The University Drive VA Medical Center in the Oakland area of Pittsburgh

In 1981, VA opened the Pittsburgh VA Special Pathogens Laboratory (SPL), headquartered at the University Drive facility, for continued Legionella studies and testing for both VA and non-VA healthcare facilities. Headed by Stout and Victor Yu, MD, for the next 25 years, the SPL was considered one of the most comprehensive sources of Legionella research. It acted as a hub for collaboration among researchers nationwide and was responsible for a better understanding of Legionnaires’ prevention and therapies. It also tested water samples from hospitals worldwide.

In 2007, however, VA closed the SPL down for funding reasons that were never clearly defined. Yu was fired and, soon after, Stout resigned.

Yu testified before a congressional committee in 2008 about his termination from the SPL and that, before researchers could arrange to have samples transferred to another facility, VA officials destroyed them. It was estimated that as many as 5,000 Legionella samples, as well as thousands more microbes and specimens related to other investigations, were lost.

Today, the SPL has been reborn as a private enterprise, still headed by Stout and Yu, both of whom are associated with the University of Pittsburgh.

In a press release following news of the outbreak at the Pittsburgh VA, their group suggested that the incident most likely could have been prevented.

“In our experience, if a hospital experiences an outbreak of Legionnaires’ disease despite the presence of a disinfection system, the failure is often traced to mismanagement of the system,” the release states. “As we discovered in our research, the necessity for maintenance and monitoring after installation is often underestimated. In the case of copper-silver ionization, ion levels need to be monitored for the life of the system.”

CDC does not officially endorse any one particular system. However, hyperchlorination has been commonly recommended during outbreaks.

The investigation into what officials knew and how the outbreak could have been prevented will likely have legal ramifications, as well. On Dec. 10, the family of William Nicklas filed a civil claim against VA, contending that his death was preventable and the fault of failures at VA to maintain its water systems.