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VA officials admit 10 more possible Legionnaires' cases, apologize and tout solutions

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What they're doing

Officials with the VA Pittsburgh Healthcare System on Tuesday outlined several efforts under way to prevent the recurrence of Legionnaires' disease in their facilities. Among them:

• Installation of more than 3,300 mixing valves on water fixtures at the VA Oakland and O'Hara campuses. The project, designed to allow hotter water that can kill Legionella while preventing scalding, is about 15 percent complete. Expected completion: Sept. 1.

• Replacement of many conventional hot-water heaters, which can harbor Legionella bacteria, with instantaneous water heaters. About 15 percent complete. Expected completion: Sept. 1.

• Mapping of plumbing at both campuses and elimination of “dead legs,” where water can stagnate. About 5 percent complete. Expected completion: Dec. 31.

• Participation in the Pittsburgh Community Legionella Partnership, a new regional task force created to help promote best practices and updated hospital standards for Legionella control. The effort is ongoing.

'American Coyotes' Series

Traveling by Jeep, boat and foot, Tribune-Review investigative reporter Carl Prine and photojournalist Justin Merriman covered nearly 2,000 miles over two months along the border with Mexico to report on coyotes — the human traffickers who bring illegal immigrants into the United States. Most are Americans working for money and/or drugs. This series reports how their operations have a major impact on life for residents and the environment along the border — and beyond.

By Adam Smeltz
Tuesday, July 2, 2013, 7:39 p.m.

Legionella bacteria in the water at VA Pittsburgh Healthcare System hospitals may have sickened 10 veterans in the four years before a deadly outbreak of Legionnaires' disease blamed for five deaths and at least 16 others sickened in 2011 and 2012, VA Pittsburgh's chief of staff acknowledged Tuesday.

“To anyone that was impacted by this tragedy, we are truly sorry,” VA Pittsburgh CEO Terry Gerigk Wolf said of the system's Legionnaires' crisis, reading from a prepared statement to reporters at a closed-door briefing at the Heinz campus in O'Hara. “Our family, the VAPHS family, is heartbroken. We remain focused on learning from this tragedy and ushering in a new era of Legionella control.”

That new era includes an investment of more than $10 million in ongoing and planned plumbing upgrades at Pittsburgh VA campuses in Oakland and O'Hara, regular disinfecting of the water lines with chlorine and more rigorous testing for the waterborne Legionella bacteria that cause Legionnaires' disease when inhaled through mist.

“We want to be national and international leaders in this,” Chief of Staff Dr. Ali Sonel said of VA Pittsburgh's response to Legionnaires'. “We want to be a resource for other health care facilities.”

Sonel said twice-monthly water testing for Legionella bacteria conducted since Jan. 1 has shown minuscule levels in just 1.19 percent of 1,926 samples, down from more than 30 percent at times during the outbreak.

Testing at the VA lab now looks for even one colony of bacteria in one liter of water, a standard greater than the five- and 10-colony levels some private labs use when giving the all-clear, he noted.

Pittsburgh VA has treated only one case of Legionnaires' disease since Jan. 1 that might have originated in a hospital, Sonel said. That case was linked to exposure in another care facility that Sonel declined to identify.

In the meantime, the Legionnaires' outbreak remains under criminal investigation by the VA Office of Inspector General in Washington, Wolf confirmed. VA workers could face discipline or firings “as appropriate” depending on the outcome of that review.

A congressional oversight subcommittee and the U.S. Attorney's Office for Western Pennsylvania also are looking into the outbreak, which the Centers for Disease Control and Prevention reviewed last fall. Wolf said VA officials have not been contacted by the U.S. Attorney's office.

The CDC found 21 veterans probably or definitely contracted Legionnaires' disease, a severe form of pneumonia, from Legionella-tainted water at the Oakland and O'Hara facilities between February 2011 and November 2012. But the CDC acknowledged it did not check water testing records from the facilities prior to 2011.

Those records, obtained by the Tribune-Review under the Freedom of Information Act, showed elevated Legionella levels appeared in the Oakland hospital at several points from 2007 to 2010. Pressed on that point, Sonel acknowledged for the first time that the VA and CDC identified Legionnaires' cases in 2007, 2008 and 2010 that might have originated in the Pittsburgh VA system. He cited three cases each in 2007 and 2008 and four cases in 2010.

One case in 2007 was definitely acquired inside the Pittsburgh VA, Sonel said. All veterans involved in those 10 cases recovered.

Wolf said it is “absolutely untrue” the Pittsburgh VA tried to hide Legionella. She said the VA consistently reported Legionnaires' disease cases to the Allegheny County Health Department. The Trib reported Sunday about days-long delays in at least a third of the outbreak reports to the Pennsylvania Department of Health's electronic reporting system that most public hospitals must make within 24 hours.

Sonel questioned the effectiveness of state and CDC reporting systems for major infectious diseases and detecting outbreaks. He admitted the VA could have been quicker in reporting to the state. But he noted the state, CDC and Allegheny County expressed no concerns about an outbreak even after the VA entered the cases in an electronic database.

Under questioning, Sonel acknowledged inconsistencies of up to several days between CDC and VA documents showing when patients were diagnosed with Legionnaires'. He said some discrepancies could appear if a patient were first diagnosed with pneumonia and only later, on another date, diagnosed with Legionnaires'.

Sonel and Wolf appeared at the media briefing with Deputy Director David Cord and two executives from Phigenics, a Naperville, Ill.-based water management company hired by the VA to help oversee testing and treatment.

VA officials met earlier Tuesday with congressional aides and veterans' groups to review the efforts to fight Legionella.

“I was pleased they're moving in the right direction,” said Rep. Tim Murphy, R-Upper St. Clair, who attended the briefing. “Part of this is an equipment change, and part of this is a cultural change. I want to make sure there's a cultural change as well. There has to be accountability and responsibility acknowledged.”

Adam Smeltz is a Trib Total Media staff writer. Reach him at 412-380-5676 or

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