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González-Rubio JM, Cascajero A, Baladrón B, González-Camacho F. Characterisation of Legionella Clinical Isolates in Spain from 2012 to 2022. Microorganisms 2024; 12:1253. [PMID: 39065022 PMCID: PMC11278951 DOI: 10.3390/microorganisms12071253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/07/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
Although cases of Legionnaires' disease are notifiable, data on the phenotypic and genotypic characterisation of clinical isolates are limited. This retrospective study aims to report the results of the characterisation of Legionella clinical isolates in Spain from 2012 to 2022. Monoclonal antibodies from the Dresden panel were used for phenotypic identification of Legionella pneumophila. Genotypic characterisation and sequence type assignment were performed using the Sequence-Based Typing scheme. Of the 1184 samples, 569 were identified as Legionella by culture. Of these, 561 were identified as L. pneumophila, of which 521 were serogroup 1. The most common subgroups were Philadelphia (n = 107) and Knoxville (n = 106). The SBT analysis revealed 130 different STs, with the most common genotypes being ST1 (n = 87), ST23 (n = 57), ST20 (n = 30), and ST42 (n = 29). Knoxville has the highest variability with 32 different STs. ST23 is mainly found in Allentown/France (n = 46) and ST42 in Benidorm (n = 18), whereas ST1 is widely distributed. The results demonstrate that clinical isolates show high genetic diversity, although only a few sequence types (STs) are responsible for most cases. However, outbreaks can also occur with rare genotypes. More data on LD and associated epidemiological studies are needed to establish the risk of an isolate causing outbreak in the future.
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Affiliation(s)
| | | | | | - Fernando González-Camacho
- Legionella Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, 28220 Madrid, Spain; (J.M.G.-R.); (A.C.)
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Harduar Morano L, Morawski BM, Herzig CTA, Edens C, Barskey AE, Luckhaupt SE. Legionnaires' disease in transportation, construction and other occupations in 39 US jurisdictions, 2014-2016. Occup Environ Med 2024; 81:163-166. [PMID: 38360725 PMCID: PMC11167715 DOI: 10.1136/oemed-2023-109108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/02/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Certain workers are at increased risk for acquiring Legionnaires' disease compared with other workers. This study aims to identify occupations at increased risk for acquiring Legionnaires' disease. METHODS Using data from the US Centers for Disease Control and Prevention's Supplemental Legionnaires' Disease Surveillance System, this study identified Legionnaires' disease confirmed patients ≥16 years of age in 39 states with reported symptom onset during 2014-2016. Age-adjusted and sex-adjusted incidence rate ratios (IRR) stratified by occupation group were calculated by comparing Legionnaires' disease patients in an occupation group (eg, transportation) to those in all other occupation groups (eg, non-transportation). RESULTS A total of 2553 patients had a known occupation group. The two occupations with the highest burden were transportation (N=287; IRR=2.11) and construction (N=269; IRR=1.82). Truck drivers comprised the majority (69.7%) of the transportation occupation group and construction labourers comprised almost half (49%) of the construction occupation group. The healthcare support occupation had the highest IRR (N=75; IRR=2.16). CONCLUSION Transportation and construction workers, who are generally not covered by guidance related to building water systems, have increased risk of Legionnaires' disease compared with other workers. One hypothesised risk factor for truck drivers is the use of non-genuine windshield cleaner in their vehicles. A simple intervention is to use genuine windshield cleaner with bactericidal properties (ie, includes isopropanol/methanol) which can reduce the risk of Legionella growth and transmission. To improve surveillance of Legionnaires' disease and identification of similar exposures, the authors encourage the collection of occupation and industry information for all patients with Legionnaires' disease.
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Affiliation(s)
- Laurel Harduar Morano
- Division of Occupational and Environmental Medicine, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
- Division of Field Studies and Engineering, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, Ohio, USA
| | - Bozena M Morawski
- Idaho Hospital Association, Boise, Idaho, USA
- CDC assignee to the Idaho Department of Health and Welfare, Boise, Idaho, USA
| | - Carolyn T A Herzig
- National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia, USA
- CDC assignee to the Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina, USA
| | - Chris Edens
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Albert E Barskey
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sara E Luckhaupt
- Division of Field Studies and Engineering, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, Ohio, USA
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Yu F, Nair AA, Lauper U, Luo G, Herb J, Morse M, Savage B, Zartarian M, Wang M, Lin S. Mysteriously rapid rise in Legionnaires' disease incidence correlates with declining atmospheric sulfur dioxide. PNAS NEXUS 2024; 3:pgae085. [PMID: 38476666 PMCID: PMC10929586 DOI: 10.1093/pnasnexus/pgae085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/09/2024] [Indexed: 03/14/2024]
Abstract
Legionnaires' disease (LD) is a severe form of pneumonia (∼10-25% fatality rate) caused by inhalation of aerosols containing Legionella, a pathogenic gram-negative bacteria. These bacteria can grow, spread, and aerosolize through building water systems. A recent dramatic increase in LD incidence has been observed globally, with a 9-fold increase in the United States from 2000 to 2018, and with disproportionately higher burden for socioeconomically vulnerable subgroups. Despite the focus of decades of research since the infamous 1976 outbreak, substantial knowledge gaps remain with regard to source of exposure and the reason(s) for the dramatic increase in LD incidence. Here, we rule out factors indicated in literature to contribute to its long-term increases and identify a hitherto unexplored explanatory factor. We also provide an epidemiological demonstration that the occurrence of LD is linked with exposure to cooling towers (CTs). Our results suggest that declining sulfur dioxide air pollution, which has many well-established health benefits, results in reduced acidity of aerosols emitted from CTs, which may prolong the survival duration of Legionella in contaminated CT droplets and contribute to the increase in LD incidence. Mechanistically associating decreasing aerosol acidity with this respiratory disease has implications for better understanding its transmission, predicting future risks, and informed design of preventive and interventional strategies that consider the complex impacts of continued sulfur dioxide changes.
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Affiliation(s)
- Fangqun Yu
- Atmospheric Sciences Research Center, University at Albany, State University of New York, Albany, NY 12226, USA
| | - Arshad A Nair
- Atmospheric Sciences Research Center, University at Albany, State University of New York, Albany, NY 12226, USA
| | - Ursula Lauper
- New York State Department of Health, Bureau of Water Supply Protection, Albany, NY 12223, USA
| | - Gan Luo
- Atmospheric Sciences Research Center, University at Albany, State University of New York, Albany, NY 12226, USA
| | - Jason Herb
- Atmospheric Sciences Research Center, University at Albany, State University of New York, Albany, NY 12226, USA
| | - Matthew Morse
- New York State Department of Health, Bureau of Water Supply Protection, Albany, NY 12223, USA
| | - Braden Savage
- New York State Department of Health, Bureau of Water Supply Protection, Albany, NY 12223, USA
| | - Martin Zartarian
- New York State Department of Health, Bureau of Water Supply Protection, Albany, NY 12223, USA
| | - Meng Wang
- School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, NY 14214, USA
| | - Shao Lin
- School of Public Health, University at Albany, State University of New York, Albany, NY 12144, USA
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Fischer FB, Bigler M, Mäusezahl D, Hattendorf J, Egli A, Julian TR, Rölli F, Gaia V, Wymann M, Fridez F, Bertschi S. Legionnaires' disease in Switzerland: rationale and study protocol of a prospective national case-control and molecular source attribution study (SwissLEGIO). Infection 2023; 51:1467-1479. [PMID: 36905400 PMCID: PMC10545568 DOI: 10.1007/s15010-023-02014-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/23/2023] [Indexed: 03/12/2023]
Abstract
Switzerland has one of the highest annual Legionnaires' disease (LD) notification rates in Europe (7.8 cases/100,000 population in 2021). The main sources of infection and the cause for this high rate remain largely unknown. This hampers the implementation of targeted Legionella spp. control efforts. The SwissLEGIO national case-control and molecular source attribution study investigates risk factors and infection sources for community-acquired LD in Switzerland. Over the duration of one year, the study is recruiting 205 newly diagnosed LD patients through a network of 20 university and cantonal hospitals. Healthy controls matched for age, sex, and residence at district level are recruited from the general population. Risk factors for LD are assessed in questionnaire-based interviews. Clinical and environmental Legionella spp. isolates are compared using whole genome sequencing (WGS). Direct comparison of sero- and sequence types (ST), core genome multilocus sequencing types (cgMLST), and single nucleotide polymorphisms (SNPs) between clinical and environmental isolates are used to investigate the infection sources and the prevalence and virulence of different Legionella spp. strains detected across Switzerland. The SwissLEGIO study innovates in combining case-control and molecular typing approaches for source attribution on a national level outside an outbreak setting. The study provides a unique platform for national Legionellosis and Legionella research and is conducted in an inter- and transdisciplinary, co-production approach involving various national governmental and national research stakeholders.
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Affiliation(s)
- Fabienne B Fischer
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Melina Bigler
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Daniel Mäusezahl
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.
- University of Basel, Basel, Switzerland.
| | - Jan Hattendorf
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Adrian Egli
- Institute for Medical Microbiology, University of Zurich, Zurich, Switzerland
| | - Timothy R Julian
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Dübendorf, Switzerland
| | - Franziska Rölli
- Lucerne University of Applied Sciences and Arts, Lucerne, Switzerland
| | - Valeria Gaia
- Service of Microbiology, Institute of Laboratory Medicine, National Reference Centre for Legionella, EOC, Bellinzona, Switzerland
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Bertolino G, Marras L, Coroneo V. The Detection Limits of Legionella According to the EU Directive 2020/2184. Could That Be Too Permissive? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023. [PMID: 37777698 DOI: 10.1007/5584_2023_790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
INTRODUCTION The problem of detecting legionella after a case of legionellosis from the source of environmental contamination has been known since a long time ago. Legionella is a bacterium present in various natural and artificial habitats and especially in surface fresh waters. It is found in greater concentration in warm waters, at temperatures between 20 °C and 42 °C. The greatest risk factor for humans is represented by the presence of Legionella in water distribution systems in hospitals, medical equipment (e.g. respirators, dialyzers, inhalers, humidifiers, water, massage equipment used in balneotherapy) and turbines used in dental practices, especially for hospitalized individuals. In the EU directive 2020/2184, issued by the European parliament on 16/12/2020, the concentration of Legionella was added to the parameters to be determined in assessing the quality of drinking water intended for human consumption. The objectives were to improve the quality standard of drinking water, reduce the consumption of bottled water and consequently reduce plastic waste. The WHO notes that Legionella causes the greatest burden from a health point of view and it is included among the parameters that require careful monitoring with a limit of less than 1000 CFU/L. The aim of this report was to evaluate the new EU directive 2020/2184 on the light of our laboratory experience. MATERIALS AND METHODS A total of 459 samples were processed at our Hygiene of food Laboratory - Department of Medical Sciences and Public Health. All statistical analyses were conducted using the SPSS statistical package (version 23 for Windows. SPSS, Inc. Chicago, Ill). RESULTS AND DISCUSSION Of the 67 structures examined where the cases occurred, 35 showed samples with at least one over-threshold value considering the reference value of 100 CFU/L, whereas using the new limit of 1000 CFU/L, only 25 structures resulted as having at least one sample above the threshold. In our experience as a regional reference laboratory for Legionella research, the increase from 100 CFU/L to 1,000 CFU/L could lead to a lower alert level. In fact, in the period between October 2017 and October 2021, the median value of CFU/L in presence of a case was 0 (0-100). Despite the large amount of studies on Legionella only a few relate the withdrawals and the consequent CFU/L with the confirmed cases of legionellosis, as in our analysis. The 75° percentile values of the Legionella concentration equal to 100 CFU/L in all samples associated with cases and clusters leads us to hypothesize that the limit equal to 1000 CFU/L that will be introduced for environmental monitoring as per recent European regulations may not be sufficiently protective for minimizing risk in the population, especially in healthcare facilities where fragile patients are assisted.
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Affiliation(s)
- G Bertolino
- Department of Pharmacy, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - L Marras
- Department of Pharmacy, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
- Clinical Laboratory, Cagliari, Italy
| | - V Coroneo
- Department of Pharmacy, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italia
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Fischer FB, Saucy A, Vienneau D, Hattendorf J, Fanderl J, de Hoogh K, Mäusezahl D. Impacts of weather and air pollution on Legionnaires' disease in Switzerland: A national case-crossover study. ENVIRONMENTAL RESEARCH 2023; 233:116327. [PMID: 37354934 DOI: 10.1016/j.envres.2023.116327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 05/03/2023] [Accepted: 06/02/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND The number of reported cases of Legionnaires' disease (LD) has risen markedly in Switzerland (6.5/100,000 inhabitants in 2021) and abroad over the last decade. Legionella, the causative agent of LD, are ubiquitous in the environment. Therefore, environmental changes can affect the incidence of LD, for example by increasing bacterial concentrations in the environment or by facilitating transmission. OBJECTIVES The aim of this study is to understand the environmental determinants, in particular weather conditions, for the regional and seasonal distribution of LD in Switzerland. METHODS We conducted a series of analyses based on the Swiss LD notification data from 2017 to 2021. First, we used a descriptive and hotspot analysis to map LD cases and identify regional clusters. Second, we applied an ecological model to identify environmental determinants on case frequency at the district level. Third, we applied a case-crossover design using distributed lag non-linear models to identify short-term associations between seven weather variables and LD occurrence. Lastly, we performed a sensitivity analysis for the case-crossover design including NO2 levels available for the year 2019. RESULTS Canton Ticino in southern Switzerland was identified as a hotspot in the cluster analysis, with a standardised notification rate of 14.3 cases/100,000 inhabitants (CI: 12.6, 16.0). The strongest association with LD frequency in the ecological model was found for large-scale factors such as weather and air pollution. The case-crossover study confirmed the strong association of elevated daily mean temperature (OR 2.83; CI: 1.70, 4.70) and mean daily vapour pressure (OR: 1.52, CI: 1.15, 2.01) 6-14 days before LD occurrence. DISCUSSION Our analyses showed an influence of weather with a specific temporal pattern before the onset of LD, which may provide insights into the effect mechanism. The relationship between air pollution and LD and the interplay with weather should be further investigated.
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Affiliation(s)
- Fabienne B Fischer
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Apolline Saucy
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - Danielle Vienneau
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Jan Hattendorf
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Julia Fanderl
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Kees de Hoogh
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Daniel Mäusezahl
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland.
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Riccò M, Ferraro P, Ranzieri S, Boldini G, Zanella I, Marchesi F. Legionnaires' Disease in Occupational Settings: A Cross-Sectional Study from Northeastern Italy (2019). Trop Med Infect Dis 2023; 8:364. [PMID: 37505660 PMCID: PMC10384770 DOI: 10.3390/tropicalmed8070364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/09/2023] [Accepted: 07/15/2023] [Indexed: 07/29/2023] Open
Abstract
In Italy, Legionnaires' Disease (LD) causes >1000 hospital admissions per year, with a lethality rate of 5 to 10%. Occupational exposures could reasonably explain a substantial share of total cases, but the role of Occupational Physicians (OPs) in management and prevention of LD has been scarcely investigated. The present survey therefore evaluates the knowledge, attitudes and practices (KAP) regarding LD from a convenience sample of Italian OPs, focusing on their participation in preventive interventions. A total of 165 OPs were recruited through a training event (Parma, Northeastern Italy, 2019), and completed a specifically designed structured questionnaire. The association between reported participation in preventive interventions and individual factors was analyzed using a binary logistic regression model, calculating corresponding multivariable Odds Ratio (aOR). Overall, participants exhibited satisfactory knowledge of the clinical and diagnostic aspects of LD, while substantial uncertainties were associated epidemiological factors (i.e., notification rate and lethality). Although the majority of participating OPs reportedly assisted at least one hospital (26.7%) and/or a nursing home (42.4%) and/or a wastewater treatment plant, only 41.8% reportedly contributed to the risk assessment for LD and 18.8% promoted specifically designed preventive measures. Working as OPs in nursing homes (aOR 8.732; 95% Confidence Intervals [95%CI] 2.991 to 25.487) and wastewater treatment plants (aOR 8.710; 95%CI 2.844 to 26.668) was associated with participation in the risk assessment for LD, while the promotion of preventive practice was associated with working as an OP in hospitals (aOR 6.792; 95%CI 2.026 to 22.764) and wastewater treatment plants (aOR 4.464, 95%CI 1.363 to 14.619). In other words, the effective participation of the OP in the implementation of preventive measures appears uncommon and is limited to certain occupational settings. Collectively, these results highlight the importance of tailoring specifically designed information campaigns aimed to raise the involvement of OPs in the prevention of LD in occupational settings other than healthcare.
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Affiliation(s)
- Matteo Riccò
- Servizio di Prevenzione e Sicurezza Negli Ambienti di Lavoro (SPSAL), AUSL-IRCCS di Reggio Emilia, Via Amendola n.2, I-42122 Reggio Emilia, Italy
| | - Pietro Ferraro
- Occupational Medicine Unit, Direzione Sanità, Italian Railways' Infrastructure Division, RFI SpA, I-00161 Rome, Italy
| | - Silvia Ranzieri
- Department of Medicine and Surgery, University of Parma, Via Gramsci, 14, I-43126 Parma, Italy
| | - Giorgia Boldini
- Department of Medicine and Surgery, University of Parma, Via Gramsci, 14, I-43126 Parma, Italy
- Servizio di Igiene Pubblica, AUSL di Parma, Via Vasari n.13/a, I-43123 Parma, Italy
| | - Ilaria Zanella
- Department of Medicine and Surgery, University of Parma, Via Gramsci, 14, I-43126 Parma, Italy
| | - Federico Marchesi
- Department of Medicine and Surgery, University of Parma, Via Gramsci, 14, I-43126 Parma, Italy
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Zacharias N, Waßer F, Freier L, Spies K, Koch C, Pleischl S, Mutters NT, Kistemann T. Legionella in drinking water: the detection method matters. JOURNAL OF WATER AND HEALTH 2023; 21:884-894. [PMID: 37515560 PMCID: wh_2023_035 DOI: 10.2166/wh.2023.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Legionella concentrations in drinking water have been regulated for decades and are evaluated with regard to their concentrations in drinking water plumbing systems (DWPS). The respective action levels differ at the international level. In Germany, the Federal Environment Agency (UBA) specifies the application of ISO 11731 for the detection of legionella in drinking water and gives a binding recommendation for the methods to be used for culturing and evaluation. Effective from 01 March 2019, the UBA recommendation was revised. The utilized culture media in the culture approach were altered, consequently affecting the spectrum of legionella colonies detected in drinking water. Using data from a routine legionella monitoring of a large laboratory, over a period of 6 years and 17,270 individual drinking water samples, allowed us to assess the impact of the alteration on the assessment of DWPS. By comparing the amount of action level exceedances before and after the method change, it could be demonstrated that exceedances are reported significantly more often under the new method. Consequently, the corresponding action level for evaluation of legionella contamination and the resulting risk to human health needs to be revised to avoid the misleading impression of increased health risk.
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Affiliation(s)
- Nicole Zacharias
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany E-mail:
| | - Felix Waßer
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Lia Freier
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Kirsten Spies
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Christoph Koch
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Stefan Pleischl
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Nico T Mutters
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Thomas Kistemann
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany; Department of Geography, University of Bonn, Meckenheimer Allee 166, Bonn 53115, Germany; Centre for Development Research, University of Bonn, Genscherallee 3, Bonn 53113, Germany
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Graham FF, Harte D, Zhang J, Fyfe C, Baker MG. Increased Incidence of Legionellosis after Improved Diagnostic Methods, New Zealand, 2000-2020. Emerg Infect Dis 2023; 29:1173-1182. [PMID: 37209673 DOI: 10.3201/eid2906.221598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023] Open
Abstract
Legionellosis, notably Legionnaires' disease, is recognized globally and in New Zealand (Aotearoa) as a major cause of community-acquired pneumonia. We analyzed the temporal, geographic, and demographic epidemiology and microbiology of Legionnaires' disease in New Zealand by using notification and laboratory-based surveillance data for 2000‒2020. We used Poisson regression models to estimate incidence rate ratios and 95% CIs to compare demographic and organism trends over 2 time periods (2000-2009 and 2010-2020). The mean annual incidence rate increased from 1.6 cases/100,000 population for 2000-2009 to 3.9 cases/100,000 population for 2010-2020. This increase corresponded with a change in diagnostic testing from predominantly serology with some culture to almost entirely molecular methods using PCR. There was also a marked shift in the identified dominant causative organism, from Legionella pneumophila to L. longbeachae. Surveillance for legionellosis could be further enhanced by greater use of molecular typing of isolates.
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Gleason JA, Conner LE, Ross KM. Associations of household factors, hot water temperature, and chlorine residual with Legionella occurrence in single-family homes in New Jersey. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 870:161984. [PMID: 36739010 DOI: 10.1016/j.scitotenv.2023.161984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 06/18/2023]
Abstract
Only 4 % of reported Legionnaires' disease (LD) cases are outbreak-associated and the remaining 96 % are sporadic, for which no known source of Legionella is identified. Although outbreaks of LD are linked to cooling towers, decorative fountains, spas and hot tubs, and other sources, the drivers of sporadic LD are less known. Residential premise plumbing is likely an important source of aerosol exposure and there are unique features of premise plumbing which could lead to proliferation of Legionella. A sampling study of Legionella in single-family homes was undertaken in NJ from 2020 to 2021 which included a household characteristic survey and collection of hot water temperature and chlorine residual during sampling. A total of 94 homeowners residing in owner-occupied, single-family units with individual hot water systems were recruited to participate through two mechanisms (1) Legionnaire's disease case-patients and (2) non-case volunteers from each NJ county. Among the 94 single-family homes sampled, 15 % had least one sample positive for Legionella by culture and 57 % had at least one sample with detection of Legionella DNA markers by PCR. Chlorine residual, hot water temperature, and season were independently associated with increased detection of Legionella in home water samples. There was limited or inconsistent evidence of the role of household characteristic factors in Legionella detection. This study identified season, insufficient chlorine residual and hot water temperature as risk factors for Legionella detection in single-family homes. Findings from this work can promote additional partnership between public health and water utilities in improving chlorine residuals in residential communities and educating homeowners on best practices for home water management.
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Affiliation(s)
- Jessie A Gleason
- Division of Epidemiology, Environmental and Occupational Health, New Jersey Department of Health, 135 East State Street, PO Box 369, Trenton, NJ, USA.
| | - Lauren E Conner
- Division of Epidemiology, Environmental and Occupational Health, New Jersey Department of Health, 135 East State Street, PO Box 369, Trenton, NJ, USA
| | - Kathleen M Ross
- Division of Epidemiology, Environmental and Occupational Health, New Jersey Department of Health, 135 East State Street, PO Box 369, Trenton, NJ, USA
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11
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Graham FF, Harte DJG, Baker MG. Environmental Investigation and Surveillance for Legionella in Aotearoa New Zealand, 2000-2020. Curr Microbiol 2023; 80:156. [PMID: 36997742 PMCID: PMC10063469 DOI: 10.1007/s00284-023-03261-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/07/2023] [Indexed: 04/01/2023]
Abstract
The reported rate of legionellosis is increasing in Aotearoa New Zealand (NZ) with most cases community-acquired, sporadic (non-outbreak) and without an identifiable source. This analysis used two datasets to describe the environmental sources that contribute to Legionella in NZ, based on linkages with outbreaks and sporadic clinical cases, and analysis of environmental testing data. These findings highlight the need for enhanced environmental investigation of clinical cases and outbreaks. There is also a need for systematic surveillance testing of high-risk source environments to support more rigorous controls to prevent legionellosis.
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Affiliation(s)
- Frances F Graham
- Department of Public Health, University of Otago, P. O. 7343, Wellington South, 6242, New Zealand.
| | - David J G Harte
- ESR, Legionella Reference Laboratory, Health Programme, Kenepuru Science Centre, Wellington, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, P. O. 7343, Wellington South, 6242, New Zealand
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Capuano R, Mansi A, Paba E, Marcelloni AM, Chiominto A, Proietto AR, Gordiani A, Catini A, Paolesse R, Tranfo G, Di Natale C. A Pilot Study for Legionella pneumophila Volatilome Characterization Using a Gas Sensor Array and GC/MS Techniques. SENSORS (BASEL, SWITZERLAND) 2023; 23:1401. [PMID: 36772440 PMCID: PMC9920052 DOI: 10.3390/s23031401] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 06/18/2023]
Abstract
Legionellosis is a generic term describing the pneumonic (Legionnaires' disease, LD) and non-pneumonic (Pontiac fever, PF) forms of infection with bacteria belonging to the genus Legionella. Currently, the techniques used to detect Legionella spp. in water samples have certain limitations and drawbacks, and thus, there is a need to identify new tools to carry out low-cost and rapid analysis. In this regard, several studies demonstrated that a volatolomics approach rapidly detects and discriminates different species of microorganisms via their volatile signature. In this paper, the volatile organic compounds (VOCs) pattern emitted in vitro by Legionella pneumophila cultures is characterized and compared to those produced by other Legionella species and by Pseudomonas aeruginosa, using a gas sensor array and gas chromatograph mass spectrometer (GC-MS). Bacterial cultures were measured at the 3rd and 7th day after the incubation. Sensor array data analyzed via the K-nearest neighbours (k-NN) algorithm showed a sensitivity to Legionella pneumophila identification at around 89%. On the other hand, GC-MS identified a bouquet of VOCs, mainly alcohols and ketones, that enable the differentiation of Legionella pneumophila in respect to other waterborne microorganisms.
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Affiliation(s)
- Rosamaria Capuano
- Department of Electronic Engineering, University of Rome Tor Vergata, Via del Politecnico 1, 00133 Rome, Italy
- Interdepartmental Centre for Volatilomics ‘A. D’Amico’, University of Rome Tor Vergata, Via del Politecnico 1, 00133 Rome, Italy
| | - Antonella Mansi
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers’ Compensation Authority (INAIL), Via Fontana Candida 1, Monte Porzio Catone, 00078 Rome, Italy
| | - Emilia Paba
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers’ Compensation Authority (INAIL), Via Fontana Candida 1, Monte Porzio Catone, 00078 Rome, Italy
| | - Anna Maria Marcelloni
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers’ Compensation Authority (INAIL), Via Fontana Candida 1, Monte Porzio Catone, 00078 Rome, Italy
| | - Alessandra Chiominto
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers’ Compensation Authority (INAIL), Via Fontana Candida 1, Monte Porzio Catone, 00078 Rome, Italy
| | - Anna Rita Proietto
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers’ Compensation Authority (INAIL), Via Fontana Candida 1, Monte Porzio Catone, 00078 Rome, Italy
| | - Andrea Gordiani
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers’ Compensation Authority (INAIL), Via Fontana Candida 1, Monte Porzio Catone, 00078 Rome, Italy
| | - Alexandro Catini
- Department of Electronic Engineering, University of Rome Tor Vergata, Via del Politecnico 1, 00133 Rome, Italy
- Interdepartmental Centre for Volatilomics ‘A. D’Amico’, University of Rome Tor Vergata, Via del Politecnico 1, 00133 Rome, Italy
| | - Roberto Paolesse
- Interdepartmental Centre for Volatilomics ‘A. D’Amico’, University of Rome Tor Vergata, Via del Politecnico 1, 00133 Rome, Italy
- Department of Chemical Science and Technology, University of Rome Tor Vergata, Via della Ricerca Scientifica, 00133 Rome, Italy
| | - Giovanna Tranfo
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Italian Workers’ Compensation Authority (INAIL), Via Fontana Candida 1, Monte Porzio Catone, 00078 Rome, Italy
| | - Corrado Di Natale
- Department of Electronic Engineering, University of Rome Tor Vergata, Via del Politecnico 1, 00133 Rome, Italy
- Interdepartmental Centre for Volatilomics ‘A. D’Amico’, University of Rome Tor Vergata, Via del Politecnico 1, 00133 Rome, Italy
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13
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Matthews S, Trigui H, Grimard-Conea M, Vallarino Reyes E, Villiard G, Charron D, Bédard E, Faucher S, Prevost M. Detection of Diverse Sequence Types of Legionella pneumophila by Legiolert Enzymatic-Based Assay and the Development of a Long-Term Storage Protocol. Microbiol Spectr 2022; 10:e0211822. [PMID: 36314908 PMCID: PMC9769756 DOI: 10.1128/spectrum.02118-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022] Open
Abstract
Legiolert is a rapid culture-based enzymatic method for the detection and quantification of Legionella pneumophila in potable and nonpotable water samples. We aimed to assess the ability of this assay to detect diverse sequence types and validated a simple method to preserve samples. We used this assay on 253 potable and 165 nonpotable cooling tower water samples from various buildings in Québec, Canada, and performed sequence-based typing on 96 isolates. Six sequence types were identified, including ST1, ST378, ST1427, ST2859, ST3054, and ST3069. Whole-genome sequencing revealed that ST2859 was a member of the L. pneumophila subspecies fraseri. Additional tests with pure isolates also found that subspecies Pascullei and Raphaeli could be detected via Legiolert. Eight storage methods, including the current recommendation to store Legiolert trays at 4°C, were evaluated for their ability to preserve viable cultures. Of those, storage of Legiolert culture with 10% glycerol at -80°C produced the best results, fully preserving culturable Legionella for at least 12.5 months. We incorporated these findings into a standard procedure for processing Legiolert packets. Overall, Legiolert captures a variety of common and new STs in addition to important L. pneumophila subspecies and can be easily stored, which allows the conservation of a population of isolates for later characterization. IMPORTANCE Legionnaires' disease is caused by the bacterium Legionella pneumophila, which can be found in a variety of water systems. When outbreaks of Legionnaires' disease occur, it is necessary to find the water systems transmitting the bacterium to humans. Access to historical isolates from water system samples is key for success in identifying sources but current regulations and isolation protocols mean very few isolates are obtained and stored long-term. We showed here that the Legiolert test could detect and produce isolates of a variety of L. pneumophila subspecies and types. In addition, the Legiolert test medium containing a representative population of isolates could be preserved for at least 12 months at -80°C with the addition of glycerol to the test medium. Therefore, we confirmed that the Legiolert method could be a useful tool for retrospective analysis of potential sources for an outbreak.
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Affiliation(s)
- Sara Matthews
- Department of Natural Resource Sciences, McGill University, Montréal, Québec, Canada
| | - Hana Trigui
- Department of Civil, Geological and Mining Engineering, Polytechnique de Montréal, Montréal, Québec, Canada
| | - Marianne Grimard-Conea
- Department of Civil, Geological and Mining Engineering, Polytechnique de Montréal, Montréal, Québec, Canada
| | | | - Gabriel Villiard
- Department of Natural Resource Sciences, McGill University, Montréal, Québec, Canada
| | - Dominique Charron
- Department of Civil, Geological and Mining Engineering, Polytechnique de Montréal, Montréal, Québec, Canada
| | - Emilie Bédard
- Department of Civil, Geological and Mining Engineering, Polytechnique de Montréal, Montréal, Québec, Canada
| | - Sébastien Faucher
- Department of Natural Resource Sciences, McGill University, Montréal, Québec, Canada
- Centre de Recherche en Infectiologie Porcine et Avicole (CRIPA), Faculté de Médecine Vétérinaire, Université de Montréal, Montréal, Québec, Canada
| | - Michèle Prevost
- Department of Civil, Geological and Mining Engineering, Polytechnique de Montréal, Montréal, Québec, Canada
- Industrial Chair on Drinking Water, Department of Civil, Geological and Mining Engineering, Polytechnique de Montréal, Montréal, Québec, Canada
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Legionella pneumonia as a rising public health threat in Argentina: Is it the time to worry? Ann Med Surg (Lond) 2022; 83:104801. [PMID: 36345419 PMCID: PMC9636435 DOI: 10.1016/j.amsu.2022.104801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022] Open
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15
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Gorzynski J, Wee B, Llano M, Alves J, Cameron R, McMenamin J, Smith A, Lindsay D, Fitzgerald JR. Epidemiological analysis of Legionnaires' disease in Scotland: a genomic study. THE LANCET. MICROBE 2022; 3:e835-e845. [PMID: 36240833 DOI: 10.1016/s2666-5247(22)00231-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Legionella pneumophila is the main cause of a severe pneumonic illness known as Legionnaires' disease and is a global public health threat. Whole-genome sequencing (WGS) can be applied to trace environmental origins of L pneumophila infections, providing information to guide appropriate interventions. We aim to explore the evolutionary and epidemiological relationships in a 36-year Scottish L pneumophila reference isolate collection. METHODS We investigated the genomic epidemiology of Legionnaires' disease over 36 years in Scotland, comparing genome sequences for all clinical L pneumophila isolates (1984-2020) with a sequence dataset of 3211 local and globally representative isolates. We used a stratified clustering approach to capture epidemiological relationships by core genome Multi-locus Sequence Typing, followed by high-resolution phylogenetic analysis of clusters to measure diversity and evolutionary relatedness in context with epidemiological metadata. FINDINGS Clustering analysis showed that 111 (57·5 %) of 193 of L pneumophila infections in Scotland were caused by ten endemic lineages with a wide temporal and geographical distribution. Phylogenetic analysis of L pneumophila identified hospital-associated sublineages that had been detected in the hospital environment up to 19 years. Furthermore, 12 (30·0%) of 40 community-associated infections (excluding a single, large outbreak) that occurred over a 13 year period (from 2000 to 2013) were caused by a single widely distributed endemic clone (ST37), consistent with enhanced human pathogenicity. Finally, our analysis revealed clusters linked by national or international travel to distinct geographical regions, indicating several previously unrecognised travel links between closely related isolates (fewer than five single nucleotide polymorphisms) connected by geography. INTERPRETATION Our analysis reveals the existence of previously undetected endemic clones of L pneumophila that existed for many years in hospital, community, and travel-associated environments. In light of these findings, we propose that cluster and outbreak definitions should be reconsidered, and propose WGS-based surveillance as a critical public health tool for real-time identification and mitigation of clinically important endemic clones. FUNDING Chief Scientist Office, Biotechnology and Biological Sciences Research Council (UK), Medical Research Council Precision Medicine Doctoral Training Programme, Wellcome Trust, and Medical Research Council (UK).
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Affiliation(s)
- Jamie Gorzynski
- The Roslin Institute, University of Edinburgh, Edinburgh, UK
| | - Bryan Wee
- The Roslin Institute, University of Edinburgh, Edinburgh, UK
| | | | - Joana Alves
- The Roslin Institute, University of Edinburgh, Edinburgh, UK
| | | | | | - Andrew Smith
- Scottish Microbiology Reference Laboratory, Glasgow Royal Infirmary, Glasgow, UK; College of Medical, Veterinary & Life Sciences, Glasgow Dental Hospital and School, University of Glasgow, Glasgow, UK
| | - Diane Lindsay
- Scottish Microbiology Reference Laboratory, Glasgow Royal Infirmary, Glasgow, UK
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16
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Ghaznavi C, Ishikane M, Yoneoka D, Tanoue Y, Kawashima T, Eguchi A, Nomura S. Effect of the COVID-19 pandemic and state of emergency declarations on the relative incidence of legionellosis and invasive pneumococcal disease in Japan. J Infect Chemother 2022; 29:90-94. [PMID: 36116719 PMCID: PMC9477788 DOI: 10.1016/j.jiac.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/03/2022] [Accepted: 08/20/2022] [Indexed: 11/27/2022]
Abstract
Introduction During the COVID-19 pandemic, the incidence of many droplet-transmitted infections decreased due to increased mask-wearing and social distancing. Contrastingly, there has been concern that COVID-19 countermeasures, such as lockdowns, may increase legionellosis incidence via water stagnation. During the pandemic in Japan, four state of emergency declarations were imposed between 2020 and 2021, which makes it particularly suitable to test this hypothesis. Methods We use country-level surveillance data from the National Institute of Infectious Diseases to track the relative incidence of legionellosis compared to invasive pneumococcal disease (IPD) during the COVID-19 pandemic in Japan, with a focus on the periods just after state of emergency declarations were lifted. Results The absolute number of legionellosis and IPD cases decreased in 2020 and 2021 compared to previous years. The average relative incidence of legionellosis as well as the variance of the relative incidence significantly increased during the pandemic compared to previous years. There were no increases in the relative incidence of legionellosis during the periods immediately following emergency declaration liftings, but the relative incidence did increase considerably during the first two states of emergency. Conclusions COVID-19 countermeasures appear more effective at decreasing the incidence of human-to-human transmitted infections, such as IPD, compared to environmentally-transmitted infections, such as legionellosis. Though no evidence was found to suggest that legionellosis cases increased after state of emergency declarations, public health efforts should continue to emphasize the importance of routine sanitation and water system maintenance to prevent water stagnation and Legionella spp. contamination.
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Affiliation(s)
- Cyrus Ghaznavi
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan; Medical Education Program, Washington University School of Medicine in St Louis, Saint Louis, USA.
| | - Masahiro Ishikane
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Daisuke Yoneoka
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan; Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Tokyo Foundation for Policy Research, Tokyo, Japan; Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Yuta Tanoue
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan; Institute for Business and Finance, Waseda University, Tokyo, Japan
| | - Takayuki Kawashima
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan; Department of Mathematical and Computing Science, Tokyo Institute of Technology, Tokyo, Japan
| | - Akifumi Eguchi
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan; Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Shuhei Nomura
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan; Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Tokyo Foundation for Policy Research, Tokyo, Japan
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17
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Rutile-TiO2/PtO2 Glass Coatings Disinfects Aquatic Legionella pneumophila via Morphology Change and Endotoxin Degradation under LED Irradiation. Catalysts 2022. [DOI: 10.3390/catal12080856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Legionella pneumophila (L. pneumophila) is the causative agent of Legionnaires’ disease and Pontiac fever, collectively known as legionellosis. L. pneumophila infection occurs through inhalation of contaminated aerosols from water systems in workplaces and institutions. The development of disinfectants that can eliminate L. pneumophila in such water systems without evacuating people is needed to prevent the spread of L. pneumophila. Photocatalysts are attractive disinfectants that do not harm human health. In particular, the TiO2 photocatalyst kills L. pneumophila under various conditions, but its mode of action is unknown. Here, we confirmed the high performance of TiO2 photocatalyst containing PtO2 via the degradation of methylene blue (half-value period: 19.2 min) and bactericidal activity against Escherichia coli (half-value period: 15.1 min) in water. Using transmission electron microscopy, we demonstrate that the disinfection of L. pneumophila (half-value period: 6.7 min) by TiO2 photocatalyst in water is accompanied by remarkable cellular membrane and internal damage to L. pneumophila. Assays with limulus amebocyte lysate and silver staining showed the release of endotoxin from L. pneumophila due to membrane damage and photocatalytic degradation of this endotoxin. This is the first study to demonstrate the disinfection mechanisms of TiO2 photocatalyst, namely, via morphological changes and membrane damage of L. pneumophila. Our results suggest that TiO2 photocatalyst might be effective in controlling the spread of L. pneumophila.
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18
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William HM, Heslin K, Kram JJF, Toberna CP, Baumgardner DJ. Association of Natural Waterways and Legionella pneumophila Infection in Eastern Wisconsin: A Case-Control Study. J Patient Cent Res Rev 2022; 9:128-131. [PMID: 35600231 PMCID: PMC9022710 DOI: 10.17294/2330-0698.1872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
Preliminary research has suggested possible associations between natural waterways and Legionella infection, and we previously explored these associations in eastern Wisconsin using positive L. pneumophila serogroup 1 urine antigen tests (LUAT) as diagnostic. This case-control study was a secondary analysis of home address data from patients who underwent LUAT at a single eastern Wisconsin health system from 2013 to 2017. Only zip codes within the health system's catchment area that registered ≥3 positive cases and ≥50 completed tests, as well as geographically adjacent zip codes with ≥2 positive cases and ≥50 tests, were included. A 1:3 ratio of cases to randomly selected controls was used. Home addresses were geocoded and mapped using ArcGIS software (Esri); nearest waterway and distance to home was identified. Distance to nearest waterway according to ArcGIS was verified/corrected using Google Maps incognito. Distances were analyzed using chi-squared and 2-sample t-tests. Overall, mean distance to nearest waterway did not differ between cases (2958 ± 2049 ft) and controls (2856 ± 2018 ft; P=0.701). However, in a subset of nonurban zip codes, cases were closer to nearest waterway than controls (1165 ± 905 ft vs 2113 ± 1710 ft; P=0.019). No association was found between cases and type of waterway. Further research is needed to investigate associations and differences between natural and built environmental water sources in relation to legionellosis.
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Affiliation(s)
- Hannah M. William
- Advocate Aurora Research Institute, Advocate Aurora Health, Milwaukee, WI
- Center for Urban Population Health, Milwaukee, WI
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Kayla Heslin
- Advocate Aurora Research Institute, Advocate Aurora Health, Milwaukee, WI
- Center for Urban Population Health, Milwaukee, WI
- Aurora UW Medical Group, Advocate Aurora Health, Milwaukee, WI
| | - Jessica J. F. Kram
- Center for Urban Population Health, Milwaukee, WI
- Aurora UW Medical Group, Advocate Aurora Health, Milwaukee, WI
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Caroline P. Toberna
- Advocate Aurora Research Institute, Advocate Aurora Health, Milwaukee, WI
- Center for Urban Population Health, Milwaukee, WI
- Aurora UW Medical Group, Advocate Aurora Health, Milwaukee, WI
| | - Dennis J. Baumgardner
- Center for Urban Population Health, Milwaukee, WI
- Aurora UW Medical Group, Advocate Aurora Health, Milwaukee, WI
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Gleason JA, Ross KM. Development and Evaluation of Statewide Prospective Spatiotemporal Legionellosis Cluster Surveillance, New Jersey, USA. Emerg Infect Dis 2022; 28:625-630. [PMID: 35202521 PMCID: PMC8888220 DOI: 10.3201/eid2803.211147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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20
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A Community Outbreak of Legionnaires' Disease with Two Strains of L. pneumophila Serogroup 1 Linked to an Aquatic Therapy Centre. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031119. [PMID: 35162143 PMCID: PMC8834728 DOI: 10.3390/ijerph19031119] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/12/2022] [Accepted: 01/17/2022] [Indexed: 11/16/2022]
Abstract
An outbreak of Legionnaires' disease affected 18 people in Montpellier, a town of the south of France, between December 2016 and July 2017. All cases were diagnosed by a positive urinary antigen test. No deaths were reported. Epidemiological, environmental and genomic investigations (nested Sequence-Based Typing (nSBT) and whole genome sequencing) were undertaken. For the cases for which we had information, four had a new isolate (ST2471), one had a different new isolate (ST2470), one had a genomic pattern compatible with the ST2471 identified by nSBT (flaA = 3), and one had a genomic pattern not compatible with two previous identified STs (pilE = 6). The analysis conducted on the pool of an aquatic therapy center revealed seven isolates of Legionella pneumophila. Whole genome analysis confirmed the link between the environmental and clinical isolates for both ST2470 and ST2471. As the outbreak occurred slowly, with several weeks between new cases, it was not possible to immediately identify a common source. The sixth case was the first to report having aquatic therapy care. Of the 18 cases, eight had attended the aquatic therapy center and the other 10 were inhabitants who lived, worked or walked close to the center. The main cause for this outbreak was the lack of facility maintenance. This investigation highlights the risk to public health of aquatic therapy centers for users and nearby populations, and emphasizes the need for risk reduction measures with specific guidelines to improve health and safety in aquatic facilities.
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Gleason JA, Cohn PD. A review of legionnaires' disease and public water systems - Scientific considerations, uncertainties and recommendations. Int J Hyg Environ Health 2021; 240:113906. [PMID: 34923288 DOI: 10.1016/j.ijheh.2021.113906] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/02/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022]
Abstract
Legionella is an opportunistic premise plumbing pathogen and causative agent of a severe pneumonia called Legionnaires' Disease (LD). Cases of LD have been on the rise in the U.S. and globally. Although Legionella was first identified 45 years ago, it remains an 'emerging pathogen." Legionella is part of the normal ecology of a public water system and is frequently detected in regulatory-compliant drinking water. Drinking water utilities, regulators and public health alike are increasingly required to have a productive understanding of the evolving issues and complex discussions of the contribution of the public water utility to Legionella exposure and LD risk. This review provides a brief overview of scientific considerations important for understanding this complex topic, a review of findings from investigations of public water and LD, including data gaps, and recommendations for professionals interested in investigating public water utilities. Although the current literature is inconclusive in identifying a public water utility as a sole source of an LD outbreak, the evidence is clear that minimizing growth of Legionella in public water utilities through proper maintenance and sustained disinfectant residuals, throughout all sections of the water utility, will lead to a less conducive environment for growth of the bacteria in the system and the buildings they serve.
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Affiliation(s)
- Jessie A Gleason
- Environmental and Occupational Health Surveillance Program, New Jersey Department of Health, 135 E. State Street, P.O. Box 369, Trenton, NJ, 08625, USA.
| | - Perry D Cohn
- Retired, Environmental and Occupational Health Surveillance Program, New Jersey Department of Health, PO Box 369, Trenton, NJ, 08625, USA.
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22
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Zhang C, Lu J. Legionella: A Promising Supplementary Indicator of Microbial Drinking Water Quality in Municipal Engineered Water Systems. FRONTIERS IN ENVIRONMENTAL SCIENCE 2021; 9:1-22. [PMID: 35004706 PMCID: PMC8740890 DOI: 10.3389/fenvs.2021.684319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Opportunistic pathogens (OPs) are natural inhabitants and the predominant disease causative biotic agents in municipal engineered water systems (EWSs). In EWSs, OPs occur at high frequencies and concentrations, cause drinking-water-related disease outbreaks, and are a major factor threatening public health. Therefore, the prevalence of OPs in EWSs represents microbial drinking water quality. Closely or routinely monitoring the dynamics of OPs in municipal EWSs is thus critical to ensuring drinking water quality and protecting public health. Monitoring the dynamics of conventional (fecal) indicators (e.g., total coliforms, fecal coliforms, and Escherichia coli) is the customary or even exclusive means of assessing microbial drinking water quality. However, those indicators infer only fecal contamination due to treatment (e.g., disinfection within water utilities) failure and EWS infrastructure issues (e.g., water main breaks and infiltration), whereas OPs are not contaminants in drinking water. In addition, those indicators appear in EWSs at low concentrations (often absent in well-maintained EWSs) and are uncorrelated with OPs. For instance, conventional indicators decay, while OPs regrow with increasing hydraulic residence time. As a result, conventional indicators are poor indicators of OPs (the major aspect of microbial drinking water quality) in EWSs. An additional or supplementary indicator that can well infer the prevalence of OPs in EWSs is highly needed. This systematic review argues that Legionella as a dominant OP-containing genus and natural inhabitant in EWSs is a promising candidate for such a supplementary indicator. Through comprehensively comparing the behavior (i.e., occurrence, growth and regrowth, spatiotemporal variations in concentrations, resistance to disinfectant residuals, and responses to physicochemical water quality parameters) of major OPs (e.g., Legionella especially L. pneumophila, Mycobacterium, and Pseudomonas especially P. aeruginosa), this review proves that Legionella is a promising supplementary indicator for the prevalence of OPs in EWSs while other OPs lack this indication feature. Legionella as a dominant natural inhabitant in EWSs occurs frequently, has a high concentration, and correlates with more microbial and physicochemical water quality parameters than other common OPs. Legionella and OPs in EWSs share multiple key features such as high disinfectant resistance, biofilm formation, proliferation within amoebae, and significant spatiotemporal variations in concentrations. Therefore, the presence and concentration of Legionella well indicate the presence and concentrations of OPs (especially L. pneumophila) and microbial drinking water quality in EWSs. In addition, Legionella concentration indicates the efficacies of disinfectant residuals in EWSs. Furthermore, with the development of modern Legionella quantification methods (especially quantitative polymerase chain reactions), monitoring Legionella in ESWs is becoming easier, more affordable, and less labor-intensive. Those features make Legionella a proper supplementary indicator for microbial drinking water quality (especially the prevalence of OPs) in EWSs. Water authorities may use Legionella and conventional indicators in combination to more comprehensively assess microbial drinking water quality in municipal EWSs. Future work should further explore the indication role of Legionella in EWSs and propose drinking water Legionella concentration limits that indicate serious public health effects and require enhanced treatment (e.g., booster disinfection).
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Affiliation(s)
- Chiqian Zhang
- Pegasus Technical Services, Inc., Cincinnati, OH, United States
| | - Jingrang Lu
- Office of Research and Development, United States Environmental Protection Agency, Cincinnati, OH, United States
- Correspondence: Jingrang Lu,
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23
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Hunter CM, Salandy SW, Smith JC, Edens C, Hubbard B. Racial Disparities in Incidence of Legionnaires' Disease and Social Determinants of Health: A Narrative Review. Public Health Rep 2021; 137:660-671. [PMID: 34185609 DOI: 10.1177/00333549211026781] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Racial and socioeconomic disparities in the incidence of Legionnaires' disease have been documented for the past 2 decades; however, the social determinants of health (SDH) that contribute to these disparities are not well studied. The objective of this narrative review was to characterize SDH to inform efforts to reduce disparities in the incidence of Legionnaires' disease. METHODS We conducted a narrative review of articles published from January 1979 through October 2019 that focused on disparities in the incidence of Legionnaires' disease and pneumonia (inclusive of bacterial pneumonia and/or community-acquired pneumonia) among adults and children (excluding articles that were limited to people aged <18 years). We identified 220 articles, of which 19 met our criteria: original research, published in English, and examined Legionnaires' disease or pneumonia, health disparities, and SDH. We organized findings using the Healthy People 2030 SDH domains: economic stability, education access and quality, social and community context, health care access and quality, and neighborhood and built environment. RESULTS Of the 19 articles reviewed, multiple articles examined disparities in incidence of Legionnaires' disease and pneumonia related to economic stability/income (n = 13) and comorbidities (n = 10), and fewer articles incorporated SDH variables related to education (n = 3), social support (none), health care access (n = 1), and neighborhood and built environment (n = 6) in their analyses. CONCLUSIONS Neighborhood and built-environment factors such as housing, drinking water infrastructure, and pollutant exposures represent critical partnership and research opportunities. More research that incorporates SDH and multilevel, cross-sector interventions is needed to address disparities in Legionnaires' disease incidence.
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Affiliation(s)
- Candis M Hunter
- 1242 Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Simone W Salandy
- 1242 Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jessica C Smith
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Chris Edens
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brian Hubbard
- 1242 Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Chambers ST, Slow S, Scott-Thomas A, Murdoch DR. Legionellosis Caused by Non- Legionella pneumophila Species, with a Focus on Legionella longbeachae. Microorganisms 2021; 9:291. [PMID: 33572638 PMCID: PMC7910863 DOI: 10.3390/microorganisms9020291] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 12/13/2022] Open
Abstract
Although known as causes of community-acquired pneumonia and Pontiac fever, the global burden of infection caused by Legionella species other than Legionella pneumophila is under-recognised. Non-L. pneumophila legionellae have a worldwide distribution, although common testing strategies for legionellosis favour detection of L. pneumophila over other Legionella species, leading to an inherent diagnostic bias and under-detection of cases. When systematically tested for in Australia and New Zealand, L. longbeachae was shown to be a leading cause of community-acquired pneumonia. Exposure to potting soils and compost is a particular risk for infection from L. longbeachae, and L. longbeachae may be better adapted to soil and composting plant material than other Legionella species. It is possible that the high rate of L. longbeachae reported in Australia and New Zealand is related to the composition of commercial potting soils which, unlike European products, contain pine bark and sawdust. Genetic studies have demonstrated that the Legionella genomes are highly plastic, with areas of the chromosome showing high levels of recombination as well as horizontal gene transfer both within and between species via plasmids. This, combined with various secretion systems and extensive effector repertoires that enable the bacterium to hijack host cell functions and resources, is instrumental in shaping its pathogenesis, survival and growth. Prevention of legionellosis is hampered by surveillance systems that are compromised by ascertainment bias, which limits commitment to an effective public health response. Current prevention strategies in Australia and New Zealand are directed at individual gardeners who use potting soils and compost. This consists of advice to avoid aerosols generated by the use of potting soils and use masks and gloves, but there is little evidence that this is effective. There is a need to better understand the epidemiology of L. longbeachae and other Legionella species in order to develop effective treatment and preventative strategies globally.
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Affiliation(s)
- Stephen T. Chambers
- Department of Pathology and Biomedical Science, University of Otago, Christchurch 8011, New Zealand; (S.S.); (A.S.-T.); (D.R.M.)
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Management of Microbiological Contamination of the Water Network of a Newly Built Hospital Pavilion. Pathogens 2021; 10:pathogens10010075. [PMID: 33467059 PMCID: PMC7829805 DOI: 10.3390/pathogens10010075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 12/28/2022] Open
Abstract
The good installation, as well as commissioning plan, of a water network is a crucial step in reducing the risk of waterborne diseases. The aim of this study was to monitor the microbiological quality of water from a newly built pavilion before it commenced operation. Overall, 91 water samples were tested for coliforms, Escherichia coli, enterococci, Pseudomonas aeruginosa and Legionella at three different times: T0 (without any water treatment), T1 (after treatment with hydrogen peroxide and silver ions at initial concentration of 20 mg/L and after flushing of water for 20 min/day for seven successive days) and T2 (15 days later). Coliforms were detected in 47.3% of samples at T0, 36.3% at T1 and 4.4% at T2. E. coli was isolated in 4.4% of the samples only at T1, while enterococci appeared in 12.1% of the samples at T1 and in 2.2% at T2. P. aeruginosa was isolated in 50.5% of the samples at T0, 29.7% at T1 and 1.1% at T2. Legionella pneumophila serogroup 8 was isolated in 80.2% of the samples at T0, 36.3% at T1 and 2.2% at T2. Our results confirmed the need for a water safety plan in new hospital pavilions to prevent the risk of waterborne diseases.
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Bertrams W, Jung AL, Schmeck B. Modeling of Pneumonia and Acute Lung Injury: Bioinformatics, Systems Medicine, and Artificial Intelligence. SYSTEMS MEDICINE 2021. [DOI: 10.1016/b978-0-12-801238-3.11689-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Steingrímsson V, Gíslason GK, Þorsteinsdóttir S, Rögnvaldsson S, Gottfreðsson M, Aspelund T, Turesson I, Björkholm M, Landgren O, Kristinsson SY. A nationwide study on inpatient opportunistic infections in patients with chronic lymphocytic leukemia in the pre-ibrutinib era. Eur J Haematol 2020; 106:346-353. [PMID: 33211356 DOI: 10.1111/ejh.13553] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Opportunistic infections in chronic lymphocytic leukemia (CLL) have been described in clinical trials, single-center studies, and case reports. We performed a nationwide study to estimate the incidence and impact of inpatient opportunistic infections. METHODS The incidence rate (IR) and incidence rate ratio (IRR) for Swedish CLL patients diagnosed 1994-2013, and matched controls were calculated, as well as the case-fatality ratio (CFR). RESULTS Among 8989 CLL patients, a total of 829 opportunistic infections were registered (IR 16.6 per 1000 person-years) compared with 252 opportunistic infections in 34 283 matched controls (IR 0.99). The highest incidence in the CLL cohort was for Pneumocystis pneumonia (200 infections, IR 4.03); Herpes zoster (146 infections, IR 2.94), and Pseudomonas (83 infections, IR 1.66) infections. The highest risk relative to matched controls was observed for Pneumocystis pneumonia (IRR 114, 95% confidence interval 58.7-252). The 60-day CFR for CLL patients with opportunistic infections was 23% (188/821), highest for progressive multifocal encephalopathy (5/7, 71%) and aspergillosis (25/60, 42%). CONCLUSION We have uniquely depicted the incidence of rare and serious infections in CLL patients and found a relatively high incidence of Pneumocystis pneumonia. Of the most common opportunistic infections, CLL patients with aspergillosis had the poorest prognosis.
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Affiliation(s)
| | | | | | | | - Magnús Gottfreðsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Infectious Diseases, Landspitali University Hospital, Reykjavik, Iceland
| | - Thor Aspelund
- Centre for Public Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Ingemar Turesson
- Department of Hematology and Coagulation Disorders, Skane University Hospital, Malmö, Sweden
| | - Magnus Björkholm
- Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Ola Landgren
- Myeloma Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Sigurdur Y Kristinsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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De Giglio O, Diella G, Lopuzzo M, Triggiano F, Calia C, Pousis C, Fasano F, Caggiano G, Calabrese G, Rafaschieri V, Carpagnano F, Carlucci M, Gesualdo L, Ricci ML, Scaturro M, Rota MC, Bonadonna L, Lucentini L, Montagna MT. Impact of lockdown on the microbiological status of the hospital water network during COVID-19 pandemic. ENVIRONMENTAL RESEARCH 2020; 191:110231. [PMID: 32976823 PMCID: PMC7511218 DOI: 10.1016/j.envres.2020.110231] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 05/08/2023]
Abstract
The COVID-19 pandemic started in China in early December 2019, and quickly spread around the world. The epidemic gradually started in Italy at the end of February 2020, and by May 31, 2020, 232,664 cases and 33,340 deaths were confirmed. As a result of this pandemic, the Italian Ministerial Decree issued on March 11, 2020, enforced lockdown; therefore, many social, recreational, and cultural centers remained closed for months. In Apulia (southern Italy), all non-urgent hospital activities were suspended, and some wards were closed, with a consequent reduction in the use of the water network and the formation of stagnant water. This situation could enhance the risk of exposure of people to waterborne diseases, including legionellosis. The purpose of this study was to monitor the microbiological quality of the water network (coliforms, E. coli, Enterococci, P. aeruginosa, and Legionella) in three wards (A, B and C) of a large COVID-19 regional hospital, closed for three months due to the COVID-19 emergency. Our study revealed that all three wards' water network showed higher contamination by Legionella pneumophila sg 1 and sg 6 at T1 (after lockdown) compared to the period before the lockdown (T0). In particular, ward A at T1 showed a median value = 5600 CFU/L (range 0-91,000 CFU/L) vs T0, median value = 75 CFU/L (range 0-5000 CFU/L) (p-value = 0.014); ward B at T1 showed a median value = 200 CFU/L (range 0-4200 CFU/L) vs T0, median value = 0 CFU/L (range 0-300 CFU/L) (p-value = 0.016) and ward C at T1 showed a median value = 175 CFU/L (range 0-22,000 CFU/L) vs T0, median value = 0 CFU/L (range 0-340 CFU/L) (p-value < 0.001). In addition, a statistically significant difference was detected in ward B between the number of positive water samples at T0 vs T1 for L. pneumophila sg 1 and sg 6 (24% vs 80% p-value < 0.001) and for coliforms (0% vs 64% p-value < 0.001). Moreover, a median value of coliform load resulted 3 CFU/100 ml (range 0-14 CFU/100 ml) at T1, showing a statistically significant increase versus T0 (0 CFU/100 ml) (p-value < 0.001). Our results highlight the need to implement a water safety plan that includes staff training and a more rigorous environmental microbiological surveillance in all hospitals before occupying a closed ward for a longer than one week, according to national and international guidelines.
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Affiliation(s)
- Osvalda De Giglio
- Regional Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis, Department of Biomedical Science and Human Oncology, University of Bari Aldo Moro, Piazza G. Cesare 11, 70124, Bari, Italy.
| | - Giusy Diella
- Regional Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis, Department of Biomedical Science and Human Oncology, University of Bari Aldo Moro, Piazza G. Cesare 11, 70124, Bari, Italy.
| | - Marco Lopuzzo
- Regional Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis, Department of Biomedical Science and Human Oncology, University of Bari Aldo Moro, Piazza G. Cesare 11, 70124, Bari, Italy.
| | - Francesco Triggiano
- Regional Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis, Department of Biomedical Science and Human Oncology, University of Bari Aldo Moro, Piazza G. Cesare 11, 70124, Bari, Italy.
| | - Carla Calia
- Regional Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis, Department of Biomedical Science and Human Oncology, University of Bari Aldo Moro, Piazza G. Cesare 11, 70124, Bari, Italy.
| | - Chrysovalentinos Pousis
- Regional Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis, Department of Biomedical Science and Human Oncology, University of Bari Aldo Moro, Piazza G. Cesare 11, 70124, Bari, Italy.
| | - Fabrizio Fasano
- Regional Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis, Department of Biomedical Science and Human Oncology, University of Bari Aldo Moro, Piazza G. Cesare 11, 70124, Bari, Italy.
| | - Giuseppina Caggiano
- Regional Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis, Department of Biomedical Science and Human Oncology, University of Bari Aldo Moro, Piazza G. Cesare 11, 70124, Bari, Italy.
| | | | | | | | | | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation-Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, 70124, Italy.
| | - Maria Luisa Ricci
- Department of Infectious Diseases, Istituto Superiore di Sanità, Viale Regina Elena, 299-00161, Rome, Italy.
| | - Maria Scaturro
- Department of Infectious Diseases, Istituto Superiore di Sanità, Viale Regina Elena, 299-00161, Rome, Italy.
| | - Maria Cristina Rota
- Department of Infectious Diseases, Istituto Superiore di Sanità, Viale Regina Elena, 299-00161, Rome, Italy.
| | - Lucia Bonadonna
- Department of Environment and Health, Istituto Superiore di Sanità, Viale Regina Elena, 299-00161, Rome, Italy.
| | - Luca Lucentini
- Department of Environment and Health, Istituto Superiore di Sanità, Viale Regina Elena, 299-00161, Rome, Italy.
| | - Maria Teresa Montagna
- Regional Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis, Department of Biomedical Science and Human Oncology, University of Bari Aldo Moro, Piazza G. Cesare 11, 70124, Bari, Italy.
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Buchholz U, Jahn HJ, Brodhun B, Lehfeld AS, Lewandowsky MM, Reber F, Adler K, Bochmann J, Förster C, Koch M, Schreiner Y, Stemmler F, Gagell C, Harbich E, Bärwolff S, Beyer A, Geuß-Fosu U, Hänel M, Larscheid P, Murajda L, Morawski K, Peters U, Pitzing R, von Welczeck A, Widders G, Wischnewski N, Abdelgawad I, Hinzmann A, Hedeler D, Schilling B, Schmidt S, Schumacher J, Zuschneid I, Atmowihardjo I, Arastéh K, Behrens S, Creutz P, Elias J, Gregor M, Kahl S, Kahnert H, Kimmel V, Lehmke J, Migaud P, Mikolajewska A, Moos V, Naumann MB, Pankow W, Scherübl H, Schmidt B, Schneider T, Stocker H, Suttorp N, Thiemig D, Gollnisch C, Mannschatz U, Haas W, Schaefer B, Lück C. Source attribution of community-acquired cases of Legionnaires' disease-results from the German LeTriWa study; Berlin, 2016-2019. PLoS One 2020; 15:e0241724. [PMID: 33237924 PMCID: PMC7688155 DOI: 10.1371/journal.pone.0241724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/20/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Sources of infection of most cases of community-acquired Legionnaires' disease (CALD) are unknown. OBJECTIVE Identification of sources of infection of CALD. SETTING Berlin; December 2016-May 2019. PARTICIPANTS Adult cases of CALD reported to district health authorities and consenting to the study; age and hospital matched controls. MAIN OUTCOME MEASURE Percentage of cases of CALD with attributed source of infection. METHODS Analysis of secondary patient samples for monoclonal antibody (MAb) type (and sequence type); questionnaire-based interviews, analysis of standard household water samples for Legionella concentration followed by MAb (and sequence) typing of Legionella pneumophila serogroup 1 (Lp1) isolates; among cases taking of additional water samples to identify the infectious source as appropriate; recruitment of control persons for comparison of exposure history and Legionella in standard household water samples. For each case an appraisal matrix was filled in to attribute any of three source types (external (non-residence) source, residential non-drinking water (RnDW) source (not directly from drinking water outlet), residential drinking water (RDW) as source) using three evidence types (microbiological results, cluster evidence, analytical-comparative evidence (using added information from controls)). RESULTS Inclusion of 111 study cases and 202 controls. Median age of cases was 67 years (range 25-93 years), 74 (67%) were male. Among 65 patients with urine typable for MAb type we found a MAb 3/1-positive strain in all of them. Compared to controls being a case was not associated with a higher Legionella concentration in standard household water samples, however, the presence of a MAb 3/1-positive strain was significantly associated (odds ratio (OR) = 4.9, 95% confidence interval (CI) 1.7 to 11). Thus, a source was attributed by microbiological evidence if it contained a MAb 3/1-positive strain. A source was attributed by cluster evidence if at least two cases were exposed to the same source. Statistically significant general source types were attributed by calculating the population attributable risk (analytical-comparative evidence). We identified an external source in 16 (14%) cases, and RDW as source in 28 (25%). Wearing inadequately disinfected dentures was the only RnDW source significantly associated with cases (OR = 3.2, 95% CI 1.3 to 7.8) and led to an additional 8% of cases with source attribution, for a total of 48% of cases attributed. CONCLUSION Using the appraisal matrix we attributed almost half of all cases of CALD to an infectious source, predominantly RDW. Risk for LD seems to be conferred primarily by the type of Legionella rather than the amount. Dentures as a new infectious source needs further, in particular, integrated microbiological, molecular and epidemiological confirmation.
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Affiliation(s)
- Udo Buchholz
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Heiko Juergen Jahn
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Bonita Brodhun
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Ann-Sophie Lehfeld
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Marina M. Lewandowsky
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Franziska Reber
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Kristin Adler
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Jacqueline Bochmann
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Christina Förster
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Madlen Koch
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Yvonne Schreiner
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Fabian Stemmler
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Corinna Gagell
- Faculty of Medicine Carl Gustav Carus, Institute of Medical Microbiology and Hygiene/Institute of Virology, National Consulting Laboratory for Legionella, TU Dresden, Dresden, Germany
| | - Edith Harbich
- Faculty of Medicine Carl Gustav Carus, Institute of Medical Microbiology and Hygiene/Institute of Virology, National Consulting Laboratory for Legionella, TU Dresden, Dresden, Germany
| | - Sina Bärwolff
- Health Department, DHA Tempelhof-Schöneberg, Berlin, Germany
| | - Andreas Beyer
- Health Department, DHA Steglitz-Zehlendorf, Berlin, Germany
| | | | - Martina Hänel
- Health Department, DHA Marzahn-Hellersdorf, Berlin, Germany
| | | | | | | | - Uwe Peters
- Health Department, DHA Pankow, Berlin, Germany
| | - Raimund Pitzing
- Health Department, DHA Friedrichshain-Kreuzberg, Berlin, Germany
| | | | | | | | | | | | - Denis Hedeler
- Health Department, DHA Treptow-Köpenick, Berlin, Germany
| | - Birte Schilling
- Health Department, DHA Tempelhof-Schöneberg, Berlin, Germany
| | - Silvia Schmidt
- Health Department, DHA Steglitz-Zehlendorf, Berlin, Germany
| | | | - Irina Zuschneid
- Health Department, DHA Charlottenburg-Wilmersdorf, Berlin, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Uwe Mannschatz
- Hygiene Inspection for Drinking Water Systems, Berlin, Germany
| | - Walter Haas
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Benedikt Schaefer
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Christian Lück
- Faculty of Medicine Carl Gustav Carus, Institute of Medical Microbiology and Hygiene/Institute of Virology, National Consulting Laboratory for Legionella, TU Dresden, Dresden, Germany
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Paranjape K, Bédard É, Shetty D, Hu M, Choon FCP, Prévost M, Faucher SP. Unravelling the importance of the eukaryotic and bacterial communities and their relationship with Legionella spp. ecology in cooling towers: a complex network. MICROBIOME 2020; 8:157. [PMID: 33183356 PMCID: PMC7664032 DOI: 10.1186/s40168-020-00926-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/20/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Cooling towers are a major source of large community-associated outbreaks of Legionnaires' disease, a severe pneumonia. This disease is contracted when inhaling aerosols that are contaminated with bacteria from the genus Legionella, most importantly Legionella pneumophila. How cooling towers support the growth of this bacterium is still not well understood. As Legionella species are intracellular parasites of protozoa, it is assumed that protozoan community in cooling towers play an important role in Legionella ecology and outbreaks. However, the exact mechanism of how the eukaryotic community contributes to Legionella ecology is still unclear. Therefore, we used 18S rRNA gene amplicon sequencing to characterize the eukaryotic communities of 18 different cooling towers. The data from the eukaryotic community was then analysed with the bacterial community of the same towers in order to understand how each community could affect Legionella spp. ecology in cooling towers. RESULTS We identified several microbial groups in the cooling tower ecosystem associated with Legionella spp. that suggest the presence of a microbial loop in these systems. Dissolved organic carbon was shown to be a major factor in shaping the eukaryotic community and may be an important factor for Legionella ecology. Network analysis, based on co-occurrence, revealed that Legionella was correlated with a number of different organisms. Out of these, the bacterial genus Brevundimonas and the ciliate class Oligohymenophorea were shown, through in vitro experiments, to stimulate the growth of L. pneumophila through direct and indirect mechanisms. CONCLUSION Our results suggest that Legionella ecology depends on the host community, including ciliates and on several groups of organisms that contribute to its survival and growth in the cooling tower ecosystem. These findings further support the idea that some cooling tower microbiomes may promote the survival and growth of Legionella better than others. Video Abstract.
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Affiliation(s)
- Kiran Paranjape
- Department of Natural Resource Sciences, Faculty of Agricultural and Environmental Sciences, McGill University, Sainte-Anne-de-Bellevue, QC, Canada
| | - Émilie Bédard
- Department of Civil Engineering, Polytechnique Montreal, Montréal, QC, Canada
| | - Deeksha Shetty
- Department of Natural Resource Sciences, Faculty of Agricultural and Environmental Sciences, McGill University, Sainte-Anne-de-Bellevue, QC, Canada
| | - Mengqi Hu
- Department of Natural Resource Sciences, Faculty of Agricultural and Environmental Sciences, McGill University, Sainte-Anne-de-Bellevue, QC, Canada
| | - Fiona Chan Pak Choon
- Department of Natural Resource Sciences, Faculty of Agricultural and Environmental Sciences, McGill University, Sainte-Anne-de-Bellevue, QC, Canada
| | - Michèle Prévost
- Department of Civil Engineering, Polytechnique Montreal, Montréal, QC, Canada
| | - Sébastien P Faucher
- Department of Natural Resource Sciences, Faculty of Agricultural and Environmental Sciences, McGill University, Sainte-Anne-de-Bellevue, QC, Canada.
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Evaluation of GVPC and BCYE Media for Legionella Detection and Enumeration in Water Samples by ISO 11731: Does Plating on BCYE Medium Really Improve Yield? Pathogens 2020; 9:pathogens9090757. [PMID: 32948082 PMCID: PMC7559527 DOI: 10.3390/pathogens9090757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 11/19/2022] Open
Abstract
Legionella spp are the causative agents of Legionnaires’ diseases, which is a pneumonia of important public health concern. Ubiquitous freshwater and soil inhabitants can reach man-made water systems and cause illness. Legionella enumeration and quantification in water systems is crucial for risk assessment and culture examination is the gold standard method. In this study, Legionella recovery from potable water samples, at presumably a low concentration of interfering microorganisms, was compared by plating on buffered charcoal yeast extract (BCYE) and glycine, vancomycin, polymyxin B, cycloheximide (GVPC) Legionella agar media, according to the International Standard Organization (ISO) 11731: 2017. Overall, 556 potable water samples were analyzed and 151 (27.1%) were positive for Legionella. Legionella grew on both BCYE and GVPC agar plates in 85/151 (56.3%) water samples, in 65/151 (43%) on only GVPC agar plates, and in 1/151 (0.7%) on only BCYE agar plates. In addition, GVPC medium identified Legionella species other than pneumophila in six more samples as compared with the culture on BCYE. Although the medians of colony forming units per liter (CFU/L) detected on the BCYE and GVPC agar plates were 2500 and 1350, respectively (p-value < 0.0001), the difference did not exceed one logarithm, and therefore is not relevant for Legionella risk assessment. These results make questionable the need to utilize BCYE agar plates to analyze potable water samples.
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Performance of Legiolert Test vs. ISO 11731 to Confirm Legionella pneumophila Contamination in Potable Water Samples. Pathogens 2020; 9:pathogens9090690. [PMID: 32842454 PMCID: PMC7560050 DOI: 10.3390/pathogens9090690] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 12/15/2022] Open
Abstract
Detection and enumeration of Legionella in water samples is of great importance for risk assessment analysis. The plate culture method is the gold standard, but has received several well-known criticisms, which have induced researchers to develop alternative methods. The purpose of this study was to compare Legionella counts obtained by the analysis of potable water samples through the plate culture method and through the IDEXX liquid culture Legiolert method. Legionella plate culture, according to ISO 11731:1998, was performed using 1 L of water. Legiolert was performed using both the 10 mL and 100 mL Legiolert protocols. Overall, 123 potable water samples were analyzed. Thirty-seven (30%) of them, positive for L. pneumophila, serogroups 1 or 2–14 by plate culture, were used for comparison with the Legiolert results. The Legiolert 10 mL test detected 34 positive samples (27.6%) and the Legiolert 100 mL test detected 37 positive samples, 27.6% and 30% respectively, out of the total samples analyzed. No significant difference was found between either the Legiolert 10 mL and Legiolert 100 mL vs. the plate culture (p = 0.9 and p = 0.3, respectively) or between the Legiolert 10 mL and Legiolert 100 mL tests (p = 0.83). This study confirms the reliability of the IDEXX Legiolert test for Legionella pneumophila detection and enumeration, as already shown in similar studies. Like the plate culture method, the Legiolert assay is also suitable for obtaining isolates for typing purposes, relevant for epidemiological investigations.
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Palazzolo C, Maffongelli G, D'Abramo A, Lepore L, Mariano A, Vulcano A, Bartoli TA, Bevilacqua N, Giancola ML, Di Rosa E, Nicastri E. Legionella pneumonia: increased risk after COVID-19 lockdown? Italy, May to June 2020. ACTA ACUST UNITED AC 2020; 25. [PMID: 32734857 PMCID: PMC7393852 DOI: 10.2807/1560-7917.es.2020.25.30.2001372] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report a case of Legionella pneumonia in a dishwasher of a restaurant in Rome, Italy, just after the end of the lockdown that was in place to control the SARS-CoV-2 epidemic. The case highlights the importance of strict monitoring of water and air systems immediately before reopening business or public sector buildings, and the need to consider Legionella infections among the differential diagnosis of respiratory infections after lockdown due to the ongoing COVID-19 pandemic.
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Affiliation(s)
- Claudia Palazzolo
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Gaetano Maffongelli
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Alessandra D'Abramo
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Luciana Lepore
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Andrea Mariano
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Antonella Vulcano
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | | | - Nazario Bevilacqua
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | | | | | - Emanuele Nicastri
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
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Palazzolo C, Maffongelli G, D'Abramo A, Lepore L, Mariano A, Vulcano A, Bartoli TA, Bevilacqua N, Giancola ML, Di Rosa E, Nicastri E. Authors' response: importance of a careful investigation to avoid attributing Legionnaires' disease cases to an incorrect source of infection. Euro Surveill 2020; 25:2001570. [PMID: 32856588 PMCID: PMC7453682 DOI: 10.2807/1560-7917.es.2020.25.34.2001570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/27/2020] [Indexed: 11/20/2022] Open
Affiliation(s)
- Claudia Palazzolo
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Gaetano Maffongelli
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Alessandra D'Abramo
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Luciana Lepore
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Andrea Mariano
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | - Antonella Vulcano
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | | | - Nazario Bevilacqua
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
| | | | | | - Emanuele Nicastri
- National Institute for Infectious Diseases 'Lazzaro Spallanzani' IRCCS, Rome, Italy
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35
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Laribi A, Allegra S, Souiri M, Mzoughi R, Othmane A, Girardot F. Legionella pneumophila sg1-sensing signal enhancement using a novel electrochemical immunosensor in dynamic detection mode. Talanta 2020; 215:120904. [PMID: 32312449 DOI: 10.1016/j.talanta.2020.120904] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 01/20/2023]
Abstract
This work presents a comparison between static and dynamic modes of biosensing using a novel microfluidic assay for continuous and quantitative detection of Legionella pneumophila sg1 in artificial water samples. A self-assembled monolayer of 16-amino-1-hexadecanethiol (16-AHT) was covalently linked to a gold substrate, and the resulting modified surface was used to immobilize an anti-Legionella pneumophila monoclonal antibody (mAb). The modified surfaces formed during the biosensor functionalization steps were characterized using electrochemical measurements and microscopic imaging techniques. Under static conditions, the biosensor exhibited a wide linear response range from 10 to 108 CFU/mL and a detection limit of 10 CFU/mL. Using a microfluidic system, the biosensor responses exhibited a linear relationship for low bacterial concentrations ranging from 10 to 103 CFU/mL under dynamic conditions and an enhancement of sensing signals by a factor of 4.5 compared to the sensing signals obtained under static conditions with the same biosensor for the detection of Legionella cells in artificially contaminated samples.
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Affiliation(s)
- Ahlem Laribi
- Environments, Territories, Societies (EVS) Lab, Mixed Research Unit (Jean Monnet University - French National Centre for Scientific Research) 5600, University of Lyon, F42023, France; Laboratory of Advanced Materials and Interfaces, Faculty of Medicine, University of Monastir, 5019, Monastir, Tunisia.
| | - Séverine Allegra
- Environments, Territories, Societies (EVS) Lab, Mixed Research Unit (Jean Monnet University - French National Centre for Scientific Research) 5600, University of Lyon, F42023, France
| | - Mina Souiri
- Laboratory of Advanced Materials and Interfaces, Faculty of Medicine, University of Monastir, 5019, Monastir, Tunisia
| | - Ridha Mzoughi
- Regional Laboratory of Hygiene, University Hospital Farhat Hached, 4000 Sousse, Tunisia and Laboratory of Analysis Treatment and Valorization of Pollutants and Products, Faculty of Pharmacy, 5000, Monastir, Tunisia
| | - Ali Othmane
- Laboratory of Advanced Materials and Interfaces, Faculty of Medicine, University of Monastir, 5019, Monastir, Tunisia
| | - Françoise Girardot
- Environments, Territories, Societies (EVS) Lab, Mixed Research Unit (Jean Monnet University - French National Centre for Scientific Research) 5600, University of Lyon, F42023, France
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36
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Correia G, Rodrigues L, Gameiro da Silva M, Gonçalves T. Airborne route and bad use of ventilation systems as non-negligible factors in SARS-CoV-2 transmission. Med Hypotheses 2020; 141:109781. [PMID: 32361528 PMCID: PMC7182754 DOI: 10.1016/j.mehy.2020.109781] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 12/14/2022]
Abstract
The world is facing a pandemic of unseen proportions caused by a corona virus named SARS-CoV-2 with unprecedent worldwide measures being taken to tackle its contagion. Person-to-person transmission is accepted but WHO only considers aerosol transmission when procedures or support treatments that produce aerosol are performed. Transmission mechanisms are not fully understood and there is evidence for an airborne route to be considered, as the virus remains viable in aerosols for at least 3 h and that mask usage was the best intervention to prevent infection. Heating, Ventilation and Air Conditioning Systems (HVAC) are used as a primary infection disease control measure. However, if not correctly used, they may contribute to the transmission/spreading of airborne diseases as proposed in the past for SARS. The authors believe that airborne transmission is possible and that HVAC systems when not adequately used may contribute to the transmission of the virus, as suggested by descriptions from Japan, Germany, and the Diamond Princess Cruise Ship. Previous SARS outbreaks reported at Amoy Gardens, Emergency Rooms and Hotels, also suggested an airborne transmission. Further studies are warranted to confirm our hypotheses but the assumption of such way of transmission would cause a major shift in measures recommended to prevent infection such as the disseminated use of masks and structural changes to hospital and other facilities with HVAC systems.
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Affiliation(s)
- G Correia
- CNC - Center for Neurosciences and Cell Biology, University of Coimbra, Portugal; FMUC - Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - L Rodrigues
- FMUC - Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - M Gameiro da Silva
- ADAI, LAETA Department of Mechanical Engineering, University of Coimbra, Portugal
| | - T Gonçalves
- CNC - Center for Neurosciences and Cell Biology, University of Coimbra, Portugal; FMUC - Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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37
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Toberna CP, William HM, Kram JJF, Heslin K, Baumgardner DJ. Epidemiologic Survey of Legionella Urine Antigen Testing Within a Large Wisconsin-Based Health Care System. J Patient Cent Res Rev 2020; 7:165-175. [PMID: 32377550 DOI: 10.17294/2330-0698.1721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose Legionella pneumophila pneumonia is a life-threatening, environmentally acquired infection identifiable via Legionella urine antigen tests (LUAT). We aimed to identify cumulative incidence, demographic distribution, and undetected disease outbreaks of Legionella pneumonia via positive LUAT in a single eastern Wisconsin health system, with a focus on urban Milwaukee County. Methods A multilevel descriptive ecologic study was conducted utilizing electronic medical record data from a large integrated health care system of patients who underwent LUAT from 2013 to 2017. A random sample inclusive of all positive tests was reviewed to investigate geodemographic differences among patients testing positive versus negative. Statistical comparisons used chi-squared or 2-sample t-tests; stepwise regression followed by binary logistic regression was used for multivariable analysis. Positive cases identified by LUAT were mapped to locate hotspots; positive cases versus total tests performed also were mapped by zip code. Results Of all LUAT performed (n=21,599), 0.68% were positive. Among those in the random sample (n=11,652), positive cases by LUAT were more prevalent in the June-November time period (86.2%) and younger patients (59.4 vs 67.7 years) and were disproportionately male (70.3% vs 29.7%) (P<0.0001 for each). Cumulative incidence was higher among nonwhite race/ethnicity (1.91% vs 1.01%, P<0.0001) but did not remain significant on multivariable analysis. Overall, 5507 tests were performed in Milwaukee County zip codes, yielding 82 positive cases by LUAT (60.7% of all positive cases in the random sample). A potential small 2016 outbreak was identified. Conclusions Cumulative incidence of a positive LUAT was less than 1%. LUAT testing, if done in real time by cooperative health systems, may complement public health detection of Legionella pneumonia outbreaks.
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Affiliation(s)
- Caroline P Toberna
- Aurora Research Institute, Aurora Health Care, Milwaukee, WI.,Center for Urban Population Health, Milwaukee, WI.,Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI
| | - Hannah M William
- Center for Urban Population Health, Milwaukee, WI.,Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI
| | - Jessica J F Kram
- Center for Urban Population Health, Milwaukee, WI.,Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI.,Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Kayla Heslin
- Aurora Research Institute, Aurora Health Care, Milwaukee, WI.,Center for Urban Population Health, Milwaukee, WI.,Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI
| | - Dennis J Baumgardner
- Center for Urban Population Health, Milwaukee, WI.,Aurora UW Medical Group, Aurora Health Care, Milwaukee, WI.,Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Schumacher A, Kocharian A, Koch A, Marx J. Fatal Case of Legionnaires' Disease After Home Exposure to Legionella pneumophila Serogroup 3 - Wisconsin, 2018. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2020; 69:207-211. [PMID: 32106217 PMCID: PMC7367070 DOI: 10.15585/mmwr.mm6908a2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
In January 2018, the Wisconsin Department of Health Services, Division of Public Health (DPH), received a report of a culture-confirmed case of Legionnaires' disease. The patient, who was immunocompromised, had died at a local hospital 10 days after being admitted. DPH and an infection preventionist from the hospital investigated to determine the source of the infection and prevent additional cases. Because the case was suspected to be nosocomial, health care facility water samples were tested for Legionella. When these samples were negative, water sources in the patient's home were tested. These tested positive for Legionella pneumophila, and the bacteria remained after an attempt to remediate. The patient and home isolates were identified as L. pneumophila serogroup 3, sequence type 93, by whole-genome multilocus sequence typing. A second resident of the home did not become ill. This case highlights the potential for immunocompromised persons and others at risk for Legionnaires' disease to be exposed to Legionella through home water systems containing the bacteria and demonstrates the difficulty of home remediation. This case also illustrates the role of lower respiratory tract specimens in the identification of less common Legionella infections (e.g., L. pneumophila serogroup 3) and confirmation of the infection source.
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Hamilton KA, Hamilton MT, Johnson W, Jjemba P, Bukhari Z, LeChevallier M, Haas CN, Gurian PL. Risk-Based Critical Concentrations of Legionella pneumophila for Indoor Residential Water Uses. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2019; 53:4528-4541. [PMID: 30629886 DOI: 10.1021/acs.est.8b03000] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Legionella spp. is a key contributor to the United States waterborne disease burden. Despite potentially widespread exposure, human disease is relatively uncommon, except under circumstances where pathogen concentrations are high, host immunity is low, or exposure to small-diameter aerosols occurs. Water quality guidance values for Legionella are available for building managers but are generally not based on technical criteria. To address this gap, a quantitative microbial risk assessment (QMRA) was conducted using target risk values in order to calculate corresponding critical concentrations on a per-fixture and aggregate (multiple fixture exposure) basis. Showers were the driving indoor exposure risk compared to sinks and toilets. Critical concentrations depended on the dose response model (infection vs clinical severity infection, CSI), risk target used (infection risk vs disability adjusted life years [DALY] on a per-exposure or annual basis), and fixture type (conventional vs water efficient or "green"). Median critical concentrations based on exposure to a combination of toilet, faucet, and shower aerosols ranged from ∼10-2 to ∼100 CFU per L and ∼101 to ∼103 CFU per L for infection and CSI dose response models, respectively. As infection model results for critical L. pneumophila concentrations were often below a feasible detection limit for culture-based assays, the use of CSI model results for nonhealthcare water systems with a 10-6 DALY pppy target (the more conservative target) would result in an estimate of 12.3 CFU per L (arithmetic mean of samples across multiple fixtures and/or over time). Single sample critical concentrations with a per-exposure-corrected DALY target at each conventional fixture would be 1.06 × 103 CFU per L (faucets), 8.84 × 103 CFU per L (toilets), and 14.4 CFU per L (showers). Using a 10-4 annual infection risk target would give a 1.20 × 103 CFU per L mean for multiple fixtures and single sample critical concentrations of 1.02 × 105, 8.59 × 105, and 1.40 × 103 CFU per L for faucets, toilets, and showers, respectively. Annual infection risk-based target estimates are in line with most current guidance documents of less than 1000 CFU per L, while DALY-based guidance suggests lower critical concentrations might be warranted in some cases. Furthermore, approximately <10 CFU per mL L. pneumophila may be appropriate for healthcare or susceptible population settings. This analysis underscores the importance of the choice of risk target as well as sampling program considerations when choosing the most appropriate critical concentration for use in public health guidance.
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Affiliation(s)
- Kerry A Hamilton
- School for Sustainable Engineering and the Built Environment , Arizona State University , Tempe , Arizona 85281 , United States
- The Biodesign Institute Center for Environmental Health Engineering , Arizona State University , Tempe , Arizona 85281 , United States
| | - Mark T Hamilton
- Microsoft Applied Artificial Intelligence Group , 1 Memorial Drive , Cambridge , Massachusetts 02142 , United States
| | - William Johnson
- American Water Research Laboratory , 213 Carriage Lane , Delran , New Jersey 08075 , United States
| | - Patrick Jjemba
- American Water Research Laboratory , 213 Carriage Lane , Delran , New Jersey 08075 , United States
| | - Zia Bukhari
- American Water Research Laboratory , 213 Carriage Lane , Delran , New Jersey 08075 , United States
| | - Mark LeChevallier
- American Water Research Laboratory , 213 Carriage Lane , Delran , New Jersey 08075 , United States
| | - Charles N Haas
- Drexel University , 3141 Chestnut Street , Philadelphia , Pennsylvania 19104 , United States
| | - P L Gurian
- Drexel University , 3141 Chestnut Street , Philadelphia , Pennsylvania 19104 , United States
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Garner E, McLain J, Bowers J, Engelthaler DM, Edwards MA, Pruden A. Microbial Ecology and Water Chemistry Impact Regrowth of Opportunistic Pathogens in Full-Scale Reclaimed Water Distribution Systems. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2018; 52:9056-9068. [PMID: 30040385 DOI: 10.1021/acs.est.8b02818] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Need for global water security has spurred growing interest in wastewater reuse to offset demand for municipal water. While reclaimed (i.e., nonpotable) microbial water quality regulations target fecal indicator bacteria, opportunistic pathogens (OPs), which are subject to regrowth in distribution systems and spread via aerosol inhalation and other noningestion routes, may be more relevant. This study compares the occurrences of five OP gene markers ( Acanthamoeba spp., Legionella spp., Mycobacterium spp., Naegleria fowleri, Pseudomonas aeruginosa) in reclaimed versus potable water distribution systems and characterizes factors potentially contributing to their regrowth. Samples were collected over four sampling events at the point of compliance for water exiting treatment plants and at five points of use at four U.S. utilities bearing both reclaimed and potable water distribution systems. Reclaimed water systems harbored unique water chemistry (e.g., elevated nutrients), microbial community composition, and OP occurrence patterns compared to potable systems examined here and reported in the literature. Legionella spp. genes, Mycobacterium spp. genes, and total bacteria, represented by 16S rRNA genes, were more abundant in reclaimed than potable water distribution system samples ( p ≤ 0.0001). This work suggests that further consideration should be given to managing reclaimed water distribution systems with respect to nonpotable exposures to OPs.
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Affiliation(s)
- Emily Garner
- Via Department of Civil and Environmental Engineering , Virginia Tech , Blacksburg , Virginia 24061 , United States
| | - Jean McLain
- Water Resources Research Center , University of Arizona , Tucson , Arizona 85719 , United States
| | - Jolene Bowers
- Translational Genomics Research Institute , Flagstaff , Arizona 86005 , United States
| | - David M Engelthaler
- Translational Genomics Research Institute , Flagstaff , Arizona 86005 , United States
| | - Marc A Edwards
- Via Department of Civil and Environmental Engineering , Virginia Tech , Blacksburg , Virginia 24061 , United States
| | - Amy Pruden
- Via Department of Civil and Environmental Engineering , Virginia Tech , Blacksburg , Virginia 24061 , United States
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