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March 8, 1985, Vol 253, No. 10 >
ARTICLE | March 8, 1985

Potable Water as a Source of Legionnaires' Disease FREE

Kathryn N. Shands, MD; John L. Ho, MD; Richard D. Meyer, MD; George W. Gorman; Paul H. Edelstein, MD; George F. Mallison, MPH; Sydney M. Finegold, MD; David W. Fraser, MD
[+] Author Affiliations

Presented in part at the 20th Interscience Conference on Antimicrobial Agents and Chemotherapy, New Orleans, Sept 20, 1980, and the National Meeting of the American Federation for Clinical Research, San Francisco, April 27, 1981.

Reprint requests to Division of Infectious Diseases, Room 1731, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048 (Dr Meyer).


JAMA. 1985;253(10):1412-1416. doi:10.1001/jama.1985.03350340064018
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References

A three-year epidemic of legionnaires' disease in a hospital was dramatically curtailed following hyperchlorination of the potable water supply. The hypothesis that potable water was the source for the outbreak was further supported by isolation of Legionella pneumophila (the agent of legionnaires' disease) from the hospital water supply, observation that a sudden upsurge had occurred in the number of cases following a peculiar manipulation of the hospital water system, and documentation of a 30-fold increase in concentration of organisms in the water when this manipulation was artificially recreated. Thus, potable water may be an important source of epidemic legionnaires' disease and continuous hyperchlorination a method of control.

(JAMA 1985;253:1412-1416)

REFERENCES

1 +
Glick TH, Gregg MB, Berman B, et al:  Pontiac fever: An epidemic of unknown etiology in a health department: I. Clinical and epidemiologic aspects . Am J Epidemiol 1978;;107:149-160.
2 +
Politi BD, Fraser DW, Mallison GF, et al:  A major focus of legionnaires' disease in Bloomington, Indiana . Ann Intern Med 1979;;90:587-591.
3 +
Cordes LG, Fraser DW, Skaliy P, et al:  Legionnaires' disease outbreak at an Atlanta, Georgia, country club: Evidence for spread from an evaporative condenser . Am J Epidemiol 1980;; 111:425-431.
4 +
Fraser DW, Deubner DC, Hill DL, et al:  Nonpneumonic, short-incubation-period legionellosis (Pontiac fever) in men who cleaned a steam turbine condenser . Science 1979;;205:690-691.
5 +
Fraser DW, Tsai TR, Orenstein W, et al:  Legionnaires' disease: Description of an epidemic of pneumonia . N Engl J Med 1977;; 297:1189-1197.
6 +
Tobin JO, Beare J, Dunhill MS, et al:  Legionnaires' disease in a transplant unit: Isolation of the causative agent from shower baths . Lancet 1980;;2:118-121.
7 +
Cordes LG, Wiesenthal AM, Gorman GW, et al:  Isolation of Legionella pneumophila from hospital shower heads . Ann Intern Med 1981;; 94:195-197.
8 +
Stout J, Yu VL, Vickers RM, et al:  Ubiquitousness of Legionella pneumophila in the water supply . N Engl J Med 1982;;306:466-468.
9 +
Fisher-Hoch SP, Bartlett CLR, Tobin JO, et al:  Investigation and control of an outbreak of Legionnaires' disease in a district general hospital . Lancet 1981;;1:932-936.
10 +
Tobin JO, Bartlett CLR, Waitkins SA, et al:  Legionnaires' disease: Further evidence to implicate storage and distribution systems as sources . Br Med J 1981;;282:573.
11 +
Best M, Yu V, Stout J, et al:  Legionellaceae in the hospital water-supply: Epidemiological link with disease and evaluation of a method for control of nosocomial legionnaires' disease and Pittsburgh pneumonia . Lancet 1983;;2:307-310.
12 +
Helms CM, Massanari RM, Zeitler R, et al:  Legionnaires' disease associated with a hospital water system: A cluster of 24 nosocomial cases . Ann Intern Med 1983;;99:172-178.
13 +
Plouffe JF, Webster LR, Hackman B:  Relationship between colonization of hospital buildings with Legionella pneumophila and hot water temperatures . Appl Environ Microbiol 1983;;46:769-770.
14 +
Tobin JO, Swann RA, Bartlett CLF:  Isolation of Legionella pneumophila from water systems: Methods and preliminary results . Br Med J 1981;;282:515-517.
15 +
Dennis PJ, Taylor JA, Fitzgeorge RB, et al:  Legionella pneumophila in water plumbing systems . Lancet 1982;;1:949-951.
16 +
Wadowsky RM, Yee RB, Mezmar L, et al:  Hot water systems as sources of Legionella pneumophila in hospital and non-hospital plumbing fixtures . Appl Environ Microbiol 1982;; 43:1104-1110.
17 +
Kirby BD, Snyder KM, Meyer RD, et al:  Legionnaires' disease: Clinical features of 24 cases . Ann Intern Med 1978;;89:297-309.
18 +
Haley CE, Cohen ML, Halter J, et al:  Nosocomial legionnaires' disease: A continuing common-source epidemic at Wadsworth Medical Center . Ann Intern Med 1978;;90:583-586.
19 +
Kirby BD, Snyder KM, Meyer RD, et al:  Legionnaires' disease: Report of 65 nosocomially acquired cases and review of the literature . Medicine 1980;;59:188-205.
20 +
Edelstein PH, Meyer RD, Finegold SM:  Laboratory diagnosis of legionnaires' disease . Am Rev Respir Dis 1980;;121:317-327.
21 +
Haley CE, Meyer RD, Cohen ML, et al:  Epidemiology of legionnaires' disease at Wadsworth Medical Center , abstract 484. Program and Abstracts of the 11th International Congress of Chemotherapy and the 19th Interscience Conference on Antimicrobial Agents and Chemotherapy, Boston, Oct 1-5, 1979 .
22 +
Pasculle AW, Feeley JC, Gibson RJ, et al:  Pittsburgh pneumonia agent: Direct isolation from human lung tissue . J Infect Dis 1980;; 141:727-732.
23 +
Cherry WB, Pittman B, Harris PP, et al:  Detection of legionnaires' disease bacteria by direct immunofluorescent staining . J Clin Microbiol 1978;;8:329-338.
24 +
Greenberg AE, Connors JJ, Jenkins D, et al: Standard Methods for the Examination of Water and Waste Waters , ed 15. Washington, DC, American Public Health Association, 1981;.
25 +
Storch G, Baine WB, Fraser DW, et al:  Sporadic community-acquired legionnaires' disease in the United States . Ann Intern Med 1979;;90:596-600.
26 +
Skaliy P, McEachern HV:  Survival of the legionnaires' disease bacterium in water . Ann Intern Med 1979;;90:662-663.
27 +
Rudin JE, Wing EJ, Yee RB:  An ongoing outbreak of Legionella micdadei , in Thornsberry C, Balows A, Feeley JC, et al (eds): Proceedings of the Second International Symposium . Washington, DC, American Society for Microbiology, 1984;, pp 227-229.

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1 +
Glick TH, Gregg MB, Berman B, et al:  Pontiac fever: An epidemic of unknown etiology in a health department: I. Clinical and epidemiologic aspects . Am J Epidemiol 1978;;107:149-160.
2 +
Politi BD, Fraser DW, Mallison GF, et al:  A major focus of legionnaires' disease in Bloomington, Indiana . Ann Intern Med 1979;;90:587-591.
3 +
Cordes LG, Fraser DW, Skaliy P, et al:  Legionnaires' disease outbreak at an Atlanta, Georgia, country club: Evidence for spread from an evaporative condenser . Am J Epidemiol 1980;; 111:425-431.
4 +
Fraser DW, Deubner DC, Hill DL, et al:  Nonpneumonic, short-incubation-period legionellosis (Pontiac fever) in men who cleaned a steam turbine condenser . Science 1979;;205:690-691.
5 +
Fraser DW, Tsai TR, Orenstein W, et al:  Legionnaires' disease: Description of an epidemic of pneumonia . N Engl J Med 1977;; 297:1189-1197.
6 +
Tobin JO, Beare J, Dunhill MS, et al:  Legionnaires' disease in a transplant unit: Isolation of the causative agent from shower baths . Lancet 1980;;2:118-121.
7 +
Cordes LG, Wiesenthal AM, Gorman GW, et al:  Isolation of Legionella pneumophila from hospital shower heads . Ann Intern Med 1981;; 94:195-197.
8 +
Stout J, Yu VL, Vickers RM, et al:  Ubiquitousness of Legionella pneumophila in the water supply . N Engl J Med 1982;;306:466-468.
9 +
Fisher-Hoch SP, Bartlett CLR, Tobin JO, et al:  Investigation and control of an outbreak of Legionnaires' disease in a district general hospital . Lancet 1981;;1:932-936.
10 +
Tobin JO, Bartlett CLR, Waitkins SA, et al:  Legionnaires' disease: Further evidence to implicate storage and distribution systems as sources . Br Med J 1981;;282:573.
11 +
Best M, Yu V, Stout J, et al:  Legionellaceae in the hospital water-supply: Epidemiological link with disease and evaluation of a method for control of nosocomial legionnaires' disease and Pittsburgh pneumonia . Lancet 1983;;2:307-310.
12 +
Helms CM, Massanari RM, Zeitler R, et al:  Legionnaires' disease associated with a hospital water system: A cluster of 24 nosocomial cases . Ann Intern Med 1983;;99:172-178.
13 +
Plouffe JF, Webster LR, Hackman B:  Relationship between colonization of hospital buildings with Legionella pneumophila and hot water temperatures . Appl Environ Microbiol 1983;;46:769-770.
14 +
Tobin JO, Swann RA, Bartlett CLF:  Isolation of Legionella pneumophila from water systems: Methods and preliminary results . Br Med J 1981;;282:515-517.
15 +
Dennis PJ, Taylor JA, Fitzgeorge RB, et al:  Legionella pneumophila in water plumbing systems . Lancet 1982;;1:949-951.
16 +
Wadowsky RM, Yee RB, Mezmar L, et al:  Hot water systems as sources of Legionella pneumophila in hospital and non-hospital plumbing fixtures . Appl Environ Microbiol 1982;; 43:1104-1110.
17 +
Kirby BD, Snyder KM, Meyer RD, et al:  Legionnaires' disease: Clinical features of 24 cases . Ann Intern Med 1978;;89:297-309.
18 +
Haley CE, Cohen ML, Halter J, et al:  Nosocomial legionnaires' disease: A continuing common-source epidemic at Wadsworth Medical Center . Ann Intern Med 1978;;90:583-586.
19 +
Kirby BD, Snyder KM, Meyer RD, et al:  Legionnaires' disease: Report of 65 nosocomially acquired cases and review of the literature . Medicine 1980;;59:188-205.
20 +
Edelstein PH, Meyer RD, Finegold SM:  Laboratory diagnosis of legionnaires' disease . Am Rev Respir Dis 1980;;121:317-327.
21 +
Haley CE, Meyer RD, Cohen ML, et al:  Epidemiology of legionnaires' disease at Wadsworth Medical Center , abstract 484. Program and Abstracts of the 11th International Congress of Chemotherapy and the 19th Interscience Conference on Antimicrobial Agents and Chemotherapy, Boston, Oct 1-5, 1979 .
22 +
Pasculle AW, Feeley JC, Gibson RJ, et al:  Pittsburgh pneumonia agent: Direct isolation from human lung tissue . J Infect Dis 1980;; 141:727-732.
23 +
Cherry WB, Pittman B, Harris PP, et al:  Detection of legionnaires' disease bacteria by direct immunofluorescent staining . J Clin Microbiol 1978;;8:329-338.
24 +
Greenberg AE, Connors JJ, Jenkins D, et al: Standard Methods for the Examination of Water and Waste Waters , ed 15. Washington, DC, American Public Health Association, 1981;.
25 +
Storch G, Baine WB, Fraser DW, et al:  Sporadic community-acquired legionnaires' disease in the United States . Ann Intern Med 1979;;90:596-600.
26 +
Skaliy P, McEachern HV:  Survival of the legionnaires' disease bacterium in water . Ann Intern Med 1979;;90:662-663.
27 +
Rudin JE, Wing EJ, Yee RB:  An ongoing outbreak of Legionella micdadei , in Thornsberry C, Balows A, Feeley JC, et al (eds): Proceedings of the Second International Symposium . Washington, DC, American Society for Microbiology, 1984;, pp 227-229.

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