Title: Legionella Outbreak Associated with St.

Columbkille
Church – Parma, Ohio
Jurisdiction: Cuyahoga County Board of Health
Type of Outbreak: Waterborne
OB ID: 2018-29-220
ODRS ID: 8273746
CDC NORS ID: 281114

Final Report Date: October 11, 2018

CONTEXT / BACKGROUND

Cases of Legionnaires’ disease and Pontiac fever are required to be reported to

the state and local health departments. As part of routine follow-up, the
Cuyahoga County Board of Health (CCBH) conducts interviews for these cases
to identify potential sources of exposure that may have contributed to the
infection. All questions asked are regarding each case’s exposure history two
weeks before their illness onset.

Legionnaires’ disease is caused by the Legionella bacteria. The reservoir for

Legionella is water. The bacteria are present in fresh water sources. They grow
well in warm water, such as hot tubs, cooling towers, hot water tanks, water
features, plumbing systems and air cooling systems in buildings. Persons can be
exposed to the bacteria, most commonly, by inhalation of aerosolized
contaminated water. Although less common, persons can also be exposed
through the aspiration (breathing in) of contaminated water. Once exposed,
individuals can develop a serious type of pneumonia (lung infection) called
Legionnaires’ disease. The bacteria can also cause a less serious illness called
Pontiac fever. Person to person transmission has not been documented. The
incubation period (the period between exposure to an infection and the
appearance of the first symptoms) for Legionnaires’ disease ranges from 2-10
days (with 5-6 days being the most often) and the incubation period for Pontiac
fever ranges from 5-72 hours (with 24-48 hours being the most often)1.

On June 25, 2018, the CCBH Epidemiology staff interviewed three individuals
with Legionnaires’ disease. During these interviews, two of the three cases (both
with onset dates of June 11, 2018, with one reported to CCBH on June 19th and

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 1 of 20

the other reported on June 20th) indicated that they attend church at St.
Columbkille, which is located at 6740 Broadview Rd. in Parma, Ohio. This was
the only potential source of exposure identified that was common to both cases.
The third case did not initially report attending St. Columbkille but was later
identified as attending the church using a supplemental questionnaire.

Subsequent to these cases, eight additional cases of Legionnaires’ disease that

also reported attending St. Columbkille were reported to CCBH. As of the date of
this report, a total of 11 cases, including one death, have been associated with
this outbreak.

INITIATION OF INVESTIGATION

On June 25, 2018, upon learning of a second case associated with St.
Columbkille, CCBH Environmental Public Health (EPH) staff was notified. A
routine environmental investigation was completed by CCBH staff on July 2,
2018.

On July 12, 2018, CCBH Epidemiology staff conducted another Legionnaire’s

disease case interview and the individual also stated that they attended services
at St. Columbkille, making the third known case associated with the church at
this time.

Given that all three cases reported St. Columbkille as a common potential
exposure, the Ohio Department of Health (ODH) was notified of the possible
disease cluster and CCBH staff reported the third case with a common exposure
to the church. On July 17, 2018, EPH staff conducted a second investigation at
St. Columbkille using the Centers for Disease Control and Prevention (CDC)
based Legionella environmental assessment form titled “Environmental
Assessment of Water Systems”.

INVESTIGATIONAL METHODS

Epidemiological Investigation
Because of the increase in cases associated with this disease cluster, CCBH
consulted with ODH to discuss strategies for active case finding. The following
strategies were selected: 1) distribution of a health advisory using the Ohio
Public Health Communication System to increase awareness among local
hospital and health department staff; 2) utilization of geographical information
system (GIS) software and the Ohio Disease Reporting System (ODRS) to
identify Legionnaires’ cases reported to area health departments since mid-May
that live(d) within a 10 mile radius of the church in order to determine if they
attended St. Columbkille within their incubation period; 3) solicitation of
parishioner names that were brought to the attention of the church staff whom
may have been ill with symptoms consistent with Legionnaires’ disease; and 4)
review of the weekly online church bulletin to identify deceased parishioners to

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 2 of 20

cross reference with preliminary death certificate data obtained on a monthly
basis through the Ohio Department of Health. If the deceased parishioner was
identified in the death certificate data, the cause of death was assessed to
determine if it may be associated with a Legionella exposure (e.g. pneumonia).

A supplemental case questionnaire was developed on July 13th (and revised on

July 19th) for cases identified through active case-finding. The questionnaire was
designed to accomplish the following: 1) to determine if case(s) had attended St.
Columbkille during the incubation period; and 2) if they did attend the church, to
determine what areas within the church they visited. This questionnaire was also
administered to the known CCBH cases who attended St. Columbkille during the
incubation period.

Environmental Investigation
The environmental investigation centered on identifying water sources that could
potentially support the growth of Legionella bacteria and provide an exposure
risk. The areas of focus included the building potable water supply and the
HVAC systems located on the church campus (Figure 1).

The environmental investigations included visual observations, direct

measurement of environmental conditions, environmental sampling, as well as
interviews with onsite personnel and outside contractors.

Investigations used both the CCBH standard complaint form as well as the CDC
based “Environmental Assessment of Water Systems” form. Sampling was
conducted by both CCBH staff as well as staff from the Northeast Ohio Regional
Sewer District (NEORSD). NEORSD also performed analysis of samples
collected on July 23rd and July 26th.

CCBH conducted the environmental investigations in routine consultation with

ODH and CDC.

The significant events of the environmental investigation as well as the site visits
occurred on the following dates: July 2nd, July 17th, July 18th, July 19th, July 23rd,
July 25th, July 26th, and July 31st. Details of these activities can be found in the
Investigation Findings/Results section of this report.

INVESTIGATION FINDINGS/RESULTS

Epidemiological Investigation
Based on the available information and to identify other cases potentially
associated with the church, a case series was used for the epidemiological study
design.

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 3 of 20

Using a timeframe of June 1st through July 31st to identify Legionnaires’ disease
cases in ODRS and using the results of the GIS-based analysis, a total of 31
Legionella cases were identified that were located within the 10 mile radius of St.
Columbkille. A total of 25 of the 31 cases were successfully contacted and
administered the supplemental questionnaire. Among these 25 cases, 11
reported attending St. Columbkille church during their incubation period. The
illness onset dates for these cases ranged from June 4, 2018 through July 10,
2018 (Figure 2).

Among the 11 cases:

 church attendance was indicated between May 27, 2018 and July 9, 2018
and the church was visited 1-2 times a week for church services only
 73% were female (8 female; 3 male)
 the median age was 78 years old (range = 74-93 years old)
 seven cases lived in the City of Parma, two in the City of Seven Hills, one
in the City of Broadview Heights, and one in the City of Independence,
Ohio
 there was one death
 all were diagnosed by Legionella urine Ag testing conducted by area
hospitals. No cultures were ordered

CCBH also investigated information obtained from the church staff. Specifically,
the staff provided the names of 11 parishioners who may have been ill with
Legionnaires’ disease. Among these individuals, six were already known cases
associated with the outbreak. There were four additional individuals who were
brought to the attention of CCBH staff as a result of media coverage associated
with the outbreak.

CCBH staff obtained additional information on these remaining nine individuals to

further determine whether or not they were associated with the outbreak. All
reported respiratory illness occurring in June and July. Seven reported being
diagnosed with pneumonia. After further investigation by CCBH, it was
determined that Legionella testing was not ordered for three of the seven cases
of pneumonia and was negative for the other four cases. The remaining two
individuals reported fever, headache, and muscle aches but were not diagnosed
with pneumonia. Eight of the nine individuals have since recovered; therefore
testing of these individuals was not possible. The additional individual diagnosed
with pneumonia died, but was not tested for Legionella.

As of the date of this report, a total of 52 deaths among St. Columbkille

parishioners were identified by reviewing the online church bulletin. Among
these, preliminary death certificates could be identified for 39 individuals. Among
these individuals, one did not have the cause of death indicated, one was the
known case of Legionnaires’ disease, and the remaining 37 death certificates did
not indicate a cause of death consistent with Legionnaires’ disease (i.e.
pneumonia).

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 4 of 20

Based on the information obtained by administering the case questionnaires,
potential sources for Legionella exposure for the 11 cases are summarized in
Table 1. Besides attending St. Columbkille, there were no other common
locations that were visited or utilized by all of the cases.

Table 2 shows the locations within St. Columbkille visited or utilized by the 11
cases. Similar to the results described in Table 1 above, there were no other
common areas visited or utilized by all of the cases.

Environmental Investigation

See Figure 1 and Figure 3 for locations assessed during the investigation. See
Table 3 for a summary of select results for select dates associated with the
environmental investigations conducted at St. Columbkille church campus.

The following information provides the details for the environmental investigation
activities that took place on the dates indicated:

JULY 2, 2018
The field investigation consisted of a discussion with staff in charge of facility
maintenance and direct observations. The church staff noted that the church
consulted with their heating and cooling contracting company, Brewer-Garrett,
who visited the facility to check and service the heating, ventilation and air
cooling (HVAC) system, in addition to their regularly scheduled visits for routine
maintenance. Subsequent to this visit, CCBH staff learned that the water
chemistry in the cooling tower is managed by G.L.A. Water, Inc. (GLA).

The intake for the air handlers was not near the condensation pans for the
system or other areas that may collect standing water. As an extra precaution,
the staff changed and/or cleaned filters in individual units in the Adoration Chapel
and attached meeting rooms and cleaned out all holy water basins.

There were no showers or other systems in the church or Adoration Chapel that
were identified as having high potential to create aerosolized water droplets.

JULY 17, 2018

The field investigation consisted of consultation with church staff members, the
head of maintenance, and the business manager, who provided access to the
buildings and consultation for the completion of the CDC based Legionella
environmental assessment form. Copies of maintenance records for the air
cooling units were also requested.

The assessment was conducted to identify: 1) the use and occupancy

characteristics of the buildings on site; 2) the design and operation of the heating

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 5 of 20

and cooling systems; 3) the design and temperature settings of the building
potable water supply system; and 4) any decorative or other types of water
fixtures on site that could potentially serve as sources of exposure.

A central air cooling system was observed in the church, that includes three air
handlers located in the basement, and a cooling tower located outside the
building at basement ground level. Church staff stated that the main system was
originally installed in 1970 with alterations in the last five years. Automatic
chemical feeders that are connected to the cooling tower, one of which feeds
sodium hypochlorite, were observed. Church staff stated that Brewer-Garrett is
under contract to provide monthly service to the system, and that GLA is under
contract to provide water testing. The air cooling system was not operating at the
time of the visit. Church staff stated that the air cooling system is turned on only
when parishioners are present for services and that they had limited knowledge
of the system.

Hot water in the church was observed to be supplied by heated storage tanks,
and tap temperatures measured at the kitchen and bathroom sinks were found to
be 90°F, 93°F, 111°F, 113°F, 115°F, and 121°F. CCBH advised that when hot
water temperatures are not maintained above 140°F in a hot water tank and
above 122°F at the tap, a routine thermal or chemical flushing of the system is
recommended2. CCBH staff provided guidance on raising the hot water tank
temperature to 168°F and flushing each fixture for 20 minutes. Church staff
stated that they would carry out the thermal flushing and that they would also
increase and maintain the temperature of the hot water tank to ensure that
temperatures at the tank and taps meet the recommendations.

Air cooling in the rectory was observed to be provided by individual units, with
condensers located outdoors at ground level. Church staff stated that the units
had been installed in 2015. Hot water was observed to be supplied by heated
storage tanks, and tap temperatures measured at the kitchen and bathroom
sinks were 129°F, 131°F and 133°F.

Air cooling in the parish center was observed to be provided by individual units,
with condensers located outdoors at ground level. Church staff stated that the
units had been installed in 2015. Hot water was observed to be supplied by
heated storage tanks and tap temperatures measured at the kitchen and
bathroom sinks were 127°F, 128°F and 127°F.

The school building was not open at the time of the visit and was not identified in
the exposure histories of the three reported cases. No other water sources were
observed on site that could potentially serve as sources of exposure. No
stagnant or pooling water was observed on the exterior premises.

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 6 of 20

JULY 18, 2018
The field investigation consisted of further consultation with church staff and
direct observations to further investigate the design and operation of the air
cooling system in the church.

The air cooling system was not in operation at the time of the visit. Condensate
water observed in the air handlers was found to be at 59°F. CCBH staff noted
that both the air supply for the system and the exhaust for the water chiller were
at ground level. Questions regarding precisely where, how often, and at what
concentration the sodium hypochlorite was fed, via the metering pump, could not
be answered by church staff. It was suggested that CCBH contact the
maintenance companies for the requested information.

Church staff was advised that the temperature measured in the condensate
water in the air handlers is sufficient to inhibit the growth of Legionella, but that
the location of its components at ground level might be a problem. Church staff
expressed concern over the cluster of cases associated with their facility and
inquired as to whether CCBH would advise that they close the church. Church
staff was advised that CCBH staff would be consulting with CDC and ODH, after
which time recommendations would be provided to the church to effectively
address potential risks for exposure.

Further follow-up with the maintenance company to inquire about the operation of
the church’s HVAC automatic chemical feeders and a work order that
documented the installation of a new meter was completed via phone. It was
reported that the automatic chemical feeders have been present and in operation
for several years and that the new meter was a water flow meter.

An additional call was placed to the company that performs the water testing,
GLA, to inquire about the sodium hypochlorite feed and the adenosine
triphosphate (ATP)/relative light units (RLU) readings documented on the
monthly service reports. It was reported that the sodium hypochlorite does feed
to the cooling tower and that residual chlorine is not routinely measured, but that
the ATP/RLU is measured and utilized to evaluate the cleanliness of
environmental surfaces, and that recent measurements were within the
acceptable limits established by industry standards.

A call was also placed to the Water Quality Manager at the Cleveland Division of
Water to discuss water service to the church property and to identify any work on
the water supply lines that may have impacted water service to the church
property.

The Superintendent of Environmental Services at the Northeast Ohio Regional

Sewer District (NEORSD) was also contacted to identify their capacity to collect
and analyze Legionella samples at their laboratory. NEORSD advised that they
would provide a crew to collect the samples at the church on July 23rd.

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 7 of 20

Copies of service reports from GLA were received (via email) by CCBH for the
following dates: July 13, 2018; July 3, 2018; June 21, 2018, May 17, 2018, April
26, 2018, September 21, 2017, August 25, 2017, and June 20, 2017.

JULY 19, 2018

The field investigation consisted of further consultation with church staff and
direct observations to further investigate the design and operation of the air
cooling system in the church, and to measure residual chlorine levels in the
potable water distribution system and in the cooling tower (later determined to be
a high-efficiency Baltimore Air Coil water tower).

Church staff turned the air cooling system on so that it could be observed in
operation by CCBH staff. The Carrier AC unit was observed in the basement, on
the west side of the building. The cooling tower was observed in a concrete pit,
outside the foundation wall on the west side of the building. The pit was covered
by open grates, through which aerosolized water droplets was observed rising
(Video 1). Church staff advised that they could not open the grates. The location
of the cooling tower was observed to be a significant distance away from the air
supply intake (Figure 3), at the northeast corner of the building. It was noted that
the cooling tower emits its aerosolized water droplets from a location that is
adjacent to the walkway that is used for entry to and egress from the building,
posing a potential exposure risk to those visiting the church.

Residual chlorine levels in the potable water distribution system were measured
at the tap of two bathroom sinks in the church and found to be undetectable.
Residual chlorine levels could not be measured in the cooling tower, as access to
the unit could not be provided by church staff at the time of the visit.

Church staff stated that the potable water distribution system was flushed that
morning, that the maximum hot water temperature that could be achieved was
approximately 150°F, and that taps were flushed for approximately 15 minutes.
Hot water temperatures measured at the kitchen and bathroom sinks were
127°F, 129°F and 134°F.

Church staff stated that the air cooling system is turned on only for church
services. Church staff was advised that CCBH staff would be consulting with the
CDC and ODH, after which recommendations would be provided to the church to
effectively address potential risks for exposure.

It was also noted by CCBH staff that observation of the internal workings of the
water cooling tower in conjunction with their maintenance service provider is
highly recommended. Direct observations require using a ladder to descend into
the cooling tower pit.

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 8 of 20

As a result of observing the emission of aerosols from the cooling tower through
a series of grates located directly adjacent to the walkways, further consultation
with ODH and CDC occurred. The operation of the cooling tower in its current
design was deemed to be a significant public health threat to church visitors
while the unit was in operation. As a result, the leadership of the parish was
instructed to cease with the operation of the air cooling system until further
notice.

The facility maintenance staff were contacted (via phone) to advise that CCBH
would like to conduct sampling of the air cooling system cooling tower on July 20,
2018 and to advise that the church must discontinue using the system until
further notice. Administrative staff agreed to ensure that the church discontinue
the use of the air cooling system and requested that sampling not be conducted
on July 20, 2018, due to church services and a funeral that were scheduled for
that morning. Given the challenges expressed by the NEORSD in rapidly
preparing sample media and these functions being held at the church, it was
determined that sampling would be scheduled for 9:00 am on Monday, July 23,
2018.

The Water Quality Manager at the Cleveland Division of Water responded (via
email) related to questions concerning any water line repair work conducted in
the area. The Manager confirmed that the work completed related to the water
mains on May 9th, May 21st, and June 17th, should have had no impact on the
church property and that no drop in water pressure / repressurization should
have occurred during the repairs that would have dislodged any materials or
biofilm coating the inside of the water lines. Chlorine residuals maintained in the
lines exceeded recommended standards.

JULY 23, 2018

The field investigation consisted of sampling of the water reservoir of the cooling
tower, with a total of three samples being collected. The first and second
samples were collected from the non-operating cooling tower. The third sample
was collected after the cooling tower was operated for 30 minutes. These
samples were collected by NEORSD staff who utilized the appropriate personal
protective equipment (PPE) and had experience in this type of sampling. At the
time of this site visit attempts were made to measure free chlorine at various
potable water outlets serving the church using a standard diethyl-p-
phenyleneldiamine (DPD) swimming pool test kit. Based on this test it was
difficult to ascertain if free chlorine was present.

The results of the three cooling tower samples were reported by NEOSRD on
July 31st as being negative for the presence of the Legionella bacteria. It should
be noted that subsequent review of the maintenance records for the cooling
tower found that it was chemically cleaned and sanitized on July 11, 2018 and
again on July 19, 2018.

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 9 of 20

JULY 25, 2018
The field investigation consisted of: 1) measuring chlorine residual of the potable
water with a HACH DR/850 Colorimeter; 2) inspection of the Adoration Chapel,
located in a separate building on the church campus; and 3) inspection of the
condensate collection trays of the church air handlers.

Cold water samples from the basement water fountain, men’s basement lavatory
sink, cry room lavatory sink, and drinking fountain in the sacristy were taken.
Only the basement water fountain contained a measurable chlorine level of 0.01
parts per million (ppm).

No obvious concerns were observed in the Adoration Chapel. A follow-up visit

(see July 31st results below) was conducted to determine the discharge location
for the condensate return lines, as the two HVAC units (i.e. mini splits) were
mounted on an interior wall.

Standing water was observed in the condensate collection trays of the church air
handlers. Church staff was advised to clean and sanitize the trays routinely.
Furthermore, they were advised that the condensate drain lines should be
repaired to drain the collected water.

JULY 26, 2018

The field investigation consisted of the collection of water and swab samples
from the drinking fountain located in the basement of the church, bathroom sinks,
and the condensate trays in the air handlers by CCBH staff.

The results of these samples (analyzed by the NEORSD Lab) were received on
August 7th and indicated that no live Legionella bacteria were present. However,
these sample results did indicate the presence of nonviable Legionella found in
samples identified as “Basement Drinking Fountain 1” and “Basement Drinking
Fountain 2”. The report attributes these finding to “the presence of environmental
DNA from dead cells”.

JULY 31, 2018

The field investigation revealed no significant findings. It consisted of a routine
inspection of the St. Columbkille School. The two air conditioner (AC) air
handlers serving the gymnasium were inspected. The AC cooling fans are
located on the roof of the gym. This system does not use a cooling tower.

Standing water was observed in the condensate pan for the gymnasium air
hander. Red and blue blocks were observed sitting in this pan. The
maintenance company representatives were unsure as to their application, but
suspected they were disinfectant blocks. The facility maintenance staff indicated
these units were serviced prior to the start of every school year. Church staff
could not conclusively identify the exact nature of the blocks.

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 10 of 20

The remainder of the school is served by a boiler, utilizing unit ventilators that
have limited functionality. The computer room is served by mini splits and select
subsets of rooms are served by window air conditioners. Condensate was
observed properly draining from these mini splits.

At the time of this visit the condensate drain lines for the Adoration Chapel were
observed discharging into a drain in the basement of the building. Another
attempt was made to utilize the colorimeter to measure total chlorine at the
lavatory sink located in the Cry Room of the church. An obvious pink color
change was observed but no reading was obtained on the colorimeter. Utilizing
a DPD test kit, a 0.2 ppm reading was observed at this location.

AUGUST 6, 2018
CCBH learned that the church contracted with the EA Group to conduct
environmental sampling at the church. This included bioaerosol sampling for
viable bacteria and water and surface wipe sampling for Legionella. This
sampling was conducted on July 19th. The samples were forwarded to EMLab
P&K for analysis. Samples were received by the lab on July 24th and a report
was generated on August 6th. No Legionella bacteria were detected in any of the
samples.

DISCUSSION/CONCLUSIONS

Historically, cooling towers have been established as a classical source of

exposure in Legionella outbreaks3. The investigation indicates that the design,
operation, and location of the current cooling system at St. Columbkille church
provided a significant risk and a very likely mode of transmission and pathway for
exposure for the Legionnaires’ disease cases. Justification to support this
determination is provided below.

Location of the Cooling Tower

The cooling tower is sited outside the foundation wall in a pit, which vents
aerosolized water droplets through grating at ground level. The tower is located
on the west side of the church immediately adjacent to the rear of the church
(Figure 3). Aerosolized water droplets were observed and captured on video
rising from these grates in front of the adjacent walk way during several of the
inspections (Video 1). This is the walkway used to enter/exit the main rear
entrances of the church from the parking lot presenting an exposure risk to those
visiting the church (Figure 3). During our investigation it was learned that the
current HVAC system was altered to its current design under a permit issued on
March 23, 2013.
 
Maintenance of the Cooling System
Since the church maintenance personnel were uncertain as to the operation and
feed schedule for automatic chemical feed systems, we were referred to their

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 11 of 20

service providers for more information. The HVAC systems located on the
church campus are serviced by the Brewer-Garrett Company. Based upon the
nine service reports obtained by CCBH, the service appears to be provided on an
“as needed” basis. Service reports #407690/407636, containing the service date
of July 11, 2018, state the description of the service as “clean and sanitize tower”.
These are the only service reports obtained by CCBH specifically mentioning the
cooling tower service. This is inconsistent with church maintenance staff
comments made on July 2nd that the system is routinely maintained by Brewer-
Garrett.

The water chemistry in the cooling tower is managed by G.L.A. Water, Inc.
Historic records obtained by CCBH, dating back to June 20, 2017 indicate
monthly service during the cooling season. In a report dated June 21, 2018, it
was stated that “biocide timer needed configured…not programmed to read
water meter counter”. In a report dated July 3, 2018, it was written: “received
phone call from office, with concerns to ATP levels at St. Columnkille (sic)
church’s cooling tower”. It also mentions the difficulty of accessing the
evaporative tower service door. In a subsequent service report dated July 13,
2018, it notes the installation of a new water meter. The report reads “original
meter’s clock wheel had frozen/did not turn, not allowing tower controller to
operate”. Water meter readings of Tower Make Up (TMU) water usage were
reported as being “TMU: 155550” as recorded on the service reports. This
reading remained unchanged from April 26, 2018 through July 3, 2018.

A service report dated July 19, 2018, indicates the first and only time
measurements of free and total chlorine levels or any other biocide in the cooling
tower were recorded among all the records reviewed by CCBH. The presence of
biocides has been shown to be effective in the control of Legionella bacteria
growth.

Furthermore, it should also be noted that the “after treatment” free and total
chlorine levels of 2.67 and 8.89 ppm respectively were reported for the cooling
tower reservoir. These are substantially higher than the readings noted prior to
the biocide treatment, which were 0.03 and 0.22 ppm respectively.

It should also be noted that an additional bacterial sample was collected by GLA
personnel for a microbiological analysis using Biosan Laboratories’ SaniCheck
system for counting total Heterotrophic bacteria. The result from this sample was
in the “good” range per the report. This finding is not surprising given that the
cooling tower was cleaned and sanitized eight days prior to this sampling, as
documented on the Brewer-Garrett service report.

Operation of the Cooling System

The system is operated intermittently and manually. The church staff stated that
the system is turned on daily only for church services and then turned off. This
mode of operation is corroborated in the GLA service reports.

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 12 of 20

The location of the aerosolized discharge from the cooling tower and its proximity
to the walkway used by parishioners entering the church, combined with the
intermittent use, and noted mechanical failure of the water meter, all lead to the
potential for Legionella growth and dispersal. In addition there is no history of
measurable biocide residual in the cooling tower, per the records obtained by
CCBH. It is not possible to conclude from the service records that there was
continuous and effective disinfection of the cooling tower water.

This conclusion is further supported by the fact that: 1) beyond church

attendance, no additional epidemiological information linking all of the 11 cases
was identified; and 2) since the church was told to cease the operation of the
current cooling system on July 19, 2018, there have been no other Legionnaires’
disease cases that have been associated with the church.

While results of the environmental samples taken from the cooling tower on July
23, 2018 were negative for Legionella bacteria, the epidemiological information
obtained for the cases could not identify other potential exposures of interest that
were common to all 11 cases (Table 1). Furthermore, information on areas
visited at the church and water exposures within the church did not identify other
potential exposures of interest that were common to all 11 cases (Table 2).

Review of the maintenance records for the cooling tower found that it was
chemically treated on July 11, 2018 and again on July 19, 2018 (which was four
days prior to the samples being collected by NEORSD). This information
provides a reasonable explanation for the negative results associated with the
cooling tower sampling conducted on July 23rd.

Results from samples taken on July 26, 2018 indicate the presence of non-viable
(dead cells) Legionella bacteria found in samples taken from the basement
drinking fountain. Non-viable Legionella can be found in a water sample as
Legionella occurs naturally in fresh water environments4. Legionella can become
a health concern when it grows and spreads in building water systems. There
was no live Legionella bacteria found in any of the collected samples.

The drinking fountain is not being considered as the likely source of the exposure
as only one of the eleven cases reported drinking from the fountain.

RECOMMENDATIONS FOR CONTROLLING DISEASE AND/OR

PREVENTING/MITIGATING EXPOSURE

Significant concerns exist with the cooling system, in particular, the design,
operation and location of the current cooling tower. Its location on the west side
of the building is below grade and its proximity to the walkways where the public

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 13 of 20

enters and leaves the church building allows for the inhalation of aerosols being
generated by the cooling tower.

Consequently, in consultation with the Ohio Department of Health (ODH) and the
federal Centers for Disease Control and Prevention (CDC), we provided the
following recommendations:

 Based on its present location, design, operation and maintenance, the

cooling tower located at the rear entrance to the church poses a significant
risk to health. As a result, the cooling tower should not be operated.

 Develop and follow an ASHRAE 188-compliant Legionella water

management plan for all of the water sources in the parish facilities. It
should directly address any conditions that could promote an environment
suitable for the growth and possible transmission of bacteria, including
Legionella. Principles to be addressed in the plan should include
maintaining proper hot water temperatures, monitoring chlorine residuals,
and routinely flushing lines to prevent stagnant water conditions.

 Consult with a qualified Heating, Ventilation and Air Conditioning (HVAC)

engineer for guidance in addressing the issues and risks related to the
location, design, operation and maintenance of the cooling tower. The
consultant should be familiar with national engineering standards relevant
to Legionella and cooling towers, such as those produced by the American
Society of Heating, Refrigeration and Air Conditioning Engineers
(ASHRAE 188), NSF International (NSF 453-2016) and the Cooling Tower
Institute (CTI Guideline: Best Practices for Control of Legionella). The
church should work with the previously-described consultant to do the
following:
o Implement use of an oxidizing biocide, non-oxidizing biocide and a
corrosion inhibitor. Chemical addition should occur at least daily.
o Eliminate intermittent use or follow shutdown and startup procedures
as specified in the above mentioned standards.
o Begin routine testing for Legionella to ensure effectiveness of the
control measures.
o Relocate or re-engineer the cooling tower to limit potential Legionella-
containing aerosols emitted into the breathing zone. An alternate
course of action would be to replace the cooling tower with a non-
aerosol generating cooling system.
o Provide detailed documentation to CCBH on your plans, proposed
actions and protocols to be implemented in response to these
recommendations.

 Develop an ongoing communication plan regarding water management to

assure that parishioners are aware of current conditions and prospective
modifications.

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 14 of 20

Key Report Authors:

Christopher Kippes, MS
Director
Epidemiology, Surveillance and Informatics Services

Tara Hanchar, RS
Communicable Disease Investigator
Epidemiology, Surveillance and Informatics Services

Rick Novickis, MPH, RS

Director
Environmental Public Health Services

John Sobolewski, RS
Deputy Director
Environmental Public Health Services

Acknowledgements
The Cuyahoga County Board of Health would like to recognize the members of
the St. Columbkille church administration and staff, the parishioners, and the
family members of the cases who provided information during the investigation.
We are grateful for the collaborative approach taken during this challenging time.

Additionally, we would like to recognize our partners at the Northeast Ohio

Regional Sewer District, the Cleveland Division of Water, the Ohio Department of
Health (Bureau of Infectious Diseases and Bureau of Environmental Health and
Radiation Protection), and the Centers for Disease Control and Prevention
(National Center for Environmental Health and National Center for Immunization
and Respiratory Diseases). Their knowledge and expertise significantly
contributed to the investigation response.

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 15 of 20

References
1
Centers for Disease Control and Prevention, Legionella. Accessible at
https://www.cdc.gov/legionella/about/index.html. Accessed September 17, 2018.
2
United States Department of Labor Occupational Safety and Health
Administration, Legionellosis: Control and Prevention. Accessible at
https://www.osha.gov/SLTC/legionnairesdisease/control_prevention.html.
Accessed October 2, 2018.
3
Centers for Disease Control and Prevention, Other Uses and Types of Water:
Cooling Towers. Accessible at
https://www.cdc.gov/healthywater/other/industrial/cooling_towers.html. Accessed
September 17, 2018.
4
Centers for Disease Control and Prevention, Legionella: Fast Facts. Accessible
at https://www.cdc.gov/legionella/fastfacts.html. Accessed September 30, 2018.

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 16 of 20

Figure 1. St. Columbkille Site Map (Parma, Ohio)

Address:
North
6740 Broadview Road
Parma, Ohio 44134

Church
School Building
Buildings

Parish Center
and located
Adoration
Chapel
Rectory

Figure 2. Epi Curve (by onset date) for the Eleven Cases of Legionnaires’
disease Associated with St. Columbkille Parish (Parma, Ohio)

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 17 of 20

Table 1. Potential Exposures of Interest Reported by the Legionnaires’ disease
Cases for the Two Weeks Prior to Illness Onset
Yes  No  Unknown 
Potential Exposures of Interest*     n (%)           n (%)        n (%) 
Attended church at St. Columbkille  11 (100%)  0 (0%)  0 (0%) 
Attended gatherings or events outside of home  7 (64%)    4 (36%)  0 (0%) 
     Facility 1  3 (27%)           8 (73%)  0 (0%) 
     Facility 2  2 (18%)    9 (82%)  0 (0%) 
     Facility 3       1 (9%)  10 (91%)  0 (0%) 
     Facility 4       1 (9%)  10 (91%)  0 (0%) 
Shopping in the produce area of grocery 
stores**  8 (73%)    2 (18%)  1 (9%) 
     Store A       6 (55%)    5 (45%)  0 (0%) 
     Store B       5 (45%)    6 (55%)         0 (0%) 
     Store C       5 (45%)    6 (55%)  0 (0%) 
     Store D                          3 (27%)    8 (73%)         0 (0%) 
     Store E                                                    2 (18%)    9 (82%)         0 (0%) 
     Store F       2 (18%)  10 (82%)  0 (0%) 
     Store G                                                                                               1 (9%)  10 (91%)         0 (0%) 
     Store H       1 (9%)  10 (91%)         0 (0%) 
     Store I       1 (9%)  10 (91%)         0 (0%) 
     Store J       1 (9%)  10 (91%)         0 (0%) 
     Store K       1 (9%)  10 (91%)         0 (0%) 
     Store L       1 (9%)  10 (91%)         0 (0%) 
Visit to any hospitals     4 (36%)    7 (64%)       0 (0%) 
Showering anywhere away from home     2 (18%)    9 (82%)       0 (0%) 
Any dental work done     1 (9%)    9 (82%)   1 (9%) 
Overnight travel     1 (9%)  10 (91%)  0 (0%) 
Swimming     1 (9%)  10 (91%)  0 (0%) 
Use of any respiratory equipment     1 (9%)  10 (91%)  0 (0%) 
Shopping trips to any area malls     1 (9%)    9 (82%)  1 (9%) 
Whirlpool/Hot tub     0 (0%)    10 (91%)  1 (9%) 
*Potential exposures of interest were assessed using the Centers for Disease Control and Prevention  
  Hypothesis Generating Questionnaire and a supplemental questionnaire developed for the outbreak.  
  Exposures in Table 1 represent those questions that had at least one case indicate a “yes” response for   
  that question. All remaining questions were answered “no” by all 11 cases. 
** During case interviews, there was a question asked in regards to where groceries were purchased and 
if they would shop in the produce area of the store. Several cases’ answered that they shop for groceries 
at multiple stores. 

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 18 of 20

Table 2. Locations Visited and Water Exposures at St. Columbkille Church Campus
by the Legionnaires’ disease Cases
Yes  No  Unknown 
Locations Visited/Water Exposures*     n (%)           n (%)        n (%) 
Locations Visited       
     Church  11 (100%)      0 (0%)  0 (0%) 
     24 hour chapel    1 (9%)        9 (82%)  1 (9%) 
     School    0 (0%)         11 (100%)  0 (0%) 
     Gathering room in chapel    0 (0%)         11 (100%)  0 (0%) 
       
Type of Water Exposure    3 (27%)       7 (64%)  1 (9%) 
     Holy Water      2 (18%)       9 (82%)   0 (0%) 
     Drinking Fountain     1 (9%)     10 (91%)   0 (0%) 
     Restroom     0 (0%)     10 (91%)   1 (9%) 
*Potential exposures of interest were assessed using the Centers for Disease Control and Prevention  
  Hypothesis Generating Questionnaire and a supplemental questionnaire developed for the outbreak.  

Figure 3. St. Columbkille Church Building: Locations of Air Intake, Cooling Tower,
and Main Entrances/Exits
Air Intake
location

Entrance/Exit 1

Church Building
Cooling Tower
location

Entrance/Exit 2

Video 1. Aerosolized Water Droplets Emitted from the St. Columbkille Cooling Tower

Cooling Tower Video - Small.avi

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 19 of 20

Table 3. Summary of Results for Select Dates Associated with the Environmental
Investigations Conducted at St. Columbkille Church Campus
Inspection 
Location  Brief Description  Results 
Date 
July 17, 2018  Church  Hot water in the church was observed to be supplied  90°F, 93°F, 111°F, 
113°F, 115°F and 
Building  by heated storage tanks, and tap temperatures 
121°F 
measured at the kitchen and bathroom sinks. 

  Rectory  Hot water was observed to be supplied by heated  129°F, 131°F and 

133°F 
storage tanks, and tap temperatures measured at the 
kitchen and bathroom sinks.  

  Parish Center  Hot water was observed to be supplied by heated 127°F, 128°F and 

127°F 
storage tanks and tap temperatures measured at the 
kitchen and bathroom sinks. 
July 19, 2018  Church  Hot water temperatures measured at the kitchen and  127°F, 129°F and 
134°F 
Building  bathroom sinks.  
    Residual chlorine levels in the potable water  Found to be 
undetectable. 
distribution system were measured at the tap of two 
bathroom sinks in the church.  
  Cooling Tower  Observed in operation. Aerosolized water 
droplets observed 
coming from the 
grating adjacent to 
main entrances/exits 
July 23, 2018  Cooling Tower  Sampling of the water reservoir of the cooling tower  Negative (i.e. <1 
CFU/mL) for 
Legionella* 
July 25, 2018  Church  Cold water samples from the basement water  Only the basement 
Building  fountain, men’s basement lavatory sink, cry room  water fountain 
lavatory sink, and drinking fountain in the sacristy  contained a 
measurable chlorine 
were taken.    level of 0.01 parts 
per million (ppm). 

July 26, 2018  Church  Collection of water and swab samples from the  No live Legionella 

bacteria were 
Building  drinking fountain located in the basement of the 
present. 
church, bathroom sinks, and the condensate trays in   
the air handlers.  Presence of 
nonviable Legionella 
found in samples 
identified as 
“Basement Drinking 
Fountain 1” and 
“Basement Drinking 
Fountain 2”.  
 
The report attributes 
these finding to “the 
presence of 
environmental DNA 
from dead cells ”. 
       
*Review of the maintenance records for the cooling tower found that it was chemically cleaned and sanitized 
on July 11, 2018 and again on July 19, 2018.  

Legionnaires’ Disease Outbreak Associated with St. Columbkille – 2018 Page 20 of 20