Western Australia recorded its first outbreak of Legionnaires Disease in July 1996 in the town of Esperance which is in the South West of that state.
The main source of sporidic cases (76%) of Legionnaires Disease in Western Australia is Legionella Longbeachae which normally is associated with potting mix

A review of 4 cases of Legionella in 1979 proved that one case in 1974 did in fact die of Legionella . The first known case of the disease in Australia
(Gilligan J, Medical J Australia 1980 -1-368-371)

Legionella Longbeachae was Isolated from two patients with community acquired pnumonia. The source of infection was is unknown as the organism has never been isolated from the SA enviroment.
(Lim I, Medical J Australia 1989 150--559-601)

Panic in the potting shed Is gardening a health hazard. Legionela longbeachae has been found in Australian potting mix
(Ruchlemann, Medical J Australia 1996--164--36-38)

First case of Legionella maceachernii 71 year old carpenter died 25 days after admission to hospital
(Merrell, Medical J Australia 1991 September. 155 415-417)

Following a statewide outbreak of legionellosis due to Legionella longbeachae in South Australia in 1988 and 1989 studies were performed to find the source. Legionella longbeachae was isolated from a number of potting mixes. The isolation of Legionella longbeachae from some potting mixes suggest that soil rather than water is the natural habitat of this species and may be the source of human infection.
(Steele.TW, Appl Environmental Microbiology 1990 56--49-53)

Legionella longbeachae and other Legionella spp, were isolated from 73% of 45 potting soils made in Australia by 13 manufactures, between March 1989 and May 1990.
(Steele TW, Appl Environmental Microbiology 1990 56 (10) 2984-2988)

Legionella fairfieldensis sp. nov. isolated from cooling tower waters in Australia DNA hybridization studies showed that the three isolates belong to a new species of Legionella, Legionella fairfieldensis.
(Thacker, J Clinical Microbiology 1991 29 March 475-478)

Legionella adelaidensis, A new species isolated from cooling tower waters. DNA hybridization confirmed that it is a new Legionella species for which the name Legionella adelaidensis is proposed.
(Benson, J Clinical Microbiology 1991 29 May 1004-1006)

Trouble in the potting shed.
(Anonymous, Lancet, 1990 july 21 151-152 336: 8708)

Pseudomonas Pyocyanea found in a EVAPORATIVE COOLER Ps. pyocyancea was cultured from the air passing through a cooling unit, which operated on the water evaporation principle. The organism was traced to the water trough, which was heavily contaminated, This evaporative cooler was serving an operating theatre in a Adelaide hospital
(Anderson K, Medical Journal of Australia 1957 page 529 April 18th.)

SEE
AUSTRALIAN CASES 1991 TO 1997

USA

Courtsey CDC Atlanta, Georgia

Arizona Tucson
Lo Que Pasa August 30, 1996

Water system chlorinated to destroy Legionella

Super-chlorination of the Arizona Health Sciences Center water system was done this week as a continuing effort to destroy Legionella bacteriaIn August, following recommendations from the Centers for Disease Control and the Arizona Department of Health Services, University Medical Center super-chlorinated its water systern to destroy the bacteria.

Since the beginning of the year, UniversityMedical Center has seen an increased incidence of Legionellosis, a bacterial disease that can cause pneumonia, with seven cases being diagnosed at UMG. All of the cases involved patients with severely suppressed immune systems.

The Legionella bacterium is common in the environment. People at greatest risk are those whose immune systems have been suppressed. Legionellosis can be easily treated with the common antibiotic, erythromycin.

"lt's important for people to know this is very common in the environment. According to the CDC, it's in 30 percent of large buildings and 50 percent of large air conditioning systems with Legionella, because it can be found everywhere in the environment. It's a serious issue and we have followed all CDC recommendations."
The disease was responisable for the deaths of two transplant patients and sickening five others.
ADHS confirmed 12 cases in this state this year, two in Pima County

1996,
Arizona and Ohio Nosocomial Legionnaires Disease

Two hospitals reported sustained transmission of nosocomial Legionnaires disease (LD). The hot water distribution systems in each hospital were implicated as the sources of infection. This report summarizes investigations in these two hospitals by hospital personnel, state and local health officials, and CDC and efforts to control transmission. Arizona, 1987–1996 In 1996, eight cases of nosocomial LD were diagnosed among cardiac and bone marrow transplant patients at hospital X. Possible nosocomial LD was first reported at hospital X in 1979, but no source had been identified. Intensified surveillance for noso-comial LD was initiated after the first three case-patients were identified in 1996. A case of definite nosocomial LD in a hospital X patient was defined as respiratory illness with a new infiltrate on chest roentgenogram occurring after ³10 days of con-tinuous hospitalization for a nonpneumonia illness and laboratory confirmation of le-gionellae infection by at least one of the following: 1) isolation of legionellae from tissue or respiratory secretions, 2) detection of Legionella pneumophila serogroup 1 (Lp-1) antigens in urine by radioimmunoassay or enzyme immunoassay, or 3) a four-fold rise in Legionella serogroup-specific antibody titer to ³128 between acute- and convalescent-phase serum specimens. Possible nosocomial LD was defined as onset of respiratory symptoms of LD after 2–9 days of continuous hospitalization (the incu-bation period for LD is usually 2–10 days). Through intensified surveillance and examination of infection-control and micro-biology laboratory records, 25 cases of LD linked to hospitalization during 1987–1996 were identified; 16 were definite cases, and nine were possible cases (Figure 1). All were diagnosed by culture. The median age of case-patients was 56 years (range: 17– 81 years); 13 (52%) were male. Most case-patients had received either heart or heart/lung transplants (11 [44%]) or bone marrow transplants (seven [28%]). Seven (28%) other patients were either immunocompromised (four) or had some form of chronic illness (three). Twelve (48%) patients died during their hospitalization; eight of these patients had LD identified on autopsy. During January–September 1996, cases of nosocomial LD occurred among eight (6%) of the 134 cardiac and bone marrow transplant patients. Based on a case-control study that matched the 25 case-patients with 49 controls (only one appropriate control was available for one case-patient) by age, date of ad-mission to hospital X, and underlying medical condition, no single risk factor for ac-quisition of disease was identified. However, information about exposure to showers, other aerosol sources, or ingested water for some patients was unavailable.

During August 1996, Lp-6, Lp-11, L. anisa, and a Legionella-like organism desig-nated D-1620 were cultured from the hot water distribution system, and Lp-1, Lp-4, Lp-6, and Lp-11 were cultured from swabs and water samples from water softeners. Water obtained from the wellhead of a private well that supplied some areas of the hospital contained Lp-1. Lp-6 was cultured from samples obtained from taps and showers in patients’ rooms and a carpet-cleaning unit used on the transplant ward. Air sampling within patient showers identified Lp-6 in respirable (1–5-micron) droplets. Seven patient isolates from 1996 were serogrouped. Of these, one was a serogroup 10; the remaining six were Lp-6, and five of these six were identical to Lp-6 environ-mental isolates from water softeners, showers, and shower aerosols by pulsed-field gel electrophoresis. Thermal decontamination of the hot water distribution system had been conducted in July 1996, but legionellae were later isolated from the potable water; three cases occurred after thermal decontamination. In response, the hot water distribution sys-tem was hyperchlorinated, and the water temperature at the taps was maintained at 120 F (49 C); however, following these measures, Lp-6 was again cultured from the potable water. As a result, additional measures that were implemented included in-stalling chlorine injection devices, removing areas of low flow (“deadlegs”) in the potable water plumbing, disconnecting the water softeners, and repeating the hyper-chlorination procedures. No new cases of nosocomial LD have been identified at hos-pital X since September 1996. Although cultures of potable water samples from the distribution system of a unit where transplant patients were not present were positive for L. bozemanni in December 1996, subsequent samples from other areas have been negative. † Respiratory illness with a new infiltrate on chest roentgenogram occurring after ³10 days of continuous hospitalization for a nonpneumonia illness and laboratory confirmation of legionel-lae infection by at least one of the following: 1) isolation of legionellae from tissue or respi-ratory secretions, 2) detection of Legionella pneumophila serogroup 1 (Lp-1) antigens in urine by radioimmunoassay or enzyme immunoassay, or 3) a fourfold rise in Legionella serogroup-specific antibody titer to ³128 between acute- and convalescent-phase serum specimens. § Onset of symptoms of LD after 2–9 days of continuous hospitalization.
(MMWR May 16, 1997 / Vol. 46 / No. 19)

1960 CALIFORNIA (LOS ANGELES)

During routine bacteriological culturing of nursery fomites in a hospital, Pseudomonas aeruginosa was found in sinks and in faucet aerators, Water from the faucets was used to wash hands and clean equipment, and may have contributed to the difficulty encountered in cleaning incubators free from Pseudomonas, The only other fomites providing a moist environment and culturing Pseudomonas were the sink sponges, Handwashing within the room with the contaminated water could easily have transmitted Pseudomonas to susceptible infants. In the nursery for premature infants. one of the 7 infants had a persistent nasopharyngeal culture of Pseudomonas. which was also obtained in pure culture from his lungs after death; the other 6 were not infected, Cultures of the humidifing water, the infants Isolette, air of his Isolette, and the room were negative for Pseudomonas.
(Wilson Miriam G, J A M A 1961 April 1 112-114)

1978 WADSWORTH MEDICAL CENTRE LOS ANGELES

A THREE YEAR EPIDEMIC OF LEGIONNAIRES DISEASE Forty nine cases of Legionnaires disease was identified from May 1977 through July 1978 in patients and employees at the Wadsworth Medical Centre, Fifteen patients died, all Legionnaires disease patients were in hospital before onset of illness.
(Haley CE, Annals of Internal Medicine 1979 90 583-586)

1978 WADSWORTH MEDICAL CENTRE LOS ANGELES

A THREE YEAR EPIDEMIC OF LEGIONNAIRES DISEASE Cases of Legionnaires disease in hospitalized patients began occurring at the rate that averaged 4.5 cases per month from May 1977 till February 1980. The monthly number of legionnaires disease cases increased suddenly and dramatically to 21 in March 1980, five additional cases were identified retrospectively, bringing the total that month to 26, Twenty five of the twenty six cases at the time of the outbreak occurred in patientys who had been in hospital in the two to ten days prior to onset of symptoms, SOURCE hospital water system
(Shands KN J A M A 1985 253 1412-1416)

1978 WADSWORTH MEDICAL CENTRE LOS ANGELES

A THREE YEAR EPIDEMIC OF LEGIONNAIRES DISEASE Twenty four cases of Legionnaires disease were diagnosed at the Wadsworth Veterans Administration Hospital during a five month period. All cases occurred in persons exposed to the hospital environment during the usual incubation period of Legionnaires disease. Four patients in whom the disease was not suspected died of Legionnaires disease, One patient died of unrelated causes. Fifteen of 19 survivors received erythromycin theray.
(Kirby BD, Annals of Internal Medicine 1978 89 297-309)

1980 CALIFORNIA (LONG BEACH)

A new species of bacteria that is an etiologic agent of human pneumonia has been isolated. The organism was isolated from respiratory tract specimens from 4 patients, Two cases in California and one in Geogia and the fouth unknown. The name LEGIONELLA longbeachae species nova is proposed for this organism.
(McKinney RM, Annals of Intern Medicine 1981 94 739-743)

1980 CALIFORNIA (SAN FRANCISCO)

During the first half of 1980, an unseasonal outbreak of legionellosis which involved 14 out of 1,000 workers occurred in a six month old building in San Franciso. An epidemiologic investigation revealed that persons 50 years of age and older were at increased risk of the disease. The outbreak was temporally associated with operation of the building`s airconditioning system, in addition, Legionella pneumophila serogrups 1 to 4 and 6 were identified in water samples taken from a rooftop airconditioning tower located directly across the street from an area of recent excavation. This outbreak was unusual in several respects . First it occurred in late winter, whereas both sporadic and emidemic legionellosis has generally been a disease of the summer and fall, the unseasonality of this outbreak was probably related to the unique weather of the San Francisco Bay area, where less variation in tempature occurs from one season to another than occurs in many other locales. The heavy rainfalls in the area during the month prior to the outbreak may have promoted growth of Legionella pneumophila in the disturbed soil of the excavation site across the street from the building. Similarly, a heavy rainstorm after a period of extensive excavation on the grounds of St. Elizabeth`s Hospital in Washington D,C. preceeded by nine days the onset of an extensive outbreak of legionellosis in that hospital in 1965.
(Conwill DE, American Rev Respir Dis. 1982 126 666-669)JAMA 253 (10): 1412-1416 (Mar 8 1985)

1986
CITY OF HOPE MEDICAL CENTRE. DUARTE
An investigation into the source of three cases of Legionnaire`s disease at the City of Hope Medical Center in Duarte is focusing on an a cooling system that was contaminated with standing water, rust and dirt , the Centers for Disease Control said.

The cooling system, on the roof of one of the hospital buildings, was an area where routine maintance had been neglected.
It was likely that the Legionella bacteria would be isolated from the system.
In Los Angles, a epidemic of Legionnaires disease caused 201 cases at the Wadsworth Veterans Administration Medical Centre between 1977 and 1981, There was 46 deaths, but the bacteria was a contributing factor in only half of these cases.
(Source Media)

Potable water as a source of Legionnaires' disease.

A three-year epidemic of legionnaires' disease in a hospital was dramatically curtailed following hyperchlorination of the potable water supply. The hypothesis that potable water was the source for the outbreak was further supported by isolation of Legionella pneumophila (the agent of legionnaires' disease) from the hospital water supply, observation that a sudden upsurge had occurred in the number of cases following a peculiar manipulation of the hospital water system, and documentation of a 30-fold increase in concentration of organisms in the water when this manipulation was artificially recreated. Thus, potable water may be an important source of epidemic legionnaires' disease and continuous hyperchlorination a method of control.
(Shands KN, Ho JL, Meyer RD, Gorman GW, Edelstein PH, Mallison GF, Finegold SM, Fraser DW)

1986
LOS ANGELES

An outbreak of Legionnaire`s disease in a Los Angeles retirement home caused the Countys Health Department Services to issue a warning to physicains as well as this outbreak there was a string of cases at the UCLA Medical Centre.
At least seven deaths have been attributcd to these outbreaks,
The outbreak at a 240-urut Westwood I-ionzons residenhal facility for the elderly occurred in June and July and resulted in four deaths,

A second outbreak of eight cnses of Legionnair` s disease at UCLA since last fall has resulted in three deaths of patients who were gravley ill.
(Source Media)

1988 CALIFORNIA SANTA CLARA COUNTY

An outbreak of Pontiac Fever occurred among 34 of 56 people attending conferences at a hotel in Santa Clare County in 1988. Two groups had an acute febrile upper respiratory illness, with a mean attack rate of 82% and a mean incubation period of 56 hours. Legionella anisa, which has not previously been associated with outbreaks of Pontiac Fever or Legionnaires disease, was isolated from a decorative fountain in the hotel lobby. The findings raise concern about water treatment protocols foer the extent of disease that might be caused by exposure to aerols containing Legionella anisa and other Legionella species.
(Fenstersheib MD, LANCET 1990 September 1 336 (8714) 576)

1988 CALIFORNIA (LOS ANGELES)

An outbreak of Legionnaires disease at a hotel for senior citizens where Legionella pneumophila was isolated from two separate water systems that produced aerosols; an evaporative condensor and the potable hot water system. Five residents and one employee of a 14 storey . 275-unit retirement home in Los Angeles developed Legionnaires disease between 10 June and 22 July 1988. Four patients died.
(Breiman RF, Journal of Infectious Diseases 1990 161 1257-1261)

1991 CALIFORNIA (RICHMOND)

An outbreak of Legionnaires disease in the Social Security Building in Richmond affected at least 9 and possible 15 workers. A 37 year old custodian died on September 9 after suffering from the Knoxville strain of the bacteria found in the buildings tepid water system, She and twelve of the 15 stricken employees worked in the basement.

1994 CALIFORNIA (SANTA ANA)

Bacteria linked to the cause of LEGIONNAIRES DISEASE have been detected in treated waste water used to irrigate local public properities including Mile square Regional Park in Fountain Valley, according to Orange County Sanitation District research. Sanitation officails, however, said the study had not determind whether people could be infected by the bacteria found in water samples taken from the Orange County Water District and the Irvine Ranch Water District.

1995 CALIFORNIA (RICHMOND)

The deadly bacteria that caused an outbreak of Legionnaires Disease in the Social Security Administration building in Richmond in 1991 which killed two people resurfaced recently in the water system of the building again. In 1991 two women that worked as janitors died, The agency conducts monthly checks for Legionella since the outbreak in 1991. The latest find posed no threat to any employees or visitors to the building

1978 COLORADO

1989 COLORADO (LAMA)

On October 16 1989 the Colorado Health Department was notified by a local physician of an elderly patient who was hospitalized with pneumonia after attending a high school class reunion at a local hotel/motel in Lamar, Colorado on September 22-24 , After the patient reported that other members of the reunion group had also developed pneumonia, and that two had died. After futher investigation it was found that the Evaporative Airconditioning (COOLER) Units on the roof were the cause of the outbreak of Legionnaires` disease. Twenty cases were reported with THREE deaths. Although Colorado reported 33 sporadic cases of Legionnaires disease between 1986 and 1988, this is the first recognized outbreak in Colorado.

1992
DENVER COLORADO.

Five cases of LD occurred at a Denver hospital between the dates of 2/18/92 and 5/24/92 . Each case had x-ray proven pnuemonia and a culture of respiratory secretions or lung tissue that was positive for Legionella pneumophila, serogroup 1 (Lpl) . An environmental investigation demonstrated that one hot water tank i the hospital was contaminated with Lpl. All cases were hospitalized in a part of the facility served by this tank. Monoclonal antibody subtyping performed on isolates from four cases and from the contaminated hot! water tank revealed they were the same subtype.

Though routes of exposure for the cases are unproven, all cases except one were exposed to respiratory therapy equipment (nebulizer medication chambers or plastic tubing attached to manual resuscitators) that may have been rinsed with tap water from the implicated hot water tank. Two cases showered with water from the implicated hot water tank. Both the use of contaminated respiratory therapy equipment and showering have been previously implicated as possible routes of Legionella transmission . The hospital disinfected the implicated hot water tank using a method of superheating and hyperchlorination and reviewed procedures to eliminate any possible use of tap water in respiratory therapy devices.

In 1995 42 cases of Legionella was reported in Colorado

1992 COLORADO

In June 1992, 13 of 34 guests experienced illness that met the symptom-based case defination of Pontiac Fever. Each guest reported using an indoor hot tub compared with six of 21 nonill guests. Water samples from the indoor tud were culture-negative for legionellae using standard techniques. Direct fluorescent antibody testing indentified the organism as serogroup 6, Seroconversion to Legionella pneumophila serogroup 6 occurred in 7 of 11 ill guests and none of 5 non ill guests.
(Miller LA Journal Infectious Disease 1993 168 769-772)

1992 COLORADO (DENVER)

An outbreak of Legionnaires disease found 10 cases with four deaths. A women was diagnosed with legionnaires disease about two weeks after she was admittted to St. Anthony Hospital`s northern branch in Westminster CO. Whether or not her case is related to the the other cases at St. Anthony Central Hospital Central in Denver is uncertain.

CENTRE FOR DISEASE CONTROL

As of 30 September 1979, 1005 confimed cases of sporadic legionellosis caused by Legionnniares disease serogroup 1 to 4 in US residents had been reported to CDC 19% were fatal. About 75% of the cases occurred in June through October. The risk of acquiring sporadic legionellosis was increasing among males and persons over 50 years or older;
(England AC, Annals of Internal Medicine 1981 94 164-170)

CENTRE FOR DISEASE CONTROL (CDC) 1980

As of April 30 83 nosocomial cases of sporadic legionellosis has been reported to CDC, in all 83 cases the patients had pneumonia. All but one patient was hospitalized at the time of onset, of the 71 patients for whom the outcome is known 22 died of causes directly attibuted to their infection, Eleven patients hjad end-stage renal disease, 28 were receiving systemic immunosppressive medication, 17 had cancer, 12 had chronic bronchitis, or emphysema, 29 were smokers and 4 had diabetes. Methods for preventing nosocomial legionellosis are not known, but comparing legionella to other water-associated organisms which have been spread from other medical devices to cause pneumonia may be fruitful
(England AC, American Journal of Medicine 1981 70 707-711)

1978 CONNECTICUT
NORWALK

An outbreak occurred here during April to September 1978, a total of 26 cases of the disease were recorded with 10 deaths.

1984 CONNECTICUT
STAMFORD

From October to February 1984 five cases of legionella bozemanii occurred in a hospital in Stamford. legionella bozemanii was cultured from four of the five infected patients, from the tap water in the patients care areas, from the hospital hot water holding tanks, and from soil in an area of excavation and new contruction on hospital property. This outbreak reaffirms that excavation and contruction are risk factors for the put break of nosocomial legionella pneumophila and is the first description of nosocomial infection due to legionella bozemanii.
(Parry MF, Annals of Internal Medicine 1985 103 205-210)

1986
Connecticut
3 WITH LEGIONNAIRES' DISEASE DIE IN CONNECTICUT HOSPITAL

At least four patients at a Connecticut hospital contracted Legionnaires' disease, and three of them have died, health authorities said Friday.
The deaths occurred in the last two months, while a fourth patient remains in the Hospital of St. Raphael in New Haven,
A hot-water pipe probably harbored bacteria that caused the disease

1986 Norco.
Riverside

Eight municipal workers underwent treatment for symptoms of Legionnaires' disease after they became ill during repair work on a broken water line.
The eight men treated had worked in or near a water-filled ditch in an area of the Riverside County community, 45 miles east of Los Angeles.

La Plata, Md.
health officials said Friday that they had exhumed the bodies of two people Thursday as part of an investigation into possible cases of Legionnaires' disease.

A rash of pneumonia cases in Charles County, Md., last month led health officials to believe that Legionnaire`s Disease had broken out. But state health officials said Monday that they were still only able to confirm the presence of the disease in one person.

Sheboygan

MYSTERY ILLNESS BREAKS OUT IN WISCONSIN NEIGHBORHOOD

The streets of a working class neighborhood have produced a medical mystery in this Lake Michigan city as authorities investigate 30 people with symptoms of Legionnaire's Disease.

One person has died of Legionnaire's Disease since mid- August and three others of atypical pneumonia.

The illness is baffling because the cases have no apparent link, other than that most of them came from a 15- block area on the city's northwest side.

The mystery began with the first admissions Aug. 10. Most of the cases were admitted between then and Aug. 15,

Health officials began their investigation Friday, Some of the victims remain hospitalized.

The ill range in age from 31 to 86, but 19 are over age 55,

Wisconsin sees about 30 isolated cases of Legionnaire's Disease each year,
The last outbreak was in 1979 in Eau Claire, where nine people became ill and four died.

Legionnaire's victim is Irene M. Potter, 67, mother of state Rep. Calvin Potter, who grew up in the neighborhood.

1994 DELAWARE (WILMINGTON)

The air-conditioning cooling tower at St. Francis Hospital was the source of a recent outbreak of Legionnaires disease, Experts say, DNA tests from two of the 23 treated for the respiratory illness matched the strain of the Legionella bacteria taken from the cooling tower.

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.
(Hlady WG, American Journal Epidemiology 1993 138 555-562)

1995 FLORIDA (ORANGE COUNTY)

All water samples drawn from the Education Building and the Reflecting Pond on March 18 have tested negative for Legionela bacteria, the Orange County Public Health Unit reported. The investigation was concentrating on two cases involving College of Eduction employees that were reported in late February and early March, Under public health protocols, two cases linked in time and associated with the same potential source of infection triggered an investigation. Two early cases, one reported over a year ago by the college of Education employee and another involving an education major who fell ill last October and reported the illness in the wake of recent publicity, could not be confirmed for legionella.

1978 GEORGIA ( ATLANTA)

An epidemic occurred among golfers at a country club in Atlanta , Three comfirmed cases and five presumptive cases of Legionnaires disease occurred among golfers from the 2 till the 7 July 1978, The output vent of the evaporative condensor in the clubs airconditioning system faces the tenth tee of the golf course approxipully 46.6 metres away. From the Evaporative condensor, organisms related to or identified to the Legionnaires disease bacterium were isolated.All cases were members of the club.
(Eickhoff Theodore C Annals of Internal Medicine 1979 90 499-502)

1979 ILLINOIS (CHICAGO)

During the three summer months of 1979 we have diagnosed presumptive Legionella pneumonia infection in 11 out of 47 patients studied. We emphaszie to our medical staff that we are learning as we accumulate information and prefer not to be rigid about diagnostic criteria. All patients tested have not had any common epidemiologic features, and this leads us to conclude that Legionela pneumonia infections have occurred endemically within the community and did not represent an epidemic or an “exotic” illness. There has been no evidence of person-to-person spread of the disease, and after a mild initial stir of excitement, Legionnaires disease patients are now treated routinely in our hospital.
(Carter JB, Annals of Internal Medicine 1979 91 794)

1980 ILLINOIS (CHICAGO)

Legionnaires pneumophila was isolated from nine of 16 shower heads in a Chicago hospital ward where three patients had contracted Legionnaires disease, the bacteria was also isolated from two other hospitals
(Lester G , Annals of Internal Medicine) 1981 94 195-197)

1978 INDIANA ( BLOOMINGTON)

Thirty nine cases of Legionnaires disease in a 16 month period were identified in visitors to and residents of Bloomington, Thirty five patients had spent at least one night at the Indiana Memorial Union in the two weeks before coming ill, five of the 32 spordic cases nationwide between January 1 and 31 March 1978 were shown to be persons who had recently visited the Union. A cooling tower may have been involved in disease spread, but it was not the only source.
(Politi BD, Annals of Internal Medicine, 1979 90 587-591)

An organism similar to or identified to the Legionnaies disease bacterium was isolated from the airconditioning cooling tower atop of the Union Building, That the involvement of the airconditioning system could not be the entire story, however,is indicated by the fact that several confirmed cases occurred during the month of February at the time the airconditioning was not in operation
(Eickhoff Theodore C Annals of Internal Medicine 1979 90 499-502)

1981 IOWA IOWA CITY

Nosocomial pneumonia caused by Legionella pneumophila serogroup 1 occurred in five patients after bone marrow transplantation for hematoligic malignancies. Two patients died as a result of the infection. Legionnaires disease remains a highly lethal infection in immunocompromised hosts.
(Kugler JW, American Journal of Medicine 1983)

1981 IOWA

Over a 10 month period, 24 cases of Legionnaires disease pneumonia occurred among patients admitted to the University of Iowa Hospital, most of whom were immunosuppressed. Eleven died. Legionella pneumophila serogroup 1 was isolated from both patients and water outlets.
(Helms CM. Annals of Internal Medicine 1983 99 172-178)

1981 IOWA JOHNSON COUNTY

In October 1981, an outbreak of 29 cases of community-acquired pneumonia occurred among adults in Johnson County. Retrospective study revealed 12 cases had laboratory evidence of Legionnaires disease. No significant differences in clinical or epidemiological features were found between Legionnaires disease cases and the other pneumonias iin the outbreak. All Legionnaires disease cases received erythromycin; one patient died. The outbreak focus could not be identified.
(Helms CM, American Journal of Public Health 1984 74 835-836)

1975 KANSAS (KANSAS CITY)

Nosocomial Legionnaires' disease.

The first proved outbreak of nosocomial Legionnaires' disease occurred in a psychiatric hospital in Washington D.C. in 1965, but the diagnosis was not established until determination of serum antibodies against Legionella pneumophila by the indirect fluorescent antibody (IFA) test was undertaken, using the bacterial antigen isolated from patients with Legionnaires' disease in the 1976 outbreak in Philadelphia. The second nosocomial outbreak of Legionnaires' disease occurred in three immunocompromised patients who received renal transplantation at the University of Kansas Medical Center and died of extensive lobar pneumonia in 1975. The direct fluorescent antibody (DFA) test revealed L. pneumophila in the lungs of all three patients after the Legionnaire`s disease agent was identified. The lack of prospective surveys using sensitive diagnostic procedures by various types has limited our knowledge on the extent of the problem caused by legionella. In fact, nosocomial Legionnaire`s disease is a worldwide problem, and control of this disease requires thorough cooperation of physicians, epidemiologists, microbiologists and expert engineers.
(Wang LS, Chin TD, Liu CChung Hua I Hsueh Tsa Chih 44 (4): 242-248 Oct 1989)

KENTUCKY
1989
SIMPSONVILLE

Two case of Legionnaires' disease, was reported at the Whitney Young Job Corps Center,
Two roommates, one age 16 and the other l 9, were stricken with the disease.
Both have fully recovered and are on leave from the center
The other 98 residents of the dormitory in which the two boys lived, have been sent home while tests are conducted on the building's Air-Conditioning and Water Systems.
There's also a possibility that the bacteria that causes the disease was brought into the center from elsewhere,
About the middle of January, the first boy became so sick that he was hospitalized at United Medical Center which is in Shelbyville,Then during the last week of.January, his roommate became ill and was hospitalized.

1990
LOUISVILLE

Two cases of Legionnaires' disease -- one involving an elderly man who died was confirmed by local health officials.

A third case is suspected, but offcials are awaiting the results of additional tests. All of the victims, residents of The Glenview, a high-rise condominiiim on Brownsboro Road in eastern Jefferson County, were taken to Hospital.

An autopsy revealed that the man's death was due to the disease. The other two victims, an elderly couple.
Tests revealed that the husband has the disease, but doctors are awaiting further test results on his wife.
The director ot the Louisville and Jefferson County Board of Health, said the couple both in their 70s were expected to recover.
A spokeswoman for the Hospital, said the man who died had been admitted March 5 .
He was in his late 80s and was suffering from severe pneumonia she said, so doctors weren't certain whether his death was due to the pneumonia or Legionnaires' disease until the autopsy.
( Source-- Media)

1989 LOUISIANA
BOGALUSA

From 10 October through 13 November 1989 34 patients were hospitalized with Legionnaires disease and two deaths in Bogalusa. Legionella pneumonphila serogroup 1 was isolated from water in the reservoir of a automatic misting machine in a grocery store. Aerosols from the grocery store mist machine was the source of this outbreak.
(Mahoney FJ, Journal of Infectious Diseases 1992 165 April 736-739

1978 MAINE (TOGUS)

September 1978
MASSACHUSETTS SCHlLMARK,

Information was beening determined to see whether an illness that felled seven people on Martha's Vineyard island is Legionnaire's Disease.Water samples near the Chilmark Pond cottage where the people stayed on this resort island off the Massachusetts coast were being tested

Investigators expected that it would be over a week before results of the tests were known

The Hospital spokesman at Martha`s Vineyard said three cases are being considered for Legionnaire's Disease, and as yet the illness has not been identified he added, there have been no further cases on the Vineyard or in the places where the people now live.
Those stricken earlier include six members of one family and a friend.

Within a few days after leaving the island for other parts of the country, each person from the group experienced fever, chest pains and pneumonia like symptoms of Legionnaire's Disease.

1993 MASSACHUSETTS (FALL RIVER)

During July-August 1993, LD was diagnosed in 11 persons living in Fall River, Massachusetts. The mean age of patients was 59 years (range: 40-72 years); six were men. Three persons died. Three persons had Legionella pneumophila serogroup 1 (Lp-1) isolated from respiratory secretions, four had Lp-1 antigens detected in respiratory secretions by direct fluorescent antibody testing, three had fourfold rises in serum antibody titer to Lp-1, and one had both a fourfold rise in serum antibody titer and Lp-1 antigens detected in urine by radio-immunoassay. A case-control study, matching the 11 patients and 22 controls by primary physician, age, sex, and underlying medical condition, indicated that patients were more likely than controls to have visited sites within a 0.04-square-mile (0.1-square-km) neighborhood of Fall River in the 2 weeks before onset of illness (matched odds ratio [OR]=14.0; 95% confidence interval [CI]=1.6- 120.8); no other activities were significantly associated with acquiring LD. Water samples from seven CTs within the neighborhood and from the homes of culture-positive patients were taken approximately 1 month after onset of the last identified case of LD in the community and cultured for legionellae. All samples from potable water taps in patients' homes were culture-negative. Five isolates were cultured from four CTs. Lp-1 was cultured from two conjoined CTs on a building within the neighborhood and had the same monoclonal antibody subtype (MAS) and pulsed-field gel electrophoresis (PFGE) patterns as all three clinical isolates. The conjoined CTs were decontaminated on an emergency basis according to guidelines previously developed by a technical work group (1). The onset of the last identified case was August 10, and the CT was decontaminated on September 24. No additional ases were identified after decontamination.
(Morbidity and Mortality Weekly Report, Vol 43 No.27July 15 1994)

1968 MICHIGAN (PONTIAC)

In July and early August 1968 an epidemic of acute febrile myalgia affecting at least 144 people occurred in a county health department building in Pontiac, A relatively uniform. self-limiting illness of chills, fever, headache, and myalgia lasting two tto five days affected 95 per cent of employees working in the department.. Adefective airconditioning system was implicated as the source and mechansim of spread of the caustive factor, Since this outbreak a bacterium similar to or identical with the agent responsible for the Legionnaires disease has been isolated from guinea pigs exposed to the Pontiac health department building.
(Glick TH, American Journal Epidemiology 1978 107 149-160)

1978 MICHIGAN (DETROIT)

1985 MICHIGAN

During may 1985 in Michigan, 14 cases of legionellosis ocurred from among 380 people at a church banquet in a hotel, Legionella pneumophila was found on the surface of the cooling coils of the airconditioning units to the hall.
(Morbidity and Mortality Weekly Report 1985 34 344-350)

1993 MICHIGAN

During August-September 1993, LD was diagnosed in 17 persons with pneumonia at a state prison in Michigan; 16 patients were inmates, and one was an employee. One patient died. The mean age of the patients was 47 years (range: 29-81 years); all were men. One person had Lp-1 cultured from respiratory secretions and, for 11, LD was diagnosed by a fourfold rise in titer of antibodies to Lp-1; five patients with pneumonia had evidence of LD by single convalescent-phase antibody titers of 512 or more. Water samples from wells and potable water taps in the prison and the prison hospital, from the prison hospital CT, and from a CT near the prison were cultured for legionellae. All of the potable water samples were culture-negative. Lp-1 was isolated from both CTs. The isolate from the CT located on the roof of the prison hospital had the same PFGE pattern as the single clinical isolate. Fourteen (0.6%) of 2253 prisoners who used exercise yards each day adjacent (within 100 yards) to the prison hospital had LD, compared with two (0.1%) of the 2270 inmates who used yards at least 400 yards from the prison hospital (relative risk=7.1; 95% CI=1.6-31.0). The CT on the prison hospital was shut down on September 17 and decontaminated according to published guidelines (1). No new cases of LD were identified with onset after September 1.
(Morbidity and Mortality Weekly Report, Vol 43, No.27, July 15 1994)

1996
MICHIGAN DETROIT

The outbreak at Farmington in September 1996 is stated to be 30 cases with 3 deaths , the Cooling Tower on a rooftop of the Cattlesmans Market was said to be the cause, it is alleged that the Legionella count was 100 000cfu/m which is very high.
It was also stated that thousands of people turned up at the areas hospitals and the Health Department for information , it was estimated that thousands of people phoned the Health Department for information over the weekend of the anouncement of the outbreak.

Retrospective study shows that a 1957 outbreak of pneumonia in Austin was Legionnaires disease, Between June 7 and August 9 1957 -78 persons were hospitalized with acute respiratory disease of unknown cause, Two patients died, 46 of the 78 patients were employees at the local meat packing plant. Serologic data and the 1957 clinical and epidemiologic observations support the contention that this is the earliest documented outbreak of Legionnaires disease.
(Osterholm MT, American Journal of Epidemiology, 1983 117 60-67)

Two Community Outbreaks of Legionnaires' Disease
Southwestern Minnesota, 1995

Minnesota Department of Health (MDH) investigated two separate clusters of community-acquired pneumonia, one in Mankato (population 34,000) and the other in Luverne (population 4,500), Minnesota. Both were determined to be outbreaks of legionnaires' disease which resulted from exposure to contaminated medical center cooling towers.

OUTBREAK #1 On Thursday, August 3, 1995, a physician in Mankato notified the MDH of an increased number of persons hospitalized with community-acquired pneumonia of undetermined etiology. Between July 16 and July 31, 32 patients were hospitalized with pneumonia at the only hospital in Mankato, representing an increase of 220% over the same time period in June of that year. The majority of these cases either lived or worked in one neighborhood. An investigation was begun on August 4 to describe the epidemiology and to determine the cause. On Sunday, August 6, the MDH clinical Laboratory Section confirmed Legionnaires' disease in a Mankato resident who had died of pneumonia This finding, along with the clinical presentation of the other cases and season of occurrence, all strongly supported Legionella pneumophila as the cause of the outbreak.

Methods In order to determine the extent and timing of the outbreak, we attempted to identify potential cases of Legionnaires' disease by examining hospital, clinic, and emergency room records for all patients with a physician-diagnosis of pneumonia or infiltrate on chest x-ray and fever identified between May 15 and August 23, 1995. Potential cases were then contacted to arrange interviews and to obtain sera for diagnostic testing. A confirmed case of Legionnaires' disease was defined as a patient with a compatible illness and either L. pneumophila isolated from a clinical specimen, a 4-fold rise in antibody titer to L. pneumophila >= 1:256, demonstration of L. pneumophila in aclinical specimen using DFA testing, or a positive urinary antigen test for L. pneumophila. A probable case was defined as a patient with physician-diagnosed pneumonia who had a single convalescent L. pneumophila antibody titer of >= 1:256. Clinical specimens for culture were obtained from potential cases whenever possible. Since cooling towers and evaporative condensors have been commonly implicated as causes of geographically localized Legionnaires' disease outbreaks, MDH staff inspected and obtained water samples for culture from all known cooling towers in Mankato prior to disinfection using chlorine bleach on August 5. Specimens obtained from patients and water samples were cultured at MDH for L. pneumophila using standard microbiologic methods . Isolates were subtyped at MDH using pulsed-field gel electrophoresis (PFGE) testing and at the Centers for Disease Control and Prevention (CDC) by monoclonal antibody (MAb) testing.

Results Interviews and convalescent sera were obtained for 113 (70%) of 162 potential cases identified through record reviews. Seventeen cases of Legionnaires' disease meeting criteria for a confirmed or probable case were identified with illness onsets between July 16 and August 15 (Figure 1); three were confirmed by culture. One death due to Legionnaires' disease occurred. The median age for cases was 51 years (range: 32 to 93 years); nine (53%) cases were male. Known risk factors (age >= 60, being a smoker, use of immunosuppresive medications, or chronic underlying disease) were identified in 15 (88%) cases. An additional 10 patients met a probable case definition (i.e., with a compatible illness and single positive antibody titer >= 1:256) but had illness onset between May 25 and July 10, 1995.

Overall, L. pneumophila serogroup 1 was isolated from 10 (45%) of the 22 cooling towers in Mankato. All three isolates obtained from patients had the same PFGE pattern. Only one of the isolates obtained from the cooling towers had this pattern; that isolate was obtained from a cooling tower which served the hospital. Exposure to the area immediately around the medical center through residence, employment, or visitation in the 10 days before illness onset was established for 16 (94%) cases. Twelve resided in the area, two were employed at the medical center and two visited the area (one to the clinic and one to another location). MAb testing failed to distinguish the outbreak strain from Legionella isolates obtained from different cooling towers. Initial testing of sera from potential cases using an FDA-licensed indirect fluorescent antibody (IFA) test kit (IFA #1) were largely negative. This finding raised concerns about a lack of sensitivity for this particular test kit, so additional laboratory evaluation was conducted using a different FDA-licensed IFA test (IFA #2) performed on the same sera. Antibody titers of >=1:256 were detected in only three (3%) of 102 potential cases using IFA #1 as compared with 27 (24%) of 113 potential cases using IFA #2. Among a cluster of potential cases who lived or worked in the implicated neighborhood near the hospital (thus were likely exposed) and who had illness onset between July 16 and August 15, antibody titers >= 1:256 were found in only three (21%) of 14 using IFA #1, versus 12 (86%) of 14 using IFA #2.

Conclusion We conclude from this investigation that an outbreak of community-acquired pneumonia due to L. pneumophila serogroup 1 occurred during July and August as a result of exposure to a contaminated cooling tower located at the hospital in Mankato. It is possible that cases occurred as early as May; however, early cases were only identified based on a single antibody titer >= 1:256. Since the positive predictive value of a single elevated convalescent titer may be low , it is not clear if these cases represent true recent Legionnaires' disease or not. The outbreak ended after this cooling tower, along with others in Mankato, were disinfected. No unusual practices in the maintenance or operation of the implicated cooling tower were identified. We alsodemonstrated intralaboratory variability between two FDA-licensed IFA test kits for detection of L. pneumophila. Had we used only IFA #1 and had the cases not clustered at a single hospital, this outbreak may have gone unrecognized. Finally, we demonstrated the utility of PFGE in identifying the outbreak strain. In this investigation, PFGE testing was a more discriminative subtyping method than MAb testing for linking the clinical and environmental isolates.

OUTBREAK #2 Background On Tuesday, August 22, 1995, an infection control practitioner (ICP) at the hospital in Luverne, Minnesota, notified MDH staff of a marked increase in hospitalizations for pneumonia of undetermined etiology. On the same day, MDH staff arranged for urinary antigen testing of a patient with a typical illness and confirmed the diagnosis of L. pneumophila serogroup 1 infection.

Methods To identify cases for Legionnaires' disease, we examined hospital, clinic and emergency room records of persons diagnosed with pneumonia and fever between June 1 and August 31, 1995.Cases were classified according to the same criteria employed during investigation of the outbreak in Mankato. Inspections were conducted of all potential environmental sources in the area, including cooling towers (N = 6) and other mist-creating devices (N = 2). Water samples from potential sources were collected for culture of Legionella species and isolates were characterized using PFGE and MAb. All cooling towers were disinfected with chlorine bleach on August 23 after appropriate water samples were obtained. A case-control study was conducted to determine risk factors for illness using cases with a positive urinary antigen test for L. pneumophila serogroup 1 and illness onset between August 17 and 20, and two age frequency-matched community controls per case. Controls were identified through a systematic selection of telephone numbers with the same first three digits as the case telephone number. Demographic information, medical history, and a history of daily activities were obtained from cases and controls for the time period from August 10 through 20, 1995. Case and control exposure to a potential environmental source was defined as being within a 1000-foot radius of the source during the 10-day period when daily activities were assessed.

Results Twenty cases meeting the confirmed (N=16) or probable (N=4) case definitions were identified with illness onsets between August 7 and August 25 (Figure 2); one case was confirmed by culture. The median age for cases was 78 years (range: 27 to 90 years). Ten cases were male and one death occurred. Results of the case-control study revealed that exposure to the medical center was the only exposure variable associated with illness (nine [100%] of nine cases vs. 10 [56%] of 18 controls; Odds Ratio = undefined; p=0.017). Of 12 cases for whom exposure histories were ascertained (including the nine who were enrolled in the case-control study), seven visited the clinic for appointments, two accompanied relatives to the clinic, one worked at the facility, one lived in the area, and one denied exposure. L. pneumophila was isolated only from the medical center cooling tower. This isolate was indistinguishable by PFGE and MAb from the single patient isolate. The PFGE pattern for this outbreak was different than the PFGE pattern identified in the Mankato outbreak. No unusual practices in the cooling tower maintenance or operation were identified.

Conclusion Results of the case-control study and microbiologic investigation demonstrated that the likely source of L. pneumophila leading to this outbreak was the hospital cooling tower. The outbreak ended after disinfection of cooling towers in the community occurred.

COMMENT

Both of these outbreaks of Legionnaires' disease occurred as a result of exposure to contaminated medical center cooling towers. In both situations, the hospital and major outpatient clinics were housed together or close to each other in one medical complex. Despite standard maintenance programs, both of the epidemiologically implicated towers harbored L. pneumophila. We know of a least six other reports where medical center cooling towers were the implicated source of an outbreak (1,5-9). Medical center cooling towers may be more likely than other cooling towers to lead to outbreaks when contaminated because persons at high-risk of disease are likely to be exposed. Severe Legionnaires' disease occurs most commonly in the elderly and persons with immunocompromising conditions, both of whom are more likely to undergo frequent and regular medical attention. In Mankato the most common type of exposure was residence in the area. However, in Luverne, the most common exposure was visiting the clinic. In Luverne, persons seeking medical care likely came into contact with contaminated mist generated by the cooling tower serving the medical center.

Microbiologic diagnosis of Legionnaires' disease is somewhat problematic. Culturing the organism from clinical specimens is the "gold" standard but requires special growth media which is not available at all laboratories, and expertise in culturing varies among laboratories. A 1989 survey of microbiologic laboratories in the U.S. found that 32% of laboratories were unable to grow L.pneumophila from a pure culture . Detection of antibodies to L. pneumophila in sera by IFA is widely used but has major drawbacks for diagnosis of acute infections. Seroconversion may be delayed up to nine weeks, and false-positive tests may occur with infections due to other gram-negative organisms, Mycobacterium tuberculosis, Streptococcus pneumoniae, and Campylobacter. Also, the positive predictive value of a single elevated antibody titer has been shown to be low for sporadic cases . although in an outbreak setting, it may be somewhathigher. Furthermore, our investigation demonstrated substantial variability between two FDA-licensed IFA test kits. Direct fluorescent antibody (DFA) testing is a well-established but technically demanding method that requires sputum or biopsy material. The sensitivity of this technique using sputum is low (25-75%), but on biopsy specimens the sensitivity (80-90%) and specificity (99%) are much better . Urinary antigen detection is a convenient method for diagnosing Legionnaires' disease. One drawback is that only L. pneumophila serogroup 1 antigen is detected, although serogroup 1 accounts for 70-90% of all cases of Legionnaires' disease. A recent study reported a high specificity for urinary antigen testing (99%), but a relatively low sensitivity (56%) . The combined use of urinary antigen testing with aggressive attempts to obtain material for culture is currently the preferred diagnostic approach . Further molecular subtyping of isolates by PFGE is available at the MDH clinical laboratory and provides a highly discriminative means of comparing epidemiologically-linked isolates. Detection of these two outbreaks was facilitated by the fact that medical care in each of these communities was provided by only one major clinic and hospital. Since cases were cared for at only one facility, clustering of these community-acquired pneumonias was identified and more dispersed fashion, this outbreak would likely have gone unrecognized. Legionnaires' disease should be considered in the differential diagnosis of persons with community-acquired and nosocomial pneumonia. It is not possible to distinguish between Legionnaires' disease and other common causes of pneumonia solely on the basis of clinical, laboratory, or roentgenographic findings. Therefore, a high index of suspicion is warranted in persons with severe illness, the elderly, persons with immunocompromising medical conditions, or in apparent clusters of pneumonia. Erythromycin with or without rifampin has been considered effective therapy for Legionnaires' disease, although recent laboratory data suggest that the fluoroquinolone and new macrolide/azalide agents may have activities against Legionella that are superior to erythromycin .Suspected or confirmed cases of Legionnaires' disease are reportable, pursuant to Minnesota Rules Governing Communicable Diseases (MN Rules 4605.7000-4605.7800). In addition, MDH can provide assistance with laboratory diagnosis and confirmation, investigation of suspected clusters, and the coordination of control measures when outbreaks are detected.

1995

It was reported that at the same time as these two outbreaks, there may have been another one at DULUTH.
A 59 year old man who was in hospital for five days with pneumonia was suspected of having Legionnaire`s Disease
The man is a heavey equipment operator, who has been working around swamps and lakes.

1986
MARYLAND

A rural outbreak of Legionnaires' disease linked to visiting a retail store.

Between May 7 and June 7, 1986, 27 residents of a rural county in Maryland developed legionellosis, and two died. Legionella pneumophila serogroup 1 was cultured from the sputum of two patients and identified in lung tissue of a third patient by direct fluorescent antibody staining. An additional 11 patients had four-fold rises in antibody titer to L. pneumophila, and 13 had single titers greater than or equal to 1:256. To determine risk factors for disease, we performed a case-control study. Twelve of 16 case-patients reported visiting store A in the two weeks before onset of illness compared with four of 28 control-patients. A serologic survey of employees showed that employees of store A were 3.63 times more likely than control employees to have titers of antibody to L. pneumophila greater than or equal to 1:256 (95% confidence intervals 0.8, 16.7). Cultures of soil specimens, samples of water from the hot water system of store A and from stagnant ponds near store A collected five weeks after the end of the outbreak were negative for Legionella species. Store A was adjacent to a site of excavation and construction during May 1986, when the community was experiencing an extended drought. This investigation suggests that exposure to excavation and construction activity may be a risk factor for legionellosis.
( Lin FY, Fields BS, Biscoe J, Plikaytis BB, Powers P, Patel J, Lim BP, Joseph JM, Devadason C, et al Am J Public Health 80 (4): 431-434 (Apr 1990)

1988-1990
MARYLAND

Legionnaire`s Disease was confirmed at the Western Maryland Center state hospital in Hagerstown. Which bought to five and possibly six the number of patients who have contracted the pneumonia at the hospital and died since November 1988,

The latest case involved a 69-year-old western Maryland man who died May 30, A spokesman for the Maryland Department of Health and Mental Hygiene. The patient had been in the Hospital since 24 April.

Ten cases of Legionnaire`s disease have been confirmed at the hospital since November 1988, Five of the patients died and five recovererl.

Another nine patients are believed to have contracted Legionnaire's Disease but tests were inconclusive. One of those nine patients died and the others recovered.
Twenty four samples out of tweny nine were positive for Legionella , all the positive samples came from the Hospitals Hot Water System
(Source Media)

October 18, 1997
The Centers for Disease Control and the Missouri health department are helping to investigate potential links among the four cases.

Four Legionnaires' disease cases including three in transplant patients have been diagnosed at St. Louis University Medical Center since late June,

Two of those, both transplant patients, have since died from the disease,

The acting director of the city health department, said it was too early to say whether all four cases were linked or what the source might be.
But the unusual cluster has prompted him to call in specialists from the Centers for Disease Control and Prevention in Atlanta and the Missouri Department of Health.

Dr. Donald Kennedy, a professor at St. Louis University Medical School, said he could not comment on specific patients or cases.

Asked what the hospital is doing to protect other patients, he said, "If there is a possibility of an environmental cause, either internal or external, we would do whatever is necessary to identify and eradicate it."

Late Friday, Fields said, "The investigation is in progress. We're not ready to say it is an outbreak at this particular facility at this time."

Fields said that tests are under way on bacteria cultured from those infected. The tests could help link the cases. Hospital and health department officials have begun inspecting the hospital's cooling system and other places where the bacteria could breed.

It could be two to four weeks before enough information is available to determine if the cases are linked, Fields said Friday.

He said that the number of cases did not exceed what would be considered normal for the area but that the unusual clustering in one facility over several months led to the decision to ask for help from the CDC.

Federal officials were first notified of the cases in July. Their help was requested last week after the latest case came to light.

Public health officials agreed Friday to release only sketchy details about the four cases.

The first case occurred in a 47-year-old woman who had kidney transplant surgery at SLU on June 19. She was discharged on June 27 but readmitted three days later.
The woman died on July 18.

A second case was diagnosed in a 47-year-old man who had heart transplant surgery in late July. The man was sent home to Springfield, Mo., on Aug. 28, only to be readmitted on Sept. 2. He is still recovering.

The third case involved a 50-year-old man who had kidney transplant surgery on Aug. 18. The man was discharged 10 days later but was readmitted on Sept. 1.
He died the next day.

The fourth case was a 40-year-old man from University City who arrived at the hospital on Oct. 3 with what was diagnosed as Legionnaires' disease. He has no previous connection to the hospital, indicating that he could have become infected elsewhere. He is recovering, officials said.

It takes between two and 12 days after exposure to the bacteria before symptoms first appear. Because of that, it's possible that some or all of the Legionnaires' disease patients identified at the hospital contracted the disease after being discharged, hospital and health department officials said. Although most people with Legionnaires' disease recover, some outbreaks have killed as many as 15 percent to 20 percent of those infected.

1978 NEW YORK

The New York Health Department investigated an outbreak of Legionnaires Disease in the garment district of Manhatten in August of 1978, five cases which involved three brothers and two deaths.
The number of suspected cases rose to 118 by September 13 1978

1979 NEW YORK (JAMESTOWN)

An outbreak of Legionnaires disease occurred here between the 2 July and the 14 September 1979, a total of 7 cases with one death.

1982 NEW YORK STATE (ROCHESTER) A small outbreak of nosocomail Legionnaires disease occurred in a 225-bed hospital in Rochester, NY. during June of 1982. The outbreak involved three patients housed on a single hospital floor. Legionella pneumophila was isolarted from water obtained from three environmental sites, water from the cooling tower located on the roof was the first site to be identified as a potential source of the organism, the hospital hot water system was contaminated with low levels of Legionella pneumophila, Water from both the boiler room and hot water tank was found to contain the organism.

1982
NEW YORK

Seven cases of nonsocomial legionellosis occurred between February and September 1982 in a small community hospital in upstate New York. All seven were cases of Legionella pneumophila serogroup 1; six were hospital patients and one a hospital employee. None of the cases died. An invironmental investigation demonstrated that the ward showers and the hospital hot water system were contaminated with Legionella pneumophila serogoup 1. (Hanrahan JP, American Journal of Epidemiology 1987 125 639-649)

1984
NEW YORK CITY (MANHATTEN)

In late April 1984, an outbreak of pontiac fever was investigated in an office building in lower Manhatten. The outbreak was characterized by a high attack rate 78%.There was a clustering of cases in an office that was air cooled by a dedicated cooling tower separate from the remainder of the building. A high concentration of live Legionella pneumophila cells in the cooling tower was quantified Airborne spread via settle plates placed along the air intake system and within the office was demonstrated. Difficulty was experienceed in eliminating organism from the tower.
(Friedman S, American Journal of Medicine 1987 77 568-572)

NEW YORK 1985

N.Y. TIMES WORKERS LINKED TO LEGIONNAIRES DISEASE

An outbreak of 29 cases of respiratory illness has been diagnosed among employees of the New York Times Co. from mid- June, and at least six of the cases have been tied to Legionnaires disease.

LEGIONNAIRES' DISEASE AT THE NEW YORK TIMES

JULY 1985

Twenty-nine cases of respiratory illness have been diagnosed among employees of the New York Times Co. since mid-June, when an apparent outbreak of Legionnaires' disease occurred at the Times' offices, and an additional 20 workers said yesterday that they had had some respiratory trouble.

Blood tests on 14 of the 29 victims showed that six had evidence of past infection with Legionella pneumophila, the causative agent of Legionnaires' disease.

1989
Manchester Village, Vermont

MANCHESTER

State health officials said 1 of 3 guests who visited Equinox Hotel Sept. 8-10 has Legionnaires' disease.
Other 2 have symptoms.

*Legionella* bacteria was found in hotel's whirlpool spa, which was closed Sept. 20.

New York
September 1989

Three cases of legionnaires' disease were reported to the New York State Department of Health in September 1989.
All three patients were members of a 20-man golf team that had stayed at a Vermont resort hotel.
The resot health club had two whirlpool-spas, only one of which was functional and was used by all three patients 3 days prior to the onset of illness. Two patients had greater than fourhold increases in Legionella pneumophila serogroup 1 (Lp1) antibody titers. The third patient was diagnosed through direct culture of Lp1 from the patient's sputum. We sought additional cases among employees and guests, but none were found.

Interviews of the golf team members identified the whirlpool-spa as the most probable source of exposure at the resort. Three (38%) of the eight team members who used the whirlpool-spa were diagnosed with legionnaires' disease, compared with none of the 12 unexposed team members.

1995 NEW YORK BEACON

Three transplant patients contracted a strain of Legionnaires disease traced to the hot water system at the Columbia-Presbyterain Medical Centre. The cases were detected early in June, and one patient died of unrelated causes. The type of pneumonia that causes this strain of Legionella disease is called micdadei-is considered a risk mostly for people with damaged immune systems, including transplant patients. The source of the Legionella bacteria was eliminated by flushing out the facility`s hot water system. The assistant hospital epidemiologist said the germ poses no threat to healthy people, and is common in water supplies.

LEGIONNAIRES DISEASE HAS SURFACED 13 TIMES AT HOSPITALS AROUND THE STATE IN THE PAST DECADE.SOME ILL N.Y. TIMES WORKERS LINKED TO LEGIONNAIRES DISEASE

LEGIONNAIRE'S DISEASE - USA

June 27

The micdadei strain of Legionnaire's disease infected three transplant patients at Columbia Presbyterian Hospital in New York City. Death of one of the three was not attributed to the bacteria; the other two are doing well, according to hospital spokesmen.

To prevent spread, the hot water system was flushed and superheated over the weekend.
See Above

Austin, Minnesota

A 1957 outbreak of Legionnaires' disease associated with a meat packing plant.

Retrospective study shows that a 1957 outbreak of pneumonia in Austin, Minnesota, was Legionnaires' disease. Between June 7 and August 9, 1957, 78 persons were hospitalized with acute respiratory disease of unknown cause. Most had fever, headache, cough, and pneumonitis; two died. Ages ranged from 14-83 years; half of the patients were aged 55 years or older. Eighty-seven per cent were men. There were no secondary cases. Forty-six (59%) of the 78 patients were employees at a local meat packing plant, in distinction to the area's total working population (32%). Serosurvey of 15 of the 1957 outbreak cases and 30 controls matched for age, sex, and either occupation or residence was carried out in 1979. Antibody titers were determined for Legionella pneumophila serogroups 1-4 by means of indirect immunofluorescence. Twelve (80%) of the 15 cases and 13 (43%) of the 30 controls had antibody titers of 1:64 or greater to one or more of the L. pneumophila serogroups. Significant differences in L. pneumophila antibody titers (prevalence and level) were found between cases and control groups matched for residence (serogroups 1-3) or occupation (serogroups 2 and 3). Only three of 20 Austin residents with pneumonia diagnosed between 1978 and 1980 had L. pneumophila antibody titers of 1:128 or greater (p less than 0.001), in comparison to cases. These serologic data and the 1957 clinical and epidemiologic observations support the contention that this is the earliest documented outbreak of Legionnaires' disease.
(Osterholm MT, Chin TD, Osborne DO, Dull HB, Dean AG, Fraser DW, Hayes PS, Hall WN Am J Epidemiol 117 (1): 60-67 (Jan 1983)

1977 OHIO (COLUMBUS)

Three patients with severe pneomonia at a community hospital in Columbus were found to have Legionnaires disease in August 1977. The hospital is located iin a primary residential section of the north west of columbus. In June 1977 excavations for the construction of an addition to the hospital began. The main hospital has two patient wings connected by a two story building that houses the main lobby, the intensive care unit and pulmonary services. The patient wings, the intensive care unit and the connecting buildings have separate ventilation systems, the air-intake vents for the connecting building open over the excavation.
(Marks JS, Annals of Internal Medicine 1979 90 565-569)

1982 OHIO (COLUMBUS)

From January 1982 through Febraury 1983, 20 cases of Legionnaires disease were identified in two adjoining hospital buildings, Although the buildings housed similar patient populations and the hot water systems in each were infected with similar numbers of legionella serogroup 1, 19 cases came from one building (A) and the other case from building (B)
(Plouffe JF, The Lancet 1983 September 17 649)

1996
Ohio
During January–June 1996, nosocomial LD occurred in two patients at hospital Y. Nosocomial LD transmission had occurred at hospital Y in 1977; however, an epidemiologic investigation had not identified the source of transmission. Beginning in 1989, as part of surveillance for nosocomial LD, urine samples from all patients with nosocomial pneumonia were tested for Lp-1 antigen. Cases of nosocomial LD were defined as in the investigation in Arizona. Examination of infection-control and microbiology laboratory records from 1989 through 1996 identified nine patients with definite nosocomial LD and 29 patients with possible nosocomial LD (Figure 2). The median age for these 38 patients was 65 years (range: 36–85 years); 21 (55%) patients were male. Fifteen (39%) had at least one underlying chronic medical illness, and another 13 (34%) were immunocompromised by disease or immunosuppressive medication. Six (16%) were inpatients on the psy-chiatric ward. Eleven (29%) died during their hospitalization. A case-control study was conducted to assess potential risk factors for infection, matching 36 case-patients (no charts were available for two patients) and 72 controls by age, date of discharge from hospital Y, and underlying condition. Information about exposure to showers, pneumatic nebulizers, other aerosol sources, or ingested water was incomplete for some case-patients and for some controls. However, case-patients were more likely than controls to have had documented exposure to common aero-sol- producing devices (showers and/or medication nebulizers) during the 2 weeks before onset (matched odds ratio [MOR]=2.9; 95% confidence interval [CI]=1.2–74.0). Medical (nonpsychiatric) case-patients were more likely than controls to have re-ceived at least one medication by nebulizer during the 2 weeks before onset (MOR=3.2; 95% CI=1.1–10.6); however, only 40% of medical case-patients had received nebulized medication. Review of respiratory therapy practices indicated that nebulizer

equipment was sometimes rinsed with tap water between doses to reduce clogging. An increased risk for nosocomial LD also was associated with hospitalization in only one of the three inpatient medical/surgical buildings (building 1) (MOR=5.0; 95% CI=1.5–22.5) and within the psychiatric facility (MOR=undefined; 95% CI=3.1–infinity). However, all three medical/surgical inpatient buildings and the inpatient psychiatric facility were implicated as sites of transmission. Lp-1 was isolated from samples obtained from multiple sites in the hot water distri-bution system during 1994–1996, and the percentage of outflow sites testing positive was consistently highest in building 1 and the psychiatric building. All Lp-1 isolated from potable hot water samples in 1994–1996, as well as Lp-1 isolated from potable water in 1984 and from a hospital Y patient with nosocomial LD in 1985, were identical to the three clinical isolates from 1992, 1994, and 1995 by monoclonal antibody and arbitrarily-primed polymerase chain reaction subtyping. Although L. pneumophila was recovered from cooling tower reservoir water collected from two hospital facili-ties, these isolates were serogroups other than Lp-1. Periodic culturing of the hot water distribution system at hospital Y since 1994 had been used to guide decontamination efforts. Thermal (heating to 160 F [71 C] at the tap for 5 minutes) and chlorine (maintaining a chlorine level of 1–2 mg/L at the tap for at least 5 minutes) decontamination had been only temporarily effective in reducing the number of sites positive for Lp-1. A copper-silver ionization system installed in 1995 neither reduced the number of positive samples nor terminated transmission. Interventions recommended at the conclusion of this investigation in June 1996 in-cluded discontinuing the use of tap water to rinse medical nebulizer equipment, repeating the hyperchlorination procedure as needed in response to positive potable water cultures, increasing the hot water temperature at the point-of-use to at least 120 F (49 C), and identifying deadlegs in the potable water plumbing. Following these interventions, no new cases of nosocomial transmission were identified until February 28, 1997, when a case of possible nosocomial LD occurred in a patient in a critical-care unit. Lp-1 isolates from a sample of the patient’s lung tissue and from the potable water supply in his room were identical to all previous isolates by monoclonal antibody subtyping. Hospital personnel discovered a pre-viously undocumented cross-connection between the hot-water tank from an adjacent outpatient-care building and the critical-care unit. This tank was cleaned, and the sup-ply system hyperchlorinated. No new cases have been identified at hospital Y since March 1997. Reported by: C Kioski, MPH, G Cage, B Johnson, C Rosales, B England, MD, State Epidemiolo- gist, Arizona Dept of Health Svcs. TJ Halpin, MD, State Epidemiologist, Div of Preventive Medicine, Ohio Dept of Health. Childhood and Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC. Editorial Note: The findings in these and other recent investigations ( 1 ) indicate the capacity for legionellae to colonize hospital plumbing systems for long periods and, in the absence of effective preventive measures, to represent an ongoing risk for in-fection. Colonization rates are higher in large hospitals with older, large hot-water tanks in which water is held at lower temperatures ( 2 ). Hospital X served a large bone marrow and organ transplant patient population, and nosocomial legionellae trans-mission resulted in substantial morbidity and mortality during at least a 17-year period in this group of immunocompromised patients. Standard respiratory disease
(MMWR May 16, 1997 / Vol. 46 / No. 19)

1979-1981 PENNSYLVANIA (PITTSBURGH) In an analysis of legionellosis at the Presbyterian-University Hospital in Pittsburg during the 28 months after the original outbreak of pneumonia caused by Legionella micdadei. The original outbreak of Legionella micdadei pneumonia was found to have subsided nine months after the last formally recognized case, but infections with Legionella pneumophila continued to occur thereafter.
(Dowling JN , Journal of Infectious Diseases 1984 149 703-713)

1981 PENNSYLVANIA (PITTSBURGH) Between November 1980 and March 1981, six nosocomial cases of Legionnaires disease were diagnosed; all were due to Legionella pneumophila serogroup 1. Environmental sampling of faucet and shower sites in the rooms and ward of these patients was performed immedaitely after daignosis to determine whether the patients had been exposed to water contaminated with Legionella pneumophila.. Legionella pneumophila was isolated from the showers and faucets used by 5 of the six patients with the disease.
(Stout Janet, The New England Medical Journal 1982 466-469 Febuary 25)

1992
PHILADELPHIA
Two men who worked at the Montgomery County Fishing reel factory have been diagnosed with Legionnaire`s disease

An outbreak in 1992 at the University of Pittsburgh Medical Center.
Seven kidney transplant patients caught the disease and one died of it.

1995 PENNSYLVANIA (CHAMBERSBURG) An outbreak at a hospital in Chambersburg claimed the lives of three women, and 10 other cases have been confirmed. Officials at the hospital said that patients and visitors to the facility may have been exposed to the bacteria that causes the illness.. Two hospital employees are among the 30 to 50 people suspected of having the disease. An 82 year old women who died on July 13 was admitted to the hospital three weeks earlier after having trouble walking, She did not exhibit symptons of the disease until 12 July, the day before she died.

Legionnaires' hits technology center Thursday, March 05, 1998

An employee at the Pittsburgh Technology Center in Hazelwood was treated last month for Legionnaires' disease, making him the third worker in the same building to contract the illness since October, Allegheny County officials disclosed yesterday.
While all three people have recovered from the illness, the county has not been able to pinpoint the source of the infection, said John Schombert, chief of public drinking water and waste management for the county Health Department.
After the first two people took ill in October, both the county and an independent firm hired by Oxford Development Co., which manages the center, tested the water supply at 2000 Technology Drive.
Both tests came out negative, leading Schombert to believe that a source outside the building could be to blame for the infections. He said it was too early to tell specifically what might be the source of the contamination. "There's a building that's perfectly clean and yet people are coming down with it," Schombert said.
The building opened in October 1996,

Researchers believe people catch the disease by inhaling infected water vapor. A few cases have been traced to drinking contaminated water, and at least two people have acquired Legionnaires' disease through a cut.
Once inside the lungs, the bacteria quickly multiply. Symptoms come two to 10 days later: headaches, nausea, fevers near 104 degrees and chest pains. Investigators tested more than 35 water samples from diverse parts of the technology center building, including the plumbing, coffee makers and a cooling tower, Schombert said. Legionnaires' disease is of most concern to those with compromised immune systems, such as people with AIDS or organ transplant recipients, Schombert said. Otherwise, "It's an extremely rare occurrence in the general population, and even in areas where we've found it, we don't believe people are at high risk," he added. The Health Department learned of the latest case this week from Oxford, which was alerted by the company that employs the worker.
All three people who have contracted the disease live outside Allegheny County, said Guillermo Cole, Health Department spokesman.
The most recent victim is from Beaver County, where he was treated at an unidentified hospital. The three, whose names, ages and hometowns were not released, work at different companies within the building, said George Whalen, vice president of property management for Oxford. Schombert planned to meet this morning with building tenants. Between 300 and 400 people work in the building at about eight companies,
Cases of Legionnaires' disease have been reported several times in the Pittsburgh area in the past few years.

About 150 people who work at the center attended a meeting with Allegheny County Health Department officials yesterday to learn more about the disease, which is a form of pneumonia. But Health Department officials, who are conducting a second set of tests on the building's water supply, believe the three cases at the technology center do not have a common source, particularly since the first worker got sick in August, the second in October and the third last month. "We feel that clearly the building was not the source in the first two cases," said Guillermo Cole, Health Department spokesman. A first test in October found the water supply at the four-story building at 2000 Technology Drive was not contaminated by the bacterium that causes the disease. "I think we want to be sure that we can again rule out the building itself as the source (in the third case)," he said. "It could turn out that it's just a coincidence and that there is no common thread."

Most recently, two employees of a company that was providing food service at the University of Pittsburgh developed the illness in the summer of 1996.

1981 RHODES ISLAND

1983 RHODES ISLAND

From June 27 to August 25 1983, 15 persons developed Legionnaires disease in a hospital, 10 of the 15 patients died, five from other underlying maligancies. Source- Hospital Cooling Tower.
(GARBE PL, J A M A 1985 254 521-524)

1993 RHODES ISLAND

During August 30-October 20, 1993, LD was diagnosed in 17 patients who lived or worked in eastern Rhode Island. The patients' mean age was 54 years (range: 28-86 years); 11 were men. Two patients died. Seven patients had Lp-1 cultured from respiratory secretions and 10 had Lp-1 antigen detected in urine. A case-control study, matching the 17 patients with 33 controls by physician practice, age, sex, and underlying medical conditions, indicated that patients were more likely than controls to visit a 0.04-square-mile (0.1-square-km) section of downtown Providence (matched OR=6.5; 95% CI=1.4-30.9) in the 2 weeks before onset of illness. Water samples from the homes of six culture-positive patients were negative for legionellae by culture, but samplesfrom 10 of 24 CTs and one of three decorative fountains in downtown Providence were positive for Lp-1. The environmental isolates were tested by MAS and PFGE; one isolate from a CT on a building located within the area had the same MAS and PFGE patterns as isolates cultured from four case-patients who reported visiting the LD-associated section of downtown Providence. No other sources of transmission were identified in the community. These Lp-1 isolates had MAS and PFGE patterns that were different than those from the Fall River outbreak (approximately 19 miles away); however, the PFGE patterns suggested that the isolates were genetically related. The CT was shut down and decontaminated on an emergency basis on October 26. No additional cases of LD associated with the area were identified after decontamination of the CT.
(Morbidity and Mortality Weekly Report, Vol 43, No.27, July 15 1994)

RHODE ISLAND
1994

Seventeen people in Rhode Island contracted Legionnaire`s Disease in a single outbreak and one person died

RHODE ISLAND
1996

Fouteen cases of Legionnaire`s Disease were being investigated by Health Officials that had been comfirmed over a one month period in September according to news reports.

1988
SOUTH DAKOTA

Association of shower use with Legionnaire`s disease. Possible role of amoebae

In an outbreak of Legionnaire`s disease that occurred for more than three and a half years at a South Dakota hospital, the investigation implicated the shower water as the means of infection. The presence of amoebae at potable water sites matched the strain that caused the infection

(Breiman RF JAMA 263(21), 2924-2926 1990)

1987
STANFORD

Seven recipients of artificial heart valves later developed a form of Legionnaires' disease, researchers at Stanford University Medical Center

All seven recovered following treatment with antibiotics but four had to have their heart valves replaced, the director of the Stanford Medical Center clinical laboratory said.
These cases didn't develop in a short period of time, so we don't have an epidemic. The first Stanford case was reported in 1983.

It wassaid there is some evidence that at least two other San Francisco Bay Area heart valve patients who didn't have their surgery at Stanford had contracted the legionella infection
(Source Media)

1977 TENNESSEE (KINGSPORT)

In August and September 1977 27 confirmed cases of Legionnaires disease and six highly presumptive cases were identified in the area of Kingsport, Three patients died. No source of the bacterium was found either by detailed case-control study of area associations or by bacterial isolation from sentinel guinea pigs or by environmental specimens.
(Dondero TJ, Annals of Internal Medicine, 90 569-573)

1978 TENNESSEE (MEMPHIS)

In August and September 1978 an outbreak of Legionnaires disease occurred at Baptist Hospital, Memphis, of the 44 ill, 39 had been either patients, employees, visitors, or passer by. After heavy rains on August 8th 1978, a flash flood inundated central Mempkis, including the ground floor of the Hospital (A), pumps for the main cooling tower were inactive causing a temporary loss of airconditioning, An auxilairy cooling tower, not operated for nearly 2 years, was used from August 8 until September 7, when the main units were fully restored, Unlike the main units, this recently filled tower had not received chemical treatment of its water.
(Dondero TJ, New England Medical Journal 1980 302 365-370)

1978 TEXAS (DALLAS)

An outbreak occurred between the 18 August and the 4 September 1978 .
19 cases of the disease were comfirned, and two deaths occurred.

Health officials have confirmed two non-fatal cases of Legionnaires' Disease among the 35,000 persons who attended a national Veterans of Foreign Wars convention in late August.

Dallas County Health Director Dr. Lowell Berry refused to disclose the names of the two persons who had the disease and recovered.

Six other persons attending the convention were known to have had recent case of pneumonia and those persons were being checked to determine if they too had contracted Legionnaires' Disease, Berry said.

Meanwhile, the New York City Health Department yesterday asked residents in a wide area of midtown Manhattan's East Side to boil their drinking and cooking water for 10 minutes before use, citing a " high bacteria" count and the possible danger of an intestinal disorder such as diarrhea.

1989 TEXAS (USAF MEDICAL CENTRE, LACKLAND)

During the year of 1989, 14 cases of nosocomial Legionnaires disease were identified by active surveillance folling the discovery of 2 culture proven cases among organ transplant recipents. Air sampling of cooling towers, hospital air intakes, and medical air and oxygen supplies were negative for Legionella organisms. This study confirms the importance of potable water in transmitting nosocomial Legionnaires disease and suggests that the organism gains access to the hospital via external water supplies. The risk factor identified in this case-control study provides evidence that Legionnaired disease may act as a superinfection in a nosocomial setting and is likely acquired by aspiration, similar to other nosocomial pneumonias.
(Blatt SP, American Journal of Medicine 1993 95 july 16-22)

TEXAS
HOUSTON
29 Jul 1997

Health authorities said Monday they are investigating an Internal Revenue Service building where one worker died and two others became ill with symptoms similar to Legionnaires' disease.
Geraldine Webster, a 59-year-old revenue officer, died earlier this month after suffering high fever and aches similar to Legionnaires' disease. IRS spokesman Steve Yost did not know the official cause of her death. Two other employees reported similar illnesses last week. Water samples were taken at the building, and employees were asked to notify supervisors if they experience any flu-like symptoms. The building houses 600 workers and was open Monday.
The Harris County Health Department and the federal Occupational Safety and Health Administration were investigating. The respiratory disease is caused by bacteria that thrive in cool, standing water such as water towers or air conditioning ducts. It was identified in 1976 after an outbreak at an American Legion convention in Philadelphia killed 34 people.
(Source: Newsmedia)

1991
We studied the characteristics of definitively diagnosed nonsocomially acquired pneumonia in our hospital over 36 months. Out of 55 cases, 27 were due to Legionella pneumonphila and 28 to other, non Legionella bacteria. The cases of legionellosis conentrated in July , August, and September. The mortality rate of legionellosis was 14.6 per cent compared to 35.7 per cent for non-Legionella group.
(Roig J, CHEST 1991 99 344-350)

1988

Outbreaks of Legionnaires disease have occurred in Hotels, Hospitals, and Homes but had not been reported yet in the work environment. The authors report the occurrence of Legionnaires disease in three employees of two industrail plants. The potable water in two plants contained high numbers of Legionella pneumophila. Legionella pneumophila was eradicated from this plant using acidic and caustic scale removers, calcium hypochlorite, and a biocide.
(Muraca PW, American Industrail Hygiene Association Journal 1988 49 584-590)

1977 VERMONT

Thirty two confirmed cases and 24 highly probable cases of Legionnaires disease occurred in Vermont between May 1 and October 15 1977, 17 patients died.
(Beaty HN , J A M A 1978 July 14, Vol 240, No 2 )

1980 VERMONT (BURLINGTON)

Eighty-five cases of Legionnaires Disease were diagnosed in two major outbreaks at a large regional medical centre in Burlington in the summer of 1980. Cases in both outbreaks were both hospital and community acquired, studies supported that the source of the outbreak was the cooling tower, located 150m from the hospital.
(Klaucke DN, American Journal Epidemiology 1984 119 382-391)

1981 VERMONT

In March 1981, an outbreak of 34 cases of Pontiac fever occurred among 74 members of a social club who had visited an inn in south west Vermont. The outbreak of Pontaic fever was most likely caused by Legionella pneumophila serogroup 6, which was identified in a whirlpool spa at the inn.. This is the first reported instance of an outbreak of Pontiac fever associated with a whirlpool spa.
(Spitalny KC. American Journal Epidemiol 1984 December 807-817)

1987 VERMONT

A multistate outbreak of Legionnaires disease occurred among nine tour groups of senior citizens returning from stays at one of two lodges in a Vermont resort in October 1987. Interviews and serologic studies of 383 of the tour members revealed 17 individuals with radiologically documented pneumophila and laboratory evidence of legionellosis. Environmental investigation of a common tour stops revealed no likely source of legionella infection outside the lodges. Legionella pneumophila serogroup 1 was isolted from water sources at both implicated lodges.
(Manolen M, Journal Clinical Microbiology 1993 31 2584-2588)

1973 JAMES RIVER V A

An outbreak of legionnaires disease occurred here between July 31 and August 31 1973, ten cases were reported with no deaths.

1978-1982 VIRGINA

An epidemic of nosocomail Legionella micdadei pneumonia occurred among renal transplant patients in the University of Virginia Hospital between 1978 and 1982, Although no further cases were daignosed after 1982 Seven cases of nosocomail Legionella micdadei pneumonia were reported during this time. Because of reports that Legionella could be isolated from showheads and the possibility that aersol exposure during showering might be an important mode of trannsmission, transplant patients were no longer allowed to take showers
(Farr BM, LANCET 1988 vol 2 669-671)

1978
VIRGIN ISLANDS

Health Authorities in Newark investigated 450 Lawyers and Judges who attended a conference in the Virgin Islands after a Pittsburg magistate died of the disease.
The conference was held between the 23 and 26 of October.

1979-1982 VIRGIN ISLANDS

An unusual number of reports of Legionnaires disease in tourists visting the US Virgin Islands prompted an investigation of risk factors for development of Legionnaires disease in this area. Twenty seven cases of Legionnaires disease were identified between 1979 and 1982 through press reports, personal communication, the national Legionnaires disease surveillance system, a review of hospital records, and a mail survey. Twenty-four of 27 persons with the disease had visited St Croix and 12 of them had stayed at a single hotel in 1981. Available evidence suggests that the infection was due to Legionella pneumonia sreogroup 1; Legionella pneumonia serogroup 1 and 3 and several new species were isolated from the potable water system at the hotel. Following hyperchlorination of the potable water system, no further cases in hotel vistors have been identified to date. (Schiech WF, Archives of Internal Medicine 1985 145 2076-2079)

1963-1975 WASHINGTON (SEATTLE)
LEGIONNAIRES DISEASE IN A PREPAID MEDICAL-CARE GROUP IN SEATTLE 1963-1975.

The community incidence of Legionnaires disease was estimated by a retrospective study of stored paired sera from 500 patients treated for pneumonia in Seattle in 1963-1975
(Foy Hjordis M , The Lancet 1979 April 7 767-770)

1964 WASHINGTON DC

An epidemic of Legionnaires disease occurred in July and August 1964 at the St. Elizabeth Hospital in Washington DC , at least 83 patients were involved, The illness was first thought to be Klebstella pneumoniae, it was not till a decade later that it was recognised as Legionnaires disease, only after serologic tests were carried out on sera that had been stored at the Centre for Disease Control. Of interest is the fact that extensive soil excavationsn were being carried out on the campus of the hospital during the summer months in order to install a sprinkler system. Several risk factors were identified including sleeping by open windows and having free access to the grounds of the hospital, Thus, both temporal and geographic relations with the excavation sites were associated with increase risk, This evidence strongly suggests airborne spread from an environmental reservoir in some way related to the excavation.
(Eickhoff Theodore C, Annals of Internal Medicine 1979 90 499-502)

1980 WASHINGTON DC

The 18 May 1980 eruption of Mt St Helens in Washington devasted 150 square miles of mountain terrain, Scientists of varied backgrounds began to enter the area to study the aftermath of the eruption. In April 1981 reports of a mild illness in persons visiting the area of destruction were received by the Washington Health Department. Six strains of a new species, Legionella sainthelensi were isolated from freshwater in areas affected by the volcanis eruption.
(Campbell Applied and Environmental Microbiology 1984 47 369-373)

1994 WASHINGTON NAVAL ACADEMY

Legionella pneumonphila was found in the air-conditioning system of the naval Academy, The bacteria was found in two cooling towers that are part of the air-conditioning system for several building at the academy,. and most affected was the Rickover Hall building. A high level of bacteria was found during tests, which are conducted every 60 days. Academy officails said risk to midshipmen or employees were negligble.
(Maze Rick, Navy Times 22-8 -1994 Vol 43, pp2)

Bone Marrow Transplant 1996 Aug;18(2):361-368

Legionellosis in a bone marrow transplant center.

We reviewed 10 cases of culture proven legionellosis that occurred at a marrow transplant center (Fred Hutchinson Cancer Research Center, Seattle, WA, USA) over a 6-year period ending in 1993. Infections were caused by four species of Legionella with no apparent clustering of cases. Detection of Legionella using direct fluorescent antibody assays proved unreliable due to the high proportion of rare Legionella species isolated. The clinical presentation, course and outcome of patients varied and did not correlate with underlying disease, type of transplant, transplant day or engraftment status. However, five of the seven patients infected with non-pneumophila species recovered from their pneumonia compared to none of the three patients infected with L. pneumophila. Persistent or relapsed infection after 3 weeks of appropriate therapy was documented in one case suggesting that prolonged antibiotic treatment is indicated in these patients.

Harrington RD, Woolfrey AE, Bowden R, McDowell MG, Hackman RC

Department of Medicine, University of Washington School of Medicine, Seattle 98122, USA.

1996
WASHINGTON BALTIMORE (Woodlawn Md)

A Social Security building at the Baltimore County Complex was closed at the weekend after the manager contracted Legionnaires`s Disease.
3,200 employees who work at the complex in Woodlawn Md were told that the illness was most likely an isolated case.

1979 WISCONSIN (EAU CLAIRE)

Between June 18 and July 9 1979 , Legionnaires disease developed in 13 persons who had visited a hotel complex in Wisconsin, Four persons died, All had visited the part of the hotel that contains the restaurants and meeting rooms, Legionnaires disease occurred in 1% who had been exclusively in the meeting rooms, and in 0.1% who had eaten only in the hotel restaurants. Legionella pneumophila was isolated from the water in the cooling tower on top of building A, Located within 5m downwind of the cooling tower exhaust, a CHIMNEY with an open damper allowed cooling tower exhaust to enter the meeting room1 via the fireplace.
(Band JD , J A M A. 1981 245 2404-2407)

In 1979 four people died and nine were hospitalized when the disease was transmitted through an air-conditioning system at a Holiday Inn in Eau Claire, Wis. Three people in California have died of the illness since March.

1986 WISCONSIN (SHEBOYGAN)

During the period August 10-29 1986 , 29 confirmed cases of Legionnaires disease occurred in Sheboygan, Two cases proved fatal. The findings associate a cooling tower with community acquired Legionnaires disease and suggest that dissemination of legionella may occur over longer than previously recongnized distances.
(Addiss DG , American Journal of Epidemoilogy 1989 130 557-568)

LEGIONNAIRE`S DISEASE TRACED TO WIS. PLANT

SEPTEMBER 1986

A fatal outbreak of Legionnaires' disease has been traced to a cooling tower at a manufacturing plant, state officials said yesterday, and the bacteria have been eliminated.

The disease has been confirmed in 17 of the 31 neighborhood residents who became ill with the pneumonia-like ailment last month. One death has been positively linked to the disease; two others previously believed to have been linked were not related,

Six of those confirmed to have the disease remain in hospital.

The source of the outbreak was at Muth Woodstock Co., which makes auto parts and accessories. The factory is on the city's northwest side, where almost all of the victims lived.

A news conference was told the bacteria probably was blown from nearby soil and "seeded in the holding tank," then blown around the 15-square-block area near the plant by an exhaust fan.

The bacterium that causes the disease can be spread through the air from contaminated water supplies or air conditioning ducts. Most Sheboygan cases were clustered in the 15-square-block area, leading epidemiologists to believe that an air conditioner or water tower in a nearby plant had been contaminated.

One resident became ill Aug. 28 and the other Aug. 30. The others developed symptoms between Aug. 10 and Aug. 23.

Two cases of Legionnaire's disease, one of them fatal, have been confirmed in an outbreak of sickness that has left 23 people ill and five dead, health officials said Tuesday in Sheboygan, Wis. Officials seeking the source of the outbreak said they were concentrating on an area about 15blocks square on Sheboygan's northwest side, a working class district where most of the people who took ill lived. Those affected range in age from 31 to 91, including 16 males and 12 females, said Dr. Jeffrey Davis, the state epidemiologist. The earliest onset was Aug. 10 and the most recent was Saturday.

1986 WISCONSIN (CUDAHY)

Two cases of Legionnaires disease were reported in Cudahy in October 1986, Patient (A) was a 51 year old man, his symptoms began on October 4 and he died on October 17 . Patient (B) was a 67 year old women, her symptoms began on the October 4, she was admitted to hospital on the 17 October, Legionella pneumophila was positive on the 19 October, after long hospitalization the patient recovered. Seven other patients with Legionnaires disease were admitted to six different hospitals in Milwaukee County during September and October 1986, Two patients died. Two new cooling towers were installed about 30 m apart on the roof of plant I in July 1986 and were supplied with potable city water. Neither tower was equipped with drift eliminators, After start-up in early August, the water in both towers was treated once aweek with a slug dose of a quaternary ammomium biocide, dimethylamio-ethylene-dichloride. After water from the towers at plant1 was found to be positive with Legionella pneumophila, on November 26 both plant1 towers were chlorinated using protocolm adopted by the Cooling Tower Institute.
(Addiss DG , Journal of Infectious Diseases, 1989 159 572-575)

1996
WISCONSIN. SISTER BAY

A small outbreak of Legionnaires`s Disease in Door County in October 1996 resulted in the death of o women and her son-in-law became ill and recovered, tests were being carried out at the resort to determine in cause, samples were taken from the shower stalls, baths and whirlpool

An out-of-court settlement was reached between the federal government and Aetna Life and Casualty Insurance Company over alleged federal government negligence resulting in an outbreak of Legionnaires disease in the Social Security Building in Richmond, California, in 1991. Ten people contracted the disease and two died. While the federal government claimed that outbreaks of Legionnaires disease (also called legionellosis) cannot be predicted and thus prevented, and that this claim was backed by federal public health policies, the private insurance company made a convincing case that if Legionella can be prevented after an outbreak, then it can certainly be prevented beforehand. The settlement for an undisclosed amount could change the way such cases are litigated in the future. How can private businesses and building owners protect themselves from such negligence suits when the federal Government cannot despite following accepted government policy with regard to Legionella outbreaks?

In the US, building systems contaminated with elevated levels of Legionella result in sixty-eight cases per day of legionellosis, a potentially life-threatening but preventable disease. While all the data that would satisfy every skeptical scientist may not be available, strategies incorporating routine testing of high risk water sources offer more hope of prudent, effective prevention than wait and see policies.