LEGIONELLA - World Health Organization

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The number of samples collected can be considerable, and it will often be necessary to use more than one laboratory to ensure that all the samples are processed in good time. If this is the case, the outbreak control team should ensure that the laboratories used are competent and experienced, and use the same method of detection, with the required sensitivity. The outbreak plan, which should be prepared in advance, should include information on: • roles that individuals may play • laboratories that are to be used • contingency plans for situations in which the local laboratory cannot cope • means to rapidly obtain sufficient laboratory media • transport arrangements for specimens, to ensure arrival within the recommended time. Chapter 11 has detailed information on sampling for legionellae. Advice on sampling that complies with the European and United Kingdom guidelines has recently been published and is freely available from the Internet (Standing Committee of Analysts, 2005). 9.3.6 High-profile outbreaks Occasionally, outbreaks may be of such magnitude or importance that all investigations should be managed from an incident room established within a national public health institution. In such cases, resources must be identified, because many staff may be required for: • interviewing patients • carrying out a case–control study to determine the epidemiological importance of certain risk factors • collecting and processing clinical and environmental samples. These staff will not be part of the outbreak control team but must be briefed regularly to ensure that all resources required for the outbreak investigation are used efficiently and effectively. Regular updates of factors such as case ascertainment, patient outcomes and environmental results must be conveyed to all core members of the outbreak control team. This does not necessarily mean convening meetings; it can be achieved using e-mail groups, video conferencing or telephone and fax communications by the chairperson of the outbreak control team. Where there is an international dimension, the relevant health departments in overseas governments, the relevant department in WHO, 22 and other stakeholders and institutions must be informed. Case searching and follow-up must be organized through national public health institutions. 22 outbreak@who.int <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS
9.4 Case studies This section describes: • a community outbreak in England (Section 9.4.1) • a health-care facility outbreak in Israel (Section 9.4.2) • an outbreak associated with hot tubs in Austria (Section 9.4.3) • a case of Legionnaires' disease associated with a concrete batcher process on a construction site in the UK (Section 9.4.4). 9.4.1 Community outbreak — England In late 2003, 27 cases and two deaths were associated with an outbreak in a small city in England. As soon as the outbreak was recognized, the outbreak control team was convened. The team constructed a case definition, and carried out detailed epidemiological and environmental investigations. The source of the outbreak was shown to be the cooling towers at an industrial plant used to make cider. The industrial process involved switching on the cooling towers once a year, when the apples used to make the cider were delivered to the plant for processing. None of the workforce became ill, but clinical isolates obtained from two of the cases were indistinguishable by sequence-based typing methods from the environmental isolates obtained from the cooling tower water samples (Gaia et al., 2003). The investigation included use of meteorological data, plume modelling, helicopter infrared surveillance of potential sources of infection, and geographical information systems for analysis of patient travel in the local vicinity over the outbreak period. The outbreak was stopped when the cooling towers were shut down (Anon, 2003). 9.4.2 Nosocomial outbreak — Israel During a two-week period in June–July 2000, a nosocomial outbreak of Legionella pneumonia caused by L. pneumophila serogroup 3 occurred in four patients, following haematopoietic stem cell transplantation, in a new bone marrow transplant unit. The causative organism was recovered from the water supply system to the same unit, just before the outbreak occurred. Serologic screening revealed no other cases of Legionella pneumonia in 19 consecutive bone marrow transplant patients hospitalized in the same unit at the same time. The outbreak was contained by early recognition, immediate restrictions of the use of tap water, antibiotic prophylaxis for all non-infected patients, and water decontamination by hyperchlorination and superheating. In November 2000 and February 2001, two more nosocomially acquired cases occurred, along with the re-emergence of Legionella in the water. <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
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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
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
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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: ecause doing anything more could un
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
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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
Page 225 and 226: Travel Work/travel in the UK: ❑ Y
Page 227 and 228: Checklist of local places Health/sp
Page 229 and 230: 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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