LEGIONELLA - World Health Organization

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• Tom Devin, Institute of Engineers of Ireland, Dublin, Ireland • Vladimir Drasar, National Legionella Reference Laboratory, Vyskov, Czech Republic • Paul Edelstein, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, United States of America (USA) • Martin Exner, Hygiene Institute, Universität Bonn, Bonn, Germany • Santiago Ewig, Arzt für Innere Medizin Pneumologie, Infektiologie — DGI Umweltmedizin — Allergologie, Bonn, Germany • Lorna Fewtrell, Centre for Research into Environmental Health, Crewe, UK • Barry Fields, Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA • Pascal Fourrier, Direction Générale de la Santé, Paris, France • Norman Fry, Health Protection Agency, London, UK • Valeria Gaia, Istituto Cantonale Microbiologia, Bellinzona, Switzerland • Brian Guthrie, Pool Water Treatment Advisory Group, Diss, UK • Philippe Hartemann, Faculté de Médecine de Nancy, Nancy, France • John Hayes, Institute of Health Care Management, High Wycombe, UK • Lauri Hicks, Division of Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, Georgia, USA • Britt Hornei, Hygiene Institute, Universität Bonn, Bonn, Germany • Birgitta de Jong, Swedish Institute for Infectious Disease Control, Solna, Sweden • Carol Joseph, Health Protection Agency, London, UK • Dick van der Kooij, Kiwa Water Research, Nieuwegein, The Netherlands • Louise Lajoie, Hygiene Institute, Universität Bonn, Bonn, Germany • John V Lee, Health Protection Agency, London, UK • Jean Francois Loret, Suez Environnement, Centre International de Recherche sur l’Eau et l’Environnement, Paris, France • William McCoy, Phigenics, Chicago, Illinois, USA • Thierry Michelon, Direction Générale de la Santé, Paris, France • Matthew Moore, Centers for Disease Control and Prevention, Atlanta, Georgia, USA xv LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS
• John Newbold, Health and Safety Executive, London, UK • Jean-Nicolas Ormsby, Direction Générale de la Santé, Paris, France • Guillaume Panie, Direction Régionale de l’Industrie, de la Recherche et de l’Environnement, Douai, France • Kathy Pond, University of Surrey, Guildford, UK • Rosa Cano Portero, Instituto de Salud Carlos III, Madrid, Spain • Jordi Roig, Hospital Nostra Senyora de Meritxell, Andorra, Spain • Roisin Rooney, World Health Organization, Delhi, India • Daniela Schmid, Institut für Medizinische Mikrobiologie und Hygiene Wien, Kompetenzzentrum Infektionsepidemiologie, Vienna, Austria • Oriane Soetens, Laboratorium Microbiologie, Academisch Ziekenhuis Vrije Universiteit Brussel, Brussels, Belgium • Janet Stout, Medical Centre, Infectious Disease Section, University of Pittsburgh, Pittsburgh, Pennsylvania, USA • Susanne Surman-Lee, Health Protection Agency, London, UK • Igor Tartakovsky, National Reference Centre on Legionellosis of the Russian Ministry of Health, Moscow, Russia • Thierry Trouvet, Ministère de L’Écologie et du Développement, Paris, France • Ans Versteegh, National Institute for Public Health and the Environment, Bilthoven, The Netherlands • France Wallet, Electricité de France, Service des Etudes Médicales, Paris, France • Günther Wewalka, Institut für Medizinische Mikrobiologie und Hygiene Wien, Kompetenzzentrum Infektionsepidemiologie, Vienna, Austria. The development of this publication was made possible with the support and collaboration of the Health Protection Agency (HPA), UK, the Swedish International Development Cooperation Agency (SIDA), the UK Department for International Development (DFID), the Japanese Ministry of Health, Labour and Welfare, and the Government of Norway. LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS x x
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 and 16: Figure 8.1 Visible biofilm on inter
Page 17: Acknowledgements The World Health O
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
Page 67 and 68: 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
Page 273 and 274:
Tully M, Williams A, Fitzgeorge RB
Page 275 and 276:
Welti M et al. (2003). Development
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LEGIONELLA - World Health Organization

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