Legionellosis historical perspective

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Ogechukwu Hannah Nnabude, MD Tarek Nafee, M.D. [2]

## Overview

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Legionnaires' disease acquired its name in 1976 when an outbreak of pneumonia occurred among people attending a convention of the American Legion in Philadelphia. On January 18, 1977 the causative agent was identified as a previously unknown bacterium, subsequently named Legionella. There have been numerous outbreaks of Legionnaires since it was first discovered. Some of the outbreaks of Legionella are listed below in chronological order.

## Historical Perspective

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### Philadelphia, 1976

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The first recognized Legionella outbreak occurred in 1976 during a meeting of the American Legion in Philadelphia, Pennsylvania. About 29 of the 182 people that contracted the infection died [1]. It was after the bacterium had been successfully isolated that previous cases of Legionella were identified.

### United Kingdom, 1985

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In 1985, Stafford District General Hospital experienced a Legionella outbreak. A total of 68 confirmed cases were treated in hospital and 22 of these patients died. A further 35 patients were suspected cases of Legionnaires' disease, 14 of whom only required treatment at home. Legionella was found in the water within the cooling tower and a chiller unit which cooled the air entering the outpatient department. The chiller unit is believed to be the major source of the outbreak [2].

### Netherlands, 1999

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During a flower exhibition in Bovenkarspel, Netherlands, an outbreak of Legionella occurred. It is believed to have been caused by a contamination of the whirlpools in halls 3 and 4, and the sprinkler in hall 8, all of which tested culture positive for Legionella. There were 133 confirmed cases and 55 possible cases out of the 77061 visitors to the exhibition [3].

### Spain, 2001

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In Murcia, Spain, over 800 suspected cases of Legionnaires' disease were recorded. Of these cases, 449 were confirmed to be caused by Legionella. This is currently the largest outbreak of Legionella ever recorded. About 1% of affected patients died from the disease [4].

### Norway, 2001

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The first recognized outbreak of Legionella in Norway was in 2001 when 28 people were infected in the city of Stavanger, and seven died. Of the 28 patients, 21 were within the city of Stavanger, five were in other areas in Norway, and two were from other countries, with one being in England and the other in Germany. This was initially a mystery to the investigators. However, it was discovered that a cooling unit from a nearby hotel was the source of the infection. The air outlet was found to be just over 16 feet above the ground and located close to a bus station. This was determined source of contact for the patient in Germany and the patient in England [5]

### Barrow-In-Furness, United Kingdom, 2002

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In 2002, six women and one man in Barrow-In-Furness died as a result of the illness, another 172 people also contracted the disease. The outbreak was traced to a contaminated cooling tower at the town’s Forum 28 arts center.

### France, 2004

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Between November 2003 and January 2004, an outbreak of Legionnaires' disease occurred in Pas-de-Calais, France. There were 18 fatalities out of the 86 laboratory-confirmed cases, giving the outbreak a mortality rate of about 21%. A Legionella pneumophila strain named Lens was isolated from samples of air, wastewater, and cooling towers from plant A. Researchers determined that the dispersion extended over a distance of at least 6 km (3.75 miles) from the plant. [6]

### Norway, 2005

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In May 2005 there was another outbreak of Legionnaires' disease in Norway, in the town of Fredrikstad. Initially, 56 patients were confirmed infected and ten people were dead. However, on serological testing of other patients with community acquired pneumonia, another 47 patients were discovered to have the disease, bringing the total for the oubreak to at least 103, 16 of whom are probable cases. The source of the outbreak unexpectedly came from an air scrubber that disseminated that bacterium over a distance of about 10 km (6.25 miles). [7] [8]

### New Zealand, 2005

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In mid-2005, Christchurch, New Zealand experienced an outbreak of Legionnaires' disease. There were 3 deaths out of the 19 confirmed cases. Legionella pneumophila serogroup 1 (Lpsg1) was identified as the causative agent for all cases. A water cooling tower located in the center of the clusters is believed to be the source of the outbreak[9].

### Toronto, Ontario, Canada, 2007

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An outbreak of Legionnaires' disease at the Seven Oaks Home for the Aged, a nursing home in Toronto, in the province of Ontario, Canada from September to October 2005 resulted in illness in 135 people, 23 (17%) of whom died. Researchers confirmed that a contaminated air conditioning cooling tower was the source of the outbreak. [10]

### Québec City, Canada, 2012

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An outbreak linked to contaminated water in an industrial cooling tower caused 181 confirmed cases, 14 of which resulted in death [11].

### Edinburg, Scotland, UK, 2012

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In 2012, 50 confirmed cases and 49 suspected cases of Legionella occurred in Edinburg, Scotland. It led to the death of 4 people. Cooling towers in the affected area are suspected to be the cause of the outbreak. [12]

### Vila Franca de Xira district, Lisbon, Portugal, 2014

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A widespread outbreak in the Vila Franca de Xira district infected 377 people, and caused the death of 14. A combination of factors led to the outbreak becoming widespread including temperatures that were unusually high for that time of the year, leading to increased proliferation of Legionella in the cooling tower to which the outbreak was traced, and the high humidity that is believed to increase the spread of Legionella [13] [14].

### Fletcher, North Carolina, United States, 2019

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Whirlpool spas at a state fair were linked to a Legionella outbreak in Fletcher, North Carolina, United States that claimed the lives of 4 out of the 136 confirmed cases people infected. [15]

## References

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1. ↑ Fraser DW, Tsai TR, Orenstein W, et al. Legionnaires’ disease: description of an epidemic of pneumonia. N Engl J Med 1977; 297: 1189–97.
2. ↑ O'Mahony MC, Stanwell-Smith RE, Tillett HE, Harper D, Hutchison JG, Farrell ID; et al. (1990). "The Stafford outbreak of Legionnaires' disease". Epidemiol Infect. 104 (3): 361–80. doi:10.1017/s0950268800047385. PMC 2271767. PMID 2347381.CS1 maint: Multiple names: authors list (link)
3. ↑ Cordasco G, Cicciù D, Lo Giudice G, Matarese G, Nucera R, Mazza M (1999). "Kinesiographic investigations in children with increased nasal airways resistance". Bull Group Int Rech Sci Stomatol Odontol. 41 (2–3): 67–72. doi:10.3201/eid0801.010176. PMC 2730281. PMID 11799746.CS1 maint: Multiple names: authors list (link)
4. ↑ García-Fulgueiras A, Navarro C, Fenoll D, García J, González-Diego P, Jiménez-Buñuales T; et al. (2003). "Legionnaires' disease outbreak in Murcia, Spain". Emerg Infect Dis. 9 (8): 915–21. doi:10.3201/eid0908.030337. PMC 3020623. PMID 12967487.CS1 maint: Multiple names: authors list (link)
5. ↑ Outbreak of legionellosis in Stavanger, Norway – final report Blystad, H and Bjorlow, E and Aavitsland, P and Holm, J, Weekly releases (1997–2007), 5, 2059 (2001), https://doi.org/10.2807/esw.05.47.02059-en.
6. ↑ Nguyen TM, Ilef D, Jarraud S, Rouil L, Campese C, Che D; et al. (2006). "A community-wide outbreak of legionnaires disease linked to industrial cooling towers--how far can contaminated aerosols spread?". J Infect Dis. 193 (1): 102–11. doi:10.1086/498575. PMID 16323138.CS1 maint: Multiple names: authors list (link)
7. ↑ Nygård K, Werner-Johansen Ø, Rønsen S, Caugant DA, Simonsen Ø, Kanestrøm A; et al. (2008). "An outbreak of legionnaires disease caused by long-distance spread from an industrial air scrubber in Sarpsborg, Norway". Clin Infect Dis. 46 (1): 61–9. doi:10.1086/524016. PMID 18171215.CS1 maint: Multiple names: authors list (link)
8. ↑ Simonsen Ø, Wedege E, Kanestrøm A, Bolstad K, Aaberge IS, Ragnhildstveit E; et al. (2015). "Characterization of the extent of a large outbreak of Legionnaires' disease by serological assays". BMC Infect Dis. 15: 163. doi:10.1186/s12879-015-0903-2. PMC 4383209. PMID 25887275.CS1 maint: Multiple names: authors list (link)
9. ↑ White PS, Graham FF, Harte DJ, Baker MG, Ambrose CD, Humphrey AR (2013). "Epidemiological investigation of a Legionnaires' disease outbreak in Christchurch, New Zealand: the value of spatial methods for practical public health". Epidemiol Infect. 141 (4): 789–99. doi:10.1017/S0950268812000994. PMID 22697112.CS1 maint: Multiple names: authors list (link)
10. ↑ Gilmour MW, Bernard K, Tracz DM, Olson AB, Corbett CR, Burdz T; et al. (2007). "Molecular typing of a Legionella pneumophila outbreak in Ontario, Canada". J Med Microbiol. 56 (Pt 3): 336–341. doi:10.1099/jmm.0.46738-0. PMC 2884934. PMID 17314363.CS1 maint: Multiple names: authors list (link)
11. ↑ Trudel L, Veillette M, Bonifait L, Duchaine C (2014). "Management of the 2012 Legionella crisis in Quebec City: need for a better communication between resources and knowledge transfer". Front Microbiol. 5: 182. doi:10.3389/fmicb.2014.00182. PMC 4017129. PMID 24829561.CS1 maint: Multiple names: authors list (link)
12. ↑ McCormick D, Thorn S, Milne D, Evans C, Stevenson J, Llano M; et al. (2012). "Public health response to an outbreak of Legionnaires' disease in Edinburgh, United Kingdom, June 2012". Euro Surveill. 17 (28). doi:10.2807/ese.17.28.20216-en. PMID 22835439.CS1 maint: Multiple names: authors list (link)
13. ↑ Russo A, Gouveia CM, Soares PMM, Cardoso RM, Mendes MT, Trigo RM (2018). "The unprecedented 2014 Legionnaires' disease outbreak in Portugal: atmospheric driving mechanisms". Int J Biometeorol. 62 (7): 1167–1179. doi:10.1007/s00484-018-1520-8. PMID 29572569.CS1 maint: Multiple names: authors list (link)
14. ↑ Simmering JE, Polgreen LA, Hornick DB, Sewell DK, Polgreen PM (2017). "Weather-Dependent Risk for Legionnaires' Disease, United States". Emerg Infect Dis. 23 (11): 1843–1851. doi:10.3201/eid2311.170137. PMC 5652433. PMID 29048279.CS1 maint: Multiple names: authors list (link)
15. ↑ Han XY (2021). "Effects of climate changes and road exposure on the rapidly rising legionellosis incidence rates in the United States". PLoS One. 16 (4): e0250364. doi:10.1371/journal.pone.0250364. PMC 8061983 Check `|pmc=` value (help). PMID 33886659 Check `|pmid=` value (help).

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