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Assessing the environmental health relevance of cooling towers--a systematic review of legionellosis outbreaks.
[legionellosis]
Bioaerosols
from
cooling
towers
are
often
suspected
to
cause
community-acquired
legionellosis
outbreaks
.
Although
Legionella
infections
can
mostly
be
assigned
to
the
emission
sources
,
uncertainty
exists
about
the
release
and
distribution
into
the
air
,
the
occurrence
of
the
respirable
virulent
form
and
the
level
of
the
infective
concentration
.
Our
study
aimed
to
evaluate
studies
on
legionellosis
outbreaks
attributed
to
cooling
towers
published
within
the
last
11
years
by
means
of
a
systematic
review
of
the
literature
.
19
legionellosis
outbreaks
were
identified
affecting
12
countries
.
Recurring
events
were
observed
in
Spain
and
Great
Britain
.
In
total
,
1609
confirmed
cases
of
legionellosis
and
a
case-fatality
rate
of
approximately
6
%
were
reported
.
Duration
of
outbreaks
was
65
days
on
average
.
For
diagnosis
the
urinary
antigen
test
was
mainly
used
.
Age
,
smoking
,
male
sex
and
underlying
diseases
(
diabetes
,
immunodeficiency
)
could
be
confirmed
as
risk
factors
.
Smoking
and
underlying
diseases
were
the
most
frequent
risk
factors
associated
with
legionellosis
in
11
and
10
of
the
19
studies
,
respectively
.
The
meteorological
conditions
varied
strongly
.
Several
studies
reported
a
temporal
association
of
outbreaks
with
inadequate
maintenance
of
the
cooling
systems
.
A
match
of
clinical
and
environmental
isolates
by
serotyping
and
/
or
molecular
subtyping
could
be
confirmed
in
84
%
of
outbreaks
.
Legionella-contaminated
cooling
towers
as
environmental
trigger
,
in
particular
in
the
neighbourhood
of
susceptible
individuals
,
can
cause
severe
health
problems
and
even
death
.
To
prevent
and
control
Legionella
contamination
of
cooling
towers
,
maintenance
actions
should
focus
on
low
-emission
cleaning
procedures
of
cooling
towers
combined
with
control
measurements
of
water
and
air
samples
.
Procedures
allowing
rapid
detection
and
risk
assessment
in
the
case
of
outbreaks
are
essential
for
adequate
public
health
measures
.
Systematic
registration
of
cooling
towers
will
facilitate
the
identification
of
the
source
of
outbreaks
and
help
to
shorten
their
duration
.
Diseases
Validation
Diseases presenting
"urinary antigen test"
symptom
legionellosis
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