Impacts of weather and air pollution on Legionnaires' disease in Switzerland: A national case-crossover study.

BACKGROUND: The number of reported cases of Legionnaires' disease (LD) has risen markedly in Switzerland (6.5/100,000 inhabitants in 2021) and abroad over the last decade. Legionella, the causative agent of LD, are ubiquitous in the environment. Therefore, environmental changes can affect the incidence of LD, for example by increasing bacterial concentrations in the environment or by facilitating transmission. OBJECTIVES: The aim of this study is to understand the environmental determinants, in particular weather conditions, for the regional and seasonal distribution of LD in Switzerland. METHODS: We conducted a series of analyses based on the Swiss LD notification data from 2017 to 2021. First, we used a descriptive and hotspot analysis to map LD cases and identify regional clusters. Second, we applied an ecological model to identify environmental determinants on case frequency at the district level. Third, we applied a case-crossover design using distributed lag non-linear models to identify short-term associations between seven weather variables and LD occurrence. Lastly, we performed a sensitivity analysis for the case-crossover design including NO2 levels available for the year 2019. RESULTS: Canton Ticino in southern Switzerland was identified as a hotspot in the cluster analysis, with a standardised notification rate of 14.3 cases/100,000 inhabitants (CI: 12.6, 16.0). The strongest association with LD frequency in the ecological model was found for large-scale factors such as weather and air pollution. The case-crossover study confirmed the strong association of elevated daily mean temperature (OR 2.83; CI: 1.70, 4.70) and mean daily vapour pressure (OR: 1.52, CI: 1.15, 2.01) 6-14 days before LD occurrence. DISCUSSION: Our analyses showed an influence of weather with a specific temporal pattern before the onset of LD, which may provide insights into the effect mechanism. The relationship between air pollution and LD and the interplay with weather should be further investigated.

Legionnaires' disease in Switzerland: rationale and study protocol of a prospective national case-control and molecular source attribution study (SwissLEGIO).

Switzerland has one of the highest annual Legionnaires' disease (LD) notification rates in Europe (7.8 cases/100,000 population in 2021). The main sources of infection and the cause for this high rate remain largely unknown. This hampers the implementation of targeted Legionella spp. control efforts. The SwissLEGIO national case-control and molecular source attribution study investigates risk factors and infection sources for community-acquired LD in Switzerland. Over the duration of one year, the study is recruiting 205 newly diagnosed LD patients through a network of 20 university and cantonal hospitals. Healthy controls matched for age, sex, and residence at district level are recruited from the general population. Risk factors for LD are assessed in questionnaire-based interviews. Clinical and environmental Legionella spp. isolates are compared using whole genome sequencing (WGS). Direct comparison of sero- and sequence types (ST), core genome multilocus sequencing types (cgMLST), and single nucleotide polymorphisms (SNPs) between clinical and environmental isolates are used to investigate the infection sources and the prevalence and virulence of different Legionella spp. strains detected across Switzerland. The SwissLEGIO study innovates in combining case-control and molecular typing approaches for source attribution on a national level outside an outbreak setting. The study provides a unique platform for national Legionellosis and Legionella research and is conducted in an inter- and transdisciplinary, co-production approach involving various national governmental and national research stakeholders.

Temporal trends in legionellosis national notification data and the effect of COVID-19, Switzerland, 2000-2020.

The notification rate of legionellosis in Switzerland and other European countries has markedly increased over the last 20 years. Here, we investigated the Swiss notification data on legionellosis from 2000 to 2020 in regards of overall time trend, content and data quality. We further explored the impact of the COVID-19 pandemic on the reported case numbers using an interrupted time series approach. Between 2000 and 2020, 5980 cases were included in our analysis. The annual crude notification rate for legionellosis cases increased from 1.1/100,000 population (CI: 0.9-1.4) in 2000 to 5.6/100,000 population (CI: 5.1-6.1) in 2020. In recent years, the summer peaks have been more pronounced and some shifted earlier in the year. The highest notification rate was recorded in 2018 with 6.7/100,000 population (CI: 6.2-7.3). The hospitalisation rate for notified cases remained high across all study years (89.9%), while the case fatality rate slightly decreased (from 7.7% to 3.6%). COVID-19 containment measures, such as travel restrictions and/or related behavioural changes, are associated with a temporary decline in cases of 35%. Overall, the quality of the notification data was good. Clinical data were more susceptible to interferences than data from laboratory reporting, which could be observed most clearly in the decline of clinical reports by 4.3 percentage points in 2020. As the case classification for Legionnaires' disease includes pneumonia symptoms, this decline could lead to an underestimation of Legionnaires' disease cases, yet the continuous reporting though the diagnostic laboratories suggested a robust surveillance system for legionellosis in Switzerland.

Legionnaires' disease - a qualitative study on Swiss physicians' approaches to the diagnosis and treatment of community-acquired pneumonia.

BACKGROUND: The number of reported cases of Legionnaires' disease has increased significantly over the last decade in Switzerland and abroad. Along with the number of cases, the volume of testing has increased as well, which has been partially attributed to a change in awareness of the disease. Yet, while there are numerous guidelines and recommendations for the case management of community-acquired pneumonia, little is known about how physicians in Switzerland perceive and manage Legionnaires' disease. METHODS: This study aimed to investigate physicians' awareness of Legionnaires' disease, their information resources and their approach to the diagnosis and treatment of pneumonia (and thus Legionnaires' disease). Using a semi-structured interview guide, we conducted in-depth interviews with physicians from different levels of care and from the German-, French- and Italian-speaking regions of Switzerland. RESULTS: We conducted 46 interviews with physicians from university, cantonal and regional hospitals as well as with general practitioners (GPs) from all three language regions. Overall, the physicians working in hospitals indicated a similar level of awareness of Legionnaires' disease, and comparable diagnosis and treatment approaches. The Legionella urine antigen test (UAT) was reported to be routinely performed in inpatients. In contrast, GPs indicated lower levels of awareness, reflecting the fact that they treat pneumonia cases empirically without identification of the causative agent, in accordance with current guidelines. The value of the diagnostic tests in general and the Legionella UAT in particular was considered to be dependent on the (preferred) antibiotic treatment approach. Some physicians saw the test as redundant, as its result would not influence treatment. This was tied to concerns about the UAT's sensitivity and its limited use for the detection of Legionella pneumophila serogroup 1. Lastly, extrinsic constraints, such as financial and time considerations also affected physicians' testing and treatment preferences. CONCLUSION: Awareness of Legionnaires' disease is overall high, yet cases are mainly diagnosed and reported by hospitals. Improved diagnostic tools are needed to support physicians in reducing underestimation of Legionnaires' disease and optimise antibiotic stewardship without compromising patient health outcomes.

Legionnaires' Disease on the Rise in Switzerland: A Denominator-Based Analysis of National Diagnostic Data, 2007-2016.

The risk of falling ill with Legionnaires' disease (LD) is suggested to increase, but the global burden of disease is unknown due to a lack of appropriate diagnosis and surveillance systems. In Switzerland, the number of LD cases, captured by the National Notification System for Infectious Diseases, has more than doubled since 2008. This study aims to investigate this increase, contextualizing disease surveillance data with denominator data, which is not routinely available, i.e., the number of tests performed for Legionella spp. We collected the testing data for Legionella spp. of 14 Swiss diagnostic laboratories and calculated the positivity, defined as the proportion of the number of positive tests to the number of tests performed. The number of positive tests increased proportionally to the number of tests performed; hence, the positivity remained stable. However, the cause of the increase in test volume is unclear and has a large impact on the interpretation of the positivity curve. Further, the test outcome was found to be dependent on regional determinants, and the diagnostic method applied. The lack of understanding if and at which stage LD is considered in current case management of pneumonia patients limits the interpretation of observed heterogeneities in incidence or underestimation of LD in Switzerland. The absence of (or non-adherence to) existing guidelines and the heterogeneity in diagnostic testing hampers the comparison of data in the Swiss public health context. Therefore, diagnostic procedures should be harmonised across Switzerland and adherence to national LD management guidelines supported.

Out of pocket expenditures of patients with a chronic condition consulting a primary care provider in Tajikistan: a cross-sectional household survey.

BACKGROUND: Within its reform efforts, the Government of Tajikistan is embracing the essential role of primary health care (PHC) in decreasing out of pocket (OOP) expenditures and increasing equity in access to health services. In the light of the increasing burden of disease relating to chronic conditions, we investigated OOP expenditures of patients with chronic conditions within a PHC setting; and if and how those expenditures are impacted by several interventions currently being implemented within Tajikistan. METHODS: A cross-sectional survey among 1600 adult patients who had visited a PHC facility was conducted. The data obtained through interviews were descriptively analysed, and logistic regressions and gamma generalized linear models were performed. RESULTS: The total OOP expenditures related to a patient's last visit to the PHC facility were 17.2 USD for those with chronic conditions and 13.9 USD for those visiting due to an acute condition. Adjustment for potential confounders reduced the discrepancy from 3.3 USD to 0.5 USD. This convergence of costs was only observed in districts covered by the Basic Benefit Package (BBP), a governmental pilot project, aiming to standardise exemptions for payment and formal co-payments for health care services. Hence, we found the BBP to have a protective impact for patients with chronic conditions. However, considering the demographics of these patients (older in age, with greater dependency on pensions and social aid, and lower socio-economic status) in combination with the 40% higher utilisation rate of PHC and the high rate of onward referrals to specialists; it is clear that patients with chronic conditions continue to face substantial long-term costs and disadvantages. CONCLUSIONS: After accounting for confounders, patients with chronic and acute conditions faced similar costs related to a single visit to a PHC facility in districts covered by the BBP. However, greater efforts are required to ensure that citizens are well informed about their rights to health care, the BBP and the services that should be provided at no cost at the point of delivery. Moreover, the needs of patients with chronic conditions warrant a more integrative approach that takes long-term expenditures and services beyond the level of PHC into account.