LEGIONELLA - World Health Organization

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Table 6.4 Example of documentation for verification and corrective action for a water system Process step Ind cator Mon tor ng What Legionella concentration Verification Legionella concentration in water CFU = colony forming unit How Employ documented, validated and quality-controlled methods When 2 times/year (4 times/year in high-risk areas) Where At the entry and at selected pointof-use sites Who Infection control officer or hospital hygienist Operat onal l m t Correct ve act on In areas for patients with classical individual risk factors, target level of
Chapter 7 Hotels and ships Roisin Rooney, John V Lee, Sebastian Crespi, Guillaume Panie, Pierre Franck Chevet, Thierry Trouvet and Susanne Surman-Lee This chapter describes how a water safety plan (WSP) can be applied to assessing and managing the risks associated with Legionella in hotels and ships. It should be read in conjunction with Chapter 3, which discusses the different elements that make up a WSP, and shows how a WSP fits within the framework for safe water quality developed by the World Health Organization (WHO). As explained in Chapter 3, a WSP has 10 steps that fit within the three main areas of system assessment, monitoring and management and communications (see Figure 3.2). A WSP must be comprehensive, and all 10 steps should be implemented in assessing and managing the risks associated with Legionella. However, this chapter focuses on parts of the WSP where information specific to hotels and ships is needed. 7.1 Background The first detected outbreak of legionellosis occurred in a hotel in Philadelphia, United States of America (USA) in 1976. Subsequently, many other cases of legionellosis have been associated with hotels worldwide. Travel and hotel stays are recognized as risk factors for legionellosis (WHO, 1990). In Europe, approximately 20% of detected legionellosis cases are considered to be travel associated (Joseph, 2002b). 7.1.1 European initiatives Most of the data currently available on the cases of legionellosis associated with travel and hotel stays originate from the European Surveillance Scheme for Travel Associated Legionnaires’ Disease, established in 1987 by the European Working Group for Legionella Infections (EWGLI). This system — now called EWGLINET — was established principally to enable rapid identification of legionellosis outbreaks among tourists of different nationalities. Its history and current activities are described in detail on the EWGLINET web site. 5 The need for a specific surveillance system for travel-associated legionellosis in the USA has also been recognized (Benin et al., 2002; Fields, Benson & Besser, 2002). Cases of legionellosis occurring in hotels have often received extensive publicity in the mass media. Additionally, the growing importance of international tourism, and the significance of morbidity 5 http://www.ewgli.org LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS 0
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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
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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
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 and 118: 6.3 System assessment This section
Page 119 and 120: Table . Type of colon zat on of wat
Page 121 and 122: 6.4.1 Identify control measures Thi
Page 123 and 124: 6.5.1 Prepare management procedures
Page 125: Until the situation is under contro
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
Page 169 and 170: Box . (cont nued) Since the incepti
Page 171 and 172: Country United Kingdom All reported
Page 173 and 174: F gure . Annual reported cases, - 0
Page 175 and 176: 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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