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

Erica Leoni, Federica Catalani, Sofia Marini and Laura Dallolio
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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

IJERPH, 2018, vol. 15, issue 8, 1-19

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.

Keywords: Legionella spp.; Legionnaires’ disease; Pontiac fever; recreational water; hot tubs; whirlpools; spa pools; swimming pools (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2018
References: View references in EconPapers View complete reference list from CitEc
Citations: View citations in EconPapers (3)

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