LEGIONELLA - World Health Organization

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Chapter 11 Laboratory aspects of Legionella . . . . . . . . . . . . . . . . . . . .175 11.1 Legionella biology and staining . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175 11.1.1 Biology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175 11.1.2 Staining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176 11.2 Diagnostic methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176 11.2.1 Diagnosing legionellosis using culture media . . . . . . . . . . . .179 11.2.2 Detecting Legionella antigens . . . . . . . . . . . . . . . . . . . . . . .181 11.2.3 Diagnosing legionellosis using nucleic acid detection . . . . .183 11.2.4 Diagnosing patients with health-care associated pneumonia 184 11.3 Analysing environmental samples for Legionella . . . . . . . . . . . . . . . .185 11.3.1 Standards for Legionella detection and recovery . . . . . . . . . .185 11.3.2 Ensuring safety during environmental sampling . . . . . . . . .185 11.4 Legionella speciation and serology typing . . . . . . . . . . . . . . . . . . . . .186 11.4.1 Identifying different Legionella species . . . . . . . . . . . . . . . . .186 11.4.2 Identifying Legionella colonies . . . . . . . . . . . . . . . . . . . . . . .187 11.4.3 Identifying appropriate sampling sites . . . . . . . . . . . . . . . . .188 11.4.4 Collecting environmental samples . . . . . . . . . . . . . . . . . . . .190 11.4.5 Sample preparation and isolation . . . . . . . . . . . . . . . . . . . .191 11.4.6 Interpreting results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192 Appendix 1 Example of a water system checklist . . . . . . . . . . . . . . . .195 Appendix 2 Example of a 2-week follow-up form . . . . . . . . . . . . . . . . .199 Appendix 3 Example of a national surveillance form . . . . . . . . . . . . .205 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215 x <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS
Tables Table 1.1 Main characteristics of Legionnaires’ disease and Pontiac fever . . . . . . . . . . .2 Table 1.2 Extrapulmonary infections caused by Legionella species. . . . . . . . . . . . . . . . .7 Table 1.3 Useful definitions for epidemiological monitoring . . . . . . . . . . . . . . . . . . . .8 Table 1.4 Category of European cases, 1994–2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Table 1.5 Risk factors for Legionella infection, by category . . . . . . . . . . . . . . . . . . . . .12 Table 1.6 Risk factors for Legionella infection, by reservoir . . . . . . . . . . . . . . . . . . . . .13 Table 1.7 Risk exposures among Legionnaires’ disease declared cases in France, 1999–2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Table 1.8 Potential treatments for different patient groups . . . . . . . . . . . . . . . . . . . . .17 Table 1.9 Legionella species and serogroups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Table 3.1 Cooling tower outbreaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 Table 3.2 Advantages and disadvantages of alternative methods for controlling Legionella in piped water systems and cooling towers . . . . . . . . . . . . . . . . .50 Table 3.3 Examples of microbiological quality monitoring and action level specifications for cooling water systems . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Table 4.1 Example of a water safety plan for potable water and in-building distribution systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 Table 4.2 Examples of health-based targets for Legionella in piped water systems . . . .60 Table 4.3 Examples of values used as levels for corrective action for Legionella in piped water systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 Table 4.4 Example of documentation for monitoring and corrective action . . . . . . . .68 Table 5.1 Water safety plan overview — cooling towers and evaporative condensers . . . .74 Table 5.2 Example documentation for monitoring and corrective action . . . . . . . . . .87 Table 6.1 Water safety plan overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92 Table 6.2 Examples of system components to be considered in system assessment and subsequent hazard analysis in health-care facilities . . . . . . .93 Table 6.3 Type of colonization of water distribution systems by Legionella in health-care facilities in Germany . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 <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 and 10: Chapter 5 Cooling towers and evapor
Page 11: Chapter 9 Disease surveillance and
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
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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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LEGIONELLA - World Health Organization

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