Four people had been infected with Legionnaires’ disease. That’s all the Centers for Disease Control and Prevention knew when the the Veterans Affairs Pittsburgh Healthcare System requested help from the federal agency on Nov. 1, 2012.
It would be another three months before the CDC revealed the infections were part of a major outbreak at the VA hospital in Oakland between July 2011 and December 2012 that led to the deaths of five veterans — a sixth death would be identified later — and the serious illness of 16 others.
But the instant a top CDC official, Cynthia Whitney, saw where the request was coming from, she fired off an email.
“Wait a second. ... Isn’t this Victor Yu’s/Janet Stout’s former VA hospital?” she wrote in the email to CDC colleagues in Atlanta.
Dr. Yu and Ms. Stout, both of Pittsburgh, are two of the world’s leading experts on Legionnaires’ disease, a type of pneumonia that is deadly to elderly and immunosuppressed people. Working as a team at the VA for 26 years, the two made significant discoveries about Legionella, the bacteria that causes the disease, particularly that it is spread through water systems. But they were pushed out of the VA in 2006 in what a Congressional committee later found was a series of unfounded allegations by VA management.
But the emails also show that the CDC commenced the investigation with the intent to condemn the copper-silver system that the VA and many other hospitals have long considered the gold standard for prevention of Legionnaires’. Rather than finding fault with the people who maintained and oversaw the system — as a separate VA Office of Inspector General investigation found — the CDC convinced the VA to switch to a chlorine disinfection system the CDC had long favored.
The emails of Dr. Whitney and seven of her CDC colleagues revealed personal biases against Dr. Yu and Ms. Stout, as well as copper-silver systems, which discharge minute amounts of copper and silver ions into water to kill Legionella. While personal bias itself does not always directly affect the related scientific research, the CDC emails show that in this case, these biases may have played a role in how and what information the CDC chose to present on its investigation, first, in a 2013 report to Congress, and later, in a 2015 article in the journal Clinical Infectious Diseases.
Here is the CDC’s 2013 report to Congress:
After her first email, Dr. Whitney directed an email to Stephen Hadler, the CDC’s deputy director of the division of bacterial diseases, and Rana Hajjeh, the director of the division of bacterial diseases and one of the officials who would approve the investigation in Pittsburgh.
“FYI for Steve/Rana — Note that Victor Yu and Janet Stout, formerly of this hospital, have made long careers from loudly going against CDC’s Legionella policies and programs going back decades,” wrote Dr. Whitney, chief of the CDC’s respiratory disease branch.
“Also, they have also been touting copper silver ionization as a means of LD control for years without much evidence,” she added. “So long story short doing this investigation will have a bit of poetic justice to it.”
Dr. Whitney’s email is one of hundreds released to the Post-Gazette in August, 3½ years after the newspaper filed a Freedom of Information Act request with the CDC. The emails document how the CDC made the rare decision to dispatch a five-member team to Pittsburgh to investigate and stop the outbreak.
Jerome Herbers, who helped lead the VA’s Office of Inspector General’s outbreak investigation, said in an interview that the emails troubled him.
“I’m appalled,” said Dr. Herbers, who left the VA last year to work as a private physician. “As a former civil servant, we’ve got nothing but our integrity. And once you start being influenced inappropriately, the slippery slope starts sliding quickly.”
The CDC mission
The CDC presents itself to the public as a bastion of impartial science, the go-to institution for health-related problems too big for any state or local health department to handle.
But other researchers and advocacy organizations have taken issue in the past with the CDC on various points and accused it of bias before. Most recently, a top CDC official, Barbara Bowman, resigned after she was found in emails to be offering guidance to a Coca-Cola company representative about ways to influence the World Health Organization on sugar and soda issues.
Despite multiple requests to speak with every CDC official mentioned in this article — after an initial interview with one of the investigators, Claressa Lucas — the CDC did not make anyone else available.
Kristen Nordlund, a CDC spokeswoman wrote in an email: “We stand behind the science in the [journal] paper and our investigation into the outbreak. At this time, we don’t have anything further to say about the Pittsburgh VA outbreak.”
Dr. Hajjeh, who recently left the CDC to work for the World Health Organization in Egypt, said in an interview that she approved the Pittsburgh investigation “based on the public health needs at the hospital at the time.”
“I’m not saying there’s not any animosity” between the CDC and Dr. Yu and Ms. Stout, she said. “But I firmly believe that this [investigation] was not done to get back at anyone.”
Anger with Yu and Stout
The emails begin at 8:46 a.m. on Nov. 1, 2012, when Laurel Garrison, an epidemiologist in the CDC’s division of bacterial diseases who would later be part of the team that came to investigate in Pittsburgh, gave her colleagues a heads up that the CDC was being asked by the Pennsylvania Department of Health to investigate four cases of Legionnaires’ disease at the VA hospital.
Ms. Garrison wrote that there was a good reason to dedicate strained resources to Pittsburgh: “Pending additional information about the outbreak, this may be a good opportunity for us to make an impact in Pittsburgh and at this hospital, as well as learn more about copper-silver system failures.”
The CDC gets many complaints from various entities — hospitals, nursing homes, hotels, ships, and other facilities — every year about Legionella outbreaks. Rarely does the CDC, which has seen its budget cut by more than $1 billion over the last decade, agree to send a team to investigate outbreaks.
Because of their significant Legionnaires’ discoveries over the years, Dr. Yu and Ms. Stout, who has a Ph.D. in infectious disease microbiology, have received multiple accolades and awards from the VA, scientific organizations, other researchers and clients.
Despite that, administrators and researchers at the CDC have had a long battle with Ms. Stout, and the more acerbic Dr. Yu, in particular. He has gotten into sometimes harsh, public debates with CDC officials at scientific conferences. Dr. Yu and Ms. Stout say the CDC has disagreed with them over everything from how Legionnaires’ might be transmitted, to testing protocols, to how to get rid of Legionella, the bacteria that causes Legionnaires’.
“There has been a rift for more than 30 years” with the CDC, Dr. Yu said in an interview. “It was because they felt they were the gurus and they were upset when we came up with this ‘ridiculous’ proposal that Legionella came from drinking water instead of cooling towers and that [we said] you should test your water regularly instead of waiting for someone to get sick first.”
More than anything, though, the CDC has tried to discredit research by Dr. Yu and Ms. Stout — who now run a private laboratory in Uptown — into the use of copper-silver ionization systems, including in debates at Legionnaires’ conferences over the last three decades. In the emails, they questioned whether the two had financial relationships with two national copper-silver manufacturers, Liquitech and Enrich. Dr. Yu and Ms. Stout said they have never had any financial relationships with either company.
“Do Stout and Yu have financial interest in [Enrich]?” Alicia Demirjian, an epidemiologist who headed the CDC’s Pittsburgh team, wrote to Lauri Hicks and others in an email on Nov. 21, 2012.
Dr. Hicks, the CDC’s Legionnaires’ expert, responded: “I suspect the Yu/Stout relationship was with Liquitech.”
In all there are 14 emails written by six CDC officials that criticize Dr. Yu and Ms. Stout between November 2012 and the end of February 2013.
For example, on Dec. 5, 2012, after a Post-Gazette article about the outbreak was passed around the CDC via email, Dr. Whitney was upset with the references in the story to Dr. Yu and Ms. Stout.
“I also find it inaccurate in the article that it says Yu and Stout left after a dispute with management, but really they were fired for operating an inappropriate (illegal?) money-making business of Legionella culturing/consultation out of the VA hospital,” Dr. Whitney wrote. “Should we let [CDC Director] Dr. [Tom] Friedan know this so he can understand some of their anger toward the hospital? I just don’t think they are going to let this end.”
The 2008 Congressional report on Victor Yu and Janet Stout:
A Congressional committee found that they had not operated an illegal, money-making business there, and that it functioned just as the VA had approved it decades earlier. But the reasons why they were pushed out and their lab was closed “remain unclear” because VA leaders gave multiple explanations that did not make sense or were not borne out when investigated, the Congressional committee concluded. Dr. Yu and Ms. Stout believe that their boss, Mona Melhem, simply saw an opportunity to save money.
Later, when the Post-Gazette published a story on Feb. 4, 2013, noting that both Dr. Yu and Ms. Stout were going to appear on a Congressional witness panel on the outbreak, Dr. Whitney wrote her colleagues: “I’m surprised that they would ask 2 people that were fired from the VA to testify. Seems obvious that they could not be objective.”
Dr. Hicks replied minutes later: “It’s now on the subcommittee website that I am on the same panel as Janet and Victor. What a nightmare!”
The Pittsburgh investigation
In her first report from Pittsburgh on Nov. 8, Dr. Demirjian wrote to Ms. Garrison at CDC headquarters back in Atlanta: “The VA facility managers specifically mentioned corrosion that they suspect is related to copper ionization, and were questioning [copper silver] ionization as an appropriate control measure for Legionella — there was little convincing to do :)”
These new CDC emails show that when the CDC arrived ready to cast doubt on the abilities of the copper-silver systems, the CDC found a willing partner at the VA.
The CDC field team quickly learned that something changed in 2011, when cases spiked significantly.
“It does look like something ‘real’ happened, with a higher number of cases in 2011,” Dr. Demirjian wrote in an email to her colleagues on Dec. 18, 2012, after historic data going back to 2007 was collected.
So why did the copper-silver system that had worked so well for so long stop controlling the Legionella?
The CDC decided not to look at that issue. In its 2013 report to Congress, the CDC wrote that: “It was outside the scope of our investigation to make an assessment of copper-silver system maintenance or effectiveness prior to the time we arrived on site.”
In a Post-Gazette story in April 2013, workers at the VA said the outbreak occurred because protocols that Dr. Yu and Ms. Stout established there were methodically stripped away after they left, including regular maintenance of the copper-silver disinfection system.
The VA Inspector General’s 2013 report on the outbreak made a similar finding: That it was the result of a series of small failures by VA employees, most prominently the inadequate maintenance and operation of the copper-silver system.
But the CDC focused on a different issue.
“Copper-silver ionization, in the absence of adequate total chlorine residual, has not been shown to reliably eradicate Legionella from water systems,” the CDC wrote in the 2015 journal article.
In their 2013 report to Congress, the CDC added a caveat about chlorine’s role: “Several independent studies have demonstrated that copper silver ionization is most effective in eradicating legionellae when used in combination with another disinfection method.”
There are many studies that copper-silver does work well, some from Dr. Yu and Ms. Stout, but others from unrelated researchers as well.
To validate their position in both the report to Congress and their journal article, the CDC included references to five studies to demonstrate their point: But two don’t mention chlorine at all and found that copper-silver works well under the right conditions and settings; one found chlorine and copper-silver did work well together, but did not evaluate copper-silver alone; another evaluated six disinfection methods, but it had problems applying copper-silver properly; the last article found that chlorine did work best but using lower doses of chlorine with copper-silver together might be best for human health.
In the hundreds of emails the Post-Gazette obtained, there are only two people from private industry with whom CDC officials corresponded.
One was Tim Keane, an ardent copper-silver opponent who is a supporter of chlorine and chlorine dioxide systems. In a series of emails with Dr. Hicks, he shared his disdain for copper-silver, views that Dr. Hicks agreed with in her replies.
The other person was Janet Horsch, who works for Dr. Yu and Ms. Stout and helps run their laboratory.
Here are the complete email chains for each quoted email in this article:
On Nov. 30, 2012, Ms. Horsch wrote the CDC’s lead spokeswoman on the outbreak, Alison Patti, asking her to clarify the statements she made in a news story deriding copper-silver systems.
When Dr. Hicks was shown the email, she told her colleagues: “Beware, Stout and Yu’s lab is fishing for information. We’re not planning to respond, but if they persist, my answer will be that we plan to share our findings in the scientific literature, as soon as possible, where we know the facts will not get distorted. Fun, Fun.”
The CDC rarely publishes in peer-reviewed, scientific journals after it investigates a case. Of the 27 Legionnaires’ outbreaks the CDC said it investigated between 2000 and 2014, it only published three in outside, peer-reviewed journals, including one on the Pittsburgh outbreak.
The CDC did not make Dr. Hicks available for comment.
But CDC microbiologist Claressa Lucas, who worked on the Pittsburgh investigation, said in an interview the reason the CDC decided to publish the journal article was because “at the time this was written, copper-silver was seen as a panacea, and in this case it was not working.”
Two years before the journal article was published, Ms. Lucas made her point a little more directly in an email to her CDC colleagues on Jan. 3, 2013, as they were discussing how to write the Congressional report.
“*Expletive* YES we must cite and refute the dominant sources for [copper-silver] efficacy and 30% risk assessment,” she wrote, in part. “To that end I put a lot of different reference in the comments. This is our (and the hospital’s) best chance to rebut the media attention since peer-reviewed articles take awhile to get published.”
Monday: Did the CDC change its data to skew the results of the investigation?
Sean D. Hamill: shamill@post-gazette.com or 412-263-2579 or Twitter: @SeanDHamill
ABOUT THIS SERIES
The emails shown in this series are just some of the hundreds finally released to the Post-Gazette last month, 3 ½ years after the paper filed a Freedom of Information Act request with the CDC asking for such documents. That response time made it one of the single slowest responses from the CDC from more than 1,000 FOIA requests it received from all sources in 2013, according to the CDC’s own data on FOIA responses.
A FOIA officer for the CDC said the Post-Gazette’s request simply “fell through the cracks” despite repeated emails and calls by a reporter since 2013. Twice a CDC FOIA officer called a reporter – once in 2014 and again earlier this year – and asked of the 2013 FOIA request: “Do you still want this?”
Among the 487 pages responding to the Post-Gazette’s FOIA, 97 pages are tough-to-read and decipher handwritten notes from the CDC researchers, while the rest are 390 pages of various email chains that occurred between Nov. 6, 2012, and March 1, 2013, about the time the Post-Gazette filed its FOIA.
Among those 390 pages – many of which are duplications of the same emails - are 55 separate email chains, and 231 distinct emails. They involve dozens of back-and-forth emails before, during and after investigators were on the ground in Pittsburgh in November, 2012, and their senior administrators. They continue up to the days before a Congressional hearing on the outbreak in February, 2013.
— Sean D. Hamill
First Published: December 11, 2016, 5:21 a.m.
Updated: December 11, 2016, 5:21 a.m.
