Australia ex Bali, Indonesia: Legionella outbreak, hotel pool suspected

[alert]

http://www.promedmail.org/pls/apex/..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,84442

Archive Number 20100826.3021
Published Date 26-AUG-2010
Subject PRO/EDR> Legionellosis - Australia: (WA) ex Indonesia (Bali) alert

LEGIONELLOSIS - AUSTRALIA: (WESTERN AUSTRALIA) ex INDONESIA (BALI) ALERT
************************************************************************
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International Society for Infectious Diseases
<http://www.isid.org>

Date: Thu 26 Aug 2010
From: Gary Dowse <Gary.Dowse@health.wa.gov.au> [edited]


Two middle-aged people in Perth, Western Australia, have recently
been diagnosed with severe pneumonia caused by _Legionella
pneumophila_ serogroup 1 (laboratory confirmed). Both cases had
independently holidayed in Bali, Indonesia at the same time
(overlapping between 29 Jul and 8 Aug 2010), and both stayed at the
same hotel in Kuta, Bali.

Onset dates were 10 Aug and 14 Aug 2010, after their return to
Australia. It seems most probable that they were infected in Bali,
quite possibly at their hotel. Information provided by people who
travelled with the cases has not identified places that both
frequented other than the hotel and airports. Both swam in the hotel
pool and one is thought to have used a jacuzzi or similar.

Please consider the diagnosis of legionellosis in people with
consistent illnesses recently returned from Bali. If you do detect
cases I would be interested to hear of this, and could provide the
name of the implicated hotel. Indonesian health authorities are being advised.

--
Dr Gary Dowse
Medical Epidemiologist
Communicable Disease Control Directorate, Department of Health
Government of Western Australia
<gary.dowse@health.wa.gov.au>

[Legionellosis is an infectious disease caused by a gram-negative
bacillus of the genus _Legionella_, most commonly _Legionella
pneumophila_. Legionnaires' disease is the acute pneumonic form of
the disease; about 70 percent of cases are due to _L. pneumophila_
serogroup 1. Pontiac fever is a non-pneumonic form of legionellosis
that is less severe than Legionnaires' disease. Pontiac fever takes
its name from an outbreak in 1968 in Pontiac, Michigan, USA. Risk
factors for Legionnaires' disease include age over 50 years,
cigarette smoking, diabetes, chronic heart or lung disease, and
immunosuppression.

Legionnaires' disease, and presumably Pontiac fever, is acquired by
inhalation of an infectious dose of aerosolized _Legionella_. Usually
a building's contaminated water system is incriminated as the source.
_Legionella_ are found primarily in the hot water portion of plumbing
systems and in cooling towers. Water temperatures of 25-40 deg C
(77-104 deg F) support the highest concentrations of the organism in
water storage tanks of plumbing systems. Aerosolization of the
contaminated warm water can occur in showers, spa pools, sprays in
groceries, fountains, and cooling towers.

Genotyping of patient and environmental isolates has become a helpful
tool to establish transmission pathways. The predominance of one
genotype in patient specimens suggests transmission from a common
source. Because _L. pneumophila_ may be found in water supplies
without linkage to any cases of legionellosis, the actual causative
infectious reservoir should be demonstrated by means of genotyping
methods (see <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC86783/> and
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2730281/>).

A map of the island of Bali can be accessed at
<http://www.baliguide.com/bali_map.html>.
Kuta, on the island of Bali and Perth in Western Australia can be
seen on the HealthMap/ProMED-mail interactive maps at
<http://healthmap.org/r/03Jc> and <http://healthmap.org/r/01tN>
respectively. - Mod.ML]

 

[alert]

Re: Australia ex Bali, Indonesia: Legionella outbreak, ongoing, single hotel suspected

Re: Australia ex Bali, Indonesia: Legionella outbreak, ongoing, single hotel suspected

http://www.promedmail.org/pls/apex/..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,86660

Archive Number 20110115.0173
Published Date 15-JAN-2011
Subject PRO/EDR> Legionellosis - Australia: (WA,VI) ex Indonesia (Bali)


LEGIONELLOSIS - AUSTRALIA: (WESTERN AUSTRALIA, VICTORIA) ex INDONESIA (BALI)
****************************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

[1]
Date: Thu 13 Jan 2011
From: Gary Dowse <gary.dowse@health.wa.gov.au> [edited]


re: _Legionella pneumophila_ serogroup 1 infections in Bali travelers -
same hotel
----------------------------------------------------------------------
There have now been 10 laboratory-confirmed cases of legionnaires' disease
due to _Legionella pneumophila_ serogroup 1 infection diagnosed in
Australians who have returned from holidays in Bali, Indonesia, in the
period between August and December 2010.

5 cases (2 from the state of Western Australia and 2 from the state of
Victoria) were holidaying in Bali in the last half of December 2010, with
dates of onset of illness between 16 Dec 2010 and 1 Jan 2011. The 10 cases
have been aged between 41 and 82 years (median 55 years), and nearly all
have been severely ill with pneumonia, requiring ICU treatment. Most, but
not all, have had identified risk conditions, such as smoking, diabetes, or
an immunocompromising illness. All have survived to date, although an 11th
possible case died in Bali from an undiagnosed pneumonia.

Notably, 9 of the 10 confirmed cases stayed at the same hotel, which is
situated in the central area of Kuta in Bali. We understand that
environmental investigations undertaken previously at and in the vicinity
of this hotel have not identified a specific source, but further
investigations are under way.

Clinicians should consider the diagnosis of legionnaires' disease in people
with consistent illnesses who have returned recently from Bali. If cases
are identified, I would be interest to hear of this, and Indonesian health
authorities should also be advised through official channels.

--
Dr Gary Dowse
Medical Epidemiologist
Communicable Disease Control Directorate Department of Health
Government of Western Australia
<gary.dowse@health.wa.gov.au>

******
[2]
Date: Fri 14 Jan 2011
Source: The Sydney Morning Herald, Australian Associated Press (AAP) report
[edited]
<http://news.smh.com.au/breaking-news-national/bali-tourists-warned-of-disease-outbreak-20110114-19r3r.html>


The West Australian [WA] government is warning people recently returned
home from Bali to be alert for signs of legionnaires' disease after a
reported outbreak. The WA Health Department said 3 West Australians and 2
[from the state of Victoria] who have returned from holidays in Bali during
December [2010] have been diagnosed with severe pneumonia. The pneumonia is
due to an infection of the _Legionella pneumophila_, which causes
legionnaires' disease.

There have now been 10 confirmed Australian cases of legionnaires' disease
connected with the central Kuta area [of Bali] since August 2010. Earlier
on Friday [14 Jan 2011], Victoria's chief health officer John Carnie said 4
Victorians, aged from 45 to 82, were among the 10 who had been treated for
the illness on their return from Bali. He said 6 cases were detected among
West Australians who had been to the Indonesian resort island.

WA acting chief health officer Andy Robertson said the West Australians
most likely contracted the infection in the central Kuta area of Bali;
however, the exact source of the outbreak is still unknown. Dr Robertson
said the Indonesian Government had been advised of the outbreak and is
working with the World Health Organisation to determine to source of the
infections.

The symptoms of the disease are similar to a severe flu like illness and
could include fever, chills, muscle soreness, headaches, tiredness, reduced
appetite, diarrhoea, dry coughing, and breathlessness.

Dr Robertson said legionella infections usually take 2 to 10 days to
develop and can be treated with antibiotics leading most people to recover
although some may contract severe pneumonia. The disease most often affects
middle-aged and elderly people, particularly those who smoke or who have
lung disease, diabetes, kidney disease, or a weakened immune system. "We
recommend that anyone who falls in one or more of these risk groups who
develops flu-like illness after returning from Bali seeks medical advice,
and notifies their doctor of their recent travel," Dr Robertson said.

--
communicated by:
Thomas James Allen
<tjallen@pipeline.com>

[The reports above are follow-ups of a prior ProMED-mail post (Australia:
(WA) ex Indonesia (Bali) alert 20100826.3021). At the time of the 1st
ProMED-mail post only 2 Australians with laboratory-confirmed pneumonia due
to _Legionella pneumophila_ serogroup 1 were linked to the same hotel in
Kuta, Bali. Now, 9 of the 10 confirmed cases in Australians who have
returned from holidays in Bali are linked to this hotel, which is situated
in the central area of Kuta, Bali. Dr Dowse also notes that unofficially he
is aware of at least 2 additional cases in Europeans linked to Bali in the
same time-frame, one of whom stayed in this hotel. It would be helpful to
know if _Legionella_ that were cultured from clinical specimens have the
same genotype.

The following is extracted from moderator ML's comments that appeared in
ProMED-mail post (Australia: (WA) ex Indonesia (Bali) alert 20100826.3021):

Legionellosis is an infectious disease caused by a Gram negative bacillus
of the genus _Legionella_, most commonly _Legionella pneumophila_.
Legionnaires' disease is the acute pneumonic form of the disease; about 70
per cent of cases are due to _L. pneumophila_ serogroup 1. Pontiac fever is
a non-pneumonic form of legionellosis that is less severe than
legionnaires' disease. Pontiac fever takes its name from an outbreak in
1968 in Pontiac, Michigan, USA. Risk factors for legionnaires' disease
include age over 50 years, cigarette smoking, diabetes, chronic heart or
lung disease, and immunosuppression.

Legionnaires' disease, and presumably Pontiac fever, is acquired by
inhalation of an infectious dose of aerosolized _Legionella_. Usually a
building's contaminated water system is incriminated as the source.
_Legionella_ are found primarily in the hot water portion of plumbing
systems and in cooling towers. Water temperatures of 25-40 deg C (77-104
deg F) support the highest concentrations of the organism in water storage
tanks of plumbing systems. Aerosolization of the contaminated warm water
can occur in showers, spa pools, sprays in groceries, fountains, and
cooling towers.

Genotyping of patient and environmental isolates has become a helpful tool
to establish transmission pathways. The predominance of one genotype in
patient specimens suggests transmission from a common source. Because _L.
pneumophila_ may be found in water supplies without linkage to any cases of
legionellosis, the actual causative infectious reservoir should be
demonstrated by means of genotyping methods (see
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC86783/> and
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2730281/>).

Kuta is a coastal town in southern Bali, Indonesia, with a long broad
Indian Ocean beachfront and is one of Indonesia's major tourist
destinations (<http://en.wikipedia.org/wiki/Kuta>). Kuta was the site of 2
Bali bombings, one in 2002 and another in 2005. A map of the island of Bali
can be accessed at <http://www.baliguide.com/bali_map.html>. Kuta on the
island of Bali and the Australian states of Western Australia and Victoria
can be seen on the HealthMap/ProMED-mail interactive maps at
<http://healthmap.org/r/03Jc> and <http://healthmap.org/r/01tN>,
respectively. - Mod.ML]