Another Circle Is Now Complete

The first week I started working at the Maryland Department of Health in 2007, we faced an interesting situation when a person who worked at a government office building came down with legionellosis. Legionellosis is a pulmonary disease caused by the Legionella species of bacteria. It is usually associated with exposures to fine water mists, and can present as a flu-like illness or full-blown pneumonia. There are many sporadic cases of legionellosis, and some are not diagnosed. People are usually just diagnosed with a “community acquired pneumonia,” given an antibiotic, and sent on their way. (Though it can be deadly if comorbidities make fighting off the infection difficult.)

Legionella were first discovered in the 1970s after a big outbreak in Philadelphia. That outbreak happened during the bicentennial celebrations, when a group of American Legion members came down with a respiratory disease of unknown origin. There were almost 200 sick and about 30 deaths during the outbreak. The local, state, and federal public health agencies who responded to the outbreak went through the hotel with a fine tooth comb. They tested everything for everything. They kept coming up empty.

It wasn’t until a group of scientists discovered Legionella as a new species of bacteria, and it was difficult to grow it in the laboratory. (We call these bacteria fastidious.) Once they had the culprit, everything else in the puzzle fell into place. Scientists were able to sample the hotel again and grow Legionella from water sources. The winning theory was that the bacteria were “seeded” in the cooling towers of the hotel building and were released as aerosols in the ventilation system or even outside into the nearby environment. People would breathe in the bacteria and get pneumonia.

When I started working at the lab in Waynesboro, PA, one of the lab techs told me how her father was one of the original victims of the outbreak in Philadelphia. I heard about Legionella from my medical technologies studies, and I heard about the outbreak. But it was always a far-away thing for me. (Being so dry, the climate systems in El Paso didn’t generally lend themselves to cooling towers. That, or I didn’t notice outbreaks of legionellosis when I was there.) When I started studying epidemiology, knowing her story made it more real. When I had the chance, I drove to Philadelphia to see the site. The hotel is still there.

Anyway, back to the case at the government building. As it turns out, the woman who had legionellosis knew about the original outbreak. (Her father or uncle were there. I don’t remember the details correctly.) She told her coworkers about legionellosis and how deadly it could be. Not understanding that legionellosis is not spread person-to-person, or believing she caught it at the building, most employees got up and out of their office spaces and walked out. It was a bit of a crisis, though no Legionella were recovered from the building, and no other people were sick.

That experience taught me much about how a state health department managed things. There were many political considerations. On the one hand, we epidemiologists knew that the odds of the woman catching the disease in the building were low. She had not spent the necessary amount of time in the building for the building to be the sole culprit of her disease. Had she been there the whole incubation period, it would have been another story… More on that later. But the authorities wanted to be seen as doing something, so we were off conducting surveys, looking for more cases of the disease associated with the building, and sampling the water systems of the building.

Of course, that would not be my last time dealing with legionellosis outbreaks or situations. There was a very public outbreak at a building housing elderly residents. That one became interesting because the relative of a well-connected political player in Baltimore lived there. Again, the authorities needed to be seen as doing something or risk backlash. Somewhere out there, there is a clip of people driving up to the building to move their relatives out while the water systems were cleaned and disinfected.

There was also an outbreak associated with a hotel in Ocean City, Maryland. That one got weird because an overzealous “fan” of the hotel threatened violence against us if we shut down the hotel. As it turns out, he was married at the hotel, and he was going to travel there soon to celebrate his anniversary. He even told us he had the hotel tattooed on his chest. I can only imagine what his Yelp reviews were like.

The saddest outbreak was one that occurred at a nursing home. There was a person there who developed legionellosis without leaving the facility. Because of this, the facility had to shut down their water and air conditioning. It was during the summer, in Baltimore. The elderly residents had a hard time staying cool, and they could only drink bottled water. Because of concerns about inhaling the bacteria, there were no showers and no running faucets until the water was tested, and all the lines were cleaned, disinfected, and flushed.

It was sad because so many of those folks had no clue what was going on, and the facility seemed overcrowded. Granted, it could have been the unbearable, humid heat, but everyone seemed so sick. They were so vulnerable, and their lack of understanding made it hard to explain why we were there. There was no panic — or they did not show it — and no one drove up to get them out of the building, like they did in the apartment complex I mentioned before. By the time everything was said and done, the index case died, and a few more cases were detected. The water was eventually clean, and everyone could go back to using water after a few days.

By 2013, I left the health department to work on the doctoral degree. You all know that story. I tried to have my dissertation be based on a novel surveillance and testing system to prevent outbreaks of legionellosis, like the ones I had seen in Maryland, or the big ones that happened in New York City. But the eggheads at Hopkins didn’t see it as something useful. So I did it on a different subject altogether.

You all know the story of what happened from 2013 to 2018. You know what I did after 2018 and how I became the editor of the History of Vaccines project by the College of Physicians of Philadelphia. You know that I worked occasionally on History of Vaccines from 2018 to 2022. You know that I worked full-time for the Fairfax County Health Department from 2019 to 2022. And now, I’ve taken another step in my career. But first, another story of another epidemiologist…

Back in 1976, the head of disease control for the Philadelphia Department of Public Health was Dr. Robert Sharrar. He and his team led the investigation and worked with state and federal public health to identify the cause and contain it. Today, Dr. Sharrar is still involved in public health. He is currently a Fellow of the College of Physicians of Philadelphia, and is the current chair of the Section on Public Health and Preventive Medicine.

Now back to me.

As of October 3, 2022, I am the director of public health for the College. (I’m still the director of History of Vaccines, too.) I’ve left my job at the Fairfax County Health Department. As challenging and rewarding as that job was, I am ready for a new adventure, new challenges. And now, in this new position, I work with Dr. Sharrar and the rest of the section members to bring together bright people to tackle some of Philadelphia’s public health problems.

From first learning about Legionella in my clinical microbiology class at UTEP, to now working with one of the epidemiologists who worked on the original outbreak. Another circle is now complete.