Halting the march of Legionnaire's

Legionnaire's disease is deadly and more commonplace than you might think. Plenty of guidance can be found on the disease, but people still seem to be ignoring it

The first thing most British people think about when they hear the words legionnaire's disease is the Forum 28 Arts Centre in Barrow-in-Furness, Cumbria.

In August 2002, this nondescript locale hosted the UK's largest outbreak of the disease. Around 180 people were infected, seven killed, and it culminated in the largest multiple manslaughter trial in recent UK history.

The blame was pinned squarely on architect Gillian Beckingham, who was eventually acquitted of seven charges of manslaughter and found guilty of breaching the Health and Safety at Work Act. Barrow Borough Council - one of the poorest in the UK and which would have been in line for a £1M fine if they had the funds - was fined £125,000.

Across the UK, managers of buildings with purpose-built water systems sat up and paid attention. "Exactly how far down the list of priorities is my Legionella bacterium monitoring," they might have been asking themselves.

Since the conclusion of the trial, Beckingham's defence lawyer, Kathryn Gilbertson, has given numerous talks about what went wrong at Barrow. She believes that the outbreak may not turn out to be a one-off, freak occurrence. "When I give talks about the Barrow case that detail where things went wrong, people have come up to me afterwards and said 'gosh, that's exactly how it is at our council'," she says ominously.

So what is the problem? Put simply: awareness.

Yes, guidance can be found in the Health and Safety executive's comprehensive 68-page Legionnaires Disease: The Control of Legionella Bacteria in Water Systems, Approved Code of Practice and Guidance (L8, 2000), while numerous succinct guides can be found online in the usual places (the HSE and the Health Protection Agency for example) but it is all for nothing if implementation is slack.

Sarah Cartwright, an associate director at RSK Health & Safety, accepts that before the Barrow tragedy many businesses simply opted to put Legionella on the backburner as the ever-rising annual death toll of asbestos-caused mesothelioma notched up the column inches.

"Legionella is like asbestos in that something needs to happen to give people a jolt. When Barrow happened it concentrated people's minds to go 'oh, Legionella. We might need to do something about that,'" she says.

RSK Health & Safety provides clients like the National Trust with a range of services that include writing and reviewing procedures for Legionella management plans, training staff to be aware of the risks and carrying out monitoring. It has even developed an innovative Legionella database that enables organisations with large property portfolios to get an at-a-glance oversight of how the problem is being dealt with.

"Post-Barrow, we had a load of enquiries about Legionella from councils and people with diverse range of buildings to look after. To co-ordinate and keep a handle of multi-site properties and who is doing what and when is a major headache. Sometimes that headache is allowed to linger longer than it should."

The genesis of the disease goes back to Philadelphia in 1976 when an outbreak of severe pneumonia ruined a meeting of the American Legion, hence its name. On that occasion 221 people received medical treatment, and 34 deaths occurred.

Legionnaire's disease is uncommon but deadly, with a mortality rate of around 10-15% for otherwise healthy individuals. This rises to as high as 30-40% for susceptible persons such as smokers or the elderly.

Initial symptoms are reminiscent of flu, though those affected can rapidly deteriorate to suffer muscle aches, respiratory failure, headache, tiredness, loss of appetite, memory loss and failure of liver and kidney functions.

As Legionella is widespread in nature it often contaminates water systems such as cooling towers used in industrial cooling water systems, central air conditioning systems, hot tubs, evaporative coolers, hot water systems, showers, whirlpool spas, architectural fountains, room-air humidifiers, ice-making machines, and misting equipment.

The list is endless. Essentially, if it has got water running through it and you do not look after it, you might have a problem. The bacteria thrive at temperatures between 20°C and 45°C and in stagnant water before being transmitted to humans through water droplets. Worldwide outbreaks on a similar scale to Barrow and Philadelphia tend to be rare, but are by no means unprecedented. In October 2005, 21 people died after an outbreak in Toronto, Canada. In 1999, 32 died from an outbreak traceable to a whirlpool and humidifier in Bovenkarspel, Netherlands. And 21 died in Pas-de-Calais, France in 2004. A study of the latter noted that the bacteria could travel as far as 7km from the original source.

In the UK the disease is becoming more commonplace, with the Health Protection Agency currently investigating a rise from 205 cases in August 2005 to more than 500 last year.

Dr Carol Joseph of the Health Protection Agency (HPA) believes that the bipolar British weather patterns and global warming are partly to blame for this upward curve. "It was definitely caused by weather effects. People use more water during the hot periods, shower more, use sprinklers, fishponds and spas. But I think towards the end of the year, a heightened awareness and increase in testing could also have played a part," she says.

"In the July period, the weather was such that it enabled the Legionella to grow and hang around much more than usual. And, in August, the high level of humidity enabled the Legionella that never got dispersed into the atmosphere to stay there a bit longer and get dispersed a bit further."

Following the publication of the HPA's figures, The Independent boldly announced: "Britain has suffered its first deaths from infectious disease attributable to global warming, official figures suggest."

Whether or not climate change will provide a consistent spike in the number of outbreaks and individual cases remains to be seen. For now though, the cause for most concern is a general understanding of the disease and what needs to be done to stop it from spreading.

"Outbreaks such as the one seen in Barrow are usually due to human error," says Joseph.

"It's not usually a breakdown in the system, it is usually a breakdown in the human actions required to maintain those systems."

Through defending Gillian Beckingham, lawyer Kathryn Gilbertson had a ringside seat to observe how a succession of simple, quotidian mistakes can make for disastrous consequences. With the benefit of hindsight, considering the sheer number of errors made by a multitude of staff at Forum 28, it seems absurd that only Beckingham was deemed culpable.

The court heard, among other things, that she had not properly maintained the contracts that provided for the upkeep of the air conditioning unit. And the HSE said in a report published this April that Beckingham's failures were "more significant than others".

Nevertheless, whichever way you slice it, this was not a tragedy that could be reducible to one lapsed task. "She was considered a 'responsible person' as she offered help to find a new contractor after the previous art centre manager had sacked the previous contractor," says Gilbertson incredulously, before giving a breathless summation of the other mistakes made at the arts centre.

"They had no system or process to supervise and monitor health and safety processes. They did not check the invoices, they did not train their staff, they didn't have any risk assessments, they didn't know what equipment they had on site, and they didn't even know what the risks were for the air conditioning equipment.

"They were totally blinkered to the risks they were running. Legionella will grow very quickly in warm water to levels that will cause illness."

In addition, they neglected to maintain a dedicated safety committee, relying instead on an under-funded, part-time safety and environmental officer to do the job. The council even paid for two independent audits that had identified Legionella as a potential problem but conducted no follow-up risk assessments.

"They identified the risks of asbestos, Legionella and fire, and they chose to deal with asbestos and fire first. It was about belief rather than knowledge," continues Gilbertson.

"Local governments have tight budgets and they will choose to spend their money on something that is tangible, whereas Legionella risk is a bit of a nebulous one and people will forget it is a problem."

Gilbertson is in no doubt as to what businesses and organisations need to be doing from the outset.

"There needs to be a roles and responsibility document. And, when a problem is identified, it needs to be factored back into the system to improve it.

"The health and safety approach and all its policies need to be reviewed to see if the procedures are working. If they aren't, take steps to improve them because, if that isn't done now, when the corporate manslaughter bill comes in people will be on a hiding to nothing."

While it is the death tolls that stick in the memory, those who survive infection often do so severely debilitated. So, while to the casual media observer, the number of deaths may seem low in the catastrophe context, an outbreak similar to Barrow has the potential to ruin the lives of hundreds.

Roger Scouse is a tragic case in point of the often-unreported life of the survivor. At the age of 61, he caught the disease from a shower in a French hotel. He used to be a fit, healthy and ambitious man. Now, at the age of 66, he finds himself catching his breath at the end of almost all of his sentences and can only bring himself to work part-time.

"You think you've got flu, you go to bed, take a Lemsip and you're shaking and all the rest of it," he says. "But then things start to happen that aren't like flu. It starts to attack your kidneys and liver, and you become very ill quite rapidly. You become delirious. Next thing you know, you're on a life-support machine."

Having returned to the UK, Scouse first experienced the onset of symptoms on a Monday. By Saturday he was on a life-support machine. "It is a nasty, horrifying disease. It's all so quick. It comes from nowhere, you inhale it and that's it. You never recover really, once you've been kissed by it, that's it. It has ruined your life," he says.

The aftermath of legionnaire's disease has left Scouse with scarred lungs, chronic fatigue, excruciating muscle pain ("so bad I can't do my shoelaces up"), shortness of breath and memory loss ("I can't watch TV for more than 20 minutes"). He is currently locked in a financially and emotionally crippling legal battle with the hotel where he caught the disease.

"You get very angry if you catch something like this due to somebody else's negligence. It is entirely preventable. It is just about keeping the public water systems clean. What more can you say? You get angry because you just think 'god, I'm never going to get over this. This has ruined my life, it stopped me working before I should have done and I'm very disabled from what I can get on with in life'.

"Awareness is the big issue. It is there. People are catching it. The medical profession and businesses that allow people into their buildings should be aware that is there. It exists and people need to know what it is."

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