Brazil
1989 San Paulo

From June 1989 to March 1990 there was eight cases of Legionnaires disease caused by Legionella pneumophila serogroup 1, Legionella anisa was cultured from tap water. This is believed to be the first reported outbreak of Legionnaires disease outbreak in Latin America.
(Levin AS, J Hospital Infection, 1991 18 243-248)

BRAZIL. SAN PAULO

Electric showers as a control measure for Legionella spp. in a renal transplant unit in Sao Paulo, Brazil. Legionellosis Study Team.

Hospital Infection Control Group, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil.

After an outbreak of legionnaires' disease Legionella pneumophila serogroup 1 in a renal transplant unit in Sao Paulo, Brazil, periodic hyperchlorination and flushing of pipes were instituted as control measures. These were only partially effective as every two to five months water cultures turned positive or new cases of the disease occurred. In November 1993 the hot water was disconnected from the unit and small, plastic electric showers were installed in each bathroom. Over a period of 12 months water from showers and taps was cultured for Legionella spp. every two weeks. On only one occasion was a water culture positive for L. pneumophila from a sink tap. No water sample obtained from showers was positive during the study period. No cases of legionnaires' disease occurred. We considered the use of electric showers an inexpensive and effective method of controlling the problem of Legionella spp. in the water system of our renal transplant unit.
(Levin AS, Gobara S, Scarpitta CM, Warschauer CL, Sinto SI, Rodrigues E, Mendes CM, Sabbaga E, Boulos M ,J Hosp Infect 30 (2): 133-137 (Jun 1995)

Legionnaire`s Disease outbreak in a haemodialysis unit

(Bernat A Nephrol Dial Transplant 9 (2) 217-218 1994)

1984 Sofia Bulgaria

Two cases of legionella pneumonia in Greek citizens at the institute for treatment of foreigners-Medical Academy, Sofia, The patients mentioned are with grave basic diseases, In one of them pneumonia was with a lethal end.
(Kadiian K, Vutreshni Bolesti, 1985 24 114-118)

CANARY ISLANDS

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.?

CANADA

1979 Ontario

Eight patients with Legionnaires disease were seen at one hospital in the summer of 1979 over a 12 day period, Seven patients responded to treatment, though one died suddenly, of unrelated cardiac disease, the other patient died of a combination of renal and respiratory failure.
(Cheung MT, Canadian Medical Association Journal, 1980 123 639-644)

1981 WINDSOR ONTARIO

From 15 to 21 August 1981, Pontiac fever affected 317 automobile assembly plant workers. The etiologic agent apparently was a new Legionella species; The name Legionella feeleii was proposed. This is the first outbreak of nonpneumonic legionellosis in which the etiologic agent was not Legionella pneumophila serogroup 1
(Herwaldt LA, Annals of Internal Medicine 1984 100 333-338)

August 1981 WINDSOR,

Ontario Medical officials have determined that the strange disease suffered by at least 260 employees at a Ford Motor Co. engine plant Two weeks ago was caused by a mild strain of Legionnaires Disease bacteria. Doctors said the illness resembled the so-called "Pontiac Fever" that hit about 100 Oakland County, Mich., Health Department workers in 1968. Most Ford-Windsor workers were able to return to work late last week but blood tests are being taken from the plant's 1,200 employees for further investigation and monitoring of the illness. The illness broke out the night of Aug. 17, A physician with the United Auto Workers' union health and safety unit. Employees stricken by the disease suffered chills, fevers ranging to 104degrees, muscle aches and joint pains, Ford officials agreed to drain and steam clean the assembly systems where two strains of the Legionnaires Disease bacteria were identified.

1985 Quebec

Five cases of Legionnaires disease caused by Legionella dumoffii were identfied within an 11 month period in a hospital in Quebec City, All the patients had been admitted to hospital within a 10 days before diagnosis, two patients were children, All the patients had been exposed to distilled water, four though resiratory theraphy equipment and one through a room humidifier. This is the first reported outbreak of Legionnaires disease caused by legionella dumoffii, and is the first time that nosocomail legionellosis has been linked to contaminated distilled water in Canada.
(Joly JR. Canadian Medical Association Journal , 1986 135 1274-1277)

1988 Canada ?

An outbreak of Legionellosis in an old hospital possessing no overall airconditioning system, merely a combination of window airconditioning (RAC) and one dedicated unit supplying the intensive care unit. Decontamination of the hot water system was arranged, no further bacteria was found.
(Matin RS. Canadian J Public Health, 1988 79 440-442)

1989 Canada

An outbreak of Legionella pneumophila occurred in 6 of 49 new renal transplant patients over thirteen months. Legionella pneumophila was cultured from the recovery room sink outside the operating room were the transplants were done.
(Le Saux NM, Canadian Medical Association Journal, 1989 140 1047-1053)

CHINA

1987 Beijing A case report of Legionnaires disease in the Beijing district.
(Lu WX. Chung Hua Nei Ko Chih , 1987 10 571-573, 621)

1988 Tangsham
Outbreak of Legionella pneumonphila in students at a college in Tangshan
(Lui XR, Chung-Hua Lui Hsing Ping Hsueh Tsa Chih , 1988 321-323, 384)

1989 Beijing

During the period from December 1989 to January 1990 an outbreak of Legionnaires Disease took place in the workers of a building site in a rural area of Beijing , results showed that the outbreak was caused by Legionella micdadei (Lm) This was the first report on Legionella micdadei in China
(Wan, Chung-Hua Liu Hsing Ping Hsueh Tsa Chih, 1990 11 (5) 272-277)

1990 China

Four elderly cases of legionellosis were reported, the outbreak occurred in July or October.
(Wen B. Chung-Hua Lui Hsing Ping Hsueh Tsa Chih , 12 (3) 150-153)

1994 China

A study on the risk factors of Legionella infection in children. The non-conditional analysis showed that age, passive smoking and touching soil were associated with legionella infection.
(Wang SP. Chung-Hua Lui Hsing Ping Hsueh Tsa Chih, 1995 16 88-91)

GREECE

Legionnaires disease usually presents as an atypical pneumomia. Legionniares disease single cases and epidemics occur mainly among people who have stayed in Hotels and Hospitals, They are usually due to aersol infection from poorly maintained cooling towers or from potable water used in showers, Legionnaires disease has been diagnosed in local people and touurists who have been infected during their visit to GREECE, Some of the visitors have been diagnosed in their countries and often the disease has been fatal, Cases of epidemics of Legionaries disease attract the attention of the media with a negative effect on the tourist industry, During the past five years ,the Athens Reference Centre for Legionnaires disease has conducted a six monthly regular control on central buildings in Athens. This investigation has been carried out as part of the action that should be taken in order to prevent an outbreak in this city. From a total of 357 samples, 12 were positive for Legionella
(Mavridou A, Acta Microbiologica Hellenica 1995 40 (4) 322-327)

CRETE

1988 Crete

Legionella pneumophila infection in hotel Aktizeus in Heraklion on Crete.
(Bijkerk H , Ned Tijdschr Geneeskd , 1989 133 Jan 28 182-183)

DENMARK

1978 Denmark

During a period july 1978 to January 1982 728 patients suspected of suffering from Legionella infection were tested for Legionella antibodies, Legionela infection was confirmed in 78 patients with pneumonia, there was 11 fatal cases among the 78 patients, 32 had contacted the disease abroad, All cases except the seven first cases among the tourists from Garda Italy were sporadic.
(Lind K, Acta Pathologica Microbiologica Et Immunologica, 1983 91 209-213)

1983
ITALY

A small epidemic focus of pulmonitis caused by Legionella
A mini-epidemic consisting of 5 cases of Legionnaire's disease treated during september 1983 is reported. These patients shared many of the symptoms distinguishing the most common form of this disease in its severe or very severe form and some characteristic features of this case series are emphasised. It was impossible to trace the source of the outbreak, in spite of the fact that the mini-epidemic took place in an open situation. It is underlined that diagnosis is mainly clinical. The Legionella pneumophila bacteria should always be considered as one of the causal agents of bronchopneumonia, particularly when the following conditions are fulfilled: a) the disease takes the form of a confined, out-of-season, mini-epidemic; b) it is accompanied by multisystemic symptomatology and/or much greater involvement of general conditions that is usually to be expected in normal cases of bronchopneumonia. Since the disease is often fatal, erythromycin or rifampicin treatment should be started upon the slightest suspicion of contagion.
(Morini A; Pelliccia G; Mauceri P; Alessandri L; Martufi T; Gusteri F; Grandi M; Clementi M; Maffei C Source Minerva Med, 1985 Nov 3, 76:42, 2019-27 )

1979
DENMARK

At a Hospital in Denmark 15 cases of leulaemic and four cases of legionnaires disease have been diagnosed, 3 patients had both diseases.
(Berlin G, Scandinavian J of Haematology, 1980 25 171-174)

1980
DENMARK

Three cases of imported Legionnaires disease, Three patients became ill after their return to Denmark from a holiday in northern Italy. The fact that the onset of illness was within 10 days of the last day the patients spent in Italy strongly suggests that the disease was imported to Denmark from Italy.
(Jrgensen KA, Scandinavain J of Infectious Diseases, 1981 13 133-136)

1993 Odense
DENMARK

During the autumn and winter of 1993-94 four cases of legionellosis were diagnosed in a Department of Nephrology. Three of the patients were kidney transplant patients, two of the three died. Legionella pneumophila was initially found in the cold and hot shower water, in ice-water from the ice machine,. It was concluded that at least one of the four patients was likely to have been infected from the water in the Department, either by inhalation of contaminated aerosols from the shower or by aspiration of the contaminated ice-water.
(Gahrn-Hansen B, Ugeskr Laeger, 1995 157 590-594)

1994
Nosocomial legionellosis in three heart-lung transplant patients:

Organ transplant recipients are at high risk of contracting Legionnaires' disease in a hospital environment contaminated with legionellae. This study describes the first cases of culture-verified Legionella infections with an established link to potable hospital water in Denmark; three patients operated on at the Cardiopulmonary Transplant Unit, Rigshospitalet, Copenhagen, became infected with legionellae. Environmental and clinical isolates of Legionella pneumophila serogroups 1 and 6 were investigated by restriction enzyme analysis and ribotyping. An ice machine located in the kitchen of the intensive care unit was implicated as a source of infection in two of the three cases.
(Bangsborg JM; Uldum S; Jensen JS; Bruun BG Address Department of Clinical Microbiology, Statens Seruminstitut, Artillerivej, Copenhagen S, Denmark. Eur J Clin Microbiol Infect Dis, 1995 Feb, 14:2, 99-104)

FRANCE
Legionnaires disease : 3 cases from the northern suburbs of Paris
1980

During the summer of 1980 3 sporadic cases of Legionnaires disease were recognized in Paris, Two patients died. Two of the three cases were among seventeen acute febrile pneumonia admitted to the Hospital Avicenne between 1st July and 1st October 1980.
(Valeyre D, Revue Francaise De Maladies Respiratoires, 1981 )

1981 Paris

During a five week period in 1981, six cases of legionellosis due to Legionella pneumophila serogroup 1 were recognized in a hospital. The entire hot water system was contaminated with Legionella pneumophila serogroup 1, although serogroup 1 was isolated from the cooling tower and its drift, this was not the cause of the outbreak.
(Neil Marguerite A , The American Journal of Medicine, 1985 78 581-588)

1982 France

Forty-seven nosocomial cases of legionellosis due to Legionella pneumophila serogroup 1 were diagnosed in one major outbreak from November 1982 to March 1983 in a 960-bed teaching hospital. Contaminated water was considered to be a possible source of infection.
(Guiguet M. International Journal of Epidemiology, 1987 16 466-467)

1989 Paris

an outbreak of Legionnaires disease at Necker (four cases) and Pitie (six case) were unrelated to each other, the outbreak at Necker was linked to contaminated tap water.
(Tram C. J Clinical Microbiology , 1990 242-245)

1986 Paris

During an outbreak of Legionnaires disease, 20 critically ill patients were admitted to the intensive care unit of Hosital Bichat , Paris. 12 patients died. source of outbreak ?
(Chastre J, CHEST, 1987 91 57-62)

FINLAND

1994 Finland .The occurrence of legionella in hot water systems of 67 buildings located in different parts of Finland was studied. Legionella pneumophila was isolated from 30% of the systems. The highest concentration of legionella was found in the shower water.
(Zacheus OM . Canadain J Microbiol, 1994 40 993-999)s

GERMANY

1980 Munich (Lode H, Dtsch Meed Wochenschr. 1982 107 326-331)

1982 Berlin

Legionella pneumophila serogroup 1 was isolated from one sample of water from a shower head in a bathroom of a hotel after an outbreak of legionella among a group of visitors who stayed in a hotel.
(Sethi KK, Zentralblatt Fur Bakteriologie Mikrobiologie, 1983 177 402-405)

1988 Frankfurt

The Frankfurt City Health Department examined the hot water systems of all public indoor swimming pools, old age homes and hospitals, in the six public indoor pools the percentage of positive legionella findings have dropped since 1988. Since the same period samples have been taken from the showers of old age homes, thus the favourable effect of corrective measures that has been demonstrated have increased the negative results for legionella. However, there was one patient with a definite legionella pneumonia in the home, this patient usually had been showering for at least 20 minutes a day. Legionella were found in 16 out of 17 hospitals in Frankfurt in 1991, more than half of the 204 samples were legionella positive, 5% of the samples had legionella contamination levels of more than 100,000 per litre.
(Kalker U , Gesundheitswesen 1992 54 579-604)

1990 Lubeck

In an outbreak in a care unit in Lubeck three Legionella pneumophila isolates and three other Legionela pneumophila strains indepentently isolated from tap water located in the care unit where the patients were hospitalized. Therefore, it is concluded that these environmental specimens were the source of the Legionnaires disease.
(Ott M, Journal Clinical Microbiology 1991 29 813-815)

1985 Innsbruck

From 1985 until 1993 14 cases of legionella puemonia were diagnosed in the surgical transplantation unit on Innsbruck University Hospital, All isolates from the patients and from the building hot water system were found to be contaminated with Legionella pneumophila serogroup 1, They were indistinguishable from each other by monoclonal antibody subtype and restriction fragment lengtsh polmorphism pattern, This indicaited a series of infections originating from the same source during a period of eight years.

1991 Germany

In a three month period at a rehabilitation centre a total of 10 cases of pneumonias with 3 deaths occurred. The warm water system was proved to be the source of the infection by isolating Legionella pneumophila serogroup 1 ,subtype Pontiac both in the warm-water and patient samples.
(Kramer M, Hygiene-Hgy Umweltmed 1992 193 262-271)

1993 Germany

A 64 year old man died from a travel-associated legionella pneumonia six weeks after the onset of the disease. A shower nozzel, contaminated with legionellae, in a German hotel room was traced to the source of the infection. The concentration of legionellae in the shower water was 15,000 per ml.
(Muhlenberg W, Gesundheitswesen, 1993 55 653-656)

GERMANY 1992?

Nosocomial outbreak of legionellosis in a rehabilitation center.
Demonstration of potable water as a source.

Ten patients from a rehabilitation center were admitted to hospital with serious respiratory infections within ten weeks. An outbreak of Legionnaire's disease was suspected based on the epidemic and atypical manifestation of pneumonia and could be proven microbiologically. Pulmonary and extrapulmonary complications included respiratory failure, lung abscess, transitory renal impairment in five patients and acute renal failure requiring dialysis in one, tetraparesis caused by peripheral neuropathy and acute psychosis. Three patients died despite immediate institution of therapy with erythromycin. Legionella pneumophila serogroup 1 subtype Pontiac was isolated from a bronchial lavage sample of one patient and from the water supply of the rehabilitation center. Monoclonal antibody subtyping and restriction endonuclease analysis were performed on both environmental and patient isolates. Potable water was identified as the source of the outbreak based on identical patterns on restriction endonuclease analysis. Despite thermic and chemical disinfection with chlorination (up to 15 ppm) in the rehabilitation clinic, an eleventh case of Legionnaire's disease was detected 11 months later.
(Nechwatal R, Ehret W, Klatte OJ, Zeissler HJ, Prull A, Lutz H Medizinische Klinik I, Klinikum Bayreuth, Germany. Infection 21 (4): 235-240 (Jul 1993)

Outbreak of legionnaires’ disease among British tourists associated with Rhine cruise

Six cases in British tourists have been linked to a single ship that was used exclusively by one British tour company for cruises on the Rhine. The first case occurred in July, the second in August, two cases became ill in September, and two in October. Four cases are men, two women (age range 72 to 78 years). None has died. One case with onset of illness in October was admitted to hospital in Germany.

The season for this particular cruise has now ended. The last cruise sailed from 24 September to 8 October with 85 passengers on board. The tour operator has contacted passengers to inform them of the outbreak and advise them to seek medical advice if they develop a respiratory illness.

The ship is Dutch owned and is being investigated by Dutch health authorities. There are no reports of illness among members of the crew. The European Working Group on Legionella (EWGLI) collaborators in Germany and the Netherlands are working closely with EWGLI’s coordinators in London to measure the extent of the outbreak and identify the source of infection. 1997

Date: Wed, 27 May 1998

The European Surveillance Scheme for Travel Associated Legionnaires' Disease, established in 1987 and coordinated by the Public Health Laboratory Service Communicable Disease Surveillance Centre in London, reports on cases of travel associated legionnaires' disease to member states and suspected countries of infection. The scheme has the following data on cases reported as traveling to India: 1990: 1, 1995: 3, 1996: 5, 1997: 2 cases. All cases were males, aged 44 - 65, 7 confirmed (diagnosis by culture or serology four fold rise in antibody titre), 3 presumptive (diagnosis by serology single high antibody titre and detection of urinary antigen). No deaths have been reported.

One cluster (two or more cases with onset in the same six months, who stayed at the same place of accommodation) was reported in April 1995 (2 cases) for the Town of Varanasi, and two separate links (two or more cases who stayed at the same place of accommodation but with onset of symptoms more than six months apart) have been recorded each involving 2 cases, in Dehli 1995 and Udaipur 1996.

With regards to the case reported to ProMED-mail, we have had one case in 1995, with travel to hotels in both Jhodpur and Udaipur. We would appreciate further information on the nationality of the reported case, and where possible, the hotel names in order to check them against the EWGLI database. -- Date: Wed, 20 May 1998

We recently cared for an elderly European man who came to Thailand after extensive travel in India, last [visiting] 5-star hotels in Jodhpur, Udaipur and Bombay.
Two days after arrival, he developed a right middle lobe infiltrate, fever and dry cough with WBC of 30,000. Sputum Gram stains and cultures revealed no clues. He was treated with azithromycin and ceftriaxone and initially improved but later developed ARDS which required ICU care with respirator and PEEP. He recovered after 2 weeks and serologies revealed a 6-fold increase in Legionella_ titers. We looked at Medline and India and found no reports of legionellosis in India. In Thailand, there have been several serologically confirmed cases and the organism has been cultured from air conditioning towers at many sites (J. Med Assoc Thai 1995; 78: 57-70 and 1987; 70: 658-666).

Hotel in Bangladesh 1996

One person reported with Legionnaires Disease from a hotel in Bangladesh in 1996. After returning to Belguim

ITALY

1980 Italy

Outbreak of Legionelosis occurred in successive groups of vacationers at an Adraitic resort in 1980, Illness was associated with two hotels , A study of guests of the suspect hotel revealed 23 cases, two patients died. Legionella pneumophila was isolated from shower heads in the suspect hotel.
(Rosmini F. American J of Epidemiology, 1984 119 124-134)

1986-1990 Island of Ischia

On the Island of Ischia a total of six cases of Legionnaires disease occurred from 1986 to 1990, all six patients had taken thermal baths and stayed at local hotels , and three of them died, these cases were associated with hotels, and the hot water supply was presumed to have transmitted the infection.
(Castellia-Pastoris M , INFECTION, 1992 20 73-77)

1986 Torino

In one year 12 of 48 patients who developed fatal pneumonia folloeing admission to the Hospital Mollinette, Torino, yeilded Legionella pneumophila serogroup 1. Two ward had airconditioning but legionellas was not isolated from these, Legionella pneumophila was detected in the water of oxygen bubble humidifiers and an underwater drain, The devices were filled with tap or distilled water and the hospital water supply was found to be contaminated with Legionella pneumophila serogroup 1.
(Moiraghi A, Journal Hospital Infection 1987 10 47-50)

1987 Rome

Report of five Danish patients affected by Legionnaires disease during the 1987 spring in Rome.
(Spinazzola F , Rivista Europea Per Le Scienze Mediche, 1990 12 185-189)

1990 Italy

The compulsory notification of Legionnaires disease was established in Febraury 1983, and a few months later a National Surveillance Programme started to operate. Up to June 30 1990 542 confirmed cases of legionellosis were reported, The fatality rate was 12.4%, The disease occurred both sporadically and epidemically. In Italy the major risk of infection appears connected with water plumbing systems of hotels, residential houses and hospitals,where oxygen bubble-humidifiers have been found to represent an important source of infection. On the contrary the association of human infection with air-condition systems has not been evidenced up-to-now.
(Castellia-Pastoris M , Ann Ist Super Sanita 1991 27 289-295)

1985 Kitasato

Seven cases of fulminant Legionnaires disease treated at Kitasato University Hospital between 1985 and 1992, All seven patients required mechancal ventilation. Four patients recovered and three died due to respiratory failure.
(Takada N. Nippon Kyobu Shikkan Gakka Zasshi, 1994 32 138-145)

JAPAN 1990
An outbreak of Legionnaires' pneumonia in a nursing home.

An outbreak of Legionnaires' pneumonia occurred at a nursing home in December 1990. A 79-year-old female and a 73-year-old male clerk who were staying at the nursing home developed pneumonia with only a 5-day interval. Legionella pneumophila serogroup I was isolated from transtracheal aspirate of the former and sputum of the latter. After treatment with a combination of erythromycin and rifampicin both patients improved. Serological surveillance of inpatients and staff of the nursing home was performed in February 1991. Seven out of 51 samples (14.0%) showed a titer higher than 1:128 of anti-Legionella pneumophila serogroup I antibody determined by indirect immunofluorescence; two of these seven complained of respiratory symptoms. Molecular epidemiology analyzed by restriction endonuclease digestion of isolated L. pneumophila showed an identical pattern which suggested a common origin.
(Maesaki S, Kohno S, Koga H, Kaku M, Yoshitomi Y, Yamada H, Matsuda H, Higashiyama Y, Hara K, Seto M, et al Intern Med 31 (4): 508-512 (Apr 1992)
Second Department of Internal Medicine, Nagasaki University School of Medicine, Japan).

1994 Shibuya-ku, Tokyo

From August 20 to 22 1994, an outbreak of acute febrile illness occurred in a training centre building of a company in Shibuya-ku, 43 trainees where affected by the outbreak which was caused by Pontiac Fever, the cooling tower that served the third floor was the source.
(Yabuuchi E, Kansenshogaku Zasshi, 69 6 1995 654-655)

NETHERLANDS

1978 Leiden

Between August 1978 and November 1983, 21 cases of Legionella pneumophila occurred in the Leiden University Hospital. A new serogroup of Legionella pneumophila, designated serogroup 10 (prototype strain Leiden) was isolated from 4 patients and serogroups 1 and 10 from the hot water supply to the building.
(Meenhorst PL, Journal of Infectious Diseases 1985 152 356-364)

1992 Netherlands ( Hospital)

21 cases of Legionellosis, 14 were of nosocomial origin and 6 others had a possible nosocomial source, The hot and cold water systems, respiratory therapy equipment, puddles of rain water on flat roofs and in gutters and deminerallized water systems were all excluded as a source, Because of further testing Legionella pneumophila was found in the cooling tower.
(Vincent-Houdek M, Journal Hospital Infection, 1993 25 117-124)

SINGAPORE

1988 Singapore Over a period of seven months 87 samples of water was collected from 48 airconditioning cooling towers on 15 sites in singapore yeilded 19 strains of legionella. Legionella were found in 7 of the fifteen sites. Only 11% of them belonged to the more pathogenic subgroup of Legionella pneumophila serogroup 1.
(Meers PD, Annals of the Academy of Medicine, Singapore. 1989 18 375-378)

PORTUGAL

1994 Santa Cruz.

Sixteen strains of Legionella pneumonphila serogroup 1 isolated from patients and the environment at a Santa Cruz Hospital. Carnaxide, Portugal. Problems concerning the microbiological examination of environmental specimens and correlation with clinical strains confirmed the difficulty of investigating an outbreak source of legionellosis and the need for careful evaluation of the results.
(Marques MT. J ournal Hospital Infect, 1995 June 103-110)

Outbreak of legionnaires’ disease among European tourists associated with Portugal 1997

Five cases have been associated with an apartment hotel in Albufeira, Portugal. The cases, one reported from the Netherlands, two from Scotland, and two from England, became ill in May, July, August (2), and October. Three cases are men, two women (age range from 30 to 67 years). No deaths have been reported.

The EWGLI collaborator and the Ministry of Health in Portugal and the UK Federation of Tour Operators have all been informed. Investigations carried out by local health authorities in Portugal on the hotel’s air conditioning and water systems are reported to be negative for legionella. 1997

NEW ZEALAND

******** In June 1985 six men resident in a long stay villa at a psychiatric hospital near Wellington developed acute respiratory illness within five days of each other, samples from the men were not collected until the convalescence period, it was noted that in each case there was evidence of infection with Legionella pneumophila.
(Chrisp, New Zealand medical J March 1987)

The first recorded outbreak of Legionnaires Disease in New Zealand was in christchurch in 1990, in a new seven storey office building.
(Mitchell, New Zealand Medical J 1991 Volume 104 July No 915)

Three cases of Legionellosis caused by Legionella pneumophia serogroup 6 are reported, and a review of similar cases in New Zealand in 1982, Legionellosis appears to be more common in New Zealand than previously thought, In 1982 50% of reported cases occurred in Wellington.
(McKeage, New Zealand Medical J 1984 97 213-215)

A 59 year old port employee was admitted to Wellington Hospital in 1979, Legionella pheumophilla was demonstrated, This is the first case of Legionella disease reported in New Zealand.
(Holst, New Zealand Medical J 1980 May 339-340)

Fatal legionellosis from gardening
(Kingston, New Zealand Medical J 1994 111 March 23)

An unusal legionellosis case yeilds the first New Zealand isolation of Legionella dumoffi.
(Badham, New Zealand Medical J 1985 March 27 204)

RUSSIA (USSR)

1987 Armavir Russia

In March and Aprril 1987 an outbreak of Legionella infection occurred among 236 workers at a rubber factory in Armavir. Legionella pneumophila serogroup 1 was isolated from the recycling-type water supply system of the factory.
(Pokrovskil SV, Zh Mikrobiol Epidemiol Immunobiol, 1988 (10) 24-27)

1988 Russia

Legionella pneumophila outbreak in a Lithuanain meat-processing factory. Among 191 fever patients examined, in 35 cases antibodies against Legionella pneumophila were detected. In 26 workers legionellosis was diagnosed, and Pontiac fever cases were predominant. The pathogenic antigen was detected in 4 of 32 water sampless taken from the factory water pipes.
(Bunikis IA, Gigiena Truda I Professionalnye Zabolevaniia, 1989 (12) 14-16)

1988 Georgia Russia

Outbreak of Legionella infection at two industrial enterprises during the period of July-August 1988. For the first time in the USSR a new form of the disease has been descibed at the territory of Georgia,This form, named Legionella fever is manifested mainly by skin eruptions.
(Sakvarelidze LA, Zh Mikrobiol Epidemiol Immunobiol, 1 1990 42-45)

1993
SAUDI ARABIA

Four patients were admitted to the medical intensive care unit at King Khalid University Hospital (KKUH) with overwhelming respiratory failure. Extensive investigations revealed serological evidence of Legionella infection. Three patients required intubation and mechanical ventilation. All patients received erythromycin; rifampin was added to two patients. Two patients survived and two patients died. We report, for the first time in Saudi Arabia, four cases of Legionella pneumophila with severe respiratory failure.
(Nabil S. Dahmash, MD; Mohamed Osman Gad-El-Rab, MD; Mohamad S. Al-Hajjaj, FRCP(
Departments of Medicine and Immunology, College of Medicine and King Khalid University Hospital, Riyadh.
Ann Saudi Med 1994;14(3):204-208.)

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)

1991 Zaragoza

An outbreak of Legionnaires disease occurred in Zaragoza (Spain) in a private apartment 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 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)

Alcala de Henares, September 1996 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 legionnaires' disease in Spain

An outbreak ofeommunity 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 Stafforde General Hospital in 1985 (68 cases and 22 deaths) and Broadcasting House, London in 1988 (70 cases and three deaths)

1. OMahony MC, Stanwell-Smith RE, Tillett HE, Harper D, Hutcliinson jGP, Farrell ID, et al. The Stafford outbreak of legionnaires' disease. Epidemiol Infect 1990; 104: 361-80.
2. Bannister B, Brook G, de Angelis D, Evans B, Joseph CA, Watson JM, et al. Quarterly communicable disease review April to June 1993. J Public Health Med 1993; 15: 358-66.

(CDR WEEKLY V6 NUMBER45 8 NOVEMBER 1996)

SOUTH AFRICA

1979 Durban

During January 1979 a strain of Salmonella typhimurium was isolated from a patient at the King Edward Hospital in Durban, In the succeeding 23 months 487 additional patients infected with multiresistant Salmonella typhimurium. Epidemiologic studies suggest that cross infection via the hands of the ward staff was the likely means of propagation of the epidemic
(Robins-Browne RM, The Journal of Infectious Diseases 1983 147 210-215)

1979 Johannesburg South Africa

The first two cases of sporadic Legionniares disease are described.
(Kaplan C, South African Medical Journal. 1980 58 13-17)

1981 Durban South Africa

An isolated case of legionnaires diseas occurred in Durban . Awareness of the fact that this disease does occur here, should result in early recognition and appropriate management of an outbreak.
(Hariparsad D, South African Medical Journal, 1981 59 977-979)

Johannesburg 1985
Legionnaires' disease in a Johannesburg teaching hospital Investigation and control of an outbreak.

During the period 11 November 1985 - 21 February 1986, 12 cases of Legionnaires' disease were identitied at a Johannesburg teaching hospital. Only 2 paticnts definitely acquircd the disease in hospital. Both respondcd well to treatment. An epidcmiological investigation was initiated to determine the source of infection and mode of transmission of thc causative agent (Legionella pneumophila), which may br recovered from a wide variety of water sources. Although L. pneumophila was cultured from the hospital hol-watcr systcm, thcrc was no association between the location of patients and culture-positive water sites. Cascs were clustered in the mcdical and surgical intensive care units. being on a ventilator was a significant risk lactor for acquiring Legionnaires' disease (relative risk 18,4; 95% confidence interval 2,4 - 142,2). The potential role ofvcntilators in the transmission ofthe disease is discussed together with the inlection control me&127;surcs adopled to interrupt the oulbreak. to our knowledge this is the tirst investigation of an outbreak of Legionnaires' disease in South Africa.
(STREBEL P M . SOUTH AFRICAN MEDICAL JOURNAL Citation : 73(6):329-33 )

SWEDEN

1979 Vasteras Sweden From August 27 to September 1979 58 patients fell ill with Legionnaires disease in Vasteras, All patients had been staying in the town some time during 2 weeks preceding their illness, as had 10 Legionnaires disease patients who fell ill from mid June till mid August, one patient died. Legionella pneumophila serogroup 1 was isolated from patients and the cooling tower on the roof of an indoor shopping centre in Vasteras, visited by 57 of the patients.
(Nordstrom K, Scandinavain J of Infectious Diseases, 1983 15 43-45)

1979 Sweden

Since 1976 173 confirmed cases of Legionellosis has been reported in Sweden, Sixty-eight cases belonged to a community outbreak in the summer and fall of 1979, Forty percent of the sporadic cases are travell related. Half of them had visited Mediterranean countries. There is an ongoing outbreak in a renal transplant unit, Legionella pneumophila serogroup 1 3 5 and 6 have been isolated from the patients or the environment ( eg. cooling tower of a shopping mall and tap water). The fatality rate has been low.
(Kallings I, , Zentralblatt Fur Bakteriologie Mikrobiologie 1983 255 71-75)

1986 Sweden

A previously healthy 50 year old greenhouse repairman fell ill with pneumonia, this report is the first probable case of Legionella longbeachae infection in Sweden.
(Eitrem R, Scandinavain J of Infectious Diseases, 1987 19 381-382)

1990 Varnamo Sweden

An outbreak of Legionnaires disease at the general hospital, Varnamo, Sweden from December 1990 to February 1991, 28 patients and 3 staff fell ill with pneumonia, three died. Legionella was isolated from the hot water supply of 17 out of 20 wards
(Darelid J, Scandinavain J of Infectious Diseases, 1994 26 417-425)

1996 MALMO SWEDEN

Reports have come in about an outbreak of Legionnaires disease in July 1996 in the Town of MALMO in the southwest of sweden. The outbreak is reported to be in a nursing home for the aged (No further details available)

SWITZERLAND

1978 Lake Zurich Six cases of Legionnaires disease occurred over 13 months, The disease was severe in all cases, 2 patients died while on artifical respiration, 5 patients were heavy smokers, 3 had probably acquired the infection in France
(Strebel U, Schweizerische Medizinische Wochenschrift J 1980 110 1720-1727)

1978 Berne and Ticino

In 1978 and 1979 eight cases of sporadic Legionella pneumophila were observed in the Berne and Ticino areas of Switzerland, All patients with a protracted course suffered from concomitant symptoms. Where as none of the patients died of legionellosis, two patients died six months later from their underlying disease.
(Mordasini C, Schweizerische Medizinische Wochenschrift J, 1980 Nov 15)

October 27, 1997

French tourists die from Legionnaire's disease:

Two French tourists died and another is in critical condition with Legionnaire's disease contracted during a visit to Turkey, the [French] Health Ministry said on Sunday. A ministry spokesman said the tourists had returned home from Istanbul earlier this month.

1. Latest information on this outbreak Wednesday 29th October 1997

Outbreak of legionnaires' disease among French tourists associated with Turkey

Three outbreaks of travel associated legionnaires’ disease have recently been reported to/detected by the European surveillance scheme for travel associated legionnaires’ disease, EWGLI. Further information on these outbreaks will be published as details are received.

Four confirmed cases and three suspected cases are linked to a hotel in Istanbul. All the cases are from France. They stayed at the hotel during September or October and became ill between 10 September and 17 October. Five of the cases are men and two are women (age range 49 to 77 years). Two cases are reported to have died.

The European Working Group on Legionella Infections (EWGLI) collaborator in Turkey and the Turkish health authorities have been informed of the outbreak. Tour operators in France have also been informed. Environmental investigations are underway. No other cases have been associated with this hotel since the EWGLI scheme began collecting data in 1987.

Reported by Carol Joseph (cjoseph@phls.co.uk) on behalf of the European Working Group on Legionella Infections (EWGLI)

Update 30 October 1997

October 28, 1997

Turkish hotel defends itself after reported cases of Legionnaires' disease:

The Istanbul hotel where two French tourists who died recently of Legionnaires' disease were staying, defended its health and safety record Monday, citing regular maintenance checks. "Regular checks are carried out, once a month and even more frequently in high season," affirmed an employee at the four-star Festival hotel, situated in the touristic Cemberlitas district of Istanbul in Turkey. The French health ministry reported Sunday the deaths of two French tourists, both of whom stayed at the hotel in early October. A third victim was in serious condition. Exact details were not given.

The management of Festival Hotel, which can accommodate 200 guests, defended the hotel's health and safety record, saying that the building's air-conditioning systems, heating systems and kitchens were regularly monitored. Further checks on the hotel, which is now practically empty, were being carried out Monday by the city's health department.

Update 15 November1997

Cases of legionellosis associated with stay at the Hotel Festival in Istanbul, Turkey: update on 6 November at 1200 hours

Further details have been received this week about the outbreak of legionnaires’ disease among French travellers to Istanbul, Turkey reported on 28 October in Eurosurveillance Weekly (1). Seventeen people, 3 women and 14 men aged from 49 to 82 years (median 65 years), have been reported to have developed respiratory symptoms after staying at the Hotel Festival in Istanbul since 10 September. Four people have died (69 to 77 years of age), seven people have recovered, and six are still in hospital.

Legionella infection has been confirmed in 13 people (Legionella pneumophila serogroup 1 was isolated from five), investigations are continuing for three, and one of the cases who died had shown clinical symptoms suggestive of legionellosis but laboratory confirmation could not be obtained. Three of the four cases who died had a bacteriologically confirmed diagnosis of legionellosis.

The epidemic curve shows that one case occurred at the beginning of September, and the remaining cases during the three weeks from 2 to 23 October (figure 1). All but the first case had stayed at the hotel between 23 September and 16 October (figure 2). To date, no cases who stayed at the hotel after 16 October (the date when the hotel was identified as the probable source of the infection) have been identified.

According to a tour operator, the hotel could have accommodated 3300 people between the 1 September and 22 October 1997, an average of 470 people each week. The 12 cases confirmed during a three week exposure period at the hotel imply an attack rate in the order of 1% (the attack rate in legionellosis epidemics is usually between 0.1% and 5% [2]).

Nine people who stayed at the hotel in September or October have reported nonspecific symptoms and are being followed up. The exact number of cases associated with this outbreak cannot be known precisely yet. Results of serological tests will be known within two weeks and the possibility that these will be positive and that further cases may come to light cannot be excluded.

This report is also available in French at the Réseau National de Santé Publique (http://www.b3e.jussieu.fr:80/rnsp/).

References:

1.Joseph C. Outbreak of legionnaires’ disease among French tourists associated with Turkey. Eurosurveillance Weekly 301097 2.AS Benenson, editor. Control of communicable diseases manual. (16th edition) Washington DC: American Public Health Association, 1995

Reported by Dr Bruno Hubert (hubert@b3e.jussieu.fr), Dr Bénédicte Decludt (decludt@b3e.jussieu.fr) Réseau National de Santé Publique, Saint Maurice, France, and Prof Jérome Etienne, Centre de Référence des Legionella, Lyon, France

1996
TURKEY

Two people who stayed at a hotel in Marmaris, Turkey in May 1996 acquired Legionnaires' disease.
The same hotel was associated with another two cases ln September 1995.


Communicable Disease Report

Cluster of cases of Legionnaires' disease associated with travel to Turkey The Swedish collaborator in the European scheme for travel associated Legionnaires' disease recently reported four cases of Legionnaires' disease in residents of Sweden. They were members of a party of 72 people who travelled from different parts of Sweden to Turkey for a bridge tournament at a hotel in the resort of Kusadasi. All four eases (2 men and 2 women. aged 52 to 72 years) became ill between 18 and 24 September 1996.
Some members of the party had spent their first night in Turkey at another hotel in Kusadasi, but all members had stayed at the same hotel from 15 September.

The Swedish Institute for Infectious Disease Control alerted clinicians and communicable disease officers, and asked them to collect specimens for testing for evidence of legionellosis from members of the party who were ill. Queslionnaires were distributed to members of the party, asking for details of illness, travel, exposure to possible sources of infection in the hotel, use of water, and vlsits to other hotels, restaurants, and other premlses ln the resort and elsewhere. The coordinator of the European seheme for travel associated legionnaires' disease Informed the Turkish collaborator and sent a `cluster alert' to the other national collaborators and the World Health Organisatfon. The Swedlsh tour operator and a British tour operator immediately withdrew their clients from the hotel.

Public health laboratories, consultants In communicable disease control, and other public health officials in England and Wales were contacted through the Epinet communlcation system and asked to report rapidly cases of pneumonia or confirmed cases of legionellosis, in people who had returned from Turkey in the past few months, to the PHLS Communicable Disease Surveillance Centre.

The Association of British Travel Agents, the Federation of Tour Operators, and the Department of Health. England were also informed about the cluster of cases, in accordance with new procedures agreed this year'. An outbreak of legionnaires' disease was associated wlth the same hotel in Kusadasi in 1995.

Control measures were Instituted and no further cases linked to the hotel were reported untll September 1996. The Turkish health authorities are carrying out further investigations in collaboration with the Swedtsh health authorities and the PHLS.

1. CDSC. Legionella and the European Couneil Directive for Package Travel. Commun Dxs I1ep CDR Wkly 1996: 6: 213.
2. Newton LH, Joseph CA, Hutchtnson EJ, Harrison TG, Watson jM, Bartlett, CLR. Legionnaires' disease surveillance: England and Wales, 1995. Commun Dis Rep CDR Rev 1996; 6: R151-5.

(CDR WEEKLY V6 NUMBER 41 11 OCTOBER 1996)

YUGOSLAVIA 1988

An epidemic of legionellosis at a hotel at the Makarska seashore

Epidemioloskog odjela, Zavod za zastitu zdravlja, Split.

The paper describes the epidemic of Legionellosis that occurred among guests and employees of a hotel at the Makarska littoral in May 1988. According to the so far reported data in the medical literature that was the third epidemic in our country and all three of them occurred in the Dalmatian touristic area. In this epidemic, nine foreign tourists were registered ill with the clinical picture of Legionnaires' disease. Five patients required hospitalization. The disease could be serologically proved in 4 patients and Legionella pneumophila SG1 was isolated from samples of 2 patients and from sediment of the hot-water tank. Since the opening of the hotel until the end of May, 19 hotel employees developed a febrile illness of short duration. The disease was serologically proved in 7 of them. The morbidity rate in tourists was 2.5%, while it amounted to 7.1% in the hotel employees. The epidemic lasted for 16 days. The infection spread through the hot water, and antiepidemic measures were limited to its pasteurization and hyperchloridation. The chain of infection was broken off by the application of those measures.
(Lijec Vjesn 112 (5-6): 152-155 (May 1990) Klismanic-Nuber Z, Milas I, Smoljanovic M, Saric M, Gjenero-Margan I)

1988 Yugoslavia

An outbreak of Legionnaires disease at a hotel in Yugoslavia, 20 hotel guest were affected with one dying. As a result of a survey the hot water system was identified as the source.
(Gjenero-Margan I , Lijec Vjesn 1989 111 81-84)