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Thursday, June 7, 2012

Legionellosis

Legionellosis is a potentially fatal infectious disease caused by gram negative, aerobic bacteria belonging to the genus Legionella. Over 90% of legionellosis cases are caused by Legionella pneumophila, a ubiquitous aquatic organism that thrives in temperatures between 25 and 45 °C (77 and 113 °F), with an optimum temperature of 35 °C (95 °F).

Legionellosis takes two distinct forms:

    Legionnaires' disease, also known as "Legion Fever", is the more severe form of the infection and produces high fever and pneumonia.
    Pontiac fever is caused by the same bacteria but produces a milder respiratory illness without pneumonia that resembles acute influenza. Pontiac fever also has a spontaneous resolution.

Legionnaires' disease acquired its name in July 1976 when an outbreak of pneumonia occurred among people attending a convention of the American Legion at the Bellevue-Stratford Hotel in Philadelphia. On January 18, 1977 the causative agent was identified as a previously unknown strain of bacteria, subsequently named Legionella. Some people can be infected with the Legionella bacteria and have only mild symptoms or no illness at all.

Outbreaks of Legionnaires' disease receive significant media attention. However, this disease usually occurs as single, isolated cases not associated with any recognized outbreak. When outbreaks do occur, they are usually in the summer and early autumn, though cases may occur at any time of year. The fatality rate of Legionnaires' disease has ranged from 5% to 30% during various outbreaks and approaches 50% for nosocomial infections, especially when treatment with antibiotics is delayed.Most infections occur in those who are middle-age or older.

Transmission

Infection normally occurs after inhaling an aerosol (fine airborne particles) containing Legionella bacteria. Such particles could originate from any infected water source. When mechanical action breaks the surface of the water, small water droplets are formed, which evaporate very quickly. If these droplets contain bacteria, the bacteria cells remain suspended in the air, invisible to the naked eye and small enough to be inhaled into the lungs. This often occurs in poorly ventilated areas such as prisons where a condensating air conditioner can spread it throughout the entire room, infecting anyone not immune to the strain of bacteria.

Potential sources of such contaminated water include cooling towers (some 40% to 60% of ones tested) used in industrial cooling water systems as well as in large central air conditioning systems, evaporative coolers, nebulizers, humidifiers, whirlpools, hot water systems, showers, windshield washers[15], whirlpool spas, architectural fountains, room-air humidifiers, ice making machines, misting equipment, and similar disseminators that draw upon a public water supply.

The disease may also be transmitted from contaminated aerosols generated in hot tubs if the disinfection and maintenance program is not done rigorously.Freshwater ponds, creeks, and ornamental fountains are potential sources of Legionella. The disease is particularly associated with hotels, fountains, cruise ships and hospitals with complex potable water systems and cooling systems.

The development of bacterial infections may cause Legionnaires’ disease. Respiratory care devices such as humidifiers and nebulizers used with contaminated tap water may contain Legionella. Using sterile water is very important, especially when using respiratory care devices.
Prevention

A recent research study provided evidence that Legionella pneumophila, the causative agent of Legionnaires' disease, can travel airborne at least 6 km from its source. In 2000, ASHRAE issued guidelines to maintain water systems and to decrease the chances of Legionnaires’ disease transmission. The guidelines were not valued because legionella multiply in such temperatures. On the other hand, a lot of states had regulations that limited temperatures in health care facilities in order to reduce scalding injuries.[12] It was previously believed that transmission of the bacterium was restricted to much shorter distances. A team of French scientists reviewed the details of an epidemic of Legionnaires' disease that took place in Pas-de-Calais in northern France in 2003–2004. There were 86 confirmed cases during the outbreak, of whom 18 died. The source of infection was identified as a cooling tower in a petrochemical plant, and an analysis of those affected in the outbreak revealed that some infected people lived as far as 6–7 km from the plant.

A study of Legionnaires' disease cases in May 2005 in Sarpsborg, Norway concluded that: "The high velocity, large drift, and high humidity in the air scrubber may have contributed to the wide spread of Legionella species, probably for >10 km. "...

In 2010 a study by the UK Health Protection Agency reported that 20% of cases may be caused by infected windscreen washer systems filled with pure water. The finding came after researchers spotted that professional drivers are five times more likely to contract the disease. No cases of infected systems were found whenever a suitable washer fluid was used.

Breeding ground

The bacteria grow best in warm water, like the kind found in hot tubs, cooling towers, hot water tanks, large plumbing systems, or parts of the air-conditioning systems of large buildings. Indoor ornamental fountains have been confirmed as a cause of Legionnaires' disease outbreaks, in which submerged lighting as a heat source was attributed to the outbreak in all documented cases. Controlling the growth of Legionella in ornamental fountains is touched on in many of the listed guidelines. However, specific guidelines for solar water heating systems http://www.wras.co.uk/PDF_Files/Preheated_Water_Report.pdfornamental fountains have also been published.

Adding an antibacterial agent to the automobiles' windshield system's reservoir is also recommended. Legionellae have been discovered in up to 40% of freshwater environments and have been in up to 80% of freshwater sites by PCR hybridization assay.
Regulations and ordinances

The guidance issued by the UK government's Health and Safety Executive (HSE) now recommends that microbiological monitoring for wet cooling systems, using a dipslide, should be performed weekly. The guidance now also recommends that routine testing for legionella bacteria in wet cooling systems be carried out at least quarterly, and more frequently when a system is being commissioned, or if the bacteria has been identified on a previous occasion.

Further non-statutory UK guidance from the Water Regulations Advisory Scheme now exists for pre-heating of water in applications such as solar water heating systems. http://www.wras.co.uk/PDF_Files/Preheated_Water_Report.pdf

The City of Garland, Texas requires yearly testing for legionella bacteria at cooling towers at apartment buildings.

Malta requires twice yearly testing for Legionella bacteria at cooling towers and water fountains. Malta prohibits the installation of new cooling towers and evaporative condensers at health care facilities and schools.

The Texas Department of State Health Services has provided guidelines for hospitals to detect and prevent the spread of nosocomial infection due to legionella.


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