title: A community outbreak of Legionnaires' disease linked to hospital cooling towers: an epidemiological method to calculate dose of exposure.
abstract: BACKGROUND
  From July to September 1994, 29 cases of community-acquired Legionnaires' disease (LD) were reported in Delaware. The authors conducted an investigation to a) identify the source of the outbreak and risk factors for developing Legionella pneumophila serogroup 1 (Lp-1) pneumonia and b) evaluate the risk associated with the components of cumulative exposure to the source (i.e. distance from the source, frequency of exposure, and duration of exposure).
  
  
  METHODS
  A case-control study matched 21 patients to three controls per case by known risk factors for acquiring LD. Controls were selected from patients who attended the same clinic as the respective case-patients. Water samples taken at the hospital, from eight nearby cooling towers, and from four of the patient's homes were cultured for Legionella. Isolates were subtyped using monoclonal antibody (Mab) analysis and arbitrarily primed polymerase chain reaction (AP-PCR).
  
  
  RESULTS
  Eleven (52%) of 21 case-patients worked at or visited the hospital compared with 17 (27%) of 63 controls (OR 5.0, 95% CI : 1.1-29). For those who lived, worked, or visited within 4 square miles of the hospital, the risk of illness decreased by 20% for each 0.10 mile from the hospital; it increased by 80% for each visit to the hospital; and it increased by 8% for each hour spent within 0.125 miles of the hospital. Lp-1 was isolated from three patients and both hospital cooling towers. Based on laboratory results no other samples contained Lp-1. The clinical and main-tower isolates all demonstrated Mab pattern 1,2,5,6. AP-PCR matched the main-tower samples with those from two case-patients.
  
  
  CONCLUSIONS
  The results of our investigation suggested that the hospital cooling towers were the source of a community outbreak of LD. Increasing proximity to and frequency of exposure to the towers increased the risk of LD. New guidelines for cooling tower maintenance are needed. Knowing the location of cooling towers could facilitate maintenance inspections and outbreak investigations.
authors.affiliation: Centers for Disease Control and Prevention Epidemiology Program Office, Division of Field Epidemiology, Atlanta, GA 30333, USA.
authors.forename: C M
authors.initials: CM
authors.lastname: Brown
authors.forename: P J
authors.initials: PJ
authors.lastname: Nuorti
authors.forename: R F
authors.initials: RF
authors.lastname: Breiman
authors.forename: A L
authors.initials: AL
authors.lastname: Hathcock
authors.forename: B S
authors.initials: BS
authors.lastname: Fields
authors.forename: H B
authors.initials: HB
authors.lastname: Lipman
authors.forename: G C
authors.initials: GC
authors.lastname: Llewellyn
authors.forename: J
authors.initials: J
authors.lastname: Hofmann
authors.forename: M
authors.initials: M
authors.lastname: Cetron
mesh_terms: D000328:Adult; D000336:Aerosols; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D000389:Air Conditioning / Q000295:instrumentation*; D016022:Case-Control Studies; D017714:Community-Acquired Infections / Q000453:epidemiology* / Q000209:etiology; D016001:Confidence Intervals; D003691:Delaware / Q000453:epidemiology; D004196:Disease Outbreaks / Q000706:statistics & numerical data*; D005260:Female; D006749:Hospital Design and Construction; D006801:Humans; D007877:Legionnaires' Disease / Q000453:epidemiology* / Q000209:etiology; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012307:Risk Factors; D017678:Sex Distribution; D014871:Water Microbiology
chemical_list: D000336:Aerosols