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Case Study
The 2015 New York City Legionnaires’ Disease
Outbreak: A Case Study on a History-Making Outbreak
Allison T. Chamberlain, PhD; Jonathan D. Lehnert, MPH; Ruth L. Berkelman, MD
O
n July 17, 2015, the Bureau of Communicable Disease of the New York City (NYC)
Department of Health and Mental Hygiene
(DOHMH) detected an abnormal number and distribution of Legionnaires’ disease (LD) cases in the
South Bronx.1-3 This cluster of cases would eventually
grow into the largest outbreak of LD in NYC history.
The NYC DOHMH led the outbreak response, part
of which included sampling numerous cooling towers within NYC for Legionella pneumophila bacteria.
In the aftermath of the outbreak, NYC became the
first large jurisdiction in the United States to take a
regulatory approach to the management of cooling
towers to prevent Legionella contamination.4 Public
health departments of all sizes can learn from how
the DOHMH responded to this historic outbreak.
Background on Legionnaires’ Disease
Legionnaires’ disease is a type of pneumonia that is
caused by inhalation of aerosolized water containing
L pneumophila bacteria, and approximately 5% to
15% of reported cases are fatal.5,6 These bacteria are
frequently present at low levels in many potable water systems but can proliferate under certain circumstances (eg, warm, stagnant water with low levels of
chlorine, such as in certain areas of buildings’ plumbing systems). The bacteria pose great risk to human
health when water containing the bacteria becomes
aerosolized.
Author Affiliation: Center for Public Health Preparedness and Research,
Department of Epidemiology, Rollins School of Public Health, Emory
University, Atlanta, Georgia.
Travel support to conduct these interviews was provided by a grant to Emory
University from the Alfred P. Sloan Foundation. The authors thank staff from
the NYC Department of Health and Mental Hygiene for allowing them to
conduct interviews for this case study.
The authors declare no conflicts of interest.
Correspondence: Allison T. Chamberlain, PhD, Center for Public Health
Preparedness and Research, Department of Epidemiology, Rollins School of
Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322
(Allison.Chamberlain@emory.edu).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/PHH.0000000000000558
410
www.JPHMP.com
Reported cases of legionellosis, which includes LD
and the milder respiratory illness, Pontiac fever, have
increased dramatically in the United States and other
developed countries.5,7 More than 5000 cases of legionellosis were reported to the Centers for Disease
Control and Prevention (CDC) in 2015, a 4-fold increase from 2001.8 Unfortunately, the number of reported cases is suspected to be just a fraction of actual cases.9 Underdiagnosis of LD could be due in
large part to the fact that LD usually can be treated
empirically with antibiotics commonly recommended
for community-acquired pneumonia, thus reducing
the need for clinicians to order diagnostic tests for
LD. A urine antigen test (UAT) for L pneumophila
serogroup 1 is the primary method of LD diagnosis in hospitalized patients.10 The test, while rapid,
is not often utilized except on the most severe cases
(Exhibit 1).
Legionnaires’ Disease in New York City
Legionellosis has been a reportable condition in New
York State since 1985. Reported cases in NYC have
risen from 47 in year 2000 to 438 in year 2015
(Figure).11 When cases are identified, positive diagnostic test results are reported from clinical laboratories
to the DOHMH via the New York State Department
of Health’s Electronic Clinical Laboratory Reporting
System. Clinicians as well as other individuals within
health care facilities, including infection control staff,
are also required to report cases. The DOHMH investigates every reported case by examining medical
records to determine whether there is a clinically compatible illness, interviewing patients or their close relations to identify potential exposures, and, when possible, obtaining clinical isolates for molecular typing.1,12
An environmental investigation will be opened when
there is more than 1 case in a building in a given year,
or 1 case in a high-risk setting (such as a nursing home
or jail), or if routine case investigations identify a common exposure among sporadic cases.
In addition to the traditional case investigation
process, the DOHMH utilizes automated systems to
help detect clusters of disease in space and time.
July/August 2017 • Volume 23, Number 4
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July/August 2017 • Volume 23, Number 4
EXHIBIT 1
Clinical Diagnosis of Legionnaires’ Disease
• There are a number of ways to diagnosis a patient with LD,
including UAT, culture, direct fluorescent antibody staining, and
polymerase chain reaction.
• UAT is the fastest test (takes less than 1 h to conduct on a urine
specimen), requires the least invasive specimen, and can
remain positive after antibiotic treatment has been initiated. As
a result, it is the most widely used diagnostic test.
• UAT is both sensitive and highly specific for L pneumophila
serogroup 1.
• Because the UAT is only capable of detecting L pneumophila
serogroup 1, the gold standard for detection of LD is bacterial
culture.
• Obtaining sputum specimens for culture is difficult and sputum
must be collected before antibiotics have been started.
• Lack of reimbursement for specimen collection and diagnostic
tests is often cited as reasons for not collecting patient
specimens for culture.
Abbreviations: LD, Legionnaires’ disease; UAT, urine antigen test.
One such tool utilized by the DOHMH is SaTScan.13
The DOHMH applies the SaTScan software daily to
identify spatial-temporal clusters in reportable disease
data.2,3 The DOHMH began using SaTScan in February 2014 to prospectively monitor occurrences of 35
diseases, including legionellosis. As one of the first
health departments to adopt SaTScan for this purpose, all signals are carefully considered for validity to
prevent premature concern over false-positive signals.
In the summer of 2015, a signal for legionellosis was
generated by the prospective space-time permutation
scan statistic in SaTScan.3,14 DOHMH staff examined
the cases that generated the signal and began prioritizing epidemiologic investigations to determine whether
the cases were related and whether an outbreak could
be verified.
Importance of the Problem
Known risk factors for LD include older age (>50
years), immunosuppression, and underlying lung
FIGURE Reported Cases of Legionellosis in New York City, 2000-2015
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411
disease, all of which are increasing in the general population and are likely contributing to
higher rates of disease.5 Engineering factors, such
as deteriorating water distribution system infrastructure, poorly maintained premise plumbing systems, and increased installation of low-flow water
fixtures conducive to Legionella growth, are also
thought to be key factors contributing to the rise in
cases.15
There is a strong association between LD and
poverty in NYC; from 2002 to 2011, the rate of
LD was 2.5 times higher in high-poverty areas than
in low-poverty areas (3.0 cases per 100 000 people
per year vs 1.2 cases per 100 000 people per year,
respectively).12 This association is sustained within
each racial and ethnic group.
Compared with other parts of NYC, the Bronx has
a disproportionally high incidence of LD.12 The area
where the outbreak occurred has a large population of
homeless and elderly people. It is also an area with a
large population of persons infected with HIV. Finally,
the area is made up of residents with a low average
income: an estimated 42% of residents live under the
poverty level.16
South Bronx Outbreak: July 2015
The response to the July 2015 cluster began as a
standard epidemiologic investigation: DOHMH
staff interviewed case patients and close contacts
in an attempt to determine the source of disease.
For the purposes of the investigation, the Bureau of
Communicable Disease defined an outbreak case as
“Legionnaires’ disease—based on clinically compatible illness with a positive laboratory test—in a person
who had spent time in any of the 7 affected zip codes
with symptom onset after July 2, 2015.”3 Knowing
that physicians do not typically test patients with
pneumonia for LD and even less frequently obtain
sputum samples for culture, DOHMH investigators
proactively contacted clinicians at Bronx hospitals
during the first week of the outbreak investigation to
specifically ask them to consider LD in patients with
appropriate respiratory symptoms and to encourage
the collection of respiratory specimens for culture.
The DOHMH also reached out to the NYC Office of
the Chief Medical Examiner, a long-standing partnership that has been particularly effective during prior
public health investigations, to request that autopsies
be performed on fatalities due to unexplained respiratory illness to assist with case identification and
further specimen collection. The increased scrutiny
and performance of additional autopsies allowed the
DOHMH to identify additional fatal cases related to
the South Bronx outbreak.17
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412
Chamberlain, et al • 23(4), 410–416
As described by one epidemiologist, “The initial
epidemiological findings did not suggest any common exposures. There were no common buildings visited by case patients, and case residences were spread
across a 6.5 mi2 area.” Officials then began operating under the working theory that those who had gotten sick were being exposed outdoors. Cooling towers
have been implicated in prior LD outbreaks, both in
NYC and elsewhere.15 The hypothesis that a cooling
tower was the source of the outbreak allowed officials to focus the scope of the environmental investigation. It also implied a large potential outbreak zone.
On July 29, the DOHMH issued a citywide health
alert aimed at all clinical staff members in internal
medicine, pediatrics, geriatrics, primary care, infectious diseases, emergency medicine, family medicine,
laboratory medicine, and infection control, requesting that they consider LD in patients presenting with
community-acquired pneumonia and to request both
culture and UAT.17
DOHMH leadership closely monitored the situation, and frequent meetings were held within
the agency to review data and assign tasks. Environmental health and communicable disease response teams worked together to conduct case interviews and to identify a common exposure source.
While the environmental and epidemiologic investigations were proceeding rapidly, rising case counts
increased concern about the potential magnitude
of the outbreak. On July 28, the DOHMH activated its incident command system (ICS) when it
was apparent that the growing outbreak was going
to require additional resources and greater logistical support to accelerate environmental testing and
conduct more extensive community outreach. The decision to activate an ICS is a complex one that each
agency must weigh within the context of the situation
(Exhibit 2).
At the time of ICS activation, DOHMH officials
had reports of more than 30 cases dispersed throughout the South Bronx.3 Environmental health staff
at the DOHMH began sampling cooling towers for
Legionella. Sampling began in the outbreak zone
on the night of July 28 and continued throughout
the following week. Towers that tested positive for
Legionella were subsequently decontaminated. Officials utilized existing lists of buildings with cooling
towers from the NYC Department of Buildings (DOB)
and Department of Environmental Protection to identify sites to sample. Knowing that the lists were incomplete, the DOHMH also used epidemiologic information from case interviews and satellite imagery from
Google Earth to identify buildings with cooling towers near where cases were clustering. One such cooling
tower—that located atop the Opera House Hotel and
New York City Legionnaires Disease Outbreak Case Study
EXHIBIT 2
Overview of an Incident Command System
• An ICS is a modular agency structure and chain of command
that is customized to maximize efficiency during an emergency
response. The ICS is led by the IC who is in charge of the
overall response. Each module, commonly referred to as a
section, is led by a Section Chief who reports to the IC. Each
section has a specific role within the response. Common
sections include Operations, Planning, Logistics, and Finance
and Administration.
• When an agency makes the decision to activate the ICS during
an emergency, staff members who are activated immediately
assume predetermined roles within the response. ICS
activation is a signal to everyone in the agency that there
is a new chain of command in place and that their job
responsibilities may be changed.
Abbreviations: IC, Incident Commander; ICS, incident command system.
sampled on July 29—would eventually be identified
as the source of the outbreak. The DOHMH then dispatched teams of inspectors to each cooling tower to
collect samples. However, not enough DOHMH staff
members were appropriately trained in environmental
sampling protocols at the start of the sampling efforts.
While all DOHMH employees have predetermined
secondary emergency response roles, few had previous
training in safely entering and sampling cooling towers. This dearth of trained individuals meant that the
environmental health staff charged with coordinating
the sampling of cooling towers struggled at first to enlist enough staff to go into the field and sample cooling towers as they were identified. Multiple requests
for volunteers were sent out within the DOHMH and
to sister agencies within the NYC government. The
DOHMH employed a “train-the-trainer” methodology to address this issue. Environmental health staff
paired individuals who possessed the necessary experience or training with those who did not, and the
number of teams that were able to be mobilized to
sample cooling towers grew.
In total, 55 cooling towers in the South Bronx
were located, sampled, and tested for Legionella.3
Other NYC agencies, including NYC Emergency
Management, NYC Police Department, and NYC Fire
Department, as well as the CDC and neighboring local
health departments, assisted DOHMH environmental
health staff with locating and sampling the towers. Investigators took water and biofilm samples from each
cooling tower. DOHMH police personnel transported
half of each water sample to the New York State Department of Health laboratory at Wadsworth Center
in Albany, New York, on the same day the sample was
collected. The state laboratory screened each sample
for L pneumophila DNA using polymerase chain reaction (PCR). PCR is only capable of detecting the presence of bacterial DNA, and while a major limitation is
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
July/August 2017 • Volume 23, Number 4
that it cannot distinguish between live and nonviable
bacteria, it served as a rapid alternative to standard
culture methods for screening samples for the presence of Legionella DNA (Exhibit 3). Upon notification that L pneumophila DNA was detected by PCR
in specific sample(s), the NYC Public Health Laboratory (PHL) confirmed the positivity by culturing the
sample for L pneumophila. Because this confirmatory
culture process requires 5 or more days, cooling tower
owners were ordered to remediate on the basis of the
results of the PCR screening test alone. While the vast
majority of owners were compliant, some owners and
property managers had limited understanding of their
cooling tower systems and difficulty finding service
companies with staffing resources to perform emergency disinfection.
In addition to PCR testing, NYC’s PHL, the
New York State Department of Health, the and
CDC utilized bacterial “fingerprinting” methods,
including pulsed-field gel electrophoresis, wholegenome sequencing, and sequence-based typing, to
further characterize the L pneumophila strains cultured from cooling tower samples and case patients
(Exhibit 4). These “fingerprinting” methods allowed
DOHMH investigators to begin comparing environmental isolates with the more than 2 dozen patient
isolates that were collected from hospitals around
NYC.
During the cooling tower investigation, disagreement between elected officials fueled negative media attention about the outbreak.18-20 On August 7,
Governor Cuomo described the outbreak as “a bad
science-fiction movie.”21 Public concern grew over
whether the city was capable of responding to an outbreak of this magnitude.22-24 Michael Benjamin, a former assembly member, political columnist, and resident of the South Bronx during the outbreak, wrote
that “in nearly 40 years since the original deadly
Legionnaires’ outbreak … it’s mind-boggling that no
rules or regulations were put into place to prevent
deadly new eruptions of the disease.”25 To address
the growing fear and anxiety of Bronx residents, the
governor announced that the state would expand free
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EXHIBIT 4
Environmental Testing by Laboratory
New York State Department
of Health
New York City Public Health
Laboratory
Centers for Disease Control
and Prevention
Private contract laboratory
PCR, whole-genome
sequencing
Culture, pulsed-field gel
electrophoresis
Sequence-based typing
Culture
Abbreviation: PCR, polymerase chain reaction.
cooling tower testing to all private building owners
in the Bronx and across the state.26 The additional
capacity required to handle the increased number of
samples ratcheted up the pressure on the state public health laboratory, which was already operating at
capacity.
Despite the public contention between the
mayor and the governor, the state and city health
departments continued to work closely with each
other during the outbreak. This collaboration ensured that essential work such as the testing of
environmental samples continued at a rapid pace.
DOHMH laboratory personnel also cited the on-site
assistance from the CDC laboratory team as useful during the response. Laboratory expertise and
data management worksheets provided by the CDC
improved the data management capabilities of PHL
and helped manage the large amount of testing
necessary for the response.
DOHMH managers in the environmental health
department and at PHL expressed concern about
maintaining employee morale amid longer work days,
changing shift requirements (some laboratory staff
were asked to work overtime into the evening/night to
allow work to continue), and short deadlines during
the response. ICS roles are often filled by a predetermined rotation of people over the course of a response
to limit employee burnout during a response. In the
case of certain roles, such as the Communications
Section chief and PHL leadership, little to no rotation
occurred. The potential benefits of rotating staff
EXHIBIT 3
Overview of Environmental Testing for Legionella During the 2015 Legionnaires’ Disease Outbreak
PCR
Culture
Use: Screening
Advantage: Rapid (test itself takes hours)
Disadvantage: Only detects the presence of bacterial DNA and
therefore unable to distinguish viable from nonviable bacteria
Disadvantage: Samples had to be sent to the state laboratory
413
Use: Confirmation
Advantage: Only captures viable bacteria
Advantage: Samples could be cultured at the city laboratory
Disadvantage: Lengthy (requires days to grow)
Abbreviation: PCR, polymerase chain reaction.
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414
Chamberlain, et al • 23(4), 410–416
members had to be weighed against the desire to not
disrupt the day-to-day response operations.
In an effort to address a growing sense of panic
among the residents of the outbreak zone, the
DOHMH conducted a number of communication
and community engagement activities.22,23,25 Members of the DOHMH communications and public
health preparedness groups attended several community town hall events, frequently accompanied
by volunteer physicians from the local Medical Reserve Corp (MRC) chapters. The physicians were
indispensable, offering medical consultations to those
concerned that they may have been exposed, as well
as providing an overall sense of comfort to the community. The DOHMH also mobilized Community
Outreach Teams (COTs) to engage vulnerable populations in the outbreak area and the organizations
that serve those populations. COTs are a relatively
recent addition to the DOHMH emergency response
toolkit, the concept becoming formalized after the
2014 Ebola virus disease crisis. Preidentified or preselected DOHMH staff members are assigned to
COTs as a potential emergency response role during
ICS activations. If the decision is made to create
and deploy COTs for a particular response, COTs
receive “just-in-time” training immediately before
they go into the field to begin outreach activities. For
this particular LD outbreak response, COTs targeted
vulnerable populations including the elderly, the
homeless, those with compromised immune systems,
and those with limited access to health care. COTs
also visited more than 100 vulnerable population
service providers during the outbreak investigation.
The partnership with the MRC again proved invaluable, as DOHMH officials were able to elicit the help
of several Spanish-speaking doctors and nurses to
provide medical assessments in high-risk areas such as
senior centers, a supportive housing building for HIVinfected patients, and at public events. These outreach
efforts, combined with a high level of media coverage,
are credited with reducing the median time from illness onset to LD diagnosis from 5 days to 1 day.3
Aftermath
Of 55 cooling towers tested, 2 were found to have
a Legionella strain indistinguishable by pulsed-field
gel electrophoresis from 26 patient isolates. Wholegenome sequencing and epidemiologic evidence
implicated a single cooling tower located at the
Opera House Hotel as the source of the outbreak.3
The hotel had begun disinfection of that particular
cooling tower on July 30. On August 3, Mayor Bill
de Blasio released a statement saying that the city was
looking into methods to proactively prevent future
New York City Legionnaires Disease Outbreak Case Study
outbreaks. The DOHMH seized on this moment of
strong political capital to gain support for a citywide
registry of cooling towers, an initiative that environmental health and communicable disease officials
within the DOHMH recognized was necessary to
expedite LD investigations. Now that there was a
large community outbreak with evidence pointing
toward a cooling tower as the culprit, the concept of
having immediate and up-to-date knowledge on all
cooling towers in the city was particularly appealing
and creation of the registry became a priority. On
August 6, DOHMH Commissioner Dr Mary Bassett
ordered all cooling towers in NYC that had not been
disinfected within the past 30 days to be evaluated
for contamination and undergo disinfection within
the next 2 weeks. Documentation of the cooling
tower evaluation and subsequent disinfection was to
be submitted to the DOB via an online portal. On
August 10, the NYC Council introduced legislation
that required all cooling towers to be registered
with the DOB and inspected at least every 90 days
during times of operation. The cooling tower legislation, officially known as Local Law 77, was enacted
8 days later on August 18. The outbreak was officially
declared to have ended on August 20. A total of 138
cases and 16 deaths were attributed to this outbreak,
making it the largest LD outbreak in NYC history.
Epilogue
A major agency-wide challenge during the response
was the efficient management of incoming data. For
example, while systems were already in place for
obtaining and managing clinical data on LD diagnoses, there was no analogous system for managing
data obtained from environmental sampling activities.
Frequent requests for data from a host of external
partners, including very important stakeholders such
as elected officials, compounded the issue. DOHMH
staff developed many new systems on the fly to reduce
the time and effort required to sort, clean, and export
environmental data in a useable fashion. In the year
after the outbreak, the DOHMH has been working
on developing a crosscutting data management workflow to ensure that epidemiologic, laboratory, and environmental data are compatible.
While improvements to data management and the
response structure will be useful during future infectious disease outbreaks, the lasting impact of the July
2015 LD outbreak included the proposal and adoption of NYC Local Law 77 among other activities.27
Local Law 77 sets stipulations for cooling tower registration and certification and imposes maintenance,
inspection, and Legionella testing requirements for
all buildings with cooling towers across the city.
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July/August 2017 • Volume 23, Number 4
Both new and existing cooling towers are required to
register with the DOB. Furthermore, building owners are required to develop a maintenance plan for
cooling towers that is in accordance with ASHRAE
(American Society of Heating, Refrigerating, and Air
Conditioning Engineers) Standard 188, an industry standard released in 2015.28 In addition, Local
Law 77 requires that cooling towers be tested for
Legionella every 90 days when the cooling tower
is in use and within 15 days prior to the initial use
during any year. The Rules of the City of New York
specify explicit maintenance activities that must be
performed routinely and the remediation steps to be
taken if routine Legionella testing procedures reveal
certain thresholds of Legionella concentrations. The
rules also establish acceptable methods for laboratory
testing of environmental samples, as well as cleaning
and disinfection of cooling towers. Finally, the rules
carry with them an enforcement mechanism in the
form of fines for buildings that fail to register a
cooling tower, submit an annual certification, or fail
an unannounced inspection by DOHMH inspectors.
Short- and long-term evaluations of the cooling
tower regulations are ongoing. Evaluating the data
in the registry will allow DOHMH officials to understand key characteristics of the city’s cooling towers,
such as the manufacturer, frequency of disinfection,
location, owner or contractor, and the average number of bacterial colony-forming units in a tower,
among others. Officials anticipate that this database
will allow them to identify certain tower characteristics that are associated with an increased risk
of Legionella amplification so that they can suggest
modifications to cooling towers or building maintenance plans to prevent disease more effectively.
Ultimately, officials hope that the cooling tower
regulations contribute to a decrease in LD cases.
Discussion Questions
1. Consider the time span between when the initial
signal was generated by SaTScan and when ICS
was activated. What do you think the pros and
cons may have been to immediately activating
ICS upon observation of that signal?
2. Why was proactively reaching out to the city
medical examiner a good idea during this outbreak response? How close is your jurisdiction’s
relationship with your medical examiner?
3. What steps could health department employees
take to improve management of environmental
sampling data?
4. What could the DOHMH have done, prior to or
during the outbreak, that could have better managed public dissatisfaction with the response?
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415
5. Should infectious disease data be released to the
public on a routine basis? How rapidly? How
should preliminary data be handled during an
outbreak?
6. What role does public health play in mitigating adverse health conditions that result from
neglected engineering or infrastructure components such as cooling towers? What is the role
of the building owner or manager? Should public health play a role in ensuring that disease risk
from neglected infrastructure is minimized? If so,
how?
7. What expectations should the public health
workforce have regarding job duties during public health emergencies such as infectious disease
outbreaks?
In 2015, the New York City Department of Health
and Mental Hygiene responded to an unprecedentedly large outbreak of Legionnaires’ disease. Cases of
Legionnaires’ disease have increased dramatically in
the United States since 2001. As epidemiologic and
environmental risk factors for Legionnaires’ disease
increase, more people will be susceptible to the disease. Other health departments can learn from the
actions DOHMH took during this outbreak and the
subsequent cooling tower legislation New York City
enacted to hopefully prevent future outbreaks. By
learning from this experience, other jurisdictions can
increase the efficiency and effectiveness of their own
responses to future outbreak scenarios.
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New York City Legionnaires Disease Outbreak Case Study
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York Daily News. August 7, 2015. http://www.nydailynews.com/
new-york/n-y-officials-test-south-bronx-areas-legionnaires-article1.2318276?cid=bitly. Accessed October 19, 2016.
22. New York Times Editorial Board. Missing the warnings on Legionnaires’ disease.“ The New York Times. August 7, 2015:A26. http://
www.nytimes.com/2015/08/07/opinion/missing-the-warningson-legionnaires-disease.html. Accessed November 7, 2016.
23. Mueller B. Bronx Residents anxious after 4th death from Legionnaires’ disease. The New York Times. August 2, 2015. http://www.
nytimes.com/2015/08/02/nyregion/bronx-residents-anxious-after4th-death-from-legionnaires-disease.html. Accessed November 7,
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24. New York Daily News Editorial Board. They missed the Legionnaires’’ disease-carrying mist. New York Daily News. August
5, 2015. http://www.nydailynews.com/opinion/editorial-missedlegionnaires-mist-article-1.2314760. Accessed November 7, 2016.
25. Benjamin M. The Bronx is furious over city’s slow response to
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2015/08/07/the-bronx-is-furious-over-citys-slow-response-tolegionnaires/. October 19, 2016.
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Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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