The Bellevue-Stratford Hotel has stood along Broad Street in Philadelphia's Center City since the early 1900s, its French Renaissance-style architecture and grandiose stature making it a landmark. Yet the elegant 19-story building, which is listed on national and local registers of historic places, is perhaps best known outside Philadelphia as the place where a mysterious and sometimes fatal disease came to light.

The Bellevue-Stratford hosted the 58th state convention of the American Legion Department of Pennsylvania July 21-24, 1976. In the days that followed the convention, the mystery disease killed 34 participants and sickened 221, all of whom had spent time at the hotel.

It is now known that legionella bacteria lurked somewhere within the hotel. Researchers still haven't identified the exact source, according to Dr. Victor L. Yu, chief of the infectious disease section at the Pittsburgh Veterans Affairs Medical Center in Oakland.

The hotel, built from 1902-1904, closed shortly after the outbreak for rehabilitation, according to Jeff Barr, a historical research technician with the City of Philadelphia Historical Commission.

It reopened in 1979 under a new name - the Fairmont Hotel - only to revert back to the Bellevue-Stratford Hotel some years later, he said. "It went through a major renovation in the early 1990s" to include a combination retail and office space, Barr said.

Today, only the upper floors of the building offer lodging accommodations, an operation that Barr described as a "high end hotel."

Survivors of outbreak struggle with memories

While the country was celebrating its 200th birthday and Americans nationwide were reveling in patriotism, veterans in Pennsylvania were mourning. Members of the American Legion were surrounded by death and sickness following the group's annual state convention held in July 1976 at Philadelphia's Bellevue-Stratford Hotel.

The disease responsible for the tragic situation proved to be a mystery killer to the medical community. Without a name or face to give the malady, it took on an identity linked to those it affected most. It became Legionnaires' disease. "It didn't make it look too good for the American Legion because people didn't want to affiliate with us," Jeannette resident Mario Maloberti recalled recently.

Maloberti, 63, a member of Jeannette American Legion Post 344, was one of 221 people who contracted Legionnaires' disease while attending the convention. Thirty-four others died. "Some of our legionnaires were upset because of the name," said Hazelwood resident Dorothy Cusick, 79, who was elected president of the American Legion Auxiliary Department of Pennsylvania during the 1976 convention.

Cusick said naming the disease after her group "cast a dark cloud" over the American Legion. The name, she said, seemed to hint that only veterans could get the disease. Maloberti and Cusick were among the thousands who attended the convention and later felt the reverberating effects of the disease.

Friends and neighbors died. Others endured lengthy hospital stays. In some cases, the sick and their family members were ostracized by their communities. "I don't hold it against anybody. It's something that doesn't happen in your home town. It happens in other places, and people just don't know how to react," said Janet Maloberti, who endured public scrutiny while her husband was treated at Monsour Medical Center in Jeannette.

American Legion volunteers Dorothy Cusick (left) and Alice Cherubin remember the outbreak of Legionnaire s' disease. (J.C. Schisler photo)

"I was losing my voice because nobody would come near me," Janet Maloberti said, explaining that she was forced to shout to people who kept their distance for fear of catching Legionnaires' disease from her.

Similar experiences were shared by Cusick and her friend Alice Cherubin, both members of the American Legion Auxiliary Fort Black Unit No. 538 in Hazelwood. No members of their families were afflicted with the disease.

Cusick and Cherubin, 76, of Beechview, and their children attended the convention with their husbands. The men stayed at the Bellevue-Stratford Hotel, where researchers say the legionella bacterium lurked, while the women and children stayed at the nearby Ben Franklin Hotel. "Everything was fine. I had my whole family there," Cusick said. "The convention was a vacation for a lot of the families. After we returned home, we started hearing about people getting sick and dying."

"I started my year as president by going to funerals and visiting the sick," she continued. "When we got back home, people were treating us so rotten."

Cherubin agreed, recalling incidents in her hometown.

"When I went to stores in Beechview, everybody knew I'm with the legion," she explained. "They didn't want to touch any of my money or nothing. They thought I was contagious."

Janet Maloberti never feared catching the disease from her husband. "We didn't know what the cause of the sickness was, but after a while doctors assured me that Mario's condition was not contagious," she said.

Mario Maloberti initially thought he had the flu when he returned home from the state convention and developed a cough and high temperature. When he heard fellow legionnaires had fallen ill and some had died, he went to the hospital.

He credits the late Edward Hoak, a Manor Borough native and American Legion state adjutant at the time, with ensuring that legionnaires across the state sought medical treatment. It was Hoak, said Maloberti, who notified the Pennsylvania Department of Health and statewide media about the mystery illness.

Meanwhile, Maloberti spent nine days in the hospital. "I watched the funerals on the TV in the hospital," he said, noting that a neighbor and fellow legionnaire, Louis Byerly, died from the disease. While in the hospital, Maloberti received numerous calls from reporters.

The disease attracted national attention, and Maloberti recalls the media attention following him and other Pennsylvania legionnaires to the August 1976 national American Legion convention in Seattle, Wash. Two decades later, Maloberti doesn't dwell on the fact that he had Legionnaires' disease. Still, he wonders whether it contributed to other health problems developed through the years.

Cusick said the negative feelings concerning the name of the disease have diminished over the years. "Now I think the name is more in their memory and their honor," she said, referring to the legion members afflicted in 1976.

By Lori Heller
TRIBUNE-REVIEW

What began 20 years ago today as a mission of patriotism and camaraderie ended in death and mystery. Across the state, 34 people died and 221 others fell ill to a malady that quietly struck during the 58th annual state convention of the American Legion Department of Pennsylvania. The convention was held July 21-24, 1976, in Philadelphia's Bellevue-Stratford Hotel.

But it wasn't until the thousands of veterans and their families returned home that the mystery killer showed its face. American Legion officials in Pennsylvania began to receive calls from across the state. Friends had died, and many more were sick.

Nobody knew why. Was it something in the air within the Bellevue-Stratford? Could it have been the abundance of pigeon droppings outside the hotel? How about the water held in galvanized canisters throughout the convention? No one was able to identify the source, to find the link connecting those who were stricken.

Almost immediately, the pneumonia-like illness garnered the name Legionnaires' disease. It wasn't until January of the following year that the Centers for Disease Control in Atlanta, Ga., identified the bacterium responsible for the outbreak.

With the cause of the disease known, researchers still were baffled as to where the legionella bacterium lives and breeds.

In 1982, microbiologist Janet E. Stout at the Pittsburgh Veterans Affairs Medical Center in Pittsburgh's Oakland Section identified the bacterium's source to be water from potable water found in household spigots to puddles along the road. It is most often found in the water systems of large buildings.

Stout, employed in the medical center's special pathogens laboratory, recently said the bacterium's mode of transmission is still in question. "There is debate over how that happens," she said. "The logical question is, `How does it get from the water to the patient?'"

The Centers for Disease Control say the bacteria get into the body through the lungs either by inhalation of airborne water droplets or by aspiration of water containing legionella bacteria. Stout agrees, but says she has found enough evidence to convince her that people also can catch the disease from drinking water containing the bacteria.

Research on legionella bacteria at the VA medical center in Oakland has been under way since the late 1970s, and today scientists from all over the world visit the hospital to learn about Legionnaires' disease. For example, medical researchers who discovered the first cases of the disease in China and Turkey were trained at the center.

Twenty years after the Bellevue-Stratford outbreak, the disease has a low mortality rate with early diagnosis and proper treatment. Researchers at the VA center are working to improve both detection and treatment. To do that, they say they must educate the public and the medical community.

The disease is still being misdiagnosed as pneumonia in many cases, according to Dr. Victor L. Yu. Yu, one of the most zealous researchers of the disease nationwide, is the chief of the Oakland VA medical center's infectious disease section.

He is displeased that the public carries misperceptions about the 1976 outbreak. Some still believe the source of the bacterium to be the Bellevue-Stratford's air conditioning system when, in fact, the source has never been identified, Yu said. "It disturbs us because many of these people are physicians," Yu said. "This is one of the great modern myths."

The legionella bacterium had eluded science for years prior to 1976, according to Yu. Following the 1977 identification of the bacterium, researchers were able to link Legionnaires' disease to earlier unexplained deaths: a single fatality in 1947 and to 15 deaths in a Washington, D.C., hospital in 1965. The legionella bacterium was also responsible for causing an illness that hit 11 members of the Odd Fellows who attended a convention at the Bellevue-Stratford Hotel in 1974, Yu said.

The link was made when tests were performed on preserved lung specimens from the dead and on blood samples taken from the Odd Fellows who survived the 1974 outbreak.

He attributes the death rate resulting from the outbreak at the 1976 American Legion convention to the advanced age, poor physical condition and heavy smoking habits of many attendees. Yu stressed that most people in good health are immune to the bacteria.

Since it was named 20 years ago, Legionnaires' disease is still a mystery to doctors. While they recognize the bacterium is viable in water, they have yet to determine how it infects people.

In the past 20 years, most notable outbreaks of the disease have occurred in hospitals or nursing homes - facilities with a high population of sickly people and people with impaired immune systems.

The Allegheny County Health Department, through a task force of which Yu is a member, three years ago established a set of guidelines to help health care centers prevent and control in-house outbreaks of the disease.

The department's standards were published in what amounted to the first practical guide to Legionnaires' disease available in the United States. Guidelines were created after a survey found that legionella control measures in area hospitals were non-existent or varied widely in scope and frequency, according to Guillermo Cole, the department's public information officer.

The following guidelines were issued:

Test water systems such as hot water tanks, faucets and shower heads annually, with more frequent checks in units serving transplant patients, who are more vulnerable to infection.When legionella bacteria are found, disinfect the water system if there are any current or prior cases of hospital-acquired Legionnaires' disease or if 30 percent or more of the samples are contaminated.

Disinfect using one or any combination of these techniques: Raise the chlorine content to 2 to 6 parts per million; heat water to 158 degrees and flush all outlets or heat water to 190 degrees and blend with cold water to achieve a purging temperature; apply ultraviolet radiation; or use metallic ionization.

The task force reconvened earlier this month to update the guidelines, which Yu expects to be used as national standards. "We are fortunate to have Victor Yu and a few others who are renowned on this issue worldwide" as task force members, Cole said.

AT HOME IN WATER

Yu and Stout currently are developing better ways to treat patients with the disease, Yu said. In addition, the two researchers want to identify better ways to control the bacterium in water systems.

Yu said the bacteria multiplies in water between 100 degrees and 120 degrees Fahrenheit. For that reason, the VA center keeps its water temperature at 140 degrees. In addition, the facility checks all patients for Legionnaires' disease at the time they are admitted to the hospital.

Although Stout spends a great deal of time in the laboratory, she said a portion of her work calls for her to travel across the country. She speaks publicly on the issue, especially before engineers, plumbers and the folks responsible for operations at health care centers. "They are not very knowledgeable about legionella at all," Stout said.

This year she will speak before the National Association of Plumbing Engineers in Phoenix, Ariz., and before the World Plumbing Conference in Chicago, Ill.

Stout noted that, at times, it's a tough job trying to convince professionals and the public that the water system is the source of legionella bacteria. Although the bacterium can show up in any water source, it's not often found in private residences. "It isn't, for example, in most homes," Yu stressed. "Over 90 percent won't have it."

During the 1980s, a study was undertaken by researchers at the VA medical center to determine how widespread the bacteria strain is in private homes. The research relied upon the people for whom the disease is named. "We asked the American Legion to open its doors to us," Yu said. "There would be no other group willing to listen to us."

Stout said the study called for six geographic areas of Pittsburgh to be tested. Researchers went into homes of legionnaires and retrieved water samples. In addition, urine and blood samples were taken from those living in the tested homes.

Results showed about 7 percent of the residences had legionella bacteria in the potable water supply, but no person had the disease. "What did we find? They weren't at risk," Yu said. "That was a relief for everybody."

A look into the Bellvue Stratford Hotel

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	BELLEVUE STRATFORD HOTEL BROAD STREET


MAP COURTESY LIBERTYNET


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Twenty Years after the outbreak, Legionnaire`s Disease marches on

The ex-Navy man healthy just days earlier -- coughed again, spraying a bloody mist Hours later, he died a suffocating death in a small town in Pennsylvania,
Then a second Legionnaire died, this time in suburban Pittsburgh. Then others.

Right around the state that weekend in July 1976, Legionnaires who had attended a state convention in Philadelphia a week earlier and others who had passed through the convention hotel were falling ill.

In all, 34 died and182 were sickened with Legionnaire`s Disease

Legionnaires' disease forced the world's heath experts to face facts: They didn't know it all.
The chief of respiratory diseases at the Centers for Disease Control and Prevention in Atlanta. said the disease is very under diagnosed.

Researchers believe people catch it by inhaling infected water vapour. A few cases have been traced to drinking contaminated water, and at least two people have acquired Legionnaires' through cuts.

About 4,400 people attended the July 21-24 convention, filling the hotel with revelry and parade preparations. Many left feeling rundown and tired.

The sickness was hitting all over the state, but the two youngest victims came from Dolan's post. Dolan's friend Ralph, the ex-Navy officer, was in terrible shape, as was Jimmy Dolan, a cousin who lived just down the block. The three men had roomed together in Philadelphia.

Jimmy Dolan died Saturday; Ralph, early Monday morning.

They were among the first to go, said Michael Dolan, now 62. When they died, he started to alert the Legion community. They were all spread out, the dead. When (Dolan and Ralph) died, that's what spearheaded the Legion to say, `This is hitting our Legionnaires."'

By Monday, 17 more Legionnaires had died. Health officials could offer little explanation. Dolan was so worried he sent his wife and child to stay with an aunt.

The newspapers reflected public unease. "Six Days, 25 Deaths And Still No Answer, read a banner headline.
Joseph Adams, elected state commander at the fateful convention, began fielding calls from around the state almost immediately.
I went to about 15 or so funerals in about 12 days," he said. I drove close to 65,000 miles that year ... meeting with people who had some kind of theory.
The answer to what it was finally came five months later, but scientists still can't say for certain how it spread at the Bellevue -- the suspected air conditioning unit was cleaned before investigators

MEMORIES OF A DEADLY GATHERING IT WAS JUST ANOTHER STATE AMERICAN LEGION CONVENTION. UNTIL A MYSTERIOUS DISEASE BEGAN KILLING PEOPLE.

July1991

They walk with canes and have trouble breathing, these Legionnaires` who have the disease named for them.

Sometimes strangers see their American Legion caps and refuse to get on an elevator with them, or walk quickly in the opposite direction, they said.

"It's funny now," said Russell Dugan, 68, a retired accountant from Wilkes-Barre who was given the last rites of his church when he was stricken 15 years ago this month. "But it wasn't funny then."

There is no humor, either, in the memorial at the Pennsylvania American Legion headquarters in Harrisburg created as a reminder that 28 men and women who had attended the 1976 state convention in Philadelphia went home to die.

Dugan is one of about 200 who stayed at the Bellevue Stratford hotel during the convention that summer and were soon hospitalized with the raging fevers and blood infections that came to be known as Legionnaires' disease.

Most of those who survived were sitting in the main meeting room of the Valley Forge Convention Center in King of Prussia, as the sessions of the state Legion's 73d annual convention began.

There was Dugan, who was in a Wilkes-Barre hospital for two weeks, packed in ice and lying in a coma. And Charles Mike, 83, also of Wilkes-Barre, who got sick on the bus on the way home and nearly died. And John Zweisdak, 61, who survived the horrendous sickness to become the Legion's state commander.

"I was so close to death, I was in the tunnel," Dugan said. "You know how people who almost die say they go into a tunnel."

On the podium, retiring state adjutant Edward Hoak was being lauded for his service to the state Legion, which opened its convention Thursday night and concludes it tomorrow. The survivors said it was Hoak's quick and insistent action that kept many of them alive.

"He started getting calls that people were getting sick after they got home," Dugan said. "He notified health authorities and convinced them to get the investigation started. He's gotten a lot of awards for that."

Researchers and scientists later concluded that the disease was caused by a bacteria that grew in the stagnant water that apparently had pooled in the hotel's air-conditioning system.

To this day, not all of the Legionnaires are convinced of the accuracy of what was determined to have been the source of the sickness.

"I slept in the same room with Charlie Mike," said Frank C. Andrukiewicz, 61, a juvenile probation officer in Luzerne County. "I didn't get sick."

But Mike said the air conditioning was blowing right on him, "and I did smell a bad odour while I was in bed."

Mike, a retired letter carrier, said he started getting a headache during the two-hour bus ride home to Wilkes-Barre and obtained some aspirin. By the end of the trip, he was ready for the hospital, where he remained for 30 days. He, too, was packed in ice by doctors fighting a fever he said reached 109 degrees.

"I was sick for a long time," Mike said. "I still go to a doctor. I'm always tired. I'm short of breath all the time. I'm always gasping for breath."

Zweisdak, who works in the furniture-finishing business, said he believed bad housekeeping at the hotel was a factor in the spread of the bacteria.

"I don't think any of the Legionnaires were happy about going there for the 1976 convention," he said. "You could see little dust balls in the rooms."

Three years later, he said, he developed asthma, and he blames his bad health on Legionnaires' disease.

While Dugan was in the hospital, another Legionnaire, Edwin Markiewicz, 64, of Nanticoke, Luzerne County, was working a construction job nearby. He managed to sneak into Dugan's makeshift isolation room each day to check on his friend.

"They kept pouring alcohol on him," Markiewicz said. "I didn't think he was going to make it."

There was such a furor over the disease, Dugan recalled, that doctors drew blood from him every 15 minutes. The samples were taken to the roof to a helicopter that flew them to laboratories for quick analysis.

The survivors started a Legionnaires' disease club, and met once in Pittsburgh. They got cards verifying they had been victims. When they could not think of any other action to take, the club disbanded.

For a time, there were hard feelings among Legionnaires` who did not want to be identified with a disease.

I said for them to leave it the way it was, Dugan said. After all, were the ones who went through it.

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HOMETOWNS OF THE VICTIMS IN THE DISEASE OUTBREAK



DEMONSTRATION OF THE AGENT OF LEGIONNAIRES` DISEASE Copyright (C) 1977 Massachsetts Medical Society.



DEMONSTRATIONS OF THE AGENT LEGIONNAIRES` DISEASE

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DEMONSTRATION OF THE AGENT OF LEGIONNAIRES` DISEASE

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As part of its commemoration of CDC’s 50th anniversary, MMWR reprinted this historical article.

Reprinted is the initial report published August 6, 1976, on an outbreak of respiratory illness among persons who attended an American Legion convention in Philadelphia during the summer of 1976.

Following that report is the special issue of MMWR published January 18, 1977, which announced the identification of the bacterium that caused Legionnaires disease.
Tables from the special issue have been recreated to resemble the originals as closely as possible.

Epidemiologic Notes and Reports

Respiratory Infection — Pennsylvania A total of 152 persons associated with a state American Legion convention in Philadelphia July 21–24 have been hospitalized with respiratory infections. Onsets of illness were in the period July 22–August 3; the majority occurred from July 25 to July 31. 

Twenty-two of these patients have died. The deaths, reported over the past week, were primarily due to pneumonia. Although information about the disease and its epidemiology is incomplete, it appears to be characterized by the acute onset of fever, chills, headache, and malaise, followed by a dry cough and myalgia. Some of the most seriously ill developed high fever and died in shock with extensive pneumonia. No etiologic agent has yet been incriminated. There is no information available concerning other Legionnaires who may be ill with less severe symptoms. The patients, among several thousand attending the convention, stayed in at least 3 or 4 hotels while in Philadelphia. There is no evidence of increase in respiratory disease in Philadelphia residents, nor has there been any confirmed secondary spread to family members or other contacts. There have been several reports of similar disease in non-conventioneers who were in Philadelphia at the same time as the convention.

TM January 24, 1997 / Vol. 46 / No. 3

From the January 18, 1977, special issue of MMWR

Epidemiologic Notes and Reports

Follow-up on Respiratory Illness — Philadelphia

Last summer an outbreak of severe respiratory illness occurred in Pennsylvania chiefly among those who had attended a state American Legion convention in Philadelphia July 21–24,1976
(MMWR 25 [30,33,34]).
An estimated 180 cases including 29 deaths occurred (MMWR 25 [38]).
An organism has now been isolated in yolk sacs of embryonated hens’ eggs that appears to be the etiologic agent. For the purpose of this report the yolk sac isolate is being called a bacterium on the basis of its size and morphology. The bacterium was first isolated from the lung tissues of 1 fatal case of Philadelphia respiratory disease and 1 fatal case of Broad Street pneumonia (see below) by inoculation of guinea pigs intraperitoneally. After a 1- to 2-day incubation period the guinea pigs developed a febrile illness that was characterized in most animals by watery eyes and prostration. Spleen suspensions of febrile guinea pigs were inoculated into yolk sacs of embryonated eggs from antibiotic-free chicken flocks. The embryos died after 4–6 days, and Gimenez-stained smears of the yolk sacs were found by microscopic examination to contain many bacilli. The bacilli were gram-negative and moderately pleomorphic.
Surviving guinea pigs were shown by indirect immunofluorescence to have developed antibody to the yolk sac isolates. Because most bacteria when inoculated into the yolk sac kill the eggs in 1–2 days, an unusual rickettsia was suspected. The organism is bigger than a rickettsia, however, and the convalescent guinea pig sera failed to react in the complement fixation test with standard rickettsial antigens prepared from Coxiella burnetii, Rickettsia rickettsii, R. prowazekii, and R. typhi. Cultivation on sheep blood agar and Trypticase Soy Agar has been attempted at each yolk sac passage.
Frequently, no growth has been observed, but yolk sacs infected with 1 isolate have sometimes given many minute colonies after 2–3 days’ incubation. The slowness of growth has delayed bacteriological identification. Evidence for the etiologic role of the yolk sac isolate in the epidemic has been ob-tained by indirect fluorescent antibody stains carried out by methods that are the same as those in regular use in the diagnosis of rickettsial diseases, except that the microdrops fixed to the slide were prepared from yolk sacs infected with isolate 1 and isolate 2 of the Philadelphia agent.
The results in Tables 1 and 2 were obtained with sera from 33 patients who were selected because they were Legionnaire delegates who were hospitalized, survived, and had radiologic evidence of pneumonia and fevers of at least 102 F; they thus represented the most typical survivors.
Table 1 shows some representative results. The sera with high titers gave bright staining at low dilutions which gradually decreased with increasing dilution. The brightness of staining and height of the titers are similar to that observed in other infectious diseases, for example, Rocky Mountain spotted fever.

TABLE 1. Results with indirect fluorescent antibody stains of the agent cultivated in yolk sacs. Sera from selected patients with Philadelphia respiratory disease. . a The reciprocal of the dilution is shown in this and other tables. b C = seroconversion or increase in titer of at least 4-fold with 1 or both antigens. P = classified as positive because the titer was high but showed little change. N = classified as negative because all specimens had low titers. c Brightness of staining: 0 = no staining, ± = questionable staining, 1+ = barely detectable but definite staining, 2+ and 3+ = increasing brightness. The 2 numbers refer to staining of the bacteria in yolk sacs infected with the first 2 isolates. d Highest dilution with definite staining with either antigen.

TABLE 2. Results with indirect fluorescent antibody stains of the agent cultivated in yolk sacs: Summary of results with patients with Philadelphia respiratory disease.

Patients 1, 2, and 3 had distinct increases in antibody titers, and 4 had only a 4-fold increase. The first specimen from patient 5 was already at a titer of 128, and there was no further in-crease between the eighth and twenty-ninth day of illness.
Table 2 summarizes the results with sera of the 33 Legionnaire patients tested to date; 29 gave results that suggest they were infected with the organism. Seroconversions were seen in 25 patients and antibody rises of more than 4-fold in 19. The maximum titers observed were 128 or greater in 26 out of 29 patients. The titers were usually low in the first week of illness, but they rose rapidly in the second and third weeks. The fact that 3 patients had no serologic response is not surprising since the cases were defined on a clinical and epidemiological basis. The staining of isolates 1 and 2 has been very similar with these sera and with the other sera reported below. Thus the 2 yolk-sac isolates are antigenically very similar if not identical. Cases of Broad Street pneumonia represent disease clinically similar to Philadel-phia respiratory disease that occurred in persons who did not attend the Convention, were within 1 block of Hotel A between July 1–August 18, but said they did not go into Hotel A during the epidemic period. Sera from 4 of the 38 such patients have been tested.
Two have shown serologic conversions from titers of 16 or less to 512 or greater. Two had unchanging titers of 32 or less. As controls for the fluorescent antibody tests, sera were tested from 40 patients unrelated to the outbreak whose specimens had been submitted for rickettsial diagnosis
(Table 3). The rickettsial complement fixation tests had failed to demonstrate rickettsial antibody. The sera were first screened at a dilution of 1:32 and those with staining at this dilution were retested at dilutions of 1:16 through 1:512. Most of the titers observed with the yolk sac isolate were low. Two specimens had titers of 64, that is, they overlapped with the lowest titers observed in Legionnaire patients in Table 2. The staining at low dilutions with these sera was only 1+ bright; however, in all the seropositive Legionnaire patients in Table 2 and in the 2 Broad Street pneumonia patients who converted, fluorescence was 3–4+ bright in low dilutions.

TABLE 3. Results with sera from control patients clinically suspected to have Rickettsia infections

TABLE 4. Serologic results with other persons who did not meet clinical criteria for a case of Philadelphia respiratory disease

In the outbreak, illness in conventioneers was associated with time spent in Hotel A.
The incidence was directly related to time spent in the lobby. Sera were available from some hotel employees of 2 categories: those who worked in the lobby and those who worked in locations removed from the lobby (Table 4). Also shown in the table are the results with sera from a group of Pennsylvania Legionnaires who did not attend the convention. One positive titer in a hotel employee was seen, a cashier checker, who had a titer of 256. The titers with the other employees and the Legionnaires who did not attend the convention were within the range of the 40 non-epidemic sera re-ported in Table 3. In 1966 an outbreak of acute pneumonia occurred at a large psychiatric hospital in the District of Columbia.
There were 94 cases and 16 deaths. Acute and convalescent sera were available from 14 patients; they were also tested against the antigens from Isolate 1 and 2. Thirteen had distinct rises in titer of 8-fold or more, and 12 had titers of 128 or more. The brightness of staining and titers were the same as those seen with the Legionnaire patients.
The intensity of public interest in the Philadelphia epidemic makes it necessary to provide a factual account of these findings now. The etiology of the outbreak has been unknown. The present findings provide very strong evidence that the 2 epidemics were caused by the bacterium isolated in yolk sacs and that nearly all the cases had the same cause. The bacterium can be identified now by the characteristic disease it produces in guinea pigs, the characteristic death pattern in eggs, the at best dysgonic growth on the bacterial media tried, and by the fluorescent antibody staining results. Other, more complex explanations are possible. For example, the bacterium might be thought of as a secondary invader associated with a virus, but extensive virological searches have failed to reveal a virus and the serologic responses for the bacterium have been present in a very high percentage of the cases.
There has not been time to identify the organism taxonomically.
The source of the organism in the outbreak is not known, but the search should now be greatly facilitated. Reported by the Leprosy and Rickettsia Br, Virology Div, Bur of Laboratories, CDC.
Follow-up Survey Data: In December 1976, selected survivors of Philadelphia respiratory disease and matched controls were interviewed concerning smoking habits, liquor and snack food preference, and knowledge of homemade liquor.
The 56 patients selected for interview represented all hospitalized male survivors who had been delegates to the American Legion convention and were known to have developed an illness characterized by temperature of 102 F or higher and pneumonia proved by X-ray. The 56 controls were male delegates matched by age who had indicated on earlier survey that they had not been ill since the convention. The interviews were completed with 52 case-control pairs. Cigarette smoking habits at the time of the convention were the only significant associations with illness. The relative risk of illness

TABLE 5. History of cigarette smoking at the American Legion Convention, Philadelphia, July 1976 among case-control pairs

among cigarette smokers was 3.4 compared to non-smokers (X 2 (1) = 5.5, p< .05, McNemar) (Table 5). Cases also smoked more cigarettes and were more likely to have smoked sample cigarettes available at the convention. A previous survey showed no single cigarette brand common among cases. Pipe or cigar smoking was not associated with illness.
Reported by RG Sharrar, MD, City of Philadelphia Dept of Public Health; E Streiff, RN, MPH, Allegheny County Dept of Health; WE Parkin, DVM, Acting State Epidemiologist, Pennsylvania State Dept of Health; Bur of Epidemiology and Bur of Laboratories, CDC.

Editorial Note—1997:
A bacterial etiology was not initially evident during the field investigation phase of the Legionnaires disease outbreak. Chest radiographs of case-patients revealed an interstitial pneumonia, which at that time was considered indica-tive of a viral infection. Because the Legionnaires disease bacterium is refractory to most stains, no bacteria could be visualized when sections of lung tissues from de-ceased patients were stained by commonly used methods, such as the Brown-Brenn technique. Additionally, no species of bacteria was reproducibly isolated from autopsy materials or clinical specimens because the special nutritional requirements of the Legionnaires disease bacterium precluded its growth on conventional culture media. The bacterium was, however, isolated in guinea pigs and in the yolk sacs of embryonated hens’ eggs and was visualized by Gimenez stain during one of several efforts to isolate Q fever rickettsiae ( Coxiella burnetii ) from specimens of lung tissue col-lected at autopsy. It subsequently was cultivated on enriched Mueller-Hinton agar using heavily infected yolk sacs as inoculum. The unique nutritional requirements of the bacterium were identified in separate studies, and a new culture medium was devel-oped that now allows routine isolation of the Legionnaires disease bacterium from clinical specimens
( 1 ). Determination of the phenotypic and genotypic properties of the Philadelphia iso-late indicated that it was a novel species ( Legionella pneumophila)
( 2 ). The genus Legionella now comprises approximately 40 named species and subspecies that are associated with water. Approximately half of the species have been implicated in hu-man disease; L. pneumophila serotype 1, the prototype strain that was isolated fol-lowing the Philadelphia outbreak, is responsible for most infections. The epidemic of pneumonia that followed the American Legion convention in August 1976 was one of the most publicized epidemics in which CDC had participated. Daily newspaper reports contained “body counts,” rumors of biological and chemical warfare, and accusations of cover-up by CDC. Reports by CDC in the MMWR, however, were limited to short back-page accounts, reporting that the epidemic had occurred and was under investigation. On Friday, January 14, 1977, the director of CDC’s Laboratory Division, Charles Shepard, M.D., and microbiologist Joseph E. McDade, Ph.D., went to the office of the CDC Director, David J. Sencer, M.D. After a few hesitant moments, they informed him that they had isolated the agent that had caused the outbreak. Dr. Shepard wanted to take the weekend to redo the isolation in a laboratory where they had not been work-ing to rule out any possibility of contamination. Although Dr. Shepard did not want to release the information until it was published in the peer-reviewed scientific literature, Dr. Sencer wanted to fulfill CDC’s responsibility to immediately release the information to state and local health departments because the outbreak had been in the national news for months and this information could prevent other cases. A solution was found: MMWR is a scientific publication, and CDC published and printed MMWR. CDC could print a special edition on the following Tuesday, January 18, 1977 (normal publication was on Thursdays). Once it was in print at 1 p.m., it could be given to the news media with an embargo until 3 p.m. Tuesday morning, as the presses were beginning to run 180,000 copies, Dr. Shepard reported that he had retrieved serum specimens from the serum bank of two earlier unsolved outbreaks of pneumonia, and they were positive for the identical organism. The presses were stopped, and the changes were made. At 1 p.m., a conference call was scheduled from CDC to the state health officers, the Surgeon General, the National Institutes of Health, and other public health officials participating in the investigation. CDC employees who had worked in any way on Legionnaires disease—from dishwashers in the laboratory to the chiefs of epidemiology and the laboratory—were invited to this conference call. Following that call, CDC con-ducted a press conference, in which Drs. Shepard and McDade presented the findings and distributed the MMWR. This is the only occasion on which an extra issue of the MMWR (weekly) has been published. Legionnaires disease is only one of many new diseases, syndromes, or etiologic agents that have been identified during the past 2 decades
( 3 ), and CDC has re-sponded to these new challenges. Other noteworthy examples include Lyme disease, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), toxic-shock syndrome, human ehrlichiosis, hantavirus pulmonary syndrome, hepatitis C virus, and Escherichia coli O157. In some instances (for example, HIV/AIDS), both the disease and its etiologic agent previously were unknown to medical science. In others, the disease already existed but was unrecognized. Legionnaires disease apparently occurred sporadically as early as the 1940s. Retrospective analysis of a “rickettsia-like agent,” which was isolated from a pneumonia patient in 1947, revealed that this agent was identical to L. pneumophila
( 4 ). However, at the time of its isolation, the source of the bacterium was erroneously attributed to the guinea pigs that were used in the isolation procedure. Since the 1940s, other technologic changes, including the introduction of air-conditioning cooling towers, have facilitated the potential for exposure through dissemination of infectious aerosols of Legionella in contaminated water
( 5 ). This realization has lead to changes in routine maintenance procedures for many aerosol-producing devices such as cooling towers, spas, and respiratory therapy equipment. The development of prevention strategies is an ongoing process involving medical professionals, engineers, and chemical disinfectant manufacturers. Identification of new etiologic agents undoubtedly will continue.

For example, of the approximately 4 million cases of pneumonia that occur in the United States each year, the etiologic agent remains unidentified in up to 50% of cases even when an etiology is actively sought
( 6 ). Similarly, no etiologic agent is found in 60% of reported foodborne disease outbreaks, most of which are studied using routine diagnostic methods, nor in 32% of diarrheal outbreaks on cruise ships, despite intensive investigation
( 7,8 ). However, in contrast to the Legionnaires disease investigation, during which the etiologic agent was identified serendipitously, new molecular techniques allow for a more systematic search for infectious etiologies. In particular, the extreme sensitivity of representational difference analysis and consensus sequence-based polymerase chain reaction technology should allow the identification of many etio-logic agents that previously have been refractory to culture
( 9 ). Editorial Note by: David J Sencer, MD, former Director, Center for Disease Control. Joseph E McDade, PhD, Associate Director for Laboratory Science, National Center for Infectious Dis- eases, CDC.

References

1. Feeley J, Gibson RJ, Gorman GW, et al. Charcoal-yeast extract agar: primary isolation medium for Legionella pneumophila.
J Clin Microbiol 1979;10:437–41.
2. Brenner DJ, Steigerwalt AG, McDade JE. Classification of the Legionnaires’ disease bacterium: Legionella pneumophila, genus novum, species nova, of the family Legionellaceae, familia nova.
Ann Intern Med 1979;90:656–8.
3. Institute of Medicine. Emerging infections: microbial threats to health in the United States. Washington, DC:
National Academy Press, 1992.
4. McDade JE, Brenner DJ, Bozeman FM. Legionnaires’ disease bacterium isolated in 1947.
Ann Intern Med 1979;90:659–61.
5. Breiman RF. Impact of technology on the emergence of infectious diseases. Epidem Rev 1996;18:4–9.
6. Marston BJ. Epidemiology of community-acquired pneumonia. Infectious Diseases in
Clinical Practice 1995;4(suppl 4):S232–S239.
7. Bean NH, Goulding JS, Lao C, Angulo FJ. Surveillance for foodborne-disease outbreaks— United States, 1988–1992. In: CDC surveillance summaries (October).
MMWR 1996;45 (no. SS-5).
8. Koo D, Maloney K, Tauxe R. Epidemiology of diarrheal disease outbreaks on cruise ships, 1986 through 1993.
JAMA 1996;275:545–7.
9. Gao SJ, Moore PS. Molecular approaches to the identification of unculturable infectious agents.
Emerging Infectious Diseases 1996;2:159–67.

1976 PENNSYLVANIA (PHILADELPHIA) The epidemic of legionnares disease that occurred at the American Legion Convention in July and August 1976 will always be remembered, One hundred and eighty two cases of legionnaires disease occurred in a sharp epidemic, and 29 were fatal.
(Eickhoff Theodore C Annals of Internal Medicine 1979 90 499-502)

THE AMERICAN LEGION CONVENTION.

LEGIONNAIRES` DISEASE FIRST DISCOVERED OUTBREAK, THE FINDING OF THE LEGIONELLA BACTERIA AFTER 43 YEARS. SINCE TATLOCK FIRST ISOLATED LEGIONELLA micdadii

1974 PENNSYLVANIA (PHILADELPHIA)

The convention of the Independent Order of Oddfellows was held in September 1974 in Philadelphia in the same hotel that hosted the American Legion Convention two years later, Eleven cases of sever pneumonia occurred among participants and were subsequently diagnosed as Legionnaires` disease, 

The epidemiologic investigation resulted in a significant association of the disease with attendance at one convention activity in the grand ballroom at the hotel on Monday 16 September 1974 A serological survey in February and March 1977, showed that people that attended the convention and became ill were more likely to have raised indirect fluorescent antibody titres than persons who had attended and remained well, The illness seen in Odd Fellows members in September 1974, was caused by the Legionnaires disease organism.
(Eickhoff Theodore C Annals of Internal Medicine 1979 90 499-502)

LEGIONNAIRES` DISEASE BACTERIA IN DRINKING WATER CHIEF SUSPECT

November 1981
CHICAGO
Seven kinds of bacteria have been found to cause Legionnaires` disease and evidence is growing that drinking water is a prime carrier,

At a meeting here of the American Society for Microbiology, doctors reported finding the bacteria in the drinking water of hospitals where outbreaks of the disease occurred.

The national Centers for Disease Control in Atlanta said it had not yet been proven that the bacteria in the water caused the disease, a type of pneumonia, but they thought that such proof eventually would be found.

We would like to find that those who got Legionnaires` disease drink more water or take more showers, The vast majority of people who bathe in that water and drink it don't get Legionnaires' disease.

After the original outbreak of the disease - in the Bellevue Stratford hotel in Philadelphia at an American Legion convention in 1976, It found that people who got the disease were drinking more water than those who did not.
A total of 29 people connected to the convention died from the disease.