year 9, Issue 4 (Winter 2016)                   Iran J Med Microbiol 2016, 9(4): 1-15 | Back to browse issues page

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1- Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran , qanizadeh@yahoo.com
2- Health school, Baqiyatallah University of Medical Sciences, Tehran, Iran
3- Medicine Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
Abstract:   (13081 Views)

Background and Aims: Several studies were investigated legionella contamination in natural and man- made water resources. The aim of this research was systematically review of legionella water contamination in natural and man-made resources in Iran and foreign countries. Materials and methods: In this systematic review study, the required data was collected using suitable keywords through PubMed, Science direct, Springer link, Google scholar, SID, Iranmedex, Irandoc and Magiran databases.

Background and Aim: Several studies were investigated legionella contamination in natural and man- made water resources. The aim of this research was systematically review of legionella water contamination in natural and man-made resources.

Materials and Methods: In this systematic review study, the required data was collected using suitable keywords through PubMed, Science direct, Springer link, Google scholar, SID, Iranmedex, Irandoc and Magiran databases. The search was conducted without publication date limitation. Survey and selection of articles was conducted based on PRISMA checklist and Cochrane quality assessment standards. Out of 1386 articles, 56 articles were considered after excluding the remaining articles which were not related to the study objectives. Identification and isolation of legionella with PCR technique and culture in BCYE is one of the article selection criteria. The relevant data were classified in extracted table and analyzed manually. Excel 2007 software was used for to draw diagrams. Due to heterogeneity of data meta-analysis could not be conducted.      

Results: Out of 56 articles, 9 and 47 articles were published in Iran and foreign countries respectively. In Iran, 5.7-70% of samples were contaminated. In Iran’s hospitals 2.85-41.75% of samples were contaminated by Legionella pneumophila. In foreign countries, 0-100% of samples were contaminated and in these countries’ hospitals Legionella pneumophila contamination was 17%-98.7%.

Conclusion: Although in Iran legionella water contamination is lower than foreign countries but, based on WHO guideline (1CFU/L) for legionella, planning for control of this bacteria and relevance infectious is one of the health priorities.  

The search was conducted without publication date limitation. Survey and selection of articles was conducted based on PRISMA checklist and Cochrane quality assessment standards. Out of 1386 articles, 56 articles were considered after excluding the remaining articles which were not related to the study objectives. Identification and isolation of legionella with PCR technique and culture in BCYE is one of the article selection criteria. The relevant data were classified in extracted table and analyzed manually. Excel 2007 software was used for to draw diagrams. Due to heterogeneity of data meta-analysis could not be conducted. Results: Out of 56 articles, 9 and 47 articles were published in Iran and foreign countries respectively. In Iran, 5.7 - 70% of samples were contaminated. In Iran’s hospitals 2.85-41. 75% of samples were contaminated by Legionella pneumophila. In foreign countries, 0-100% of samples were contaminated and in these countries’ hospitals Legionella pneumophila contamination was 17%-98. 7%.

Conclusion: The results of this study revealed that the conventional water treatment processes were not effective for legionella elimination and eradication of this agent should be considered in point off-use with effective techniques.

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Type of Study: Review Article | Subject: Medical Bacteriology
Received: 2014/05/27 | Accepted: 2015/09/14 | ePublished: 2016/02/26

References
1. Jalila T, Benchekroun MN, Ennaji MM, Mekkour M, Cohen N. Nosocomial Legionnaires’ disease: Risque and prevention. Int J Environ Sci Res. 2012;1(3):72-85. 2. Muder RR, Yu VL. Infection due to legionella species other than L. pneumophila. Clin Infect Dis. 2002;35(8):990-998. 3. Lo Presti F, Riffard S, Meugnier H, Reyrolle M, Lasne Y, Grimont PAD, et al. Legionella gresilensis sp. nov. and Legionella beliardensis sp. nov. Isolated from water in France. Int J Syst Evol Microbiol.. 2001;51(6): 1949–1957. 4. Allegra S, Grattard F, Girardot F, Riffard S, Pozzetto B, Berthelot P. Longitudinal evaluation of the efficacy of heat treatment procedures against Legionella spp. in hospital water systems by using a flow cytometric assay. Appl Environ Microbiol. 2011;77(4):1268-1275. 5. Fuchslin HP, Kotzsch S, Keserue HA, Egli T. Rapid and quantitative detection of Legionella pneumophila applying immunomagnetic separation and flow cytometry. Cytometry A. 2010;77(3):264-274. 6. Blyth CC, Adams DN, Chen SCA. Diagnostic and typing methods for investigating Legionella infection. N S W Public Health Bull. 2009;20(9-10);157-161. 7. Newton HJ, Ang DK, van Driel IR, Hartland EL. Molecular pathogenesis of infections caused by Legionella pneumophila. Clin Microbiol Rev. 2010;23(2):274-298. 8. Kojicic M, Li G, Gajic O. Acute respiratory distress syndrome in patients with Legionella pneumonia. Acta Med Acad. 2011;40(1):39-44. 9. Diederen BM. Legionella spp. and Legionnaires' disease. Infection. 2008;56(1):1-12. 10. Gaia V, Casatia S, Tonolla M. Rapid identification of Legionella spp. by MALDI-TOF MS based protein mass fingerprinting. Syst Appl Microbiol. 2011;34(1):40-44. 11. Waterer GW, Baselski VS, Wunderink RG. Legionella and community-acquired pneumonia: a review of current diagnostic tests from a clinician's viewpoint. Am J Med. 2001;110(1):41-48. 12. Huang SW, Hsu BM, Wu SF, Fan CW, Shih FC, Lin YC, et al. Water quality parameters associated with prevalence of Legionella in hot spring facility water bodies. Water Res. 2010;44(16):4805-4811. 13. Merault N, Rusniok C, Jarraud S, Gomez-Valero L, Cazalet C, Marin M, et al. Specific real-time PCR for simultaneous detection and identification of Legionella pneumophila serogroup 1 in water and clinical samples. Appl Environ Microbiol. 2011;77(5):1708–1717. 14. Bargellini A, Marchesi I, Righi E, Ferrari A, Cencetti S, Borella P, et al. Parameters predictive of Legionella contamination in hot water systems: Association with trace elements and heterotrophic plate counts. Water Res. 2011;45(6):2315-2321. 15. Declerck P, Behets J, Margineanu A, van Hoef V, De Keersmaecker B, Ollevier F. Replication of Legionella pneumophila in biofilms of water distribution pipes. Microbiol Res. 2009;164(6): 593-603. 16. Lau HY, Ashbolt NJ. The role of biofilms and protozoa in Legionella pathogenesis: implications for drinking water. J Appl Microbiol. 2009;107(2):368-378. 17. Cheng VC, Wong SS, Chen JH, Chan JF, To KK, Poon RW, et al. An unprecedented outbreak investigation for nosocomial and community-acquired legionellosis in Hong Kong. Chin Med J (Engl). 2012;125(23):4283-4290. 18. Ozerol IH, Bayraktar M, Cizmeci Z, Durmaz R, Akbas E, Yildirim Z, et al. Legionnaire’s disease: a nosocomial outbreak in Turkey. J Hosp Infect. 2006;62(1):50-57. 19. Fields BS, Benson RF, Besser RE. Legionella and Legionnaires’ Disease: 25 Years of Investigation. Clin Microbiol Rev. 2002;15(3): 506–526. 20. Carratala J, Garcia-Vida C. An update on Legionella. Curr Opin Infect Dis. 2010; 23(2):152–157. 21. Darby J, Buising K. Could it be Legionella? Aust Fam Physician. 2008;37(10):812-815. 22. Nazarian EJ, Bopp DJ, Saylors A, Limberger RJ, Musser KA. Design and implementation of a protocol for the detection of Legionella in clinical and environmental samples. Diagn Microbiol Infect Dis. 2008;62(2):125–132. 23. Allen JG, Myatt TA, MacIntosh DL, Ludwig JF, Minegishi T, Stewart JH, et al. Assessing risk of health care-acquired Legionnaires’ disease from environmental sampling: The limits of using a strict percent positivity approach. Am J Infec Cont. 2012;40(10):917-921. 24. Kim BR, Anderson JE, Mueller SA, Gaines WA, Kendall AM. Literature review--efficacy of various disinfectants against Legionella in water systems. Water Res. 2002;36(18):4433-4444. 25. Zhang Z, McCann C, Hanrahan J, Jencson A, Joyce D, Fyffe S, et al. Legionella control by chlorine dioxide in hospital water systems. J Am WWA. 2009;101(5): 117-127. 26. Campese C, Bitar D, Jarraud S, Maine C, Forey F, Etienne J, et al. Progress in the surveillance and control of Legionella infection in France, 1998-2008. Int J Infect Dis. 2010;15(1):30-37. 27. Szymansaka J. Risk of exposur to Legionella in dental practice. Ann Agric Environ Med. 2004; 11(1): 9-12. 28. Kumpers P, Tiede A, Kirschner P, Girke J, Ganser A, Peest D. Legionnaires' disease in immunocompromised patients: a case report of Legionella longbeachae pneumonia and review of the literature. J Med Microbiol. 2008;57(3): 384-387. 29. Jespersen S, Sogaard OS, Schonheyder HC, Fine MJ, Ostergaard L. Clinical features and predictors of mortality in admitted patients with community- and hospital-acquired legionellosis: a Danish historical cohort study. BMC Infect Dis. 2010;10(124):1-12. 30. Daumas A, El-Mekaou F, Bataille S, Daniel L, Caporossi JM, Fournier PE, et al. Acute tubulointerstitial nephritis complicating Legionnaires’ disease. J Med Case Rep. 2012;6(100):1-6. 31. Lai CC, Tan CK, Chou CH, Hsu HL, Huang YT, Liao CH, et al. Hospital-acquired pneumonia and bacteremia caused by Legionella pneumophila in an immunocompromised patient. Infection. 2010;38(2):135-137. 32. Azuma K, Uchiyama I, Okumura J. Assessing the risk of Legionnaires’ disease: The inhalation exposure model and the estimated risk in residential bathrooms. Regul Toxicol Pharmacol. 2013;65(1):1-6. 33. Tai J, Benchekroun MN, Mekkour M, Ennaji MM, Nader H, Cohen N. Investigation of Legionella Pneumophila in Hot Water Systems in Morocco. Int J Sci Technol. 2012; 1(10):524-530. 34. Stojek NM, Szymanska J, Dutkiewicz J. Gram-negative bacteria in water distribution systems of hospitals. Ann Agric Environ Med. 2008;15(1):135–142. 35. WHO. Legionella and the prevention of legionellosis. Bartram J, Chartier Y, Lee JV, Pond K, Lee SS. editors. 2007. 36. O'Neill E, Humphreys H. Surveillance of hospital water and primary prevention of nosocomial legionellosis: what is the evidence? J Hosp Infect. 2005;59(4): 273–279. 37. Guyard C, Low DE. Legionella infections and travel associated legionellosis. Travel Med Infect Dis. 2011;9(4):176-186. 38. Hoffman P, Friedman H, Bendinelli M, . Legionella pneumophila: Pathogenesis and Immunity. New York . Springer Science & Business Media. 2010. 39. Higgins J, Steering CC. A new infrastructure for Cochrane Methods. Cochrane Methods. 2010:2. 40. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009:151(4); 264-269. 41. Ghotaslou R, Yeganeh Sefidan F, Akhi MT, Soroush MH, Hejazi MS. Detection of legionella contamination in tabriz hospitals by PCR assay. Adv Pharm Bull. 2013; 3(1):131-134. 42. Moghadam J, Ahmadi M, Honarmand H, Meshginshahr SA, Tehrani BS, Nojavan M. Frequency of Legionella Pneumophila in Tap Water and Water of Infant Incubators in Guilan Hospitals, Iran. J Mazandaran Univ Med Sci. 2013; 23(98):312-321. 43. Baghal Asghari F, Nikaeen M, Hatamzadeh M, Vahid Dastjerdi M, Hassanzadeh A. Detection of Legionella Spp. in Water from Cooling Towers. J Isfahan Med School. 2012; 30(195): 891-902.(persian). 44. Eslami A, Momayyezi MH, Esmaili D, Joshani GH. Presence of Legionella Pneumophila and environmental factors affecting its growth, in the water distribution system in Taleghani hospital, Tehran. Pajoohandeh J. 2012; 17(1):32-37.(persian). 45. Motaharinia Y, Shapuri R, Rahnama M, Aliramaie MR, Rahmani MR , Rezaie MA. Isolation of legionella pneumophila from environment and water system samples and evaluation of immuno-protective efficiency of its whole killed cell in mice model. Sci J Kurd Uni Med Sci. 2010; 15(2): 70-78.( In Persian). 46. Mirhoseyni SH, Mohammadi M, Birjandi M, Hoseinzadegan H, Kamarei B, Jafari A, Moharari A, Survey of Khoramabad hospital water resources to Legionella pneumophila on 2008. 12th Environmental health congress. Shahid Beheshti University of medical sciences. 2009. 534-541. ( In Persian). 47. Mojtaba mobarez A, Hosseini doust SR, Esmaili D. Identification of legionella in hospital water networks and ventilation systems. Iran J Infec Dis Trop Med. 2007; 12(36): 33-37. ( In Persian). 48. Ahmadinejad M, Shakibaie MR, Shams K, Khalili M. Detection of Legionella pneumophila in cooling water systems of hospitals and nursing homes of Kerman city, Iran by semi-nested PCR. Int J Biol Life Sci. 2011; 7(2):70-73. 49. Khosroshahi N, Moosavian SM. Isolation and identification of Legionnaire’s disease agents from the medical equipments and environmental water sources. J Qazvin Univ Med Sci. 2004; 29(70):70-74.(Persian). 50. Tachibana M, Nakamoto M, Kimura Y, Shimizu T, Watarai M. Characterization of Legionella pneumophila isolated from environmental water and ashiyu foot spa. Biomed Res Int. 2013;514395:1-8. 51. Kao PM, Tung MC, Hsu BM, Chiu YC, She CY, Shen SM, et al. Identification and quantitative detection of Legionella spp. in various aquatic environments by real-time PCR assay. Environ Sci Pollut Res Int. 2013; 20(9):6128-6137. 52. Sydnor ER, Bova G, Gimburg A, Cosgrove SE, Perl TM, Maragakis LL. Electronic-eye faucets: Legionella species contamination in healthcare settings. Infect Control Hosp Epidemiol. 2012; 33(3):235-240. 53. Arvand M, Jungkind K, Hack A. Contamination of the cold water distribution system of health care facilities by Legionella pneumophila: do we know the true dimension? Euro Surveill. 2011;16(16):1-6. 54. Alli OT, Olusoga OD, Adedokun S, Ogundare O. Isolation of Legionella pneumophila from surface and ground waters in Osogbo, Nigeria. Afr J Microbiol Res. 2011;5(18):2779-2785. 55. Fragou K, Kokkinos P, Gogos C, Alamanos Y, Vantarakis A. Prevalence of Legionella spp. in water systems of hospitals and hotels in South Western Greece. Int J Environ Health Res. 2012; 22(4):340-354. 56. Ditommaso S, Giacomuzzi M, Gentile M, Zotti CM. Evaluation of the usefulness of a new direct immunofluorescence assay (ScanVIT-Legionella) for monitoring hospital water systems contaminated with Legionella spp. Lett Appl Microbiol. 2010;50(4):341-346. 57. Lee HK, Shim JI, Kim HE, Yu JY, Kang YH. Distribution of Legionella species from environmental water sources of public facilities and genetic diversity of L. pneumophila serogroup 1 in South Korea. Appl Environ Microbiol. 2010; 76(19):6547-6554. 58. Mouchtouri VA, Goutziana G, Kremastinou J, Hadjichristodoulou C. Legionella species colonization in cooling towers: risk factors and assessment of control measures. Am J Infect Control. 2010; 38(1):50-55. 59. Yong SF, Goh FN, Ngeow YF. Legionella species and serogroups in Malaysian water cooling towers: identification by latex agglutination and PCR-DNA sequencing of isolates. J Water Health. 2010; 8(1):92-100. 60. Bonetta S, Bonetta S, Ferretti E, Balocco F, Carraro E. Evaluation of Legionella pneumophila contamination in Italian hotel water systems by quantitative real-time PCR and culture methods. J Appl Microbiol. 2010; 108(5):1576-1583. 61. Aprea L, Cannova L, Firenze A, Bivona MS, Amodio E, Romano N. Can technical, functional and structural characteristics of dental units predict Legionella pneumophila and Pseudomonas aeruginosa contamination? J Oral Sci. 2010; 52(4):641-646. 62. Napoli C, Fasano F, Iatta R, Barbuti G, Cuna T, Montagna MT. Legionella spp. and legionellosis in southeastern Italy: disease epidemiology and environmental surveillance in community and health care facilities. BMC Public Health. 2010; 660(10):1-10. 63. Napoli C, Iatta R, Fasano F, Marsico T, Montagna MT. Variable bacterial load of Legionella spp. in a hospital water system. Sci Total Environ. 2009 20; 408(2):242-244. 64. Oberdorfer K, Mussigbrodt G, Wendt C. Genetic diversity of Legionella pneumophila in hospital water systems. Int J Hyg Environ Health. 2008; 211(1-2):172-178. 65. Morio F, Corvec S, Caroff N, Le Gallou F, Drugeon H, Reynaud A. Real-time PCR assay for the detection and quantification of Legionella pneumophila in environmental water samples: utility for daily practice. Int J Hyg Environ Health. 2008; 211(3-4):403-411. 66. Mathys W, Stanke J, Harmuth M, Junge-Mathys E. Occurrence of Legionella in hot water systems of single-family residences in suburbs of two German cities with special reference to solar and district heating. Int J Hyg Environ Health. 2008; 211(1-2):179-185. 67. Goutziana G, Mouchtouri VA, Karanika M, Kavagias A, Stathakis NE, Gourgoulianis K, et al. Legionella species colonization of water distribution systems, pools and air conditioning systems in cruise ships and ferries. BMC public health. 2008; 390(8):1-7. 68. Rivera JM, Aguilar L, Granizo JJ, Vos-Arenilla A, Gimenez MJ, Aguiar JM, et al. Isolation of Legionella species/serogroups from water cooling systems compared with potable water systems in Spanish healthcare facilities. J Hosp Infect. 2007; 67(4):360-366. 69. Mouchtouri V, Velonakis E, Tsakalof A, Kapoula C, Goutziana G, Vatopoulos A, et al. Risk factors for contamination of hotel water distribution systems by Legionella species. Appl Environ Microbiol. 2007; 73(5):1489-1492. 70. Mouchtouri V, Velonakis E, Hadjichristodoulou C. Thermal disinfection of hotels, hospitals, and athletic venues hot water distribution systems contaminated by Legionella species. Am J Infect Control. 2007; 35(9):623-627. 71. Stout JE, Muder RR, Mietzner S, Wagener MM, Perri MB, DeRoos K, et al. Role of environmental surveillance in determining the risk of hospital-acquired legionellosis: a national surveillance study with clinical correlations. Infect Control Hosp Epidemiol. 2007; 28(7):818-824. 72. Yaradou DF, Hallier-Soulier S, Moreau S, Poty F, Hillion Y, Reyrolle M, et al. Integrated real-time PCR for detection and monitoring of Legionella pneumophila in water systems. Appl Environ Microbiol. 2007; 73(5):1452-1456. 73. Erdogan H, Arslan H. Colonization of Legionella Species in Hotel Water System in Turkey. J Travel Med. 2007;14(6):369-373. 74. Veronesi L, Capobianco E, Affanni P, Pizzi S, Vitali P, Tanzi ML. Legionella contamination in the water system of hospital dental settings. Acta Biomed. 2007;78(2):117-122. 75. Hsu BM, Chen CH, Wan MT, Cheng HW. Legionella prevalence in hot spring recreation areas of Taiwan. Water Res. 2006; 40(17):3267-3273. 76. Joly P, Falconnet PA, Andre J, Weill N, Reyrolle M, Vandenesch F, et al. Quantitative real-time Legionella PCR for environmental water samples: data interpretation. Appl Environ Microbiol. 2006; 72(4):2801-2808. 77. Borella P, Montagna MT, Stampi S, Stancanelli G, Romano-Spica V, Triassi M, et al. Legionella Contamination in Hot Water of Italian Hotels. Appl Environ Microbiol. 2005; 71(10): 5805–5813. 78. Leoni E, De Luca G, Legnani PP, Sacchetti R, Stampi S, Zanetti F. Legionella waterline colonization: detection of Legionella species in domestic, hotel and hospital hot water systems. J Appl Microbiol. 2005; 98(2):373-379. 79. Hosein IK, Hill DW, Tan TY, Butchart EG, Wilson K, Finlay G, et al. Point-of-care controls for nosocomial legionellosis combined with chlorine dioxide potable water decontamination: a two-year survey at a Welsh teaching hospital. J Hosp Infect. 2005; 61(2):100-106. 80. Costa J, Tiago I, da Costa MS, Verissimo A. Presence and persistence of Legionella spp. in groundwater. Appl Environ Microbiol. 2005; 71(2):663-671. 81. Singh T, Coogan MM. Isolation of pathogenic Legionella species and legionella-laden amoebae in dental unit waterlines. J Hosp Infect. 2005; 61(3):257-262. 82. Borella P, Montagna MT, Romano-Spica V, Stampi S, Stancanelli G, Triassi M, et al. Legionella infection risk from domestic hot water. Emerg Infect Dis. 2004;10(3):457-464. 83. Doleans A, Aurell H, Reyrolle M, Lina G, Freney J, Vandenesch F, et al. Clinical and environmental distributions of Legionella strains in France are different. J Clinl Microbiol. 2004; 42(1):458-460. 84. H J, Wdowiak L, Puacz E, Stojek NM. Microbial quality of water in dental unit reservoirs. Ann Agric Environ Med . 2004;11(2):355-358. 85. Pedro-Botet ML, Stout JE, Yu VL. Legionnaires' disease contracted from patient homes: the coming of the third plague? Eur J Clin Microbiol Infect Dis. 2002; 21(10)699-705. 86. Stojek NM, Dutkiewicz J. Legionella in sprinkling water as a potential occupational risk factor for gardeners. Ann Agric Environ Med. 2002; 9(2):261-264. 87. Wellinghausen N, Frost C, Marre R. Detection of legionella in hospital water samples by quantitative real-time LightCycler PCR. Appl Environ Microbiol. 2001; 67(9):3985-3893. 88. Leoni E, Legnani PP, Bucci Sabattini MA, Righi F. Prevalence of Legionella spp. in swimming pool environment. Water Res. 2001;35(15):3749-3753. 89. Zanetti F, Stampi S, De Luca G, Fateh-Moghadam P, Antonietta M, Sabattini B, et al. Water characteristics associated with the occurrence of Legionella pneumophila in dental units. Euro J Oral Sci. 2000; 108(1):22-28. 90. Atlas RM, Williams JF, Huntington MK. Legionella contamination of dental-unit waters. Appl Environ Microbiol. 1995; 61(4):1208-1213. 91. Palmer CJ, Tsai YL, Paszko-Kolva C, Mayer C, Sangermano LR. Detection of Legionella species in sewage and ocean water by polymerase chain reaction, direct fluorescent-antibody, and plate culture methods. Appl Environ Microbiol. 1993; 59(11):3618-3624. 92. Stout JE, Yu VL, Yee YC, Vaccarello S, Diven W, Lee TC. Legionella pneumophila in residential water supplies: environmental surveillance with clinical assessment for Legionnaires' disease. Epidemiology and infection. 1992; 109(1):49-57. 93. Alary M, Joly JR. Risk factors for contamination of domestic hot water systems by legionellae. Appl Environ Microbiol. 1991; 57(8):2360-2367. 94. Hsu SC, Martin R, Wentworth BB. Isolation of Legionella species from drinking water. Appl Environ Microbiol. 1984; 48(4):830-832. 95. 9Plouffe JF, Webster LR, Hackman B. Relationship between colonization of hospital building with Legionella pneumophila and hot water temperatures. Appl Environ Microbiol. 1983; 46(3):769-770. 96. Edelstein PH. Comparative study of selective media for isolation of Legionella pneumophila from potable water. J Clin Microbiol. 1982; 16(4):697-699. 97. Edelstein PH. Nosocomial Legionnaires disease : a global perspective . J Hosp Infect . 1988;56:182-188. 98. Vickers RM, YU VL, Hanna SS, Muraca p, Diven W, Carmen N, Taylor FB. Determinants of Legionella pneumophila contamination of water distribution systems: 15- hospital prospective study. Infect Control .1987 ;(9): 357-363. 99. Persing DH, smith TF, Tenover FC, white TJ. Diagnostic molecular microbiology . principles and applications.5th ed . Washington. DC. American society for Microbiology. 1993; 342-345. 100. Ducret A, Chabalier M, Dukan S. Characterization and resuscitation of non-culturable cells of Legionella pneumophila. BMC Microbiol. 2014; 14 (3):1-6. 101. Blatny JM, Ho J, Skogan G, Fykse EM, Aarskaug T, Waagen V. Airborne Legionella bacteria from pulp waste treatment plant: aerosol particles characterized as aggregates and their potential hazard. Aerobiol. 2011; 27(2):147-162. 102. Bartie C, Venter SN, Nel LH. Identification methods for Legionella from environmental samples. Water Res. 2003; 37(6):1362-1370. 103. Mirmohammadlo A, Ghanizadeh G, Esmaeili D, Sepandi M, Avakh P. Legionelle pneumophila water contamination in three military hospitals of Tehran in 2013. J Kermanshah Uni Med Sci. 2014;18(7):398-408. 104. Darelid J, Lofgren S, Malmvall BE. Control of nosocomial Legionnaires disease by keeping the circulating hot water temperature above 55 degrees C: experience from a 10-year surveillance programme in a district general hospital. J Hosp Infect. 2002;50(3):213-219. 105. Serrano-Suarez A, Dellunde J, Salvado H, Cervero-Arago S, Mendez J, Canals O, et al. Microbial and physicochemical parameters associated with Legionella contamination in hot water recirculation systems. Environ Sci Pollut Res Int. 2013;20(8):5534-44. 106. Arirachakaran P, Luengpailin S, Banas JA, Mazurkiewicz JE, Benjavongkulchai E. Effects of manganese on Streptococcus mutans planktonic and biofilm growth. Caries Res. 2007;41(6):497-502. 107. Borella P, Guerrieri E, Marchesi I, Bondi M, Messi P. Water ecology of Legionella and protozoan: environmental and public health perspectives. Biotechnol Annu Rev. 2005;11:355-380. 108. Lee Y. An Evaluation of Microbial and Chemical Contamination Sources Related to the Deterioration of Tap Water Quality in the Household Water Supply System. Int J Environ Res Public Health. 2013;10:4143-4160.

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