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Monday, 3 September 2012

Legionnaire’s disease - the tragedy of outbreaks and impact on colleagues

So far, eleven deaths and at neatly 170 illnesses have been reported in Quebec  City related to Legiononnaire’s disease, or Legionella pnuemophilia. 

For all the relatively quiet days in public health spent in slow progress on improving health, our colleagues in  Quebec have been facing what is likely continuous adrenalin filled stress that has lasted over a month, and will continue until resolved and then chronic stress  for years into the future.  It is a repeat of the blood system crisis, Walkerton, SARS, H1N1 and one of the major reasons for an integrated and geographically dispersed public health system.   Professional best wishes should be extended to the local health unit and INSPQ staff who are facing the stressful mystery of what is actually occurring, while further tragedies mount, public and media pressure is unrelenting, and the daunting challenge ahead of a legal inquiry that will take months to years.

In the wake of these events have fallen the professional careers of Roger Perrault, John Furesz, Donald Boucher (key figures for Canadian Red Cross who were only acquitted some 15 years after the Krever Commission report),   Murray McQuiggie (MOH for Walkerton), Colin d’Cunha (Chief MOH Ontario during SARS).  These are career ending events and the exit is not adorned with glitter for individuals who worked with the available information and resources to make what were quite possibly the right decisions at the time, but fail in the retrospectoscope when all the facts are available. Let us hope the names of Francois Desbiens and Chantale Giguere are not added to this list.  Quebec City has been a leader in many public health initiatives and innovations under their leadership.  

The current outbreak has reemphasized the risks associated with humid environments and air conditioning systems with a focus on two building structures.  Most Legionnaire’s disease is sporadic and not associated with a definitive source.  The US reports some 4000 cases per year, but only 12 outbreaks (and typically not more than a few dozen per outbreak).  Ontario reported 162 cases in 2011 and historically mirrored Canadian rates, suggesting Canada might have about 400 cases per year – putting the Quebec City outbreak in perspective as a significant and major outbreak and anomaly for what is the normal experience with this organism. 

The organism is found widely in the environment. A more relevant question is why do we not see more cases?   It can frequently be recovered from pipes, moist environments, biofilms, lakes, rivers, spas, swimming pools, decorative fountains, nebulizers, compost and potting soil.   An even more relevant question is given the number of sporadic cases indicating many people are exposed, why are outbreaks relatively uncommon?  and what characterizes outbreak scenarios since exposure must be relatively common routinely?

Those wanting to delve deeper into Legionella might review a series of presentation from a Public Health Ontario conference  Public heath Ontario workshop June 2012   pages 112- 126 speaking to the challenge of even identifying outbreaks.  Page 158 provides a community example showing outbreak versus sporadic distribution and puts outbreaks as a relatively uncommon scenario.  

Foremost is sympathy for individuals and families affected by the outbreak.  Remember also our public health colleagues who are likely strained by the disastrous situation.  Someday, it might be you. Are you ready for the task? 

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