{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T13:05:49Z","timestamp":1790600749989,"version":"4.1.0"},"reference-count":72,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2018,7,30]],"date-time":"2018-07-30T00:00:00Z","timestamp":1532908800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>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\u2019 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.<\/jats:p>","DOI":"10.3390\/ijerph15081612","type":"journal-article","created":{"date-parts":[[2018,7,30]],"date-time":"2018-07-30T11:55:08Z","timestamp":1532951708000},"page":"1612","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":50,"title":["Legionellosis Associated with Recreational Waters: A Systematic Review of Cases and Outbreaks in Swimming Pools, Spa Pools, and Similar Environments"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4002-9153","authenticated-orcid":false,"given":"Erica","family":"Leoni","sequence":"first","affiliation":[{"name":"Unit of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, University of Bologna, via S. Giacomo 12, 40126 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9934-4641","authenticated-orcid":false,"given":"Federica","family":"Catalani","sequence":"additional","affiliation":[{"name":"School of Hygiene and Preventive Medicine, Department of Biomedical and Neuromotor Sciences, University of Bologna, via S. Giacomo 12, 40126 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7025-4271","authenticated-orcid":false,"given":"Sofia","family":"Marini","sequence":"additional","affiliation":[{"name":"Department of Life Quality Studies, University of Bologna, Campus of Rimini; Corso d\u2019Augusto 237, 47921 Rimini, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7555-9659","authenticated-orcid":false,"given":"Laura","family":"Dallolio","sequence":"additional","affiliation":[{"name":"Unit of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, University of Bologna, via S. Giacomo 12, 40126 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2018,7,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1607","DOI":"10.1001\/archinte.1986.00360200183030","article-title":"Mode of transmission of Legionella pneumophila: A critical review","volume":"146","author":"Muder","year":"1986","journal-title":"Arch. Int. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1080\/15459624.2016.1229481","article-title":"Existence and control of Legionella bacteria in building water systems: A review","volume":"14","author":"Springston","year":"2017","journal-title":"J. Occup. Environ. Hyg."},{"key":"ref_3","unstructured":"ECDC (2018, July 09). European Technical Guidelines for the Prevention, Control and Investigation of Infections Caused by Legionella Species, Available online: https:\/\/ecdc.europa.eu\/sites\/portal\/files\/documents\/Legionella%20GuidelinesFinal%20updated%20for%20ECDC%20corrections.pdf."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1016\/j.idc.2016.10.008","article-title":"Legionnaire\u2019s Disease and its mimics: A clinical perspective","volume":"31","author":"Cunha","year":"2017","journal-title":"Infect. Dis. Clin. N. Am."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"5805","DOI":"10.1128\/AEM.71.10.5805-5813.2005","article-title":"Legionella contamination in hot water of Italian hotels","volume":"71","author":"Borella","year":"2005","journal-title":"Appl. Environ. Microbiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1111\/j.1365-2672.2004.02458.x","article-title":"Legionella waterline colonization: Detection of Legionella species in domestic, hotel and hospital hot water systems","volume":"98","author":"Leoni","year":"2005","journal-title":"J. Appl. Microbiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1016\/j.ijheh.2013.08.002","article-title":"Assessing the environmental health relevance of cooling towers\u2014A systematic review of legionellosis outbreaks","volume":"217","author":"Walser","year":"2014","journal-title":"Int. J. Hyg. Environ. Health"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2064","DOI":"10.3390\/ijerph110202064","article-title":"Effect of different disinfection protocols on microbial and biofilm contamination of dental unit waterlines in community dental practices","volume":"11","author":"Dallolio","year":"2014","journal-title":"Int. J. Environ. Res. Public Health"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"684","DOI":"10.1016\/S0140-6736(12)60074-9","article-title":"Pneumonia associated with a dental unit waterline","volume":"379","author":"Ricci","year":"2012","journal-title":"Lancet"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1076","DOI":"10.1111\/jam.12761","article-title":"Prevalence of Simkania negevensis in chlorinated water from spa swimming pools and domestic supplies","volume":"118","author":"Donati","year":"2015","journal-title":"J. Appl. Microbiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"3749","DOI":"10.1016\/S0043-1354(01)00075-6","article-title":"Prevalence of Legionella spp. in swimming pool environment","volume":"35","author":"Leoni","year":"2001","journal-title":"Water Res."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"716","DOI":"10.1086\/504364","article-title":"Control of Legionella pneumophila contamination in a system for respiratory hydrotherapy with sulphurous spa water","volume":"27","author":"Leoni","year":"2006","journal-title":"Inf. Control Hosp. Epidemiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"996","DOI":"10.2166\/wh.2015.033","article-title":"Controlling Legionella and Pseudomonas aeruginosa re-growth in therapeutic spas: Implementation of physical disinfection treatments, including UV\/ultrafiltration, in a respiratory hydrotherapy system","volume":"13","author":"Leoni","year":"2015","journal-title":"J. Water Health"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"506","DOI":"10.1128\/CMR.15.3.506-526.2002","article-title":"Legionella and Legionnaire\u2019s disease: 25 year of investigation","volume":"15","author":"Fields","year":"2002","journal-title":"Clin. Microbiol. Rev."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2344","DOI":"10.3390\/ijerph120302344","article-title":"Impact of a risk management plan on Legionella contamination of dental unit water","volume":"12","author":"Leoni","year":"2015","journal-title":"Int. J. Environ. Res. Public Health"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1007\/s40572-018-0201-4","article-title":"Outbreaks of Legionnaires\u2019 Disease and Pontiac Fever 2006\u20132017","volume":"5","author":"Hamilton","year":"2018","journal-title":"Curr. Environ. Health Rep."},{"key":"ref_17","unstructured":"WHO (2006). Guidelines for Safe Recreational Water Environments. Volume 2, Swimming Pools and Similar Environments, WHO. Available online: http:\/\/www.who.int\/water_sanitation_health\/bathing\/srwe2full.pdf."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1111\/jtm.12225","article-title":"Legionnaires\u2019 Disease in hotels and passenger ships: A systematic review of evidence, sources, and contributing factors","volume":"22","author":"Mouchtouri","year":"2015","journal-title":"J. Travel Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1016\/S0140-6736(89)91319-6","article-title":"Lochgoilhead fever: Outbreak of non-pneumonic legionellosis due to Legionella micdadei","volume":"1","author":"Goldberg","year":"1989","journal-title":"Lancet"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1405","DOI":"10.3201\/eid1109.050345","article-title":"Legionellosis from Legionella pneumophila serogroup 13","volume":"11","author":"Faris","year":"2005","journal-title":"Emerg. Infect. Dis."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1017\/S0950268801005258","article-title":"Different growth rates in amoeba of genotypically related environmental and clinical Legionella pneumophila strains isolated from a thermal spa","volume":"126","author":"Molmeret","year":"2001","journal-title":"Epidemiol. Infect."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"90","DOI":"10.11150\/kansenshogakuzasshi1970.78.90","article-title":"An outbreak of legionellosis in a new facility of hot spring bath in Hiuga City","volume":"78","author":"Yabuuchi","year":"2004","journal-title":"Kansenshogaku Zasshi"},{"key":"ref_23","first-page":"393","article-title":"Hot tub legionellosis","volume":"94","author":"Tolentino","year":"1996","journal-title":"J. Ky. Med. Assoc."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"153","DOI":"10.2169\/internalmedicine.37.153","article-title":"Legionnaires\u2019 disease diagnosed by bronchoalveolar lavage","volume":"37","author":"Chiba","year":"1998","journal-title":"Intern. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"898","DOI":"10.11150\/kansenshogakuzasshi1970.78.898","article-title":"Legionella pneumonia which occurred in a private whirlpool bath user","volume":"78","author":"Ishikawa","year":"2004","journal-title":"Kansenshogaku Zasshi"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"859","DOI":"10.2169\/internalmedicine.41.859","article-title":"Hot spring bath and Legionella pneumonia: An association confirmed by genomic identification","volume":"41","author":"Ito","year":"2002","journal-title":"Intern. Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"201","DOI":"10.7883\/yoken.JJID.2009.201","article-title":"Bathwater-associated cases of legionellosis in Japan, with a special focus on Legionella concentrations in water","volume":"62","author":"Kuroki","year":"2009","journal-title":"Jpn. J. Infect. Dis."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"78","DOI":"10.7883\/yoken.63.78","article-title":"A case of Legionella pneumonia linked to a hot spring facility in Gunma Prefecture, Japan","volume":"63","author":"Kurosawa","year":"2010","journal-title":"Jpn. J. Infect. Dis."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"163","DOI":"10.11150\/kansenshogakuzasshi1970.67.163","article-title":"A case of Legionnaires\u2019 disease due to aspiration of hot spring water and isolation of Legionella pneumophila from hot spring water","volume":"67","author":"Mashiba","year":"1993","journal-title":"Kansenshogaku Zasshi"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1242","DOI":"10.1099\/jmm.0.016089-0","article-title":"Isolation of Legionella rubrilucens from a pneumonia patient co-infected with Legionella pneumophila","volume":"59","author":"Matsui","year":"2010","journal-title":"J. Med. Microbiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1111\/j.1348-0421.1997.tb01190.x","article-title":"Molecular determination of infection source of a sporadic Legionella pneumonia case associated with a hot spring bath","volume":"41","author":"Miyamoto","year":"1997","journal-title":"Microbiol. Immunol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"73","DOI":"10.2169\/internalmedicine.44.73","article-title":"Legionella pneumonia associated with adult respiratory distress syndrome caused by Legionella pneumophila serogroup 3","volume":"44","author":"Nozue","year":"2005","journal-title":"Intern. Med."},{"key":"ref_33","first-page":"211","article-title":"Two cases of Legionella pneumophila pneumonia improved by parenteral ciprofloxacin administration","volume":"41","author":"Sasaki","year":"2003","journal-title":"Nihon Kokyuki Gakkai Zasshi"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1093\/ndt\/14.2.455","article-title":"The haemodialysis patient who developed acute respiratory distress syndrome after a trip to a hot spring spa","volume":"14","author":"Shimizu","year":"1999","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"169","DOI":"10.11150\/kansenshogakuzasshi1970.71.169","article-title":"A case of fatal pneumonia caused by Legionella pneumophila serogroup 6 developed after drowning in a public bath","volume":"71","author":"Tokuda","year":"1997","journal-title":"Kansenshogaku Zasshi"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1111\/j.1348-0421.2006.tb03803.x","article-title":"A legionellosis case due to contaminated spa water and confirmed by genomic identification in Taiwan","volume":"50","author":"Su","year":"2006","journal-title":"Microbiol. Immunol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1356","DOI":"10.11150\/kansenshogakuzasshi1970.69.1356","article-title":"Legionella pneumophila serogroup 3 isolated from a patient of pneumonia developed after drowning in bathtub of a hot spring spa","volume":"69","author":"Shiota","year":"1995","journal-title":"Kansenshogaku Zasshi"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1097\/01.inf.0000107016.09468.80","article-title":"Legionella pneumonia: Infection during immunosuppressive therapy for idiopathic pulmonary hemosiderosis","volume":"23","author":"Watson","year":"2004","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"809","DOI":"10.1093\/oxfordjournals.aje.a113953","article-title":"Pontiac fever associated with a whirlpool spa","volume":"120","author":"Spitalny","year":"1984","journal-title":"Am. J. Epidemiol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1001\/jama.1985.03350280091026","article-title":"An outbreak of Pontiac fever related to whirlpool use, Michigan 1982","volume":"253","author":"Mangione","year":"1985","journal-title":"JAMA"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"769","DOI":"10.1093\/infdis\/168.3.769","article-title":"Use of polymerase chain reaction in an epidemiologic investigation of Pontiac fever","volume":"168","author":"Miller","year":"1993","journal-title":"J. Infect. Dis."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1374","DOI":"10.1086\/516354","article-title":"An outbreak of Pontiac fever among children following use of a whirlpool","volume":"26","author":"Vinther","year":"1998","journal-title":"Clin. Infect. Dis."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1289","DOI":"10.1086\/324211","article-title":"Pontiac fever due to Legionella micdadei from a whirlpool spa: Possible role of bacterial endotoxin","volume":"184","author":"Fields","year":"2001","journal-title":"J. Infect. Dis."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1017\/S0950268801005313","article-title":"Whirlpool associated outbreak of Pontiac fever at a hotel in Northern Sweden","volume":"126","author":"Tegnell","year":"2001","journal-title":"Epidemiol. Infect."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"18934","DOI":"10.2807\/ese.13.30.18934-en","article-title":"Pontiac fever outbreak associated with a spa-pool, United Kingdom, April 2008","volume":"13","author":"Modi","year":"2008","journal-title":"Euro Surveill."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"596","DOI":"10.7326\/0003-4819-107-4-596_1","article-title":"Legionnaires\u2019 disease and whirlpool-spa","volume":"107","author":"Vogt","year":"1987","journal-title":"Ann. Intern. Med."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1016\/S0140-6736(05)78145-9","article-title":"Legionnaire\u2019s disease and saunas","volume":"351","author":"Yzerman","year":"1998","journal-title":"Lancet"},{"key":"ref_48","first-page":"601","article-title":"An outbreak of Legionnaire\u2019s disease associated with a Japanese spa","volume":"37","author":"Nakadate","year":"1999","journal-title":"Nihon Kokyuki Gakkai Zasshi"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"806","DOI":"10.2169\/internalmedicine.42.806","article-title":"A large outbreak of Legionnaires\u2019 disease due to an inadequate circulating and filtration system for bath water, epidemiologic manifestations","volume":"42","author":"Nakamura","year":"2003","journal-title":"Intern. Med."},{"key":"ref_50","first-page":"325","article-title":"A major outbreak of Legionnaire\u2019s disease due to a public bathhouse, clinical examination","volume":"41","author":"Nakamura","year":"2003","journal-title":"Nihon Kokyuki Gakkai Zasshi"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"173","DOI":"10.11150\/kansenshogakuzasshi1970.81.173","article-title":"Largest outbreak of legionellosis associated with spa baths, comparison of diagnostic tests","volume":"81","author":"Kawano","year":"2007","journal-title":"Kansenshogaku Zasshi"},{"key":"ref_52","first-page":"75","article-title":"An outbreak of Legionnaires\u2019 disease associated with a circulating bath water system at a public bathhouse","volume":"42","author":"Matsumoto","year":"2004","journal-title":"Nihon Kokyuki Gakkai Zasshi"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1007\/s10156-008-0591-6","article-title":"An outbreak of Legionnaires\u2019 disease associated with a circulating bathwater system at a public bathhouse. II: Radiological findings of pneumonia","volume":"14","author":"Matsumoto","year":"2008","journal-title":"J. Infect. Chemother."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"365","DOI":"10.11150\/kansenshogakuzasshi1970.79.365","article-title":"The largest outbreak of legionellosis in Japan associated with spa baths, epidemic curve and environmental investigation","volume":"79","author":"Okada","year":"2005","journal-title":"Kansenshogaku Zasshi"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1007\/s10156-008-0592-5","article-title":"An outbreak of Legionnaires\u2019 disease associated with a circulating bathwater system at a public bathhouse. I: A clinical analysis","volume":"14","author":"Sasaki","year":"2008","journal-title":"J. Infect. Chemother."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"19602","DOI":"10.2807\/ese.15.26.19602-en","article-title":"Cluster of Legionnaires\u2019 disease associated with a public whirlpool spa, France, April\u2013May 2010","volume":"15","author":"Campese","year":"2010","journal-title":"Euro Surveill."},{"key":"ref_57","first-page":"1556","article-title":"Genomic investigation of a Legionellosis outbreak in a persistently colonized hotel","volume":"6","author":"Guiral","year":"2016","journal-title":"Front. Microbiol."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"349","DOI":"10.3201\/eid2302.161012","article-title":"Outbreak of Legionnaire\u2019s Disease caused by Legionella pneumophila serogroups 1 and 13","volume":"23","author":"Kuroki","year":"2017","journal-title":"Emerg. Infect. Dis."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"479","DOI":"10.1136\/jcp.43.6.479","article-title":"Microbiological investigations into an outbreak of Pontiac fever due to Legionella micdadei associated with use of a whirlpool","volume":"43","author":"Fallon","year":"1990","journal-title":"J. Clin. Pathol."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"2597","DOI":"10.1001\/archinte.1993.00410220113013","article-title":"Hot tub legionellosis. Legionnaires\u2019 Disease and Pontiac Fever after a point-source exposure to Legionella pneumophila","volume":"153","author":"Thomas","year":"1993","journal-title":"Arch. Intern. Med."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1086\/338060","article-title":"An outbreak of travel-associated Legionnaires disease and Pontiac fever, the need for enhanced surveillance of travel-associated legionellosis in the United States","volume":"185","author":"Benin","year":"2002","journal-title":"J. Infect. Dis."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"173","DOI":"10.2310\/7060.2005.12401","article-title":"Outbreak of travel-related Pontiac fever among hotel guests illustrating the need for better diagnostic tests","volume":"12","author":"Huhn","year":"2005","journal-title":"J. Travel Med."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1086\/510387","article-title":"Legionellosis outbreak investigation team. A large, travel-associated outbreak of legionellosis among hotel guests, utility of the urine antigen assay in confirming Pontiac fever","volume":"44","author":"Burnsed","year":"2007","journal-title":"Clin. Infect. Dis."},{"key":"ref_64","first-page":"E060921.2","article-title":"Outbreak of legionellosis associated with a spa pool, United Kingdom","volume":"11","author":"Foster","year":"2006","journal-title":"Euro Surveill."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"910","DOI":"10.3109\/00365548.2010.509331","article-title":"Legionnaires\u2019 disease and Pontiac fever after using a private outdoor whirlpool spa","volume":"42","author":"Euser","year":"2010","journal-title":"Scand. J. Infect. Dis."},{"key":"ref_66","unstructured":"Josef, C.A., Lee, J., van Wijngaarden, J., Draser, V., and Castellanis Pastoris, M. (2018, July 09). European Guidelines for Control and Prevention of Travel Associated Legionnaires\u2019 Disease. Available online: http:\/\/www.legionellaonline.it\/linee-guidaEWGLI_gen2005.pdf."},{"key":"ref_67","unstructured":"WHO (2007). Legionella and the Prevention of Legionellosis, WHO. Available online: http:\/\/www.who.int\/water_sanitation_health\/emerging\/legionella.pdf."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"1228","DOI":"10.1111\/j.1539-6924.2012.01909.x","article-title":"Quantitative risk estimation for a Legionella pneumophila infection due to whirlpool use","volume":"33","author":"Bouwknegt","year":"2013","journal-title":"Risk Anal."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.yrtph.2012.11.003","article-title":"Assessing the risk of Legionnaires\u2019 disease: The inhalation exposure model and the estimated risk in residential bathrooms","volume":"65","author":"Azuma","year":"2013","journal-title":"Regul. Toxicol. Pharmacol."},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"1034","DOI":"10.2105\/AJPH.81.8.1034","article-title":"The health hazards of saunas and spas and how to minimize them","volume":"81","author":"Press","year":"1991","journal-title":"Am. J. Public Health"},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"20271","DOI":"10.2807\/ese.17.37.20271-en","article-title":"An outbreak of Legionnaires\u2019 disease associated with a display spa pool in retail premises, Stoke-on-Trent, United Kingdom, July 2012","volume":"17","author":"Coetzee","year":"2012","journal-title":"Euro Surveill."},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"37","DOI":"10.3201\/eid0801.010176","article-title":"A large outbreak of Legionnaires\u2019 disease at a flower show, the Netherland, 1999","volume":"8","author":"Yzerman","year":"2002","journal-title":"Emerg. Infect. Dis."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/15\/8\/1612\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T15:15:19Z","timestamp":1760195719000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/15\/8\/1612"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,7,30]]},"references-count":72,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2018,8]]}},"alternative-id":["ijerph15081612"],"URL":"https:\/\/doi.org\/10.3390\/ijerph15081612","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2018,7,30]]}}}