CDC Reports Rare Cases of Legionella Infections in Infants After Water Birth

A new report on the cases of two infants who contracted Legionnaires’ disease during water births highlights the dangers of the bacteria, and has prompted new efforts for more safety education on water-immersion delivery.

Although there are about 6,000 reported cases of Legionnaires’ disease in the United States each year, the Centers for Disease Control and Prevention (CDC) notes that many such infections go undiagnosed and unreported. The disease is caused by the Legionella bacterium, a pathogen found in freshwater sources that can also contaminate hot tubs, showers and faucets, cooling towers, public decorative fountains, hot water tanks, and the plumbing systems of large facilities. The bacteria thrive and multiply best in warm tap water, and spread to humans when they breathe in small droplets of Legionella-contaminated water, leading to a respiratory condition called Legionellosis. This can present as a mild flu-like condition called Pontiac disease or the more serious lung infection known as Legionnaires’ disease. Fewer than 5% of people exposed to an outbreak source go on to develop Legionnaires’ disease, though the condition is fatal in about 10% of cases.

Individuals with chronic lung disease, weak immune systems, cancer, and underlying illnesses—along with smokers and those age 50 years or older—are at greater risk of getting sick from Legionella exposure. However, a new report recently published in the CDC’s Morbidity and Mortality Weekly Report examined 2 cases involving infants who contracted Legionella infections during water births that occurred in Arizona in 2016. Both infants were delivered at home in birthing tubs—shallow pools used for laboring in water. The first case was reported in January 2016 and the second case was reported in April 2016. Both cases were reported to the Maricopa County Department of Public Health (MCDPH).

The first infant was taken to the emergency room the day after delivery with symptoms including severe respiratory distress. Although the infant was diagnosed with a congenital heart disease, the doctors discovered the presence of Legionella pneumophila in the infant’s lungs after further testing. Through their investigation, the MCDPH found that the birthing tub used in the delivery was new and cleaned with vinegar and water before being filled with municipal tap water using a new water hose. The mother delivered the infant within an hour of entering the tub and the infant was not noted to have aspirated any water.

The second infant was taken to the emergency room 3 days after delivery after coming down with a high fever and signs of possible pneumonia. Upon evaluation of urine and respiratory tract samples taken from the infant, doctors found Legionella pneumophila. In this case, the mother delivered the infant in a rented jetted Jacuzzi hot tub, which was filled using a new hose. The water had been kept at 98.0°F for 1 week before the delivery. During the birth, the mother labored outside the tub and entered the tub for delivery only.

In both cases, the infants were successfully treated for the Legionella infections with 10-day courses of azithromycin. The first infant remained in the hospital for more than 2 months due to congenital heart disease.

The MMWR report notes that the number of Legionnaire’s disease cases in Arizona has increased in recent years, and more than doubled from 2011 to 2015, when the state had 93 reported cases. Arizona’s Department of Health Services reported 76 cases of Legionellosis in 2016 and 39 cases have been reported for January 2017 through May 2017.

“This increase in cases is most likely due to improved clinical and public health awareness, two factors that can greatly impact reporting of Legionnaires’ disease,” explains Otto Schwake, PhD, a Virginia Tech researcher and Editorial Advisory Board member for Contagion^®. Dr. Schwake also noted that Legionellosis has been on the rise across the country. “That being said, socially driven behaviors can lead to novel transmission routes of water-borne disease, such as was seen with neti pot usage and naegleriasis. Perhaps more relevant is the advent of certain technologies, namely water recycling and ‘green’ buildings, which could have negative side effects on the microbiology of our drinking water.”

Dr. Schwake noted that healthy infants tend to be at low risk for Legionellosis, even when experiencing the same exposure routes as adults. Such cases during water birth are uncommon; however, notable cases have occurred in recent years in the United Kingdom and Texas.

“For the recent Arizona cases, we have 1 example of a water birth conducted with many obvious safety risks, namely filling a rented Jacuzzi with warm tap water allowed to stagnate for a week,” noted Dr. Schwake. “However, in the other case, a new disposable birthing tub was disinfected and filled immediately prior to the birth using a new hose. Other than using tap water without additional disinfection, such as boiling, no obvious safety issues seemed to be present in this latter case, suggesting that further research may be prudent to examine this form of transmission.”

In response to the 2 cases, the Arizona Department of Health Services and the MCDPH teamed up with Texas health officials, infection prevention specialists, and licensed midwives to develop a set of guidelines for water-immersion birth safety. The new guidelines note the benefits of water birth and detail the possible risks, and provide recommendations on birthing-pool safety and water disinfection.