Rising Incidence of Legionnaires’ Disease and Associated Epidemiologic Patterns, United States, 1992–2018

Barskey, Albert E.; Derado, Gordana; Edens, Chris

doi:10.3201/eid2803.211435

Cited by 35 publications

(56 citation statements)

References 34 publications

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“…The analysis does not include any data from the Southeastern US because these states either do not contribute to the HCUP dataset or do not provide monthly data; this is a major limitation, as states in this region are most prone to cyclonic storms. However, regions with the highest incidence of Legionnaires’ disease were included in the analysis, and states that did not contribute to the HCUP dataset generally had lower incidence compared to the national average [ 71 ]. A recent analysis of Legionnaires’ disease epidemiological trends in the United States between 1992 and 2018 found that age-standardized average incidence was higher in the Northeast and Midwest compared to the South and West, and highest in New England and the Mid-Atlantic states [ 71 ]; these geographic differences in incidence were more pronounced later in the time series (after 2002), which overlaps with most of the study period in this analysis.…”

Section: Discussionmentioning

confidence: 99%

“…However, regions with the highest incidence of Legionnaires’ disease were included in the analysis, and states that did not contribute to the HCUP dataset generally had lower incidence compared to the national average [ 71 ]. A recent analysis of Legionnaires’ disease epidemiological trends in the United States between 1992 and 2018 found that age-standardized average incidence was higher in the Northeast and Midwest compared to the South and West, and highest in New England and the Mid-Atlantic states [ 71 ]; these geographic differences in incidence were more pronounced later in the time series (after 2002), which overlaps with most of the study period in this analysis. Future studies should examine the associations among hydrometeorological conditions and Legionnaires’ disease throughout the US, particularly in the Southeast, but the regions included in the study capture the states with the highest Legionnaires’ disease burden.…”

Section: Discussionmentioning

confidence: 99%

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The effect of seasonal and extreme floods on hospitalizations for Legionnaires’ disease in the United States, 2000–2011

Lynch

Shaman

2022

BMC Infect Dis

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Background An increasing severity of extreme storms and more intense seasonal flooding are projected consequences of climate change in the United States. In addition to the immediate destruction caused by storm surges and catastrophic flooding, these events may also increase the risk of infectious disease transmission. We aimed to determine the association between extreme and seasonal floods and hospitalizations for Legionnaires’ disease in 25 US states during 2000–2011. Methods We used a nonparametric bootstrap approach to examine the association between Legionnaires’ disease hospitalizations and extreme floods, defined by multiple hydrometeorological variables. We also assessed the effect of extreme flooding associated with named cyclonic storms on hospitalizations in a generalized linear mixed model (GLMM) framework. To quantify the effect of seasonal floods, we used multi-model inference to identify the most highly weighted flood-indicator variables and evaluated their effects on hospitalizations in a GLMM. Results We found a 32% increase in monthly hospitalizations at sites that experienced cyclonic storms, compared to sites in months without storms. Hospitalizations in months with extreme precipitation were in the 89th percentile of the bootstrapped distribution of monthly hospitalizations. Soil moisture and precipitation were the most highly weighted variables identified by multi-model inference and were included in the final model. A 1-standard deviation (SD) increase in average monthly soil moisture was associated with a 49% increase in hospitalizations; in the same model, a 1-SD increase in precipitation was associated with a 26% increase in hospitalizations. Conclusions This analysis is the first to examine the effects of flooding on hospitalizations for Legionnaires’ disease in the United States using a range of flood-indicator variables and flood definitions. We found evidence that extreme and seasonal flooding is associated with increased hospitalizations; further research is required to mechanistically establish whether floodwaters contaminated with Legionella bacteria drive transmission.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

The effect of seasonal and extreme floods on hospitalizations for Legionnaires’ disease in the United States, 2000–2011

Lynch

Shaman

2022

BMC Infect Dis

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“…In recent years, Legionella spp. have been shown to be increasing in incidence ( Barskey et al., 2022 ). Recent findings from our group have shown that the distribution of legionella serogroups varies greatly between geographic regions and the prevalence of other serogroups may be underestimated due to the widespread clinical use of urinary antigen tests in diagnosis, which selectively targets Legionella pneumophila serogroup 1 ( Head et al., 2019 ).…”

Section: Effects Of Existing and Potential Immunomodulators On Pneumo...mentioning

confidence: 99%

“…had shown that non- pneumophila serogroup 1 Legionella (including L. bozemanae , L. micdadei , L. anisa , and other strains of L. pneumophila ) were found to increase mortality while also doubling the likelihood of requiring intensive care unit (ICU) care in individuals coinfected with HIV and M. tuberculosis or HIV and P. jirovecii ( Head et al., 2019 ). As reported by the CDC, cases of Legionella in the US have been increasing significantly over the past 20 years ( Barskey et al., 2022 ). A similar trend had also been noted in France by Campese et al., following the establishment of mandatory reporting of Legionella and stricter detection protocols ( Campese et al., 2011 ).…”

Section: Effects Of Existing and Potential Immunomodulators On Pneumo...mentioning

confidence: 99%

Increased susceptibility to pneumonia due to tumour necrosis factor inhibition and prospective immune system rescue via immunotherapy

Keynan

Rueda

2022

Front. Cell. Infect. Microbiol.

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Immunomodulators such as tumour necrosis factor (TNF) inhibitors are used to treat autoimmune conditions by reducing the magnitude of the innate immune response. Dampened innate responses pose an increased risk of new infections by opportunistic pathogens and reactivation of pre-existing latent infections. The alteration in immune response predisposes to increased severity of infections. TNF inhibitors are used to treat autoimmune conditions such as rheumatoid arthritis, juvenile arthritis, psoriatic arthritis, transplant recipients, and inflammatory bowel disease. The efficacies of immunomodulators are shown to be varied, even among those that target the same pathways. Monoclonal antibody-based TNF inhibitors have been shown to induce stronger immunosuppression when compared to their receptor-based counterparts. The variability in activity also translates to differences in risk for infection, moreover, parallel, or sequential use of immunosuppressive drugs and corticosteroids makes it difficult to accurately attribute the risk of infection to a single immunomodulatory drug. Among recipients of TNF inhibitors, Mycobacterium tuberculosis has been shown to be responsible for 12.5-59% of all infections; Pneumocystis jirovecii has been responsible for 20% of all non-viral infections; and Legionella pneumophila infections occur at 13-21 times the rate of the general population. This review will outline the mechanism of immune modulation caused by TNF inhibitors and how they predispose to infection with a focus on Mycobacterium tuberculosis, Legionella pneumophila, and Pneumocystis jirovecii. This review will then explore and evaluate how other immunomodulators and host-directed treatments influence these infections and the severity of the resulting infection to mitigate or treat TNF inhibitor-associated infections alongside antibiotics.

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“…The reason for this widespread increase is unclear. Apart from improved disease surveillance, the design and maintenance of building infrastructure, and an ageing and increasingly susceptible population, Barskey et al suggest that the geographical distribution and increasing seasonal frequency of cases in summer indicate weather patterns may play a role in the increasing LD incidence 7 . Studies from the European Centre for Disease Prevention and Control (ECDC) and others also consider climate change as one of the potential drivers of the increasing temporal trend 6,8 .…”

Section: Introductionmentioning

confidence: 99%

Impacts of weather and air pollution on Legionnaires’ disease in Switzerland: a national case-crossover study

Fischer

Saucy

Vienneau

et al. 2022

Preprint

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BackgroundThe number of cases of Legionnaires’ disease (LD) has risen markedly in Switzerland (6.5/100,000 inhabitants in 2021) and abroad over the last decade.Legionella, the causative agent of LD, are ubiquitous in the environment. Therefore, environmental changes can affect the incidence of LD, for example by increasing bacterial concentrations in the environment or facilitating transmission.ObjectivesThe aim of this study is to understand the environmental determinants, in particular weather conditions, for the regional and seasonal distribution of LD in Switzerland.MethodsWe conducted a series of analyses based on the Swiss LD notification data from 2017 to 2021. First, we used a descriptive and hotspot analysis to map LD cases and identify regional clusters. Second, we applied an ecological model to identify environmental determinants on case frequency at the district level. Third, we applied a case-crossover design using distributed lag non-linear models to identify short-term associations between seven weather variables and LD occurrence. Lastly, we performed a sensitivity analysis for the case-crossover design including NO2levels available for the year 2019.ResultsCanton Ticino in southern Switzerland was identified as a hotspot in the cluster analysis, with a standardised notification rate of 14.3 cases/100,000 inhabitants (CI: 12.6, 16.0). The strongest association with LD frequency in the ecological model was found for large-scale factors such as weather and air pollution. The case-crossover study confirmed the strong association of elevated daily mean temperature (OR 2.83; CI: 1.70, 4.70) and mean daily vapour pressure (OR: 1.52, CI: 1.15, 2.01) 6-14 days before LD occurrence.DiscussionOur analyses showed an influence of weather with a specific temporal pattern before the onset of LD, which may provide insights into the effect mechanism. The relationship between air pollution and LD and the interplay with weather should be further investigated.

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Rising Incidence of Legionnaires’ Disease and Associated Epidemiologic Patterns, United States, 1992–2018

Abstract: Rising incidence was associated with increasing racial disparities, geographic focus, and seasonality.

Cited by 35 publications

References 34 publications

The effect of seasonal and extreme floods on hospitalizations for Legionnaires’ disease in the United States, 2000–2011

The effect of seasonal and extreme floods on hospitalizations for Legionnaires’ disease in the United States, 2000–2011

Increased susceptibility to pneumonia due to tumour necrosis factor inhibition and prospective immune system rescue via immunotherapy

Impacts of weather and air pollution on Legionnaires’ disease in Switzerland: a national case-crossover study

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