THE WORLDS LARGEST OUTBREAK
Alcala de Henares
1996




Alcala de Henares
The Most Extensive Legionella Epidemic in the World

In September 1996 there was a outbreak of Legionella in the city of Alcala de Henares, near Madrid, that seemed to spread via the water system. The finding of Legionella in water from showerheads in dwellings is potentially pretty scary (might be nice to get some numbers--incidence, any pattern vis a vis the city water delivery system. This might make some interesting comparisons with the cholera epidemics in mid-19th Century London that was traced to particular wells.) Some of the fault seems to lie in an old water system -- dead ends that could harbor bacteria. Other findings implicated cooling towers, but no evidence of Legionella was reported.

Excerpts:
Last September 11 [1996],
Public Health Area 3 became aware that during the previous two weeks Carmen Calzado Center and Principe de Asturias Hospital, both in Alcala de Henares, were receiving an unusual number of patients presenting with atypical pneumonia. The Official College of Veterinarians of Madrid, conscious of the responsibility assumed by the veterinary profession in the field of environmental health prevention, exhaustively pursued events, which they have summarized in this report. Starting September 11 there began to appear in the press and the media in general, news of the appearance of a growing epidemic of atypical pneumonia in Alcala de Henares. As an immediate consequence, social unrest surged. This news had an alarming impact, due in part to sensationalism in some of the media, and also to memories of the not very distant cases of rapeseed oil poisoning.

Alcala de Henares has approximately 160,000 inhabitants. This is a traditionally working class area, with a complex and extensive social structure, with all the complexity of a varied industrial area, city center, services and bedroom community. Chronological summary

Sep.11:
Detection of the outbreak, and beginning of sampling patients
Sep.20:
Taking water samples
Sep.23:
Confirmation of high titres of antibodies against Legionella pneumophila serotype 1 (Pontiac) in some patients
Sep.24:
Start of application of preventive measures concerning water use
Sep.26:
Increase in these measures, i.e., to abstain from using water
Oct.3:
An outbreak of Legionella is considered the most probable hypothesis
Oct.11:
The outbreak of Legionella is confirmed epidemiologically, and a high risk zone is identified in the north part of Alcala de Henares, cooling towers are implicated as a source of the infection.
Oct.18:
The epidemic is considered controlled.

Chronology of events and actions:

Sep.11-13:
A growing number of cases of atypical pneumonia is confirmed in Alcala de Henares. Start of the epidemiological investigation. Start of collection of epidemiological data; opening of investigation of patients. Clinical picture of atypical pneumonia. Median age of the cases: 68 years. No response to amoxicillin or clavulanic acid; excellent response to erythromycin. Grouping of cases in the north area of Alcala de Henares. No detection of person to person transmission. Elimination of animals as the source of infection. Discarded any implication of food in the outbreak.
Sep.14-18:
A provisional hypothesis is pieced together that one can treat an atypical pneumonia caused by Legionella without considering infectious causes, environmental effects, etc. There are no indications implicating any toxin. The media are informed daily. There are requests for system diagrams and technical information about the water distribution system in Alcala de Henares.
Sep.20-22:
Samples of running water are taken from the dwellings of those affected and unaffected, water supply wells, water trucks and the fountain in San Isidro Park.
Sep.23:
The National Center of Microbiology reports the finding of high titres against Legionella pneumophila Serotype 1 in 5 patient samples.
Sep.24:
They report that among the most probable hypotheses, the outbreak could be caused by Legionella, and the Public Health office orders the first preventive measures: Avoid aerosols of water in the home, prohibit spray irrigation, stop cooling systems, and substitute baths for showers.
Sep.25:
Technicians and specialists were assigned to the job of investigating cooling towers in the areas at risk. Water samples were sent to laboratories specializing in the detection of bacteria in environmental water samples.
Sep.26:
Hyperchlorination of the entire water distribution system in Alcala de Henares. Cleaning of cooling towers to established standards in the high risk zones and adjacent areas.
Sep.28:
As a precaution even before taking water samples, closed automatic car washes.
Sep.30: Correlation of bacteria in samples obtained from bathroom showerheads and infection begin to appear in the dwellings of those affected by Legionella pneumophila.
Oct.1:
Perform the task of finding dead ends in the water distribution system, verifying a lack of chlorination in some of them.

Source:Report by the Official College of Veterinarians of Madrid

Communicable Disease Report

An Outbreak of Legionnaire`s Disease in Spain

An outbreak of community acquired legionnaires' disease in Alcala de Henares, a town about 15 miles east of Madrid, has been reported. The outbreak was first detected when a greater than expected number of people in the town were admitted to hospital with pneumonia during the first half of September. By 18 October 1996, 197 cases of atypical pneumonia had been admitted to hospital and 11 had died. The mean age of the cases was 68 years, over two thirds were aged 60 or over, and almost two thirds were males. Most cases were from the northern part of the town.

Microbiological investigations of clinical and environmental samples are being carried out in Madrid by the Centro Nacional de Microbiologica (CNM) at the Carlos III Institute of Public Health. By 18 October, a total of 49 cases of legionnaires' disease had been confirmed, six by eulture ofthe organisrn and the others by serology (seroconversion [fourfold or greater rise in antibody titre] or single high titre) . The strains isolated from the six cases, and strains isolated from sarnples taken frorn six cooling towers and two water storage tanks in Alcala de Henares, have all been identified as Legionella pneumophila serogroup 1 subgroup 'Pontiac'. CNM is undertaking rnolecular studies of these strains. The PHLS Legionella Reference Unit has received four of these strains (two clinical and two environmental) and confirmed their identification and typing.

All cooling systerns in the affected area have been shut down by local public health officials. The entire water supply grid has been hyperchlocinated. Cooling towers in the north of the town, and drinking and hot water storage tanks have been cleaned and disinfected. Epidemiological investigations into the source of the outbreak are continuing .

This outbreak may be the largest reported in Europe. The two largest outbreaks reported in the United Kingdom were associated with Stafford General Hospital in 1985 (68 cases and 22 deaths) and Broadcasting House, London in 1988 (70 cases and three deaths)

(CDR WEEKLY V6 NUMBER45 8 NOVEMBER 1996)


Informe sobre el brote de Neumonía en Alcalá de Henares

Madrid. España

El día 11 de Septiembre de 1996 los servicios sanitarios de INSALUD de Alcalá de Henares (Madrid, España), notificaron al Servicio de Salud Pública del Area III un aumento sobre lo habitual del número de neumonías extrahospitalarias atendidas en el hospital Príncipe de Asturias en las dos semanas anteriores.

La investigación epidemiológica emprendida inmediatamente confirmó la existencia de un brote de neumonía y la agrupación de casos en la zona norte de Alcalá de Henares.

Se identificaron retrospectivamente 72 casos de neumonía atendidos e ingresados en el hospital desde el 25 de Agosto (fecha en la que se evidenció el comienzo manifiesto del brote) y se diseñó y aplicó una encuesta epidemiológica orientada a describir el brote e identificar factores de riesgo comunes a los casos y asociados a cuadros de afectación pulmonar neumónica.

Los resultados de dicha encuesta, así como las evidencias clínicas disponibles y la buena respuesta al tratamiento con eritromicina, orientaron la hipótesis etiológica hacia un brote de neumonía infecciosa presumiblemente debido a Legionella.

Los resultados microbiológicos de muestras clínicas y medioambientales así como los estudios epidemiológicos desarrollados de muestran que el brote epidémico de neumonía ocurrido en Septiembre y Octubre de 1996 en la ciudad de Alcalá de Henares ha sido producido por la bacteria Legionella pneumophila SG1, subgrupo mayor Pontiac, subgrupo menor Knoville.

Los resultados de las investigaciones epidemiológicas, microbiológica y ambiental coinciden en señalar como origen del brote una o varias torres de refrigeración de agua.

Atendiendo a criterios clínicos, epidemiológicos y microbiológicos se han incluido en el brote 224 casos, clasificados en casos confirmados (92 casos), probables (42 casos) y sospechosos (90 casos). Todos ellos fueron atendidos entre el 25 de Agosto y el 26 de Octubre de 1996.


Manuel Martín VICTIMA

Manuel Martín Mediavilla es un hombre jovial y de aspecto saludable a sus 73 años. Vecino de la localidad madrileña de Alcalá de Henares, donde habita junto a su mujer, reconoce que le gusta dejar la ciudad para pasar unos días en el pueblo de su familia. De allí regresó a principios de septiembre y no pasaron ni dos horas cuando uno de sus vecinos le habló de esa dichosa epidemia de legionella que estaba llevando al hospital, y a veces a la tumba, a muchos alcalaínos. El domingo 22 de septiembre Manuel comenzó con un proceso de fiebre y espasmos musculares que fue empeorando a lo largo de la noche. "Al día siguiente estaba bastante mal, así que mi hija me llevó a urgencias del hospital Príncipe de Asturias. Me hicieron todas las pruebas y enseguida me dijeron que tenía neumonía por la legionella esa". Cuando lo subieron a la habitación, la fiebre llegaba a los 40 grados, tenía vómitos y cada músculo de su cuerpo temblaba. Los chorros de sudor obligaban a las enfermeras a cambiar las sábanas dos veces en un par de horas. Sus dos hijas y su mujer esperaban las noticias de los médicos con la angustia de saber que esa misma infección ya había matado a tres personas en aquel hospital. "Afortunadamente, un par de días después ya me encontraba mucho mejor". La lista de afectados aumentó hasta 261, de los que 14 murieron, cifras que han hecho de este brote de legionella el más grave de los diez que se han producido en España desde 1973. En octubre, con la epidemia ya controlada, el grupo de expertos que había dirigido las investigaciones concluyó que los focos donde se habían concentrado las bacterias de la legionella eran seis torres de refrigeración que se encontraban en la zona norte de Alcalá de Henares.

Carlos Alcelay

BOLETIN Instituto de Salud Carlos III
Nº 10
NOVIEMBRE - DICIEMBRE 1996
UNIDADES DEL ISC III

EL ESTUDIO DEL BROTE DE ALCALÁ DE HENARES COMO EJEMPLO DEL PAPEL DE UN LABORATORIO DE REFERENCIA

Carmen Pelaz (*), Ana Ibáñez (*) y Cecilia Martín Bourgon (**)

(*) Centro Nacional de Microbiología del ISC III

(**) Secretaría Técnica del ISC III

El brote de Enfermedad del Legionario (EL), ocurrido recientemente en Alcalá de Henares puede servirnos de ejemplo para revisar el papel de un laboratorio de referencia como es el Laboratorio de Legionela del Centro Nacional de Microbiología (CNM).

ANTECEDENTES

El laboratorio de Legionella se creó en 1983 como consecuencia de un brote ocurrido en un hotel de Benidorm que afectó a turistas británicos. Desde entonces, varias personas del Servicio de Bacteriología han colaborado en él. Este laboratorio ha participado de forma directa o indirecta en la mayoría de los brotes de EL ocurrido en España, algunos de los cuales como el de la Residencia Militar de los Castillejos o el de Almuñecar, tuvieron una gran resonancia y otros, por su menor envergadura, desconocidos por la opinión pública. También se ha participado en el estudio de brotes internacionales.

PAPEL DEL LABORATORIO DE REFERENCIA
Como laboratorio de referencia el laboratorio de Legionella ha desarrollado las siguientes funciones:
- Aislamiento e identificación de Legionella en muestras clínicas de enfermos con neumonía, recibidas de los hospitales del SNS.
- Caracterización y tipado de aislados recibidos de los distintos laboratorios del SNS.
- Mantenimiento de una colección de aislados autóctonos. En el momento actual se conservan mas de 1500 cepas españolas, 300 de las cuales son de origen clínico y el resto ambientales.
- Aislamiento e identificación de Legionella en muestras ambientales de edificios asociados a casos, recibidas a través de los Servicios de Salud de las CCAA.
- Desarrollo de nuevos métodos de aislamiento, identificación y/o tipado y mejora de los métodos existentes. Elaboración y control de los medios de cultivo empleados.
- Elaboración de antígenos y antisueros para diagnóstico.
- Participación en estudios europeos, especialmente en lo que se refiere a seguimiento de casos de legionelosis en viajeros y estudios de armonización de métodos de caracterización.
- Apoyo a las CCAA en asesoramiento sobre prevención y control de legionelosis.

- Colaboración con el CNE en el seguimiento de casos contraídos en España.

- Colaboración con el CNE en la elaboración del protocolo para notificación de legionelosis al Sistema Nacional de Vigilancia Epidemiológica.
- Elaboración de normas y recomendaciones para el tratamiento de instalaciones de edificios.
- Formación de personal del SNS que visita el laboratorio para aprender la tecnología de aislamiento e identificación de la bacteria.
Como consecuencia de todas estas tareas, el laboratorio mantiene una actividad constante en el aislamiento de Legionella a partir de muestras tanto clínicas como ambientales, habiendo puesto en práctica diversos procedimientos de mejora en el rendimiento del aislamiento, y tomando parte en los controles de calidad europeos de aislamiento en aguas, liderados por el laboratorio del PHLS inglés de Norttingham (Dr. Lee) desde hace 5 años.

ACTITUD ANTE UN BROTE
Esta actividad, propia de un laboratorio de referencia, es la que permite abordar sin problemas el estudio de brotes, como el ocurrido recientemente en Alcalá de Henares o como los anteriormente citados. Ante un brote de esas características el laboratorio tiene dos retos principales que resolver:
1- Diagnosticar lo antes posible el agente responsable de la infección, utilizando técnicas reconocidas en cuanto a su sensibilidad y especificidad.

2- Buscar la fuente de infección, que será aquel foco ambiental que presente contaminación con el mismo aislado que el encontrado en las muestras de pacientes.

Aunque el reto 1 se puede abordar con diversos métodos diagnósticos disponibles, de entre los cuales la serología es el más consolidado, presentando una buena sensibilidad y especificidad, no debe olvidarse que en bacteriología el diagnóstico clásico e indiscutible por definición es el aislamiento del microorganismo, por lo que el laboratorio de referencia debe intentar el cultivo del mismo. Este razonamiento se ve reforzado por la necesidad de contar con aislados clínicos para su comparación con los posibles aislados que se recuperen de las fuentes ambientales.

Con objeto de estudiar la posible identidad de los aislados, tal como se pretende en el segundo reto , se hace necesario realizar el cultivo de la bacteria y no son de aplicación otras pruebas, como la PCR, que detectan la presencia de la bacteria pero no aportan información sobre la posible identidad de la misma con los aislados clínicos.

MÉTODOS DE CARACTERIZACIÓN

Para el estudio de identidad de los aislados de L. pneumophila serogrupo (SG) 1 en el laboratorio del CNM se realiza un primer tipado con un panel internacional de anticuerpos monoclonales que subdividen a las cepas en tres subgrupos mayores conocidos como Pontiac, Olda y Bellingham, divididos a su vez en ocho subtipos menores, de la forma siguiente: Pontiac presenta cinco subtipos con los nombres Philadelphia, Allentown, Benidorm, France y Knoxville; Olda presenta cuatro subtipos llamados, OLDA, Oxford, Camperdown y Heysham y Bellingham presenta un único subgrupo que conserva el nombre de Bellingham. Una vez conocido el subgrupo monoclonal correspondiente, aplicamos un segundo método de tipificación, la electroforesis en campo pulsado (PFGE) tras digestión enzimática de los lisados de la bacteria con las enzimas SfiI y NotI. La comparación de las bandas que se obtienen en los geles permite comprobar la identidad de los aislados con un elevado grado de certeza.

BROTE DE ALCALÁ DE HENARES

Los principales rasgos epidemiológicos del brote ocurrido en Alcalá de Henares se encuentran resumidos en la tabla 1. La agregación espacial de los casos, tasa de ataque, distribución etaria y por sexos es característica de los brotes de EL descritos en la literatura. Sin embargo, hay que resaltar que por el número de afectados, este brote representa el mayor de los ocurridos en Europa.

Tabla 1. Características epidemiológicas del Brote de Enfermedad del Legionario. Alcalá de Henares 1996. (Datos del 18 de octubre).

Duración: Finales de Agosto a mediados de Octubre

Nº Afectados: 260 ()

Nº Ingresos: 197

Nº Fallecidos: 11 (16)

Tasa de ataque: < 1 % (35000 habitantes)

Tasa de mortalidad: 6.1 %

Distribucion de casos: agregación geográfica, no familiar

Edad media: 68.2 (69.5 % mayores 60 años)

Sexo: 63 % varones y 36.7 % mujeres

Diagnóstico

El diagnóstico etiológico inicial fue realizado por serología, ya que el Hospital Príncipe de Asturias, en el que se ingresaron los casos, envía al CNM de forma habitual sueros para diagnóstico de infecciones respiratorias. Tras las primeras evidencias serológicas de infección por Legionella se pidieron muestras respiratorias para el aislamiento de la bacteria, recibiéndose en primera instancia un elevado número de muestras de esputo que produjeron muy bajo rendimiento, en gran medida por tratarse de enfermos con bastantes días de evolución o, incluso, ya tratados con antibióticos. Se procesaron también muestras de tejidos de necropsia de la mayoría de los casos fatales y finalmente se decidió la toma de muestras de fluidos respiratorios por broncoscopia, lo que garantiza una calidad de muestra mucho mas idónea para el aislamiento de Legionella. Paralelamente se continuaron los estudios serológicos. En total se cultivaron nueve aislados de L. pneumophila SG 1 correspondientes a siete enfermos, según se puede ver en la tabla 2. Por otra parte a fecha 30 de Octubre, nuestros compañeros del laboratorio de serología (F de Ory) habían encontrado un total de 133 enfermos con serología positiva a L. pneumophila SG 1, bien por seroconversión, bien por título alto mantenido.

Tabla 2. Aislamiento de L. pneumophila en muestras clínicas

Muestra
Total
Pos
Neg
Esputos
70
1
69
Tejidos de necropsias
30
1
29
Aspirados bronquiales
10
2
8
Lavados broncoalveolares
10
2
8
Cepillados bronquiales
4
2
2
Biopsias pulmón
5
0
5
Aspirados telescopados
4
1
3
Líquido pleural
3
0
3
Gargarismos
6
0
6
Total
142
9
133

Todos los aislamientos se identificaron como Legionella pneumophila SG 1 Pontiac ( Knoxville )

Búsqueda de la fuente de infección

Una vez demostrada la etiología por L. pneumophila se procedió a la búsqueda de la fuente de infección, para lo cual los técnicos en epidemiología y sanidad ambiental del área 3 de Salud Pública de la CAM realizaron una recogida amplísima de muestras, incluyendo tomas de la red en viviendas particulares, comercios, bancos, bocas de riego, ets, así como muestras de tramos ciegos (también llamados testeros) y de torres de refrigeración de la zona céntrica de la ciudad en la que se han dado la mayor incidencia de casos. En total se han estudiado 116 muestras ambientales de las que 55 resultaron positivas, según se puede ver en la tabla 3.

Tabla 3. Muestras ambientales estudiadas y resultados obtenidos

Muestra
Total
Pos
Neg
T Refrigeración
65
37
28
Depósitos
17
9
8
Grifos, Duchas
10
4
6
Pozo
7
2
5
Autolavados
5
0
5
Testeros
2
0
2
Camión cisterna
2
1
1
Agua del rio
2
1
1
Fuente
2
0
2
Filtros aire
1
0
1
Hidrante
1
1
0
Humidificador
1
0
1
Depuradora
1
0
1
Total
116
55
61

Los resultados de la caracterización de los aislados produjeron el siguiente resultado:

- Aislados clínicos: Todos ellos resultaron ser L. pneumophila subgrupo Pontiac (Knoxville) e iguales entre sí por PFGE.

- Aislados ambientales: De los 55 aislados recuperados, 45 resultaron ser L.pneumophila SG 1, mientras que 10 pertenecían a otras especies o serogrupos, según se puede ver en la tabla 4. Los correspondientes a L. pneumophila SG 1 se subdividen en 30 Olda y 15 Pontiac y siendo estos últimos a su vez subdivididos en 12 Knoxville y 3 Benidorm. Los lugares que albergan el tipo Knoxville serían considerados las posibles fuentes de infección. De ellas, por su localización geográfica unas serían candidatas mas probables que las otras. C.P., A. Y., C.M.B.


Tabla 4. Distribución en serogrupos y subgrupos de los aislados ambientales de Legionella pneumophila.

Muestra
SG 1:Olda
SG 1:Pontiac
Otras sp/SG
T Refrigeración (37)
21
9 (6 Knoxville)
(3 Benidorm)
7 (1 SG 2,3)
(1 SG 6)
(2 SG 10)
(2 L.mic.)
(1 L.boz.)
Depósitos (9)
4
5 (5 Knoxville)
0
Grifos, duchas (4)
4
0
0
Hidrante (1)
0
0
1 (SG 9,14)
Camión cisterna (1)
0
0
1 (SG 8)
Río (1)
0
0
1 (SG 10)
Pozo (2)
1
1 (1 Knoxville)
Total (55)
30
15
10


1996
AUGUST
MADRID, SPAIN

An 88-year-old man became the 12th resident of a Spanish town to die from Legionnaire`s Disease, health officials said Wednesday.
More than 200 people have been treated for pneumonia since late August at a hospital in Alcala de Henares, a university town of 165,000 people 15 miles northeast of Madrid.

Officials at the Principe de Asturias hospital said 33 people remain hospitalized for pneumonia. Health officials said laboratory tests show 31 percent of the pneumonia patients have Legionnaire`s Disease.
The bacteria that causes Legionnaire`s Disease lives in hot-water systems, showers, whirlpools and condensers and, under the right conditions, can breed to deadly levels.

Chlorination of the water supply has been increased and residents have been urged to disinfect their faucets and shower heads with vinegar, and to take baths instead of showers.
Symptoms include headaches, nausea, fever, and chest pains. The disease can be treated with antibiotics, but nearly one in six victims, especially the elderly and smokers, still die from the disease.

Las industrias creen que la legionella está en el aire urbano de Alcalá.
Las autoridades culpan hasta ahora a las instalaciones fabriles. Aumenta la preocupación en Alcalá por dos nuevas muertes por legionella.
Las autoridades aún desconocen la causa de la epidemia.
Hallan la bacteria de la legionella en la biopsia de un enfermo de Alcalá de Henares.
Sanidad tardará dos semanas en confirmar el origen del brote de neumonia en Alcalá. Las autoridades siguen sin confirmar que se deba a la legionella. El brote de legionella causa al cuarta víctima mortal en Alcalá.
Asturias no reúne condiciones para desarrollar la legionella. Detectados nuevos casos de legionella en Madrid y Zaragoza. Fallecen dos enfermos más afectados por el brote de legionella en Alcalá.
Los expertos rechazan vaticinar que no habrá otro rebrote. Aumenta la preocupación en Alcalá por dos nuevas muertes por legionella.
Las autoridades aún desconocen la causa de la epidemia. Sanidad asegura que nunca ha confirmado que la legionella sea la causa de la muerte en Alcalá. El brote de legionella causa al cuarta víctima mortal en Alcalá. Siguen sin poder controlar el brote de legionella que afecta ya a 130 personas.


Las industrias creen que la legionella está en el aire urbano de Alcalá. Las autoridades culpan hasta ahora a las instalaciones fabriles.

Aumenta la preocupación en Alcalá por dos nuevas muertes por legionella.Las autoridades aún desconocen la causa de la epidemia. Hallan la bacteria de la legionella en la biopsia de un enfermo de Alcalá de Henares.
Sanidad tardará dos semanas en confirmar el origen del brote de neumoniaen Alcalá. Las autoridades siguen sin confirmar que se deba a la legionella. El brote de legionella causa al cuarta víctima mortal en Alcalá.
Asturias no reúne condiciones para desarrollar la legionella. Detectados nuevos casos de legionella en Madrid y Zaragoza. Fallecen dos enfermos más afectados por el brote de legionella enAlcalá.
Los expertos rechazan vaticinar que no habrá otro rebrote. Aumenta la preocupación en Alcalá por dos nuevas muertes por legionella.Las autoridades aún desconocen la causa de la epidemia. Sanidad asegura que nunca ha confirmado que la legionella sea la causade la muerte en Alcalá. El brote de legionella causa al cuarta víctima mortal en Alcalá. Siguen sin poder controlar el brote de legionella que afecta ya a 130 personas.

The industries think that the legionella one is in the urban air of Alcala. The authorities blame until now to the manufacturing facilities. It increases the preoccupation in Alcala by two new deaths by legionella. The authorities still do not know the causeof the epidemic.They find the bacterium of the legionella one in the biopsy of a patient of Alcala de Henares Health will take two weeks in confirming the origin of the bud of neumonia in Alcala. The authorities follow without confirming that it must the legionella one.The bud of legionable cause to the fourth mortal victim in Alcala. Asturias does not reunite conditions to develop the legionella one.Detected new cases of legionella in Madrid and Zaragoza. Two patients affected by the bud of legionella pass away more in Alcala. The experts reject to predict that there will be no another sprout again. He increases the preoccupation in Alcala by two new deaths by legionella. The authorities still do not know the causnhe bud of legionable that already affects 130 people.

A _Legionella_ epidemic has been detected in Alcala de Henares (Madrid, Spain); first case was diagnosed on August 25 [1996]; up to November 21 there had been 260 patients (197 admitted [to hospital], 14 deaths), most of them more than 60 years old; all patients lived or had been north of the city.

The _Legionella_ [bacterium] has been recovered from autopsy specimens, six refrigeration-towers and two water-towers for the city supply.

[This kind of outbreak reporting by ProMED-mail readers is VERY much appreciated! - Mod.JW]

Internal Medicine Dep Hospital Can Misses Ibiza (Spain) E-mail:


June 1996

Legionnaires' Disease alert

A HOTEL apartment block on the island of Minorca was inspected by health experts yesterday after three Britons who stayed there developed Legionnaires' Disease.

Teams scoured the Anabel complex at Cala Galdana on the south coast after being alerted by health authorities in Britain.

The director of public health for the Balearics, said: "We should have the results of tests in a week.



Euro Surveillance

Outbreak report Vol 2 / No 6 (June 1997)

Outbreak of legionnaire`s Disease in two groups of tourists staying at camp sites in France and Spain, June 1996

On 11 June 1996, three suspected cases of legionnaires' disease in a group of 42 Dutch tourists were reported to the local public health authority by Millau hospital in south west France. The group (group 1) had been touring with caravans and staying at different camp sites in France and Spain since 15 May. On 15 June, two people in a second group of 52 Dutch tourists following the same organised tour with a delay of one week (group 2), were admitted to hospital in Millau with pneumonia. The present report summarises the epidemiological and environmental investigations undertaken to identify the source of infection. Materials and methods

A descriptive and retrospective cohort study of the two tourist groups was conducted using a self administered questionnaire to identify further cases and potential risk factors in the four camp sites visited during the incubation period.

A case was defined as a tourist of group 1 or group 2 with evidence of fever >38.0 °C and cough during or within 10 days after the trip. Cases were classified as confirmed (culture of legionella or fourfold rise in antibody titre to Legionella pneumophila or presence of soluble urinary antigen or positive direct immunofluorescence), probable (single antibody titre > 256 for L. pneumophila), or possible (no laboratory confirmation).

The incubation period of legionellosis and dates of stay in the camp sites allowed us to suspect one specific camp site to be the possible source of infection.

The list of tourists who stayed at the camp site where exposure was likely to have occurred was obtained from the camp site manager and sent to the health authorities of the regions of residence of Spanish tourists exposed. Microbiologically diagnosed cases were reported to the European surveillance scheme for travel associated legionnaires' disease (EWGLI).

Clinical descriptions were obtained from hospital records and from the general practitioner of one case diagnosed in the Netherlands. Serological tests (IFA) for anti-Legionella antibodies (Lp1 to Lp10) and urinary antigen tests (EIA, BinaxTM, specific to Lp1) were performed at the National Reference Centre for Legionella in Lyon (France) for all but one case, which was diagnosed in the Netherlands.

Local public health authorities visited camp sites B and C and sampled water. Water samples were processed with standard methods for culture of legionella.

Data were entered and analysed using Epi Info version 6.04. Attack rates (AR) were compared by calculating relative risks (RR). Confidence intervals at 95% were computed for each RR. Statistical significance (p <0.05) was evaluated by Fisher's exact test.

Results

Thirty-five out of 42 people in group 1 and all 52 members of group 2 responded to the questionnaire (age: mean: 64 years, range: 56-75). Fifty per cent of respondents were men. Six people described a febrile lower respiratory illness consistent with the clinical case definition, an overall AR of 7% (4 cases in group 1, AR: 11% and 2 in group 2, AR: 4%).

Four of the cases were men and two were women, aged 60 to 74 years. Two cases (a couple) were confirmed (2 seroconversions to L. pneumophila sg1, one of whom had positive urinary antigen), one case was probable (titre of 512 to L. pneumophila pooled antigens sg1 to 6), and three cases were possible (3 with negative urinary antigen test and 2 no seroconversions). Five cases were admitted to hospital. Among these, chest X-ray showed uni (n=3) or bilateral (n=2) infiltrates. The case treated as an outpatient had fever, unproductive cough, and mild dyspnoea. All cases recovered.

Symptoms were reported to have begun between 2 and 7 June for group 1, and on 15 June for group 2 (figure 1). Figure 1 shows the length of stay at each camp site during the incubation period.

Case 1 left the tour on 31 May and had thus stayed only in camp sites A and B. Exposure during stay in camp site B was compatible with the date of onset of symptoms for all cases. The incubation period associated with exposure in camp site B ranged from 3 to 10 days for cases in group 1, and from 9 to 12 days for cases in group 2.

No air conditioning system was present in or around camp sites B, and no spas or other recreational waters were attended by the cases. The only exposures at risk identified among cases in camp site B were showers taken in the sanitary buildings. Cases and non-cases had taken a similar mean number of showers in camp site B. Two sanitary buildings were available and each person always took showers in the same building. The tourists (five cases and 46 non-cases) who took showers in one building were 2.9 times (95% CI: 0.36-24) more likely to be ill than tourists who showered elsewhere. The three cases who provided information about the time of showers had taken showers in the morning.

Between 25 May and 4 July about 405 people registered in camp site B, 192 of whom were Spanish (47%), residing in five different regions. Neither regional health authorities nor the European surveillance scheme for travel associated legionnaires' disease reported other cases associated with camp sites A, B, C, and D.

Environmental investigations

In camp site B, water is taken from a well to a 800 m3 tank where it is chlorinated before distribution. Residual chlorine concentration is recorded daily on a logbook. Two electric boilers (2 m3 each) provide warm water to the whole camp site. Samples were taken at different points of the distribution system but not from the boilers. L. pneumophila sg1 was found in six out of 16 samples taken at taps and shower heads in both sanitary buildings; the concentration was not reported.

In camp site C, water samples were taken from the two sanitary buildings used by both groups and included swabbing of the shower heads. All samples were negative.

Control measures

A hyperchloration of the water system was performed in camp site B on 4 July. The existing procedure of chlorination was not modified and water samples taken thereafter were negative for legionella.

Discussion

Travel is increasingly recognised as a common risk factor for legionnaires' disease. Fifty-six per cent of cases reported in England in 1995 were associated with travel, particularly travel abroad (1). One hundred and seventy-two travel associated cases were reported to EWGLI in 1995 (2).

Climate, type of accommodation, and standards for disinfecting and maintenance of water and air conditioning systems can influence the incidence of legionnaires' disease in tourists travelling to a specific country. Surveillance of legionnaires' disease differs among European countries and reported information on exposures to risk are difficult to compare.

The sensitivity of the notification system for legionnaires' disease has been estimated to be 9% in France (unpublished data) and small travel-related outbreaks in which cases are diagnosed in different places can easily go undetected. The proportion of diagnosed/incident cases can vary markedly according to the laboratory techniques used in each country (3). Urinary antigen detection, which accounts for 21% of diagnoses in countries that participate in EWGLI (2), was used in France for the first time during this outbreak. Only one case out of five tested was positive, a lower than expected sensitivity possibly due to very early testing in two cases.

Far fewer travel related outbreaks have been reported in association with camp sites than with hotels. One outbreak associated with a camp site was reported in France in 1989, in which hot water showers were heavily contaminated with L. pneumophila (4). The only common exposure identified in the present outbreak was the hot water used for showers in the camp sites. The three cases who provided information took showers in the morning and the concentration of legionella in hot water can be enhanced after stagnation overnight.

The dates of onset of symptoms are compatible with the hypothesis of a common exposure in camp site B, even though the incubation period is slightly longer than the 5 to 6 days usually reported.

The presence of L. pneumophila sg1 in the hot water in showers of camp site B supported the epidemiological findings, although no clinical isolate was available for comparison with the environmental strains. Water samples analysed in camp site C were negative and no investigation was carried out in camp site D where only cases 2 to 6 had stayed.

The fact that no other cases associated with the four camp sites were reported in Spain or through EWGLI may reflect underdiagnosis and/or a low sensitivity of the Spanish and the European surveillance systems.

According to European legislation (5), tour operators may under some circumstances be considered responsible for preventable health hazards of their clients and the issue of legionnaires' disease is becoming sensitive. Informed of the present outbreak, the tour operator removed camp site B from the tour of a third group scheduled in August 1996.

To improve prevention and control of legionnaires' disease outbreaks and avoid unnecessary economic consequences:

- rapid diagnostic techniques should be available, to allow diagnoses to be confirmed quickly;

- a more structured coordination between reference laboratories and public health institutions would ensure thorough outbreak investigation and improve the identification of specific exposures to risk during travel;

- standard recommendations to prevent multiplication of legionella in water could be made available to hotels, camp sites, and other facilities open to the public, and their implementation verified if two or more cases were associated with a single facility.





Euro Surveillance

Surveillance report Vol 2 / No 6 (June 1997)

Travel associated legionellosis among European tourists in Spain

Introduction

Travel associated Legionnaire`s Disease has caused concern among European countries since the second half of the 1980s because of the morbidity among citizens of the European Union and because of the threat posed to the economies of the Mediterranean countries by the occurrence of the disease among tourists. As a result, the European Working Group for Legionella Infections (EWGLI ) (1) was set up in 1986 coordinated by the National Bacteriology Laboratory in Stockholm until 1993 when this role was transferred to the Public Health Laboratory Service Communicable Disease Surveillance Centre in London. Case reports are sent from patients' countries of residence to countries they have visited.

EWGLI has developed a surveillance scheme based on a computer software program, the European Legionellosis Surveillance Scheme (ELSS). Monthly updates are sent to all collaborators of all available data from throughout Europe since 1987 (2). The aim of this study was to analyse data covering cases of legionellosis associated with travel to Spain, including the Balearic and Canary islands.

Method

An Epi Info analysis was run on the ELSS program database, updated as of 31 December 1995. The numbers of travellers who had arrived from other European countries and stayed in tourist accommodation in Spain were obtained from the Spanish National Statistics Office (INE) (3,4) and used as denominators to calculate rates.

The ELSS program contains two interrelated databases: each record on one database consists of a single accommodation address for a given patient during the incubation period, so that for any one case there are as many records as there are accommodation addresses during a specific trip; the second database contains information about individual patients, with one record per case. These two databases can be linked and cross-referenced using a case-ID field. For the purposes of analysis, Dbase III Plus and Epi Info 6.01 software packages were used. Since all cases reported in Europe are pooled in the same databases, the first task was to separate patients who had travelled to Spain from those who had been to other European destinations. The second step was to code regions (using the designated Spanish Autonomous Region codes) and accommodation addresses.

Hotels and holiday apartments in Spain have a similar structure and management and so we studied both together.

The duration of stay in Spain was calculated for all patients, as were the periods between arrival in Spain and the onset of symptoms and between return to country of permanent residence and the onset of symptoms. These periods were calculated for all hotel stays in the case of travellers who had stayed in more than one hotel.

The incubation period for legionellosis was taken as two to 10 days (5). The disease was said to be confirmed if any legionella was cultured or if a fourfold rise in the titre of antibodies against Legionella pneumophila sg1 titre was observed. A presumptive diagnosis of L. pneumophila sg1 infection was made if the case was diagnosed on the basis of a single high antibody titre or if another method was used, that is the word “other” appeared in the report of the case. Infections with all other Legionella species or serotypes were regarded as presumptive unless diagnosed by culture.

The criterion chosen in this study to define case-clustering in any one hotel was the appearance of more than one case in the same calendar year or the appearance of a single case in two or more successive years.

Results

A total of 281 cases were reported from 1987 to 1995. In 1995 two duplicate cases (repetition of case ID codes) were eliminated. Men accounted for 69% of cases overall, 54% of whom were aged 45 to 64 years. Women accounted for 29% of cases, 46% of whom were aged 45 to 64 years, the most numerous group (table 1). The sex of 2% of cases was unknown.

Table 1:
Legionellosis among European tourists in Spain, 1987-1995. Distribution by age and sex.

AGE GROUP MALE FEMALE UNKNOWN

TOTAL NUMBER %

0-24 0 3 0 3 (1)
25-44 29 16 0 45 (16)
45-64 104 37 1 142 (51)
> 64 58 24 0 82 (29)
UNKNOWN 3 1 5 9 (3)
TOTAL 194 (69) 81 (29) 6 (2) 281 (100)


The largest number of cases (53) was reported in 1990 .The average of 40 cases were reported each year from 1989 to 1995. Only six cases had been registered before 1989.

The diagnosis of 154 cases (55%) was confirmed by culture or fourfold rise in antibody titre and presumed in 121 cases (43%). The method of diagnosis was unknown in 6 cases (2.1%).

When reported, 21 cases were ill (7%), 123 (44%) had recovered, 28 (10%) had died, and no data were available on the health status of the remaining 109 (39%).

Date of onset of symptoms was known for 265 (94%) cases. Length of stay in Spain was unknown in 60 cases (21%) and less than three days in three cases (figure 2). In 66 cases (23%), analysis of the dates of symptom onset and dates of stay in Spain failed to show whether the patient had been in Spain during the incubation period of the disease. Data on a further 10 yielded periods of time incompatible with having acquired infection in Spain: five having become ill too soon after arrival in Spain and five too long after returning home or reaching another destination.

The 281 cases had stayed at a total of 303 hotels. Two hundred and eight (69%) such stays occurred within the likely incubation periods, 20 stays occurred outside the incubation period and the dates of 75 (25%) were unknown . Nineteen cases had stayed at a total of 62 hotels, yet data on the tourist stays during the disease incubation period were available from only 21 of these establishments.

Two hundred and fifty-nine of the 281 reported cases had stayed at hotels. Of these, 240 had been at only one hotel, 19 at more than one (from two to five hotels; 62 in all), and 10 in more than one Autonomous Region. Six stayed in private homes, one in a caravan, and details of accommodation remained unknown for 15 patients.

In all, 186 hotels, 32 of which are classified as apartments on the EWGLI database, were associated with cases and 49 of these hotels were associated with between two and nine cases during the study period. Forty-three of the 49 hotels met the definition of single hotel case clustering in 12 of which all the cases occurred in the same year. When stays during the incubation period were analysed, however, only 38 hotels met the compatibility criteria (78% of all those associated with more than one case) and within this group, case clustering was considered to have occurred in 34 (table 2).

Table 2:
Legionellosis among European tourists in Spain, 1987-1995. Associated hotels broken down by Autonomous Region.

Autonomous Region Cases Hotels Associated with more
than one case
Clustering criteria
met (1)
Balearie Isles 103 60 19 17
Catalonia 55 33 9 9
Valencian region 39 26 9 6
Canary Islands 33 27 4 3
Andalousie 34 32 6 6
Rest os Spain 4 9 2 2
Other (2) 10 - - -
Unknown 3 - - -
TOTAL 281 186 49 43

Visited more than one region, without it being possible to ascertain in which infection took place.

From 1989 to 1995, the highest mean annual incidence occurred in the Valencian Region (0.85 cases per 100 000 European tourists) and the lowest in Andalusia (0.31 per 100 000). Rates varied considerably from year to year owing to the small number of cases. The only region with a stable incidence was the Balearic Isles (0.50/100 000; 95% confidence interval (CI) 0.03-1.12), from which 101 cases were reported, a little over a third of the overall total

Distribution of cases by country of residence showed that Swedish tourists had the highest rate of illness (mean annual rate of 2.52 cases/100 000 European tourists) and Germans had the lowest (0.06/100 000). As with regional case distribution, rates by country of origin proved unstable from year to year, and statistical significance was observed only for British cases, with 184 diagnosed cases from 1989 to 1995 (70% of the total) and a rate of 1.12/100 000 (95% CI 0.33-2.10). Both rates were calculated for years 1989-95, given that until 1989, only 6 cases had been reported.

Discussion

Cases of legionellosis among European visitors to Spain show a similar age and sex distribution as reported elsewhere .

The differences in rates of legionellosis between travellers from different European countries to the same region is remarkable , and suggests the existence of an information bias, due to differences in national surveillance systems or degrees of participation in the European system. We were unable to adjust rates we calculated for country of residence for lack of appropriate denominators distributed by age and sex.

The crude rates showed that tourists visiting the Balearic Isles and the Valencian Region were the most greatly affected. As above, adjusted rates could not be calculated .

The high proportion of hotels associated with more than one case plus the appearance in many such establishments of patients in successive years suggested that their control measures are inadequate.

Recommendations

The results obtained highlight the need for EWGLI to adopt stricter case reporting criteria, especially with regard to the dates when cases stayed at particular places of accommodation, and dates of onset of symptoms, and the compatibility of those dates with the incubation period of legionellosis. Countries where the disease is diagnosed need to investigate risk factors more thoroughly and forward detailed information to the countries in which cases have travelled. Countries associated with the appearance of cases should monitor the maintenance of control measures over time, particularly in hotels repeatedly associated with cases. ELSS program records should be updated continually, by filing epidemiological and environmental data of interest. We would argue that all accommodation shown by subsequent investigation to be irrelevant to the development of the disease should be deleted from the registry. Similarly, if a patient has stayed at several establishments and environmental studies enable the case to be linked with just one of these, the establishments no longer under suspicion should be removed from the register.

THIS REPORT HAS BEEN CUT BECAUSE OF ITS SIZE.


EWGLI comment Vol 2 / No 6 (June 1997)

Travel associated legionellosis among European tourists in Spain - a comment from the EWGLI coordinating centre

C A Joseph, PHLS Communicable Disease Surveillance Centre, London, England.

This interesting paper has analysed the data on cases of legionellosis associated with travel to Spain and highlighted some issues which are relevant to the European Working Group for Legionella Infections (EWGLI) surveillance system, eg the reporting of cases with missing information, particularly in the early years when the scheme first started and the difficulty of interpreting data when information is incomplete. EWGLI's software is currently being rewritten to take account of further developments in the scheme and to include improved methods for analysis. The new software will be distributed to all centres later this year.

The authors argue that the names of hotels should be removed from the database when there is no evidence to link them to a case of legionnaires' disease. This issue has been raised in the past and discussed at length at annual EWGLI meetings. The consensus view of the group has been that such deletion of hotel names would severely limit the scheme's ability to fulfil its objective of detecting hotel outbreaks and clusters. The name and address of any accommodation where a case stayed during the second to tenth day before they became ill should remain on the database indefinitely. The database is dynamic and includes travel histories of all reported cases, not just hotels that have been epidemiologically or environmentally implicated in an episode of legionella infection. For single cases of legionnaires' disease (which make up the majority of cases on the database) it is not recommended that environmental investigations be carried out at the hotel of stay unless the database shows that previous cases have stayed there. The chance of the hotel being the source of infection increases when two or more cases are known to have stayed there during the ten days before becoming ill. Links can be made to hotels where cases have stayed during their incubation period only if they are on the database. Furthermore, pointing out to the country concerned that more than one case has stayed at a particular hotel over a period of time, strengthens the request of the collaborator in that country that the hotel be investigated and its control measures monitored. There are several examples on the database of outbreaks occurring at particular hotels, investigations being carried out and control measures applied, only to be followed by further cases or outbreaks at the same hotel one or two years later. Any subsequent cases are a measure of the success or otherwise of control measures taken by individual hotels in tourist resorts.

The publication of this paper is timely and will encourage debate of these issues when the EWGLI group next meets in June 1997.

SPAIN

1983 Llutxent (Valencia)

Outbreak of Legionnaires disease in Llutxent Spain, in July to August 1983, 35 cases of Legionella pneumonphila serogroup 1, Legionella was found in the shower heads and toilet tanks(in the context of the entry of sand into the drinking water supply). One must emphasize the involvement of the distribution system for drinking water to the population in this first outbreak of Legionnaires disease in an open community.
(Ciscar MA. Enfermedades Infecciosas y Microbiologia Clinica, 1994 12 325-331)

Legionnaires' disease. Report of a case from the epidemic outbreak at Los Castillejos

(Latorre Vilallonga X, Albanell Tortades N, Badia Trilla J, Canut Esteva L, Margalef Mir N Med Clin (Barc) 82 (5): 230 (Feb 11 1984)

Nosocomial pneumonia caused by Legionella pneumophila at Sagunto Hospital. Epidemiology and preventive measures

Uriel Latorre B, Pinazo Murria M, Vila Pastor B, Redon Masa J, Quesada Fernandez de la Puente E, Perez Martin MV, Garcia de Lomas JRev Sanid Hig Publica (Madr) 62 (5-8): 1459-1468 (May 1988) Rev Sanid Hig Publica (Madr) 62 (5-8): 1459-1468 (May 1988)


1987 Spain

Four cases of legionellosis reported in children aged from 10 days to 7 years, in whom Legionella pneumophila serogroup 6 was isolated, all cases were sporadic occurring during a two year period. All the patients where immunologically depressed and three died. (Ferrer, Enfermedades Infecciosas y Microbiologia Clinicsa, 1990 8 278-281)

1987 Spain

An outbreak of Legionnaires disease among Dutch tourists in Spain.
(Lowenberg A . Netherlands J Medicine , 1988 Jun 270-277)


1988 Barcelona.

The investigation of an outbreak of legionellosis in Barcelona in February 1988. The tempatures were unusally high, with a low humidity,It cannot be ruled out, that the source of the outbreak was the removal of demolition materials in the affected area on the days preceding th epidemic outbreak.
(Cayla, Medicina Clinica, 1989 )


1989 Barcelona

In February and March 1989 an outbreak of Legionnaires disease developed involving 56 patients (48 males 8 females) all cases were Legionella pneumonphila serogroup 1, 7 patients died., cause of outbreak unknow.
A causative focus was not detected, it cannot be ruled out, however that the source of the outbreak was the removal of demolition materials in the affected area on the days preceding the epidemic outbreak.
(Monforte Meed Clin (Barc) , 1989 93 521-525)


1991 Barcelona

Barcelona Outbreak of Legionnaires disease at the Universitary Hospital Germans Trais I Pujol, Legionella pneumophila serogroup 1 and 9 was found in the domestic hot water and heating systems, and Legionella micdadei in the cooling water system.
(Pedro-Botet Montoya ML, Meed Clin (Barc), 1992 Dec 12 761-765)


AN INTERNATIONAL INVESTIGATION OF AN OUTBREAK OF LEGIONNAIRES-DISEASE AMONG UK AND FRENCH TOURISTS

JOSEPH-C, MORGAN-D, BIRTLES-R, et al.

Five cases of legionnaires disease and one death were associated with four members of a tour group from the United Kingdom (UK) and one French tourist who all visited Spain in the spring of 1993.
The UK group stayed at four hotels, one of which was also used by the French tourist, Phenotypic and genotypic comparison of isolates of Legionella pneumophila obtained from one of the UK cases and the French patient demonstrated that they were indistinguishable from each other and from environmental isolates obtained from the water supply of the hotel at which all five cases had stayed, A cohort study of the UK tour group was carried out to determine the extent of the outbreak and showed that three further members of the group had respiratory illness but were serologically negative to legionella infection. International participation in this investigation has highlighted the value of a European surveillance scheme and the benefit of microbiological collaboration between legionella reference laboratories in Europe.

EUROPEAN JOURNAL OF EPIDEMIOLOGY Vol. 12 No. 3, JUN 1996 p. 215-219


1991 Zaragoza

An outbreak of Legionnaires disease occurred in Zaragoza (Spain) in a private aartment building, three cases admitted to hospital , six cases in all, one patients shower contained Legionella pneumophila. The probable source of the infection was the potable water, (Aldea, Enferm infecc Microbiol Clin, 1992 Aug-Sep 403-408)


1994
L'Espluga de Francoli, Tarragona.

Description and study of the etiology of a community outbreak of a typical pneumonia in L'Espluga de Francoli, Tarragona.

Medicos titulares de L'Espluga de Francoli.

A community outbreak of atypical pneumonia occurred in summer 1994 in L'Espluga de Francoli, Tarragona, Spain, affecting 20 people.
PATIENTS AND METHODS: The clinical and epidemiologic description of the outbreak are performed, as well as the sanitary actions leading to the discovery of the original focus (an hotel refrigerating tower). Through case-control studies (among the 17 in-home contagions according to their nearness) and using the causality criteria of Evans and Bradford-Hill. RESULTS: Although the symptomatical description brings forth new symptoms such as hyperglycemia or livedo reticularis, the comparative clinical-therapeutical study bears no significant differences with other series, and the radiological data as well as the response to the treatment are wholly overlapping, with results less coincident in those coming from the lab, very specially due to the small sensibility the indirect immuno-fluorescence showed. CONCLUSIONS: The epidemiologic study demonstrates the etiology of the outbreak (Legionella), their source in the refrigerating tower, in so much sterilization coincided with the end of the epidemy.
Ramon Duch F, Ruiz de Porras L, Elizalde G, Abella M
Med Clin (Barc) 1997 Apr 5;108(13):490-494


1994 Benidorm

Alicante Outbreak of Legionnaires disease occured among a group of tourists between the ages of 65 to 80. It was not possible to link an individual Legionella pneumophila strain to the occurrence of this outbreak.
(Ledesma E. Canadian J Microbiol, 1995 41 Sep 846-848)


1996 Canary Islands ??

Reports have been made that two cases of the disease have been reported from Gran Canaria , the two cases of the disease had stayed in the same accommodation during March and April of this year. (1996)


May 3, 1996

LEGIONELLOSIS, POSSIBLE - CANARY ISLANDS

Reports of an outbreak of Legionella [sp.] from an apartment block in Gran Canaria [the largest island in this cluster of islands, which belong to Spain, are situated off the west coast of North Africa, and which are a tourist destination for many Europeans]. Apparently there have been three `confirmed' [serologic diagnosis] cases.

Apparently the `bug' has been confirmed in the water supply and [the authorities] have drained the system and tried hyperchlorination at this stage.?


June 1996

A HOTEL apartment block on the island of Minorca was inspected by health experts yesterday after three Britons who stayed there developed Legionnaires' Disease.

Teams scoured the Anabel complex at Cala Galdana on the south coast after being alerted by health authorities in Britain.

Thomson Holidays has moved up to 400 clients "as a precaution".

The director of public health for the Balearics, said: "We should have the results of tests in a week. If they are positive, we can eradicate the problem."


RUSSIA BLAME U.S. FOR SPANISH EPIDEMIC

May 1981
MOSCOW

The news agency Tass reported yesterday that a viral epidemic in Spain had spread from a U.S. military base near Madrid, where it said germ weapons may be stockpiled.

Tass said the outbreak was similar to that of the Legionnaires' disease outbreak in Philadelphia in 1976. Spanish health authorities have reported the deaths of 18 people and the hospitalization of 1,500 from an unidentified type of pneumonia that appeared a month ago at Torrejon de Ardoz, near Madrid, and spread to other parts of the country.

A U.S. Air Force base is situated at Torrejon, but Spanish sources said not a single case of the disease had been reported at the installation.
The news agency said a "similar outbreak" of the virus in 1976 killed more than 28 people in Philadelphia near a U.S. base.
That was an apparent reference to the Legionnaires' disease, the mysterious virus that struck delegates to an American Legion convention at the Bellevue Stratford hotel that summer.. 28 died and 182 were hospitalized in the epidemic.

The new agency said that several hundred cases of this disease have been diagnosed in the United States since it was first reported, and now the epidemic has spread to the European continent.

Western observers in Moscow speculated that the news agency report reflected continuing Soviet anger about U.S. government claims that a 1979 outbreak of anthrax in the Soviet Union may have been the result of a bacteriological warfare accident. Anthrax is an infectious disease of wild and domesticated animals, especially cattle and sheep, that can be transmitted to man. The State Department said in March 1980 that there was strong evidence of an anthrax epidemic a year earlier in Sverdlovsk, an important industrial and scientific center 1,000 miles east of Moscow, with a great number of fatalities.

THE REPORT OF THE OUTBREAK AT ALCALA DE HENARES TRANSLATED TO ENGLISH FROM SPANISH


Email Denis   legion@q-net.net.au



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