PITTSBURGH – A Veterans Affairs hospital lab in Pittsburgh failed to immediately report positive test results for Legionnaires disease that killed five patients in an outbreak linked to the hospitals’ water supply, according to a Centers for Disease Control and Prevention report released Wednesday.
The report noted the VA hospital lab didn’t report some positive test for more than two days in violation of hospital protocols. Five patients who were infected at Pittsburgh’s Veterans Affairs hospitals died while others were successfully treated.
The CDC report said extensive construction work may have contributed to the outbreak and suggested that water treatment equipment wasn’t effectively killing the Legionella bacteria.
Exactly why the water-borne bacteria wasn’t effectively dealt with was discussed at a Congressional hearing Tuesday.
The chairman of the company a water treatment system used by the VA said his employees found “obvious evidence that there were maintenance shortcomings” on a December 2011 visit. LiquiTech chairman Steve Schira also testified that VA staff acknowledged maintenance wasn’t being performed as required.
Not only that, Schira said, his employees found a VA staffer falsifying the levels of copper – an important bacteria-killing element – in the equipment last April.
Dr. Lauri Hicks, a CDC epidemiologist, said in her testimony that the CDC found “a highly pathogenic strain of Legionella in the potable water system” for two years, and claimed the metal levels in the LiquiTech system were appropriate for controlling Legionella, but weren’t doing so. Wednesday’s report, however, noted that four of the 11 tests it took failed to show the levels of metals that LiquiTech recommended.
LiquiTech chief operating officer Tory Schira told the AP that the company is “very puzzled” by the CDC testimony, since it hasn’t had access to the CDC report or the VA records of the outbreak.
A firm that reviewed the LiquiTech system last year told the Congressional panel the VA had refused to release Legionella test results. Enrich Products, Inc. operations manager Aaron Marshall said his company would have ordered more testing and cleaning if it had known of the positive tests.
Kathleen Dahl, president of the union that represents workers at the Pittsburgh hospitals, testified that VA management violated “OSHA requirements and VA policy” by not telling the union about the positive Legionella tests until November, 2012. But she added that the VA “is currently doing everything in its means to appropriately manage Legionella in our water system.”
U.S. Rep. Mike Doyle, D-Pa., said after Tuesday’s hearing the testimony raised more questions than it answered. Doyle says the VA needs to address the allegations of concealed test results and faulty maintenance promptly.
VA spokeswoman Victoria Dillon said Wednesday that they have no new comments about the outbreak.
The CDC has said that after the investigation began last November the VA “rapidly implemented CDC’s recommendations and has taken several steps to protect patient safety.” The water system was declared clear of Legionella and no further cases have been detected.