The Missouri Department of Health and Senior Services (DHSS) has investigated over 100 cases of Legionnaires’ disease, a serious lung infection, across Missouri so far this year; five of those who have contracted the disease are reported to have died. Although most people exposed do not develop illness, approximately 10-25 percent of Legionnaires’ disease cases are fatal. Reports of Legionnaires’ disease are increasing in Missouri and nationally. In response, DHSS has strengthened Legionnaires’ disease detection and prevention efforts.

Recently, DHSS filed emergency rules to reduce the timeframe for reporting legionellosis from three days to one day and introduced new testing methods at the Missouri State Public Health Laboratory (MSPHL).

“The timely diagnosis of legionellosis, and the identification of the water sources from which it arises, is crucial for preventing morbidity and mortality in the larger community,” said Dr. Randall Williams, director of DHSS. “We are committed to raising awareness and continuing to work with local health departments and the CDC during outbreaks, and we are excited about the innovative testing that MSPHL has instituted to aid in timely detection of Legionella in water sources.”

The MSPHL’s Environmental Bacteriology Unit can test water samples for the presence of Legionella pneumophila using the Idexx Legiolert system. The Legiolert test method provides highly sensitive results in just seven days that can also be used for further comparison to patient samples to link individual cases with environmental sources. 89 samples have been tested at the MSPHL for Legionella pneumophila since June 19.

“The MSPHL now provides high-quality testing services to detect Legionella pneumophila in a timely manner,” said Bill Whitmar, director, MSPHL. “This service not only protects our communities but also those who visit our communities.”

DHSS and local public health partners have completed over 50 environmental assessments this year at lodging and health care facilities in Missouri. DHSS has also been working to educate management of these types of facilities on the disease and what proactive measures can be taken to prevent anyone from contracting the disease from their water systems.

Legionella can be found naturally in the environment, but generally is not present in sufficient numbers to cause disease. In human-made water systems, like the interior plumbing of large buildings, cooling towers, decorative fountains, or hot tubs, Legionella can grow and be transmitted to susceptible people by breathing in small water droplets containing the bacteria. People at higher risk for getting sick include those over age 50, former or current smokers or those with chronic lung diseases, cancer, or other underlying illnesses. It is not spread from person to person.

While public health efforts are focused on investigating cases associated with lodging and health care facilities, you can take steps to protect yourself at home. Improper CPAP machine use (commonly used to treat sleep-related breathing disorders) is a frequently reported risk factor. You can reduce your risk of exposure by proper maintenance of CPAP machines, humidifiers and other household equipment where bacteria may grow that may create water vapor.

Outbreaks of Legionnaires’ disease often occur in hotels, health care facilities and pools. Although over 800 cases have been reported in the state since 2014, this disease is not a concern isolated only to Missouri. Earlier this month, a hotel in downtown Atlanta voluntarily closed after at least nine guests contracted the disease.

Please see the most frequently cited deficiencies report from the second quarter of 2019.

The Department of Social Services (DSS) wants to alert providers to a genetic testing scheme that is currently happening in many states, including Missouri. On June 3, 2019, the U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG) issued an alert regarding scammers offering individuals cheek swabs for genetic testing to obtain their Medicare or Medicaid information for identify theft or fraudulent billing purposes. Fraudsters are targeting beneficiaries through door-to-door visits, booths at public events, health fairs, and telemarketing calls.

DSS has received reports that genetic testing marketers have been contacting Missouri residents throughout the state. They might put on some type of game like bingo with prizes or food to get residents to come to them. Sometimes announcements are made to all senior housing residents over a building intercom system. They typically try to determine if the individual has Medicare or Medicaid coverage. They may be dressed in scrubs or white coats to give the appearance they are a health care professional. In some cases, they may indicate they represent a medical research facility.

They typically have a short questionnaire and ask whether any of the individual’s relatives have had cancer or other diseases. They indicate a genetic test can be conducted to determine if the individuals already has a disease, or if they are susceptible to acquiring the condition. In some cases, they indicate the test will tell whether the combination of prescription and over the counter medications the individual is taking are having an undesired interactions or adverse effects on their metabolism.

If the individual agrees to be tested, the representative obtains their Medicare or Medicaid numbers and uses a swab to take a saliva sample from inside their mouth. The individual might be asked to sign the questionnaire. They are typically told the test results will be sent to them in several weeks, usually somewhere between four and eight weeks. The individuals might not receive the results of a lab test later.

MO HealthNet participants who have been solicited by a genetic testing marketer to provide a saliva sample using a cheek swab, or have already provided one, please report it to the Missouri Medicaid Audit & Compliance (MMAC) by email at MMAC.ReportFraud@dss.mo.gov or by phone to the MMAC Fraud Hotline at (573) 751-3285.

On June 6, 2019, the Missouri Department of Health and Senior Services (DHSS) distributed information from the Centers for Disease Control and Prevention (CDC) that provided patient care and public health recommendations in the context of the nationwide shortage of tuberculosis skin test (TST) antigens.

This information is available on the DHSS website, health.mo.gov/emergencies/ert/alertsadvisories/pdf/cdc-advisory6-6-19.pdf.

The following SLCR recommendations provide additional guidance for long-term care providers:
The Section for Long-Term Care Regulation (SLCR) recognizes that there may be some delay in obtaining the supplies needed to do the required TST testing and will allow the following:

• Make every effort to obtain the TST testing supplies including checking with your local health department, all suppliers, etc. in a timely manner.
• Document all attempts to obtain the TST testing supplies and estimated times of delivery.
• Until you can obtain the necessary TST testing supplies:
  • Establish a written plan for the TST shortage for testing of potential new employees and new residents within the same timeframes as required for the TST testing.
  • The plan must, at a minimum, include assessing new employees for signs and symptoms of TB prior to allowing direct contact with residents.
  • The plan must include assessing any new resident upon admission for signs and symptoms of TB.
  • Upon admission of residents, complete an evaluation to rule out signs and symptoms of TB and postpone the TST until supplies are available.
  • Document this assessment.
• During the shortage, if supplies are still available, new employees should be administered the one-step TST upon hire, and then defer the second step TST until the shortage resolves. If supplies are not available, conduct a symptom screen and document. Defer the two-step until the shortage resolves.
• Defer the annual testing of current employees, but if the annual comes due during this time, assess the current employee for signs and symptoms.

If the assessment of any employee or resident results in signs and symptoms of possible TB, instruct them to see their physician or their local public health department.

Once the TST testing supplies become available all employees or residents who required testing and were not tested, must be tested. SLCR expects the testing to be completed within a reasonable time period, usually within 30 days of obtaining the supplies.

TST testing is not an annual requirement for residents. Some homes have elected to do the TST instead of an annual review of symptoms. The only requirement for residents after the admission two-step TST is an annual review of symptoms to assure no signs of TB.

OR

You may follow the CDC guidance as noted below:
CDC recommends any of three general approaches for addressing the shortages of tuberculin skin test antigens:

• Substitute IGRA blood tests for TSTs. The costs associated with using the blood tests can be greater than the cost of TSTs. The blood tests require phlebotomy, preparation of blood specimens, and specific laboratory services for analysis. Thus, these tests are not available in all practice settings. Clinicians who use the IGRA blood tests should be aware that the criteria for test interpretation are different than the criteria for interpreting TSTs.
• Allocate TSTs to priority indications, such as TB contact investigations, as determined by public health authorities. This might require deferment of testing some persons. CDC does not recommend testing persons who are not at risk of TB.
• Substitute TUBERSOL® for APLISOL® for skin testing. In cross-sectional studies, the two products give similar results for most patients.

If you have any questions, please contact the Missouri Department of Health and Senior Services (DHSS) Bureau of Communicable Disease Control and Prevention at 573-751-6113.