LEGIONELLA - World Health Organization

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Surve llance dataset Comment Exposure h story Hosp tal acqu red (nosocom al) Necessary to establish nosocomial association Date(s) of admission to hospital(s) before onset of symptoms Commun ty acqu red Necessary to begin environmental investigations Known exposure to cooling towers, whirlpool spas, showers, etc. Travel assoc ated Necessary to begin environmental investigations Country visited, dates of stay, name and address of accommodation used, room number, name of tour operator, use of showers, spa pools, etc. Domest cally acqu red If no other source of infection identified, this should Use of domestic water system during be considered incubation period, in absence of other risk exposures Single cases Single cases reported to a surveillance scheme are normally entered into a database that is then searched for links in time or place to previously reported cases. If no links are found, the environmental actions in response to a single case will be determined locally or nationally. However, whenever possible, these actions should include: • a review of the possible sources of infection • a risk assessment of potential or suspected sources (see Chapter 3). A memorandum of understanding or a local or national protocol agreed in advance between all the relevant agencies helps to facilitate this process and to ensure that all the appropriate measures have been taken. Local documentation or registration of cooling towers is also extremely helpful when searching for potential community sources of infection. A flowchart for investigating single cases of legionellosis is given in Figure 9.1. LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS
F gure . Invest gat ng a s ngle case of leg onellos s Confirm diagnosis by urine, culture or serology Negative Positive/ presumptive No further action Confirm at reference laboratory Suspected case of Legionnaires’ disease Confirm pneumonia Inform health officials in area of patient’s residence LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS Inform local health officials Obtain two–week exposure history Report to national centre Follow up source of infection Health–care acquired Community acquired Travel associated • Review risk assessment document and hospital maintenance records. • Search for other cases associated with the hospital. • If case(s) definitely or probably nosocomial, convene incident control team and conduct environmental sampling. • Institute remedial control measures. • Review possible sources of infection. • Examine maintenance records of suspected source(s). • Check for associated cases locally and nationally. • Convene incident control team and conduct environmental sampling if relevant. • Institute remedial control measures. • Obtain details of place and dates of travel and report to national centre. • If case associated with travel in own country, inform local health officials in area of travel. • Review water systems at accommodation site and conduct environmental sampling if relevant. • Institute remedial control measures. Domestic premises • Review as possible source of infection if patient not associated with hospital or community acquired infection or if domestic water system unused for several days before infection. • Conduct sampling
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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
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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
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 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: Exposure histories allow cases to b
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
Page 181 and 182: 9.4 Case studies This section descr
Page 183 and 184: 9.4.4 Concrete batcher process on a
Page 185 and 186: Chapter 10 Regulatory aspects David
Page 187 and 188: • validation of the effectiveness
Page 189 and 190: • operating conditions, such as t
Page 191 and 192: 10.4.6 Outbreak investigation and n
Page 193 and 194: hot water (e.g. health-care facilit
Page 195 and 196: General prevent on Country DW Wp SB
Page 197 and 198: Country General prevent on DW Wp SB
Page 199 and 200: Chapter 11 Laboratory aspects of Le
Page 201 and 202: • detection of the bacterium in t
Page 203 and 204: Method Sens t v ty (%) PCR • Rapi
Page 205 and 206: 11.2.2 Detecting Legionella antigen
Page 207 and 208: DFA has been used successfully with
Page 209 and 210: • Serologic testing can be used f
Page 211 and 212: Although not all strains can be rel
Page 213 and 214: Generally, any water source that ma
Page 215 and 216: 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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