It was not the machines, it was the people.
That is the essential conclusion of a four-month federal review looking into the cause of the Legionnaires' disease outbreak at the Pittsburgh Veterans' Affairs facilities in 2011 and 2012 that sickened 22 men and killed at least five of them.
The much-anticipated, 32-page review -- which could spur other investigations -- was released Tuesday by the U.S. VA's Office of the Inspector General.
The review found that maintenance, testing and communications problems by employees of the Pittsburgh VA led to the outbreak of the waterborne Legionella bacteria, and it made five recommendations to correct those problems, which the VA said it would do.
The review did not attribute the outbreak to the copper-silver ionization water disinfection system as the Pittsburgh VA did on Nov. 16 -- the day the VA first said it had a problem with Legionella in its water system.
"That's why I called for this in the early stages because you cannot audit, review and look at yourself critically when you're looking at a problem like this," said U.S. Sen. Bob Casey, D-Pa., who first made the request for the review in December. "I think this report conveys a level of deficiency which is substantial, and substantial enough that it warrants legislative action."
U.S. Rep. Tim Murphy, R-Upper St. Clair, who also requested the review, said it also needs to lead to accountability.
The findings of the review "are my worst fears," Mr. Murphy said. "We were hoping that all of this wasn't true, but it is."
"There has to be accountability. What the inspector general's report doesn't say is who made the decisions that led to this. And if the U.S. attorney can look into this and find that out, I think the accountability should lead to their dismissal, whoever it is," he said.
The office of inspector general's review made five main findings that it said led to the outbreak:
• During the outbreak's two years, when a copper-silver ionization system was in use, staff at the Pittsburgh VA "allowed ion levels inadequate for Legionella control to persist" and the Legionella flourished in the system.
• There was little documentation of system monitoring and poor communication and coordination between the infection prevention and facilities management staff.
• Staff did not do routine flushing of hot water faucets and showers, particularly in infrequently used areas, as copper-silver manufacturers advise.
• While the staff followed the VA's environmental surveillance guidelines, when it performed heat-and-flushes to try to clear Legionella out, it did not raise the temperature of the hot water in violation of its own guidelines.
• Staff did not test all health care-associated pneumonia patients for Legionella, as VHA guidelines for transplant centers with a history of Legionnaires' disease recommend.
The review's five recommendations addressed each of the problems the inspector general found: monitor and maintain the disinfection system properly; routinely flush the hot-water faucets and shower heads; get infection prevention and facilities management staff to work more closely together; take proper action when environmental cultures of the water are positive; and make sure all health care-associated pneumonia patients are tested for Legionnaires'.
Though the report appeared to put blame on the employees rather than the copper-silver system, Pittsburgh VA Director Terry Wolf said she and other officials were in "total agreement" with the findings.
"They validated what we already knew," she said.
Pittsburgh VA Chief of Staff Ali Sonel said there may have been other factors in the University Drive hospital building Oakland that caused the copper-silver system there to not be effective -- it was replaced by a chlorine disinfection system -- including elevated levels of pH in the water.
Victor Yu, who was chief of infectious disease at the Pittsburgh VA until being fired in 2006 in a dispute with management, said he felt somewhat vindicated by the report because it doesn't blame the copper-silver system itself and it cites his work and that of his colleague, Janet Stout.
Dr. Yu and Dr. Stout, who oversaw the copper-silver system's maintenance at the Pittsburgh VA until she resigned in 2007, were responsible for installing the original copper-silver systems there in 1996 and believed it was effective in controlling Legionella.
"In one sense, I feel good that they cited our work," Dr. Yu said after reading the review. "But at the same time, it's very bittersweet because the hospital that we aimed our efforts at for so long screwed everything up and people died. In the end, it doesn't give me that much satisfaction."
The Pittsburgh VA was dealing with persistent Legionella findings in its water systems, mainly at University Drive, but also the H.J. Heinz nursing home near Aspinwall, since at least summer of 2011.
The first patient to contract Legionnaires' during the outbreak occurred in February 2011, but it was in the summer that it began to take hold, killing John Ciarolla, 83, of North Versailles, in July 2011 and then rapidly infecting six more veterans in the fall of 2011.
Plumbers and pipefitters worked on the problem for months trying to get the copper-silver system operating properly.
But the inspector general's review found that copper and silver ions were consistently testing outside of the effective range, and even outside consultants and manufacturers' recommendation didn't seem to help, or were not acted on by Pittsburgh VA employees.
After six months of no hospital-acquired Legionnaires' cases, in the spring of 2012, Legionella was again being found in the water and patients began getting infected again.
In all, 22 veterans would get sick -- that's one more than previous reports found -- and five would die.
The inspector general's report also notes that three of the 17 patients who probably or definitely contracted Legionnaires' in the Pittsburgh VA facilities later died. Two died more than a year after infection and the third, 61 days after infection, and their deaths are not considered to be related to contracting Legionnaires'.
Ward Morrow, assistant general counsel to the American Federation of Government Employees, which represents Pittsburgh VA employees, said the sentiment online among VA employees was that "most people are disappointed that the IG didn't dig a little deeper."
"I think it's important to find out the whys and the whos not only for the staff, but the families involved," he said.
Maureen Ciarolla, daughter of the first victim, John Ciarolla, agreed.
"I'm a little disappointed how the inspector general didn't interview the families and how the VA treated them," she said.
"It gave me satisfaction on the one hand that we were right that they made mistakes," she said. "But it left me mad on the other hand that these people still haven't been held accountable."
Correction/Clarification: (Updated April 25, 2013)In an earlier version, the number of patients who had not previously been known to have died was given incorrectly. The inspector general's report cites three additional deaths above the five that were previously known.
Sean D. Hamill: firstname.lastname@example.org or 412-263-2579. First Published April 24, 2013 12:00 AM