A Large Community Outbreak of Legionnaires' Disease Associated With a Cooling Tower in New York City, 2015.

OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Fatal and nonfatal drowning outcomes related to dangerous underwater breath-holding behaviors - New York State, 1988-2011.

Drowning is an important cause of preventable injury and mortality, ranking fifth among leading causes of unintentional injury death in the United States. In 2011, two healthy young men died in a drowning incident at a New York City (NYC)-regulated swimming facility. The men became unconscious underwater after performing intentional hyperventilation before submersion. The phenomenon of healthy swimmers becoming unconscious underwater has been described elsewhere as hypoxic blackout. Prompted by this incident, the NYC Department of Health and Mental Hygiene (DOHMH) in collaboration with the New York State Department of Health (SDOH) conducted a case review of New York state fatal and nonfatal drownings reported during 1988-2011 to investigate similar behaviors in other incidents. DOHMH identified 16 cases, three in NYC, with a consistent set of voluntary behaviors associated with unintentional drowning and designated this class of behaviors as "dangerous underwater breath-holding behaviors" (DUBBs). For this small sample, the frequency of different DUBBs varied by age and swimming level, and practicing more than one DUBB increased the risk for fatality. This research contributes to the literature on drowning by focusing on contributing behaviors rather than drowning outcomes. NYC recently enacted public health education and regulations that discourage DUBBs; these interventions have the potential to effectively reduce unintentional drowning related to these behaviors and could be considered by other municipalities and jurisdictions.