It seemed like a simple request to Victor Yu and Janet Stout.
It was the first week of January 2006, and the two longtime colleagues and respected Legionnaires' researchers went together to the office of Mona Melhem, who oversaw the Pittsburgh Veterans' Affairs laboratories.
By then, it had been 26 years since Dr. Stout, a former Navy brat with a calming personality, had come to work as a graduate student with Dr. Yu, the son of Chinese immigrants known for his prickly personality and tenaciousness. In the interceding years, Dr. Stout had gotten her master's degree, her doctorate and a great deal of recognition for making -- in partnership with Dr. Yu -- some of the most important discoveries in the detection and prevention of the often-deadly Legionella bacteria.
Because of all of that, Dr. Yu believed his friend and research colleague deserved a raise.
Dr. Melhem, a VA employee and researcher who had risen through the ranks over 20 years to a top administrative position at the Pittsburgh VA, didn't agree -- and quickly saw an opportunity.
"Raise? I should fire her and close the lab and save money," she later told a colleague about the request for Dr. Stout.
Dr. Melhem began reviewing the "productivity" of the Special Pathogens Laboratory that Dr. Yu and Dr. Stout set up and ran at the Pittsburgh VA since 1980.
Her conclusion several months later was that the lab was a "drain" on VA resources.
That finding led to the closure of the lab on July 21, 2006, destruction of its collection of Legionella and other bacteria samples, Dr. Yu's firing, Dr. Stout's resignation and -- many familiar with recent events believe -- the Legionnaires' outbreak in 2011 and 2012 at the Pittsburgh VA that sickened 22 veterans and killed at least five of them.
"As soon as they closed the lab, I knew they were going to have another outbreak eventually, because they were losing all of their knowledge," said Angella Goetz, a former Pittsburgh VA infection control practitioner who worked with Dr. Yu and Dr. Stout for two decades.
That view is held by many familiar with the roles they and their lab played in controlling Legionella at the hospital: Dr. Stout, overseeing the testing of water and patient samples, as well as maintenance of the copper-silver ionization water treatment system; and Dr. Yu, educating and keeping physicians and nurses up to date on the Legionella risk and how to treat patients.
The Pittsburgh Post-Gazette reviewed internal VA documents and interviewed more than two dozen current and former Pittsburgh VA employees, consultants and outside researchers. The newspaper found that the steps leading to the outbreak that began five years after the two doctors left the VA did not come in one fell swoop.
Instead, it was a steady erosion of protocols and methodologies that Dr. Yu and Dr. Stout had put in place over the prior 25 years -- practices that had prevented the Pittsburgh VA from having even one hospital-acquired case of Legionnaires' disease for nearly a decade before they left.
"The standards dropped when Dr. Stout left," said a VA employee who worked with Dr. Stout on water treatment and asked not to be named. "Everything we did weekly when Dr. Stout was here, they changed to monthly. Things we did daily, they changed to weekly."
Five out of five
Of the five recommendations made last week in a review of the outbreak by the U.S. Veterans' Affairs Office of the Inspector General, all are practices that were in place when Dr. Yu and Dr. Stout oversaw Legionella control and prevention at the Pittsburgh VA.
In addition, their very success in preventing Legionnaires' appears to have created a sense of overconfidence that, first, led VA officials to believe that they could do without Dr. Yu and Dr. Stout, and, second, left infection control employees and doctors reluctant to believe any case of Legionnaires' could have been acquired from inside the VA, stalling an identification of the outbreak for more than a year.
"My guess is that doctors there were involved in the complacency, thinking there hadn't been a hospital-acquired case in almost 20 years," said one prominent Legionnaires' researcher who, like many interviewed for this article, asked not to be named because of the politically charged nature of the fallout from the outbreak.
Dr. Melhem, who did not respond to a phone message seeking comment, seemed to feel the same way.
After Ms. Goetz wrote an email to the VA in August 2006, asking that the lab be kept open, Dr. Melhem responded: "We at the Pittsburgh VA appreciate all the effort that was put forth to help advance the knowledge about Legionella. As the field of infection control evolved over the past 25 years, efforts are now redirected to more timely and more devastating organisms, namely the eradication of MRSA.
"The efforts to control Legionella will continue as a mainstream effort," she added.
MRSA (methicillin-resistant Staphylococcus aureus) is another potentially deadly hospital-acquired bacteria that hospitals have been fighting, and the Pittsburgh VA has received national recognition for its treatment and prevention efforts.
The inspector general's report did not look back in time to determine if Dr. Yu and Dr. Stout's departure was a factor. But the inspector general's two top officials overseeing the report say it was clear to them that a series of seemingly small mistakes combined to cause the outbreak.
"There were failures at a several levels," said Jerome E. Herbers, the associate director of medical consultation and review in the office of health care inspections, who was the lead doctor working on the outbreak review.
"And if you don't accomplish at several levels what you're trying to do, it can rise to the level where it affects people," he said. "If there are breakdowns in the management of the copper-silver, and breakdowns in the care and testing of patients, the risk to patients goes up."
That breakdown was particularly evident at the University Drive hospital in Oakland, where nearly all of the 22 patients who were sickened are believed to have acquired Legionnaires'.
As the inspector general's report points out, and as first was reported by the Post-Gazette last year, the copper and silver ion levels from the water treatment system at University Drive in 2011 and 2012 were rarely in the effective range that has been shown to control Legionella. The levels frequently were much higher or lower than the effective range.
Though it was not noted in the inspector general's report, at the Pittsburgh VA's H.J. Heinz facility near Aspinwall, in those same years, the copper-silver levels were nearly always in the effective range, according to VA documents and the inspector general's office.
"That's right," said John D. Daigh, assistant inspector general for health care inspections who oversaw the review. "And one of the differences may have been the people."
Current and former employees say that at University Drive, of the half-dozen plumbers, pipe fitters and their supervisors who work on the water system there, not one was in that position when Dr. Yu and Dr. Stout were there and were never trained by them, while several employees at Heinz were.
Among employees at University Drive, blame over the past five months since the outbreak was first revealed on Nov. 16 has been directed at the two pipe fitters who were responsible for checking, cleaning and adjusting the copper-silver water treatment system.
Reached by phone, both of those employees deny that they were at fault and say the VA and their attorneys told them not to comment to reporters.
A consultant familiar with the VA's water treatment operations said such blame is unfair because it is clear -- as pointed out in the inspector general's review -- that it was a communications problem among people higher up in the VA.
"When you have something like this [outbreak] happen, it can't be the guy at the bottom's fault," the consultant said. "The blame falls on facilities management and infection control, period. Anybody in a supervisory position in this failed, because they could have done more."
In addition, current and former employees said, in the years since Dr. Stout left, infection control staff rarely worked directly with the plumbers and pipe fitters who handled the maintenance of the copper-silver system and regular testing.
One current employee said even though staff regularly collected information about the operation of the copper-silver system, "no one cared about what we did" until near the beginning of the outbreak in August 2011. "Then [now-retired supervisor] Mary DeRiso started asking for copies of everything."
Ms. DeRiso did not return a call seeking comment.
That was in contrast to Dr. Stout, who oversaw the maintenance of the system, and "was completely anal about things to the point where she was annoying," one former plumber said. "She wanted to see the daily check sheets. And she'd be down here regularly. Even though she trusted me, she'd come by a couple times a month to see how I was cleaning the [copper-silver] cells."
On the clinical side, which was Dr. Yu's area, one change the Pittsburgh VA made last fall after the outbreak was revealed was to try to get sputum, or mucus, cultures, for every patient with suspected hospital-acquired pneumonia, and to first do urine antigen testing to look for Legionella, since Legionnaires' is a form of pneumonia.
Only nine of the 22 patients who got sick at the VA in 2011 and 2012 had had sputum cultures taken and analyzed. Taking cultures from all of the patients would have allowed the VA to compare the bacteria in the patient to an environmental sample in the hospital to determine whether the disease was contracted at the VA.
But that practice was standard when Dr. Yu was at the VA.
"When we knew there was Legionella in the water, even at one site, I would talk to the doctors and remind them to take sputum cultures so we could figure out if they got sick in the hospital," Dr. Yu said.
Asked why the Pittsburgh VA ended this practice, regional VA director Michael Moreland said he doesn't know that it was the practice under Dr. Yu because "there's no written evidence that it was."
Yet even when orders were given that might have helped during the outbreak, they weren't always followed, resulting in another example of the communication problems that occurred at the Pittsburgh VA.
In September 2011, early in the outbreak, Pittsburgh VA chief of staff Ali Sonel sent a memo to his staff telling them to do urine antigen tests -- a quicker initial test to determine if a patient has Legionnaires' -- as well as to take sputum cultures for everyone with hospital-acquired pneumonia.
The inspector general's review found that in the three months after Dr. Sonel's memo was sent, however, only seven of the 17 patients in the hospital with suspected hospital-acquired pneumonia were tested for Legionnaires'.
'There are other experts'
Even with all of that, VA officials still reject the idea that the Pittsburgh VA would have been better off with Dr. Yu and Dr. Stout on staff.
Rajiv Jain, who was Pittsburgh VA chief of staff in 2006 and is now assistant deputy for patient care services for the national VA, said he acknowledges that Dr. Yu and Dr. Stout are experts on Legionnaires'. "But my point is, there are other experts in the field," he said.
When asked whether the outbreak still would have occurred if Dr. Yu and Dr. Stout were at the Pittsburgh VA, Dr. Sonel, who replaced Dr. Jain, pointed to a 2003 article that Dr. Yu and Dr. Stout wrote on the first seven years of the use of copper-silver treatment systems in hospitals.
"It says that they averaged one hospital-acquired Legionnaires' case [at the Pittsburgh VA a year] for the first seven years," Dr. Sonel said. "That's the science."
Dr. Yu pointed out, however, that all seven of those cases occurred in the first three years of the copper-silver system's use, when it was still novel, and, after 1998, there was not one more hospital-acquired case at the Pittsburgh VA until he and Dr. Stout left.
"You want to compare it?" Dr. Yu said in a separate interview. "Well, let's use his standard. You [at the VA] had five deaths. We had seven cases where no one died over a decade ago and then no cases at the VA until after we left. The comparison is not a scientific comparison."
At one point last fall, when the outbreak was near its peak, the infectious control chief at the Pittsburgh VA, Robert Muder, who worked with Dr. Yu and Dr. Stout, did something drastic: He called them to see if they would be willing to come in and help the VA figure out how to stop the outbreak.
"We agreed," Dr. Yu said. "We would have been happy to help."
But Dr. Muder first had to ask his bosses at the VA, who quickly turned him down.
It was part of the continuing frustration for Dr. Yu and Dr. Stout as they watched what happened over the past six months.
"The theme of the decisions some administrators made, to me, is to do less, spend less and maybe there will be no consequences," Dr. Stout said. "And now the VA is spending $10 million [on new water faucets] for a problem that could have been solved for less than $100,000?"
"Who is making these decisions?" she asked. "People died, and it was because of their decisions."
Sean D. Hamill: firstname.lastname@example.org or 412-263-2579.