BARROW-IN-FURNESS LEGIONNAIRES DISEASE OUTBREAK AUGUST 2002
RECOGNITION OF THE OUTBREAK LOCAL Discussion re: Ix and Rx D/W CCDC, Virologist, PHL 1 patient urine Ag positive cases of CAP 2 further patients Uag positive Urine results confirmed – Outbreak Meeting arranged Friday 26 July Saturday 27 July Sunday 28 July Monday 29 July Tuesday 30 July Wednesday 31 July Thursday 1 Aug
PUBLIC HEALTH Thursday, 1 st August – another case linked to Barrow. Outbreak meeting arranged Telephone call to EHO
OUTBREAK CONTROL MEETING Friday, 2 nd August 2002
PUBLIC HEALTH ACTIONS EHO’s Questionnaires Testing Strategy Information to GP’s Incident Room Database
Environmental 7 major plants registered with LA/HSE 552 premises with suspected hazardous/?unregistered plant Hot & cold systems at Forum 28 2 nursing/residential homes
Environmental (2) Visit by HSE, PHL and EHOs Visual inspection Review of maintenance records Sampling of pooled/residual waters
Epidemiology
Environmental (3) Only one plant culture positive for Legionella pneumophila L. pneumophila – Benidorm Indistinguishable from clinical isolates
TRUST RESPONSE Activated Major Incident Plan including Ambulance/Police liaison Incident Room Telephone helpline Database Cancellation of elective admissions
CLINICAL OBSERVATIONS Wide age distribution Very high fever Diarrhoea Hepatorenal dysfunction Raised troponin T Often looked disproportionally well Sudden deterioration common
CLINICAL MANAGEMENT Protocols for assessment and management Severity scoring system (EWS) and people to monitor. Protocol for actions. Early transfer to ITU Consultant staff re-organisation
PHARMACY WORKLOAD 2000 doses iv clarithromycin (1600 in 2001) erythromycin tabs (us 2500) Rifampicin 370 vials, 4000 caps by 9 th August 2002
SUPPLIES ISSUES Kits Hardware Clinical supplies
LABORATORY ORGANISATION Microbiology workforce (1x4, 2x2, 3.5x1, 1.4xMLA) Re-distribution of specimens Physical reconfiguration Dissemination of results and reports Variable impact on other pathology disciplines
Specimen labelling Portering requirements Specimen storage Transportation to reference labs (planes, trains and automobiles) Co-ordination with PHL locally and nationally CDSC LABORATORY ORGANISATION
Medicolegal Aspects Politics AND IT WAS AUGUST … LABORATORY ORGANISATION
LABORATORY DIAGNOSIS OF LEGIONELLA INFECTION Urinary antigen testing Serology Culture
CULTURE POSITIVE SPUTA = 21 FROM 16 PATIENTS Serology Pos Serology Neg Serology N/A Urine Ag Pos 9 (+ 1 low level)22 Urine Ag Neg 1 Urine N/A 1
COMPARISON OF SEROLOGY AND URINARY ANTIGEN RESULTS Serology Urinary antigen Total PositiveUnresolvedNegativeN/A Positive Equivocal Negative N/A Total
LEGIONNAIRES DISEASE OUTBREAK Number of cases seroconverting by week
THE BARE FACTS Urine antigen tests performed 2475 Admissions 489 Confirmed cases so far 167 Deaths 5
CLASSIFICATION OF CASES CLASSIFICATIONTOTAL Definite legionnaires disease126 Probable legionnaires disease17 Possible legionnaires disease17 Maybe legionnaires disease Definite Pontiac fever14 Maybe Pontiac fever6 20
LEGIONNAIRES DISEASE OUTBREAK Age, distribution, definite and probable cases
PROBLEMS Interpretation of unfamiliar tests Controlling demand for tests IT/system for reports Fatigue/boredom Impact on other roles
THE AFTERMATH Follow up clinics and testing Phlebotomy, specimen transport Trying to reconcile 3 different databases Medicolegal
LESSONS LEARNED That both informal and formal surveillance are of value That the PHL and NHS laboratories can work together That there is tremendous goodwill in the NHS and other services
LESSONS LEARNED You can never give too much information Make sources of information clear Assume nothing
Trust Major Incident Plans should cover a sustained high admission rate Need to incorporate our experience into disaster/major incident planning If you’re walking down an alleyway and it’s full of water vapour – hold your breath! LESSONS LEARNED