Outbreak of Legionnaires' disease on a cruise ship linked to spa-bath filter stones contaminated with <i>Legionella pneumophila</i> serogroup 5

Kura, Fumiaki; Amemura-Maekawa, Junko; Yagita, Kenji; Endo, Tokiko; Ikeno, M.; Tsuji, Hidetaka; Taguchi, Masumi; Kobayashi, Kazuhiro; Ishii, Eiji; Watanabe, Haruo

doi:10.1017/s095026880500508x

Cited by 40 publications

(34 citation statements)

References 14 publications

(20 reference statements)

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“…The number of bacteria in film droplets can be 20-fold higher than that in the bulk water (34). The presence of high numbers of L. pneumophila organisms in spa pool water does not always result in infection, and in previous investigations, the absence or low level of illness has been attributed to the absence of air compressors or failure to use the air injection system (7,27). The results of the current investigation support these conclusions.…”

Section: ϫ3supporting

confidence: 81%

“…However, Legionella spp. have been recovered from public spa pools that have been treated and/or emptied appropriately (11,26,27), implying that the concentration of disinfectant necessary to achieve microbial control may be higher than that normally recommended. Thus, domestic spa pool users may be at risk from Legionella despite complying with manufacturers' maintenance instructions.…”

Section: Discussionmentioning

confidence: 99%

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Aerosolization of Respirable Droplets from a Domestic Spa Pool and the Use of MS-2 Coliphage and Pseudomonas aeruginosa as Markers for Legionella pneumophila

Moore

Hewitt

Stevenson

et al. 2015

Appl Environ Microbiol

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Legionnaires' disease can result when droplets or aerosols containing legionella bacteria are inhaled and deposited in the lungs. A number of outbreaks have been associated with the use of a spa pool where aeration, a high water temperature, and a large and variable organic load make disinfectant levels difficult to maintain. Spa pool ownership is increasing, and the aim of this study, using two surrogate organisms (MS-2 coliphage and Pseudomonas aeruginosa [a natural contaminant]), was to assess the potential risk to domestic users when disinfection fails. A representative "entry level" domestic spa pool was installed in an outdoor courtyard. The manufacturer's instructions for spa pool maintenance were not followed. A cyclone sampler was used to sample the aerosols released from the spa pool with and without activation of the air injection system. Samples were taken at increasing heights and distances from the pool. An aerodynamic particle sizer was used to measure the water droplet size distribution at each sample point. When the air injection system was inactivated, neither surrogate organism was recovered from the air. On activation of the air injection system, the mean mass of droplets within the respirable range (10 cm above the water line) was 36.8 g cm ؊3 . This corresponded to a mean air concentration of P. aeruginosa of 350 CFU m ؊3 . From extrapolation from animal data, the estimated risk of infection from aerosols contaminated with similar concentrations of Legionella pneumophila was 0.76 (males) and 0.65 (females). At 1 m above and/or beyond the pool, the mean aerosol mass decreased to 0.04 g cm ؊3 and corresponded to a 100-fold reduction in mean microbial air concentration. The estimated risk of infection at this distance was negligible.L egionellae are Gram-negative bacteria found naturally in freshwater environments such as rivers, lakes, and reservoirs and, as such, may also inhabit the municipal water supply and be found in industrial, commercial, and domestic hot and cold water systems (1-3). Legionellosis, primarily Legionnaires' disease (a serious form of pneumonia) but also including nonpneumonic legionellosis and Pontiac fever (a self-limiting flu-like illness), can result when droplets or aerosols containing legionella bacteria are inhaled and deposited in the lungs.Legionnaires' disease is most commonly, but not exclusively, caused by Legionella pneumophila. It is a rare but serious disease. In 2009, there were 344 confirmed cases in England and Wales (4), while in the United States, 3,522 cases were reported to the Centers for Disease Control and Prevention (5). It is likely, however, that many more cases are unreported and/or undiagnosed, and it is estimated that Legionnaires' disease accounts for between 3% and 6% of the community-acquired pneumonias that occur in the United Kingdom and United States each year (4, 6). Even with treatment, the case fatality rate of community-acquired Legionnaires' disease ranges from 10% to 15% (4). It is, therefore, important to investigate and asses...

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Section: ϫ3supporting

confidence: 81%

Section: Discussionmentioning

confidence: 99%

Aerosolization of Respirable Droplets from a Domestic Spa Pool and the Use of MS-2 Coliphage and Pseudomonas aeruginosa as Markers for Legionella pneumophila

Moore

Hewitt

Stevenson

et al. 2015

Appl Environ Microbiol

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“…Several isolated and clustered cases of legionellosis have been associated with the use of whirlpool spas (Nagai et al 2003;Foster et al 2006;Kura et al 2006;Beyrer et al 2007;Burnsed et al 2007;Yoder et al 2008). To prevent such outbreaks, specific recommendations for spas have been established.…”

Section: Introductionmentioning

confidence: 99%

Assessment of real-time PCR for quantification of Legionella spp. in spa water

Guillemet

Lévesque

Gauvin

et al. 2010

Letters in Applied Microbiology

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Aims: Legionella bacteria ubiquitously colonize natural freshwater and are responsible for legionellosis in humans. Several cases of legionellosis have been associated in particular with the use of whirlpool spas. The objective of this study was to verify whether real‐time PCR is applicable for the quantification of Legionella spp. in spa water. Methods and Results: The study compared concentrations obtained by real‐time PCR vs that obtained by conventional culture for 101 spa water samples. For the culture method, Legionella spp. were detected and quantified in 14 of 101 samples with measured concentrations ranging from 250 to 3·5 × 105 CFU l−1. With the real‐time PCR method, Legionella spp. were detected and quantified in 42 of 101 samples with concentrations ranging from 1000 to 6·1 × 107 GU l−1. Results revealed a significant but weak correlation (r2 = 0·1867) between the two methods. The positive predictive value (35%) of the PCR method compared to conventional culture herein was low. In contrast, the negative predictive value was excellent, reaching 93%. Conclusions: Real‐time PCR could be used as a screening tool to rapidly ascertain the absence of Legionella spp. in spa water. However, a positive result involves the need to resort to conventional culture. Significance and Impact of the Study: Data of this study highlighted the pros and cons of quantification of Legionella spp. in spa water with real‐time PCR using a commercial quantitative PCR kit in a routine laboratory, when compared to conventional culture.

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“…In Japan, more than 900 cases of infection by Legionella species from contaminated artificial whirlpool spas or natural hot springs have emerged in the past decade (Anonymous 2000; Nakamura et al. 2003; Kura et al. 2006); in particular, a major outbreak in 2002 originating from a newly opened hot spring spa involved 295 people, including seven deaths (Okada et al.…”

Section: Introductionmentioning

confidence: 99%

Detection of culturable and nonculturableLegionellaspecies from hot water systems of public buildings in Japan

Edagawa

Kimura

Doi

et al. 2008

Journal of Applied Microbiology

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Aims: To investigate the prevalence of culturable and nonculturable Legionella species in hot water systems of public buildings in Japan and assess the risk factors associated with Legionella contamination in hot water systems. Methods and Results: Legionella species were detected by conventional culture and molecular methods in 130 water samples collected from 40 buildings. A total of 26 (20·0%) water samples from 17 (42·5%) buildings were positive by culture, qualitative PCR or both methods: Legionella pneumophila and Leg. anisa were detected in four samples by a culture method, whereas 23 samples were positive by qualitative PCR, with the presence of various Legionella species confirmed by sequencing. Of these 23 samples, bacterial counts were quantifiable in 21 by real‐time PCR (from 1·7 × 105 to 2·6 × 1011 cells per litre). Phylogenetic analysis of amplified partial 16S rRNA gene showed close relations to various species of Legionella, including Leg. anisa and Leg. micdadei, all of which have been associated with respiratory diseases or increased antibody titres in human sera. Assessment of risk factors showed that turbidity, free chlorine concentration, iron concentration and heterotrophic plate count (HPC) were significantly associated with Legionella contamination (P < 0·05). Conclusions: Contamination of hot water systems of public buildings with culturable and nonculturable Legionella species may be a potential risk factor for Legionella infection in Japan. Adequate levels of chlorine, low levels of iron and HPC are important maintenance measures in the reduction of Legionella contamination in hot water systems. Significance and Impact of the Study: More than 40% of hot water systems in the Japanese public buildings examined were contaminated by not only culturable Leg. pneumophila and Leg. anisa but also by nonculturable pathogenic species. To our knowledge, this is the first report of both culturable and nonculturable Legionella contamination in hot water systems of public buildings in Japan.

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Outbreak of Legionnaires' disease on a cruise ship linked to spa-bath filter stones contaminated with Legionella pneumophila serogroup 5

Cited by 40 publications

References 14 publications

Aerosolization of Respirable Droplets from a Domestic Spa Pool and the Use of MS-2 Coliphage and Pseudomonas aeruginosa as Markers for Legionella pneumophila

Aerosolization of Respirable Droplets from a Domestic Spa Pool and the Use of MS-2 Coliphage and Pseudomonas aeruginosa as Markers for Legionella pneumophila

Assessment of real-time PCR for quantification of Legionella spp. in spa water

Detection of culturable and nonculturableLegionellaspecies from hot water systems of public buildings in Japan

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