Epidemiology of Legionnaires Disease in Europe Birgitta de Jong on behalf of ELDSNet ESGLI conference 22 September 2016

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1 Epidemiology of Legionnaires Disease in Europe 2015 Birgitta de Jong on behalf of ELDSNet ESGLI conference 22 September 2016

2 ELDSNet annual data set

3 Methods ECDC coordination Collection of disaggregate data through TESSy EU + Iceland and Norway (each country s own residents) Confirmed and probable cases of Legionnaires disease with onset in 2015 EU case definition

4 LD notification rate per 1,000,000 population EU/EEA, n/million Year 2015 has highest notification rate ever: 1.37 per 100,000 pop cases reported by 30 countries 17% increase in total cases in last 2 years Continuous increase over the period

5 Rate of confirmed Legionnaires disease cases per 100,000 pop. by country, EU/EEA, 2015 France, Germany, Italy and Spain reported 69% of all cases Denmark, France, Italy, Netherlands, Slovenia and Spain had agestandardised rates >2 cases per 100,000 pop.

6 Rate of Legionnaires disease cases per 100,000 population, by age and gender, EU/EEA, 2015 Rate per population 6,0 5,0 4,0 3,0 2,0 1,0 0,0 Male Female Age (year) 89% of cases aged 45 years and older Notification rate increased with age

7 Completeness of reporting for a selection of variables, EU/EEA, % Outcome Place of residence Setting 80% 60% 40% 20% 0% Completeness of place of residence and outcome are improving Completeness for setting is slightly decreasing

8 Number of confirmed Legionnaires disease cases by month, EU/EEA, 2015 and Peak in August-September 59% of all cases reported from June to October

9 Number of confirmed Legionnaires disease cases by month and 12-month moving average, EU/EEA, Steady increase over the period

10 Cases by probable setting of infection, EU/EEA, 2015 Setting No. % Community-acquired Travel abroad Domestic travel Healthcare-associated Other Total Probable setting of infection comparable with previous years Proportion of healthcare-associated cases increases with age (4% below 50 years to 17% in cases aged 80 years+ )

11 Reported case-fatality by age group and sex, EU/EEA, % 30% Case-fatality 20% Females Males 10% 0% Age (years) Overall case-fatality of 8% Case fatality comparable between genders Steep increase of case fatality beyond 50 years old

12 Reported laboratory methods, EU/EEA, % Culture PCR Single high titre 10% 5% 0% % of cases diagnosed by urinary antigen test (highest ever) Continuous increase of proportion of cases reported with a PCR

13 Reported pathogens, EU/EEA, 2015 Of 831 culture-confirmed cases o 796 (95%) were due to L. pneumophila o 679 (82%) were due to L. pneumophila serogroup 1 o 7 (0.8%) were due to L. longbeachae Of 173 SG1 isolates subtyped with monoclonal antibodies (MAb) o 43 (25%) Knoxville o 42 (24%) were Philadelphia o 29 (17%) Benidorm o 22 (13%) Allentown/France Distribution of pathogens comparable to previous years 80% L. pneumophila serogroup 1 MAb 3/1 positive

14 Conclusions In 2015, both number and notification of LD were the highest ever observed o Continuing the increase observed since 2011 o Contrary to 2014, no large outbreak o Main characteristics of the cases reported in 2015 similar to previous years o No increase was observed in countries with low notification rate An increasing trend affected by: o o o o Improved surveillance Ageing population Travel trends Climate (both 2014 and 2015 were the warmest years on record in Europe)

15 ECDC surveillance outputs

16 ECDC surveillance outputs

17 TRAVEL ASSOCIATED LEGIONNAIRES DISEASE, 2015 Emmanuel Robesyn, Annual Meeting ELDSNet, London, September 2014

18 Methods Daily reporting of disaggregate data through TESSy Confirmed and probable cases of Legionnaires disease with onset in 2015 and that had been travelling 2-10 days before onset of disease Reported by EU member states and ELDSNet contacts outside EU EU case definition

19 Number of TALD reports Number of cases cases in 2015 (+ 20%) Year

20

21 Reported TALD cases, Europe, 2015

22 Non EU/EEA reporting countries countries 21 cases 3 countries 38 cases Switzerland 10 Israel 4 USA 3 Andorra 1 New Zealand 1 Thailand 1 Turkey 1 Switzerland 30 USA 6 Australia 2

23 Median time to reporting = 17 days

24

25 Clinical outcome TALD, 2015 Status at time of reporting Number Percentage Outcome Number Percentage Known % Unknown % Total 1141 Died % * Alive % Total 611 * Case fatality rate (CFR) among cases with known outcomes

26 Number of test by laboratory method used (n=1215) Laboratory method Count % Urinary antigen test PCR 94 8 Culture 48 4 Single high level of Ab titre 11 <1 Significant rice in Ab titre 3 <1

27 Reported pathogens, TALD 2015 Of 1141 reported cases o 1074 (94%) were due to L. pneumophila o 770 (72%) were due to L. pneumophila serogroup 1 o 27 were due to L. pneumophila non-sg1 o 2 were due to L. pneumophila serogroup 3 o 2 were due to L. pneumophila serogroup 6 o 4 were due to L. pneumophila mixed serogroups o 1 were due to L. longbeachae Of 14 SG1 isolates subtyped with monoclonal antibodies (MAb) o 4 Knoxville o 2 Philadelphia o 6 Benidorm o 2 Allentown/France o 17 cases were reported to be sequenced, 3 cases has type 42 and 2 cases type 23

28 Travel visits of cases by destination country Destination country Number visits Percentage Italy 417 France 290 Spain 130 Germany 75 Greece 75 Turkey 71 United Kingdom 48 United States 45 United Arab Emirates 39 Thailand 37 Other % 18% 8% 5% 5% 4% 3% 3% 2% 2% 24% 100%

29 Travel regions, TALD 2014 vs # cases 2015 # cases EU / EEA Outside EU Ships Total

30 Clusters 167 clusters notified 155 standard clusters 12 complex clusters Activity Form A submitted 178 Form B submitted 162 Summary report I Summary report II Number 409 associated cases (reported by 19 countries) Clusters in 33 countries, plus on board ships: 17 EU countries 16 non EU countries 3 ships 39 new + 16 updates 14 new + 8 updates 60% of accommodations sampled were reported positive according form B

31 Number of cluster per country (n=155, standard clusters) Cluster country count Italy 44 France 26 Spain 15 Turkey 9 Germany 8 Greece 8 Thailand 8 United Arab Emirates 6 Portugal 3 Ships 3 United States of America 3 Belgium 2 Hungary 2 Tunisia 2 Bulgaria 1 Cluster country count China 1 Croatia 1 Cuba 1 Guadeloupe 1 Ireland 1 Kosovo 1 Moldova 1 Philippines 1 Poland 1 Romania 1 Serbia 1 South Africa 1 Sweden 1 United Kingdom 1 Viet Nam 1

32 Reported TALD clusters, world wide, 2015

33 Reported TALD clusters, Europe, 2015

34 Eight accommodation sites published (2015) Paris, France - 31 March Riva del Garda, Italy - 24 June Napoli, Campania, Italy - 3 August Palermo, Sicily, Italy - 5 August Indre, France 6 August Aulla, Toscana, Italy - 20 August Trapani, Sicily, Italy 30 October Avignon, Vaucluse, France 12 October (compare to 0 in 2014, 2 in 2013, 1 in 2012)

35 Added value of European surveillance/eldsnet Proportion of clusters that could only have been detected through ELDSNet 60 % (=93/155) of the new standard clusters in 2015

36 Thanks to all reporters and investigators! ELDSNet team ECDC

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