Legionnella. You can t t see it but you can catch it. Dr Charmaine Gauci MD, MSc, PhD Head of Disease Surveillance Unit

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1 Legionnella You can t t see it but you can catch it Dr Charmaine Gauci MD, MSc, PhD Head of Disease Surveillance Unit

2 Legionella infections First documented outbreak name from 221 cases of pneumonia occurred amongst 4,000 delegates attending the 58th American Legion convention in Philadelphia in July 1976 Bellevue Stratford Hotel, Philadelphia 15% fatality rate (34 died) was intensely investigated.

3 Vendetta waged against Legionnaires America s s finest fighting men Five months later: BUG was identified Other previous outbreaks explained- earliest documented 1947

4 The Bug

5 Gram negative bacillus Legionella pneumophila

6 Legionella pneumophila Gram negative bacteria Invisible to the naked eye 1-22 micrometer long 0,5 micrometer wide Found naturally in environmental waters Rivers, lakes Reservoirs

7 Legionella pneumophila Can get into water systems Airconditioning systems Hot tubs, Whirpools,, spas Hot/ Cold water tanks Showers

8 Legionella pneumophila Proliferate Temperatures around degrees Celsius Stagnant water

9 Transmission Breathing of aerosols (mists) that come from a water source contaminated with Legionella bacteria No transmission via drinking water No documented person to person transmission

10 Legionnaires disease Bacteria enter lungs by inhalation of aerosols of contaminated water Cause pneumonia

11 Susceptibility Middle-aged and older persons smokers diabetes mellitus chronic lung disease renal disease malignancy Immunosuppressed (kidney failure, cancer, AIDS)

12 Clinical symptoms Incubation period: days up to 18 days Bacteria grow in lung Pneumonia Spread via blood or lymph system Extrapulmonary manifestations

13 Clinical symptoms fever, malaise, myalgia,, headache and often diarrhoea high fever and non productive cough which becomes productive chest signs non impressive. case fatality rate is high- 15%.

14 Chest X-RayX

15 Chest X-RayX

16 Diagnosis Clinical picture High index of suspicion Chest X-RayX Urinary antigen testing Culture of organism from secretions Serological testing

17 Outcomes Serious disease Can be fatal Up to 10% of cases In Malta : death deaths

18 Treatment Antibiotics (Erythromycin/ Rifampicin) Respiratory Supportive care

19 Frequency and Distribution About cases occur in the UK each year mostly sporadic or small groups 8,000-18,000 occur in US each year

20 Outbreaks Outbreaks do occur Hotels Institutions Hospitals Community

21 Outbreaks Associated with: Hot and cold water systems- e.g. taking showers Cooling towers Whirlpool spas Fountains

22 Investigating outbreaks Patients with legionnaires disease Place of residence Whereabouts of patients Activities in the previous days Travel Investigating suspected water sources Testing water sources

23 Netherlands Community OB Large increase in number of cases in 1999 Environmental investigation Case control epidemiological analysis Serologic cohort study Associated with flower show Of 77,061 visitors, 188 became ill Positive for legionella bacteria 2 whirlpool spas of exhibits Sprinkler in a hall Control Actions

24 Muricia Community OB On 7 th July 2001 start of an epidemic 470 cases identified Of these one died

25 Epidemiological investigation 75% lived in Northern Region of city Case Control Study Environmental Investigation Positive cooling towers of city hospital

26 Australia Community OB April cases of legionnaires Aged years 2 deaths Had visited Melbourne Aquarium Confirmed Legionella bacteria in cooling towers Disinfection

27 OB in Hotel Sweden February 2005 Luxury hotel and spa in centre of Sweden 50 guests with Pontiac fever Fever, chills, fatigue, muscle aches, headache Suspected 2 whirpools Swimming pool

28 OB in Oklahoma Hotel March 2004 National basketball tournament for children and family members Staying in hotel in Oklahoma 65 cases with Pontiac fever Suspected Hotel pool and hot tub

29 OB in Hospital, Barcelona Hospital Lasts i Reynals February cases, 1 death Immunodeficient patients (on cancer treatment) Nosocomial origin Problem in internal circuit of water Infection propagated through cloud of gotitas that leave showers and water faucets Hyperchlorination and disinfection

30 Hotel in Turkey 55 year old notified Sept 28th 2004 Ten more guests in early October Staying in hotel in Turkey Hotel closed down

31 Disease Surveillance Unit Department of Public Health

32 Legionnaires disease Malta

33 Underestimate Many go unreported We may have more cases Not reported Not diagnosed

34 EWGLI European Working Group for Legionnella Infections EU Working group Aim to link cases of legionelloses European Guidelines for Control and Prevention of Travel Associated Legionnaire s s Disease

35 Outbreak in Malta 2003 One case reported from EWGLI in September 2003 Inspection done Another case diagnosed in Malta in October Inspection & Sampling risk assessment and treatment recommended Two other cases diagnosed in Malta in November Closure of hotel for further control measures

36 Outbreak in Malta 2004 One case reported from EWGLI 24 th Sept 2004 Inspection Another three cases from EWGLI 8 th, 11 th 12 th October Closure of hotel for control actions th,

37 Constant vigilance Active Surveillance Awareness General public Health Professionals Personnel in hotels, institutions Information Web site of DSU: Code of practice Lectures, seminars Legislation

38 Prevention is better than cure

Legionnaires Disease Q&A (General) (Source: OSHA) (4/29/10)

Legionnaires Disease Q&A (General) (Source: OSHA) (4/29/10) Q. What is Legionnaires Disease? A. Legionnaires disease is a common name for one of the several illnesses caused by Legionella bacteria. Legionnaires