Outbreak exposes oversight gap at VA facilities in Pittsburgh region
Inspectors in Pennsylvania and other states scour restaurants for faulty refrigerators or rodents, but when it comes to a deadly bacteria in hospital water pipes, America's largest health care system operates on its honor.
Neither the Centers for Disease Control and Prevention nor state or county health departments has oversight of the national Veterans Affairs Healthcare System to make sure it reports outbreaks of infectious diseases, such as the Legionnaires' at the VA's Pittsburgh-area campuses that is linked to five deaths and possibly a sixth.
“Like anything else with the government, they know how to make stuff disappear,” said Army veteran Pamela Thomas, 50, of Monroeville, who has received treatment often at the VA hospital on University Drive in Oakland since the early 1990s.
Thomas said the VA has not disclosed whether she risked exposure to contaminated hospital tap water found in the outbreak, despite her repeated questioning. Legionella are the waterborne bacteria that cause Legionnaires' disease.
“You all have this bacteria, and you don't even tell us,” Thomas said. “When we see it on the news and ask questions, they act like it's no big deal or that they don't know what we're talking about.
“We're free guinea pigs,” she said.
Top officials at VA Pittsburgh refused to answer specific questions from the Tribune-Review about their disclosure of Legionnaires' cases to public health authorities.
Two reporters who sought to interview VA Pittsburgh Director and CEO Terry Wolf at the Oakland hospital were told by VA police chief Jack Crawford she was unavailable. The reporters, who went there because an interview request was ignored, handed Crawford written questions to give to Wolf and were escorted out of the building.
VA Pittsburgh's spokesman Dave Cowgill, who is paid more than $120,000 annually to respond to media inquiries, among other things, avoided phone calls about the Legionnaires' issue, responding to some questions by email.
Cowgill said the VA Pittsburgh “has followed” state law, which requires hospitals to disclose Legionnaires' diagnoses within 24 hours. He would not say whether that specifically includes the 21 cases of Legionnaires' that the CDC believes probably were contracted at the VA campuses in Oakland and O'Hara from January 2011 through November 2012.
Even if the VA abides by Pennsylvania law, state law prohibits state and county health departments from disclosing which facilities report cases of Legionnaires' disease, a form of pneumonia that preys on hospitalized patients with other illnesses. The Trib requested a breakdown of Legionella cases by specific medical facility in Allegheny County, but officials provided only the county's total cases by month.
State lacks authority
The Pennsylvania Department of Health has neither the authority nor the manpower to make sure VA hospitals report infectious diseases, said Dr. Kirsten Waller, director of surveillance for the Bureau of Epidemiology in the state Department of Health.
“We don't go out and do audits, review charts, anything like that. That's the way that reportable disease surveillance is done throughout the country,” Waller said. The same is true for the Allegheny County Health Department, by far the largest county-run operation in Western Pennsylvania, officials there said.
“If (hospitals) don't send any information in, we don't know what they don't send us,” Waller said.
The CDC recommends hospitals initiate extra safety precautions if they find two cases of Legionnaires' within six months. In early 2011, the VA had two cases within four months, one in February and one in June, according to a CDC report.
Then, over three months starting in September 2011, the hospital system had six more Legionnaires' cases that probably or definitely were acquired at the VA, according to the CDC report.
“The easy way to find out about an outbreak is if someone calls you and tells you about it, but that doesn't always happen,” Waller said.
Congressional investigators are looking into why the CDC didn't learn about the VA outbreak until October 2012, more than 14 months after the June 2011 diagnosis. Sens. Pat Toomey, R-Lehigh Valley, and Bob Casey Jr., D-Scranton, sent letters to VA Secretary Eric Shinseki asking for information about the VA's practices.
“Senator Casey is very concerned about the obvious gaps in reporting and oversight here,” said his spokeswoman, April Mellody. “He believes the lack of information provided is unacceptable.”
The VA didn't inform county health authorities of concerns about Legionella in its water distribution system until September or October of 2012, said Dr. Ronald Voorhees, director of the Allegheny County Health Department.
When hospitals report cases of Legionnaires' individually, inspectors have trouble spotting an outbreak, Waller said.
A bigger problem is that the state assigns Legionnaires' reports to investigators in each patient's home county — not based on the county where the patient was diagnosed, Waller said. Once the state inspectors have completed a standard CDC-issued reporting form, the information is passed along to Harrisburg, where it is analyzed “to see if there are any unusual patterns,” he said.
Hospitals — and the VA health care system in particular — often treat people from a wide service area that goes beyond county borders. So, discovering that multiple patients got the same bacteria at one hospital could, at the least, take more time to determine.
Seeing several cases at one hospital doesn't automatically arouse suspicion about that hospital because most Legionnaires' cases result in hospitalization, whether they were contracted inside the hospital or elsewhere, Waller said.
“Long-term, long-simmering Legionella hospital-related outbreaks are extremely difficult to identify, to separate out from the underlying, sporadic cases,” Waller said.
Neither Waller nor health department representatives would say when the VA Pittsburgh first reported its Legionnaires' cases to the state, citing state law. Cowgill declined to say when the VA notified the state, citing federal health care privacy laws.
Policies being reworked
The VA is rewriting its reporting policies, said Mark Ballesteros, a national VA spokesman.
“Federal hospitals are not generally required to comply with the reporting requirements of state laws,” Ballesteros said. “However, VA is developing new guidance and policies for the reporting of communicable diseases to state and/or local public health departments to improve consistency and uniformity across the health system.”
Ballesteros declined to elaborate.
By the time the VA Pittsburgh notified the CDC on Oct. 5, 2012, about its outbreak, as many as 17 veterans probably or definitely contracted the disease in the Oakland or O'Hara facilities, according to the CDC report. Four of them died, the CDC said.
“If you had a couple of cases that were able to be diagnosed, you would definitely start worrying about the water system and some kind of exposure,” said Dr. David Snydman, chief of geographic medicine and infectious diseases at Tufts Medical Center in Boston.
The VA Oakland hospital flushed superheated water through all or part of its water systems six times between January 2011 and October 2012, the CDC report says. The report does not specify when the Oakland flushing occurred. The CDC deferred the question to the VA, and Cowgill declined to answer.
The CDC told VA Pittsburgh administrators on Oct. 30 that the strain of Legionella in two patients matched bacteria found in the Oakland hospital's water system. The bacteria is “almost identical” to a strain that caused a Legionnaires' outbreak at the hospital in 1982 that killed about 30 people, according to the CDC report.
“Knowing that the Pittsburgh VA had a problem with Legionella before, certainly it would make me very nervous about some kind of common source exposure, so you'd have to really start looking hard at those exposures,” Snydman said.
The VA Pittsburgh ordered stepped-up Legionella testing in November, when it required doctors to order both types of Legionella tests — urinary antigen and respiratory secretions — for all patients diagnosed with pneumonia, Cowgill said. The CDC report noted that before November, most patients received only the standard urinary test.
VA administrators alerted the public and its employees for the first time in mid-November, more than a month after alerting the CDC and two weeks after the CDC linked the disease to the VA's water system.
The CDC is exploring whether some patients might have contracted the illness as far back as 2007. In its report this month, the agency said Legionella bacteria were widespread throughout the VA Pittsburgh.
Immediate reporting of positive Legionella test results would give public health authorities a faster, better look at the status of Legionella outbreaks in the state, said Dr. Gary W. Procop, chair of molecular pathology and a pathology professor at the Cleveland Clinic. Peaks in diagnoses would show up clearly, and that could help identify outbreak sources, such as water systems. Such reporting could decrease the size of epidemics, he said.
“The quicker you can get it, the quicker you can stop it,” Procop said.
Mike Wereschagin, Luis Fábregas and Adam Smeltz are Trib Total Media staff writers. Reach Wereschagin at 412-320-7900 or firstname.lastname@example.org. Reach Fábregas at 412-320-7998 or email@example.com. Reach Smeltz at 412-380-5676 or firstname.lastname@example.org.