Legionnaires' Update: Investigation Points to Davis Event Center And Hot Tub Displays

Sep 24, 2019

10/3 Update:  4 p.m.

State Health officials have released preliminary findings of their investigation into the source of the Legionnaires' outbreak at the Mountain State Fair in Fletcher, September 6-15. 128 cases of the severe lung infection have now been confirmed. One person has died. State Epidemiologist Dr. Zack Moore told reporters during a phone conference that fairgoers who were diagnosed were much more likely to report being in the Davis Event Center - an indoor facility.

"The second thing that has come out of the data so far is that people who were diagnosed were much more likely to be walking by hot tub displays when in the Davis Event Center, " says Dr. Moore, "Then a third finding we think is relevant is that people who developed Legionnaires disease attended fair in latter half of fair compared to people who didn’t get sick."

Dr. Moore says health investigators have taken samples from the building and some of the vendors including one of the two hot tub displays, and they are still waiting for results. One sample taken from the sink in a ladies room at center turned up positive.

Finding Legionella in one water sample is an important piece of the puzzle, but it does not tell us how so many people were exposed at this event,” said Dr. Moore. “To get Legionnaires’ disease or Pontiac fever, you have to breathe in Legionella in aerosolized water, meaning small droplets like mists or vapors.”

Taken together, health officials say these early findings suggest that low levels of Legionella present were able to grow in hot tubs or possibly some other source in the Davis Event Center leading to exposure through breathing in aerosolized water that contained the bacteria; however, this is an ongoing investigation.

Health officials visited the Western North Carolina Agricultural Center on Sept. 25 and Sept. 27 — after the fair had ended — and did not identify any significant sources of aerosolized water on the site. Very little aerosolized water is created from hand washing sinks, toilets and other currently operating water sources at the Agricultural Center, meaning the risk of exposure to Legionella is low.

The North Carolina Department of Agriculture and Consumer Services shared the following information:

"The decision has been made to suspend the rental of the Davis Event Center at this time while we review and implement mitigation plans for the facility. This is being done out of an abundance of caution and to reassure event attendees, fairgoers and Ag Center employees that the center is safe for occupancy. Additionally, in collaboration with public health, we have taken steps to minimize water aerosolization opportunities on the grounds, as this is considered the means by which the Legionella bacteria is contracted. While we all feel confident that the facility is safe, we want to take these proactive mitigation measures to reassure the public and our employees."

"Although Legionnaires’ disease is a rare infection, this is a reminder that the bacteria that cause it are common in nature and can be found in man-made water systems," said Dr. Moore. "This means it’s very important for owners and managers of water systems that can create aerosols to take steps to prevent Legionella from growing and spreading in water systems."

4 p.

1 p.m. The WNC Ag Center released the following statement announcing the temporary closing of the Davis Event Center:

Date: Oct 03 - Oct 31, 2019

"Based on the latest reports and in consultation with State Public Health Officials, we have voluntarily decided to suspend rental of the Davis Event Center while it undergoes an aggressive and comprehensive mitigation plan. This is being done out of an abundance of caution and to reassure event attendees, fairgoers and Ag Center employees that the center is safe for occupancy." "In collaboration with public health, we have taken steps to minimize water aerosolization opportunities on the grounds, as this is considered the means by which the Legionella bacteria is contracted. While we all feel confident that the facility is safe, we want to take these proactive mitigation measures to reassure the public and our employees. Because of the seriousness of Legionnaires Disease, we would rather err on the side of being overly proactive."

"Throughout the investigation, we have followed every recommendation of State Public Health officials and we continue to work hand-in-hand with them as they continue their investigation and try to determine the source of this outbreak and prevent future outbreaks."

10/2 Update:There are now 116 confirmed cases of the Legionnaires’ disease linked to the Mountain State Fair in Western North Carolina. One person has died and nearly 70% of the cases, mostly in people aged 60, have landed in the hospital. It is the state’s largest documented outbreak of the severe lung illness and while health officials search for the source, they say there are signs the worst may soon be over. BPR’s Helen Chickering has the latest.

Health officials say Legionnaires’ disease has an average incubation period, of 2 days to 2 weeks. The mountain state fair ended September 15 which means cases should start tapering off says Henderson County Health Director Steve Smith.

“Well if there is any good news, we’re really passed the outside window of transmission, given that point in time exposure at the state fair. So we will likely identify a few more cases, but that should really tail off very quickly.”

About a week after the Mountain State Fair ended on September 15th Smith says lab reports of Legionnaires disease trickled into his office and soon it was apparent an outbreak was underway.

“I was contacted by the state epidemiologist Dr. Zack Moore that other cases had emerged in counties other than Henderson and that there was a growing concern and we would need to connect and collaborate on investigating that.”

The health department deployed a public health team to help document, investigate and control the outbreak. Something Steve Smith says happens much more than the public realizes.

“I think this is something that is unseen by the public but probably one of the most vital roles of public health departments across the state.

Henderson County Health Director, Steve Smith, MPA
Credit ncalhd.org

We do this every day. Many cases we deal with are not paid much attention to or are not visible to the public, but we have a standing epidemiology team internal to our department that’s populated with all kinds of disciplines - from our medical director to communicable disease nurses, public information specialists to environmental health personnel. It’s a broad multi-disciplinary team that knows how to go through a communicable disease investigation in a kind of organized process. We use an incident command system structure and do that in a very purposeful way to deal with cases that are evolving as well as looking upstream very quickly with intent of prevention of additional cases.

In this investigation was quickly discovered that the common thread among the cases was the fair in Fletcher, which is held at the WNC Ag center. Legionella bacteria are spread through tiny water droplets that are inhaled into the lungs – it is not spread person to person. Local health departments are working with state health officials to help pinpoint the source of the outbreak – which is proving to be a challenge, since the fair and vendors were packed up and gone once cases started trickling in.

“It’s a little bit challenging, “ says Smith, “because many of exhibits and things that were there at the Mountain State Fair are no longer there because the fair has ended but they have a lot of historical info about those sites. And then I think next step is really evaluating info we might acquire through surveys that have been requested of all people who attended the fair.”

Meantime Steve Smith says there’s been lots of speculation and social media chatter as the public waits for an answer.

“I have seen some of the same comments on social media and other places, individuals speculating the cause, everything from air conditioning systems to hot tub display to a misting station. It is certainly true, we’re targeting or looking at closely that environment where water was aerosolized in some way into a fine mist or fine droplets that made it possible for people to inhale that.”

Health officials urge anyone who attended the Mountain State Fair in Fletcher and comes down with cough, shortness of breath, fever or flu like symptoms to contact their health provider immediately. I’m Helen Checkering, BPR news.

You can find the latest on the outbreak here

10/1 Update:The outbreak of Legionnaires' disease linked to last month’s Mountain State Fair in Fletcher has grown to 108 confirmed cases - making it the largest documented Legionnaires' outbreak in the state's history.

Most of the cases are in Buncombe and Henderson counties - in people in their 60s.  Health officials are still trying to pinpoint the source of the outbreak and they are seeking the public's help - asking anyone who attended the fair to take an online survey. Legionnaires' is spread through contaminated water droplets that are inhaled into the lungs. It is not spread from person to person. Symptoms are similar to pneumonia - coughing, fever and shortness of breath.

9/30 Update: There are now 95 of confirmed cases of Legionnaires' disease linked with the Mountain State Fair in Fletcher (Sept 6-15) has according to the latest data from the NC Department of Health and Human Services and local health departments. You can check the latest case count from the NC-DHHS here. Please note that the numbers may not reflect the latest updates from local health departments.

The North Carolina Division of Public Health is conducting a survey of people who attended the fair NC Mountain State Fair in Fletcher, NC, between September 6-15, even if they did not become ill. According to health officials, participation will help investigators understand the outbreak and could help prevent similar outbreaks in the future.

From the NCDHHS: Answers will be kept confidential, and the information will be used for public health purposes only. The survey should take less than 5 minutes to complete. If multiple people in a household attended the fair, each person should complete a survey.

If someone cannot answer the survey questions, then someone else can answer on their behalf. Start a new survey for each person at https://www.surveymonkey.com/r/dhhs_survey.

For questions about this survey, the investigation, or to report possible cases, call the Public Health Hotline at (828) 694-4040 or contact the NCDHHS Division of Public Health at (919) 733-3419.

State health officials have visited the WNC Agricultural Center in Fletcher and determined that there are not currently any significant sources for aerosolized water — small droplets such as mists or vapors that could pose a risk if contaminated with Legionella bacteria and inhaled into the lungs. Investigations are ongoing into other possible sources of aerosolized water that were present at the fair.

9/27 Update: The number of confirmed cases of Legionnaires' disease linked with the Mountain State Fair has jumped to 63 according to the latest data from the NC Department of Health and Human Services and local health departments. You can check the latest case count from the NC-DHHS here. Please note that the numbers may not reflect the latest updates from local health departments.

Legionella colonies in a petri dish
Credit allbacteria.com

Most of the cases are being reported in Buncombe and Henderson Counties. Legionnaires’ disease is a lung infection that is spread through contaminated water droplets in the air. It is not spread from person to person. State Health investigators are still working to pin down the source of the outbreak. As a precaution health officials are recommending anybody who attended the event and has symptoms of pneumonia, like cough, fever or shortness of breath contact their doctor. Health officials note that most healthy people do not get the illness when exposed to the bacteria.

9/25  Update: The NC DHHS now confirms fifteen cases of Legionnaires' disease in people who attended the Mountain State Fair, nine of those cases have been confirmed in Buncombe County, including one death. Six cases have been confirmed in Henderson County.

The North Carolina Department of Health and Human Services is working with Buncombe and Henderson County Health officials to investigate multiple cases of Legionnaires’ disease involving people who attended the NC Mountain State Fair in Fletcher earlier this month.

As of Tuesday, September 24th, health officials say there are nine confirmed cases of Legionnaires’ disease in Buncombe County residents, including one fatality caused by the illness.

“We don’t yet know whether people might have been exposed to Legionella bacteria at the NC Mountain State Fair,” said State Epidemiologist Dr. Zack Moore in a news release. “As a precaution, we are recommending that anyone who went to the fair and has symptoms of pneumonia, like cough, fever or shortness of breath, see a doctor right away and talk with them about Legionnaires’ disease.”

According to the release, Legionnaires’ disease is a form of bacterial pneumonia (lung infection) that people may develop after they breathe in mist or accidentally swallow water into the lungs that contains Legionella bacteria, which are found naturally in the environment. According to the Centers for Disease Control the incubation period for Legionnaires’ disease is most commonly 2 to 10 days from the time of exposure to symptom onset, with an average of 5 to 6 days, but public health officials have reported incubation periods up to 26 days under rare circumstances

Health officials say most healthy people exposed to Legionella bacteria do not get sick. The people at highest risk for Legionnaires' disease include individuals 50 years or older, current or former smokers, and those who have a chronic lung disease or a weakened immune system.

Doctors advise people who attended the NC Mountain State Fair and are now experiencing cough, fever or shortness of breath should call a doctor right away.

For additional information or to report possible cases of Legionnaires’ disease, please call the Division of Public Health at (919) 733-3419 or contact your local health department. In Buncombe County, call (828) 250-5109. In Henderson County, call (828) 694-6019.

Find out more about Legionellabacteria and Legionnaires disease on the CDC website at https://www.cdc.gov/legionella/resources/materials.html.

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