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van der Lugt W, Euser SM, Bruin JP, den Boer JW, Yzerman EPF. Wide-scale study of 206 buildings in the Netherlands from 2011 to 2015 to determine the effect of drinking water management plans on the presence of Legionella spp. Water Res 2019; 161:581-589. [PMID: 31238223 DOI: 10.1016/j.watres.2019.06.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 06/13/2019] [Accepted: 06/16/2019] [Indexed: 05/25/2023]
Abstract
Previous analysis of the Dutch National Legionella Outbreak Detection Program 2002-2012 has shown that buildings required to maintain a Legionella control plan for their drinking water installation are more likely to test positive for Legionella spp. Than buildings without such a plan (38% versus 22% of samples). To clarify this discrepancy, we analysed the results of mandatory water sample testing conducted as part of risk assessments in 206 buildings in the Netherlands from 2011 to 2015. Of the 6171 samples analysed, 16.2% exceeded the Dutch drinking water standard for Legionella spp. of 100 CFU/litre. In buildings with ≤50 tap points, the average percentage of samples containing ≥100 CFU/litre was 28.2%, and from buildings with >50 tap points, it was 12.2%. Analysis of serial samples (taken every 6 months) from each building showed that 33.2% of all buildings tested positive for at least one sample every 6 months. The overall increase was 4.4% per year. Analysis of Legionella subgroups showed that while the majority of positive samples contained L. non-pneumophila (96.9%), some samples did contain L. pneumophila serogroup 1 (1.0%) and serogroups 2-14 (2.1%). Our data suggest that the Dutch mandatory risk assessment and drinking water management plan is not sufficiently effective in preventing the proliferation of Legionella spp. and may even contribute to proliferation. This analysis should now be expanded to include other areas of the Netherlands in order to understand the geographical differences that we observed in our results, and why smaller buildings appear to be more likely to test positive for Legionella spp.
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Affiliation(s)
| | - Sjoerd M Euser
- Regional Public Health Laboratory Kennemerland, Boerhaavelaan 26, 2035, RC, Haarlem, the Netherlands
| | - Jacob P Bruin
- Regional Public Health Laboratory Kennemerland, Boerhaavelaan 26, 2035, RC, Haarlem, the Netherlands
| | - Jeroen W den Boer
- Regional Public Health Laboratory Kennemerland, Boerhaavelaan 26, 2035, RC, Haarlem, the Netherlands
| | - Ed P F Yzerman
- Regional Public Health Laboratory Kennemerland, Boerhaavelaan 26, 2035, RC, Haarlem, the Netherlands
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Loenenbach AD, Beulens C, Euser SM, van Leuken JPG, Bom B, van der Hoek W, Husman AMDR, Ruijs WLM, Bartels AA, Rietveld A, den Boer JW, Brandsema PS. Two Community Clusters of Legionnaires' Disease Directly Linked to a Biologic Wastewater Treatment Plant, the Netherlands. Emerg Infect Dis 2019; 24:1914-1918. [PMID: 30226165 PMCID: PMC6154163 DOI: 10.3201/eid2410.180906] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A biologic wastewater treatment plant was identified as a common source for 2 consecutive Legionnaires' disease clusters in the Netherlands in 2016 and 2017. Sequence typing and transmission modeling indicated direct and long-distance transmission of Legionella, indicating this source type should also be investigated in sporadic Legionnaires' disease cases.
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van Heijnsbergen E, Schalk JAC, Euser SM, Brandsema PS, den Boer JW, de Roda Husman AM. Confirmed and Potential Sources of Legionella Reviewed. Environ Sci Technol 2015; 49:4797-815. [PMID: 25774976 DOI: 10.1021/acs.est.5b00142] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Legionella bacteria are ubiquitous in natural matrices and man-made systems. However, it is not always clear if these reservoirs can act as source of infection resulting in cases of Legionnaires' disease. This review provides an overview of reservoirs of Legionella reported in the literature, other than drinking water distribution systems. Levels of evidence were developed to discriminate between potential and confirmed sources of Legionella. A total of 17 systems and matrices could be classified as confirmed sources of Legionella. Many other man-made systems or natural matrices were not classified as a confirmed source, since either no patients were linked to these reservoirs or the supporting evidence was weak. However, these systems or matrices could play an important role in the transmission of infectious Legionella bacteria; they might not yet be considered in source investigations, resulting in an underestimation of their importance. To optimize source investigations it is important to have knowledge about all the (potential) sources of Legionella. Further research is needed to unravel what the contribution is of each confirmed source, and possibly also potential sources, to the LD disease burden.
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Affiliation(s)
- Eri van Heijnsbergen
- †National Institute for Public Health and the Environment, A. van Leeuwenhoeklaan 9, 3721 MA Bilthoven, The Netherlands
| | - Johanna A C Schalk
- †National Institute for Public Health and the Environment, A. van Leeuwenhoeklaan 9, 3721 MA Bilthoven, The Netherlands
| | - Sjoerd M Euser
- ‡Regional Public Health Laboratory Kennemerland, Haarlem, Boerhaavelaan 26, 2035 RC Haarlem, The Netherlands
| | - Petra S Brandsema
- †National Institute for Public Health and the Environment, A. van Leeuwenhoeklaan 9, 3721 MA Bilthoven, The Netherlands
| | - Jeroen W den Boer
- ‡Regional Public Health Laboratory Kennemerland, Haarlem, Boerhaavelaan 26, 2035 RC Haarlem, The Netherlands
| | - Ana Maria de Roda Husman
- †National Institute for Public Health and the Environment, A. van Leeuwenhoeklaan 9, 3721 MA Bilthoven, The Netherlands
- §Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 2, 3584 CM Utrecht, The Netherlands
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Schalk JAC, Euser SM, van Heijnsbergen E, Bruin JP, den Boer JW, de Roda Husman AM. Soil as a source of Legionella pneumophila sequence type 47. Int J Infect Dis 2014; 27:18-9. [PMID: 25130616 DOI: 10.1016/j.ijid.2014.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 05/09/2014] [Accepted: 05/13/2014] [Indexed: 11/19/2022] Open
Abstract
Legionella pneumophila sequence type (ST) 47 was isolated from soil in a garden. We speculate that this strain was transmitted from soil to the whirlpool in the garden where it caused an outbreak of Legionnaires' disease and Pontiac fever. In the Netherlands, ST47 is frequently isolated from patients, but hardly ever from environmental sources. It is possible that human pathogenic Legionella strains, with ST47 as one of the predominant strains, are transmitted to humans from sources such as natural soil that are currently not targeted in outbreak investigations.
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Affiliation(s)
- Johanna A C Schalk
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands.
| | - Sjoerd M Euser
- Regional Public Health Laboratory Kennemerland, Haarlem, the Netherlands
| | - Eri van Heijnsbergen
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Jacob P Bruin
- Regional Public Health Laboratory Kennemerland, Haarlem, the Netherlands
| | - Jeroen W den Boer
- Regional Public Health Laboratory Kennemerland, Haarlem, the Netherlands
| | - Ana M de Roda Husman
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands; Institute for Risk Assessment Sciences, Utrecht, the Netherlands
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Bruin JP, Ijzerman EP, den Boer JW, Mouton JW, Diederen BM. Wild-type MIC distribution and epidemiological cut-off values in clinical Legionella pneumophila serogroup 1 isolates. Diagn Microbiol Infect Dis 2012; 72:103-8. [DOI: 10.1016/j.diagmicrobio.2011.09.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 09/12/2011] [Accepted: 09/13/2011] [Indexed: 10/15/2022]
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Euser SM, Pelgrim M, den Boer JW. Legionnaires' disease and Pontiac fever after using a private outdoor whirlpool spa. ACTA ACUST UNITED AC 2010; 42:910-6. [DOI: 10.3109/00365548.2010.509331] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Yzerman E, den Boer JW, Caspers M, Almal A, Worzel B, van der Meer W, Montijn R, Schuren F. Comparative genome analysis of a large Dutch Legionella pneumophila strain collection identifies five markers highly correlated with clinical strains. BMC Genomics 2010; 11:433. [PMID: 20630115 PMCID: PMC3091632 DOI: 10.1186/1471-2164-11-433] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 07/15/2010] [Indexed: 11/10/2022] Open
Abstract
Background Discrimination between clinical and environmental strains within many bacterial species is currently underexplored. Genomic analyses have clearly shown the enormous variability in genome composition between different strains of a bacterial species. In this study we have used Legionella pneumophila, the causative agent of Legionnaire's disease, to search for genomic markers related to pathogenicity. During a large surveillance study in The Netherlands well-characterized patient-derived strains and environmental strains were collected. We have used a mixed-genome microarray to perform comparative-genome analysis of 257 strains from this collection. Results Microarray analysis indicated that 480 DNA markers (out of in total 3360 markers) showed clear variation in presence between individual strains and these were therefore selected for further analysis. Unsupervised statistical analysis of these markers showed the enormous genomic variation within the species but did not show any correlation with a pathogenic phenotype. We therefore used supervised statistical analysis to identify discriminating markers. Genetic programming was used both to identify predictive markers and to define their interrelationships. A model consisting of five markers was developed that together correctly predicted 100% of the clinical strains and 69% of the environmental strains. Conclusions A novel approach for identifying predictive markers enabling discrimination between clinical and environmental isolates of L. pneumophila is presented. Out of over 3000 possible markers, five were selected that together enabled correct prediction of all the clinical strains included in this study. This novel approach for identifying predictive markers can be applied to all bacterial species, allowing for better discrimination between strains well equipped to cause human disease and relatively harmless strains.
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Affiliation(s)
- Ed Yzerman
- Regional Public Health Laboratory of Haarlem, Haarlem, the Netherlands
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Diederen BMW, Bruin JP, den Boer JW, Peeters MF, Yzerman EPF. Sensitivity of Legionella pneumophila DNA detection in serum samples in relation to disease severity. J Med Microbiol 2007; 56:1255. [PMID: 17761495 DOI: 10.1099/jmm.0.47258-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Bram M W Diederen
- Regional Laboratory of Public Health Haarlem, Boerhaavelaan 26, 2035 RC Haarlem, The Netherlands
| | - Jacob P Bruin
- Regional Laboratory of Public Health Haarlem, Boerhaavelaan 26, 2035 RC Haarlem, The Netherlands
| | - Jeroen W den Boer
- Municipal Health Service Kennemerland, PO Box 5514, 2000 GM Haarlem, The Netherlands
| | - Marcel F Peeters
- Laboratory of Medical Microbiology and Immunology, St Elisabeth Hospital, PO Box 747, 5000 AS Tilburg, The Netherlands
| | - Ed P F Yzerman
- Regional Laboratory of Public Health Haarlem, Boerhaavelaan 26, 2035 RC Haarlem, The Netherlands
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Yzerman EPF, den Boer JW, Lettinga KD, Schel AJ, Schellekens J, Peeters M. Sensitivity of three serum antibody tests in a large outbreak of Legionnaires' disease in the Netherlands. J Med Microbiol 2006; 55:561-566. [PMID: 16585643 DOI: 10.1099/jmm.0.46369-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In 1999, an outbreak involving 188 patients with Legionnaires' disease (LD) occurred at a flower show in the Netherlands. This large outbreak provided the opportunity to evaluate serum antibody tests to assay anti-Legionella pneumophila, since limited data are available on the sensitivity of these tests. The sensitivities of an indirect serotype 1-6 immunofluorescence antibody test (IFAT), a rapid micro-agglutination test (RMAT) IgM serotype 1 antibody assay, and an ELISA to detect IgM and IgG serotype 1-7 antibodies, were evaluated using serum samples from LD patients related to the 1999 outbreak. Sensitivity was calculated using positive culture and/or a positive urinary antigen test as the gold standard in outbreak-related patients with radiographically confirmed pneumonia who fulfilled the epidemiological criteria. The IFAT, RMAT and ELISA showed sensitivities of 61, 44 and 64%, respectively. The sensitivity of the three tests combined was 67%. In epidemic situations, however, high standing titres may be included in the laboratory evidence of LD cases. In the study population, high standing titres were found in 16% of cases. If the presence of high standing antibody titres was added to the criteria of a positive test, the sensitivities of IFAT, RMAT and ELISA were 86, 48 and 75%, respectively. The sensitivity was 91% for all tests combined. The higher sensitivity for the combined use of tests is offset by a reduction in specificity to 97.6%. The results of this study indicate that using a combination of serologic tests in pneumonia patients suspected to have LD does not substantially improve sensitivity. The results suggest that in the microbiological diagnosis of LD, both IFAT and ELISA are reasonably sensitive assays. In an epidemic situation, both tests are highly sensitive, the IFAT more so than the ELISA.
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Affiliation(s)
- Ed P F Yzerman
- Academic Medical Center, Amsterdam, The Netherlands
- Regional Laboratory of Public Health Haarlem, Boerhaavelaan 26, 2035 RC Haarlem, The Netherlands
| | | | | | | | - Joop Schellekens
- National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Marcel Peeters
- Regional Laboratory of Public Health Tilburg, Tilburg, The Netherlands
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Bencini MA, Yzerman EPF, Koornstra RHT, Nolte CCM, den Boer JW, Bruin JP. A case of Legionnaires' disease caused by aspiration of ice water. Arch Environ Occup Health 2005; 60:302-6. [PMID: 17447574 DOI: 10.3200/aeoh.60.6.302-306] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The authors discuss the case of a 79-year-old patient who suffered from a swallowing disorder and developed Legionnaires' disease 2 days after her dismissal from an orthopedics ward, where she had recovered from hip surgery. To determine the source of the Legionnaires' disease, the authors performed an environmental investigation, which included a national, standardized questionnaire and a microbiological investigation of suspected sources. The investigation revealed ice from an ice-making machine in the hospital as the most probable source of the infection through aspiration, even though the hospital had rigorously adhered to strict assessment and decontamination schedules. The infectious serogroup was one that was not common to the area. From the data available, the authors inferred that a dose of 1-2000 colony-forming units might have caused Legionnaires' disease in this patient.
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Affiliation(s)
- Max A Bencini
- Regional Public Health Laboratory of Haarlem, The Netherlands.
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Yzerman EPF, den Boer JW, Lettinga KD, Schellekens J, Dankert J, Peeters M. Sensitivity of three urinary antigen tests associated with clinical severity in a large outbreak of Legionnaires' disease in The Netherlands. J Clin Microbiol 2002; 40:3232-6. [PMID: 12202558 PMCID: PMC130686 DOI: 10.1128/jcm.40.9.3232-3236.2002] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In 1999 an outbreak involving 188 patients with Legionnaires' disease (LD) occurred among visitors to a flower show in the Netherlands. Two enzyme immunoassays (Binax and Biotest) and one immunochromatographic assay (Binax NOW) were tested, using urine samples from LD patients from the 1999 outbreak. Sensitivity was calculated using positive culture and/or seroconversion as the "gold standard" in outbreak-related patients with radiographically confirmed pneumonia who fulfilled the epidemiological critera. The Binax EIA, Biotest EIA, and Binax NOW assay showed overall sensitivities of 69, 71, and 72%, respectively. When the tests were performed with concentrated urine samples, the overall sensitivities increased to 79, 74, and 81%, respectively. Using multiple logistic regression analysis with backward elimination, a statistically significant association was found between clinical severity and test sensitivity for all tests. For patients with mild LD, the test sensitivities ranged from 40 to 53%, whereas for patients with severe LD who needed immediate special medical care, the sensitivities reached 88 to 100%. These findings have major implications for the diagnostic process in patients with mild pneumonia and suggest that patients with mild pneumonia may go underdiagnosed if urine antigen tests alone are used.
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Affiliation(s)
- Ed P F Yzerman
- Regional Laboratory of Public Health Haarlem, The Netherlands.
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