{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T05:49:04Z","timestamp":1789019344219,"version":"build-2803163510"},"reference-count":30,"publisher":"SAGE Publications","issue":"1","license":[{"start":{"date-parts":[[2023,3,27]],"date-time":"2023-03-27T00:00:00Z","timestamp":1679875200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Public Health Rep"],"published-print":{"date-parts":[[2024,1]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives:<\/jats:title>\n                    <jats:p>On September 23, 2019, the North Carolina Division of Public Health identified a legionellosis increase in western North Carolina; most patients had recently attended the North Carolina Mountain State Fair. We conducted a source investigation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>Cases were fair attendees with laboratory-confirmed legionellosis and symptom onset within 2 to 14 days (Legionnaires\u2019 disease) or \u22643 days (Pontiac fever). We conducted a case-control study matching cases to non-ill fair attendees as control participants and an environmental investigation, and we performed laboratory testing ( Legionella bacteria culture and polymerase chain reaction) of 27 environmental samples from fairgrounds and hot tubs and 14 specimens from case patients. We used multivariable unconditional logistic regression models to calculate adjusted odds ratios for potential Legionella exposure sources and risk factors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>Of 136 people identified with fair-associated legionellosis, 98 (72%) were hospitalized and 4 (3%) died. Case patients were more likely than control participants to report walking by hot tub displays (adjusted odds ratio\u2009=\u200910.0; 95% CI, 4.2-24.1). Complete hot tub water treatment records were not kept, precluding evaluation of water maintenance conducted on display hot tubs. Legionella pneumophila sequence types (STs) were consistent among 10 typed clinical specimens (ST224) but distinct from the only positive environmental sample from the fair (ST7 and ST8).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>Hot tub displays were identified as the most likely outbreak source, making this the largest hot tub\u2013associated Legionnaires\u2019 disease outbreak worldwide. Following the investigation, the North Carolina Division of Public Health and the Centers for Disease Control and Prevention released guidance on mitigating risk of Legionella exposure from hot tub displays. Results highlight the importance of properly maintaining equipment that aerosolizes water, including hot tubs intended for display purposes only.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/00333549231159159","type":"journal-article","created":{"date-parts":[[2023,3,27]],"date-time":"2023-03-27T07:02:06Z","timestamp":1679900526000},"page":"79-87","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":4,"title":["Legionnaires\u2019 Disease Outbreak Associated With a Hot Tub Display at the North Carolina Mountain State Fair, September 2019"],"prefix":"10.1177","volume":"139","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5447-0329","authenticated-orcid":false,"given":"Catherine V.","family":"Donovan","sequence":"first","affiliation":[{"name":"North Carolina Department of Health and Human Services, Raleigh, NC, USA"},{"name":"Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA"},{"name":"Now with the Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer K.","family":"MacFarquhar","sequence":"additional","affiliation":[{"name":"North Carolina Department of Health and Human Services, Raleigh, NC, USA"},{"name":"Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erica","family":"Wilson","sequence":"additional","affiliation":[{"name":"North Carolina Department of Health and Human Services, Raleigh, NC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Megan","family":"Sredl","sequence":"additional","affiliation":[{"name":"North Carolina Department of Health and Human Services, Raleigh, NC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4191-7427","authenticated-orcid":false,"given":"Lauren J.","family":"Tanz","sequence":"additional","affiliation":[{"name":"North Carolina Department of Health and Human Services, Raleigh, NC, USA"},{"name":"Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer","family":"Mullendore","sequence":"additional","affiliation":[{"name":"Buncombe County Health and Human Services, Asheville, NC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aaron","family":"Fleischauer","sequence":"additional","affiliation":[{"name":"North Carolina Department of Health and Human Services, Raleigh, NC, USA"},{"name":"Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica C.","family":"Smith","sequence":"additional","affiliation":[{"name":"Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claressa","family":"Lucas","sequence":"additional","affiliation":[{"name":"Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jasen","family":"Kunz","sequence":"additional","affiliation":[{"name":"Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zack","family":"Moore","sequence":"additional","affiliation":[{"name":"North Carolina Department of Health and Human Services, Raleigh, NC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2023,3,27]]},"reference":[{"key":"bibr1-00333549231159159","doi-asserted-by":"publisher","DOI":"10.3201\/eid0801.010176"},{"key":"bibr2-00333549231159159","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/29.6.1092"},{"issue":"1","key":"bibr3-00333549231159159","first-page":"43","volume":"3","author":"McEvoy M","year":"2000","journal-title":"Commun Dis Public Health"},{"key":"bibr4-00333549231159159","doi-asserted-by":"publisher","DOI":"10.2807\/ese.17.37.20271-en"},{"issue":"1243","key":"bibr5-00333549231159159","volume":"119","author":"Ruscoe Q","year":"2006","journal-title":"N Z Med 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Legionnaires\u2019 disease outbreak associated with the North Carolina Mountain State Fair, 2019. 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What owners and managers of buildings and healthcare facilities need to know about the growth and spread of\n                      Legionella\n                      . Accessed August 5, 2021. https:\/\/www.cdc.gov\/legionella\/wmp\/overview\/growth-and-spread.html"},{"key":"bibr23-00333549231159159","first-page":"56","volume":"59","author":"Hunter CM","year":"2017","journal-title":"ASHRAE J"},{"key":"bibr24-00333549231159159","doi-asserted-by":"publisher","DOI":"10.3201\/eid0908.030337"},{"key":"bibr25-00333549231159159","doi-asserted-by":"publisher","DOI":"10.3201\/eid2311.170308"},{"key":"bibr26-00333549231159159","unstructured":"Hammell C. State fair hot tub sales: how to win big. Aqua Magazine. April 12, 2016. Accessed June 15, 2021. https:\/\/aquamagazine.com\/retail\/a-fair-advantage.html"},{"key":"bibr27-00333549231159159","unstructured":"Hot Tub Insider. The top 10 largest state fairs to buy a hot tub. Accessed June 15, 2021. https:\/\/hottubinsider.com\/top-10-largest-state-fairs-buy-hot-tub"},{"key":"bibr28-00333549231159159","unstructured":"North Carolina Department of Health and Human Services. Legionellosis risk mitigation for temporary event vendors. September 25, 2019. Accessed June 15, 2021. https:\/\/epi.dph.ncdhhs.gov\/cd\/docs\/LegionellaTemporaryFactSheet25Sep19.pdf"},{"key":"bibr29-00333549231159159","unstructured":"Centers for Disease Control and Prevention. Hot tub displays and\n                      Legionella\n                      risk\u2014guidance for environmental and public health practitioners. March 25, 2020. 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