The CDC also encouraged staff doing mandatory flushing of faucets to wear protective masks, to avoid letting water splash in sinks, and to be sure no residents are in their rooms during the 20-minute flushing process.

That warning even extended to staff.

“After turning on the water, staff members may choose to step out of the room while flushing is ongoing,” the report said.

The state again sought intervention from the CDC after a new Legionnaires’ case was diagnosed in November, marking the sixth time someone was sickened in 2017. Originally, the state Department of Veterans’ Affairs, which manages the Quincy facility, told WBEZ that only three Legionnaires’ cases occurred in 2017. Rauner’s administration amended that total when confronted by WBEZ in late December, confirming five residents and one staff member at the complex were sickened.

Two of the illnesses arose in October, including an 88-year-old Korean War veteran from west-suburban Lisle who died after being exposed to Legionella, according to the local coroner.

The CDC noted that, after the two October cases, the facility’s staff identified “inconsistent levels of disinfectant in the water main supplying” the complex. Staff at the facility theorized that “may have been the result of inadvertent mixing directly with municipal water due to a redundant water main valve that was found in a partially open position.” Once the valve was closed, the report said, adequate disinfectant levels resumed.

The CDC said that there appeared to be no common exposures to contaminated water by the six who were sickened in 2017. In one instance, a sickened resident told the CDC that he “occasionally performed flushing on the sink located in his room … and stood in close proximity to the sink throughout the process.”

In another instance, a resident told CDC interviewers he had visited a facility greenhouse to water plants during the period when he was exposed to Legionella.

Rauner’s administration did not respond to emailed questions about Thursday’s report that were sent to the Department of Veterans’ Affairs, the Department of Public Health and the governor’s office. But one lawmaker, who was briefed on the CDC findings and is helping head joint House-Senate legislative hearings on Quincy’s Legionnaires’ crisis, called the report troubling.

“It doesn’t comfort me at all,” said state Rep. Linda Chapa LaVia, an Aurora Democrat and chairwoman of the House Veterans’ Affairs Committee.