Legionnaires’ disease is an uncommon infection of the lungs (pneumonia) caused by Legionella bacteria. The bacteria are commonly found in the environment, particularly water and soil. Infection occurs two to 10 days after a person breathes in the bacteria in contaminated water vapours or dust.
Symptoms of Legionnaires’ disease include fever, chills, a cough and shortness of breath. Some people also have muscle aches, headache, tiredness, loss of appetite and diarrhoea. People can become very sick with pneumonia; most people recover, but around 10 per cent of patients die.
There are many different species of Legionella bacteria but the two that most commonly cause disease in NSW are Legionella pneumophila (found in water) and Legionella longbeachae (found in soil). Legionella pneumophila bacteria can contaminate air conditioning cooling towers, whirlpool spas, shower heads and other bodies of water. Legionella longbeachae can contaminate soil or potting mix. People may be exposed to the bacteria at home, at work or in public places. Legionnaires’ disease is not normally spread from person to person.
Legionnaires’ disease most often affects middle-aged and older people, particularly those who smoke or who have chronic lung disease. People whose immune systems are suppressed by medications or diseases such as cancer, kidney failure, diabetes or AIDS are also at increased risk.
NSW Health’s public health units actively investigate all cases of Legionnaires’ disease. Their investigation includes:
The Legionella CBD outbreak report summarises the findings of the public health investigations into Legionella outbreaks in Sydney CBD, March and May 2016. The report outlines public health actions, case identification, environmental investigations, testing, results and actions taken.
Following the CBD outbreak in 2016, NSW Health established the Legionella Taskforce to consider changes to the already strong regulatory approach to preventing Legionnaires’ disease in NSW. For the ammended Legislation on Legionella Control, refer to Public Health Amendment (Legionella Control) Regulation 2018.
There are no specific precautions people should take in relation to the current clusters, however susceptible people who have been in areas where Legionnaires’ clusters have been detected should seek medical attention if they develop the following symptoms: fever, chills, cough, headache, aching muscles, lethargy. Legionnaires’ disease most often affects middle-aged and older people, particularly those who smoke or who have underlying health conditions such as chronic lung disease.
While exposure to contaminated water vapour from cooling towers and other sources may lead to a person to contracting the disease, Legionnaires’ disease can also be contracted through exposure to soil and potting mix where Legionella longbeachae may be found. NSW Health recommends reducing exposure to potting mix dust by following manufacturers’ warnings present on potting mix labels, including:
Although 10 per cent or more of cooling towers may be contaminated in a city, most are never found to cause outbreaks of disease. The reason why some cooling towers are associated with outbreaks is unclear, but probably relates to a range of conditions occurring coincidentally. These are likely to include: contamination of the cooling tower; weather conditions such as the level of humidity, sunlight, temperature and wind direction, and susceptible people being located in a position where they can breathe in contaminated water vapour.
Most people who breathe in contaminated water vapour will never get sick. The people most likely to become ill are those who smoke, have underlying illnesses and who are elderly.
Internationally, outbreaks of Legionnaires’ disease can vary in size, ranging up to hundreds of identified patients. In 2015 in New York City, 133 patients were reported with Legionnaires’ disease, 16 of whom died. In Melbourne in 2000, 125 patients with Legionnaires’ disease were reported in association with an outbreak linked to the Melbourne Aquarium.
Laboratories and hospitals are required to confidentially notify cases of Legionnaires’ disease to public health units in NSW. Public health unit staff carefully interview patients or their carers about their illness and possible exposures. This often includes multiple interviews to identify all possible locations where they travelled, worked, stayed or visited during the two to 10 days before onset of illness. Public health epidemiologists then map these locations and compare them closely with the exposures reported by other patients who have recently been diagnosed with Legionnaires’ disease.
As the bacteria that cause Legionnaires’ disease are common in the environment, it is rarely possible to know how an individual patient became infected. However, where multiple patients are infected, public health epidemiologists search for common areas of exposure. Should multiple patients be diagnosed with the disease, then potential sources of infection can be more accurately pinpointed.
Two people with the illness visiting the same place, such as a busy shopping centre, may be coincidental and does not necessarily indicate that’s where they were infected, as people may report common exposures by chance. However public health units take a precautionary approach to such reports. Where two cases report a common exposure, public health unit staff work with local council environmental health officers to review possible sources of infection (such as cooling towers) in the area to assess whether they may have been a risk for infection and, if necessary, require them to be cleaned.
In addition, alerts may be issued to laboratories and doctors serving the area where patients have been reported to check whether other patients may have the disease. This is called active surveillance. Where there is no reasonable evidence that the common exposure area reported by the two cases is the location at which they were infected, public health warnings are not usually necessary. There is the risk that such warnings may have quite negative effects on the community if they inappropriately imply that a certain area was the cause of an outbreak, adversely affecting local businesses.
Should active surveillance identify more than two cases reporting common exposures, then there is an increased probability that the source of infection may be in that location. In response, public health units continue with the actions identified above and, in the absence of an alternative source, a public health media alert may be issued to raise awareness about the disease to encourage early diagnosis of other cases, and remind building owners of the need to ensure cooling towers are clean and disinfected. Additional steps including specific alerts may be issued directly to cooling tower operators.
It’s tragic when somebody dies from a communicable disease. Around 10 per cent of people with Legionnaires disease die despite treatment. Deaths tend to be more common in vulnerable patients with underlying disease. However the proportion of people who die with Legionnaires disease is not related to whether or not the person acquired the infection as part of an outbreak or not. The extent and severity of an outbreak is usually measured by the number of patients who have been affected, rather than the number of deaths.
Strict privacy rules apply to the release of information about patients and it’s important that patients know their privacy is respected. Even if their name is not included, the release of other information about a patient (for example, their date of birth, sex, disease, risk factors and treating hospital) could allow other people to identify that person and infer private information about them. So when a death occurs in someone with Legionnaires’ disease, there is need for careful consideration of whether the release of that information would help protect public health, or risk breach of privacy.
It is often very difficult to pinpoint the source of an outbreak with accuracy. The main aim of a public health response is to stop the outbreak continuing as soon as possible by ensuring that cooling towers and other possible sources of infection in a location suspected to be the cause of the outbreak are controlled as quickly as possible. To achieve this, building owners are warned to maintain cooling towers to ensure they are free of contamination, and environmental health officers carry out door to door inspections of cooling towers.
A cooling tower that is the source of an outbreak may not be identified despite careful investigations. This is because a cooling tower may be only transiently contaminated by Legionella bacteria floating through the air, and water vapour from that cooling tower may infect people walking by, as well as contaminate other nearby cooling towers. However that cooling tower’s continuous disinfection and regular cleaning processes may automatically decontaminate it, even before infected patients are diagnosed. Should the first cooling tower be tested, it may therefore test negative for Legionella (because it’s been automatically disinfected), even though it’s the real source of patients’ infection, while the nearby cooling towers (contaminated by the first cooling tower, but not yet disinfected) may test positive, even if they have not caused any infections in patients.
NSW Health is developing special tests (such as whole genome sequencing) that can match the strains of bacteria found in patients and in cooling towers. However even if a patient’s strain matches a cooling tower strain, it does not prove it was the source of infection, as both the patient and that cooling tower may simply have been contaminated by another cooling tower that may never be identified (e.g. because it already had been disinfected).