A Large Outbreak of Legionnaires’ Disease at a Flower Show, the Netherlands, 1999

Boer, Jeroen W. Den; Yzerman, Ed P. F.; Schellekens, J. F. P.; Lettinga, Kamilla D.; Boshuizen, Hendriek C.; Steenbergen, Jim E. van; Bosman, A; Hof, Susan van den; Vliet, Hans A. Van; Peeters, Marcel; Ketel, R J van; Speelman, Peter; Kool, J. L.; Spaendonck, Marina A E Conyn van

doi:10.3201/eid0801.010176

Cited by 238 publications

(98 citation statements)

References 26 publications

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“…1), such as fountains (84,85,(172)(173)(174)(175)(176), building water systems (75,79,(177)(178)(179)(180)(181)(182)(183)(184), cooling towers (185)(186)(187)(188)(189)(190)(191)(192)(193), and whirlpool spas (194)(195)(196)(197)(198), among others. U.S. surveillance data from 2001 to 2010 have consistently included Legionella as one of the leading causes of drinking waterassociated outbreaks, accounting for 58% of cases in 2010 (199).…”

Section: Epidemiology and Diseasementioning

confidence: 99%

Current and Emerging Legionella Diagnostics for Laboratory and Outbreak Investigations

2015

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SUMMARY Legionnaires' disease (LD) is an often severe and potentially fatal form of bacterial pneumonia caused by an extensive list of Legionella species. These ubiquitous freshwater and soil inhabitants cause human respiratory disease when amplified in man-made water or cooling systems and their aerosols expose a susceptible population. Treatment of sporadic cases and rapid control of LD outbreaks benefit from swift diagnosis in concert with discriminatory bacterial typing for immediate epidemiological responses. Traditional culture and serology were instrumental in describing disease incidence early in its history; currently, diagnosis of LD relies almost solely on the urinary antigen test, which captures only the dominant species and serogroup, Legionella pneumophila serogroup 1 (Lp1). This has created a diagnostic “blind spot” for LD caused by non-Lp1 strains. This review focuses on historic, current, and emerging technologies that hold promise for increasing LD diagnostic efficiency and detection rates as part of a coherent testing regimen. The importance of cooperation between epidemiologists and laboratorians for a rapid outbreak response is also illustrated in field investigations conducted by the CDC with state and local authorities. Finally, challenges facing health care professionals, building managers, and the public health community in combating LD are highlighted, and potential solutions are discussed.

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Section: Epidemiology and Diseasementioning

confidence: 99%

Current and Emerging Legionella Diagnostics for Laboratory and Outbreak Investigations

2015

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“…We were able to reveal a considerable degree of variation among different L. pneumophila strains, and WGM seems to be a useful typing tool to identify outbreaks. WGM was able to confirm the two L. pneumophila outbreaks and link the likely source of each outbreak with isolates obtained from patients (20,21).…”

Section: Discussionmentioning

confidence: 99%

“…The second outbreak comprised 28 isolates obtained from the large L. pneumophila outbreak at the Westfriese flower show in Bovenkarspel (20), of which 23 isolates originated from patients and 5 isolates came from different sampling points from the likely source, a whirlpool. Previous characterization showed that all isolates yielded serogroup 1 and ST62.…”

Section: Resultsmentioning

confidence: 99%

“…L. pneumophila strains A9001(derived from a patient) and D9010 were selected for comparison of whole-genome maps created in our laboratory with in silico maps based on their whole-genome sequences obtained using a hybrid assembly approach of Illumina and PacBio sequencing (BaseClear, Leiden, The Netherlands). The discriminatory power of whole-genome mapping for L. pneumophila and the capability to identify transmission events was studied using 35 isolates obtained during two well-documented outbreaks in the Netherlands of L. pneumophila (20,21) and 15 epidemiologically unrelated isolates originating from different patients in the Netherlands (Table 1). These 15 isolates, as well as the three strains used for reproducibility and stability experiments (A9001, B9006, and D9010) were collected within the Dutch National Legionella Outbreak Detection Program between 2002 and 2012.…”

Section: Methodsmentioning

confidence: 99%

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Whole-Genome Mapping as a Novel High-Resolution Typing Tool for Legionella pneumophila

et al. 2015

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bLegionella is the causative agent for Legionnaires' disease (LD) and is responsible for several large outbreaks in the world. More than 90% of LD cases are caused by Legionella pneumophila, and studies on the origin and transmission routes of this pathogen rely on adequate molecular characterization of isolates. Current typing of L. pneumophila mainly depends on sequence-based typing (SBT). However, studies have shown that in some outbreak situations, SBT does not have sufficient discriminatory power to distinguish between related and nonrelated L. pneumophila isolates. In this study, we used a novel high-resolution typing technique, called whole-genome mapping (WGM), to differentiate between epidemiologically related and nonrelated L. pneumophila isolates. Assessment of the method by various validation experiments showed highly reproducible results, and WGM was able to confirm two well-documented Dutch L. pneumophila outbreaks. Comparison of whole-genome maps of the two outbreaks together with WGMs of epidemiologically nonrelated L. pneumophila isolates showed major differences between the maps, and WGM yielded a higher discriminatory power than SBT. In conclusion, WGM can be a valuable alternative to perform outbreak investigations of L. pneumophila in real time since the turnaround time from culture to comparison of the L. pneumophila maps is less than 24 h. Legionella is a rod-shaped, Gram-negative bacterial pathogen that is ubiquitous in aquatic reservoirs. It is the causative agent for Legionnaires' disease (LD), an acute pneumonia, characterized by clinical symptoms such as cough, fever, and radiological signs of infiltration that do not differ from pneumonia caused by other pathogens. LD is thought to account for 2% to 15% of all community-acquired pneumonias (1-3) and proves fatal in about 6% of cases (4).Several large outbreaks of LD have been reported worldwide. Examples include Murcia, Spain (449 confirmed cases); Barrowin-Furness, United Kingdom (179 confirmed cases); and Quebec City, Canada (182 confirmed cases). These outbreaks often involved contaminated cooling towers that can infect hundreds of people within a short time period, until the source of infection is detected and appropriate control measures are taken (5-7). In the source investigation of such outbreaks, epidemiological analyses together with genotypic comparisons between clinical and environmental isolates are essential (8, 9).More than 90% of LD cases are caused by Legionella pneumophila, and as this species is commonly found in the environment, adequate typing methods are needed to differentiate between isolates in order to confirm or reject a potential source of infection (10). Sequence-based typing (SBT), a variant of the classic multilocus sequence typing schemes (11), is an internationally recognized procedure for genotyping L. pneumophila isolates. It is a rapid, discriminatory, and reproducible seven-gene molecular typing method that is recommended as the method of choice by the European Society of Clinical Microbiology and...

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“…Pond reviewed altogether 30 outbreaks of legionellosis linked to recreational waters and found that the greatest risk of infection has been linked to either thermal spas where no disinfection is allowed or hot tubs/spa pools [52]. Display hot tubs operated without disinfection have caused severe outbreaks on several occasion, evidencing that the risk of infection is high without immersing in the contaminated water [74][75][76]. Although Legionella bacteria were incidentally isolated from swimming pools, they have never been identified to cause legionellosis, except for cases linked to poolside showers [77].…”

Section: Biofilm Mediated Organismsmentioning

confidence: 99%

The risk of contracting infectious diseases in public swimming pools. A review

Barna

Kádár

2012

Annali Dell'Istituto Superiore Di Sanità

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Summary.A review of pathogenic microorganisms presenting risk of infection in pool based artificial recreational water venues is extracted from the available scientific literature. The microorganisms are grouped both according to their way of spread and their survival and growth strategies and their characteristics relevant for the pool and spa based recreation are discussed. In order to put the proposed risks on a solid basis, among others a ten year excerpt of the waterborne disease statistics of the Centers for Disease Control and Prevention (CDC) is used throughout the article.Key words: man-made water recreational environment, risk of infection, waterborne disease outbreaks, swimming pool, hot tub.Riassunto (Il rischio di contrarre malattie infettive nelle piscine pubbliche. Una rassegna). Viene presentata una sintesi della letteratura scientifica disponibile sui microorganismi patogeni potenzialmente infettivi, in ambienti acquatici ricreativi artificiali, come le piscine. I microorganismi sono raggruppati sia in base alle loro vie di diffusione che in base alle loro strategie di sopravvivenza e di crescita; successivamente vengono discusse le loro caratteristiche più importanti negli ambienti ricreativi considerati, piscine e terme. Per fornire adeguate e solide basi scientifiche ai tipi di rischi presentati, vengono analizzate, oltre ad altri documenti, le statistiche relative a dieci anni di osservazione di malattie legate all'acqua del Centers for Disease Control and Prevention (CDC).Parole chiave: ambienti ricreativi acquatici artificiali, rischio di infezione, epidemie di malattie legate all'acqua, piscine, vasche da idromassaggio.

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A Large Outbreak of Legionnaires’ Disease at a Flower Show, the Netherlands, 1999

Cited by 238 publications

References 26 publications

Current and Emerging Legionella Diagnostics for Laboratory and Outbreak Investigations

Current and Emerging Legionella Diagnostics for Laboratory and Outbreak Investigations

Whole-Genome Mapping as a Novel High-Resolution Typing Tool for Legionella pneumophila

The risk of contracting infectious diseases in public swimming pools. A review

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