A Feb. 5 hearing by the House Committee on Veterans’ Affairs subcommittee on oversight and investigations focused on VA’s actions to prevent the spread of Legionella at its Pittsburgh facility. Panelists included Dr. Robert Jesse of VA, Dr. Lauri Hicks of CDC, Victor Yu, professor of medicine at the University of Pittsburgh, and Dr. Janet Stout of the Special Pathogens Laboratory in Pittsburgh.

Stout testified that the University Drive Campus failed to recognize the Legionella outbreak and take preventive actions. “The delay may have contributed to additional cases and deaths.” She also said the facility failed to operate its water disinfection system properly, and “finally, failure to communicate with physicians, staff, patients and families regarding the increase in cases. The delay in alerting physicians may have contributed to additional morbidity and mortality.”

Many medical facilities use a copper-silver ionization system to disinfect their water supplies and keep Legionella at bay; other systems use chlorine or chlorine dioxide.

“The only way an outbreak of this magnitude could have occurred is if the water system at the Pittsburgh VA had become heavily contaminated with Legionella,” Stout told the subcommittee. “The environmental testing performed by the VA microbiology laboratory should have detected this increase.”

Yu, an expert on infectious diseases, testified that once a hospital’s water system is infected with Legionella, it stays there “for the rest of the lifetime of the hospital.” He said the bacteria has been at the Pittsburgh facility since 1982. “You can suppress it pretty easily, but if you don’t maintain a system, that organism is going to come out.”

With new antibiotics, Yu said. the mortality rate for Legionnaires’ Disease has dropped effectively to zero. The five veterans who died “either didn’t get the antibiotic or they got it too late while they were dying. The fact that Legionella had recontaminated the system was not communicated to the emergency room physician … or the intensive care physician,” he said.

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