VA had Legionella bug 5 years before disclosure
By Luis Fábregas, Adam Smeltz and Mike Wereschagin
Published: Saturday, June 15, 2013, 9:26 p.m.
Legionella bacteria flourished in the water lines in rooms housing the most vulnerable patients at the VA Pittsburgh hospital in Oakland at least five years before officials disclosed a deadly outbreak of Legionnaires' disease in November 2012, a Tribune-Review investigation has found.
VA workers found potentially deadly Legionella in at least 30 percent of faucets, shower heads and public water fountains tested at the University Drive hospital on seven occasions between September 2007 and November 2011, according to documents obtained through the federal Freedom of Information Act. The 30 percent threshhold is supposed to automatically trigger a local action plan under Department of Veterans Affairs rules.
The bug was so rampant that a report dated Sept. 21, 2007, showed Legionella in 17 of 19 samples taken from surgical and medical intensive-care units at the VA hospital in Oakland. The positive results gave rise to a years-long battle with the bacteria that by 2010 appeared out of control: 75 percent of ICU rooms tested in July that year had Legionella.
“Whenever you have numerous sites within a facility growing Legionella, there is a direct risk to patients,” said Dr. Joseph S. Cervia, a Legionnaires' expert and clinical professor of medicine at Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y.
Cervia said “it's a concern for patients and hospitals everywhere that water continues to be an under-recognized source for health care-associated infections and that the approach to preventing these infections has been somewhat erratic in general.”
VA officials in Pittsburgh did not respond to requests for comment. Two VA workers who conducted tests declined to comment.
Veterans groups, lawmakers and families of patients have lashed out at the VA Pittsburgh management for delaying disclosures of a confirmed Legionnaires' disease outbreak from February 2011 to November 2012. The Centers for Disease Control and Prevention said five veterans died among 21 patients sickened at VA facilities in Oakland and O'Hara.
But it is not known whether any additional patients contracted Legionnaires' disease, a form of pneumonia, during the nearly 3½ years between the first positive test results found by the Trib and the reported February 2011 start of the outbreak. That's largely because VA Pittsburgh officials didn't begin checking every patient who might have acquired pneumonia in the hospital for Legionnaires' disease until November 2012, when they publicly disclosed the problem.
A simple urine test or a mouth swab of aspirated sputum can be used to determine if a pneumonia patient has Legionnaires' disease.
“Something is wrong at the VA … I can't believe it,” said Dave Coffman, 65, an Army veteran from Rector, Westmoreland County. “I'm afraid to go down there for anything serious.”
Legionnaires' is acquired when people breathe water mist or vapor containing Legionella bacteria. It is most apt to impact people with a weak immune system, like most of the patients in the Oakland hospital's ICUs.
The CDC has said it knows of no safe levels of Legionella.
Patients at risk
The Trib reviewed all Legionella testing records the VA made available, which were from March 2007 through February. Three experts reviewed the results at the newspaper's request.
Documents show testing focused on several medically sensitive areas in the Oakland hospital, including rooms in a surgical intensive care unit where transplant patients often recover following surgery. The first positive tests surfaced on Sept. 11, 2007, when workers found Legionella in two of 23 samples. Both positive tests came from the 3A surgical and medical intensive care units.
“I would not tolerate positivity in critical care units with severely immune-compromised patients,” said Bob Miller, president of Earthwise Environmental near Chicago, a water treatment firm with expertise in Legionella bacteria.
Those patients, who are generally older and might be intubated or hooked to machines, face greater risk of being sickened by the bacteria. The pneumonia caused by Legionella mimics other forms of the illness and can be difficult to detect.
“Intuitively, someone who's sick and immune-compromised is far more likely to be affected than someone who isn't,” said Cervia, the Legionnaires' expert.
In some cases, positive tests appear to have prompted measures to eradicate the bacteria. Two weeks after the September 2007 spike, workers returned and found just one positive out of 20 samples.
Yet documents show gaps in testing even after findings that should have prompted corrective action. On one occasion, workers waited seven months to retest locations where the bacteria surged in early 2011, the period when CDC officials say the outbreak likely began. Even though those subsequent tests found Legionella, a full year passed before workers returned to collect water samples.
“When you look at the cultures and you see so many outlets growing Legionella, it certainly arouses a level of concern,” Cervia said.
The documents show workers found worrisome levels of Legionella pneumophila serogroup 1, the type responsible for 80 percent of cases of Legionnaires' disease. Rules issued by the VA's Veterans Health Administration in February 2008 call for corrective action when more than 30 percent of inspected sites turn up positive. The rules also say that VA facilities with a history of hospital-acquired Legionnaires' should routinely test pneumonia patients for the disease.
Doctors diagnosed about 100 cases of the disease in 1982 at the VA hospital in Oakland. About 30 patients died.
VA workers used two methods to collect samples taken for laboratory testing of Legionella. In addition to taking water samples, workers swabbed faucets — a method that one expert suggested might be inefficient.
“They think the problem is associated with the cleanliness of the faucet, not the water,” said Nigel Richardson, director of Legionella Control International in the United Kingdom. Richardson, who reviewed the test results for the Tribune-Review, pointed out several tests in which swab samples were negative for Legionella but water samples were positive. He questioned why workers would take swab samples.
“In order to catch Legionnaires' disease, you need to breathe an infected aerosol, so normally you would take a water sample as that is what is in the aerosol,” he said.
The VA Office of Inspector General in Washington found VA Pittsburgh workers responded inconsistently to Legionella, although regional director Michael Moreland told federal lawmakers in February that the Pittsburgh VA often flushed the bacteria over the past decade. He said officials took a more aggressive stance in late 2011, purging the pipes every time Legionella appeared in any amount.
But an effort to flush pipes in February 2011 — when the CDC said the outbreak probably began — used water that was not hot enough to eradicate the bacteria, the IG's April 23 report said.
Seven months earlier, in July 2010, records show VA workers found Legionella in six out of eight rooms tested. Testing in February 2011 showed Legionella in three of the eight rooms.
All of those rooms were in the surgical and medical intensive care units. By September 2011, widespread testing found Legionella throughout the hospital — again.
“You can only so long say, ‘We love you, veterans,' ” said Joseph D. Hughes, 89, of Glenshaw, a World War II veteran who has used VA services since the 1950s. He believes VA's senior managers insulate themselves from patients. “You have to come down, put an office down there on the floor so that we can talk.”
Staff writer Lou Kilzer contributed to this report. Luis Fábregas, Adam Smeltz and Mike Wereschagin are staff writers for Trib Total Media. Fábregas can be reached at 412-320-7998 or firstname.lastname@example.org. Smeltz can be reached at 412-380-5676 or email@example.com. Wereschagin can be reached at 412-320-7900 or firstname.lastname@example.org.
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