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Legionella Human Health Criteria Document

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Legionella Human Health Criteria Document United States Office of Science and Technology EPA-822-R-99-001 Environmental Protection Office of Water November 1999 Agency Washington, DC 20460 www.epa.gov Legionella: Human Health Criteria Document ACKNOWLEDGMENTS This document was prepared for the U. S. Environmental Protection Agency, Office of Ground Water and Drinking Water (OGWDW) by the Office of Science and Technology (OST) under contract with ICF Consulting Group (Contract No. 68-C6-0029). Overall planning and management for the preparation of this document was provided by Latisha S. Parker, MS of OST. EPA acknowledges the valuable contributions of those who reviewed this document. They include Lisa Almodovar MPH, Robin Oshiro, MS and Stephen Schaub, Ph.D. of the U.S. EPA. EPA also recognizess the following external peer reviewers for their excellent review and valuable comments on the draft document: Janette E. Stout Ph.D. and Paul H. Eldelstein M.D. TABLE OF CONTENTS I. Summary ............................................................................ I-1 II. General Information and Properties .......................................................II-1 A. History .......................................................................II-1 B. Taxonomy .....................................................................II-2 C. Microbiology, Morphology, and Ecology ............................................II-6 D. Symbiosis in Microorganisms .....................................................II-7 III. Occurrence ........................................................................ III-1 A. Worldwide Distribution ......................................................... III-1 B. Occurrence in Water ............................................................ III-9 1. Natural Surface Water ..................................................... III-9 2. Groundwater ........................................................... III-10 3. Man-Made Waters ...................................................... III-11 C. Occurrence in Soil ............................................................ III-19 D. Occurrence in Air ............................................................. III-20 E. Specific Disease Outbreaks ..................................................... III-21 1. Nosocomial Outbreaks ................................................... III-22 2. Outbreaks Among Travelers ............................................... III-22 3. Community Outbreaks ................................................... III-32 F. Environmental Factors Affecting Legionella Survival ................................. III-32 1. Symbiotic Microorganisms ................................................ III-32 2. Water Temperature ...................................................... III-35 3. Other Factors ........................................................... III-36 G. Summary ................................................................... III-37 IV. Health Effects in Animals .............................................................IV-1 A. Laboratory Studies .............................................................IV-1 B. Summary ....................................................................IV-4 V. Health Effects in Humans ............................................................. V-1 A. Symptoms and Clinical Manifestations ............................................. V-1 B. Clinical Laboratory Findings ..................................................... V-5 C. Mechanism of Action ........................................................... V-6 D. Immunity .................................................................... V-9 E. Chronic Conditions ............................................................ V-11 F. Treatment ................................................................... V-11 G. Summary ................................................................... V-14 VI. Risk Assessment ....................................................................VI-1 A. Hazard Identification ...........................................................VI-1 B. Dose-Response Information ......................................................VI-2 C. Potential for Human Exposure to Legionella .........................................VI-3 1. Prevalence of Legionella in the Environment ...................................VI-3 2. Mode of Transmission to Humans ...........................................VI-3 i D. Risk Factors ..................................................................VI-6 E. Quantification of Potential Health Effects ...........................................VI-9 F. Minimizing Risk ..............................................................VI-10 G. Summary ...................................................................VI-12 VII. Analysis and Treatment ............................................................. VII-1 A. Analysis of Samples ........................................................... VII-1 1. Collection of Legionella .................................................. VII-1 2. Detection of Legionella in Environmental and Biological Samples ................. VII-3 B. Disinfection as a Water Treatment Practice ......................................... VII-8 C. Summary .................................................................. VII-13 VIII. Research Requirements ............................................................VIII-1 IX. References .........................................................................IX-1 ii LIST OF FIGURES Figure III-1. Summary of Reported Cases of Legionellosis in the United States, 1984-1996 ..................................................... III-4 LIST OF TABLES Table II-1. Approved Legionella Species ..................................................II-3 Table III-1. Summary of Reported Cases of Legionellosis in the United States, 1984-1996 ..................................................... III-3 Table III-2. Legionnaires’ Disease in 24 European Countries in 1996 ............................ III-7 Table III-3. Occurrence of Legionella Bacteria in Potable Water Supplies and Distribution Systems ....................................................... III-12 Table III-4. Occurrence of Legionella Bacteria in Cooling Towers ............................. III-16 Table III-5. Occurrence of Legionellosis Outbreaks ......................................... III-23 Table V-1. Frequency of Symptoms of Legionnaires’ Disease ................................. V-3 Table V-2. Extrapulmonary Sites of Legionella Infection ..................................... V-4 Table V-3. Common Clinical Laboratory Findings in Patients with Legionnaires’ Disease ....................................................... V-5 Table V-4. Recommendations for Antibiotic Treatment of Legionnaires’ Disease ................. V-13 iii (this page intentionally left blank) iv I. Summary This document was prepared to update information in the Environmental Protection Agency’s (EPA) Drinking Water Criteria Document on Legionella (EPA 1985) and is intended to serve as an addendum to that report. Where appropriate, a summary of relevant information from the 1985 document is presented in each chapter of this addendum. For a more detailed description of information published before 1986, please refer to the 1985 document. This chapter presents a summary of the information contained in Chapters II through VII. Chapter VIII contains a discussion of research recommendations and Chapter IX lists references. Legionella bacteria are aerobic gram-negative rods associated with respiratory infections. Legionella pneumophila was first recognized as a disease entity from a pneumonia outbreak at a 1976 Convention of the American Legion in Philadelphia. Of the 42 known species of Legionella, 18 have been linked to pneumonia infections in humans. The species L. pneumophila (particularly serogroups 1-6) has been accepted as the principal cause of human outbreaks of legionellosis, which includes both legionnaires’ disease and Pontiac fever. Legionella are ubiquitous in natural aquatic environments, capable of existing in waters with varied temperatures, pH levels, and nutrient and oxygen contents. They can be found in groundwater as well as fresh and marine surface waters. Their widespread survival in nature can be attributed to their relationships with other microorganisms in the environment. Symbiotic existence with algae and other bacteria, particularly in biofilms, increases the availability of nutrients. They also are able to infect protozoans and subsequently reproduce within these organisms. These relationships provide protection against adverse environmental conditions, including standard water disinfection techniques. Consequently, Legionella are also prevalent in anthropogenic waters such as potable water, cooling tower reservoirs, and whirlpools. Aerosol-generating systems such as faucets, showerheads, cooling towers, and nebulizers aid in the transmission of Legionella from water to air. Human inhalation of contaminated aerosols leads to Legionella infections and disease outbreaks. Historically, many of the reported outbreaks were nosocomial (i.e., hospital- acquired), resulting from the adulteration of hospital potable water supplies, air conditioning systems, or cooling towers. Due to increased awareness of the disease, numerous community-acquired and travel-acquired outbreaks are now reported each year as well. However, most cases of legionnaires’ disease are sporadic (i.e., non-outbreak related) and are acquired
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