INDOOR CLIMATE - 11222

Project name: Legionella

Spring 2020 · 13 Week Period

G ROUP 8
Contents
1 Process 1

2 Introduction 1

3 Exposure 2
3.1 Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3.2 Infection route . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3.3 Concentration levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4 Effects on Humans 3

5 Remedial actions 4
5.1 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5.2 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5.3 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
5.3.1 In humans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
5.3.2 In water systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

6 Conclusions 6

Bibliography 7
1 Process
The process of documentation began with searching key-words such as "Legionella", "Le-
gionella & Indoor Climate", "Legionella & Concentration", "Legionella & WHO", "Legionella
& Health", "Legionellosis", "Pontaic Fever" in research websites such as DTU FindIt, Science
Direct, Scopus and Engineering Village. Filtering was necessary for selecting the proper liter-
ature, that was relevant and accurate. Literature with technical accuracy that is acknowledged
by the scientific community and high on citations; was chosen. Only electronic materials were
reviewed such as research articles, electronic books and conference papers and to acquire a more
broad aspect on the topic, information from the 1980’s have been found, when the disease was
firstly recognized and strengthened by studies from recent years.

2 Introduction
The family Legionellaceae is comprised by the genus Legionella, which is a thin aerobic flagel-
lated, non-spore forming gram negative bacteria. Their size is measured between 0.3 - 0.9 µm in
width and 2 – 20 µm in length (Diederen, 2008). Out of the Legionella’s gene, LL.pneumophila
is the most pathnogenic, it can lead to severe inflamation of the lungs. The intracellular environ-
ment is the natural habitat for Legionella as the L. pneumophila invades and replicates within at
least two distinct hosts, free-living protozoa and mammalian cells. In nature, it can be found as
a free-living microbe or as an intracellular parasite of amoeba (File and Plouffe, 1998).
The Legionnaires’ disease is a global occurring phenomenon. It was first noticed after a great
outbreak in an American Legion convention in Philadelphia (July 1976) and thus the origin of
the disease’s name. During this outbreak, 182 people got affected and 21 out of them died.
So far 39 species have been recognized, with most of them being dangerous when exposed to
human beings (Van Kenhove et al., 2019). The most fatal cases are related to the species Le-
gionella pneumophila (the primary pathogen bacteria causing Legionnaires disease also known
as legionellosis). Despite the fact that the bacterium was not identified prior to that incident,
outbreaks of the disease were later recognised to have occurred since the 1940s (Gillespie and

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Hawkey, 2006). Plenty information has come into light Since then, about the spreading condi-
tions, diagnosis and possible treatments (Imperato, 1981).
Sporadic episodes as well as respiratory illness outbreaks in humans are the most frequent oc-
currences. As the population rates are rising and with more individuals with weakened immune
system, Legionnaire’s disease will become a problem with increasing significance (File and
Plouffe, 1998).

3 Exposure

3.1 Sources

The bacteria can be found in natural freshwater, for instance stagnant lakes, rivers or other hu-
mid environments. The concentration in natural sources is quite low, due to fact that these water
sources are usually exposed to ambient air, thus they are lower than 37 °C , which are the op-
timal conditions for Legionella to proliferate (Borella et al., 2005). More sources can include
cooling towers, swimming pools, domestic water systems and showers, waste water treatment
plants and generally artificial water facilities (File and Plouffe, 1998).
A much important site of contamination is the nosocomial environment, as the disease can arise
from the presence of Legionella in the water system. It can also be found in the biofilm through-
out the entire water distribution system as well as in hot water tanks (File and Plouffe, 1998).
Lots of epidemic incidences have started from a hospital environment.

3.2 Infection route

Legionnaire’s disease is different from most respiratory pathogens as it cannot pass from per-
son to person. The most common form of Legionella transmission is when the organism is
aerosolized in water and inhaled by humans (Ulloa F., 2008). Infection can also occur by aspi-
ration (when water accidently ends up into the lungs while drinking) of contaminated water or
ice (World Health Organization, a).

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3.3 Concentration levels

The concentration levels of these bacteria mainly in the artificial water sources is measured
in CFU/liter or CFU/ml (Colony Forming Units). These concentration values are measured in
order to monitor the microbial growth and to decide as when action needs to be taken. As
per European Technical Guidelines 2017, different scales have been devised for water sources
namely hot and cold water systems, spa pools and cooling towers (European Working Group for
Legionella Infections, 2017).

Table 1: Action Levels following Legionella in cooling towers.

CFU/ml < 1000 or less 10000 > CFU/ml > 1000 CFU/ml > 10000
Ensure real time monitoring Review risk assessment program, Implement action plan, e.g.
operation and results shut down the cooling tower

4 Effects on Humans
Legionella sp. causes two main diseases in humans namely Legionnaire’s Disease (Legionel-
losis) and Pontiac Fever. Former being a pneumonic illness, which is more severe than the later
one, which is just an influenza like illness causing a mild respiratory infection. The incubation
time for Legionellosis can vary from 2 to 10 days compared to just 5 hours to 3 days for Pontiac
fever. It also takes less time to cure Pontiac fever; 2 to 5 days as compared to weeks for Le-
gionnaire’s Disease. No death has been recorded from Pontiac fever while as for Legionellosis
mortality can vary from 5 to 10 %. Heavy smokers, middle aged & elderly people with respira-
tory disease as well as patients with weak immune system are mostly affected.
The common symptoms in both the diseases include fever, chills, headache and muscle pain,
with the only difference for these symptoms being more severe in Legionellosis. Furthermore,
some patients affected by Legionellosis may show symptoms of nausea, vomiting, diarrhoea and
confusion.

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Legionellosis can either be sporadic or it may occur as an outbreak. Regarding the outcome
of the disease, a study of outbreak survivors showed persistence in symptoms considering fa-
tigue (75%), neurologic symptoms (66%) and neuromuscular symptoms (63%) months after an
outbreak. Most patients fully recovered within one year (Lettinga et al., 2002)

5 Remedial actions

5.1 Prevention

There are no vaccines that can prevent Legionnaires’ disease. As it is not contagious between
humans, there are not any special necessary precaution measures. Instead, initiatives for con-
trolling the growth and spread of Legionella in water need to be undertaken (File and Plouffe,
1998). Cold water that may warm up uncontrollably or hot water circulation loops that can
cool down significantly, should be prevented. Moreover, during the design phase, special atten-
tion must be paid into not implementing plumbing dead legs and stagnant fixtures (Decker and
Clancy, 2017). In order to reduce the risk of infection in buildings, different guidelines exist for
residential and commercial buildings. These standards can be different due to country specific
nuances.

5.2 Diagnosis

The diagnosis of Legionnaire’s disease is yet a difficult task. Specialized laboratory tests are
needed but not available in many hospitals. The preferred diagnostic tests is the urinary antigen
test (detects Legionella in the urine) and a laboratory test that involves taking a sample of sputum
(phlegm) or washing from the lung. The sample is then placed onto the culture media. However,
the urine antigen testing has about a 25 - 30 % false negative rate. An additional test is the
fluorescent antibody test. It involves taking blood sample and making all the antibodies that are
reactive against Legionella inside the human body, visible under a fluorescent microscope.
Serologic studies are useful but because they are required, results are delayed and cultures must
be incubated for at least 3 days. Thus may not be useful for acute case diagnosis or during active

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outbreak investigations.
The Binax urinary antigen assay appears to be more commonly used as they are useful early in
clinical disease. Several outbreak investigations were prompted by diagnoses made by positive
urinary antigen assays.

5.3 Treatment

5.3.1 In humans

When it comes to treatment of the infection in humans: Pontiac fever and Legionnaire’s dis-
ease must be differentiated. The first illness does not require serious medical attention and it’s
treatment is similar to a regular flu. On the other hand Legionnaire’s disease can have a fatal
outcome in absence of medication. The antimicrobial agents that are effective and able to treat
infections caused by Legionella sp. are limited. This is due to the fact that they must be able to
penetrate into cells as Legionella is an intracellular pathogen (File and Plouffe, 1998). Research
is ongoing for the development of a vaccination, but the first line of defence is our immune
system supported by antibiotic treatment.

5.3.2 In water systems

There can be found few techniques for the disinfection of water distribution systems from Le-
gionella. These include:

1. Copper / silver ionization

The reduction in Legionella colonization after copper / silver ionization was significant.
One considerable advantage is the fact that a copper / silver unit can be rotated among
several buildings to maintain a Legionella-free environment (File and Plouffe, 1998).

2. Ultraviolet light
Using an adequate UV light dose against "Legionella-occupied" water distribution system
is a very efficient method.

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 3. Instantaneous heating systems
The bacteria thrives in temperatures between 20 °C and 45 °C and grows best in stagnant
water. The optimal temperature for Legionella to spread is between 32 °C and 42 °C.
Thus, heating up the water up to 70 °C could kill them (Decker and Clancy, 2017).

4. Hyperchlorination
There is a need for cautiousness with the supplemental chlorination as it has been associ-
ated with an increased number of plumbing leaks (File and Plouffe, 1998).

6 Conclusions
Treatment of infections caused by Legionella species is vital as there has been a lot of morbid
incidents and occasionally mortal ones. There has been underdiagnosis and under-reporting of
the incidents so far and there is a big need for more cases to be diagnosed as to provide a better
understanding of the infections caused by these organisms and the ways to treat them (File and
Plouffe, 1998).
The fact that Legionella is being a global issue, lead to the existance of individual standards
and guidelines for each country, as there is an aim to limit the possibility for exposure. In the
future an international unified standard has to be developed in order to reduce the number of
guidelines, creating a unified document, which takes into consideration the specific features of
each country (Van Kenhove et al., 2019).

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Bibliography
P. Borella, E. Guerrieri, I. Marchesi, M. Bondi, and P. Messi. Water ecology of Legionella and
protozoan: Environmental and public health perspectives. Biotechnology Annual Review, 11
(SUPPL.):355–380, 2005. ISSN 13872656. doi: 10.1016/S1387-2656(05)11011-4.

B. K. Decker and C. J. Clancy. Testing water for Legionella prevention, 2017.

B. M. Diederen. Legionella spp. and Legionnaires’ disease. Journal of Infection, 56(1):1–12,

2008. ISSN 01634453. doi: 10.1016/j.jinf.2007.09.010.

European Working Group for Legionella Infections. for the Prevention , Control and Investiga-
tion , of Infections Caused by Legionella species. (June), 2017.

T. File and J. Plouffe. The role of atypical pathogens. 12(3):569–592, 1998.

S. H. Gillespie and P. M. Hawkey. Principles and Practice of Clinical Bacteriology: Second Edition.
2006. ISBN 0470849762. doi: 10.1002/9780470017968.

P. J. Imperato. Legionellosis and the indoor environment. Bulletin of the New York Academy
of Medicine: Journal of Urban Health, 57(10):922–935, 1981. ISSN 00287091.

K. Lettinga, A. Verbon, P. Nieuwkerk, R. Jonkers, B. Gersons, and J. Prins. Health-related qual-

ity of life and posttraumatic stress disorder among survivors of an outbreak of Legionnaires
disease. Technical report, Department of Internal Medicine, Division of Infectious Diseases,
Tropical Medicine, and AIDS, Academic Medical Center, 1105 AZ Amsterdam, The Nether-
lands., 2002.

M. T. Ulloa F. Legionella pneumophila. Revista Chilena de Infectologia, 25(3):208, 2008. ISSN

07161018. doi: 10.4067/S0716-10182008000300013.

E. Van Kenhove, K. Dinne, A. Janssens, and J. Laverge. Overview and comparison of Legionella
regulations worldwide. American Journal of Infection Control, 47(8):968–978, 2019. ISSN
15273296. doi: 10.1016/j.ajic.2018.10.006.

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World Health Organization. Legionellosis, a. URL
https://www.who.int/news-room/fact-sheets/detail/legionellosis.

World Health Organization. Indoor Climate data, b. URL https://www.who.int/.