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Legionnaires' at Pittsburgh VA prompts probe of all VA facilities

“It’s really the way government should work. When you find a problem, there should be follow-up,” U.S. Sen. Bob Casey told the Tribune-Review on Thursday. “If a series of recommendations were made in 2007 and not implemented, that’s obviously a problem.” File photo

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By Adam Smeltz, Lou Kilzer and Mike Wereschagin
Thursday, March 14, 2013, 2:54 p.m.

Nonexistent planning and spotty disease surveillance in Veterans Affairs hospitals could leave patients, staff and visitors vulnerable to deadly Legionnaires' disease, a VA inspector general's report warned nearly six years ago.

Now, in the aftermath of the 2011-12 Legionnaires' outbreak at the VA Pittsburgh Healthcare System, the Office of the Inspector General is investigating more than 150 VA medical facilities to see how well — or even whether — the recommendations from its 2007 report for preventing Legionnaires' have been followed.

The follow-up is separate from the office's probe targeting the Pittsburgh outbreak, which the federal Centers for Disease Control and Prevention linked to five deaths.

“I won't discuss how far along we are,” said Cathy Gromek, spokeswoman for the national VA inspector general's office.

Gromek did say the office expects to finish the national investigation this summer. A report on the Pittsburgh examination is expected by the end of March.

The IG started the national investigation in December as a result of inquiries from Sen. Bob Casey Jr., D-Scranton, and Rep. Tim Murphy, R-Upper St. Clair, Gromek said. The House Veterans Affairs Committee's Oversight and Investigations subcommittee held a hearing Feb. 5, and the committee's investigators continue to look into the outbreak.

“It's really the way government should work. When you find a problem, there should be follow-up,” Casey told the Tribune-Review on Thursday. “If a series of recommendations were made in 2007 and not implemented, that's obviously a problem.”

Casey voiced concern to VA Inspector General George J. Opfer in a letter on Thursday that the VA Pittsburgh system prematurely suggested that no wrongdoing occurred in the Legionnaires' outbreak in the Oakland and O'Hara hospitals, citing a story the Trib published on Tuesday.

That story quoted VA spokesman David Cowgill as saying VA Pittsburgh officials have “no evidence of wrongdoing,” but acknowledging “reviews are ongoing,” including the IG's investigation.

“Our response to the Tribune-Review last Friday indicated that there have been several reviews already completed,” including by the CDC and the VA Central Office, Cowgill said. “None of those reviews have found wrongdoing but did offer suggestions for improvement. We have worked to improve our processes per this guidance. The response I shared with the Trib last Friday also stated that if the VA Office of Inspector General report finds something different, we will certainly act on that.”

The 2007 inspector general's report prompted similar promises for action from VA officials nationwide and painted a grim picture for veterans. It said Legionnaires' disease was the second-most-common cause of pneumonia among patients in VA intensive care units, yet only nine of the VA's 159 acute care and extended care facilities had a policy of routinely testing pneumonia patients for Legionnaires'.

Since clinical testing remains a primary means of stopping Legionnaires' outbreaks, the report said, “medical treatment facilities should be able to demonstrate that clinicians routinely test for (the disease) in patients with pneumonia. In VA hospitals, however, preliminary data suggest a wide range in the use of the most common test ... with numerous facilities testing very infrequently.”

Forty-three percent of the facilities performed fewer than 10 tests a year, and only 8 percent had a “Legionella-specific disinfection system” at that time, the report stated.

The CDC, in its investigation of the recent Pittsburgh outbreak, found VA doctors here “tested most patients with pneumonia” for Legionella bacteria. However, the CDC probe did not report numbers to define “most.”

The VA first publicly disclosed the outbreak in November, two weeks after the CDC linked Legionnaires' disease to the hospital's water system and 16 months after a second diagnosed case should have alerted VA Pittsburgh to a problem under CDC guidelines. Since November, Cowgill said, administrators have required doctors to test pneumonia patients for Legionnaires'.

Adam Smeltz, Lou Kilzer and Mike Wereschagin are Trib Total Media staff writers. Reach Smeltz at 412-380-5676 or Reach Kilzer at 412-380-5628 or Reach Wereschagin at 412-320-7900 or

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