Legionella Bacteria Identified in Townships Served by Trenton Water Works, Health Officials Urge Precautions

The presence of Legionella bacteria was identified in water samples collected from more than half of 30 homes within several municipalities served by Trenton Water Works (TWW), the New Jersey Department of Health (NJDOH) announced this weekend. This includes homes from Trenton, Ewing, and parts of Lawrence and Hopewell Township served by TWW.

The testing was conducted in September 2022 following the detection of Legionella, the bacteria that causes Legionnaires’ disease, in several homes that were voluntarily tested within the Hamilton Township area served by TWW in July 2022.

The homes tested in Hamilton Township were part of an ongoing investigation to determine potential causes of Legionnaires’ disease previously detected in Hamilton Township, with five cases including one death reported since December 2021. The most recent case was reported to health in September 2022.

To determine if other municipalities served by TWW were affected, health officials recruited an additional 30 homeowners from across the TWW distribution area, focusing on areas outside of Hamilton Township, to voluntarily have their homes tested for Legionella. NJDOH has notified all volunteer homeowners of the results from this sampling.

Legionnaires’ disease is a type of pneumonia that people can get after breathing in aerosolized water (small droplets of water in the air) containing Legionella bacteria. Individuals cannot get Legionnaires’ disease by drinking water that has Legionella.

Though uncommon, people can get sick when water containing Legionella is aspirated into the lungs while drinking (“goes down the wrong pipe”). NJDOH receives approximately 250-350 reports of Legionnaires’ disease each year throughout New Jersey.

Photo from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

NJDOH is now urging that all residents and building owners who receive water from TWW take action to reduce the risk of Legionella growth in their household and building plumbing. These recommendations are included below.

It is not known if individuals with Legionella detected in their homes are more likely to develop Legionnaires’ disease. While it remains rare for a healthy person who is exposed to Legionella to become sick with Legionnaires’ disease, people who are 50 years or older, especially those who smoke, or those with certain medical conditions, including weakened immune systems, chronic lung disease or other chronic health conditions, are at increased risk.

Symptoms of Legionnaires’ disease include cough, shortness of breath, fever, muscle aches, and headaches, which are similar to symptoms caused by other respiratory infections, including COVID-19.

Legionnaires’ disease can be fatal but is treatable with antibiotics. It is important that anyone who thinks they have symptoms of Legionnaires’ disease contact their health care provider and seek medical evaluation immediately.

Health officials are urging healthcare providers to collect lower respiratory specimens for Legionella PCR and/or culture, in conjunction with the use of the urinary antigen test, when suspecting Legionnaires’ disease. This is especially important among residents who receive water from TWW.

The urinary antigen test is the most common diagnostic method but can only detect Legionella pneumophila serogroup 1. PCR and culture of lower respiratory specimens can detect all Legionella species and serogroups.

NJDOH continues to work with the New Jersey Department of Environmental Protection (NJDEP) and Trenton Water Works (TWW) to investigate factors that may be promoting the growth of Legionella bacteria and to evaluate remedial actions that can be taken to reduce Legionella in the system.

NJDEP recently uncovered significant concerns with TWW’s operations and management, including intermittent failures to fully maintain treatment processes, monitor water quality, employ adequately trained operating personnel, and invest in required maintenance and capital needs such as upgrades to aging infrastructure.

Following NJDEP's findings, Governor Phil Murphy and  NJDEP Commissioner Shawn M. LaTourette issued a Unilateral Administrative Order that, among other things, facilitates the immediate deployment of a capacity-building force comprised of managerial and technical experts who will focus on improving routine operations and maintenance, as well as resolving immediate capital needs.

How to Decrease Risks of Legionella Exposure

According to NJDOH, individuals, particularly those at high risk, can follow recommended steps to decrease the risk of Legionella exposure and best practices to limit the growth of Legionella in household water systems and devices:

• Avoid high-risk activities. If you are at an increased risk for Legionnaires’ disease, consider avoiding hot tubs, decorative fountains, power washing, or similar activities, which may generate increased amounts of aerosols or mist. A conversation with your healthcare provider may help you assess your individual level of risk based on underlying health conditions and co-morbidities.
• Maintain in-home medical equipment. If using medical equipment that requires water for use or cleaning such as non-steam generating humidifiers, CPAP or BiPAP machines, nasal irrigation devices such as Neti Pots, and attachments for nebulizers, follow the manufacturer’s instructions for use and maintenance. This often includes using sterile water instead of tap water in the device.
• Clean and/or replace your showerheads and faucet aerators (screens) per the manufacturer’s instructions whenever buildup is visible. This is particularly important if you haven’t cleaned your showerheads or faucet aerators recently. Cleaning might require you to remove the showerhead and hose and soak in a solution (such as white vinegar or a bleach solution) to remove buildup. If using chemicals, follow the instructions found on the back of the bottle for safe use.
• Keep your water heater set to a minimum of 120o This temperature will reduce Legionella growth and avoid the potential for scalding (hot water burns). Setting the heater to a higher temperature may better control Legionella growth, especially if you have household members at increased risk for Legionnaires’ disease. 
• After cleaning showerheads and faucet aerators and increasing the temperature of the water heater, thoroughly flush the water at each tap (e.g., sink, showerhead) for 20 minutes. Try to minimize exposure to splashing and mist generation, for example, by leaving the room while the water is running.
• Conduct routine flushing. Sinks and shower taps that are not used often can increase the risk of Legionella growth in other areas of the home. Let your faucets and showers run for at least three minutes when they have been out of use for more than a week. Minimize exposure to splashing and mist generation, for example, by leaving the room while the water is running. Additionally, you may consider flushing your water following any water disruption to your home, such as low pressure or discoloration, resulting from a water main break or nearby hydrant flushing.
• Follow the manufacturer’s instructions for maintaining your water heater and expansion tank, including periodic flushing, draining, and removal of sediment. If the manufacturer’s instructions are unavailable, seek advice from a licensed professional.
• Clean and/or replace all water filters per the manufacturer’s instructions. All whole-house (e.g., water softeners) and point-of-use filters (e.g., built-in refrigerator filters) must be properly maintained.
• Drain garden hoses and winterize hose bibs. Detach and drain the hose, shut the water valve off inside the home, and drain the pipe when not in use for the season.
• Follow the manufacturer’s instructions for maintaining your hot tub. Ensure disinfectant levels (e.g., chlorine) and maintenance activities (e.g., cleaning, scrubbing, replacing the filter and water) are followed. For more information, be sure to review CDC’s recommendations for residential hot tub owners.
• Operate and maintain your indoor and outdoor decorative fountains according to the manufacturer’s instructions to limit your exposure to Legionella. Household members at increased risk for Legionnaires’ disease should avoid exposure to decorative fountains. If the manufacturer’s instructions for cleaning and maintenance are not available, minimum cleaning frequency recommendations can be found in CDC’s Legionella Control Toolkit.
• Remove, shorten, or regularly flush existing dead legs. Plumbing renovations can lead to the creation of dead legs, a section of capped pipe that contains water but has no flow (or is infrequently used). For future renovations, ensure your plumber avoids creating dead legs.

RECOMMENDED ACTIONS FOR BUILDING OWNERS

• Complete this quick yes/no worksheet to determine if your building, or certain devices in your building, need a Water Management Program. Resources to help you develop a Water Management Program and for Legionella control in common sources of exposure are available at NJDOH’s Legionella website.
• Store hot water at temperatures above 140°F and ensure hot water in circulation does not fall below 120°F (or at the highest temperature allowable by local regulations and codes). Install thermostatic mixing valves as close as possible to fixtures to prevent scalding while permitting circulating hot water temperatures above 120°.
• Clean and maintain water system components. This includes devices such as thermostatic mixing valves, aerators, showerheads, hoses, filters, water heaters, storage tanks, and expansion tanks, regularly per manufacturer instructions.
• Flush hot and cold water at all points of use (faucets, showers, drinking fountains) at least weekly to replace the water that has been standing in the pipes. Healthcare settings and facilities that house vulnerable populations should flush at least twice a week.
• Remove dead legs or, where unavoidable, make them as short as possible. Where a dead leg (a section of pipe capped off with little or no water flow) cannot be avoided, it should be flushed regularly to avoid water stagnation. This may require the installation of a drain valve.
• Monitor water quality parameters such as temperature, disinfectant residuals, and pH regularly. Adjust the frequency of monitoring based on the stability of values. For example, increase the frequency of monitoring if there is a high degree of measurement variability. Pay particular attention to water quality parameters following a water disruption event, such as low pressure or discoloration, resulting from a water main break or nearby hydrant flushing.
• Safely operate and conduct regular maintenance of cooling towers to protect staff, visitors, and the adjacent community from exposure to Legionella. Use a Water Management Program to establish, track, and improve operation and maintenance activities.
• Follow recommendations from the NJ Department of Health when reopening your facility following a prolonged shutdown or reduced operation due to the COVID-19 Pandemic. Recommendations are available here.

ABOUT LEGIONNAIRES’ DISEASE AND LEGIONELLA

Legionnaires’ disease is a type of pneumonia (lung infection) caused by Legionella bacteria.

Legionella is a type of bacteria found naturally in freshwater environments such as lakes and streams and becomes a health concern when it enters and grows inside human-made water systems.

People can get Legionnaires’ disease by breathing in aerosolized (small droplets) water containing Legionella.

Photo from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

Aerosolized water can come from plumbing systems and devices such as cooling towers (part of the cooling system for large buildings), hot tubs, cooling misters, and decorative fountains.

Less commonly, people can get sick by aspiration of tap water containing Legionella. This happens when water accidentally goes into the lungs while drinking (“goes down the wrong pipe”).

People at increased risk of aspiration include those with swallowing difficulties.

Home A/C units do not use water to cool, so these home units do not aerosolize water and are not a risk for Legionella growth.

Legionnaires’ disease is generally not spread from person to person.

Additional information regarding Legionnaires’ disease and Legionella can be found here.

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