title: A Large Community Outbreak of Legionnaires' Disease Associated With a Cooling Tower in New York City, 2015.
abstract: Infections caused by Legionella are the leading cause of waterborne disease outbreaks in the United States. We investigated a large outbreak of Legionnaires' disease in New York City in summer 2015 to characterize patients, risk factors for mortality, and environmental exposures.
  
  
  
  We defined cases as patients with pneumonia and laboratory evidence of Legionella infection from July 2 through August 3, 2015, and with a history of residing in or visiting 1 of several South Bronx neighborhoods of New York City. We describe the epidemiologic, environmental, and laboratory investigation that identified the source of the outbreak.
  
  
  
  We identified 138 patients with outbreak-related Legionnaires' disease, 16 of whom died. The median age of patients was 55. A total of 107 patients had a chronic health condition, including 43 with diabetes, 40 with alcoholism, and 24 with HIV infection. We tested 55 cooling towers for Legionella, and 2 had a strain indistinguishable by pulsed-field gel electrophoresis from 26 patient isolates. Whole-genome sequencing and epidemiologic evidence implicated 1 cooling tower as the source of the outbreak.
  
  
  
  A large outbreak of Legionnaires' disease caused by a cooling tower occurred in a medically vulnerable community. The outbreak prompted enactment of a new city law on the operation and maintenance of cooling towers. Ongoing surveillance and evaluation of cooling tower process controls will determine if the new law reduces the incidence of Legionnaires' disease in New York City.
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Don
authors.initials: D
authors.lastname: Weiss
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Boyd
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Rakeman
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Sharon K
authors.initials: SK
authors.lastname: Greene
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Fitzhenry
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Trevor
authors.initials: T
authors.lastname: McProud
authors.affiliation: 2 The Wadsworth Center, New York State Department of Health, Albany, NY, USA.
authors.forename: Kimberlee
authors.initials: K
authors.lastname: Musser
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Li
authors.initials: L
authors.lastname: Huang
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: John
authors.initials: J
authors.lastname: Kornblum
authors.affiliation: 2 The Wadsworth Center, New York State Department of Health, Albany, NY, USA.
authors.forename: Elizabeth J
authors.initials: EJ
authors.lastname: Nazarian
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Annie D
authors.initials: AD
authors.lastname: Fine
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Braunstein
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Kass
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Keren
authors.initials: K
authors.lastname: Landman
authors.affiliation: 2 The Wadsworth Center, New York State Department of Health, Albany, NY, USA.
authors.forename: Pascal
authors.initials: P
authors.lastname: Lapierre
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Scott
authors.initials: S
authors.lastname: Hughes
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Anthony
authors.initials: A
authors.lastname: Tran
authors.affiliation: 2 The Wadsworth Center, New York State Department of Health, Albany, NY, USA.
authors.forename: Jill
authors.initials: J
authors.lastname: Taylor
authors.affiliation: 2 The Wadsworth Center, New York State Department of Health, Albany, NY, USA.
authors.forename: Deborah
authors.initials: D
authors.lastname: Baker
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Lucretia
authors.initials: L
authors.lastname: Jones
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Kornstein
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Boning
authors.initials: B
authors.lastname: Liu
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Rodolfo
authors.initials: R
authors.lastname: Perez
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: David E
authors.initials: DE
authors.lastname: Lucero
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Peterson
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.|3 Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Isaac
authors.initials: I
authors.lastname: Benowitz
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Kristen F
authors.initials: KF
authors.lastname: Lee
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Ngai
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.
authors.forename: Mitch
authors.initials: M
authors.lastname: Stripling
authors.affiliation: 1 New York City Department of Health and Mental Hygiene, Queens, NY, USA.|3 Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Jay K
authors.initials: JK
authors.lastname: Varma
mesh_terms: D000328:Adult; D000368:Aged; D004196:Disease Outbreaks; D004781:Environmental Exposure; D005260:Female; D006801:Humans; D007875:Legionella / Q000302:isolation & purification*; D007877:Legionnaires' Disease / Q000453:epidemiology* / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D009519:New York City / Q000453:epidemiology; D014871:Water Microbiology
keywords: Legionnaires’ disease; cooling tower; outbreak