Perspective

Arizona newborns diagnosed with Legionnaires’ disease after water births

Researchers identified numerous gaps in infection prevention for water births after two Arizona newborns delivered this way were diagnosed with Legionnaires’ disease.

According to a report in MMWR, both cases occurred in Maricopa County last year. The first, in January, involved a newborn delivered by a midwife in a birthing tub filled with tap water. Around 3 months later, a newborn delivered by a different midwife in a jetted whirlpool bath also was diagnosed with Legionnaires’ disease. Both infants lived.

The incidence of Legionnaires’ disease quadrupled in the U.S. between 2000 and 2014, the CDC announced last year. Researchers said in MMWR that cases have also been on the rise in Arizona. The disease, which is fatal in around 10% of cases, particularly affects the immunocompromised and is widespread in the health-care facilities, according to the CDC.

The newborn in the first case was delivered on Jan. 6 and taken to the ED the next day with “severe respiratory distress, tachypnea, and hypoxemia,” researchers wrote. The patient was diagnosed with congenital heart disease and transferred to a children’s hospital, where a radiograph showed possible pneumonia, they said.

According to the report, infection with Legionella pneumophila was confirmed through a bronchoscopy at a second children’s hospital. The researchers said the patient was treated with a 10-day course of azithromycin and remained hospitalized for more than 2 months, primarily because of the congenital heart disease.

Investigators from the Maricopa County Department of Public Health (MCDPH) found that the birthing tub had been cleaned with vinegar and water, then filled with municipal tap water using a new drinking hose immediately before delivery, according to the report.

“The mother delivered the child within an hour of entering the tub, and no aspiration by the infant was noted. No other risk factors for Legionella transmission were identified,” the researchers wrote.

According to the researchers, the second case was reported to MCDPH by a children’s hospital infection preventionist who was familiar with the first case and had asked about the method of birth. The infant was delivered in a jetted whirlpool bath that had been filled with municipal water using a new hose and kept at 98°F for 1 week before delivery.

“During the birth, the mother labored outside the tub and entered the tub for delivery only. No aspiration by the infant was noted,” the researchers wrote.

Over the next several days, the newborn developed a fever and was taken to a children’s hospital ED, where the patient was admitted for treatment of neonatal sepsis and suspected pneumonia, the researchers said. The patient tested positive for L. pneumophila via urine and upper respiratory tract tests and was started on a 10-day course of azithromycin and released from the hospital around 1 week after being admitted, according to the report.

“Investigation of these two cases identified numerous gaps in infection prevention for water births, including use of a jetted Jacuzzi rather than a disposable birthing tub, and allowing the water to remain for a week at 98.0°F, which is within the optimum range for Legionella growth,” the researchers wrote. “Although the tub for delivery in the first case was filled immediately before the birth, tap water is not sterile, and Legionella can grow and spread in man-made water systems, such as plumbing systems. Because both tubs were emptied immediately after the births, no environmental sampling was performed.”

In response to the cases, the Arizona Department of Health Services and MCDPH helped develop educational resources and guidelines to assist licensed midwives conducting water births, the researchers said. They were based on guidelines developed in Texas after the death of an infant from legionellosis in 2014 was linked to a water birth.

The guidelines recommend running hot water through a hose for 3 minutes before filling a tub for a water birth to reduce the risk of Legionella infection.

“These resources aim to increase knowledge about the risk for Legionella infection and maximize the safety for women choosing water immersion for labor or birth by providing a review of information on labor and birth in water,” the researchers wrote in MMWR. – by Gerard Gallagher

Reference:

ADHS. Guidelines for water immersion and water births. 2016. http://www.azdhs.gov/documents/licensing/special/midwives/training/guidelines-for-water-immersion-water-birth.pdf. Accessed June 9, 2017.

ADHS. Legionnaires’ disease: a water birth concern. 2016. http://www.azdhs.gov/documents/licensing/special/midwives/training/legionella-infographic.pdf. Accessed June 9, 2017.

Granseth G, et al. MMWR Morb Mortal Wkly Rep. 2017;doi:10.15585/mmwr.mm6622a4.

Disclosure: The researchers report no relevant financial disclosures.

Researchers identified numerous gaps in infection prevention for water births after two Arizona newborns delivered this way were diagnosed with Legionnaires’ disease.

According to a report in MMWR, both cases occurred in Maricopa County last year. The first, in January, involved a newborn delivered by a midwife in a birthing tub filled with tap water. Around 3 months later, a newborn delivered by a different midwife in a jetted whirlpool bath also was diagnosed with Legionnaires’ disease. Both infants lived.

The incidence of Legionnaires’ disease quadrupled in the U.S. between 2000 and 2014, the CDC announced last year. Researchers said in MMWR that cases have also been on the rise in Arizona. The disease, which is fatal in around 10% of cases, particularly affects the immunocompromised and is widespread in the health-care facilities, according to the CDC.

The newborn in the first case was delivered on Jan. 6 and taken to the ED the next day with “severe respiratory distress, tachypnea, and hypoxemia,” researchers wrote. The patient was diagnosed with congenital heart disease and transferred to a children’s hospital, where a radiograph showed possible pneumonia, they said.

According to the report, infection with Legionella pneumophila was confirmed through a bronchoscopy at a second children’s hospital. The researchers said the patient was treated with a 10-day course of azithromycin and remained hospitalized for more than 2 months, primarily because of the congenital heart disease.

Investigators from the Maricopa County Department of Public Health (MCDPH) found that the birthing tub had been cleaned with vinegar and water, then filled with municipal tap water using a new drinking hose immediately before delivery, according to the report.

“The mother delivered the child within an hour of entering the tub, and no aspiration by the infant was noted. No other risk factors for Legionella transmission were identified,” the researchers wrote.

According to the researchers, the second case was reported to MCDPH by a children’s hospital infection preventionist who was familiar with the first case and had asked about the method of birth. The infant was delivered in a jetted whirlpool bath that had been filled with municipal water using a new hose and kept at 98°F for 1 week before delivery.

“During the birth, the mother labored outside the tub and entered the tub for delivery only. No aspiration by the infant was noted,” the researchers wrote.

Over the next several days, the newborn developed a fever and was taken to a children’s hospital ED, where the patient was admitted for treatment of neonatal sepsis and suspected pneumonia, the researchers said. The patient tested positive for L. pneumophila via urine and upper respiratory tract tests and was started on a 10-day course of azithromycin and released from the hospital around 1 week after being admitted, according to the report.

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“Investigation of these two cases identified numerous gaps in infection prevention for water births, including use of a jetted Jacuzzi rather than a disposable birthing tub, and allowing the water to remain for a week at 98.0°F, which is within the optimum range for Legionella growth,” the researchers wrote. “Although the tub for delivery in the first case was filled immediately before the birth, tap water is not sterile, and Legionella can grow and spread in man-made water systems, such as plumbing systems. Because both tubs were emptied immediately after the births, no environmental sampling was performed.”

In response to the cases, the Arizona Department of Health Services and MCDPH helped develop educational resources and guidelines to assist licensed midwives conducting water births, the researchers said. They were based on guidelines developed in Texas after the death of an infant from legionellosis in 2014 was linked to a water birth.

The guidelines recommend running hot water through a hose for 3 minutes before filling a tub for a water birth to reduce the risk of Legionella infection.

“These resources aim to increase knowledge about the risk for Legionella infection and maximize the safety for women choosing water immersion for labor or birth by providing a review of information on labor and birth in water,” the researchers wrote in MMWR. – by Gerard Gallagher

Reference:

ADHS. Guidelines for water immersion and water births. 2016. http://www.azdhs.gov/documents/licensing/special/midwives/training/guidelines-for-water-immersion-water-birth.pdf. Accessed June 9, 2017.

ADHS. Legionnaires’ disease: a water birth concern. 2016. http://www.azdhs.gov/documents/licensing/special/midwives/training/legionella-infographic.pdf. Accessed June 9, 2017.

Granseth G, et al. MMWR Morb Mortal Wkly Rep. 2017;doi:10.15585/mmwr.mm6622a4.

Disclosure: The researchers report no relevant financial disclosures.

    Perspective
    Janet E. Stout

    Janet E. Stout

    Surprisingly, medical staff remain unaware of the risk of Legionnaires' disease associated with warm potable water — not only for neonates but for all hospitalized patients. The CDC report of more cases of illness associated with water birth is a tragic example.

    These cases are not the first to be reported and sadly will likely not be the last. The wet internal plumbing and jets of hot tubs, spas and birthing tubs are places Legionella hides and grows. It is not a simple task to rid them of this bacteria.

    In the same issue of MMWR, CDC sounded the alarm for health care facilities that Legionella is a problem and cases of hospital-acquired disease have been reported across the U.S. 

    Recognizing this problem, CMS issued changes in Legionella and waterborne pathogens guidance that mandated specific actions for immediate implementation.

    The solution is targeted water management to address the Legionella threat, especially to protect the immunocompromised, such as neonates. Testing the water before illness occurs is the key to prevention and can verify control measures are working.

    • Janet E. Stout, PhD
    • President and director Special Pathogens Laboratory Pittsburgh

    Disclosures: Stout reports no relevant financial disclosures.