LEGIONELLA - World Health Organization

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6.3.2 Assess hazards and prioritize risks This step involves collecting and evaluating information on specific hazards associated with health-care settings, and conditions leading to their presence, to decide which are significant for safety and therefore should be addressed in a safety plan. The hazards considered here include those associated with the system components listed in Table 6.2. Hot and cold-water systems — risk factors The risk of nosocomial Legionnaires’ disease associated with the colonization of hot and cold-water systems by Legionella is well established. For example, Joly & Alary (1994) performed a follow-up study for 9 months at 20 hospitals, and found that the 10 hospitals containing readily detectable Legionella experienced significantly more frequent cases of Legionnaires’ disease than did the 10 hospitals where Legionella was not readily detected (P = 0.054). A five-year prospective study in 20 hospitals in Spain analysed the incidence of new cases of nosocomial legionellosis. In 64.7% of hospitals, Legionella-positive water cultures were found and nosocomial legionellosis was diagnosed; however, in hospitals where Legionella was not detected, no nosocomial legionellosis was reported. The reported incidence of nosocomial legionellosis has increased significantly since environmental studies increased detection of the organism (Sabrià et al., 2004). The proportion of distal sites in the water system of a hospital that are positive for Legionella directly correlates with the incidence of Legionnaires’ disease; that is, the greater the percentage of sites holding Legionella, the more likely it is that cases will occur. The opposite is also true — if Legionella is not detected in the water supply, cases will not occur (Stout & Yu, 2001). Based on the evidence of a link between the colonization of hot and cold-water systems in hospitals and other buildings and the risk of a Legionella infection, Exner et al. (1993) investigated hospitals, residential units and other buildings that could be affected by the colonization of water systems with Legionella. The study distinguished between: • a local or non-systemic colonization (defined as a colonization of isolated parts of the system, such as water outlets or shower heads) • a systemic colonization of the water system (defined as a colonization of the whole system, including the central parts of the water supply). Table 6.3 shows the type of colonization of water distribution systems by Legionella in healthcare facilities in Germany. <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS
Table . Type of colon zat on of water d str but on systems by Legionella n health-care Bu ld ng type fac l t es n Germany <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS Type of colon zat on System c number Local number Not detected n l tre Hospitals (n = 73) 46 (63%) 11 (15%) 16 (22%) Residential institutions (n = 77) 28 (36%) 9 (18%) 40 (52%) Concentrat on range >10 000/l 100–10 000/l
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LEGIONELLA AND THE PREVENTION OF LE
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LEGIONELLA AND THE PREVENTION OF LE
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Foreword Legionellosis is a collect
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Contents Foreword . . . . . . . . .
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Chapter 5 Cooling towers and evapor
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Chapter 9 Disease surveillance and
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Tables Table 1.1 Main characteristi
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Figure 8.1 Visible biofilm on inter
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Acknowledgements The World Health O
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• John Newbold, Health and Safety
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Executive summary Legionellosis is
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• Health-care facilities — Chap
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Chapter 1 Legionellosis Britt Horne
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Legionnaires’ disease is often in
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1.1.2 Pontiac fever Symptoms Pontia
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Table . Extrapulmonary nfect ons ca
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Proteins produced by the body’s i
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Aspiration may occur in patients wi
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Table . R sk factors for Legionella
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In the outbreak of Legionnaires’
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Table . Potent al treatments for d
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1.4.2 Species and serogroups associ
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Other causes of infection In Europe
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The interaction of virulent legione
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1.5.2 Surface structures involved i
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1.5.4 Host defence The host defence
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Chapter 2 Ecology and environmental
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L. pneumophila is thermotolerant an
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2.2.3 Environmental factors and vir
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Figure 2.1 Biofilm formation Biofil
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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
Page 67 and 68: Even when a source reaches a state
Page 69 and 70: The WSP should be prepared in conju
Page 71 and 72: Identify control measures Control m
Page 73 and 74: F gure . Dec mal reduct on t mes fo
Page 75 and 76: Method Advantages D sadvantages Dos
Page 77 and 78: Validate effectiveness of water saf
Page 79 and 80: • clear statements of responsibil
Page 81 and 82: Chapter 4 Potable water and in-buil
Page 83 and 84: The remainder of this chapter provi
Page 85 and 86: 4.3.1 Document and describe the sys
Page 87 and 88: Construction materials — risk fac
Page 89 and 90: Where temperature controls (discuss
Page 91 and 92: 4.4.2 Monitor control measures This
Page 93 and 94: Chapter 5 Cooling towers and evapor
Page 95 and 96: 5.1.1 Cross-flow cooling towers As
Page 97 and 98: water treatments (including chemica
Page 99 and 100: 5.3 System assessment This section
Page 101 and 102: Spray drift — risk factors Even w
Page 103 and 104: The section on control measures for
Page 105 and 106: • periodic or continuous bleed-of
Page 107 and 108: Box . Po nts to be noted when clean
Page 109 and 110: In certain circumstances, samples m
Page 111 and 112: Table . Example documentat on for m
Page 113 and 114: Chapter 6 Health-care facilities Ma
Page 115 and 116: For 1999 and 2000, a total of 384 c
Page 117: 6.3 System assessment This section
Page 121 and 122: 6.4.1 Identify control measures Thi
Page 123 and 124: 6.5.1 Prepare management procedures
Page 125 and 126: Until the situation is under contro
Page 127 and 128: Chapter 7 Hotels and ships Roisin R
Page 129 and 130: F gure . Detected and reported case
Page 131 and 132: Table . Rev ew of outbreaks (more t
Page 133 and 134: 7.2 Water safety plan overview WSPs
Page 135 and 136: The risk of legionellosis is increa
Page 137 and 138: Kingdom to 66% in Spain (Starlinger
Page 139 and 140: Agency, Legionella Section, United
Page 141 and 142: Given the complexity of distributio
Page 143 and 144: Chapter 8 Natural spas, hot tubs an
Page 145 and 146: Spas “Natural spa”, denotes fac
Page 147 and 148: Rare cases of Legionnaires’ disea
Page 149 and 150: Process step P pework Water n hot t
Page 151 and 152: Hosepipes may sometimes be used to
Page 153 and 154: Hot tubs that are not effectively d
Page 155 and 156: Nutrients — control measures Bath
Page 157 and 158: Various additives may also be used
Page 159 and 160: • descriptions of any significant
Page 161 and 162: Table . Examples of m crob olog cal
Page 163 and 164: Chapter 9 Disease surveillance and
Page 165 and 166: Exposure histories allow cases to b
Page 167 and 168: 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
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Ingram JG, Plouffe JF (1994). Dange
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Ko KS et al. (2003). Molecular evol
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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
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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
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Tully M, Williams A, Fitzgeorge RB
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Welti M et al. (2003). Development
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