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Short-term associations between Legionnaires' disease incidence and meteorological variables in Belgium, 2011-2019. Epidemiol Infect 2020; 148:e150. [PMID: 32345387 PMCID: PMC7374801 DOI: 10.1017/s0950268820000886] [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] [Indexed: 11/07/2022] Open
Abstract
The number of reported cases with Legionnaires' disease (LD) is increasing in Belgium. Previous studies have investigated the associations between LD incidence and meteorological factors, but the Belgian data remained unexplored. We investigated data collected between 2011 and 2019. Daily exposure data on temperature, relative humidity, precipitation and wind speed was obtained from the Royal Meteorological Institute for 29 weather stations. Case data were collected from the national reference centre and through mandatory notification. Daily case and exposure data were aggregated by province. We conducted a time-stratified case-crossover study. The 'at risk' period was defined as 10 to 2 days prior to disease onset. The corresponding days in the other study years were selected as referents. We fitted separate conditional Poisson models for each day in the 'at risk' period and a distributed lag non-linear model (DLNM) which fitted all data in one model. LD incidence showed a yearly peak in August and September. A total of 614 cases were included. Given seasonality, a sequence of precipitation, followed by high relative humidity and low wind speed showed a statistically significant association with the number of cases 6 to 4 days later. We discussed the advantages of DLNM in this context.
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Fisman DN. Of Time and the River: How Our Understanding of Legionellosis Has Changed Since 1976. J Infect Dis 2018; 217:171-173. [PMID: 29211906 DOI: 10.1093/infdis/jix532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/11/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- David N Fisman
- Division of Epidemiology, Dalla Lana School of Public Heath, University of Toronto, Canada
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Brown KA, Fisman DN, Daneman N. Hospital Clostridium difficile Infection Testing Rates: Is “Don’t Ask, Don’t Tell” at Play? Infect Control Hosp Epidemiol 2016; 35:911-2. [DOI: 10.1086/676881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Smith SS, Ritger K, Samala U, Black SR, Okodua M, Miller L, Kozak-Muiznieks NA, Hicks LA, Steinheimer C, Ewaidah S, Presser L, Siston AM. Legionellosis Outbreak Associated With a Hotel Fountain. Open Forum Infect Dis 2015; 2:ofv164. [PMID: 26716104 PMCID: PMC4692259 DOI: 10.1093/ofid/ofv164] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/30/2015] [Indexed: 12/04/2022] Open
Abstract
Background. In August 2012, the Chicago Department of Public Health (CDPH) was notified of acute respiratory illness, including 1 fatality, among a group of meeting attendees who stayed at a Chicago hotel during July 30–August 3, 2012. Suspecting Legionnaires' disease (LD), CDPH advised the hotel to close their swimming pool, spa, and decorative lobby fountain and began an investigation. Methods. Case finding included notification of individuals potentially exposed during July 16–August 15, 2012. Individuals were interviewed using a standardized questionnaire. An environmental assessment was performed. Results. One hundred fourteen cases were identified: 11 confirmed LD, 29 suspect LD, and 74 Pontiac fever cases. Illness onsets occurred July 21–August 22, 2012. Median age was 48 years (range, 22–82 years), 64% were male, 59% sought medical care (15 hospitalizations), and 3 died. Relative risks for hotel exposures revealed that persons who spent time near the decorative fountain or bar, both located in the lobby were respectively 2.13 (95%, 1.64–2.77) and 1.25 (95% CI, 1.09–1.44) times more likely to become ill than those who did not. Legionella pneumophila serogroup 1 was isolated from samples collected from the fountain, spa, and women's locker room fixtures. Legionella pneumophila serogroup 1 environmental isolates and a clinical isolate had matching sequence-based types. Hotel maintenance records lacked a record of regular cleaning and disinfection of the fountain. Conclusions. Environmental testing identified Legionella in the hotel's potable water system. Epidemiologic and laboratory data indicated the decorative fountain as the source. Poor fountain maintenance likely created favorable conditions for Legionella overgrowth.
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Affiliation(s)
| | | | - Usha Samala
- Chicago Department of Public Health, Illinois
| | | | | | | | | | - Lauri A Hicks
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Hines SA, Chappie DJ, Lordo RA, Miller BD, Janke RJ, Lindquist HA, Fox KR, Ernst HS, Taft SC. Assessment of relative potential for Legionella species or surrogates inhalation exposure from common water uses. WATER RESEARCH 2014; 56:203-13. [PMID: 24681377 DOI: 10.1016/j.watres.2014.02.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 01/07/2014] [Accepted: 02/03/2014] [Indexed: 05/22/2023]
Abstract
The Legionella species have been identified as important waterborne pathogens in terms of disease morbidity and mortality. Microbial exposure assessment is a tool that can be utilized to assess the potential of Legionella species inhalation exposure from common water uses. The screening-level exposure assessment presented in this paper developed emission factors to model aerosolization, quantitatively assessed inhalation exposures of aerosolized Legionella species or Legionella species surrogates while evaluating two generalized levels of assumed water concentrations, and developed a relative ranking of six common in-home uses of water for potential Legionella species inhalation exposure. Considerable variability in the calculated exposure dose was identified between the six identified exposure pathways, with the doses differing by over five orders of magnitude in each of the evaluated exposure scenarios. The assessment of exposure pathways that have been epidemiologically associated with legionellosis transmission (ultrasonic and cool mist humidifiers) produced higher estimated inhalation exposure doses than pathways where epidemiological evidence of transmission has been less strong (faucet and shower) or absent (toilets and therapy pool). With consideration of the large uncertainties inherent in the exposure assessment process used, a relative ranking of exposure pathways from highest to lowest exposure doses was produced using culture-based measurement data and the assumption of constant water concentration across exposure pathways. In this ranking, the ultrasonic and cool mist humidifier exposure pathways were estimated to produce the highest exposure doses, followed by the shower and faucet exposure pathways, and then the toilet and therapy pool exposure pathways.
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Affiliation(s)
| | | | | | | | - Robert J Janke
- U.S. Environmental Protection Agency, National Homeland Security Research Center, 26 West Martin Luther King Drive, Cincinnati, OH 45268, USA
| | - H Alan Lindquist
- U.S. Environmental Protection Agency, National Homeland Security Research Center, 26 West Martin Luther King Drive, Cincinnati, OH 45268, USA
| | - Kim R Fox
- U.S. Environmental Protection Agency, National Homeland Security Research Center, 26 West Martin Luther King Drive, Cincinnati, OH 45268, USA
| | - Hiba S Ernst
- U.S. Environmental Protection Agency, National Homeland Security Research Center, 26 West Martin Luther King Drive, Cincinnati, OH 45268, USA
| | - Sarah C Taft
- U.S. Environmental Protection Agency, National Homeland Security Research Center, 26 West Martin Luther King Drive, Cincinnati, OH 45268, USA.
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Viasus D, Di Yacovo S, Garcia-Vidal C, Verdaguer R, Manresa F, Dorca J, Gudiol F, Carratalà J. Community-acquired Legionella pneumophila pneumonia: a single-center experience with 214 hospitalized sporadic cases over 15 years. Medicine (Baltimore) 2013; 92:51-60. [PMID: 23266795 PMCID: PMC5348137 DOI: 10.1097/md.0b013e31827f6104] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Legionella pneumophila has been increasingly recognized as a cause of community-acquired pneumonia (CAP) and an important public health problem worldwide. We conducted the present study to assess trends in epidemiology, diagnosis, clinical features, treatment, and outcomes of sporadic community-acquired L. pneumophila pneumonia requiring hospitalization at a university hospital over a 15-year period (1995-2010). Among 3934 nonimmunosuppressed hospitalized patients with CAP, 214 (5.4%) had L. pneumophila pneumonia (16 cases were categorized as travel-associated pneumonia, and 21 were part of small clusters). Since the introduction of the urinary antigen test, the diagnosis of L. pneumophila using this method remained stable over the years (p = 0.42); however, diagnosis by means of seroconversion and culture decreased (p < 0.001 and p = 0.001, respectively). The median age of patients with L. pneumophila pneumonia was 58.2 years (SD 13.8), and 76.4% were male. At least 1 comorbid condition was present in 119 (55.6%) patients with L. pneumophila pneumonia, mainly chronic heart disease, diabetes mellitus, and chronic pulmonary disease. The frequency of older patients (aged >65 yr) and comorbidities among patients with L. pneumophila pneumonia increased over the years (p = 0.06 and p = 0.02, respectively). In addition, 100 (46.9%) patients were classified into high-risk classes according to the Pneumonia Severity Index (groups IV-V). Twenty-four (11.2%) patients with L. pneumophila pneumonia received inappropriate empirical antibiotic therapy at hospital admission. Compared with patients who received appropriate empirical antibiotic, patients who received inappropriate therapy more frequently had acute onset of illness (p = 0.004), pleuritic chest pain (p = 0.03), and pleural effusion (p = 0.05). The number of patients who received macrolides decreased over the study period (p < 0.001), whereas the number of patients who received levofloxacin increased (p < 0.001). No significant difference was found in the outcomes between patients who received erythromycin and clarithromycin. However, compared with macrolide use during hospital admission, levofloxacin therapy was associated with a trend toward a shorter time to reach clinical stability (median, 3 vs. 5 d; p = 0.09) and a shorter length of hospital stay (median, 7 vs. 10 d; p < 0.001). Regarding outcomes, 38 (17.8%) patients required intensive care unit (ICU) admission, and the inhospital case-fatality rate was 6.1% (13 of 214 patients). The frequency of ICU admission (p = 0.34) and the need for mechanical ventilation (p = 0.57) remained stable over the study period, but the inhospital case-fatality rate decreased (p = 0.04). In the logistic regression analysis, independent factors associated with severe disease (ICU admission and death) were current/former smoker (odds ratio [OR], 2.96; 95% confidence interval [CI], 1.01-8.62), macrolide use (OR, 2.40; 95% CI, 1.03-5.56), initial inappropriate therapy (OR, 2.97; 95% CI, 1.01-8.74), and high-risk Pneumonia Severity Index classes (OR, 9.1; 95% CI, 3.52-23.4). In conclusion, L. pneumophila is a relatively frequent causative pathogen among hospitalized patients with CAP and is associated with high morbidity. The annual number of L. pneumophila cases remained stable over the study period. In recent years, there have been significant changes in diagnosis and treatment, and the inhospital case-fatality rate of L. pneumophila pneumonia has decreased.
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Affiliation(s)
- Diego Viasus
- From the Departments of Infectious Diseases (DV, SDY, CGV, FG, JC), Microbiology (RV), and Respiratory Medicine (FM, JD), Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona; and Department of Clinical Science (FM, JD, FG, JC), University of Barcelona, Barcelona, Spain
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Fisman DN, Tang P, Hauck T, Richardson S, Drews SJ, Low DE, Jamieson F. Pertussis resurgence in Toronto, Canada: a population-based study including test-incidence feedback modeling. BMC Public Health 2011; 11:694. [PMID: 21899765 PMCID: PMC3189138 DOI: 10.1186/1471-2458-11-694] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Accepted: 09/07/2011] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Pertussis continues to challenge medical professionals; recently described increases in incidence may be due to age-cohort effects, vaccine effectiveness, or changes in testing patterns. Toronto, Canada has recently experienced increases in pertussis incidence, and provides an ideal jurisdiction for evaluating pertussis epidemiology due to centralized testing. We evaluated pertussis trends in Toronto using all available specimen data, which allowed us to control for changing testing patterns and practices. METHODS Data included all pertussis culture and PCR test records for Greater Toronto from 1993 to 2007. We estimated incidence trends using Poisson regression models; complex relationships between disease incidence and test submission were explored with vector autoregressive models. RESULTS From 1993 to 2007, 26988 specimens were submitted for testing; 2545 (9.4%) were positive. Pertussis incidence was 2 per 100,000 from 1993 to 2004 and increased to 10 per 100,000 from 2005-2007, with a concomitant 6-fold surge in test specimen submissions after the introduction of a new, more sensitive PCR assay. The relative change in incidence was less marked after adjustment for testing volumes. Bidirectional feedbacks between test positivity and test submissions were identified. CONCLUSIONS Toronto's recent surge in pertussis reflects a true increase in local disease activity; the apparent size of the outbreak has likely been magnified by increasing use of pertussis testing by clinicians, and by improved test sensitivity since 2005. These findings may be applicable to changes in pertussis epidemiology that have been noted elsewhere in North America.
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Affiliation(s)
- David N Fisman
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, M5T 3M7, Canada
- Department of Health Policy, Evaluation and Management, University of Toronto, 155 College Street, Toronto, M5T 3M7, Canada
- Department of Medicine, University of Toronto, 1 Kings College Circle, Toronto, M5S 1A8, Canada
| | - Patrick Tang
- Public Health Laboratory--Toronto, Ontario Agency for Health Protection and Promotion, 81 Resources Road, Toronto, M9P 3V6, Canada
| | - Tanya Hauck
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, M5T 3M7, Canada
| | - Susan Richardson
- Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 Kings College Circle, Toronto, M5S 1A8, Canada
- Department of Microbiology, Hospital for Sick Children, 555 University Avenue, Toronto M5G 1X5, Canada
| | - Steven J Drews
- Alberta Provincial Public Health Laboratory, 3030 Hospital Drive Northwest, Calgary, T2N 4W4, Canada
| | - Donald E Low
- Public Health Laboratory--Toronto, Ontario Agency for Health Protection and Promotion, 81 Resources Road, Toronto, M9P 3V6, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 Kings College Circle, Toronto, M5S 1A8, Canada
- Department of Microbiology, Mount Sinai Hospital, 600 University Avenue, Toronto, M5G 1X5, Canada
| | - Frances Jamieson
- Public Health Laboratory--Toronto, Ontario Agency for Health Protection and Promotion, 81 Resources Road, Toronto, M9P 3V6, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 Kings College Circle, Toronto, M5S 1A8, Canada
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Legionella pneumophila monoclonal antibody subgroups and DNA sequence types isolated in Canada between 1981 and 2009: Laboratory Component of National Surveillance. Eur J Clin Microbiol Infect Dis 2009; 29:191-205. [DOI: 10.1007/s10096-009-0840-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 11/01/2009] [Indexed: 10/20/2022]
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Ng V, Tang P, Jamieson F, Guyard C, Low DE, Fisman DN. Laboratory-based evaluation of legionellosis epidemiology in Ontario, Canada, 1978 to 2006. BMC Infect Dis 2009; 9:68. [PMID: 19460152 PMCID: PMC2695468 DOI: 10.1186/1471-2334-9-68] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Accepted: 05/21/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Legionellosis is a common cause of severe community acquired pneumonia and respiratory disease outbreaks. The Ontario Public Health Laboratory (OPHL) has conducted most testing for Legionella species in the Canadian province of Ontario since 1978, and represents a multi-decade repository of population-based data on legionellosis epidemiology. We sought to provide a laboratory-based review of the epidemiology of legionellosis in Ontario over the past 3 decades, with a focus on changing rates of disease and species associated with legionellosis during that time period. METHODS We analyzed cases that were submitted and tested positive for legionellosis from 1978 to 2006 using Poisson regression models incorporating temporal, spatial, and demographic covariates. Predictors of infection with culture-confirmed L. pneumophila serogroup 1 (LP1) were evaluated with logistic regression models. RESULTS 1,401 cases of legionellosis tested positive from 1978 to 2006. As in other studies, we found a late summer to early autumn seasonality in disease occurrence with disease risk increasing with age and in males. In contrast to other studies, we found a decreasing trend in cases in the recent decade (IRR 0.93, 95% CI 0.91 to 0.95, P-value = 0.001); only 66% of culture-confirmed isolates were found to be LP1. CONCLUSION Despite similarities with disease epidemiology in other regions, legionellosis appears to have declined in the past decade in Ontario, in contrast to trends observed in the United States and parts of Europe. Furthermore, a different range of Legionella species is responsible for illness, suggesting a distinctive legionellosis epidemiology in this North American region.
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Affiliation(s)
- Victoria Ng
- Child Health Evaluative Sciences, Research Institute of the Hospital for Sick Children, Toronto, Canada
- National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia
| | - Patrick Tang
- Ontario Agency for Health Protection and Promotion, Toronto, Canada
| | - Frances Jamieson
- Ontario Agency for Health Protection and Promotion, Toronto, Canada
- Department of Pathobiology and Laboratory Medicine, University of Toronto, Toronto, Canada
| | - Cyril Guyard
- Ontario Agency for Health Protection and Promotion, Toronto, Canada
- Department of Pathobiology and Laboratory Medicine, University of Toronto, Toronto, Canada
| | - Donald E Low
- Ontario Agency for Health Protection and Promotion, Toronto, Canada
- Department of Pathobiology and Laboratory Medicine, University of Toronto, Toronto, Canada
- Department of Microbiology, Mount Sinai Hospital, Toronto, Canada
| | - David N Fisman
- Child Health Evaluative Sciences, Research Institute of the Hospital for Sick Children, Toronto, Canada
- Ontario Agency for Health Protection and Promotion, Toronto, Canada
- Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
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