Jail-house Cough

When the world of somewhat rare infectious diseases collides with prison and inmate issues, it causes an uproar of excitement in my house. Education and advocacy are large themes in my marriage. It's obvious that STEM education is my driving force, but my husband focuses his efforts on issues associated with significantly skewed stigma and underrepresented topics, such as advocacy for mental health patients and inmates. He actually teaches a class on prison issues at UC Berkeley, and leads a volunteer group that takes UC Berkeley students into San Quentin Prison to tutor inmates that are working towards obtaining a GED. Its not uncommon that he will have to cancel volunteer shifts due to prison-wide lockdowns (most often due to fog), but Thursday night's lockdown had us talking.

As I've mentioned before, prisons are an epidemiological hotbed for infectious diseases. Sticking a large number of people in small, confined communal living quarters with inadequate medical care is one of the fastest ways to allow diseases to spread. So, hearing that the lockdown on Thursday and Friday were due to the potential spread of disease, we were not alarmed. When we heard it was Legionnaires' Disease and that one case had been confirmed with 30 other inmates presenting symptoms, we were surprised.

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Image from PrimeWater Membranes

Legionnaires' Disease, or "legionellosis", is a bacterial infection caused by Legionella spp. (most commonly Legionella pneumophila) and leads to the development of atypical pneumonia. Legionnaire's disease is most well known for its debut in 1976, when a L. pneumophila epidemic was traced back to the Philadelphia Convention of the American Legion. More than 30 people died as a result. Yet, L.micdadei had already been isolated from human blood in the mid 1940s. As usual, only a handful of disease nerds care about a disease before an epidemic occurs.

These two, specifically. (Credit: Wikipedia)

 Legionnaire's Disease is spread through droplets of water containing the bacteria, especially in warm environment that cause steam and aerosolization, like showers, hot tubs, wet saunas, humidifiers, and faucets.The CDC also lists "decorative fountains" as a potential source, which, I have to admit, made me laugh. I mean, think about all the major hospitals that have massive decorative fountains in their entrance/courtyards! Double threat!

Legionella spp. have developed a somewhat symbiotic relationship with larger protozoae, such as amoebas, that create large biofilms that can protect the Legionella bacteria. Outbreaks are most common in places that house lots of people for extended periods of time, like hotels, office buildings, retirement homes and convalescent facilities, hospitals, cruise ships, and prisons. Legionella spp. also like to live in wet soils.  Despite the dependency on aerosolization for transmission, Legionnaires' Disease is not spread from person to person. A reservoir, like water or soil, is required for the transmission of the disease.

Amoeba engulfing and releasing bacteria. (Via Pall Corp.)

 If you inhale contaminated water, the bacteria travel through your respiratory tract and into your lungs. This triggers your immune system, and trolling macrophages engulf the bacteria. While engulfing the bacteria through phagocytosis is one method (of many) your immune system uses to identify and destroy invaders, many infectious agents have learned to exploit this mechanism. Once in the macrophage, the bacterium will multiply, causing tons of bacterial cells to explode out of the macrophage and continue spreading the infection throughout your tissues.

While your body is working to fight off the rapidly replicating Legionella bacteria, you'll start to experience symptoms, such as fever, chills, and a cough. Depending on the severity of your infection, you can cough up blood, sputum, or a combination of the two. Chest pains are common, and some people can also experience diarrhea and vomiting. A combination of chest x-rays and bacterial culturing will land you with a diagnosis of Legionnaires' Disease. Since this is mostly rare form of pneumonia, it is incredibly important to get an accurate diagnosis. Since Legionnaires' Disease is caused by a bacterial infection, there are specific antibiotics that can be used to treat your infection. As always, when left untreated, the disease will get significantly worse, and may be fatal. Pneumonia is a significant cause of death for those who have compromised immune systems, and for children without access to medical care.

So, San Quentin Prison has shut off their water supply (with the exclusion of toilets, that have now been deemed okay), but this still raises the question of how extensive the contamination is. If only one person was affected, it may have been an isolated incident from an isolated source. Yet, with 30 potential patients, this is a larger issue that most likely stems from the prison's water source.