Legionnaire's Disease

Dr REFSHAUGE (Marrickville - Deputy Leader of the Opposition) [3.42]: I move:

That this House notes as a matter of public importance the recent outbreak of legionella disease in Sydney's west and southwest.

I am sure the House joins with me in offering our condolences and sympathy to the families whose members have died from the recent outbreak of Legionnaire's disease and our hopes for a speedy recovery of those suffering from the disease at present. A number of things need to be brought to light by questions that should be seen as a constructive way of trying to ensure that the efficacy of our attack on Legionnaire's disease is improved. The high regard in which New South Wales is held in the fight against outbreaks of Legionnaire's disease is in no way diminished by this motion. In fact, we hope to reduce the effects of outbreaks of Legionnaire's disease in the future. However, a number of issues of concern should be raised. I am quite mindful of the statements by the Chief Health Officer, Dr Sue Morey, that the outbreak of Legionnaire's disease is now over but, while this outbreak is still in the minds of the community and obviously the Government, it is worth while focusing our attention on this issue, although not in any way trying to cause concern to those who would see themselves at potential risk living in the areas that have been identified.

The issues I would like to raise revolve around regulations; support for the medical profession, particularly those working in hospitals where legionella might turn up and general practitioners who would be faced with having to give advice to potential victims, namely, those who have had outbreaks of Legionnaire's disease in the area in which they live; the resources available for the implementation of regulations; and a number of other issues which I raise but do not see as of great significance concerning the way in which this outbreak has been handled. From the beginning, I put on record my support of and thanks to the people from the public health unit in the specific area. I believe that they have worked as fast and as effectively as they could have from the time they found out about the disease, although certain problems need to be investigated.

The regulations relating to Legionnaire's disease were gazetted in November 1991 but will not come into effect until 18th May, 1992. This is the place to start discussions. The first outbreak of Legionnaire's disease occurred in 1987 in Wollongong when the Labor Party was in Government. I believe that we showed we had expertise in this field but this needed to be further developed in order to cope with an outbreak of Legionnaire's disease. I and the former Labor Minister for Health have put on record that we believe we behaved in an appropriate way in light of our knowledge at the time, and we have built upon that knowledge; we have worked well. The necessary regulations have been introduced, but we have had to wait five years, and that is too long a time in my view. An attempt was made to introduce the Public Health Act at the end of 1990, but because of a lack of consultation by a former Minister of this Government that legislation did not go through Parliament in that year. Further consultation was required.

The Minister's departmental officers told me during that consultation that if the consultation had occurred before the bill was brought into Parliament we would have had agreement and the bill would have been passed unanimously. But because that previous Minister, a Minister of this Government, refused the effective, bipartisan consultation
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which had been offered a number of times that legislation had to be delayed over the Christmas period and was introduced in the beginning of 1991. Despite that, one would have thought that the regulations in the Public Health Act pertaining to Legionnaire's disease control - which were neither under debate nor contentious, and which had in fact from the beginning on both sides of the Parliament had been supported very strongly - could have been developed and introduced so that people could have been protected during the well-known danger periods when Legionnaire's disease is more likely to break out. It is well known that this is the time of year when there is likely to be an outbreak of Legionnaire's disease. Why were the regulations not in place before this time of the year?

Although I have made some constructive criticisms about the regulations, it concerns me that it has taken so long for these regulations to be gazetted, let alone implemented. I take on board the Minister's statements earlier that there needs to be a phase-in period so that the regulations can be understood by the councils and organisations which have to put them in place - those which have cooling towers - so that they are able to meet the requirements. It seems to me that self-regulation needs to be tightened up. There is no need to get rid of self-regulation because this is an appropriate area in which to attempt it to ensure that public health measure controls are utilised, but it would be worth while for the Government to look at the option of having each business have test results on cooling towers sent to a register held at the council so that the results can be checked. I believe that there would be a very simple way of doing this. Limited discussion with councils leads me to believe they are not opposed to such a register. On further reflection, they might be concerned about the work done to date. The option of a register needs to be considered so that councils can quickly check, using computers, whether a cooling tower has been tested. The number of organisms per million could be measured. If there were less than 10, councils would not have to worry about it; if there were 10 to 100, the council might think about what it wants to do; and if there were 100 to 1,000, obviously something would have to be done. That would be a disaster. Councils might be able to discover a slow increase and monitor changes. They may be able to compile useful evidence.

If, as is often said, this State is at the forefront of Legionnaire's disease control, why not maintain and use that effective early detection tool? Practitioners in the field are often in the front line in diagnosing the first cases of Legionnaire's disease and need information from the department. Diagnosis of Legionnaire's disease is not easy. Bacteriological testing can take some time and it is unlikely that the disease can be diagnosed with only one test. A number of tests may need to be done to ascertain the presence of the disease. A number of factors affect early diagnosis. The Opposition agreed - and the Minister may check with his advisers - that Legionnaire's disease should be notifiable by general practitioners with clinical acumen at the coalface rather than solely by bacteriological or serological testing. That message was agreed to and hammered out in discussions that should have been held before and not after the bill was introduced into Parliament. If that message had been given in that agreed simplified form, though people's lives may not have been saved, potentially the efforts made could have been more successful.

I am concerned that the Minister has said that Legionnaire's disease is rare. The disease is not common and does not occur every day, but a rate of six cases per month, as mentioned by the Minister, is higher than the rate mentioned by the chief medical officer as being reported in the Sydney Morning Herald and other newspapers. Legionnaire's disease is not rare. Practitioners working in the field should be encouraged to be more aware of and alert to the disease. Recent history shows that in hospitals in
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the Fairfield area a number of atypical pneumonias were diagnosed clinically rather than bacteriologically or through serology as Legionnaire's disease. The clinical acumen of general practitioners in the field, especially given the five or six cases of atypical pneumonia admitted to hospital per month, would have enabled an earlier diagnosis of the presence of the disease. The public health department could have swung into action and alerted the public through the media - an action with which I would not disagree - to advise people to put chlorine through the super heating systems to eliminate the bacteria. That would probably end any further spread of the disease. Any new cases would usually be those that were already developing. It is not surprising that only one source has been found that is the likely source of 40 per cent of this specific outbreak, though the source of other outbreaks probably will not be found because cleaning has been completed.

I am concerned that general practitioners and others in the medical front line have little knowledge and support from the health department about what advice they should give their patients or clients. A 16-year-old check-out assistant working in an affected area may be concerned about potential risk and whether it is safe to go to work. That person may approach a general practitioner for advice. What should that practitioner tell that person and other patients with similar concerns? Practitioners can look up the books but most books are out of date and do not contain the latest information. New South Wales health units are probably at the forefront in this field and can give expert advice. I have sought advice from a number of experts, and that advice should be available to general field practitioners regularly. Certainly, as soon as an outbreak occurs the department could easily determine which doctors live and work in the affected area and could provide them in written form with the advice they should give to their patients. The advice may not be absolute but would thus be consistent from practitioner to practitioner. I have heard that general practitioners in the area say to their patients they are unaware of the degree of risk involved but recommend a course of erythromycin, the antibiotic treatment of choice for Legionnaire's disease.

But is it appropriate to prescribe a prophylaxis of erythromycin during an outbreak? Not being an expert, I do not want to express a firm view, but the advice I have is that it probably makes no difference. I should have thought that local general practitioners have a right to obtain information from the department, which is a world leader in the fight against Legionnaire's disease outbreaks. The department should be able to provide advice quickly. One could say that 16-year-olds, those who do not smoke, those who do not have lung disease and those who are not immuno-suppressed are unlikely to contract Legionnaire's disease but general practitioners should have accurate information to be able to advise all their patients when an outbreak occurs. I support the suggestion that the public health units should be notified at the very beginning of an outbreak as an appropriate public health measure. I understand that Fairfield council offered the local public health unit immediate support when it learnt of the outbreak of Legionnaire's disease in its area. Though I do not think in this case the outcome would have differed greatly, the assistance offered was refused. I understand, but I could be mistaken, that the matter could have been handled slightly more sensitively at the time. [Time expired.]

Mr PHILLIPS (Miranda - Minister for Health Services Management) [3.57]: Though I appreciate the more considerate approach taken by the Deputy Leader of the Opposition on this matter of public importance, I question his motives and standards. On the one hand he decided together with his colleagues, the honourable member for Fairfield - though I am not sure he is a true factional colleague - and the mayor of Liverpool, to quickly seek headlines during a most difficult public health time. On the other hand the Deputy Leader of the Opposition has pontificated on radio about how the
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public health unit could have done better. The immediate reaction in the media when it hears about such issues is to question whether the matter has been pursued properly, and that is disturbing. The Deputy Leader of the Opposition has total access to the public health units, to the department and all the advice that he needs and wants, and can make any suggestions that he wishes to make. I do not mind that course being taken in a considered manner in Parliament but do not regard it as appropriate for the honourable member to go public with his approach on radio while there is still an epidemic. Honourable members are aware that notice of this motion was given only yesterday, within a period of 48 hours. I emphasise that such an epidemic must be handled responsibly rather than politically. On that issue I have been severely castigated by the Liverpool City Champion newspaper. Its editorial was headed "Speak Up or Get Out Mr Phillips" and went on to say:

The administration of public health in the Liverpool district is in tatters. There is confusion about what is required by the State Government to keep Legionnaire's disease under control.

It finishes by saying:

If Mr Phillips has nothing to say, he should resign his post to make way for someone who can discharge the office with efficiency and compassion.

This is supposed to be a responsible newspaper in an area in which the community is concerned about the epidemic. The department and public health officers have been bending over backwards to provide all the responsible information available. At least two bulletins a day, I would have thought, were published and there was total access to any information required. As Minister, clearly recognising that this was a public health matter and not a political matter, I gave every assistance and my total support to the department. I ensured the department gave all the resources necessary to cover the problem. I told the department to go public as soon as it could be sure and to keep the public informed. I believe that is the most responsible approach on this type of issue. I take great exception to lord mayors and newspapers having cheap shots at the expense of public health. The Deputy Leader of the Opposition raised concern about when the department found out. For the record I shall clearly identify the course of events. There was no delay. Every year 11,500 patients are admitted to New South Wales hospitals with pneumonia. The majority of cases are not due to legionella. Normally, six cases a month of legionella are treated.

Diagnosis of the disease is not always immediately apparent and tests are not instant. It takes from three to 14 days to grow the legionella organism from blood or sputum samples. Blood tests do not produce definitive results until 10 days after the onset of symptoms. With that in mind, the first death from Legionnaire's disease occurred on 18th April. Legionella was not confirmed as being involved until 21st April. At midday on 21st April the infection control officer at Liverpool Hospital notified the area's public health unit that two cases had been confirmed. The unit began follow-up procedures. At 2 p.m. on 22nd April, the next day, Fairfield Hospital advised that there was concern at the high number of atypical pneumonia. This was the first evidence of a possible epidemic. The chief health officer was notified and a major investigation was launched. The media were notified that evening, once it was confirmed. On 23rd April, the next day, the chief health officer issued a public health warning to people, especially those living in southwestern Sydney experiencing symptoms of the disease, that they should seek early medical attention. Detailed histories of confirmed or suspected patients were taken, including what buildings they had visited.


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Samples were taken from cooling towers in the Fairfield, Liverpool, Campbelltown and Camden districts. Department and local government officers requested all water cooled air-conditioning equipment in southwestern Sydney not serviced in the previous month be shut down, cleaned and disinfected immediately. Further follow-up is continuing in liaison with local councils in the area. The Deputy Leader of the Opposition suggested that maybe we could have found out and taken action more quickly. This is the second major outbreak of this disease in New South Wales, the third if we count the small outbreak at Merrylands. Of course we are learning more about this disease all the time. As the Deputy Leader of the Opposition clearly understands, this is not a simple issue. When the department and public health officers have prepared their total report on this issue they will carefully examine how best to further improve what the honourable member recognised is one of the best and most up-to-date systems which is leading the field in this area. I assure the honourable member and this House that the recommendations will be implemented. The matter is not always simple.

The Deputy Leader of the Opposition also raised concern about the delay in the implementation of regulations. I do not know how productive it is to go over old ground but it is important to put this on the record: the introduction of the new regulations was part of a new Public Health Act which came into force in November last year. This was a huge task. Until then the ancient and unwieldy Public Health Act of 1902 had operated. So there was a major overhaul of that Act. Compilation of the new Act was a vast exercise covering all aspects of public health. Review of the Legionnaire's disease regulations involved extensive consultation with local government authorities, engineering experts, air-conditioning experts, building owners and managers and government authorities. The Public Health Bill was presented to Parliament in November 1990. However, its passage was delayed in the upper House by a range of amendments. Parliament was prorogued before they could be considered. There was also a delay while there were arguments as to whether there should be a smaller number of notifiable diseases, which was an issue raised by the Deputy Leader of the Opposition.

He should be reminded of his comments in the Parliament at that stage. He criticised the legislation for being too regulatory and "like a medical policeman's bible". He said that a Public Health Bill's effectiveness relied on co-operation and consultation with community groups, particularly at-risk groups. Nobody disagrees with that. The bill was reintroduced in February 1991 and passed all stages. It received assent on 26th April, 1991. Regulations to give effect to all provisions of the Act, including those relating to Legionnaire's disease, were drafted. The requirement of the Subordinate Legislation Act for public consultation was met. The regulations commenced operation on 18th November, 1991. It was considered that six months was not an unreasonable time to give local councils to compile a register of water cleaning towers in their area, remembering that there are approximately 11,000 cooling towers to be on the register. Time is needed to advise the groups, to compile information on where the cooling towers are and to make up the register. That leads me to a point raised by the Deputy Leader of the Opposition about self-regulation needing to be tightened up. It is always an interesting challenge in health to determine where priority shall be given for health dollars. The honourable member suggested that owners should advise councils of the results of tests so that councils can put the information on to their register. Every month there needs to be a test to ensure that the required chemicals are present. Overall cleaning and testing is required every three months. The cost to the community and to local government and the State of a significant number of people in local government sitting at computers inputting data constantly trying to find the person who is not complying with the chemical or cleaning test is huge; it is a very expensive task.

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I would be interested to hear the opinions of the Department of Health and the councils about whether going through that process, finding the persons responsible and moving to prosecute them will assist in combating or eliminating the development of Legionnaire's disease in those cooling towers. A huge cost problem is involved and obviously it is important to have regard to whether it is better to spend that money on other health services or to set up banks of computers to compile information and hope that everyone is keeping up to date so that cooling towers can be kept clean. As the department is investigating this recent outbreak of Legionnaire's disease, it will take into account the suggestions of the Deputy Leader of the Opposition and ascertain whether those suggestions constitute effective ways of handling the problem or whether there are other more effective ways of receiving an earlier indication or notification of the disease and communicating that information to the community. It should be remembered that so far as New South Wales is concerned, this is a recent disease. The first outbreak was in 1987.

The present outbreak is the third or possibly only the second major outbreak. The Department of Health is clearly recognised as a leader in this field in New South Wales. It has some of the toughest air cooling regulations in Australia, indeed in the world. As the Deputy Leader of the Opposition and this House have clearly recognised, public health units in New South Wales are doing an excellent job. I am sure the Deputy Leader of the Opposition will join me in commending Dr Sue Morey and the staff of the public health units both at head office and in the areas concerned for the open, honest, efficient and professional way in which they have informed the public and quickly taken steps to stem the outbreak to restrict the number of people affected by this disease. I have taken note of the comments made by the Deputy Leader of the Opposition and assure him that a full report will be forthcoming. The information in that report will be made known to him.

Mr IRWIN (Fairfield) [4.12]: The most recent outbreak of Legionnaire's disease in southwestern Sydney is a tragedy for the victims and their families. Many of the grieving relatives of the victims of this latest outbreak are left asking how this can happen in a world which is regarded as having overcome horrific epidemics of infectious diseases and how it is that the familiar environment of shops and offices can prove to be a threat to life itself. Legionnaire's disease continues to demonstrate that vigilance in public health policy cannot be disregarded or taken lightly. The most frightening feature of Legionnaire's disease is not merely its potential to kill but its potential to kill scores of victims at a time. This potential must place Legionnaire's disease high on the list of public health concerns for State and local governments.

After tracing the sequence of events leading up to and following the most recent outbreak, I became alarmed at the seeming complacency of health authorities in this State. It is now five years since the first major outbreak of Legionnaire's disease left 10 people dead in Wollongong. Governments would be expected to act swiftly to put into place regulations designed to ensure that water cooling towers, the known source of the disease, are properly cleaned and maintained. I believe it is also reasonable to expect that buildings with water cooling towers would be closely monitored by health surveyors to ensure compliance with the requirements. However, what has happened clearly shows that health authorities in this State have not taken seriously the threat to public health posed by Legionnaire's disease.

Five years after the Wollongong outbreak, regulations requiring local councils to maintain registers of all buildings containing water cooling towers do not come into force until 18th May. Anticipated inspections of towers to confirm that cleaning
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measures are carried out depend upon the compilation of registers. What has happened in April 1992? As a result of the latest outbreak, health surveyors are seeking information door to door about the location of water cooling towers, at a time when the public is at risk of a killer disease. It is no wonder that it has taken more than two weeks to even roughly identify the possible source of the epidemic. The fact that it has taken five years to implement regulations to prevent the onset of a killer disease is scandalous. Surely the situation demanded greater urgency, particularly after a further outbreak at Merrylands in 1989. The Minister mentioned the detailed work that was required in relation to the Public Health Act. If health authorities had taken this matter seriously, interim measures would have been put in place which would have ensured that registers were prepared not six months ago, but years ago. The incidence of this disease thus may well have been prevented.

Even now, with the regulations about to come into force, there is some doubt as to their adequacy to prevent outbreaks of the disease. Let us look at what happened when health authorities finally tried to do something. From the time of the first death on 18th April, Easter Saturday, it took six days before thorough inspections and sampling were carried out in Fairfield. The first information received by Fairfield City Council about the outbreak was a news broadcast on the morning of Thursday, 23rd April. An offer of assistance to carry out inspections of suspected locations was refused by officers of the Department of Health. Only after persistent efforts was the offer to provide health surveyors taken up. But by then the horse had well and truly bolted. One is left to wonder, however, about the consequences of an undetected source continuing to infect people long after the first cases had been identified. Similarly, the announcement of the outbreak so long after it may have been confirmed as a dangerous strain of legionella may well have meant that later victims may have been alerted by local doctors and early appropriate treatment given.

As a result of discussions with the family of Mr Brian Page, the first to die as a result of the outbreak, it is apparent that after his admission to Liverpool Hospital on 17th April a diagnosis of Legionnaire's disease was considered. What came as a shock to Mr Page's family were comments by staff at Liverpool Hospital that there would not be an immediate investigation. One comment suggested that an urgent investigation would be undertaken only when there had been a number of deaths. On the following day Mr Page's family received a request for further information about his movements. However, it was not until 23rd April that a thorough check was undertaken. Was the entire staff of the Department of Health on its Easter holiday at the time this outbreak became apparent? Were appropriate resources directed to the problem as soon as the alarm bells began to ring? These questions, as well as the unseemly delay in implementing what in the end may be ineffective regulations, demand responses. It is essential that a full inquiry be conducted into the actions of the Department of Health in dealing with the recent outbreak of Legionnaire's disease in southwestern Sydney. I conclude my remarks by extending my condolences to the family of the late Mr Brian Page of Mount Pritchard and, indeed, the families of all the victims of this tragic event.

Dr MACDONALD (Manly) [4.17]: I am pleased to add a different perspective to debate on this matter of public importance. That different perspective comes from some years of medical experience. Unfortunately some of the comments made in the debate have been political. Such comments are unnecessary. An outbreak of this magnitude and severity is sad and tragic. An evaluation, which should be taking place to some extent now and certainly when the true facts are available, is important. Politicising a problem such as Legionnaire's disease causes enormous hurt to those who have been affected by the tragedy. The Minister commented that the local media have
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made some clear but inaccurate statements. Those statements by the media in the southwestern area of Sydney highlight the fact that those who do not know what they are talking about should sometimes keep right out of the debate.

The efficiency with which the Southwest Sydney Public Health Service has dealt with this particular issue is a credit to the service. The previous speaker talked about his concern that infectious diseases remain a problem. There is an element of truth in that statement. The people of New South Wales are getting to the point where they are almost blasé about the high technology of modern medicine and are alarmed and surprised, because of our high levels of public health, when there is such an outbreak. I do not believe there is any evidence of complacency. It is worth making a couple of comments about Legionnaire's disease. It is a mysterious and very rare disease. Studies in the United States of America have shown that the legionnella bug actually lives in pristine lakes. It can be found in quite large numbers in fresh, pristine water. Even the life cycle of the legionnella pneumophilia bacteria is still a mystery. There are great elements of mystery about it. The public health unit has worked very efficiently on this problem. It is a very difficult disease to diagnose, mainly because it has a number of atypical symptoms and it mimics other types of pneumonia.

It is important to give credit where credit is due. It is very easy to be wise with clarity of hindsight, but the medical profession recognises the specific difficulties associated with legionnella. One thing that makes it remarkable is that epidemiologically it is quite an easy disease to trace. The reason for that is, of course, that it is not passed from person to person. The disease can only be contracted from the source. It is a very interesting detective exercise for those involved in public health. That is evident if honourable members look at the chronology of events that have occurred in the southwest. Within a week - and not two weeks, as the previous speaker suggested - it was fairly clear that the source could be located down to almost a few streets. That is not only to the credit of the public health unit but also an indication of the specific features of the condition itself - the fact that it does not pass from person to person. That is very much in contrast with other forms of atypical pneumonia where the time from infection to the time of onset of symptoms can often be two or three weeks. That makes the disease enormously difficult to trace. Legionnella pneumophilia is a fascinating disease. It is one that remains a great challenge to the public health unit. It remains a mystery. Comments have been made about the Public Health Act 1991. The Government should be commended for introducing that particular legislation. The notifications have improved considerably since the Act was fine tuned, simplified and strengthened in 1991. I know that as a consumer. It was difficult notifying up to 52 diseases. [Time expired.]

Debate adjourned on motion by Mr Scully.