Results from the National Legionella Outbreak Detection Program, the Netherlands, 2002–2012 - Volume 21, Number 7—July 2015 - Emerging Infectious Disease journal - CDC
Volume 21, Number 7—July 2015
Results from the National Legionella Outbreak Detection Program, the Netherlands, 2002–2012
Legionnaires’ disease (LD) is an acute pneumonia characterized by clinical symptoms and signs (e.g., cough, fever, lung infiltration observed on a chest radiograph) similar to those of pneumonias resulting from other pathogens. LD is caused by infection with Legionella spp. bacteria, which are most often transmitted to persons through inhalation of bacteria disseminated into the air as an aerosol from natural or man-made sources of water (1). The incubation period is 2–14 days. LD is thought to account for 2%–20% of all community-acquired pneumonias (2) and is fatal in ≈6%–11% of cases (3,4).
After a large outbreak of LD at a flower show in Bovenkarspel, the Netherlands, in 1999 (5), prevention and control of Legionella spp. infections became a national concern in the Netherlands, and legislation to preventLegionella spp. in drinking water systems was introduced (6,7). This legislation obligated owners of aerosol-producing devices (e.g., shower heads and whirlpools), if third parties may be exposed to them, to conduct a risk analysis, develop a control plan, keep logs of control measures, and perform regular sampling for Legionella spp. contamination. In addition, in 2002, a National Legionella Outbreak Detection Program (NLODP) was implemented (8) on the basis of a report that LD outbreaks are often preceded and followed by small clusters of solitary cases (9). The aims of NLODP are early detection of small clusters of cases, identification of sources of infection, and implementation of early control measures to prevent additional LD cases or an outbreak. For evaluation of transmission pathways, infection sources are sampled, and genotypes of Legionella strains found in these samples are compared with those of clinical isolate(s) from the patient(s) associated with that source. To evaluate the findings of the NLODP during 2002–2012, we analyzed data to determine whether extensive investigation efforts could detect Legionella spp. in collected samples and conclusively identify environmental sources.
Dr. Den Boer is a public health physician and epidemiologist at the Regional Public Health Laboratory Kennemerland, Haarlem, the Netherlands. His research interests include prevention and control of infectious diseases.
We thank the public health physicians and nurses of the MHSs for providing epidemiologic data and source identification results; the treating physicians and microbiologists for making patient isolates available for genotyping; and Jacqueline De Vries and Wim Houtenbos for their support with source investigations.
- Fields BS, Benson RF, Besser RE. Legionella and Legionnaires’ disease: 25 years of investigation. Clin Microbiol Rev. 2002;15:506–26.
- Torres A, Blasi F, Peetermans WE, Viegi G, Welte T. The aetiology and antibiotic management of community-acquired pneumonia in adults in Europe: a literature review. Eur J Clin Microbiol Infect Dis. 2014;33:1065–79.
- Joseph CA, Ricketts KD. Legionnaires’ disease in Europe 2007–2008. Euro Surveill. 2010;15:19493.
- Beauté J, Zucs P, de Jong B; European Legionnaires’ Disease Surveillance Network. Legionnaires disease in Europe, 2009–2010. Euro Surveill.2013;18:20417.
- Den Boer JW, Yzerman EP, Schellekens J, Lettinga KD, Boshuizen HC, Van Steenbergen JE, A large outbreak of Legionnaires' disease at a flower show, the Netherlands, 1999. Emerg Infect Dis. 2002;8:37–43.
- Netherlands Ministry of Housing, Spatial Planning and the Environment. Water supply decree. Besluit van 26/10/2004 to wijziging van het Waterleidingbesluit en het Besluithygiëne en veiligheid badinrichtingen en zwemgelegenheden (preventie van legionella in leidingwater). The Hague (the Netherlands): the Ministry; 2004.
- Sonder GJ, van den Hoek JA, Bovée LP, Aanhane FE, Worp J, De Ry van Beest Holle M, Changes in prevention and outbreak management of Legionnaires’ disease in the Netherlands between two large outbreaks in 1999 and 2006. Euro Surveill. 2008;13:18983.
- Den Boer JW, Verhoef L, Bencini MA, Bruin JP, Jansen R, Yzerman EP. Outbreak detection and secondary prevention of Legionnaires’ disease: a national approach. Int J Hyg Environ Health. 2007;210:1–7.
- Bhopal RS. Geographical variation of Legionnaires’ disease: a critique and guide to future research. Int J Epidemiol. 1993;22:1127–36.
- Fry NK, Bangsborg JM, Bernander S, Etienne J, Forsblom B, Gaia V, Assessment of intercentre reproducibility and epidemiological concordance ofLegionella pneumophila serogroup 1 genotyping by amplified fragment length polymorphism analysis. Eur J Clin Microbiol Infect Dis.2000;19:773–80.
- Gaia V, Fry NK, Afshar B, Lück PC, Meugnier H, Etienne J, Consensus sequence-based scheme for epidemiological typing of clinical and environmental isolates of Legionella pneumophila. J Clin Microbiol. 2005;43:2047–52.
- Ratzow S, Gaia V, Helbig JH, Fry NK, Lück PC. Addition of neuA, the gene encoding N-acylneuraminate cytidylyl transferase, increases the discriminatory ability of the consensus sequence-based scheme for typing Legionella pneumophila serogroup 1 strains. J Clin Microbiol.2007;45:1965–8.
- Helbig JH, Bernander S, Castellani Pastoris M, Etienne J, Gaia V, Lauwers S, Pan-European study on culture-proven Legionnaires’ disease: distribution of Legionella pneumophila serogroups and monoclonal subgroups. Eur J Clin Microbiol Infect Dis. 2002;21:710–6.
- Koide M, Saito A, Okazaki M, Umeda B, Benson RF. Isolation of Legionella longbeachae serogroup 1 from potting soils in Japan. Clin Infect Dis.1999;29:943–4.
- Steele TW, Lanser J, Sangster N. Isolation of Legionella longbeachae serogroup 1 from potting mixes. Appl Environ Microbiol.1990;56:49–53.
- Casati S, Gioria-Martinoni A, Gaia V. Commercial potting soils as an alternative infection source of Legionella pneumophila and other Legionellaspecies in Switzerland. Clin Microbiol Infect. 2009;15:571–5.
- Schalk JA, Docters van Leeuwen AE, Lodder WJ, De Man H, Euser SM, Den Boer JW, Isolation of Legionella pneumophila from pluvial floods by amoebal coculture. Appl Environ Microbiol. 2012;78:4519–21.
Suggested citation for this article: Den Boer JW, Euser SM, Brandsema P, Reijnen L, Bruin JP. Results from the National Legionella Outbreak Detection Program, the Netherlands, 2002–2012. Emerg Infect Dis. 2015 July [date cited]. http://dx.doi.org/10.3201/eid2107.141130