UNITED KINGDOM

1972 London
Between April 1971 and January 1972

40 patients in St. Thomas Hospital London acquired infectious, usually bacteraemia or urinary or respiratory-tact infections, caused by Pseudomonas thomasii, a previously undescribed organism related to P. cepacia, The source of the outbreak was softened, deinised, and distilled water manufactured in the pharmacy and widely used throughout the hospital. When used for cooling bottles of parenteral and other sterilised fluids in a rapid-cooling autocave this water often remained on the bung beneath the crimped foil seal, entering the bottle and contaminating its contents when the bung was disturbed, Water from the same source was also used in the humidifers of mechanical ventilators, resulting in the general contamination of the machines and colonisation of the patients respiratory tracts.
(Phillips Ian , The Lancet June 10 1972)

1977
Nottingham England

Legionnaires` disease bacterium was identifid in some Nottingham patients in 1977, studies that were not restricted to Nottingham and included several other areas in England. The 41 cases identified were evenly divided between areas, they also accounted for one half of all cases for the whole country. No source of infection has been identified in these sporadic cases.
(Macrea AD, Annals of Intern Medicine 1979 90 580-583)

1978
Nottingham

An outbreak of Legionnaires` disease in Nottingham claimed two lives, 13 people caught the disease, No common source of the infection has yet been identified.
(Jenkins P, British Journal of Diseases of the Chest , 1979 73 31-38)

1978
Great Britain

During the period of 1st January 1976 and 30th September 1978 there was 84 sporadic cases of Legionnaires` Disease reported

1979
Kingston

Between December 1997 and July 1980, 12 cases of Legionnaires` disease were recognised at Kingston General Hospital, 11 patients acquired their infection within the hospital. Studies indicated that the plumbing system and possibly the cooling tower exhaust in the new building of the hospital were the source of infection.
(Fisher-Hoch SP, The Lancet 1981 April 25 932-936)

1979
Oxford England

Renal Transplant patients Legionnaires` disease was found in two patients in a transplant unit,both patients having used the same postoperative cubicle shortly before the onset of their illness, Legionella pneumophila was found in the water taken from the cubicle shower bath and from other showers in the unit.
(Tobin JO, The Lancet 1980 2 118-121)

1981
England

In September and October 1981 six cases of pneumonia occurred among men working on a power station under construction. Three were identified as cases of legionella pneumonia and two others had serology suggestive of legionella infection.
Legionella pneumophila serogroup 1 was isolated from the four towers. This is the first outbreak of Legionnaires` disease to be recorded in an industrial setting in the United Kingdom.
(Morton S, British Journal Ind Medicine, 1986 43 Sep 630-635)

1982 England National surveillance of Legionnaires` disease in England and Wales identified 588 cases during the years 1979-1982, The majority of cases were sporadic, but 32 clusters of two or more cases were recognised, 24 in association with hotels, seven with hospitals and one with a construction site. only in the construction site outbreak was a cooling water system shown to be the principal source of infection.
(Bartlett CL, Zentralblatt Fur Bakteriologie Mikrobiologie Hygiene , 1983 255 64-70)

1983
England ??

From January 1983 until December 1985, 35 cases of sporadic legionella pneumonia. all caused by Legionella pneumophila were diagnosed in a University hospital, Legionella pneumophila was isolated from water oulets in the patients immediate environment. From the hospital water supply four different subtypes of Legionnaires pneumophila serogroup 1 were isolated.
(Ruf B, Epidemiology and Infection, 1988 101 647-654)

1985
Stafford

In April 1985 a large outbreak of Legionnaires` disease occurred in the Distrct General Hospital in Stafford , 103 cases of the disease were reported, and 28 people died, this was the largest outbreak to occur in the world since the first outbreak in America in 1976, were 234 people acquired the disease and 34 died.

Source of the outbreak was reported to be the cooling tower No.4. Two committees of inquires have been held and also the EXPERT ADVISORY COMMITTEE ON BIOCIDES. Many articles have been written on this outbreak.

(Sir John Badenoch, Chairman, First report of the committee on inquiry into the outbreak of Legionnaire`s disease in Stafford in April 1985)

(Sir John Badenoch, Chairman, Second report of the committee on inquiry into the outbreak of Legionnaire`s disease in Stafford in April 1985)

(Wright AE, Chairman, EXPERT ADVISORY COMMITTEE ON BIOCIDES. 1986)

The Stafford outbreak of Legionnaires' disease.

A large outbreak of Legionnaires' disease was associated with Stafford District General Hospital. A total of 68 confirmed cases was treated in hospital and 22 of these patients died. A further 35 patients, 14 of whom were treated at home, were suspected cases of Legionnaires' disease. All these patients had visited the hospital during April 1985. Epidemiological investigations demonstrated that there had been a high risk of acquiring the disease in the out patient department (OPD), but no risk in other parts of the hospital. The epidemic strain of Legionella pneumophila, serogroup 1, subgroup Pontiac 1a was isolated from the cooling water system of one of the air conditioning plants. This plant served several departments of the hospital including the OPD. The water in the cooling tower and a chiller unit which cooled the air entering the OPD were contaminated with legionellae. Bacteriological and engineering investigations showed how the chiller unit could have been contaminated and how an aerosol containing legionellae could have been generated in the U-trap below the chiller unit. These results, together with the epidemiological evidence, suggest that the chiller unit was most likely to have been the major source of the outbreak. Nearly one third of hospital staff had legionella antibodies. These staff were likely to have worked in areas of the hospital ventilated by the contaminated air conditioning plant, but not necessarily the OPD. There was evidence that a small proportion of these staff had a mild legionellosis and that these 'influenza-like' illnesses had been spread over a 5-month period. A possible explanation of this finding is that small amounts of aerosol from cooling tower sources could have entered the air-intake and been distributed throughout the areas of the hospital served by this ventilation system. Legionellae, subsequently found to be of the epidemic strain, had been found in the cooling tower pond in November 1984 and thus it is possible that staff were exposed to low doses of contaminated aerosol over several months. Control measures are described, but it was later apparent that the outbreak had ended before these interventions were introduced. The investigations revealed faults in the design of the ventilation system.
(O'Mahony MC; Stanwell-Smith RE; Tillett HE; Harper D; Hutchison JG; Farrell ID; Hutchinson DN; Lee JV; Dennis PJ; Duggal HV; et; al Address Public Health Laboratory Service Communicable Disease Surveillance Centre, London. Epidemiol Infect, 1990 Jun, 104:3, 361-80)

1985
England

Legionnaires` disease was diagnosed in three mineworkers at a colliery, Investigation of water samples from various sites at the colliert failed to discover the source of the infection.
(Davies DM, British Journal of Industrail Medicine 1985 42 421-425)

1985
England

In Otober 1985 six cases of Legionnaires` disease were associated with the police headquarters building. Four were among the staff who worked in or visisted the communications wing of the headquarters, and two cases occured in the local community. Legionella pneumophila serogroup 1 subgroup Pontiac was isolated from water and sludge in the cooling tower pond.
(O`Mahony M. Epidemiology and Infection, 1989 103 285-292)

1985
Legionnaires' disease and the sick-building syndrome.

In October 1985, six cases of legionnaires' disease were associated with a police headquarters building. Four were amongst staff who worked in or visited the communications wing of the headquarters and two cases occurred in the local community. A case-control study implicated the operations room of the communications wing as the main area associated with infection.
This wing was air-conditioned and smoke tracer studies showed that drift from the exhaust as well as from the base of the cooling tower entered the main air-intake which serviced the air-conditioning system.
Legionella pneumophila serogroup 1 subgroup pontiac was isolated from water and sludge in the cooling tower pond. Contaminated drift from the top of the cooling tower was probably responsible for the two community cases. An additional discovery was that symptoms suggestive of the sick-building syndrome were associated with working in this wing.
(O'Mahony M, Lakhani A, Stephens A, Wallace JG, Youngs ER, Harper D
PHLS Communicable Surveillance Disease Centre, London. Epidemiol Infect 103 (2): 285-292 Oct 1989)

1986
Gloucester

Between 27 August and 27 October 1986 fourteen people living in Gloucester fell ill with Legionnaires` disease, One patient had fallen ill on the 30 may, There was three deaths, Three cases of Pontiac Fever.
Cooling towers near the areas of the outbreak may have been the sources but the evidence is insufficient to incriminate any single one.
(Hunt DA, Epidemiology and Infection , 1991 107 133-141)

1988
London

An outbreak of Legionnaires` disease was reported from the BBC cooling Tower in London. at the end of April 1988, Source of the infections was one of the two cooling towers on the roof. A 63 year old male smoker who worked for the BBC was admitted to the infectious unit of Rush Green Hospital on the 27 April 1988 at 2130 hours. A 46m year old man was admitted to the medical unit at 1700 hours on 27 April.
This patient had been working on the fifth floor of the BBC Broadcasting House. A 52 year old man who had been working as a roofer 200metres from Portland Place was admitted on the 2 may to a medical ward of another hospital, he was sent home, He was admitted to the infectious unit on 4 may, All three were daignosed with Legionnaires disease.
The Communicable Disease Surveillance Centre reported that by 27th may this outbreak had yeilded 43 cases with two deaths
(Zumla A , The Lancet June 4 1988)

On 1st May 1988 a senior Naval Officer serving on HMS Warrior was admitted to RAF Halton where a diagnosis of Legionnaire`s disease was made. On the 19th. April he was in the vicinity of the BBC at the time of the outbreak of Legionnaires disease.
(Richards NC, Journal of the Royal Naval Medical Service, 1989 75 117-120)

1988
Bolton, Lancs

In 1988 there was two outbreaks of Legionnaires` disease in Bolton, a total of 37 cases of the disease and 23 cases of non-pneumonic legionellosis were identified, twenty five cases with Legionnaires disease were associated with an engineering plant, four with the Bolton town centre and eight with both the engineering plant and town centre.
Twenty two people with non-pneumonic legionellosis were linked with the engineering plant and one with the engineering plant and the town centre.
(Mitchell E , Epidemiology and Infection, 1990 104 159-170)

1989
London

An outbreak of Legionnaires` disease occurred in central London in January and Febraury 1989, Thirty three confirmed cases, including FIVE deaths and Ten suspected cases. Legionella pneumophila of the same serogroup was isolated from water samples from Five cooling towers in the area under investigation.Many of the cooling towers examined were indequately maintained, including one of the two above a building adjacent to Piccadilly Circus from which a strain indistinguishable from the outbreak strain isolated.
(Watson JM, Journal Public Health Med, 1994 16 341-347)

1991
England One hundred and eleven case of Legionnaires` disease were reported in England and Wales in 1991, a smaller total than in any year since reporting began in the late 1970s. Four cases were hospital acquired and a further nime may have been associated with a hospital stay, Fifty-two cases were linked with travel abroad.
(Watso H, Communicable Disease Report 1992 2 r130-131)

1991 *****MERSEY LIVERPOOL*****

MERSEY HEALTH AUTHORITY ON NOVEMBER 5th 1991 DEFENDED ITS DECISION TO KEEP QUIET ABOUT AN OUTBREAK OF LEGIONNAIRES DISEASE AT A $6 MILLION UNIT OPENED FOUR MONTHS BEFORE. (GUARDIAN NEWSPAPER, NOVEMBER 6th 1991) ****(WHY)*****

Legionellosis in travellers

Legionellosis and travel

Fifty-two cases of legionellosis in residents of England and Wales had beenreported to the National Surveillance Scheme for legionnaires’ disease by the end ofweek 34 in 1991. Forty-six had legionnaires’ disease (pneumonic legionellosis) and sixhad Pontiac fever (non-pneumonic legionellosis). Thirty-three cases (24 male, 9female; age range 34-87 years) were associated with travel: 32 abroad and one withinthe UK (Figure). There were three deaths: a 48 year old female who had been onholiday to Florida; a 40 year old male who had travelled to Spain and France; and a 60year old male who had recently returned from Pakistan. Most travel-associated cases(13) had visited Spain, including the Balearic and Canary islands. Five had travelledto Greece and the Greek islands (including Crete). Five cases had visited France, twohad visited the USA (both Florida) and two had travelled to Austria.
outbreaks (in 1987, 1989 and 1990). The case which occurred following travel within
the UK was associated with a hotel in the Midlands. The same hotel had been linkedwith a case in 1990. The premises were inspected and guidance given about watersystem maintenance. No other associated cases have since come to light.
Whenever a cluster of cases is recognised, the health authorities in the country
concerned are informed so that local investigations can be carried out. In addition,
details of the cases are reported to the European Working Group on Legionellathroughout Europe in order to inform collaborating countries of identified clusters.
Legionellosis should always be considered in patients with pneumonic illnesswho have recently travelled. The diagnosis is usually established by serology(antibody levels may be elevated at the time of admission to hospital). However,culture of the organism, or direct fluorescent demonstration of the antigen, whereavailable, permit speedier diagnosis. Appropriate antibiotics should be givenwhenever the diagnosis is suspected. CDSC will be grateful for details of anyconfirmed or suspected cases of legionellosis and can indicate whether other casesmay be linked to the reported case.
Three clusters of two cases were associated with hotels. Two women, aged71 years and 50 years, contracted thedisease after staying at the same hotel, onthe Greek island of Kos, in May and June,respectively. A 73 year old man and a 65year old woman stayed at a hotel inCordoba, Spain, in March and May,respectively. The third cluster was associated with a hotel on the island ofIbiza. A female of 49 years and a male of48 years had stayed there in June and July,respectively. Cases had previously beenlinked to this hotel in 1983 and 1985. Onthe island of Majorca, two cases wereassociated with two different hotelswhich had previously been implicated in

CDR 1Number 35 30 August 1991

Legionellosis in Winchester

Two confirmed and one presumptive case of legionnaires’ disease have beenreported among staff of an army camp near Winchester, with dates of onset between25 September and 9 October 1991. Three other suspected cases of non-pneumoniclegionellosis were also reported and all have recovered. Control measures have beencarried out at the suspected source building and no further associated cases have beenascertained.

CDRVolume 1 Number 49 6 December 1991

1991

Legionellosis update

Sixty-six cases of legionellosis have been reported to the national surveillance
scheme for legionnaires’ disease at CDSC with dates of onset during 1991 (to week 43).
Sixty patients had legionnaires’ disease (pneumonic legionellosis) and six had
Pontiac fever (non-pneumonic legionellosis). Forty-one of the cases were associated
with travel (38 abroad and 3 in this country) and four were hospital associated.
Two confirmed cases of legionella infection have been diagnosed among individuals
who had recently been inpatients at a hospital unit in the Mersey region.
The first case
occurred in a middle-aged woman who became ill in mid-September 1991 and the
second in a middle-aged man who became ill in mid-October. An outbreak control
committee has been set up to manage the incident. Water systems in the implicated
unit have been investigated and comprehensive control measures applied. A search
among recent patients and staff of the unit has not yet revealed any other associated
cases. The outbreak control group would be interested to hear, through the regional
epidemiologist (telephone 051 525 2323), of any suspected cases of legionellosis which
could be associated with this outbreak.
The Health and Safety Commission has recently published an approved code of
practice and a revised guidance booklet on the prevention and control of legionellosis
(including legionnaires’ disease). These give advice to those involved in the design,
building and maintenance of water systems in buildings. They, and an accompanying
video, are available from HMSO and booksellers.

CDR
Volume 1Number 44
1st. November 1991

 1992
 Legionnaires disease in Grimsby

Two confirmed cases and one suspected case of legionnaires disease were admitted
to hospital in Grimsby between 5-14 April 1992. One of the confirmed cases and the suspected case worked at a local factory, whilst the remaining case lived nearby.Subsequent case-finding revealed a further case in another worker at the factory andan apparently unconnected case who lived in an adjacent town.
An investigation was carried out which involved the Health and Safety Executiveand the local environmental health department. Water samples from evaporativecondensers at the factory were examined at the Leeds and Hull Public HealthLaboratories, where Legionella pneumophila serogroup 1 was identified. The condenserswere taken out of commission. Remedial work has been undertaken, including the installation of continuous bromination equipment. Following further satisfactoryinspections, the condensers will be returned to normal working. Cooling towers andsimilar installations within a one kilometre radius of the site have also beeninvestigated, the outcome of which is awaited.

CDR Number 24 12 June 1992

CDR No 20 Volume 3

14 May 1993

Legionnaires’ disease in central London There have been three confirmed cases of legionnaires’ disease with onset between4 and 13 April 1993. All three had visited or worked in the Piccadilly Circus/Leicester Square area of London in the ten days before onset. One patient died andthe other two recovered. A search was made for further suspected or confirmedcases who may have visited the area. No further cases have been identified.
Water cooling towers have often been implicated as a source of Legionellainfection in the past. Westminster City Council inspected all cooling towers in thepossible exposure area and instructed operators to shut down, clean and disinfecttheir plants according to the Code of Practice of the Health and Safety Executive 1 , as a precautionary measure. This investigation revealed a generally high level ofcompliance with operational standards and a general improvement in maintenancecompared with conditions found in the past. The investigation was assisted bycurrent cooling tower registration requirements (see CDR 1993; 3: 5) and operatorsare reminded of the need to register and follow established maintenance guidelines.
1. Health and Safety Executive. The control of legionellosis including legionnaires’disease. London: HMSO, 1991.

Legionnaires’ disease in Birmingham

An outbreak of legionnaires’ disease acquired in the community occurred between9iJune and 7iAugust 1994, affecting residents of, and visitors to, Birmingham. Thirteencases (eight confirmed and five suspected) have been identified so far, and one died.
Five confirmed cases and one suspected case were associated with the east ofBirmingham and the others were associated with the north of the city. One hundredand twenty-five samples of water were collected in a comprehensive environmentalsurvey of these areas of the city and examined by Birmingham Public Health Laboratory(CDR 1994; 4: 151). Twelve samples were from domestic premises, 13 from sourcesother than cooling towers, and 100 from cooling towers. One or more legionella specieswere found in only nine samples (all from cooling towers), and two were Legionellapneumophila serogroup 1. These isolates, along with isolates from two patients, were forwarded to the Legionella Reference Unit at the PHLS Central Public Health Laboratoryfor further typing. One environmental isolate was indistinguishable from one of the human isolates, both being L. pneumophila serogroup 1, monoclonal antibody type ‘Allentown’, restriction fragment length polymorphism type 10. Prohibition noticeswere served by the Health and Safety Executive at three firms. All the cooling towersat the sites that yielded L. pneumophila serogroup 1 have been disinfected and treated. Surveillance is continuing to ensure that the control measures undertaken are adequate.

CDRVolume 4Number 3716 September 1994

CDRVolume 4Number 45

11 November 1994

Legionnaires’ disease in England and Wales

The PHLS National Surveillance Scheme for Legionnaires’ Disease at the CommunicableDisease Surveillance Centre collects microbiological and epidemiological informationabout cases using a standard questionnaire. CDSC has received information on 42 cases of legionnaires’ disease in the past four weeks, compared with nine in thepreceding four weeks. This increase reflects the seasonal rise in cases associated with travel and late reporting of cases. One hundred and thirteen cases have been reportedwith dates of onset in the first ten months of 1994, compared with 119 in the first tenmonths of 1993 (figure). Completed questionnaires have not yet been received for a further 21 cases. The interval between the date of onset and the receipt of a completedquestionnaire currently ranges from two weeks to six months. Early reporting of cases,followed by the prompt return of completed questionnaires, assists in the timelydetection of clusters of cases, and the prevention and control of legionnaires’ disease.

1992 October

Legionnaires’ disease in Corfu

Three cases of legionnaires’ disease have been reported in residents of England and Wales who had stayed at the same hotel in Corfu during 1992. The first two casesoccurred in June and the third in July. All three survived their illness. Three other cases have been reported from this hotel in previous years. The Greek healthauthorities were informed of each case this year and have instigated investigationand control measures in the hotel. No further cases have since been reported eitherto the National Surveillance Scheme for Legionnaires’ Disease at CDSC, or through the reporting network of the European Working Group on Legionella Infections,based in Stockholm.

1992
Outbreak of Legionnaires' disease at University Hospital, Nottingham.
Epidemiology, microbiology and control.

Twelve patients in a large teaching hospital contracted Legionnaires' disease over a period of 11 months. The source was a domestic hot water system in one of the hospital blocks, which was run at a temperature of 43 degrees C. Five different subtypes of Legionella pneumophila serogroup 1 have been isolated from water in different parts of the hospital, over a period of time. Only one subtype, Benidorm RFLP 14, was implicated in disease. Circumstantial evidence suggested that the outbreak may have been due to recent colonization of the hot water system with a virulent strain of Legionella pneumophila. The outbreak was controlled by raising the hot water temperature to 60 degrees C, but careful surveillance uncovered two further cases in the following 30 months. Persistent low numbers of Legionella pneumophila were isolated from the domestic hot water of wards where Legionnaires' disease had been contracted, until an electrolytic unit was installed releasing silver and copper ions into this supply.
(Colville A, Crowley J, Dearden D, Slack RC, Lee JV Epidemiol Infect 110 (1): 105-116 (Feb 1993)

1993
England One hundred and twenty nine cases of Legionnaires disease were reported in England and Wales in 1993, Twenty-two of the cases died, Sixty-six cases were associated with travel, six were associated with a stay in hospital, and the remainung 57 were thought to have acquired infection in the community. FOUR outbreaks were recognised in England and Wales and four outbreaks were detected in travellers from the Ukvto spain, Greece, and the United Stated.
(Joseph CA, Communicable Disease Report 1994 4 R109-111)

Legionnaires’ disease associated with travel to the USA

There has been one confirmed case of legionnaires’ disease, one suspected case,and one death from atypical pneumonia of unknown aetiology, in a group of 301people who were members of a male voice choir from South Wales, their relativesand friends. They had been to Georgia and Florida in the last two weeks of Marchand returned to the United Kingdom on 1 April 1993. CDSC (Welsh Unit) iscoordinating an investigation of the group. CCDCs have been alerted to membersof the group in their areas and have been encouraged to identify and contact GPsto arrange follow-up. So far, 164 members of the group have been surveyed and 23 are reported to have developed a febrile respiratory illness in the United States or within two weeks of their return to the United Kingdom.

 would welcome clinical and laboratory reports on people in this group and other people with suspectedlegionellosis who have recently been to the southern United States.

CDR April 1993

LONDON
September 1993

The fountains in Trafalgar Square were dry yesterday and nearby water cooling towers shut down while authorities checked for the source of a Legionnaires` disease outbreak, which has killed at least one person.
The victim and two people who recovered from the disease had been in the area 10 days before the onset of symptoms, officials said. Each year more than 4 million people visit Trafalgar Square.
Initial tests found no trace of the bacteria that cause Legionnaires` disease.
 

 European surveillance of legionnaires’ disease associated withtravel

Since 1987, European countries have collaborated in the surveillance of legionnaires’disease associated with travel, through the European Working Group on LegionellaInfections. This surveillance scheme aims to improve the detection of ‘clusters’ (twoor more cases within six months) associated with particular hotels or otheraccommodation, to help identify common source outbreaks, and to alert nationalauthorities so that appropriate control measures can be applied rapidly. On 1 July1993, coordination of the scheme transferred to the PHLS Communicable DiseaseSurveillance Centre (CDSC). The communications component of the scheme isbeing developed as part of the Early Warnings system of the ENS-CARE Telematicsproject 1 . Twenty-five centres in 20 countries now collaborate in the scheme (11 in the European Union and nine other European countries).

A total of 571 cases, including more than 50 ‘clusters’, of legionnaires’ diseaseassociated with travel have been reported to the scheme since 1987. From 1987 toJune 1993, 484 cases were reported.
 
 

Table Legionnaires’ disease associated with travel destinations
(July to December 1993*)

From 1 July to 31 December 1993, a further 87 cases were reported to CDSC by13 collaborating centres. They were associated with travel to 19 different countries,16 in Europe and three elsewhere (Table). Many cases were associated withcountries around the Mediterranean Sea, which reflects the large numbers ofEuropeans who spend their holidays in these countries. Seven ‘clusters’, involving20 cases, were associated with travel to the same hotel or campsite (Spain 3; Italy 2; Estonia 1; Turkeyi1). Five other cases stayed at hotels associated with cases inprevious years (Spain 2; Greece 2; Turkey 1). Four of these 12 case groupingsincluded cases that were reported by more than one centre, and three wouldprobably not have been detected by national surveillance systems alone.
All cases had laboratory evidence of legionella infection. Sixty-one were male and 26 female,a ratio of 2.3:1. The median age was 56 years for males (range 28 to 67) and 68 years for females (range 19 to 87). The outcome was reported for 67 patients; 51 are knownto have recovered and seven died.

1. Commission of the European Communities Directorate – General XIII. Research and technology development on transnational telematic systems for administrations. ENS1993. Office for Official Publications of the European Communities, Luxembourg.

CDR.. 11th February 1994

New code of practice for the control of legionella in healthcare premises

Health Technical Memorandum (HTM) 2040, The control of legionellae in health care premises – a code of practice, provides recommendations, advice, and guidance on the control of legionellas in health care premises. It focuses on legal and mandatoryresponsibilities of estate and general managers and the design, maintenance, andoperation of systems. Regional and district estate managers, general managers ofspecial health authorities, and chief executives of National Health Service (NHS)trusts have been briefed, and copies of HTM 2040 have been sent to regions,districts, and NHS trusts.

HTM 2040 is published in five volumes. Management policy details managers’responsibilities and legal obligations. It provides a checklist of major tasks neededto assess risks of legionellosis. Design considerations specifies design features of hotand cold water services, evaporative cooling towers, air conditioning and ventilation,and other water uses. Validation and verification advises building service managerson the commissioning of water systems, including initial disinfection. Operationalmanagement includes recommendations for routine maintenance, including cleaning, disinfection, monitoring, and risk assessment. Good practice guide includes asample logbook, sample questionnaire on serviceability of cooling systems,operational checks on cooling towers, advice on the use of sodium hypochlorite,and the course of action if an outbreak of legionnaires’ disease is suspected.

HTM 2040 takes precedence over the document of the same name, published in1988 by the Department of Health and Welsh Office, except in topics covered in twofurther volumes to be published later this year. These are HTM 2027, Hot and cold water supply, storage and mains services, and HTM 2025, Ventilation of health care premises.
The 1988 code of practice will be withdrawn fully when these are published.

Legionnaires’ disease associated with hospitals

Between 1980 and 1992, the National Surveillance Scheme for Legionnaires’ Diseaseat the PHLS Communicable Disease Surveillance Centre received reports of 218cases of legionnaires’ disease associated with hospitals 1 . One hundred and ninety-sixcases were classified as nosocomial (hospital acquired) and 22 as possiblynosocomial. Sixty-eight patients died. Twenty-two hospital outbreaks accountedfor 135 cases; the remainder were sporadic cases. Of the 135 cases, 92 occurred inthree large outbreaks, including 68 cases at Stafford District General Hospital in1985. Hospital domestic water systems were believed to be the source of infectionin 19 outbreaks. Cooling towers (wet cooling systems) alone were thought to be thesource in one hospital and may have contributed to two other outbreaks in whichthe domestic water system was suspected to be the main source.
1. Joseph CA, Watson, JM, Harrison TG, Bartlett CLR. Nosocomial legionnaires’disease in England and Wales, 1980-1992. Epidemiol Infect 1994 (in press).

CDR February 1994

Legionnaires’ disease – Edinburgh

Lothian Health Board have reported an outbreak of legionnaires’ disease in southwest Edinburgh. Nine cases have been confirmed, one of whom died, and sevensuspected cases are being investigated. Cases became ill between November andmid December. Legionella pneumophila serogroup 1, monoclonal antibody subgroup 2, has been isolated from three of the cases.
Twenty-two cooling towers within a defined area of south west Edinburgh havebeen inspected and samples have been taken. Some towers were found to be poorlymaintained and in breach of published guidelines 2 . L. pneumophila serogroup 1,monoclonal antibody subgroup 2, has been isolated from one cooling tower, and the cases all live or work in an area to the north east of this tower. L. pneumophilaserogroup 1 has also been isolated from two other cooling towers, but these isolateshave not yet been typed. Doctors throughout the United Kingdom are advised toconsider the possibility of legionella infection in patients who present with arespiratory infection and who have been in south west Edinburgh since the middleof November.

2. Health and Safety Executive. The prevention and control of legionellosis including legionnaires’ disease. London: HSE Books, 1993. (HS(G)70).

CDR 23rd  December 1994
 

Cluster of cases of legionnaires’ disease associated with travelto Turkey

Seven cases of legionnaires’ disease, with dates of onset from 21 May to 28iAugust,have been reported to the European surveillance scheme for travel associatedlegionnaires’ disease. No deaths have been reported. Four of the cases were men (aged 43 to 68 years) and three were women (aged 49 to 66 years) and they allstayed at the same hotel in the resort of Kusadasi, Turkey, between May andAugust 1995. Three cases live in England and Wales, two in Scotland, one in NewZealand, and one in the Netherlands. The diagnosis was confirmed byseroconversion in one case and by isolation of Legionella pneumophila serogroupe1from a lung biopsy in another case. Presumptive diagnoses were made in fivecases (single high titre of antibodies in serum in three and detection of urinaryantigen specific for L. pneumophila serogroup 1 in two).

The Department of Health has alerted the health authorities in Turkey andinformation has been disseminated to members of the European surveillancescheme and the European office of the World Health Organisation.

CDR September 1995

Legionnaires’ disease associated with Turkey: update

Another two cases of legionnaires’ disease associated with a hotel in Kusadasi,Turkey have been reported to the European surveillance scheme (CDR 1995; 5: 175),bringing the total to nine cases so far. Dates of onset of infection range from the end of May to mid-September. The most recent case occurred in a person whovisited the hotel once for a Turkish bath and did not stay at the hotel.
The Department of Health has asked the Federation of Tour Operators toinform all British tour operators using the resort of the outbreak, and hasrecommended that they advise clients of a possible risk to people staying at ornear the hotel. Tour operators were also recommended to advise their clients toseek medical help if they developed respiratory symptoms within two weeks oftheir return from Kusadasi. Most British tour operators have now withdrawntheir clients from the hotel. It has been reported that control measures, whichinclude chlorination and heat treatment of the water supply, have now beenintroduced at the hotel.

CDR October 1995

1995 NOVEMBER

OUTBREAK OF LEGIONNAIRES’ DISEASE IN WALSALL

1. INTRODUCTION

An outbreak of Legionnaires’ Disease occurred in November 1995 on an Industrial Estate in Walsall. Two people contracted Legionnaires’ disease, a rare form of Pneumonia, one of whom, a female Walsall resident, died of the illness; the other person, a male South Staffordshire resident, was treated for the illness and subsequently recovered well. Two other people who also work on the Industrial Estate were found to have had a milder form of the infection known as pontiac fever. Both of patients have recovered with no long term health effects.

The Department of Public Health Medicine was advised on 14 November 1995 of the diagnosis of the dead woman. An investigation began immediately in conjunction with the Environmental Health Department of Walsall Metropolitan Borough Council, which then uncovered the second case on 16 November. An Outbreak Control Team was convened which comprised the following membership:

· Dr Sam Ramaiah, Director of Public Health Medicine · Dr Diane Wallis, Senior Registrar in Public Health Medicine · Dr Iain Blair, Regional Epidemiologist · Dr H Duggal, CCDC, South Staffordshire Health Authority · Mr M J Dixon, Health and Safety Executive · Dr Ian Farrell, Director, PHLS Laboratory, Birmingham · Dr T Boswell, Public Health Laboratory Service, Birmingham · Mr Ken Rhodes, Head of Environmental Health Division, Walsall MBC · Mr Peter Axton, Senior Environmental Health Officer, Walsall MBC · Dr Hassam, Consultant Microbiologist, Manor Hospital

The Team met on four occasions over the ensuing two week period, during which the outbreak was fully investigated and brought under control.

2. ACTION TAKEN

2.1 Sampling of all water cooling towers on the Industrial Estate in question and in the surrounding area.

2.2 Inspection of suspect cooling towers and enforcement of immediate cleaning and disinfection of these towers, after which further water samples were taken for bacteriological investigation.

2.3 Communication with GPs in Walsall and select GPs in South Staffordshire, to inform them of the outbreak and the appropriate course of action to take in people whom they might suspect of having the illness. This was to include a blood and urine sample for investigation by the Public Health Laboratory at Birmingham. Blood samples from over 190 patients were received by the Public Health Laboratory and processed to look for antibodies to the bacteria which cause Legionnaires’ disease. The high number was due to a concurrent outbreak of Influenza A which gives similar symptoms to Legionnaires’ disease in the first instance, necessitating the full investigation of these patients by their GPs.

2.4 Communication with Hospital clinicians to inform and advise them.

2.5 Appropriate communications with the media.

2.6 Good communication was maintained throughout with employers on the Industrial Estate and employees at risk were given both verbal and written information.

2.7 The Department of Health and the Communicable Disease Surveillance Centre were kept fully informed of progress.

3. OUTCOME

No positive source of the infection was identified in this case, although several industrial cooling towers were found to be infected with Legionella, the bacteria which causes Legionnaires’ disease. Those found were not of the same type which caused the illness in this outbreak. It is not unusual for the source to be not fully identified in a small outbreak such as this. A large number of people have been tested and subsequently re-tested for signs of infection with the germ which causes Legionnaires’ disease, and this was made possible due to the goodwill and co-operation of Walsall and South Staffordshire General Practitioners.

We are grateful to all the members of the Outbreak Control Team who freely gave their time and expertise to help us in Walsall. The Public Health Laboratory in Birmingham processed and funded all the blood, urine and environmental water specimens from the outbreak. Relationships between the Department of Public Health Medicine and the Environmental Health Department of Walsall Metropolitan Borough Council have been further strengthened by the joint working performed during the course of this outbreak.

Legionnaires’ disease : a cluster of cases in Reading

Between 24 January and 13 March 1995, five cases of legionnaires’ disease (threeconfirmed and two presumptive) occurred in and around Reading. One case died,one is being treated in hospital, and three are recovering at home. Legionellapneumophila serogroup 1 was isolated from the sputum of the case who died. Threecases were male and two female; their ages ranged from 36 to 68 years. Three caseslived in the centre of Reading; the other two lived in south Oxfordshire, but probably visited Reading during their incubation periods. Four cases were cigarette smokers.

An outbreak of 16 cases of legionnaires’ disease in Reading occurred during the winter of 1983/84. Infection with L. pneumophila serogroup 1 was confirmedserologically in 15 of these cases, and the outbreak was thought to have beenassociated with a cooling tower in the city centre 1 .
Measures being taken to investigate the cluster include an active search for casesof legionnaires’ disease that have arisen since 1 January 1995, detailed follow up ofcases to determine possible common exposures, and investigation of cooling towersin the centre of Reading by environmental health officers.

1. Anderson PD, Bartlett CLR, Cook GA, Woodward M. Legionnaires’ disease inReading – possible association with a cooling tower. Community Med 1985; 7: 202-7.

CDR March 1995

Legionnaires' disease--a potential hazard of rationalisation.

The cases of two elderly patients who complained of general malaise after they had undergone ward transfer (due to rationalisation of the rehabilitation service) are discussed. Both were pyrexial and had signs of pneumonic consolidation. Subsequent investigation revealed that their symptoms were due to infection with Legionella pneumophila. Their cases highlight the problems associated with ward closures and the hazards of stagnant water.
Jack CI, Smith T, Jones R, Ibreck R, Malster MG, Lye M
Department of Geriatric Medicine, University of Liverpool.
Br J Clin Pract 1996 Mar;50(2):106-107

Legionella and the European Council for Package Travel

The recently implemented European Council Directive for Package Travel makestour operators responsible for the acts and omissions of their suppliers. Touroperators can be held liable if they knowingly place clients in hotels that may beassociated with legionella infection. New procedures have therefore been agreedwith the Association of British Travel Agents (ABTA) and the Federation of TourOperators (FTO) for the PHLS to report to them anonymised summary informationon single cases of travel associated legionnaires’ disease in residents of Englandand Wales. ABTA and FTO will identify tour operators using the hotels at whichcases have stayed. The tour operators will then remind managers of the hotels –on the understanding, however, that a single case does not mean the hotel was necessarily the source of infection – to check that their water and cooling systemsare being maintained to appropriate standards to mimimise any risk of legionellainfection. The European Surveillance Scheme for Travel Associated Legionnaires’Disease (EWGLI), which is coordinated by the PHLS Communicable DiseaseSurveillance Centre (CDSC), will inform ABTA and FTO when they detect travelassociated clusters (two or more cases linked to the same accommodation arisingwithin a six month period). The information will enable tour operators to makeinformed decisions on whether they wish to continue using hotels that mightpresent a health risk to their clients.
Two clusters of travel associated legionnaires’ disease recently reported toCDSC have provided the first opportunity to use the new procedures. In the firstcluster, two people who stayed at a hotel in Marmaris, Turkey in May 1996acquired legionnaires’ disease. The same hotel was associated with another twocases in September 1995. EWGLI collaborators, the World Health Organisation

(WHO), and the Department of Health who were alerted to the cluster and ABTAand FTO were sent summary information. Tour operators from the UnitedKingdom have withdrawn clients from the hotel while public health officialsinvestigate possible sources of infection.

The second cluster was associated with an apartment block in Cala Galdana,Minorca where three cases of legionnaires’ disease had stayed in the ten daysbefore becoming ill in May. Within 24 hours of being sent summary information,the tour operator with sole use of the apartment block had withdrawn all itsclients to alternative accommodation. Investigations by local public healthofficials have shown that the outbreak may have been caused by the installationof a new hot water system at the hotel during the first three weeks of May.

Prompt communications from EWGLI, swift withdrawal of clients fromimplicated hotels, and the rapid launch of investigations by local public healthofficials should contribute to improved control and prevention of cases andoutbreaks of legionnaires’ disease linked to package travel.

CDR June 1996

This service is run and maintained by the Institute of Public and Environmental Health

Volume 7 Number 3 17 January 1997
Communicable Disease Report
Legionnaires' disease in Corby, Northamptonshire

Two outbreaks of legionnaires` disease in Corby, Northamptonshire, in August (see CDR Weekly 1996; 6: 329) and in December 1996, are believed to be associated the with an industrial estate.
The industrial estate covers an area of about 1.5 square miles to the east of Corby, and includes large and small lndustrlal premises.
Fourteen cases were Identified in the first outbreak; ten worked on the Industrial estate, two were drlvers who visited the estate regularly, and two often drove through the estate. All 14 cases became ill between 4 and 28 August 1996, and all recovered.
Twelve were men and two were women, and there ages ranged from 29 to 83 years. Infection with Leglonella pneumophila serogroup 1 was diagnosed by urinary antigen detectlon and/or a four fold rise in antibody levels in seven cases, and by a single high antibody titre in the other seven. Legionellas were not cultured from any of the eases. All industrial premises on the estate were inspected, and samples were taken for microbiologteal analysis from 48 weekscoollng towers or evaporatlve condensers on 15 premises. Control rneasures were taken at all premises on the estate. Legionellas were cultured from 18 samples from seven premises.
No clinical isolates were obtalned for comparison wlth these environmental isolates.
Seven cases have been detected so far in the second outbreak, all of whom became ill between 1 December 1996 and 1 January 1997.
Flve cases either work on or regularly visit the industrial estate, and the other two travel through the estate to visit nearby shopping centres. Five are men and two are women, and their ages range from 42 to 64 years. One case is currently in an intensive care unit. Legionella pneumophila serogroup I has been isolated from one case.
The PHLS Leglonella Reference Unit is carrying out subgrouping and subtyping studies of this isolate and of environmental isolates from the industrlal estate.
Local clinicians, general practitioners, and occupatlonal health departments are helping to identlfy further cases, and the local media have been informed about the outbreaks. The consultant in communicable disease control (CCDC), Corby Environmental Health Department, the local Health and Safety Executive, and other publlc health professlonals are lnvestigating suspected sources of infection.
All premises visited ln the ffrst outbreak are betng revisited and retested and control measures revlewed. Other sites are also being Investigated as possible sourees of infection. The investigatlon of the outbreak is being coordinated by Dr Patrick Morgan, CCDC, Northamptonshire Health Authority (tel 01604 615 394), who would welcome reports of cases of legionnalres' disease that might be associated with Corby.

GO.........OUTBREAKS AT CORBY..........
HOW SAFE ARE YOU IN THIS CITY

SEE ALSO

LEGIONNAIRES DISEASE ......ENGLAND AND WALES 1995

LEGIONNAIRES DISEASE ......ENGLAND AND WALES 1996

Most cases of legionnaires' disease contracted abroad

Since 1979, 2,800 cases of legionnaires' disease have been reported in England and Wales. ln 1995, 160 cases were reported to the Communicable Disease Surveillance Centre and 20 cases were known to have died. Of the total number of cases, 90 were associated with travel, four with a stay in hospital and the remaining 66 were assurned to have acquired the infection in the commiinity. 'The epidemiulogical features in 1995 were similar to those reported in recent years, bar the fact that more ofthe travel-related cases were associated with outbreaks or clusters abroad in 1995.

There was a gradual increase in the number of cases associated with travel to Turkey
( 17.3 infected per million travellers in 1995, and 9.7 in 1994 mainly due to the outbreak in Kusadasi}. 'The rate of infection per million travellers to Spain rose from less than three per million in 1994 to over four per million in 1995 .

However, the number of cases associated with stays in hospital fell. There were no acquired outbreaks for the second consecutive year and the lowest number of sporadic cases acquired in hospital since 1994. The rate of mortality also fell, from 13 per cent in 1993 and 1994 to 13 per cent in 1995. These reductions are believed to be due to effective design, monitoring and maintenance of hospital water systems, as well as to continued reporting. Six cases of legionnaire's disease in August 1996 were found to be associated with an industrial estate in Corby, Northants. The bacterium was isolated from 11 cooling towers which served cooling systems on six sites in the area. All those affected recovered and are now convalescing.
(Communicable Disease Report)

1973 Scotland

The first known cases of Legionnaires` disease in Scotland occurred in 1973 in a group of tourists who had been on holiday in Benidorm in Spain, Three tourists died from that unknown outbreak.
A further case was noted in 1976 and a further two cases in 1977, These cases were not realised until several years later
(Fallon RJ, Journal Hygine Cambridge 1882 89 439-448)

1978 Glasgow

POSSIBLE PERSON TO PERSON TRANSMISSION OF LEGIONNAIRES` DISEASE.

A general practitioner was treated for pneumonia in 1974, The clinical features suggested infection with Mycoplasma pneumoniae,chlamydia B or Coxiella burnetii, but the serlogy was negative, The doctor himself was positive that he had contacted the infection from a patient whom he had attended 2 weeks before and had sent to hospital with sever pneumonia which had developed during a holiday in Benidorm, Sera taken from the patient during his illness have proved, retrospect, that he had Legionnaires` disease.
No acute-phase serum was available from the general practitioner, but a sample taken more than three years later had an antibody of 1:512 This is a strong circumstantial evidence of a case-to-case transmission.
(W Campbell Love, The Lancet, December 9 1978)

1984 Glasgow

An outbreak of legionellosis in Glasgow, Scotland in 1984, 33 people caught the disease and one died, 26 of the patients lived in Dennistown district. Cases occurred downwind of the cooling tower up to a distance of 1700 metres
(AD-HOC COMMITTEE, The Lancet August 16 1986)

1985 Glasgow

An outbreak of Legionnaires disease at the Royal Infirmary in Glasgow in November 1985, 15 patients and one staff member in the phase 1 block developed the disease, The source on the infection was traced to contamination of a cooling tower from which a plune of spray discharged into the intake vents of the two ventilation systems.
(Timbury MC, Journal Hygiene Cambridge 1986 97 393-403)

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 )

1990 Glasgow

A survey to assess the maintainance of cooling towers in Glasgow was held after two Legionnaires disease outbreaks, Information was obtained from 76 of 81 premises and a maintainance score was calculated for each of the 174 towers, Low maintainance scores were associated with no log book, no guidelines, no change in procedures in the last five years, solitary cooling towers and towers on industrial premises. Despite intense publicity the standard of cooling tower maintainance in Glasgow remains a concern
(Bhopal RS, Epidemiology and Infection, 1990 104 29-38)

Fatal nosocomial Legionnaires' disease:

The investigation, epidemiology, and effectiveness of control procedures during an outbreak of Legionnaires' disease involving three immunosuppressed patients are described.
The source of infection appeared to be a network of fire hydrant spurs connected directly to the incoming hospital mains water supply. Removal of these hydrants considerably reduced, but failed to eliminate, contamination of water storage facilities. As an emergency control procedure the incoming mains water was chlorinated continuously. Additional modifications to improve temperature regulation and reduce stagnation also failed to eliminate the legionellae. A perspex test-rig was constructed to model the pre-existing hospital water supply and storage system. This showed that through the hydraulic mechanism known as 'temperature buoyancy', contaminated water could be efficiently and quickly exchanged between a stagnant spur pipe and its mains supply. Contamination of hospital storage tanks from such sources has not previously been considered a risk factor for Legionnaires' disease. We recommend that hospital water storage tanks are supplied by a dedicated mains pipe without spurs.
(Patterson WJ; Seal DV; Curran E; Sinclair TM; McLuckie JC Address Glasgow Royal Infirmary, Edinburgh. Source Epidemiol Infect, 1994 Jun, 112:3, 513-25)

OUTBREAKS SCOTLAND