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Travel-Associated Legionnaires' disease:
Common questions & answers for health departments
Why should travel-associated Legionnaires' disease be a priority?
About 21% of all Legionnaires' disease reported to the CDC between 1980 and 1999 was travel-associated-and that number is rising as reporting improves.
Legionnaires' disease is important to diagnose and to report because its identification implies the presence of an environmental source to which other susceptible individuals are likely to be exposed. Clusters of Legionnaires' disease associated with travel to hotels or aboard cruise ships are rarely detected by individual clinicians or health departments; travelers typically disperse from the source of infection before developing symptoms. Therefore, a travel history should be actively sought from patients with community-acquired pneumonia and Legionella testing should be performed for those who have traveled in the 2 weeks before onset of symptoms.
Because of the multi state nature of travel in the U. S., national-level surveillance is necessary to detect outbreaks of travel-associated Legionnaires' disease. CDC relies upon state and local health departments to conduct this surveillance. Surveillance through the National Notifiable Diseases Surveillance System (NNDSS) is still important for monitoring national trends; all cases should be reported through NNDSS.
CSTE adopted a position statement relevant to travel-associated Legionnaires' disease in 2005. Click here to see the new CSTE position statement (
PDF).
What can CDC do to assist us as we begin to investigate a potential cluster of Legionnaires' disease?
- Epidemiologic assistance
CDC staff, including Epidemiologic Intelligence Service officers (EIS), is available to assist you as you define terms of your outbreak, as well as to help centralize communication among state health departments in a travel-associated case or outbreak. We can also assist with: case definitions, travel-associated reporting, and reporting in general. Download a case report form. PDF 21KB
Inform CDC about travel-associated cases by emailing travellegionella@cdc.gov. We are trying to improve the efficiency of travel-associated surveillance at CDC and need your help. See the home page for more details. Please continue official reporting mechanisms through NNDSS and through submission of case report forms PDF 21KB.
Public inquiries: Please contact CDC INFO at 1-800-CDC-INFO, (800-232-4636), TTY: (888) 232-6348 24 Hours/Every Day, cdcinfo@cdc.gov
- Laboratory testing
CDC does not accept laboratory specimens of any type without clearance through the Respiratory Diseases Branch prior to submission. This includes urine antigen testing, specimens for culture, or other submissions for either initial or confirmatory testing.
CDC Laboratory testing is only done under special circumstances, e.g., an outbreak investigation that CDC is involved with, or if CDC has granted prior permission for submission of specimens. Routine laboratory submissions are not accepted by the CDC laboratories.
- Sample outbreak questionnaires and other tools
Samples of questionnaires used in institutional outbreaks, tracking travel-associated cases, or other situations are available on our website. They are free for you to download and use as tools or 'starter points' as you begin your investigation. (See the home page for examples.)
How should I report a travel-associated case of Legionnaires' disease?
Because of the public health importance of timely reporting, inform CDC of travel-associated cases by emailing travellegionella@cdc.gov .
For a single case residing in your jurisdiction, inform the other relevant state health departments. Click here for a list of state health department websites .
Post a "call for cases" on Epi-X. Epi-X is CDC's secure information exchange network that provides a useful means for communicating information of public health importance, including the possibility of Legionnaires' disease cases associated with individual hotels or cruise ships. Timely recognition of clusters of travel-associated disease can lead to earlier intervention and prevention of additional cases.
- If the case is cruise ship related, inform the CDC Division of Global Migration & Quarantine and the CDC Vessel Sanitation Program. (Can be a single email: VSP@cdc.gov , FMA0@cdc.gov., and travellegionella@cdc.gov)
- Inform the cruise line.
- Sample letter to give to a hotel. PDF 171KB
What diagnostic tests can confirm Legionnaires' disease?
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Culture |
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| Serology |
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| DFA |
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Where can I get information on environmental sampling?
Download environmental testing guidelines.
How do I start interviews?
Interview the patient or the patient's proxy (spouse, adult offspring, etc.) about the patient's actions 10- 14 days prior to diagnosis. Be sure to ask about travel history and occupation. Check this LD home page for sample questionnaires.
What should I tell providers in my state or area?
Let them know to be alert for new cases. Encourage them to obtain lab testing, the preferred methods being cultures of respiratory secretions or tissue, and urine antigen testing.
Who has authority over cruise ships?
Where can I get Legionella statistics?
What do I tell hospitals, hotel operators, hot tub maintenance staff, or others about de-contamination?
There are many options for remediation of water cooling towers. The American Society of Heating, Refrigerating, and Air Conditioning Engineers has developed Guideline 12-2000 "Minimizing the Risk of Legionellosis Associated with Building Water Systems". This document is available at www.ashrae.org, as well as at www.baltimoreaircoil.com, and www.marleyct.com/publications.asp.