THE NETHERLANDS
Veilinghallen - Bovenkarspel
1999

The Westfriese Flora flower exhibition and fair

RIVM Rapport 213690003

Onderzoek naar de bron van een epidemie van legionellose na de Westfriese Flora in Bovenkarspel

Investigation into de source of the legionellose epidemic after the Westfriese Gardenshow at Bovenkarspel Boer JW den ; Yzerman E ; Schellekens J ; Bruin JP ; Leeuwen W van ; Mooijman K ; Veenendaal H ; Bergmans AMC ; Zee AN van der ; Ketel RJ van ; Tijsen H ; Conyn-van Spaeandonck

NLG 40 RIVM Rapport 213690003

Abstract English

Abstract Nederlands


Abstract English

In March 1999 results from an exploratory case-control study indicated that the most probable origin of a large epidemic of legionnaire's disease had to be directly located at or in the surroundings of the Westfriese Flora (WF) in Bovenkarspel (Province of Noord-Holland, Netherlands). The WF is a yearly exhibition of flowers, and agricultural and consumer products, which was held in 1999 from 19 to 28 February. After inspecting the premises and making an inventory of all exhibits, a list of potential sources was drawn up. The water supply system and all the still available equipment using water were sampled. A risk assessment was done for each potential source by interviewing exhibitors. In total, sixteen products were found potentially hazardous: two whirlpools, two bubblemats (perforated rubber mats meant for the bottom of a water-filled bathtub through which air can be blown at high speed), eleven fountains and a sprinkler installation. Legionella pneumophila was isolated from two whirlpools and a sprinkler installation. With the use of molecular-biological techniques (PFGE, ERIC/REP-PCR and AFLP), three different genotypes were identified. These were B-1, B-2 and B-3 (B for Bovenkarspel). To enable comparison of these isolates with patient isolates, all microbiology laboratories in the Netherlands collaborated in collecting patient isolates related to the epidemic. In total 29 isolates were collected, 28 of which were genetically identical to B-1; the other one was genetically identical to B-2. Through the risk assessment based on the reported use and estimating the degree of contamination from the microbiological investigation of the three culture-positive products, the most probable source contributing the most to the spread of L. pneumophila was found to be the whirlpool located in hall 3 of the WF premises. It is not possible to rule out the contribution made to spreading by the whirlpool in hall 4, whereas the sprinkler's contribution to spreading is not probable. The contribution to spreading by the fountains and bubblemats is also unlikely. Although Legionella spp was not isolated from the water supply system, the organism was likely introduced into the three products from this system. These results were confirmed by the outcome of a case-control study and a cohort study, both designed to pinpoint the exact location of exposure to Legionella spp on the WF premises. They showed the whirlpool in hall 3 to be the most probable source of infection (reported separately).


Abstract Nederlands

In maart 1999 kwam uit de resultaten van een orienterend patient-controle onderzoek naar voren dat de bron van een omvangrijke Legionella epidemie zich op of rond de Westfriese Flora (WF) te Bovenkarspel (Noord-Holland) moest bevinden. De WF is een jaarlijkse tentoonstelling van bloemen en agrarische en consumentenproducten, die in 1999 werd gehouden van 19 tot en met 28 februari. Na inspectie van het terrein en inventarisatie van de exposanten werd een lijst opgesteld van potentiele bronnen. Het waterleidingsysteem en alle watergebruikende installaties die nog voorhanden waren, werden bemonsterd. Aan de hand van interviews met exposanten, werd een risico-inschatting voor elke potentiele bron gemaakt. In totaal waren zestien producten potentieel risicovol: twee whirlpools, twee bubbelmatten (geperforeerde rubber matten, bedoeld om op de bodem van een met water gevuld bad te leggen, waardoorheen met hoge snelheid lucht kan worden geblazen), elf fonteinen en een vernevelaar. Uit drie apparaten, twee whirlpools en een vernevelaar, werd Legionella pneumophila geisoleerd. Gebruikmakend van serotypering en moleculair-biologische technieken (PFGE, ERIC/REP en AFLP), werden drie verschillende genotypen onderscheiden: B-1, B-2 en B3 (B van Bovenkarspel). Om deze isolaten met patienten-isolaten te kunnen vergelijken werkten alle microbiologische laboratoria van Nederland mee met het verzamelen van patienten-isolaten gerelateerd aan de epidemie. Van in totaal 29 verzamelde isolaten waren 28 genetisch identiek aan B-1, het andere was genetisch identiek aan B-2. Gebruikmakend van risico-inschatting gebaseerd op gemeld gebruik en gebruikmakend van een microbiologische inschatting van de mate van besmetting van de drie kweek-positieve producten, droeg de whirlpool in hal 3 van het WF-terrein zeer waarschijnlijk het meeste bij aan verspreiding van L. pneumophila. Het is niet uit te sluiten dat de whirlpool in hal 4 een bijdrage heeft geleverd aan de verspreiding, terwijl een bijdrage van de vernevelaar onwaarschijnlijk is. Ook een bijdrage aan de verspreiding door de fonteinen en de bubbelmatten is onwaarschijnlijk. Hoewel Legionella spp niet werden geisoleerd uit het waterleidingsysteem, is het waarschijnlijk dat de Legionella bacterien de drie producten binnenkwamen vanuit dit systeem. Deze resultaten worden bevestigd door de uitkomsten van een patient-controle en een cohort onderzoek, uitgevoerd om de exacte locatie van blootstelling aan Legionella spp op het WF-terrein vast te stellen, die aangeven dat de whirlpool in hal 3 de meest waarschijnlijke bron van infectie is.

Source: RIVM Rapport 213690003

INFORMATION IN DUTCH

Updated 25th June 1999





Updated 24th April 1999


Updated 22nd April 1999


Updated 12th. April 1999


Updated 7th. april 1999
in Dutch


Updated 2nd.April 1999


Updated 2nd. April 1999


Updated 1st. April 1999


Updated 27th. March 1999


Update 26th. March 1999


Updated 25th. March 1999


Updated 23rd. March 1999


Updated 21st.March 1999


Update 19th. March 1999


Update 17th.March 1999


 

   
 

The annual West-Friese Flora
The world's largest covered bulb flower 
show, is held in the buildings February. 

This exhibition and fair are visited by 
about 80,000 people from the Netherlands 
and other countries every year. 

 


17 Mar 1999
Reported to the LCI up to today 16.00 hrs

Hospital admissions

Confirmed cases 79, of which 7 died

Probable cases 113, of which 5 died

Outpatients
Confirmed cases 1, non-fatal
Probable cases 0
Possible cases (not reported except 1 death)
No new deaths reported but several confirmed cases are in a critical condition.
Still expecting some data from hospitals.
No news from bacteriological investigations.
Please note that the title in ProMED-mail (flower show) in fact is misleading. There was indeed a flower show but the water in the fountains was rather cold but on the adjacent exhibition grounds there were consumer goods demonstrated like bubble baths, whirlpools andthe like.
They are definitely more suspect.

Source..ProMED-mail


1992 FLORIDA (ORLANDO)

The incubation period of Legionnaires disease in five patients was traced to attendance at conventions in a hotel in the Orlando, Florida. area between January 6 and February 2 1992. Water from the fountain was the only one from 55 environmental specimens to test positve for Legionella. The fountain`s recirculating system had been irregulary maintained, and water in the fountain may have been heated by submersed lighting.
Decorative fountains may be a potentail source of infection with Legionella pneumophila, and emphasize the need for standard maintainance and disinfection procedures.
(Hiady WG, American Journal Epidemiology 1993 138 555-562)


Westfriese Flora '99 - February 19-28, 1999

The Westfriese Flora is an internationally celebrated flower exhibition held for 10 days each year in Bovenkarspel, only 60 kilometers north of Amsterdam.

In 6,000 square metres of exhibition space, top growers will exhibit over 100,000 tulips, lilies, narcissi, hyacinths and other special bulb flowers, which will be on display in countless shapes, colours and arrangements.

During the Westfriese Flora, a five-day Agricultural Trade Fair is specially held for and by the flower bulb business.

Bulb growers, exporters, merchants and others in the trade meet here to familiarize themselves with new developments and cultivate business relationships.
The Westfriese Flora will take place in the Cooperative Dutch Bulb Centre (CNB) auction halls in Bovenkaspel.

The Westfriese Flora is an internationally acclaimed flower exhibition held for ten days each year in Bovenkarspel in West Friesland. It is the world’s largest covered flower bulb exhibition featuring a garden covering 6,000 square metres.
In the heart of winter the garden has more than a hundred thousand tulips, lilies, daffodils, hyacinths and other unusual bulb flowers in every shape and form in glorious bloom.
The Westfriese Flora 1999 will be held from 19-28 February. It is a great day out just around 60 kilometres from Amsterdam.

The Westfriese Flora 1999 Homepage


 

   

In Holland there has been an outbreak of L. pneumophia
Two patients died, at least another 20 in hospital.
Cause probably a water fountain in a flower-exhibition.

15th.MARCH 1999

Latest news:
Nine people died who visited the Westfriese Flora (yearly indoor exhibition of mostly spring-flowers (our famous tulips, narcissus etc. etc.).

In five of them Legionella has not yet been confirmed. The total number of hospitalized cases is now over 40. The exhibition finished Feb.28, so more cases are not expected. All patients visited the exhibition.

The suspected source is the water-spraying-system. Of course that involves only cold water. Rumours go that in hothouses etc. these days waterbasins are used, so, stagnant water, warm environment, etc. Nothing has been confirmed yet.

Patients are mostly young and healthy people.

Source..Personal Email..........Loes Buisman.... (Many Thanks)

Following an annual one week flower exhibition from 19-28 February 1999 in the northwest of the Netherlands (Bovenkarspel) with over 80 000 visitors, at least 26 people have been admitted in hospitals in the province of North Holland with severe legionella pneumonia. Two persons died.*

After a public alarm for the whole country on Friday evening 13 Mar 1999 several other cases, including some deaths, were reported to us.

The installation of stands and equipment on the exhibition grounds started from 12 Feb 1999. The exhibition normally has many international visitors. As the theme of this year's exhibition was Russia, many people from the former USSR have visited the exhibition grounds, from the onset of the preparations. [Also] as in previous years, many visitors from Indonesia were present.

We would like to receive reports of all possible linked (old) cases, i.e. legionellosis in people that visited the exhibition grounds in Bovenkarspel in the period 12-28 February 1999.

Confirmed case: X-ray confirmed pneumonia with laboratory confirmation of legionellosis with onset of disease in the period from 12 Feb 1999 to 12 Mar 1999 in people that visited or worked at the exhibition grounds.

Probable case: X-ray confirmed atypical pneumonia e.c.i. (without laboratory confirmation of legionellosis or any other specific causative microorganism), with onset of disease in the period from 12 Feb 1999 to 12 Mar 1999 in people that visited or worked at the exhibition grounds.

Possible case: clinical atypical pneumonia e.c.i. (without laboratory confirmation of legionellosis or any other specific causative microorganism) with onset of disease in the period from 12 Feb 1999 to 12 Mar 1999 in people that visited or worked at the exhibition grounds.

Cases should be reported through the usual international channels or directly to e-mail address:
secr@lci.lcr.nl

Please note in the report: ---------------------------- Name, date of birth, sex, date of onset of disease, date of X-ray confirmation, date of visit to the exhibition grounds, phone number and snail-mail address of notifier.

LCI (Outbreak Management Communicable Disease Control)
Postbus 16071
Schoolstraat 25 2500
BB Den Haag.............................. 3581 PP Utrecht
tel 070-3656713 ...........................030-2313701
The Netherlands
Email........secr@lci.lcr.nl

Source.......... promed@usa.healthnet.org

Source: media

Several new cases of the potentially fatal Legionnaires' disease were contracted over the weekend and a third victim died from the illness, the Dutch Health Ministry said Monday.

"We are trying to take inventory of all those who have been affected by the bacteria, but it's hard to track everyone down,'' said ministry spokeswoman Fanny Bod.

Two of the victims were men, aged 41 and 69, from Bovenkarspel, a town 40 miles north of Amsterdam where some 80 000 people visited a weeklong flower show that ended 28 Feb 1999.

The third was a 50-year-old woman from Delftzijl, 75 miles northeast of the capital, who also visited the annual flower event.

Bod said at least 35 people, including the three deceased, have been diagnosed with the disease, whose symptoms are similar to those of pneumonia. All the infections are believed to have originated from the show.

Investigations started on Monday to determine how many people were at risk. "We are doing everything we can to find out why some people got sick and others didn't in order to learn more about the illness,'' Bod added.

The exact source of the bacteria has not been confirmed but authorities suspect it may have been a drinking fountain, a decorative water curtain or water particles spread by sprinklers, Bod said.

Source.....promed@usa.healthnet.org

Date: Mon, 15 Mar 1999

Source: media

Up to nine people may have died from Legionnaire's disease in the Netherlands, after the airborne bacteria spread through a flower show, health minister Els Borst said on Monday.

Four of the nine victims were confirmed to have died from the deadly disease, while autopsies are still being performed on the other five, she said.

More than 40 people are also sick with the illness, and the minister expressed shock at the rapidly rising number of casualties.

The victims were all infected with Legionnaire's disease after attending a flower show held in Bovenkarspel, in the western Netherlands, during the last week of Feb 1999.

Health authorities believe the bacteria was spread through a fountain.

UPDATED 17th. MARCH 1999

16 Mar 1999 Reported to the LCI up to today 16.00 hrs:
LCI (Outbreak Management Communicable Disease Control)

Confirmed cases 34, of which 4 died Probable cases 125, of which 8 died Possible cases (only registered if from other countries) 0.

The case-control study to investigate the possible source in the exhibition grounds has started. Specimens from all man-made aquatic sources are taken, results are expected by the end of the week.


17th March 1999

AMSTERDAM, Netherlands.
The outbreak of Legionnaires' Disease at the Dutch flower show held in February has resulted in three more deaths.
Bringing the death toll to 13

At least 39 other people were infected with the pneumonia-like illness while visiting an annual flower event in Bovenkarpsel, about 60 Klms. north of Amsterdam.

Health officials said autopsies confirmed that all 12 victims died from the bacterial infection, which is spread through tiny droplets of contaminated water. There have been a total of 159 reports of possible infection, though not all have been confirmed as cases of the disease.

The health department continues to trace visitors to the Westfriese Flora show in an attempt to establish the exact source of the bacteria.

The source is believed to have been a fountain that served as a centrepiece at the exhibition which was attended by about 80,000 people.

Source Media

Return to top

Outbreak of legionnaires’ disease in the Netherlands

A large outbreak of legionnaires’ disease has arisen in the Netherlands among people who visited the Westfriese Flora, a flower exhibition in Bovenkarspel, between 21 and 28 February 1999. The first case was admitted to hospital on 7 March. Sixty-eight cases have been confirmed either by legionella urine antigen detection test or by culture of Legionella pneumophila, and there are a further 89 suspected cases. Thirteen people have died, four of whom are confirmed cases of legionnaires’ disease and nine suspected.

The Health Inspectorate has informed all doctors and the general public. The Flora was visited by people from throughout the Netherlands and from abroad. People who visited the Flora between 21 and 28 February and who have symptoms of a respiratory infection are advised to seek medical attention. The National Institute of Public Health (Rijksinstituut voor de Volksgezondheid en Milieu - RIVM) has begun an investigation and case control study to identify the source of the outbreak.

18th. March 1999
Eurosurveillance Weekly
PHLS Communicable Disease Surveillance Centre
61 Colindale Avenue
London NW9 5EQ

Source: media, 18 Mar 1999

The Netherlands Health Ministry said Thurs 18 Mar 1999 that there have been 50 cases & 13 deaths so far from legionellosis associated with the Westfriese Flora show in Bovenkarpsel, about 40 miles north of Amsterdam, in February 1999, & as many as 200 visitors have reported pneumonia-like symptoms compatible with the disease.

This is an increase from the 33 cases & 9 deaths reported earlier this week.

The following background data on Legionnaire's disease in the Netherlands were extracted from the GIDEON software program:

Year Cases
1989 55
1990 48
1991 32
1992 21
1993 43 (6 fatal)
1994 52
1995 42
1996 40 (rate = 0.258/100 000)
1997 48
1998 44

24 cases were acquired by Dutch tourists in Spain during 1987 to 1995.

Six cases (2 fatal) were acquired from a sauna in Haarlem during 1991 to 1996.

SOURCE....A ProMED-mail post
16th March 1999

Netherlands

Dutch Legionnaires' Disease Toll Reaches 13

An outbreak of Legionnaires' disease at a Dutch flower show has killed 13 people and infected at least 50, the Health Ministry

. The government said as many as 200 visitors of last month's Westfriese Flora show in Bovenkarpsel, about 60 Klms north of Amsterdam, have reported symptoms usually associated with the pneumonia-like disease.
The latest infection toll is an increase of 17 from the 33 cases reported earlier this week. Local health officials on Thursday intensified efforts to find the bacteria's source and opened additional hotlines to answer thousands of questions from concerned citizens.
Early reports that the bacteria, which is spread through tiny droplets of water, came from a fountain or similar installation were still not confirmed. The week-long annual flower show, one of many held in the country each spring, attracted about 80,000 people this year

Frday 19 March 1999
Reported to the LCI up to today 16.00 hrs

Confirmed cases 91 (86 hospital admissions, 7 deaths)
--Probable cases 108 (86 hospital admissions, 6 deaths)

Still expecting more data.
No big news from bacteriological investigations yet. One (experimental!) PCR on a specimen taken from a bubblebath is positive.
No clues yet from the case control.

Source ProMed.


19th. March 1999

Is it a coincidence that the numbers of hospital admissions are the same for both confirmed & probable cases? And isn't it strange that no associated cases have been reported from other countries?
Europe has an efficient Internet-connected working group on legionellosis
[Mod.JW]

Source ProMed.

SatelLife is an international not-for-profit organization employing satellite, telephone and radio networking technology to serve the health communication and information needs of countries in the developing world.

Update 21st March 1999

Dutch blame whirlpool for Legionnaires outbreak

AMSTERDAM

A preliminary investigation has traced a deadly outbreak of Legionnaires' disease in the Netherlands to a whirlpool bath, the health ministry said Friday.

Thirteen visitors to a flower show last month died after contracting the sickness. Another 150 have become ill.

Early investigations showed legionella bacteria in a whirlpool at the Westfriese Flora show in the northern Dutch town of Bovenkarpsel.

The disease, which is carried through bacteria in water, was originally believed to have been passed through water fountains.

Source... Media

Legionnaires' Death Toll Rises

Saturday March 20, 1999

BOVENKARSPEL, Netherlands

Farmers in muddy clogs and faded berets wander around a complex of brick warehouses, chatting about tractors and trying to forget that this bucolic setting became a breeding ground for death.

Last month, they were displaying bulbs and cut flowers at a renowned flower show to 80,000 visitors from around the world. But somewhere in the complex - experts still haven't figured out where - the rare but deadly bacteria that cause Legionnaires' disease were lurking.

A week ago, people started dying.

By Saturday, the toll had risen to 16. At least 90 other people were confirmed to have been infected by the disease that attacks the lungs, and 199 more with similar symptoms were being checked.

Anxiety about Legionnaires' disease has spread across the Netherlands, and this village 40 miles north of Amsterdam normally associated with the beauty of blooms has become synonymous with catastrophe.

This was the 66th exhibit. We do it every year and this time it was a calamity of unknown proportions, said Wim Boon, an organizer of Westfriese Flora, the country's largest bulb show.

With new deaths and infections reported almost daily, Bovenkarspel Mayor Jan Haanstra, chairman of the annual show, is anxiously awaiting the results of investigations that are trying to trace the source.

Initial speculation on the outbreak's source pointed to a water fountain or other water decorations at the flower show, but investigators have not confirmed that.

On Friday, medical teams widened their probe to two other events held simultaneously with Westfriese Flora in the same 1930s complex: a household goods show and a consumer products show.

"If you see how the bacteria works, you realize the source could be anywhere. We can't rule anything out.

Although the focus has been on the flower show, a government health agency said Friday the source might have been a whirlpool display filled from a fire hose in the building. The agency urged people nationwide not to use whirlpool baths or hot tubs unless they have been cleaned, and said inspections of venues for all public events would be stepped up.

The outbreak prompted Environment Minister Jan Pronk this past week to propose tighter laws on drinking water systems.

The bacteria that are believed to cause the illness are found in soil and thrive in air-conditioning ducts, storage tanks and rivers. Experts say the germ, spread through the air via tiny water particles, kills one of every six people it infects.

It is, by all accounts, a terrible death - the lungs fill with a bloody foam and the victim suffocates.

Because the disease is relatively young, medical experts still have a lot to learn about it, and the latest outbreak may offer them new clues.

"We were surprised that the cases were among people of all ages and that those who became ill were not physically weak to begin with the director of Westfriese Gasthuis hospital said.

He said the hospital had dealt with one or two cases of the illness each year, but it had to request assistance to cope with this outbreak.

The hospital is caring for 26 people with the disease, six of whom were in intensive care.

Their health is slightly better, but it's going very slowly, Timmer said.

Westfriese Flora is one of more than 100 flower and bulb events held each year in the Netherlands, where tourists, farmers and buyers inspect the goods of a multibillion-dollar industry.

Evelien Engelman, spokeswoman for the Horticulture Product Board, which represents the country's flower industry, said there are concerns the outbreak could discourage people from attending future flower shows even if it was found to have come from the non-flower events.

We are concerned and want to know the source of the bacteria, although we don't have any reason to believe that it came from here, said Nico Huisman, manager of Bovenkarspel's exhibit halls.

After a briefing at city hall on March 12, the day of the first death, all 30 exhibit hall employees went back to work. None has become infected.

But a reminder of the outbreak greets them each morning - a flag flapping at half-staff in respect for the victims.

"Spring Starts In Bovenkarspel," it reads.

Source.......... Media


Dutch Legionnaire's Disease Toll 17

Monday, March 22, 1999

AMSTERDAM, Netherlands

Another person infected with Legionnaires' disease died over the weekend in the Netherlands, bringing the death toll to 17 in the last month.

Of 231 others who have complained of symptoms, 94 have been confirmed as Legionnaires' cases, officials said Monday.

The conditions of those infected with the deadly pneumonia-like illness were not released.

Authorities have traced the outbreak to a convention hall in Bovenkarpsel, 40 miles north of Amsterdam, where a flower show, a consumer products show and a household goods show were held in February.

Although the precise cause is not known, investigators are examining the possibility that the bacteria that cause the disease were spread through warm water circulating in a whirlpool. They have not said whether the whirlpool was part of the flower show or belonged to one of the other shows.

An estimated 80,000 people attended the Westfriese Flora flower show alone. The outbreak has prompted officials to step up inspections of exhibit halls and other public venues nationwide.

Source...Media

Dutch Legionnaires' Toll Hits 18
24th.March 1999
 
 

AMSTERDAM, Netherlands

A deadly outbreak of Legionnaires' disease in the Netherlands claimed another victim Wednesday, raising the death toll to 18, health officials said. The number of people with symptoms similar to those of the pneumonia-like disease remained stable at 231, as did the confirmed infection toll of 94, the Health Ministry said. Although the exact source of the bacteria has not yet been confirmed, it has been traced to a convention hall in Bovenkarpsel, 40 miles north of Amsterdam, where a flower show, a consumer products show and a household goods show were held in February. Medial experts were looking into the possibility that the bacteria was spread through a warm-water whirlpool. It was unclear if the whirlpool was part of the flower show or belonged to one of the other shows.

An estimated 80,000 people attended the Westfriese Flora flower show, the largest of its kind in the Netherlands, which does a booming export business in bulbs and cut flowers.

Officials stepped up inspections of exhibit halls and other public venues nationwide and swiftly proposed tighter water safety laws to Parliament.

Source..Media

Firehose

Van 231 meldingen is bekend dat zij de afgelopen weken na een bezoek aan de Flora ziek zijn geworden met verschijnselen van een longontsteking. Bij 94 van de 231 nten is met zekerheid vastgesteld dat ze nfecteerd zijn met de legionellabacterie. Deze gegevens zijn sinds gisteren niet meer veranderd.Mensen met vragen over de veteranenziekte kunnen bellen met het algemene informatienummer van de overheid: 0800-8051.(Special phone number of the Dutch government for questions about the illness).

Dutch Ministry of Health. (http://www.minvws.nl). Zoeken

Stand van zaken legionella-besmetting

Dinsdag 23 maart 1999, persbericht nummer 29

Vandaag is er op het ministerie van VWS 1 nieuw sterfgeval als gevolg van de legionella-epidemie gemeld. Hierdoor komt het totaal aantal mensen dat is overleden na een bezoek aan de Flora in Bovenkarspel op 18. Bij 10 van de 18 patiënten is de diagnose veteranenziekte met zekerheid gesteld. In de andere gevallen zal het moeilijk zijn het verband met de ziekte nu nog aan tonen.

Today another reported death. Total deaths after visiting the Flora in Bovenkarspel (about 55 km. north of Amsterdam) now 18, of which 10 confirmed Legionellosis. In the other cases Legionellosis will be hard to prove.

Van 231 meldingen is bekend dat zij de afgelopen weken na een bezoek aan de Flora ziek zijn geworden met verschijnselen van een longontsteking. Bij 94 van de 231 patiënten is met zekerheid vastgesteld dat ze geïnfecteerd zijn met de legionellabacterie. Deze gegevens zijn sinds gisteren niet meer veranderd.

231 people have been reported having symptoms of pneumonia after visiting the exhibition. In 94 cases Legionellosis has been confirmed.

Mensen met vragen over de veteranenziekte kunnen bellen met het algemene informatienummer van de overheid: 0800-8051. (Special phone number of the Dutch government for questions about the illness).

Lots of testing is being done on all sorts of things that were on display. Besides the big flower-exhibition (Our famous Dutch bulbs etc., tulips do not grow in Amsterdam) there were also all kinds of stands with useful and useless things for in and around the house. On display was a bubble-bath, which has been tested positive by use of an "experimental test", says the ministry, I presume it's been a PCR. No further proof yet. It's now thought that the fire-hose used to fill the bath might be the source.

Source DejaNews
24th. March 1999

tand van zaken legionella-besmetting

Donderdag, 25 maart 1999, persbericht nummer 30

Vandaag is er op het ministerie van VWS één nieuw sterfgeval als gevolg van de legionella-epidemie gemeld.
Hierdoor komt het aantal mensen dat is overleden na een bezoek aan de Flora in Bovenkarspel op 19. Bij 12 van de 19 patiënten is de diagnose veteranenziekte met zekerheid gesteld.
Bij één melding is de relatie met de veteranenziekte erg onwaarschijnlijk. In de andere gevallen zal het moeilijk zijn het verband met de ziekte nu nog aan te tonen.

Van 231 meldingen is bekend at zij de afgelopen weken na een bezoek aan de Flora ziek zijn geworden met verschijnselen van een longonsteking.
Bij 106 van de 231 patiënten is met zekerheid vastgesteld dat ze geïnfecteerd zijn met de legionella-bacterie.

Source Dutch Health Ministry
25th. March 1999

26th.March 1999

Legionnaire Death Toll Hits 19

Legionnaire Death Toll Hits 19 AMSTERDAM, Netherlands

A 19th victim of an outbreak of deadly Legionnaires' disease has died, and the number of people confirmed to have been infected has risen to 106, the Health Ministry said Friday.

More deaths appeared likely after 12 additional cases of infection were confirmed Thursday.
The number of people suffering from unconfirmed symptoms similar to those of the pneumonia-like illness stood unchanged at 231, the ministry said. All those infected with the bacteria attended a flower show last>


Transfer interrupted!

of Amsterdam. However, health officials are still pondering the exact source, and a warm-water whirlpool has become the focus of investigations. The whirlpool was part of a consumer products show held alongside the Westfriese Flora event. An estimated 80,000 people attended the flower show, the largest of its kind in the Netherlands, which does a booming export business in bulbs and cut flowers.

LegionnaireS` Disease claims 20th victim

  AMSTERDAM
30th March 1999

The world's worst outbreak of  Legionnaires` Disease has claimed a 20th victim, the Dutch  health ministry said Tuesday.

All were visitors to the Westfriese Flora, the world's  largest indoor bulb show held in February, in the Dutch  town of Bovenkarspel.

Of 80,000 people who visited the event, 231 have fallen ill.  The health authorities have confirmed the presence of  Legionnaires` bacteria in a record 106 cases.

The victims succumbed to a particularly virulent form of the  bacterium, which normally strikes down the weak and elderly.

The results of an investigation into the source of the  outbreak are due next week.

Preliminary indications are that a bubble pool was harboring  the bacteria.

Health Minister Els Borst and Environment Minister Jan Pronk  last wee said the government was seeking tougher health control  measures, particularly for public events.

   

Information kindly supplied by

Eurosurveillance Weekly

Legionnaires’ disease in the Netherlands

A total of 226 cases (see table1) of legionnaires’ disease among visitors to the Westfriese Flora (1) in Bovenkarspel have been reported to the National Coordinating Centre for Communicable Disease (LCI) by 29 March 1999. Eighteen people so far have died.

The Westfriese Flora, a flower and consumer products exhibition, was held from 21st. to 28th. February and was attended by 5000 to 12 000 people each day, some of whom attended on more than one day.

Table 1 Cases of legionnaires’ disease
 

  Number of cases Deaths
Number of cases Deaths Confirmed Legionella pneumonia 97 8
Pneumonia (suspected Legionella) 42 5
Other symptoms (after visiting flower exhibition) 87 5
Total 226 18

The male: female ratio for cases is 2:1. The average age of the cases is 63 years for men and 65 years for women.
All cases visited the exhibition between 23 and 28 February.

Figure 1 Dates of onset of illness of cases


Figure 2
Dates of last visit to the exhibition by cases and incidence per 10 000
visitors per day

A case control study of 90 cases and 390 controls (people living in Bovenkarspel and visitors to the exhibition) has shown that the consumer products exhibition, which was on the main route to the flower exhibition, is the suspected source of the outbreak (see figure 3). A water sample from one of the whirlpool spas in the consumer products show was positive by PCR for Legionella pneumophila but legionella could not be cultured.

Figure 3 Map of the Westfriese Flora

A cohort study of 1500 exhibition employees to investigate the source of the outbreak and how infection risk varied with where and for how long they worked has begun.

Reference:

1. van Wijngaarden J.
Legionnaires’ disease in the Netherlands. Eurosurveillance Weekly 1999; 3: 990318. (http://www.eurosurv.org/1999/990318.htm#2)

Reported by Lynette Wijgergangs (lynette.wijgergangs@rivm.nl) Rijksinstituut voor de Volksgezondheid en Milieu (RIVM), Bilthoven, the Netherlands lksgezondheid en Milieu (RIVM), Bilthoven, the

Updated 2nd April 1999

Legionnaires' Disease deaths now 21

AMSTERDAM, Netherlands

An outbreak of Legionnaires' disease among visitors to a Dutch flower show last month claimed another life on Thursday, raising the death toll to 21, the Health Ministry said.
Some 231 people have become ill after visiting the Westfriese Flora show in Bovenkarspel, 40 miles north of Amsterdam, in February.
The outbreak is one of the worst in the short history of the disease. Some 106 people are known to have been infected by the disease, according to the ministry.
Government medical staff are trying to confirm that a warm-water whirlpool was the source of the bacteria.

The whirlpool was part of a consumer products show held alongside the Westfriese Flora, which attracted 80,000 visitors.

Source Media


Stand van zaken legionella-besmetting

Donderdag 1 april 1999, persbericht nummer 33

Vandaag is er op het ministerie van VWS 1 nieuw sterfgeval als gevolg van de legionella-epidemie gemeld. Hierdoor komt het totaal aantal mensen dat is overleden na een bezoek aan de Flora in Bovenkarspel op 21. Bij 14 van de 21 patiënten is de diagnose veteranenziekte met zekerheid gesteld. Bij 3 meldingen is de relatie met de veteranenziekte uit Bovenkarspel erg onwaarschijnlijk. In de andere gevallen zal het moeilijk zijn het verband met de ziekte nu nog aan te tonen.

Van 231 meldingen is bekend dat zij de afgelopen weken na een bezoek aan de Flora ziek zijn geworden met verschijnselen van een longontsteking. Bij 106 van de 231 patiënten is met zekerheid vastgesteld dat ze geïnfecteerd zijn met de legionellabacterie.

Bacteria that can cause the deadly Legionnaires' disease have been discovered at a popular Dutch health spa, the government announced.

The bacteria were found Thursday at the Thermae 2000 spa in the southern city of Valkenburg during inspections ordered in the wake of a Legionnaires' outbreak at a flower show in late February which has so far killed 21 visitors, the health ministry said in a press release late Friday.

No new cases of pneumonia-like illness have been reported among people known to have visited the spa, but hundreds of visitors on Saturday called an information line set up after the February outbreak.

Health inspectors found the bacteria in a so-called water jet massage bath at the spa 120 miles south of Amsterdam.

The bath, which can only be used by one person at a time, has to be booked in advance, meaning spa management have been able to trace and warn most of the 40 people who used it in recent weeks.

None of the other baths, pools or water sources at the spa was infected, the health ministry said.

Government medical staff believe a warm-water whirlpool was the source of the bacteria at the Westfriese Flora flower show in February in a town near Amsterdam and ordered precautionary checks at similar baths throughout the Netherlands.

4th April 1999


7th. April 1999

Saunabezoeker in Oldenzaal besmet met legionella

OLDENZAAL, woensdag

Een mannelijke bezoeker van Sauna Sare in Oldenzaal blijkt in januari van dit jaar besmet te zijn geraakt met de gevreesde legionella-bacterie.

Toen de patiënt ziek werd, kwam de besmetting aan het licht. De man, van wie de GGD Twente de personalia niet vrij geeft, is inmiddels in het ziekenhuis behandeld en maakt het volgens een woordvoerster weer goed. De zaak speelde zich af voor de spraakmakende besmettingsgolf bij de West-Friese Flora, maar werd tot nog toe stilgehouden.

Direct nadat de besmetting aan het licht kwam, werd een grootscheeps onderzoek in de sauna ingesteld. Daaruit kwam naar voren dat de bacterie zich in de koudwaterleiding van het stoombad had genesteld. De douches en de baden bleken in orde.
Volgens eigenaar R. ten Have van Sauna Sare zijn inmiddels maatregelen getroffen die volgens hem nieuwe besmettingen onmogelijk maken.

Thanks for sending me this newspaper report. I did not know it, it has happend in a other part of the country and I did not read it in my papers. Its says: in Oldezaal ( not Bovenkarspel, actually 200 km from here) there was a patient who acquired the legionella in the sauna. This was in januari but the kept it out off the press. They checkt the sauna and found the legionella in the coldwater system, not in the baths and showers. The GGD is the local heath department, that wo'nt give the name of the person, but after a stay in a hospital he has been recovered. In the sauna they toke precuations now .

22 DEATHS NOW

Stand van zaken legionella-besmetting

Vrijdag 9 april 1999, persbericht nummer 37

Vandaag is er op het ministerie van VWS 1 nieuw sterfgeval als gevolg van de legionella-epidemie gemeld. Hierdoor komt het totaal aantal mensen dat is overleden na een bezoek aan de Flora in Bovenkarspel op 22. Bij 15 van de 22 patiënten is de diagnose veteranenziekte met zekerheid gesteld.

Source Dutch Health Ministry
9th. April 1999


Wednesday, 21st. April 1999

Reported to the LCI

Confirmed cases 106, of which 15 died probable cases 48, of which 2 died other reported cases 79, of which 5 died

The RIVM (public health laboratory) found positive growth in a whirlpool with identical fingerprinting pattern as was found in patients. The RIVM is analysing the case-control study performed by district (municipal) health departments. With 95 confirmed cases and 262 controls (visitors without complaints) there seems to be a relation between disease and visiting certain demonstrations of consumer goods such as whirlpools/ bubblebaths, steam pressing irons and anti-condensing materials. There is no relation with visiting the agricultural show or the flower show. The RIVM expects no further results within the next four weeks.

Source ProMed.
22nd April 1999


23rd April 1999

Legionnaires' Outbreak Kills 23

THE HAGUE, Netherlands.

A Legionnaires' disease outbreak traced to a flower show claimed another victim Friday, raising the death toll from the pneumonia-like illness to 23 since February, the Dutch Health Ministry said Friday.

It was the latest fatality traced to the Westfriese Flora flower show in a town just north of Amsterdam.

More than two dozen people remain hospitalized with the disease. Government medical experts traced the source of the bacteria to a warm-water whirlpool located at either the flower show or a household goods display held in the same exhibition complex.

Source Media


Out the binnenland section from the
Telegraaf-i from 22 June 1999
THE HAGUE,

The illness from the legionella bacteria on the flower exhibition Westfriese Flora in Bovenkarspel, conclusion February from this year, appears to now be 28 people the lifes to have cost.

Total its 242 registered people sick become after the sorrowful flower outing. That mention the Rijks institute for the people healthy health and environment( RIVM) to Bilthoven in the second between report age, on ge make about the infection disaster from veteran illness those eventually a considerable big extent have receive then healthy health expert and responsible politician at the time have provide.

For with this between times digit from illness cases and dead have the Flora epidemic the females lachtige honor in the wait drag that they the big legionella catastrophe at world be become.

It is true real definite in 1976 in the American state Philadelphia during a congress from American war veteran 29 dead to regret( one more then in the Flora), but the number illness cases growth on considerable low: 182. On this moment lie still always a unknown number Dutch Flora victims in the sick house. The dead number from 28 zal still further rise, become expected. From the now known 28 numbered dead be, thus the RIVM, in elf people not with been firm to pose whether they indeed its bezweken on the legionella bacteria. Seven from them have well a same type illness image, like pulmonary, influenza symptoms and/ whether a bronchial infection. But the diagnosis legionella can in them not balanced become established. They fall therefore among not to be found technical among the category" about ige death cases".

The investigator( from among more the RIVM, the GGD's, the region laboratory in the country, e. a. ),Have total 281 water specimens taken about the legionella pneumophila bacteria on to show. But nevertheless its still always no hard prove find whether the malicious sick leaves awaker in two bubble bathe on the exhibition the crucial source from infection be geweest.

The bubble baths stand in two various halls and the be unlikely that definite mutual infection have place find, thus G. Elzinga from the RIVM. The most plauseable explanation be that the bacteria those the veteran illness have cause, in the water sit where also the bathe its fill. In the ring guidance and firehoses be however nothing was found.

(I need a little help with the translation please)..anyone...


De Telegraaf

Inspectie alle Friese sauna's en zwembaden Inspection of all sauna's and swimmingpools in Friesland

De provincie Friesland heeft gisteren besloten alle sauna's en zwembaden te inspecteren op de legionella bacterie, die deze weekis aangetroffen in sauna De Woudfennen in Joure. Gebleken is dat het om eengevaarlijke soort gaat, die net als tijdens de Westfriese Flora in Bovenkarspel de veteranenziekte kan veroorzaken en slachtoffers kan eisen.
just like during the Westfriese Flora..

Twee personen die recent een bezoek aan De Woudfennen hadden gebracht, verblijven momenteel in het ziekenhuis. Zij hebbenklachten die wijzen op de veteranenziekte. Volgens GGD-arts Bert Voet verkeren zij niet in levensgevaar.
Two people that visited De Woudfennen are now in hospital.
Their complaints look like Legionnaires` disease.
According to the GGD-doctor B. Voet they are not in mortal danger, (GGD: city health department).

Saunabezoekers in Joure mogelijk met legionella besmet

Er zijn twee mensen in Friesland opgenomen die misschien besmet zijn met de legionella-bacterie die is aangetroffen in sauna De Woudvennen in Joure. Het gaat om een man en een vrouw. Zij zijn respectievelijk opgenomen in het Antonius-ziekenhuis in Sneek en het Medisch Centrum Leeuwarden (MCL).

De twee, die recent een bezoek aan de betreffende sauna hadden gebracht, hebben klachten die wijzen op besmetting met de bacterie, waarvan de soort en dus ook de schadelijkheid nog niet is vastgesteld. Volgens GGD-arts B. Voet in Sneek hebben de man en de vrouw klachten aan de luchtwegen.

"Zij hebben koorts en ze moeten hoesten. Kortom, de twee zieken hebben een ziektebeeld dat het gevolg kan zijn van een besmetting, maar ze verkeren niet in levensgevaar", aldus Voet. Van de twee mensen die zijn opgenomen, worden het bloed, de urine en het sputum onderzocht. Daaruit moet blijken of ze werkelijk zijn besmet met de bacterie die de veteranenziekte kan veroorzaken en als gevolg waarvan 23 bezoekers aan de West-Friese Flora inmiddels zijn overleden.

Bij de huisartsen in de regio Zuidwest-Friesland en de GGD in Sneek komen veel telefoontjes binnen van verontruste mensen en saunagasten die zich willen laten informeren over de bacterie, de besmetting en het ziektebeeld. Voet verwacht niet dat er nog veel opnames volgen.

Volgens bestuurslid Ter Elst van de Nederlandse Sauna Vereniging (NSV) leveren sauna's totaal geen besmettingsgevaar opleveren: "De legionella-bacterie kan alleen leven in water met een temperatuur van tussen de 20 en 40 graden. Wel, die waarden liggen in sauna's altijd hoger of lager." Ter Elst laat weten dat de autoriteiten in Joure hadden kunnen volstaan met het sluiten van de waterton waarin de bacterie is ontdekt.

Legionella- bacterie in sauna Joure

JOURE, donderdag

In sauna De Woudvennen in Joure is de legionellabacterie aangetroffen die de gevreesde veteranenziekte kan veroorzaken. De sauna is gistermiddag na overleg tussen de provincie Friesland en de Inspectie voor de Gezondheidszorg gesloten.

Tot nog toe hebben zich geen slachtoffers gemeld, deelt de GGD mee. Vandaag wordt bekend om welk type legionellabacterie het gaat; van de 35 soorten zijn er twee schadelijk.

Het onderzoek in De Woudvennen maakt deel uit van een grootscheepse landelijke inspectie naar aanleiding van de sterfgevallen onder bezoekers van de West-Friese Flora, waar de legionellabacterie is geconstateerd. Volgens arts B. Voet van de GG en GD in Sneek moeten sauna-bezoekers, die koorts, griep of een longontsteking hebben of krijgen, direct hun huisarts waarschuwen. "Verkoudheid is nog niet zorgelijk", zegt hij.

Het rampenplan is gisteren meteen in werking getreden en alle instanties zijn direct op de hoogte gebracht: de provincie, de ziekenhuizen en alle huisartsen. Alleen de gemeente Skarsterlân werd tot verbazing van het college van burgemeester en wethouders niet op de hoogte gesteld.

Op tweede paasdag zijn in de sauna twee monsters genomen. Eentje in het bubbelbad en eentje in een voorraadton, waaruit water werd gepompt voor het Turkse stoombad. Gisteren werd de uitslag van het in opdracht van de provincie verrichte onderzoek bekend. De sauna bleek positief te zijn. Het is de eerste in Nederland, want het kuuroord in Valkenburg, waar ook de legionellabacterie is aangetroffen, is een bronnenbad. In de Nederlandse sauna's wordt volgens voorschrift chloor gebruikt en in chloorwater heeft de bacterie absoluut geen overlevingskans.

De onheilstijding betekende een grote schrik voor bedrijfsleider Jan Boerema en zijn echtgenote Maaike. "Alles is hier altijd superschoon en we komen immer moeiteloos door de keuringen. Hier gaat je hart sneller van slaan. Volgens mij kan het ook niet kloppen. Er moeten monsters verwisseld zijn", zo luidt het ongeloof van Boerema, die gistermiddag het zwembad net had opengesteld voor het schoolzwemmen, toen hij het nieuws vernam. De Woudvennen is namelijk tevens een gecontroleerde badinrichting voor het zwemmen voor bejaarden en minder-validen. De sauna voldoet volgens de provincie ruimschoots aan de criteria voor het verkrijgen van het 'veilig-schoon-vignet'.


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