Improvements to the Success of Outbreak Investigations of Legionnaires' Disease: 40 Years of Testing and Investigation in New York State.

Since 1978, the New York State Department of Health's public health laboratory, Wadsworth Center (WC), in collaboration with epidemiology and environmental partners, has been committed to providing comprehensive public health testing for Legionella in New York. Statewide, clinical case counts have been increasing over time, with the highest numbers identified in 2017 and 2018 (1,022 and 1,426, respectively). Over the course of more than 40 years, the WC Legionella testing program has continuously implemented improved testing methods. The methods utilized have transitioned from solely culture-based methods for organism recovery to development of a suite of reference testing services, including identification and characterization by PCR and pulsed-field gel electrophoresis (PFGE). In the last decade, whole-genome sequencing (WGS) has further refined the ability to link outbreak strains between clinical specimens and environmental samples. Here, we review Legionnaires' disease outbreak investigations during this time period, including comprehensive testing of both clinical and environmental samples. Between 1978 and 2017, 60 outbreaks involving clinical and environmental isolates with matching PFGE patterns were detected in 49 facilities from the 157 investigations at 146 facilities. However, 97 investigations were not solved due to the lack of clinical or environmental isolates or PFGE matches. We found 69% of patient specimens from New York State (NYS) were outbreak associated, a much higher rate than observed in other published reports. The consistent application of new cutting-edge technologies and environmental regulations has resulted in successful investigations resulting in remediation efforts. IMPORTANCE Legionella, the causative agent of Legionnaires' disease (LD), can cause severe respiratory illness. In 2018, there were nearly 10,000 cases of LD reported in the United States (https://www.cdc.gov/legionella/fastfacts.html; https://wonder.cdc.gov/nndss/static/2018/annual/2018-table2h.html), with actual incidence believed to be much higher. About 10% of patients with LD will die, and as high as 90% of patients diagnosed will be hospitalized. As Legionella is spread predominantly through engineered building water systems, identifying sources of outbreaks by assessing environmental sources is key to preventing further cases LD.

Understanding the distribution of positive Legionella samples in healthcare-premise water systems: Using statistical analysis to determine a distribution for Legionella and to support sample size recommendations.

OBJECTIVE: To significantly fit a statistical distribution to the proportion of positive Legionella samples in a series of water samples from multiple facility-premise water systems. DESIGN: Statistical fit test. SETTING: A hospital and associated long-term care facility (LTCF) in New York State, as well as temporal and culture data from a deidentified hospital site supplied by one of the vendor laboratories. METHODS: Culture samples (n = 1,393) were segmented into 139 test cycles with roughly 10 samples in each. The proportion of positive samples was standardized to 25 total samples per test to give a distribution of discrete values. These values were analyzed for fit with the following discrete distributions: Poisson, negative binomial, geometric, and zero-inflated Poisson. RESULTS: The zero-inflated Poisson distribution fitted to the copper-silver ionization (CSI)-treated and untreated test cycles indicates that 88% of the expected positive proportions should occur by the 30% cutoff (rounded up to 8 positive samples among 25 total samples), similar to the 93% expectation for just CSI-treated test cycles. The other treatment in these data (chlorine dioxide) was not effective in treating Legionella in the sampled buildings, and if there is an underlying distribution to these specific test cycles, it is not the zero-inflated Poisson distribution. CONCLUSIONS: In a well-maintained or well-treated premise water distribution system, ~30% or lower proportion of positive Legionella samples should occur. Anything above that cutoff is either very unlikely or not expected at all and indicates a problem in the water system.

Use of copper-silver ionization for the control of legionellae in alkaline environments at health care facilities.

BACKGROUND: There are multiple treatment options for the control of legionellae in premise hot water systems. Water chemistry plays a role in the efficacy of these treatments and should be considered when selecting a treatment. This study demonstrated the efficacy of copper-silver ionization (CSI) under alkaline water conditions in 2 health care facilities. METHODS: Monitoring for copper (Cu) and silver (Ag) ions was performed, and the corresponding percentage of positive Legionella cultures was monitored. Low Legionella colony forming units (CFU), with a mean <10 CFU/100 mL, and ≤30% positive culture for each sampling period, along with no recurrent disease, were considered indicative of control. RESULTS: CSI treatment was shown to reduce both the number of CFU found and the percentage of samples found to be culture positive. After treatment was established, culture positivity was, for example, reduced from 70% (>10(3) CFU/100 mL) to consistently <30% (38 CFU/100 mL). CONCLUSION: Control of legionellae in premise water systems may be a complex process requiring long-term assessments for adequate control. This work found that CSI could be successful in controlling Legionella under alkaline water conditions, and the evidence suggests that Ag ions are responsible for the control of Legionella pneumophila 1, L pneumophila 6, and L anisa.

A pilot study on the assessment of trace organic contaminants including pharmaceuticals and personal care products from on-site wastewater treatment systems along Skaneateles Lake in New York State, USA.

On-site wastewater treatment systems (OWTSs or septic systems) are designed to treat and dispose effluents on the same property that produces the wastewater. Approximately 25% of the U.S. population is served by such facilities. Nevertheless, studies on the treatment efficiency and discharge of organic contaminants through septic effluents are lacking. This pilot study showed the occurrence of organic contaminants including pharmaceuticals and personal care products (PPCPs), perfluoroalkyl surfactants (PFASs), polybrominated diphenyl ethers (PBDEs), and polychlorinated biphenyls (PCBs) in septic effluents, adjacent lake water samples, household drinking water in homes that use lake water or a well adjacent to the lake as a source of drinking water, and offshore lake water samples. Septic effluent as well as lake and tap water samples were collected from several households with OWTSs around Skaneateles Lake located in central New York. The advanced on-site systems were installed in some households for the purpose of limiting nutrient levels in the effluent to protect the local surface water. Additionally, because many of these systems serve homes with limited land, advanced treatment systems were needed. The median concentrations of ten PPCPs (ranged from 0.45 to 388 ng/L) and eleven PFASs (ranged from 0.20 to 14.6 ng/L) in septic water were significantly higher (p ≤ 0.01) than in lake water samples. The median concentrations of PPCPs and PFASs in lake and tap water samples were not significantly different (p ≥ 0.65). The median concentrations of ∑PBDEs in septic, lake, and tap water samples were 7.47, 3.49, and 2.22 ng/L, respectively, and those for ∑PCBs were 33.1, 29.2, and 28.6 ng/L, respectively. The mass flux of PPCPs (i.e. the mass flow of PPCPs per unit area per unit time) through the disposal of treated septic effluent from textile biofilter and aerobic treatments to the dispersal unit ranged from 12 (carbamazepine) to 66900 µg/m(2)/day (caffeine) whereas that for PFASs ranged from 7.0 (perfluorobutanesulfonate) to 833 µg/m(2)/day (perfluorooctanoic acid). Based on the ratio of measured concentrations and method detection limit, triclocarban, perfluorooctanoic acid, and perfluorooctanesulfonate have the potential to be used as chemical tracers of septic water contamination in Skaneateles Lake. The median concentrations of atenolol, a beta-blocker drug, in septic water were significantly (ρ = 0.86, p = 0.01) correlated with enterococci counts.

Assessing the health of migrant and seasonal farmworkers in New York State: statewide data 2003-2005.

OBJECTIVES: New York State data were used to document demographic characteristics and identify the top five most prevalent disease conditions among migrant and seasonal farmworkers and their families working in the state from 2003 to 2005. METHODS: Prevalence estimates were derived using enumeration and diagnosis data provided by New York State Department of Health contractors. The sample totals ranged from 6,500 to 8,000 migrant and seasonal farmworkers and their families. RESULTS: The majority of migrant and seasonal farmworkers were Hispanic with New York or Mexico the most frequently reported migrant home. Infections, muscular skeletal problems, respiratory disease, hypertension, and diabetes were the five most prevalent diseases identified. CONCLUSION: Migrant and seasonal farmworkers in New York State experienced health conditions common among agricultural workers. Additional research and surveillance are necessary for understanding and serving their health needs.

Diabetes in relation to serum levels of polychlorinated biphenyls and chlorinated pesticides in adult Native Americans.

BACKGROUND: Recent research suggests that diabetes, a condition whose incidence is increasing, is associated with exposure to polychlorinated biphenyls (PCBs) and chlorinated pesticides. OBJECTIVES: We investigated the potential association between diabetes and serum levels of PCBs, dichlorodiphenyldichloroethylene (DDE), hexachlorobenzene (HCB), and mirex in a cross-sectional study of an adult Native-American (Mohawk) population. METHODS: Through a standardized questionnaire we collected demographic, medical, and lifestyle information from 352 adults, > or =30 years of age. We collected fasting serum samples that were analyzed for 101 PCB congeners, DDE, HCB, and mirex along with fasting glucose, triglycerides, and cholesterol. Participants who had fasting-glucose values > 125 mg/dL and/or who were taking antidiabetic medication were defined as persons with diabetes. We conducted logistic regression to assess the potential association between organochlorine serum levels and diabetes, while controlling for the potential confounding variables of age, body mass index (BMI), smoking, sex, and serum lipid levels. Organochlorine serum levels were categorized in tertiles, and the lowest tertile was used as the reference category. RESULTS: The prevalence of diabetes was 20.2%. The odds ratio (OR) of having diabetes for participants in the highest tertile of total PCB concentration compared with the lowest tertile was 3.9 (95% confidence interval, 1.5-10.6). The corresponding ORs for DDE and HCB were even higher. Elevated serum mirex was not associated with diabetes. After adjustment for other analytes, the OR for HCB remained significant, whereas ORs for PCBs and DDE remained elevated but not statistically significant. In contrast, after adjustment for other analytes, the OR for mirex became statistically significant and indicated an inverse association. CONCLUSIONS: In this study of adult Native Americans, elevated serum PCBs, DDE, and HCB were positively associated with diabetes after controlling for potential confounders, whereas a negative association was observed for mirex.