Legionnaires' disease: Evaluation of a quantitative microbial risk assessment model

Journal of Water and Health

Volumn 6, Issue 2, 2008, Pages 149-166

  Armstrong, Thomas W ^a,b   Haas, Charles N ^c  

^a EXXONMOBIL UPSTREAM RESEARCH COMPANY   (United States)

^b Civil Architectural and Environmental Engineering ^*  (United States)

^c Drexel University   (United States)

Author keywords

Legionella; Legionella pneumophila; Legionnaires' disease; Quantitative microbial risk assessment; Risk assessment

Indexed keywords

DISEASE CONTROL; DISEASE SPREAD; ESTIMATION METHOD; NUMERICAL MODEL; QUANTITATIVE ANALYSIS; RISK ASSESSMENT; WATER POLLUTION;

ARTICLE; CALCULATION; DISEASE MODEL; DISEASE SEVERITY; ENVIRONMENTAL EXPOSURE; EPIDEMIC; HOSPITALIZATION; HUMAN; INFECTION RATE; LEGIONELLA; LEGIONNAIRE DISEASE; MODEL; MORTALITY; NONHUMAN; QUANTITATIVE STUDY; RISK ASSESSMENT; WATER CONTAMINATION;

ANIMALS; COLONY COUNT, MICROBIAL; DISEASE OUTBREAKS; HOT SPRINGS; HUMANS; HYDROTHERAPY; LEGIONELLA PNEUMOPHILA; LEGIONNAIRES' DISEASE; LETHAL DOSE 50; MODELS, ANIMAL; MODELS, STATISTICAL; PROBABILITY; RISK ASSESSMENT; WATER MICROBIOLOGY;

ANIMALIA; LEGIONELLA; LEGIONELLA PNEUMOPHILA;

EID: 37249029971     PISSN: 14778920     EISSN: None     Source Type: Journal    
DOI: 10.2166/wh.2008.026     Document Type: Article

References (77)

1. Anonymous 2003 Legionellosis, April 1999-December 2002, Japan. IASR 24, 27-28.
2. Anonymous 2007 Exact Binomial and Poisson Confidence Intervals Accessed: 10 March, 2007, Web-based statistical calculation applet http://statpages.org/confint.html
3. Armstrong, T.W. 2005 A Quantitative Microbial Risk Assessment Model for Human Inhalation Exposure to Legionella Doctor of Philosophy, Drexel University, Philadelphia, USA. Available at: http://dspace.library.drexel.edu/handle/1860/615
4. Armstrong, T. W. & Haas, C. N. 2003 Inter-Species Extrapolation Factors in Quantitative Microbial Risk Assessment. Society for Risk Analysis, Baltimore.
5. Armstrong, T. W. & Haas, C. N. 2006 A quantitative microbial risk assessment model for Legionella: summary of methods and evaluation results. In Legionella: State of the Art 30 Years after its Recognition (ed. N. P. Cianciotto, Y. A. Kwaik, P. H. Edelstein, B. S. Fields, D. F. Geary, T. G. Harrison, C. A. Joseph, R. M. Ratcliff, J. E. Stout & M. S. Swanson), ASM Press, Washington, DC., USA. pp. 486-489.
6. Armstrong, T. W. & Haas, C. N. 2007a A quantitative microbial risk assessment model for Legionnaires disease: assessment of human exposures for selected spa outbreaks. J. Occup. Environ. Hyg. 4(8), 634-646.
7. Armstrong, T.W. & Haas, C.N. 2007b A quantitative microbial risk assessment model for Legionnaires' disease: animal model selection and dose-response modeling. Risk Anal. 27(6), 1581-1596.
8. Baskerville, A., Fitzgeorge, R. B., Broster, M., Hambleton, P. & Dennis, P. J. 1981 Experimental transmission of legionnaires' disease by exposure to aerosols of Legionella pneumophila. Lancet 2, 1389-1390.
9. Baskerville, A., Fitzgeorge, R. B., Broster, M. & Hambleton, P. 1983 Histopathology of experimental Legionnaires' disease in guinea pigs, rhesus monkeys and marmosets. J.Pathol. 139, 349-362.
10. Berendt, R. F., Young, H. W., Allen, R. G. & Knutsen, G. L. 1980 Dose-response of guinea pigs experimentally infected with aerosols of Legionella pneumophila. J.Infect.Dis. 141, 186-192.
11. Berk, S. G., Ting, R. S., Turner, G. W. & Ashburn, R. J. 1998 Production of respirable vesicles containing live Legionella pneumophila cells by two Acanthamoeba spp. Appl. Environ. Microbiol. 64, 279-286.
12. Bhopal, R. S. & Fallon, R. J. 1991 Variation in time and space of non-outbreak Legionnaires' disease in Scotland. Epidemiol. Infect. 106, 45-61.
13. Blanchard, D. C. 1983 The production, distribution, and bacterial enrichment of the sea- salt aerosol. In Air-Sea Exchange of Gases and Particles (ed. P. S. Liss & W. G. N. Slinn), Reidel, NATO ASI, C 108. pp. 407-454.
14. Blanchard, D. C. 1989 The size and height to which jet drops are ejected from bursting bubbles in seawater. J. Geophys. Res. 94, 10999-11002.
15. Blanchard, D. C. & Syzdek, L. 1970 Mechanism for the water-to-air transfer and concentration of bacteria. Science 170, 626-628.
16. Blanchard, D. C. & Syzdek, L. D. 1982 Water-to-air transfer and enrichment of bacteria in drops from bursting bubbles. Appl.Environ.Microbiol. 43, 1001-1005.
17. Boshuizen, H. C., Neppelenbrock, S. E., van Vliet, H., Schellekens, J. F., den Boer, J. W., Peeters, M. F., Verbakel, H., Heijnene, M. & Conyn-van Spaendonck, M. A. Serological findings and health complaints in exhibitors working on the 1999 Westfriese Flora in Bovenkarspel. RIVM report 213690.006
18. Boshuizen, H. C., Neppelenbroek, S. E., van Vliet, H., Schellekens, J. F., den Boer, J. W., Peeters, M. F. & Conyn-van Spaendonck, M. A. 2001 Subclinical Legionella infection in workers near the source of a large outbreak of legionnaires disease. J. Infect. Dis. 184, 515-518.
19. Boshuizen, H. C., Nagelkerke, N. J., Den Boer, J. W., De Melker, H., Schellekens, J. F., Peeters, M. F., Van Vliet, H. & Conyn-Van Spaendonck, M. A. 2006 Estimation of minimum infection rates with Legionella pneumophila in an exposed population. Epidemiol. Infect. 134, 579-584.
20. Breiman, R. F. & Horwitz, M. A. 1987 Guinea pigs sublethally infected with aerosolized Legionella pneumophila develop humoral and cell-mediated immune responses and are protected against lethal aerosol challenge. A model for studying host defense against lung infections caused by intracellular pathogens. J. Exp. Med. 165, 799-811.
21. Burmaster, D. E. & Anderson, P. D. 1994 Principles of good practice for the use of Monte Carlo techniques in human health and ecological risk assessments. Risk Anal. 14, 477-481.
22. Colbourne, J. S., Dennis, P. J., Lee, J. V. & Bailey, M. R. 1987 Legionnaires' disease: reduction in risks associated with foaming in evaporative cooling towers (letter). Lancet 1, 684-684.
23. Crump, K. S. 1994 Risk of benzene-induced leukemia: a sensitivity analysis of the Pliofilm cohort with additional follow-up and new exposure estimates. J. Toxicol. Environ. Health 42, 219-242.
24. Crump, K. S. 1996 Risk of benzene-induced leukemia predicted from the Pliofilm cohort. Environ. Health Perspect. 104, 1437-1441.
25. Davis, G. S., Winn, C. W. Jr., Gump, D. W., Craighead, J. M. & Beaty, H. N. 1983 Legionnaires' pneumonia in guinea pigs and rats produced by aerosol exposure. Chest 83, 15S-16S.
26. den Boer, J. W., Yzerman, E. P., Schellekens, J., Lettinga, K. D., Boshuizen, H. C., Van Steenbergen, J. E., Bosman, A., Van den Hof, S., Van Vliet, H. A., Peeters, M. F., van Ketel, R. J., Speelman, P., Kool, J. L. & Conyn-van Spaendonck, M. A. 2002 A large outbreak of Legionnaires' disease at a flower show, the Netherlands, 1999. Emerg. Infect. Dis. 8, 37-43.
27. Dourson, M. L., Felter, S. P. & Robinson, D. 1996 Evolution of science-based uncertainty factors in noncancer risk assessment. Regul. Toxicol. Pharmacol. 24, 108-120.
28. Dowling, J. N., Saha, A. K. & Glew, R. H. 1992 Virulence factors of the family Legionellaceae. Microbiol. Rev. 56, 32-60.
29. Edelstein, P. H. & Meyer, R. D. 1984 Legionnaires' disease. A review. Chest 85, 114-120.
30. EPA U.S. 1999 Guidelines for Carcinogen Risk Assessment. Accessed: 13 November, 2005. http://www.epa.gov/iris/cancer_gls.pdf
31. European Chemicals Bureau 2003 Technical Guidance Document on Risk Assessment. Accessed: 13 November, 2005. http://ecb.jrc.it/ home.php?CONTENU=/Technical-Guidance-Document/sommaire.php
32. Fields, B. S., Benson, R. F. & Besser, R. E. 2002 Legionella and Legionnaires' disease: 25 years of investigation. Clin. Microbiol. Rev. 15, 506-526.
33. Fitzgeorge, R. B., Baskerville, A., Broster, M., Hambleton, P. & Dennis, P. J. 1983 Aerosol infection of animals with strains of Legionella pneumophila of different virulence: comparison with intraperitoneal and intranasal routes of infection. J. Hyg (Lond) 90, 81-89.
34. Fliermans, C. B., Cherry, W. B., Orrison, L. H., Smith, S. J., Tison, D. L. & Pope, D. 1981 H Ecological distribution of Legionella pneumophila. Appl. Environ. Microbiol. 41, 9-16.
35. Georgescu, S. -C., Achard, J. -L. & Canot, E. 2002 Jet drops ejection in bursting gas bubble processes. Eur. J. Mech. B/Fluids 21, 265-280.
36. Haas, C. N. 1983 Estimation of risk due to low doses of microorganisms: a comparison of alternative methodologies. Am. J. Epidemiol. 118, 573-582.
37. Haas, C. N. 1994 Dose-response analysis using spreadsheets. Risk Anal. 14, 1097-1100.
38. Haas, C. N., Rose, J. B. & Gerba, C. P. 1999 Quantitative Microbial Risk Assessment. John Wiley, New York, USA.
39. Health Canada 2004 Federal Contaminated Site Risk Assessment. In: Canada Part I: Guidance on Human Health Preliminary Quantitative Risk Assessment (PQRA). Accessed: 13 November, 2005. http://www.hc-sc.gc.ca/ewh-semt/pubs/contamsite/part-partie_i/ index_e.html
40. Hejkal, T. W., LaRock, P. A. & Winchester, J. W. 1980 Water-to-air fractionation of bacteria. Appl. Environ. Microbiol. 39, 335-338.
41. Izu, K., Yoshida, S., Miyamoto, H., Chang, B., Ogawa, M., Yamamoto, H., Goto, Y. & Taniguchi, H. 1999 Grouping of 20 reference strains of Legionella species by the growth ability within mouse and guinea pig macrophages. FEMS Immunol. Med. Microbiol. 26, 61-68.
42. Jacobs, R. F., Locksley, R. M., Wilson, C. B., Haas, J. E. & Klebanoff, S. J. 1984 Interaction of primate alveolar macrophages and Legionella pneumophila. J.Clin.Invest. 73, 1515-1523.
43. Jepras, R. I., Fitzgeorge, R. B. & Baskerville, A. 1985 A comparison of virulence of two strains of Legionella pneumophila based on experimental aerosol infection of guinea-pigs. J. Hyg (Lond) 95, 29-38.
44. Joly, J. R., Boissinot, M., Duchaine, J., Duval, M., Rafrafi, J., Ramsay, D. & Letarte, R. 1984 Ecological distribution of Legionellaceae in the Quebec city area. Can. J. Microbiol. 30, 63-67.
45. Kaufmann, A. F., McDade, J. E., Patton, C. M., Bennett, J. V., Skaliy, P., Feeley, J. C., Anderson, D. C., Potter, M. E., Newhouse, V. F., Gregg, M. B. & Brachman, P. S. 1981 Pontiac fever: isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission. Am. J. Epidemiol. 114, 337-347.
46. Kishimoto, R. A., Kastello, M. D., White, J. D., Shirey, F. G., McGann, V. G., Larson, E. W. & Hedlund, K. W. 1979 In vitro interaction between normal cynolmolgus monkey alveolar macrophages and Legionnaires disease bacteria. Infect. Immun. 25, 761-763.
47. Koide, M., Arakaki, N. & Saito, A. 2001 Distribution of Legionella longbeachae and other legionellae in Japanese potting soils. J. Infect. Chemother. 7, 224-227.
48. Korvick, J. A., Yu, V. L. & Fang, G. -D. 1987 Legionella species as hospital-acquired respiratory pathogens. Semin. Resp. Infect. 2, 34-47.
49. Lattimer, G. L., Rhodes, L. V., III., Salventi, J. S., Galgon, J. P., Stonebraker, V., Boley, S. & Haas, G. 1979 The Philadelphia epidemic of Legionnaire's disease: clinical, pulmonary, and serologic findings two years later. Ann. Intern. Med. 90, 522-526.
50. Lewis, S. C., Lynch, J. R. & Nikiforov, A. I. 1990 A new approach to deriving community exposure guidelines from "no-observed-adverse- effect levels". Regul. Toxicol. Pharmacol. 11, 314-330.
51. McDade, J. E., Shepard, C. C., Fraser, D. W., Tsai, T. R., Redus, M. A. & Dowdle, W. R. 1977 Legionnaires' disease: isolation of a bacterium and demonstration of its role in other respiratory disease. N. Engl. J. Med. 297, 1197-1203.
52. Meek, M. E., Renwick, A., Ohanian, E., Dourson, M., Lake, B., Naumann, B. D. & Vu, V. 2002 Guidelines for application of chemical-specific adjustment factors in dose/concentration-response assessment. Toxicology 181-182, 115-120.
53. Meenhorst, P. L., Reingold, A. L., Gorman, G. W., Feeley, J. C., van Cronenburg, B. J., Meyer, C. L. & van Furth, R. 1983 Legionella pneumonia in guinea pigs exposed to aerosols of concentrated potable water from a hospital with nosocomial Legionnaires' disease. J. Infect. Dis. 147, 129-132.
54. Millar, J. D. 1997 Legionnaires' disease: seeking effective prevention. ASHRAE J. 39, 22-29.
55. Muller, D., Edwards, M. L. & Smith, D. W. 1983 Changes in iron and transferrin levels and body temperature in experimental airborne legionellosis. J. Infect. Dis. 147, 302-307.
56. Nagelkerke, N. J., Boshuizen, H. C., de Melker, H. E., Schellckens, J. F., Peeters, M. F. & Conyn-van Spaendonck, M. 2003 Estimating the incidence of subclinical infections with Legionella pneumonia using data augmentation: analysis of an outbreak in The Netherlands. Stat. Med. 22, 3713-3724.
57. O'Brien, S. J. & Bhopal, R. S. 1993 Legionnaires' disease: the infective dose paradox. Lancet 342, 5-6.
58. Okada, M., Kawano, K., Amemura-Maekawa, J., Watanabe, H., Yagita, K., Endo, T. & Suzuki, S. 2005 The largest outbreak of legionellosis in Japan associated with spa baths: epidemic curve and environmental investigation (in Japanese). Kansenshogaku Zasshi 79, 365-374.
59. Ortiz-Roque, C. M. & Hazen, T. C. 1987 Abundance and distribution of Legionellaceae in Puerto Rican waters. Appl. Environ. Microbiol. 53, 2231-2236.
60. Paustenbach, D. J., Price, P. S., Ollison, W., Blank, C., Jernigan, J. D., Bass, R. D. & Peterson, H. D. 1992 Reevaluation of benzene exposure for the Pliofilm (rubberworker) cohort (1936-1976). J. Toxicol. Environ. Health 36, 177-231.
61. Paustenbach, D. J., Bass, R. D. & Price, P. 1993 Benzene toxicity and risk assessment, 1972-1992: implications for future regulation. Environ. Health Perspect. 101, 177-200.
62. Paxton, M. B. 1996 Leukemia risk associated with benzene exposure in the Pliofilm cohort. Environ. Health Perspect. 104, 1431-1436.
63. Quinn, J. A., Steinbrook, R. A. & Anderson, J. L. 1975 Breaking bubbles and the water-to-air transport of particulate matter. Chem. Eng. Sci. 30, 1177-1184.
64. Rechnitzer, C., Williams, A., Wright, J. B., Dowsett, A. B., Milman, N. & Fitzgeorge, R. B. 1992 Demonstration of the intracellular production of tissue- destructive protease by Legionella pneumophila multiplying within guinea-pig and human alveolar macrophages. J. Gen. Microbiol. 138, 1671-1677.
65. Renwick, A. G. & Lazarus, N. R. 1998 Human variability and noncancer risk assessment-an analysis of the default uncertainty factor. Regul. Toxicol Pharmacol. 27, 3-20.
66. Riffard, S., Douglass, S., Brooks, T., Springthorpe, S., Filion, L. G. & Sattar, S. A. 2001 Occurrence of Legionella in groundwater: an ecological study. Wat. Sci. Technol. 43(12), 99-102.
67. Rinsky, R. A., Smith, A. B., Hornung, R., Filloon, T. G., Young, R. J., Okun, A. H. & Landrigan, P. J. 1987 Benzene and leukemia. An epidemiologic risk assessment. N. Engl. J. Med. 316, 1044-1050.
68. Schaechter, M., Engleberg, N. C., Eisenstein, B. I. & Medoff, G. (eds) 1999 Mechanisms of Microbial Disease. Lippincott Williams & Wilkins, Philadelphia, USA.
69. Schnatter, A. R., Nicolich, M. J. & Bird, M. J. 1996 Determination of leukemogenic benzene exposure concentrations: refined analyses of the Pliofilm cohort. Risk Anal. 16, 833-840.
70. Shelton, B. G., Flanders, W. D. & Morris, G. K. 1994 Legionnaires' disease outbreaks and cooling towers with amplified Legionella concentrations. Curr. Microbiol. 28, 359-363.
71. Steele, T. W., Moore, C. V. & Sangster, N. 1990 Distribution of Legionella longbeachae scrogroup 1 and other Legionellae in potting soils in Australia. Appl. Environ. Microbiol. 56, 2984-2988.
72. Sugiyama, K., Nishio, T., Goda, Y., Masuda, K., Fanfei, Z., Akiyama, M. & Miyamoto, H. 2000 An outbreak of legionellosis linked to bath water circulating through a filter at a spa resort, March-April 2000 - Shizuoka. IASR 21, 188.
73. Twisk-Meijssen, M. J., Meenhorst, P. L., van Cronenburg, B. J., Mulder, J. D., Scheffer, E. & van Furth, R. 1987 The course of Legionella pneumonia in guinea pigs after inhalation of various quantities of L. pneumophila. Immunobiology 176, 108-124.
74. Williams, P. R. & Paustenbach, D. J. 2003 Reconstruction of benzene exposure for the Pliofilm cohort (1936-1976) using Monte Carlo techniques. J. Toxicol. Environ. Health A 66, 677-781.
75. Wright, E. K., Goodart, S. A., Growney, J. D., Hadinoto, V., Endrizzi, M. G., Long, E. M., Sadigh, K., Abney, A. L., Bernstein-Hanley, I. & Dietrich, W. F. 2003 Naip5 affects host susceptibility to the intracellular pathogen Legionella pneumophila. Curr. Biol. 13, 27-36.
76. Yabuuchi, E. & Agata, K. 2004 An outbreak of legionellosis in a new facility of hot spring bath in Hiuga City (in Japanese). Kansenshogaku Zasshi 78, 90-98.
77. Zacheus, O. M. & Martikainen, P. J. 1994 Occurrence of Legionellae in hot water distribution systems of Finnish apartment buildings. Can. J. Microbiol. 40, 993-999.