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Legionnaires’ disease among patients hospitalised with pneumonia in South Africa
Nicole Wolter Centre for Respiratory Diseases and Meningitis (CRDM)
National Institute for Communicable Diseases (NICD) Johannesburg, South Africa
ESGLI Conference, Amsterdam, 22-23 September 2016
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South Africa • Middle-income country
• Population: ± 54 million
• 30% of population <15 years of age
• Life expectancy: 59.1 years for males and 63.1 years for females
• Infant mortality rate: 34,4 per 1000 live births
• Estimated overall HIV prevalence: 10.2%
• HIV prevalence adults 15-49 years: 16.8%
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Statistics South Africa, 2014
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• Notifiable to the Department of Health (National Health Act no. 61 of 2003)
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Legionella in South Africa
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Legionella in South Africa
Legionella cases
Cases rarely reported
Urinary Antigen Test
Few laboratories offering testing
Low clinical index of suspicion
Limited data
Underestimation of disease burden
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Study aims: • Determine the prevalence of Legionella infections amongst individuals
hospitalised with pneumonia and,
• Describe the epidemiological characteristics of patients with
Legionnaires’ Disease
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Surveillance for Legionella: Methods
• Initiated in June 2012 through National Pneumonia Surveillance Programme.
• Patients hospitalised with lower respiratory tract infection (LRTI) with any
symptom duration.
• 2 sentinel sites:
Klerksdorp-Tshepong Hospital Complex
Edendale Hospital
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Surveillance for Legionella: Methods
• Demographic and clinical information
• Standardised questionnaires Case investigation form Hospital results form Final outcome form
Clinical specimens Nasopharyngeal swab/aspirate Induced sputum Whole blood
Consent and enrol patients
National Institute for Communicable Diseases
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Nucleic acid extraction
Real-time PCR
Surveillance for Legionella: Methods
*Thurman et al., Diag Microbiol. Infect. Dis., 2011
Legionella spp.*
Legionella pneumophila Legionella longbeachae
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Demographic and clinical characteristics of patients enrolled in National Pneumonia Surveillance, South Africa, June 2012 – May 2016
(N=6422)
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Surveillance for Legionella: Results
Characteristic All patients n/N (%)
Klerksdorp-Tshepong Hospital 3522/6422 (55.3)
Male gender 3260/6407 (50.9)
<5 years of age 2345/6404 (36.6)
HIV-infection* 3090/6044 (51.1)
Underlying illness 1242/6409 (19.4)
Died 503/6247 (8.1)
* HIV-infection highest in 25-44 year age group, 90.6% (1728/1908)
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• Of 5898 individuals tested, Legionella spp. identified in 29 (0.5%, 95% confidence interval 0.3 – 0.7%)
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Surveillance for Legionella: Results
4
24
1
Nasopharyngeal specimen
Induced sputum
Both specimen types
• Legionella spp. identified in 0.8% (25/3006) sputum specimens, and 0.09% (5/5648) NP specimens
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Cases of Legionella detected in the National Pneumonia Surveillance programme by month and year, South Africa, June 2012 – May 2016 (N=29)
11
0
1
2
3
4
5
6
7
8
Jun Jul
Aug
Sep
Oct
Nov De
cJa
nFe
bM
ar Apr
May Jun Jul
Aug
Sep
Oct
Nov De
cJa
nFe
bM
ar Apr
May Jun Jul
Aug
Sep
Oct
Nov De
cJa
nFe
bM
ar Apr
May Jun Jul
Aug
Sep
Oct
Nov De
cJa
nFe
bM
ar Apr
May
2012 2013 2014 2015 2016
Klerksdorp-Tshepong (n=20)
Edendale (n=9)
L. pneumophila SG1
Surveillance for Legionella: Results
L. longbeachae
L. longbeachae
Change in transport of induced sputum
No.
of c
ases
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Surveillance for Legionella: Results
Cases of Legionella detected in the National Pneumonia Surveillance programme by age group South Africa, June 2012 – May 2016 (N=29)
00,10,20,30,40,50,60,70,80,91
02468
1012141618
<1 1-4 5-24 25-44 45-64 >64Age group (years)
No.
of c
ases
D
etection rate (%)
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Characteristic All patients n/N (%)
Legionella cases n/N (%)
Klerksdorp-Tshepong Hospital
3522/6422 (55.3) 20/29 (69.0)
Male gender 3260/6407 (50.9) 14/28 (50.0)
<5 years of age 2345/6404 (36.6) 2/29 (6.9)
Median age (years) 28.9 38.8
HIV-infection 3090/6044 (51.1) 18/27 (66.7)
Underlying illness 1242/6409 (19.4) 1/28 (3.6)
Died 503/6247 (8.1) 3/27 (11.1)
Demographic and clinical characteristics of Legionella cases, National Pneumonia Surveillance South Africa, June 2012 – May 2016 (N=29)
Surveillance for Legionella: Results
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Suspected Legionnaires’ Disease Case Investigation
• Interviews conducted for 22/29 cases
• No common exposure identified
• Most likely community-acquired infections
• Potential sources of infection identified:
• Waste management
• Plumbing
• Mining
• Dam reservoirs
• Only few diagnosed with and treated for Legionnaires’ disease
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Surveillance for Legionella: Results
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Surveillance for Legionella: Conclusions
• 0.5% detection rate amongst hospitalised pneumonia cases
• Cases occurred predominantly in 25-44 year age group
• Sporadic disease
• Sputum more sensitive than NP for diagnosis
• Species identification limited:
• L. pneumophila serogroup 1 and L. longbeachae
• Patients are rarely diagnosed and optimally treated
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• Increase awareness, improve diagnostic testing and reporting
• Legionella action group (LAG)
• NICD guidelines on diagnosis, reporting and public health response to
Legionnaires’ disease
• South African National Standards (SANS) 893 – Legionella: Risk
management and the control of Legionella in water systems
• Active case investigation for every case identified
• Public health response to individual and cluster cases
Ongoing Legionella work in South Africa
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SARI surveillance and related projects acknowledgments
SARI Surveillance Programme Members National Institute for Communicable Diseases a division of the National Health Laboratory Service: Executive Director: Shabir Madhi Centre for Respiratory Diseases and Meningitis: Amelia Buys, Maimuna Carrim, Cheryl Cohen, Mignon du
Plessis, Orienka Hellferscee, Mokupi Manaka, Jo McAnerney, Alexandra Moerdyk, Senzo Mtshali, Fahima Moosa, Jocelyn Moyes, Makatisane Papo, Adrian Puren, Azeeza Rangunwala, Mpho Seleka, Florette K Treurnicht, Anne von Gottberg, Sibongile Walaza, Nicole Wolter, Claire von Mollendorf
Centre for HIV and STIs: Mark Goosen, Deidre Greyling Centre for opportunistic, Tropical and hospital infectious : Desiree du Plessis, John Frean, Bhavani
Poonsamy, Vivian Mothibe, Lisa Ming Sun, Ntswaki Seolwanyane Centre for tuberculosis: Andries Dreyer, Nazir Ismail, Ananta Nanoo, Ivy Rukasha Edendale Hospital: Meera Chhagan, Halima Dawood, Sumayya Haffejee, Portia Mutevedzi, Fathima Naby, Klerksdorp/Tshepong Hospital Complex: Erna du Plessis, Omphile Mekgoe, Ebrahim Variava Rahima Moosa Mother and Child and Helen Joseph Hospitals : Ashraf Coovadia, Zodwa Kgapola, Ranmini
Kuleratne , Jeremy Nel, Gary Reubenson, David Spencer MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt): Kathleen Kahn, Stephen Tollman,
Rhian Twine South African National Department of Health - Communicable Diseases Directorate: Frew Benson United States Centre for Disease Control and Prevention (CDC): Adam Cohen, Stefano Tempia
Surveillance Officers & Research Assistants*
Nelisiwe Buthelezi
Vanesa Kok Lerato Mthombeni
Phindile Ngema Julia Malapane
Nhlakanipho Malinga Seipati Matshogo Bekiwe Ncwana
Wendy Ngubane Andrina Sambo
Khadija Shangase Louisa Phalatse Myra Moremi
Keitumetse Baloyi Annalet Moodley
Thulisile Mthembu Kholiwe Mgidlana
All the patients who kindly agreed to participate in the
surveillance
Data Entry Team Nthabiseng Mampa Boitumelo Letlape Wanga Makamba
Kelebogile Motsepe Robert Musetha
Mpho Ntoyi Shirley Mhlarhi
Dimakatso Maraka Pertunia Sekhula Cleopatra Mdluli