LEGIONELLA - World Health Organization

and mortality of hotel-associated legionellosis, justify the attention given to this issue by the
tourism and medical community. Since the implementation of the European Community’s
Directive for Package Travel in 1996, the International Federation of Tour Operators in Europe,
together with some tour operators in individual European countries, has been informed of
travel-associated cases of Legionnaires’ disease in people who purchased holidays through tour
operators. The aim of this scheme was to prevent additional cases (Anon, 1996a).
The European tourism industry has developed several initiatives to reduce travel-associated cases
(Cartwright, 2000). In some regions and countries with important tourist industries, such as
the Balearic Islands (Spain), Portugal and Malta, tourist and health authorities have issued
specific recommendations for the prevention of legionellosis in tourist accommodation. In
2002, the European Guidelines for the Control and Prevention of Travel Associated Legionnaires’
Disease were introduced (EWGLI, 2003).
The number of detected and reported cases of travel-associated legionellosis in Europe rose
between 1994 and 2003 (see Figure 7.1). In 1996, travel-associated cases made up 16% of the
total number of detected legionellosis cases in Europe; in 1999, they made up 21%. Of these
cases, 90% were associated with hotels or apartments; the rest were associated with camp
sites, cruise ships, private houses and other sites (EWGLI, 2001).
The sex and age distributions of travel-associated legionellosis cases differ little from those of
other cases: they occur mainly in the fifth and sixth decades of life, and with an incidence in
men that is approximately three times as high as in women (Ricketts & Joseph, 2004). The
mortality rate in travel-associated cases in Europe has dropped over the years, from 10–12%
in the early 1990s to 6% in 2003 (Ricketts & Joseph, 2004). This trend probably reflects the
improved treatment that follows rapid diagnosis of the illness due to the introduction of the
urinary antigen assay (see Chapter 11).
Tourism-associated legionellosis exhibits a clear seasonal distribution that corresponds to the
holiday periods usually chosen by older tourists. Most European cases occur between May and
November, with the highest peaks in June and September (EWGLI, 1999, 2001, 2004ab).
These peaks have been attributed to tourists without school-age children preferring not to
holiday during July and August, when the average age of tourists is generally younger, because
of school breaks.
0 LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS