Legionella transmission through cooling towers: towards better control and research of a neglected pathogen

Lessons learned from a one-year study of Legionella spp. cultivation from activated sludge samples

Risk assessment and management of Legionella spp. contamination in activated sludge in wastewater treatment plants is carried out using the culture method. Underestimation of Legionella spp. is frequently reported in the literature, but a comprehensive long-term study of the performance of the method under comparable conditions is still lacking. The aim of this study is to evaluate the recovery rate and limit of detection of the culture method for Legionella spp. from activated sludge samples collected during the different seasons of the year. Activated sludge samples spiked with Legionella pneumophila subsp. pneumophila strain Philadelphia-1 (mean concentration 5.2 ± 0.35 logCFU/mL) were analysed monthly for one year using the culture method. Three different sample pre-treatments were compared, namely filtration, acid treatment and thermal treatment, and the recovery rate and limit of detection were assessed for each. The recovery rate of the culture method for Legionella spp. depended on the type of sample pre-treatment and the season of activated sludge sampling, while the limit of detection depended only on the sample pre-treatment. The best performance of the culture method, defined as the combination of the highest recovery rate and lowest limit of detection, was obtained for the filtered acid pre-treated samples (recovery rate: 89 ± 4 %; limit of detection: 1.3 logCFU/mL in 83 % of the samples). The lowest limit of detection was observed for the filtered thermally pre-treated samples (1.0 logCFU/mL in 93 % of the samples). Simultaneously, both thermally pre-treated samples showed up to a third lower recovery rates than the other pre-treatments in winter, while untreated and acid pre-treated samples showed consistently high recovery rates (>80%, logCFU/mL). The recovery rates of the unfiltered and filtered thermally pre-treated samples showed significant weak to strong positive correlations with the organic and phosphorus load in the influent as well as with the water and atmospheric temperatures, indicating that the recovery rate depends on the seasonal variation of the wastewater composition. This study presents new insights into the detection and quantification of Legionella spp. in activated sludge samples and considers seasonal dependencies in analytical results.

Increasing Detection of Legionnaires' Disease in a Large Italian Hospital in the Period 2016-2023

The pandemic marked the beginning of an era of dynamic and rapid changes in the diagnosis of respiratory infections. Herein we describe Legionnaires' disease trend in the years 2016-2023 in a large Italian hospital showing how improvements in diagnostic algorithms impact on its detection.

Automated cooling tower detection through deep learning for Legionnaires' disease outbreak investigations: a model development and validation study

BACKGROUND

Cooling towers containing Legionella spp are a high-risk source of Legionnaires' disease outbreaks. Manually locating cooling towers from aerial imagery during outbreak investigations requires expertise, is labour intensive, and can be prone to errors. We aimed to train a deep learning computer vision model to automatically detect cooling towers that are aerially visible.

METHODS

Between Jan 1 and 31, 2021, we extracted satellite view images of Philadelphia (PN, USA) and New York state (NY, USA) from Google Maps and annotated cooling towers to create training datasets. We augmented training data with synthetic data and model-assisted labelling of additional cities. Using 2051 images containing 7292 cooling towers, we trained a two-stage model using YOLOv5, a model that detects objects in images, and EfficientNet-b5, a model that classifies images. We assessed the primary outcomes of sensitivity and positive predictive value (PPV) of the model against manual labelling on test datasets of 548 images, including from two cities not seen in training (Boston [MA, USA] and Athens [GA, USA]). We compared the search speed of the model with that of manual searching by four epidemiologists.

FINDINGS

The model identified visible cooling towers with 95·1% sensitivity (95% CI 94·0-96·1) and a PPV of 90·1% (95% CI 90·0-90·2) in New York City and Philadelphia. In Boston, sensitivity was 91·6% (89·2-93·7) and PPV was 80·8% (80·5-81·2). In Athens, sensitivity was 86·9% (75·8-94·2) and PPV was 85·5% (84·2-86·7). For an area of New York City encompassing 45 blocks (0·26 square miles), the model searched more than 600 times faster (7·6 s; 351 potential cooling towers identified) than did human investigators (mean 83·75 min [SD 29·5]; mean 310·8 cooling towers [42·2]).

INTERPRETATION

The model could be used to accelerate investigation and source control during outbreaks of Legionnaires' disease through the identification of cooling towers from aerial imagery, potentially preventing additional disease spread. The model has already been used by public health teams for outbreak investigations and to initialise cooling tower registries, which are considered best practice for preventing and responding to outbreaks of Legionnaires' disease.

FUNDING

None.

Host-bacteria interactions: ecological and evolutionary insights from ancient, professional endosymbionts

Interactions between eukaryotic hosts and their bacterial symbionts drive key ecological and evolutionary processes, from regulating ecosystems to the evolution of complex molecular machines and processes. Over time, endosymbionts generally evolve reduced genomes, and their relationship with their host tends to stabilize. However, host-bacteria relationships may be heavily influenced by environmental changes. Here, we review these effects on one of the most ancient and diverse endosymbiotic groups, formed by-among others-Legionellales, Francisellaceae, and Piscirickettsiaceae. This group is referred to as Deep-branching Intracellular Gammaproteobacteria (DIG), whose last common ancestor presumably emerged about 2 Ga ago. We show that DIGs are globally distributed, but generally at very low abundance, and are mainly identified in aquatic biomes. Most DIGs harbour a type IVB secretion system, critical for host-adaptation, but its structure and composition vary. Finally, we review the different types of microbial interactions that can occur in diverse environments, with direct or indirect effects on DIG populations. The increased use of omics technologies on environmental samples will allow a better understanding of host-bacterial interactions and help unravel the definition of DIGs as a group from an ecological, molecular, and evolutionary perspective.

Heterotrophic Plate Count Can Predict the Presence of Legionella spp. in Cooling Towers

Legionella pneumophila (Lp) colonizes aquatic environments and is a potential pathogen to humans, causing outbreaks of Legionnaire’s disease. It is mainly associated with contaminated cooling towers (CTs). Several regulations, including Spanish legislation (Sl), have introduced the analysis of heterotrophic plate count (HPC) bacteria and Legionella spp. (Lsp) in management plans to prevent and control Legionella outbreaks from CTs. The 2003 Sl for CTs (RD 865/2003) considered that concentrations of HPC bacteria ≤10,000 cfu/mL and of Lsp ≤100 cfu/L are safe; therefore, no action is required, whereas management actions should be implemented above these standards. We have investigated to what extent the proposed standard for HPC bacteria is useful to predict the presence of Lsp in cooling waters. For this, we analyzed Lsp and HPC concentrations, water temperature, and the levels of chlorine in 1376 water samples from 17 CTs. The results showed that in the 1138 water samples negative for Legionella spp. (LN), the HPC geometric mean was significantly lower (83 cfu/mL, p < 0.05) than in the positive Lsp. samples (135 cfu/mL). Of the 238 (17.3%) LP samples, 88.4% (210/238) were associated with values of HPC ≤10,000 cfu/mL and most of them showed HPC concentrations ≤100 (53.7%). In addition, a relatively low percentage of LP (28/238, 11.6%) samples were associated with HPC bacteria concentrations >10,000 cfu/mL, indicating that this standard does not predict the colonization risk for Legionella in the CTs studied. The present study has demonstrated that a threshold concentration ≤100 cfu/mL of HPC bacteria could better predict the higher concentration of Legionella in CTs, which will aid in preventing possible outbreaks.

Legionella pneumophila Risk from Air–Water Cooling Units Regarding Pipe Material and Type of Water

Legionellosis is a respiratory disease related to environmental health. There have been manifold studies of pipe materials, risk installations and legionellosis without considering the type of transferred water. The objective of this study was to determine the potential development of the causative agent Legionella pneumophila regarding air–water cooling units, legislative compliance, pipe material and type of water. Forty-four hotel units in Andalusia (Spain) were analysed with respect to compliance with Spanish health legislation for the prevention of legionellosis. The chi-square test was used to explain the relationship between material–water and legislative compliance, and a biplot of the first two factors was generated. Multiple correspondence analysis (MCA) was performed on the type of equipment, legislative compliance, pipe material and type of water, and graphs of cases were constructed by adding confidence ellipses by categories of the variables. Pipe material–type of water (p value = 0.29; p < 0.05) and legislative compliance were not associated (p value = 0.15; p < 0.05). Iron, stainless steel, and recycled and well water contributed the most to the biplot. MCA showed a global pattern in which lead, iron and polyethylene were well represented. Confidence ellipses around categories indicated significant differences among categories. Compliance with Spanish health legislation regarding the prevention and control of legionellosis linked to pipe material and type of water was not observed.

Cooling tower Legionella pneumophila surveillance results: Vancouver, Canada, 2021

Cooling towers have been linked to Legionnaires' disease cases and outbreaks. Legionella pneumophila results (from a culture-based method) are presented for 557 cooling towers across the City of Vancouver, Canada for 2021. Results of 10 CFU/mL or greater (defined as exceedances) were reported for 30 cooling towers (5.4%), including six >1,000 CFU/mL, and L. pneumophila serogroup 1 (sg1) was identified in 17 of these cooling towers (out of 28 with serogroup-level analysis). The data indicate highly localised Legionella issues, with exceedances concentrated within 16 facilities, including two hospitals. In the 3 months preceding each cooling tower exceedance, the nearest municipal water sampling station had a free chlorine residual of at least 0.46 mg/L and a temperature of <20 °C. There was not a statistically significant correlation between the L. pneumophila concentration of a cooling tower in exceedance and the municipal water free chlorine residual, temperature, pH, turbidity or conductivity. There was a statistically significant negative correlation between the concentrations of L. pneumophila sg1 and other L. pneumophila serogroups in cooling towers. This unique dataset underscores the pivotal role of building owners and managers in preventing the growth of Legionella bacteria and the value of regulations to verify operations and maintenance practices.

Efficient cooling tower operation at alkaline pH for the control of Legionella pneumophila and other pathogenic genera

Efficient control of pathogenic bacteria, specifically Legionella pneumophila, is one of the main concerns when operating industrial cooling towers. Common practices to limit proliferation involves use of disinfectants, leading to formation of disinfection by-product and increase in water corrosiveness. A disinfectant-free Legionella control method would make the industry more environmentally friendly. A pilot-scale cooling tower (1 m³/h) operated with demineralized water was used to investigate the potential of high-pH conditioning as a disinfectant-free alternative for control of L. pneumophila and other pathogens. One control experiment was performed under standard full-scale operation involving sodium hypochlorite dosage. Thereafter 3 alkaline pHs of the cooling water were tested: 9.0, 9.4 and 9.6. The tests lasted between 25 and 35 days. The cooling water from the basins were analysed for total cell count by flow cytometry, L. pneumophila concentration by plate count and occasional qPCR analyses targeting the mip-gene, bacterial and eukaryotic community analyses with 16S and 18S rRNA gene amplicon sequencing, relative abundance of eukaryotic to prokaryotic DNA by qPCR of the 16S and 18S rRNA gene. The L. pneumophila analyses showed considerable growth at pH 9.0 and pH 9.4 but was maintained below detection limit (< 100 CFU/L) at pH 9.6 without disinfection. Interestingly, the results correlated with the overall abundance of protozoa in the water samples but not directly with the relative abundance of specific reported protozoan hosts of Legionella. The pathogenicity based on 16S rRNA gene amplicon sequencing of the cooling water DNA decreased with increasing pH with a strong decline between pH 9.0 and pH 9.4, from 7.1% to 1.6% of relative abundance of pathogenic genera respectively. A strong shift in microbiome was observed between each tested pH and reproducibility of the experiment at pH 9.6 was confirmed with a duplicate test lasting 80 days. High-pH conditioning ≥ 9.6 is therefore considered as an efficient disinfectant-free cooling tower operation for control of pathogenicity, including L. pneumophila.

Unravelling the importance of the eukaryotic and bacterial communities and their relationship with Legionella spp. ecology in cooling towers: a complex network

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.