[Skip to Content]
[Skip to Content Landing]
November 14, 1994

Surveillance for Legionnaires' DiseaseRisk Factors for Morbidity and Mortality

Author Affiliations

From the Childhood and Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases (Drs Marston and Breiman) and Biostatistics and Information Management Branch (Dr Lipman), Division of Bacterial and Mycotic Disease, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga.

Arch Intern Med. 1994;154(21):2417-2422. doi:10.1001/archinte.1994.00420210049006

Background:  To augment available information about the epidemiology of legionnaires' disease, we analyzed data reported to the passive surveillance system at the Centers for Disease Control and Prevention, Atlanta, Ga, from 1980 through 1989.

Methods:  Risk of disease associated with specific demographic characteristics and health conditions was calculated by comparing the surveillance group with the US population. Risk of death was calculated using multivariate logistic regression models.

Results:  A diagnosis of legionnaires' disease was confirmed on the basis of clinical and laboratory criteria for 3254 patients. Disease rates did not vary by year, but were higher in the northern states and during the summer. Legionella pneumophila, serogroup 1, constituted 71.5% of fully identified isolates. This study confirmed previously identified risk factors for legionnaires' disease. In addition, a markedly elevated risk was identified for persons with acquired immunodeficiency syndrome (rate ratio, 41.9; 95% confidence interval, 12.9, 71.0), or hematologic malignancy (rate ratio, 22.4; 95% confidence interval, 19.0, 25.9). Likelihood of death was increased in patients who were elderly or male; those with hospital-acquired infection, renal disease, malignancy, or immunosuppression; and those from whom L pneumophila, serogroup 6, was isolated.

Conclusions:  Infection with Legionella remains an important cause of disease and death in the United States. Diagnosis and treatment of legionnaires' disease should be targeted at patients at increased risk for illness and complications due to Legionella infection. Diagnostic tests for legionnaires' disease based on species other than L pneumophila, serogroup 1, should be developed and tested. Recommendations for prevention of legionnaires' disease should be focused on settings where there are persons at greatest risk for illness or serious outcome.(Arch Intern Med. 1994;154:2417-2422)

Haley CE, Cohen ML, Halter J, Meyer RD.  Nosocomial Legionnaires' disease: a continuing common-source epidemic at Wadsworth Medical Center . Ann Intern Med. 1979;90:583-586.Article
Kirby BD, Snyder KM, Meyer RD, Finegold SM.  Legionnaires' disease: report of 65 nosocomially acquired cases and review of the literature . Medicine. 1980; 59:188-204.Article
England AC, Fraser DW, Plikaytis BD, Tsai TF, Storch G, Broome CV.  Sporadic legionellosis in the United States: the first thousand cases . Ann Intern Med. 1981;94:164-170.Article
Friede A, Reid JA, Ory HW. WONDER: CDC's Online Public Health Information System . Atlanta, Ga: US Dept of Health and Human Services, Public Health Service, Centers for Disease Control; 1990.
Feldman AR, Kessler L, Myers MH, Naughton MD.  The prevalence of cancer: estimates based on the Connecticut Tumor Registry . N Engl J Med. 1986;315: 1394-1397.Article
Eggers PW, Connerton R, McMullan M.  The Medicare experience with end-stage renal disease: trends in incidence, prevalence, and survival . Health Care Finance Rev. 1984;5:69-88.
Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report . Atlanta, Ga: Centers for Disease Control and Prevention; 1992:1-22.
Kleinbaum D, Kupper L, Morgenstern H. Epidemiologic Research: Principles and Quantitative Methods. Belmont, Calif: Lifetime Learning Publications; 1982.
Portmore AC, Graman PS.  Five cases of Legionella pneumophila in patients with advanced HIV disease . Abstracts of the 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy; October 11-14, 1992 ; Anaheim, Calif. Abstract No. A374.
Allam AA, Kamholz SL.  Legionella pneumonia and AIDS . Chest. 1989;95:707-708.Article
Johnson JT, Best MG, Goetz A, Sicker H, Yu V, Vickers RM.  Nosocomial legionellosis in surgical patients with head-and-neck cancer: implications for epidemiological reservoir and mode of transmission . Lancet. 1985;2:298-300.Article
Fallon RJ, Abraham WH.  Legionnaires' disease: serogroup 6 . Lancet. 1980;2: 857-858.Article
Dowling JN, Saha AK, Glew RH.  Virulence factors of the family Legionellaceae . Microbiol Rev. 1992;56:32-60.
Fields BS, Barbaree JM, Shotts EBJ, Feeley JC, Morrill WE, Sanden GN.  Comparison of guinea pig and protozoan models for determining virulence of Legionella species . Infect Immun. 1986;53:553-559.
Bollin GE, Plouffe JF, Para MF, Prior RB.  Difference in virulence of environmental isolates of Legionella pneumophila . J Clin Microbiol. 1985;21:674-677.
Dennis PJ, Lee JV.  Differences in aerosol survival between pathogenic and non-pathogenic strains of Legionella pneumophila serogroup 1 . J Appl Bacteriol. 1988;65:135-141.Article
Summersgill JT, Raff MJ, Miller RD.  Interactions of virulent and avirulent Legionella pneumophila with human monocytes . J Leuk Biol. 1990;47:31-38.
Reingold AL, Thomason BM, Brake BJ, Thacker L, Wilkinson HW, Kuritsky JN.  Legionella pneumonia in the United States: the distribution of serogroups and species causing human illness . J Infect Dis. 1984;149:819.Article
Aguero-Rosenfeld ME, Edelstein PH.  Retrospective evaluation of the Du Pont radioimmunoassay kit for detection of Legionella pneumophila serogroup 1 antigenuria in humans . J Clin Microbiol. 1988;26:1775-1778.
Birtles RJ, Harrison TG, Samuel D, Taylor AG.  Evaluation of urinary antigen ELISA for diagnosing Legionella pneumophila serogroup 1 infection . J Clin Pathol. 1990;43:685-690.Article
Kohler RB, Wheat LJ, French MLV, Meenhorst PL, Winn WC, Edelstein PH.  Cross-reactive urinary antigens among patients infected with Legionella pneumophila serogroups 1 and 4 and the Leiden 1 strain . J Infect Dis. 1985;152: 1007-1012.Article
Tang PW, Toma S.  Broad-spectrum enzyme-linked immunosorbent assay for detection of Legionella soluble antigens . J Clin Microbiol. 1986;24:556-558.
Tang P, Krishnan C.  Legionella antigenuria: 6-year study of broad-spectrum enzyme-linked immunosorbent assay as a routine diagnostic test . In: Barbaree J, Breiman RF, Dufour A, eds. Legionella, Current Status and Emerging Perspectives . Washington, DC: American Society for Microbiology; 1993:12-13.
Ruf B, Schurmann D, Horbach I, Fehrenbach FJ, Pohle HD.  Prevalence and diagnosis of Legionella pneumonia: a 3-year prospective study with emphasis on application of urinary antigen detection . J Infect Dis. 1990;162:1341-1348.Article
Fang GD, Fine M, Orloff J, Arisumi D, Yu VL, Kapoor W.  New and emerging etiologies for community-acquired pneumonia with implications for therapy: a prospective multicenter study of 359 cases . Medicine. 1990;69:307-316.Article
 Inpatient utilization of short-stay hospitals by diagnosis . In: US 1982 Annual Summary . Washington, DC: National Center for Health Statistics, US Dept of Health and Human Services; 1983. Series 13, No. (72) (PHS-83-1733)
Statistical Abstract of the US . 108th ed. Washington, DC: US Dept of Commerce, Bureau of Census; 1988.
Marston BJ, Plouffe JF, Breiman RF, et al.  Preliminary findings of a community-based pneumonia incidence study . In: Barbaree J, Breiman RF, Dufour A, eds. Legionella, Current Status and Emerging Perspectives . Washington, DC: American Society for Microbiology; 1993:36-37.
Centers for Disease Control.  Summary of notifiable diseases: United States, 1990 . MMWR Morb Mortal Wkly Rep. 1990;39:55.
Blander SJ, Horwitz MA.  Vaccination with the major secretory protein of Legionella pneumophila induces cell-mediated and protective immunity in a guinea pig model of Legionnaires' disease . J Exp Med. 1989;169:691-705.Article
Horwitz MA.  Prospects for vaccine development . In: Barbaree J, Breiman RF, Dufour A, eds. Legionella, Current Status and Emerging Perspectives . Washington, DC: American Society for Microbiology; 1993:294-297.