2. Why is Las Vegas Different Clark County has a population of 2 million 40 million visitors each year 150,000 hotel rooms 91% weekend occupancy

4. Press Coverage Legionnaires' disease infects 6 at Las Vegas hotel; Aria hotel finds legionella bacteria in rooms (NY Daily News, July 15, 2011) Las Vegas: Health district says Luxor guest died of Legionnaires‘ (Los Angeles Times, January 31, 2012)

5. Investigation Trigger SNHD receives a report from the CDC or local health care provider that an individual contracted Legionellosis with a possible exposure from either a hotel room or exposed to a potential aerosolized source of Legionella The report includes how the Legionellosis was diagnosed and the exposures. The Legionella bacteria species and serotype diagnosed are considered the target organism.

6. Investigation Trigger As soon as SNHD has enough information such as: – Dates of stay – Names of cases – Room numbers Contact is made with the facility and an investigation is scheduled within 24 hours.

8. Investigation Environmental Assessment INTERVIEW Building Schematics Water systems Water management plans Recent sample results Water System Consultants HVAC system Bodies of water and/or water systems

9. Environmental Assessment Environmental Assessment ONSITE SURVEY Tour of water system All buildings Collection of chorine residuals and water temperatures Guest rooms Bodies of water Collection of water and biofilm samples Guest Rooms Bodies of water Investigation

19. If the target organism is identified in the results of room fixtures or hot water system, SNHD will require that the water system supplying the room water system be remediated based on the following results: – Target organism in bulk water greater than 10 cfu/ml – Environmental swabs from two different fixtures greater than 10 cfu/ml – Water or environmental swabs from two different fixtures less than 10 cfu/ml

27. 60˚C (140˚F) 90% Kill in 2 Minutes >70˚C (158˚F) 100% Rapid Kill

36. Rationale Behind Investigating a Single Case Between 2000 and 2012 SNHD investigated seven outbreaks related to large hotels. The data indicated there was one sporadic case, shortly followed by several other cases. Being proactive by looking at one reported case as a canary in a mine can prevent other cases from occurring later. Since implementation of investigating single cases there have been no other outbreaks identified by SNHD

37. SNHD is proactive by responding to and investigating each case + Facility acting proactively by using the best practices and taking the appropriate corrective action = No further action if SNHD receives report of a case associated with the facility prior to the remediation.

38. If SNHD investigation does not identify the target organism, then the investigation is closed and potential outbreak can be ruled out Minimizes the need for public notification/media attention

39. Cost/Benefit Analysis Prior to conducting investigations of single cases, SNHD spent an estimated $5,611 annually investigating to outbreaks. Now SNHD spends $82,675 per year. Costs to the facility has a wide range: – a low of $16,000 – a high of $1,000,000

40. Cost/Benefit Analysis Costs of an outbreak – Hospitalization costs range Low of $13,000 High of $71,000 – Cost to SNHD of one outbreak in Las Vegas was $21,000 Liability costs – In 2011, eight guests sought $337,500,000 in damages Reputation costs – Internet has sped the speed of information

41. Cost/Benefit Analysis Summary – Responding to every case may cost SNHD ten times more over a year – Mechanisms are in place to have the costs covered by the resort industry – While costing the resort industry $150,000 per investigation outweighs the costs of hundreds of millions in litigation along with reputation damage.

44. Thanks SNHD Office of Epidemiology SNHD Environmental Health – Special Programs Office – Safe Drinking Water Program – Public Accommodations Office Bureau of Safe Drinking Water, Nevada Division of Environmental Protection UNLV, School of the Community Health Sciences

45. Contact Information Mark Bergtholdt, MPH, REHS Environmental Health Supervisor Special Programs Division of Environmental Health Southern Nevada Health District Phone: (702) 759-0677 E-mail: bergtholdt@snhd.mail.org