Community Legionella outbreak linked to a cooling tower, 2022

Background

Thirty-five laboratory-confirmed legionellosis cases were reported to the Simcoe Muskoka District Health Unit (Ontario, Canada) between September 27, 2022, and October 15, 2022, resulting in one death and 29 hospitalizations. This article describes the Legionella outbreak and highlights activities for managing the outbreak, including various environmental and infrastructural controls associated with the public health response and some of the unique challenges and potential solutions to mitigate future outbreaks.

Methods

All cases of legionellosis were reported to and investigated by the local provincial health unit. Within a 6 km radius around the community, 27 cooling towers (CTs) were identified as potential sources of Legionella. Environmental samples were collected from 19 CTs and a long-term care home.

Outcome

Of the 35 cases, 29 (83%) were hospitalized (including three long-term care residents) with two requiring intubation/ventilation. Of the five sputa (clinical isolates) collected from confirmed cases, four tested positive for Legionella pneumophila (one was positive for L. pneumophila serogroup 1-with the same sequence type as one of the CT isolates). Education and recommendations were provided by the local provincial health unit to operators to improve CT operation.

Conclusion

Detection and management of community legionellosis outbreaks associated with CTs involve resources and time to properly identify and control risks. Measures for community risk mitigation included coordinating with provincial and community partners, developing methods to rapidly identify CTs as a likely source of infection and applying operational/maintenance/testing standards for CTs to control bacterial growth and minimize the dispersion of contaminated aerosols.

Assessment of the Impact of Temperature on Biofilm Composition with a Laboratory Heat Exchanger Module

Temperature change over the length of heat exchangers might be an important factor affecting biofouling. This research aimed at assessing the impact of temperature on biofilm accumulation and composition with respect to bacterial community and extracellular polymeric substances. Two identical laboratory-scale plate heat exchanger modules were developed and tested. Tap water supplemented with nutrients was fed to the two modules to enhance biofilm formation. One “reference” module was kept at 20.0 ± 1.4 °C and one “heated” module was operated with a counter-flow hot water stream resulting in a bulk water gradient from 20 to 27 °C. Biofilms were grown during 40 days, sampled, and characterized using 16S rRNA gene amplicon sequencing, EPS extraction, FTIR, protein and polysaccharide quantifications. The experiments were performed in consecutive triplicate. Monitoring of heat transfer resistance in the heated module displayed a replicable biofilm growth profile. The module was shown suitable to study the impact of temperature on biofouling formation. Biofilm analyses revealed: (i) comparable amounts of biofilms and EPS yield in the reference and heated modules, (ii) a significantly different protein to polysaccharide ratio in the EPS of the reference (5.4 ± 1.0%) and heated modules (7.8 ± 2.1%), caused by a relatively lower extracellular sugar production at elevated temperatures, and (iii) a strong shift in bacterial community composition with increasing temperature. The outcomes of the study, therefore, suggest that heat induces a change in biofilm bacterial community members and EPS composition, which should be taken into consideration when investigating heat exchanger biofouling and cleaning strategies. Research potential and optimization of the heat exchanger modules are discussed.

Local Adaptation of Legionella pneumophila within a Hospital Hot Water System Increases Tolerance to Copper

In large-building water systems, Legionella pneumophila is exposed to common environmental stressors such as copper. The aim of this study was to evaluate the susceptibility to copper of L. pneumophila isolates recovered from various sites: two clinical and seven environmental isolates from hot water system biofilm and water and from cooling tower water. After a 1-week acclimation in simulated drinking water, strains were exposed to various copper concentrations (0.8 to 5 mg/liter) for over 672 h. Complete loss of culturability was observed for three isolates following copper exposure to 5 mg/liter for 672 h. Two sequence type 1427 (ST1427)-like isolates were highly sensitive to copper, while the other two, isolated from biofilm samples, maintained higher culturability. The expression of the copper resistance gene copA evaluated by reverse transcription-quantitative PCR (RT-qPCR) was significantly higher for the biofilm isolates. All four ST1427-like isolates were recovered from the same water system during an outbreak. Whole-genome sequencing results confirmed that the four isolates are very close phylogenetically, differing by only 29 single nucleotide polymorphisms, suggesting in situ adaptation to microenvironmental conditions, possibly due to epigenetic regulation. These results indicate that the immediate environment within a building water distribution system influences the tolerance of L. pneumophila to copper. Increased contact of L. pneumophila biofilm strains with copper piping or copper alloys in the heat exchanger might lead to local adaptation. The phenotypic differences observed between water and biofilm isolates from the hot water system of a health care facility warrants further investigation to assess the relevance of evaluating disinfection performances based on water sampling alone.IMPORTANCELegionella pneumophila is a pathogen indigenous to natural and large building water systems in the bulk and the biofilm phases. The immediate environment within a system can impact the tolerance of L. pneumophila to environmental stressors, including copper. In health care facilities, copper levels in water can vary, depending on water quality, plumbing materials, and age. This study evaluated the impact of the isolation site (water versus biofilm, hot water system versus cooling tower) within building water systems. Closely related strains isolated from a health care facility hot water system exhibited variable tolerance to copper stress, shown by differential expression of copA, with biofilm isolates displaying highest expression and tolerance. Relying on the detection of L. pneumophila in water samples following exposure to environmental stressors such as copper may underestimate the prevalence of L. pneumophila, leading to inappropriate risk management strategies and increasing the risk of exposure for vulnerable patients.

The Impact of Storms on Legionella pneumophila in Cooling Tower Water, Implications for Human Health

At the U.S. Department of Energy’s Savannah River Site (SRS) in Aiken, SC, cooling tower water is routinely monitored for Legionella pneumophila concentrations using a direct fluorescent antibody (DFA) technique. Historically, 25–30 operating SRS cooling towers have varying concentrations of Legionella in all seasons of the year, with patterns that are unpredictable. Legionellosis, or Legionnaires’ disease (LD), is a pneumonia caused by Legionella bacteria that thrive both in man-made water distribution systems and natural surface waters including lakes, streams, and wet soil. Legionnaires’ disease is typically contracted by inhaling L. pneumophila, most often in aerosolized mists that contain the bacteria. At the SRS, L. pneumophila is typically found in cooling towers ranging from non-detectable up to 10⁸ cells/L in cooling tower water systems. Extreme weather conditions contributed to elevations in L. pneumophila to 10⁷–10⁸ cells/L in SRS cooling tower water systems in July–August 2017. L. pneumophila concentrations in Cooling Tower 785-A/2A located in SRS A-Area, stayed in the 10⁸ cells/L range despite biocide addition. During this time, other SRS cooling towers did not demonstrate this L. pneumophila increase. No significant difference was observed in the mean L. pneumophila mean concentrations for the towers (p < 0.05). There was a significant variance observed in the 285-2A/A Tower L. pneumophila results (p < 0.05). Looking to see if we could find “effects” led to model development by analyzing 13 months of water chemistry and microbial data for the main factors influencing the L. pneumophila concentrations in five cooling towers for this year. It indicated chlorine and dissolved oxygen had a significant impact (p < 0.0002) on cooling tower 785A/2A. Thus, while the variation in the log count data for the A-area tower is statistically greater than that of the other four towers, the average of the log count data for the A-Area tower was in line with that of the other towers. It was also observed that the location of 785A/2A and basin resulted in more debris entering the system during storm events. Our results suggest that future analyses should evaluate the impact of environmental conditions and cooling tower design on L. pneumophila water concentrations and human health.

Bacterial Respiration Used as a Proxy to Evaluate the Bacterial Load in Cooling Towers

Evaporative cooling towers to dissipate excess process heat are essential installations in a variety of industries. The constantly moist environment enables substantial microbial growth, causing both operative challenges (e.g., biocorrosion) as well as health risks due to the potential aerosolization of pathogens. Currently, bacterial levels are monitored using rather slow and infrequent sampling and cultivation approaches. In this study, we describe the use of metabolic activity, namely oxygen respiration, as an alternative measure of bacterial load within cooling tower waters. This method is based on optical oxygen sensors that enable an accurate measurement of oxygen consumption within a closed volume. We show that oxygen consumption correlates with currently used cultivation-based methods (R² = 0.9648). The limit of detection (LOD) for respiration-based bacterial quantification was found to be equal to 1.16 × 10⁴ colony forming units (CFU)/mL. Contrary to the cultivation method, this approach enables faster assessment of the bacterial load with a measurement time of just 30 min compared to 48 h needed for cultivation-based measurements. Furthermore, this approach has the potential to be integrated and automated. Therefore, this method could contribute to more robust and reliable monitoring of bacterial contamination within cooling towers and subsequently increase operational stability and reduce health risks.

Air-conditioner cooling towers as complex reservoirs and continuous source of Legionella pneumophila infection evidenced by a genomic analysis study in 2017, Switzerland

Introduction

Water supply and air-conditioner cooling towers (ACCT) are potential sources of Legionella pneumophila infection in people. During outbreaks, traditional typing methods cannot sufficiently segregate L. pneumophila strains to reliably trace back transmissions to these artificial water systems. Moreover, because multiple L. pneumophila strains may be present within these systems, methods to adequately distinguish strains are needed. Whole genome sequencing (WGS) and core genome multilocus sequence typing (cgMLST), with their higher resolution are helpful in this respect. In summer 2017, the health administration of the city of Basel detected an increase of L. pneumophila infections compared with previous months, signalling an outbreak.

Aim

We aimed to identify L. pneumophila strains populating suspected environmental sources of the outbreak, and to assess the relations between these strains and clinical outbreak strains.

Methods

An epidemiological and WGS-based microbiological investigation was performed, involving isolates from the local water supply and two ACCTs (n = 60), clinical outbreak and non-outbreak related isolates from 2017 (n = 8) and historic isolates from 2003–2016 (n = 26).

Results

In both ACCTs, multiple strains were found. Phylogenetic analysis of the ACCT isolates showed a diversity of a few hundred allelic differences in cgMLST. Furthermore, two isolates from one ACCT showed no allelic differences to three clinical isolates from 2017. Five clinical isolates collected in the Basel area in the last decade were also identical in cgMLST to recent isolates from the two ACCTs.

Conclusion

Current outbreak-related and historic isolates were linked to ACCTs, which form a complex environmental habitat where strains are conserved over years.

Influence of Flue Gas Injection on the Long-Term Durability of a Natural Draft Concrete Cooling Tower

The article undertakes the very important topic of the long-term durability of concrete in a natural draft concrete cooling tower with flue gas injection. The corrosive conditions, including temperature, relative humidity, and CO₂ and SO₂ gas concentrations, near the inner wall of a cooling tower with flue gas injection were monitored in real time to obtain the long-term durability performance of concrete. The pH and chemical compositions of the condensed liquid that adhered to the tower's inner face and the macromorphology, compressive strength, and neutralization depth of in situ specimens were tested periodically. In addition, a finite element numerical simulation was conducted to simulate and verify the concentration distributions of CO₂ and SO₂ in the flue gas in the cooling tower. The results showed that the cleaned flue gas was enveloped, diluted, and uplifted by hot vapor in the cooling tower, and its concentration decreased. Meanwhile, the effective diffusion radius increased gradually as the flue gas rose. With the same elevation in the cooling tower, the concentration of flue gas decreased rapidly from the central point to the surrounding area. The air near the inner surface of the cooling tower was merely dampened air with a low concentration of acidic gas due to the gigantic diameter of the cooling tower. As a result, the injection of cleaned flue gas will not evidently increase the corrosion risk in a natural draft concrete cooling tower.

Analysis of Genetic Characterization and Clonality of Legionella pneumophila Isolated from Cooling Towers in Japan

We investigated the genetic characteristics of 161 Legionella pneumophila strains isolated over a period of 10 years from cooling towers in Japan. Minimum spanning tree analysis based on the sequence-based typing (SBT) of them identified three clonal complexes (CCs); CC1 (105/161, 65.2%), CC2 (22 /161, 13.7%), and CC3 (20/161, 12.4%). CC1 was formed by serogroup (SG) 1 and SG7, whereas CC2 was mainly formed by SG1. All of the CC3 isolates except two strains were SG13. The major sequence types (STs) in CC1 and CC2 were ST1 (88/105, 83.8%) and ST154 (15/22, 68.2%), respectively. These STs are known as typical types of L. pneumophila SG1 in Japanese cooling tower. Additionally, we identified 15 strains of ST2603 as the major type in CC3. This ST has not been reported in Japanese cooling tower. Whole genome sequencing (WGS) analysis of the representative strains in the three CCs, which were isolated from various cooling towers over the 10 years, elucidated high clonal population of L. pneumophila in Japanese cooling tower. Moreover, it revealed that the strains of CC2 are phylogenetically distant compared to those of CC1 and CC3, and belonged to L. pneumophila subsp. fraseri.

Pseudomonas-Specific NGS Assay Provides Insight Into Abundance and Dynamics of Pseudomonas Species Including P. aeruginosa in a Cooling Tower

Pseudomonas species are frequent inhabitants of freshwater environments and colonizers of water supply networks via bioadhesion and biofilm formation. P. aeruginosa is the species most commonly associated with human disease, causing a wide variety of infections with links to its presence in freshwater systems. Though several other Pseudomonas species are of ecological and public health importance, little knowledge exists regarding environmental abundances of these species. In the present study, an Illumina-based next-generation sequencing (NGS) approach using Pseudomonas-specific primers targeting the 16S rRNA gene was evaluated and applied to a set of freshwater samples from different environments including a cooling tower sampled monthly during 2 years. Our approach showed high in situ specificity and accuracy. NGS read counts revealed a precise quantification of P. aeruginosa and a good correlation with the absolute number of Pseudomonas genome copies in a validated genus-specific qPCR assay, demonstrating the ability of the NGS approach to determine both relative and absolute abundances of Pseudomonas species and P. aeruginosa. The characterization of Pseudomonas communities in cooling tower water allowed us to identify 43 phylotypes, with P. aeruginosa being the most abundant. A shift existed within each year from a community dominated by phylotypes belonging to P. fluorescens and P. oleovorans phylogenetic groups to a community where P. aeruginosa was highly abundant. Co-occurrence was observed between P. aeruginosa and other phylotypes of P. aeruginosa group as well as the potentially pathogenic species P. stutzeri, but not with phylotypes of the P. fluorescens group, indicating the need to further investigate the metabolic networks and ecological traits of Pseudomonas species. This study demonstrates the potential of deep sequencing as a valuable tool in environmental diagnostics and surveillance of health-related pathogens in freshwater environments.

A Large Community Outbreak of Legionnaires' Disease Associated With a Cooling Tower in New York City, 2015

OBJECTIVES

Infections caused by Legionella are the leading cause of waterborne disease outbreaks in the United States. We investigated a large outbreak of Legionnaires' disease in New York City in summer 2015 to characterize patients, risk factors for mortality, and environmental exposures.

METHODS

We defined cases as patients with pneumonia and laboratory evidence of Legionella infection from July 2 through August 3, 2015, and with a history of residing in or visiting 1 of several South Bronx neighborhoods of New York City. We describe the epidemiologic, environmental, and laboratory investigation that identified the source of the outbreak.

RESULTS

We identified 138 patients with outbreak-related Legionnaires' disease, 16 of whom died. The median age of patients was 55. A total of 107 patients had a chronic health condition, including 43 with diabetes, 40 with alcoholism, and 24 with HIV infection. We tested 55 cooling towers for Legionella, and 2 had a strain indistinguishable by pulsed-field gel electrophoresis from 26 patient isolates. Whole-genome sequencing and epidemiologic evidence implicated 1 cooling tower as the source of the outbreak.

CONCLUSIONS

A large outbreak of Legionnaires' disease caused by a cooling tower occurred in a medically vulnerable community. The outbreak prompted enactment of a new city law on the operation and maintenance of cooling towers. Ongoing surveillance and evaluation of cooling tower process controls will determine if the new law reduces the incidence of Legionnaires' disease in New York City.

Limitations of Using Propidium Monoazide with qPCR to Discriminate between Live and Dead Legionella in Biofilm Samples

Accurately quantifying Legionella for regulatory purposes to protect public health is essential. Real-time PCR (qPCR) has been proposed as a better method for detecting and enumerating Legionella in samples than conventional culture method. However, since qPCR amplifies any target DNA in the sample, the technique’s inability to discriminate between live and dead cells means that counts are generally significantly overestimated. Propidium monoazide (PMA) has been used successfully in qPCR to aid live/dead discrimination. We tested PMA use as a method to count only live Legionella cells in samples collected from a modified chemostat that generates environmentally comparable samples. Counts from PMA-treated samples that were pretreated with either heat or three types of disinfectants (to kill the cells) were highly variable, with the only consistent trend being the relationship between biofilm mass and numbers of Legionella cells. Two possibilities explain this result: 1. PMA treatment worked and the subsequent muted response of Legionella to disinfection treatment is a factor of biofilm/microbiological effects; although this does not account for the relationship between the amount of biofilm sampled and the viable Legionella count as determined by PMA-qPCR; or 2. PMA treatment did not work, and any measured decrease or increase in detectable Legionella is because of other factors affecting the method. This is the most likely explanation for our results, suggesting that higher concentrations of PMA might be needed to compensate for the presence of other compounds in an environmental sample or that lower amounts of biofilm need to be sampled. As PMA becomes increasingly toxic at higher concentrations and is very expensive, augmenting the method to include higher PMA concentrations is both counterproductive and cost prohibitive. Conversely, if smaller volumes of biofilm are used, the reproducibility of the method is reduced. Our results suggest that using PMA is not an appropriate method for discriminating between live and dead cells to enumerate Legionella for regulatory purposes.

Mycobacteria in Finnish cooling tower waters

Evaporative cooling towers are water systems used in, e.g., industry and telecommunication to remove excess heat by evaporation of water. Temperatures of cooling waters are usually optimal for mesophilic microbial growth and cooling towers may liberate massive amounts of bacterial aerosols. Outbreaks of legionellosis associated with cooling towers have been known since the 1980's, but occurrences of other potentially pathogenic bacteria in cooling waters are mostly unknown. We examined the occurrence of mycobacteria, which are common bacteria in different water systems and may cause pulmonary and other soft tissue infections, in cooling waters containing different numbers of legionellae. Mycobacteria were isolated from all twelve cooling systems and from 92% of the 24 samples studied. Their numbers in the positive samples varied from 10 to 7.3 × 10(4) cfu/L. The isolated species included M. chelonae/abscessus, M. fortuitum, M. mucogenicum, M. peregrinum, M. intracellulare, M. lentiflavum, M. avium/nebraskense/scrofulaceum and many non-pathogenic species. The numbers of mycobacteria correlated negatively with the numbers of legionellae and the concentration of copper. The results show that cooling towers are suitable environments for potentially pathogenic mycobacteria. Further transmission of mycobacteria from the towers to the environment needs examination.

Spatial arrangement of legionella colonies in intact biofilms from a model cooling water system

There is disagreement among microbiologists about whether Legionella requires a protozoan host in order to replicate. This research sought to determine where in biofilm Legionellae are found and whether all biofilm associated Legionella would be located within protozoan hosts. While it is accepted that Legionella colonizes biofilm, its life cycle and nutritional fastidiousness suggest that Legionella employs multiple survival strategies to persist within microbial systems. Fluorescent in situ hybridization (FISH) and confocal laser scanning microscopy (CLSM) demonstrated an undulating biofilm surface architecture and a roughly homogenous distribution of heterotrophic bacteria with clusters of protozoa. Legionella displayed 3 distinct spatial arrangements either contained within or directly associated with protozoa, or dispersed in loosely associated clusters or in tightly packed aggregations of cells forming dense colonial clusters. The formation of discreet clusters of tightly packed Legionella suggests that colony formation is influenced by specific environmental conditions allowing for limited extracellular replication. This work represents the first time that an environmentally representative, multispecies biofilm containing Legionella has been fluorescently tagged and Legionella colony morphology noted within a complex microbial system.

Comprehensive Evaluation of Biological Growth Control by Chlorine-Based Biocides in Power Plant Cooling Systems Using Tertiary Effluent

Recent studies have shown that treated municipal wastewater can be a reliable cooling water alternative to fresh water. However, elevated nutrient concentration and microbial population in wastewater lead to aggressive biological proliferation in the cooling system. Three chlorine-based biocides were evaluated for the control of biological growth in cooling systems using tertiary treated wastewater as makeup, based on their biocidal efficiency and cost-effectiveness. Optimal chemical regimens for achieving successful biological growth control were elucidated based on batch-, bench-, and pilot-scale experiments. Biocide usage and biological activity in planktonic and sessile phases were carefully monitored to understand biological growth potential and biocidal efficiency of the three disinfectants in this particular environment. Water parameters, such as temperature, cycles of concentration, and ammonia concentration in recirculating water, critically affected the biocide performance in recirculating cooling systems. Bench-scale recirculating tests were shown to adequately predict the biocide residual required for a pilot-scale cooling system. Optimal residuals needed for proper biological growth control were 1, 2-3, and 0.5-1 mg/L as Cl₂ for NaOCl, preformed NH₂Cl, and ClO₂, respectively. Pilot-scale tests also revealed that Legionella pneumophila was absent from these cooling systems when using the disinfectants evaluated in this study. Cost analysis showed that NaOCl is the most cost-effective for controlling biological growth in power plant recirculating cooling systems using tertiary-treated wastewater as makeup.