Epidemiology of Legionella Hallym University Kangdong Sacred Heart Hospital Jae-Seok Kim

History July 1976 in Philadelphia Serologic studies 58th Annual convention of the American Legion Severe pneumonia; 182/4,000 Hospitalized; 146/182 Death; 29/182 New pathogen Identified after 10 months Serologic studies 1947, 1957 (meat packing plant), 1974 (hotel)

Incidence of Legionellosis Each year an estimated 8,000-18,000 hospitalized cases occur in the U.S. 157 cases in Maryland, 2009 True incidence Not available Underutilization of diagnostic testing and under-reporting CDC

Legionellosis Common cause of severe pneumonia requiring hospitalization Sporadic cases; major reported cases Outbreak cases Travel-associated outbreaks Outbreaks in community settings Nosocomial outbreak Occupational outbreaks

Two Clinical Syndrome Legionnaires' disease Pontiac fever Clinical features Pneumonia: cough, fever, chest pain Flu-like illness (fever, chills, malaise) without pneumonia Radiographic pneumonia Yes No Incubation period 2-14 days after exposure 24-48 hours after exposure Etiologic agent Legionella species Attack rate* < 5% > 90% Isolation of organism Possible Virtually never Outcome Hospitalization common Case-fatality rate: 5-40%** Hospitalization uncommon Case-fatality rate: 0% * Percent of persons who, when exposed to the source of an outbreak, become ill. ** Percent of persons who die from Legionnaires' disease or Pontiac fever. Legionnaires' disease can have symptoms like many other forms of pneumonia, so it can be hard to diagnose at first. Signs of the disease can include: a high fever, chills, and a cough. Some people may also suffer from muscle aches and headaches. Chest X-rays are needed to find the pneumonia caused by the bacteria, and other tests can be done on sputum (phlegm), as well as blood or urine to find evidence of the bacteria in the body. These symptoms usually begin 2 to 14 days after being exposed to the bacteria. A milder infection caused by the same type of Legionella bacteria is called Pontiac Fever . The symptoms of Pontiac Fever usually last for 2 to 5 days and may also include fever, headaches, and muscle aches; however, there is no pneumonia. Symptoms go away on their own without treatment and without causing further problems. Pontiac Fever and Legionnaires' disease may also be called "Legionellosis" (LEE-juh-nuh-low-sis) separately or together. CDC

Source of Legionella spp. Natural environments Insufficient numbers to cause disease Man-made environment Common sources of outbreaks Potable (drinking) water systems Whirlpool spas Cooling towers 3 conditions needed for Legionella transmission Heat, stasis, and aerosolization

Route of infection Inhalation; aerosolized water droplets Aspiration; water, oropharynx

Risk Factors of Legionellosis Recent travel with an overnight Exposure to whirlpool spas Recent repairs or maintenance work on domestic plumbing Renal failure / hepatic failure DM Systemic malignancy Smoking Immune system disorders People most at risk of getting sick from the bacteria are older people (usually 65 years of age or older), as well as people who are smokers, or those who have a chronic lung disease (like emphysema). People who have weak immune systems from diseases like cancer, diabetes, or kidney failure are also more likely to get sick from Legionella bacteria. People who take drugs to suppress (weaken) the immune system (like after a transplant operation or chemotherapy) are also at higher risk.

국내 발생현황 (2001-2008) Increasing in incidence Seasonal variation Korea CDC

Legionella in Korea (2001-2008) Old age Male predominent Male; 72% Korea CDC

Diagnosis Serology Direct immunofluorescence Culture PCR Urinary antigen test

Diagnostic Testing IDSA/ATS. CAP management guideline. 2007

레지오넬라증 (Legionellosis) 제 3군 전염병 (19종) 간헐적 유행 가능성 계속발생감시 및 방역대책 수립 말라리아, 결핵, 인플루엔자, AIDS, Leptospirosis 진단기준 환자 검체에서 균분리 항체가 4배 이상 상승 소변 레지오넬라 항원 검출 의사환자 단일항체가 1:128 이상 타당한 유전자 검사법에 의해 레지오넬라 균 검출 호흡기 검체에서 레지오넬라균 항원 검출

Indication of testing Hospitalized patients with enigmatic pneumonia Enigmatic pneumonia sufficiently severe to require care in the ICU Compromised host with pneumonia Legionellosis outbreak Failure of treatment to a ß-lactam or cephalosporin Patients with a travel history 2 weeks before the onset Nosocomial pneumonia with unknown etiology CDC

Differentiation of Legionella species; rpoB Ko KS. JCM 2002

16s rRNA / mip seqeuncing

Combined data set - rnpB - mip - 16s rRNA - rpoB Gomez-Valero. Infect Gen Evol 2009

Legionella other than L. pneumophila Fang GD. Medicine 1989

Legionella outbreak - Scotland (June 2012 )- Cases; South-west of the city Confirmed; 41 Suspected; 48 Died; 2

Pontiac fever Self-limited (mortality 0%) Fever, headache, myalgia, malaise, cough, chest pain Incubation period; 1-2 days Pontiac Firebird - KITT

Pontiac Fever in LA (2011. 2) Pontiac Firebird - KITT

CAP in Asia-Pacific Legionella CAP 0.6%(China), 1.5%(Japan), 4% (NZ), 1.2% (Taiwan) Song JH. Int J Antimicrob Agents 2011

CAP in Spain Immunocompromised Pts (n = 115) Non-immunocompromised Pts (n = 205) L. pneumophila 3 (2.6%) 12 (5.8%) Legionella Ag (+) 3 (4.4% of tested) 12 (7.9% of tested) S. pneumoniae 33 (28.7%) 43 (20.9%) Pneumococcal Ag (+) 27 (31.4% of tested) 31 (18.1% of tested) Sousa D. Clin Microb Infect 2012.

Travel-associated Legionellosis Joseph CA. Euro Surveill 2010

Travel-associated Legionellosis Joseph CA. Euro Surveill 2010

Legionellosis in Singapore Contamination of cooling tower and water fountains Stable (2004-2008); 12.1-15.3% Lam MC. EID 2011

Legionella in Japan 86 clinical isolates (1980-2008) Amenura-Maekawa J. J Med Microbiol 2010

Waterborne disease outbreak MMWR 2011

Previously unreported outbreak in USA (1997-2002) MMWR 2011

Molecular epidemiology Ribotyping, AFLP, RFLP, REA, AP-PCR, PFGE Sequence-based typing CRISPR spacer sequence AFLP European working group for Legionella infections (EWGLI); Standard method MLST flaA, pilE, asd, mip, mompS, proA, neuA Method of choice for L. pneumophila Sg1 infections Nested PCR-based SBT Directly to clinical specimens

Asphalt paving machine Coscolla M. EID 2010

SBT

Pseudo-outbreak - Environment; ice machine not bronchoscope L. pneumophila Sg 8 Schuetz AN. Infect Control Hosp Epidemiol 2009

NPSBT ; clinical specimens Complete allelic profiles of SBT SBT; 3.2% NPSBT; 53.9% Ginevra C. JCM 2009.

국내의 레지오넬라 관리 - 질병관리본부 - 병원 등 보건시설 냉·온수시설 관리 의료용 분무기, 가습기 국내의 레지오넬라 관리 - 질병관리본부 - 병원 등 보건시설 냉·온수시설 관리 장기이식센터, 중환자실 균주 불검출. 그렇지 않을 경우 사용지점에 필터 사용 의료용 분무기, 가습기 멸균수로 세척 호흡기관련 의료장치, 샤워기 등을 사용한 후에는 감염될 위험 요인들에 대한 적극적인 감시와 수계시설의 소독 및 관리가 필요함 과거에 환자발생이 있었던 병원 의무기록 검토 병원 내 환경수계에 대한 레지오넬라균 오염의 여부를 재검토 면역억제요법환자 집중적인 관리

Legionella in Korea Detection rate Contamination 1.6-12.3% Korean Sauna; 12.3% Fountain; 1.6% Contamination Decrease of 10-1000 CFU/mL 20% in 2008

레지오넬라증 (2001.1.-2012.6) 2012년 1-6월; 총 7 건서울 2건, 부산 1건, 강원 3건, 전북 1건 Korea CDC

2005-2011년:서울

2009, Seoul 10 legionella cases

PFGE / SBT / CRISPR spacer Université de Lyon, Centre National de Référence des légionelles, Lyon Ginevra C. JCM. 2012

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