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. 2002 Jan;8(1):37-43.
doi: 10.3201/eid0801.010176.

A large outbreak of Legionnaires' disease at a flower show, the Netherlands, 1999

Jeroen W Den Boer  1 , Ed P F Yzerman, Joop Schellekens, Kamilla D Lettinga, Hendriek C Boshuizen, Jim E Van Steenbergen, Arnold Bosman, Susan Van den Hof, Hans A Van Vliet, Marcel F Peeters, Ruud J Van Ketel, Peter Speelman, Jacob L Kool, Marina A E Conyn-Van Spaendonck
Affiliations

A large outbreak of Legionnaires' disease at a flower show, the Netherlands, 1999

Jeroen W Den Boer et al. Emerg Infect Dis. 2002 Jan.

Erratum in

  • Emerg Infect Dis 2002 Feb;8(2):180

Abstract

In 1999, an outbreak of Legionnaires' disease affected many visitors to a flower show in the Netherlands. To identify the source of the outbreak, we performed an environmental investigation, as well as a case-control study among visitors and a serologic cohort study among exhibitors to measure exposure to possible sources. Of 77,061 visitors, 188 became ill (133 confirmed and 55 probable cases), for an attack rate of 0.23% for visitors and 0.61% for exhibitors. Two whirlpool spas in halls 3 and 4 of the exhibition and a sprinkler in hall 8 were culture positive for Legionella pneumophila. One of three genotypes found in both whirlpool spas was identical to the isolates from 28 of 29 culture-positive patients. Persons who paused at the whirlpool spa in hall 3 were at increased risk for becoming ill. This study illustrates that whirlpool spas may be an important health hazard if disinfection fails.

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Figures

Figure 1
Figure 1
Dates of onset of illness in 186 cases of Legionnaires’ disease, February 16-March 18, 1999.
Figure 2
Figure 2
Confirmed and probable cases of Legionnaires’ disease per day of visit to flower show. Incidence per 10,000 visitors per day of visit, February 16-March 2, 1999.
Figure 3
Figure 3
a. Smoothed mean geometric immunoglobulin (Ig) M antibody titers to Legionella pneumophila of nearest 35 exhibitors in hall 3 and 4 per 63 cm2 of exhibition area; confirmed and probable cases among exhibitors in halls 3 and 4. = confirmed case in exhibitor; = probable case in exhibitor; Bu = bubblemat; W = whirlpool spa. b. Smoothed mean geometric IgG antibody titers to L. pneumophila of 35 exhibitors nearest to whirlpool in halls 3 and 4 per 63 cm2 of exhibition area; exhibitors ill with confirmed and probable cases in halls 3 and 4. l = confirmed exhibitor case; = probable exhibitor case; Bu = bubblemat; W = whirlpool spa.
Figure 4
Figure 4
Water-supply system for exhibition hall, Bovenkarspel the Netherlands, 1999. PE = polyethylene.
Figure 5
Figure 5
Pulsed-field gel electrophoresis (PFGE) and amplified fragment-length polymorphism (AFLP) patterns of a representative selection of clinical and environmental Legionella pneumophila isolates; the dendrogram shows clustering in PFGE. The AFLP and PFGE pattern of the isolate of patient 15 (genotype B-1) was found in 28 of the 29 isolates of culture-positive cases; the same pattern was found in isolates cultured from the whirlpool spas in halls 3 and 4. The AFLP and PFGE pattern of the isolate of patient 25 (genotype B-2) was unique among culture-positive cases; the same pattern was found in isolates cultured from the whirlpool spa in hall 3 and the sprinkler. 1A bubblemat is an inflatable rubber mat that causes a whirlpool-like effect when placed in a normal bathtub.
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