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Memo confirms VA Pittsburgh officials knew of Legionella threat early on

| Tuesday, March 11, 2014, 11:44 p.m.

The top physician in the VA Pittsburgh Healthcare System encouraged doctors to give bottled water to high-risk patients more than a year before the hospital system disclosed dangerous Legionella bacteria levels in its tap water, the Tribune-Review has learned.

Dr. Ali Sonel was so concerned about the threat that he sent a seven-point memorandum in September 2011 to all VA Pittsburgh doctors, according to internal communications obtained by the Trib. The chief of staff warned medical workers that a copper silver water system meant to curtail Legionella in the VA hospital in Oakland was operating below standards. However, he said he lacked evidence that anyone was sick from the bacteria, which can lead to Legionnaires' disease, a potentially deadly form of pneumonia.

In fact, a Legionnaires' outbreak now blamed in at least six patient deaths likely began in February 2011, according to the Centers for Disease Control and Prevention. The Pittsburgh VA waited until November 2012 to tell the public, patients and non-medical workers about the contamination that caused the outbreak, which remains under investigation by the House Committee on Veterans' Affairs.

“These emails paint a troubling picture,” said Rep. Jeff Miller, R-Fla., the committee chairman overseeing the investigation. “VA Pittsburgh officials knew they had a Legionella problem on their hands for more than a year. But instead of immediately asking for proper outside help in addressing the situation, they opted for a ‘learning as you go' approach in which they repeatedly failed to adhere to proven Legionella control measures and even VA's own policies.”

A Department of Veterans Affairs spokeswoman in Washington said she was looking into questions raised by the Trib. She said the department remains “dedicated to doing whatever it takes to minimize the risk of Legionella and create the safest environment possible.”

Sonel declined to comment.

While Sonel's email to doctors arrived a year before the outbreak became public, a Trib investigation published last year found evidence of Legionella at least four years earlier. The newspaper found the bacteria reached alarming levels on seven occasions between September 2007 and November 2011 at the Oakland campus.

Uptown-based microbiologist Janet Stout said Sonel acted appropriately in drafting the September 2011 advisory. She said public disclosures typically do not happen unless doctors have confirmed an outbreak.

It wasn't until February 2013 that a CDC report identified at least 21 patients who probably or definitely contracted Legionnaires' disease in the VA outbreak, which ended in November 2012.

“I think it makes clear that people within the VA sort of were in denial. That probably explains Dr. Sonel's comments. I think he was being told that the cases that had been identified were acquired in the community. He was going off of information provided to him,” said Stout, a Legionella researcher and former Pittsburgh VA worker who has criticized hospital leaders.

Other VA communications obtained by the Trib show executives corresponded regularly about Legionella before and after they announced the outbreak. Their messages show they knew in June 2012 that Legionella flared again in the Oakland hospital, but they did not appear to realize the bacteria were sickening so many patients.

Other records chronicle concerns outlined by federal investigations, including reports of poor record-keeping, tap water that wasn't hot enough to control Legionella, and inconsistent maintenance of treatment equipment.

VA officials have said they would conduct a review to determine whether they should discipline workers, but have not confirmed any punishments. A regional director overseeing the Pittsburgh VA, Michael Moreland, retired suddenly in November with little public explanation.

“I think they responded too slowly, but it's typical government,” said Kit Watson, adjutant for the Pennsylvania American Legion. He encouraged a remembrance of the victims as his organization runs its own review of the outbreak.

“These people had families. They had loved ones,” Watson said. “There's an empty seat at the table now where they used to sit, and that could have been avoided.”

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

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