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Int. J. Environ. Res. Public Health 2018, 15(8), 1612; https://doi.org/10.3390/ijerph15081612

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

1
Unit of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, University of Bologna, via S. Giacomo 12, 40126 Bologna, Italy
2
School of Hygiene and Preventive Medicine, Department of Biomedical and Neuromotor Sciences, University of Bologna, via S. Giacomo 12, 40126 Bologna, Italy
3
Department of Life Quality Studies, University of Bologna, Campus of Rimini; Corso d’Augusto 237, 47921 Rimini, Italy
*
Author to whom correspondence should be addressed.
Received: 12 July 2018 / Revised: 20 July 2018 / Accepted: 25 July 2018 / Published: 30 July 2018
(This article belongs to the Special Issue Recreational Water Illnesses)
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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. View Full-Text
Keywords: Legionella spp.; Legionnaires’ disease; Pontiac fever; recreational water; hot tubs; whirlpools; spa pools; swimming pools Legionella spp.; Legionnaires’ disease; Pontiac fever; recreational water; hot tubs; whirlpools; spa pools; swimming pools
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Leoni, E.; Catalani, F.; Marini, S.; Dallolio, L. Legionellosis Associated with Recreational Waters: A Systematic Review of Cases and Outbreaks in Swimming Pools, Spa Pools, and Similar Environments. Int. J. Environ. Res. Public Health 2018, 15, 1612.

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