UK: Aircraft Disinsection Ordered For Zika

Scheduled airline traffic around the world, circa June 2009 – Credit Wikipedia

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Although infected travelers are the most likely way for Zika (or Dengue, CHKV, or malaria) to make it from endemic regions to North America or Europe, aircraft and ships often carry unauthorized passengers; stowaway mosquitoes.


Up until now, `Airport Malaria'  has been the biggest concern, and the CDC even has a definition for it on their Malaria Transmission in the United States web page:

"Airport" Malaria

"Airport" malaria refers to malaria caused by infected mosquitoes that are transported rapidly by aircraft from a malaria-endemic country to a non-endemic country. If the local conditions allow their survival, they can bite local residents who can thus acquire malaria without having traveled abroad

In 2008, the American Society of Tropical Medicine and Hygiene warned:

Warmer climate changes in major U.S. cities with a large presence of international air traffic, such as New York and Los Angeles, seem to have created a more welcoming environment where these infected mosquitoes can survive. It begins with a mosquito that is transported during an international flight from a malaria-endemic region. Once the infected female mosquito leaves the aircraft, it can survive long enough to seek blood meals and transmit the disease to other humans within the airport. This type of international transmission creates an increased possibility for the reintroduction of not just malaria, but other detrimental diseases such as dengue and Chikungunya fever, into areas where they are not normally found.

Today the UK has announced that all aircraft inbound from Zika endemic regions will be required to undergo disinsection, a procedure which is currently done for flights from regions where malarial diseases are endemic.

 Planes returning from Zika areas to be sprayed with insecticide

From: Department of Health, Department for Transport and Public Health England

First published: 5 February 2016

All aircraft returning to the UK from countries currently affected by active Zika virus transmission will be sprayed with insecticide as part of a comprehensive government response to the disease.

On Monday, the World Health Organisation (WHO) declared the issue of microcephaly - which may be linked to Zika - a public health emergency of international concern.

As a precautionary measure, the government is asking airlines to ensure that disinsection (spraying with insecticide) takes place on all flights to the UK from countries with confirmed transmission of Zika.

Disinsection involves spraying a simple insecticide inside the aircraft to reduce the risk of passengers being bitten by any mosquitoes that could have entered the aircraft. It already occurs on the majority of flights from the region as a precaution against malaria.

The move is consistent with advice from WHO Europe. The type of mosquito that transmits the virus is extremely unlikely to survive and breed here given the lower temperatures in the UK.

(Continue . . . )

This practice, which is likely to become more common as Zika spreads, is not without its controversy. Although WHO weighed in on its safety 20 years ago (see below), some passengers have reported temporary ill effects or discomfort from the exposure. 

The choice, however, is to either to spray flights or allow potentially infected mosquitoes free international travel, with complementary in-flight blood meals thrown in as a bonus. 

The United States Transportation Department explains the procedures and the law:

Aircraft Disinsection Requirements
 
Overview

Disinsection is permitted under international law in order to protect public health, agriculture and the environment. The World Health Organization and the International Civil Aviation Organization stipulate two approaches for aircraft disinsection--either spray the aircraft cabin, with an aerosolized insecticide, while passengers are on board or treat the aircraft's interior surfaces with a residual insecticide (residual method) while passengers are not on board. Panama and American Samoa have adopted a third method, in which aircraft are sprayed with an aerosolized insecticide while passengers are not on board.

Although the Report of the Informal Consultation on Aircraft Disinsection sponsored by the World Health Organization (November 6-10, 1995) concluded that aircraft disinsection, if performed appropriately, would not present a risk to human health, the report also noted that some individuals may experience transient discomfort following aircraft disinsection by aerosol application.

Although few countries now require that aircraft be disinsected, most countries reserve the right to do so, and, as such, could impose a disinsection requirement should they perceive a threat to their public health, agriculture or environment. Accordingly, travelers are advised to check with their travel agent or airline reservations agent when booking flights. Listed below are representatives of airlines who are knowledgeable on disinsection requirements. 

(Continue . . .)

The UK appears to be the first major country to order the spraying of all flights from Zika affected regions, but other nations are no doubt considering similar steps.

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Hong Kong CHP Notified Of 19 Additional H7N9 Cases On Mainland

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As I mentioned yesterday (see H7N9 : Hunan Province Reports 2nd Case In Two Days), while official reporting of H7N9 cases from China has declined in reliability over the past year, recent media reports suggested there were roughly 20 unannounced cases on the Mainland, but where they occurred - and when - wasn't known.

Today, via a very brief (and data sparse) announcement from Hong Kong's CHP we are informed of 19 previously unannounced cases, with onsets going back as far as December 21st, hailing from three provinces (Zhejiang, Jiangsu & Fujian).

As always, surveillance only picks up those who are sick enough to be hospitalized, and lucky enough to then be tested for the virus. We know that mild and asymptomatic H7N9 infections do occur, but how often, is an open question.


This from Hong Kong's CHP.

CHP notified of additional human cases of avian influenza A(H7N9) in Mainland

The Centre for Health Protection (CHP) of the Department of Health (DH) today (February 5) received notification of 19 additional human cases of avian influenza A(H7N9) with onset of symptoms between December 21, 2015 and January 25 this year from the National Health and Family Planning Commission, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

     The patients comprise 11 men and eight women aged from 42 to 91, four of whom (three men and one woman) have died. Eleven cases are from Zhejiang, five are from Jiangsu and three are from Fujian.

     "H5 and H7N9 avian influenza viruses can cause severe infections in humans. Due to the seasonal pattern, our risk assessment shows that the activity of avian influenza viruses is expected to remain at a high level in winter months. Human H5N6 and H7N9 cases have been recorded in the Mainland since this winter. Locally, birds positive for H5N6 were also detected this winter. The public, particularly poultry traders, travellers and those who may visit the Mainland in the coming Lunar New Year, should be highly alert. Do not visit poultry markets and farms. Avoid poultry contact. We will continue to monitor the regional and global disease situation," a spokesman for the CHP said.

     From 2013 to date, 702 human cases of avian influenza A(H7N9) have been reported by the Mainland health authorities.

     The DH's Port Health Office conducts health surveillance measures at all boundary control points. Thermal imaging systems are in place for body temperature checks on inbound travellers. Suspected cases will be immediately referred to public hospitals for follow-up.

     The display of posters and broadcast of health messages in departure and arrival halls as health education for travellers is under way. The travel industry and other stakeholders are regularly updated on the latest information.

     Travellers, especially those returning from avian influenza-affected areas with fever or respiratory symptoms, should immediately wear masks, seek medical attention and reveal their travel history to doctors. Health-care professionals should pay special attention to patients who might have had contact with poultry, birds or their droppings in affected areas.

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RESEP SETUP MAKARONI KEJU SUSU KHAS SOLO

RESEP SETUP MAKARONI

Olahan masakan dari pasta makaroni bisa mencoba resep setup makaroni khas Solo berikut ini. Olahan makaroni yang direbus empuk lalu dimasak berkuah susu bertabur keju ini konon digemari para bangsawan di masa kolonial Belanda. Menu kuliner enak asli Solo ini sering disajikan saat acara keraton surakarta maupun acara pesta pernikahan bahkan acara-acara hajatan lainnya.

Kuah susu membuat kuahnya menjadi lebih sedap dan creamy, makaroni yang empuk namun tidak lembek dengan taburan keju menjadi hidangan yang spesial beserta paduan daging ayam, kocokan telur, serta bumbu merica dan pala.

Perispan Bahan Bumbu Setup Makaroni

• 225 gram makaroni direbus cukup hingga empuk saja atau tidak sampai lembek
• 200 gram daging ayam dipotong dadu, lalu rebus hingga matang
• 3 buah sosis ayam dipotong korek
• 2 butir telur dikocok lepas
• 1 buah bawang bombay dipotong dadu
• 2 siung bawang putih
• 400 ml susu cair
• 1 liter air
• 1,5 sdt garam
• 1 sdt gula pasir
• 1 sdt merica
• 1 sdt pala bubuk
• 1 sdm margarin untuk menumis
• keju cheddar diparut seperlunya

Cara Membuat Setup Makaroni

1. Panaskan margarin, tumis bawang bombay dan bawang putih hingga harum. Masukkan daging ayam dan sosis, aduk rata kemudian tuang susu cair dan 1 liter air, beri garam, gula, merica, dan pala bubuk.
2. Aduk-aduk dan masak hingga mendidih, lalu masukkan makaroni yang sudah direbus dan kocokan telur, aduk-aduk dan masak sebentar hingga telur matang dan berbulir lalu matikan api. Angkat dan tuang setup makaroni dalam mangkuk saji serta sajikan hangat dengan taburan keju parut di atasnya.

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Eurosurveillance: Emergence of A(H1N1)pdm09 Genogroup 6B In India, 2015

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In February of 2015, in India’s H1N1 Outbreak, we looked at the persistent media reports of unusually severe H1N1 flu activity on the Indian subcontinent, and the insistence by India’s National Institute of Virology (NIV) and their National Centre for Disease Control (NCDC) that there were No mutations in H1N1.

A few weeks later, in MIT: Genetic Changes In A 2014 Indian H1N1pdm09 Virus,  we saw analysis of at least one flu isolate collected in 2014 that researchers said contained  `amino acid changes linked to enhanced virulence and are potentially antigenically distinct from the current vaccine containing 2009 (Cal0709) H1N1 viral hemagglutinin.

The entire report/commentary – which emphasizes the need for more robust and timely influenza surveillance and sequencing data -  can be accessed at:  Influenza Surveillance: 2014–2015 H1N1 “Swine”-Derived Influenza Viruses from India.

Fast forward to today, and the ECDC's Eurosurveillance has done just that.  

They've published an analysis of sequencing data from H1N1pdm09 isolates gathered in India during the first half of 2015. One that not only finds the rapidly rising Genotype 6B present but provides evidence of additional mutations as well.


This study also references the MIT study mentioned above. I've only excerpted a small piece, so follow the link to read it in its entirety.

Rapid communication

Emergence of influenza A(H1N1)pdm09 genogroup 6B and drug resistant virus, India, January to May 2015

M Parida ¹ , PK Dash ¹ , JS Kumar ¹ , G Joshi ¹ , K Tandel ¹ , S Sharma ¹ , A Srivastava ¹ , A Agarwal ¹ , A Saha ¹ , S Saraswat ¹ , D Karothia ¹ , V Malviya ¹

+ Author affiliations

Received:11 December 2015; Accepted:04 February 2016

---

To investigate the aetiology of the 2015 A(H1N1)pdm09 influenza outbreak in India, 1,083 nasopharyngeal swabs from suspect patients were screened for influenza A(H1N1)pdm09 in the state of Madhya Pradesh. Of 412 positive specimens, six were further characterised by phylogenetic analysis of haemagglutinin (HA) sequences revealing that they belonged to genogroup 6B. A new mutation (E164G) was observed in HA2 of two sequences. Neuraminidase genes in two of 12 isolates from fatal cases on prior oseltamivir treatment harboured the H275Y mutation.

An epidemic of influenza A(H1N1)pdm09, affecting over 39,000 persons and causing more than 2,500 deaths occurred in India in 2015 [1]. We show that genotype 6B strains forming two sub-lineages circulated during the outbreak.

Comparison of the sequences of six outbreak strains recovered in this work, to other published genotype 6B sequences, also reveals a unique combination of previously-reported mutations in the haemagglutinin (HA) gene. Two of the six sequences additionally display a E164G mutation in HA2, which has not been reported to date, moreover a N129D mutation in HA1 is observed for two sequences derived from patients with severe disease. Among strains analysed from 12 fatal cases on prior oseltamivir treatment, two harbour the H275Y mutation in the neuraminidase (NA) gene, which confers resistance to this antiviral.  

(Continue . . .)

The H275Y amino acid change, which confers resistance to Oseltamivir, has yet to take hold with the H1N1pdm09 virus, showing up in only 1%-2% of samples tested. That said, we have seen a few worrisome clusters of NAI resistant flu (see HERE & HERE), raising concerns that a resistant strain could evolve.


As mentioned previously, the A/H1N1pdm09 virus has remained remarkably stable since it first emerged as a pandemic strain in the spring of 2009.  But over time - and as all influenza A viruses do - the virus has picked up small genetic changes due to antigenic drift.

Most of these genetic changes go nowhere. They either offer no evolutionary advantage, or worse for the virus, they are detrimental to its survival.  

But occasionally - and through random chance -  a mutation (or set of mutations) provides the virus a biological advantage over its competitors; it infects its host more readily, transmits more easily, or replicates more efficiently.

The tendency is to become complacent with seasonal flu, and to worry only about the novel flu strains.  But the virulence of seasonal flu is not constant, and it is always possible for an old and familiar flu to learn new tricks. 

The changes observed in this study - and those recently reported by the Russians (see Week 5 Epi Report) - are intriguing and beg further investigation and study.  But it remains to be seen how much of an effect they will actually have on the virulence and future impact of the H1N1pdm09 virus.

 

Stay tuned. 

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H7N9 : Hunan Province Reports 2nd Case In Two Days

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Between Hong Kong CHP's tracking and the terrific work done by Sharon Sanders with FluTracker's H7N9 line listing, we've seen just over two dozen H7N9 cases announced by Chinese authorities since the fall flu season began.

While China earned praise during the first two H7N9 epidemic seasons for their daily updates on cases, for the past year we've seen the quality and quantity of reporting drop to abysmal levels. 

Earlier this week a Chinese media report alluded to there being nearly 20 unannounced cases (see China reports H7N9 since September last year 44 cases), but where they occurred - and when - isn't known.  


Over the past two days we've seen Xinhau reports announcing two recent H7N9 cases in Hunan Province (details below), and today's report indicates that Hunan has reported 5 cases since the 1st of the year.

A bit of a surprise because until yesterday, they'd only reported one.

 First an excerpt from yesterday's CHP announcement, followed by today's Xinhua report.

4 February 2016
CHP closely monitors additional human case of avian influenza A(H7N9) in Mainland 

     The Centre for Health Protection (CHP) of the Department of Health (DH) is today (February 4) closely monitoring an additional human case of avian influenza A(H7N9) in the Mainland, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

     According to the Health and Family Planning Commission (HFPC) of Hunan Province, the 60-year-old male patient lived in Yongzhou, Hunan. 

(Continue . . .)

New human H7N9 case reported in central China

CHANGSHA, Feb. 4 (Xinhua) -- A new human H7N9 avian flu case was reported in central China's Hunan Province Thursday, bringing the total number of cases to five, local authorities said.

A 48-year-old man surnamed Xie died Thursday at a hospital in Yongzhou City, the provincial health and family planning commission said in a press release.

Xie, a native of Lingling District in Yongzhou, sought medication Wednesday and was diagnosed of human H7N9 avian flu. The immediate cause of his death was liver and kidney failures, the document said.

But it did not say how Xie contracted the illness.

Hunan Province has reported five cases of human H7N9 avian flu since the beginning of this year. Two of the patients have died and the other three are still receiving treatment, the document said.

Sporadic human H7N9 cases have been reported in Shanghai, Guangdong and Fujian. H7N9 is a bird flu strain first reported to have infected humans in March 2013 in China. It is most likely to strike in winter and spring.

While H7N9 activity appears lighter this winter in China than in previous years, the lack of dependable reporting out of China makes it very difficult to put a lot of faith in appearances.

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JID: Benefits Of Early Use of Influenza Antivirals In Pregnancy

Credit - CDC

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With a warning earlier this week that severe H1N1 cases are beginning to be reported in younger adults around the country, the timing for a study and commentary on the benefits of early antiviral treatment for pregnant women with influenza that appears today in the Journal of Infectious Diseases couldn't be much better. 

Pregnant women have an enhanced risk for serious complications from influenza, something we've looked at repeatedly over the years:

• During the 2009 H1N1 pandemic, pregnant women were six times more likely to be hospitalized than non-pregnant women (see Pregnancy & Flu: A Bad Combination).
• And in 2011, in BMJ: Perinatal Outcomes After Maternal 2009/H1N1 Infection we saw a study where pregnant women who were admitted to the hospital with an  H1N1 infection experienced a 3 to 4 times higher rate of preterm birth, 4 to 5 times greater risk of stillbirth, and a 4 to 6 times higher rate of neonatal death.

It is for this reason that flu vaccinations are so highly recommended for women who are pregnant (see CDC's Pregnancy and Influenza Vaccine Safety). But even with the vaccine, infection can sometimes occur, and here is where antivirals come into play.


Despite their frequent demonization in the press, antivirals have a proven track record of reducing the impact of severe influenza when taken early in one's illness, particularly for those at greatest risk of complications

I've reviewed the evidence for using antivirals many times over the years, including The Conversation: The Rise & Fall Of The Challenge To Tamiflu and Revisiting Tamiflu Efficacy (Again).

Although we've seen evidence of the value of treating pregnant women with antivirals in the past (see Study: Antivirals Saved Lives Of Pregnant Women), we have another study showing the outcomes for pregnant women hospitalized with lab-confirmed influenza, who either received antivirals early (< 48 hrs after onset), late (> 48hrs) , or not at all.

The benefit of early influenza antiviral treatment of pregnant women hospitalized with laboratory-confirmed influenza

Ikwo Oboho1,2, Carrie Reed1,Paul Gargiullo1, Michelle Leon1,Deborah Aragon3, James Meek4,Evan J. Anderson5,6,Patricia Ryan7,Ruth Lynfield8,Craig Morin8, Marisa Bargsten9,Shelley Zansky10,Brian Fowler11,Ann Thomas12,Mary Lou Lindegren13,William Schaffner13,Ilene Risk14,Lyn Finelli1 and Sandra S. Chaves1 

Abstract

Background. We describe the impact of early antiviral treatment among pregnant women hospitalized with laboratory-confirmed influenza (2010−14 influenza seasons). 

Methods. Severe influenza was defined as intensive care unit admission, mechanical ventilation, respiratory failure, pulmonary embolism, sepsis, or death. Within severity stratum, we used parametric survival analysis to compare length of stay (LOS) by timing of antiviral treatment, adjusting for underlying conditions, influenza vaccination, and pregnancy trimester.

Results. Among 865 pregnant women, median age was 27 years (interquartile range [IQR], 23−31). Most (68%) were healthy, and 85% received antiviral treatment. Sixty-three (7%) women had severe influenza, 4 died. Severity was associated with preterm delivery and fetal loss.

Women with severe influenza were less likely to be vaccinated than those without (14% vs. 26%, p=0.03). Comparing women treated with antivirals ≤2 vs. >2 days from illness onset, median LOS (days) was respectively 2.2 (IQR 0.9−5.8; n=8) vs. 7.8 (IQR 3.0−20.6; n=7) for severe (p=0.03), and 2.4 (IQR 2.3−2.5; n=153) vs. 3.1 (IQR 2.8−3.5; n=62) for non-severe influenza (p<0 .01="" span="">

Conclusions.  Early influenza antiviral treatment for pregnant women hospitalized with influenza may reduce LOS, especially if severe influenza. Influenza during pregnancy is associated with maternal and infant morbidity and annual influenza vaccination is warranted.

The full study can be downloaded at Full Text (PDF).


The IDSA (Infectious Disease Society of America) has a press release on this study, excerpts of which follow:

For pregnant women with flu, the earlier the better for antiviral treatment

Prompt use of medication beneficial, especially in cases of severe illness, study suggests Infectious Diseases Society of America

Pregnant women are at higher risk for serious illness and complications, including death, from influenza. For expectant mothers hospitalized with flu, early treatment with the influenza antiviral drug oseltamivir may shorten their time in the hospital, especially in severe cases, suggests a new study published in The Journal of Infectious Diseases and available online. The findings also underscore the importance of flu vaccination for this risk group.

"Treating pregnant women who have influenza with antiviral drugs can have substantial benefit in terms of reducing length of stay in the hospital," said Sandra S. Chaves, MD, MSc, of the Centers for Disease Control and Prevention (CDC) and senior author of the study. CDC recommends treatment of suspected cases of flu among pregnant women with antiviral drugs as soon as possible, without waiting for test results to confirm influenza. "The earlier you treat, the better chances you have to modify the course of the illness."

Past studies have suggested that flu antiviral therapy is safe and beneficial for pregnant women. The current study, based on data from a nationwide flu surveillance network including 14 states, focused on pregnant women hospitalized with laboratory-confirmed flu over four recent flu seasons, from 2010 to 2014.

During the study period, 865 pregnant women were hospitalized with flu. Sixty-three of these patients, or about 7 percent, had severe illness.
After adjusting for underlying medical conditions, vaccination status, and pregnancy trimester, the researchers found that early treatment with the antiviral drug oseltamivir was associated with a shorter hospital stay. Among pregnant women with severe flu illness who were treated early -- within two days of the start of symptoms -- the median length of stay was about five days shorter compared to hospitalized pregnant women with severe flu illness who were treated later (2.2 days vs. 7.8 days). Pregnant women hospitalized with less severe illness who were treated early also had a shorter hospital stay than those treated later, but the difference was not as great.

In the study, pregnant women hospitalized with severe flu illness were half as likely to have been vaccinated as women hospitalized with milder illness (14 percent vs. 26 percent). CDC recommends annual flu vaccination for everyone 6 months of age and older, including pregnant women during any trimester of their pregnancy. Earlier studies have suggested that immunization during pregnancy may protect not only the mother from flu, but also her newborn baby during the first 6 months of life.

"All pregnant women should receive annual influenza vaccination to prevent influenza and associated complications for themselves and their infants," the study authors wrote.

A related editorial commentary by Alan T. N. Tita, MD, PhD, and William W. Andrews, PhD, MD, of the University of Alabama at Birmingham, accompanies the new study in The Journal of Infectious Diseases.

"Overall, considering the accumulating evidence of fetal benefit and safety, influenza vaccination of pregnant and postpartum women should be a public health priority in accordance with national recommendations," the commentary authors wrote. "Prompt initiation of antiviral therapy if infection occurs, preferably within two days of suspected or confirmed influenza infection, is encouraged."

###

Fast Facts

• Among pregnant women hospitalized with severe flu who were treated early with an antiviral medication, the median length of their hospital stay was about five days shorter compared to similar patients treated later.
• Pregnant women who were hospitalized with severe cases of flu illness were half as likely to have been vaccinated as women with non-severe illness.
• Annual vaccination against flu is recommended for everyone 6 months of age and older, including pregnant women, who are at high risk of serious flu illness and complications.

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NEJM: Probable Person-to-Person Transmission Of Legionnaires’ Disease

Legionella Bacteria - Photo Credit CDC PHIL

 
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Conventional wisdom just isn't what it used to be.

For nearly forty years - since it famously sparked a major pneumonia outbreak at Philadelphia’s Bellevue Stratford Hotel during an American Legion convention in 1976 - Legionella pneumonia has been considered strictly an environmental illness.

The mantra - oft repeated in this blog - is that it cannot be transmitted from person to person. Because . . . well . . . it had never been shown to do so.

While still likely 99.99% true, we have an outlier to look at - published today in the NEJM - that strongly suggests that while exceedingly rare, person-to-person transmission of Legionnaires Disease may have occurred in 2014 during an outbreak in Portugal.


The outbreak, which I blogged on a couple of times in late 2014 (see ECDC: Rapid Risk Assessment On Portugal’s Legionnaire’s Disease Outbreak), was one of the largest outbreaks of Legionella that we’d seen in years; with more than 300 cases reported in a week’s time.  At the time I wrote:

Based on the size and rapid growth of the cluster, the WHO called it a `major public health emergency’.  But Legionnaire’s is not a communicable disease, and so the threat is limited to those who are directly exposed to the environmental source of the bacteria.

Here's where it gets interesting.  


One of the earliest victims of this outbreak was a maintenance worker (Pt #1 M, 48) who worked on one of the cooling towers in Vila Franca de Xira that was later found to be contaminated with the Legionella bacteria.
  

His first respiratory symptoms began to appear on October 14th.

He returned to his home in Porto - 300 km distant from the outbreak - which he shared with his elderly mother (Pt #2, F, 74) on Oct. 11th, and again on Oct. 19th. By the 19th, his respiratory symptoms had become severe, and his mother cared for him through the night (approx. 8 hours), until he was admitted to a local hospital the following morning. 

Three days later Pt #1 was transferred to another hospital to be placed on ECMO, and he died on January 7th, 2015.

Meanwhile, the patient's mother - who had never visited the site of the outbreak - began to experience respiratory symptoms on Oct. 27th. She was admitted to the local hospital on Nov. 3rd with septic shock and pneumonia, and died on December 1st.

The following NEJM correspondence provides additional details, and rationale for their conclusions.

Probable Person-to-Person Transmission of Legionnaires’ Disease

N Engl J Med 2016; 374:497-498 February 4, 2016 

DOI: 10.1056/NEJMc1505356

From a practical standpoint, this probably doesn't change much. This report notwithstanding - H-2-H transmission of Legionella is probably extraordinarily rare.

Still, it is a fascinating report.

And a reminder why epidemiologists never like to to say `never'.

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