Scand J Infect Dis. 2012 Feb 19;
Skaza AT, Beskovnik L, Storman A, Kese D, Ursic S

Background: August 2010 marked the beginning of the largest outbreak of legionellosis in a Slovenian nursing home. This article presents our experiences with the outbreak investigation. Methods: In order to collect the necessary patient epidemiological data, we used individual epidemiological questionnaires. Samples were available from 15 patients and were subject to laboratory investigation. Urine and sputum samples were difficult to obtain due to the underlying diseases of the patients. Serological diagnostics constituted an important part of the epidemiological investigation. Sixty-four environmental samples were taken to identify the sources of infection. By genotyping, we assessed the affinity of the allelic profile of Legionella pneumophila serogroup 1 in environmental samples and in patient samples. Results: Legionnaires' disease was diagnosed in 10 patients based on a combination of various tests. Legionella pneumophila serogroup 1, Legionella pneumophila serogroups 2-14, and Legionella sp., in concentrations of < 10 to 61,000 CFU/l, were isolated from 51 out of 64 environmental samples. The source of the outbreak was confirmed by genotyping the isolates from patients and the isolates from the water supply system. The 2 isolates had identical allelic profiles corresponding to that of L. pneumophila serogroup 1 allelic profile 2,3,9,10,2,1,6, designated sequence type 23 (according to the European Working Group for Legionella Infections). Conclusion: We describe a Legionella pneumophila serogroup 1 outbreak in a Slovenian nursing home. The source of infection was demonstrated using sequence-based typing. Water flow disturbances were determined as the most probable cause of Legionella growth. Overall, the risk of a Legionella outbreak is underestimated in Slovenia.

Int J Microbiol. 2012; 2012: 218791
Travis TC, Brown EW, Peruski LF, Siludjai D, Jorakate P, Salika P, Yang G, Kozak NA, Kodani M, Warner AK, Lucas CE, Thurman KA, Winchell JM, Thamthitiwat S, Fields BS

Members of the Gram-negative genus Legionella are typically found in freshwater environments, with the exception of L. longbeachae, which is present in composts and potting mixes. When contaminated aerosols are inhaled, legionellosis may result, typically as either the more serious pneumonia Legionnaires' disease or the less severe flu-like illness Pontiac fever. It is presumed that all species of the genus Legionella are capable of causing disease in humans. As a followup to a prior clinical study of legionellosis in rural Thailand, indigenous soil samples were collected proximal to cases' homes and workplaces and tested for the presence of legionellae by culture. We obtained 115 isolates from 22/39 soil samples and used sequence-based methods to identify 12 known species of Legionella represented by 87 isolates.

J Hosp Infect. 2012 Mar; 80(3): 259-61
Higa F, Koide M, Haroon A, Haranaga S, Yamashiro T, Tateyama M, Fujita J

For prevention of nosocomial legionellosis, environmental investigation to identify possible infectious sources is essential. An environmental study in a ward of our hospital revealed that a steam towel warmer was contaminated with legionella whereas no legionella was detected in tap water supplies and shower heads. Water in the apparatus may be a reservoir of legionella. We abandoned the use of all steam towel warmers in our hospital. Based on this finding, we recommend that steam towel warmers in hospital settings be avoided. Otherwise, the apparatus should be drained, cleaned and dried every day.

Am J Transplant. 2012 Jan; 12(1): 250-3
Hicks LA, Garrison LE, Nelson GE, Hampton LM

Neurol Sci. 2012 Jan 11;
Konno S, Kono H, Kitazono H, Murata M, Nakazora H, Nomoto N, Sugimoto H, Sanno K, Fujioka T

We report a 71-year-old man with legionellosis, who presented with abducens nerve palsy, singultus, confusion, memory impairment, ataxia, and hyporeflexia. Legionella pneumonia was diagnosed on the basis of detection of Legionella pneumophila antigen in the urine. The cerebrospinal fluid was negative for the antigen and antibody, but an oligoclonal band was detected, and the IgG index was elevated. It was speculated that an undetermined immune-mediated mechanism had contributed to the development of the neurological manifestations.

Ann Agric Environ Med. 2011 Dec; 18(2): 286-93
Dutkiewicz J, Cisak E, Sroka J, Wójcik-Fatla A, Zając V

There are two main groups of biological agents regarded as occupational hazards: allergenic and/or toxic agents forming bioaerosols, and agents causing zoonoses and other infectious diseases. Bioaerosols occurring in the agricultural work environments comprise: bacteria, fungi, high molecular polymers produced by bacteria (endotoxin) or by fungi (β-glucans), low molecular secondary metabolites of fungi (mycotoxins, volatile organic compounds) and various particles of plant and animal origin. All these agents could be a cause of allergic and/or immunotoxic occupational diseases of respiratory organ (airways inflammation, rhinitis, toxic pneumonitis, hypersensitivity pneumonitis and asthma), conjunctivitis and dermatitis in exposed workers. Very important among zoonotic agents causing occupational diseases are those causing tick-borne diseases: Lyme borreliosis, anaplasmosis, babesiosis, bartonellosis. Agricultural workers in tropical zones are exposed to mosquito bites causing malaria, the most prevalent vector-borne disease in the world. The group of agents causing other, basically not vector-borne zoonoses, comprises those evoking emerging or re-emerging diseases of global concern, such as: hantaviral diseases, avian and swine influenza, Q fever, leptospiroses, staphylococcal diseases caused by the methicillin-resistant Staphylococcus aureus (MRSA) strains, and diseases caused by parasitic protozoa. Among other infectious, non-zoonotic agents, the greatest hazard for health care workers pose the blood-borne human hepatitis and immunodeficiency viruses (HBV, HCV, HIV). Of interest are also bacteria causing legionellosis in people occupationally exposed to droplet aerosols, mainly from warm water.

Intern Med. 2012; 51(1): 129
Hashizume Y, Takise A

Przegl Epidemiol. 2011; 65(3): 441-5
Zborowska-Dobosz R, Kuziemski A, Maron M, Bahn D, Owczarek A

The aim of the study was to assess the level of Legionella sp. contamination in the hot water supply systems at the premises of inpatient healthcare facilities. In the years 2008-2010 the State Poviat Sanitary Inspector in Bydgoszcz tested the hot water supply systems in 8 hospitals. A total of 88 samples of hot water were collected in the years 2008-2010. The analysis involved temperature measurements and microbiological testing of the hot water. Contamination levels exceeding the applicable standards were discovered in 6 hospitals. The corrective measures introduced allowed for a significant improvement in each case. The hospital hot water systems revealed Legionella sp. contamination levels considerably exceeding the approved standards. Of the 88 water samples tested, 37 contained excessive numbers of Legionella sp. bacteria (i.e. above 100 CFU in 100 ml of water), which constituted 63.6% of the samples tested. In 6 of the 8 investigated hospitals the Legionella sp. contamination of the hot water supply system was found to be on the medium or high level. The analysis of temperature measurements revealed that the lowest temperature readings were associated with high bacterial colonization of the plumbing system. After the implementation of corrective measures, 50 control samples were collected, and in 37 of them the bacterial levels were below 100 CFU per 100 ml of water. The Legionella sp. contamination was found to be associated with low temperature of the hot water.

Przegl Epidemiol. 2011; 65(3): 433-9
Pancer K, Napiórkowska A, Gut W, Stypułkowska-Misiurewicz H

In Poland, all forms of legionellosis are obligatory reported: Legionella pneumonia and extrapulmonary legionellosis (such as Pontiac fever). Total 210 cases caused by Legionella sp. were reported in years 2003-2010. In our study analysis of age, sex, place of residence of 163 patients with legionellosis reported in 2005-2009 were done. The majority (74.2%) cases were reported in Region Mazowieckie. Age and sex structure of patients in Poland in years 2005-2009 differ from the data of EWGLI. In Poland, legionellosis was much more frequently reported in children - 46.6% of the total reported, than in other countries. It might be a result of collaboration with the paediatricians during research conducted by our team in 2005-2007. Reported cases of legionellosis were also observed in 10 children aged < or = 2 years. Totally, legionellosis was observed more frequently among girls than in boys (M: F = 1:1,71), and in males (M: F = 1,64:1). It was also found that in smaller towns (< 100 thousand inhabitants) legionellosis was much more frequently diagnosed in girls (Po = 0.0152, 71.1% of ill children) and men (65.8% of adults). In larger cities (> 100 thousand.) differences in incidence between girls and boys and men and women were lower. To sum up: the number of reported cases of legionellosis depends largely on the availability of laboratory tests and the knowledge of physicians. Extension of diagnostic testing in the direction of Legionnaires' disease patients belonging to other than the high risk group increased number of detected cases, including those not so severe.

Am J Epidemiol. 2011 Dec 1; 174(11 Suppl): S36-46
Hadler SC, Castro KG, Dowdle W, Hicks L, Noble G, Ridzon R

Infectious respiratory pathogens were the suspected cause of 480 outbreaks investigated by the Centers for Disease Control and Prevention's Epidemic Intelligence Service officers during 1946-2005. All epidemic-assistance investigation reports and associated articles from scientific journals were reviewed. Investigations identified 25 different infectious respiratory pathogens including, most frequently, tuberculosis, influenza, and legionellosis. Other bacterial-, viral-, and fungal-related pathogens also were identified. Epidemic-assistance investigations were notable for first identifying Legionnaires disease and Pontiac fever, hantavirus pulmonary syndrome, and new strains of human and avian influenza, as well as emerging challenges (e.g., multidrug-resistant tuberculosis and pneumococcus). The investigations provided clinical insights into such diseases as pulmonary anthrax and identified high risks of serious respiratory illnesses for persons infected with human immunodeficiency virus, other immunocompromised persons, and persons with diabetes. They identified settings placing persons at high risk of acquiring disease, including nursing homes, prisons, homeless shelters, and hospitals. Travel also placed persons at risk. Key environmental factors related to spread of diseases and occupational risks for brucellosis and psittacosis were identified. The outbreak investigations constitute a wealth of prevention experience and provide the basis for recommendations to mitigate outbreaks and reduce future risks.

Eur J Clin Microbiol Infect Dis. 2011 Nov 26;
Helbig JH, Jacobs E, Lück C

Legionnaires' disease is diagnosed predominantly by urinary antigen detection, and patient isolates are rarely available. The lipopolysaccharide (LPS) epitope pattern of isolates detected by monoclonal antibodies is an accepted marker for the phenotyping of L. pneumophila serogroup 1 strains into monoclonal subgroups. L. pneumophila LPS is the dominant antigen in patients' urinary specimens. By using commercially available microtiter wells coated with rabbit anti-Legionella serogroup 1 IgG as the catching antibody, LPS components in urine specimens were bound and detected separately by corresponding monoclonal antibodies of the Dresden Panel. The subtyping of LPS on urinary antigen molecules by using enzyme-linked immunosorbent assay (ELISA) allows deducing of first evidences for the identity/non-identity of environmental isolates and the legionellosis pathogen. Most importantly in our study, urinary antigen typing possesses high probability to distinguish (or does not distinguish) if the pathogen belongs to the MAb 3/1-negative L. pneumophila strains, which are widespread contaminants of water systems, but represent the minority of patient isolates.

Euro Surveill. 2011; 16(45):
Rozentale B, Bormane A, Perevosčikovs J, Lucenko I, Brila A

An increased number of legionellosis cases in 2011 has been reported in Latvia, compared to the ten previous years. A total of 30 legionellosis cases (1.35 per 100,000 inhabitants), including 19 females, have been confirmed until the end of September 2011. The majority of cases (n=23) were inhabitants of the capital city Riga. The reason for the increase in legionellosis is unclear. Twenty-six of the 30 cases are not travel-related.