LEGIONELLA - World Health Organization

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Box 8.3 Additional risk factors for hot tubs in commercial and domestic settings . . . . . . .129 Box 9.1 Definition of disease surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140 Box 9.2 Case classifications for legionellosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140 Box 9.3 European Working Group for Legionella Infections . . . . . . . . . . . . . . . . .144 Box 9.4 Recommended composition of an outbreak control team . . . . . . . . . . . . .150 Box 9.5 Example of terms of reference for an outbreak control team . . . . . . . . . . .153 Box 10.1 WHO publications relevant to the control of Legionella . . . . . . . . . . . . . .162 xv LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS
Acknowledgements The World Health Organization (WHO) wishes to express its appreciation to all whose efforts made this production possible. In particular, WHO gratefully acknowledges the contributions of the following international group of experts, who contributed to, and reviewed, the publication: • Franz Allerberger, Institut für medizinische Mikrobiologie und Hygiene Wien Kompetenzzentrum Infektionsepidemiologie, Vienna, Austria • Jamie Bartram, Coordinator, Programme on Assessing and Managing Environmental Risks to Health, WHO Headquarters, Geneva, Switzerland • Richard Bentham, Department of Environmental Health, School of Medicine, Flinders University, Adelaide, Australia • Konrad Botzenhart, Universität Tübingen, Institut für Allgemeine Hygiene und Umwelhygiene, Tübingen, Germany • Emmanuel Briand, Centre Scientifique et Technique du Bâtiment, Marne la Vallée, France • Clive Broadbent, Clive Broadbent and Associates Pty Ltd, Canberra, Australia • Geoffrey Brundrett, Brundrett Associates, Kingsley, United Kingdom (UK) • Pierre Andre Cabannes, Electricité de France, Service des Etudes Medicales, Paris, France • Philip Callan, National Health and Medical Research Council, Canberra, Australia • Yves Chartier, Programme on Assessing and Managing Environmental Risks to Health, WHO Headquarters, Geneva, Switzerland • Pierre Franck Chevet, Direction Régionale de l’Industrie, de la Recherche et de l’Environnement, Douai, France • Simon Cole, Wessex Water, Bristol, UK • Sebastian Crespi, Policlinica Miramar, Palma de Mallorca, Spain • David Cunliffe, Department of Human Services, Environmental Health Service, Adelaide, Australia • Friederike Dangendorf (deceased), Universität Bonn, Bonn, Germany • Dr Annette Davison, Water Futures Pty Ltd, Australia • Dr Daniel Deere, Water Futures Pty Ltd, Australia • Julian Dennis, Thames Water Utilities, Reading, UK LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS xv
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 and 12: Chapter 9 Disease surveillance and
Page 13 and 14: Tables Table 1.1 Main characteristi
Page 15: Figure 8.1 Visible biofilm on inter
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
Page 63 and 64: Chapter 3 Approaches to risk manage
Page 65 and 66: 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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