QUINCY -- A waterborne bacteria sickened 54 residents and led to 12 deaths at the Illinois Veterans Home between July and September, among the nation's most widespread outbreaks of an ailment that was first diagnosed in 1976.
Centers for Disease Control environmental health specialists cited an "extensive and poorly understood water distribution system" and a "general lack of understanding of water system details" pertinent to the prevent and control" of the Legionella bacteria that causes the severe form of pneumonia.
Among the findings in the CDC's report:
º Maintenance of a cooling tower built in 2012 to help air-condition the dozens of buildings on the 210-acre campus didn't meet industry standards for containing Legionnaires' disease, which is transmitted by breathing vapor or mist from contaminated water systems. The report said "operation and maintenance record keeping was largely absent."
º A pressure valve failure inside the main water tower in early September -- at the height of the outbreak -- potentially led to water sitting stagnant "for an unspecified period of time," increasing the risks of contamination.
º There was an absence of electronic medical records for residents of the long-term care facility, nearly half of whom suffer from dementia, which the CDC said hinders the ability to quickly track health patterns, trends and shifts.
The naturally-occuring Legionella bacteria is especially dangerous for people with weakened immune systems.
Several CDC team members worked in coordination with the Illinois Department of Public Health (IDPH), Blessing Hospital and the Illinois Department of Veterans' Affairs. The multi-jurisdictional team stayed in Quincy doing testing and prevention work for 10 days.
The team initially ordered that water sources at the Veterans Home be shut down, tested and cleaned. Bottled water was used for cooking, drinking and sponge baths. Cooling towers were sanitized, and the water system was infused with extra chlorine to kill any bacteria.
Medical officials said Legionnaire's usually is caused when someone inhales the aersolized bacteria, so fountains, showers, cooling towers and other sources were given special attention.
"We are focused on preventing this from ever happening again," said Erica Jeffries, director of the Illinois Department of Veterans Affairs.
State officials pledged to fix the problem and work on a $4.8 million upgrade of the Veterans Home's water system began in late November.
The emergency health and safety project includes the installation of a new water main and other water lines at the home. An existing garage is being converted into a chemical treatment station. Mixing valves will be installed in the hot water system, which will be heated to higher temperatures. Disinfection equipment, backflow valves and other upgrades also are going into the cold water system to prevent the growth of Legionella bacteria.
"The work is anticipated to be complete by the end of April 2016," said Allie Bovis, a spokeswoman for the state.
The Veterans Home is a 129-year-old facility and traditionally houses close to 400 veterans who need care. It is the oldest and largest of four veterans homes operated by the IDVA, with a staff of more than 400 and an operational budget of more than $24 million per year.