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Unsafe practices are an underestimated contributor to the disease burden of bloodborne viruses. Outbreaks associated with failures in basic infection prevention have been identified in nonhospital settings with increased frequency in the United States during the past 15 years, representing an alarming trend and indicating that the challenge of providing consistently safe care is not always met. As has been the case with most medical specialties, there have been public health investigations by state and local health departments, and the Centers for Disease Control and Prevention have identified some instances of unsafe practices that have placed podiatric medical patients at risk for viral, bacterial, and fungal infections. All health-care providers, including podiatric physicians, must make infection prevention a priority in any setting in which care is delivered.

Since 1978, the New York State Department of Health’s public health laboratory, Wadsworth Center (WC), in collaboration with epidemiology and environmental partners, has been committed to providing comprehensive public health testing for Legionella in New York. Statewide, clinical case counts have been increasing over time, with the highest numbers identified in 2017 and 2018 (1022 and 1426, respectively). Over the course of more than 40 years, the WC Legionella testing program has continuously implemented improved testing methods. The methods utilized have transitioning from solely culture-based methods for organism recovery to development of a suite of reference testing services including identification and characterization by PCR and pulsed-field gel electrophoresis (PFGE). In the last decade, whole-genome sequencing (WGS) has further refined the ability to link outbreak strains between clinical specimens and environmental samples. Here we review Legionnaires' disease outbreak investigations during this time period including comprehensive testing of both clinical and environmental samples. Between 1978 and 2017, 60 outbreaks involving clinical and environmental isolates with matching PFGE patterns were detected in 49 facilities from the 157 investigations at 146 facilities. However, 97 investigations were not solved due to the lack of clinical or environmental isolates or PFGE matches. We found 69% of patient specimens from New York State (NYS) were outbreak-associated, a much higher rate than other published reports. The consistent application of new cutting-edge technologies and environmental regulations have resulted in successful investigations resulting in remediation efforts. Importance Legionella , the causative agent of Legionnaires’ disease (LD) can cause severe respiratory illness. In 2018, there were nearly 10,000 cases of LD reported in the United States (1), with actual incidence believed to be much higher. About 10% of patients with LD will die and as high as 90% of patients diagnosed will be hospitalized. As Legionella are spread predominantly through engineered building water systems, identifying sources of outbreaks by assessing environmental sources is key to preventing further cases LD.

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