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Investigators link 5 Legionnaires' deaths to Pittsburgh VA

| Tuesday, Feb. 5, 2013, 12:29 p.m.
Roiled by a fatal disease outbreak, a secret waiting list and congressional criticism, federal veterans hospitals in Allegheny County might be hard-pressed to recruit a top-tier executive who could stabilize the beleaguered health care network, management scholars warn.
Keith Hodan | Trib Total Media
VA Pittsburgh
The House Subcommittee on Oversight & Investigations holds a hearing on analyzing the Veterans Affairs Department actions to prevent Legionnaires Disease in Pittsburgh after a recent outbreak at the Pittsburgh V.A. Medical Center, Tuesday, Feb. 5, 2013, on Capitol Hill in Washington. From right to left are Steve Schira, chairman and CEO of Liquitech, Inc., Kathleen Dahl, president of AFGE Local 2028, Pittsburgh Veterans Affairs Medical Center, Aaron Marshall, operations manager for Enrich Products, Inc., Janet Stout, director of the Special Pathogens Laboratory, and Victor Yu, professor of medicine at the University of Pittsburgh. (AP Photo/J. Scott Applewhite)

WASHINGTON — Five patients died among 21 veterans who appear to have contracted Legionnaires' disease from the VA Pittsburgh Healthcare System during the past two years, the Centers for Disease Control and Prevention revealed on Tuesday.

Officials previously acknowledged only one death and five ill patients from the waterborne outbreak, which took on scandalous new dimensions in a three-hour investigative hearing on Capitol Hill.

The head of a company that made the copper-silver treatment system designed to prevent Legionnaires' told lawmakers that Pittsburgh VA workers falsified records documenting treatment levels.

A VA leader said he had no evidence of any fabrication. Lawmakers said they would investigate.

Employees who helped flush the tainted pipes had no protective masks, said Kathi Dahl, president of American Federation of Government Employees Local 2028. She said a VA official later told her she could pretend to be sick and skip testifying at the hearing. A department spokesman would not respond to the claim.

“VA Pittsburgh has been caught manipulating their own data to cover poor maintenance of the copper-silver system. VA has been caught intimidating its own employees,” said Rep. Mike Coffman, a Colorado Republican who led the hearing under the House Committee on Veterans' Affairs. He cited “a tragic failure in leadership” from Pittsburgh to the federal level of the VA.

“Make no mistake: The VA will be closely scrutinized for its actions toward those testifying today and toward those who do the right things,” Coffman said.

VA leaders including Dr. Robert Jesse, a top department health official, voiced general regret and pledged improvement but appeared stoic, arguing they followed guidelines for Legionnaires' prevention and called for CDC help when they spotted a major problem late last year. Department officials told the public in November about an outbreak of Legionella, the bacteria that cause the sometimes-fatal form of pneumonia known as Legionnaires'.

They confirmed five cases linked to contaminated tap water at the Oakland hospital on University Drive, suggesting the water-purification systems that use copper and silver ions might not have been as effective as once thought.

The Allegheny County Health Department confirmed in late November that one patient, identified by his family as World War II veteran William E. Nicklas of Hampton, died from Legionnaires' at the hospital. The facility has since switched to chlorination for Legionella prevention.

Officials would not identify the other dead patients. Maureen Ciarolla of Monroeville said her father, John Ciarolla, 83, of North Versailles died from pneumonia at the VA in July 2011. It's unclear whether he is one of the five.

Witnesses told lawmakers that Nicklas and the others could be alive had the VA followed standard practices for monitoring and maintaining water systems. The Oakland hospital went about a decade without hospital-acquired Legionnaires' cases before Dr. Victor Yu and Janet Stout, who are Legionella researchers, left the VA roughly six years ago, Yu testified.

The VA failed to recognize the outbreak quickly, which led to more illnesses and deaths, said Stout, the director at the Special Pathogens Laboratory, Uptown.

“Policies should not be rewritten due to the management failures of this facility,” Stout said.

Aaron Marshall, operations manager at Wilkinsburg-based Enrich Products Inc., said the VA sought help with its copper-silver systems last summer but never told the company its Legionella levels were high. The company would have offered a different solution, Marshall said.

VA officials also fell short in communicating with Illinois-based LiquiTech Inc., the manufacturer that made the copper-silver systems used in Oakland, company CEO Steve Schira testified.

During a visit in April, Schira said, VA workers admitted to LiquiTech the treatment systems were not being maintained properly. The VA workers said a colleague responsible for the systems was on disability leave and remaining employees didn't know what to do.

“We told them we'd clean the cells (in the systems) if necessary. We never got a response,” he said.

Schira alleged the fabrication of records documenting copper and silver treatment levels. Three trained engineers working for LiquiTech witnessed that falsification by Oakland VA staff, he said.

Under questioning by Coffman, regional VA Director Michael Moreland twisted a paper clip in his hands and said he had heard no evidence of that.

Rep. Tim Murphy, R-Upper St. Clair, called the accusation deeply disturbing.

“We don't know that those employees were properly trained” to track treatment levels, said Murphy, who with Rep. Mike Doyle, D-Forest Hills, sought the subcommittee hearing.

Separate findings from a review by the VA Office of Inspector General, prompted by Sen. Bob Casey Jr., D-Scranton, are expected in March.

Coffman said he expects the VA to contact his subcommittee within 30 days “to chart out the road ahead.”

CDC and VA officials said they were collaborating to bolster anti-Legionella efforts. CDC epidemiologist Lauri Hicks said the Pittsburgh VA had tested for and found the bacteria with some success. She said the hospital was taking extra steps to eradicate Legionella when it appeared in more than 30 percent of water samples, a routine threshold among VA facilities.

“I think what happened here is that folks on the ground, they had a false sense of security” after years of effective Legionella prevention, she said.

Moreland was aware of several confirmed Legionnaires' cases in fall 2011 in the Pittsburgh VA, he testified.

Although those cases were not confirmed then as having originated within the health system, Moreland said, VA officials started at that point to flush the pipes any time Legionella showed up.

The testimony left Maureen Ciarolla sick to her stomach. She said the VA suggested John Ciarolla may have contracted the disease elsewhere — perhaps at her own home — and never hinted at other cases inside the VA.

“My father obviously wasn't the first case,” she said. “And he certainly wasn't the last.”

Adam Smeltz is a staff writer for Trib Total Media. He can be reached at 412-380-5676 or

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