An outbreak investigation of Legionella non-pneumophila Legionnaires' disease in Sweden, April to August 2018: Gardening and use of commercial bagged soil associated with infections.

In early June 2018, an increase in non-travel-related cases of Legionella non-pneumophila Legionnaires' disease (LD) was observed in Sweden and a national outbreak investigation was started. Outbreak cases were defined as notified confirmed or probable cases of L. non-pneumophila LD, with symptom onset after 1 April 2018. From April to August 2018, 41 cases were reported, 30 of whom were identified as L. longbeachae. We conducted a case-control study with 27 cases and 182 matched controls. Results from the case-control study indicated that gardening and handling commercial bagged soil, especially dusty dry soil, were associated with disease. L. longbeachae was isolated in soils from cases' homes or gardens, but joint analysis of soil and human specimens did not identify any genetic clonality. Substantial polyclonality was noted between and within soil samples, which made finding a genetic match between soil and human specimens unlikely. Therefore, whole genome sequencing may be of limited use to confirm a specific soil as a vehicle of transmission for L. longbeachae. Handling soil for residential gardening was associated with disease and the isolation of L. longbeachae in different soils provided further evidence for Legionella non-pneumophila infection from soil.

Early outbreak detection by linking health advice line calls to water distribution areas retrospectively demonstrated in a large waterborne outbreak of cryptosporidiosis in Sweden.

BACKGROUND: In the winter and spring of 2011 a large outbreak of cryptosporidiosis occurred in Skellefteå municipality, Sweden. This study summarizes the outbreak investigation in terms of outbreak size, duration, clinical characteristics, possible source(s) and the potential for earlier detection using calls to a health advice line. METHODS: The investigation included two epidemiological questionnaires and microbial analysis of samples from patients, water and other environmental sources. In addition, a retrospective study based on phone calls to a health advice line was performed by comparing patterns of phone calls between different water distribution areas. RESULTS: Our analyses showed that approximately 18,500 individuals were affected by a waterborne outbreak of cryptosporidiosis in Skellefteå in 2011. This makes it the second largest outbreak of cryptosporidiosis in Europe to date. Cryptosporidium hominis oocysts of subtype IbA10G2 were found in patient and sewage samples, but not in raw water or in drinking water, and the initial contamination source could not be determined. The outbreak went unnoticed to authorities for several months. The analysis of the calls to the health advice line provides strong indications early in the outbreak that it was linked to a particular water treatment plant. CONCLUSIONS: We conclude that an earlier detection of the outbreak by linking calls to a health advice line to water distribution areas could have limited the outbreak substantially.

Association between heavy precipitation events and waterborne outbreaks in four Nordic countries, 1992-2012.

We conducted a matched case-control study to examine the association between heavy precipitation events and waterborne outbreaks (WBOs) by linking epidemiological registries and meteorological data between 1992 and 2012 in four Nordic countries. Heavy precipitation events were defined by above average (exceedance) daily rainfall during the preceding weeks using local references. We performed conditional logistic regression using the four previous years as the controls. Among WBOs with known onset date (n = 89), exceedance rainfall on two or more days was associated with occurrence of outbreak, OR = 3.06 (95% CI 1.38-6.78), compared to zero exceedance days. Stratified analyses revealed a significant association with single household water supplies, ground water as source and for outbreaks occurring during spring and summer. These findings were reproduced in analyses including all WBOs with known outbreak month (n = 186). The vulnerability of single households to WBOs associated with heavy precipitation events should be communicated to homeowners and implemented into future policy planning to reduce the risk of waterborne illness.

Large outbreak of Cryptosporidium hominis infection transmitted through the public water supply, Sweden.

In November 2010, ≈27,000 (≈45%) inhabitants of Östersund, Sweden, were affected by a waterborne outbreak of cryptosporidiosis. The outbreak was characterized by a rapid onset and high attack rate, especially among young and middle-aged persons. Young age, number of infected family members, amount of water consumed daily, and gluten intolerance were identified as risk factors for acquiring cryptosporidiosis. Also, chronic intestinal disease and young age were significantly associated with prolonged diarrhea. Identification of Cryptosporidium hominis subtype IbA10G2 in human and environmental samples and consistently low numbers of oocysts in drinking water confirmed insufficient reduction of parasites by the municipal water treatment plant. The current outbreak shows that use of inadequate microbial barriers at water treatment plants can have serious consequences for public health. This risk can be minimized by optimizing control of raw water quality and employing multiple barriers that remove or inactivate all groups of pathogens.

Microbial risk assessment of local handling and use of human faeces.

Dry urine-diverting toilets may be used in order to collect excreta for the utilisation of nutrients. A quantitative microbial risk assessment was conducted in order to evaluate the risks of transmission of infectious disease related to the local use of faeces as a fertiliser. The human exposures evaluated included accidental ingestion of small amounts of faeces, or a mixture of faeces and soil, while emptying the storage container and applying the material in the garden, during recreational stays to the garden, and during gardening. A range of pathogens representing various groups of microorganisms was considered. Results showed that 12-months' storage before use was sufficient for the inactivation of most pathogens to acceptable levels. When working or spending time in the garden the annual risk of infection by Ascaris was still slightly above 10(-4) in these scenarios, although the incidence rate for Ascaris is very low in the population in question. Measures to further reduce the hygienic risks include longer storage, or treatment, of the faeces. The results can easily be extended to other regions with different incidence rates.

Identification of the microbiological community in biogas systems and evaluation of microbial risks from gas usage.

The plans for introducing biogas produced from organic waste to the pipe system for natural gas has raised concerns about the risk of transmitting disease via the gas. To assess this risk, condensate water from gas pipes and gas from different parts of a biogas upgrading system were sampled and cultured for microbial content. On average, 10(5) cfu ml-1 were found in the condensate water throughout the system, while in the gas between 10 and 100 cfu m-3 were found. The microorganisms were subjected to further identification and found to represent a wide variety, e.g. fungi and spore-forming and non-spore-forming bacteria, including species such as Enterobacteriaceae. The number of microorganisms found in the biogas corresponded to the densities in sampled natural gas, which also held 10-100 cfu m-3. Since no pathogens were identified and since the exposure to gas from e.g. cookers and refuelling of cars may only result in the inhalation of small volumes of gas, the risk of spreading disease via biogas was judged to be very low.

Faecal contamination of source-separated human urine based on the content of faecal sterols.

Transmissible pathogens in source-separated human urine, intended for reuse in agriculture, mainly originate from faeces that cross-contaminate the urine. The health risks associated with the enteric pathogens will largely be dependent on their initial concentration and their inactivation during storage in the urine. Faecal sterols have proven stable in urine and can, rather than indicator bacteria, be used to quantify the faecal cross-contamination. In this study, urine collection tanks were sampled and ratios between various faecal sterols were used to determine if the urine was contaminated by faeces. Twenty-two percent of samples from the upper part of the tanks and 37% of samples from the bottom sludge were found to be contaminated. Coprostanol concentrations in the contaminated urine samples corresponded to a mean faecal contamination of 9.1+/-5.6 mg l(-1) urine. E. coli was absent in a majority of the samples. Faecal streptococci and clostridia were enumerated but not found to correlate with coprostanol concentrations in contaminated samples.