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This study examined 184 legionellosis outbreaks in the United States reported to the Centers for Disease Control and Prevention's Waterborne Disease and Outbreak Surveillance System, from 2001 to 2017. Drinking water characteristics examined include source water type, disinfectant type, exposure setting, geographical distribution by U.S. Census Divisions, and the public water system size (population served). This study found that most of the reported drinking water-associated legionellosis outbreaks occurred in eastern United States, including 35% in the South Atlantic, 32% in the Middle Atlantic, and 16% in the East North Central Census Divisions were linked with building water systems in healthcare and hotel settings; and were associated with buildings receiving drinking water from public water systems serving >10,000 people. Targeted evaluations and interventions may be useful to further determine the combination of factors, such as disinfectant residual type and drinking water system size that may lead to legionellosis outbreaks. HIGHLIGHTS Most of the reported legionellosis outbreaks associated with drinking water in the United States (2001–2017) have been documented in healthcare and hotel/motel settings.; Reported legionellosis outbreaks were more often associated with buildings obtaining water from large, chlorinated, surface water systems than with small systems (serving 10,000 or fewer), using disinfectants other than chlorine and ground water sources.;

Reported Legionnaires’ disease (LD) cases began increasing in the United States in 2003 after relatively stable numbers for >10 years; reasons for the rise are unclear. We compared epidemiologic patterns associated with cases reported to the Centers for Disease Control and Prevention before and during the rise. The age-standardized average incidence was 0.48 cases/100,000 population during 1992–2002 compared with 2.71 cases/100,000 in 2018. Reported LD incidence increased in nearly every demographic, but increases tended to be larger in demographic groups with higher incidence. During both periods, the largest number of cases occurred among White persons, but the highest incidence was in Black or African American persons. Incidence and increases in incidence were generally largest in the East North Central, Middle Atlantic, and New England divisions. Seasonality was more pronounced during 2003–2018, especially in the Northeast and Midwest. Rising incidence was most notably associated with increasing racial disparities, geographic focus, and seasonality.

ABSTRACT Previous COVID-19 vaccine efficacy (VE) studies have estimated neutralizing and binding antibody concentrations that correlate with protection from symptomatic infection; how these estimates compare to those generated in response to SARS-CoV-2 infection is unclear. Here, we assessed quantitative neutralizing and binding antibody concentrations using standardized SARS-CoV-2 assays on 3,067 serum specimens collected during 27 July 2020 to 27 August 2020 from COVID-19-unvaccinated persons with detectable anti-SARS-CoV-2 antibodies. Neutralizing and binding antibody concentrations were severalfold lower in the unvaccinated study population compared to published concentrations at 28 days postvaccination. In this convenience sample, ~88% of neutralizing and ~63 to 86% of binding antibody concentrations met or exceeded concentrations associated with 70% COVID-19 VE against symptomatic infection; ~30% of neutralizing and 1 to 14% of binding antibody concentrations met or exceeded concentrations associated with 90% COVID-19 VE. Our study not only supports observations of infection-induced immunity and current recommendations for vaccination postinfection to maximize protection against COVID-19, but also provides a large data set of pre-COVID-19 vaccination anti-SARS-CoV-2 antibody concentrations that will serve as an important comparator in the current setting of vaccine-induced and hybrid immunity. As new SARS-CoV-2 variants emerge and displace circulating virus strains, we recommend that standardized binding antibody assays that include spike protein-based antigens be utilized to estimate antibody concentrations correlated with protection from COVID-19. These estimates will be helpful in informing public health guidance, such as the need for additional COVID-19 vaccine booster doses to prevent symptomatic infection. IMPORTANCE Although COVID-19 vaccine efficacy (VE) studies have estimated antibody concentrations that correlate with protection from COVID-19, how these estimates compare to those generated in response to SARS-CoV-2 infection is unclear. We assessed quantitative neutralizing and binding antibody concentrations using standardized assays on serum specimens collected from COVID-19-unvaccinated persons with detectable antibodies. We found that most unvaccinated persons with qualitative antibody evidence of prior infection had quantitative antibody concentrations that met or exceeded concentrations associated with 70% VE against COVID-19. However, only a small proportion had antibody concentrations that met or exceeded concentrations associated with 90% VE, suggesting that persons with prior COVID-19 would benefit from vaccination to maximize protective antibody concentrations against COVID-19.

Provision of safe drinking water in the United States is a great public health achievement. However, new waterborne disease challenges have emerged (e.g., aging infrastructure, chlorine-tolerant and biofilm-related pathogens, increased recreational water use). Comprehensive estimates of the health burden for all water exposure routes (ingestion, contact, inhalation) and sources (drinking, recreational, environmental) are needed. We estimated total illnesses, emergency department (ED) visits, hospitalizations, deaths, and direct healthcare costs for 17 waterborne infectious diseases. About 7.15 million waterborne illnesses occur annually (95% credible interval [CrI] 3.88 million–12.0 million), results in 601,000 ED visits (95% CrI 364,000–866,000), 118,000 hospitalizations (95% CrI 86,800–150,000), and 6,630 deaths (95% CrI 4,520–8,870) and incurring US $3.33 billion (95% CrI 1.37 billion–8.77 billion) in direct healthcare costs. Otitis externa and norovirus infection were the most common illnesses. Most hospitalizations and deaths were caused by biofilm-associated pathogens (nontuberculous mycobacteria, Pseudomonas, Legionella), costing US $2.39 billion annually.

Through the use of published estimates of medical costs and new calculations of productivity losses, we estimate the lifetime economic burden of 2014 Legionnaires’ disease cases in the United States at ≈$835 million. This total includes $21 million in productivity losses caused by absenteeism and $412 million in productivity losses caused by premature deaths.

BackgroundThe Coronavirus Disease 2019 (COVID-19) pandemic, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), evolved rapidly in the United States. This report describes the demographic, clinical, and epidemiologic characteristics of 544 U.S. persons under investigation (PUI) for COVID-19 with complete SARS-CoV-2 testing in the beginning stages of the pandemic from January 17 through February 29, 2020.MethodsIn this surveillance cohort, the U.S. Centers for Disease Control and Prevention (CDC) provided consultation to public health and healthcare professionals to identify PUI for SARS-CoV-2 testing by quantitative real-time reverse-transcription PCR. Demographic, clinical, and epidemiologic characteristics of PUI were reported by public health and healthcare professionals during consultation with on-call CDC clinicians and subsequent submission of a CDC PUI Report Form. Characteristics of laboratory-negative and laboratory-positive persons were summarized as proportions for the period of January 17-February 29, and characteristics of all PUI were compared before and after February 12 using prevalence ratios.ResultsA total of 36 PUI tested positive for SARS-CoV-2 and were classified as confirmed cases. Confirmed cases and PUI testing negative for SARS-CoV-2 had similar demographic, clinical, and epidemiologic characteristics. Consistent with changes in PUI evaluation criteria, 88% (13/15) of confirmed cases detected before February 12, 2020, reported travel from China. After February 12, 57% (12/21) of confirmed cases reported no known travel- or contact-related exposures.ConclusionsThese findings can inform preparedness for future pandemics, including capacity for rapid expansion of novel diagnostic tests to accommodate broad surveillance strategies to assess community transmission, including potential contributions from asymptomatic and presymptomatic infections.

Detection of clusters of Legionnaires' disease, a leading waterborne cause of pneumonia, is challenging. Clusters vary in size and scope, are associated with a diverse range of aerosol-producing devices, including exposures such as whirlpool spas and hotel water systems typically associated with travel, and can occur without an easily identified exposure source. Recently, jurisdictions have begun to use SaTScan spatio-temporal analysis software prospectively as part of routine cluster surveillance. We used data collected by the Active Bacterial Core surveillance platform to assess the ability of SaTScan to detect Legionnaires' disease clusters. We found that SaTScan analysis using traditional surveillance data and geocoded residential addresses was unable to detect many common Legionnaires' disease cluster types, such as those associated with travel or a prolonged time between cases. Additionally, signals from an analysis designed to simulate a real-time search for clusters did not align with clusters identified by traditional surveillance methods or a retrospective SaTScan analysis. A geospatial analysis platform better tailored to the unique characteristics of Legionnaires' disease epidemiology would improve cluster detection and decrease time to public health action.