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

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

• 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

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

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)

• 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

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24

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Nasopharyngeal specimen

Induced sputum

Both specimen types

• Legionella spp. identified in 0.8% (25/3006) sputum specimens, and 0.09% (5/5648) NP specimens

Cases of Legionella detected in the National Pneumonia Surveillance programme by month and year, South Africa, June 2012 – May 2016 (N=29)

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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

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May Jun Jul

Aug

Sep

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cJa

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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

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

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