1978
CAMBRIDGE ENGLAND

The first reported case of Legionnaire`s Disease in the UK was at Cambridge in 1978, The Patient was a 29 year old man.
After seven days his condition deteriorated rapidly and he was admitted to hospital with pneumonia, despite intensive care he died eighteen hours later on November 3 1978.

Wiles WA:
Legionnaires' disease :
first reported case in Zimbabwe.
Cent.Afr.J.Med. 1981; 27: 196-198.

First case of Legionella maceachernii 71 year old carpenter died 25 days after admission to hospital

(Merrell, Medical J Australia 1991 September. 155 415-417)Medical J Australia 1991)

A case of Legionnaire`s disease, the first case in Hokkaido Prefecture

Although 18 cases of Legionnaires' disease have been reported in Japan, these have included none from the northern areas of Japan. The first confirmed case of Legionnaires' disease in Hokkaido distrrct, a northern isiand ofJapan, is reported. A 48 year-old male was admitted for fulminant pneumonia, and died the next day. Legioneila pneumophila, serogroup, was cultured and determined from the sputum and lung tissue obtained at autopsy. Postportem examination by means of the indirect immunofluorescent method, using group specific antisera against Legionella pneumophila as a primary antibody, revealed phagocytized baciiti in the alveoli of the lung.
(Matsuda K KANSENSHOGAKU ZASSHI. JOLIRNAL OF THE JAPANESE ASSOCIATION FOR INFECTIOUS DISEASES Citation : 64(9): 1 I62-7 1990)
, cal J Australia 1991 September. 155 415-417)tember. 155 415-417)

Nosocomial Legionnaire's disease--a case report and review of the literature.

We report a case of nosocomial legionellosis in a 63 year-old man who was managed with neurosurgery under the diagnosis of subarachnoidal hemorrhage and complicated pneumonia in the intensive care unit. A legionella species was reported from sputum culture and direct immunofluorescent antibody test revealed L. pneumophila (serogroup 2). Our patient's pneumonia was cured with medical therapy including erythromycin and was the first case of microbiologically confirmed legionellosis in Korea.
(Woo JH, Kim SA, Park CS, Choi TY, Chang IC, Lee IS Korean J Intern Med 7
(1): 68-72 (Jan 1992)

Department of Internal Medicine, Soon Chun Hyang University, College of Medicine, Seoul, Korea.

Legionella and other bacteria in air humidifiers and cooling systems of air conditioning units--a survey

Air humidifiers using cold water and cooling towers of air-conditioning systems provide the best settings for the growth of bacteria. Hence, we investigated 90 water samples for humidifiers and 15 water samples from cooling towers of hospitals, authorities, schools, and factories. The colony forming units/ml at 20 degrees C and 36 degrees C, the biological activity of added biocidal substances, and the occurrence of legionella were determined. About 90 percent of the samples showed no activity of the biocidal substance added, suggesting the uselessness of such substances. Furthermore, they exercised neither an influence on the CFU of the water samples nor on the occurrence of legionella. Legionella were isolated in 7 per cent of the humidifiers investigated, in 3 per cent of air conditioned buildings, respectively. 13 per cent of the cooling towers contained legionella. The risk of infection by air conditioning systems, humidifiers, cooling towers, and other emitters of infections agents should be controlled by the public health service.
(Dermitzel A, Geuenich HH, Muller HE Gesundheitswesen 54 (12): 716-719 (Dec 1992)

This is the First Outbreak of Legionnaires Disease to Occur in Western Australia
Australia had four outbreaks in 1996

Western Australian Communicable Diseases Bulletin
September 1996 Volume 6: No 4 ISSN 1327-0168

Report of a Joint Legionella / Q Fever Outbreak at an Abattoir in the Goldfields by Dr Declan McKeown, Acting General Manager and Public Health Physician, Goldfields Public Health Unit.

Introduction In mid-June 1996, the first reports of a flu-like illness affecting workers at an abattoir came to the notice of the Goldfields Public Health Unit. The fact that all those affected came from an abattoir, and none from the general community caused no concern at first, as the symptoms were sufficiently non-specific to represent any one of a number of community-acquired viral infections.

The possibility of a more significant underlying pathology was suggested when one of the workers was transferred to Royal Perth Hospital for investigation of a sudden onset right-sided hemianaesthesia: MRI suggested peri-thalamic demyelination. A second worker was also transferred to RPH for sudden onset cerebellar ataxia. Both these individuals developed neurological complications one week after the onset of their symptoms.

The provisional diagnosis in the first instance was of a post-infective demyelination similar to Guillain-Barr syndrome. The possibility of viral myalgia was also mooted, although a causative organism had not been detected.

Other workers were manifesting symptoms, predominantly swinging fever, headache, profound myalgia and dry cough; some lasted 2-3 days, others required hospitalisation of up to a week. It is believed that between 12 and 13 people were affected at this stage.

Because of the occupational link between all the individuals, there was a strong underlying suspicion of a zoonotic infection. Therefore from the onset, serology was sent for leptospirosis, Q fever, brucellosis and psittacosis as well as legionellosis and respiratory infections (adenovirus, parainfluenzae, influenza A). Empirical treatment for affected workers was with erythromycin or tetracycline.

In the last week of June, serology from the initial case showed a convincing rise in titre to Legionella pneumophila serogroup 4. One week later, the second individual also showed serological evidence of exposure to Legionella, but with concurrent rises to mycoplasma, parainfluenzae 1 and Q fever. The broad reactivity was confusing, but revealed sufficient cause to consider an outbreak.

Investigation - Part 1 The local Environmental Health Officer (EHO) was alerted and immediately took water samples from cooling towers, storage tanks and hose reservoirs. Samples were also taken from the bores that supplied the plant with all of its water. After testing, the water was superchlorinated to 5 ppm by the addition of chlorine to the two storage tanks that feed throughout the plant.

An initial site inspection (11th and 12th July 1996) and interview with employees who had been symptomatic was largely inconclusive. The major difficulty lay in determining a workable case definition in an abattoir and community that was experiencing an Influenza A epidemic. Workers who had been unwell at any time since May were asked to come forward to complete a questionnaire that detailed where they worked, what their symptoms had been etc. During this investigation, a third case was notified, a trainee meat inspector.

Case definition The following was used as a working definition of a “possible case”:

An individual working at the abattoir during the time period 1st May 1996 until the present time who had three of the following symptoms: fever, headache, cough, myalgia, muscle weakness, lethargy or nausea.

Preliminary results - Part 1 Of the 82 workers at that stage, 22 (27%) came forward for questionnaire completion and serology. Eight “possible cases” were identified, in addition to the three already notified. The approximate dates of onset of illness did not follow any pattern, suggesting continuing transmission of the organism(s) over at least two months. There was no apparent social connection between any of the cases, and no other cases of the same definition outside the abattoir.

A diagram of the abattoir was provided by the local EHO. The three confirmed cases all worked in the “wet” areas where they would be most likely to be exposed to water (the slaughter floor, meat meal shed and by-products section). The water supply was held to be the most likely source as the air-conditioning system was ammonia-based. Initial water testing failed to isolate a causative organism, despite intensive re-testing post-superchlorination.

The conclusion formed on the basis of the initial serology and investigation was that it was most like to be a Legionella outbreak, spread through a contaminated water supply. The solution decided upon was to continue containment by superchlorination of the water supply and to encourage empirical treatment of all possible cases with erythromycin.

Immediately after the investigation, a fourth individual seroconverted to Legionella pneumophila serogroup 4. This gentleman also worked on the slaughter floor. A number of workers became ill subsequently, with little or no time off work and symptoms that suggested nothing more sinister than a bad influenza, which was prevalent in the community at that stage.

Around the middle of July, a number of individuals began to show definite serological evidence of acute phase Q fever. These results were surprising, and it was unclear whether they represented a dual infection, or a broad antigenic cross reactivity. The fact that almost all of these people had recovered from their illness by the time they had seroconverted allowed a certain latitude in determining the exact nature of the outbreak. In total, five had converted to Legionella pneumophila serogroup 4, seven to acute phase Q fever and three to both.

The sera from those individuals infected with both organisms was tested to determine whether either titre was a false positive. Repeated testing revealed what had been suspected; that both Legionella and Coxiella were causative agents. Worksafe was notified of the Q fever cases, and visited the site to serve a number of improvement notices. These included an order to skin test, serotest and vaccinate all workers against Q fever.

Investigation - Part II On 19th and 20th September, Goldfields Public Health approached all workers at the abattoir, including management, administered a questionnaire and conducted blood testing and skin testing as a prelude to determine who should be vaccinated against Q fever.

The questionnaire inquired into tobacco and alcohol intake, usual place of work and time spent in the meat industry. Questions were also formulated to define more clearly social habits, and clubs and pubs frequented, that may have provided a common link between the cases outside of work.

Sera were taken for Q fever pre-vaccination levels, and also for Legionella. This provided the first seroprevalence survey of all the workers at the abattoir. Skin testing was also carried out by intradermal injection of 0.1 ml of diluted Q-Vax for skin test. The skin test was read at day 7, and any induration taken as a positive result.

Results - Part II A preliminary analysis only has been completed, however, some interesting trends have come to light. Eighty four individuals filled in the questionnaire, eight of whom did not have a skin test performed.

Eleven had positive skin tests: seven had not been ill during the recent epidemic, but had spent ten years or more in the meat industry; three had been ill at some stage during the previous three months; and one had only recently commenced work at the abattoir.

The same ratio of slaughtermen and boners admitted to having been “unwell” in the previous three months; many had attended their own doctor for serology. On reviewing this initial serology, however, three of the slaughtermen seroconverted for acute phase Q fever, and two for Legionella, whereas none of the boning room staff had any significant serology results.

Discussion It may be that this dual infection happened immediately after a community epidemic of influenza A. It may be also that the Q fever was the “original” infection, followed opportunistically by Legionella. It is difficult to draw a true epidemic curve at this time, as most affected have forgotten the exact onset date. It may also be possible to track down the original source of the Q fever infection through back projection from the earliest case(s) to specific carcases handled by the abattoir before the outbreak occurred. A true picture will only be determined when the serology results can be analysed side-by-side with the survey results.

It is most fortunate that most of the abattoir workers constituted a young, relatively fit population and Legionella pneumophila serogroup 4 was involved. Few suffered severe symptoms; those that were more profoundly affected were older and more vulnerable. A recent outbreak of Legionnaire's disease in South Australia where Legionella pneumophila serogroup 1 was implicated, resulted in two deaths; we are fortunate that this outbreak had a better outcome.

Spontaneous rupture of the spleen in Legionnaires' disease.

A case of Legionnaires' disease is described in a 63 year old man who presented with pneumonia and confusion. Eleven days after admission he became acutely hypotensive and attempts at resuscitation failed. Post-mortem examination revealed spontaneous splenic rupture and massive hepatocellular necrosis--an outcome that has not previously been associated with Legionnaires' disease.
(Holmes AH, Ng VW, Fogarty P Postgrad Med J 66 (780): 876-877 (Oct 1990)
Intensive Care Unit, Whittington Hospital, Highgate Hill, London, UK.