BARROW-IN-FURNESS
LEGIONNAIRES DISEASE
OUTBREAK
AUGUST 2002
RECOGNITION OF
THE OUTBREAK
LOCAL
Friday
26 July
Saturday
27 July
Sunday
28 July
Monday
29 July
Tuesday Wednesday Thursday
31 July
1 Aug
30 July
 cases of CAP
Discussion re: Ix and Rx
D/W CCDC, Virologist, PHL
1 patient urine Ag positive
2 further
patients Uag
positive
Urine results
confirmed – Outbreak
Meeting arranged
PUBLIC HEALTH
Thursday, 1st August – another case
linked to Barrow. Outbreak meeting
arranged
Telephone call to EHO
OUTBREAK CONTROL
MEETING
Friday, 2nd August 2002
PUBLIC HEALTH ACTIONS
EHO’s
Questionnaires
Testing Strategy
Information to GP’s
Incident Room
Database
Environmental
7 major plants registered with
LA/HSE
552 premises with suspected
hazardous/?unregistered plant
Hot & cold systems at Forum 28
2 nursing/residential homes
Environmental (2)
Visit by HSE, PHL and EHOs
Visual inspection
Review of maintenance records
Sampling of pooled/residual waters
Epidemiology
Environmental (3)
Only one plant culture positive for
Legionella pneumophila
L. pneumophila – Benidorm
Indistinguishable from clinical
isolates
TRUST RESPONSE
Activated Major Incident Plan
including Ambulance/Police liaison
Incident Room
Telephone helpline
Database
Cancellation of elective admissions
CLINICAL OBSERVATIONS
Wide age distribution
Very high fever
Diarrhoea
Hepatorenal dysfunction
Raised troponin T
Often looked disproportionally well
Sudden deterioration common
CLINICAL MANAGEMENT
Protocols for assessment and
management
Severity scoring system (EWS) and
people to monitor. Protocol for
actions.
Early transfer to ITU
Consultant staff re-organisation
PHARMACY WORKLOAD
2000 doses iv clarithromycin (1600 in
2001)
45500 erythromycin tabs (us 2500)
Rifampicin 370 vials, 4000 caps by 9th
August 2002
SUPPLIES ISSUES
Kits
Hardware
Clinical supplies
LABORATORY
ORGANISATION
Microbiology workforce (1x4, 2x2,
3.5x1, 1.4xMLA)
Re-distribution of specimens
Physical reconfiguration
Dissemination of results and reports
Variable impact on other pathology
disciplines
LABORATORY
ORGANISATION
Specimen labelling
Portering requirements
Specimen storage
Transportation to reference labs
(planes, trains and automobiles)
Co-ordination with PHL locally and
nationally
CDSC
LABORATORY
ORGANISATION
Medicolegal Aspects
Politics
AND IT WAS AUGUST …
LABORATORY DIAGNOSIS
OF LEGIONELLA
INFECTION
Urinary antigen testing
Serology
Culture
CULTURE POSITIVE SPUTA =
21 FROM 16 PATIENTS
Serology
Pos
Urine Ag Pos
Urine Ag Neg
Urine N/A
Serology
Neg
9 (+ 1 low level)
Serology
N/A
2
2
1
1
COMPARISON OF SEROLOGY AND
URINARY ANTIGEN RESULTS
Urinary antigen
Serology
Unresolved
Positive
46
3
17
6
72
Equivocal
29
1
11
3
44
Negative
43
8
409
298
758
11
1
1665
21
1698
129
13
2102
328
2572
N/A
Total
Negative
Total
Positive
N/A
LEGIONNAIRES DISEASE OUTBREAK
Number of cases seroconverting by week
30
25
Number of cases
20
No. converting (default onset date)
15
No converting (actual onset date)
10
5
0
1
2
3
4
5
6
7
8
9
10
11
Weeks from date of onset
12
13
14
15
16
17
18
THE BARE FACTS
 Urine antigen tests performed 2475
 Admissions 489
 Confirmed cases so far 167
 Deaths 5
CLASSIFICATION OF CASES
CLASSIFICATION
TOTAL
Definite legionnaires disease
126
Probable legionnaires disease
17
Possible legionnaires disease
17
Maybe legionnaires disease
10
170
Definite Pontiac fever
Maybe Pontiac fever
14
6
20
Age band
10
10
5
0
05
_1
0
_9
5
_9
0
_8
5
_8
0
_7
5
_7
0
_6
5
_6
0
_5
5
_5
0
_4
5
_4
0
_3
5
_3
0
_2
5
_2
0
_1
5
1_
1
96
91
86
81
76
71
66
61
56
51
46
41
36
31
26
21
16
11
6_
1_
Number of cases
LEGIONNAIRES DISEASE OUTBREAK
Age, distribution, definite and probable cases
30
25
20
15
10
5
0
ADMISSIONS FOR CHEST INFECTION, PNEUMONIA & LEGIONNAIRE’S
DISEASE
APRIL - AUGUST
PROBLEMS
Interpretation of unfamiliar tests
Controlling demand for tests
IT/system for reports
Fatigue/boredom
Impact on other roles
THE AFTERMATH
Follow up clinics and testing
Phlebotomy, specimen transport
Trying to reconcile 3 different
databases
Medicolegal
LESSONS LEARNED
That both informal and formal
surveillance are of value
That the PHL and NHS laboratories
can work together
That there is tremendous goodwill in
the NHS and other services
LESSONS LEARNED
You can never give too much
information
Make sources of information clear
Assume nothing
LESSONS LEARNED
 Trust Major Incident Plans should cover a
sustained high admission rate
 Need to incorporate our experience into
disaster/major incident planning
 If you’re walking down an alleyway and it’s
full of water vapour – hold your breath!