LEGIONELLA - World Health Organization

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7.1.3 Ship-associated cases Legionnaires’ disease was first associated with a ship in 1977 (Rowbotham, 1998). At least 55 incidents (outbreaks or cases) were associated with cruise ships, ferries, cargo ships, fishing vessels or naval ships between 1977 and 2004. Outbreaks of two or more cases are summarized in Table 7.1. Some of these incidents have been linked to ship’s water systems, air-conditioning systems and recreational hot tubs. However, in the majority of cases, the source of the infection and/or the mode of transmission were not established. The risk of exposure to Legionella on ships is difficult to assess. Surveys carried out on general cargo ships have shown drinking-water and air-conditioning systems to be contaminated with L. pneumophila. Serologic surveys of some seafarers on cargo ships showed that a high proportion had antibodies to L. pneumophila, suggesting that those on some ships could be at increased risk of legionellosis compared with communities on shore (Temeshnikova et al., 1996). The number of outbreaks and cases reported in the literature is probably an underestimate of the true incidence of the disease. As for hotels, outbreaks and cases associated with ships, especially ferries, are difficult to detect because the incubation period of 2–10 days or more (see Chapter 1) means that passengers may have dispersed widely, including to different countries, before developing symptoms. To detect such outbreaks, an international surveillance scheme, such as the European Surveillance Scheme for Travel Associated Legionnaires’ Disease, is necessary (see Section 7.1.1). Even when an outbreak or cluster of cases is detected on a ship or ferry, it is often difficult to implicate that vessel as the source of infection, if passengers disembarked at different locations or stayed in hotels before or after the voyage. Tracking previous incidents associated with ships can also be a problem if the vessel’s name has changed, particularly if ownership has also changed. To implicate a particular source during an outbreak investigation, it is necessary to isolate environmental strains of Legionella and match them with clinical isolates. However, this is often more difficult to do for ships, because the suspect vessel will often have sailed to another country before a case is recognized. Unless there is good cooperation between international port health authorities and maritime authorities in different countries, ships may escape adequate investigation. 0 <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS
Table . Rev ew of outbreaks (more than one case) of Leg onna res’ d sease assoc ated w th sh ps, – 00 Reference Christenson et al., 1986 Rowbotham, 1998 Rowbotham, 1998 Jernigan et al., 1996 Rowbotham, 1998 Pastoris et al., 1999 Rowbotham, 1998; Joseph, 1997 Year of event Type of sh p Geograph cal reg on 1984 Cruise Europe and North Africa 1992 Russian training 1994 Cruise Eastern Mediterranean Mortal ty and morb d ty Comments • 70 suspected • Outbreak occurred cases after air-conditioning • 295/335 was turned on at passengers had Bordeaux influenza-like illness • 16 hospitalized • Ship built in 1948 — • 4 cases • Legionellae isolated from water on ship 1994 Cruise USA • 16 confirmed and 34 probable (1 fatal), over 9 cruises 1995 River cruise Rhine River, Germany • 2 cases • Onsets on the last day of a 15-day cruise and 2 days after a 13-day cruise • L. fallonii and amoebae isolated from the ship • Exposure to a spa pool, not adequately disinfected by the brominator, strongly associated with disease • 2 cases, 1 fatal • Onset 4 days after 7-day cruise 1995 Cruise Italy • 3 cases (1 fatal) • Same serogroup isolated from water supply and from a case 1997 River cruise Germany • 6 cases (British) • Spa pool suspected source; L. pneumophila isolated from spa • Chlorine was not applied to the water or monitored <strong>LEGIONELLA</strong> 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
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Method Advantages D sadvantages Dos
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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 and 126: Until the situation is under contro
Page 127 and 128: Chapter 7 Hotels and ships Roisin R
Page 129: F gure . Detected and reported case
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
Page 177 and 178: Box . Example of terms of reference
Page 179 and 180: 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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