Four people have died and more than 140 have fallen ill after attending a North Carolina state fair. State health officials believe the illness is linked to a hot tub display.

At least 133 of those sickened were diagnosed with Legionnaire’s disease, a type of pneumonia caused by legionella bacteria. Eight people were diagnosed with a less serious form of Legionnaires called Pontiac fever. At least 94 of those sickened have been hospitalized. Most of those who fell ill said they walked by a hot tub display in the Davis Event Center at last month’s North Carolina Mountain State Fair.

At least two weeks after the fair ended, samples were collected from the hot tubs on display, but they tested negative for legionella bacteria. A sample from a women’s restroom at the Davis Event Center tested positive for legionella, but the strain was genetically different from the one that sickened the fair goers.

North Carolina Health Department officials said they are still collecting samples, but believe the hot tub display is the likely culprit. Hot tubs have been linked to previous Legionnaire’s outbreaks.

According to the Mayo Clinic, Legionnaire’s disease is a severe form of pneumonia. About 1 in 10 people who develop the lung inflammation will die. People can contract Legionnaire’s by inhaling the bacteria from water or soil.

Symptoms develop two to 10 days after exposure and usually begin with headache, muscle aches, and fever of 104 or higher, and progress to cough (which may bring up mucus or blood), shortness of breath, chest pain, and gastrointestinal symptoms. Pontiac fever, a more mild form of Legionnaire’s, can produce flu-like symptoms. Pontiac fever doesn’t infect the lungs, and is usually not fatal.

In August, one person sickened in an outbreak of Legionnaire’s disease believed to be connected to a downtown Atlanta hotel died.

The DeKalb medical examiner’s office confirmed that 49-year-old Cameo Garrett, who attended a Top Ladies of Distinction Conference at the Atlanta Sheraton Hotel in June, died from Legionnaire’s disease. She was one of 12 confirmed cases of Legionnaires’ disease connected to the hotel, although the Georgia Department of Public Health believes there were at least 55 “probable” cases of the disease associated with the outbreak.

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