VA lapses cited in fatal Legionnaires' disease outbreak

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The Pittsburgh Veterans Affairs Healthcare System had its first real chance to put an end to an outbreak of Legionella in its water system in July 2011, when its first patient died of the infection.

But because of shortcomings by its infection-control, laboratory and engineering and plumbing staffs, another 16 months would pass and four more deaths would be linked to the outbreak before the VA publicly declared it had a problem in November 2012, according to internal VA documents and a VA official who is not authorized to speak publicly about the situation.

The outbreak that eventually sickened 21 patients, killing at least five people, is the focus of congressional and VA inspector general investigations.

According to VA documents and the official:

• When a patient tested positive for Legionnaires' disease, the infection-control staff checked for Legionella -- the bacteria that causes Legionnaires' -- only in water in rooms where the patient stayed. Several experts said this is inadequate because Legionella could be found in water samples taken from other outlets of the same water system at the facility.

PG graphic: Legionnaires' cases at VA
(Click image for larger version)

• In most cases early in the outbreak, the VA did not have a sample of the bacteria from a patient, which hospitals get from a "sputum" sample obtained when a patient with Legionnaires', a form of pneumonia, coughs up mucus from the lungs. Though it had been hospital protocol as recent as seven years ago to always obtain sputum, such practices were no longer required. That means that even if the hospital did find a Legionella sample in the water system, it did not have a patient sample to compare it to.

• Robert Muder, the chief of infection control, has complained to VA leaders that his staff did not do additional testing because it was short-staffed and stretched thin. The VA official says Dr. Muder never made a request for additional staff. Dr. Muder did not return a phone call seeking comment.

• Results of urine antigen tests -- the initial tests that would determine if a patient had Legionnaires' -- were delayed two or three days after they were ordered by doctors because the Pittsburgh VA lab staff for efficiency reasons waited until it had a batch of five or more samples to test. The delay may have played a role in slowing the most effective treatment for patients.

• Because the Pittsburgh VA did not regularly obtain patient sputum or environmental samples for comparison, and it did not do so even after the second "probable" case in violation of federal Centers for Disease Control and Prevention guidelines, its infection-control staff lacked all the evidence it needed to determine if a Legionnaires' case originated in the hospital. As a result, infection-control officials concluded that the patient contracted the disease elsewhere and didn't look deeper into the problem until the fall of 2012, when it finally called in the CDC.

• Because the origin of cases was either unknown or ruled as coming from outside the hospital, the Pittsburgh VA's chief of staff, Ali Sonel, did not know about three of the five cases in which veterans died after contracting Legionnaires'. This may have prevented the VA from taking quicker action early in the outbreak. Dr. Sonel did not return a phone call seeking comment.

PG graphic: Legionnaires' case details
(Click image for larger version)

Despite all of these points, Terry Wolf, director of the Pittsburgh VA health system, believes its staff did everything it could over the last two years to get the outbreak under control -- even if, in retrospect, it now would have done many things differently.

"Employee morale is really low right now, and people fear they're going to be fired," she said in her first interview about the outbreak. "But nobody should have reason to feel they're going to lose their job. We want to learn from this experience and never let it happen again."

She points to changes in policies the Pittsburgh VA has made in the wake of the outbreak and the problems it has uncovered as evidence that it is responding the way a health care system should.

Testing is no longer delayed to wait for a batch of samples, and Legionella cultures and environmental samples are obtained in every case when a patient tests positive, she said.

But Mrs. Wolf said she remains concerned about some of the actions and statements made by both the Pittsburgh VA's infection-control staff, its laboratory and its plumbing and engineering staff, in the first few months of the outbreak in 2011.

Most important, Mrs. Wolf still wonders why the bells that finally went off in the fall of 2012, when the Pittsburgh VA called the CDC in to help, didn't go off in July 2011, when the first patient, John Ciarolla, 83, died after contracting Legionnaires'.

"I have asked that question," Mrs. Wolf said, "and we're going to get to the bottom of it."

The VA's infection-control department, which is charged with testing the Pittsburgh VA's water for Legionella, did not ignore Ciarolla's case, she emphasized.

In fact, infection control was so worried about the man's positive urine antigen test that Mrs. Wolf and her office staff put out an "Issue Brief" on the case and its implications July 5, 2011.

Issue Briefs are sent to the VA's regional office run by regional director Michael Moreland.

The brief on Ciarolla's case was the first mention to the regional office in 2011 that there was a Legionnaires' problem in the Pittsburgh VA -- even though at least one prior patient, who later recovered, had contracted the disease in February 2011.

That was the same month that the VA's University Drive hospital detected an unusual amount of Legionella in its water system. It found the bacteria in six of 16 sites in the hospital and put the hospital's water system through a "heat and flush" procedure that increased the temperature of the water in the pipes to kill much of the bacteria and flush out water for up to 30 minutes at sites that tested positive.

Follow-up testing in March found no positive results at the hospital.

But four months later, Ciarolla, a Navy veteran from North Versailles who was a resident at the VA's H.J. Heinz nursing home facility near Aspinwall, got sick the last week of June.

More than in any other case, how Ciarolla's illness was handled by the Pittsburgh VA demonstrates the shortcomings that allowed the outbreak to flourish.

His daughters, Maureen Ciarolla of Monroeville and Sharon Heinnickel of Greensburg, say their father first went to live at Heinz sometime in spring 2011 because of problems with diabetes. He had previously broken both hips and was having trouble caring for himself.

He stayed there full time, except for doctor visits at the University Drive hospital. He was doing so well that in June his daughters took him out for two half-day visits, June 12 at Ms. Ciarolla's home and Father's Day, June 19, at Ms. Heinnickel's home.

On June 27, John Ciarolla was transferred to University Drive because he had a fever and was disoriented. The immediate diagnosis was pneumonia, and he was put on intravenous antibiotics for three days, according to the Issue Brief on his case.

A urine antigen test to confirm the presence of Legionella was done June 28. But, because of the batch system, the test was not completed until July 1 and it showed he had Legionnaires'.

The CDC report says doctors never got a sputum sample from Ciarolla. And though the Issue Brief said the VA's infection-control staff attempted to get an environmental culture from Heinz, it only tried to get a sample from rooms where he stayed, according to the VA official, and apparently found no Legionella there.

That's also what Ron Voorhees, interim director of the Allegheny County Department of Health, said he was told when he asked about the VA's Legionnaires' cases in 2011. The VA said "all their environmental samples were negative."

With no environmental or sputum samples to review, the VA's infection-control team turned its attention to the half-day visits to his daughters' homes. They were both asked to take water samples and send them back in to the VA for testing.

"I felt too guilty to even send them in," Ms. Ciarolla said. "I didn't want to know if he got sick at my house the same way the VA didn't want to know if he got sick in their buildings."

After her father died on July 18, 2011, one of John Ciarolla's doctors, Gilles Clermont, listed his primary cause of death as "septic shock," with a secondary cause as "pneumonia," but no mention of Legionnaires'. Dr. Clermont did not return a call or email seeking comment.

At the Congressional hearing on the outbreak Feb. 5 in Washington, D.C., the family of William Nicklas, 87, the last of the five veterans to die during the outbreak, said Ms. Ciarolla approached each of them and apologized for not doing more to find out what happened to her father.

"I had to apologize to them," Ms. Ciarolla said recently. "If I hadn't felt so guilty, maybe I ask more questions and maybe they figure this out then and maybe those other four veterans don't die. That's why I'm not letting this go now."

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Sean D. Hamill: or 412-263-2579.


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