Legionella breaks out in Pittsburgh

Over the past two years, deadly Legionella bacteria infected 21 patients at the University Drive Campus of the Department of Veterans Affairs Pittsburgh Healthcare System. Five of those veterans died of pneumonia less than 30 days after testing positive for legionellosis, commonly known as Legionnaires’ Disease.

In July 1976, more than 200 members of The American Legion attending their national convention in Philadelphia were stricken by a "mystery disease" that killed 34 of them. Because the outbreak occurred within days of America’s 200th birthday and in the city where the Declaration of Independence was signed, the incident was widely publicized and created much public concern at the time.

Legionella bacteria can be found in cooling towers, central air-conditioning systems, hot-water systems and spas. Symptoms of Legionnaires’ Disease include fever, chills, coughing, muscle aches and loss of appetite. At least 50 species of Legionella have been identified, which can be carried airborne more than three miles.

A collaborative review by VA Pittsburgh and the Centers for Disease Control (CDC) identified 29 cases of veterans with Legionella pneumonia, from January 2011 to Dec. 6, 2012. Eight cases contracted the disease in their communities, five caught it at the University Drive Campus and the other 16 patients probably were infected at the hospital as well.

Responding to the Pittsburgh outbreak, several members of Congress asked VA’s Office of Inspector General to review the incidence of Legionnaires’ Disease at VA medical facilities nationwide. The review began Dec. 20 and is expected to be completed next month.

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.

Hicks, a medical epidemiologist at CDC, estimated the annual number of Legionnaires’ Diseases cases to be between 8,000 and 18,000, "and a good proportion of those are health-care associated. So this is not an uncommon occurrence in hospitals, and - this will be very disturbing to many of you - I suspect that many of these outbreaks go undetected."

Stout reminded the subcommittee of its role "to hold people in the administration accountable for the failures that led to this outbreak. And accountability needs to come from the top down, not the bottom up.... It was the responsibility of the Pittsburgh VA to be current in knowledge and vigilant in following the policies and procedures that were already in place. The system isn’t broken, so don’t fix it."