The disease burden from Legionella spp. infections has been increasing in many industrialized countries and, despite decades of scientific advances, ranks amongst the highest for waterborne diseases. We review here several key research areas from a multidisciplinary perspective and list critical research needs to address some of the challenges of Legionella spp. management in engineered environments. These include: (i) a consideration of Legionella species diversity and cooccurrence, beyond Legionella pneumophila only; (ii) an assessment of their environmental prevalence and clinical relevance, and how that may affect legislation, management, and intervention prioritization; (iii) a consideration of Legionella spp. sources, their definition and prioritization; (iv) the factors affecting Legionnaires' disease seasonality, how they link to sources, Legionella spp. proliferation and ecology, and how these may be affected by climate change; (v) the challenge of saving energy in buildings while controlling Legionella spp. with high water temperatures and chemical disinfection; and (vi) the ecological interactions of Legionella spp. with other microbes, and their potential as a biological control strategy. Ultimately, we call for increased interdisciplinary collaboration between multiple research domains, as well as transdisciplinary engagement and collaboration across government, industry, and science as the way toward controlling and reducing Legionella-derived infections.

Inhalation of aerosols produced during showering exposes people to chemical and microbial contaminants present in the water. To improve quantitative estimates of exposure and to inform the efficacy of potential interventions to reduce exposures, the number and size distributions of aerosols generated during showering events were monitored and a mass balance model of the generated aerosols was developed. The aerosol generation rates were calculated through calibrating the model with the measured aerosol data. Specifically, aerosol count concentrations and size distributions were measured with an aerodynamic particle sizer over the duration of mock showering events under various conditions, including different water temperatures and different showerhead types (conventional and rain showers). The empirical data were then used to fit a mass balance model to obtain aerosol generation rates and decay rates for each aerosol size class through least square fitting. An initial high peak concentration of aerosols was observed under hot water conditions relative to cold water conditions which resulted in a rapid increase in aerosol exposure during the first 1–2 min of showering. This suggests that people showering in hot water conditions will have a potentially increased exposure during the first 1–2 min. The model-fitted values suggest large inter-experiment variation in estimated aerosol generation and decay rates, even among triplicates of the same showering conditions. Current exposure assessment approaches assume constant aerosol concentrations during showers which might lead to miscalculated cumulative risk for microbial hazards because of their uneven distribution in building plumbing systems and biofilm detachment process during flushing. Thus, considering aerosol dynamics is beneficial during shower exposure assessments to inform risk management interventions. The data set and associated modeling results provided can support this, as they can be readily integrated into microbial risk assessments for waterborne pathogens such as Legionella spp., nontuberculous Mycobacteria (NTM) and Pseudomonas aeruginosa.