Inspired To Heal
Stories of clinicians, educators, innovators, and researchers who built or led programs of excellence in government health institutions. Each guest has excelled in clinical medicine, program building, or public health. They persevered and succeeded through a clear vision, collaboration, and a passion for the mission of government-run health systems. Their stories will inspire those seeking change in their own organizations.
Inspired To Heal
Decoding a Legionnaire's Outbreak, New York City
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Using molecular methods and shoe-leather epidemiology, Don Weiss and Kim Musser teamed up to resolve a Legionnaires’ outbreak in the Bronx in 2015. It’s a classic tale of combining surveillance and field investigations with advanced molecular methods to pinpoint and eradicate the lethal source of infections. Future deaths were prevented when the New York City Department of Health, the New York State Department of Health, and the CDC worked together to realize this public health success story. You can read about this and other cases in Don’s new book Disease Detectives: True Stories of NYC Outbreaks.
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Inspired to Heal, Season 2, Public Health Stories. In this season, we recount important public health advances, whether through outbreak investigations, policies, or program building. In each story, government agencies have played critical roles. I'm Bill Trick, the host for Inspired to Heal. Today I welcome Don Weiss and Kim Mutzer. For 23 years, Don worked as an infectious diseases epidemiologist at New York City's Department of Health. He recently published a book of interesting outbreaks entitled Disease Detectives True Stories of New York City Outbreaks. Dr. Kim Mutzer has had a 27-year career in public health. He is now the Chief of Bacterial Disease and Clinical Laboratory Director at the Wadsworth Center for the New York State Department of Health. Kim and Don collaborated closely to stop one of New York City's largest outbreaks of Legionnaires disease, which occurred in the Bronx in the summer of 2015. The investigation you will hear about is one of the chapters in Don's book. So before we dive into Legionnaires disease and the outbreak, I'd like to hear a little bit about your backgrounds and how you got interested in public health.
SPEAKER_04In medical school, you have a course in epidemiology. The professor was a well-known infectious disease expert, Donald Loria, and that heaked my interest in it. I thought, well, at some point in time I'll go back and get an MPH. The opportunity came up. Either emergency department or in underserved neighborhoods. Had the opportunity to go back, get my degree, and then what was circulating in my brain was that the public health was a way of addressing people's problems, not doing it one patient at a time, but on a population level.
SPEAKER_01For me, I didn't know microbiology or public health was in my path when I was younger. I ended up doing a degree in biology and then a PhD in biomedical sciences focused on neuroscience. My project included a lot of molecular methods. So when I was finishing up that degree, I was looking for the next step to do something more impactful with the skill set I had. And I found the APHL CDC Emerging Infectious Diseases Fellowship. I was very lucky, applied for that, and got a position at Wadsworth Center and did a two-year postdoc there, which was my transition into public health.
SPEAKER_02But the fellowship that you had sponsored by CDC was pivotal in you deciding that public health was a career for you.
SPEAKER_01Absolutely. I say it all the time. I never would have found public health without that fellowship. And obviously I stayed and have enjoyed 25 years since that fellowship in public health.
SPEAKER_02Don, you as a pediatrician probably have an orientation toward prevention. I would think a lot of kids are healthy, and how do you keep them healthy? So you found that calling. What was the path to to change or pivot from being a clinical pediatrician to a public health disease detective?
SPEAKER_04I started out my career as a chemist. I was originally going to get a PhD in organic chemistry and maybe teach in college. I didn't really like that laboratory work. So that's when I applied to medical school. And pediatrics is what spoke to me, and I liked working with populations that actually needed more health care than they were receiving. After doing that for a number of years, especially when I moved to St. Louis and I saw how bad the lead poisoning problem was, I knew that something had to be done at a larger level than just me individually referring kids for treatment. So prevention was really the only way to approach lead poison. And that's really getting lead out of kids' environment. Originally from New York City, an opportunity opened to work there in infectious disease, which is another interest of mine.
SPEAKER_02Just calling attention to the lead crisis in in Flint, Michigan, that was also a pediatrician who detected lead poisoning, and that led her from her clinical career to go into public health and think about prevention. So talking about Legionnaires disease, I I know you both are experts in it. So I'm not sure exactly who this question is for, but could one of you speak to the origin of Legionnaires? It's kind of an interesting name for a bacteria and and how that came about and when that was.
SPEAKER_04Sure, I'll be happy to start. There's two components to it, the clinical and the laboratory. And I f actually find the laboratory more interesting, but I'll let Kim cover that. So that we're going back to 1976, there was a convention, a Legionnaires Convention that was held in Philadelphia, and a lot of people got sick. Not only people who attended the convention, but people who worked in the hotel where it was held. I think it was a hundred and eighty plus and almost thirty deaths. And the cause was unknown, but they did seem to track it as much as they could tell at the time to the ventilation and air conditioning systems. To determine what the aging was, that was a lot of detective work and I'll let Kim take it from there.
SPEAKER_01Sure. Yeah, I was just rereading an interview with Joe McDade at at the CDC from 2016, which I believe marked the 40 years anniversary. And for us at Wasworth Center, we went and trained at CDC in 1978 to get somebody able to do this. But back in 1976, when this happened in the summer, there was no solution as to what agent was causing this outbreak. I think maybe five or six months later, around the holidays, Joe McDade went back to his laboratory and started to relook at everything he had seen. He had noted while he was looking for Ricketsia and other organisms that there were some gram-negative rods available in some of the specimens, and they were never able to culture that with any of their methods. But he went back to some of the guinea pig work they had done, as well as to slides that were available. And looking again, a second look was able to identify there was a bacterium present. They utilized some pathology methods and then later some culture techniques to be able to grow out what they eventually called Legionella, which was the culprit of this outbreak. And it had long been around, just not identified, not seen by a laboratory method until there was this large outbreak and this real need to identify the source. So it was really terrific detective and laboratory work at the CDC at this time.
SPEAKER_02And so just to let people know, a gram negative is is a kind of bacterium where the stain is not picked up by the cell wall. So it it's called negative, meaning you can't you can't see the stain on the cell wall. Did I get that close enough, Kim? You'll let it be.
SPEAKER_01Yeah, that's it shows up red with a bit that very traditional method that we use in the laboratory to differentiate bacteria. So it categorized it for them at the CDC to start to understand and name that bacteria.
SPEAKER_02And so they saw something that looked unique, but they hadn't been able to culture. It's hard to grow. The term we use is fastidious, I guess. Being like an orchid, you know, you can't grow it very easily. How did they get it to grow? What was the do you remember how it is just experimentation? Let's put a bunch of media together and see what what it grows on.
SPEAKER_01I I don't have all the details on that, but my guess is they tried many different types of culture media at the time. And in the end, the media that we trained on a few years later and that we still use today is a buffered charcoal yeast extract media that contains L-cysteine for growth. And we utilize that with some different antibiotics to help us be able to see the Legionella on the plates because they grow slower than many other gram-negative bacteria. But my guess is they tried a whole bunch of different media just to see where they could get some growth.
SPEAKER_02Again, the first time that was grown and discovered was that outbreak in 1976 in Philadelphia. So, what makes a Legionella outbreak so challenging? And Don, I think I'll start with you. What you you have cases all the time in New York City, every year, and you have to determine when it's an outbreak and then find the source. What is what makes that so challenging?
SPEAKER_04Well, I think this is again an example of both the clinical and the laboratory side that make legionella challenging. On the clinical side, causes a pneumonia. And most physicians, when they see pneumonia, will treat it what's called empirically. They'll not try to diagnose what organism is causing pneumonia, they'll just give the person antibiotics. What the clue to Legionella pneumonia is a couple of them. One is that it's not the typical season. You'll see legionella pneumonia during the warm weather months, you know, July and August, when that's not the typical season for the usual pneumonia is called by caused by pneumococcal or hermophilus influenza or even viral diseases. It's very difficult to get specimens. In order to culture and get a positive test for Legionella, you need someone to cough up what is called sputum. This is phlegm from deep in the lung. And so that doesn't happen, especially in Lionella patients, their coughs are not as productive as other types of pneumonia. So those are some things that make the diagnosis difficult. There is a urine antigen test, which is highly effective, but the physician has to order it. The second thing is that there's lots of sources of uh legionella in the environment. You know, we're going to talk uh specifically about what cooling towers are during this uh conversation. But Legionelle is an environmental bacteria, it colonizes plumbing systems. So there's lots of different sources from it. And when you have a city of eight million people packed together, the likelihood of a couple cases being close to each other isn't all that unusual. So there are some challenges in detecting when a true cluster is happening as as opposed to the spurious cluster.
SPEAKER_01Yeah, absolutely. Thank you, Don. Really great description. I I think I would say that, you know, we already talked about how they these bacteria are very difficult to culture. So very few clinical laboratories actually keep on hand the specialized media that's needed to culture these bacteria. And like Don said, many labs, unless it's specifically ordered, aren't able to get that sputum specimen from the lower lung. They're doing this great urine antigen test that was brought on the market in about 2000, which is really terrific because it can identify these cases, but only of one subset of the cases, the most common, Legionella nemophila CR group one. The other part is that if the physician is only taking a urine sample for this testing, we can't do culture or PCR from that specimen. And so while we know the cases there and we're missing some cases that may be not detected by this test, and we're not getting that organism to understand the source and be able to compare it to any environmental samples that are collected. So it's it's really tricky. I think it's great there's this test, but it also confounds some of the public health work that usually it isn't a urine and a respiratory or sputum sample that's ordered at the same time. And it's only in these larger outbreaks that the physicians and the clinical labs and the epidemiologists start to be much more proactive about really trying to get the right specimen for the investigative work.
SPEAKER_04And that's the key point there, Kim mentioned, and we'll talk about this later in in the conversation, is that linking between a clinical specimen and an environmental specimen. And here we borrow heavily from our colleagues in criminology. So if you get a DNS DNA specimen of the crime scene, you want to match that to an actual person, their DNA. And once you have that match, you know, that's pretty good evidence that those two, that person in that event are linked. So in our world, it's saying, okay, we have these people who have Legionella, we've gotten cultures on, and we have that DNA profile of that organism. Can we find it in the environment?
SPEAKER_02Mm-hmm. That was great. I'm going to walk just through what happens as a clinician. So when I would see patients with pneumonia in the hospital, you've you've touched on these just to reiterate, sometimes we wouldn't test for Legionella because the treatment that we're going to give, as you mentioned empirically, we're going to treat Legionella regardless of the test results. And so I would try to get a specimen for Legionella for public health reasons. And that specimen, as Kim mentioned, is a urinary test for an antigen, which is just the protein. No genetic material in that. So we would know, oh, they have Legionella. And then if there were a cluster of cases, Don's team would come in and say, Can you get a specimen? So I think it makes for a very challenging outbreak. And probably one in public health that you have to be a bit of a saint, maybe, I know, to want to do Legionella work because I uh as I read in I I think one of the papers that you had, you don't find the source most of the times. You you do a lot of the times, but there's some times you just can't find the source. So let's go to the the New York City outbreak in the Bronx. I I know, Don, that you were alerted to this and you recognize that it was a problem. Can you walk us through what happened and how you responded to that outbreak?
SPEAKER_04Sure. We're we're back in July of 2015. We had a set up a system, a statistical system that scanned the cases as they came in. It would uh look for clustering in space and time using something called SAT scan. And it would just set out an alert, and then you know, that alert would have a certain probability along with it on how unusual it was. And as you mentioned, a lot of these alerts would get investigated and didn't go anywhere. I think the original SAT scan alert had eight cases in an area of the South Bronx. But over time that that grew, you know, expanded to some twenty and eventually thirty or so cases over the course of a couple of weeks. Whenever you have that many cases, it is invariably what's the source is a cooling tower, at least in New York City. Cooling towers are engineering devices. They're used to create air conditioning for buildings. They use uh the principle of water evaporation to cool a second water system. So there's two water systems, one that's open to the air and the other that goes circulating through the building, and one cools the other. What happens is that there's a tray, uh reservoir at the bottom of this cooling tower. It's open to the air, it can contaminate with bacteria, and because the water is warm, it's an ideal growth situation for Legion Noah. And what the cooling tower will do is it'll draw air in from the surrounding environment and then funnel it up through the tower in order to cause that evaporation and cooling of the water in the pipes that is in the cooling tower. And some of that vapor then gets exhausted out the top of the cooling tower. Now we think that the cooling towers lower to the ground pose a greater risk to people because obviously that vapor will not be affected by UV light as long. It'll fall to the ground where or where people can inhale it. And so we started right away at the end of uh July looking for the source. It was complicated because at the time there was no registry of cooling towers, which means that we had to use a bunch of different methods going door to door. There were some partial lists. You know, if you had a new building permit, you would list a cooling tower there. There was also a rebate program where you were using recycling water so you didn't have to pay as much for your sewer bill. So these were partial lists. And so we sent inspectors out looking in this area, trying to find a cooling tower. But the tooling tower that was the source wasn't actually on any of those lists.
SPEAKER_02Yeah, in your chapter, it really describes shoe leather epidemiology at its finest, literally, walking the streets and looking at the tops of buildings and also looking at satellite imagery. So you have a list from the city, the Department of Buildings, and I think environmental protection, a couple of different departments within New York City. But you went out and you walked the streets and found, I think that's how you found the cooling tower that ended up being the source.
SPEAKER_04Yeah, in this particular outbreak, I didn't do any walking in the streets, but Dan Chimini, who was our legional epidemiologist for a number of years, that's what he had to do. That was before Google imagery. You know, Robert FitzHenry, who took over for Dan Chemini, showed me how to look on Google Earth. He was busy reviewing the investigations, so I had the time. I took a map of where the cases were, and they were all around this park in the South Bunk St. Mary's Park, and they seemed to be clustered there. So I started there and started moving opposite the way the wind would go, looking for anything that looked like a cooling tower, which is just a big bunch of fan blades on top of a building. Lo and behold, relatively close to that park, I saw one. It wasn't on any lists, it was on top of a hotel there. We had our environmental inspectors go out the next day. Sure enough, there was a cooling tower there. They grabbed samples, and those samples turned out to be positive.
SPEAKER_03Mm-hmm.
SPEAKER_02One aspect of the investigation that I wanted to ask about was that the CDC had recognized or a case of Legionella was reported to CDC where the individual is from North Carolina, but had visited New York City and had stayed in a hotel that I think ultimately had the cooling tower. How did that assist having a central federal agency connect the cases and report that to you?
SPEAKER_04Well, there were several things that had an impact that were very close in space and time. So right behind the hotel was a assisted living housing facility for individuals with various uh medical problems. And there was an outbreak of pneumonia in that building, which was literally, you know, maybe a hundred yards away from the source. The one thing that we haven't talked about, which I think we have to talk about here, is well, how did we even know that a cooling tower had Legionella? So the process would be to culture it, which takes several weeks. But Kim's lab developed a PCR technique that was instrumental in us not only uh uncovering this outbreak, but an outbreak before this and outbreaks after that. So, Kim, maybe you should talk a little bit about your development of that PCR test.
SPEAKER_01Sure, thanks. Thanks, Don. And this is bringing back all sorts of memories from this time. I'm I'm imagining my office and those initial calls with you and others. But in my fellowship that I mentioned, one of my two projects was to develop a Legionella PCR assay that we later transformed into a much better assay using real-time PCR technologies in 2002. Anything that was positive with this Legionella assay, we would do culture on, so we could really direct our culture efforts. And the PCR we developed detected the Legionella genus, so any species of Legionella, it detected Legionella nemophila specifically, all of the 15 SIR groups that could cause Legionnaire's disease, as well as Legionella Neumophila SIR Group 1, which is that major pathogen in the Legionella family, and that was the culprit in this case. And so when Don called and asked if we could help out in conjunction with the work happening in the New York City Public Health Lab, that we could screen samples, give very rapid PCR results, we started doing that right away. We would send spreadsheets the day of receipt back to to Don and all of the others that became a big part of the list of the reporting, I think pretty much for a three-week period almost every day.
SPEAKER_02Yeah, I did read in the book that these specimens could come in at any time from New York City and that you had to be open and receive them, and and that turnaround is really impressive. So going back to the PCR, just for people who haven't heard those, that acronym, if you could give a little description of what PCR is.
SPEAKER_01It's been a very important part of infectious disease work, but lots of work on for all diseases and many different types of research. But but we use PCR, polymerase chain reaction, as a test that allow us to detect what we're interested in. So in this case, detecting DNA from Legionella. And the way it works is if the target of interest is present, so let's say the Legionella Numopilis zero group one, we have a set of specific small pieces of DNA referred to as primers that only bind to that type of DNA in all the world. It's very, very specific, and a probe that will fluoresce if the target is present. And so we will mix the unknown sample with this cocktail of these specific primers and probes. Polymerase will create copies of the DNA if it is present. And we will do this for 35 to 40 cycles, which can create 35 billion copies of that initial piece of DNA so that we have enough to visualize either on a gel or when we use the probe, we can visualize the fluorescence.
SPEAKER_02One thing that people talk about is quantitative PCR. Is that useful in these outbreak investigations to understand the density or how much legionelle is in that source? Or is this a yes-no, you have it or you don't have it?
SPEAKER_01It's kind of both. So we develop the assay as a yes-no, but we develop it to be as sensitive as it can possibly be. We do as much optimization of the temperatures and the times to make a highly sensitive assay that gives us a qualitative yes or no. But we also get a CT value, and that is a value with a real-time PCR using that probe so that every cycle we monitor fluorescence that's detected, and it gives us this value, CT cycle threshold of where it crosses a background level of DNA. And that level is something that we were reporting during this outbreak to Don just to help guide the investigation. And if the CT value is very low, say you start to see it at cycle 15, the 15th time it cycles through the temperatures, that means there's a lot of Legionella DNA present. And we can, if we do 40 cycles of PCR, we might see some come up very late, like 36 or 37. And those would be very low amount of DNA in the initial sample, but we did provide that information. And I think at times that was helpful to see that on these reports.
SPEAKER_04Mm-hmm. And if I could just give some context to how important this was to our investigations. So prior to having the ability to check the environment for Lichenoa, it was as if we were looking for our car keys in a room that was totally dark. And you were just fumbling around trying to find them. And then by getting this tool, it was like handing us a flashlight so we could go, oh, there they are.
SPEAKER_02Great metaphor for the yeah, for for the work that you had to do as a disease detective. I I I also wanted to ask, it it sounded like this was a developed by public health laboratories, that there may not have been a commercial interest in this, and public health had to step in for this specific purpose, protecting the public from these outbreaks.
SPEAKER_01Yeah, I think that's a really great point that sometimes, you know, certainly being in a state like New York, and and there are many others with big cities that that start to see infectious diseases maybe before lots of places around the country, sometimes we have to be very forward-thinking to develop assays that we might get requests for, or we're starting to get requests for. We do work very closely with CDC. And in the case of our PCR assay, they provided us a lot of strains to do that specificity work that were very valuable to us having the resources available to do a really good development of this assay. Wasworth Center had this thought that our public health role is ever changing and that we're always trying to be ahead and have methods that are available before they become commercially available.
SPEAKER_02Mm-hmm. So back to Don, you had PCR results that that identified cooling towers. You know there's Legionella. Legionella is probably in a lot of cooling towers. So it was important for you to combine the epidemiology or your work in identifying clusters of cases and which ones were positive. And then I think it leads us, you can speak a little to that and what happened next, but you talked about the fingerprinting like a crime scene. So what were your you had the positive towers, the cases, and what happened next?
SPEAKER_04Yeah, so Kim covered the sort of the first phase where we identified cooling towers that had the species that was causing the outbreak. And then that triggered immediate remediation. So all these towers, and you're right, it wasn't just the implicated tower. There were a number of towers that came back positive, and they're all were remediated to remove them as possible this for Legionella. But to identify the one, or there could have been more than one, but the one cooling tower that was responsible for the outbreak, we had to take it to another level of uh laboratory diagnosis. And I'll let Kim expound on that in just a second. But that that was the DNA fingerprinting. So we had cultures. I think we had 26 patients, which was a remarkable. Out of the 138 cases that we had, 26 of them had cultures. Some of them were post-mortem cultures, which was again thanks to Kim's laboratory, because she did that work. And we were able to sequence that DNA using a technique, whole genome sequencing. And then we compared that with the sequences from the various cooling towers. And Kim, why don't you take it from there?
SPEAKER_01We were very fortunate also that really right before this happened in the previous year, we had received a contract through the Association of Public Health Laboratories to investigate and explore whole genome sequencing as a method of fingerprinting for Legionella. We had been using PFGE or pulse field gel electrophoresis since the 1990s, I think a total of about 28 years until 2018. But we had that method in place. We had a long archive, a long history of solving and doing some of the work with that method. But while the method is very good, it is not nearly as discriminatory as a method like whole genome sequencing, where we get the whole genome of each of those clinical cases that Don mentioned and each of those cooling tower cultures. I think it's 4.4 million base pairs. When this outbreak happened, we said we have PFGE, which is a great tool and will be helpful. But when we utilized it initially, all the clinical cases and a number of the cooling towers all looked identical with that method. That only interrogates about 1% of the genome. We just started to look at many of our cases with this new method, whole genome sequencing. Let's take a look at these samples with that method to see what else we can learn. And it really was critical to this investigation that in the end, looking at that whole genome of all of the cooling towers, or many of them that were SEER group one positive, as well as many of the linked outbreak case samples of those 26 that Don mentioned, along with other clinical samples from around New York or New York City, we were able to see that they were identical with this method. So every base of the genome was identical for the 26 patients, as well as from three different samplings of the hotel, cultured by two different laboratories. We looked at, I think, five different samples of that hotel. And they were all zero differences between those genomes, where we did see some others that were two, five, ten, twenty, and and bigger, but it really let us look at this set of data that we're so fortunate, as Don mentioned. We had that many clinical samples from one outbreak to compare and try to do the source findings. So it it that method being able to be overlaid to this investigation was really a terrific tool.
SPEAKER_02It's quite remarkable. I think of Don's uh mentioning that this is like a fingerprint in a crime scene. And we used to think pulse field gel electrophoresis was a fingerprint, but it's probably more like a lineup where you say, yeah, that looks kind of like the guy, you know, but but now it's actually DNA.
SPEAKER_04Well, we ended up with two cooling towers that, as Kim said, were identical on all the methods until we got to a whole genome sequence. One cooling tower is a little further north in the Bronx. It was part of a shelter. There were no cases in the shelter. In that surrounding zip code, the rate was pretty low compared to the hotel in which had a lot of cases in the zip code. There were the cases in the the assisted living facility behind it, there was a case across the street from it. So all the apity was pointing to this. But these two were exact. When the whole genome sequence came back, they were one what's called a single nucleotide. They were one different. So we would never pick this up on PFG. They would have continued, no matter what we did with any other technique other than the whole genome sequence, they would have looked identical and we couldn't have decided, well, is it this one that doesn't make sense? It's north, it doesn't have the cases, or is it the one that really suspected? So that was critical in in def definitively pointing to the source.
SPEAKER_02Mm-hmm. That's such a wonderful example of how molecular methods complemented the epidemiology, and having the whole genome sequencing made it a lot easier to look for that needle in the haystack, or find the right haystack and then find the needle. It's remarkable. And we went from not knowing what the organism was and then finding it under a microscope and now being able to look at the genetic material and sequence the whole genome and be able to match what's found in the environment to the patient. So, Kim, what's next in the microbiology world?
SPEAKER_01So I guess one thing I would say is I I think whole genome sequencing is really critical and important and here to stay. But for a disease like Legionella, where we're really struggling to get those clinical samples, we've been able to go back to some samples even from this outbreak, some of the autopsy samples that we received where we couldn't do culture. We developed an adjustment to that method where we can do direct specimen whole genome sequencing. So where no culture is available, but we do have some clinical material like a respiratory sample. I think we we applied it to sputums, other respiratory samples, and autopsy, fresh lung tissue samples, we could apply through a specialized hybridization capture or a baiting to pull out all the DNA in that sample, even if there's no culture, and then perform a whole genome sequencing test in a slightly different way. And we've been able to utilize that in some cases to help solve outbreaks where there is no culture material available. I don't think we can do it on the urine, but I think that's kind of improving and fine-tuning this these genomic methods we have, and also metagenomics may also play a bigger role in the future.
SPEAKER_02At the risk of getting very technical, metagenomics is well, I'm gonna stop. You brought the word up, it's your responsible. Can you exemplify that for us and and how you think that's gonna play a role?
SPEAKER_01Yeah, so completely fair. I'm trying to be careful and and not get too technical, but what metagenomics does is it randomly will detect and sequence all of the DNA in a particular sample. And you can also do this with RNA, but so if you have, like, say, a clinical sputum sample, if you apply a method that's a metagenomics method, it will try to amplify everything in that sample. You will get human DNA, you will get normal flora within the lung or the mouth, detect it, but you will amplify everything in that, and then you'll use a series of analysis tools on the genomic data to try to take out any human DNA and then to look at what is of what is present in that sample. And some labs are starting to use this clinically on samples like cerebral spinal fluid, where there's no culture available. And it's a much cleaner sample than, say, a sputum sample. There's been a lot of success trying to use these methods where you can look for any DNA, whether it's culturable or not, and then try to use analysis tools to understand what's meaningful in that sample to come up with the right treatment and diagnosis for the person.
SPEAKER_02Mm-hmm. So there'll be some diseases that are discovered as infectious that we never grew anything, but there's some DNA that we didn't expect, I'm guessing, is where this is going. The mystery diseases and why someone died, and we never figured it out clinically. But but now we'll see DNA that we didn't expect.
SPEAKER_01Yes, and Don and I have also worked over the years on bacterial meningitis cases, and so we have a freezer full of these CSF samples and DNA from those samples that we've applied all of the typical bacteria to look for what's present with PCR assays, but we want to go back with some of these newer methods.
SPEAKER_02Sounds like your public health career is not over, Don. Back to the Bronx. There are a couple of things that I thought were important that often get involved in public health. It's public, it's part of the political system. Are you willing to describe some of the challenges with the politics? And I I think there was an ethical stand that that was taken and and some battles between the health department and the political system.
SPEAKER_04Sure, Bill. It's already out there. It's in the book, so it's in the public domain. I'm happy to discuss it.
SPEAKER_02Politics inserts itself into outbreaks. They're in the news, the public is clamoring for solutions, and the solutions that could be science-driven, and that's what the public health departments are trying to do, there can be some interference. What interference did you encounter and and how was that dealt with?
SPEAKER_04Well, let me preface it by saying we had about a decade or maybe a dozen years where the health department was recognized as being the authority, and at least the local government, even the state government, just sort of deferred to us with the outbreaks. That seemed to change in 2014 and 15. And clearly there's a difference between what the objectives of, say, the mayor or the governor was and what the objectives of health departments were. Obviously, our only concern is protecting the public health. That it, that's it. None of us are looking to get any publicity for ourselves. In fact, we're looking for the opposite. We'd like to do our jobs and not have anybody know that we're doing our jobs. And so that's where there seemed to be crisis or a conflict. Our approach was all right, we have data, we know where the cases are, we've mapped the cases. The map tells us a lot. We're gonna move out from where the the center of the cases are in concentric circles and test those cooling towers and keep screaving out and out until we've found what we needed to find, and then we would stop. The mayor decided that he wanted every cooling tower in the entire city tested. He pulled inspectors, they were food inspectors, lead inspectors from every part of the city, and they weren't even trained to do this work. And that diluted the person power we had to actually focus in the area of concern. And he wouldn't listen to reason. You know, he said, Hey, I'm the person that's in charge of communication. You know, he he once told us that we think too much or we let science tell us what to do. I'm paraphrasing here. And so that really put us in conflict. And then he lost trust in us. He sent a couple of his staff to stand behind uh our people while they were making the maps. And this is a kid, he couldn't have been any more than twenty or twenty two years old, didn't have any public health background. He didn't know what he was looking at, but he was reporting back to his superiors at City Hall, and about all they wanted to do was change the shade of green that we used. You know, so it was it's quite frustrating to have these people just kind of like in your face all the time. And they were they weren't like polite, you know, they were very dogmatic and and dictatorial about what was gonna happen. And that probably leads into your next question, which is about that ethical conflict that we ran into.
SPEAKER_02Yeah, yeah. So so one of the characters in the chapter, I think his name was Dan Cass. There was an intention to enter buildings without permissions, and that's illegal for the health department, and there were pressures on the health department and him in particular, but he remained steadfast.
SPEAKER_04Yes. So Dan Cass was the deputy commissioner over the environmental section of the health department. So all the inspectors and the supervisors were under him. Inspecting a cooling tower is not exactly a simple thing. It's not like you're going to a lake, you're grabbing grabbing some water and you're leaving. These things are, you know, the m mechanical thing, the moving parts. You don't want to do it in the dark. You want to do it light. So we were being forced to do these inspections at all times of the day. If the building owner wasn't there, the mayor was telling the police and the fire department to knock down the door. And we checked with our lawyers, or I said, no, you can't do that. We had no, I guess you would call it probable cause. Now clearly, if if there's somebody inside a building causing a health hazard, we could enter with the police. But we didn't have for most of these buildings any uh probable cause to to go in and knock down the door. So he told inspectors, no, you can't do that. And he received increasing pressure. The health commissioner received pressure. But both the health commissioner and Dan stood their ground and said, No, we will not break the law.
SPEAKER_02They actually were able to continue beyond this clear. Well, most importantly, you get through an outbreak, you solve it, you do the remediation, that's done. But what public health prides itself on is let's prevent the next one. So, what were the policy changes that resulted from this and how were you involved in that?
SPEAKER_04Yeah, so as I mentioned, at the time there was no a single registry of cooling towers. So that was the first thing that was implemented. And then after that, there were some maintenance and other regulations regarding how often the cooling towers needed to be sampled, both for general chemical like pH and chlorine contact, and then specifically any bacterial growth, and then most specifically cultures for Legionella. Unfortunately, as you may know, there's a current outbreak that started about two weeks ago. Not in that area of the Bronx, but just across the East River estuary in central Harlem. Last count over the weekend were 83 cases and three deaths suspected to be due to cooling towers. So just to get to this regulations, how carefully they were followed. So there were 97 cooling towers in this area where the outbreak is. About 72% of them, almost three-quarters, were sampled for cultures according to the legislation. So more than a quarter were not tested. And that's within three months, which is a really long time. Meaning if you tested the cooling tower when you started it up in in April or May, you wouldn't have to test it again until July or August. And most people think that's too long an interval. When you look at just the last sixty days, that's the cooling towers in this air that were either sampled in July or June, it drops to 42%. So there's a lack of compliance with the regulation. This was a good first step, you know, getting a registry, putting these laws in, but I think we need to take it further.
SPEAKER_02Before I get to the closing question, I'm going to ask either of you, is there anything I've missed that you think you that you would like to talk about, about this outbreak or or Legionella in particular?
SPEAKER_04I would like to point something out. Now, if you look at the populations of both the South Bronx and this area of Harlem, these were vulnerable populations. These are populations in which the poverty level is higher than the rest of the city. They have a higher comorbidity, diabetes, HIV, other lung diseases. So these are populations in which I think public health needs to do a little bit better job at surveillance. So they whereas maybe a cluster of four or five cases in another part of the city wouldn't trigger as much alarm or concern. In these neighborhoods, I think we have a higher level of concern because of susceptibility to Legionella.
SPEAKER_01But I'll just add in that while we've talked about that urine antigen test is a really valuable test, we've now had that test 25 years. It really would be fantastic if we had some additional tests available that look for other types of Legionella, not just pneumophila seri, because we don't know what we're missing in lots of undiagnosed pneumonias and respiratory disease. So I think we only have part of the picture, and it really would be great if we're going to rely on a urinary test like that to have more testing, more Legionella detected, then that really relies on us getting more clinical samples.
SPEAKER_02And touches on so many aspects to a public health response. The coordination of epidemiology and the laboratory, policy changes, the original shoe leather epidemiology work to find those clusters and the the intersection of clinical medicine and public health. And also CDC. So fantastic case. My final question to you would be if you could choose one item to put into your public health bag, literal or figurative, what would it be? Kim, do you want to start?
SPEAKER_01Sure, I can start. So I I I knew you were gonna ask this question. I've been thinking about it, and at different points I was like, you know, thinking of testing, of course, from my perspective, but PCR was something I thought of that is just really made a huge difference in all the work we do for infectious diseases. And then I thought laboratory developed tests, which is our methods that we're able to develop and bring on when needed. But in the end, genomics, I think, and hearing the discussion we had earlier and some of the comments from you both that having a method that can be as discriminatory as a whole genome sequencing method is is really critically important, I think, to solving outbreaks in public health on the laboratory side.
SPEAKER_02Yes, thank you.
SPEAKER_04The reason I say that is because there's no one part of public health that you can use and do your whole job. So your friend and my friend Sharon Ball used to like to say that to a hammer everything's a nail. So to me, being a surveillance person, surveillance would be the thing they would pick up, but just having surveillance alone wouldn't really get us anywhere. So sure we would know there's a lot of cases in in an area of New York City. But if we didn't have the other tools of public health, that really wouldn't do us any good. I thought of this about well, what if if I was on a desert island, I could only have one food. What one food would I have? Well, it sort of makes sense there. Maybe I would choose uh choose a vegetarian pizza or something, you know, and I probably could survive for a while only eating that alone. But as a public health practitioner, I don't think I could survive on surveillance alone. I would need Kim's components of uh of uh diagnostics. I would need our press office, you know, to be able to tell the community what's going on. I would need our field investigators, I would need the people because you know all the data that we use to decide what was going on. People were phone calling and and and asking questions of patients and their relatives. So there's all these components that have to fit together. So that's why I say it's a trick question.
SPEAKER_02Well, to I'll turn that into collaboration. You need all those pieces to work together and not be uh independent.
SPEAKER_01There's a large team here, past and present, that was really involved in developing the tools and doing the work. Liz Nazarian in our group and Pascal Lapierre developed our analysis tools for the sequencing. Really thankful for many contributions that took place then and now. But I also wanted to mention that a lot of the work and especially the genomics that we've been building this infrastructure and bringing on these great tools, so much of it is at risk right now for being taken away from some of the federal changes in funding. And so it worries me a great deal in public health that we've been had some great opportunities to build infrastructure and build our methods over many years, but especially since the COVID-19 pandemic, and the possibility of that funding going away is really scary for the impact that it could have on future public health investigations.
SPEAKER_02Yeah, I yeah. Well said. Um the system might be more fragile than any of us expected over the last several generations, and hope that uh science and public health prevails. Well, I again I thank you both for this wonderful uh example of public health that works and um uh appreciate your time. Thank you.
SPEAKER_04Thanks for having us.
SPEAKER_01Yes, thank you.
SPEAKER_02Many thanks to our guests for sharing their words, but more importantly, their acts of service. Please email us your inspiring governmental healthcare or public health stories at info at inspired to heal.net. Thank you for listening.
SPEAKER_00Inspired to Heal podcasts are for informational purposes only and should not be considered as health or professional advice. You're not responsible for any losses, damages, or liabilities that may arise from the use of this podcast. The views expressed do not necessarily represent those of the host or the guest's current or past employers.
