Chicago Department of Public Health Commissioner Bechara Choucair, M.D. City of Chicago Mayor Rahm Emanuel Legionellosis Outbreak Associated with a Hotel Fountain, Chicago 2012 June 11, 2013 Shamika Smith, MPH Epidemiologist

Legionellosis Bacteria ubiquitous in environment, typically water Transmitted through aerosolization or aspiration of Legionella-contaminated water Immunocompromised individuals are most susceptible

Legionnaires' disease (LD) Pontiac Fever (PF) Clinical features Pneumonia, cough, feverFlu-like illness (fever, chills, malaise) without pneumonia Radiographic pneumonia YesNo Incubation period 2-14 days after exposure24-72 hours after exposure Etiologic agent Legionella species Attack rate < 5%> 90% Isolation of organism PossibleNever Outcome Hospitalization common Case-fatality rate: 5-30% Hospitalization uncommon Case-fatality rate: 0% Difference between LD and PF CDC. Top 10 Things Every Clinician Needs to Know About Legionellosis Retrieved from

Reported Legionellosis Case Counts, * *Counts for U.S. (2011) not yet published.

September 2006 N=12 August 2007 N=14 June-Aug N=18 Reported Legionellosis cases by month of onset, Chicago, Reported residences of cluster case- patients

Outbreak Identification Aug. 14, 2012: Company A contacted CDPH reporting: --30 cases of respiratory illness --several cases of pneumonia; 1 death CDPH contacted Hotel X-learned that guest (not Company A) also reported illness Conference held at Hotel X from Jul. 30- Aug Approximately 600 attendees -- Event I (7/30-8/1): 427 people -- Event II (8/2-8/3): 266 people people attended both event

July and August Events SundayMondayTuesdayWedThursdayFridaySaturday JULY AUG CDPH notified

July and August Events SundayMondayTuesdayWedThursdayFridaySaturday JULY AUG Water Closures

July and August Events SundayMondayTuesdayWedThursdayFridaySaturday JULY AUG Water Closures 15 Water Drained

Case Finding Hotel reached out to guests 7/16-8/15 --Earliest exposure date: 7/ days= 7/16 --The day fountain, pool, spa drained: 8/15 CDPH contacted other hotel event organizers Hotel unable to obtain mailing addresses for ~40% of guests by 8/20 Three press releases; media interviews

Methods: Survey Development Exploratory interviews with Company A employees Etiology unknown, therefore reviewed –Legionella questionnaire –CDC’s acute respiratory illness questionnaire Piloted draft questionnaire, 8/15 (morning) Questionnaire sent to all Company A hotel guests via Health Alert Network (HAN), 8/15 (afternoon)

July and August Events SundayMondayTuesdayWedThursdayFridaySaturday JULY AUG CDPH notified 15 Survey EPI-X Sample

Methods: Environmental Health Illinois Department of Public Health (IDPH), Environmental Health inspected/sampled: –Whirlpool spa –Indoor pool –Fountain in lobby –Locker rooms –Steam room –Sauna –Guest shower heads CDC consulted

July and August Events SundayMondayTuesdayWedThursdayFridaySaturday JULY AUG CDPH notified 15 Survey EPI-X 1617 Data analysis 18 Sample 1Sample 2Sample

Preliminary Data Analysis Fountain exposure significantly associated with illness Case definition: hospitalized, pneumonia dx, chest x-ray ordered P-value=.0074 YesNo Yes13720 No Case Fountain Exposure

Number of calls received (N=250) Dates of press releases

HAN Survey Results and Data from CDPH Phone Bank HAN Survey from Company A 328 responses, ~ 1/3 reporting illness 1 confirmed case (1 expired) Phone Bank 145 surveys completed, most reporting illness 10 confirmed cases (2 expired)

Confirmed Legionnaires’ Disease (LD) Case definition: A person who stayed at or visited the hotel with illness onset within 2-14 days of exposure to the hotel, AND with radiographically- or autopsy- confirmed pneumonia AND with laboratory evidence of Legionella infection.

Confirmed LD Laboratory Criteria Isolation, through culture, of any Legionella organism from resp. secretions, lung tissue, pleural fluid, or other normally sterile site Detection of Legionella pneumophila serogroup 1 (Lp1) antigen in urine Seroconversion (4-fold increase in antibody titer to Lp1 between acute and convalescent titers) Detection by Lp1 molecular testing (e.g., PCR)

Suspect Legionnaires’ Disease Case definition: A person who stayed at or visited the hotel with illness onset within 2-14 days of exposure to the hotel, who had radiographically- - confirmed pneumonia, or clinical diagnosis of pneumonia, but without laboratory confirmation of Legionella infection.

Pontiac Fever Case definition: Fever, either subjective or documented, in a person who stayed at or visited the hotel with illness onset within 3 days of exposure to hotel, AND at least one of the following: cough, headache, SOB, myalgias, diarrhea, or vomiting, and who does not meet definition for confirmed or suspect LD.

JulyAugust Respiratory Illness by Date of Symptom Onset (N=114) Fountain, pool and spa drained CDPH notified

Case-patient Characteristics All cases (N=114)Confirmed LD (N=11) % Male6491 Median age (range) 47 yrs (22-82 yrs)65.5 yrs (49-82 yrs) % Hospitalized1382 Deaths03 Underlying illness/ risk N/AObesity (1), HIV (1), COPD (1), HTN/CVD (5), current/former smokers (2/2)

Case-patients’ Symptoms All casesConfirmed LD Symptoms(n/N)% % Fever113/ /1191 Cough76/110699/1090 Shortness of Breath 65/107618/1080 Vomiting or Diarrhea 57/105545/1145

Exposure Assessment (106 ills, 194 wells) Exposure# ExposedRR(CI)p Lobby Fountain (1.64, 2.77)< Lobby Bar (1.09, 1.44)0.003 Whirlpool Spa52.38 (0.40, 13.99)0.378 Pool44.76 (0.50, 45.10)0.302 Sauna30.79 (0.07, 8.63)1.000 Steam Room41.59 (0.23, 11.08)0.322 Guest Shower (0.92, 1.07)0.899 Guest Bath (0.53, 1.50)0.666

Environmental Results Positive: Lobby fountain, locker rooms (men and women shower heads and sinks), swimming pool, whirlpool Negative: Guest room shower heads

Matching Isolates Lp1 environmental isolates and a clinical isolate from a confirmed LD case-patient had matching sequence-based types.

Contributing Factors to Legionella Growth in Fountain Lack of written cleaning and maintenance program Presence of submerged lighting Presence of dirt, organic matter, or other debris in the water basin

Before After

Remediation Fountain removed Installation of chlorine dioxide treatment system to water supply –Must keep monthly operational records –IDPH inspection every 2 years

Conclusions Point source outbreak Environmental testing identified Legionella in the hotel’s potable water system. Poor fountain maintenance likely created favorable conditions for Legionella overgrowth Epidemiologic and molecular typing data confirmed that fountain was likely the source

Acknowledgements Centers for Disease Control and Prevention –National Center for Immunization and Respiratory Diseases, Division of Bacterial Diseases Illinois Department of Public Health –Craig Conover, MD, MPH –Connie Austin, DVM, PhD –Division of Environmental Health –Division of Infectious Diseases

Acknowledgements AL, AR, AZ, CA, CO, FL, GA, IA, IN, KS, MA, MD, ME, MI, MN, MO, NC, NE, NJ, NY, OH, OR, PA, TN, TX, VA, WI, WV, Ireland, Canada Chicago Department of Public Health –Communicable Disease Program –Emergency Preparedness Program

Public health Messaging IDPH Environmental laboratory results Exposures eliminated –Fountain removed –Pool, spa, locker rooms inaccessible to public Updating case counts

Legionellosis cases by month of onset, Number of cases

Reported 10-year incidence rates per 100,000 adult residents, by Chicago community area, 2001-August 2010 Approximate reported residence of Chicago case-patients, with spatial clustering denoted in gray Reported cases per 100,000 adults

Case-patients’ Characteristics All Cases (N=114)Confirmed LD (N=11) % Male6491 Median age (range)47 (22-82 yrs)65.5 (49-82 yrs) % Hospitalized1382 Deaths03 Underlying Illness/riskN/AObesity(1), HIV(1), COPD(1), HTN/CVD(5), current/former smokers (2/2)

Timeline JulyAugust = outbreak Bakery closure Inspection and product recall Bakery re-opening 3

Why the Increase? Increasing population of older persons Increasing population of persons at high risk for infection Improved diagnosis and reporting Weather conditions..

July and August Events SundayMondayTuesdayWedThursdayFridaySaturday JULY AUG CDPH notified

July and August Events SundayMondayTuesdayWedThursdayFridaySaturday July August CDPH notified

July and August Events