List of Legionnaires' disease outbreaks explained

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

1960s

Year City Venue Source Cases Deaths Fatality rate Notes
1965Unknown 94 16 17% The outbreak occurred in 1965, but was not identified as legionnaires' disease until saved blood serum was exposed to bacterial samples from the 1976 Philadelphia Legionnaires' disease outbreak.[5]

1970s

Year City Venue Source Cases Deaths Fatality rate Notes
1973,1977Shower pipes at least 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.[6]
1976Air conditioning15.4% 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.[7] [8] [9]
1978air-conditioning cooling tower 44 1978 Memphis Legionnaire's Disease Outbreak
1979Melbourne, Australia light industrial building medium-sized evaporative condenser [10]
1979Ballarat, Australia psychiatric hospital shower water system

1980s

Year City Venue Source Cases Deaths Fatality rate Notes
1985Wollongong, Australia social club building small cooling tower
1985Stafford, England 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.
1986Adelaide, Australia community small cooling tower at hospital
1987Wollongong, Australia shopping centre small cooling tower at a shop
1988Adelaide, Australia community potting mixes
1988Westminster, England BBC headquarters
1989Sydney, Australia bowling club small cooling tower
1989Burnie, Australia community small cooling tower at hospital

1990s

Year City Venue Source Cases Deaths Fatality rate Notes
1992Sydney, Australia shopping centre small cooling tower
1994Sunshine Coast, Australia holiday apartment unit private spa pool
1995Sydney, Australia shopping centre small cooling tower at hospital
1999 Bovenkarspel, Netherlands Hot tub10% In March 1999, an outbreak occurred in the Netherlands 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.[11] [12]

2000s

Year City Venue Source Cases Deaths Fatality rate Notes
2000 Melbourne, Australia 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.[13] Since this outbreak, legionella infection statistics are required to be reported by the state government as a notifiable disease.[14] Regulations were introduced by the state to control legionella in 2001.[15]
2000 Public square Decorative fountain 0% In August 2000, an outbreak of Legionnaires' disease occurred in Vizela, Northern Portugal.[16] A total of 11 persons with Legionnaires' disease were admitted to the hospital.[17] 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. Investigators traced the source of the outbreak to a decorative fountain located in the square.
2001Murcia, Spain Hospital Cooling Towers[18] + 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%.
2002 Barrow-in-Furness, England 4.1% In 2002, Barrow-in-Furness in England had 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.[19] 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 20.93% This was the worst outbreak of Legionnaires in French history.[20] [21]
2004 Zaragoza, Spain Hospital 26% Five out of seven of the fatalities were above the age of 50.
2005 Toronto, Canada Seven Oaks Home for the Aged 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.[22]
2005 Fredrikstad, Norway Factory 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.[23]
2007Jastrzębie Zdrój, Poland2nd District Specialist Hospital, Ophthalmic WardWater system4375%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 had 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 had legionellosis. The disease proved to be the cause of death of one of the patients, the other also had circulatory failure. The bacteria responsible for legionellosis was found in four patients from this hospital.[24] In total the outbreak resulted in three deaths[25]
2008 33.3% Chlorination in the water system had dropped below effective levels.[26]

2010s

Year City Venue Source Cases Deaths Fatality rate Notes
2010 WalesSouth Wales ValleysLikely cooling towers9% Thought to be cooling towers in local industry.[27]
2011Dayton, Ohio, United StatesDaytonHospital air conditioning 45% Was the largest outbreak in Ohio since 1994 at the time.
2012Québec City, CanadaLower Québec City Possibly cooling towers7.22%180 confirmed cases as of September 14, 2012, probably due to contaminated water in industrial cooling towers.[28]
2012 Calp, SpainAR Diamante Beach Hotel Plumbing system 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.[29]
2012Edinburgh, Scotland South west of Edinburgh Possibly cooling towers3% 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.[30]
2012Chicago, Illinois, United States JW Marriott Hotel Decorative Lobby Fountain30% 8 confirmed cases with people who stayed at the JW Marriott Chicago during July–August 2012.[31]
2012 Auckland, New Zealand UnknownWater Source and/or Air Conditioning9% The number of people affected in a major outbreak of Legionnaires' disease in Auckland, which has claimed one life, has risen to 11.[32]
2012Stoke-on-Trent, EnglandWarehouse, Fenton Hot tub5.2% Infection began in warehouse hot tub. Seventeen of the confirmed cases visited the warehouse a couple of weeks before becoming ill.[33]
2012Pittsburgh, Pennsylvania, United StatesVeteran's Administration Hospitalunknown27% 2012 Pittsburgh legionellosis outbreak[34] [35] [36]
2014Portugal2014 Legionella outbreak in PortugalCooling tower[37] 3.2% A widespread outbreak in Vila Franca de Xira district, Portugal.[38]
2015Bronx, New York, United StatesCo-op City, South Bronx, and Morris ParkCooling Towers in the Bronx, such as Co-op City, Lincoln Hospital, and Concourse Plaza. 9.3% 12 people sickened in January 2015. No fatalities reported.[39] The 2015 New York Legionnaires' disease outbreak was investigated the New York City Health Department[40] [41] Out of 17 buildings with cooling towers, five tested positive for the disease, including cooling towers in the Concourse Plaza Hotel and Lincoln Hospital.[42] The Opera House Hotel in the South Bronx is also considered a source of the outbreak.[43] The outbreak is currently being investigated by the New York City Health Department[44] [45] "Environmentalists sampled 35 cooling towers in the Morris Park area, and 15 came back with positive results."[46] In total 52 buildings were sampled and 20 of them came back positive.
2015Northland, New ZealandPahiatua Fonterra PlantUnknown30UnknownThis 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.
2015Quincy, Illinois, United StatesVeterans home Unknown 27.7% The outbreak investigation is ongoing[47] [48] [49]
2014–2016 Flint, Genesee County, Michigan, United StatesCountywide McLaren Regional Medical Center13.8%Investigation by Frontline also examined cases diagnosed as pneumonia that could have been misdiagnosed and diagnosed as Legionnaires' Disease.[50] McLaren and the Michigan Department of Environmental Quality is being sued for $100 million in regards to the outbreak.[51] See also Flint water crisis, possibly linked to legionnaires disease
2016Sydney, AustraliaSydney Town HallSuspected cooling towerat least 40[52]
2016Hopkins, Minnesota, United StatesCitrus Systems, Inc.Cooling tower2314.3%Confirmed by Minnesota Department of Health. 23 people became sick, 17 were hospitalized, and one person died.[53]
2017Manhattan, New York, United StatesLenox HillTBD7114.3%[54]
2017Las Vegas, Nevada, United StatesRio Hotel and CasinoWater system200
2017Round Rock, Texas, United StatesSpringHill Suites hotelSwimming pool and hot tub6[55] [56] 00
2017Anaheim, California, United StatesDisneylandCooling towers2214.5%[57]
2017Lisbon, PortugalSão Francisco Xavier HospitalCooling tower[58] 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.[59] The investigation traced the source of the infection to a cooling tower in the hospital.[60] [61]
2018Bloomsbury, LondonUniversity College LondonWater cooler10
2018Washington Heights, New York, United StatesThe Sugar Hill Project (Building)[62] [63] Cooling towers[64] [65] 27[66] 13.7%
2019Westminster, London, EnglandDolphin SquareWater System300%First case confirmed by NHS England 20 March 2019.[67] 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.
2019Evergem, BelgiumGhent/Evergem Port[68] Stora Enso[69] Cooling Towers32[70] 2[71] 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.[72] Genetic testing confirmed 1 of 2 towers with high quantities to have links with the patients.[73] Swedish-Finnish Stora Enso admitted to be responsible.[74]
2019Ohio, New Jersey and Michigan, United StatesMultiple locationsNot yet determined Flint MI Water Crisis32618.75%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.
2019Atlanta, United StatesSheraton downtown110Legionnaires' Disease Outbreak May Have Sickened Dozens in Atlanta
2019Fletcher, North Carolina, United StatesNorth Carolina Mountain State Fairhot tub display1414Four People Have Died From A Legionnaires' Outbreak Linked To A Hot Tub Display At A State FairLegionnaires' outbreak linked to hot tub display kills third North Carolina fairgoerN.C. Officials Trace 124 Legionnaires' Disease Cases To Hot Tub At A FairInvestigation of an Outbreak of Legionellosis in Western North Carolina

2020s

!Year!City!Venue!Source!Cases!Deaths!Fatality Rate!Notes
2020Vernon Hills, Illinois,United StatesBrookdale Senior LivingUnder investigation5120%Outbreak of Legionnaires' disease up to five reported cases at Vernon Hills senior living center.[75] Number Of Legionnaires Cases Rises To Five At Brookdale Vernon Hills Senior Living Facility.[76]
2020Vila do Conde, Póvoa do Varzim, Matosinhos, Porto District,PortugalMultiple locationsUnder investigation881517%88 cases and 15 deaths (11 of these were also infected with SARS-CoV-2). The source of the bacteria is still unknown. The deadliest Legionella outbreak in Portugal, it was declared extinct on January 13, 2021.[77]
2022San Miguel de Tucumán, Tucumán Province,ArgentinaHealth clinicUnder investigation22627%Cluster of pneumonia cases associated with a health clinic. 22 cases and 6 deaths (all with comorbidities). The source of the bacteria is still unknown.[78]
2023Rzeszów, Subcarpathian Voivodeship,PolandMultiple locationsUnder investigation1644125%Ongoing outbreak. The source of the bacteria is suspected to be contaminated water sources.[79]
2024Lincoln, New Hampshire, United StatesRiverWalk ResortCooling Tower500%[80]

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.[81] 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.[82]

The City of Garland, Texas, United States requires yearly testing for legionella bacteria at cooling towers at apartment buildings.[83]

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.[84]

The Texas Department of State Health Services has provided guidelines for hospitals to detect and prevent the spread of nosocomial infection due to legionella.[85] The European Working Group for Legionella Infections (EWGLI)[86] 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[87] 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):

width=22% 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.

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.[88] Additional studies indicate ionization is superior to thermal eradication.[89]

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.[90]

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.[21]

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."[91]

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.[92]

Temperature affects the survival of Legionella as follows:[93]

Removing slime, which can carry legionellae when airborne, may be an effective control process.[94]

See also

External links

Notes and References

  1. Book: Ryan KJ, Ray CG . Sherris Medical Microbiology . 4th . McGraw Hill . 2004 . 0-8385-8529-9 .
  2. Book: Swanson M, Heuner K . Legionella: Molecular Microbiology . Caister Academic Pr . 2008 . 978-1-904455-26-4.
  3. News: Lawrence K. . Altman . vanc . August 1, 2006 . In Philadelphia 30 Years Ago, an Eruption of Illness and Fear . The New York Times .
  4. Web site: Legionella Outbreak Toolbox. 2020-07-01. legionnaires.ecdc.europa.eu.
  5. News: 'Legion Fever' Germ Killed 16 Here in 1965 . Washington Post. 16 December 2021. 1977-01-31 . B. D. Colen .
  6. News: Timeline: legionnaires' disease outbreaks in Britain . . 31 July 2015. 2012-06-06.
  7. McDade JE, Brenner DJ, Bozeman FM . Legionnaires' disease bacterium isolated in 1947 . Annals of Internal Medicine. 90 . 4 . 659–61 . April 1979 . 373548 . 10.7326/0003-4819-90-4-659 .
  8. Fraser DW, Tsai TR, Orenstein W, Parkin WE, Beecham HJ, Sharrar RG, Harris J, Mallison GF, Martin SM, McDade JE, Shepard CC, Brachman PS . Legionnaires' disease: description of an epidemic of pneumonia . New England Journal of Medicine. 297 . 22 . 1189–97 . December 1977 . 335244 . 10.1056/NEJM197712012972201 .
  9. Tsai TF, Finn DR, Plikaytis BD, McCauley W, Martin SM, Fraser DW . Legionnaires' disease: clinical features of the epidemic in Philadelphia . Annals of Internal Medicine . 90 . 4 . 509–17 . April 1979 . 434627 . 10.7326/0003-4819-90-4-509 .
  10. Book: Broadbent . Clive . vanc . 1996 . Guidance for the Control of Legionella . National Environmental Health Forum Monographs . 978-0-642-25247-0 .
  11. Web site: The Westfriese Flora flower exhibition and fair . Q-net.net.au . 2010-09-11 . 2009-03-02 . https://web.archive.org/web/20090302015541/http://www.q-net.net.au/~legion/Legionnaires%60_Disease_Netherlands_1999.htm . dead .
  12. Web site: 25 februari 1999: Legionellabesmetting Westfriese Flora, Bovenkarspel . Zwaailichten disaster website . 2005 . December 2, 2011. nl.
  13. Greig JE, Carnie JA, Tallis GF, Ryan NJ, Tan AG, Gordon IR, Zwolak B, Leydon JA, Guest CS, Hart WG . An outbreak of Legionnaires' disease at the Melbourne Aquarium, April 2000: investigation and case-control studies . Medical Journal of Australia. 180 . 11 . 566–72 . June 2004 . 10.5694/j.1326-5377.2004.tb06093.x . 15174987 . 15441893 .
  14. Web site: Legionella pneumophila cases . Docs2.health.vic.gov.au . 2015-08-30 . 2016-02-04 . https://web.archive.org/web/20160204110407/http://docs2.health.vic.gov.au/docs/doc/F268771876D8B028CA257ACA0012BB28/$FILE/cts_ehindicators.pdf . dead .
  15. Web site: Health (Legionella) Regulations 2001 S.R. No. 13/2001 . 2017-07-01. Legislation.vic.gov.au.
  16. 13 November 2014 . Vizela já enfrentou a legionella em Agosto de 2000 com 11 infectados . Vizela already faced legionella in August 2000, with 11 cases . pt . 5 March 2019 . Porto Canal .
  17. Correia . AM . Gonçalves . G . Reis . J . Cruz . JM . Castro e Freitas . JA . July 2001 . An outbreak of legionnaires disease in a municipality in northern Portugal. . Euro Surveill . 6. 7. 121–4 . 10.2807/esm.06.07.00228-en. 12631957 . free .
  18. García-Fulgueiras A, Navarro C, Fenoll D, García J, González-Diego P, Jiménez-Buñuales T, Rodriguez M, Lopez R, Pacheco F, Ruiz J, Segovia M, Balandrón B, Pelaz C . Legionnaires' disease outbreak in Murcia, Spain . Emerging Infectious Diseases . 9 . 8 . 915–21 . August 2003 . 12967487 . 3020623 . 10.3201/eid0908.030337 .
  19. Web site: legionnaires disease, Barrow-in-Furness . https://archive.today/20020816113347/http://www.multiline.com.au/~mg/legionnaires_disease_Barrow-in-Furness.html . dead . 2002-08-16 . 2013-08-30 .
  20. Web site: The 12 Worst Legionnaires Outbreaks in the World . Healthcare Business & Technology . May 11, 2012 . 3 June 2019.
  21. Nguyen TM, Ilef D, Jarraud S, Rouil L, Campese C, Che D, Haeghebaert S, Ganiayre F, Marcel F, Etienne J, Desenclos JC . A community-wide outbreak of legionnaires disease linked to industrial cooling towers--how far can contaminated aerosols spread? . The Journal of Infectious Diseases . 193 . 1 . 102–11 . January 2006 . 16323138 . 10.1086/498575 . free .
  22. News: Toronto legionnaires' outbreak linked to 3 more deaths . October 21, 2005 . CBC News.
  23. Simonsen Ø, Wedege E, Kanestrøm A, Bolstad K, Aaberge IS, Ragnhildstveit E, Ringstad J . Characterization of the extent of a large outbreak of Legionnaires' disease by serological assays . BMC Infectious Diseases . 15 . 163 . March 2015 . 25887275 . 4383209 . 10.1186/s12879-015-0903-2 . free .
  24. Web site: Legionellosis case in Jastrzębie-Zdrój will be included in subject literature News Science & Scholarship in Poland. www.ideo.pl. Ideo Sp. z o.o. -. scienceinpoland.pap.pl. 2017-08-02. 2017-08-02. https://web.archive.org/web/20170802130858/http://scienceinpoland.pap.pl/en/news/news,17022,legionellosis-case-in-jastrzebie-zdroj-will-be-included-in-subject-literature.html. dead.
  25. Web site: Wyborcza.pl. wyborcza.pl. 2017-08-02.
  26. News: Second patient with Legionnaires' disease dies at New Brunswick hospital . . September 24, 2008 . 2011-10-08 .
  27. Web site: South Wales legionnaires' disease outbreak declared over . . 12 October 2010 . 6 June 2012.
  28. News: DRSP - Direction régionale de santé publique de la Capitale-Nationale . September 12, 2012 . fr . dead . https://web.archive.org/web/20121017100521/http://www.dspq.qc.ca/legionellose.html . 2012-10-17 . 2013-08-30.
  29. News: Legionnaires' disease that killed three Britons at Spanish hotel was detected a month before action taken. Govan. Fiona . vanc . 7 February 2012. The Daily Telegraph. 2017-01-18 .
  30. Web site: Legionnaires' Disease outbreak: Third death reported. bbc.co.uk . 3 July 2012 . 3 July 2012.
  31. News: 3 dead in Legionnaires' outbreak tied to downtown hotel. . August 27, 2012 . 2012-08-27 .
  32. News: Legionnaires' cases rise to 11 . [The Press] . April 6, 2012 . 2012-06-04 .
  33. News: Stoke-on-Trent Legionnaires' source 'could be hot tub' . [The Press] . July 31, 2012 . 2012-08-02 .
  34. Pittsburgh Veteran's Administration Hospital water contamination investigation ongoing
  35. Web site: Investigation Reveals Failures of Pittsburgh VA Hospital in Legionnaires' Outbreak. Noah Brode. wesa.fm. 23 April 2013.
  36. Web site: Families of Legionnaires' victims outraged by report on VA outbreak. Pittsburgh Post-Gazette.
  37. Web site: Joint Communication — Preliminary report of Legionnaries' disease 07 to 21 November 2014 . . 21 November 2014 . . 5 March 2019 .
  38. Web site: Extinto o surto de legionella . November 21, 2014 . rr.sapo.pt . pt . November 23, 2014.
  39. Web site: Co-op City towers contaminated with Legionnaires' Disease . New York Daily News. 2015-01-13 . 2015-08-29.
  40. Web site: Legionnaires' Disease Bacteria Found in A/C on Bronx Hospital, Mayor says. DNAinfo New York. dead. https://web.archive.org/web/20150801133024/http://www.dnainfo.com/new-york/20150730/civic-center/legionnaires-disease-bacteria-found-ac-of-bronx-hospital-mayor-says. 2015-08-01.
  41. Web site: There have been 65 cases since mid-July. David Shortell. 2 August 2015. CNN News.
  42. Web site: City confirms 71 cases of Legionnaire's Disease. capitalnewyork.com.
  43. News: Hotel that enlivened the Bronx is now a 'hot spot' for Legionnaire's. The New York Times. 10 August 2015 . Hu . Winnie . Remnick . Noah .
  44. City of New York . September 28, 2015 . Health Department Investigating Cluster of Legionnaires' Disease in Morris Park Section of the Bronx . September 30, 2015 . dead . https://web.archive.org/web/20150930213255/http://www.nyc.gov/html/doh/html/pr2015/pr039-15.shtml . September 30, 2015 .
  45. Web site: Legionnaires' Disease . Department of Health and Mental Hygiene . City of New York . October 6, 2015 . dead . https://web.archive.org/web/20151007070021/http://www.nyc.gov/html/doh/html/diseases/cdlegi.shtml . October 7, 2015 .
  46. News: Campanile . Carl . vanc . September 30, 2015 . Latest Bronx Legionnaires' disease outbreak turns fatal . . September 30, 2015.
  47. Web site: Illinois is spending $2.3M to fix a Legionnaires disease outbreak in Quincy . Journal Star . Peoria, IL . 2015-09-10 . 2017-07-01.
  48. Web site: Death toll stands at 13 after Quincy Legionnaires' outbreak . Abc7chicago.com . 2015-09-17 . 2017-07-01.
  49. News: Fourth case of Legionnaires' disease confirmed at Quincy veterans home in one week. 2018-02-21. WQAD.com. 2018-07-24 .
  50. https://www.pbs.org/wgbh/frontline/article/flint-water-crisis-legionnaires-disease-deaths (April 25, 2019). Retrieved October 28, 2019.
  51. John Wisely & Jennifer Dixon, Fieger files $100-million suit over Flint Legionnaires' disease cases, Detroit Free Press (February 2, 2016).
  52. Web site: Town Hall area cooling tower suspected after four men contract Legionnaires disease. The Sydney Morning Herald. 2016-03-10. 2016-03-09.
  53. News: Source of Legionnaires' outbreak in Hopkins ID'd. Thiede. Data. 2016-10-12. Kare 11. 2023-05-24.
  54. News: Legionnaires' Outbreak on Upper East Side Kills One and Sickens Six. Nir. Sarah Maslin . vanc . 2017-06-16. The New York Times. 2017-06-17 . 0362-4331.
  55. News: Sixth case of Legionnaires' disease confirmed at Round Rock hotel. Austin. CBS. KEYE. 2017-10-10 .
  56. News: Sixth case of Legionnaires' disease confirmed from Round Rock hotel. Osborn. Claire. vanc. 2017-10-10. Austin American-Statesman. 2017-10-10. 2017-10-11. https://web.archive.org/web/20171011021834/http://www.statesman.com/news/local/sixth-case-legionnaires-disease-confirmed-from-round-rock-hotel/2At7rMDESHTxTTgbtSJWlM/. dead.
  57. News: Disneyland shuts down two cooling towers after Legionnaires' disease outbreak. Perez. Maria . vanc . November 11, 2017. Newsweek. November 11, 2017 .
  58. News: Surto de legionella com origem pelo menos numa das torres de arrefecimento do São Francisco Xavier. Legionella outbreak with origin in at least one of the cooling towers of São Francisco Xavier. November 16, 2017. Jornal de Negócios. November 24, 2017. pt.
  59. Web site: Comunicado — 03/12/2017 . . 3 December 2017 . . pt . Communiqué — 3 December 2017 . 5 March 2019 .
  60. Web site: Torre de arrefecimento do S. Francisco Xavier tinha estirpe fatal de Legionella . Campos . Alexandra . 17 November 2017 . Público . pt . Cooling tower in S. Francisco Xavier Hospital had the fatal strain of Legionella . 5 March 2019 .
  61. Web site: Torre de refrigeração na origem do surto tinha manutenção deficiente, diz DGS . David Cardoso . Margarida . 29 November 2017 . Público . pt . Cooling tower at the origin of the outbreak had poor maintenance, says Directorate General for Health . 5 March 2019 .
  62. Web site: pr065-18. www1.nyc.gov. 2018-09-06. 2018-09-06. https://web.archive.org/web/20180906124539/https://www1.nyc.gov/site/doh/about/press/pr2018/pr065-18.page. dead.
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  64. News: New York Today: A Legionnaires' Disease Outbreak. The New York Times . 17 July 2018 . 2018-07-18 . Levine . Alexandra S. .
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