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Legionella- The facts. The epidemiology of legionella in the W est M idlands.

Legionella- The facts. The epidemiology of legionella in the W est M idlands. K ate James- lead Health Protection Practitioner West Midlands West Public Health England Team Kate.james@phe.gov.uk. Aims of presentation. What is legionella Epidemiology of legionella

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Legionella- The facts. The epidemiology of legionella in the W est M idlands.

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  1. Legionella- The facts.The epidemiology of legionella in the West Midlands. Kate James- lead Health Protection Practitioner West Midlands West Public Health England Team Kate.james@phe.gov.uk

  2. Aims of presentation • What is legionella • Epidemiology of legionella • Who are Public Health England PHE • Legionella cases and clusters and outbreaks • Multi agency response to legionella • Control measures • Questions Legionella the facts KJ 2013

  3. What is legionella • Legionella is a bacteria that is found naturally in the environment, usually in water sources. The bacteria likes to live in biofilms a thin layer of micro organisms, usually in a free living amoeba. Water temperatures between 20 degrees and 40 degrees centigrade favour growth. Legionella the facts KJ 2013

  4. Sources of legionella • Air-conditioning equipment (cooling water systems, humidifiers, cooling coils, condensers) • Air washers • Cold water systems • Condensers (e.g. evaporative, steam turbine) • Fire sprinklers • Hot water systems • Humidifiers (atomising, spray, portable) • Spa pools (Jacuzzis) Legionella the facts KJ 2013

  5. Sources Continued • Nebulisers and humidifiers (for medical use) • Showers • Spray taps/mixer taps • Swimming pools • Ventilation bags (for medical use) • Water-based coolants (lathes, diamond wheels and other rotating machines generate aerosols) • Wet cooling towers • Compost heaps • E.T.C Legionella the facts KJ 2013

  6. Compost link to Legionella outbreak Second Legionnaires' outbreak death • Three die in Legionnaires' outbreak • A third British holidaymaker has died from contracting Legionnaires' disease while on holiday in Spain, the Valencia regional government has said. • Fresh Legionnaires' case confirmed A seventh case of Legionnaires' Disease has been discovered amid an outbreak which has claimed two lives, it has been confirmed. • Two pensioners in their 70s from Hereford have died after catching the disease. • Six cases have involved Herefordshire residents, while another involved a Welshman who had twice visited the town • A second person has died after catching Legionnaires' disease in the outbreak in Edinburgh, NHS Lothian has said. Legionella the facts KJ 2013

  7. Legionnaires’ Disease • Legionnaires' disease is an uncommon form of pneumonia caused by the legionella bacterium. The majority of cases are reported as single (isolated) cases but outbreaks can occur. All ages can be affected but the disease mainly affects people over 50 years of age, and generally men more than women. Smokers and the immunocompromised are at a higher risk. Legionella the facts KJ 2013

  8. The symptoms • The early symptoms of Legionnaires' disease include a 'flu-like' illness with muscle aches, tiredness, headaches, dry cough and fever. Sometimes diarrhoea occurs and confusion may develop. Deaths occur in 10-15% of the general population and may be higher in some groups of patients. The incubation period can range from 2 to 19 days with a median of 6 to 7 days after exposure. Legionella the facts KJ 2013

  9. How legionnaires’ develops • People become infected when they inhale legionella bacteria which have been released into the air in aerosolised form from a contaminated source. Once in the lungs the bacteria multiply and cause either pneumonia or a less serious flu like illness (Pontiac fever). Legionella the facts KJ 2013

  10. Epidemiology of legionella Number of confirmed cases in the West Midlands since 2010 Legionella the facts KJ 2013

  11. UK Cases of legionella by setting 1990-2011source http://www.hpa.org.uk/ Legionella the facts KJ 2013

  12. Number of cases by Local Authority in West Midlands West PHE Team (probable and confirmed) 2010-2013 Legionella the facts KJ 2013

  13. Age Profile of cases by gender 2010-2013 Legionella the facts KJ 2013

  14. Roles and Responsibilities • Who is responsible for stopping the spread of legionella? • Business-L8 • Environmental Health • Health and Safety Executive • Home owners • Public Health England Legionella the facts KJ 2013

  15. Public Health England • Who are we and what do we do? • We used to be the Health Protection Agency HPA. • In April 2013 HPA became a non executive branch of the Department of Health DOH. • Our mission is to protect and improve the nation’s health and to address inequalities Legionella the facts KJ 2013

  16. How does PHE deal with Legionnaires’ • There is a legal duty for doctors and laboratories to notify PHE of cases of probable legionnaires’ disease. • A case is classed as probable by PHE until it is confirmed by our centre for infections in London. They will confirm the serogroup and can genetically link human cases to environmental samples. • Initially a case is diagnosed by a Urinary antigen test in hospital. Legionella the facts KJ 2013

  17. The Investigation • We need to quickly find any likely • sources. • PHE complete questionnaire if • Possible with case or family. • We go back 14 days from onset • Of symptoms. • We risk assess sources • We contact EHO and HSE Legionella the facts KJ 2013

  18. Investigation of sources • Cooling towers- Is this a one off or the start of an outbreak! • We check the HSE cooling tower map. Firms have a legal duty to notify the Local Authority of any cooling towers. HSE map the towers on a website. • Any cooling towers within a KM of a case we ask HSE or EH to risk assess and EH to possibly sample with assistance from PHE. Legionella the facts KJ 2013

  19. Sources continued • We consider all possible sources. • We may ask EH to sample spas,showers,domestic premises. • NOTE OF WARNING. • Some laboratories say they can use rapid PCR testing to get result. PHE laboratories advise caution these tests are very complex and many commercial labs don’t have correct techniques. PHE lab in London is the UK expert. Legionella the facts KJ 2013

  20. Environmental testing • PHE need environmental samples to go to a PHE lab so that any human sputum samples can be compared and typed by experts in London. Dr Tim Harrison and his team are classed as UK and worldwide experts. • Environmental samples currently take 10 days to culture but new rapid techniques are speeding process up. Legionella the facts KJ 2013

  21. Legonnaires’ outbreak • DON’T PANIC!!!! • An outbreak is usually classed as two or more cases linked in time and place but two cases of legionella in the same area within 6 months warrants further review. Legionella the facts KJ 2013

  22. Outbreak control team • An outbreak control meeting will be held within 24 hours of becoming aware of a cluster of cases. • Team will be made up of PHE, Local Authority public health and EH, HSE, microbiologists from food and water lab and Heartlands Hospital and PHE,epidemiologists, comms, emergency planners, and in the new NHS clinical commissioning groups and NHS England. • If a cooling tower is considered the source, representatives from business may be invited. Legionella the facts KJ 2013

  23. Aim of OCT • Case definition. • Collect information: case finding, identifying potential sources of infection • Collate information:, hypothesis generation, GIS investigation to look for links with home to work and work related travel routes • Communicate- alerting GPs and clinicians, partner agencies, public • Control- stop any more cases. Legionella the facts KJ 2013

  24. Control measures • HSE approved code of practice L8 • Shock dose • Thermal disinfection • Chlorination • Remove the source • Re engineer/ re design Legionella the facts KJ 2013

  25. Questions Legionella the facts KJ 2013

  26. Useful Information • West Midlands Joint Plan for the Investigation and Control of legionella Infection • Health Protection Legislation (England) Guidance 2010 available at http://www.dh.gov.uk/pulications • The Health Protection( Local Authority Powers) Regulations 2010 No 657 available at http://www.opsi.gov.uk/si/si2010/uksi_20100657_en_1 • The Health Protection (Part 2A orders) Regulations 2010 NO 658 www.opsi.gov.uk/si/si2010/uksi_20100658_en_1 • The Health Protection (Notification) Regulations 2010 No 659 • www.opsi.gov.uk/si/si2010/uksi_20100659_en_1 • Health and Social care Act 2008 (c.14) Part 3. • http://www.opsi.gov.uk/acts/acts2008/ukpga_20080014_en_9 • Legionnaires' disease. The control of legionella bacteria in water systems. Approved Code of Practice and guidance www.hse.gov.uk Legionella the facts KJ 2013

  27. Acknowledgments • Thank you to Joanne Corrall PHE West Midlands West Information Officer and Harriet James- My daughter. Legionella the facts KJ 2013

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