4-Year Study in Monitoring the Presence of Legionella in the Campania Region’s Healthcare Facilities
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe study highlights the importance of surveillance for pathogens which may be considered in many cases "neglected", such as Legionella. The prevalence of the bacterium reveals the importance of considering it and its spread when evaluating patients with signs and symptoms that may suggest an infection by Legionella.
The manuscript is well written, methods are clear and well exposed, as are the results.
I suggest instead a revision of the discussion: a confrontation with other studies and epidemiological data could add to the research. Perhaps you may consider to add the following reference, which I think may be valuable to the paper:
- "Epidemiology and Ecology of Opportunistic Premise Plumbing Pathogens: Legionella pneumophila, Mycobacterium avium, and Pseudomonas aeruginosa" DOI: 10.1289/ehp.1408692
- "A meta-analysis of Legionella pneumophila contamination in hospital water systems" DOI: 10.1016/j.ajic.2023.04.002
Line 257: capital letter at the beginning.
Author Response
Comment 1: The manuscript is well written, methods are clear and well exposed, as are the results.
I suggest instead a revision of the discussion: a confrontation with other studies and epidemiological data could add to the research. Perhaps you may consider to add the following reference, which I think may be valuable to the paper:
- "Epidemiology and Ecology of Opportunistic Premise Plumbing Pathogens: Legionella pneumophila, Mycobacterium avium, and Pseudomonas aeruginosa" DOI: 10.1289/ehp.1408692
- "A meta-analysis of Legionella pneumophila contamination in hospital water systems" DOI: 10.1016/j.ajic.2023.04.002
Response 1: Thank you for your valuable suggestion.
We have taken into consideration the first bibliographic reference you suggested. We have inserted this reference in the discussion on page 10, lines 352-354.
Comment 2: Line 257: capital letter at the beginning.
Response 2: Thank you, we have entered the capital letter
Reviewer 2 Report
Comments and Suggestions for AuthorsThe manuscript presents a comprehensive study on the presence of Legionella in healthcare facilities within the Campania Region, Italy, over a 4-year period. The study assesses the effectiveness of the Italian National Guidelines for Legionella prevention in water systems, identifies the most prevalent Legionella pneumophila serogroups and analyzes the correlation between water temperature and Legionella contamination.
Areas for improvement:
The selection of healthcare facilities based on previous Legionella outbreaks may have introduced selection bias, potentially overestimating contamination rates.
The discussion could benefit from additional visualizations (e.g., heatmaps or trend graphs) to illustrate contamination patterns across different regions and years.
While the manuscript mentions the pandemic’s influence on monitoring activities, further elaboration on how changes in facility usage or hygiene protocols affected the results would strengthen the discussion.
The exclusion of post-remediation sampling limits the study’s capacity to evaluate the effectiveness of intervention measures.
Specific comments:
Include a section discussing the potential impact of selection bias on the findings and any strategies used to mitigate this bias.
Enhance data presentation with heatmaps or line graphs showing Legionella positivity rates over time and across different facility types.
Provide a more detailed analysis of how the pandemic’s hygiene protocols may have influenced water stagnation and contamination rates.
If possible, include data on post-remediation sampling to offer insights into the long-term effectiveness of intervention measures.
Discuss the implications of Legionella pneumophila serogroup diversity for clinical diagnosis and public health interventions.
Author Response
Comment 1: Include a section discussing the potential impact of selection bias on the findings and any strategies used to mitigate this bias.
Response 1: Thank you for your observation. The healthcare management give to ARPAC instructions on sites for sampling. This is part of the monitoring plan, which can certainly be improved over time.
Comment 2: Enhance data presentation with heatmaps or line graphs showing Legionella positivity rates over time and across different facility types.
Response 2: Thanks for the suggestion. We have added a line graph to page 7, called figure 1.
Comment 3: Provide a more detailed analysis of how the pandemic’s hygiene protocols may have influenced water stagnation and contamination rates.
Response 3: Thank you. We Provided more datails to page 10, lines 317-321.
Comment 4: If possible, include data on post-remediation sampling to offer insights into the long-term effectiveness of intervention measures.
Response 4: Thanks for the suggestion. At the moment, post-remediation checks are only carried out at the request of individual facilities and are therefore not part of the monitoring practice. We have inserted this sentence into the text on page 10, line 354: "Since this is a bias, we are also working to include post-remediation checks in the monitoring practice."
Comment 5: Discuss the implications of Legionella pneumophila serogroup diversity for clinical diagnosis and public health interventions.
Response 5: Thank you for the suggestion. We have provided an answer by inserting a portion of text on page 10, lines 329-334.
