The number of affected by the outbreak of legionella of Murcia reaches the 575
The bacterium has detected itself in the regional seat of the government and in two councils
 

MURCIA July 13th 2001

The advisor of Health and Consumption of the Region of Murcia, Francisco Marquess, showed yesterday that the number of patients by legionella in Murcia ascends already to 228 confirmed cases, whereas the number of possible patients of pneumonía is of 575. Marquess revealed that in the analyses made until now has been DNA of legionella in fourteen
facilities of refrigeration of downtown, 
located in the English Court, the seats of the Presidency of the regional Government, the councils of Health and Agriculture, and the central offices of CajaMurcia.

Marquess indicated that in the different units from intensive cares they are entered 12 people, one of who, of 31 years of age, he is in " very serious " state. The advisor indicated that of the 575 affected people, 413 remain entered in hospitals of eight hospitable centers, the majority mayores men of 50 years and residents in downtown. 
The advisor did not discard the appearance of more cases.

Clients of department store and associations of consumers of Murcia had expressed their indignation before the ignorance that still exists on the true center or centers of legionella.

This situation, and affirmation of advisor of Health, Francisco Marquess, of which other towers exist in which the bacterium has been discovered, have caused to malaise between associations and users of commercial centers reason why they describe as " lack of informative transparency " of the Administration.

The president of the independent community, Ramon Luis Valcárcel, denied those accusations assuring: " we come to make a show, neither to make holders of press, nor to do photos to us. We want to manage a crisis with the rigor that this government characterizes. 
The important thing - Valcárcel- added is that the epidemic is sending, that the center is controlled " .

In Emergencies

From the first moment, the regional Executive and expert in the matter has wanted to make clear that the finding of the bacterium of legionella in four cooling towers " does not mean that that one has been the cause of the epidemic outbreak of Murcia " . In order to know still it will be necessary it to hope, at least one week, to be able to compare the results of the analyses obtained in the possible centers and the practiced ones to the affected ones.

From the regional Government he insists himself on which normality in the doors of urgencies of the hospitals of Murcia, something that the managing directors of Morales Meseguer, Domingo Coronado confirmed, and of the Virgin of the Arrixaca, Mariano Guerrero, who assured that the facultative ones were working with less pressure than in previous days before the smaller affluence of patients.

Source Spanish Media 
Edited

Update

Barcelona,

15th  July  2001

Nine of the 670 affected by legionella in Murcia follow entered in the UCI 

Murcia.

the epidemic of legionella untied the last week in Murcia has affected until the moment to 670 people, of whom nine remain entered in units of intensive cares with favourable evolution, informed the advisor into
Health, Francisco Marquess, whom it emphasized that the episode tends to send. Marquess, who made these declarations during his visit to the services of urgencies of the Hospital Morales Meseguer of Murcia,
advanced that this noon the cabinet of crisis will meet constituted in the occasion of the epidemic and integrated by people in charge of the Council of Health, the Presidency and the City council, for " adopting
measures of homogenous character " in all the facilities of air conditioning susceptible to propagate legionella.

source .Media

As of 18th July, the National Centre for Epidemiology, Spain, has reported a total of 751 cases of suspected legionellosis in Murcia

Three-hundred-ten of these cases have been laboratory confirmed.
The first case was hospitalized on 1st July. Two deaths (one confirmed case and one suspected case) have been reported. No cases have been reported among tourists.

Since the 7th July, incidence has declined rapidly and there have been no new cases reported since 14 July.
The epidemiological investigation and surveillance are continuing.
The most likely source of the outbreak is a cooling tower in the city centre. The cooling tower has now been disinfected.

Information received after this posting indicates that several cooling towers in the area were positive for Legionella by the polymerase chain reaction (PCR), but the organism has not been isolated thus far. Control measures have focused on all cooling towers which may be involved, as well as other potential sources.

Source..WHO

Update on the outbreak of legionnaires' disease in Murcia,

Spain 

22nd July 2001

Between the end of June and the first few days of July a very large and explosive outbreak of legionnaires' disease occurred in Murcia, a Spanish city of 360 000 people (1). As of 18 July a total of 745 cases of pneumonia had been diagnosed, of which 315 have been confirmed as legionnaires’ disease by detection of legionella antigen in urine. Dates of onset of illness of confirmed cases ranged from 26th June to 16th July, with a peak on 5th to 6th July (figure 1). 

From 6th July the incidence declined rapidly. One death has been reported in a case in which legionella pneumophila serogroup 1 has been isolated. A total of 12 cases were admitted to intensive care units. 
Seventy-six per cent of cases were male, and about two thirds of cases were aged over 50 years.

Nearly 70% of all cases lived in a small area to the north and northwest of the city centre. Preliminary information from patient interviews indicated that the other cases had visited the city centre in the last week of June or the first few days of July. The likely source of infection for the outbreak is a cooling tower in the city centre. Several cooling towers in that area were positive by PCR but no legionella pneumophila sg1 have so far been isolated. Control measures have been applied to this and all other cooling towers in the vicinity, and also to other potential sources of infection in the area.

Murcia is the host city for this year’s European Youth Olympic Days, to be held from 22nd to 27th July. Because of concern for the health of the several thousand sports people and other visitors due to arrive in Murcia, the European Olympic Committee (EOC) arranged for an international group of legionella experts to visit Murcia between 11-15 July to assess rapidly the impact of the outbreak and discuss control measures with the local public health team. The international group were a total of five epidemiologists and microbiologists, two from the UK Public Health Laboratory Service, one from the Netherlands National Institute of Public Health and one each from the National Centres of Epidemiology and Microbiology in Spain. 

All are national representatives in the European Surveillance Scheme for Travel Associated Legionnaires’ Disease and members of the European Working Group for Legionella Infections (http://www.ewgli.org/). They concluded that the local health authorities had taken rapid steps to investigate and control the outbreak, and had implemented appropriate control measures to prevent the occurrence of further cases. 
The outbreak now seems to be over.

 
On the basis of these findings, the international group recommended to the EOC and to the International Olympic Committee (IOC) that the games should continue. The IOC accepted the recommendation, and the games are to go
ahead as planned.

Comment

This seems to be the world’s largest outbreak of legionnaires' disease since the disease was first recognised in 1976. Remarkably, only one death is associated with this outbreak, which may be due in part to the fast diagnosis and adequate treatment of the patients concerned. Another very large outbreak, the Melbourne aquarium outbreak of 2000 (2), was also recognised early and showed a case fatality rate of <2% (3). Moreover, in Australia and Spain, many pneumonia patients are treated empirically with antibiotics that have activity against legionella. In contrast, the Dutch flower show outbreak of 1999 (4,5) was only recognised when a large majority of the cases were already ill and in that outbreak the case fatality rate was 11% (6). Empirical therapy for pneumonia in the Netherlands is with beta-lactam antibiotics rather than macrolides. 

Other factors may also have contributed to the absence of deaths in the Murcia outbreak. The legionella strain may have been less virulent, and patients may have had prior exposure to this strain.

References:

1. Cano Portero R, Joseph C. Community outbreak of legionnaires’ disease in Murcia,
Spain. Eurosurveillance Weekly 2001; 5: 010712.
(http://www.eurosurv.org/2001/010712.html) 

2. Joseph C. Outbreak of legionnaires’ disease associated with aquarium in Australia.
Eurosurveillance Weekly 2000; 4: 000504.
(http://www.eurosurv.org/2000/000504.htm)

3. Tallis G, Greig J, Zwolak B, Carnie J, Hart W, Tan A, et al. A descriptive analysis of
the Melbourne aquarium outbreak of Legionnaires' disease. Fifth international
conference on legionella infections. Ulm, Germany, September 2000.
(http://www.uni-ulm.de/legionella/abstracts/v-tallis.doc) 

4. van Wijngarden J. Outbreak of legionnaires’ disease in the Netherlands.
Eurosurveillance Weekly 1999; 3: 990318.
(http://www.eurosurv.org/1999/990318.html) 

5. Wijgergangs L. Legionnaires’ disease in the Netherlands - update. Eurosurveillance
Weekly 1999; 3: 990401. (http://www.eurosurv.org/1999/990401.html) 

6. den Boer JW, Yzerman EPF, Schellekens J, Lettinga KD, Boshuizen H, van
Steenbergen J, et al. A large outbreak of Legionnaires' disease at a Dutch flower
show. Fifth international conference on legionella infections. Ulm, Germany,
September 2000. (http://www.uni-ulm.de/legionella/abstracts/v-denboer.doc) 

Reported by Carmen Navarro (carmen.navarro@carm.es) and Ana
Garcia-Fulgueiras (AnaM.Garcia9@carm.es), Regional Health Council of
Murcia, Spain; 

Jacob Kool (jlkool@hetnet.nl), Rijksinstituut voor
Volksgezondheid en Milieu, Netherlands; 

Carol Joseph
(cjoseph@phls.org.uk), Public Health Laboratory Service (PHLS)
Communicable Disease Surveillance Centre, London, England; 

John Lee
(jvlee@phls.org.uk), PHLS Water and Environmental Microbiology Research
Unit, London, England; 

Carmen Pelaz (cpelaz@isciii.es), National Centre of
Microbiology, 

and Odorina Tello (otello@isciii.es), National Centre of
Epidemiology, Health Institute of Carlos III, Madrid, Spain.

 This information kindly supplied by http://www.eurosurveillance.org/

Email Denis
legion@q-net.net.au