Clusters of Legionnaires' disease in period hotels with complex water systems: lessons learnt in the West Midlands, UK. (November 2018)

• Record Type: Journal Article
• Authors: Buckley, Karen; Afza, Musarrat; Coetzee, Nic; Kirrage, David; Knapper, Elizabeth; Duffin, Sharron; Fenelon, Deborah; Johnston, Rob; Foulkes, Sarah
• Is Part Of: Lancet. Volume 392(2018)Supplement 2
• Page Start: S22
• Publication Date: 2018-11
• Subjects: Medicine -- Periodicals; Medicine -- Periodicals; Medicine; Medicine; Electronic journals; Periodicals; 610.5
• DOI: 10.1016/S0140-6736(18)32195-0
• Languages: English
• ISSNs: 0140-6736

Abstract

Abstract: Background: In 2017 there were two distinct clusters of local travel-associated Legionnaires' disease associated with period hotels built in the 17th and 18th centuries in the West Midlands, UK. Both hotels had undergone frequent structural modifications. Five cases occurred 3 months to 2 years apart. The aim of this report is to share the learning from the investigations and challenges faced in achieving control of Legionella pneumophila in the water systems of dated buildings. Methods: Epidemiological information was obtained through structured cases interviews and through linked cases by the national surveillance scheme database. Hotel water system maintenance records were reviewed, and samples were taken at numerous timepoints and different locations, with an initial focus on facilities and rooms used by the cases. Sputum and environmental samples were tested in the reference laboratory and sequence-based typing was undertaken. Findings: Unsatisfactory levels of L pneumophila serogroup 1 were detected from hot and cold water outlets in both hotels. At one of the hotels L pneumophila serogroup 1, sequence type ST62 subtypes in clinical and environmental samples were indistinguishable. Both hotels were closed for business for months to undertake extensive remediation work. This closure was temporarily effective in achieving adequate control of legionella but 6 months later routine monitoring detected unsatisfactory levels. Achieving sustained legionella control in dated water systems and verifying safe endpoints for hotel re-opening has proven challenging for the regulatory bodies. Interpretation: Sustaining legionella control in the dated water systems of period buildings was demanding, and public confidence in the effectiveness of control measures was compromised. There were four key challenges: defining a cluster and the timely confirmation of when an outbreak has developed; using the cluster and outbreak definitions to inform the risk assessments and review of control measures in the environmental investigations; communicating the risk to the public and the media through clear messages; and seeking assurance on safety of water management systems in defining the endpoint for a cluster or outbreak investigation. Funding: None.