Report issued after Pittsburgh outbreak finds VA medical facilities' record poor on Legionnaires' regulations

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The deadly outbreak of Legionnaires' disease last year at Veterans Affairs medical facilities in Pittsburgh had local political leaders worried that there might be a problem with how the disease was handled at VA hospitals nationwide.

But a review of all VA hospitals released Thursday by the VA inspector general found that the problems that led to the local outbreak were contained to Pittsburgh.

The review did find, however, that VA medical facilities do not fully comply with the department's own directive aimed at preventing the infection, which causes a severe form of pneumonia. It found that 37 percent of VA facilities required by the 2008 directive to conduct an "action plan" to prevent Legionnaires' still have not done so; 18 percent did not provide evidence of their annual appraisals of activities they have taken to prevent the disease; and 29 percent had no documentation of Legionnaires'-related testing in the hospitals.

Even so, the risk of contracting Legionnaires' or dying from it in a VA facility is low, according to the findings of the 44-page report from the Veterans Affairs Office of Inspector General, which quizzed all 182 VA medical facilities nationwide.

The report reached that conclusion because the data collected showed that in fiscal year 2012, which ended Sept. 30, 2012, 112 patients nationwide were found to have Legionnaires' but only four of them were confirmed to have contracted the disease at a VA facility -- and all four got it during the outbreak in Pittsburgh.

Legionnaires' is caused by bacteria in water, and people become infected when they inhale it through mist or drinking water. Patients with weakened immune systems are most susceptible to the disease.

The review was requested in December by U.S. Sen. Bob Casey, D-Pa.; U.S. Rep. Tim Murphy, R-Upper St. Clair; and other leaders of both the U.S. House and U.S. Senate Veterans' Affairs committees. It was part of a larger request that included an investigation of the Pittsburgh VA outbreak specifically. A report on the outbreak by the inspector general was released in April.

"The report shows a clear lack of understanding at VA facilities across the country about proper protocol when testing for Legionella," Mr. Casey said in a statement Thursday. "The Inspector General's findings only bolster the case for significant reform at [VA Pittsburgh Healthcare System] and around the country and the need to pass legislation to require the VA to report outbreaks of infectious diseases to the appropriate public officials."

Mr. Casey has introduced a bill in the U.S. Senate that would require VA facilities to report all infectious diseases to local, state and federal health officials. Two similar bills have been introduced in the U.S. House, one by Mr. Murphy and Rep. Mike Doyle, D-Forest Hills, and another by Rep. Mike Coffman, R-Colo. Mr. Coffman's bill was incorporated into a larger bill that was approved in committee Thursday.

Mr. Murphy said in a statement: "VA leadership needs to prove to veterans, Congress and the public that they are committed to providing the best possible care. This starts with adhering to their own clinical standards and infection-control protocols and supporting the Infectious Disease Reporting Act."

The request to investigate VA facilities nationally was prompted by the Legionnaires' outbreak in 2011 and 2012 at the Veterans Affairs Pittsburgh Healthcare System that killed at least five veterans and sickened as many as 22. On Monday, the Pittsburgh Post-Gazette reported that a sixth veteran's death may be tied directly to the outbreak.

One of the most troubling aspects to investigators was that a similar review done in 2009 to see how VA medical facilities were complying with the 2008 directive on the prevention of Legionnaires' disease found the same problems.

"That was something we did notice," Robert Yang, a senior physician in the office of health care inspection in the VA inspector general's office, said Thursday. "Unfortunately, despite efforts to increase education and awareness to improve compliance [since 2009], it did not seem to have enough of an impact."

Dr. Yang said the requirements in the 2008 directive might be too complicated to implement and that perhaps procedures need to be simplified.

The report -- which looked at data from fiscal year 2012 at the height of the Pittsburgh outbreak -- found that the Pittsburgh VA was the most aggressive VA facility in the country when it came to looking for Legionnaires'.

Even though 12 other VA facilities across the country have had to deal with hospital-acquired cases before, "there's not another facility that even comes close" to Pittsburgh's efforts, Dr. Yang said.

The Pittsburgh VA performed, by far, the most urinary antigen tests and the most respiratory cultures to look for Legionella in patients.

Perhaps as a result of more testing, the Pittsburgh VA also had, by far, the most Legionnaires' cases -- either hospital or non-hospital acquired -- of any VA facility. It had 18 cases, 13 more than the facility with the next highest number, which was in Washington, D.C., according to the report.

Ali Sonel, Pittsburgh VA chief of staff, has long argued that the Pittsburgh VA has gotten more attention, in part, because it tests more and finds more cases.

David Cowgill, the Pittsburgh VA spokesman, reiterated that in an email Thursday in response to the review: "The Inspector General has confirmed that VAPHS leads VA nationwide in aggressive testing measures for Legionella."

The report found the Pittsburgh VA also was one of nine VA facilities with a history of hospital-acquired Legionnaires' cases that did not properly conduct testing to look for Legionella, based on the 2008 directive.

That finding is similar to the problems the inspector general disclosed in the April report, which looked at the reasons behind the Pittsburgh VA outbreak, essentially concluding that a series of decisions large and small by VA employees in Pittsburgh led to the outbreak.

U.S. Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans' Affairs, said about Thursday's report: "This report is troubling proof that the mismanagement and incompetence that led to the Pittsburgh Legionnaires' disease tragedy is present at numerous VA medical centers across the country. The report very clearly documents how VA facilities put patients at risk by ignoring internal VA policies as well as federal guidelines governing infectious disease management and reporting."

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Sean D. Hamill: or 412-263-2579 First Published August 1, 2013 7:30 PM


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