you can’t see it but you can catch it -...

LegionnellaLegionnellaYou canYou can’’t see it but you can t see it but you can

catch itcatch it

Dr Dr CharmaineCharmaine Gauci MD, MSc, PhDGauci MD, MSc, PhD

Head of Disease Surveillance Unit Head of Disease Surveillance Unit

Legionella infectionsLegionella infections

�� First documented outbreakFirst documented outbreak

�� name from 221 cases of pneumonianame from 221 cases of pneumonia

�� occurred amongst 4,000 delegates occurred amongst 4,000 delegates attending the 58th American Legion attending the 58th American Legion convention in Philadelphia in July 1976convention in Philadelphia in July 1976

�� Bellevue Stratford Hotel, PhiladelphiaBellevue Stratford Hotel, Philadelphia

�� 15% fatality rate (34 died)15% fatality rate (34 died)

�� was intensely investigated.was intensely investigated.

�� Vendetta waged against LegionnairesVendetta waged against Legionnaires’’

�� AmericaAmerica’’s finest fighting mens finest fighting men

�� Five months later:Five months later:

–– BUG was identifiedBUG was identified

–– Other previous outbreaks explainedOther previous outbreaks explained--

earliest documented 1947earliest documented 1947

The BugThe Bug

Gram negative bacillus Gram negative bacillus

Legionella Legionella pneumophilapneumophila


�� Gram negative bacteriaGram negative bacteria

�� Invisible to the naked eyeInvisible to the naked eye

–– 11--2 micrometer2 micrometer longlong

–– 0,5 micrometer wide0,5 micrometer wide

�� Found naturally in environmental watersFound naturally in environmental waters

–– Rivers, lakesRivers, lakes

–– ReservoirsReservoirs


�� Can get into water systemsCan get into water systems

–– AirconditioningAirconditioning systemssystems

–– Hot tubs, Hot tubs, WhirpoolsWhirpools, spas, spas

–– Hot/ Cold water tanksHot/ Cold water tanks

–– ShowersShowers


�� ProliferateProliferate

�� Temperatures Temperatures

around 20around 20--45 45

degrees Celsiusdegrees Celsius

�� Stagnant waterStagnant water

TransmissionTransmission

�� Breathing of aerosols (mists) that come Breathing of aerosols (mists) that come

from a water source contaminated with from a water source contaminated with

Legionella bacteriaLegionella bacteria

�� No transmission via drinking waterNo transmission via drinking water

�� No documented person to person No documented person to person

transmissiontransmission

LegionnairesLegionnaires’’ diseasedisease

�� Bacteria enter lungs Bacteria enter lungs

by inhalation of by inhalation of

aerosols of aerosols of

contaminated watercontaminated water

�� Cause pneumoniaCause pneumonia

SusceptibilitySusceptibility

�� MiddleMiddle--aged and older personsaged and older persons

�� smokerssmokers

�� diabetes mellitusdiabetes mellitus

�� chronic lung diseasechronic lung disease

�� renal diseaserenal disease

�� malignancymalignancy

�� ImmunosuppressedImmunosuppressed (kidney failure, cancer, (kidney failure, cancer,

AIDS)AIDS)

Clinical symptomsClinical symptoms

�� Incubation period: 2Incubation period: 2--10 days up to 18 10 days up to 18

daysdays

�� Bacteria grow in lung Bacteria grow in lung

–– PneumoniaPneumonia

�� Spread via blood or lymph systemSpread via blood or lymph system

–– ExtrapulmonaryExtrapulmonary manifestationsmanifestations

Clinical symptomsClinical symptoms

�� fever, malaise, fever, malaise, myalgiamyalgia, headache and , headache and

often often diarrhoeadiarrhoea

�� high fever and non productive cough high fever and non productive cough

which becomes productivewhich becomes productive

�� chest signs non impressive. chest signs non impressive.

�� case fatality rate is highcase fatality rate is high-- 15%. 15%.

Chest XChest X--RayRay

DiagnosisDiagnosis

�� Clinical pictureClinical picture

�� High index of suspicionHigh index of suspicion

�� Chest XChest X--RayRay

�� Urinary antigen testingUrinary antigen testing

�� Culture of organism from secretionsCulture of organism from secretions

�� Serological testingSerological testing

OutcomesOutcomes

�� Serious diseaseSerious disease

�� Can be fatalCan be fatal

�� Up to 10% of casesUp to 10% of cases

�� In Malta :In Malta :

–– 2003 1 death2003 1 death

–– 2004 2 deaths2004 2 deaths

Treatment Treatment

�� Antibiotics (Erythromycin/ Antibiotics (Erythromycin/ RifampicinRifampicin))

�� Respiratory Supportive care Respiratory Supportive care

Frequency and DistributionFrequency and Distribution

–– About 200About 200--300 cases occur in the UK each 300 cases occur in the UK each

year mostly sporadic or small groupsyear mostly sporadic or small groups

–– 8,0008,000--18,000 occur in US each year18,000 occur in US each year

OutbreaksOutbreaks

�� Outbreaks do occurOutbreaks do occur

–– HotelsHotels

–– InstitutionsInstitutions

–– HospitalsHospitals

–– CommunityCommunity

OutbreaksOutbreaks

�� Associated with:Associated with:

�� Hot and cold water systemsHot and cold water systems-- e.g. taking e.g. taking

showersshowers

�� Cooling towersCooling towers

�� Whirlpool spasWhirlpool spas

�� FountainsFountains

Investigating outbreaksInvestigating outbreaks

�� Patients with legionnairesPatients with legionnaires’’ diseasedisease

–– Place of residencePlace of residence

–– Whereabouts of patientsWhereabouts of patients

–– Activities in the previous daysActivities in the previous days

–– TravelTravel

�� Investigating suspected water sourcesInvestigating suspected water sources

–– Testing water sourcesTesting water sources

Netherlands Community OBNetherlands Community OB

�� Large increase in number of cases in 1999Large increase in number of cases in 1999

�� Environmental investigationEnvironmental investigation

�� Case control epidemiological analysisCase control epidemiological analysis

�� Serologic cohort studySerologic cohort study

�� Associated with flower showAssociated with flower show

�� Of 77,061 visitors , 188 became illOf 77,061 visitors , 188 became ill

�� Positive for Positive for legionellalegionella bacteriabacteria–– 2 whirlpool spas of exhibits2 whirlpool spas of exhibits

–– Sprinkler in a hallSprinkler in a hall

�� Control ActionsControl Actions

MuriciaMuricia Community OBCommunity OB

�� On 7On 7thth July 2001 July 2001

start of an epidemicstart of an epidemic

�� 470 cases identified470 cases identified

�� Of these one diedOf these one died

�� Epidemiological investigationEpidemiological investigation

�� 75% lived in Northern Region of city75% lived in Northern Region of city

�� Case Control StudyCase Control Study

�� Environmental InvestigationEnvironmental Investigation

�� Positive cooling towers of city hospitalPositive cooling towers of city hospital

Australia Community OBAustralia Community OB

�� April 2000April 2000

�� 101 cases of legionnaires 101 cases of legionnaires

�� Aged 23Aged 23--89 years89 years

�� 2 deaths2 deaths

�� Had visited Melbourne AquariumHad visited Melbourne Aquarium

�� Confirmed Legionella bacteria in cooling Confirmed Legionella bacteria in cooling

towerstowers

�� DisinfectionDisinfection

OB in Hotel SwedenOB in Hotel Sweden

�� February 2005February 2005

�� Luxury hotel and spa in centre of SwedenLuxury hotel and spa in centre of Sweden

�� 50 guests with Pontiac fever50 guests with Pontiac fever

–– Fever, chills, fatigue, muscle aches, headacheFever, chills, fatigue, muscle aches, headache

�� Suspected Suspected

–– 2 2 whirpoolswhirpools

–– Swimming poolSwimming pool

OB in Oklahoma HotelOB in Oklahoma Hotel

�� March 2004March 2004

�� National basketball tournament for National basketball tournament for

children and family memberschildren and family members

�� Staying in hotel in OklahomaStaying in hotel in Oklahoma

�� 65 cases with Pontiac fever65 cases with Pontiac fever

�� SuspectedSuspected

–– Hotel pool and hot tubHotel pool and hot tub

OB in Hospital , BarcelonaOB in Hospital , Barcelona

�� Hospital Lasts i Hospital Lasts i ReynalsReynals

�� February 2005February 2005

�� 9 cases, 1 death9 cases, 1 death

�� ImmunodeficientImmunodeficient patients (on cancer patients (on cancer treatment)treatment)

�� NosocomialNosocomial originorigin

�� Problem in internal circuit of waterProblem in internal circuit of water–– Infection propagated through cloud of Infection propagated through cloud of gotitasgotitas that that leave showers and water faucetsleave showers and water faucets

�� HyperchlorinationHyperchlorination and disinfectionand disinfection

Hotel in TurkeyHotel in Turkey

�� 55 year old notified Sept 2855 year old notified Sept 28th th 20042004

�� Ten more guests in early OctoberTen more guests in early October

�� Staying in hotel in TurkeyStaying in hotel in Turkey

�� Hotel closed downHotel closed down

Disease Surveillance Unit

Department of Public Health

LegionnairesLegionnaires’’ diseasediseaseMalta 1989Malta 1989--20042004

UnderestimateUnderestimate

�� Many go unreported Many go unreported

�� We may have more casesWe may have more cases

�� Not reportedNot reported

�� Not diagnosedNot diagnosed

EWGLIEWGLI

�� European Working European Working Group for Group for LegionnellaLegionnellaInfectionsInfections

�� EU Working group EU Working group

�� Aim to link cases of Aim to link cases of legionelloseslegionelloses

�� European Guidelines for European Guidelines for Control and Prevention Control and Prevention of Travel Associated of Travel Associated LegionnaireLegionnaire’’s Diseases Disease

�� http://http://www.ewgli.orgwww.ewgli.org

Outbreak in Malta 2003Outbreak in Malta 2003

�� One case reported from EWGLI in September One case reported from EWGLI in September 20032003

�� Inspection done Inspection done

�� Another case diagnosed in Malta in OctoberAnother case diagnosed in Malta in October

�� Inspection & Sampling Inspection & Sampling –– risk assessment and risk assessment and treatment recommendedtreatment recommended

�� Two other cases diagnosed in Malta in Two other cases diagnosed in Malta in NovemberNovember

�� Closure of hotel for further control measuresClosure of hotel for further control measures

Outbreak in Malta 2004Outbreak in Malta 2004

�� One case reported from EWGLI 24One case reported from EWGLI 24thth Sept Sept

20042004

�� Inspection Inspection

�� Another three cases from EWGLI Another three cases from EWGLI –– 88thth, 11, 11thth, ,

1212thth October October

�� Closure of hotel for control actionsClosure of hotel for control actions

Constant vigilanceConstant vigilance

�� Active Surveillance Active Surveillance

�� AwarenessAwareness–– General publicGeneral public

–– Health ProfessionalsHealth Professionals

–– Personnel in hotels, institutionsPersonnel in hotels, institutions

�� InformationInformation–– Web site of DSU: Web site of DSU: http://www.health.gov.mt/dsuhttp://www.health.gov.mt/dsu

–– Code of practiceCode of practice

–– Lectures, seminarsLectures, seminars

�� LegislationLegislation

““Prevention is better than curePrevention is better than cure””

you can’t see it but you can catch it -...

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