Honorable Mike Coffman, Chairman, Subcommittee on Oversight and Investigations
Good morning. This hearing will come to order.
I want to welcome everyone to today’s hearing titled “Analyzing VA’s Actions to Prevent Legionnaire’s Disease in Pittsburgh.” I would also like to ask unanimous consent that several of our Pennsylvania colleagues be allowed to join us here on the dais today to hear about an issue very specific to their constituents. Hearing no objection, so ordered.
Today’s hearing is based on a recent outbreak of Legionnaire’s Disease at the Pittsburgh VA Medical Center. At least 29 recent cases of Legionnaire’s Disease have been associated with the Pittsburgh VAMC. While VA has stated that eight of these cases were definitely not contracted at their hospital, it has also stated that it cannot determine whether 16 of these cases were contracted at the hospital.
VA contacted the CDC last fall to investigate the issue. The CDC’s report, just released on Friday, not only determined that many veterans likely contracted Legionnaire’s Disease through the Pittsburgh VA health care system but that, tragically, five veterans have died over the past two years from Legionnaire’s Disease acquired at the hospital. The CDC report paints a more complete picture, and it turns out that problems originated much earlier than what VA has stated and are much more widespread. While VA’s public acknowledgment of Legionella bacteria in the water at Pittsburgh VAMC did not occur until November 2012, the Subcommittee in the course of its investigation uncovered a great deal of evidence that officials at the Pittsburgh VAMC were aware of serious problems with their water sterilization system well before this time.
What’s more- this outbreak was more than likely preventable.
This event is rooted to the history of the Special Pathogens Lab that at one time was the hallmark of the Pittsburgh VAMC and the flagship of Legionella research across the globe. Its abrupt closure in 2006, under questionable circumstances, was followed by a congressional hearing in 2008 that led to the exoneration of Dr. Stout and Dr. Yu, the Lab’s directors, and the admonition of VA. But the loss of the Special Pathogens Lab and the experts within it directly impacted VA on both a local as well as a national scale.
According to VA’s own documents, the Legionella protocol in place at Pittsburgh from 1997 to 2006 resulted in no hospital acquired Legionnaire’s Disease. This protocol mandated testing copper-silver levels and Legionella testing every other month. How is it that a successful system is now blamed for the problems in Pittsburgh?
VA also tells us that Legionella is a national problem. I agree that there should be a more comprehensive program with a single focal point. However, VA provided documents to this Subcommittee stating that, as of December 17, 2012, there have been only five Legionella cases across the entire VA healthcare system, and all five cases were community acquired. Even basic news reports tell us that these numbers are far from accurate. Does VA even know how many cases of Legionnaire’s Disease exist in its patients and where they could have originated?
The recent CDC report indicates VA either has no idea or is deliberately downplaying what actually happened. The deaths of five veterans- and the many other cases of Legionnaire’s Disease- are nothing to be downplayed.
I understand that different agencies have different protocols for preventing and responding to Legionella bacteria. It is my wish that today’s discussion and the recent outbreak in Pittsburgh can provide an opportunity for appropriate agencies put forth a unified effort to establish a national framework on addressing Legionella. From that framework, local protocols can be put in place so that a local facility can respond appropriately. This Subcommittee is not advocating for any one method of Legionella treatment - just that whatever proven system is put in place be used correctly. Regardless of the method, what happened in Pittsburgh could have been prevented, and veterans have unnecessarily paid the price.
I look forward to a thoughtful discussion today on what VA officials knew about Legionella in the water at the Pittsburgh VAMC, when they knew it, and what actions they took to address this serious problem in a responsible and timely manner. However, I am disappointed that, despite several requests to VA from the Subcommittee, no one from the Pittsburgh VAMC who was there during the incident is here to deliver first-hand knowledge of events. Hopefully the witnesses that are here today can, at the very least, recommit to the Department following its own protocols and holding accountable those employees who fail to do so.