Legionnaires' disease still puzzles Pittsburgh VA officials

By SEAN D. HAMILL | Pittsburgh Post-Gazette | Published: August 6, 2013

PITTSBURGH — Bob Muder still couldn't believe what he was hearing.

On Oct. 31, the day after the federal Centers for Disease Control and Prevention told Robert Muder, chief of infection prevention at the Veterans Affairs Pittsburgh Healthcare System, that genetic testing confirmed that two patients contracted Legionnaires' disease during stays at the VA, he wrote to two top Pittsburgh VA officials to express his doubts.

"I remain skeptical that the patients actually acquired infection here, but the results don't exclude that," Dr. Muder wrote to Ali Sonel, the chief of staff, and Mona Melhem, associate chief of staff at the Pittsburgh VA.

The next day, as the concept sank in that the Pittsburgh VA — once one of the world's leading research centers for Legionnaires' — was in the midst of a serious outbreak of the disease, he reached out to a top VA official in Washington, D.C.

"I really don't know what's going on here because we historically don't see cases until there is a much higher level of contamination," Dr. Muder wrote in an email to Richard Martinello, chief consultant of the clinical public health group at the central VA office.

That view of resistance and confusion in the Pittsburgh VA as it came to accept that it was in the midst of a deadly outbreak is contained in a trove of 3,200 pages of emails, memos, reports and other documents recently provided to the Pittsburgh Post-Gazette by the VA in response to a Freedom of Information Act request.

The documents provide a unique look inside the Pittsburgh VA in 2011 and 2012 when as many as six veterans would die and another 16 would get sick from Legionnaires'.

They show the chaos and tension that grew inside the Pittsburgh VA as the public became aware of the outbreak in November 2012 and everyone, it seemed — from politicians, to media, to union officials, company salesmen and concerned citizens — called with concerns.

Perhaps most importantly, the emails and other documents demonstrate how the increasing and persistent problems with the copper-silver ionization system, designed to control the Legionella bacteria in the VA's water system, were met by confusion and bewilderment by VA officials.

In November 2011, it was confirmed that Greg Jenkins, 53, — who would die less than a year later — had contracted Legionnaires' while a patient at the Pittsburgh VA.

His was the only such case the VA conceded was hospital-acquired until the CDC stepped in a year later. But even then infection-prevention officials weren't sure what to do about it.

"It is next to impossible to determine exactly where he acquired the Legionella within the facility during the six weeks he has been there," the Infection Prevention Team minutes from Nov. 17, 2011, conclude about Mr. Jenkins' case.

Seven months later, on July 26, 2012, an infection prevention team report says that, despite various problems maintaining the level of copper and silver ion levels in the VA's water and difficulty in adjusting the copper-silver system: "At this point [Facilities Management Service] does not feel levels are a problem."

The CDC's report later found that 11 veterans had probably or definitely contracted Legionnaires' at the Pittsburgh VA since February 2011, and three of them had died of the disease.

Ultimately, the documents show that no one within or outside the VA is ever able to answer why it was that the copper-silver system that had worked so well for so long had begun to fail to control the Legionella, not just in 2011, but as early as 2007, when the first hospital-acquired cases of Legionnaires' in a decade began to appear at the Pittsburgh VA.

As the potential Legionnaires' cases mount — and Dr. Muder and his staff dismiss all but one of them as hospital-acquired — Pittsburgh VA staff throw out a hodgepodge of possible reasons that the copper-silver system is not working properly, all of them eventually discounted.

Dr. Melhem, who was the VA official most responsible for closing the Legionnaires' research laboratory in 2006 and firing and forcing out two top experts on the disease, Victor Yu and Janet Stout, embraced the CDC's view that the copper-silver system just didn't work anymore.

"Also, you have to know that the system is ineffective, and other hospitals dismantled it to go back to the good old chlorination, that works," Dr. Melhem wrote in an email on Nov. 29, 2012, to laboratory supervisor Kevin Frank, after he complained to her about an article in which U.S. Sen. Bob Casey, D-Pa., said the outbreak was preventable.

Emails reveal that the chlorination system that Dr. Melhem said she liked so much will have to be replaced with chlorine dioxide because it is less corrosive than heavy doses of chlorine alone.

Internal VA politics occasionally rear their head in the emails as more cases begin to appear.

At one point in October and November 2011, Dr. Muder is seen in emails trying to find someone to do the genetic testing of some patient and environmental Legionella samples. But he is having a hard time tracking someone down.

Finally, in an email on Nov. 1, 2011, after trying at least two other experts, William Pasculle, director of UPMC's clinical microbiology laboratories, tells him he can't do it, either, but he advises Dr. Muder: "No. But Janet Stout can."

Dr. Muder wrote Dr. Pasculle back: "I would love to have Janet do it but that's not possible due to her association with a certain person, the administration would go ballistic when they saw the invoice."

The certain person is Dr. Yu, the former longtime Pittsburgh VA researcher who got in a heated dispute with VA management in 2006 and was fired. He and Dr. Stout, who oversaw maintenance of the copper-silver system at the VA for three decades, run a private lab together in Pittsburgh. They are still considered international experts on Legionnaires', but the VA would never allow Dr. Muder to hire them to help.

The U.S. House Veterans Affairs Committee will hold a public hearing Sept. 9 in Pittsburgh to examine the VA's nationwide efforts to stop preventable deaths and medical errors.

Part of the hearing, set for 9 a.m. at the Allegheny County Courthouse, will focus on the 2011 and 2012 Legionnaires' outbreak at the Pittsburgh VA and events in VAs in Atlanta, Buffalo, Dallas and Jackson, Miss.



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