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An outbreak of Legionnaires’ Disease in a Swedish Hospital
Department of Infectious Diseases, Ryhov Hospital, Jönköping, Sweden.
Värnamo Hospital, Stockholm, Sweden.
National Bacteriological Laboratory, Stockholm, Sweden.
National Bacteriological Laboratory, Stockholm, Sweden.
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1994 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, E-ISSN 1651-1980, Vol. 26, no 4, 417-425 p.Article in journal (Refereed) Published
Abstract [en]

We report a nosocomial outbreak of Legionella pneumophila serogroup (sg) 1 infection at the general hospital, Värnamo, Sweden. From December 1990 to February 1991, 28 patients and 3 staff fell ill with pneumonia and 3 died. L. pneumophila sg 1 together with several other Legionellae were isolated from the hot water supply to 17 of 20 hospital wards, probably being spread by aerosolization via shower nozzles. Raising the hospital's hot water temperature from 45°C to 65°C, together with heat disinfection of the shower equipment, arrested the outbreak within a week. Keeping the hot water temperature < 60°C without chlorination eliminated L. pneumophila from < 75% of the wards. During a period of 2 years after the outbreak we have diagnosed only 1 case of nosocomial legionellosis at the hospital despite an active surveillance program.

Place, publisher, year, edition, pages
1994. Vol. 26, no 4, 417-425 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-84311DOI: 10.3109/00365549409008615OAI: oai:DiVA.org:liu-84311DiVA: diva2:558676
Available from: 2012-10-04 Created: 2012-10-04 Last updated: 2017-12-07Bibliographically approved
In thesis
1. Epidemiology and long term control of nosocomial legionnaires' disease
Open this publication in new window or tab >>Epidemiology and long term control of nosocomial legionnaires' disease
2003 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The first nosocomial legionella outbreak in a Scandinavian general district hospital was identified in an epidemiological investigation of a cluster of pneumonia cases in Värnamo in 1991. During 3 months, 28 patients and 3 staff fell ill and 3 died. Legionella pneumophila serogroup (sg) 1, was found in high counts throughout the hospital hot water system and was probably spread by aerosolisation via shower nozzles. The outbreak was arrested when the circulating hot water temperature was raised from <45°C to >55°C.

The nosocomial infections proved to be part of a wider legionella outbreak and 10 cases contracted outside the hospital were also detected. Legionellae were cultured from 7 of 15 community buildings and 31% (109/354) of subjects living in the Värnamo area had an elevated titre (≥6) to L. pneumophila sg 1 in 1991, indicating a temporary spread of legionella in the community. Subclinical infection was demonstrated and it was estimated that only 10% of all infections had been clinically identified. Nosocomial legionnaires' disease should alert physicians to possible legionella transmission in the community.

In 21 patients from the nosocomial outbreak, the median L. pneumophila sg 1 antibody titre fell from 1:256 to 1:16 in 3 years. After 10 years, the titre level in this clinical cohort had reached the same level as observed in the background population 5 years earlier. Current international serological criteria (a fourfold or greater rise in antibody titre to ≥1:128) identified only 40% (21/52) of pneumonia cases caused by L. pneumophila sg 1 in a Swedish population in 1991-2001. When the antibody response was related to the antibody titre in local residents, the sensitivity rose to 87% (45/52).

Keeping the circulating hospital hot water temperature above 55°C, and vigilant clinical surveillance of nosocomial pneumonia as a method for control of nosocomial legionnaires' disease was evaluated after 10 years of practice. Infection with L. pneumophila sg 1 was diagnosed in 4 out of 366 (1.1 %) patients treated for nosocomial pneumonia, representing 1 case per 26,000 admissions. All patients were cured without complications. L. pneumophila sg 1 was isolated in 30 of 251 (12%) cultured hospital water samples during the monitoring period. It was concluded that this approach was safe and effective for long term control of nosocomial legionnaires' disease in a primary referral hospital.

The hospital hot water system was found to be colonised with a single genotype of L. pneumophila sg 1 over a 12-year period. The same genotype, identified using amplified fragment length polymorphism (AFLP) analysis, was also demonstrated in 18/20 (90%) community isolates. The phenotypic variation was confined to the monoclonal antibody subtypes Benidorm and Bellingham. The hospital genotype was identified in 2 out of 6 Swedish hospitals, both located within 100 km of Värnamo. Obviously, an entire municipal water network may constitute a distinct ecological niche for a single legionella strain. Certain clones also seem to be widely spread in the environment. This implies that results from molecular subtyping must be interpreted cautiously in epidemiological investigations of legionnaires' disease.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet, 2003. 88 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 814
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26648 (URN)11213 (Local ID)91-7373-497-7 (ISBN)11213 (Archive number)11213 (OAI)
Public defence
2003-10-24, Föreläsningssalen, Qulturum, Hus B4, Länssjukhuset Ryhov, Jönköping, 13:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-10-04Bibliographically approved

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