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VA on Defensive with Five Possible Deaths from Pittsburgh Legionnaires’ Outbreak

USM By U.S. Medicine
March 5, 2013

By Sandra Basu

WASHINGTON – Lawmakers are demanding answers from VA in the wake of a national Centers for Disease Control and Prevention (CDC) report that as many as five veterans may have died over the past two years from Legionnaire’s Disease (LD) linked to the Pittsburgh VAMC.

CDC representatives suggested at a hearing before a House subcommittee that VA’s standards and safeguards against the disease were inadequate.

The VA had previously identified 29 cases and one death due to LD between January 2011 and November 2012 at the facility. Now, the VA Office of Inspector General has opened an investigation to determine whether the outbreak could have been prevented and is expected to issue a report this month.

At a hearing held last month, lawmakers attempted to unravel what exactly had occurred in response to the outbreak. But after three hours of testimony and several accusations against VA, some lawmakers said that hearing had only “raised more questions than it answered.”

“We’re going to stay on top of this until all the facts are clear and the problems have been fixed — and this is only the beginning of this process,” Rep. Mike Doyle (D-PA) said in a written statement. “I am confident that the Veterans Affairs Committee will follow up and demand answers from the VA. The VA Inspector General is looking into the outbreak as well, and his report is due out in March.”

The CDC’s suggestion that five patients could have died during the LD outbreak was news to lawmakers.

“VA provided documents to this subcommittee stating that, as of Dec. 17, 2012, there have been only five Legionella cases across the entire VA healthcare system, and all five cases were community-acquired. Even basic news reports tell us that these numbers are far from accurate. Does VA even know how many cases of Legionnaire’s Disease exist in its patients and where they could have originated?” asked Rep. Mike Coffman (R-CO), who chaired the subcommittee hearing.

In total, CDC discovered five definite and 16 probable hospital-associated cases of LD. In 13 cases, the exposure was related only to the University Drive campus, in two cases only to the Heinz campus, and in six cases to both.

CDC medical epidemiologist Lauri Hicks, DO, who spoke about the investigation into the outbreak, said she believed that “a “false sense of security” contributed to the outbreak after years of effective Legionella prevention at the medical center.

For example, she said that VA recommended 30% of distal sites testing positive for Legionella to prompt action, but outbreaks can occur below that threshold. CDC has a standard of zero tolerance for Legionella, she said.

“[VA’s policy] implies that, if your testing reveals you are below 30%, then you won’t have healthcare-associated cases] or you won’t be at risk for healthcare cases,” Hicks said. “In our experience, that hasn’t been the truth. We have investigated several outbreaks where we have found fewer than 30% of sites colonized and, in fact, this situation perfectly illustrates why this policy doesn’t work. VA repeatedly detected fewer than 30% of their sites colonized over and over again, so they thought they had their Legionella problem under control.”

Hicks also said VAPHS’s copper-silver ionization system to control Legionella in its water distribution system was not effective at the time of CDC’s investigation. The hospital had been collecting small volumes (100 ml) of water for routine culture-based monitoring of the potable water system for Legionella, but those samples likely were too small to detect the scope of the problem, she noted in written testimony.

“Compared to the 1L volumes recommended by CDC, this smaller volume likely resulted in decreased sensitivity to detect widespread colonization of the potable water system,” she explained.

Extensive construction at the facility also might have played a role in the contamination, Hicks said.

“Construction likely introduced organic matter to the potable water system, increasing consumption of chlorine in the municipal water supply leading to amplification of Legionella,” according to her testimony.

Water Remediation

VA officials said that, due to CDC’s findings, the Pittsburgh facility promptly instituted an aggressive, multiphase water remediation effort.

Robert Jesse, MD, VA principal deputy under secretary for health, said officials will take any other actions necessary to implement corrective actions.

“Currently, VA is updating its directives regarding Legionella which will incorporate the lessons learned from the activities going on in Pittsburgh now, new scientific evidence, recommendations from the CDC and current industry standards,” he said.

Lawmakers indicated they were displeased with how the situation was handled. For example, they wanted to know when the hospital staff was actually told there was a problem.

Mike Moreland, network director for VA VISN 4, explained that some Legionella cases had been detected nearly every year since data was collected and that those had been addressed.

With the most recent outbreak, however, officials notified CDC as soon as they suspected the situation was unusual, he said. Providers were alerted about the outbreak only once CDC finished its investigation in November of 2012.

“Wouldn’t physicians want to know that you had a concern so serious that you were bringing the Alleghany Health Department in?” Rep. Jeff Miller (R-FL) asked, questioning why notification of medical staff was delayed.

Rep. Tim Murphy (R-PA) called that a “serious problem.”

“Here you have some cases showing up and the medical staff wasn’t notified,” he said.

Subcommittee members also questioned why no one from the medical center showed up to testify.

“Dr. Jesse, why aren’t the people who are involved in [this] here, why are you here?” asked Rep. David Roe (R-TN).

Legionella Prevention

Witnesses testifying on a second panel said the outbreak was preventable and blamed the VA.

Janet Stout, a microbiologist and director of the Special Pathogens Laboratory in Pittsburgh who formerly was part of the VA Special Pathogens Laboratory before it was shut down, said the “only way an outbreak of this magnitude could have occurred is if the water system in the Pittsburgh VA was heavily contaminated with Legionella” and that “the environmental testing performed by the VA microbiology lab should have detected this increase.”

Stout said the subcommittee will “hear excuses and diversions trying to shift responsibility to methodology, policies, public-health authorities and even blaming the disinfection technology that protected VA patients from 1994 to 2006,” cautioning legislators not to be “distracted” in their investigation.

Steve Schira, chairman of LiquiTech, the Lombard, IL-based manufacturer of the copper-silver ionization system, accused the VA of not performing the maintenance essential to keeping system effective. He said that a company walkthrough of the facility in December 2011 found evidence of maintenance shortcomings and said VA staff knew this had been the case.

Schira even alleged that his employees saw VA staffers fabricating copper-level data. When Coffman questioned Moreland earlier in the hearing about the allegations, he was told there was no such evidence.

Meanwhile, Kathi Dahl, RN, a union representative who testified at the hearing, told lawmakers that a VA official suggested before the hearing that she could choose to pretend to be sick and skip testifying.

Lawmakers seemed flabbergasted and demanded more explanations from VA.

“It’s very troubling that the VA has been accused of gross negligence and, if that’s the case, the responsible parties need to be held accountable. If they’re not true, VA needs to provide a comprehensive response disproving these allegations,” Doyle said in a written statement after the hearing.

CDC’s Recommendations for Long-Term Legionella Control at Pittsburgh VAMC

  • The long-term disinfection system for prevention of Legionella growth in the hospital’s potable water system should be reevaluated in consultation with experts.
  • The facility should strive for eradication of Legionella from the potable water system, as there is no known safe level of Legionella.
  • The hospital should continue testing for Legionella every two weeks for three months, and then every month for three months to ensure remediation has been effective. If any Legionella is detected during this time frame, remediation throughout the facility will need to be adjusted, and the testing cycle must start over.
  • LD surveillance should be conducted at the hospital according to CDC recommendations, with a strict case definition and action upon identifying one definite or two possible healthcare-associated cases.
  • Close communication among hospital staff and between the hospital and public health would improve surveillance.
  • The Legionella control protocols of the hospital, the Veterans Health Administration, and the Allegheny County Health Department should be carefully reevaluated to include changes in surveillance methodology, including action thresholds and sampling methods.
  • The hospital should modify their Legionella sample collection procedures. Both swabs and 1L water bottles should be collected at various sampling sites, with samples processed as soon after collection as possible and results communicated to infection preventionists, building facilities managers, hospital administrators, and CDC. Chlorine, pH, and maximum temperature should be measured at the water heaters and at least a couple of distal sites.
  • A standard operating procedure for appropriate maintenance, including regular cleaning, of decorative fountains should be drafted and followed. Facility managers should consult with the manufacturer of the decorative fountain to determine an acceptable biocide for Legionella control.

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