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Results from the National Legionella Outbreak Detection Program, the Netherlands, 2002–2012 - Volume 21, Number 7—July 2015 - Emerging Infectious Disease journal - CDC

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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

Jeroen W. Den BoerComments to Author , Sjoerd M. Euser, Petra Brandsema, Linda Reijnen, and Jacob P. Bruin
Author affiliations: Regional Public Health Laboratory Kennemerland, Haarlem, the Netherlands (J.W. Den Boer, S.M. Euser, L. Reijnen, J.P. Bruin)National Institute for Public Health and the Environment, Bilthoven, the Netherlands (P. Brandsema)


In 2002, the National Legionella Outbreak Detection Program was implemented in the Netherlands to detect and eliminate potential sources of organisms that cause Legionnaires’ disease (LD). During 2002–2012, a total of 1,991 patients with LD were reported, and 1,484 source investigations were performed. Of those sources investigated, 24.7% were positive for Legionella spp. For 266 patients with LD, 105 cluster locations were identified. A genotype match was made between a strain detected in 41 patients and a strain from a source location. Despite the systematic approach used by the program, most sources of LD infections during 2002–2012 remained undiscovered. Explorative studies are needed to identify yet undiscovered reservoirs and transmission routes for Legionella bacteria, and improved laboratory techniques are needed to detect Legionella spp. in clinical samples with a high background of microbial flora (such as soil).
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.


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Technical Appendices

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
DOI: 10.3201/eid2107.141130

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