During October 2003 - February 2004, eight cases (seven confirmed cases and one possible) of Legionnaires disease (LD) be identified among guests at a hotel within Ocean City, Maryland. This tittle-tattle summarize the subsequent inspection conduct by means of the Worcester County Health Department (WCHD), Maryland Department of Health and Mental Hygiene (DHMH), and CDC, which implicated the potable humid moisturize agenda of the hotel in leave of the utmost plausible wellspring of pollution. The unearthing of this setting off underscore the highlighting of enhanced, state-based scrutiny all for timely detection of travel-associated LD and effecting of generate conform measures.
On December 1, 2003, a district influence department (LHD) notify DHMH of two LD cases in Maryland residents who have stay at hotel A during the 2–10-day incubation breathing space. The two patients had stay in hotel A of 3 and 4 days; their beginning of illness materialize 8 and 5 days, respectively, after departure hotel A. Both patients had radiographically confirmed pneumonia and beneficial Legionella urinary antigen test that were homogeneous beside L. pneumophila serogroup 1 (Lp1) infection. The two patients had stayed at hotel A rainy-day 1 time of respectively other and were associated epidemiologically through roam data collected by LHDs in Maryland by using the DHMH report contour for LD. This form pool information on the subject of position, bungalow, and date of travel for the 10 days formerly illness. Review of LD suitcase report form revealed six added LD patients with report travel to Ocean City during the preceding year; on the other hand, none had stayed at hotel A.
After unprocessed inspection and water sampling of hotel A by WCHD, multiple standard from multiple spot in the hotel revealed the someone in that of Lp1. On January 26, 2004, hotel A attempt remediation by superheating water system, be in motion red in the frontage all water bang, and hyperchlorinating the make colder battlement. Showers and faucets were reportedly disinfected, and deluge commander and sink aerators were replace in rooms where against slush patients had stayed.
Case Findings After the pilot cases were identified, enhanced surveillance be conducted, with postings on the CDC Epidemic Information Exchange (Epi-X) and a swift department of all DHMH case report forms for LD. In February 2004, two additional LD patients were identified, including one soul who had stayed at hotel A after remediation. On the point of this finding and the hidden for ongoing but undetected conveyance of Legionella, CDC was call to go in the investigation.
To identify additional cases, neighboring jurisdiction, acute ticket sanatorium emergency department, and all LHDs in Maryland were notified. Press release and hotel A guest notification were subdivision by DHMH, WCHD, and hotel A. Reports of society with illness after a drop by to Ocean City were review by WCHD and DHMH to learn whether model for the LD case definition were meet. A confirmed case of LD was defined as radiographically confirmed pneumonia with laboratory substantiation of Legionella infection in a resident or firm to Ocean City during October 2003–February 2004, whose illness start off within 10 days of phenomenon spent in Ocean City. Laboratory confirmation integrated permit of Legionella by thought, send fluorescent antibody trialling, urine antigen assay, or an extend in antibody titer indicating recent infection. Possible LD cases were defined the same but lacking laboratory confirmation of Legionella infection or other transmittable etiology.
Enhanced surveillance identified in the pressure of 50 in dependent health persons with fair to hotel A. Further investigation resulted in identification of three additional confirmed cases and one prospective case, for overall full of seven confirmed and one possible case of LD during October 2003–February 2004. The median length of end at hotel A was 3 night (range: 1–4 nights). Symptom onset occurred a median of 7.5 days (range: 4–9 days) after leaving hotel A. The median age of the eight patients was 63 years (range: 37–70 years), and six (75%) patients were man.
Underlying medical machines associated with increased hang over for LD included smoke (five patients), diabetes (four patients), and an immunocompromised set of symptom (one patient). Five cases were confirmed by urine antigen testing and two by serology. Seven patients were hospitalized; none pass by the ghost.
A review of possible exposure at hotel A among the patients with confirmed LD revealed that all had shower or bathed in their respective rooms, and one had once own the current spa. Six patients reported exposure to the go for a swim baths and whirlpool speckle. No other agreed source of exposure linking all cases were identified.
Environmental Investigation During December 2003–February 2004, WCHD, DHMH, and CDC conducted three environmental inspections and four rounded of water testing at hotel A. The hotel loiter unambiguous during the inspections and testing. The rooms where the seven confirmed patients stayed were placed in not like area and on different floor of the hotel. During all rounds of testing, water warmth in multiple location were in an extraordinary leash for slab and amplification of Legionella (77F–108F 25C–42C). Lp1 was recovered from multiple sites in hotel A, including the hot water storage reservoir; cooling tower; multiple hot water heaters; and shower and faucets in rooms inhabited by patients and economically guests. All environmental Lp1 isolate were resembling monoclonal antibody category 1,2,5,* (testing for type 6 was not conducted). Despite inaccessibility of Lp1 from sites in hotel A, scholarly isolates from patients were not untaken to correlation with environmental isolates through exploitation of monoclonal antibody testing.
After the third and fourth cases of LD were identified, a second superheating remediation was conducted at hotel A in February 2004. In tally, shower neck and faucets in all hotel rooms and condominiums were reportedly disinfected with a bleach medication. The whirlpool spa sand filter was sweep up aware. In March 2004, given the superficial fault of the initial remediation, the potable water system was hyperchlorinated, and a postremediation decoration for water testing for Legionella was instituted. Since the hyperchlorination exposure, no further cases of LD associated with hotel A include be identified. During postremediation follow-on testing, one Lp1 isolate from the cooling tower was identified at a thin smooth, and the cooling tower was hyperchlorinated. DHMH continue to display for additional cases associated with hotel A and for all travel-associated LD cases.
Reported by: D Goeller, MS, Worcester County Health Dept, Snow Hill; D Blythe, MD, M Davenport, MD, M Blackburn, MPH, Maryland Dept of Health and Mental Hygiene. B Flannery, PhD, C Lucas, PhD, B Fields, PhD, M Moore, MD, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; AD Castel, MD, L Hicks, DO, EIS officer, CDC.
Editorial Note: Hotels have been common locations for LD outbreak since the disease was initial decent among hotel guests in Philadelphia in 1976 (1,2). In this report, the exposure of patients to the hotel’s potable water system, the defect of other epidemiologic links, and the repossession of Legionellae from multiple point in the system recommend that the hotel potable water system was the source of the outbreak. Approximately 8 million people travel to Ocean City each year; that`s why, a link involving the first two cases was not in half a shake evident. Available background were dig out to identify additional cases associated with the hotel or travel to Ocean City. Active surveillance accomplishments lead to more rapid identification of other cases. The traditional identification of these cases prompted further investigation and subsequent control and remediation not easy toil at hotel A.
In 2003, DHMH began conduct enhanced surveillance because of increased reports of LD. All patients reported to DHMH be administered a follow-up questionnaire by local or situation health departments. The questionnaire identify travel that precede the illness, including location, accommodations, dates, and information roughly speaking exposures to common sources for infection, such as whirlpool spa and cooling tower.
Surveillance data submit to CDC symbolize that approximately 21% of LD cases each year are travel associated (3). However, several factor rest paid to identification of travel-associated cluster of the disease. The LD incubation period be prolonged adequate for persons to spread out from the thorn source of infection. In addition, LD can be pleasure proudly with empiric antibiotics, which obviates the scrounging for confirmatory testing. When diagnostic testing is perform, isolation of the organism is failing out, prevent comparison of environmental isolates with clinical isolates.
Improved national surveillance for travel-associated LD may perhaps back detect clusters of the disease. Surveillance for LD in the United States consists of two systems, a national, paper-based system and an electronic system reported through the National Electronic Telecommunications System for Surveillance. Only the discourse case-report form collects information on location of travel and lodging. Although the paper case-report form is pragmatic for track overall trend, a lack of timeliness and inflammation, habitually consequential in an inability to link cases, precincts its effectiveness in identify clusters (4).
The European Working Group for Legionella Infections, verified in 1986, have mechanized a glorious surveillance system for identifying clusters of travel-associated LD. The European Surveillance Scheme for Travel-Associated Legionnaires Disease, which consists of 36 collaborate country, compile case data electronically and cross-checks travel accommodations with other cases to identify clusters. During 2000–2002, a total of 113 travel-associated LD clusters were reported, with the majority linked to hotels. Since prelude of the European group’s guidelines in July 2002, all LD clusters are investigate, and remediation and control measures are instituted when vital (5,6).
The European and DHMH programs epitomize how timely, affecting surveillance can identify clusters of travel-associated LD. Prompt confession and investigation of clusters can implicate a point source for infection and scout remediation and control efforts. Recognizing the benefits of enhanced surveillance, CDC devices to work with state health departments on baffling strategy to remodel surveillance for travel-associated LD at the national, state, and local level.
Acknowledgments The findings here report are stub, in part, on contributions by R Thompson, P Dietrich, Baltimore County Health Dept, Baltimore; R Shockley, D Stevens, E Potetz, K Malloy, T Possident, Worcester County Health Dept, Snow Hill, Maryland. J Li, Office of Workforce and Career Development, CDC.
References 1 Benin AL, Benson RF, Arnold KE, et al. An outbreak of travel-associated Legionnaires disease and Pontiac confusion: the need for enhanced surveillance of travel-associated LD in the United States. J Infect Dis 2002;185:237–43.
2 Fraser DW, Tsai TR, Orenstein W, et al. Legionnaires disease: characterization of an epidemic of pneumonia. N Engl J Med 1977;297:1189–97.
3 Benin AL, Benson RF, Besser RE. Trends in Legionnaires disease, 1990–1998: diminishing mortality and new pattern of diagnosis. Clin Infect Dis 2002;35:1039–46.
4 Fields BS, Benson RF, Besser RE. Legionella and Legionnaires disease: 25 years of investigation. Clin Microbiol Rev 2002;15:506–26.
5 Joseph CA, European Working Group for Legionella Infections. Legionnaires disease in Europe 2000–2002. Epidemiol Infect 2004; 132:417–24.
6 European Surveillance Scheme for Travel Associated Legionnaires Disease, European Working Group for Legionella Infections. European guidelines for control and overthrow of travel associated Legionnaires disease. London, England: European Surveillance Scheme for Travel Associated Legionnaires Disease, European Working Group for Legionella Infections; 2005. Available at /pdf_files/guidelinesjanuary2005.pdf.
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