Legionnaires' Disease Outbreak in Murcia, Spain

Ana García-Fulgueiras, Carmen Navarro, Daniel Fenoll, José García, Paulino González-Diego, Teresa Jiménez-Buñuales, Miguel Rodriguez, Rosa Lopez, Francisco Pacheco, Joaquín Ruiz, Manuel Segovia, Beatriz Baladrón, Carmen Pelaz


Emerging Infectious Diseases. 2003;9(8) 

In This Article


This LD outbreak is the largest to date in the world, with 449 confirmed cases and an estimated total number of cases of 650. The reported case-fatality rate (1%) is much lower than those observed in other community outbreaks.[22,23] This rate can be attributed, at least partially, to the quick detection of the outbreak, early diagnosis of the disease, and appropriate treatment of patients. The explosive quality of the outbreak not only led patients to seek quick assistance at hospital emergency units but also helped clinicians to perform an accurate diagnosis and to immediately initiate adequate treatment, factors reported as linked to low case fatality.[24,25] This explosive appearance could also be related to a lower presence of predisposing factors in case-patients in comparison with other community outbreaks,[7,9,13] which could also partially explain the low case-fatality rate.

The initial investigation encountered obstacles, such as a large number of potential sources of environmental contamination located in the northern part of the city and the absence of environmental Legionella isolates identical to those of patients. The case-control study showed a significant association, with a high consistency between the analyzed models and with a high magnitude of association, between passing through the zone around hospital H and being ill with LD. Results were similar even when the area radius was expanded to 400 m. However, large overlap of areas was observed within this radius, and multicollinearity among zones was a common finding.

The case-control study was designed to select patients residing outside the city of Murcia. We decided on this approach for two reasons. First, the incidence of LD was almost 1% in some neighborhoods, a rate within the 0.1% to 5% attack rate described for this disease.[26] Therefore, all the persons living in these quarters could possibly have been exposed to Legionella, as has been described in outbreaks of other transmissible diseases.[27] If everyone had been exposed, finding incidence differences between persons exposed and those not exposed would have been almost impossible. Second, persons residing outside the city would probably have a more accurate memory of the itineraries they followed in Murcia some weeks previously and would probably have a lesser number of routes than persons living within the city. Conducting 255 personal interviews with questions about itineraries within 2 weeks from the last case and 4 weeks from the outbreak onset may also have been important to our findings.

One concern in case-control studies is that participation rate is not reported consistently.[21] Indeed, this information is usually omitted in case-control studies of outbreaks, especially when controls are selected from a population database, as was our situation. A further complication was that the study had to be conducted in July, when many people go on holiday. In spite of achieving the participation of one in two controls whom we initially selected, we evaluated possible selection bias. We determined that it was unlikely to have occurred since neither socioeconomic status nor predisposing risk factors for LD differed significantly among cases and controls. Information bias overestimating this outcome was ruled out since news media did not mention hospital H among the probable sources of the outbreak.

Meteorologic conditions were favorable for the emission of aerosols to be dispersed in a horizontal manner. Low wind speed together with atmospheric thermal inversion between June 29 and July 1 would have facilitated the presence of the aerosols in the environment.[9]

The result of the epidemiologic study was subsequently confirmed by the isolation of a strain retrieved on October 30 from a sample from one of the cooling towers of the same hospital; that strain is identical to the strain isolated from the patients. The difficulties found previously in the isolation of this strain were not unexpected. The day after the outbreak was detected, when the first sample was taken, the cooling towers of hospital H were highly chlorinated, which could explain why these first samples gave negative results. Later samples retrieved on four different dates between July 28 and September 13 showed positive results to L. pneumophila but were characterized as different strains from those from patients. This strain was only isolated upon the restarting of one tower after it was shut down for more than 1 month, a condition that favors the reappearance of Legionella.[8,12,13] The fact that the same clone of Legionella can be found in an installation for long periods is also documented.[28,29] The possible contamination of the tower by new Legionella from the water supply was ruled out since the strain linked to the outbreak was not found in samples collected from many other installations during the same period, including July to November.

The coincidence of a nosocomial LD outbreak in hospital H reinforces the previous hypothesis. A nosocomial outbreak of LD as part of a wider community outbreak of the disease has been described,[12,30] although in other outbreaks originating in the cooling towers of a hospital no cases of nosocomial LD were identified.[7] The use of double HEPA filters on air-intake vents in some hospitals could justify, at least in part, these contradictory observations.

Our research indicates that the cooling towers of a hospital located in the northeastern part of the city of Murcia were the origin of this community outbreak. This study underlines important risk factors that must be taken into account to prevent a new LD outbreak. First, cooling towers had to be identified by aerial and direct inspection in the absence of any census of such installations. Second, the size, location, and state of maintenance of cooling towers are very important. In contrast with epidemics associated with relatively small systems,[8] this outbreak was related to a large refrigeration system that seems to have infected patients up to 1.3 km downwind to the west from the cooling tower; this finding suggests that airborne infection with L. pneumophila may extend over a large distance from the dissemination source, as has been reported elsewhere.[9,10] Although most of the installations in the area showed inadequate maintenance, the cooling towers from hospital H were poorly maintained and had a high-risk size and location. Once the outbreak was identified, urgent measures were undertaken to clean, disinfect, or close possibly contaminated sources. The cooling tower that was the source of the outbreak was subsequently replaced by an air-cooled system.

Before June 2001, no specific national legislation existed in Spain concerning LD, although a recommendation guide and legislation existed in several Spanish autonomous regions that had had community LD outbreaks.[31] As an immediate consequence of this outbreak, a national law about prevention and control of LD was enacted in Spain 20 days after the outbreak began.[32] The extent of this outbreak is useful to assess the relative role of cooling towers as a source of LD and highlights the importance of prioritizing control measures related to cooling towers among strategies to prevent LD in the community. Compliance with these measures would help to reduce not only community outbreaks but also, perhaps, sporadic cases that could be due to infected cooling towers.[33]


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: