Legionella and Public Health Natalia Kozak-Muiznieks, PhD - - PowerPoint PPT Presentation

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Legionella and Public Health Natalia Kozak-Muiznieks, PhD - - PowerPoint PPT Presentation

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Legionella and Public Health Natalia Kozak-Muiznieks, PhD Microbiologist Centers for Disease Control and Prevention Division of Bacterial Diseases May 18, 2015 National Center for Immunization & Respiratory Diseases Division of Bacterial

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SLIDE 1

Natalia Kozak-Muiznieks, PhD

Microbiologist Centers for Disease Control and Prevention Division of Bacterial Diseases May 18, 2015

Legionella and Public Health

National Center for Immunization & Respiratory Diseases Division of Bacterial Diseases

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SLIDE 2

Legionella

Holland/Özel, Robert Koch-Institut

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SLIDE 3

Temperature range of Legionella

Celsius Fahrenheit

25 77 35 95 42 108 45 113 55 131 Dormant Growth Death

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SLIDE 4

Legionella are biofilm associated

secreted slime surface free-floating bacteria biofilm-associated bacteria

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SLIDE 5

Disease Transmission

Water Supplies Amplification Aerosolization Host Transmission

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SLIDE 6

Incidence of Legionellosis—United States, 1998-2011*

  • *National Notifiable Disease Surveillance System
  • 2013: provisional report until Sept 2013

0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Incidence per 100,000 pop. Year

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SLIDE 7

Average Annual Rates of Reported Legionellosis Cases per 100,000 Population, NNDSS, 2000-2009

< 0.50 0.50 - 1.00 1.01 - 1.50 1.51 - 2.00 2.01 - 2.50 2.51 - 3.00

Note: Alaska and Hawaii are part of the Pacific Reporting Area

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SLIDE 8

What is an outbreak?

  • An outbreak is 2+ cases within 1 year
  • Exception: hospitals 1 confirmed case or 2 suspect
  • Responses:
  • Consultation
  • Collaboration
  • Epi-Aid
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SLIDE 9

Epidemiology

  • Patient Questionnaires
  • Case definition
  • Case finding
  • Initial recommendations
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SLIDE 10

What is the source?

1 2 3 4 5 6

8/31/2013 9/30/2013

Case Count Symptom Onset Date 1 2 3 4

Number of cases Illness onset

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SLIDE 11

Legionella Environmental Assessment

  • Facility characteristics
  • Outside water supply
  • Premise plumbing system
  • Hot tubs and whirlpool spas
  • Cooling towers
  • Recent or ongoing major constructions
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SLIDE 12

Commonly Sampled Locations

  • Central distribution point (hot water heater)
  • Aerosol generating devices (cooling towers,

humidifiers, etc.)

  • Medical devices (hydrotherapy pools, CPAP

machines, etc.)

  • Rooms where patients were housed (potable)
  • Recreational and decorative features

(whirlpool spas, fountains, etc.)

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SLIDE 13

Sample Processing, Legionella Isolation and Characterization

BCYE BCYE without L-cysteine

5-8 hours - Initial sample processing Up to 7 days - Incubation Up to 2 days - Confirming Legionella isolates to genus level

  • 3- 4 days - Getting single colony

isolates

  • Up to 2 weeks - Identification

species, serogroups and genotypes

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SLIDE 14

Genus Legionella

60 species of Legionellae > 90% of the isolates associated with Legionnaires’ disease - L. pneumophila 79% of cases are due to L. pneumophila serogroup 1 (Lp1) majority of Lp1 clinical isolates reacts with MAb2

Virulent genotypes 17 serogroups of

  • L. pneumophila

Lp6, Lp5, Lp8 are also frequent “offenders” MAb panel contains 7 monoclonal antibodies There are > 2000 sequence types

  • f L. pneumophila, yet only 16

STs are responsible for the majority of sporadic LD cases

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SLIDE 15

Recommendations and Conclusions

  • Water restrictions
  • Notify residents
  • Begin (or continue) active surveillance
  • Emergency remediation (heat flush and/or

hyperchlorination)

  • Post remediation sampling 2X monthly for 3

months

  • Post remediation sampling 1X monthly for

additional 3 months

  • Strive for eradication
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SLIDE 16

Knowledge Gaps

  • Better methods of acute remediation
  • Best methods for long term control –

situational?

  • How to evaluate emerging

technologies?

  • Safe level of Legionella?
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SLIDE 17

Case Studies

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SLIDE 18

VA Hospital

 Background:

  • High rate LD testing
  • Routine environmental testing
  • Cu/Ag disinfection

 Investigation

  • Aug: 2 clinical isolates
  • Oct: 1 environmental isolate
  • Since 2010: 5 confirmed, 21 suspect
  • Similar to 1982 environmental

 Conclusions:

  • Long term persistence
  • Low suspicion
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SLIDE 19

Las Vegas Condominiums

  • Silk BJ et al. Epidemiol Infect. 2012 Nov;140(11):1993-2002. Epub 2012 Jan 4.

 Background:

  • 2001: 3 travel cases
  • 2002: chlorine dioxide
  • 2008: 4 travel cases

 Investigation

  • 16 confirmed, 19 probable
  • Transmission through showers
  • ST35 in 2001, 2002, & 2008
  • ST35: one of the “bad” STs

 Conclusions:

  • Long term persistence
  • Increase temp & ClO2
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SLIDE 20

GA Resort

 Background:

  • 2007 – 2014 six LD cases
  • Stayed in 6 different rooms or

chalets

 Investigation:

  • Water supplied by 5 wells w/out

disinfectant or filtration

  • Outdoor spas inside rooms
  • Staff couldn’t describe water

system in reasonable details

  • 35% sites positive for Lp1 ST36

 Conclusion:

  • Importance of residual disinfection
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SLIDE 21

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank you!

National Center for Immunization & Respiratory Diseases Division of Bacterial Diseases

Natalia Kozak-Muiznieks Centers for Disease Control and Prevention 1600 Clifton Rd NE MS G03 Atlanta, GA 30333 Phone (404) 639-2305