title: Legionnaires' Disease in Hotels and Passenger Ships: A Systematic Review of Evidence, Sources, and Contributing Factors.
abstract: BACKGROUND
  Travel-associated Legionnaires' disease (LD) is a serious problem, and hundreds of cases are reported every year among travelers who stayed at hotels, despite the efforts of international and governmental authorities and hotel operators to prevent additional cases.
  
  
  METHODS
  A systematic review of travel-associated LD events (cases, clusters, outbreaks) and of environmental studies of Legionella contamination in accommodation sites was conducted. Two databases were searched (PubMed and EMBASE). Data were extracted from 50 peer-reviewed articles that provided microbiological and epidemiological evidence for linking the accommodation sites with LD. The strength of evidence was classified as strong, possible, and probable.
  
  
  RESULTS
  Three of the 21 hotel-associated events identified and four of nine ship-associated events occurred repeatedly on the same site. Of 197 hotel-associated cases, 158 (80.2%) were linked to hotel cooling towers and/or potable water systems. Ship-associated cases were most commonly linked to hot tubs (59/83, 71.1%). Common contributing factors included inadequate disinfection, maintenance, and monitoring; water stagnation; poor temperature control; and poor ventilation. Across all 30 events, Legionella concentrations in suspected water sources were >10,000 cfu/L, <10,000 cfu/L, and unknown in 11, 3, and 13 events, respectively. In five events, Legionella was not detected only after repeated disinfections. In environmental studies, Legionella was detected in 81.1% of ferries (23/28) and 48.9% of hotels (587/1,200), while all 12 cruise ships examined were negative.
  
  
  CONCLUSIONS
  This review highlights the need for LD awareness strategies targeting operators of accommodation sites. Increased standardization of LD investigation and reporting, and more rigorous follow-up of LD events, would help generate stronger, more comparable evidence on LD sources, contributing factors, and control measure effectiveness.
authors.affiliation: Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece.
authors.forename: Varvara A
authors.initials: VA
authors.lastname: Mouchtouri
authors.affiliation: Communicable Diseases Policy Research Group, London School of Hygiene & Tropical Medicine, Bangkok Office, Mahidol University, Bangkok, Thailand.
authors.forename: James W
authors.initials: JW
authors.lastname: Rudge
mesh_terms: D004196:Disease Outbreaks / Q000517:prevention & control / Q000706:statistics & numerical data*; D006801:Humans; D016952:Legionella pneumophila / Q000302:isolation & purification*; D007877:Legionnaires' Disease / Q000175:diagnosis / Q000453:epidemiology*; D012307:Risk Factors; D012767:Ships; D014195:Travel / Q000706:statistics & numerical data*