Legionnaires Disease HPA Surveillance Outbreak Management Rebecca Ingham
Legionnaire’s Disease HPA Surveillance & Outbreak Management Rebecca Ingham Health Protection Practitioner West Yorkshire Health Protection Unit
The West Yorkshire HPU: 5 CCDC’s (Consultant in Communicable Disease Control): All CCDC’s are Dr’s in our Unit Patch work – 1 CCDC to each patch Duty CCDC - on daily basis 9 Health Protection Specialists: 8 HP Nurses + 1 HP Practitioner Patch work – 2 HPS to each patch Duty Professional – approx 1 or 2 days/ week Surveillance team PA support/ Administration Team Trainees Specialist Registrars (medic trained) & Specialist Trainees (non medic)/ FY 2’s – Junior Dr’s
Legionella pneumophilia • Ubiquitous: Aquatic: lakes and streams • 46 species including L. pneumophilia (serogroup 1 causes most LD) • Spread through aerosols • Cooling towers, spas, shower heads, taps, humidifiers • No person-to-person transmission
Clinical features • Legionnaires’ disease: Incubation Period 2 -10 days Non specific flu like illness: fever, malaise, myalgia, headache, dry cough, anorexia often with diarrhoea and confusion • Difficult to differentiate clinically from other atypical pneumonias • Become ill quickly • Complications: resp failure, pericarditis, acute renal failure • Treatment: Erythromycin • 5 -15% mortality • Pontiac fever: self limiting, Incubation Period 5 -66 hrs
Microbiological Investigation • Culture: need special media • Antibody detection: takes 3 -6 weeks to rise to diagnostic levels • Serogroup 1 urinary antigen: early diagnosis – fast and dirty testing of urine • Usual to also get sputum or other respiratory samples (bronchial washings) for testing • Genotyping available to support epidemiological investigations i. e. human and env samples ‘fingerprint’ the same • Environmental sampling to investigate suspected sources. Routine sampling not worthwhile
Epidemiology • Incidence ? ? Over 200 cases a year in the UK • 70% in Males • 90% in the over 30’s • Travel associated accounts for about 50% of cases Spain, Turkey, France, Italy, Greece • 15% associated with outbreaks • 2% hospital acquired • Risk factors: Age, smoking, lung and kidney disease, immunosuppression, alcohol • Incidence appears to be rising, probably due to better awareness and testing
Travel Associated Deaths (Abroad & UK) Year Total Cases Male Cases Female Cases 1997 226 165 61 28 114 1998 227 162 65 25 115 1999 200 150 50 28 91 2000 180 143 37 25 101 2001 182 142 40 26 100 2002 387 256 131 33 154 2003 314 238 76 35 174 2004 318 239 79 38 173 2005 355 271 83 30 179 2006 551 433 118 53 213 2007 442 328 114 53 199 2008# 359 281 78 34 152
Surveillance: Why? • See trends: descriptive epidemiology, at risk populations – age, travel • Detect outbreaks • New infections: seasonal flu virus, pandemic virus • Implement interventions to prevent spread of disease • Monitor effectiveness of interventions
Dissemination of Surveillance Data • Health Protection Report and HPA website • European Legionnaires’ disease Surveillance Network (ELDSNet ) • European Centre for Disease Prevention and Control (ECDC) • World Health Organisation (WHO)
Investigation of a Case • Confirm case: Test validated at Cf. I • Notifiable in Eng&Wales (since 2010) • – Risk factor history for previous 2 weeks Travel, place of work, hospital acquired? • Other cases? (diagnosed, undiagnosed? ) • Inform LA H&S and HSE • LA holds a database of cooling towers (is it up to date? ) Check out sampling records
Surveillance Data Set: • Patients demographics: Age/ Do. B/ Gender/ Home & Work Address/ Occupation • Clinical History: Onset/ Relevant med history/ Hospital admission/ Outcome • Exposure history: ? hospital acquired Community acquired (known exposure to cooling towers, whirlpool spas, showers) Travel associated Country (s) visited, dates of stay, name & address of accommodation, room number, tour operator, use of showers, spa pools Household acquired - Use of household water system during incubation period, in absence of other exposures
Clusters, Outbreaks & Travel Associated Clusters • Cluster • Outbreak • Travel Associated Cluster Strength of evidence for outbreaks • High • Low
Outbreaks • Active case finding • Detailed analysis of movements • Mapping • Identify potential sources: inspections and detailed look at records • Hospital acquired: check all sources • Engineer’s advice • Typing results
Legionella
Prevention and Control • Health and Safety – Employers should identify, assess and manage risks – Cooling towers notified and maintained – Testing and addition of biocides to limit growth • Reporting of cases: locally and nationally • Investigation of cases • Increasing awareness – Professionals: thinks of Legionella and if you find it report it – Employers aware of risks and duties – Public beware of the risks
Managing Outbreaks Requires All of us Working Together
How to reach us: West Yorkshire HPU 6 th floor South East Quarry House Quarry Hill LEEDS LS 2 7 UE Telephone: 0113 386 0300 NB soon to be Public Health England HPA website: www. hpa. org. uk Duty desk: option 1 1 st April 2013 Email: westyorksdutypro@hpa. org. uk rebecca. ingham@hpa. org. uk 1 st April 2013: rebecca. ingham@phe. gov. uk www. phe. gov. uk
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