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Table 2. Domains of Expertise Represented on Hospital Water Management Plan Development Teams, 29 SHEA Research Network Respondents, October– November 2017
Domain of Expertisea Infection control
Facilities and engineering Microbiology Compliance and administration Risk management Public health Occupations
Hospital epidemiologist, Infection preventionist
Facilities manager or engineer, Maintenance Staff
Clinical microbiologist, Environmental microbiologistb
Hospital administrator, Accreditation/compliance officer
Risk or quality management, Industrial hygienist
State or local public health staff
No. (%) (N=29) 27 (93)
26 (90) 15 (52) 13 (45) 11 (38) 3 (10) aBecause various Legionella prevention guidance documents currently differ in regard to suggested expertise represented on a WMP team, the domains presented here represent general
categories of expertise. The CDC toolkit suggests all domains and roles mentioned in Table 2, although there is no hierarchy of importance conveyed in various guidance documents. bAll provided by external consultants.
Hospitals with top 4 domains of expertise 7 (24)
Hospitals with all 6 domains of expertise 1 (3)
capacity, it more likely reflects the greater attention and capacity for LD prevention among the hospitals responding to this survey. Although UAT may be the easiest and most ubiquitous diagnostic, it is not comprehensive; it only detects infections caused by Legionella pneumophila serogroup 1.8 Although sero- group 1 is responsible for more than 80% of LD cases, relying solely on this test would miss cases caused by other pathogenic strains.9,10 Notably, 72% of respondents reported the capacity to perform culture-confirmation testing in house, whereas only 14% reported doing so routinely. Thus, exploration of barriers to routinely culturing pneumonia patients should be considered. The response rate for this survey was low, which limited our
ability to conduct statistical analyses. While we lacked ample data on nonrespondents, they did not differ substantially from respondents in facility size or type. It is also likely that facilities participating in the SRN represent more prepared facilities; therefore, the SRN members who responded may substantially over represent Legionella preparedness in the general population of healthcare facilities. If true, these data still offer a timely snapshot of LD diagnostic capacities and water management planning at what may be the most prepared facilities in the country.
Although our results suggest that some facilities may meet
current LD prevention guidelines, there is room for improvement. Infection control and facilities and engineering departments are frequently involved in WMP development, but consideration should be given to a broader range of expertise, including environmental health, environmental microbiology and industrial hygiene. At a time when LD cases are rising and pressures to improve LD prevention are increasing, lessons learned from facilities with robust WMP may benefit facilities developing or updating their plans.
Acknowledgments. We would like to thank Laura A. Cooley, MD, MPHTM, from the Respiratory Diseases Branch in the Division of Bacterial Diseases within the CDC’s National Center for Immunization and Respiratory Diseases for her input on survey design and earlier versions of this manuscript.
Financial support. This study was supported in part through funding from the O. Wayne Rollins Foundation.
Conflicts of interest. The authors declare no conflicts of interests. References
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2. Soda EA, Barskey AE, Shah PP, et al. Vital signs: healthcare-associated Legionnaires’ disease surveillance data from 20 states and a large metropolitan area—United States, 2015. Morb Mortal Wkly Rep 2017;66:584–589.
3. American Society of Heating Refrigerating and Air-Conditioning Engineers. Standard 188-2015. Legionellosis: risk management for building water systems. Atlanta: ASHRAE; 2015, p. 8.
4. Centers for Disease Control and Prevention. Developing a water management plan to reduce Legionella growth and spread in buildings: a practical guide to implementing industry standards. Atlanta: CDC; 2016.
5. Center for Clinical Standards and Quality/Survey and Certification Group. Requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires’ disease. Baltimore, MD: US Department of Health and Human Services; 2017.
6. Danila RN, Koranteng N, Como-Sabetti KJ, Robinson TJ, Laine ES. Hospital water management programs for Legionella prevention, Minnesota, 2017. Infect Control Hosp Epidemiol 2018;39:336–338.
7. Garrison LE, Shaw KMS, McCollum JT, et al. On-site availability of Legionella testing in acute care hospitals, United States. Infect Control Hosp Epidemiol 2016;35:898–900.
8. Formica N,Yates M, Beers M, et al. The impact of diagnosis by legionella urinary antigen test on the epidemiology and outcomes of Legionnaires’ disease. Epidemiol Infect 2001;127:275–280.
9. Yu VL, Plouffe JF, Pastoris MC, et al. Distribution of Legionella species and serogroups isolated by culture in patients with sporadic community- acquired legionellosis: an international collaborative survey. J Infect Dis 2002;186:127–128.
10. Kazandjian D, Chiew R, Gilbert GL. Rapid diagnosis of Legionella pneumophila serogroup 1 infection with the Binax enzyme immunoassay urinary antigen test. J Clin Microbiol 1997;35:954–956.
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