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EDITORIALS: Carol Joseph New outbreak of legionnaires' disease in the United Kingdom BMJ 2002; 325: 347-348 [Full text]

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Consider ECMO for patients with severe Legionella

Nikki C Jones, Giles J Peek, Neil Roberts, Chris Harvey, David Jenkins, Andrej Sosnowski, Hilliary Killer, Richard Firmin, Ann Trusedale, Diana Elbourne   (23 August 2002)

Legionnaires’ disease: vigilance will be eternal but must be balanced

Raj S. Bhopal   (29 August 2002)

A large outbreak of legionnaires' disease in Japan

Hiroshi Kawane, 1-2 Ajinadai-higashi, Hatsukaichi City, Hiroshima, 738-0052, Japan   (5 September 2002)

Consider ECMO for patients with severe Legionella 23 August 2002
Nikki C Jones, CESAR Trial Research Fellow Glenfield Hospital, Groby Road, Leicester, LE3 9QP, Giles J Peek, Neil Roberts, Chris Harvey, David Jenkins, Andrej Sosnowski, Hilliary Killer, Richard Firmin, Ann Trusedale, Diana Elbourne Send response to journal: Re: Consider ECMO for patients with severe Legionella	Sir, Re: New outbreak of Legionnaires’ disease in the United Kingdom A wake up call for continued vigilance We write in response to the recent editorial regarding the outbreak of legionella pneumonia in Cumbria [1]. The sudden influx of around 92 patients with 19 ICU admissions is a significant strain on any health service. The number of reported cases of legionella in the UK has increased steadily from 147 in 1993 to 226 in 1998 [2,3]. As the author suggests, Legionnaires disease is often underdiagnosed, and sporadic, with only the very severely ill patients being detected and reported. The most seriously affected patients develop fulminant respiratory and multi-system failure, and this is the main cause for death for the 10-15% who die[1,4]. We have used extra-corporeal membrane oxygenation (ECMO) in 16 adult patients with the most severe form of legionella between 1989 and 2001. Their modal pre-ECMO PaO2/FIO2 ratio was 8.7 Kpa ( range 4.1 to 27.1 Kpa), 13 were male, and mean age was 43 years (SD=10.6). They all received veno-venous ECMO for a mean time of 258 hours (SD=235 hours). Survival to hospital discharge was 69%, with 11/16 patients surviving at 6 months. This is similar to the 66% survival that we have reported for adult patients with a variety of respiratory diagnoses [5]. All adult ECMO in the UK now falls within the remit of the CESAR Trial (http://www.cesar-trial.org). To be eligible for the trial, patients must be between 18 and 65 years old, have a Murray Lung Injury Score of > 3.0 and have a duration of high pressure/high FIO2 ventilation of < 7 days. We recommend that any patients with severe legionella who are deteriorating despite optimal conventional intensive care should be considered for the CESAR trial. Further details are available on the website at http://www.cesar-trial.org. Sincerely, N Jones, CESAR Trial Research Fellow, ECMO Dept, Glenfield Hospital, Leicester LE3 9QP Tel: 0116 287 1471 Fax: 0116 250 2374 E-mail: nikki.jones@uhl-tr.nhs.uk G J Peek, Lecturer in Cardiac Surgery ECMO Dept, Glenfield Hospital, Leicester LE3 9QP N Roberts, ECMO Fellow, ECMO Dept, Glenfield Hospital, Leicester LE3 9QP C Harvey, ECMO Fellow, ECMO Dept, Glenfield Hospital, Leicester LE3 9QP D Jenkins, Consultant in Microbiology, Microbiology Dept, Leicester General Hospital, Leicester AW Sosnowski, Consultant Cardiac Surgeon, Cardiothoracic Dept, Glenfield Hospital, Leicester LE3 9QP HM Killer, Head of Cardiac Services, Glenfield Hospital, Leicester LE3 9QP RK Firmin, Director of Cardiac Surgery and ECMO, ECMO Dept, Glenfield Hospital, Leicester LE3 9QP A Truesdale, Trials Co-ordinator, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT D Elbourne, Professor of Health Care Evaluation Medical Statistics Unit London School of Hygiene and Tropical Medicine Keppel Street London WC1E 7HT References: 1. Joseph C. New outbreak of Legionnaires’ disease in the United Kingdom A wake up call for continued vigilance. BMJ 2002 Aug; 325(17):347-348. 2. Joseph CA, Dedman D, Birtles R, Watson JM, Bartlett CL. Legionnaires’ disease surveillance: England and Wales 1993. Commun Dis Rep CDR Rev 1994 Sep 16; 4 (10): R109-11 3. Joseph Ca, Harrison TG, Ilijic-Car D, Bartlett CL. Legionnaires’ disease surveillance: England and Wales 1998. Commun Dis Public Health 1999 Dec; 2 (4): 280-4. 4. Van Riemsdijk-van Overbeeke IC, van den Berg B. Severe Legionnaires’ disease requiring intensive care treatment. Neth J Med 1996 Nov; 49 (5): 196-201. 5. Peek GJ, Moore HM, Moore N, Sosnowski AW, Firmin RK. Extracorporeal membrane oxygenation for adult respiratory failure. Chest 1997 Sep; 112 (3): 759-64.
Legionnaires’ disease: vigilance will be eternal but must be balanced 29 August 2002
Raj S. Bhopal, Professor of public health Public Health Sciences Section, Department of Community Health Sciences, University of Edinburgh Send response to journal: Re: Legionnaires’ disease: vigilance will be eternal but must be balanced	Editor, Carol Joseph’s editorial underlines the paradox of larger outbreaks of Legionnaires’ disease in an era when understanding of the causal chain is greater than ever[1]. She points to four explanations - loss of vigilance in maintenance of complex water systems, greater clinical awareness, better surveillance and easier diagnosis uncovering non- pneumonic disease. She calls for enhanced surveillance with attention to both sporadic and Legionnaires’ disease, and greater vigilance in control. Some lessons from studies of Legionnaires’ disease in Scotland remain highly pertinent to current concerns, fuelled by two outbreaks in England this summer. In Glasgow, following two outbreaks, including the largest in the UK up to 1984[2], a survey of cooling tower maintenance in 1985 showed difficulties in maintaining an accurate register of cooling towers, poor understanding among some managers of premises about the nature and location of cooling towers and evaporative condensers, and breaches of guidelines usually on structural issues, e.g. control of cooling tower drift, rather than non-use of chemicals[3]. The problems would surely have been even greater without the publicity of the preceding outbreaks. Breaches of guidelines on the maintenance of hot water systems were also of concern, and comprised a hazard for Legionnaires’ disease[4]. Apparently ‘sporadic’ cases were often, on careful review, part of mini-clusters[5]. The inevitable conclusion, anticipating that of Joseph1, was that surveillance needed strengthening, and that solitary cases needed investigation promptly for potential early warning of an outbreak. Sadly, information vital to surveillance - address, postcode and date of onset - was often missing from laboratory request forms, which are an important component of surveillance[6]. Clinicians must understand why such information is needed so they are motivated to provide it. Studies of sporadic disease suggested the sources of infection were similar to those for outbreaks, for the epidemiological patterns were similar[7], with proximity of the home to a cooling tower being a risk factor[8]. The costs of maintaining water systems, both financially and in terms of environmental contamination are high, so choices need to be made. Preliminary economic analysis showed the emphasis needs to be placed on cooling tower maintenance rather than domestic water systems[9], but much more work is needed on this matter. Despite our knowledge, elimination of Legionnaires’ disease is a formidable task[10,11] so eternal vigilance combined with a balanced response based on an understanding of costs and benefits is required - neither panic nor media pressure can be allowed to drive priorities. These lessons based on studies in the 1980’s, published in the 1990’s, remain relevant to understanding and controlling the outbreaks that are now gripping the nation. 1. Joseph C. New outbreak of Legionnaires' disease in the United Kingdom. BMJ 2002; 325:347-348 2. Ad-hoc Committee Legionellosis - a combined study of a community outbreak. Lancet 1986;ii:380-382 3. Bhopal R S, Barr G. Maintenance of cooling towers following two outbreaks of Legionnaires' disease in a city. Epidemiol Infect 1990;104:29 -38 4. Bhopal R S, Barr G. Are hot and cold water systems maintained in accord with published guidelines? A preliminary answer. Health and Hygiene 1991;12:159-165 5. Bhopal R S, Diggle P, Rowlingson B. Pinpointing clusters of apparently sporadic Legionnaires' disease. Br Med J 1992;304:1022-1027 6. Bhopal R S. Surveillance of disease and information on laboratory request forms: the example of Legionnaires' disease. Journal of Infection 1991;22:97-98 7. Bhopal R S, Fallon R J. Variations in time and space of non- outbreak Legionnaires' disease in Scotland. Epidemiol Infect 1991;104:29- 38 8. Bhopal R S, Fallon R J, Buist E C, Black R J, Urquart J D. Proximity of the home to a cooling tower and the risk of non-outbreak Legionnaires' disease. Br Med J 1991;302:378-383 9. Smith K R, Parkin D W, Bhopal R S. Costs and benefits of preventing Legionnaires' disease by maintenance of cooling towers and hot water systems. J Epidemiol Community Health 1993;47:402 10. Bhopal R S, Wagstaff R. Prospects for the elimination of Legionnaires' disease. J Infect 1993;26:239-243 11. Bhopal R S. Source of infection for sporadic Legionnaires' disease. J Infect l995:30:9-12
A large outbreak of legionnaires' disease in Japan 5 September 2002
Hiroshi Kawane, professor The Japanese Red Cross Hiroshima College of Nursing, 1-2 Ajinadai-higashi, Hatsukaichi City, Hiroshima, 738-0052, Japan Send response to journal: Re: A large outbreak of legionnaires' disease in Japan	I have already reported the large outbreak of legionnaires' disease in Japan [1]. After reading the editorial by Joseph [2], I would like to add new information. According to the latest official announcement by Hyuga City, 294 (158 men and 136 women) became ill (29 confirmed and 265 probable cases) and six people (four men and two women over 60 years old) had died. All had visited the same hot-spring resort in Hyuga City and had been bathing in contaminated spas with Legionella pneumophila. It was revealed that the facility had not followed health ministry cleaning and disinfection procedures in spa and public bath facilities. Most Japanese are fond of hot-spring bathing, but substandard cleaning methods at spa and public bath facilities nationwide are putting patrons at risk from potentially lethal microorganisms [3]. Scientists of the National Institute of Infectious Diseases found amoebas at 151 (64%) of the 237 facilities they tested. In 2000, there was another large outbreak of legionnaires' disease at a municipal public bath in Ishioka City in Ibaragi Prefecture. Three people had died and 42 other people had been diagnosed as the disease. The facility had seldom exchanged re- circulated hot water of the public bath. The importance of following ministry-established cleaning and disinfection procedures to the letter should be emphasized. References 1. Kawane H. Outbreak of legionnaires' disease in Japan. bmj.com/cgi/eletters/325/7359/295/a, 27 Aug 2002. 2. Joseph C. New outbreak of legionnaires' disease in the United Kingdom. BMJ 2002;325:347-348. (17 August.) 3. Anon. Report:Onsen hygiene lacking. IHT/Asahi 16 August 2002.