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Abstract

Between 1 August and 6 September 2013, an outbreak of Legionnaires’ disease (LD) with 159 suspected cases occurred in Warstein, North Rhine-Westphalia, Germany. The outbreak consisted of 78 laboratory-confirmed cases of LD, including one fatality, with a case fatality rate of 1%. , serogroup 1, subtype Knoxville, sequence type 345, was identified as the epidemic strain. A case–control study was conducted to identify possible sources of infection. In univariable analysis, cases were almost five times more likely to smoke than controls (odds ratio (OR): 4.81; 95% confidence interval (CI): 2.33–9.93; p < 0.0001). Furthermore, cases were twice as likely to live within a 3 km distance from one identified infection source as controls (OR: 2.14; 95% CI: 1.09–4.20; p < 0.027). This is the largest outbreak of LD in Germany to date. Due to a series of uncommon events, this outbreak was most likely caused by multiple sources involving industrial cooling towers. Quick epidemiological assessment, source tracing and shutting down of potential sources as well as rapid laboratory testing and early treatment are necessary to reduce morbidity and mortality. Maintenance of cooling towers must be carried out according to specification to prevent similar LD outbreaks in the future.

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2015-11-19
2018-11-14
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References

  1. Fields BS, Benson RF, Besser RE. Legionella and Legionnaires’ disease: 25 years of investigation. Clin Microbiol Rev. 2002;15(3):506-26.  https://doi.org/10.1128/CMR.15.3.506-526.2002  PMID: 12097254 
  2. European Centre for Disease Prevention and Control (ECDC). Technical Document. European Legionnaires' Disease Surveillance Network (ELDSNet). Operating procedures. Stockholm: ECDC; 2012. Available from: http://ecdc.europa.eu/en/publications/publications/1202-ted-eldsnet-operating-procedures.pdf
  3. Marston BJ, Lipman HB, Breiman RF. Surveillance for Legionnaires’ disease. Risk factors for morbidity and mortality. Arch Intern Med. 1994;154(21):2417-22.  https://doi.org/10.1001/archinte.1994.00420210049006  PMID: 7979837 
  4. Balabanova Y, Gilsdorf A, Buda S, Burger R, Eckmanns T, Gärtner B, et al. Communicable diseases prioritized for surveillance and epidemiological research: results of a standardized prioritization procedure in Germany, 2011. PLoS ONE. 2011;6(10):e25691.  https://doi.org/10.1371/journal.pone.0025691  PMID: 21991334 
  5. Faensen D, Claus H, Benzler J, Ammon A, Pfoch T, Breuer T, et al. [email protected] multistate electronic reporting system for communicable diseases. Euro Surveill. 2006;11(4):100-3. PMID: 16645245 
  6. Freudenmann M, Kurz S, von Baum H, Reick D, Schreff AM, Essig A, et al. [Interdisciplinary management of a large Legionella outbreak in Germany]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2011;54(11):1161-9.  https://doi.org/10.1007/s00103-011-1362-6  PMID: 22015788 
  7. von Baum H, Härter G, Essig A, Lück C, Gonser T, Embacher A, et al. Preliminary report: outbreak of Legionnaires disease in the cities of Ulm and Neu-Ulm in Germany, December 2009 - January 2010. Euro Surveill. 2010;15(4):19472. PMID: 20122385 
  8. Poggensee G, Benzler J, Eckmanns T, Krause Gund die Mitarbeiter der Abteilung für Infektionsepidemiologie. [On the 2007 edition of case definitions for the surveillance of notifiable infectious diseases in Germany]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2006;49(12):1189-94.  https://doi.org/10.1007/s00103-006-0088-3  PMID: 17149664 
  9. Institut RK. (RKI). Falldefinitionen des Robert Koch-Instituts zur Übermittlung von Erkrankungs- oder Todesfällen und Nachweisen von Krankheitserregern § 4 (2) des Gesetzes zur Verhütung und Bekämpfung von Infektionskrankheiten beim Menschen (Infektionsschutzgesetz - IfSG). [Case definitions of the Robert Koch Institute for the reporting of cases or deaths of communicable diseases and laboratory confirmation of infectious disease pathogens; §4 (2) of the German Infection Protection Act]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2000 Nov 1;43(11):845-69. German. Available from: http://link.springer.com/article/10.1007%2Fs001030050371
  10. European Commission. Commission Implementing Decision 2012/506/EU of 8 August 2012 amending Decision 2002/253/EC laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council. Official Journal of the European Union. Luxembourg: Publications Office of the European Union. 27.09.2012:L 262/1. Available from: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2012:262:0001:0057:EN:PDF
  11. Entfernungen berechnen mit Javascript und Bing Maps [Distance calculator with Javascript and Bing Maps]. German. [Accessed September 2013]. Available from: http://www.mg2.de/map.html
  12. International Organization for Standardization (ISO). ISO 11731. Water quality - Detection and enumeration of Legionella. Geneva: ISO; 1998. Available from: https://www.iso.org/obp/ui/#iso:std:iso:11731:ed-1:v1:en
  13. Lück C. Legionella pneumophila : Genetische Diversität von Patienten- und Umweltisolaten. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2011;54(6):693-8.  https://doi.org/10.1007/s00103-011-1282-5  PMID: 21626373 
  14. European Study Group for Legionella Infections (ESGLI). The EWGLI SBT database for the typing of Legionella pneumophila. London: Public Health England. [Accessed 1 Jan 2014]. Available from: http://bioinformatics.phe.org.uk/legionella/legionella_sbt/php/sbt_homepage.php
  15. IT.NRW Landesdatenbank, Information und Technik Nordrhein-Westfalen, Düsseldorf 2013, effective 18.11.2013. 2013.
  16. European Centre for Disease Prevention and Control (ECDC). Legionnaires' disease in Europe, 2011. Stockholm: ECDC; 2013. Available from: http://ecdc.europa.eu/en/publications/publications/legionnaires-disease-in-europe-2011.pdf
  17. Planimeter ACME. Measure areas using Google Maps. [Accessed Sep 2013]. Available from: http://www.acme.com/planimeter/
  18. Siegmund-Schultze N. Legionelleninfektionen in Warstein: Größter Ausbruch in Deutschland. [Legionnaires’ disease in Warstein: biggest outbreak in Germany]. Dtsch Arztebl Int. 2013;110(38):A-1736. German. Available from: https://www.aerzteblatt.de/archiv/literatur/146512
  19. Siegmund-Schultze N. Seltener Legionellenstamm Auslöser für Epidemie in Warstein. [Rare subtype of Legionella as the cause of the epidemic in Warstein] Dtsch Arztebl Int. 2013;110(39):A-1768. German. Available from: http://www.aerzteblatt.de/archiv/146768/Seltener-Legionellenstamm-Ausloeser-fuer-Epidemie-in-Warstein
  20. Robert Koch Institute (RKI). Infektionsgeschehen von besonderer Bedeutung: Ausbruch von Legionärskrankheit in Warstein, Landkreis Soest. [Infectious disease incident of particular importance: Outbreak of Legionnaires' disease in Warstein, administrative district of Soest]. Epid Bull. 2013(35):345-364. German. Available from: https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2013/Ausgaben/35_13.pdf?__blob=publicationFile
  21. Federal Ministry of Justice. Gesetz zur Verhütung und Bekämpfung von Infektionskrankheiten beim Menschen (Infektionsschutzgesetz - IfSG). [Regulation on preventing and control of infectious diseases in humans (Act on protection against infection)]. Berlin: Bundesministeriums der Justiz und für Verbraucherschutz; 20 Jul 2000.Available from: http://www.gesetze-im-internet.de/bundesrecht/ifsg/gesamt.pdf
  22. Den Boer JW, Yzerman EP, Schellekens J, Lettinga KD, Boshuizen HC, Van Steenbergen JE, et al. A large outbreak of Legionnaires’ disease at a flower show, the Netherlands, 1999. Emerg Infect Dis. 2002;8(1):37-43.  https://doi.org/10.3201/eid0801.010176  PMID: 11749746 
  23. García-Fulgueiras A, Navarro C, Fenoll D, García J, González-Diego P, Jiménez-Buñuales T, et al. Legionnaires’ disease outbreak in Murcia, Spain. Emerg Infect Dis. 2003;9(8):915-21.  https://doi.org/10.3201/eid0908.030337  PMID: 12967487 
  24. Telford D, Partridge S, Cumming I, Smith A, Calvert N. The legionnaires’ outbreak in Barrow-in-Furness, summer 2002. J Epidemiol Community Health. 2006;60(6):464-6.  https://doi.org/10.1136/jech.2005.037127  PMID: 16698973 
  25. Gosselin F, Duval JF, Simonet J, Ginevra C, Gaboriaud F, Jarraud S, et al. Impact of the virulence-associated MAb3/1 epitope on the physicochemical surface properties of Legionella pneumophila sg1: An issue to explain infection potential? Colloids Surf B Biointerfaces. 2011;82(2):283-90.  https://doi.org/10.1016/j.colsurfb.2010.08.040  PMID: 20889314 
  26. Nygård K, Werner-Johansen Ø, Rønsen S, Caugant DA, Simonsen Ø, Kanestrøm A, et al. An outbreak of legionnaires disease caused by long-distance spread from an industrial air scrubber in Sarpsborg, Norway. Clin Infect Dis. 2008;46(1):61-9.  https://doi.org/10.1086/524016  PMID: 18171215 
  27. Kusnetsov J, Neuvonen LK, Korpio T, Uldum SA, Mentula S, Putus T, et al. Two Legionnaires’ disease cases associated with industrial waste water treatment plants: a case report. BMC Infect Dis. 2010;10(1):343.  https://doi.org/10.1186/1471-2334-10-343  PMID: 21126333 
  28. Wedege E, Bergdal T, Bolstad K, Caugant DA, Efskind J, Heier HE, et al. Seroepidemiological study after a long-distance industrial outbreak of legionnaires’ disease. Clin Vaccine Immunol. 2009;16(4):528-34.  https://doi.org/10.1128/CVI.00458-08  PMID: 19225076 
  29. Blázquez RM, Espinosa FJ, Martínez-Toldos CM, Alemany L, García-Orenes MC, Segovia M. Sensitivity of urinary antigen test in relation to clinical severity in a large outbreak of Legionella pneumonia in Spain. Eur J Clin Microbiol Infect Dis. 2005;24(7):488-91.  https://doi.org/10.1007/s10096-005-1361-3  PMID: 15997369 
  30. Bundesrat. Beschluss des Bundesrates: Entschließung des Bundesrates zur Notwendigkeit immissionsschutzrechtlicher Regelungen der Anforderungen an Errichtung und Betrieb von Verdunstungskühlanlagen, Drucksache 795/13 (Beschluss) [Decision of the Federal Council: Resolution of the Federal Council on the need for pollution control law regulations of the requirements for the construction and operation of cooling systems]. Cologne: Bundesanzeiger; 14 Feb 2014. German. Available from: http://www.umwelt-online.de/PDFBR/2013/0795_2D13B.pdf
Epidemiological investigation and case–control study: a Legionnaires’ disease outbreak associated with cooling towers in Warstein, Germany, August–September 2013
<p class="citation"> <span>Citation style for this article:</span> <span class="meta-value authors"> <a href="/search?value1=Anna+Maisa&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Maisa Anna</a>, <a href="/search?value1=Ansgar+Brockmann&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Brockmann Ansgar</a>, <a href="/search?value1=Frank+Renken&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Renken Frank</a>, <a href="/search?value1=Christian+L%C3%BCck&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Lück Christian</a>, <a href="/search?value1=Stefan+Pleischl&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Pleischl Stefan</a>, <a href="/search?value1=Martin+Exner&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Exner Martin</a>, <a href="/search?value1=Inka+Daniels-Haardt&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Daniels-Haardt Inka</a>, <a href="/search?value1=Annette+Jurke&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Jurke Annette</a></span>. Epidemiological investigation and case–control study: a Legionnaires’ disease outbreak associated with cooling towers in Warstein, Germany, August–September 2013. <a href="/content/ecdc">Euro Surveill.</a> 2015;20(46):pii=30064. <a href="https://doi.org/10.2807/1560-7917.ES.2015.20.46.30064" title="doi link" target="_blank">https://doi.org/10.2807/1560-7917.ES.2015.20.46.30064</a> <span class="ES_Article_citation"> <span class="generated">Received</span>: 23 Sep 2014;&nbsp;&nbsp; <span class="generated">Accepted</span>: 13 Apr 2015 </span> </p>
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