LEGIONNAIRES DISEASE OUTBREAKS 
 SPA`S, WHIRLPOOL BATHS, HOT TUBS, HOT SPRINGS
2000

Bacteria from hot tubs can cause lung disease, doctors say

May 13, 2000 

Bacteria that bubble up from indoor hot tub jets can cause lung disease in some people who
 regularly use them, according to case studies documented by lung specialists. Doctors at National Jewish Medical and Research Center in Denver recently treated nine people, including four children, for lung disease caused by nontuberculosis mycobacteria found in hot tub water or in the air of their homes.
The jets from hot tubs aerosolize the bacteria, which is how this becomes a problem," said Cecile Rose, a specialist in environmental and occupational lung diseases, who reported the illnesses this week at the American Thoracic Society's International Conference in Toronto. Unlike tuberculosis, which is transmitted from person to person, this bacteria isn't contagious.
Normally, the organisms live only in brackish ocean water, such as tidal pools.

But researchers at National Jewish say several strains of the bacteria have
been found to thrive in floating "slime layers" in hot water heaters, indoor pools, ornamental waterfalls and hot tubs, and they've been treating more  and more people for the disease.
According to the federal Centers for Disease Control and Prevention, the  infections are most common in the Southeastern United States. In many instances, "if you just turn on your shower you can aerosolize these organisms," said Gwen Huitt, another physician at the center familiar with the bacteria. "If you're healthy, it may mean nothing to be exposed to the bacteria. But if you already have a lung disease, you may have a greater chance of  becoming infected." 
Rose suggested the substantial mist produced from hot tub bubbles "disperse> the bacteria throughout a room," and give people in the home a steady spray.

People with this bacterial infection often experience a fever, tiredness, night
sweats, coughing and weight loss. "For people with mild cases ..., removing the hot tub from the home is the primary treatment," she said. 
However, the respiratory problems are often misdiagnosed as being caused either  by tuberculosis or other lung diseases, and they may stay in their  and continue to be exposed to the bugs. Rose said she believes with hot tubs becoming more common, "I believe there will be an increasing recognition and understanding of the risk associated with their use" among both physicians and consumers. In severe cases like> those described by Rose, the infections require treatment with corticosteroids andantimyco bacterial antibiotics, sometimes three or four antibiotics at once, given intravenously. In some cases, doctors have to surgically remove part of a patient's lung to stop the disease

Source Media

An outbreak of Pontiac fever among guests at a hotel in Lycksele, Västerbotten County (Sweden) in April 1999

Götz HM^1,2, Broholm KA³, Sjödin L³, Nilsson KE⁴, Kuusi M^2,5, Tegnell A¹, Ekdahl K¹

October 1998

Legionella pneumophila

North Thames and Wessex region UK

6 Cases on several sites associated with a new design of spa pool from a single manufacturer

I have just been made aware of this outbreak in 1998

Four children developed a folliculitis approximately 24 hours after bathing in a whirlpool spa at the home of a relative they were visiting for the weekend. Swabs were collected from each of the patients and Pseudomonas aeruginosa was isolated from two of them. Although the owners had used the pool each day they had not developed a rash. The mother only developed a mild rash. The spa pool had only been installed for ten days but had previously been on display at a garden centre for about six months. Samples collected from the pool had greater than 100000 Ps. aeruginosa per 100ml.
The isolates from the spa pool and patients were all serotype O11 and were all of the same phage type.

May 1999

Outbreak of legionnaires' disease associated with a spa resort in Spain

An outbreak of legionnaires' disease has been identified in north east Spain among people who stayed in the natural spa resort of Cestona in the province of Guipúzcoa between 1 and 22 May 1999.

The first case was diagnosed on 20th. May.

By 31st. May 1999, two confirmed cases had been diagnosed by legionella urine antigen detection test, there were six suspected cases, and 35 people were being investigated. Local health authorities have established that 432 people were staying in the resort during the period under investigation. Six visitors were from other European Union countries, four from the United Kingdom (UK) and two from Portugal - none of these is known to have become ill. All people who may have been exposed have been identified and are being investigated for legionella infection.

The spa resort was closed on 22nd. May. The regional public health director of País Vasco (Basque Country) has informed all doctors and the general public. The coordinating centre of the European Working Group on Legionella Infections (EWGLI) was informed of the outbreak in order to follow up the possible British and Portuguese cases and will be notified officially when all the details of the cases have been obtained for reporting purposes.
The regional surveillance unit, in collaboration with the National Centre for Epidemiology, has begun an epidemiological and environmental investigation to identify the source of the outbreak. Legionella pneumophila serogroup (sg) 1 has been recovered from water samples taken in the spa resort.

Reported by Rosa Cano (rcano@isciii.es) Centro Nacional de Epidemiología, Madrid, and Txema Arteagoitia (vigipro1-san@ej-gv.es) Dirección de Salud Pública del País Vasco, Vitoria, Spain.

SAFETY INFORMATION
This document is based on a publication developed by the
Department of Health in British Columbia
and the
Environmental Health Division of the City of Burnaby Health Department.

An outbreak of Pontiac fever among children following use of a whirlpool.

We investigated an outbreak of fever, most likely due to a contaminated whirlpool, among nine adults and six children residing in a summerhouse. The outbreak was characterized by a high attack rate, short incubation periods, influenza-like symptoms, and rapid recoveries, all features typical of Pontiac fever. However, the children had less-characteristic symptoms than the adults, and they did not have any sequelae. Findings on the children's chest radiographs were unremarkable, and none of the children had leukocytosis. Evidence of Legionella pneumophila infection was found in six cases: in one case by isolation of L. pneumophila serogroup 1 and detection of legionellae by PCR, and in five cases by seroconversion to the clinical isolate. Six additional cases had presumptive evidence of legionella infection, with seroconversion to Legionella micdadei antigen; a PCR assay was also positive for legionellae for one of these cases. In contrast, two adult nonusers of the whirlpool had no symptoms and no serological evidence of infection. Serological testing and cultures for other pathogens, as well as cultures of all environmental samples, were negative. This investigation demonstrates the differences between adults and children with respect to the clinical picture of Pontiac fever; furthermore, it shows that culture and PCR assay of tracheal aspirates for legionellae can be performed in a hospital setting for rapid diagnosis, although the sensitivities of these methods are low.
Clin Infect Dis 1998 Jun;26(6):1374-8
Luttichau HR, Vinther C, Uldum SA, Moller J, Faber M, Jensen JS
Department of Internal Medicine, Esbjerg County Hospital, Denmark.

Boys get hepatitis A from playing in spa Media Source December 31st 1997 Melbourne Victoria Australia Health authorities are warning people to take care in spas after seven Melbourne boys caught hepatitis A in a domestic spa. The case, believed to be the first involving a domestic spa, involved boys aged between eight and 15 who attended a party in the eastern suburbs after a football club function. One of the boys became ill on the night and tests revealed he had hepatitis A, which causes severe inflamation of the liver, resulting in tell-tale jaundice (yellowing of the skin and especially of the eyeballs), nausea and often acute fever. A Human Services Department medical officer, said the boys were whale spitting in the spa - taking mouthfuls of water and spitting it at one another. He said this was more likely to have been the transmission route rather than sharing food and drink because 10 young females at the party who did not enter the spa were unaffected. The adults present and another 10 young males were also unaffected. The state's chief health officer, said the sick boys had broken one of the cardinal rules of spa and pool safety: not swallowing the water. Inevitably they would have swallowed some water. Spas are fairly high-risk venues and not easily or frequently well-managed and . . . even a domestic spa can be a problem, The public health message is that spas do provide an environment for potential health problems. The pool had been treated with hydrogen peroxide, but The state's chief health officer said spas had to be regularly monitored to ensure that whatever disinfecting system used was working because the high temperatures and bubbling effect dissipated some chemicals such as chlorine much faster. The incidence of hepatitis A has dropped from about 2000 cases a year in the 1960s to 370 this year. It is most commonly transmitted by the faecal-oral route, with the infection getting on to fingers and hands and then being swallowed. Young children are particularly susceptible. The spokeman said the seven boys affected in the spa would have been ill for several weeks, but then would be immune from the disease - unlike hepatitis B and C, which have long-term consequences. An outbreak of hepatitis A associated with a spa pool Graham Tallis and Joy Gregory, Infectious Diseases Unit, Department of Human Services Victoria Introduction The Victorian Infectious Diseases Unit received three notifications of hepatitis A between 17 and 20 October 1997 from a general practitioner in the eastern suburbs of Melbourne. The three cases were all young males who attended the same primary school, but were also members of the local junior football club. An earlier case notified was also a member of the football club, but attended a different school. Active surveillance was initiated through the club and the affected schools. Methods Using the National Health and Medical Research Council (NHMRC) case definition (anti-HAV IgM positive or demonstration of a clinical case of hepatitis, and epidemiologically linked to a serologically confirmed case), seven cases in six families were identified. All cases were young males (age range 8 to 15 years) and dates of onset ranged from 31 August to 13 October (Figure 1). Using a standard questionnaire that elicited data on potential sources of infection including food and water, it was found that all cases had attended a presentation at the football club on 31 August 1997. Families attending the presentation brought their own food, although sausages were cooked on a public barbecue and canned drinks were served. After the presentation, all the cases attended a private function at one of the case’s homes. Food and drinks were shared, and all of the cases used a spa pool. At this private function the index case felt ill and left early; his illness was subsequently confirmed serologically as hepatitis A. Excluding the case and his two siblings, 27 other children and adolescents and an unknown number of adults attended the function. Of these, 17 were males ranging in age from 8 to 16 years, and 10 were females ranging in age from 3 to 17 years. Some males including the index case, but none of the females, used the spa pool. Whilst in the pool, ‘whale spitting’ was performed, in which mouthfuls of spa water were spat in a projectile fashion. Discussion Six of the 17 young males became ill with hepatitis A. None of the adults or young females became ill. It is believed the gender difference in cases of hepatitis A observed after this private function is best explained by the hypothesis that hepatitis A virus was shed by the index case whilst in the spa pool, and subsequently ingested by other participants, all male, who became secondary cases. The break in notifications observed after the index case on 31 August (Figure 1) is consistent with the known incubation period for hepatitis A. Other modes of transmission such as sharing of food and drink cannot be excluded, although these would not explain the confinement of cases to young males. The outdoor spa pool was being treated with hydrogen peroxide solution. Hydrogen peroxide used with ultraviolet (UV) light inhibits microbial growth, but is unlikely to provide adequate disinfection with respect to contamination with the hepatitis A virus. The use of UV-hydrogen peroxide systems is not allowed in public pools in Victoria due to poor performance in trials.1 A study of a multistate outbreak of hepatitis A in the United States of America, found it to be linked to a public swimming pool.2 In this study, cases were found to be more likely than non-cases to have swum in the spa pool than the swimming pool. Cases were also more likely to have swum for more than one hour and to have put their heads under water. Our findings support the conclusion from this study that recreational pools may serve as a mode of transmission of hepatitis A virus, particularly in children. References 1. Broadbent C. Guidance on water quality for heated spas. National Environmental Health Forum Monographs, Water Series No 2. Adelaide: South Australian Health Commission; 1996 2. Mahoney FJ, Farley TA, Kelso KY, Wilson SA, Horan JM, McFarland LM. An outbreak of hepatitis A associated with swimming in a public pool. J Infect Dis 1992; 165(4):613-8 Communicable Diseases - Australia National Centre for Disease Control/Communicable Diseases Network Australia New Zealand Department of Health and Family Services

1975
MINNESOTA

Pseudomonas aeruginosa Rash Associated With A Whirlpool

A rash was reported by 32 of 61 persons who had used the swimming pool and whirlpool at a Minnesota motel in march 1975.
Pseudomonas aeruginosa serogroup 11 was isolated from the skin lesions of two of the cases and from the water from both pools.Circumstantial evidence implicated the whirlpool as the most probable source of infection.
(Washburn John. JAMA 235: 2205-2207, 1975)

1978
Pseudomonas Folliculitis Acquired From a Health Spa Whirlpool

Three cases of an unusual Pseudomonas skin infection acquired from a health spa whirlpool were reported, and a epidemiologic survey showed 17 additional cases. This dermatosis is characterzied by the abrupt onset of urticarial papules and superficial and deeppapulopustutes that spare onlythe head and neck and occur eight to fourtyeight hours after using the whirlpool.
Cultures from one patient`s pustules and from the spa whirlpool environment were positive for P aeruginosa, serogroup 0-11. The condition cleared up in all but one patient, without treatment within seven to ten days. This patient continues to have recurrent follicular pustuies three months after exposure.
Samples from whirlpools at six other selected establishments were alos positive for P areuginosa
(Maj Willaim F Sausker. MC USA JAMA 239 2362-2365 1978)

1981
VERMONT

Pontiac fever associated with a whirlpool spa.

An outbreak of 34 cases of Pontiac fever occurred among 74 members of a social club who visited an inn in south-central Vermont. Environmental and epidemiologic investigations were done to identify the causes of the illness. The outbreak of Pontiac fever was most likely caused by L. 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; Vogt RL; Orciari LA; Witherell LE; Etkind P; Novick LF Source Am J Epidemiol, 1984 Dec, 120:6, 809-17 1981)

1972-1982

National survey on outbreaks associated with whirlpool spas.

A national survey of state epidemiologists sought information on reported outbreaks of illness associated with non-residential whirlpool spas for the period April 1972-July 1, 1982. Reports were received from 49 states. Of the 74 whirlpool-associated outbreaks reported, 72 were characterized as having patients with papular or pustular rash and two were associated with cases of Pontiac fever.
(Spitalny KC; Vogt RL; Witherell LE ; Am J Public Health, 1984 Jul, 74:7, 725-6)

Hot tub dermatitis: a familial outbreak of Pseudomonas folliculitis.

Pseudomonas folliculitis resulting from the use of spa pools, whirlpools, and hot tubs is a newly described disease that typically develops 8 to 48 hours after exposure in a contaminated facility. The eruption consists of pruritic papules, papulopustules, nodules, and urticarial lesions on the trunk and extremities. A family of three and a neighbor developed Pseudomonas folliculitis after using a home hot tub from which P. aeruginosa was cultured. Skin biopsies showed an acute, suppurative folliculitis and dermal abscess formation. Although the eruption usually resolves spontaneously within 7 to 10 days, proper maintenance of equipment and adequate disinfectant levels are necessary to prevent its recurrence.
(Silverman AR, Nieland ML J Am Acad Dermatol 8 (2): 153-156 (Feb 1983)

1982
MICHIGAN

Fourteen of 23 females members of a church group experienced chills, fever, chest pain, coughs and nausea, consistent with the diagnosis of Pontiac fever. All fourteen affected women had used the whirlpool spa located in the womens locker room during a racqueball party. Legionella pneumophila serogroup 6 was isolated from the womens whirlpool
(Mangione Ellen J ..JAMA..253 535-539 1985)

1982

Pseudomonas folliculitis associated with the use of health-spa whirlpools.

The occurrence of pustular folliculitis in eight people after the use of health-spa whirlpools is described for the frst time in Australia. The lesions were discovered ad identifed during the peak season in two resorts in the Snowy Mountains area near lindabyne, New South Wales.
Pseudomonas aeruginosa, identified as serotype 0:6, was isolated from pus swabs of the lesions, water in the spa pools and pool filters.
( Gibson AR; fle lager J; McCrossin I Med J Aust, 1 : 8, 1983 Apr 16, 38 1 -3)

Whirlpool-associated folliculitis caused by Pseudomonas aeruginosa: report of an outbreak and review.

An outbreak of folliculitis caused by Pseudomonas aeruginosa serotype 0:7 occuried among the guests uf a hotel in St. John`s, Newfoundland, Canada, and the source of the infection was traced to the hotel whirlpool. Of 36 persons who used the whirlpool, 26 (72%) developed folliculitis with in 1 to 5 days afier exposure; the altack rate was significantly higher for children (90%) than for adults (50%). 'The rash characteristics were consistcnt with those of Pseudomonas folliculitis previously described ('T. L. Gustafson, J. D. Band, R. H. Hutcheson, Jr., and W. Schaffner, Rev. lnfect. Dis. S: 1-8, 1983). This is considered to be the first outbreak in which P. aeruginosa serotype 0:7 has becn incriminatcd. Published reports to date of outbreaks of Pseudornonas folliculitis associated with the use of whirlpools, hot tubs, swimming pools, etc., were reviewed.
(S. Ratnam, K. Hogan, S. B. March & K. W. Butler .J Clinical Microbiol 23 655-9 1986)

DF-2 septicemia following whirlpool spa immersion.

We describe the case ofa 31-year-old asplenic man who developed DF-2 bacterumia, septic shock, and pneumonia after recreational immersion in a whirlool spa. The patient did not have a history of dog bits or contact with canine secretions, although he owned two dogs. DF-2 could not be isolated from the whirlpool spa
(Holmes R L, Kozinn W P Journal Clinical Microbiol 23 627-8 1986).

Vermont.
Pseudomonas aeruginosa skin infections in persons using a whirlpool in Vermont.

Four guests at a ski resort in Vermont reported contracting a characteristic papular, pustular, or vesicular rash after using the resort's whirlpool. Pseudomonas aeruginosa serotype l, bacteriophape type 86, was isolated trom a pustule on one patient, water within the whirlpool, and the whirlpool diatomaceous carth filter. This appears to be the first outbreak of dermatitis associated with P aeruginosa serogroup 1. Previous reports of whirlpool-associated dermatitis outbreaks have identified serogroup9 and 11 isolates of P aeruginosa as the causative agents.
(R Vogt, D. LaRue, M. F. Parry, C. D. Brokopp, D. Klaucke & J. Allen .
Journal Clinical Microbiol 15: 571-4 1982)

1987 Lochgoilhead

Between December 31 1987 and January 4 1988, about 200 hundred people visited a hotel and leisure complex in Lochgoilhead, a village on the west coast of Scotland 187 people who had visited the complex had had an acute illness.. Legionella micdadei was isolated from the leisure whirlpool spa.
This outbreak is thought to be the first of a Pontiac fever like illness ascribed to L. micdadei and the first large scale outbreak of its kind to have occurred outside North America.
(Goldberg DJ, The Lancet 1989 Febraury 11 )

1988
Incidence and persistence of Pseudomonas aeruginosa in whirlpools.

Pseudomonas aeruginosa was isolated from seven commercial and two residential whirlpools that were treated with halogens. None ofthe commercial whirlpools was constantly maintained at appropriate disinfection levels. Superchlorination or the draining, cleaning, disinfection, and refilling of whirlpools markedly reduced densities of P. aeruginosa in whirlpool water, but the bacterial populations were rapidly reestablished (less than 10(3) cells per ml) when disinfectant concentrations decreased below recommended levels (chlorine, 3.0 ppm (3.0 micrograms/ml); bromine, 6.0 ppm). P. aeruginosa in the water was replenished from various sources, such as hoses used to fll the whirlpool and the biofilm in the flter and piping ofthe whirlpool systems. Daily monitoring and adjustrnent of chemical characteristics (regardless of bather load) were essential for controlling densities of P. aeruginosa.
(D. Price & D. G. Ahearn Journal Clinical Microbiol 26: I 650-4 1988)

1989
VERMONT
Three cases of Legionnaires' Disease reported to the New York Health Department in September 1989, All three cases were members of a 20-man golf team that had stayed at the Vermont resort hotel.
The resort health club had two whirlpool spas, only one was in use, and was used by the three cases , 3 days prior to the illness.
The whirlpool spa was identified as the most probable source of exposure at the resort.
(Zingeser J A. JAMA v264 n20 p2625(2) Nov 28 1990)

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.

Exposure to Legionellaceae at a hot spring spa:

A prospective clinical and serological study Following the occurrence of five cases of Legionnaires' disease among patients and therapists at a French hot spring spa, a series of cleansing procedures and an epidemiological study were undertaken. During a 3-month period, the spring water was repeatedly sampled. Serum samples were taken from 689 randomly selected patients, 230 therapists, 134 administrative staff and a control group of 904 blood donors. Legionellaceae were present in the spring water at concentrations of 10(3)-10(5) colony forming units/l. Fifteen different species or serogroups were isolated with Legionella pneumophila serogroups 3 and 1 predominating. No clinical cases of Legionnaires disease were observed during the study. However, 11% of the therapists and 5% of the patients either had a high titre of antibody (greater than or equal to 256) to at least one species or serogroup or seroconverted during the study. Mean antibody titres in the three study groups were significantly higher than those in the blood donors against 11 of the 32 legionella antigens tested. Nine of these 11 antigens corresponded to species or serogroups isolated from the spring water. The highest mean antibody titres in all three study groups were against L. pneumophila serogroup 3, the most common legionella in the spring water.
These findings have important implications for the maintenance of adequate standards of hygiene, bacteriological sampling and clinical surveillance in this and similar establishments.
[published erratum appears in Epidemiol Infect 1989 Jun;102(3):541] Author Bornstein N; Marmet D; Surgot M; Nowicki M; Arslan A; Esteve J; Fleurette J Address Centre National de Référence des Légionelloses, Faculté de Médecine Alexis Carrel, Lyon. Source Epidemiol Infect, 1989 Feb, 102:1, 31-6)

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)

Use of polymerase chain reaction in an epidemiologic investigation of Pontiac fever. (38%) of 34 resort guests experienced illness that met a symptom-based case definition of Pontiac fever. Each ill guest reported using an indoor hot tub compared with 6 (29%) of 21 nonill guests (P < .001). Water samples from the indoor hot tub were culture-negative for legionellae using standard techniques, coculture with amebae, and intraperitoneal inoculation of guinea pigs. However, polymerase chain reaction (PCR) testing of the water samples indicated the presence of Legionella pneumophila. Direct fluorescent antibody testing identified the organism as serogroup 6. Seroconversion to L. pneumophila serogroup 6 occurred in 7 (64%) of 11 ill guests and none of 5 nonill guests (P = .03). These results suggest that in certain circumstances, culture of environmental samples should be supplemented with additional tests such as PCR. These results are also consistent with the concept that Pontiac fever can be caused by nonviable legionellae.
(Miller LA; Beebe JL; Butler JC; Martin W; Benson R; Hoffman RE; Fields BS Address Colorado Dept. of Health, DCEED-EE-A3, Denver 80222-1530. J Infect Dis, 1993 Sep, 168:3, 769-72 Abstract In June 1992, 13)

Pseudomonas aeruginosa folliculitis acquired through use of a contaminated loofah sponge: an unrecognized potential public health probblem.

Pseudomonas aeruginosa folliculitis is a well-known entity that occurs among users ofclosed-cycle recreational water sources such as whirlpools, swimming pools, and hot tubs. In the absence of this epidemiologic link, isolated cases are difticuit to diagnose. We encountered a patient who developed P. aeruginosa follwulitis subsequent to tbe use of a loofah sponge grossly contaminated with the same P. aeruginosa (serotype 10; pyocin type Ila 4,b) that was reovered from her skin, Furthermore, we demonstrated that sterile unused loofah sponges can serve as the sole growth-promoting substrate for P. aeruginosa. To obviate the potential public health problem of contaminated loofah sponges, it is strongly recommended that manufacturers append, and consumers adhere to, instructions as to the care of loofah sponges, which includes allowing the sponge to dry afier use.
(E. J. Bottone & A. A. Perez J C'lin Microbiol 3 1 : 480-3 ( 1993)(932 l 006 1)

1994 NEW YORK CRUISE SHIP

An outbreak of Legionnaires disease among cruise ship passengers that occurred in April 1994, but went unrecognized until july 1994. 50 passengers with Legionnaires' disease (16 confirmed, 34 probable) were identified from nine cruise embarking between April 30 and July 9 1994.
Exposure to whirlpool spas was strongly associated with the disease.
(Jernigan DB, The Lancet 1996 347; Febuary 24 494-499)

1994 NEW YORK CRUISE SHIP

About 300 passengers aboard a Caribbean cruise ship which was struck by Legionnaires disease last year, suffered symptoms of Salmonella poisoning A spokeman from the US Centre for Disease Control and Prevention, said several of the crew members aboard also reported the symptons, There was a total of 1800 passengers on board. The CDC said a prelimmary investigation found contaminated food on board the ship was the probable cause of the sickness.
Last year 17 confirmed cases and 38 suspected of Legionnaires' disease was diagnosed aboard the ship, with one death, Contaminated Spa Bath water was believed to have been the cause of the outbreak.

1994
QUEENSLAND AUSTRALIA
Legionnaires' disease kills two people on holiday from Victoria in Queensland.
PRIVATE SPA -TWO CASES -TWO DEATHS

Hot tub legionellosis.

Legionella pneumophila is the cause of Legionnaires' disease, and Pontiac fever, an influenza-like condition without pneumonia. We present a case of Pontiac fever after exposure to a hot tub contaminated with L pneumophila. A 37 y/o wf presented to the office with acute onset of sore throat, fever, headache, and myalgia. Patient was hospitalized 3 days later because of worsening shortness of air. Chest x-ray was normal. Patient was treated with 2 days of IV erythromycin and was discharged home on oral erythromycin. Her Legionella IFA was 1:16,384. Two days later, she developed chest tightness, pleuritic chest pain, and increasing shortness of air but did not have any cough or sputum production. She was re-hospitalized with a diagnosis of Pontiac fever and treated with IV erythromycin plus oral rifampin. A repeat chest x-ray remained normal. After a detailed epidemiologic history was obtained, it was noted that she became ill after using a hot tub, which her two children also used and they themselves developed a self limited illness. Water from the hot tub was positive for L pneumophila by DFA, culture, and PCR. Patient improved gradually with therapy and was discharged home. This report emphasizes the importance of a complete epidemiologic history in the diagnosis of respiratory infections. It also demonstrates that aquatic environment can be contaminated with Legionella and serve as a source of infection.
(Tolentino A, Ahkee S, Ramirez J. Ky Med Assoc 1996 Sep;94(9):393-394 )
Division of Infectious Diseases, University of Louisville, School of Medicine, KY, USA.

1995
Pseudomonas aeruginosa wound infection associated with a nursing home's whirlpool bath.

Whirlpool baths are ftted with hydrojet circulation and/or air induction bubble systems. Water in a whirlpool bath, unlike a spa pool, is not fltered or chemically treated but the bath is drained and cleaned between each bather. This is, we believe, the frst report of Pseudomonas aeruginosa wound infection associated with the use of a whirlpool bath in a nursing home. Microbiologically confrmed infections with P. aeruginosa ofidentical antibiotic sensitivity patterns arose in one week in wounds of four of 24 residents who used a whirlpool bath from which P. aeruginosa was also isolated. P. aeruginosa was not isolated from the wounds ofa further seven residents who did not use the whirlpool bath. The incident control team advised that use of the whirlpool bath should be restricted to continent residents with intact skin, and that the bath should be cleaned with a degreasing agent and disinfected with hypochlorite between use by individual residents. The hazard of infection posed by whirlpool baths, particularly in nursing homes, needs to be assessed. National guidance for their cleaning, maintenance, and disinfection is required.
(Hollyoak V; Allison D; Summers J ..Address County Durham Health Commission. Commun Dis Rep CDR Rev, 5 : 7, 1995 Jun 23, R I 00-2)

PUBLIC HEALTH ALERT
THIS NOTICE MUST BE BROUGHT TO THE ATTENTION OF ALL DOCTORS

SUBJECT: LEGIONELLA PNEUMONIA

BRIEFING: The South Australian Health Commission is investigating 2 cases of Legionella pneumophila, both of whom visited Kingscote, Kangaroo Island during their incubation period. The symptoms of this infection are typically anorexia, malaise, myalgia and headache, followed by high fevers (39-40.5 degrees), a non-productive cough, and often abdominal pain and diarrhoea. The incubation period is two - 10 days, commonly five - six days. Serology is frequently unhelpful during the acute phase of the illness, therefore patients should be treated on clinical suspicion.

ACTION REQUESTED: Consider a diagnosis of Legionella pneumonia in patients presenting with the above symptomatology. If there is a high degree of suspicion please notify the Communicable Disease Control Branch. (phone: 08 2266352)

ISSUED: Friday 19th July, 1996 at 5 pm.
CDC Bulletin VOLUME 5, NUMBER 32, SEPTEMBER 1996

1996

CASES OF LEGIONNAIRES' DISEASE ASSOCIATED WITH KANGAROO ISLAND

In the week of 14-20th July 1996, the South Australian Health Commission was notified of two cases of Legionnaires disease, both of whom had stayed in the same hotel on Kangaroo Island during the incubation period of their illness. Both patients, who subsequently died, were infected with the same strain of Legionella identified by molecular typing. The spa pool at the hotel was not properly disinfected and also contained the same strain of Legionella. Recent renovations had also interrupted hot water supply to hotel rooms, causing problems with water flow and temperature. As a precautionary measure, the hotel spa pool was closed on 17 th July 1996 and the hot water system heat disinfected.

A search for other cases of Legionnaires' disease revealed that one other person, a resident of Kangaroo Island, had also been infected. The person had been to the main street of Kingscote, but had not been to the hotel. It is possible that fine droplets from the spa pool may have been carried to the main street by the exhaust fan from the spa room.

The only place that Legionella were found in Kingscote was the hotel spa pool, which was closed on 17th July, 1996. No other sources of Legionella were identified in Kingscote despite water samples being taken from many different sites. The most likely cause of this outbreak was the hotel spa pool, although a definite link was not confirmed. Spas have been shown to be a source of Legionnaires' disease, even where people had not entered the spa pool but had only been in the vicinity. This incident emphasises the need to properly disinfect spa pools with chlorine or bromine.

Editorial Note: Infection with Legionella can cause a severe pneumonia (Legionnaires' disease) or a mild flu-like illness. Most cases of Legionnaires' disease occur in elderly people with other serious underlying disease or in people with weakened immune systems. There are approximately ten cases of Legionnaires' disease in South Australia each year caused by Legionella pneumophila. Another species, Legionella longbeachae found in potting mix and soils, is responsible for approximately another ten cases each year. The source of infection is not identified for the majority of cases.

Legionella are commonly found in soil and water and do not normally cause illness in healthy people. Infection occurs when people breathe in aerosols (fine droplets) containing the bacteria. These fine water droplets are produced by equipment such as spa pools, water-based air conditioning systems and showers. The bacteria grow particularly well when the water temperature is around 40 Celsius. Proper disinfection of spa pools and air-conditioning systems with chlorine or bromine will kill the bacteria. Provided the water temperature of hot water systems are maintained above 55 Celsius the bacteria should not be able to survive. Evaporative coolers used in many homes are not thought to be a source of the bacteria, as the water temperature is not optimum for growth and aerosols are not generated.
(Martin Kirk, Epidemiology Registrar, Communicable Disease Control Branch, SAHC)

OUTBREAK
Two linked cases of Legionnaires' disease, South Australia
Martyn Kirk , Rachel Wells , Carolyn Walker 1 and Jan Lan-ser

In the week of 14-20 July 1996, the South Australian Health Commission was notified of two cases of Legionnaires' disease, both of whom had stayed in the same hotel during the incubation period. The patients, a 54 year old female and a 49 year old male, were both smokers with no other obvious risk factors. Both patients had Legionella pneumo-phila serogroup 1 isolated from clinical specimens and subsequently died. An environmental assessment of the hotel revealed that the spa pool was inadequately disin-fected and that recent renovations had interrupted the hot water supply to hotel rooms. No epidemiological link with these sources was confirmed, although one of the cases had been in the room housing the spa pool while the spa was operating. The other case had not been near the spa, although he may have worked near an exhaust vent for the spa pool room. As a precautionary measure, the hotel spa pool was closed and the hot water system heat disinfected. Active surveil- lance for Legionnaires' disease, initiated as a result of this cluster, did not detect any other cases associated with the hotel. A media release alerted people who had stayed at the hotel since the beginning of July to seek medical atten-tion if they had symptoms consistent with legionellosis. Culture of a water sample from the spa pool grew L. pneumophila serogroup 1 pontiac strain. Legionella isolates from the cases and the spa pool were identical by restric-tion fragment length polymorphism testing. This particular strain of L. pneumophila serogroup 1 has been found previously in South Australia; from an outbreak in 1986 and from sporadic cases, including two epidemiologically unrelated cases this year. No Legionellae were cultured from samples of water entering the hotel or from showers in guests’ rooms.
In South Australia this year, there have been seven notified cases of L. pneumophila serogroup 1 infection with four deaths. One case notified in New South Wales had been in South Australia during the incubation period. Except for the two cases visiting the same hotel, no epidemiological links between the cases were identified. Five of the eight cases investigated had been in or near (separate) spa pools during the incubation period.

1996 Virginia.

Legionnaires' Disease Associated with a Whirlpool Spa Display .

September–October, 1996 Contaminated whirlpool spas have been reported as a source of legionellosis.
This report describes the preliminary findings of an ongoing investigation by the Virginia Department of Health (VDH) and CDC of a recent outbreak of Legionnaires' disease in Virginia, which implicated a whirlpool spa display at a retail store as the source of infection.
On October 15, 1996, a district health department in southwestern Virginia con-tacted the Office of Epidemiology, VDH, about a hospital (hospital A) report that 15 pa-tients had been admitted during October 12–13 with unexplained pneumonia.
On October 21, another hospital (hospital B), located approximately 15 miles from hospi-tal A, reported its pneumonia census to be higher than expected for the first 2 weeks of October. On October 23, the district health department was informed about three area residents with legionellosis (with Legionella pneumophila serogroup 1 [Lp1] an-tigen detected in urine); one was a patient at hospital A, and two were patients at hospitals outside the jurisdiction of the health department.
To identify all outbreak-associated cases, investigators reviewed medical records and laboratory reports of admissions to the three hospitals for pneumonia during September 1–November 12.
Hospital personnel and area health-care providers collected and submitted specimens from patients with pneumonia, including serum for the determination of acute Lp1 antibody titers (to be followed by convalescent titers); sputum, when possible, for Legionella culture; and urine to detect Lp1 antigens.
A case of Legionnaires' disease was defined as pneumonia in an area resident with onset of illness during September 1–November 12 with Lp1 identified by culture of sputum, antigen assay of urine, or fourfold rise in serum antibody titers. Based on the review of records, 23 cases eventually were identified, including 15 by urine anti-gen, seven by serology, and three by sputum culture; two were identified by urine antigen and sputum culture. Of the 23 case-patients, 22 were hospitalized, and two died.
The mean age of case-patients was 65 years (range: 42–86 years), and most (17) were male. Although patients had onsets of illness during September 29–October 22, most (18 [78%]) had onsets during October 8–14 (Figure 1).

To identify potential exposures associated with Legionnaires disease, case-patients were asked about their activities during the 2 weeks before onset of illness. Based on these interviews, a questionnaire was developed and a case-control study was initiated on November 2 to assess potential risk factors for and exposures related to infection.
Three controls were selected for each confirmed case by using office records of the primary-care physicians of the case-patients; controls were matched by

age (within 10 years), sex, and underlying medical conditions. All case-patients and controls were asked whether, during the 2 weeks before onset of illness, they had visited any of 14 retail and manufacturing sites. Of the 23 cases, 15 were included in the case-control study (one person died before the case-contol study was initiated and had no available exposure history, and seven patients were identified after convalescent serum became available 2 months follow-ing the case-control study).
A history of having visited a large home-improvement center during the 2 weeks before onset of illness was reported by 14 (93%) of the 15 cases, compared with 12 (27%) of the 45 controls (matched odds ratio [MOR]=23.3; 95% confidence interval [CI]=3.0–182). Of the 13 case-patients and 12 controls who had visited the store and for whom there was a detailed in-store exposure history, cumulative duration of total store visits averaged 79 minutes for cases, compared with 29 minutes for controls (F-test p<0.01); in addition, 10 (77%) case-patients reported spending time in the area surrounding the spas during their visits to the store, compared with three (25%) of the 12 controls (MOR=5.5; 95% CI=0.7–256).
Four of these case-patients and one of the controls reported only “walking by” the spa.
No other activity, including drinking from the store’s water fountains or visiting the 14 other locations in the community, was associated with illness. Whirlpool Spas Drained Samples were collected and cultured for the presence of Legionella from water sources in the home-improvement center, including a whirlpool spa basin, spa filters, a greenhouse sprinkler system, a decorative fish pond and fountain, potable water fountains, urinals, and hot and cold water taps in the store’s restrooms. In addition to these potential sources, a second whirlpool spa had been sold, drained on October 9, and removed from the store floor on October 11.
Three filters were available for testing from the two spas. One of these filters was from the purchased spa, and the other two had been used in the spa that was in operation until October 28, but that had been drained and out of service during October 9–17. Lp1 was isolated from the filter from the purchased spa; that isolate was an exact match, by monoclonal antibody sub-typing and arbitrarily primed polymerase chain reaction, to the sputum isolates cul-tured from two of the cases. A third isolate from the case-patient that did not visit the home-improvement center had a different monoclonal antibody pattern. All other en-vironmental sources, including the other two filters, tested negative.
Approximately 10,000–15,000 cases of Legionnaires' disease occur each year in the United States; most occur sporadically Investigations of out-breaks have documented aerosol transmission of Legionella from contaminated cooling towers and evaporative condensers showers decorative fountains, humidifiers, respiratory therapy equipment , and whirlpool spas , However, the proportion of sporadically occurring disease attributable to these sources has not yet been determined. In contrast with other spa- or whirlpool-associated outbreaks, in this outbreak, none of the case-patients actually entered the water. Instead, all were most likely exposed by walking by or spending time in the area surrounding the spa.
Although most community-wide outbreaks of legionellosis have resulted from transmission from an outdoor source (e.g., cooling towers), this report underscores the potential for such outbreaks in association with contaminated indoor sources. Even though the epidemiologic findings of the case-control study indicated that the source of the outbreak was located in a home-improvement center, the laboratory findings were critical in identifying the exact source of exposure within the store. Case-patients were more likely than controls to have reported exposure to the spas, but the difference was not statistically significant.
By matching the two clinical Lp1 isolates to the isolate from the purchased spa, molecular epidemiologic typing helped link the spa to illness. Enhanced surveillance during investigations of legionellosis outbreaks may result in the detection of some sporadically occurring cases. For example, in the investigation of this outbreak, one case-patient did not report visiting the home-improvement center.
(MMWR VOL 46 NO 4 JANUARY 31st 1997)

Revised Date: 04/26/97
Outbreak Information/Health Alerts

Posted: 11/15/96

Preliminary Evidence Strongly Suggests That Hot Tub Was Source of Legionnaires' Disease Outbreak In The New River Valley

Preliminary evidence from the investigation of a Legionnaires' disease outbreak in the New River Valley supports the theory that a hot tub displayed at the Lowe's store in Christiansburg was the source of the outbreak, reported Dr. Jody Hershey, Director of the New River Health District. The implicated hot tub was taken out of service on October 8 or 9, 1996, and other possible sources for disease transmission within the store were removed early in the investigation. The investigative team believes that the last case related to this outbreak had onset on October 18, 1996.

"There should be no risk of acquiring Legionnaires' disease from this store now," stated Dr. Hershey. "Since the incubation period is 2-10 days, anyone who visited the store while the hot tub was in use and who did not develop flu-like symptoms or pneumonia by now should be reassured that he/she did not contract the disease." he added.

The investigative team based its conclusions on information gained from a study that compared exposure of 15 confirmed cases with the exposure of 45 persons who did not have Legionnaires' disease (controls). Of the 15 cases included in the comparative study, 14 had been to the Lowe's store prior to developing illness and each had spent an average of 78 minutes in the store. Only 12 of the controls had been to the store and those that went were in the store an average of less than 30 minutes each.

In further support of the hot tub theory, special DNA laboratory studies determined that the Legionella bacteria isolated from the filter of the tub matched the bacteria from at least one of the patients.

Legionnaires' disease cases are often reported as single, isolated events and a source may never be identified.
Last year, 28 such cases were reported in Virginia. The disease usually affects men over 50 years of age, especially those who have underlying medical problems.

Legionnaires' disease is acquired from inhaling water droplets that contain the bacteria and is not spread from one person to another. Outbreaks of Legionnaires' disease have been reported from sources such as cooling towers, evaporative condensers, humidifiers, whirlpool spas, respiratory therapy devices, grocery store vegetable misters, and decorative fountains. Design and maintenance guidelines to prevent Legionnaires' disease from such sources are constantly under review and may minimize disease transmission, but cannot guatantee freedom from the organism.

Posted: 10/28/96

An intensive investigation to identify the cause and source of an increase in community-acquired pneumonias in the New River Health District is being conducted by a team composed of New River and neighboring health district staff, state public health authorities and epidemiologists from the Centers for Disease Control and Prevention.

To date, thirteen of these pneumonias have been confirmed as Legionella (Legionnaires' Disease) and tests are pending on others. Public health officials consider this an outbreak and are searching for a possible environmental source. The investigation is focusing on identifying and confirming additional causes and finding an exposure that may link the cases. Investigators believe the bulk of the cases peaked around October 10, 1996 and do not expect many new cases of pneumonia to be identified. They do expect, however, that more of the previously identified pneumonia cases will be confirmed as Legionnaires' ease.

WISCONSIN. SISTER BAY 1996

A small outbreak of Legionnairess' Disease in Door County in October 1996 resulted in the death of A 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
(Source Media)

Molecular determination of infection source of a sporadic Legionella pneumonia case associated with a hot spring bath

To determine the infection source of a sporadic Legionella pneumonia case associated with a hot spring bath, we used five molecular methods, including repetitive element polymerase chain reaction (rep-PCR), arbitrarily primed PCR (AP-PCR), ribotyping, restriction endonuclease analysis (REA), and macrorestriction endonuclease analysis (MREA) by pulsed-field gel electrophoresis. L. pneumophila serogroup (SG) 3 strain EY 3702, isolated from an intratracheal specimen of a 71-year-old Japanese female who developed pneumonia after nearly drowning in a hot spring spa bath, produced rep-PCR and AP-PCR fingerprints identical to those of L. pneumophila SG 3 strains EY 3768 and EY 3769 isolated from the bath water. Four epidemiologically unrelated L. pneumophila SG 3 strains showed different rep-PCR or AP-PCR fingerprints from those of the three EY strains (EY 3702, 3768, and 3769). The three EY strains were also genotypically indistinguishable by ribotyping with EcoRI and PstI, by REA with EcoRI or HindIII, and by MREA with NotI. Based on these results, we identified the bath water of the hot spring spa as the source of infection of this patient, even though the viable number of the organisms in the bath water was low (3 CFU/100 ml) when determined 27 days after her nearly drowning.
(Miyamoto H, Jitsurong S, Shiota R, Maruta K, Yoshida S, Yabuuchi EMicrobiol Immunol 41 (3): 197-202 (1997)
Department of Microbiology, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan.)

Legionella pneumophila serogroup 3 isolated from a patient of pneumonia developed after drowning in bathtub of a hot spring spa

A 71-year-old Japanese female, was found unconscious by drawing, in a hot spring spa, at around noon of 20 October 1994. She recovered by emergency cardiopulmonary resuscitation, and admitted to the Takinomiya General Hospital, with adult respiratory distress syndrome (ARDS).
Although she recovered from ARDS within 4 days after her admission, she developed severe pneumonia accompanied with the second attack of ARDS. Ordinary bacteriological culture of her respiratory specimens failed to yield any significant pathogen for her pneumonia, and neither cefazolin nor imipenem/cilastatin was effective.
Thus minocyclin was given on the 7th hospital-day and this was effective for blood gas and C-reactive protein (CRP) levels. Intratracheal exsudate inoculated on BCYE alpha agar plate yielded grayish white colonies. Cells of the colonies were clearly agglutinated by anti-Legionella pneumophila serogroup (SG) 3 serum. Antibody titers of patient's paired sera against the strain L. pneumophila SG3 Bloomington-2 and the patient's strain (Y-1) were determined by microplate agglutination test, and a significant rise from 1:20 to 1:320 was demonstrated. Patient recovered by erythromycin treatment and was discharged on the 59th hospital day. L. pneumophila SG3 organisms were again isolated from the spa water where the patient drawn. From these findings described above, we diagnosed the patient as pneumonia due to L. pneumophila SG3, and the spa water was the most probable source of infection.
(Kansenshogaku Zasshi 69 (12): 1356-1364 (Dec 1995) Shiota R, Takeshita K, Yamamoto K, Imada K, Yabuuchi E, Wang L
Department of Clinical Laboratory, Takinomiya General Hospital.)

A case of Legionnaires' disease due to aspiration of hot spring water and isolation of Legionella pneumophila from hot spring water

We report a case of fulminant pneumonia that was due to aspiration of contaminated hot spring water and was not affected by beta-lactam antibiotics. We suspected that the patient had Legionnaires' disease and treated the clinical symptoms with erythromycin. Legionellaceae could not be isolated from sputum or lung biopsy material, but an elevated titer to Legionella pneumophila serogroup 4 was found by indirect immunofluorescence test. We diagnosed the patent as having Legionnaires' disease with improved clinical symptoms. Furthermore, we went to the hot spring that he visited and tried to isolate Legionellaceae. Hot spring water was collected from the bathroom and water, hot water, and shower water from the guest-room. After using a low-pH method, samples were cultured on BCYE alpha medium. Serogroups are classified by agglutination method with immune rabbit serum. As a result, we successfully isolated Legionella pneumophila serogroup 4 from hot spring water (42 degrees C) from the bath. No bacteria could be isolated from the other samples. Therefore, we believe that this case of Legionnaires' disease was caused by aspiration of contaminated hot spring water. The infection route of Legionnaires' disease is unclear. There are no previous reports of isolation of Legionellaceae from Japanese hot springs. This case would provide important information when considering the infection route of Legionnaires' disease in Japan.
(Mashiba K, Hamamoto T, Torikai K Kansenshogaku Zasshi 67 (2): 163-166 (Feb 1993)
(Department of Internal Medicine, Fujita Health University, School of Medicine.)

A case of fatal pneumonia caused by Legionella pneumophila serogroup 6 developed after drowning in a public bath

A 57-year-old male was admitted to our hospital because of high fever, productive cough and dyspnea. Six days prior to admission he had an episode of drowning in a public bath. On admission chest X-ray showed wide-spread pneumonia causing severe respiratory distress for which mechanical ventilatory support was started. Despite chemotherapy including erythromycin and rifampicin his condition continued to deteriorate. Chemistry showed marked elevation of CPK and findings of acute renal failure. He eventually passed away with septic shock. During the course Legionellae remained negative with culture of broncho-alveolar lavage fluid. L. pneumophila serogroup 1 (SG1) antigen in the urine was not detected, and no elevation of serum antibody titer was noted. Culture of the material obtained from the lung abscess at autopsy revealed L. pneumophila SG6 and serum antibody titer against SG6 also was found to be extremely high. With this evidence we concluded that this case of pneumonia was caused by L. pneumophila SG6.
We believe this is the first reported case of the SG6 pneumonia in Japan. Another remarkable feature of this case was massive rhabdomyolysis pathologically confirmed after autopsy.
Although the pathogenesis of this process has not been clarified, there are several case reports of rhabdomyolysis complicated with Legionnairs' disease in the past. Therefore, we should bear in mind and pay careful attention while coping with this disease.
(Tokuda H, Yahagi N, Kasai S, Kitamura S, Otsuka Y Kansenshogaku Zasshi 71 (2): 169-174 (Feb 1997)
Department of Internal Medicine, Social Health Insurance Medical Center.)

Water-related nosocomial pneumonia caused by Legionella pneumophila serogroups 1 and 10.

Between August 1978 and November 1983, 21 cases of pneumonia caused by Legionella pneumophila occurred in the Leiden University Hospital, mainly among immunocompromised patients.
A new serogroup of L. pneumophila, designated serogroup 10 (prototype strain Leiden 1), was isolated from bronchial secretions of four patients, and five patients had serological evidence of infection with this organism. Nine patients had a culture-confirmed infection with L. pneumophila serogroup 1. L. pneumophila serogroups 1 and 10 were also isolated from the hot potable water supply in the building to which 19 of the 21 patients had been admitted. The isolates of L. pneumophila serogroup 1 from patients and the hot potable water were identical in studies with monoclonal antibodies and had the same plasmid profiles.
These findings provide further evidence that in our hospital potable water contaminated with L. pneumophila is a source of infection, mainly in immunocompromised patients.
(Meenhorst PL, Reingold AL, Groothuis DG, Gorman GW, Wilkinson HW, McKinney RM, Feeley JC, Brenner DJ, van Furth R J Infect Dis 152 (2): 356-364 (Aug 1985)

Exposure to Legionellaceae at a hot spring spa: a prospective clinical and serological study

Following the occurrence of five cases of Legionnaires' disease among patients and therapists at a French hot spring spa, a series of cleansing procedures and an epidemiological study were undertaken. During a 3-month period, the spring water was repeatedly sampled. Serum samples were taken from 689 randomly selected patients, 230 therapists, 134 administrative staff and a control group of 904 blood donors. Legionellaceae were present in the spring water at concentrations of 10(3)-10(5) colony forming units/l. Fifteen different species or serogroups were isolated with Legionella pneumophila serogroups 3 and 1 predominating. No clinical cases of Legionnaires' disease were observed during the study. However, 11% of the therapists and 5% of the patients either had a high titre of antibody (greater than or equal to 256) to at least one species or serogroup or seroconverted during the study. Mean antibody titres in the three study groups were significantly higher than those in the blood donors against 11 of the 32 legionella antigens tested. Nine of these 11 antigens corresponded to species or serogroups isolated from the spring water. The highest mean antibody titres in all three study groups were against L. pneumophila serogroup 3, the most common legionella in the spring water. These findings have important implications for the maintenance of adequate standards of hygiene, bacteriological sampling and clinical surveillance in this and similar establishments.
(Bornstein N, Marmet D, Surgot M, Nowicki M, Arslan A, Esteve J, Fleurette J Epidemiol Infect 102 (1): 31-36 (Feb 1989)

Hot tub legionellosis.

Legionella pneumophila is the cause of Legionnaires' disease, and Pontiac fever, an influenza-like condition without pneumonia. We present a case of Pontiac fever after exposure to a hot tub contaminated with L pneumophila. A 37 y/o wf presented to the office with acute onset of sore throat, fever, headache, and myalgia. Patient was hospitalized 3 days later because of worsening shortness of air. Chest x-ray was normal. Patient was treated with 2 days of IV erythromycin and was discharged home on oral erythromycin. Her Legionella IFA was 1:16,384. Two days later, she developed chest tightness, pleuritic chest pain, and increasing shortness of air but did not have any cough or sputum production. She was re-hospitalized with a diagnosis of Pontiac fever and treated with IV erythromycin plus oral rifampin. A repeat chest x-ray remained normal. After a detailed epidemiologic history was obtained, it was noted that she became ill after using a hot tub, which her two children also used and they themselves developed a self limited illness. Water from the hot tub was positive for L pneumophila by DFA, culture, and PCR. Patient improved gradually with therapy and was discharged home. This report emphasizes the importance of a complete epidemiologic history in the diagnosis of respiratory infections. It also demonstrates that aquatic environment can be contaminated with Legionella and serve as a source of infection.
(Tolentino A, Ahkee S, Ramirez J J Ky Med Assoc 94 (9): 393-394 (Sep 1996)

Legionnaires' disease on an oil drilling platform in the Mediterranean:
A case report.

(Pastoris MC, Greco D, Cacciottolo JM, Vassallo A, Grech A, Bartlett CL
Br J Ind Med 44 (9): 645-646 (Sep 1987)

CDR (Lond Engl Wkly) 1 (49): 217 (Dec 6 1991)

Legionellosis in Winchester.

Isolation of amoebae and Pseudomonas and Legionella spp. from eyewash stations.

Forty eyewash units were sampled for protozoa, bacteria, and fungi. Total heterotrophic bacterial counts on nutrient agar and R2A agar (Difco Laboratories, Detroit, Mich.) ranged from 0 to 10(5) CFU/ml, with Pseudomonas spp. being the most frequently isolated. Total counts of 10(4) and 10(8) cells per ml were obtained with the acridine orange staining procedure. All samples were examined for Legionella spp. by direct fluorescent-antibody staining and by culturing on buffered charcoal-yeast extract agar containing alpha-ketoglutarate and glycine and supplemented with cycloheximide, vancomycin, and polymyxin B. DNA-DNA hybridization was used to confirm identification of the Legionella isolates. Legionellae were detected in 35 of 40 (87.5%) samples by direct fluorescent-antibody staining, with 3 samples yielding both Legionella spp. and amoebae. Amoebae identified as Hartmannella, Vahlkampfia, Acanthamoeba, and Cochliopodium spp. were detected in 19 of 40 (47:5%) samples. Sabouraud dextrose agar was used to obtain a crude estimate of viable fungal populations, pH, hardness, and ammonia, alkalinity, chlorine, copper, and iron contents were recorded for all water samples collected from eyewash stations; 33% of the samples had greater than or equal to 10 mg of CO2 per liter. It is concluded that eyewash stations not regularly flushed and/or cleaned and used to flush traumatized eye tissue may be a source of infection and can contaminate laboratory environments via aerosol transmission
(Paszko-Kolva C, Yamamoto H, Shahamat M, Sawyer TK, Morris G, Colwell RR
(Appl Environ Microbiol 57 (1): 163-167 (Jan 1991)
Department of Microbiology University of Maryland, College Park 20742.

Legionnaires' disease in Vancouver.

A female patient presented at the end of a holiday cruise with the pneumonitis of Legionnaires' disease. The radiographic appearance was indistinguishable from any other cause of air-space consolidation.
(Hicken P, Johnson MA, Gourley T J Can Assoc Radiol 30 (3): 179 (Sep 1979)

Outbreak of respiratory illness on board a ship cruising to ports in southern Europe and northern Africa.

A large outbreak of influenza-like and diarrhoeal illness took place over a period of 21 days in April 1984 on board a ship cruising to ports in southern Europe and northern Africa. A cohort study of the 418 passengers was made by postal questionnaire and personal interview. Of the 391 passengers who were interviewed or who returned a questionnaire, 335 (86%) were affected. Of the ill passengers, 295 (88%) had an influenza-like illness.
These included 20 with signs of lower respiratory tract infection. In 24 passengers, a viral infection was diagnosed. Influenza B virus infection was identified in 14 cases; other diagnoses were influenza A, para-influenza, respiratory syncytial virus and Epstein-Barr virus infections. In two of the 81 patients tested for Legionella antibodies, a titre of 128 was found; in 16 and 44 patients, titres of 64 and 32 respectively.
The outbreak was thus evidently caused by multiple pathogens mainly affecting the respiratory tract. Although most of the passengers acquired their infections on board the ship, a common source was not discovered.
A steep rise in the epidemic curve the day after the air-conditioning was switched on, however, is worth noting. If and when similar instances of the 'Sick Boat Syndrome' recur, a search for environmental sources of infection is to be recommended.
(Christenson B, Lidin-Janson G, Kallings I J Infect 14 (3): 247-254 (May 1987)

Colonisation of the respiratory tract with Legionella pneumophila for 63 days before the onset of pneumonia.

We report the case of a 70-year-old man who was admitted to hospital A 66 days before developing Legionella pneumophila pneumonia 6 days after open heart surgery at hospital C. The strain of L. pneumophila recovered from the patient's sputum was of the same subtype (monoclonal antibody type, enzyme type, plasmid profile, and restriction endonuclease pattern) as a strain of L. pneumophila in the potable water supplied to the room where he stayed in hospital A. We conclude that the patient's respiratory tract became colonised by L. pneumophila while he was in hospital A and persisted for at least 63 days until he developed pneumonia requiring antibiotic treatment while in hospital C.
(Marrie TJ, Bezanson G, Haldane DJ, Burbridge S J Infect 24 (1): 81-86 (Jan 1992)

A case of Legionnaires' disease due to aspiration of hot spring water and isolation of Legionella pneumophila from hot spring water

We report a case of fulminant pneumonia that was due to aspiration of contaminated hot spring water and was not affected by beta-lactam antibiotics. We suspected that the patient had Legionnaires' disease and treated the clinical symptoms with erythromycin. Legionellaceae could not be isolated from sputum or lung biopsy material, but an elevated titer to Legionella pneumophila serogroup 4 was found by indirect immunofluorescence test. We diagnosed the patent as having Legionnaires' disease with improved clinical symptoms. Furthermore, we went to the hot spring that he visited and tried to isolate Legionellaceae. Hot spring water was collected from the bathroom and water, hot water, and shower water from the guest-room. After using a low-pH method, samples were cultured on BCYE alpha medium. Serogroups are classified by agglutination method with immune rabbit serum. As a result, we successfully isolated Legionella pneumophila serogroup 4 from hot spring water (42 degrees C) from the bath. No bacteria could be isolated from the other samples. Therefore, we believe that this case of Legionnaires' disease was caused by aspiration of contaminated hot spring water.
The infection route of Legionnaires' disease is unclear. There are no previous reports of isolation of Legionellaceae from Japanese hot springs. This case would provide important information when considering the infection route of Legionnaires' disease in Japan.
(Mashiba K, Hamamoto T, Torikai K Kansenshogaku Zasshi 67 (2): 163-166 (Feb 1993)

Plumbing system shock absorbers as a source of Legionella pneumophila.

Water distribution systems have been demonstrated to be a major source of nosocomial legionellosis. We describe an outbreak in our institution in which a novel source of Legionella pneumophila was identified in the plumbing system. METHODS: After an outbreak of 10 cases of legionellosis in our hospital, recommended measures including superheating of the hot water to 80 degrees C, hyperchlorination to 2 ppm, and flushing resulted in no new cases in the following 5 years. Recently, despite these control measures, three new cases occurred. Surveillance cultures of shower heads and water tanks were negative; cultures of tap water samples remained positive.
This prompted a search for another reservoir. Shock absorbers installed within water pipes to decrease noise were suspected. RESULTS: One hundred twenty-five shock absorbers were removed and cultured. A total of 13 (10%) yielded heavy growth of L. pneumophila (serogroup 1).
Since their removal, no new cases have been found and the percentage of positive results of random tap water culture has dropped from 20% to 5%.

CONCLUSIONS: This is the first report that identifies shock absorbers as a possible reservoir for L. pneumophila. We recommend that institutions with endemic legionellosis assess the water system for possible removal of shock absorbers.
(Memish ZA, Oxley C, Contant J, Garber GE Am J Infect Control 20 (6): 305-309 (Dec 1992)

Community-acquired Legionella micdadei (Pittsburgh pneumonia agent) infection in Sweden.

The first case of Legionella micdadei (Pittsburgh Pneumonia Agent) infection in Sweden is presented. A previously healthy 68-yr-old man fell ill with diarrhoea, fever, and mental confusion.
Subsequently chest roentgenography revealed pneumonic infiltrates and a seroconversion to L. micdadei was shown. No source or transmission of infection was established.
The only notable event was that the patient had been drinking rain-water from a barrel 1 day prior to his illness. An alimentary route of infection was considered.
(Back E, Schvarcz R, Kallings I Scand J Infect Dis 15 (3): 313-315 (1983)

Pool-associated Pseudomonas aeruginosa dermatitis and other bathing-associated infections.

The growing popularity of heated pools, especially whirlpools and hot tubs, has been accompanied by increasingly frequent outbreaks of an illness produced by Pseudomonas aeruginosa.
The illness usually includes folliculitis, pruritic skin rash, and/or otitis externa and occasionally mastitis and systemic symptoms. Although usually self-limited, rare severe cases have been described. Motel and hotel whirlpools are most often implicated as the source of outbreaks.
The relative importance of pool conditions and the bacteriology of P. aeruginosa in the pathogenesis of this illness remain to be elucidated. Implementing CDC Guidelines for public spas and hot tubs seem the most reasonable way of reducing the risk of large outbreaks. Prevention of cases arising from home hot tubs or whirlpools will be very difficult and may depend on extensive public education or the development of simple, inexpensive and effective disinfection systems
(Jacobson JA Infect Control 6 (10): 398-401 (Oct 1985)

Is eczema herpeticum associated with the use of hot tubs?

Cutaneous bacterial infections, most commonly caused by Pseudomonas aeruginosa, have been clearly linked to use of hot tubs. A 10-year-old female with atopic eczema developed eczema herpeticum after hot tub use with a friend who had "fever blisters"; herpes simplex virus was recovered from cutaneous vesicles. Since herpesvirus has been shown to survive in the hot tub environment, herpes simplex should be considered as another potential cause of disease in the spa setting.
(Cox GF, Levy ML, Wolf JE Jr Pediatr Dermatol 2 (4): 322-323 (Jul 1985)

Survival of herpes simplex virus in water specimens collected from hot tubs in spa facilities and on plastic surfaces.

Several health spas were closed temporarily because of possible nonvenereal spread of herpes simplex virus (HSV) in spa water at these facilities.
We collected water specimens from two health spas and studied them for (1) the presence of HSV; (2) bromine (Br2), chlorine (Cl2), and pH levels; and (3) the ability of HSV to survive in water. No HSV could be isolated from the spa water specimens.
Spa water had high levels of Cl2 and Br2, tap water specimens had low levels of Cl2, and distilled water had no detectable Cl2 or Br2. The addition of spa water to laboratory stock virus immediately inactivated the virus. The HSV survived four hours in the tap water and 24 hours in distilled water.
The survival of HSV appeared to be related to the free halogen content of water. To approximate the conditions of survival of HSV on plastic-coated benches and seats in spa facilities, HSV was placed on plastic surfaces in a humid atmosphere at 37 to 40 degrees C.
The virus was found to survive up to 4.5 hours under these conditions. The survival of HSV from human lesions may be different due to the presence of tissue secretions and proteins.
Furthermore, transmission may require other factors, such as rubbing of skin or penetration through abrasions.
However, survival of significant amounts of virus for 4.5 hours on plastic surfaces suggests that fomites such as these may be nonvenereal routes of HSV transmission.
(Nerurkar LS, West F, May M, Madden DL, Sever JL JAMA 250 (22): 3081-3083 (Dec 9 1983)

Pseudomonas folliculitis: an outbreak and review.

In November 1980, an outbreak of folliculitis due to Pseudomonas aeruginosa occurred in members of a health spa in Tennessee.
The source of infection was traced to the health spa swimming pool, which had not been chlorinated for two days due to equipment malfunction.
Thirty-seven (62%) of 60 members who used the swimming pool on these two days developed a papulopustular rash within eight hours to five days after swimming in the pool.
The rash had a characteristic distribution, predominantly involving the buttocks, hips, and axillae.
Other manifestations of infection included otitis externa (49%) and mastitis (11%). P. aeruginosa serogroup 0-11 was isolated from pustules of six people. A swab from the edge of the swimming pool also grew P. aeruginosa serogroup 0-11.
With the rising popularity of home whirlpools and hot tubs, physicians may expect to encounter this disease with increasing frequency.
(Gustafson TL, Band JD, Hutcheson RH Jr, Schaffner W Rev Infect Dis 5 (1): 1-8 (Jan 1983)

Methods for preventing pseudomonas folliculitis.

This outbreak highlights a number of significant factors related to most pseudomonas folliculitis outbreaks.
The bath water had not been changed in more than four weeks which led to a build-up of high levels of organic carbon.
There was an extended interval of six days between subsequent OTD chlorine residual tests, allowing the chlorine residual to decrease to low levels between tests. It should also be noted that the OTD test, by design, measures both the active free chlorine and the inactive combined chlorine residual. Therefore OTD residual readings in the low normal range may actually represent below normal free active chlorine residual levels.
The following measures are suggested to reduce the growth of pseudomonads in hot tubs and whirlpool baths and to prevent subsequent cases of pseudomonas folliculitis:
1. The OTD chlorine residual should be checked every day. The residual should be well above the minimum level suggested for the bath. Or, preferably, an automatic chlorinator should be installed. This device measures the free chlorine residual and automatically adds chlorine to keep the residual in the desired range.
2. The water in the bath should be changed at least every eight weeks in order to reduce the total organic carbon level. The water should be changed more frequently if the bath is used by a large number of persons.
3. If an outbreak of pseudomonas folliculitis is associated with a bath, thewater should be changed and the bath washed with a chlorine-based solution.
Also, the method of keeping the chlorine residual in the operating range should be re-evaluated.
(Smith GL. Cutis 29 (4): 378 (Apr 1982)

Pseudomonas folliculitis..

Previous reports of Pseudomonas folliculitis in children identified heated pools, hot tubs or spa baths as the source of the infection.
This report presents a 4-year-old female with Pseudomonas folliculitis acquired from the family bath tub.
The source of the infection was contaminated bath toys and bath plug.
(Hogan PA .Australas J Dermatol 38 (2): 93-94 (May 1997)
Department of Dermatology, New Children's Hospital, Westmead, New South Wales, Australia

Pulmonary illness associated with exposure to Mycobacterium-avium complex in hot tub water. Hypersensitivity pneumonitis or infection?

Mycobacterium avium complex is common in water. When aerosolized, it is frequently inhaled but rarely causes illness in healthy people. Hypersensitivity pneumonitis to inhaled aerosols has been described; these aerosols are from several sources of water.

The pneumonitis forms are collectively known as humidifier lung; the responsible agent in the water remains uncertain. PURPOSE: To report five cases of respiratory illness in healthy subjects using hot tubs contaminated with M avium complex. DESIGN: Descriptive case reports. SETTING: Consultations in two teaching hospitals.

PATIENTS: Five healthy people developed respiratory illnesses characterized by bronchitis, fever, and "flu-like" symptoms after using a hot tub. Acute exacerbations of their illness developed within hours of heavy use of the hot tubs. INVESTIGATIONS: A chest radiograph and sputum culture in all, BAL in one, CT scan and lung biopsy in another were performed. Culture of the water of the two hot tubs also was done.
RESULTS: Chest radiographs showed interstitial infiltrates or a miliary nodular pattern. Cultures of all sputum samples, the lung biopsy specimens, lung lavage and water samples were positive for M avium complex. The lung biopsy specimen revealed noncaseating granulomas. All patients recovered with no treatment for Mavium complex.
CONCLUSION: We conclude that the M avium complex in the water was responsible for the pulmonary illnesses. The symptoms and the results of investigations are more suggestive of a hypersensitivity pneumonitis than of an infection, but no serologic proof of an immunologic reaction to the M avium complex or water was obtained
(Embil J, Warren P, Yakrus M, Stark R, Corne S, Forrest D, Hershfield E Chest 111 (3): 813-816 (Mar 1997)
Department of Medicine, University of Manitoba, Winnipeg, Canada.)

The health hazards of saunas and spas and how to minimize them.

The rapidly increasing number of spas, hot tubs, and saunas intensifies the potentials for deaths from hyperthermia and drowning. METHODS: I analyzed 54 such deaths reported to me by 55 medical examiners and coroners in the United States and 104 deaths reported to the US Consumer Product Safety Commission (CPSC).

RESULTS: Only seven of the 158 deaths analyzed occurred in saunas. All of the remaining deaths occurred in spas, jacuzzis, or hot tubs, which were far more numerous. The chief risk factors identified were alcohol ingestion, heart disease, seizure disorders, and cocaine ingestion (alone or in combination with alcohol ingestion). These factors accounted for 71 or 44.7% of the 159 fatalities. Of these risk factors, alcohol represented 38%; heart disease, 31%; seizure disorders, 17%; and cocaine ingestion, alone or in combination with alcohol, 14%. Sixty-one of the 151 spa-associated deaths occurred in children under 12 years of age.

Accidental drownings from uncovered or improperly covered spas and, to a lesser extent, entrapment by suction, were the chief causes of childhood drownings.

CONCLUSIONS: Children and older persons who have heart disease or seizure disorders or who use alcohol or cocaine are especially vulnerable. Recommended preventive measures include shortening the time of exposure, lowering the temperature, establishing safety standards for covers and for baffles for suction outlets, and using warning notices.
(Press E Am J Public Health 81 (8): 1034-1037 (Aug 1991)
Oregon Health Sciences University, School of Medicine, Portland.

Unusual presentation of Pseudomonas aeruginosa infections: a review.

Pseudomonas aeruginosa is an opportunistic, gram negative bacillus that causes serious hospital acquired infections. However, it also causes infections with unusual presentations which are acquired in a non-hospital environment. This report will discuss the pathogenesis, clinical manifestations, and therapy of this uncommon infection, such as:
1) Pseudomonas folliculitis: a superficial or deep bacterial infection associated with the use of public hot tubs, whirlpools and swimming pools.
2) Invasive external otitis: an infection that can progress to skull base mostly associated to elderly diabetic patients. It is usually secondary to aural irrigation with contaminated water.
3) Pseudomonas osteomyelitis: an infection usually associated with nail puncture wounds especially if wearing tennis shoes.
4) Toe with infection: mostly associated with individuals using topical antibacterial agents.
5) Green nail syndrome: a non tender paronychia lesion that appears most often in persons whose hands are constantly exposed to water, soaps and detergents or are subject to mechanical trauma.
6) Corneal ulcer keratitis: mostly associated with the use of soft lenses, eye drops, mascara or contaminated whirlpools. This condition may terminate in panophthalmitis.
7) Endocarditis: most commonly associated with intravenous drug addicts.
(Molina DN, Colon M, Bermudez RH, Ramirez-Ronda CH Bol Asoc Med P R 83 (4): 160-163 (Apr 1991)
Infections Disease Program, University of Puerto Rico School of Medicine, San Juan Department of Veterans Affairs 00927-5800.

Young children who drown in hot tubs, spas, and whirlpools in California: a 26-year survey.

A survey of drownings in hot tubs, spas, and whirlpools in California 1960-85 suggests a person- and site-specific profile. The identified 74 deaths occurred mostly in White children, under two years of age, in Southern California, during the late afternoons, from May through August. From 1967 to 1985, the drowning rate increased tenfold.
The deaths were associated with access to the water, lack of supervision, neuromotor handicaps, and entrapment by suction. Educational and environmental control efforts are required to reduce the incidence
(.Shinaberger CS, Anderson CL, Kraus JF Am J Public Health 80 (5): 613-614 (May 1990)
Department of Epidemiology, UCLA School of Public Health 90024-1772.

Is there a need for state health department sanitary codes for public hydrotherapy and swimming pools?

The Board of Health of the Commonwealth of Virginia has an outdated sanitary code for its public hydrotherapy and swimming pools. The code is restricted to pools in hotels and other lodging places.
The absence of modern regulations for public hydrotherapy and swimming pools has permitted serious deficiencies in pool maintenance, which are highlighted in this report.
The most notable of these deficiencies was the presence of high levels of bacterial contamination that could predispose to infect in the water of one public hot tub. The results of this study indicate that the Virginia Board of Health sanitary code for pool water must be revised immediately and should include all public hydrotherapy and swimming pools.
Other states and communities may want to assess their codes for swimming pools and hydrotherapy tubs to avoid deficiencies that could be detrimental to public health.
(Zura RD, Groschel DH, Becker DG, Hwang JC, Edlich RF J Burn Care Rehabil 11 (2): 146-150 (Mar 1990)
Department of Plastic Surgery, University of Virginia School of Medicine, Charlottesville 22908.

Hot tub (Pseudomonas) folliculitis.

Folliculitis caused by Pseudomonas aeruginosa is a rare, adverse effect of the therapeutic or recreational use of hot tubs, whirlpools, and occasionally swimming pools. The condition is characterized by painful, papulopustular skin lesions often accompanied by low-grade fever, malaise, and other systemic symptoms. Prompt recognition and treatment may shorten the duration of the disease and, more importantly, prevent further cases by identifying the source of exposure.
(Fowler JF Jr, Stege GC 3d J Ky Med Assoc 88 (2): 66-68 (Feb 1990)

Whirlpool folliculitis: a review of its cause, treatment, and prevention.

Folliculitis caused by Pseudomonas aeruginosa has been increasing due to the popularity of hot tubs, swimming pools, and whirlpools. The follicular pustules and inflammatory papules usually occur after an incubation period of two to four days and improve spontaneously in seven to ten days.
Despite the discomforts of the condition, treatment is usually not necessary and may even prolong the infection. Since it is difficult to control the growth of Pseudomonas in hot tubs and whirlpools, attention to water conditions is the best way to prevent this irritating skin condition.
(Berger RS, Seifert MR Cutis 45 (2): 97-98 (Feb 1990)
University of Medicine and Dentistry, New Jersey-Robert Wood Johnson Medical School, New Brunswick 08901.

Pseudomonas infections associated with hot tubs and other environments.

Infections due to Pseudomonas aeruginosa are not confined to the hospital intensive care unit. This paper examines the association of P. aeruginosa and several community-acquired infections. Hot tub folliculitis is a recently described disorder occurring in outbreaks among persons who unknowingly immerse themselves in contaminated whirlpools, spas, or swimming pools. The green nail syndrome and other dermatoses are also reviewed. Infective endocarditis, invasive external otitis, and puncture would osteomyelitis are serious infections that carry high risks for the patient and challenge the physician's most potent therapies.
(Gregory DW, Schaffner W Infect Dis Clin North Am 1 (3): 635-648 (Sep 1987)
Vanderbilt University School of Medicine, Nashville, Tennessee.

Whirlpool-associated folliculitis caused by Pseudomonas aeruginosa: report of an outbreak and review.

An outbreak of folliculitis caused by Pseudomonas aeruginosa serotype O:7 occurred among the guests of a hotel in St. John's, Newfoundland, Canada, and the source of the infection was traced to the hotel whirlpool. Of 36 persons who used the whirlpool, 26 (72%) developed folliculitis within 1 to 5 days after exposure; the attack rate was significantly higher for children (90%) than for adults (50%).
The rash characteristics were consistent with those of Pseudomonas folliculitis previously described (T. L. Gustafson, J. D. Band, R. H. Hutcheson, Jr., and W. Schaffner, Rev. Infect. Dis. 5:1-8, 1983). This is considered to be the first outbreak in which P. aeruginosa serotype O:7 has been incriminated. Published reports to date of outbreaks of Pseudomonas folliculitis associated with the use of whirlpools, hot tubs, swimming pools, etc., were reviewed.
(Ratnam S, Hogan K, March SB, Butler RW J Clin Microbiol 23 (3): 655-659 (Mar 1986)

Host factors in whirlpool-associated Pseudomonas aeruginosa skin disease.

Pseudomonas aeruginosa folliculitis is the most common recognizable infectious disease occurring after use of whirlpools and hot tubs. The factors that affect the host's susceptibility to whirlpool-related infection are the anatomic and physiologic defenses of normal skin, the microecology of the skin surface, factors intrinsic to the individual host, and behavioral factors. The structural components of the skin maintain an environment at the skin surface that makes human skin an inhospitable habitat for microflora. However, natural and experimental models of P. aeruginosa skin infection suggest that immersion in whirlpools may negate many of the body's normal host defenses, especially the very low humidity at the skin surface. Transient colonization of skin with P. aeruginosa may lead to elaboration of toxins in vivo, resulting in the characteristic dermatitis.
(Solomon SL Infect Control 6 (10): 402-406 (Oct 1985)

Public health implications regarding the epidemiology and microbiology of public whirlpools.

High temperature bathing in hot tubs, spas and whirlpools poses four potential public health concerns: injury/death, disease transmission, possible teratogenic effects, and congestive heart failure or dysrhythmias for individuals with cardiac problems.
Health departments need criteria before initiating environmental and epidemiologic investigations. These criteria must include severity of the disease and number of individuals possibly exposed. In addition, public health officials are obligated to define the magnitude of the problem, inform affected individuals and institute appropriate control measures. Optional information should be collected during an environmental and epidemiologic investigation to clarify the mechanisms of disease transmission and design control measures. The public health response to improving hot water bathing safety and sanitation should be directed at primary prevention. Educational efforts would be directed toward whirlpool operators, users and the medical community. Included should be a review of regulations addressing the construction and operation of public spas and whirlpools.
(Castle SP Infect Control 6 (10): 418-419 (Oct 1985)

Pseudomonas infections associated with hot tubs and other environments.

Infections due to Pseudomonas aeruginosa are not confined to the hospital intensive care unit. This paper examines the association of P. aeruginosa and several community-acquired infections.
Hot tub folliculitis is a recently described disorder occurring in outbreaks among persons who unknowingly immerse themselves in contaminated whirlpools, spas, or swimming pools. The green nail syndrome and other dermatoses are also reviewed. Infective endocarditis, invasive external otitis, and puncture would osteomyelitis are serious infections that carry high risks for the patient and challenge the physician's most potent therapies.
(Gregory DW, Schaffner W J Clin Microbiol 23 (3): 655-659 (Mar 1986)

Whirlpool-associated folliculitis caused by Pseudomonas aeruginosa: report of an outbreak and review.

An outbreak of folliculitis caused by Pseudomonas aeruginosa serotype O:7 occurred among the guests of a hotel in St. John's, Newfoundland, Canada, and the source of the infection was traced to the hotel whirlpool. Of 36 persons who used the whirlpool, 26 (72%) developed folliculitis within 1 to 5 days after exposure; the attack rate was significantly higher for children (90%) than for adults (50%).
The rash characteristics were consistent with those of Pseudomonas folliculitis previously described (T. L. Gustafson, J. D. Band, R. H. Hutcheson, Jr., and W. Schaffner, Rev. Infect. Dis. 5:1-8, 1983).
This is considered to be the first outbreak in which P. aeruginosa serotype O:7 has been incriminated. Published reports to date of outbreaks of Pseudomonas folliculitis associated with the use of whirlpools, hot tubs, swimming pools, etc., were reviewed. Ratnam S, Hogan K, (March (SB, Butler RWJ Clin Microbiol 23 (3): 655-659 (Mar 1986)

Host factors in whirlpool-associated Pseudomonas aeruginosa skin disease.

Pseudomonas aeruginosa folliculitis is the most common recognizable infectious disease occurring after use of whirlpools and hot tubs.
The factors that affect the host's susceptibility to whirlpool-related infection are the anatomic and physiologic defenses of normal skin, the microecology of the skin surface, factors intrinsic to the individual host, and behavioral factors. The structural components of the skin maintain an environment at the skin surface that makes human skin an inhospitable habitat for microflora. However, natural and experimental models of P. aeruginosa skin infection suggest that immersion in whirlpools may negate many of the body's normal host defenses, especially the very low humidity at the skin surface. Transient colonization of skin with P. aeruginosa may lead to elaboration of toxins in vivo, resulting in the characteristic dermatitis.
(Solomon SL Infect Control 6 (10): 402-406 (Oct 1985)

Public health implications regarding the epidemiology and microbiology of public whirlpools.

High temperature bathing in hot tubs, spas and whirlpools poses four potential public health concerns: injury/death, disease transmission, possible teratogenic effects, and congestive heart failure or dysrhythmias for individuals with cardiac problems.
Health departments need criteria before initiating environmental and epidemiologic investigations. These criteria must include severity of the disease and number of individuals possibly exposed.
In addition, public health officials are obligated to define the magnitude of the problem, inform affected individuals and institute appropriate control measures. Optional information should be collected during an environmental and epidemiologic investigation to clarify the mechanisms of disease transmission and design control measures.
The public health response to improving hot water bathing safety and sanitation should be directed at primary prevention.
Educational efforts would be directed toward whirlpool operators, users and the medical community. Included should be a review of regulations addressing the construction and operation of public spas and whirlpools
(Castle SP Infect Control 6 (10): 418-419 Oct 1985)

Hot tub legionellosis.

Legionella pneumophila is the cause of Legionnaires' disease, and Pontiac fever, an influenza-like condition without pneumonia.
We present a case of Pontiac fever after exposure to a hot tub contaminated with L pneumophila. A 37 y/o wf presented to the office with acute onset of sore throat, fever, headache, and myalgia. Patient was hospitalized 3 days later because of worsening shortness of air. Chest x-ray was normal. Patient was treated with 2 days of IV erythromycin and was discharged home on oral erythromycin. Her Legionella IFA was 1:16,384.
Two days later, she developed chest tightness, pleuritic chest pain, and increasing shortness of air but did not have any cough or sputum production. She was re-hospitalized with a diagnosis of Pontiac fever and treated with IV erythromycin plus oral rifampin.
A repeat chest x-ray remained normal. After a detailed epidemiologic history was obtained, it was noted that she became ill after using a hot tub, which her two children also used and they themselves developed a self limited illness. Water from the hot tub was positive for L pneumophila by DFA, culture, and PCR. Patient improved gradually with therapy and was discharged home. This report emphasizes the importance of a complete epidemiologic history in the diagnosis of respiratory infections. It also demonstrates that aquatic environment can be contaminated with Legionella and serve as a source of infection.
(Tolentino A, Ahkee S, Ramirez J J Ky Med Assoc 94 (9): 393-394 (Sep 1996)
Division of Infectious Diseases, University of Louisville, School of Medicine, KY, USA.)

Hot tub legionellosis. Legionnaires' disease and Pontiac fever after a point-source exposure to Legionella pneumophila.

Legionella pneumophila is associated with outbreaks of either Pontiac fever, a self-limited influenzalike condition without pneumonia, or Legionnaires' disease, a severe pneumonic disease affecting elderly or immunocompromised individuals. An outbreak of both Legionnaires' disease and Pontiac fever after a point-source exposure to L pneumophila was studied.
Our observations demonstrated the spectrum of illness that L pneumophila may cause and emphasized the importance of host factors in affecting the expression of infection.
(Thomas DL, Mundy LM, Tucker PC Arch Intern Med
153 (22): 2597-2599 (Nov 22 1993)
Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Md.)

An outbreak of Pontiac fever due to Legionella pneumophila serogroup 7. II. Epidemiological aspects

From August 20 to 22, 1994, an outbreak of acute febrile illness occurred in a Training Center building of a company in Shibuya-ku, Tokyo. All 43 trainees attended in two groups and 2 Center staffs were attacked. Illness was self- limiting, generally lasting three days.
Though strains of legionellae, isolated from the water of the cooling tower located at the top of the building, were identified as Legionella pneumophila by microplate DNA-DNA hybridization, they failed to agglutinate with antisera against L. pneumophila serogroups 1 through 6. Two strains were sent to the Centers for Disease Control, Atlanta, Georgia, USA, and determined as serogroup 7 of the species. Since the clinical courses agreed with the definition of Pontiac fever by Glick et al. and seroconversion in a patient against the cooling tower strain (EY3698)from 1:16 to 1:256 was determined by indirect fluorescent antibody technique, the epidemic of acute febrile illness was concluded as an outbreak of Pontiac fever due to L. pneumophila serogroup 7.
The cooling tower was a cylindrical open style, with volumetric flow rate of 130 liter/min, and was used for air- conditioning exclusively to the third floor of the building.
The building equipped no air-inlet, and indoor-air of the training room exchanged at every break time through windows of 168 cm in height and 72 cm in width.
The cooling tower was not operated for five days before the Group A trainees checked in the Center on 18 August followed by Group B trainees on 19 August. It was speculated that high atmospheric temperature and stagnation of cooling water during this period would lead L. pneumophila to overly multiply, which could be a source of infection by flowing in through opened windows to the training rooms.
(Kansenshogaku Zasshi 69 (6): 654-665 (Jun 1995)Yabuuchi E, Mori M, Saito A, Kishimoto T, Yoshizawa S, Arakawa M, Kinouchi R, Wang L, Furuhata K, Ko