Legionnaires' Disease in Infants Linked to Water Births

Diana Phillips

June 08, 2017

Gaps in infection prevention for water births likely contributed to Legionnaires' disease in two Arizona infants in early 2016, health officials report in the June 8 issue of Morbidity and Mortality Weekly Report.

In one of the two cases, an infant subsequently diagnosed with congenital heart disease was delivered at home by a midwife in a newly purchased birthing tub that had been cleaned with vinegar and water before being filled with tap water using a new hose. The infant was delivered within an hour of the mother's entry into the tub, write Geoffrey Granseth, MPH, from the Arizona Department of Health Services (ADHS) in Phoenix, and colleagues.

In the second case, which was attended by an independently operating midwife, the infant was delivered at home in a rented jetted Jacuzzi hot tub filled with tap water using a newly purchased hose. In the latter case, the water remained for a week before the birth at 98.0°F (36.7°C), and the mother did not enter the tub for delivery only.

Both infants developed respiratory symptoms and were hospitalized within days of birth and underwent multiple diagnostic laboratory tests and chest radiographs. Both tested positive for Legionella pneumophila — serogroup 1 in the first infant and serogroup 6 in the second — and were ultimately treated with a 10-day course of azithromycin. The first infant remained hospitalized for more than 2 months because of complications related to congenital heart disease, while the second was discharged after treatment, the authors report.

Legionella, which is naturally found in warm water and is spread by inhalation of bacteria-containing water droplets, "can grow and spread in man-made water systems, such as plumbing systems," the authors write. The use of a jetted tub rather than a disposable birthing tub, allowing the water to remain at 98.0°F (36.7°C) — "which is within the optimum range for Legionella growth 77.0°F–108.0°F (25.0°C–42.2°C)," — and using tap water, which is not sterile, increased the possibility of infection in these cases, they explain.

"Because both tubs were emptied immediately after the births, no environmental sampling was performed," the authors write.

As part of their investigation, Arizona public health officials reviewed a legionellosis death in a Texas infant in 2014, reported previously by Medscape Medical News, which led to the development of guidelines by the health officials in Texas. On the basis of these guidelines, the ADHS, together with the Maricopa County Department of Public Health and the Arizona Healthcare-Associated Infection and Midwife Advisory Committees, developed educational resources and guidelines for water births, which are available through the ADHS website, the authors report.

"These resources aim to increase knowledge about the risk for Legionella infection and maximize the safety for women choosing water immersion for labor or birth by providing a review of information on labor and birth in water," the authors write. "For example, although the risk for Legionella infection cannot be eliminated because of the need for warm tap water to fill the tub, it can be reduced by running hot water through the hose for 3 minutes before filling the tub to clear the hose and pipes of stagnant water and sediment."

These guidelines and educational materials have been widely disseminated to infection specialists and licensed midwives in Arizona, according to the authors.

The authors have disclosed no relevant financial relationships.

MMWR Morb Mortal Wkly Rep. 2017;66:589-591. Full text

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