1. BARROW-IN-FURNESS LEGIONNAIRES DISEASE OUTBREAK AUGUST 2002

2. 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

3. PUBLIC HEALTH  Thursday, 1 st August – another case linked to Barrow. Outbreak meeting arranged  Telephone call to EHO

4. OUTBREAK CONTROL MEETING Friday, 2 nd August 2002

5. PUBLIC HEALTH ACTIONS  EHO’s  Questionnaires  Testing Strategy  Information to GP’s  Incident Room  Database

6. 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

7. Environmental (2)  Visit by HSE, PHL and EHOs  Visual inspection  Review of maintenance records  Sampling of pooled/residual waters

8. Epidemiology

12. Environmental (3)  Only one plant culture positive for Legionella pneumophila  L. pneumophila – Benidorm  Indistinguishable from clinical isolates

13. TRUST RESPONSE  Activated Major Incident Plan including Ambulance/Police liaison  Incident Room  Telephone helpline  Database  Cancellation of elective admissions

15. CLINICAL OBSERVATIONS  Wide age distribution  Very high fever  Diarrhoea  Hepatorenal dysfunction  Raised troponin T  Often looked disproportionally well  Sudden deterioration common

16. 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

17. PHARMACY WORKLOAD  2000 doses iv clarithromycin (1600 in 2001)  45500 erythromycin tabs (us 2500)  Rifampicin 370 vials, 4000 caps by 9 th August 2002

18. SUPPLIES ISSUES  Kits  Hardware  Clinical supplies

19. 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

22.  Specimen labelling  Portering requirements  Specimen storage  Transportation to reference labs (planes, trains and automobiles)  Co-ordination with PHL locally and nationally  CDSC LABORATORY ORGANISATION

23.  Medicolegal Aspects  Politics AND IT WAS AUGUST … LABORATORY ORGANISATION

24. LABORATORY DIAGNOSIS OF LEGIONELLA INFECTION  Urinary antigen testing  Serology  Culture

25. 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

26. COMPARISON OF SEROLOGY AND URINARY ANTIGEN RESULTS Serology Urinary antigen Total PositiveUnresolvedNegativeN/A Positive 46317672 Equivocal 29111344 Negative 438409298758 N/A 1111665211698 Total 1291321023282572

27. LEGIONNAIRES DISEASE OUTBREAK Number of cases seroconverting by week

28. THE BARE FACTS  Urine antigen tests performed 2475  Admissions 489  Confirmed cases so far 167  Deaths 5

29. CLASSIFICATION OF CASES CLASSIFICATIONTOTAL Definite legionnaires disease126 Probable legionnaires disease17 Possible legionnaires disease17 Maybe legionnaires disease10 170 Definite Pontiac fever14 Maybe Pontiac fever6 20

30. LEGIONNAIRES DISEASE OUTBREAK Age, distribution, definite and probable cases

32. PROBLEMS  Interpretation of unfamiliar tests  Controlling demand for tests  IT/system for reports  Fatigue/boredom  Impact on other roles

33. THE AFTERMATH  Follow up clinics and testing  Phlebotomy, specimen transport  Trying to reconcile 3 different databases  Medicolegal

34. 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

35. LESSONS LEARNED  You can never give too much information  Make sources of information clear  Assume nothing

36.  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