Lapses at Pittsburgh VA stoked spread of Legionella bacteria
Aaron Marshall didn't know what he was walking into.
The VA Pittsburgh Healthcare System wanted his germ-fighting company to inspect the water treatment system used to control Legionella bacteria in the hospital.
As he tried to assess how well the system worked, Marshall, the operations manager for Wilkinsburg-based Enrich Products Inc., said he asked for past Legionella test results.
The VA Pittsburgh, he said, refused.
That was early June 2012. By then, nine cases of Legionnaires' disease — a potentially fatal form of pneumonia — were diagnosed in Department of Veterans Affairs hospitals in Oakland and O'Hara since February 2011; two patients died.
During the six months that followed Marshall's visit, doctors diagnosed 12 similar cases and three more people died.
“They never told us there was a problem,” said Neil Silverberg, Enrich's president. Marshall's recommendations to the VA would have been different if they had, he said. “We asked them for more information. We asked them to communicate with us, and they just didn't.”
The VA declined to comment, citing an investigation by the VA Office of Inspector General.
The VA didn't disclose the outbreak to patients, their families, hospital workers or the public until Nov. 16 — 17 days after the federal Centers for Disease Control and Prevention confirmed a match between Legionella in the water and a patient. By then, 20 of 21 cases the CDC linked to the VA were diagnosed.
A Tribune-Review examination of the outbreak, which the CDC says lasted from February 2011 to November 2012, shows missteps, misjudgments and missed opportunities:
• Inadequate testing: VA guidelines for Legionella testing called for using water samples one-tenth the size recommended by CDC guidelines to detect the bacteria. Screening pneumonia patients for Legionnaires' was done for serious cases and at doctors' discretion, rather than uniformly. VA officials said on Wednesday they have changed both protocols.
• Delayed disclosure: The first case of Legionnaires' disease definitively tied to the hospital was diagnosed on Nov. 9, 2011, a year before the VA warned the public, according to the CDC.
• Water treatment problems: The president of LiquiTech, maker of the VA's copper-silver ionization system, said his employee saw a VA worker falsifying records about the anti-Legionella system in early 2012 and was told the system wasn't being maintained because the worker tasked with the job was on disability leave.
• Leadership change: The VA appointed Lovetta Ford as associate director in April 2011, two months after the outbreak started. She is in charge of facilities management that would include Legionnaires' prevention systems. At other VA hospitals, a Trib review found, the job is held by people with engineering, science or administration backgrounds. Ford had no declared credentials in engineering or science. Her background was in social work and she served in administrative positions. In a news release announcing her appointment, she acknowledged needing to learn the way large medical centers operate.
Ford didn't respond to requests for comment and was not among VA officials made available for an interview on Wednesday.
• Misunderstanding the bacteria's reach: The widow of William Nicklas, 87, of Hampton, who died of heart failure and Legionnaires' disease, said the VA's chief of infectious diseases, Dr. Robert Muder, told her that her husband wasn't in the infected part of the hospital. Weeks earlier, the CDC warned the bacteria was widespread because it was in the building's water system. Muder declined to comment and was not made available for an interview on Wednesday.
• The lessons of history: The VA Oakland endured a three-year Legionnaires' outbreak that sickened more than 100 starting in 1979, one of the worst ever recorded in the country. Because Legionella is nearly impossible to eradicate, the VA should have been extra vigilant, CDC and other experts said. The strain linked to the recent outbreak matches bacteria found there in 1982.
“I think they knew exactly what they were dealing with inside the facility,” said Maureen Ciarolla of Monroeville. Her father, Navy veteran John Ciarolla, 83, of North Versailles, died July 18, 2011, in the Oakland VA. “I don't believe for a minute anymore that they didn't know.”
The VA Pittsburgh said it plans a $10 million upgrade to its water system. The plan includes plumbing changes such as installing 2,700 faucet valves that allow water to run hotter than 130 degrees Fahrenheit to kill Legionella, and eliminating parts of the plumbing system where Legionella might find shelter.
“Everything we've done in the past is to reduce the risk of Legionella infection. There is no such thing as eliminating the risk. You never eliminate the risk,” VA Regional Director Michael Moreland told the Trib.
Moreland shut down the hospital's world-renowned Legionnaires' laboratory here in 2006, when he was VA Pittsburgh CEO. Moreland and VA officials said later they did not understand the value of the lab's research samples for future treatment when they destroyed them.
Doctors who treat pneumonia patients don't typically think about Legionnaires' and instead suspect organisms such as staph, said Dr. Joseph S. Cervia, a Legionnaires' expert and clinical professor of medicine and pediatrics at Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y.
“It's under-recognized because it's under-suspected,” Cervia said. “A clinician has to go out of his or her way to make this diagnosis.”
Distinguishing Legionnaires' from more common forms of pneumonia requires a urinary antigen or respiratory culture test. The CDC recommends both. The Pittsburgh VA ordered mostly urine tests for suspected cases, largely at doctors' discretion until November, when stricter testing was ordered.
The VA conducted 1,051 urinary antigen tests in 2012, including mandatory tests that began for all pneumonia and suspected pneumonia patients when the outbreak became public in November. However, VA officials would not say how many of the urine tests were conducted before November.
The CDC says the first case of hospital-acquired Legionnaires' found in its review probably occurred in February 2011 and a second occurred in June 2011. The CDC says two cases in a single hospital within four months should alert medical staff, though a CDC report does not specify whether the early cases in the Pittsburgh VA originated in Oakland or O'Hara. Moreland told Congress at a Feb. 5 hearing that he learned in fall 2011 that his employees were worried about the number of diagnoses.
Workers started disinfecting pipes with a superheated water-and-flush technique every time they found Legionnella in a water sample, rather than only when the bacteria appeared in 30 percent of all samples, Moreland said.
That 30-percent threshold followed VA standards, but the CDC says there's no safe level of Legionella. What's more, the VA tested water in 100-milliliter samples, rather than the 1-liter size the CDC recommends. The CDC technique later proved nearly four times more effective in finding Legionella at the VA.
The CDC says copper-silver ionization systems work best in conjunction with heat-and-flush and hyper-chlorination treatments.
Still waiting for that call
Despite Moreland's stated concern, the VA never called LiquiTech — which built the disinfection system and managed it from 1993 through 2007 — about the Legionella problem, said LiquiTech President Steve Schira.
“Why they would never pick up the phone and call us is beyond me,” Schira told the Trib.
The VA declined to comment, citing the investigation by the VA Office of Inspector General.
Moreland told Congress he believed the heat-and-flush worked because the VA diagnosed no hospital-related cases for five months beginning in December 2011.
LiquiTech initiated two meetings with the VA, in December 2011 and April 2012, Schira said. During the second visit, Schira said, one of his employees reported seeing an unidentified VA worker falsifying reports about the operation of the LiquiTech system.
“(The worker) was writing down numbers and didn't seem to be using notes,” Schira said. “Maybe he had a great memory.”
Whether through human error, improper maintenance or a shortcoming in the ionization system, the VA's prevention efforts failed.
The bug roared back.
Luis Fábregas, Mike Wereschagin, Adam Smeltz and Lou Kilzer are staff writers for Trib Total Media.