Legionnaires: Who's To Blame?
The Age
Saturday May 6, 2000
ROBERT CAMPBELL isn't sure what to call it. Premonition? Foreboding? Perhaps simply the ancient, unbreakable bond between a son and his mother. But on Good Friday, on holiday in Broome, he was struck by a strange, but unshakeable, certainty that something was wrong with his mum, Nellie, 3200 kilometres away in Templestowe.
Campbell had moved to Melbourne from Perth 10 months earlier to look after the ailing 83-year-old. This was his first holiday. But now, six days in, he had to get to a phone.
His sister, Liz, answered and confirmed his fears. She told him that what had begun as a mild headache on the day he flew out apparently had turned into a cold which worsened during the week. Now Nellie was suffering severe headaches, pains and chronic lethargy.
``When Liz put Mum on, she could hardly speak and I told Liz to take her straight to the hospital," Campbell says. ``When the ambulance came, she didn't have the strength to get out of bed."
Campbell caught the first flight home and went straight to the Austin Hospital, where his mother was now fighting for life. She only managed to whisper a few precious words to him before slipping into unconsciousness. At 3am on Tuesday, April 25, Nellie Campbell died.
That same Easter weekend, Margaret Brown was taking a few days off in Ballarat. On Sunday, she phoned her father, Ernie, 78, his home at the Summer Hill Residential Park in Reservoir. He said he was tired and was going back to bed. Margaret called again on Easter Monday and Ernie said he thought he might be coming down with the flu.
Worried now, Margaret returned home next morning to find her father with a fever and complaining of aches and pains. Next day he could barely breathe and she took him to his doctor. After x-rays he was taken to the Austin Hospital, diagnosed with pneumonia.
The next morning, Don Storer, a 69-year-old Englishman visiting his son, Jonathan, and grandchildren, was admitted to Box Hill Hospital with almost the same symptoms. On Easter Sunday, Storer had complained of feeling desperately tired. By the time the family had a barbecue on Monday, he was groggy and could hardly keep his eyes open. Over the next two days, Jonathan says, his father could not eat or drink, suffered severe headaches, finally becoming delirious with a high fever. By next afternoon he was in a critical condition in Box Hill.
At the same time Jonathan began hearing media reports about a possible outbreak of legionnaires' disease. The symptoms, he learnt, were almost identical to those being suffered by his father. He returned to the hospital and asked staff to test his father for the deadly disease. Two days later, the test was confirmed.
Late that Thursday, Margaret Brown contacted the Austin and asked for the same tests for her father. On Friday morning, while awaiting the results, Ernie became critically ill and was transferred to intensive care, where he began to be treated for legionnaires' disease.
Liz and Robert Campbell had heard the reports, too. They noticed that the outbreak was being linked to the new Melbourne Aquarium on the Yarra, and for a moment suspected the worst. They had taken Nellie on a rare excursion on the Thursday before Easter - during what the Health Department was now calling the danger period.
``But we both decided that it couldn't have happened to Mum," says Robert, ``because we hadn't heard anything from the department."
At 5.30pm on Thursday, 27 April, a Health Department official phoned Liz. Nellie had a urine test while in hospital, he said, and it had returned positive for the legionella bacteria. It was their first contact with public health officials, the first they had heard of any tests or suspicion their mother had the illness.
Too late: Nellie's funeral had been held at the Springvale Crematorium that morning.
ON WEDNESDAY, April 26, Dr Graham Tallis took a call from a scientist at the Victorian Infectious Diseases Reference Laboratory. Expect three cases of legionnaires' disease was the message.
Tallis is leader of the Department of Human Service's 12-person response team, which investigates every case of legionnaires' disease. Professor William Hart, head of infectious diseases at the department, calls them the ``bug busters". Tallis prefers ``disease detective".
When Tallis was talking to the lab, they told him they had an unusually high number of tests to do that day. The reasons, Tallis assumed, was a post-Easter backlog and the peak after-summer time for legionnaires' disease.
Soon after the call, the fax machine began receiving official notification, including the patient's name, test result and the referring doctor, laboratory or hospital.
All three patients were too ill to be interviewed, but there seemed no links between any of them. Next morning four more notifications had arrived and Tallis, who would normally follow up all legionnaires' cases himself, called on three of the department's public health nurses, Marion Moloney, Pauline Lynch and Anne Murphy, to help.
While Lynch and Murphy were interviewing on the phone, Tallis heard Moloney put down the phone. ``I asked her where her case had gone and she told the story and mentioned the aquarium and I said: `Oh, that's interesting, the man yesterday also went to the aquarium.'
``Then Pauline, who was still on the phone interviewing a family member, but was listening in, said: `My case went to the aquarium, too.'
``That was when the penny dropped."
Within 20 minutes, epidemiology registrar Dr Jane Greig and two environmental health officers had been sent to the aquarium. By 10.45am they were at the main entrance, carrying a small Esky with dozens of empty plastic sample containers.
``We had to be careful not to jump to conclusions, but this felt unusual because it was three cases simultaneously virtually, and all were in intensive care," says Tallis.
The officials were taken to the museum's curator, marine biologist Craig Thorburn. They told him they suspected the aquarium was spreading legionella and wanted water samples from all the fish tanks and the air-conditioning cooling towers.
They took their samples. Then they went to break the bad news to Peter O'Brien.
O'Brien came to the aquarium business late. He bought his first, Underwater World on the Sunshine Coast, after it went into receivership in 1993 and turned it into a success. Then the Melbourne businessman, scion of the O'Brien catering family, began thinking of building one in his home town.
It was to take five years. Plans to build in St Kilda were scuttled by a planning dispute, Asian investors withdrew, and the then Premier, Jeff Kennett, tried to persuade him to build it in Docklands. Finally, with the help of Melbourne City Council, the Yarra site was selected.
``Peter's put his head on the chopping block a number of times to get this project up," a close friend says. Now he discovered that his $33million baby might have been the source of the fatal outbreak.
ROBERT and Liz Campbell had been trying to get their mum, Nellie, out of her house since late last year. But her poor health - she had suffered kidney problems - and her need for a wheelchair made it hard.
Finally, on Thursday, April 13, everything seemed to come together. Nellie, was in good spirits and a day at the new aquarium seemed perfect. That choice has since racked them with guilt.
``We had really battled to take get her out and give her some pleasure, and now we can't help thinking if we had not talked her into going she would probably still be alive today," says Campbell.
After lunch they joined the queue at the side of the complex. Now, Campbell suspects the half-hour wait brought them within range of the fine mist from the aquarium's air-conditioning cooling towers.
Greensborough security worker Dick Smithson, 53, remembers the same gossamer mist when he visited three days later. Weekend crowds meant he and his family waited in line for almost an hour.
``As I was standing there, I could feel all this stuff coming down on top of us," he says from a hospital bed at the Austin. ``I kept looking because I thought it might have been raining, but it wasn't: it seemed to be coming out of the building."
As the health officials met with O'Brien that Thursday, 27 April, one of their mobiles rang. It was Tallis: a fourth case had been confirmed. The victim had also been to the aquarium. Craig Thorburn phoned the cooling tower maintenance firm, Tamar Australia, and an employee arrived in 20 minutes to ``slug dose" the system with chlorine.
Bob Adams, the aquarium's general manager, says one of the first questions they asked health officials was whether legionella could grow in saltwater, which is in most of the aquarium's 30-odd tanks.
The officials didn't know, but it turns out there was no evidence of legionella in any. In light of plummeting attendances following the revelations, Adams allows himself a rare joke: ``The fish are all right, they're just lonely."
But a priority was to limit the damage. As soon as the Human Services staff left O'Brien's office he rang PR troubleshooter John Fetter. Fetter, the former chief of staff of Kennett government minister Phil Gude, established the firm GFB&S with Gude and several other Kennett refugees after last year's election loss.
O'Brien spelt out a PR nightmare: four people were in hospital and the department's infectious diseases section was about to make an announcement linking the aquarium with a legionnaires' outbreak. He had another meeting with the department in half an hour. Could Fetter come?
Fetter told O'Brien to be honest and proactive. At the meeting O'Brien offered to close the aquarium. Surprised departmental staff said it wasn't necessary as the tower had already been treated.
``I obviously requested Human Services to put something in the press release to reassure the public and say it was safe," Fetter says. ``Dr Graham Rouch was good enough to put that in his name."
Rouch, Victoria's chief health officer, was due to retire on the next day after 29 years of service. He threw the aquarium a PR life-raft. The aquarium was now ``the safest place to visit in Melbourne", he said in the press release, a quote the aquarium would repeat many times.
BUT ANOTHER quote from Rouch was less widely disseminated. Victoria has often boasted of having world-leading guidelines to control legionnaires' disease. But well before the tourist facility had opened, the Government had conceded the guidelines were inadequate in at least one important respect.
Last August, Rouch said the department had ``made a mistake" by not encouraging specific tests for legionella in the guidelines and, instead, recommending general bacteria tests to indicate the likelihood of legionella. The department was ``now encouraging legionella testing and would later legislate for it".
But the aquarium never tested specifically for legionella. Rather it relied on general bacteria counts as recommended in the outdated guidelines. A sample taken by health officials the day the outbreak was traced to the aquarium revealed levels of 6900 legionella organisms per millilitre, almost seven times the 1000-organism level that indicates high risk. However, general bacteria levels, meant to be a guide for the effectiveness of biocide in the tower, returned a low reading the same day.
That contradiction calls into question the worth of the current system of relying on general bacteria to indicate likely legionella status. According to Neil Duncan, managing director of the water treatment company Hydro-Chem, other evidence shows no positive correlation at all - higher general bacteria counts indicate legionella is less likely to be present.
In fact, legionella is everywhere. Clive Broadbent, an air-conditioning expert hired by the aquarium, described how the bacteria can be found in moisture on the leaves of trees in tropical forests and at the bottom of holes drilled more than a kilometre into the earth. Other experts say it exists in tap water and soil. However, it is rarely dangerous unless inhaled.
Air-conditioning towers are a perfect breeding ground for the bug. To Dr John Carnie of the department, the real issue is not how legionella entered the towers, but why the chemical treatment regime failed.
The most likely theory, says aquarium consultant Dr Vyt Garnys, is that the biocide chemicals in the towers were overcome by an abnormally large bacterial load from building sites nearby.
Preliminary results have revealed dust containing iron - which promotes legionella growth - in the towers matching dust from the building site, he says. According to the aquarium, staff saw plumes of dust from the work, particularly when girders on the site, a raised railway line, were replaced.
One person not persuaded by the dust theory is Peter Bird, a consultant to the Construction, Forestry, Mining and Energy Union. ``Any system with adequate biocide levels should be able to handle the ingress of dust unless you have massive quantities. What remains to be answered are a number of questions relating to how the towers were (chemically) doused and serviced in the leadup to the outbreak."
That system has been clouded by corporate chaos from the start, and there, perhaps, lies the problem. J.C. Taylor and Sons was originally awarded the contract, but went belly-up during construction early last year.
After a rushed re-tender, Airchief Airconditioning took over the $1.3 million job. The firm contracted by the aquarium to build the complex, Construction Engineering, was initially nervous about the change and pressured Airchief to work quickly.
Work progressed relatively smoothly and concerns eased. By December the system was installed and running by January. By then the aquarium faced a more pressing issue, the high death toll among the valued exhibits. The RSPCA investigated and cleared the centre following the deaths of sharks, stingrays and other fish.
Once running, responsibility for maintaining the air-conditioning fell to another part of the Airchief group, Airchief Airconditioning Services. This company, in turn, contracted chemical specialist Tamar to test and treat the system and its water-cooling towers.
As required under Victorian regulations, Tamar was contracted to provide testing at monthly intervals. The first two tests, in January and February, went smoothly, although the cooling tower report described it as ``mildly dirty" with up to 3mm of sludge.
On March 15, when Tamar's testers visited the aquarium, they again reported low bacterial counts. But its report to Airchief noted problems with the pump injecting biocide into the cooling towers' water. The system had inadequate chemical levels and the pump had to be reprimed, Airchief was told.
Airchief was owned and run by Ron Mook, a 64-year-old air-conditioning specialist with a penchant for snappy dressing, unusual in this blue-collar trade. Mook likes flashy sports jackets and smart cars. Last year his new maroon Jaguar V8 arrived at Airchief's Dandenong factory.
In May, Mook's wife, Penny, resigned as an Airchief director, leaving Ron in sole control. On Christmas Eve, Penny registered a debt against Airchief of $160,000 for all ``loans and advances" made to the company. All ``property and assets held by the company in its own right" were mortgaged to Penny. The charge was signed and verified by Ron Mook.
On the surface Airchief's finances appeared healthy at the start of this year, with $5 million-worth of work booked in. Yet some staff noticed specialised, expensive installation equipment began to go missing and debts went unpaid.
Among those owed money was Tamar. After the March 15 test, Tamar wrote to Airchief stating that it would stop testing and treating the aquarium's system until it was paid. An aquarium spokesman confirmed that it was aware of the threat, but said it was ``never carried through". Government regulations state that cooling towers should be ``inspected at least monthly", supposedly within each 30-day period.
Tamar did not return to the aquarium until the department warned it of the legionella outbreak on April 27, 43 days later. The official risk period for contracting legionnaires' disease at the aquarium was from April 13 to 25.
Brian Conwell, a director of Construction Engineering, says he is ``not terribly interested" in the public debate over the outbreak. ``I have no legal obligation to talk to the media. That's all I am saying."
A spokesman for Airchief Airconditioning also refused to comment. Asked why, he said ``personal choice". Mook has refused to return calls all week, as has Tamar.
LATE on the afternoon of Thursday, April 27, after the press conference, all hell was breaking loose in the department's communicable diseases section. A hotline was activated and volunteers called to staff it from the ``war room" on the 17th floor of the department's offices at 120 Spencer Street.
The team had to sift through rumors and false information; many victims didn't speak English and families were either grieving or angry, with their loved ones in intensive care. Asked how she would measure the success of their efforts, epidemiologist Jane Greig replies: ``There would have been more deaths if it hadn't been picked up so quickly. You have 66 people who all possibly may have progressed to severe pneumonia; some of these haven't even had to go to hospital."
On the same afternoon as news of the first few cases emerged, the law firm Maurice Blackburn Cashman had a telephone call from a man whose mother was in a critical condition with legionnaires' disease. He was booked for an appointment the following week, but events were soon to move much faster.
On Sunday, a partner, Eugene Arocca, went into the office early, so early he left before the newspapers hit his doorstep. About 10.30am a colleague rang: ``Eug, have you read the papers? Get home and have a look?"
Arocca did just that. ``What really twigged me was that comment (by the aquarium) that it was an act of God. What I did know about legionnaires' was it's rarely an act of God. It's created by God, but spread by man."
The other thing that sparked his interest was the sheer number of people involved.
When staff got in on Monday morning, after media reports quoted Arocca flagging a class action, there were already about 10 inquiries on the answering machine. By the end of the day there were more than 50. Within a week the firm had at least 30 of the victims, or their relatives, on the books.
Should the case reach court, the main issue will be the adequacy of the Victorian Government's standards. Another question is whether the aquarium should have exceeded the minimum standards because its client group included elderly people at high risk of the disease.
``Satisfying the guidelines is not an indication of what the courts may deem to be reasonable and acceptable," Arocca says.
AROCCA'S concerns are just a few of the issues raised by the outbreak. Who was responsible for the testing and maintenance of the towers: the aquarium, the construction firm, the air-conditioning firm or the maintenance sub-contractor?
How did the bacteria get into a new system? Why didn't the towers' chemicals kill the bacteria once they entered? Why does Victoria, which boasts of having the best prevention regime in the world, not insist on a specific test for legionella?
Whatever the answers, they will come too late for Nellie Campbell and Ilse Junge and their grieving families.
And almost too late, as well, for victims such as Ernie Brown and Dick Smithson, now neighbors in ward 7C at the Austin Hospital. Ernie had gone to the complex with 61 members of his Darebin senior citizens club, the Golden Oldies. One other member is now also in the Austin and five more are awaiting test results for legionnaires' disease.
Margaret Brown says her father had been looking forward to the trip for weeks. ``This was a very big day because he spent some time in hospital last September with a heart condition and he had not been able to get out and about very much. Luckily my father is a real fighter and I think that is the only thing that got him through this."
On Easter Sunday, a week after his visit, Brown was struck down with chronic pain and fever. He put off seeing his doctor, but the following Thursday night was rushed to the hospital. It was the first time in his life he had spent a night in hospital and, he says now, the closest he has come to death. ``Honestly, I thought I was going to die, I really thought this is it."
© 2000 The Age
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