{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,31]],"date-time":"2025-10-31T07:56:48Z","timestamp":1761897408528,"version":"build-2065373602"},"reference-count":24,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2021,1,1]],"date-time":"2021-01-01T00:00:00Z","timestamp":1609459200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Microorganisms"],"abstract":"<jats:p>We piloted a methodology for collecting and interpreting root cause\u2014or environmental deficiency (ED)\u2014information from Legionnaires\u2019 disease (LD) outbreak investigation reports. The methodology included a classification framework to assess common failures observed in the implementation of water management programs (WMPs). We reviewed reports from fourteen CDC-led investigations between 1 January 2015 and 21 June 2019 to identify EDs associated with outbreaks of LD. We developed an abstraction guide to standardize data collection from outbreak reports and define relevant parameters. We categorized each ED according to three criteria: ED type, WMP-deficiency type, and source of deficiency. We calculated the prevalence of EDs among facilities and explored differences between facilities with and without WMPs. A majority of EDs identified (81%) were classified as process failures. Facilities with WMPs (n = 8) had lower prevalence of EDs attributed to plumbed devices (9.1%) and infrastructure design (0%) than facilities without WMPs (n = 6; 33.3% and 24.2%, respectively). About three quarters (72%) of LD cases and 81% of the fatalities in our sample originated at facilities without a WMP. This report highlights the importance of WMPs in preventing and mitigating outbreaks of LD. Building water system process management is a primary obstacle toward limiting the root causes of LD outbreaks. Greater emphasis on the documentation, verification, validation, and continuous program review steps will be important in maximizing the effectiveness of WMPs.<\/jats:p>","DOI":"10.3390\/microorganisms9010089","type":"journal-article","created":{"date-parts":[[2021,1,1]],"date-time":"2021-01-01T22:35:48Z","timestamp":1609540548000},"page":"89","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":13,"title":["A Methodology for Classifying Root Causes of Outbreaks of Legionnaires\u2019 Disease: Deficiencies in Environmental Control and Water Management"],"prefix":"10.3390","volume":"9","author":[{"given":"Benjamin R.","family":"Clopper","sequence":"first","affiliation":[{"name":"Oak Ridge Institute for Science and Education, P.O. Box 117, Oak Ridge, TN 37830, USA"},{"name":"Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Mailstop S106-5, 4770 Buford Highway, Atlanta, GA 30341, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jasen M.","family":"Kunz","sequence":"additional","affiliation":[{"name":"Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Mailstop S106-5, 4770 Buford Highway, Atlanta, GA 30341, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Simone W.","family":"Salandy","sequence":"additional","affiliation":[{"name":"Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Mailstop S106-5, 4770 Buford Highway, Atlanta, GA 30341, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"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, Mailstop H24-6, 1600 Clifton Road, Atlanta, GA 30333, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brian C.","family":"Hubbard","sequence":"additional","affiliation":[{"name":"Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Mailstop S106-5, 4770 Buford Highway, Atlanta, GA 30341, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6409-2114","authenticated-orcid":false,"given":"John P.","family":"Sarisky","sequence":"additional","affiliation":[{"name":"Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Mailstop S106-5, 4770 Buford Highway, Atlanta, GA 30341, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,1,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1190","DOI":"10.15585\/mmwr.mm6442a2","article-title":"Active Bacterial Core Surveillance for Legionellosis\u2014United States, 2011\u20132013","volume":"64","author":"Dooling","year":"2015","journal-title":"MMWR Morb. 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