LEGIONELLA - World Health Organization

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Chapter 7 Hotels and ships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 7.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 7.1.1 European initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 7.1.2 Hotel-associated cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105 7.1.3 Ship-associated cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106 7.2 Water safety plan overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 7.3 System assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 7.3.1 Document and describe the system . . . . . . . . . . . . . . . . . . .109 7.3.2 Assess hazards and prioritise risks . . . . . . . . . . . . . . . . . . . .110 7.4 Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114 7.4.1 Identify control measures . . . . . . . . . . . . . . . . . . . . . . . . . .114 7.4.2 Monitor control measures . . . . . . . . . . . . . . . . . . . . . . . . . .117 7.5 Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118 Chapter 8 Natural spas, hot tubs and swimming pools . . . . . . . . . .119 8.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119 8.2 Water safety plan overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123 8.3 System assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125 8.3.1 Assemble the team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125 8.3.2 Document and describe the system . . . . . . . . . . . . . . . . . . .125 8.3.3 Assess hazards and prioritize risks . . . . . . . . . . . . . . . . . . . .126 8.4 Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130 8.4.1 Identify control measures . . . . . . . . . . . . . . . . . . . . . . . . . .130 8.4.2 Monitor control measures . . . . . . . . . . . . . . . . . . . . . . . . . .135 8.5 Management and communication . . . . . . . . . . . . . . . . . . . . . . . . . .135 8.5.1 Establish documentation and communication procedures . .135 8.5.2 Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136 8.6 Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136 x <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS
Chapter 9 Disease surveillance and public health management of outbreaks . . . . . . . . . . . . . . . . . . . . . . . . . .139 9.1 Surveillance systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139 9.1.1 Standardized case definitions . . . . . . . . . . . . . . . . . . . . . . . .140 9.1.2 Defined datasets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140 9.2 International surveillance of legionellosis . . . . . . . . . . . . . . . . . . . . .144 9.2.1 Effect of improved surveillance . . . . . . . . . . . . . . . . . . . . . .147 9.3 Management of outbreaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149 9.3.1 Confirmation of an outbreak . . . . . . . . . . . . . . . . . . . . . . . .150 9.3.2 Outbreak control team . . . . . . . . . . . . . . . . . . . . . . . . . . . .150 9.3.3 Policies and practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151 9.3.4 Roles and responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . .152 9.3.5 Engineering and environmental investigations. . . . . . . . . . .154 9.3.6 High-profile outbreaks . . . . . . . . . . . . . . . . . . . . . . . . . . . .156 9.4 Case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157 9.4.1 Community outbreak — England . . . . . . . . . . . . . . . . . . . .157 9.4.2 Nosocomial outbreak — Israel . . . . . . . . . . . . . . . . . . . . . .157 9.4.3 Hot tub outbreak — Austria . . . . . . . . . . . . . . . . . . . . . . . .158 9.4.4 Concrete batcher process on a construction site — UK . . . .159 Chapter 10 Regulatory aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .161 10.1 Existing guidelines and regulations for risk prevention . . . . . . . . . . .161 10.2 Legionella testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162 10.3 Scope of regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163 10.4 Designing regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164 10.4.1 Managerial responsibilities, registration and notification . . .164 10.4.2 System assessment and design . . . . . . . . . . . . . . . . . . . . . . .164 10.4.3 Operational monitoring and verification . . . . . . . . . . . . . . .164 10.4.4 Documentation of management plans and record keeping . . .166 10.4.5 Surveillance and audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166 10.4.6 Outbreak investigation and notification of disease . . . . . . . .167 10.5 Outbreak impact and economic consequences . . . . . . . . . . . . . . . . .167 <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS x
Page 1 and 2: LEGIONELLA AND THE PREVENTION OF LE
Page 3 and 4: LEGIONELLA AND THE PREVENTION OF LE
Page 5 and 6: Foreword Legionellosis is a collect
Page 7 and 8: Contents Foreword . . . . . . . . .
Page 9: Chapter 5 Cooling towers and evapor
Page 13 and 14: Tables Table 1.1 Main characteristi
Page 15 and 16: Figure 8.1 Visible biofilm on inter
Page 17 and 18: Acknowledgements The World Health O
Page 19 and 20: • John Newbold, Health and Safety
Page 21 and 22: Executive summary Legionellosis is
Page 23 and 24: • Health-care facilities — Chap
Page 25 and 26: Chapter 1 Legionellosis Britt Horne
Page 27 and 28: Legionnaires’ disease is often in
Page 29 and 30: 1.1.2 Pontiac fever Symptoms Pontia
Page 31 and 32: Table . Extrapulmonary nfect ons ca
Page 33 and 34: Proteins produced by the body’s i
Page 35 and 36: Aspiration may occur in patients wi
Page 37 and 38: Table . R sk factors for Legionella
Page 39 and 40: In the outbreak of Legionnaires’
Page 41 and 42: Table . Potent al treatments for d
Page 43 and 44: 1.4.2 Species and serogroups associ
Page 45 and 46: Other causes of infection In Europe
Page 47 and 48: The interaction of virulent legione
Page 49 and 50: 1.5.2 Surface structures involved i
Page 51 and 52: 1.5.4 Host defence The host defence
Page 53 and 54: Chapter 2 Ecology and environmental
Page 55 and 56: L. pneumophila is thermotolerant an
Page 57 and 58: 2.2.3 Environmental factors and vir
Page 59 and 60: Figure 2.1 Biofilm formation Biofil
Page 61 and 62:
2.4 Sources of Legionella infection
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Chapter 3 Approaches to risk manage
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Table . Cool ng tower outbreaks Fac
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Even when a source reaches a state
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The WSP should be prepared in conju
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Identify control measures Control m
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F gure . Dec mal reduct on t mes fo
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Method Advantages D sadvantages Dos
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Validate effectiveness of water saf
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• clear statements of responsibil
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Chapter 4 Potable water and in-buil
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The remainder of this chapter provi
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4.3.1 Document and describe the sys
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Construction materials — risk fac
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Where temperature controls (discuss
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4.4.2 Monitor control measures This
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Chapter 5 Cooling towers and evapor
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5.1.1 Cross-flow cooling towers As
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water treatments (including chemica
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5.3 System assessment This section
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Spray drift — risk factors Even w
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The section on control measures for
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• periodic or continuous bleed-of
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Box . Po nts to be noted when clean
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In certain circumstances, samples m
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Table . Example documentat on for m
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Chapter 6 Health-care facilities Ma
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For 1999 and 2000, a total of 384 c
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6.3 System assessment This section
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Table . Type of colon zat on of wat
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6.4.1 Identify control measures Thi
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6.5.1 Prepare management procedures
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Until the situation is under contro
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Chapter 7 Hotels and ships Roisin R
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F gure . Detected and reported case
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Table . Rev ew of outbreaks (more t
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7.2 Water safety plan overview WSPs
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The risk of legionellosis is increa
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Kingdom to 66% in Spain (Starlinger
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Agency, Legionella Section, United
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Given the complexity of distributio
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Chapter 8 Natural spas, hot tubs an
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Spas “Natural spa”, denotes fac
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Rare cases of Legionnaires’ disea
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Process step P pework Water n hot t
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Hosepipes may sometimes be used to
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Hot tubs that are not effectively d
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Nutrients — control measures Bath
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Various additives may also be used
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• descriptions of any significant
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Table . Examples of m crob olog cal
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Chapter 9 Disease surveillance and
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Exposure histories allow cases to b
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F gure . Invest gat ng a s ngle cas
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Box . (cont nued) Since the incepti
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Country United Kingdom All reported
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F gure . Annual reported cases, - 0
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Training opportunities Trainees in
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Box . Example of terms of reference
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ecause doing anything more could un
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9.4 Case studies This section descr
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9.4.4 Concrete batcher process on a
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Chapter 10 Regulatory aspects David
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• validation of the effectiveness
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• operating conditions, such as t
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10.4.6 Outbreak investigation and n
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hot water (e.g. health-care facilit
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General prevent on Country DW Wp SB
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Country General prevent on DW Wp SB
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Chapter 11 Laboratory aspects of Le
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• detection of the bacterium in t
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Method Sens t v ty (%) PCR • Rapi
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11.2.2 Detecting Legionella antigen
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DFA has been used successfully with
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• Serologic testing can be used f
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Although not all strains can be rel
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Generally, any water source that ma
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During outbreak investigations, swa
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• other Legionella species that d
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Appendix 1 Example of a water syste
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Weekly water system check list Week
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Appendix 2 Example of a 2-week foll
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Travel Work/travel in the UK: ❑ Y
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Checklist of local places Health/sp
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Appendix 3 Example of a national su
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Strictly Confidential 2 Hospital Ac
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Glossary aerobic bacteria Bacteria
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health-care acquired Legionellosis
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surveillance The process of systema
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References Abu KY, Eisenstein BI, E
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Barbaree JM et al. (1987). Protocol
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Blatt SP et al. (1994). Legionnaire
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Byrne B, Swanson MS (1998). Express
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Crespi S (1993). Legionella y legio
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Edelstein PH (1982b). Comparative s
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Falguera M et al. (2001). Nonsevere
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Gaia V et al. (2003). Sequence-base
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Hayden RT et al. (2001). Direct det
Page 257 and 258:
Ingram JG, Plouffe JF (1994). Dange
Page 259 and 260:
Ko KS et al. (2003). Molecular evol
Page 261 and 262:
Loret JF et al. (2003). Comparison
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McEvoy M et al. (2000). A cluster o
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Olaechea PM et al. (1996). A predic
Page 267 and 268:
Regan CM et al. (2003). Outbreak of
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Schulze-Robbecke R, Rodder M, Exner
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Surman SB, Morton LHG, Keevil CW (1
Page 273 and 274:
Tully M, Williams A, Fitzgeorge RB
Page 275 and 276:
Welti M et al. (2003). Development
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LEGIONELLA - World Health Organization

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