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Legionellosis Associated with Recreational Waters: A Systematic Review of Cases and Outbreaks in Swimming Pools, Spa Pools, and Similar Environments

Author

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  • Erica Leoni

    (Unit of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, University of Bologna, via S. Giacomo 12, 40126 Bologna, Italy)

  • Federica Catalani

    (School of Hygiene and Preventive Medicine, Department of Biomedical and Neuromotor Sciences, University of Bologna, via S. Giacomo 12, 40126 Bologna, Italy)

  • Sofia Marini

    (Department of Life Quality Studies, University of Bologna, Campus of Rimini; Corso d’Augusto 237, 47921 Rimini, Italy)

  • Laura Dallolio

    (Unit of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, University of Bologna, via S. Giacomo 12, 40126 Bologna, Italy)

Abstract

Legionella spp. is widespread in many natural and artificial water systems, such as hot water distribution networks, cooling towers, and spas. A particular risk factor has been identified in the use of whirlpools and hot tubs in spa facilities and public baths. However, there has been no systematic synthesis of the published literature reporting legionellosis cases or outbreaks related to swimming/spa pools or similar environments used for recreational purposes (hot springs, hot tubs, whirlpools, natural spas). This study presents the results of a systematic review of the literature on cases and outbreaks associated with these environments. Data were extracted from 47 articles, including 42 events (17 sporadic cases and 25 outbreaks) and 1079 cases, 57.5% of which were diagnosed as Pontiac fever, without any deaths, and 42.5% were of Legionnaires’ disease, with a fatality rate of 6.3%. The results are presented in relation to the distribution of Legionella species involved in the events, clinical manifestations and diagnosis, predisposing conditions in the patients, favourable environmental factors, and quality of the epidemiological investigation, as well as in relation to the different types of recreational water sources involved. Based on the epidemiological and microbiological criteria, the strength of evidence linking a case/outbreak of legionellosis with a recreational water system was classified as strong, probable, and possible; in more than half of the events the resulting association was strong.

Suggested Citation

  • Erica Leoni & Federica Catalani & Sofia Marini & Laura Dallolio, 2018. "Legionellosis Associated with Recreational Waters: A Systematic Review of Cases and Outbreaks in Swimming Pools, Spa Pools, and Similar Environments," IJERPH, MDPI, vol. 15(8), pages 1-19, July.
    • Handle: RePEc:gam:jijerp:v:15:y:2018:i:8:p:1612-:d:160818
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    References listed on IDEAS

    as
    1. Press, E., 1991. "The health hazards of saunas and spas and how to minimize them," American Journal of Public Health, American Public Health Association, vol. 81(8), pages 1034-1037.
    2. Martijn Bouwknegt & Jack F. Schijven & Johanna A.C. Schalk & Ana Maria de Roda Husman, 2013. "Quantitative Risk Estimation for a Legionella pneumophila Infection Due to Whirlpool Use," Risk Analysis, John Wiley & Sons, vol. 33(7), pages 1228-1236, July.
    3. Erica Leoni & Laura Dallolio & Francesca Stagni & Tiziana Sanna & Giovanni D'Alessandro & Gabriela Piana, 2015. "Impact of a Risk Management Plan on Legionella Contamination of Dental Unit Water," IJERPH, MDPI, vol. 12(3), pages 1-15, February.
    4. Laura Dallolio & Amalia Scuderi & Maria S. Rini & Sabrina Valente & Patrizia Farruggia & Maria A. Bucci Sabattini & Gianandrea Pasquinelli & Anna Acacci & Greta Roncarati & Erica Leoni, 2014. "Effect of Different Disinfection Protocols on Microbial and Biofilm Contamination of Dental Unit Waterlines in Community Dental Practices," IJERPH, MDPI, vol. 11(2), pages 1-13, February.
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    Cited by:

    1. Federica Valeriani & Lory Marika Margarucci & Vincenzo Romano Spica, 2018. "Recreational Use of Spa Thermal Waters: Criticisms and Perspectives for Innovative Treatments," IJERPH, MDPI, vol. 15(12), pages 1-22, November.
    2. Maša Knežević & Dobrica Rončević & Darija Vukić Lušić & Mirna Mihelčić & Rok Kogoj & Darja Keše & Marin Glad & Arijana Cenov & Mateja Ožanič & Daniela Glažar Ivče & Marina Šantić, 2022. "Decreasing Pasteurization Treatment Efficiency against Amoeba-Grown Legionella pneumophila —Recognized Public Health Risk Factor," IJERPH, MDPI, vol. 19(3), pages 1-19, January.
    3. Agapi I. Doulgeraki & Vasiliki Bikouli & Anthoula A. Argyri & Nikos Chorianopoulos & Elisavet Mitre & Georgia Charvourou & Patra Sourri & Chrysoula C. Tassou & Alexandra Oikonomou, 2020. "Exploring the Bacterial Communities of the Kaiafas Thermal Spring Anigrides Nymphes in Greece Prior to Rehabilitation Actions," IJERPH, MDPI, vol. 17(23), pages 1-12, December.

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