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In July 2002, a large outbreak of legionellosis occurred in a bathhouse with spa facilities in Miyazaki Prefecture. Two hundred-ninety-five patients (including suspected cases) that had pneumonia and/or symptoms of fever, cough and so forth were reported; 37% of them were hospitalized and seven people died. In environmental investigations, Legionella pneumophila serogroups (SGs) land 8, L. dumoffii, L. londiniensis, some other Legionella species and many kinds of amoeba were isolated from 55 samples of bathtub water, tank water, filters and so forth in the spa facilities. The dominant isolates from the bathtab waters belonged to L. londiniensis, L. dumoffii and L. pneumophila SG1, and their maximum concentrations were 1.5 x 10(6), 5.2 x 10(5) and 1.6 x 10(5) cfu/100 mL, respectively. L. pneumophila SG1 strains isolated from bathtub water, tank water, filters and sputa of patients showed a indistinguishable DNA fingerprint pattern by pulsed-field gel electrophoresis (PFGE), confirming that the source of infection was the spa water. Our study indicate that spas may be a significant health hazard if hygienic management fails.

Objectives: The aim of this study was to survey mental health status among patients of a large outbreak of Legionnaires Disease (LD) occurring at a public bath in Hyuga City, Miyazaki Prefecture, from June through July, 2002. It also aimed to provide a basis for establishing a mental health care support system for persons suffering from ill health., Methods: Some 295 patients were reported by medical institutions to public health centers as being infected with LD or having suspected infection after using a hot springs bath, where hygiene was assumed to be maintained by regular water circulation, from 6/20 through 7/23, 2002 in Hyuga City, Miyazaki Prefecture. A total of 153 subjects consented to interviews after being informed of the objectives. They were visited and interviewed with a questionnaire from 10/12 through 12/5, 2002. Questions about mental health were written to identify "feeling stressed", based on diagnostic criteria for Post Traumatic Stress Disorder (PTSD) as noted in the DSM-IV. The Japanese version of the General Health Questionnaire (GHQ28) was used to identify high risk subjects for mental disorder, as well as the following four symptoms: "somatic symptoms", "anxiety and insomnia", "social dysfunction", and "severe depression". Factors associated with these were assessed with regard to knowledge and/or information about LD and its effects on daily life., Results: Regarding mental health, 27 (17.6%) were "feeling stressed". High risk patients for mental disorder numbered 39 (25.5%) according to the GHQ28. Patients with "somatic symptoms" numbered 44 (28.8%), those with "anxiety and insomnia" 21 (13.7%), those with "social dysfunction" 18 (11.8%) and with "severe depression" 5 (3.3%). Among the effects on daily life, "changes of human relationships" was related with "feeling stressed" in those suspected of LD infections (P = 0.022). High risk was related to "economic support" (P = 0.009) in LD, and also to "cause and survey" (P = 0.035) in those cases suspected of LD., Conclusions: At 3 to 4 months after the outbreak, the patients still exhibited mental health problems. Therefore we should provide health and social support that deals with the factors identified on a longer-term or continuous basis.

The largest epidemic outbreak of legionnaires' disease occurred in Japan, where there were 45 cases, including three deaths. There was a high degree of homology at the genetic level between Legionella pneumophila sero-group 1 isolated from two patients and water samples collected from a public bath, and this highlighted the public bath visited by the patients as the source of the infection. We report our clinical observations of 34 cases with a pneumonia type (20 definite and 14 probable) of the 42 cases for whom a diagnosis was made and follow-up care was subsequently provided at our hospital or hospital-affiliated facilities, out of the initial total of 45 cases. Twenty-one cases had underlying diseases, but the disease was mild in all patients. Three cases showed different neuropsychiatric symptoms such as reduced capacity for memorization, somnolence or delirium. Diarrhea was found in three cases, and relative bradycardia in ten. Clinical laboratory test results indicated that a severe inflammatory reaction, renal or hepatic dysfunction, an electrolyte abnormality and abnormal urinalysis were common in the 34 cases. Chest radiography showed a shadow suggestive of infection of the pulmonary parenchyma with multilobar involvement in most cases and pleural effusion in nine cases.

For the sake of water conservation, a system for circulating hot water is widely used at public baths in Japan. Recently, large outbreaks of Legionella infection have occurred in public baths in Miyazaki and Kagoshima prefectures. More than three hundred persons were infected with Legionella pneumophila, and eight died. These outbreaks revealed that the Manual of Prevention Measures against Legionella Infection in a Circulating Hot Water Bath, which was published by the Ministry of Health, Labour and Welfare in Japan in 2001, was not fully understood or conformed to by managers of the baths. Microbiological features about legionellae should be fully understood for prevention of Legionella infection in a circulating hot water or spring bath. This review describes the microbiological characteristics of legionellae, their habits in the environment, pathogenesis, symptoms of Legionella infection, and disease outbreaks in Japan. I also describe practical prevention measures to deal with this organism in a circulating hot water or spring bath.

The number of reported Japanese cases was smaller than those in European countries and the United States. The scarcity of clinical cases may reflect underdiagnosis rather than low incidence. The reported incidence of nosocomial pneumonia is directly correlated with two factors: the ready availability of specialized diagnostic tests in-house(especially sputum culture and urinary antigen assay) and the presence of Legionella in the hospital water supply. The Guideline for Prevention of Nosocomial Pneumonia published in 1994 by the Hospital Infection Control Practiced Advisory Committee of the CDC contains two strategies. The first addressed the prevention of Legionnaires' disease in hospitals with no identified cases(primary prevention), while the second deals with prevention in hospitals with identified cases(second prevention). Many excellent reviews have been published, but this review focuses on preventing nosocomial Legionella pneumonia.

From June 24 to July 5, 1996, 3 patients were admitted to the same hospital with atypical pneumonia. One of the patients, a 52-year-old man, demonstrated progressive pulmonary infiltrates and severe hypoxemia, and finally required mechanical ventilation. All 3 patients had elevated antibody titers for Legionella pneumophila serogroup 1, and had visited the same spa prior to the onset of their symptoms. On September 25, 1996 the district health department inspected the spa, and isolated Legionella pneumophila serogroup 1 from the facility's hot water tanks and outlets. Although it has been reported that many spas in Japan are contaminated with Legionellaceae, the outbreak we encountered suggests that Japanese spas, like whirlpool spas in Europe and North America, can be a source of Legionnaire's disease.

We prospectively analyzed the clinical and laboratory features of 74 patients with community-acquired pneumonia who required hospitalization between May 1996 and October 1997. Typical pathogens were identified in 47, and atypical pathogens in 27. The average age was higher in patients affected by typical pathogens (73.9 years), than in patients affected by atypical pathogens (50.9 years). Univariable analysis found that atypical pneumonias were more frequent in healthy patients than typical pneumonias. Moreover, the presence of relatives with symptoms of airway infection, headache, and earache was more common among the patients with atypical pneumonias, while leukocytosis and elevated C-reactive protein levels were more frequent among patients with typical pneumonias. Typical pathogens accounted for up to 79.6% of the cases of pneumonia with in older patients (aged 60 years or more), whereas atypical pathogens accounted for up to 80% of the cases of pneumonia in younger patients (aged under 60 years). This difference was statistically significant. Of all 74 patients, 39 (52.7%) were afflicted by severe community-acquired pneumonia, as categorized by American Thoracic Society guidelines. The most common pathogen among these patients was Streptococcus pneumoniae. Legionella was one of the top four. Selection of the initial antimicrobial treatment is an important clinical decision that should be made on the basis of clinical features at admission, age, and severity of the patient's illness.

From August 20 to 22, 1994, an outbreak of acute febrile illness occurred in a Training Center building of a company in Shibuya-ku, Tokyo. All 43 trainees attended in two groups and 2 Center staffs were attacked. Illness was self- limiting, generally lasting three days. Though strains of legionellae, isolated from the water of the cooling tower located at the top of the building, were identified as Legionella pneumophila by microplate DNA-DNA hybridization, they failed to agglutinate with antisera against L. pneumophila serogroups 1 through 6. Two strains were sent to the Centers for Disease Control, Atlanta, Georgia, USA, and determined as serogroup 7 of the species. Since the clinical courses agreed with the definition of Pontiac fever by Glick et al. and seroconversion in a patient against the cooling tower strain (EY3698)from 1:16 to 1:256 was determined by indirect fluorescent antibody technique, the epidemic of acute febrile illness was concluded as an outbreak of Pontiac fever due to L. pneumophila serogroup 7. The cooling tower was a cylindrical open style, with volumetric flow rate of 130 liter/min, and was used for air- conditioning exclusively to the third floor of the building. The building equipped no air-inlet, and indoor-air of the training room exchanged at every break time through windows of 168 cm in height and 72 cm in width. The cooling tower was not operated for five days before the Group A trainees checked in the Center on 18 August followed by Group B trainees on 19 August. It was speculated that high atmospheric temperature and stagnation of cooling water during this period would lead L. pneumophila to overly multiply, which could be a source of infection by flowing in through opened windows to the training rooms.

The Working Party for Legionellosis headed by the Japanese Ministry of Health and Welfare processed to standardize the diagnostic procedures for Legionella pneumonia, as the first step to clarify the actual occurrence of patients with this respiratory disease. All the clinical data were collected and analysed on the 28 culture-confirmed patients in Japan during the past 11 years, from 1980 through 1990. The 28 patients were distributed throughout Japan, from Hokkaido to Kyushu. Out of 28 patients, 18 were community-acquired and 10 were nosocomially infected. In 8 of 18 community-acquired patients, any significant underlying disease was not observed. Though it was dominant in the age group in their 60s & 70s, victims were distributed in adults over 20 years of age and even in a new born baby. Only 5 out of 28 patients recovered successfully. From the autopsy findings, in 5 out of the remaining 23 expired patients, Legionella pneumonia seemed to be successfully treated, but other disease or other bacterial pneumonia put an end to the patients. The results of clinical laboratory tests and the efficacy of antibiotics to Legionella pneumonia were essentially the same as those reported in the literature.