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Published Date: 2019-07-07 13:14:26
Subject: PRO/EDR> Legionellosis - Europe (04): UK, Legionnaires' dis. Pontiac fever, salt cave spa
Archive Number: 20190707.6555856
LEGIONELLOSIS - EUROPE (04): UK, LEGIONNAIRES' DISEASE, PONTIAC FEVER, SALT CAVE SPA
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Date: Sat 6 Jul 2019
Source: BBC [edited]
https://www.bbc.com/news/uk-england-dorset-48892538


Healax Salt Caves officials said it was closed "until further notice." A health spa is the "likely source" of an outbreak of _Legionella_ infection, which has left 9 people in hospital, Public Health England (PHE) has said.

14 people who attended Healax Salt Caves in Bournemouth in June [2019] have contracted either Legionnaire's disease or the less serious Pontiac fever. A further 39 people who reported symptoms have not had infections confirmed by laboratory tests. The 9 worst-affected patients are now recovering at home.

[A woman, 63 years old], said she and a friend both contracted Pontiac fever after visiting the spa on 10 Jun [2019]. "When I got home, I had a headache, was sick, and felt like my chest was being crushed," she said. [She] said she slept for more than 24 hours, not realising that she had missed work. "I live alone. It's really frightened me," she said.

Dr Fiona Neeley from PHE said: "We understand that there will be concern among people who visited Healax Salt Caves and spa. "Thankfully, in all cases of illness that have been reported to Public Health England to date, those affected are now recovering from their illness. There are no ongoing risks to health for the wider population in relation to this incident." She said the business owner and health officials had "acted quickly" to ensure that any further risk was controlled.

_Legionella_ bacteria can live in spa pools, Public Health England said. The affected customers visited the spa between 1-18 Jun [2019], PHE said. The business in Kinson Road has been closed until further notice, its Facebook site said. A repossession notice has been posted on the door, the Bournemouth Echo reported. Therapies offered at the centre include a saltwater hot tub and a "salt cave" with a salt-covered floor and walls made from salt blocks.

_Legionella_ bacteria live in natural and man-made water systems. They become a health risk when maintenance problems occur in systems such as spa pools. Legionnaire's disease is a serious lung infection, which can cause pneumonia. Men aged over 50, smokers and ex-smokers, and patients with underlying medical conditions are most at risk of the disease. Pontiac fever is a mild flu-like illness also caused by _Legionella_ bacteria. Symptoms of both conditions include fever, coughs, muscle aches, and fatigue.

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Communicated by:
ProMED-mail from HealthMap Alerts
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[Bournemouth, with a population of 183 491 residents, is a resort town on the south coast of England, in Dorset (https://en.wikipedia.org/wiki/Bournemouth). A map showing the location of Bournemouth can be found at https://www.google.com/maps/place/Bournemouth,+UK.

Inhaling salty air ("halotherapy") is touted as having health benefits (https://www.lung.org/about-us/blog/2016/06/promising-placebo-salt-halotherapy.html). There are 100s of "salt rooms and beds" in the U.S. that offer "haloherapy" (https://www.organicspamagazine.com/2015/08/28/benefits-of-salt-therapy/). Some facilities combine "halotherapy" with "salt stone" massage (https://www.handandstonebradenton.com/himalayan_salt_stone_massage.html), and some hot tubs are designed to be used with salt water (https://www.hotspring.com/blog/pros-and-cons-salt-water-hot-tubs).

_Legionella_ are gram-negative bacilli that are found in both natural freshwater environments, like lakes and streams, and in manufactured plumbing systems, such as showerheads and sink faucets, cooling towers, decorative fountains, hot tubs/spas, and hot water tanks and heaters. Warm water temperatures of 25-40 C [77-104 F] support the highest concentrations of the organism in plumbing systems.

_Legionella_ have also been found to survive in salt solutions up to 3% NaCl at temperatures between 4-20 C [39-68 F]; however, bacterial die-off at higher temperatures was not observed in natural seawater (https://www.ncbi.nlm.nih.gov/pubmed/9489037). The average concentration of salt in seawater is about 3.5%.

Amebae harbor _Legionella_ intracellularly, and the long-term persistence of _Legionella_ within various water systems is favored by their intracellular location within several species of protozoa, which provide protection from environmental stressors, like biocides and heat treatment. Amebae that were isolated from marine environments have been found to contain _Legionalla_ species potentially pathogenic to humans (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3109871/).

The formation of biofilms allows adherence of _Legionella_ to the inner surfaces of the plumbing systems (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5835138/). _Legionella pneumophila_ have been shown to persist for long periods in biofilms in a viable but nonculturable (VBNC) state after exposure to a biocide or heat treatment (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5515819/). Monitoring _L. pneumophila_ in water systems that is usually done by culture would miss VBNC _Legionella_, which can be revived by the subsequent addition of amebae (https://www.ncbi.nlm.nih.gov/pubmed/18839249).

Legionellosis is an infectious disease caused by various species of _Legionella_, most commonly _Legionella pneumophila_. Legionnaires' disease (LD) is the acute pneumonic form of the disease. Pontiac fever is a non-pneumonic form of legionellosis with fever, malaise and muscle aches that are less severe than LD; symptoms resolve in 2 to 5 days without antibiotic treatment (https://www.cdc.gov/legionella/clinicians/clinical-features.html). Pontiac fever develops hours to 3 days after initial infection, versus 2 to 10 days for LD. Attack rates for Pontiac fever are high; up to 95 percent of exposed persons become ill, versus less than 5% for LD. Unlike LD, there appear to be no predisposing host conditions for Pontiac fever. Risk factors for LD include: Age greater than or equal to 50 years, Smoking (current or historical); Chronic lung disease (such as emphysema or COPD); Immune system disorders due to disease or medication; Systemic malignancy; and Underlying illness such as diabetes, renal failure, or hepatic failure (https://www.cdc.gov/legionella/clinicians/disease-specifics.html). LD takes its name from an outbreak among people attending an American Legion convention at the Bellevue-Stratford Hotel in Philadelphia in 1976. Pontiac fever takes its name from an outbreak in 1968 in Pontiac, Michigan.

Both LD and presumably Pontiac fever are acquired by inhalation of an infectious dose of aerosolized _Legionella_. People who are prone to aspiration can also develop LD following aspiration of _Legionella_-contaminated potable water. Possible person-to-person transmission has also been described (Correia AM, Goncalves J, Gomes JP, et al. Probable person-to-person transmission of Legionnaires' disease. N Engl J Med 2016;374(5):497-8. http://www.nejm.org/doi/full/10.1056/NEJMc1505356).

Aerosolization of the contaminated warm water can occur in showers, spa pools, sprays in groceries, water fountains, and cooling towers. Why some persons exposed to contaminated aerosols develop LD and others develop Pontiac fever is unknown.

The diagnosis of Pontiac fever is usually made on the basis of epidemiologic, clinical, serological, environmental microbiology findings, and, in a variable portion of the affected people, the development of antibodies to the bacterium isolated from the environment. Urinary antigen testing, an assay that detects only _L. pneumophila_ serogroup 1 antigen, is uncommonly positive, and cultures are rarely positive for _Legionella_ in patients with Pontiac fever. For a discussion of the pathogenesis and diagnosis of Pontiac fever, see Edelstein PH. Urinary antigen tests positive for Pontiac fever. Clin Infect Dis 2007; 44:2229-31.

There have been several outbreaks of LD where the cause was traced back to a hot tub. See prior ProMED-mail post Legionellosis, spa pool - UK (England) 20060929.2787. People can be exposed not only while using a hot tub but also by being close enough to breath in the fine spray created by the hot tub.

Genotyping the clinical isolates from cases of LD will help to establish whether this "salt cave" outbreak is a common source outbreak, if the genotypes match. Matching the genotypes of clinical and environmental isolates of _Legionella_ will identify the environmental source for the individual cases. However, if the diagnoses were confirmed through urine antigen testing, there will be no clinical isolates for genotyping. - Mod.ML

HealthMap/ProMED map available at:
United Kingdom: http://healthmap.org/promed/p/40]

See Also

Legionellosis - USA (07): (WV) racetrack hot tub 20190505.6456308
2018 
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Legionellosis - USA (05): (FL) spa, pool, hot water heater 20180313.5684579
Legionellosis - USA (04): (FL) spa, pool, irrigation system susp 20180301.5659038
2017 
----
Legionellosis - USA (22): (NV) Legionnaires' dis, Pontiac fever, hotel, RFI 20171117.5450851
Legionellosis - USA (12): (TN) hotel, hot tub/pool, RFI 20170720.5192558
Legionellosis - USA (09): (TN) hotel, hot tub/pool susp. 20170701.5143756
Legionellosis - Australia (03): (VI) gym spa susp. 20170626.5130629
Legionellosis - USA (06): (FL) adult community, hot tub 20170615.5107309
Legionellosis - USA (03): (FL) spa & showers susp, RFI 20170422.4987402
Legionellosis - USA: (NY) commercial spa pool 20170107.4747816
2012
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Legionellosis - UK (13): (England) fatal, hot tub 20120816.1246273
Legionellosis - UK (12): (England) fatal, hot tub implicated 20120802.1225198
2010 
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Legionellosis - Spain (03): Barcelona, Pontiac fever 20100718.2405

2006 
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Legionellosis, spa pool - UK (England) 20060929.2787
2004 
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Legionellosis, spa - Austria (Upper Austria) 20040331.0881
2003 
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Legionellosis, spa outbreak - Spain (Canary Islands) (02) 20030603.1352
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