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

YearCityVenueSourceCasesDeathsFatality rateNotes
1965Washington, D.C., United StatesSt. Elizabeths HospitalUnknown941617%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

YearCityVenueSourceCasesDeathsFatality rateNotes
1973,1977Benidorm, SpainHotel Rio ParkShower pipesat least 44unknownThe 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]
1976Philadelphia, Pennsylvania, United States1976 Philadelphia Legionnaires' disease outbreakAir conditioning2213415.4%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]
1978Memphis, Tennessee, United StatesBaptist Memorial Hospital-Memphis (1912–2000)air-conditioning cooling tower441978 Memphis Legionnaire's Disease Outbreak
1979Melbourne, Australialight industrial buildingmedium-sized evaporative condenser[10]
1979Ballarat, Australiapsychiatric hospitalshower water system[10]

1980s

YearCityVenueSourceCasesDeathsFatality rateNotes
1985Wollongong, Australiasocial club buildingsmall cooling tower[10]
1985Stafford, EnglandStafford District HospitalAir conditioning1752816%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, Australiacommunitysmall cooling tower at hospital[10]
1987Wollongong, Australiashopping centresmall cooling tower at a shop[10]
1988Adelaide, Australiacommunitypotting mixes[10]
1989Sydney, Australiabowling clubsmall cooling tower[10]
1989Burnie, Australiacommunitysmall cooling tower at hospital[10]

1990s

YearCityVenueSourceCasesDeathsFatality rateNotes
1992Sydney, Australiashopping centresmall cooling tower[10]
1994Sunshine Coast, Australiaholiday apartment unitprivate spa pool[10]
1995Sydney, Australiashopping centresmall cooling tower at hospital[10]
1999Bovenkarspel, Netherlands1999 Bovenkarspel legionellosis outbreakHot tub3183210%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

YearCityVenueSourceCasesDeathsFatality rateNotes
2000Melbourne, AustraliaSea Life Melbourne AquariumCooling tower12543.2%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]
2000Vizela, PortugalPublic squareDecorative fountain1100%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.[16] Investigators traced the source of the outbreak to a decorative fountain located in the square.[17]
2001Murcia, SpainHospitalCooling Towers[18] 800+60.8%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%.[18]
2002Barrow-in-Furness, England2002 Barrow-in-Furness legionellosis outbreakAir conditioning17274.1%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.
2003-2004Pas-de-Calais, FrancePetrochemical plantCooling tower861820.93%This was the worst outbreak of Legionnaires in French history.[20][21]
2004Zaragoza, SpainHospitalCooling tower27726%Five out of seven of the fatalities were above the age of 50.[20]
2005Toronto, CanadaSeven Oaks Home for the AgedCooling tower1272116.5%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]
2005Fredrikstad, NorwayFactoryAir scrubber103109.7%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]
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 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]

2008New Brunswick, New Jersey, United StatesSaint Peter's University HospitalDrinking water6233.3%Chlorination in the water system had dropped below effective levels.[26]

2010s

YearCityVenueSourceCasesDeathsFatality rateNotes
2010WalesSouth Wales ValleysLikely cooling towers2229%Thought to be cooling towers in local industry.[27]
2011Dayton, Ohio, United StatesDaytonHospital air conditioning11545%Was the largest outbreak in Ohio since 1994 at the time.[20]
2012Québec City, CanadaLower Québec CityPossibly cooling towers180137.22%180 confirmed cases as of September 14, 2012, probably due to contaminated water in industrial cooling towers.[28]
2012Calp, SpainAR Diamante Beach HotelPlumbing system18317%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, ScotlandSouth west of EdinburghPossibly cooling towers9243%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 StatesJW Marriott HotelDecorative Lobby Fountain10330%8 confirmed cases with people who stayed at the JW Marriott Chicago during July–August 2012.[31]
2012Auckland, New ZealandUnknownWater Source and/or Air Conditioning1119%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, FentonHot tub1915.2%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 Hospitalunknown22627%2012 Pittsburgh legionellosis outbreak[34][35][36]
2014Portugal2014 Legionella outbreak in PortugalCooling tower[37]375123.2%A widespread outbreak in Vila Franca de Xira district, Portugal.[38]
2015Bronx, New York, United StatesCo-op City, South Bronx, and Morris ParkAll Cooling Towers in the Bronx area such Co-op City, Lincoln Hospital, and Concourse Plaza.140139.3%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 to 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.
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.
2015Quincy, Illinois, United StatesVeterans homeUnknown581327.7%The outbreak investigation is ongoing[47][48][49]
2014–2016Flint, Genesee County, Michigan, United StatesCountywideMcLaren Regional Medical Center871213.8%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
2016 Sydney, Australia Sydney Town Hall Suspected cooling tower at least 4 0 [52]
2016 Hopkins, Minnesota, United States Citrus Systems, Inc. Cooling tower 23 1 4.3% Confirmed by Minnesota Department of Health. 23 people became sick, 17 were hospitalized, and one person died.[53]
2017 Manhattan, New York, United States Lenox Hill TBD 7 1 14.3% [54]
2017 Las Vegas, Nevada, United States Rio Hotel and Casino Water system 2[54] 0 0
2017 Round Rock, Texas, United States SpringHill Suites hotel Swimming pool and hot tub 6[55][56] 0 0
2017 Anaheim, California, United States Disneyland Cooling towers 22 1 4.5% [57]
2017 Lisbon, Portugal São Francisco Xavier Hospital Cooling tower[58] 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.[59] The investigation traced the source of the infection to a cooling tower in the hospital.[60][61]
2018 Bloomsbury, London University College London Water cooler 1 0
2018 Washington Heights, New York, United States The Sugar Hill Project (Building)[62][63] Cooling towers[64][65][62][63] 27[66][65] 1[65] 3.7%
2019 Westminster, London, England Dolphin Square Water System 3 0 0% 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.
2019 Evergem, Belgium Ghent/Evergem Port[68] Stora Enso[69] Cooling Towers[68] 32[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.[68][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]
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 Vernon Hills, Illinois,

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.[75]

Number Of Legionnaires Cases Rises To Five At Brookdale Vernon Hills Senior Living Facility.[76]

2020 Vila do Conde, Póvoa do Varzim, Matosinhos, Porto District,

Portugal

 Multiple locations Under investigation 88 15 17% 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]
2022 San Miguel de Tucumán, Tucumán Province,

Argentina

 Health clinic Under investigation 22 6 45% 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]
2023 Rzeszów, Subcarpathian Voivodeship,

Poland

 Multiple locations Under investigation 164 41 25% Ongoing outbreak. The source of the bacteria is suspected to be contaminated water sources.[79]

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.[80] 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.[81]

The City of Garland, Texas, United States requires yearly testing for legionella bacteria at cooling towers at apartment buildings.[82]

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.[83]

The Texas Department of State Health Services has provided guidelines for hospitals to detect and prevent the spread of nosocomial infection due to legionella.[84] The European Working Group for Legionella Infections (EWGLI)[85] 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[86] 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 countLegionellaAction required
10,000 or less1,000 or lessSystem 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 100,000more than 10,000Implement 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.[87] Additional studies indicate ionization is superior to thermal eradication.[88]

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.[89]

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."[90]

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.[91]

Temperature affects the survival of Legionella as follows:[92]

  • 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.[93]

See also

References

  1. ↑ Ryan KJ, Ray CG (editors) (2004). Sherris Medical Microbiology (4th ed.). McGraw Hill. ISBN 0-8385-8529-9. {{cite book}}: |author= has generic name (help)
  2. ↑ Swanson M, Heuner K (2008). Legionella: Molecular Microbiology. Caister Academic Pr. ISBN 978-1-904455-26-4.
  3. ↑ Altman LK (August 1, 2006). "In Philadelphia 30 Years Ago, an Eruption of Illness and Fear". The New York Times.
  4. ↑ "Legionella Outbreak Toolbox". legionnaires.ecdc.europa.eu. Retrieved 2020-07-01.
  5. ↑ B. D. Colen (1977-01-31). "'Legion Fever' Germ Killed 16 Here in 1965". Washington Post. Retrieved 16 December 2021.
  6. ↑ "Timeline: legionnaires' disease outbreaks in Britain". The Daily Telegraph. 2012-06-06. Retrieved 31 July 2015.
  7. ↑ McDade JE, Brenner DJ, Bozeman FM (April 1979). "Legionnaires' disease bacterium isolated in 1947". Annals of Internal Medicine. 90 (4): 659–61. doi:10.7326/0003-4819-90-4-659. PMID 373548.
  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 (December 1977). "Legionnaires' disease: description of an epidemic of pneumonia". New England Journal of Medicine. 297 (22): 1189–97. doi:10.1056/NEJM197712012972201. PMID 335244.
  9. ↑ Tsai TF, Finn DR, Plikaytis BD, McCauley W, Martin SM, Fraser DW (April 1979). "Legionnaires' disease: clinical features of the epidemic in Philadelphia". Annals of Internal Medicine. 90 (4): 509–17. doi:10.7326/0003-4819-90-4-509. PMID 434627.
  10. 1 2 3 4 5 6 7 8 9 10 11 Broadbent C (1996). Guidance for the Control of Legionella. National Environmental Health Forum Monographs. ISBN 978-0-642-25247-0.
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  16. 1 2 Vizela já enfrentou a legionella em Agosto de 2000 com 11 infectados [Vizela already faced legionella in August 2000, with 11 cases] (in Portuguese). Porto Canal. 13 November 2014. Retrieved 5 March 2019.
  17. 1 2 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. doi:10.2807/esm.06.07.00228-en. PMID 12631957.
  18. 1 2 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 (August 2003). "Legionnaires' disease outbreak in Murcia, Spain". Emerging Infectious Diseases. 9 (8): 915–21. doi:10.3201/eid0908.030337. PMC 3020623. PMID 12967487.
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  24. ↑ www.ideo.pl, Ideo Sp. z o.o. -. "Legionellosis case in Jastrzębie-Zdrój will be included in subject literature | News | Science & Scholarship in Poland". scienceinpoland.pap.pl. Retrieved 2017-08-02.
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  34. ↑ Pittsburgh Veteran's Administration Hospital water contamination investigation ongoing
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  40. ↑ "Legionnaires' Disease Bacteria Found in A/C on Bronx Hospital, Mayor says". DNAinfo New York. Archived from the original on 2015-08-01.
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  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. ↑ "Town Hall area cooling tower suspected after four men contract Legionnaires disease". The Sydney Morning Herald. 2016-03-09. Retrieved 2016-03-10.
  53. ↑ Thiede, Data (2016-10-12). "Source of Legionnaires' outbreak in Hopkins ID'd". Kare 11. Retrieved 2023-05-24.
  54. 1 2 Nir SM (2017-06-16). "Legionnaires' Outbreak on Upper East Side Kills One and Sickens Six". The New York Times. ISSN 0362-4331. Retrieved 2017-06-17.
  55. ↑ Austin, CBS. "Sixth case of Legionnaires' disease confirmed at Round Rock hotel". KEYE. Retrieved 2017-10-10.
  56. ↑ Osborn C (2017-10-10). "Sixth case of Legionnaires' disease confirmed from Round Rock hotel". Austin American-Statesman. Retrieved 2017-10-10.
  57. ↑ Perez M (November 11, 2017). "Disneyland shuts down two cooling towers after Legionnaires' disease outbreak". Newsweek. Retrieved November 11, 2017.
  58. ↑ "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]. Jornal de Negócios (in Portuguese). November 16, 2017. Retrieved November 24, 2017.
  59. ↑ "Comunicado — 03/12/2017" [Communiqué — 3 December 2017]. Direção-Geral da Saúde (in Portuguese). 3 December 2017. Retrieved 5 March 2019.
  60. ↑ 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.
  61. ↑ 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.
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