Legionnaires outbreak in Warstein 2013

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The legionnaire's disease outbreak in Warstein in 2013 was an increased occurrence of atypical, severe pneumonia . The wave of illnesses began on August 10, 2013. By September 25, a total of 165 cases of illness and suspected cases were known. Three patients have died up to this point. Microbiological findings show that the cause of the disease, also known as Legionnaires' disease , is the pathogen Legionella pneumophila . This bacterium multiplies at temperatures between 25 and 40 ° C in water supply facilities and especially in evaporative cooling systems and is - spread as bioaerosol - ingested by those affected via the respiratory tract .

According to Martin Exner , Director of the Center for Infectious Diseases and Protection from Infections at the University of Bonn , the cases of illness in Warstein are the most extensive outbreaks of this disease in Germany to date , and at the same time it is the third largest known Legionella outbreak in Europe. The worst outbreak to date, with 65 cases of illness and 5 deaths, occurred in Ulm at the beginning of 2010 .

Course of the outbreak

View of the Warsteiner Stadtberg with the old church, in the foreground the Maria-Hilf hospital

Starting on August 10, 2013 , an increasing number of patients with severe pneumonia were admitted for inpatient treatment at the local hospital, the Maria-Hilf Warstein Hospital . With ten or more inpatient admissions daily for community- acquired pneumonia , the number of patients referred was well above the average of the referrals expected at this time of year. Several patients had to receive intensive care. Artificial ventilation was required in three cases . A critically ill patient was transferred by helicopter to a special clinic two days later . The accumulation of severe pneumonia observed over the weekend was reported to the responsible health authorities on the following working day .

Most of the sick recovered quickly with combined antibiotic therapy. However, one patient died a few days later under the impression of multiple organ failure , another patient was still being treated in intensive care, and the patient who had been transferred to a special clinic was also still in critical condition on August 22nd. In a short press release from the Soest district health department , however, it was announced on August 23 that she was not suffering from legionellosis but from another bacterial infection. The second previously known fatality was found dead in his apartment; according to third-party information, the symptoms known from the reports of other sick people were also present here . Another death occurred on the morning of August 26th. On September 24th, the investigating public prosecutor from Arnsberg announced that the 62-year-old woman, who was seriously ill in health, had died of pneumonia and was also infected with Legionella. That is clear from the report of the coroner out that the autopsy was performed. Up until September 5, the number of new cases fluctuating was reported every day. From September 6th to September 8th, no further new cases were known. On Monday, September 9th, the Soest district announced that another patient suspected of having legionnaires was being treated in the Warsteiner hospital. No further new cases were known until September 17th. The case of the disease reported on September 9th was also assigned to the outbreak by the health department; the typing of the pathogens found by the Konsiliarlabor in Dresden had proven the same Legionella subtype whose genetic fingerprint was also discovered in the Esser-Werke's recooling plant. With reference to a publication by the European Legionnaires' Disease Surveillance Network (ELDSNet) it was found that the incubation period of normally two to ten days could in exceptional cases be 16 to 20 days. Thus, this last case so far also fits the assumption that after the shutdown and disinfection of the recooling plant, there was no further infection.

Treatment and confirmation of the diagnosis

Legionella pneumophila under the scanning electron microscope

In view of the severity of the clinical picture of the assigned patients, the treating physicians gave immediate, effective treatment priority over the requirements of establishing a diagnosis. The early, consistent treatment with a suitable combination of antibiotics has probably contributed to the fact that the mortality rate of 10 to 15% cited in the literature was clearly undercut, possibly at the expense of clear microbiological findings. In the meantime (as of September 11th) Legionella has been bacteriologically detected in 92 patients and in the lungs of the two patients who died in hospital .

After a concentration of legionella was found in a recooling plant that is suitable to trigger legionnaires (see below), the Legionella found in the recooling plant and in the patients were further bred and typified by the responsible consulting laboratory in Dresden in order to create a complete chain of causalities from the found Legionella on the pathogens found in the patient. At the press conference on September 4, it was announced that this evidence could be obtained by means of extensive investigations (see below).

After the outbreak was over, Exner pointed out at a special public council meeting that the Warsteiner citizens had received the best possible care from their hospital. The combination of antibiotics given to the patients from the start had been the best experience, the mortality of the treated patients was around two percent, normally an average of seven percent is expected. “The hospital worked with good diagnostics and adequate therapy. In the past, this would have meant that 15 or 16 would have died out of 165 sick people. ”( M. Exner ) the director of the Center for Infectious Diseases and Infection Protection at the University of Bonn is quoted verbatim.

Media coverage

Since August 20, 2013, the media have been reporting on the unusual accumulation of pneumonia under different headings (“Puzzling wave of illness”, “Influenza outbreak in Warstein”, etc.). The official hope that the peak of the wave of illnesses had passed since August 21 was not fulfilled: On the following days, a large number of other sick people came to the Maria-Hilf Warstein hospital, but also to hospitals in the area added. Because of the long incubation period , which can be three to five days, but also up to ten days in exceptional cases, further cases were expected. In the further course, steadily increasing case numbers were reported.

Since August 26th, almost all the relevant print media and their online appearances have been reporting on the illness in Warstein.

On September 2, the outbreak was first mentioned in the " Epidemiological Bulletin " of the Robert Koch Institute . Doctors who treat community-acquired pneumonia were advised to have a urine test for Legionella, especially if they had a travel history to Warstein.

Find the source of infection

Recooling plant of the Esser works in the Westertal. This cooling system, which was operated with water from the Wester, spread the legionella as an aerosol.
Warstein sewage treatment plant; high concentrations of legionella were found here, which may have got into the west and then polluted the cooling system.
The Warsteiner Brewery : Legionella were also found in the company's own sewage treatment plant and in two recooling plants. A connection with the wave of the disease could not be proven until September 11th.

Based on the first investigation results and the course of the outbreak, Martin Exner assumed that the spread of legionella in the air was caused by one of the evaporative cooling systems on industrial or commercial buildings in Warstein. Only so-called recooling plants come into question , in which the waste heat is dissipated by evaporating water that is released into the atmosphere in vapor. The district health authority, supported by a 60-strong crisis team, tried from August 21 to locate the source of the spread of Legionella. Samples for bacteriological analysis were taken from all the systems in question. All the systems concerned were disinfected and temporarily shut down following the investigation .

On August 27, the district health authority announced in a press release that the Institute for Hygiene and Public Health at the University of Bonn had presented the first preliminary results of the samples taken between August 21 and 23. The sample from a company's recooling plant produced a positive result; all other samples were negative or harmless. This is "[...] a concrete trace, but not yet definitely the source. We are responsible for not yet giving the all-clear. ”( F. Renken, Head of the Soest Health Department ) continued the message. The suspicion is corroborated by the appropriate meteorological conditions, and the serotype found belongs to the legionella strains that, according to M. Exner, can be spread by such a recooling plant. The concentration of Legionella found is also suitable for triggering diseases. The plant presumably responsible for the spread of the disease has been shut down since August 21 and is meanwhile being cleaned and disinfected by a specialized company. For legal reasons, the health department has not announced which company it is.

In the daily press, however, on August 27, the Esser works were named as the allegedly causative company. The company's managing director admitted that an increased number of legionella was detected in the water in his company's cooling system, but this does not necessarily mean that this is the sole source of legionella.

On September 4, 2013, new, sometimes surprising, findings were made public at a press conference at the Soest district. According to this, the legionellosis diseases in Warstein could be traced back to the legionella emitted from the recooling plant of the Esser works. Evidence was provided by complex genetic typing of the 19 Legionella strains found in the recooling plant, whose “ genetic fingerprint ” was compared with the patient's samples. At the same time, however, an extraordinarily high occurrence of Legionella was detected in a basin of the Warsteiner sewage treatment plant operated by the Ruhrverband . Up until then, this possibility had always been ruled out - despite repeated indications from the population. Therefore, the basin was only sampled on Friday, August 30th (and not during the inspection on August 21st, during which the sole purpose of looking for recooling plants). At the press conference it was suspected that the sewage treatment plant had discharged legionella-colonized water into the Wester . The downstream Esser works are said to have taken water from the Wester and trickled it into their recooling works. This then made it possible to spread it further.

The Ruhrverband commented on the results of the investigation in a press release on September 4th. The burden on the biological purification stage and, to a lesser extent, on the sewage treatment plant process was acknowledged. The causal connection between this pollution of the Wester and the recooling plant of the Esser works must be examined in more detail. The procurement of a mobile disinfection system for the process had been initiated as a precaution. Further measures to prevent the formation of aerosols and an intensive measurement program would also be implemented at short notice.

In a press release by the Soest district crisis management team on September 6th, it was confirmed that the fine typing of the samples by the consulting laboratory in Dresden is now proof that the legionella spread through the Esser-Werke's recooling plant is the cause of the disease. According to M. Exner, everything speaks in favor of the fact that the bacteria from the sewage treatment plant got into the Wester and through water extraction from the Wester into the recooling plant.

On September 11, the Warsteiner Brewery announced that Legionella had also been found in the wastewater pre-treatment basins of the company's sewage treatment plant and in a cooling system. Investigations by the Gelsenkirchen Hygiene Institute, commissioned by the brewery itself, had initially shown harmless values: three samples taken on August 20 had no findings, and three other samples showed a legionella load of 100 to 4,500 CFU . In a second test on September 4, the Gelsenkirchen Hygiene Institute found 70,000 CFU per 100 ml and on September 6, the Institute for Hygiene at the University of Bonn found 500,000 CFU per 100 ml. After a meeting with representatives of the State Environment Ministry, a number of measures were taken decided. These essentially correspond to the measures that also apply to the municipal sewage treatment plant: Covering the company's own clarification basin, UV disinfection of the drain and continuous disinfection of the recooling plants. A connection with the wave of illness could not be proven on September 11th, further investigations are being carried out on this.

In the following days it was found that the flow of the brewery's own waste water supply basin (i.e. the waste water discharged from the brewery) was free of Legionella and that the bacterial load could only be detected in this supply basin. Together with the responsible authorities, measures to reduce the Legionella content and to prevent its spread by means of aerosols were ordered, decided and initiated. This includes, among other things, the covering of the feed basin with foils and the disinfection of the wastewater given off to the municipal sewage treatment plant. Furthermore, after the cover has been installed around the contaminated flow basin, unpolluted brewery wastewater is to be diverted to the brewery's wastewater treatment basin that has not been used until then, so that only unpolluted wastewater is discharged into the municipal sewage treatment plant after the sewer has been disinfected. The implementation of these measures should be completed by Wednesday, September 18.

In the meantime, the Ruhrverband, as the operator of the municipal sewage treatment plant, has completed the cover of its activated sludge basin, and the UV disinfection system is running.

On September 23, 2013, M. Exner announced at a public special council meeting in the Warsteiner Gymnasium that after the examinations had been completed, the Legionella strain that caused the disease in the recooling plant of the Esser works, in low concentration also in the recooling plant of the Warsteiner brewery and in high concentration in the clarification basin of Brewery and the municipal sewage treatment plant had been identified. The identification strain of the disease-causing Legionella will now be linked to the Warsteiner outbreak as sequence type 345 of the Knoxville subtype .

Effects of the outbreak

Due to the outbreak situation, which cannot yet be finally assessed, the city of Warstein followed the recommendations of the Soest district health authority not to approve any major events for the time being. This mainly affected the Warsteiner Internationale Montgolfiade (WIM) - the largest hot air balloon competition in Europe, to which 100,000 visitors were expected - for which the city of Warstein withdrew its approval. "[...] It has not yet been established with certainty whether the source of infection that has meanwhile been found in the urban area was solely responsible for the illnesses of more than 100 citizens that have occurred in Warstein for two weeks." “We fully share the community's sense of responsibility. The health and protection of the population have top priority, ”write the managing directors of WIM.

Since August 30, 2013, the Soest district officially warned against traveling to Warstein, with reference to the pending final confirmation of the test results. The residents were informed that staying in closed rooms reduced the risk of infection. The new development meant that the Soest district could not lift its "travel warning" for Warstein on September 4th. The environment minister of North Rhine-Westphalia , Johannes Remmel ( Bündnis 90 / Die Grünen ), also prohibited the extraction of water from the west below the sewage treatment plant from September 4th. At the same time, the Ministry of the Environment ordered a nationwide investigation of around 20 identical sewage treatment plants. In order to avert acute danger, the ministry advised the Ruhr Association to install a UV disinfection system. Such a system could already be available at the weekend.

On September 6th, the Soest district's crisis team announced that the travel warning could possibly be lifted on Monday, September 10th. Until then, the Ruhrverband will take further measures to ensure that the sewage treatment plant can no longer pose any further danger. M. Exner described the planned measures as adequate.

After the occurrence of a new illness on September 9, the travel warning for Warstein was renewed, provisionally until Thursday, September 12. The visitor center of the Warsteiner Brewery was closed for the duration of the "travel warning". On September 12, the travel warning was not lifted due to the fact that the security measures had not yet been completed; On Monday, September 16, the Soest district announced in a comprehensive press release that the measures ordered were expected to be completed on September 18, until then the "travel warning" remained in force.

On Wednesday, September 18, the crisis team and the health department of the Soest district lifted the travel warning because the security measures that had been decided had largely been completed. Both the sewage basin of the brewery and the activated water basin of the municipal sewage treatment plant were covered, and the UV disinfection systems at the brewery and the sewage treatment plant were operational. In order to avoid any risk during the upcoming cleaning of the sewer between the brewery and the municipal sewage treatment plant, all manhole covers were sealed. The workers carrying out the work were provided with suitable protective clothing; the completion of the cleaning work was scheduled for September 19th. Until then, the brewery had stopped discharging wastewater into the municipal sewage treatment plant. Since no further cases of illness were reported on September 18, the crisis team assumed that the measures taken had brought the outbreak to a standstill. The ban on water abstraction from the Wester initially remained in place, and close monitoring of the water quality is planned. District Administrator Eva Irrgang explained to the press: “We now have to check how intensively the installed UV cleaning works on the clarifier and how this affects the legionella load in the water. The ban can only be lifted if this is below the limit values. "

On the occasion of a special council meeting on September 23, it was announced that the abstraction of water from Wester and parts of the Möhne would continue to be prohibited, as the monitoring still showed significant contamination of the rivers with Legionella. In Völlinghausen, about 12 km away, 11,000 to 14,000 CFU / 100 ml were measured.

During this meeting, M. Exner demanded mandatory reporting for recooling plants and binding rules for their maintenance.

Before the Environment Committee of the Landtag in Dusseldorf the provincial environment minister gave Johannes Remmel on February 11, 2014 announced that in January 2014, the Warsteiner brewery very high concentrations were measured by Legionella in the aeration tank of the WWTP. Several million so-called colony-forming units (CFU) of legionella were found per 100 milliliters of water. In the case of drinking water, there is a legionella limit value of 100 colony-forming units (CFU). According to estimates by the Ruhr Association , the planned renovation and permanent protection of the Legionella-contaminated facilities in Warstein will cost around seven million euros. The company's sewage treatment plant from Warsteiner, the sewage system (brewery canal), which connects the company sewage treatment plant from Warsteiner with the communal sewage treatment plant, and the communal sewage treatment plant are to be renovated. The planned renovation of the brewery canal alone would cost 1.8 million euros and the renovation of the Ruhrverband's sewage treatment plant would cost 5.5 million euros. The brewery duct is to be provided with pressure-tight sealed inspection shafts so that no more pathogens can get into the air. In the brewery's sewage treatment plant, the biological primary clarification is to be dispensed with in the future and only to function as a collecting basin. It was still unclear how the legionella can be removed from a bioreactor, here the aeration basin of the brewery sewage treatment plant, since a complete decommissioning and disinfection of the operational sewage treatment plant, sewerage and communal sewage treatment plant is not possible. For the rivers Wäster and Möhne , into which the water from the municipal sewage treatment plant is discharged, the water abstraction ban that had been in force since September 2013 still applied in February 2014. The concentrations of Legionella in these rivers were harmless. In February 2014 it was still unclear where exactly Legionella had their first breeding ground.

Legal regulations

For large systems from which drinking water is released to the public, there is an annual inspection obligation.

The operators of drinking water installations in which there is a large system for heating drinking water must have the drinking water checked routinely every three years if drinking water is supplied from this within the scope of an exclusively commercial activity (e.g. in larger residential buildings). The first investigation had to be completed by December 31, 2013.

Reports to the health department are necessary if the technical measure value for legionella, which was introduced in the drinking water ordinance in 2011, is exceeded. The Federal Ministry of Health has issued appropriate regulations for this.

However, no regulations regarding Legionella pollution have been issued for sewage treatment plants. According to the Environment Minister Johannes Remmel, there has not yet been a regulation that sewage treatment plants are also examined. He calls for strict controls of sewage treatment plants for pathogens. In the meantime, UV disinfection systems are installed before the water is introduced.

Web links

See also

Individual evidence

  1. ↑ a b The wave of illnesses in the Sauerland is not subsiding. WDR , August 23, 2013, archived from the original on August 25, 2013 ; accessed on August 23, 2013 .
  2. ↑ a b c New figures on the Warsteiner disease wave - as of 12 noon, 17.09.2013. (No longer available online.) Soest District Health Department , September 16, 2013, archived from the original on September 28, 2013 ; Retrieved September 16, 2013 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.kreis-soest.de
  3. ↑ a b c Legionella in Warstein cause third death. WAZ , September 24, 2013, accessed September 25, 2013 .
  4. ↑ a b The wave of illnesses in Warstein continues to rise - 86 people are affected. WAZ , August 22, 2013, accessed August 23, 2013 .
  5. ↑ Dt. Ärzteblatt, vol. 110, issue 38, p. 1532f
  6. ↑ M. Exner: Legionella: Life-threatening infection is avoidable - memorandum on the occasion of a wave of Legionella disease in Ulm. Institute for Hygiene and Public Health, University Hospital Bonn, February 24, 2010, accessed on August 27, 2013 .
  7. ↑ New figures on the wave of Legionella infections. (No longer available online.) Soest District Health Department , August 23, 2013, archived from the original on September 28, 2013 ; Retrieved August 24, 2013 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.kreis-soest.de
  8. ↑ a b c Warsteiners have earned solidarity from everyone. Soester Anzeiger, September 23, 2013, accessed on September 23, 2013 .
  9. ↑ Warstein: Already two dead from flu epidemic. ShortNews, August 19, 2013, accessed August 23, 2013 .
  10. ↑ supraregional reporting
  11. ↑ RKI (Ed.): Epidemiologisches Bulletin . No. 35 , September 2, 2013, ISSN  1430-0265 , p. 20 ( rki.de (PDF; 202.04 kB) [accessed on September 5, 2013]).
  12. ↑ Concrete trace in the legionella outbreak. (No longer available online.) Soest District Health Department, August 27, 2013, archived from the original on August 8, 2014 ; Retrieved August 27, 2013 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.kreis-soest.de
  13. ↑ Warsteiner Montgolfiade canceled due to Legionella. WAZ , August 27, 2013, accessed August 27, 2013 .
  14. ↑ A source for Legionella outbreak identified - pathogens in patients come from the Esser-Werke's recooling plant. (No longer available online.) Soest District , Press Office, September 4, 2013, formerly in the original ; Retrieved September 4, 2013 .  ( Page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.@1@ 2Template: Toter Link / www.kreis-soest.de  
  15. ↑ Legionella - evidence at the Warstein sewage treatment plant - Ruhrverband initiates first immediate measures for precautionary reasons. (PDF; 93 kB) Ruhrverband , September 4, 2013, accessed on September 5, 2013 .
  16. ↑ a b Recommendation of the health department probably only until Monday - Crisis team of the Soest district sees improvement in the situation. (No longer available online.) Soest district , September 6, 2013, archived from the original on August 9, 2014 ; Retrieved September 6, 2013 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.kreis-soest.de
  17. ↑ a b Legionella in "Warsteiner". WDR , September 11, 2013, accessed on September 11, 2013 .
  18. ↑ a b Legionella: Repeal of the recommendations only after completion of the measures. (No longer available online.) Soest district , September 16, 2013, archived from the original on January 10, 2014 ; Retrieved September 16, 2013 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.kreis-soest.de
  19. ↑ Warsteiner Internationale Montgolfiade 2013 is canceled. (No longer available online.) Warsteiner Internationale Montgolfiade GmbH, August 27, 2013, archived from the original on August 31, 2013 ; Retrieved August 27, 2013 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.warsteiner-montgolfiade.com
  20. ↑ No confirmation for legionella source yet. Health department turns to citizens with recommendations. Press release of August 30, 2013  ( page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice. accessed on August 31, 2013@1@ 2Template: Toter Link / www.kreis-soest.de  
  21. ↑ W. Goebels, A. Gemünd: Legionella in Warstein come from the sewage treatment plant. WAZ , September 5, 2013, accessed September 5, 2013 .
  22. ↑ New illness is a mystery. WDR , September 9, 2013, archived from the original on October 6, 2013 ; accessed on August 17, 2015 .
  23. ↑ Legionella: Health Department cancels recommendations. (No longer available online.) Soest district , September 18, 2013, archived from the original on August 8, 2014 ; Retrieved September 18, 2013 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.kreis-soest.de
  24. ↑ Anna Gemünd: Travel warning for Warstein has been lifted. WAZ , September 18, 2013, accessed September 18, 2013 .
  25. ↑ Legionella remediation in Warstein costs millions. derwesten.de , February 14, 2014, accessed on February 27, 2014 .
  26. ↑ Warstein is arming itself in the fight against Legionella. welt.de , February 12, 2014, accessed on February 27, 2014 .
  27. ↑ a b Drinking water ordinance and regulations for legionella
  28. ↑ Master text of the Drinking Water Ordinance and Legionella ( Memento of the original from May 12, 2013 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. (As of January 3, 2013) @1@ 2Template: Webachiv / IABot / www.bmg.bund.de
  29. ↑ Gap in controls of sewage treatment plants