LEGIONELLA - World Health Organization

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The principles outlined here apply to the investigation of all outbreaks in which microbiological and epidemiological expertise is used, regardless of the disease under investigation. 9.3.1 Confirmation of an outbreak The first stage in any investigation is to confirm that an outbreak exists. Most outbreaks of Legionnaires’ disease will be detected through local or national surveillance schemes. 9.3.2 Outbreak control team Most outbreaks will be managed by epidemiologists, microbiologists, environmental health specialists and hygienists from the country concerned. The outbreak control team should be identified and convened before an outbreak occurs. The team must reflect all the relevant organizations responsible for the management of water systems used in industrial, commercial, hospital or leisure facilities, many of whose operations are controlled by legally enforceable codes of practice. A media spokesperson is also essential for preparing and disseminating information to public health officials and the general public, because of the high media interest following detection of an outbreak. Box 9.4 outlines the recommended composition of an outbreak control team. Box . Recommended compos t on of an outbreak control team An outbreak control team should include at least the following members: • public health specialists in the area in which the outbreak has occurred • consultant epidemiologist with expertise in Legionella • consultant microbiologist with expertise in Legionella • environmental microbiologist with expertise in detection and control of Legionella • consultant from the local microbiology laboratory • environmental health officer or hygienist • data manager to take responsibility for all aspects of data structure, storage, security and dissemination • health and safety enforcement officer • infection control nurse or national equivalent • representative from the local department of public health medicine • people responsible for the engineering services at the community, industrial, commercial, hospital or other premises suspected to be associated with the outbreak • general manager at the community, industrial, commercial, hospital or other premises suspected to be associated with the outbreak • senior media spokesperson • other members as decided by the chairperson of the outbreak control team. 0 <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS
Training opportunities Trainees in public health medicine, epidemiology, microbiology or environmental health welcome the opportunity to become involved in outbreak investigations. However, their training activities role should not hinder the work of the outbreak control team, and trainees should not be put into roles with responsibilities beyond their level of expertise or competence. The trainees should be a resource for the outbreak control team at a level appropriate to their training needs. 9.3.3 Policies and practices Good public health practice must be paramount when planning the management of an outbreak of Legionnaires’ disease. International travel-associated outbreaks will be managed differently (see below). The outbreak control plan should outline the local or national lines of communication in response to the diagnosis of one or more linked cases of legionellosis. The plan should specify who is responsible for convening the outbreak control team, and the key groups of staff to be included in the team. Once an outbreak is suspected or confirmed, the control team should be convened immediately. At its first meeting, the team should: • elect a chairperson, who will be responsible for convening all future meetings and organizing secretarial support for taking and promptly distributing minutes and any other information associated with the outbreak • establish terms of reference for the outbreak investigation (see Section 9.3.4) • determine which groups of public health professionals will be enforcement or legislative authorities for prevention and control of Legionella infection • agree on a plan for ensuring that immediate action is taken to eliminate the source of infection, once it has been identified • review epidemiological information to decide where to focus the initial environmental investigations and control measures (see Section 9.3.5). Resources Regardless of the size, magnitude and duration of an outbreak, it is vital that sufficient resources are mobilized and maintained until the investigation is complete. This includes resources for managing all aspects of the outbreak investigation, analysing data and producing an outbreak report. <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS
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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
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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
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 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: F gure . Annual reported cases, - 0
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
Page 217 and 218: • other Legionella species that d
Page 219 and 220: Appendix 1 Example of a water syste
Page 221 and 222: Weekly water system check list Week
Page 223 and 224: 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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LEGIONELLA - World Health Organization

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