Conclusion 1 Two cases were epidemiologically linked to the hospital. Hospital predominant strain- L. pneumophila mAb sg Benidorm ST42. Hospital minority strain - L. pneumophila mAb sg Bellingham ST42. Despite extensive and continuous environmental investigation following the identification of the remaining cases; no environmental sources could be confirmed. Epi link b/c never got any clinical samples.

Conclusion 2: Out of date risk assessments. Out of date schematics. Inadequate control programme. Undersized plate heat exchanger supplying the hot water to main block. Engineering investigation highlight the value of temperature monitoring of the flow and return pipes Significant colonisation can be very localised. Cases can still occur even when only a small proportion of outlets are positive for legionellae. The findings emphasize the importance of a multifactorial approach to risk assessment of hospital water systems.

Community sampling All cases were offered home, garden hose & car windscreen reservoir sampling. Two homes tested legionella positive - distinct strains from cases. No car windscreen washes tested positive. One dental surgery tested positive but no isolate from case. Bus and bus station – negative. Cooling towers.

Assisted (Freedom) baths

Facilitator notes: Acknowledgements The creation of this training material was commissioned in 2010 by ECDC to Health Protection Agency (UK) and the University of Chester (UK) with the direct involvement of Louise Brown, Janice Gidman, Emma Gilgunn-Jones, Ian Hall (on behalf of the ECDC Legionnaires Disease Outbreak Toolbox Development Group), Tim Harrison, Rob Johnston, Carol Joseph, Sandra Lai, John Lee, Falguni Naik, Nick Phin, Michelle Rivett, and Susanne Surman-Lee. The revision and update of this training material was commissioned in 2017 by ECDC to Transmissible (NL) with the direct involvement of Arnold Bosman and Kassiani Mellou.