* December 20, 2017…
Gov. Bruce Rauner said Wednesday the state is taking “aggressive action” to keep residents safe at the Quincy Veterans’ Home, but declined to say if he bears any moral responsibility after more cases of Legionnaires’ disease were found at the facility following a 2015 outbreak that left a dozen people dead. […]
On Wednesday, Rauner said the state is following all recommended procedures from the CDC and that it was due to increased testing for the bacteria that new cases have been identified, not necessarily because of remediation failures involving some pipes at the facility that are more than a century old.
* Illinois Auditor General’s report issued today…
In December 2015, the Centers for Disease Control and Prevention (CDC) recommended point-of-use filter installation on all fixtures fed from the potable hot-water system. Filters were not installed on all fixtures other than the showers until after the February 2018 outbreak, in April 2018.
That would be four months after Rauner claimed that the state was doing everything the CDC said it should do.
* The Auditor General also has a timeline of events…
Thursday, August 6, 2015
(1st Case Identified)
9:52 AM 1st confirmed case of legionellosis from the Quincy Veterans’ Home (IVHQ).
Hot water tank number 2 has been out of service since the beginning of July due to a valve issue. The tank is unheated and was cycled back into service on this day.
That’s the hot water tank which pumped a “broth of Legionella” into the facility, but nobody realized it at the time.
A second legionellosis case was identified on August 21st. Officials determined the following day that the two cases weren’t related and they appeared to relax a little…
IDPH Director emails the IDVA Director stating: “While this situation is serious because it involves lives, it is not unprecedented or atypical. Legionella is a risk in any situation of this sort. You may have seen that the City of New York has been grappling with a major outbreak. Even in Illinois, we are dealing with another set of cases at a prison facility. Fortunately, Legionella is a disease we know how to diagnose and treat. And from an epidemiology standpoint, we know how to track it down.”
The next day, however, 3 more residents tested positive. And 3 more tested positive the following day. By the morning off August 25th, 10 residents were in the hospital. By early afternoon, 11 residents were in the hospital, with 3 of those in ICU. On August 26th, they finally began to suspect the water heater, with 18 people now in the hospital. But no conclusive evidence is found until September 2nd. By then, 7 people had died and 45 confirmed cases had been identified.
* Back to the audit…
IDPH did not go on-site at Quincy Veterans’ Home until midday on Monday, August 24. That was nearly 3 days (approximately 67 hours) after the 2nd case was confirmed late in the afternoon on August 21st. […]
Based on our review of communications between IDPH and the Quincy Veterans’ Home, auditors determined that there was limited communication between IDPH management and the Quincy Veterans’ Home staff. As identified in our timeline in Chapter 2, IDPH officials often did not know the seriousness of the problem at the Quincy Veterans’ Home
Additionally, more than a week after multiple Legionnaires’ cases were confirmed, former state Public Health Director Nirav Shah concluded that he did not “think it’s necessary right now” to call in the federal Centers for Disease Control and Prevention to assist in the 2015 outbreak, according to the audit.
At that point, Aug. 28, 2015, two people had died from Legionnaires’, and 29 residents and staff had tested positive for Legionella. By the end of the next day, Shah reversed course and recommended that the CDC be brought in to assist the state, the report said.
Since 2015, 66 residents and eight staff members were sickened in rolling Legionnaires’ outbreaks at the facility, with 13 deaths directly attributable to the pneumonia-like illness tied to Legionnaires’. Another resident died in 2018, several months after being sickened by Legionnaires’.