Federal health officials believe a fatal outbreak of Legionnaires' disease in the VA Pittsburgh Healthcare System started in 2011, but they did not check hospital records that show Legionella bacteria appeared nearly four years earlier, a Pittsburgh Tribune-Review investigation found.
The bacteria can cause Legionnaires' disease, a form of pneumonia, when inhaled through shower steam or other mist. The elderly and others with weakened immune systems are especially susceptible to Legionella, which turned up at the VA's University Drive hospital in Oakland at alarmingly high rates on four occasions from September 2007 to July 2010, according to VA records obtained under the Freedom of Information Act.
Testing of faucets and other water fixtures revealed the bug appeared regularly in intensive-care units, where many of the infection-prone patients at the Oakland VA hospital receive treatment.
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The federal Centers for Disease Control and Prevention in Atlanta did not ask the VA for those water test records when the agency reviewed the scope of the Legionnaires' outbreak that ended in November 2012, CDC spokeswoman Alison Patti acknowledged. Five veterans died among 21 the CDC determined likely contracted Legionnaires' disease in 2011 and 2012 at VA facilities in Oakland and O'Hara.
"We can't say with 100 percent certainty that there weren't other cases of hospital-associated Legionnaires' disease that were never identified from 2006-2010," Patti stated in an email. "But we are confident that the 2011 outbreak was an acute one and that the bacteria were successfully remediated from the potable water system."
In fact, the CDC declined an offer from the Trib to review the records for 2007 to 2010. Patti cited her colleagues' busy workload in addressing other pressing health care matters.
"Without (water test) records, it would be impossible to draw any kind of assumptions regarding possible cause," said Dr. Joseph S. Cervia, a Legionnaires' expert and clinical professor at Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y. He said the water test results would help medical experts identify possible links among cases of human illness and contamination in the water.
"Obviously, the more information you have about an outbreak, the better. I would expect some interest from the CDC for that data," said Cervia, who was among three experts who reviewed Legionella test results for the Trib.
VA spokesman David Cowgill did not respond to the newspaper's questions about the water tests.
The Trib investigation shows the tallies of those sickened or even killed by Legionnaires' could be incomplete. The newspaper revealed Sunday that VA water test samples show Legionella spikes in the VA Pittsburgh water system as far back as September 2007 based on available VA records. It was not until November 2012 that the Pittsburgh VA began checking for Legionella in each pneumonia patient who might have contracted the disease inside the hospital system, Chief of Staff Ali Sonel told the Trib in April. Earlier testing had been left to clinicians' discretion.
Sonel said VA officials should have adopted the toughened patient testing standard sooner.
CDC reviewers looked at some 2011-2012 water test results for their initial review, requested by the VA Pittsburgh administration, CDC's Dr. Lauri Hicks told a congressional panel on Feb. 5. She said a CDC investigation in November was meant to assess the Legionnaires' risk in the Pittsburgh VA, prevent future flare-ups and identify other cases of the disease there.
"It's my impression that they had a false sense of security," Hicks told the congressional panel, referring to the Pittsburgh VA. "It goes back to the perception that they were doing everything they could to control Legionella in the environment."
CDC reviewers determined an uptick in Legionnaires' cases associated with exposure to the Pittsburgh VA began in February 2011, Patti said. She said reviewers looked for patient cases as far back as 2007 to make that determination, relying on the VA's own record-keeping for earlier patient cases.
Records for earlier water testing results were not reviewed, but Patti said the CDC didn't need water test results from the hospital plumbing because "the investigation was to stop ongoing disease transmission." The CDC has no plans to investigate the Pittsburgh outbreak further, Patti said.
Still, independent observers agreed veterans could have fallen sick from the contamination before 2011 without being documented as Legionnaires' cases. A urine test or a mouth swab culture of aspirated sputum can be used to determine if pneumonia is Legionnaires' disease.
"It is notoriously difficult to decide the difference between Legionnaires' disease and pneumonia on paper, but a simple test can show the difference," said Nigel Richardson, director of Legionella Control International in the United Kingdom. "So I would suggest CDC does not really know the answer fully and (is) taking an educated guess."
Cervia, the Hofstra professor, said a failure to confirm tap water caused earlier Legionnaires' cases could leave open speculation about how the illnesses began.
"I would think if you wanted to examine the outbreak in its totality and understand the epidemiological link, one would want to have (water test) records as well as clinical" test results from patients, he said.
Several investigations into the outbreak are ongoing, including those by a congressional oversight subcommittee, the VA Office of Inspector General in Washington and the U.S. Attorney's Office for Western Pennsylvania.