Fatal nosocomial Legionnaires' disease: relevance of contamination of hospital water supply by temperature-dependent buoyancy-driven flow from spur pipes.

The investigation, epidemiology, and effectiveness of control procedures during an outbreak of Legionnaires'' disease involving three immunosuppressed patients are described. The source of infection appeared to be a network of fire hydrant spurs connected directly to the incoming hospital mains water supply. Removal of these hydrants considerably reduced, but failed to eliminate, contamination of water storage facilities. As an emergency control procedure the incoming mains water was chlorinated continuously. Additional modifications to improve temperature regulation and reduce stagnation also failed to eliminate the legionellae. A perspex test-rig was constructed to model the pre-existing hospital water supply and storage system. This showed that through the hydraulic mechanism known as ''temperature buoyancy'', contaminated water could be efficiently and quickly exchanged between a stagnant spur pipe and its mains supply. Contamination of hospital storage tanks from such sources has not previously been considered a risk factor for Legionnaires'' disease. We recommend that hospital water storage tanks are supplied by a dedicated mains pipe without spurs.