June 11 2013 Shamika Smith MPH Epidemiologist Legionellosis Bacteria ubiquitous in environment typically water Transmitted through aerosolization or aspiration of Legionella contaminated water ID: 330244
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Legionellosis Outbreak Associated with a Hotel Fountain, Chicago 2012June 11, 2013
Shamika Smith, MPH
EpidemiologistSlide2
Legionellosis
Bacteria ubiquitous in environment, typically water
Transmitted through aerosolization or aspiration of
Legionella
-contaminated water
Immunocompromised individuals are most susceptibleSlide3
Legionnaires' disease(LD)
Pontiac Fever
(PF)
Clinical features
Pneumonia, cough, fever
Flu-like illness (fever, chills, malaise) without pneumoniaRadiographic pneumoniaYesNoIncubation period2-14 days after exposure24-72 hours after exposureEtiologic agentLegionella speciesLegionella speciesAttack rate< 5%> 90%Isolation of organismPossibleNeverOutcomeHospitalization commonCase-fatality rate: 5-30%Hospitalization uncommonCase-fatality rate: 0%
Difference between LD and PF
CDC. Top 10 Things Every Clinician Needs to Know About Legionellosis. 2013. Retrieved
from http://www.cdc.gov/legionella/clinicians.htmlSlide4
Reported Legionellosis Case Counts, 1990-2011**Counts for U.S. (2011) not yet published
.Slide5
September 2006
N=12
August 2007 N=14
June-Aug. 2010 N=18
Reported Legionellosis cases
by month of onset,
Chicago, 2001 - 2010
Reported residences of cluster case-patientsSlide6
Outbreak IdentificationAug. 14, 2012: Company A contacted CDPH reporting: --30 cases of respiratory illness --several cases of pneumonia; 1 deathCDPH contacted Hotel X-learned that guest (not Company A) also reported illness
Conference held at Hotel X from Jul. 30- Aug. 3
-- Approximately 600 attendees
-- Event I (7/30-8/1): 427 people
-- Event II (8/2-8/3): 266 people-- 80 people attended both eventSlide7
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78910111213 WaterClosures1516171819202122232425262728293031Slide9Slide10Slide11Slide12
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78910111213 WaterClosures15 WaterDrained16171819202122232425262728293031Slide13
Case FindingHotel reached out to guests 7/16-8/15 --Earliest exposure date: 7/26- 10 days= 7/16 --The day fountain, pool, spa drained: 8/15CDPH contacted other hotel event organizers
Hotel unable to obtain mailing addresses for ~40% of guests by 8/20
Three press releases; media interviewsSlide14
Methods: Survey DevelopmentExploratory interviews with Company A employeesEtiology unknown, therefore reviewedLegionella questionnaireCDC’s acute respiratory illness questionnaire
Piloted draft questionnaire, 8/15 (morning)
Questionnaire sent to all Company A hotel guests via Health
Alert
Network (HAN),
8/15 (afternoon) Slide15
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78910111213CDPHnotified15 SurveyEPI-X161718Sample 119202122232425262728293031Slide16
Methods: Environmental HealthIllinois Department of Public Health (IDPH), Environmental Health inspected/sampled:Whirlpool spaIndoor poolFountain in lobby
Locker rooms
Steam room
SaunaGuest shower heads
CDC consultedSlide17
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78910111213CDPHnotified15 SurveyEPI-X1617 Data analysis18Sample 1Sample 2Sample 319202122232425262728293031Slide18
Preliminary Data AnalysisFountain exposure significantly associated with illnessCase definition: hospitalized, pneumonia dx, chest x-ray ordered
P-value=.
0074
Yes
No
Yes
13
7
20
No
51
99
150
64
106
170
Case
Fountain ExposureSlide19
Number of calls received (N=250)
Dates of press releasesSlide20
HAN Survey Results and Data from CDPH Phone BankHAN Survey from Company A328 responses, ~ 1/3 reporting illness1 confirmed case (1 expired)
Phone Bank
145 surveys completed, most reporting illness
10 confirmed cases (2 expired)Slide21
Confirmed Legionnaires’ Disease (LD)Case definition: A person who stayed at or visited the hotel with illness onset within 2-14 days of exposure to the hotel, AND with radiographically- or autopsy-confirmed pneumonia AND with laboratory evidence of Legionella infection.Slide22
Confirmed LD Laboratory CriteriaIsolation, through culture, of any Legionella organism from resp. secretions, lung tissue, pleural fluid, or other normally sterile siteDetection of
Legionella pneumophila
serogroup 1 (Lp1) antigen in urine
Seroconversion (4-fold increase in antibody titer to Lp1 between acute and convalescent titers)
Detection by Lp1 molecular testing (e.g., PCR) Slide23
Suspect Legionnaires’ Disease Case definition: A person who stayed at or visited the hotel with illness onset within 2-14 days of exposure to the hotel, who had radiographically- -confirmed pneumonia, or clinical diagnosis of pneumonia, but without laboratory confirmation of
Legionella
infection.Slide24
Pontiac FeverCase definition: Fever, either subjective or documented, in a person who stayed at or visited the hotel with illness onset within 3 days of exposure to hotel, AND at least one of the following: cough, headache, SOB, myalgias, diarrhea, or vomiting, and who does not meet definition for confirmed or suspect LD.Slide25
JulyAugust
Respiratory Illness by Date of Symptom
Onset
(N=114
)
Fountain, pool and spa drainedCDPH notifiedSlide26
Case-patient CharacteristicsAll cases (N=114)
Confirmed LD (N=11)
% Male
64
91
Median age (range)47 yrs (22-82 yrs)65.5 yrs (49-82 yrs)% Hospitalized1382Deaths03Underlying illness/ riskN/AObesity (1), HIV (1), COPD (1), HTN/CVD (5), current/former smokers (2/2) Slide27
Case-patients’ Symptoms All cases
Confirmed
LD
Symptoms
(n/N)
%(n/N) %Fever113/1149910/1191Cough76/110699/10
90Shortness of Breath65/10761
8/10
80
Vomiting
or Diarrhea
57/105
54
5/11
45Slide28
Exposure Assessment (106 ills, 194 wells) Exposure
# Exposed
RR(CI)
p
Lobby
Fountain1232.13 (1.64, 2.77)
<0.0001
Lobby
Bar
211
1.25 (1.09, 1.44)
0.003
Whirlpool
Spa
5
2.38 (0.40, 13.99)
0.378
Pool
4
4.76 (0.50, 45.10)
0.302
Sauna
3
0.79 (0.07, 8.63)
1.000
Steam Room
4
1.59 (0.23, 11.08)
0.322
Guest Shower2361.00 (0.92, 1.07)0.899Guest Bath500.89 (0.53, 1.50)0.666Slide29
Environmental ResultsPositive: Lobby fountain, locker rooms (men and women shower heads and sinks), swimming pool, whirlpoolNegative: Guest room shower headsSlide30
Matching IsolatesLp1 environmental isolates and a clinical isolate from a confirmed LD case-patient had matching sequence-based types.Slide31
Contributing Factors to Legionella Growth in FountainLack of written cleaning and maintenance programPresence of submerged lightingPresence of dirt, organic matter, or other debris in the water basinSlide32
Before
AfterSlide33
RemediationFountain removedInstallation of chlorine dioxide treatment system to water supplyMust keep monthly operational recordsIDPH inspection every 2 yearsSlide34
Conclusions Point source outbreakEnvironmental testing identified Legionella in the hotel’s potable water system.Poor fountain maintenance likely created favorable conditions for Legionella overgrowthEpidemiologic and molecular typing data confirmed that fountain was likely the sourceSlide35
AcknowledgementsCenters for Disease Control and PreventionNational Center for Immunization and Respiratory Diseases, Division of Bacterial DiseasesIllinois Department of Public HealthCraig Conover, MD, MPHConnie Austin, DVM, PhDDivision of Environmental HealthDivision of Infectious DiseasesSlide36
AcknowledgementsAL, AR, AZ, CA, CO, FL, GA, IA, IN, KS, MA, MD, ME, MI, MN, MO, NC, NE, NJ, NY, OH, OR, PA, TN, TX, VA, WI, WV, Ireland, Canada Chicago Department of Public HealthCommunicable Disease ProgramEmergency Preparedness ProgramSlide37Slide38
Public health MessagingIDPH Environmental laboratory resultsExposures eliminatedFountain removedPool, spa, locker rooms inaccessible to publicUpdating case countsSlide39
Legionellosis cases by month of onset, 2011-2012Number of casesSlide40Slide41Slide42
Reported 10-year incidence rates per
100,000 adult residents, by Chicago
community area, 2001-August 2010
Approximate reported residence of Chicago case-patients, with spatial clustering denoted in gray
Reported cases per 100,000 adultsSlide43
Case-patients’ Characteristics
All Cases (N=114)
Confirmed LD (N=11)
% Male
64
91Median age (range)
47 (22-82 yrs)
65.5 (49-82 yrs)
% Hospitalized
13
82
Deaths
0
3
Underlying Illness/risk
N/A
Obesity(1), HIV(1), COPD(1), HTN/CVD(5), current/former smokers (2/2)Slide44
Timeline
July
August
30
12
18
29
1
22
= outbreak
Bakery closure
Inspection and product recall
23
30
Bakery re-opening
3Slide45
Why the Increase?
Increasing population of older persons
Increasing population of persons at high risk for infection
Improved diagnosis and reporting
Weather conditions..Slide46
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