OUTBREAK OF LEGIONNAIRES' DISEASE

NORWAY

Follow-up after the Legionnaires’ Disease outbreak

June 9th, 2005

It was confirmed yesterday that the occurrence of legionella bacteria in a lignin spray dryer scrubber at the Borregaard Sarpsborg plant in Norway is the probable source of the Legionnaires’ Disease outbreak in south-eastern Norway. The outbreak has affected 52 people in total of whom 10 have regrettably died.

“Borregaard greatly regrets what has happened and we wish to express our deep sympathy for the innocent victims of Legionnaires’ Disease and for their relatives. We are extremely upset that our company has experienced an outbreak and is probably the cause of the spread of legionella bacteria, which has resulted in such serious consequences for so many people. Our company depends on the trust and confidence of the local community, so this is also sad for everyone who works at Borregaard,” says Per Sørlie, President and CEO of Borregaard.

We are concerned about the situation of the people who have contracted Legionnaire’s Disease and their relatives. In cooperation with the authorities and other experts, we will also discuss how we can help to meet the needs of the people who have been affected.

We want to help the people who have suffered. We will give closer consideration to how this can best be done.

Borregaard has now taken a number of initiatives and measures as a result of this situation.

In this initial phase, we are focusing on ensuring that the people in the vicinity of the plant are safe. This means that we are now disinfecting the plant, checking the equipment and technical installations, and establishing the necessary monitoring system and procedures to ensure that future operations take place in a safe way. Borregaard co-operates closely with the authorities and external experts in this process.

Borregaard has similar scrubbers at production facilities in six other countries. On the basis of what we now know about the Sarpsborg plant scrubber, similar inspections are being carried out at the other installations.

Scrubber start-up with new operating routines

June 10th, 2005

Borregaard’s plant in Sarpsborg have received permission from the Sarpsborg health authorities to start up the scrubber that was closed down for cleaning and disinfection after legionella were found in the installation on Monday 6 June.

The scrubber was immediately closed down for cleaning and disinfection at the request of the health authorities as soon as it was clear that legionella bacteria had been found. Borregaard itself decided to close down and clean its other two scrubbers of the same type, even though they were not infected with the bacteria. Since 6 June, Borregaard has been working with the authorities to discover the cause of the bacterial growth and has also implemented a number of measures to make the plants as safe as possible. The new routines have been formulated in cooperation with the Health Authorities.

New routines introduced
Improved operating routines, better monitoring and control of bacterial growth, clear limits for safe operations and routines for frequent, thorough cleaning are intended to eliminate the risk of new legionella outbreaks in the company’s scrubbers.

Careful start-up
The scrubbers are about to be started up this weekend when the disinfection process has been completed. The company will carefully monitor the start-up process and will stop it immediately if anything abnormal should occur.

Borregaard has similar scrubbers at plants in six other countries. All the scrubbers have been closed down for cleaning and inspection this week.

Compensation for the victims of the Legionnaires’ Disease outbreak

June 10th, 2005

Borregaard and its insurance company, If Skadeforsikring (If), have reviewed the liability and insurance aspects of the situation. It is now clear that If will deal with compensation claims from the bereaved and from persons who became ill due to the spread of the disease.

In If’s view, Borregaard is not to blame for the spread of Legionnaires’ Disease but, pursuant to the law, the company is nevertheless liable to pay compensation based on strict liability, and the company’s liability insurance will apply.

The insurance company has established a special personal injury team who will now begin to register cases from the bereaved and persons who have been treated or who are still being treated for Legionnaires’ Disease. If and Borreegaard will in the near future provide further information concerning measures that will make the registration process in connection with compensation as easy as possible for the people concerned.

“Borregaard is concerned about the situation of the people who have been affected by Legionnaires Disease outbreak and it is important for us that the victims receive compensation for the loss they have suffered,” says Per Sørlie, President & CEO of Borregaard.

Results from the legionnaires' disease outbreak

Updated: 13.06.2005

Saturday May 21th, the Østfold Hospital in Fredrikstad sent out a warning regarding an outbreak of legionnaires’ disease in Sarpsborg and Fredrikstad municipality in Southeast Norway. The municipality started immediately the work to find the source of the infection and The Norwegian Institute of Public Health (NIPH) has supported the work with a field epidemiologic group, expertise in water systems and microbiology testing. A total of 55 persons have been infected with legionella and among these ten have died.

During the investigation, several samples from possible sources in cooling towers and other water treatment installations in the area of Sarpsborg and Fredrikstad were taken. These environmental samples were cultured by AS Telelab, Skien and by Norsk matanalyse. Samples from patients were cultured at Department of Microbiology at Østfold Hospital. Isolates of the legionella bacteria were sent to NIPH for DNA analysis of the bacteria.

DNA fingerprints of the legionella bacteria from patients and potential sources were compared. The DNA analysis showed that the same bacteria were found in the patients and in samples from an air scrubber at the Borregaard Sarspborg plant. Together with the results of DNA analysis, results from the population based study including information about home address and movements of patients and modelling of airflow in the area of Sarpsborg and Fredrikstad, indicated that the source of infection was found. These results were announced by the Chief Medical Officer in Sarpsborg on a press conference Wednesday June 8th 2005.

Appearance of the Legionella bacterium and its probable spread from Borregaard

8 June 2005:

The Legionella bacterium has been detected in a scrubber facility at Borregaard's site in Sarpsborg. The facility is probably the source of the epidemic of Legionnaires' Disease in the area.

"Borregaard deeply regrets what has happened and wishes to express its profound sympathy with persons who through no fault of their own have been infected by Legionella, and with their families. Knowing that Legionella has been identified on our site, and probably spread from there into the community with such grave consequences for many people, weighs very heavily upon us. Our business depends on the confidence and trust of the community around us, which is why this is also a sad day for everyone working at Borregaard," says CEO Per Sørlie.

Our main task now is to satisfy ourselves that people on-site and in our neighbourhood can feel safe and secure when operations resume.

We are currently disinfecting the facility and will establish routines for monitoring and eliminating Legionella before the facility is switched on.

That an epidemic of legionnaires' disease can have its source in a scrubber facility of this type is new knowledge to us. Neither we, our equipment suppliers, trade experts or health authorities are aware that facilities of this type have caused the spread of Legionella. We have operated regular cleaning routines at the facility concerned, involving thorough cleaning, every three to four weeks.

We have devoted substantial resources to scrutinising the entire facility on a broad front. This process is continuing with the assistance of external specialists to ensure safe operation of the facility in future.

Dag Arthur Aasbø, dag.arthur.aasbo@borregaard.com

Outbreak of community-acquired legionnaires’ disease in southeast Norway, May 2005

Hans Blystad (hans.blystad@fhi.no), Arne Broch Brantsæter and Øistein Løvoll, Nasjonalt folkehelseinstitutt (Norwegian Institute of Public Health), Oslo, Norway

Norwegian health authorities are investigating an outbreak of legionnaires’ disease in the neighbouring cities of Sarpsborg and Fredrikstad in southeastern Norway, close to the border with Sweden. As of 26 May, 39 cases, including five deaths, have been reported in this outbreak. All cases have been confirmed by urinary antigen testing. Cultures of clinical specimens have not yet been completed. The mean age of patients is 67 years (range: 35-94). Twenty three cases (59%) are in men. All cases are in Norwegian nationals, and there is no information on any international events in the area in the period. Thirty five of the cases (90%) are in local residents, while the remaining 4 cases have been diagnosed in patients elsewhere in Norway who had visited the area during the probable exposure period.

The two cities are situated very close to each other with a total of 120 000 inhabitants. The area is heavily industrial and is not a particular tourist destination.

The source is still unknown. Because the outbreak is large with many cases including deaths, occurring over a wide geographical area within a short time period (Figure), cooling towers are the most likely source. All of the known 19 cooling towers in the area have been closed down, pending results of bacteriological testing and disinfection. Epidemiologists from Nasjonalt folkehelseinstitutt (Norwegian Institute of Public Health) are assisting local health authorities with the outbreak investigation. Other probable sources are also being investigated. Clinical and environmental samples are being genotyped to support other epidemiological data.

Figure. Epidemic curve of the outbreak of legionnaires’ disease in Fredrikstad-Sarpsborg, Norway, May 2005

The rate of case reporting has now diminished, and based on epidemiological data, it is probable that the source is now inactive. Local health authorities have not issued any specific restrictions regarding staying in or travel to the area.

The outbreak has stimulated public discussion about statutory regulations for cooling towers and similar installations. Following a similar outbreak in Stavanger in 2001 [1], all owners of cooling towers are now required to notify local health authorities of their installation and to have an adequate system of control and maintenance. Local authorities have a statutory responsibility.

References:

Blystad H, Bjorlow E, Aavitsland P, Holm J. Outbreak of legionellosis in Stavanger, Norway – final report. Eurosurveillance Weekly 2001; 5(47): 22/11/2001. (http://www.eurosurveillance.org/ew/2001/011122.asp#2)

Source Eurosurveillance Weekly

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Anatomy of an Air Scrubber

A venturi air scrubber removes polluting particles from gas emissions by spraying a scrubber liquid directly into the emissions. The scrubber liquid surrounds the dirty particles, which are carried with the gas emissions into the separator cylinder. As the gas cycles upward through the cylinder, the liquid-covered particles drop from the gas into the contaminated liquid reservoir

An air scrubber is used to clean air or other gases of various pollutants and dust particles by mixing the polluted gas with a water mist. The dirt and pollutants are encased by the water particles and when the mixture is condensed the pollutants stay in the water while the gas rises up and can be put back into circulation.

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New legislation in Norway targets prevention of legionnaires’ disease

Elmira Isakbaeva and Hans Blystad

Infectious Disease Epidemiology Department, Norwegian Institute of Public Health, Oslo, Norway

Changes in policy can promote public health and prevent disease effectively. On 12 July 2005, a new set of regulations regarding measures to minimise the risk of spread of Legionella bacteria from aerosol-generating equipment was enacted in Norway by the Social- og helsedirektoratet (Social and Health Directorate, www.shdir.no) [1]. The regulations were proposed and then passed as a result of policy level interventions implemented in Norway following two large community outbreaks of legionnaires’ disease, linked to a hotel cooling tower in 2001 [2] and an industrial air scrubber in 2005 [3,4]. The previous legislation to target prevention of legionnaires’ disease was adopted in 2003 [5] and focused on measures to reduce the risk of legionellosis associated mainly with cooling towers. It was difficult to achieve compliance among local authorities and owners of cooling towers despite the possibility of prosecution for failing to comply with the regulations. The new legislation is aimed to reduce the health risks associated with Legionella infection and to prevent occurrences of future outbreaks.

The new legislation covers measures concerning cooling towers and also other aerosol-generating equipment that can release Legionella in air, such as air scrubbers, shower heads, air coolers, humidifiers, misters, taps and indoor fountains. Existing legislation already covers the management of spa pools and swimming pools [6]. The new regulations also include control measures for industrial waste management systems that can release Legionella in waste water and have potential for subsequent generation of aerosol, such as waste management systems used in the paper industry [7]. The owners of non-residential facilities with aerosol-generating equipment are required to report the status of their installed systems and control and maintenance procedures to local health authorities in the respective municipalities by 15 August 2005. The regulation requires physical and chemical monitoring, and monitoring of organic load in water by using aerobic count. The local health authorities will be responsible for maintaining a list of sites with aerosol-generating equipment in their municipality and carrying out the risk assessment and remedial measures in case of detected deficiencies.

The new legislation emphasises the increased responsibility of owners and operators in inspection and maintenance of systems with aerosol-generating equipment. In case of failure to report, owners may be subject to penalty including criminal offense. The role of local public health authorities will be critical in ensuring compliance with the new regulation and monitoring is needed to maximise awareness of this legislation.

References:

Midlertidig forskrift om tiltak for å hindre overføring av Legionella via aerosol. Sosial- og helsedirektoratet 2005. (http://www.shdir.no/vp/multimedia/archive/00003/Midlertidig_forskrift_3362a.pdf) [in Norwegian]
Blystad H, Bjorlow E, Aavitsland P, Holm J. Outbreak of legionellosis in Stavanger, Norway: final report. Eurosurveillance Weekly 2001; 5 (47): 22/11/2001. (http://www.eurosurveillance.org/ew/2001/011122.asp#2)
Blystad H, Brantsæter AB, Løvoll Ø. Outbreak of community-acquired legionnaires’ disease in southeast Norway, May 2005. Eurosurveillance Weekly 2005; 10(5): 26/5/2005. (http://www.eurosurveillance.org/ew/2005/050526.asp#1)
Nygard K et al. Update: outbreak of legionnaires’ disease in Norway traced to air scrubber. Eurosurveillance Weekly 2005; 10(6): 09/6/2005. (http://www.eurosurveillance.org/ew/2005/050609.asp#1)
Helse-og omsorgsdepartementet. Forskrift om miljørettet helsevern 2003. (http://lovdata.no/for/sf/ho/ho-20030425-0486.html) [in Norwegian]
Helse-og omsorgsdepartementet. Forskrift om for badeanlegg, bassengbad og badstu 1996. (http://www.lovdata.no/frame-sf.html) [in Norwegian]
De Jong B, Allestam G, Lundberg AK. Biological treatment of industrial wastewater: an overlooked source of Legionella infection? 20th Annual meeting, European Working Group for Legionella Infections, May 2005.

New Norwegian legionella legislation is consistent with the European guidelines

John V Lee

Collaborator for England & Wales, European Surveillance Scheme for Travel Associated Legionnaires' Disease (EWGLINET), Health Protection Agency Centre for Infections, London, United Kingdom

Norway is to be congratulated on improving its legislation governing the control of Legionella in water systems. It is interesting to observe that the emphasis of the legislation in individual states often reflects their initial experience of a large outbreak of legionnaires’ disease. If a country’s first experience of the disease was with a cooling tower outbreak, then the emphasis is on control in cooling towers and other potential sources may not be considered. This is unfortunate, since it may cause other potential sources to be overlooked, with tragic consequences. The Norwegians have quite rightly extended the scope of their legislation to cover other sources following their recent experience with an outbreak due to an air scrubber and the French experience with an effluent treatment plant in Lens.

Although cooling towers, evaporative condensers, hot and cold water systems and spa pools are the most common sources of outbreaks, all systems that use water that may reach temperatures conducive to the growth of legionellae should be considered as potential sources of infection, be subjected to risk assessments and have suitable control measures applied where necessary. This is the basis of the advice in the technical parts of the European Guidelines for Control and Prevention of Travel Associated Legionnaires' Disease (http://www.ewgli.org/public_info/publicinfo_europeanguideline_download.asp), which are largely based on the United Kingdom guidance. It is to be hoped that more countries improve their legislation to ensure all potential sources are considered.

Denis

legion@q-net.net.au