LEGIONELLA - World Health Organization

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The development of this publication was guided by the recommendations of an expert meeting hosted by the Health Protection Agency’s Centre for Infections (formerly the Central Public Health Laboratory), Colindale, London, on 18–20 June 2002, chaired by Dr John V Lee. It was also guided by a series of critical reviews undertaken by specialists in the field. The production of this document was led by the Department of Public Health and Environment — Programme on Assessing and Managing Environmental Risks to Health at WHO, in cooperation with the Department of Epidemic and Pandemic Alert and Response at WHO. This book will be useful to all those concerned with Legionella and health, including environmental and public health officers, health-care workers, the travel industry, researchers and special interest groups. v LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS
Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi Chapter 1 Legionellosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1.1 Types of disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1.1.1 Legionnaires’ disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 1.1.2 Pontiac fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 1.1.3 Extrapulmonary syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . .5 1.2 Prevalence and risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 1.2.1 Community-acquired pneumonia . . . . . . . . . . . . . . . . . . . . . .9 1.2.2 Nosocomial infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 1.2.3 Sporadic cases of pneumonia . . . . . . . . . . . . . . . . . . . . . . . . .13 1.2.4 Rates of mortality and survival . . . . . . . . . . . . . . . . . . . . . . .14 1.3 Treatment of Legionnaires’ disease . . . . . . . . . . . . . . . . . . . . . . . . . . .15 1.4 Types of organism causing disease . . . . . . . . . . . . . . . . . . . . . . . . . . .18 1.4.1 Taxonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 1.4.2 Species and serogroups associated with disease. . . . . . . . . . . .19 1.5 Virulence and pathogenicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 1.5.1 Overview and life-cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 1.5.2 Surface structures involved in pathogenicity . . . . . . . . . . . . .25 1.5.3 Virulence factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 1.5.4 Host defence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 1.5.5 Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Chapter 2 Ecology and environmental sources of Legionella . . . . .29 2.1 Natural sources of Legionella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 2.2 Factors affecting growth of Legionella . . . . . . . . . . . . . . . . . . . . . . . . .30 2.2.1 Influence of temperature . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS v
Page 1 and 2: LEGIONELLA AND THE PREVENTION OF LE
Page 3 and 4: LEGIONELLA AND THE PREVENTION OF LE
Page 5: Foreword Legionellosis is a collect
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 and 18: Acknowledgements The World Health O
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
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Figure 2.1 Biofilm formation Biofil
Page 61 and 62:
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
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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
Page 243 and 244:
Blatt SP et al. (1994). Legionnaire
Page 245 and 246:
Byrne B, Swanson MS (1998). Express
Page 247 and 248:
Crespi S (1993). Legionella y legio
Page 249 and 250:
Edelstein PH (1982b). Comparative s
Page 251 and 252:
Falguera M et al. (2001). Nonsevere
Page 253 and 254:
Gaia V et al. (2003). Sequence-base
Page 255 and 256:
Hayden RT et al. (2001). Direct det
Page 257 and 258:
Ingram JG, Plouffe JF (1994). Dange
Page 259 and 260:
Ko KS et al. (2003). Molecular evol
Page 261 and 262:
Loret JF et al. (2003). Comparison
Page 263 and 264:
McEvoy M et al. (2000). A cluster o
Page 265 and 266:
Olaechea PM et al. (1996). A predic
Page 267 and 268:
Regan CM et al. (2003). Outbreak of
Page 269 and 270:
Schulze-Robbecke R, Rodder M, Exner
Page 271 and 272:
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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