Legionnaires’ Disease or Legionella Facts
July 21, 1976, the American Legion had a three-day convention at the Bellevue-Stratford Hotel in Philadelphia, Pennsylvania. Within a week, more than 130 people, mostly men, had been hospitalized, and 25 had died.
In January 1977, the U.S. Centers for Disease Control and Prevention (CDC) identified the cause of the outbreak as Legionella bacterium. Legionella was found to be breeding in the cooling tower of the hotel’s air conditioning system, which then spread it through the building.
In April 1985, 175 patients were admitted to Kingsmead Stafford, United Kingdom hospitals, a total of 28 people died. The source was found to be an air-conditioning cooling tower on the roof of Stafford District Hospital.
In March 1999, an outbreak in the Netherlands occurred during the Westfriese Flora flower exhibition in Bovenkarspel, Netherlands. In this outbreak, 318 people became ill and at least 32 people died. The outbreak was traced to a hot tub used as a display in the exhibition area.
In April 2000, an outbreak of Legionella was documented in Melbourne, Australia, with 125 confirmed cases of Legionnaire's disease, 4 died from the outbreak. The outbreak was traced to a cooling tower at the newly opened aquarium.
40 Years Later U.S. CDC Spreading Cruise Industry Misinformation
Now, 40 years after Legionella was identified, the CDC 2016 edition of their Traveler's Health, Yellow Book, states in Chapter 6, "Legionnaires’ disease is a severe pneumonia caused by inhalation or possibly aspiration of warm, aerosolized water containing Legionella organisms. The organism is not transmitted from person to person. Contaminated ships’ whirlpool spas and potable water supply systems are the most commonly implicated sources of shipboard Legionella outbreaks."
The "most commonly implicated" includes only a single documented event
of cruise ship Legionella, 22 years ago. The "outbreak" as it was called was aboard Celebrity Cruises' cruise ship Horizon for a cruise to Bermuda, with the outbreak period being from June 26 to July 2, 1994. Pasquale Cantone, 68, who was a bus driver for the West Babylon School District in Long Island, New York died in a Long Island hospital after the cruise. The outbreak included 24 suspected cases, 11 in New Jersey, 7 in New York City and 6 in other parts of New York State.
The CDC documents no other verified cruise ship Legionella cases in their cruise ship outbreaks annual reports. Cases from November 2003 to May 2004 which the CDC mentions in some articles related to Legionella, were never proven as originating from a cruise ship, only that the person had cruised prior to becoming ill.
More importantly, stating "The organism is not transmitted from person to person. ", is incorrect, as a Cruise Bruise investigation discovered.
A lawsuit was filed by passenger Sue Myhra, who survived her husbands Tore Myhra's Legionella death. Tore Myhra, was a former Royal Caribbean Cruise Lines captain, who had resigned after being involved in two major incidents at sea, on which caused a death. Myhra was alleged to have contracted Legionella aboard Royal Caribbean Cruise Lines' Liberty of the Seas in October 2009, which followed a Legionella passenger death from September 2009, who had sailed aboard the same cruise ship. Sue Myhra sought to blame RCCL for her husband's death.
Testing of the Liberty of the Seas water supply showed beyond doubt, the source of the Legionella disease was not the cruise ship. According to a UK Coroner's report by Coroner Tom Osborne, water samples were taken from the ship in July 2009 before another passenger, Jean Young, who was also from the UK, came down with Legionella. Then, water samples were taken while Mr Myhra was on board in October, and after he disembarked. All three samples tested negative for Legionella. Both Young and Myhra who were from the United Kingdom and embarked from Miami, Florida, died from the same strain of Legionella.
United Kingdom Legionella Connection
In 2009, the United Kingdom had 344 cases of Legionella with a 12% mortality rate, the highest mortality rate year for Legionella from 2005 to 2014, according to a Public Health England report titled, Legionnaires’ Disease in England and Wales 2014
The United Kingdom population was 62.28 million in 2009. The U.S. had 3,522 case and their population was 306.8 million. Since the rate of Legionella in the United Kingdom was 5.52% and and the U.S. rate was 1.14%, it was nearly five times as likely Legionella was contracted in England before the cruise, where both Myhra and Young may have come in contact with the disease.
Miami Hotel Legionella Connection
However, during that period of time, the Epic Hotel in Miami was accused of a Legionella infection resulting in the death of a hotel guest. One cruise ship passenger died right before he boarded a cruise ship, after leaving the hotel in September 2009, with two others sick from Legionella Disease in November and December the same year. The hotel was cleared of the related death, but the two Legionella illnesses were confirmed as coming from the hotel.
The Epic Hotel is located at 270 Biscayne Blvd Way on the Miami waterfront, a short distance to the cruise ship terminal and has a view of the cruise ship terminal. It's popular with cruise ship passengers due to the close proximity to the cruise ships.
From 1973 to 2012, there were 30 documented outbreaks of Legionella, including the Miami Epic Hotel, only five of which were in the United states, three at hotels, two in hospitals, 17% of all Legionella outbreaks over a period of 39 years. With only a single outbreak on a cruise ship 22 years ago.
From January 2014 to April 2016, there were 40 outbreaks, worldwide, 20 were in the United States. Of the U.S. cases, nine were attributed to hospitals, nursing homes and a prison, five to hotels and five to apartment complexes and one other, which the CDC travel statistics don't document.
Human to Human Transmission Connection
The New England Journal of Medicine (NEJM) documented the first person-to-person transmission of Legionella in February 2016. Researchers concluded that a 48-year-old man was exposed to Legionella when working around cooling towers in 2014 and then transmitted Legionella via coughing to his mother while she was caring for him. The mother died on December 1, 2014 and her son about a month later, on January 7, 2015. The Legionella strain found in both the mother and son matched the strain found in the son’s workplace.
A February 4, 2016 NEJM article says, "Patients 1 and 2 lived alone in Porto, and their house consisted of small nonventilated rooms without air-conditioning units or room humidifiers. Collected water samples from the bathroom and the kitchen and a swab of the shower drain were negative for legionella. Patient 1 did not take water from Vila Franca de Xira to Porto.
We suspect that person-to-person transmission probably occurred when Patient 2 cared for her severely ill son. Factors that suggest person-to-person transmission
are the severity of the respiratory symptoms in Patient 1, the very close contact that occurred during the 8 consecutive hours when Patient 2 took care of Patient 1, and the small area of the nonventilated room where this contact took place. In addition, the timeline of the events was highly coherent (i.e., the symptoms in Patient 2 developed 1 week after the close contact with Patient 1; this is consistent with the typical incubation period of Legionnaires’ disease — a median of 6 to 7 days)."
The probability of a Legionella outbreak being attributed to a hotel stay before or after a cruise, or a hospital stay after the cruise, would account for many if not all cruise ship passenger Legionella cases. The CDC reports don't give those facts.
Further, in the case of the Celebrity Horizon Legionella case, there is no proof the person wasn't infected elsewhere before the cruise and their coughing infected the cruise ship water/air.
However, given the NEJM article in 2016, prior cases of passengers who showed Legionella symptoms and tested positive after a cruise, may have resulted from Legionella infection in close quarters with someone infected at a hotel before the cruise.
All previously documented Legionella cases around the world assume infections via water or air ventilation systems. When, in fact, infection may have actually been human to human, at least in part.