Legionella Infection during and after the COVID-19 Pandemic (2020)

InfoMetricsFiguresRef. ACS ES&T WaterVol 1/Issue 1Article This publication is Open Access under the license indicated. Learn More CiteCitationCitation and abstractCitation and referencesMore citation options ShareShare onFacebookX (Twitter)WeChatLinkedInRedditEmailJump toExpandCollapse ViewpointSeptember 23, 2020Legionella Infection during and after the COVID-19 PandemicClick to copy article linkArticle link copied!Rafik Dey*Rafik DeySchool of Public Health, University of Alberta, Edmonton, AB T6G 1C9, CanadaDepartment Medical Microbiology & Immunology, University of Alberta, Edmonton, AB T6G 2R3, Canada*Email: [email protected]More by Rafik Deyhttp://orcid.org/0000-0002-4532-1751Nicholas J. AshboltNicholas J. AshboltSchool of Public Health, University of Alberta, Edmonton, AB T6G 1C9, CanadaDepartment Medical Microbiology & Immunology, University of Alberta, Edmonton, AB T6G 2R3, CanadaProvincial Laboratory for Public Health (ProvLab), Alberta Health Services, Edmonton, AB T2N 4W4, CanadaMore by Nicholas J. Ashbolthttp://orcid.org/0000-0002-3853-0096Open PDFACS ES&T WaterCite this: ACS EST Water 2021, 1, 1, 13–14Click to copy citationCitation copied!https://pubs.acs.org/doi/10.1021/acsestwater.0c00151https://doi.org/10.1021/acsestwater.0c00151Published September 23, 2020 Publication History Received 8 September 2020Accepted 16 September 2020Revised 12 September 2020Published online 23 September 2020Published in issue 8 January 2021article-commentaryCopyright © 2020 American Chemical Society. This publication is licensed under these Terms of Use. Request reuse permissionsACS PublicationsCopyright © 2020 American Chemical SocietySubjectswhat are subjectsArticle subjects are automatically applied from the ACS Subject Taxonomy and describe the scientific concepts and themes of the article.Atmospheric chemistryBacteriaCOVID-19HumidityImmunologyInfectious diseasesVirusesThere were two key lessons from the past devastating influenza pandemics (The 1918 "Spanish flu", 1957, 1968, and 2009). The first is that most fatalities were due to bacterial co-infections. (1,2)Reports of co-infection with respiratory pathogens in the current coronavirus pandemic (COVID-19) are also on the increase throughout the world. (3) Recently, Zhou and colleagues reported that 50% of patients with COVID-19 who died had secondary bacterial infections. (4)Legionella and COVID-19 co-infection has been also described in patients, which can be fatal if untreated. (3,5)Legionella is a waterborne bacterium that is responsible for Legionnaires' disease (LD), a severe pneumonia that occurs most frequently in susceptible persons, and those with comorbid conditions or immunosuppression. Legionella grows best in building water systems that are not well maintained, with Legionnaires' disease outbreaks most often reported for hotels, long-term care facilities, and hospitals. (6) In fact, the bacteria can cause community and nosocomial acquired pneumonia, with some 85% being sporadic cases. Up to 50% of sporadic cases of hospital-acquired pneumonia are caused by legionellae, and LD most commonly occurs after inhalation of Legionella-containing aerosols from showerheads, certain medical equipment (e.g., respiratory equipment), cooling towers, hot tubs, hydrotherapy equipment, or decorative fountains. (7)During the current worldwide pandemic, we suggest that patients with COVID-19 should be screened for Legionella; this is particularly important because the signs and symptoms of both infections are similar. (8)The second lesson learned is that the mortality rate and severity scores were higher after the pandemics. (9,10)COVID-19 infections can predispose patients to Legionella co-infections associated with subsequent waves of infections and consequently pose a serious threat to high-risk COVID-19 patients after the peak(s) of the pandemic, which can lead to an increase in disease severity and mortality.Cases and outbreaks due to legionellae are expected to continue to be a major health burden as they were prior to the COVID-19 pandemic. (11) Exposure to these agents is particularly problematic, especially after building closures or reduced operations with fewer people returning to full-time building operations. The reduced consumption of water can cause water stagnation in building water systems, increasing the risk for growth and spread of Legionella and its natural environmental reservoirs, free-living amoebae. (8,12)In addition, the warm season also brings with it the risk of LD, because risk factors (use of air conditioners, spray parks/fountains, etc.) increase when weather is warm and humid. (13)It will remain important for people to continue to take prudent steps to protect themselves and follow the recommendations specific to reopening after prolonged shutdowns. (14−16) As described in the new Centers for Disease Control and Prevention guidance, the LD threat also applies to hot tubs, water fountains, sprinkler systems, and millions of water cooling towers atop commercial buildings. (14)Ideally, as was previously implemented during the H1N1 influenza pandemic, (17) new recommendations for the post-COVID-19 pandemic period will be important for preventing the consequences of bacterial pneumonia co-infections and avoiding unexpected increases in mortality.Author InformationClick to copy section linkSection link copied!Corresponding AuthorRafik Dey - School of Public Health, University of Alberta, Edmonton, AB T6G 1C9, Canada; Department Medical Microbiology & Immunology, University of Alberta, Edmonton, AB T6G 2R3, Canada; http://orcid.org/0000-0002-4532-1751; Email: [email protected]AuthorNicholas J. Ashbolt - School of Public Health, University of Alberta, Edmonton, AB T6G 1C9, Canada; Department Medical Microbiology & Immunology, University of Alberta, Edmonton, AB T6G 2R3, Canada; Provincial Laboratory for Public Health (ProvLab), Alberta Health Services, Edmonton, AB T2N 4W4, Canada; Present Address: N.J.A.: School of Environment, Science and Engineering, Southern Cross University, Lismore, NSW 2480, Australia; http://orcid.org/0000-0002-3853-0096NotesThe authors declare no competing financial interest.AcknowledgmentsClick to copy section linkSection link copied!This work was supported by Alberta Innovates (Grant 201300490), Alberta, Canada.ReferencesClick to copy section linkSection link copied! This article references 17 other publications. 1Morens, D. M.; Taubenberger, J. K.; Fauci, A. S. Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness. J. Infect. Dis. 2008, 198 (7), 962– 70, DOI: 10.1086/591708 Google Scholar1Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparednessMorens David M; Taubenberger Jeffery K; Fauci Anthony SThe Journal of infectious diseases (2008), 198 (7), 962-70 ISSN:0022-1899. BACKGROUND: Despite the availability of published data on 4 pandemics that have occurred over the past 120 years, there is little modern information on the causes of death associated with influenza pandemics. METHODS: We examined relevant information from the most recent influenza pandemic that occurred during the era prior to the use of antibiotics, the 1918-1919 "Spanish flu" pandemic. We examined lung tissue sections obtained during 58 autopsies and reviewed pathologic and bacteriologic data from 109 published autopsy series that described 8398 individual autopsy investigations. RESULTS: The postmortem samples we examined from people who died of influenza during 1918-1919 uniformly exhibited severe changes indicative of bacterial pneumonia. Bacteriologic and histopathologic results from published autopsy series clearly and consistently implicated secondary bacterial pneumonia caused by common upper respiratory-tract bacteria in most influenza fatalities. CONCLUSIONS: The majority of deaths in the 1918-1919 influenza pandemic likely resulted directly from secondary bacterial pneumonia caused by common upper respiratory-tract bacteria. Less substantial data from the subsequent 1957 and 1968 pandemics are consistent with these findings. If severe pandemic influenza is largely a problem of viral-bacterial copathogenesis, pandemic planning needs to go beyond addressing the viral cause alone (e.g., influenza vaccines and antiviral drugs). Prevention, diagnosis, prophylaxis, and treatment of secondary bacterial pneumonia, as well as stockpiling of antibiotics and bacterial vaccines, should also be high priorities for pandemic planning. >> More from SciFinder ®https://chemport.cas.org/services/resolver?origin=ACS&resolution=options&coi=1%3ACAS%3A280%3ADC%252BD1cros1Omsg%253D%253D&md5=41c6e68adfbfe8dcde07efada909c1d42Chertow, D. S.; Memoli, M. J. Bacterial coinfection in influenza: a grand rounds review. JAMA 2013, 309 (3), 275– 82, DOI: 10.1001/jama.2012.194139 Google Scholar2Bacterial coinfection in influenza: a grand rounds reviewChertow, Daniel S.; Memoli, Matthew J.JAMA, the Journal of the American Medical Association (2013), 309 (3), 275-282CODEN: JAMAAP; ISSN:0098-7484. (American Medical Association) Bacterial coinfection complicated nearly all influenza deaths in the 1918 influenza pandemic and up to 34% of 2009 pandemic influenza A(H1N1) infections managed in intensive care units worldwide. More than 65,000 deaths attributable to influenza and pneumonia occur annually in the United States. Data from 683 critically ill patients with 2009 pandemic influenza A(H1N1) infection admitted to 35 intensive care units in the United States reveal that bacterial coinfection commonly occurs within the first 6 days of influenza infection, presents similarly to influenza infection occurring alone, and is assocd. with an increased risk of death. Pathogens that colonize the nasopharynx, including Staphylococcus aureus, Streptococcus pneumoniae, and Streptococcus pyogenes, are most commonly isolated. Complex viral, bacterial, and host factors contribute to the pathogenesis of coinfection. Redns. in morbidity and mortality are dependent on prevention with available vaccines as well as early diagnosis and treatment. >> More from SciFinder ®https://chemport.cas.org/services/resolver?origin=ACS&resolution=options&coi=1%3ACAS%3A528%3ADC%252BC3sXht1Kisbk%253D&md5=d15e8d3f4ec4cb65cc0b2d33f50d12fb3Lai, C. C.; Wang, C. Y.; Hsueh, P. R. Co-infections among patients with COVID-19: The need for combination therapy with non-anti-SARS-CoV-2 agents?. J. Microbiol Immunol Infect 2020, 53 (4), 505– 512, DOI: 10.1016/j.jmii.2020.05.013 Google Scholar3Co-infections among patients with COVID-19: The need for combination therapy with non-anti-SARS-CoV-2 agents?Lai, Chih-Cheng; Wang, Cheng-Yi; Hsueh, Po-RenJournal of Microbiology, Immunology and Infection (2020), 53 (4), 505-512CODEN: JMIIFG; ISSN:1995-9133. (Elsevier Taiwan LLC) A review. Co-infection has been reported in patients with severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome, but there is limited knowledge on co-infection among patients with coronavirus disease 2019 (COVID-19). The prevalence of co-infection was variable among COVID-19 patients in different studies, however, it could be up to 50% among non-survivors. Co-pathogens included bacteria, such as Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumonia, Legionella pneumophila and Acinetobacter baumannii; Candida species and Aspergillus flavus; and viruses such as influenza, coronavirus, rhinovirus/enterovirus, parainfluenza, metapneumovirus, influenza B virus, and human immunodeficiency virus. Influenza A was one of the most common co-infective viruses, which may have caused initial false-neg. results of real-time reverse-transcriptase polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Lab. and imaging findings alone cannot help distinguish co-infection from SARS-CoV-2 infection. Newly developed syndromic multiplex panels that incorporate SARS-CoV-2 may facilitate the early detection of co-infection among COVID-19 patients. By contrast, clinicians cannot rule out SARS-CoV-2 infection by ruling in other respiratory pathogens through old syndromic multiplex panels at this stage of the COVID-19 pandemic. Therefore, clinicians must have a high index of suspicion for coinfection among COVID-19 patients. Clinicians can neither rule out other co-infections caused by respiratory pathogens by diagnosing SARS-CoV-2 infection nor rule out COVID-19 by detection of non-SARS-CoV-2 respiratory pathogens. After recognizing the possible pathogens causing co-infection among COVID-19 patients, appropriate antimicrobial agents can be recommended. >> More from SciFinder ®https://chemport.cas.org/services/resolver?origin=ACS&resolution=options&coi=1%3ACAS%3A528%3ADC%252BB3cXhtVGms73I&md5=03220276f2e447c277470132e8d759124Zhou, F.; Yu, T.; Du, R.; Fan, G.; Liu, Y.; Liu, Z.; Xiang, J.; Wang, Y.; Song, B.; Gu, X.; Guan, L.; Wei, Y.; Li, H.; Wu, X.; Xu, J.; Tu, S.; Zhang, Y.; Chen, H.; Cao, B. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020, 395 (10229), 1054– 1062, DOI: 10.1016/S0140-6736(20)30566-3 Google Scholar4Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort studyZhou, Fei; Yu, Ting; Du, Ronghui; Fan, Guohui; Liu, Ying; Liu, Zhibo; Xiang, Jie; Wang, Yeming; Song, Bin; Gu, Xiaoying; Guan, Lulu; Wei, Yuan; Li, Hui; Wu, Xudong; Xu, Jiuyang; Tu, Shengjin; Zhang, Yi; Chen, Hua; Cao, BinLancet (2020), 395 (10229), 1054-1062CODEN: LANCAO; ISSN:0140-6736. (Elsevier Ltd.) Since Dec., 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiol. and clin. characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clin. course of illness, including viral shedding, have not been well described. In this retrospective, multicenter cohort study, we included all adult inpatients (≥18 yr old) with lab.-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demog., clin., treatment, and lab. data, including serial samples for viral RNA detection, were extd. from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors assocd. with in-hospital death. One hundred ninety-one patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. Ninety-one (48%) patients had a comorbidity, with hypertension being the most common (58 patients), followed by diabetes (36 patients) and coronary heart disease (15 patients). Multivariable regression showed increasing odds of in-hospital death assocd. with older age, higher Sequential Organ Failure Assessment (SOFA) score, and d-dimer >1μg/L on admission. Median duration of viral shedding was 20·0 days (IQR 17·0-24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest obsd. duration of viral shedding in survivors was 37 days. The potential risk factors of older age, high SOFA score, and d-dimer >1μg/L could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. >> More from SciFinder ®https://chemport.cas.org/services/resolver?origin=ACS&resolution=options&coi=1%3ACAS%3A528%3ADC%252BB3cXkvVGktL8%253D&md5=66ea14f4f585df80553e63820aad3f005Arashiro, T.; Nakamura, S.; Asami, T.; Mikuni, H.; Fujiwara, E.; Sakamoto, S.; Miura, R.; Shionoya, Y.; Honda, R.; Furukawa, K.; Nakamura, A.; Saito, H. SARS-CoV-2 and Legionella co-infection in a person returning from a Nile cruise. Journal of Travel Medicine 2020, 27 (3), taaa053, DOI: 10.1093/jtm/taaa053 Google ScholarThere is no corresponding record for this reference.6Soda, E. A.; Barskey, A. E.; Shah, P. P.; Schrag, S.; Whitney, C. G.; Arduino, M. J.; Reddy, S. C.; Kunz, J. M.; Hunter, C. M.; Raphael, B. H.; Cooley, L. A. Vital Signs: Health Care-Associated Legionnaires' Disease Surveillance Data from 20 States and a Large Metropolitan Area - United States, 2015. MMWR Morb Mortal Wkly Rep 2017, 66 (22), 584– 589, DOI: 10.15585/mmwr.mm6622e1 Google Scholar6Vital Signs: Health Care-Associated Legionnaires' Disease Surveillance Data from 20 States and a Large Metropolitan Area - United States, 2015Soda Elizabeth A; Barskey Albert E; Shah Priti P; Schrag Stephanie; Whitney Cynthia G; Arduino Matthew J; Reddy Sujan C; Kunz Jasen M; Hunter Candis M; Raphael Brian H; Cooley Laura AMMWR. Morbidity and mortality weekly report (2017), 66 (22), 584-589 ISSN:. BACKGROUND: Legionnaires' disease, a severe pneumonia, is typically acquired through inhalation of aerosolized water containing Legionella bacteria. Legionella can grow in the complex water systems of buildings, including health care facilities. Effective water management programs could prevent the growth of Legionella in building water systems. METHODS: Using national surveillance data, Legionnaires' disease cases were characterized from the 21 jurisdictions (20 U.S. states and one large metropolitan area) that reported exposure information for ≥90% of 2015 Legionella infections. An assessment of whether cases were health care-associated was completed; definite health care association was defined as hospitalization or long-term care facility residence for the entire 10 days preceding symptom onset, and possible association was defined as any exposure to a health care facility for a portion of the 10 days preceding symptom onset. All other Legionnaires' disease cases were considered unrelated to health care. RESULTS: A total of 2,809 confirmed Legionnaires' disease cases were reported from the 21 jurisdictions, including 85 (3%) definite and 468 (17%) possible health care-associated cases. Among the 21 jurisdictions, 16 (76%) reported 1-21 definite health care-associated cases per jurisdiction. Among definite health care-associated cases, the majority (75, 88%) occurred in persons aged ≥60 years, and exposures occurred at 72 facilities (15 hospitals and 57 long-term care facilities). The case fatality rate was 25% for definite and 10% for possible health care-associated Legionnaires' disease. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Exposure to Legionella from health care facility water systems can result in Legionnaires' disease. The high case fatality rate of health care-associated Legionnaires' disease highlights the importance of case prevention and response activities, including implementation of effective water management programs and timely case identification. >> More from SciFinder ®https://chemport.cas.org/services/resolver?origin=ACS&resolution=options&coi=1%3ACAS%3A280%3ADC%252BC1cnmtleqtw%253D%253D&md5=4b3a924ba3968af7054a245cebc9ddf17 Legionella and the prevention of legionellosis. https://apps.who.int/iris/handle/10665/43233pdf. World Health Organization, Geneva, 2007 (accessed 2012-06-01).Google ScholarThere is no corresponding record for this reference.8Keane, T. COVID-19 and Legionella: Preparations to consider for municipal and building potable water systems. https://legionellae.org/wp-content/uploads/COVID-19-and-Legionella-Preparations-to-Consider-4-23-2020.pdf. 2020 (accessed 2020-04-23).Google ScholarThere is no corresponding record for this reference.9Morens, D. M.; Taubenberger, J. K. 1918 influenza, a puzzle with missing pieces. Emerging Infect. Dis. 2012, 18 (2), 332– 5, DOI: 10.3201/eid1802.111409 Google Scholar91918 influenza, a puzzle with missing piecesMorens David M; Taubenberger Jeffery KEmerging infectious diseases (2012), 18 (2), 332-5 ISSN:. There is no expanded citation for this reference. >> More from SciFinder ®https://chemport.cas.org/services/resolver?origin=ACS&resolution=options&coi=1%3ACAS%3A280%3ADC%252BC383gsVygsQ%253D%253D&md5=87a70d32687c2b218143376ba725af8710Martin-Loeches, I.; Diaz, E.; Vidaur, L.; Torres, A.; Laborda, C.; Granada, R.; Bonastre, J.; Martin, M.; Insausti, J.; Arenzana, A.; Guerrero, J. E.; Navarrete, I.; Bermejo-Martin, J.; Suarez, D.; Rodriguez, A.; Group, H. N. S. R. C. W. Pandemic and post-pandemic influenza A (H1N1) infection in critically ill patients. Critical Care 2011, 15 (6), R286, DOI: 10.1186/cc10573 Google ScholarThere is no corresponding record for this reference.11Cassini, A.; Colzani, E.; Pini, A.; Mangen, M. J.; Plass, D.; McDonald, S. A.; Maringhini, G.; van Lier, A.; Haagsma, J. A.; Havelaar, A. H.; Kramarz, P.; Kretzschmar, M. E. Impact of infectious diseases on population health using incidence-based disability-adjusted life years (DALYs): results from the Burden of Communicable Diseases in Europe study, European Union and European Economic Area countries, 2009 to 2013. Eurosurveillance 2018, 23 (16), 17-00454, DOI: 10.2807/1560-7917.ES.2018.23.16.17-00454 Google ScholarThere is no corresponding record for this reference.12 Management of Legionella in Water Systems; National Academies of Sciences, Engineering, and Medicine, The National Academies Press: Washington, DC, 2020; p 305.Google ScholarThere is no corresponding record for this reference.13Simmering, J. E.; Polgreen, L. A.; D. B.; D. K.; Polgreen, P. M. for Legionnaires' United States. Emerging Infect. Dis. 2017, 23 DOI: Google for Legionnaires' United E; A; Daniel K; infectious diseases (2017), 23 ISSN:. Using the and weather data, we the of pneumonia being as Legionnaires' disease LD risk increases when weather is warm and humid. warm we a between and the odds for the was with high the odds for being with LD were higher than with of in some (e.g., the LD is the cause of In other and (e.g., the in LD is suspicion for LD should increase when weather is warm and humid. when weather is or all patients for LD contribute to antimicrobial use at a population >> More from SciFinder for Disease Control and for and Public and 2020 (accessed ScholarThere is no corresponding record for this for Disease Control and for and to Disease 2019 (COVID-19), 2020. 2020 (accessed ScholarThere is no corresponding record for this Legionella Management in Water The of American 2020; p ScholarThere is no corresponding record for this Health Influenza A(H1N1) 2009 current and post-pandemic 2011, ScholarThere is no corresponding record for this By to copy section linkSection link copied! This article is by Li, Xu, Wu, H. of Legionella in a Public Water COVID-19 & Health S. D. J. L. L. COVID-19 of the to Science & 2021, 8 B. between and or for Legionella Science & 2021, 8 J. J. of Legionella in an Assessment of potable water Science of The S. Song, C. A. L. R. J. J. J. Legionella pneumophila in in during the COVID-19 pandemic. Water & (11) and health care of in Disease & Health An the Microbiology, and of Legionella A of (3) of for Legionella pneumophila in Microbiology C. environmental and health risk when returning to COVID-19 in Science & Health P. S. D. N. J. Water management during the initial of the and Journal of Water 4 A. N. Daniel Legionnaires' disease in to and patients. Journal of and 2021, 18 Matthew A. surveillance during the water Water 2021, The is in the of the pathogens in the Journal of Hospital Infection 2021,