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Eurosurveillance 1998; 3: 48-50
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Introduction
Legionnaires’ disease is transmitted by inhalation of water aerosols infected with Legionella spp. These bacteria are frequently encountered in man-made water reservoirs and grow optimally in warm water. Hot water distribution systems and air conditioning cooling towers are frequently identified sources of infection. Legionellas are often found in water, and environmental sampling to identify the source of contamination may therefore be inconclusive when performed to investigate single cases (1). Such sampling is usually recommended only for clustered cases (2,3), although it is also carried out for hospital acquired or spa-associated cases. A major objective of the surveillance of legionnaires’ disease is to identify clusters in order to implement control measures. Complete case reporting is essential because clusters are often small, and clusters of travel associated cases are often diagnosed after travellers have returned home, in scattered facilities, which hampers the identification of common exposures. In France, surveillance of legionnaires’ disease started in 1987 with a mandatory clinician-based notification system. An average of 54 cases were reported yearly between 1988 and 1995 and six non-nosocomial clusters were identified. In 1995 the surveillance systems for infectious diseases in France were reviewed and a reappraisal of the surveillance of legionnaires’ disease was considered a priority (4). We surveyed public hospital laboratories to estimate the level of underreporting and to evaluate the feasibility of a laboratory based reporting system. The cases identified through this survey were matched to cases identified in the notification system and at the National Reference Laboratory in order to estimate the number of cases diagnosed in France in 1995. Materials and Methods Case definition A case was defined as any person from whom Legionella spp. had been cultured or in whom a fourfold increase in antibody titre to Legionella of any species/serogroup up to a minimum of 1:128 (indirect fluorescence assay is mainly used in France), whose symptoms began in 1995 or, since no clinical information was available from the laboratory sources, had a first specimen taken in 1995 in France. Cases with both culture and seroconversion were classified as ‘culture confirmed’. Cases in whom seroconversion to several species/serogroups was observed were classified with the following priority: L. pneumophila serogroup 1 (sg1), L. pneumophila other serogroups, and other species of Legionella. Sources of information 1. Notification system Cases are reported by clinicians to local public health officers who in turn notify national health authorities. The case definition used in this system included a clinical diagnosis of pneumonia as well as microbiological confirmation (culture or fourfold increase in antibody titre to any species and serotype of Legionella). 2. Centre National de Référence des Legionella This centre was appointed as the national reference laboratory in 1980. It has facilities for confirming the diagnosis and considerable experience of handling specimens and strains referred voluntarily by private and public laboratories. 3. Survey of hospital laboratories In April 1996, the laboratories of all public general hospitals (n=432) were asked to report using a questionnaire the type and number of tests performed and the cases of legionnaires disease diagnosed in 1995. Capture-recapture analysis Duplicate cases within each source and cases common to two or three sources were identified through a set of personal (first name, initial of surname, date of birth, and sex) and time-place (date of onset/first sample taken, place of diagnosis) identifiers. Duplicate cases within each source were eliminated. Log-linear regression models were applied to the three data sources to test for possible dependence between sources, assess "variable catchability" (5) (that is, different probabilities of capture according to the diagnostic methods used by different sources), and estimate the total number of cases diagnosed in France in 1995. For these analyses, the module 4F of BMDP software was used, excluding the unknown cells from the modelling procedure (structural zero). To test interactions between the sources (that is, the fact that the presence of a case in a source affects the probability of the same case to be present in the other sources), a model without interactions between the sources and several models with combinations of interactions between pairs of sources were constructed and compared. The final model retained was the one with a good fit between expected and observed values and in which the c ² likelihood ratio was not higher than the one in the model at the next level of complexity (including more interactions). The estimate of the total number of cases and its 95% confidence intervals (95% CI) were obtained according to Bishop’s formulae (6). Results In 1995, 37 of the 51 cases reported in the notification system fulfilled the case definition of the study. The reference laboratory performed 1673 cultures and 10 076 serological tests, and diagnosed 170 cases in 1995. Sixty per cent (261/432) of the hospital laboratories contacted took part. These belonged to hospitals and/or received specimens from hospitals that represented 67% of acute medical admissions in France. The response rate was higher for teaching hospitals (72%) than for other general hospitals (57%). The 261 laboratories performed at least 20 754 cultures and 47 742 serological tests in 1995, and diagnosed 193 cases (figure 1). None of them used urinary antigen detection tests.
After matching the three sources, 256 cases were identified. Thirty per cent (76) were culture confirmed and 70% (180) were diagnosed serologically. The proportion of culture confirmed cases was higher in the notification system than in the other sources (table 1).
* Cases identified in more than one source are counted only once All culture confirmed cases were L. pneumophila infections, 67 (88%) of which were due to L. pneumophila sg 1. Forty-five per cent (81) of the 180 cases diagnosed by seroconversion were classified as L. pneumophila sg1, 22% (39) as other serogroups of L. pneumophila, 16% (29) L. pneumophila of undetermined serogroup, and 17% (31) as other Legionella spp. The log-linear model retained assumed no dependence between sources. This model provided an estimate of 292 cases of legionnaires’ disease diagnosed in France in 1995, with a good fit between observed and expected values (p=0.26). To take into account the differences between sources in the relative proportions of cases diagnosed by culture or seroconversion, a stratification by type of laboratory confirmation was then introduced in the model. The stratified model we retained included an interaction term between the notification system and the diagnostic method and gave a similar estimate of 291 cases (95% CI 276-308), with a better fit (p=0.35). With this model, the estimated sensitivity was 13% for the notification system, 58% for the reference laboratory, and 66% for the laboratory survey. The sensitivity of notification system and reference laboratory together was 63%. In the notification system, but not in the other two sources, the sensitivity of the system was significantly higher for culture confirmed cases (23%) than for serologically confirmed cases (9%) (p <0.001). In a preliminary analysis including cases with single antibody titre > 256 found in the same three sources we estimated a total of 528 diagnosed cases, (95% CI 509-547) and a sensitivity of the notification system of 9% (7). Discussion In this study, we used two routinely available sources of information and the results of a survey to perform a capture-recapture analysis. The use of three sources allowed us to exclude major interactions between sources and to control for the variable catchability according to the type of laboratory confirmation. The higher proportion of culture confirmed cases reported to the notification system compared with those diagnosed in the other sources may be due to the long delay for results of serology. The laboratories that took part in the survey (60%) represented 67% of all admissions in acute medical wards in France and 66% of the estimated number of cases diagnosed in France. This suggests that it was reasonable to consider them as representative for the purpose of our study. Only one out of eight laboratory confirmed cases of legionnaires’ disease was reported in France in 1995. Underreporting was much higher for legionnaires’ disease than for AIDS, meningococcal disease, and tuberculosis (8). To our knowledge, the completeness of reporting of legionnaires’ disease has not been evaluated in other countries. In the United States, where legionnaires’ disease is notified by clinicians, it has been estimated that only 3% of total incident cases are reported, but the proportion of cases diagnosed was not stimated (9). With such levels of underreporting it is very likely that a substantial proportion of community acquired clusters will not be identified through reporting, therefore missing a major objective necessary for the timely control of sources of infection. According to our estimate, the incidence of legionnaires’ disease in France in 1995 would be of the order of 0.6 cases/million if based only on reporting, 5 cases/million if based on our estimate of laboratory confirmed cases, and 9 cases/million if cases diagnosed on the basis of single high antibody titres were included. Besides differences in the climate and the possible impact of prevention strategies, the wide variations in reported incidence in European countries (from 0.1 to 30 cases/million) (10) are likely to reflect major differences in both the characteristics of surveillance (underreporting) and the use of diagnostic techniques (underdiagnosis). As an example of differences in diagnostic practices, urinary antigen tests were not available in France until 1996, whereas they represented 20% to 30% of cases reported in 1995 in other European countries (10). In France, urinary antigen tests were licensed and added as a confirmation criterion for reporting of legionnaires’ disease in 1997. Although the specificity of a single high titre is very low (11), cases with pneumonia and single convalescent antibody titre >256 are now also notifiable by clinicians as "probable cases", to further increase the sensitivity of the notification system. Since May 1997, as a complement to clinician notification, local public health doctors are informed of each confirmed case of legionnaires’ disease diagnosed at the reference laboratory. They are required to obtain notification forms from clinicians who have treated cases of legionnaires’ disease who have not already returned the forms. These two systems together, which represent an estimated 63% of laboratory confirmed cases in France, should allow better detection of community acquired and travel related clusters of legionnaires’ disease. Acknowledgements We thank Mrs M. Reyrolle for providing data from the Centre National de Référence des Legionella and Mrs E. Laurent for logistic support during the laboratory survey. |
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Joseph C, Watson J, Bartlett C. Comment: Legionella
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CJP, Joseph CA, Watson JM. Investigating a single case of legionnaires’
disease: guidance for consultants in communicable disease control. 3. Guide
d’investigation d’un ou plusieurs cas de légionellose. 4.
Hubert B, Haury B. (rapporteurs) Orientations pour la révision des
modalités de surveillance des maladies transmissibles en France.
5. Hook EB, Regal RR. Capture-recapture methods in epidemiology: methods and limitations. Epidemiol Rev 1995; 17: 243-64. 6.
Bishop YMM, Fienberg SE, Holland PW. Discrete multivariate analysis:
theory and practice. Cambridge: 7. Infuso A, Hubert B, Etienne J, Reyrolle M, Laurent E. A three source estimate of the incidence of legionnaires disease in France. 12th EWGLI meeting Lisbon, 1-3 June 1997. Abstract book: 15 8. Epidémiologie des maladies à déclaration obligatoire en France. Bulletin Epidémiologique Hebdomadaire, 1997 February, special issue 9.
Marston BJ, Lipman HB, Breiman RF. Surveillance for Legionnaires' disease
: risk factors for mortality and morbidity. 10. Joseph CA, Hutchinson EJ. Legionnaires' disease in Europe - 1995. EWGLI 1996. Proceedings of the 11th Annual Meeting, Oslo, Norway, 2-4 June 1996. 11.
Plouffe JF, File TM, Breiman RF, Hackman BA, Salstrom SJ, Marston, BJ et
al. Reevaluation of the definition of Legionnaires' disease: use of the
urinary antigen assay. |
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 Disease outbreaks reported Date 13 August 1998 Legionellosis in Paris, France Since early June 1998, 19 cases of legionellosis have been identified among visitors to Paris. Ten of the cases were French nationals and 9 were tourists from other European countries. All cases occurred between 6 June and 3 July. Three patients died. Ten of the cases had visited the 9th arrondissememt (administrative area of Paris) while 7 had visited the adjacent 2nd arrondissment. Specimens from 4 patients were sent to the National Reference Centre for Legionellosis and found to be of identical type. Investigations to identify the source of the outbreak are being carried out but no results have been obtained to date. As a precautionary measure, owners of cooling towers in the 2nd and 9th arrondissements have been ordered to clean and disinfect their installations. No new cases have been detected since 3 July 1998. Heightened surveillance and investigations to identify the source continue. Source... World Health Organisation 13th. August 1998 UPDATE 7th. AUGUST I998 PARIS French health authorities were cited as saying today that four people died and 16 fell ill during the World Cup soccer championships from an outbreak of Legionnaires' disease in central Paris. Three of the dead were French and the other a Scot, one of four Scottish tourists who came down with the infection while the World Cup was being played in France. The National Public Health Centre and the Labour Ministry's General Health Directorate had earlier issued statements announcing three deaths. The ministry later said another case, Frenchman who died on July 31, had just been reported to it. The centre said officials suspected the disease broke out in water-cooling tanks atop buildings in the area. July 3, 1998 Legionnaires' disease strikes four Scots in France French health ministry officials said Friday that four Scottish people have been struck down by Legionnaires' disease, and one has died. The officials said the cases had been discovered by a health monitoring network set up for the World Cup tournament. The cases have been identified since June 29. One of those diagnosed with the potentially lethal infection has died, one is in the hospital in France and two others were hospitalized in Britain, they said. The three still alive were all in serious condition requiring round-the-clock care. It was not immediately known if the four had come to France for the World Cup. Scotland was knocked out in the first round of the competition. An investigation carried out with British health authorities found no link between the four cases. Ministry investigators were attempting to contact friends and family members who may have accompanied the four people to pin down where they had been before falling ill and the likely cause of the infection. Cases of legionnaires’ disease associated with travel to France, June 1998 A Scottish resident admitted to hospital in France with legionellosis was reported to the French legionellosis surveillance system on 30 June 1998. On 1 July 1998 the European Working Group on Legionella Infection (EWGLI) surveillance network notified the Réseau National de Santé Publique (RNSP) of three cases of legionellosis among residents of the United Kingdom who had travelled to France in June. This report summarises the results of the epidemiological investigation initiated after these cases of legionellosis associated with travel to France were identified. For this investigation a case of legionnaires’ disease was defined as an acute lower respiratory tract illness with onset of symptoms in June 1998 associated with a positive Legionella pneumophila urinary antigen test and/or the isolation of L. pneumophila in respiratory secretions. Cases were searched for in three ways: 1) by asking each of the national correspondents of the EWGLI surveillance network to notify the RNSP of any confirmed or suspected cases of legionellosis with onset in June and associated with travel to France during the 10 days before the onset of illness, 2) by asking each French District Health Department to notify immediately all confirmed and suspected cases of legionellosis with onset in June, and 3) by reviewing the database of the National Reference Centre for Legionellosis. In addition all hospitals in the region of Paris have been asked to notify cases with onset in June that they have not yet notified. All cases among European travellers to France (or their travelling companions) were interviewed about travel history by either epidemiologists of the RNSP or the EWGLI national correspondent using a standardised questionnaire. Five confirmed cases were identified among European travellers to France. Dates of onset ranged from June 11 to June 20; all patients were men aged between 32 and 60 years (median 50 years). Four patients were from the United Kingdom (2 from Scotland and 2 from England) and one was from Denmark. Four were confirmed by the detection of urinary antigen and one by culture. One patient was admitted to hospital in France and the others in their own countries on return from France. One patient died. Three patients were supporters of the Scottish football team playing in the World Cup. The other two had travelled to France for other reasons. They had travelled to France on dates between 5 and 27 June. All patients had been in Paris at some time during their incubation periods (1 to 10 days before onset), but no more specific common exposure was identified (mode of transportation, hotel, bars, restaurants…). One case had been to the football match between Scotland and Brazil on 10 June and two had been to the football match between Scotland and Norway in Bordeaux on 16 June. Fourteen cases of legionellosis were notified in France in June 1998, no more than in each of the previous months. The National Reference Centre identified no increase in the number of positive isolates in June. Among cases reported in France in June only one was a Paris resident and none of the others had travelled to Paris. Despite intensive epidemiological investigation no epidemiological link has been made between the five cases associated with travel to France in June and we have no evidence of an outbreak of legionellosis in France. Intensified surveillance is continuing in France and throughout the EWGLI network. Reported by B. Decludt, A. Perrocheau, JC. Desenclos (desenclo@b3e.jussieu.fr) Unité Maladies Infectieuses, Réseau National de Santé Publique, Saint Maurice, France. We thank all EWGLI correspondents, French practitioners, and French public health officers for their collaboration . Update 25th. July 1998 Legionnaires' disease associated with Paris in June - update 1 Nine men who developed legionnaires' disease between 11 and 20 June 1998 were in Paris in the two to ten days before becoming ill. Four of the cases are from Scotland, three from England, one from Denmark, and one from Sweden. The cases have been reported to the European Surveillance Scheme for Travel Associated Legionnaires' Disease of the European Working Group for _Legionella_ Infections (EWGLI). The Reseau National de Sante Publique (RNSP) has identified 11 cases of legionnaires' disease in residents of France who live in or travelled to the Ile de France region (Paris and surrounding districts) and became ill in June. They are not clustered by residence and are being followed up to see if they have links with the cases reported to EWGLI. Local investigations have shown that five of the EWGLI cases had stayed in a particular area of Paris. Several of the French cases who have been interviewed had travelled to the same and neighbouring areas, where cooling towers and other potential sources of infection are being checked. Two cases were identified by culture of a respiratory specimen, one in England and one in France (a Scottish case admitted to hospital in St Etienne). Isolates from these cases are being exchanged and subtyped at the national _Legionella_ reference laboratories in Colindale and Lyons, as part of the European scheme for standardisation of typing methods for clinical isolates of _Legionella_. The PHLS Communicable Disease Surveillance Centre (CDSC), which coordinates the European surveillance scheme on behalf of EWGLI, has received anecdotal reports of several men from the United Kingdom and elsewhere who were treated with antibiotics for severe respiratory diseases after staying in Paris during June but not tested for legionnaires' disease. The Respiratory Diseases Section of CDSC would be grateful for information about confirmed and suspected cases of _Legionella_ infection associated with travel to Paris since the beginning of June (tel 0181 200 6868 ext 4497/4481/4014 or fax 0181 200 7868 or e-mail: respcdsc@phls.co.uk).
Mondial: 4 cas de légionellose, dont un mortel, depuis le 29 juin (03/07/1998) Mondial: 4 cas de légionellose, dont un mortel, depuis le 29 juin Jeudi 02 Juillet 1998 - 18h36 heure de Paris PARIS (AFP) - Quatre cas de légionellose dont un a entraîné le décès du malade, ont été détectés en France chez des ressortissants britanniques depuis la mise en place de la cellule de veille sanitaire pour la Coupe du monde de football, a indiqué le secrétariat à la Santé jeudi soir dans un communiqué. Sur les quatre personnes atteintes de cette maladie, une est décédée, une est hospitalisée en France et deux en Grande-Bretagne. L'enquête, menée en collaboration avec les autorités sanitaires britanniques, ne montre pas à ce jour de lien entre ces quatre cas, précise-t-on de même source. Le réseau européen de surveillance de cette maladie a contacté les services de surveillance des pays de la communauté européenne pour les informer et la direction générale de la santé a demandé aux médecins des directions départementales d'informer quotidiennement le Réseau national de Santé Publique (RNSP) des cas portés à leur connaissance. La légionellose, ou maladie du légionnaire, se déclare sous la forme d'une pseudo-grippe, par une fièvre isolée ou des signes respiratoires comme la toux. Elle peut être grave chez des personnes déjà fragilisées par une pathologie pré-existante (immuno-dépression, affection respiratoire chronique) si elle n'est pas traitée à temps, avec des antibiotiques. Cette infection pulmonaire porte le nom de maladie du légionnaire depuis l'épidémie observée en 1976 aux Etats-Unis parmi des anciens combattants de l'American Legion réunis en congrès dans un hôtel de Philadelphie. La bactérie, baptisée Legionella pneumophila, responsable de la plupart des cas de légionellose pulmonaire, peut survivre dans l'eau, notamment celle des systèmes de climatisation et du réseau urbain.
FRANCE Legionnaires disease
: During the summer of 1980
3 sporadic cases of Legionnaires disease were recognized in Paris, Two
patients died. Two of the three cases were among seventeen acute febrile
pneumonia admitted to the Hospital Avicenne between 1st July and 1st October
1980. 1981 Paris During a five week period
in 1981, six cases of legionellosis due to Legionella pneumophila serogroup
1 were recognized in a hospital. The entire hot water system was contaminated
with Legionella pneumophila serogroup 1, although serogroup 1 was isolated
from the cooling tower and its drift, this was not the cause of the outbreak. 1982 France Forty-seven nosocomial cases
of legionellosis due to Legionella pneumophila serogroup 1 were diagnosed
in one major outbreak from November 1982 to March 1983 in a 960-bed teaching
hospital. Contaminated water was considered to be a possible source of
infection. 1989 Paris an outbreak of Legionnaires
disease at Necker (four cases) and Pitie (six case) were unrelated to each
other, the outbreak at Necker was linked to contaminated tap water. 1986 Paris During an outbreak of Legionnaires
disease, 20 critically ill patients were admitted to the intensive care
unit of Hosital Bichat , Paris. 12 patients died. source of outbreak ?
Presse Med 1996 Nov 23;25(36):1786-1788 Legionnaires' disease in the Paris area: epidemiology and mortality. Apropos of a series of 81 culture-positive cases. [Article in French] Nauciel C, Guilhin P, Matsiota-Bernard P, Ronco E Service de Microbiologie, Hopital Raymond Poincare, Garches. OBJECTIVES: Evaluate etiological
circumstances and prognosis in Legionnaires' disease. METHODS: A series
of 81 culture-proven cases of Legionnaires' disease was collected in the
Paris area between 1989 and 1994. RESULTS: Direct immunofluorescence assay
was positive for Legionella pneumophilia in 48% of the cases. Serogroup
1 was isolated in 88% of the cases. The median age of the patients was
51 years and 74% were males. Infection was nosocomial in 28% of the cases.
Immunosuppression was present in 45% of the patients (transplantation,
cancer, leukemia). Among the immunosuppressed patients, 7 were HIV-infected.
Mortality due to legionellosis reached 27%. This high mortality was probably
related to patient selection criteria.
1998 Fri, 07 Aug 1998 PARIS -- French health authorities were cited as saying today that four people died and 16 fell ill during the World Cup soccer championships from an outbreak of Legionnaires' disease in central Paris. Three of the dead were French and the other a Scot, one of four Scottish tourists who came down with the infection while the World Cup was being played in France. The National Public Health Centre and the Labour Ministry's General Health Directorate had earlier issued statements announcing three deaths. The ministry later said another case, Frenchman who died on July 31, had just been reported to it. The centre said officials suspected the disease broke out in water-cooling tanks atop buildings in the area.
PARIS 1998 Comme son nom ne l'indique pas, la légionellose est une infection d'origine bactérienne qui se traduit dans la plupart des cas par une forte toux qui dégénère peu à peu en pneumonie, parfois mortelle. Les bactéries du genre legionella sont très répandues dans l'environnement. On les trouve à l'état naturel dans les lacs et les rivières, ou dans les circuits de distribution d'eau chaude, de climatisation et de refroidissement. Chaque année en France, pour reprendre les chiffres cités dans «Le Monde», on recense entre 500 et 600 cas de légionellose, mais les spécialistes estiment à plus de 2.000 le nombre de cas effectifs. Cette maladie est en effet difficile à détecter, alors qu'elle demande un diagnostic et un traitement antibiotique rapide. Cette détection a pu s'effectuer pendant le Mondial, grâce à un système de veille sanitaire exceptionnellement mis en place. Dès le 3 juin, le réseau national de santé publique (RNSP) avait mis sur pied un dispositif au cours duquel on rendait compte, entre autres et quotidiennement, des données épidémiologiques. Et c'est ainsi que fin juin, des cas groupés de légionellose furent recensés: le germe toucha d'abord des supporters anglais, puis scandinaves, et enfin des Français. Vingt cas sont aujourd'hui répertoriés. Trois Français et un Anglais sont décédés de cette subite épidémie. A LA RECHERCHE D'UN TOIT Les spécialistes se sont longtemps demandé d'où provenaient ces bactéries. Ils ont acquis aujourd'hui une quasi-certitude: l'origine de cette vague de légionellose se trouve sur le toit d'un immeuble des 2e ou 9e arrondissements de Paris. Toutes les personnes atteintes avaient en effet fréquenté ces deux arrondissements voisins. Et selon Jacques Drucker, directeur du RNSP, il y a eu une contamination environnementale massive à partir d'une tour de réfrigération, située au sommet de certains grands immeubles et qui servent à la climatisation. Trente-neuf immeubles de la sorte ont été recensés. Leurs propriétaires ont désormais neuf jours pour nettoyer et désinfecter leurs installations. Mais depuis le 14 juillet à Paris, aucun autre cas n'a été recensé. La bactérie fut identifiée en 1976, lors d'un congrès à Philadelphie de l'«American Legion», les vétérans américains. Vingt-neuf d'entre eux allaient décéder d'une maladie infectieuse et inconnue qu'on baptisa ensuite «légionellose».
Mondial: 4 cas de légionellose,
dont un mortel, Jeudi 02 Juillet 1998 - 18h36 heure de Paris PARIS Sur les quatre personnes atteintes de cette maladie, une est décédée, une est hospitalisée en France et deux en Grande-Bretagne. L'enquête, menée en collaboration avec les autorités sanitaires britanniques, ne montre pas à ce jour de lien entre ces quatre cas, précise-t-on de même source. Le réseau européen de surveillance de cette maladie a contacté les services de surveillance des pays de la communauté européenne pour les informer et la direction générale de la santé a demandé aux médecins des directions départementales d'informer quotidiennement le Réseau national de Santé Publique (RNSP) des cas portés à leur connaissance. La légionellose, ou maladie du légionnaire, se déclare sous la forme d'une pseudo-grippe, par une fièvre isolée ou des signes respiratoires comme la toux. Elle peut être grave chez des personnes déjà fragilisées par une pathologie pré-existante (immuno-dépression, affection respiratoire chronique) si elle n'est pas traitée à temps, avec des antibiotiques. Cette infection pulmonaire porte le nom de maladie du légionnaire depuis l'épidémie observée en 1976 aux Etats-Unis parmi des anciens combattants de l'American Legion réunis en congrès dans un hôtel de Philadelphie. La bactérie, baptisée Legionella pneumophila, responsable de la plupart des cas de légionellose pulmonaire, peut survivre dans l'eau, notamment celle des systèmes de climatisation et du réseau urbain. PARIS FRANCE French authorities said they had ordered the cleaning of 23 cooling towers in two Paris districts after eight people were infected, one fatally, by Legionnaires' disease, The airborne bacterium. In a statement, the prefect of the Ile de France, the region that includes Paris and its suburbs, said the Cooling Towers were located in the northern part of the 14th and 15th districts, in the southern part of the city. So far there is no sign to confirm that the source of exposurel has disappeared, the statement said. The eight cases were detected in August
and September among people who lived or worked in the 14th and 15th districts. The bacterium breeds in sanitary installations, such as hot-water pipes or air conditioning, and becomes airborne, mixed with fine water droplets, if these systems leak. It is not transmitted from person to person. The prefect said Cooling Towers were
being targeted for disinfection. Source Media Cases of legionnaires’ disease associated with Paris, August 1999 Three cases of legionellosis, all residents of the same district of Paris (arrondissement XV), were notified to the French National Institute for Public Health Surveillance (Institut de Veille Sanitaire (InVS)) on 1 September 1999. On 27 August the European Working Group on Legionella Infections (EWGLI) notified the InVS of a British traveller who had stayed in a hotel in the same area at the beginning of August and subsequently developed legionellosis. These notifications by two independent systems suggested an outbreak in people who had visited XV district of Paris. For the purposes of epidemiological investigation a case was defined as a person who developed pneumonia in August 1999 having resided in or visited the XVth and neighbouring districts of Paris in the ten days before onset, associated with either a positive Legionella pneumophila urinary antigen test and/or the isolation of L. pneumophila in respiratory secretions and/or a fourfold rise in specific serum antibody titre. An active search of cases initiated through the district public health officers, the National Reference Centre, hospitals in the Paris area, and the EWGLI network identified four further cases. All cases (or their close relations) were interviewed in detail about their activities during the incubation period, using a standardised questionnaire. All eight cases had stayed in a small area of the XVth arrondissement of Paris, near Montparnasse. One patient died (aged 42 years). Dates of onset ranged from 8 to 20 August (figure 1). Seven patients were men, aged 42 to 78 years (median 54). Seven patients were residents of France. Six cases were confirmed by the detection of urinary antigen and two by culture of L. pneumophila serogroup 1. The two isolates had indistinguishable and unique pulsed-field gel electrophoresis profiles. No specific common exposure was identified (hotel, bars, restaurant, shopping centre, etc). Exposure to the same area of the XVth arrondissement and the absence of any other potential source led us to investigate the possibility of contamination by cooling towers. Selected cooling towers to which patients may have been exposed in August have been investigated intensively by the Direction des Affaires Sanitaires et Sociales of Paris. No further cases with dates of onset since 20 August have been notified, but intensified surveillance is continuing in France and through the EWGLI network. Owners of all the cooling towers in the suspected area have been requested to disinfect their installations. Figure 1. Number of cases of legionnaires' disease: Paris, August 1999
We thank the EWGLI correspondents, the French practitioners, and the public health officers for their collaboration. Reported by B Decludt, I Capek, JC Desenclos (jc.desenclos@invs.sante.fr) Infectious Diseases Department, Institut de Veille Sanitaire, Saint Maurice, L Guillotin, Direction des Affaires Sanitaires et Sociales de Paris, and J Etienne, National Reference Centre, Lyon, France. Source at ...http://www.eurosurv.org/update/ July 5th 1999 European Synchrotron Radiation Facility
(Installation Européenne de Rayonnement Synchrotron) Operating a powerful source of light in the X-ray range, the ESRF is a large experimental facility for basic and applied research in physics, chemistry, materials and life sciences ESRF Announcement Partial Closure of the Guest House The ESRF has been informed that two users who stayed in the Guest House during recent months (one in February, the other in May) have contracted Legionnaires' Disease. This illness is caused by exposure to water aerosols polluted by a bacterium which may be present in water networks and air conditioning systems. Evidence of contamination in buildings A and B of the Guest House has been found and they have been closed to enable the water network to be cleaned by a thermal shock treatment. Given the time required for the preparation and execution of this measure, and for the subsequent verification of its effectiveness, buildings A and B will not be re-opened before the end of the ESRF's summer shutdown (i.e. mid August 1999). The new building of the guesthouse (building C) is unaffected and will remain open. FRANCE Three
cases of Légionellose in thermal baths in Charente-Maritime Three cases of légionellose, respiratory infection of bacterial origin, were detected these last days in the hydropathic establishment of Jonzac (Charente-Maritime), one learned near the prefecture. The prefect of Charente-Maritime took a decree pronouncing the temporary closing of the thermal baths in waiting of the epidemiologic and environmental surveys carried out in collaboration with the departmental Management of the medical and social action (DDASS) and the national Institute of medical day before. All the people having attended the establishment in the last weeks will be informed of the situation. The légionellose is a respiratory infection caused by a bacterium of the Légionella kind which generally appears by a feverish pneumonia. Its diagnosis rests on clinical and biological signs specific. The disease is not transmitted person to person but it can appear mortal in cases of late diagnosis on fragile people Legionnaires' disease at French hospital kills two France Oct 11 Two aged patients have died and three other people are ill following an outbreak of Legionnaires' disease late last month in a hospital in this southwest France town, health officials revealed on Sunday. A further 70 people who were treated in the same hospital recently were also prescribed antibiotic treatments as a precaution, the officials said. The virus was transmitted in the hospital by vapours rising from hot water used in treatments, the officials said. The contamination came from the water, they said. July 2000 France Five died by legionella from July in a
French region Five died and other thirteen affected from the past month of
July are the provisional balance of the center of legionella detected in
the Community Cluster of Legionnaires' Disease in
France, 2000 PARIS, FRANCE.. December 2000 Legionnaire's Disease Cited in Paris Update NEWLY-OPENED PARIS HOSPITAL HAS
LEGIONNAIRE` CASES Tourists suffer legionella infection 11 October 2002 MENEN Four British tourists were infected with the legionella bacteria at a hotel in Menen recently, it was revealed on Thursday. The Menen Mayor, Gilbert Bossuyt, resolved at the request of the Health Inspectorate to temporarily close the hotel, forcing it to find temporary accommodation for 50 people. Daily newspaper De Standaard said the British tourists were treated in hospital after becoming ill while visiting the Elzas, a mountainous area in northern France. The legionella infection was traced back to the Ambassador hotel in Menen after tests discovered the presence of the bacteria in the hotel's water pipes. The newspaper report said the water pipes will be rinsed with hot water of 80 degrees Celsius to kill the bacteria and the hotel is expected to re-open on 20 October. Legionella
infections recently killed several people in Britain in what BBC News said was
the worst outbreak of infections in 10 years. France Two patients reached of légionellose died last week in the hospital complex of Meaux (Seine-et-Marne), where sixteen cases of this disease were detected in ten days. The two patients died in the current of the week: Monday, woman a 90 year old, and Friday, man a 53 years old. On the whole, sixteen cases were diagnosed in the hospital complex, which accomodates approximately 500 people. The origin of this epidemic was detected Friday. Following a series of taking away, carried out the shortly after the first death, an abnormal concentration of bacteria "legionella" was noted in the turns aéroréfrigérantes of the system of air-conditioning of the hospital complex, explained the direction. In addition, a new case of légionellose was diagnosed Saturday in the hospital complex of Sarlat (the Dordogne), changing to twelve the number of patients reached by this infection. "We fear however that new cases are still discovered", explained the director of the hospital, Jean Romon. The establishment calls any hospitalized person with Sarlat as from June 25 and which presents abnormal signs (fever, pulmonary infection) to approach its attending practitionar. On the twelve old patients from 38 to 94 years, nine are currently hospitalized to Sarlat and three in Périgueux. According to Jean Romon, "their state is stationary but we are anxious because the majority of these people are old of more than 70 years". The hospital complex of Sarlat had announced Friday the discovery of seven cases of légionellose. A first patient presenting the symptoms of the disease had been announced Tuesday. "A titrates conservatory and in waiting of the investigations, the new hospitalizations will be temporarily suspended but the service of the urgencies will continue to function normally and to ensure the care necessary. Preventive measures were taken as of Friday by the hospital to stop any risk of contamination Légionellose à Sarlat France Il semble
que tous aient transité antérieurement par l'hôpital de Sarlat.
Bien que
n'ayant pas pu déceler la cause de la contamination, l'administration de cet
établissement à décidé de désinfecter l'ensemble de ses
installations sanitaire et son sytème de climatisation. Seven cases of
pneumopathy to legionella were diagnosed by the Hospital complex of Sarlat.
Five of the patients were hospitalized on the spot and two in Périgueux. It
seems that all forwarded before by the hospital of Sarlat. TWO DIE
OF LEGIONNAIRES` DISEASE IN FRENCH HOSPITAL MEAUX, France Officials were cited as saying Sunday that patients at a hospital in the town of Meaux, 40 kilometres (25 miles) east of Paris, have died of Legionnaire's disease in the last week, A 90 year-old woman died on Monday and a 53 year-old man died on Friday. Overall 16 cases of the disease have been detected in the hospital, the officials said. ****** Two
patients deceased France
The
prefect of the Batch-and-Garonne decided by decree the provisional closing of
the Thermal baths of Casteljaloux after the discovery of the bacterium
"legionella pneumophila" at the exit of the drilling which feeds the
establishment out of water. "the
care was suspended and the cures from now on are stopped until is noted a
return to a strict microbiological quality of water", the prefecture in
an official statement specifies. This
measurement was taken on proposal of the departmental Management of the
medical and social action (DDASS)"under the terms of the principle of
precaution". The
legionella is a bacterium which is propagated in an optimal way in a water
with approximately 40° and causes acute pulmonary infections, the légionellose
or "disease of the légionary". The duration of incubation is two to
ten days and 10 to 15% of the cases are mortals. Four
cases of légionellose, of which a mortal, detected in
The
hydropathic establishments of Support-the-Baths and Saline-the-Thermal baths ( The
departmental direction of the medical and social businesses (DDASS) of
Thereafter,
three other cases were highlighted. One of the four victims died on June 23.
Environmental
research is in hand on the water supply networks of the two hydropathic
establishments where the victims carried out a cure but also in the places
where they resided in The
thermal baths of Support-the-Baths and Saline-the-Thermal baths were closed by
measurement of precaution until the investigation made it possible to identify
the origin of the contaminations. The légionellose is a respiratory infection caused by a bacterium, the légionella. The latter is transmitted by contaminated water inhalation diffused by aerosol in the environment.
NOTE
Tuesday June 17, 2003
The Batch-and-Garonne: Thermal baths closed following discovered the légionelle one BORDEAUX The activity of the care of the Thermal baths of Casteljaloux (the Batch-and-Garonne) was suspended by the prefecture of the Batch-and-Garonne after the discovery, during lawful controls of thermal spring, the presence of bacteria légionella pneumophila at the exit of the drilling which feeds the establishment, announced the prefecture. No case of disease was detected and it is about a measure "taken under the terms of the principle of precaution". The close center thermoludic, supplied with another collecting, remains open. The Thermal baths of Casteljaloux were inaugurated on July 15, 2002, after an investment of 8 million euros. FRANCE One
death and 17 patients in Hérault
Occurred,
in the department of Hérault, of seventeen cases of légionellose, and one
death during the last ten days is
worrying the local medical authorities. Yesterday,
its first victim died, a 81 year old man. The whole of the infected people are
currently hospitalised within The
source of the first recorded contamination on July 28, then of the sixteen
others counted between the 4 and August 8 in the agglomeration montpelliéraine
and with Palavas-the-Floods is for the unknown hour. So that the departmental
Management of the medical and social businesses (Ddass) of Hérault put itself
as of yesterday on the track possible new cases, in particular by inviting the
people having fever, pains muscular, headaches and a dry cough to consult
their general practitioner.
Update France Legionnaires'
outbreak claims 2 8th August 2003 Montpellier
- A second elderly man in two days has died of legionnaires' disease in the
southern French city of Montpellier, a local police spokesperson said.
Update
France Montpellier health authorities say there are aware of 22 further cases of the disease in the city, eight of whom are in intensive care. A further two cases -- one diagnosed in Paris, the other in Italy -- are also believed to have been contracted in Montpellier. 14 August 2003 Grouped cases
of légionellose identified in Montpellier
|
Une cinquième personne est décédée de la légionellose dans le Pas-de-Calais et six nouveaux cas ont été signalés, a annoncé lundi la préfecture, ce qui porte à 48 le nombre de patients atteints de cette grave infection pulmonaire depuis fin novembre dans le département.La nouvelle victime est une femme de 69 ans, décédée à Hénin-Beaumont, a précisé le préfet Cyrille Schott au cours d'une conférence de presse. M. Schott a qualifié cette épidémie de "situation exceptionnelle, grave, qui nous inquiète".
es autorités évoquent désormais l'existence d'une deuxième source possible de contamination. Jusqu'à présent, seule l'usine pétrochimique Noroxo de Harnes (Pas-de-Calais) a été formellement identifiée.Deux des victimes présentaient
une souche de bactérie commune avec celle retrouvée dans la tour réfrigérante
de l'usine Noroxo, arrêtée depuis le 3 décembre.
Toutefois, huit cas déclarés entre le 20 et le 25 décembre "semblent
difficilement rattachables à cette source" (ndlr : Noroxo), selon le Dr
Iles, "car les derniers cas sont apparus 22 jours après l'arrêt de la
source contaminante" et le temps d'incubation de la légionellose n'est que
d'une dizaine de jours.
Selon la préfecture, deux vagues différentes auraient touché le bassin minier
lensois. La première vague, celle dont l'usine Noroxo semble à l'origine, était
localisée autour de Harnes, la seconde toucherait le secteur d'Hénin-Beaumont,
où quatre des nouveaux cas ont été identifiés.
Un arrêté préfectoral a été pris pour obliger les entreprises à pratiquer
des analyses hebdomadaires. En outre, les résultats des analyses en cours
seront communiqués dans les prochains jours.
En tout, 563 établissements
et sociétés ont été inspectés sur dix communes, et des prélèvements réalisés
pour certains.
Parmi les 48 cas déclarés depuis fin novembre, on dénombre 16 femmes et 32
hommes. 21 personnes sont encore hospitalisées et 22 sont guéries.
Vendredi, la veuve d'une victime de la maladie, Martine Delaby, a annoncé avoir
porté plainte contre X pour que soient établies "les responsabilités"
dans la propagation de la légionellose.
Selon la vice-présidente de l'association nationale des victimes de la légionellose, Marie-Josée Payot, jointe à Tarbes (Hautes-Pyrénées) "douze ou 13 autres personnes vont porter plainte dans les jours qui viennent".
Pour cette ancien médecin généraliste en invalidité après avoir elle-même contracté la maladie, l'épidémie du Pas-de-Calais est également "exceptionnelle de par la multiplicité des cas et des sources probables de contamination".
Cinquante trois cas de légionellose
ont été signalés à la Ddass du Pas-de-Calais depuis le 28 novembre 2003.
Trente cinq (66 %) sont de sexe masculin. La moyenne d’âge est de 70 ans.
Pour 52 des cas renseignés, la date de début des signes cliniques se situe
entre le 10 novembre et le 27 décembre 2003. A ce jour, 22 patients sont
hospitalisés, 25 sont sortis et six personnes sont décédées.
Le diagnostic de légionellose est confirmé pour 51 cas par la présence
d’antigène soluble urinaire et deux par séroconversion. A ce jour, parmi les
prélèvements reçus au Centre National de Référence Legionella (CNR), 7
souches ont été isolées. Deux de ces souches isolées des premiers patients
présentent un même profil génomique. Les 5 autres souches cliniques sont en
cours d’analyse génomique. Dix autres prélèvements sont actuellement en
culture et seront analysés dès que des souches seront isolées.
L’enquête épidémiologique est effectuée par la Cellule Inter Régionale d’Epidémiologie Nord et la DDASS du Pas de Calais, avec l’appui de l’InVS. Les interrogatoires auprès des cas ou de leurs proches sont effectués afin de documenter leurs habitudes de vie et leurs déplacements dans les 10 jours précédant la survenue de la maladie, la durée maximum d’incubation de la légionellose étant généralement de 10 jours. D’après les informations recueillies, la majorité des patients résident ou ont fréquenté une zone à l’est de la ville de Lens : Harnes et les communes avoisinantes. Les informations recueillies auprès des derniers cas identifient une zone géographique située plus à l’est.
L’enquête environnementale est
conduite par la DRIRE et la DDASS et les mesures de contrôle ont été prises
concernant des installations à risque (désinfection des systèmes de
refroidissement). Ces investigations ont tout d’abord concerné 18 communes où
résident les premiers cas. Elles ont été étendues depuis le 29/12/03 à 4
autres communes situées plus à l’est.
Des prélèvements révélant des taux élevés de Legionella ont permis
d’identifier une entreprise située à Harnes (Noroxo) comme source de
contamination. En effet, ces souches environnementales sont identiques à celles
de 2 patients. L’entreprise Noroxo a été fermée entre le 3 et le 20 décembre
pour désinfection.
Les autres installations investiguées ont fait l’objet de prélèvements qui
ont été transmis pour analyse au CNR et des désinfections systématiques ont
été effectuées.
A ce jour, des prélèvements pour recherche de Legionella ont été pratiqués
aux domiciles de 33 patients. Un prélèvement positif a été obtenu chez
seulement un patient, ce qui indique que cette source de contamination au
domicile des patients ne peut être retenue comme source de l’épidémie.
Compte tenu de l’évolution de la courbe épidémique et des données disponibles à ce stade, il est possible qu’une autre source de contamination non identifiée à ce jour puisse être l’origine de la survenue des cas dans la deuxième quinzaine de décembre ou que la contamination par la source identifiée (NOROXO) persiste.
Des analyses de prélèvements sont encore en cours au CNR. La comparaison des souches humaines et des souches environnementales, pourra renseigner sur l’existence d’une ou plusieurs sources de contamination.
En raison de cet épisode important et inhabituel de légionellose, le Ministère de la santé et le ministère de l’écologie et du développement durable, ont désigné une mission d’experts spécialisés en épidémiologie, dans la lutte contre la prolifération des légionelles dans les tours de refroidissement et dans le transport des bactéries dans l’environnement afin d’apporter un soutien technique au préfet du Pas de Calais et à ses services.
Quoiqu’il en soit, une surveillance renforcée se poursuit car il est important d’identifier et de traiter précocement les nouveaux malades afin de prévenir le risque de forme grave et de décès.
LINKS TO
Légionellose in Pas-de-Calais 2003/2004:
FRENCH CODE OF PRACTICE 1 (IN FRENCH)
FRENCH CODE OF PRACTICE 2 (IN FRENCH)
FRENCH CODE OF PRACTICE (IN ENGLISH)
Email Denis
legion@q-net.net.au
ppPas
contagieuse. Les premiers cas de légionellose ont été
