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This is a list of Legionnaires' disease outbreaks; Legionnaire's is a potentially fatal infectious disease caused by gram negative, aerobic bacteria belonging to the genus Legionella.[1][2] The first reported outbreak was in Philadelphia, Pennsylvania in 1976 during a Legionnaires Convention at the Bellevue-Stratford Hotel.[3]

An outbreak is defined as two or more cases where the onset of illness is closely linked in time (weeks rather than months) and in space, where there is suspicion of, or evidence of, a common source of infection, with or without microbiological support (i.e. common spatial location of cases from travel history).[4]

Worldwide listings by year

1970s

Year City Venue Source Cases Deaths Fatality rate Notes
1973,1977 Benidorm, Spain Hotel Rio Park Shower pipes at least 4 4 unknown The first outbreak in Hotel Rio Park occurred in 1973, four tourists died, but at the time it was not recognized as Legionnaires' disease until a subsequent outbreak in the same hotel in 1977.[5]
1976 Philadelphia, Pennsylvania, United States 1976 Philadelphia Legionnaires' disease outbreak Air conditioning 221 34 15.4% This was the first recognized outbreak of legionellosis, although earlier cases of legionellosis were later discovered to have occurred as far back as 1947. The Philadelphia outbreak, however, had the highest death rate.[6][7][8]
1979 Melbourne, Australia light industrial building medium-sized evaporative condenser [9]
1979 Ballarat, Australia psychiatric hospital shower water system [9]

1980s

Year City Venue Source Cases Deaths Fatality rate Notes
1985 Wollongong, Australia social club building small cooling tower [9]
1985 Stafford, England, United Kingdom Stafford District Hospital Air conditioning 175 28 16% In April 1985, 175 patients were admitted to the District or Kingsmead Stafford Hospitals with chest infection or pneumonia. A total of 28 people died. Medical diagnosis showed that Legionnaires' disease was responsible and the immediate epidemiological investigation traced the source of the infection to the air-conditioning cooling tower on the roof of Stafford District Hospital.
1986 Adelaide, Australia community small cooling tower at hospital [9]
1987 Wollongong, Australia shopping centre small cooling tower at a shop [9]
1988 Adelaide, Australia community potting mixes [9]
1989 Sydney, Australia bowling club small cooling tower [9]
1989 Burnie, Tasmania community small cooling tower at hospital [9]

1990s

Year City Venue Source Cases Deaths Fatality rate Notes
1992 Sydney, Australia shopping centre small cooling tower [9]
1994 Sunshine Coast, Australia holiday apartment unit private spa pool [9]
1995 Sydney, Australia shopping centre small cooling tower at hospital [9]
1999 Bovenkarspel, Netherlands 1999 Bovenkarspel legionellosis outbreak Hot tub 318 32 10% In March 1999, an outbreak in the Netherlands occurred during the Westfriese Flora flower exhibition in Bovenkarspel. 318 people became ill and at least 32 people died. There is a possibility that more people died from it (which might make it the deadliest recorded outbreak), but these people were interred before the Legionella infection was recognized. The source of the bacteria was a hot tub in the exhibition area.[10][11]

2000s

Year City Venue Source Cases Deaths Fatality rate Notes
2000 Melbourne, Australia Melbourne Aquarium Cooling tower 125 4 3.2% In April 2000, an outbreak of Legionella pnemophila serogroup 1 occurred in Melbourne, Australia. The outbreak resulted in 125 confirmed cases of Legionnaire's disease, with 95 (76%) hospitalised. It is reported that 4 died from the outbreak. The investigation traced the source of the infection to the cooling tower at the newly opened aquarium.[12] Since this outbreak, legionella infection statistics are required to be reported by the state government as a notifiable disease.[13] Regulations were introduced by the state to control legionella in 2001.[14]
2000 Vizela, Portugal Public square Decorative fountain 11 0 0% In August 2000, an outbreak of Legionnaires' disease occurred in Vizela, Northern Portugal.[15] A total of 11 persons with Legionnaires' disease were admitted to the hospital.[16] There were no fatalities. All patients had been in the main square of Vizela in the night of August 11–12, 2000, where the annual festivities of the municipality were being held.[15] Investigators traced the source of the outbreak to a decorative fountain located in the square.[16]
2001 Murcia, Spain Hospital Cooling Towers [17] 800+ 6 0.8% The world's largest outbreak of Legionnaires' disease happened in July 2001 with patients appearing at the hospital on July 7, in Murcia, Spain. More than 800 suspected cases were recorded by the time the last case was treated on July 22; 636–696 of these cases were estimated and 449 confirmed (so, at least 16,000 people were exposed to the bacterium) and 6 died . A case-fatality rate of approximately 1%.[17]
2002 Barrow-in-Furness, UK 2002 Barrow-in-Furness legionellosis outbreak Air conditioning 172 7 4.1% In 2002, Barrow-in-Furness in the U.K. suffered an outbreak of Legionnaires' disease. Six women and one man died as a result of the illness; another 172 people also contracted the disease. The cause was found to be a contaminated cooling tower at the town's Forum 28 arts centre.[18] Barrow Borough Council later became the first public body in the UK to be charged with corporate manslaughter but were cleared. They were, however, along with architect Gillian Beckingham, fined for breaches of Health and Safety regulations in a trial that ended in 2006.
2003-2004 Pas-de-Calais, France Petrochemical plant Cooling tower 86 18 20.93% This was the worst outbreak of Legionnaires in French history.[19][20]
2004 Zaragoza, Spain Hospital Cooling tower 27 7 26% Five out of seven of the fatalities were above the age of 50.[19]
2005 Toronto, Ontario, Canada Seven Oaks Home for the Aged Cooling tower 127 21 16.5% In late September, 2005, 127 residents of a nursing home became ill with Legionella pneumophila. Within a week, twenty-one of the residents had died. Culture results at first were negative. The source of the outbreak was traced to the air-conditioning cooling towers on the nursing home's roof.[21]
2005 Fredrikstad, Norway Factory Air scrubber 103 10 9.7% At least 103 people became ill and ten died from Legionnaires' disease caused by bacteria growing in an air scrubber of a nearby factory.[22]
2007 Jastrzębie Zdrój, Poland 2nd District Specialist Hospital, Ophthalmic Ward Water system 4 3 75% In January 2007 in the 2nd district specialist hospital in Jastrzębie-Zdrój two patients on the ophthalmic ward unexpectedly died. It was noted that they suddenly suffered from a high fever, coughs and hallucinations. First they were transferred to the infectious diseases ward for some hours with a suspicion of pneumonia, later they were transferred to intensive care.

Tests showed that both patients suffered from legionellosis. The disease proved to be the cause of death of one of the patients, the other also suffered from circulatory failure. The bacteria responsible for legionellosis was found in four patients from this hospital.[23] In total the outbreak resulted in three deaths [24]

2008 New Brunswick, New Jersey, United States Saint Peter's University Hospital Drinking water 6 2 33.3% Chlorination in the water system had dropped below effective levels.[25]

2010s

Year City Venue Source Cases Deaths Fatality rate Notes
2010 Wales, United Kingdom South Wales Valleys Likely cooling towers 22 2 9% Thought to be cooling towers in local industry.[26]
2011 Dayton, Ohio, United States Dayton Hospital air conditioning 11 5 45% Was the largest outbreak in Ohio since 1994 at the time.[19]
2012 Québec City, Canada Lower Québec City Possibly cooling towers 180 13 7.22% 180 confirmed cases as of September 14, 2012, probably due to contaminated water in industrial cooling towers.[27]
2012 Calp, Spain AR Diamante Beach Hotel Plumbing system 18 3 17% Large hotel with solar water heating system for spa and domestic hot water. A month before the deaths, local government authorities may have known about the problem, but were accused of not alerting the public to avoid disruption of the tourism industry.[28]
2012 Edinburgh, Scotland, UK South west of Edinburgh Possibly cooling towers 92 4 3% 56 confirmed cases, with a further 36 suspected cases, bringing the total number of people affected to 92. Four people are known to have died from the outbreak.[29]
2012 Chicago, Illinois, United States JW Marriott Hotel Decorative Lobby Fountain 10 3 30% 8 confirmed cases with people who stayed at the JW Marriott Chicago during July–August 2012.[30]
2012 Auckland, New Zealand Unknown Water Source and/or Air Conditioning 11 1 9% The number of people affected in a major outbreak of Legionnaires' disease in Auckland, which has claimed one life, has risen to 11.[31]
2012 Stoke-on-Trent, England Warehouse, Fenton Hot tub 19 1 5.2% Infection began in warehouse hot tub. Seventeen of the confirmed cases visited the warehouse a couple of weeks before becoming ill.[32]
2012 Pittsburgh, Pennsylvania, United States Veteran's Administration Hospital unknown 22 6 27% 2012 Pittsburgh legionellosis outbreak[33][34][35]
2014 Portugal 2014 Legionella outbreak in Portugal Cooling tower[36] 375 12 3.2% A widespread outbreak in Vila Franca de Xira district, Portugal.[37]
2015 Bronx, New York, United States Co-op City Co-Op City Cooling Towers 12 0 0.0% 12 people sickened in January 2015. No fatalities reported.[38]
2015 Bronx, New York, United States South Bronx Lincoln Hospital and Concourse Plaza Cooling Towers 113 12 10.6% The 2015 New York Legionnaires' disease outbreak was investigated the New York City Health Department[39][40] Out of 17 buildings with cooling towers, five tested positive to the disease, including cooling towers in the Concourse Plaza Hotel and Lincoln Hospital.[41] The Opera House Hotel in the South Bronx is also considered a source of the outbreak.[42]
2015 Bronx, New York, United States Morris Park Unknown 15 1 6.6% The outbreak is currently being investigated by the New York City Health Department[43][44] "Environmentalists sampled 35 cooling towers in the Morris Park area, and 15 came back with positive results."[45]
2015 Northland, New Zealand Pahiatua Fonterra Plant Unknown 3 0 Unknown This outbreak occurred at one of Fonterra's milk plants in Northland, New Zealand, in November 2015. Currently three cases have been reported, though currently no deaths.
2015 Quincy, Illinois, United States Veterans home Unknown 58 13 27.7% The outbreak investigation is ongoing[46][47][48]
2014–2016 Flint, Genesee County, Michigan, United States Countywide McLaren Regional Medical Center 87 12 13.8% Investigation by Frontline also examined cases diagnosed as pneumonia that could have been misdiagnosed and diagnosed as Legionnaires' Disease. [49] McLaren and the Michigan Department of Environmental Quality is being sued for $100 million in regards to the outbreak.[50] See also Flint water crisis, possibly linked to legionnaires disease
2016 Sydney, Australia Town Hall, CBD Suspected cooling tower at least 4 0 [51]
2017 Manhattan, New York, United States Lenox Hill TBD 7 1 14.3% [52]
2017 Las Vegas, Nevada, United States Rio Hotel and Casino Water system 2[52] 0 0
2017 Round Rock, Texas, United States SpringHill Suites hotel Swimming pool and hot tub 6[53][54] 0 0
2017 Anaheim, California, United States Disneyland Cooling towers 22 1 4.5% [55]
2017 Lisbon, Portugal São Francisco Xavier Hospital Cooling tower[56] 56 6 11% In November 2017, an outbreak of Legionnaires' disease occurred in São Francisco Xavier Hospital, in Lisbon, Portugal. The outbreak resulted in 56 confirmed cases of Legionnaire's disease, of which 6 died.[57] The investigation traced the source of the infection to a cooling tower in the hospital.[58][59]
2018 Bloomsbury, London, UK University College London Water cooler 1 0
2018 Washington Heights, New York, United States The Sugar Hill Project (Building)[60][61] Cooling towers [62][63][60][61] 27[64][63] 1[63] 3.7%
2019 Westminster, London, England Dolphin Square Water System 3 0 0% First case confirmed by NHS England 20 March 2019.[65] Samples taken from the flexible shower hose and bathroom sink of the affected resident's flat, showed legionella bacteria present in those specific locations. Third case confirmed by Public Health England 1 July 2019.
2019 Evergem, Belgium Ghent/Evergem Port[66] Stora Enso[67] Cooling Towers[66] 32[68] 2[69] 6.7% Five samples collected from 17 initially suspected cooling towers at the Port of Ghent near Evergem, tested positive for Legionella pneumophila, 3 with average and 2 in high quantities.[66][70] Genetic testing confirmed 1 of 2 towers with high quantities to have links with the patients.[71] Swedish-Finnish Stora Enso admitted to be responsible.[72]
2019 Ohio, New Jersey and Michigan, United States Multiple locations Not yet determined Flint MI Water Crisis 32 6 18.75% As of June 4, 2019, 32 have fallen sick during the outbreaks across the states of New Jersey and Ohio. Many have fallen sick and died from drinking or being near the contaminated water in Flint, Mi.
2019 Atlanta, United States Sheraton downtown 11 0 Legionnaires’ Disease Outbreak May Have Sickened Dozens in Atlanta
2019 Fletcher, North Carolina, United States North Carolina Mountain State Fair hot tub display 141 4

Four People Have Died From A Legionnaires' Outbreak Linked To A Hot Tub Display At A State Fair Legionnaires’ outbreak linked to hot tub display kills third North Carolina fairgoer N.C. Officials Trace 124 Legionnaires' Disease Cases To Hot Tub At A Fair Investigation of an Outbreak of Legionellosis in Western North Carolina

2020s

Year City Venue Source Cases Deaths Fatality Rate Notes
2020 Brentwood,Tennessee,

United States

.

Brookdale Senior Living Under investigation 5 1 20% Outbreak of Legionnaires’ disease up to five reported cases at Vernon Hills senior living center.[73]

Number Of Legionnaires Cases Rises To Five At Brookdale Vernon Hills Senior Living Facility.[74]

Governmental controls to prevent outbreaks

Regulations and ordinances

The guidance issued by the UK government's Health and Safety Executive (HSE) now recommends that microbiological monitoring for wet cooling systems, using a dipslide, should be performed weekly. The guidance now also recommends that routine testing for legionella bacteria in wet cooling systems be carried out at least quarterly, and more frequently when a system is being commissioned, or if the bacteria have been identified on a previous occasion.[75] Further non-statutory UK guidance from the Water Regulations Advisory Scheme now exists for pre-heating of water in applications such as solar water heating systems.[76]

The City of Garland, Texas requires yearly testing for legionella bacteria at cooling towers at apartment buildings.[77]

Malta requires twice yearly testing for Legionella bacteria at cooling towers and water fountains. Malta prohibits the installation of new cooling towers and evaporative condensers at health care facilities and schools.[78]

The Texas Department of State Health Services has provided guidelines for hospitals to detect and prevent the spread of nosocomial infection due to legionella.[79] The European Working Group for Legionella Infections (EWGLI)[80] was established in 1986 within the European Union framework to share knowledge and experience about potential sources of Legionella and their control. This group has published guidelines[81] about the actions to be taken to limit the number of colony forming units (i.e., the "aerobic count") of micro-organisms per mL at 30 °C (minimum 48 hours incubation):

Aerobic count Legionella Action required
10,000 or less 1,000 or less System under control.
more than 10,000
up to 100,000		 more than 1,000
up to 10,000		 Review program operation. The count should be confirmed by immediate re-sampling. If a similar count is found again, a review of the control measures and risk assessment should be carried out to identify any remedial actions.
more than 100,000 more than 10,000 Implement corrective action. The system should immediately be re-sampled. It should then be 'shot dosed' with an appropriate biocide, as a precaution. The risk assessment and control measures should be reviewed to identify remedial actions.

Almost all natural water sources contain Legionella and their presence should not be taken as an indication of a problem. The tabled figures are for total aerobic plate count, cfu/ml at 30 °C (minimum 48 hours incubation) with colony count determined by the pour plate method according to ISO 6222(21) or spread plate method on yeast extract agar. Legionella isolation can be conducted using the method developed by the US Center for Disease Control using buffered charcoal yeast extract agar with antibiotics.

Many other governmental agencies, cooling tower manufacturers, and industrial trade organizations have developed design and maintenance guidelines for preventing or controlling the growth of Legionella in cooling towers. However, in the US, there are no regulations requiring testing or maintaining any specified levels in these facilities.

Eliminating breeding grounds

The bacteria grow best in warm water, like the kind found in hot tubs, cooling towers, hot water tanks, large plumbing systems, or parts of the air-conditioning systems of large buildings. Indoor ornamental fountains have been confirmed as a cause of Legionnaires' disease outbreaks, in which submerged lighting as a heat source was attributed to the outbreak in all documented cases.[citation needed] Controlling the growth of Legionella in ornamental fountains is touched on in many of the listed guidelines,[citation needed] especially for solar water heating systems.[76]

Adding an antibacterial agent to the automobiles' windshield system's reservoir is also recommended Legionellae have been discovered in up to 40% of freshwater environments and have been in up to 80% of freshwater sites by PCR hybridization assay.[citation needed]

Legionella bacteria themselves can be inactivated by UV light. However, Legionella bacteria that grow and reproduce in amoebae or that are sheltered in corrosion particles cannot be killed by UV light alone.[citation needed]

Legionella will grow in water at temperatures from 20 to 50 °C (68 to 122 °F). However, the bacteria reproduce at the greatest rate in stagnant water at temperatures of 35 to 46 °C (95 to 115 °F).[citation needed]

Copper-Silver ionization is an effective industrial control and prevention process to eradicate Legionella in potable water distribution systems and cooling towers found in health facilities, hotels, nursing homes and most large buildings. In 2003, ionization became the first such hospital disinfection process to have fulfilled a proposed four-step modality evaluation; by then it had been adopted by over 100 hospitals.[82] Additional studies indicate ionization is superior to thermal eradication.[83]

A 2011 study by Lin, Stout and Yu found Copper-Silver ionization to be the only Legionella control technology which has been validated through a 4-step scientific approach.[84]

A recent research study provided evidence that Legionella pneumophila, the causative agent of Legionnaires' disease, can travel airborne at least 6 km from its source. In 2000, ASHRAE issued guidelines to maintain water systems and to decrease the chances of Legionnaires' disease transmission. The guidelines were not valued because legionella multiply in such temperatures. On the other hand, a lot of states had regulations that limited temperatures in health care facilities in order to reduce scalding injuries.[citation needed]

It was previously believed that transmission of the bacterium was restricted to much shorter distances. A team of French scientists reviewed the details of an epidemic of Legionnaires' disease that took place in Pas-de-Calais in northern France in 2003–2004. There were 86 confirmed cases during the outbreak, of whom 18 died. The source of infection was identified as a cooling tower in a petrochemical plant, and an analysis of those affected in the outbreak revealed that some infected people lived as far as 6–7 km from the plant.[20]

A study of Legionnaires' disease cases in May 2005 in Sarpsborg, Norway concluded that: "The high velocity, large drift, and high humidity in the air scrubber may have contributed to the wide spread of Legionella species, probably for >10 km."[85]

In 2010 a study by the UK Health Protection Agency reported that 20% of cases may be caused by infected windscreen washer systems filled with pure water. The finding came after researchers spotted that professional drivers are five times more likely to contract the disease. No cases of infected systems were found whenever a suitable washer fluid was used.[86]

Temperature affects the survival of Legionella as follows:[87]

  • 70 to 80 °C (158 to 176 °F): Disinfection range
  • At 66 °C (151 °F): Legionellae die within 2 minutes
  • At 60 °C (140 °F): They die within 32 minutes
  • At 55 °C (131 °F): They die within 5 to 6 hours
  • Above 50 °C (122 °F): They can survive but do not multiply
  • 35 to 46 °C (95 to 115 °F): Ideal growth range
  • 20 to 50 °C (68 to 122 °F): Growth range
  • Below 20 °C (68 °F): They can survive but are dormant

Removing slime, which can carry legionellae when airborne, may be an effective control process.[88]

See also

References

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  57. ^ "Comunicado — 03/12/2017" [Communiqué — 3 December 2017]. Direção-Geral da Saúde (in Portuguese). 3 December 2017. Retrieved 5 March 2019.
  58. ^ Campos, Alexandra (17 November 2017). "Torre de arrefecimento do S. Francisco Xavier tinha estirpe fatal de Legionella" [Cooling tower in S. Francisco Xavier Hospital had the fatal strain of Legionella] (in Portuguese). Público. Retrieved 5 March 2019.
  59. ^ David Cardoso, Margarida (29 November 2017). "Torre de refrigeração na origem do surto tinha manutenção deficiente, diz DGS" [Cooling tower at the origin of the outbreak had poor maintenance, says Directorate General for Health] (in Portuguese). Público. Retrieved 5 March 2019.
  60. ^ a b "pr065-18". www1.nyc.gov. Retrieved 2018-09-06.
  61. ^ a b "NYC Health Officials ID Source Of Legionnaires' Outbreak In Upper Manhattan". 2018-08-15. Retrieved 2018-09-06.
  62. ^ "New York Today: A Legionnaires' Disease Outbreak". Retrieved 2018-07-18.
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  64. ^ "Notice to Residents of Lower Washington Heights" (PDF). NYC Department of Heath. NYC Department of Health. 24 June 2018. Retrieved 24 July 2018.
  65. ^ "Health officials probe case of deadly Legionnaires' Disease at one of London's most famous apartment blocks". Evening Standard. Retrieved 18 June 2019.
  66. ^ a b c "5 positieve stalen met legionella in Evergem". Het Nieuwsblad (in Flemish). Retrieved 2019-05-20.
  67. ^ "karton- en papierfabrikant Stora Enso".
  68. ^ lla, SVG. "Overeenkomst gevonden tussen vijf legionellapatiënten en koeltoren, mogelijk raakten nog meer mensen besmet". Het Nieuwsblad Mobile (in Flemish). Retrieved 2019-05-29.
  69. ^ Maes, Thierry Goeman en Cédric. "50-jarige man eerste dodelijk slachtoffer legionella-uitbraak: "Op het laatste had hij 2 procent longcapaciteit"". Het Nieuwsblad Mobile (in Flemish). Retrieved 2019-05-14.
  70. ^ "Legionella gevonden in stalen Gentse haven".
  71. ^ lla, SVG. "Overeenkomst gevonden tussen vijf legionellapatiënten en koeltoren, mogelijk raakten nog meer mensen besmet". Het Nieuwsblad Mobile (in Flemish). Retrieved 2019-05-29.
  72. ^ tg. "Papierfabrikant veroorzaakte legionella in Gents havengebied". Het Nieuwsblad (in Flemish). Retrieved 2019-06-14.
  73. ^ Norman, James T. "Outbreak of Legionnaires' disease up to five reported cases at Vernon Hills senior living center". chicagotribune.com. Retrieved 2020-07-06.
  74. ^ "Number Of Legionnaires Cases Rises To Five At Brookdale Vernon Hills Senior Living Facility". 2020-02-20. Retrieved 2020-07-06.
  75. ^ [1] Archived 2012-10-20 at the Wayback Machine
  76. ^ a b Makin T (November 2014). "Preheated Domestic Hot Water: Storage of Preheated Domestic Hot Water and Possible Growth of Legionella Bacteria" (PDF). The Water Regulations Advisory Scheme.
  77. ^ "The Dallas Morning News, Garland tough on bacteria". Dallasnews.com. 2007-02-01. Retrieved 2010-09-11.
  78. ^ "299601 Legionella" (PDF). Retrieved 2010-09-11.
  79. ^ Report of the Texas Legionnaires' Disease Task Force, Texas Department of State Health Services[full citation needed]
  80. ^ "European Working Group for Legionella Infections". Ewgli.org. Archived from the original on 2012-12-25. Retrieved 2010-09-11.
  81. ^ "European Guidelines for Control and Prevention of Travel Associated Legionnaires' Disease". Archived from the original on 2011-07-06. Retrieved 2017-07-01.
  82. ^ Stout JE, Yu VL (August 2003). "Hospital-acquired Legionnaires' disease: new developments". Current Opinion in Infectious Diseases. 16 (4): 337–41. doi:10.1097/00001432-200308000-00005. PMID 12861086.
  83. ^ Lin, Yu-Sen E.; Stout, Janet E.; Yu, Victor L. (2001). "Control of Legionella". In Block, Seymour Stanton (ed.). Disinfection, Sterilization, and Preservation. Lippincott Williams & Wilkins. pp. 505–12. ISBN 978-0-683-30740-5. {{cite book}}: External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help); Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  84. ^ Lin YE, Stout JE, Yu VL (February 2011). "Controlling Legionella in hospital drinking water: an evidence-based review of disinfection methods". Infection Control and Hospital Epidemiology. 32 (2): 166–73. doi:10.1086/657934. PMID 21460472.
  85. ^ Nygård K, Werner-Johansen Ø, Rønsen S, Caugant DA, Simonsen Ø, Kanestrøm A, Ask E, Ringstad J, Ødegård R, Jensen T, Krogh T, Høiby EA, Ragnhildstveit E, Aaberge IS, Aavitsland P (January 2008). "An outbreak of legionnaires disease caused by long-distance spread from an industrial air scrubber in Sarpsborg, Norway". Clinical Infectious Diseases. 46 (1): 61–9. doi:10.1086/524016. PMID 18171215.
  86. ^ Wilkinson, Emma (2010-06-13). "Windscreen water infection risk". BBC News. Retrieved 2010-09-11. {{cite news}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  87. ^ "Legionella: What is Legionnaires' Disease?". Reliance Worldwide. Archived from the original on October 9, 2007.[unreliable medical source?]
  88. ^ Potera C (December 1998). "Studying slime". Environmental Health Perspectives. 106 (12): A604-6. doi:10.1289/ehp.98106a604. PMC 1533243. PMID 9831548.
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