Legionellosis Investigation Guideline Contents CASE DEFINITION ............................................................................................................ 1 LABORATORY ANALYSIS .............................................................................................. 3 EPIDEMIOLOGY ............................................................................................................... 3 DISEASE OVERVIEW ....................................................................................................... 3 NOTIFICATION TO PUBLIC HEALTH AUTHORITIES ........................................... 5 INVESTIGATOR RESPONSIBILITIES .......................................................................... 6 STANDARD CASE INVESTIGATION AND CONTROL ............................................. 6 Case Investigation .......................................................................................................................................... 6 Contact Investigation ..................................................................................................................................... 7 Isolation, Work and Daycare Restrictions...................................................................................................... 7 Case Management .......................................................................................................................................... 7 Contact Management ..................................................................................................................................... 7 Environmental ................................................................................................................................................ 8 MANAGING SPECIAL SITUATIONS ............................................................................. 8 A. Outbreak Investigation: ......................................................................................................................... 8 DATA MANAGEMENT AND REPORTING .................................................................. 9 ADDITIONAL INFORMATION / REFERENCES ....................................................... 10 ATTACHMENTS .............................................................................................................. 10 Fact Sheet Attachments can be accessed through the Adobe Reader’s navigation panel for attachments. Throughout this document attachment links are indicated by this symbol ; when the link is activated in Adobe Reader it will open the attachments navigation panel. The link may not work when using PDF readers other than Adobe. Effective Date: 09/2009 Published Date: 01/06/2019 Current version: 01/2020 Last Updated: 11/07/2019 Revision History: Date Replaced Comments 01/2020 05/2018 New case definition for 2020. Investigations now cover a 14-day exposure period (increased from 10 days) and asks about more possible exposures. Updated Epidemiology, Disease Overview, Notification, Case Investigation, and Outbreak sections. 05/2018 07/2013 Updated Notification sections and Isolation, Work and Daycare Restrictions sections with updated regulations. 05/2014 05/2013 Edited notification section in association to travel/hotel related notifications. 05/2013 09/2009 Added notification section. Removed references to KS-EDSS (02/2012). Effective Date: 09/2009 Published Date: 01/06/2019 Current version: 01/2020 Revision History, Page 2 Legionellosis Disease Management and Investigative Guidelines CASE DEFINITION (CDC 2020) Clinical Description for Public Health Surveillance: Legionellosis is associated with three clinically and epidemiologically distinct illnesses: Legionnaires’ disease, Pontiac fever, or extrapulmonary legionellosis. • Legionnaires’ disease (LD): LD presents as pneumonia, diagnosed clinically and/or radiographically. Evidence of clinically compatible disease can be determined several ways: a) a clinical or radiographic diagnosis of pneumonia in the medical record OR b) if “pneumonia” is not recorded explicitly, a description of clinical symptoms that are consistent with a diagnosis of pneumonia Clinical symptoms of pneumonia may vary but must include acute onset of lower respiratory illness with fever and/or cough. Additional symptoms could include myalgia, shortness of breath, headache, malaise, chest discomfort, confusion, nausea, diarrhea, or abdominal pain. • Pontiac fever (PF): PF is a milder illness. While symptoms of PF could appear similar to those described for LD, there are distinguishing clinical features. PF does not present as pneumonia. It is less severe than LD, rarely requiring hospitalization. PF is self-limited, meaning it resolves without antibiotic treatment. Clinical symptoms may vary but must include acute symptom onset of one or more of the following: fever, chills, myalgia, malaise, headaches, fatigue, nausea and/or vomiting. • Extrapulmonary legionellosis (XPL): Legionella can cause disease at sites outside the lungs (for example, associated with endocarditis, wound infection, joint infection, graft infection). A diagnosis of extrapulmonary legionellosis is made when there is clinical evidence of disease at an extrapulmonary site and diagnostic testing indicates evidence of Legionella at that site. Laboratory Criteria for Case Classification: Confirmatory laboratory evidence: • Isolation of any Legionella organism from lower respiratory secretions, lung tissue, pleural fluid, or extrapulmonary site • Detection of any Legionella species from lower respiratory secretions, lung tissue, pleural fluid, or extrapulmonary site by a validated nucleic acid amplification test • Detection of Legionella pneumophila serogroup 1 antigen in urine using validated reagents • Fourfold or greater rise in specific serum antibody titer to Legionella pneumophila serogroup 1 using validated reagents Version 01/2020 Legionellosis, Page 1 Kansas Department of Health and Environment Investigation Guidelines Supportive laboratory evidence: • Fourfold or greater rise in antibody titer to specific species or serogroups of Legionella other than L. pneumophila serogroup 1 (e.g., L. micdadei, L. pneumophila serogroup 6) • Fourfold or greater rise in antibody titer to multiple species of Legionella using pooled antigens. • Detection of specific Legionella antigen or staining of the organism in lower respiratory secretions, lung tissue, pleural fluid, or extrapulmonary site associated with clinical disease by direct fluorescent antibody (DFA) staining, immunohistochemistry (IHC), or other similar method, using validated reagents Epidemiologic Linkage for Case Classification: 1) Epidemiologic link to a setting with a confirmed source of Legionella (e.g., positive environmental sampling result associated with a cruise ship, public accommodation, cooling tower, etc.), OR 2) Epidemiologic link to a setting with a suspected source of Legionella that is associated with at least one confirmed case. Case Classification: Confirmed Legionnaires’ disease (LD): A clinically compatible case of LD with confirmatory laboratory evidence for Legionella. Probable Legionnaires’ disease (LD): A clinically compatible case with an epidemiologic link during the 14 days before onset of symptoms. Suspect Legionnaires’ disease (LD): A clinically compatible case of LD with supportive laboratory evidence for Legionella. Confirmed Pontiac fever (PF): A clinically compatible case of PF with confirmatory laboratory evidence for Legionella. Probable Pontiac fever (PF): A clinically compatible case with an epidemiologic link during the 3 days before onset of symptoms. Suspect Pontiac fever (PF): A clinically compatible case of PF with supportive laboratory evidence for Legionella. Confirmed Extrapulmonary legionellosis (XPL): A clinically compatible case of XPL with confirmatory laboratory evidence of Legionella at an extrapulmonary site. Suspect Extrapulmonary legionellosis (XPL): A clinically compatible case of XPL with supportive laboratory evidence of Legionella at an extrapulmonary site. Version 01/2020 Legionellosis, Page 2 Kansas Department of Health and Environment Investigation Guidelines LABORATORY ANALYSIS Isolates are not required to be sent to the State Public Health Laboratory (KHEL); but they are equipped to confirm isolates of Legionella spp. Specimens for Legionella testing will be forwarded to the CDC only after prior clearance by the CDC Respiratory Diseases Branch. • When sending isolates to the state laboratory: Contact the laboratory at 785-620-1620. Use IDS (infectious disease shipper) for shipping. • When sending serology, urine, or pathologic specimens for testing at the CDC: Contact KDHE Epidemiology services for approval at 1-877-427-7317. An epidemiologist will request the information needed to verify an outbreak related case or if other special circumstances exist in which the CDC would need to assist. The epidemiologist will contact the Respiratory Disease Branch within the CDC Division of Bacterial Disease at 404-639-2215. After approval, specimen collection and delivery instructions will be given. Note: For serology, paired serum specimens taken at least 14 days apart are required. A single antibody titer at any level is not diagnostic for legionellosis. • For additional information, call (785) 296-1620. EPIDEMIOLOGY Legionellosis has a worldwide distribution. In the United States an estimated 8,000 - 18,000 cases occur annually; most are isolated and are not associated with outbreaks. Outbreaks usually occur in the summer and