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Background  From June to November 2005, 18 cases of community-acquired Legionnaires' disease (LD) were reported in Rapid City South Dakota. We conducted epidemiologic and environmental investigations to identify the source of the outbreak.    Methods  We conducted a case-control study that included the first 13 cases and 52 controls randomly selected from emergency department records and matched on underlying illness. We collected information about activities of case-patients and controls during the 14 days before symptom onset. Environmental samples (n = 291) were cultured for  Legionella . Clinical and environmental isolates were compared using monoclonal antibody subtyping and sequence based typing (SBT).    Results  Case-patients were significantly more likely than controls to have passed through several city areas that contained or were adjacent to areas with cooling towers positive for  Legionella . Six of 11 case-patients (matched odds ratio (mOR) 32.7, 95% CI 4.7-∞) reported eating in Restaurant A versus 0 controls.  Legionella pneumophila  serogroup 1 was isolated from four clinical specimens: 3 were Benidorm type strains and 1 was a Denver type strain.  Legionella  were identified from several environmental sites including 24 (56%) of 43 cooling towers tested, but only one site, a small decorative fountain in Restaurant A, contained Benidorm, the outbreak strain. Clinical and environmental Benidorm isolates had identical SBT patterns.    Conclusion  This is the first time that small fountain without obvious aerosol-generating capability has been implicated as the source of a LD outbreak. Removal of the fountain halted transmission.

Restaurant outbreak of Legionnaires' disease associated with a decorative fountain: an environmental and case-control study