Dr. Robert Jesse
Good morning, Chairman Coffman, Ranking Member Kirkpatrick and Members of the Subcommittee. Thank you for the opportunity to discuss the cases of Legionnaires’ disease identified at the Department of Veterans Affairs’ (VA) Pittsburgh Healthcare System (VAPHS). I am accompanied today by Mr. Michael E. Moreland, Director, Veterans Integrated Service Network 4, and Dr. Gary Roselle, National Director, VHA Infectious Diseases Service.
VA is committed to providing quality care to our Veterans and has partnered nationally and locally in an ongoing effort to understand and control Legionella. Legionnaires' disease is a form of pneumonia caused by a bacterium known as Legionella, discovered and named following an outbreak of pneumonia among attendees of a July 1976 American Legion convention at the Bellevue Stratford Hotel in Philadelphia. Legionnaires' disease is contracted by breathing in an aerosol (mist or vapor) of water containing the Legionella bacteria. The disease is not contagious and cannot be transmitted from one person to another. Most people exposed to the bacteria do not become ill, though patients who are immune-suppressed are most at risk.
According to the Centers for Disease Control and Prevention (CDC) website, between 8,000 and 18,000 people are hospitalized with Legionnaires' disease or Legionellosis in the United States each year. However, it is likely that many Legionella infections are not diagnosed or reported, so this number may be higher. In a recent publication, CDC reported that Legionellosis is increasing in the United States with an increase of 217 percent reported through surveillance between 2000 and 2009. This publication reports the highest age-adjusted incidence rate is found in the Middle Atlantic region (New York, New Jersey, and Pennsylvania).
As a national health care system, the Veterans Health Administration (VHA) recognizes that there are two critical components to the management of Legionella in its facilities. The first consists of surveillance of both clinical infection of patients and the presence of Legionella in the environment. The second is preventing the growth of Legionella in the facilities’ water systems. VHA has one of the most comprehensive Legionella prevention policies in the United States, including very specific algorithms for annual evaluation of risk at the facility level. The VHA Policy requires an annual evaluation of facility risk. For example, in transplant centers, VHA specifically directs twice-yearly testing of water samples, consistent with CDC guidance. VA Pittsburgh is a transplant center and performs water sampling at a rate more frequent than the VHA Policy or CDC require. Of note, the CDC makes no recommendations regarding long-term, supplemental systemic treatment of hospital water systems to prevent Legionella growth. Several supplemental treatment systems exist including copper-silver ionization and several methods of chlorination. These are in addition to the primary prevention strategy which is control of water temperature limits for the hot water distribution system. While these practices will not entirely eliminate the possibility of hospital acquired Legionella, the risk of it can be substantially reduced.
Background on Legionella Prevention at VA Pittsburgh Health Care System (VAPHS)
Legionella is naturally present in water and is particularly prevalent in the area around Pittsburgh, and is most problematic in late summer through the fall. Legionella prefers warm water, and can grow at temperatures as high as 115 degrees Fahrenheit. As a result, there is a need to maintain the hot water supply at a temperature that can balance the risk of Legionella growth versus the risk of scalding individuals. Generally, this is done by maintaining a temperature gradient that is high at the source but reduced at the taps.
It is expected that Legionella would be sporadically detected in some VAPHS water samples, and this has been the case over the years. Regardless of whether the levels detected met VAPHSthresholds for action, the facility would typically perform remediation when detection levels rose. When Legionella is confirmed in a facility’s water system, two methods of remediation are most commonly used in this country; super-heating or hyper-chlorination of the water. For VAPHS, remediation included super-heating of water systems where feasible as well as manual disinfection of water outlets. Remediation is not always successful and successive remediation efforts may be required to reduce Legionella contamination.
Additionally, VAPHS has used a supplemental, continuous copper-silver ionization system to maintain long-term suppression of Legionella bacteria in the water supply. Ion levels may be affected by water pH or other elements present in municipal water systems. The protocol for the routine examination of the water system and copper-silver Legionella control consisted of visual checks of the amperage and voltage of the copper-silver ionization system, monthly rotation and cleaning of the flow cell units of the copper-silver ionization system and periodic water sampling to evaluate ion levels. The copper-silver ionization system requires frequent monitoring and ion levels may vary based on fluctuations in the character of the incoming municipal water source. More recently, continuous chlorine infusion into the water supply has been introduced as a method of Legionella suppression. The long-term solution is a plumbing project which will add instantaneous water heaters and mixing valves in order to maintain consistently high hot water temperatures while preventing the risk of scald injuries. This will be coupled with a chlorine dioxide water treatment system, which will provide Legionella suppression to all water entering the facility.
Recent Cases of Legionella
On October 5, 2012 a Legionella specimen from two patients and one from an environmental culture were transmitted to the CDC via a protocol that involved the state and local public health authorities. The purpose was to determine if the patients might have a hospital-acquired infection even though they had limited contact with VAPHS. Following this, a third patient was diagnosed and a specimen was sent to CDC on October 23, 2012. A positive relationship, i.e., DNA sub-type similarity between the patient and environmental strains of Legionella, for the first two patients was communicated to VAPHS on October 30, 2012, at which time these two were counted among the hospital-acquired Legionnaires'disease group. Working again through Allegheny County Health Department (ACHD) and the Pennsylvania Department of Health (PDoH), VAPHS requested assistance from CDC, and on Nov 7, 2012 a team representing CDC, ACHD, and PDoH arrived at VAPHS to initiate their case review and environmental assessment.
The CDC used its water sample collection technique, which results in a more sensitive screening process. For the patient case review, they expanded the definition of the incubation period for Legionella pneumonia in order to capture the widest possible number of Veterans who may have been infected. When the first 44 water sample tests were complete, more than half of them demonstrated Legionella growth.
During the course of the collaborative review by VAPHS and the CDC, a total of 29 cases of Veterans with Legionella pneumonia were identified from January 1, 2011 through November 2012. Five of those cases were confirmed to have originated at VAPHS. Of the five cases confirmed as hospital-acquired, four patients recovered and one died within 30 days of the Legionnaires’ disease diagnosis. The Veteran who died suffered primarily from congestive heart failure, but Legionella pneumonia was listed as a contributing cause of his death. Sixteen cases were identified to have had contact with VAPHS, which means that they may have contracted the disease at the VAPHS but a definitive determination cannot be made. CDC refers to these cases as “probable hospital-acquired”. Eight cases were determined to be community-acquired, meaning that they contracted the infection outside of the hospital. It is important to note that none of the probable or confirmed cases was in a transplant patient.
CDC confirmed the linkage of Legionella in the water supply with pneumonia patients in a communication that VAPHS received on October 30, 2012, and on November 15, 2012, after performing its environmental assessment, CDC recommended remediation. VAPHS promptly instituted an aggressive, multiphase water remediation effort. Phase one of this effort involved superheating the potable water system from 160 to 170 degrees Fahrenheit and then flushing this system with a goal of eliminating any existing Legionella bacteria. Due to the complexity of the water systems, the heat and flush procedure was successfully implemented at some, but not all, parts of the water system. As an added measure, VAPHS then hyper-chlorinated its water system per CDC guidelines and instituted water-use restrictions. Water restrictions at University Drive and H.J. Heinz campuses were initiated on November 16, 2012. The restrictions were lifted on November 30, 2012 at the University Drive campus after water cultures, which require two weeks to process, confirmed successful remediation. On December 7, 2012, the restriction was lifted at the H.J. Heinz campus. VAPHS continues to conduct water testing at various locations in the water distribution system, every 2 weeks as per CDC recommendations and protocol. Bimonthly water testing will continue until CDC recommends lower frequency of testing and any areas testing positive are immediately remediated.
VAPHS had concerns about Legionella growing in water samples with sufficient copper-silver ion levels, and there had been numerous past adjustments to the copper-silver ion levels in response to both low and high levels of one or the other ions. As a result, VAPHS took the copper-silver ionization system off-line. VAPHS also instituted a continuous chlorine drip to help maintain control of Legionella levels in the water system until a permanent supplemental treatment strategy is formalized.
VAPHS had been balancing the need for maintenance of high hot water temperatures with the need for preventing scald injuries, which resulted in water temperatures that were low enough to permit the growth of Legionella. The decision regarding the circulating hot water temperature was made with the belief that copper-silver ionization provided sufficient supplemental protection. However, as previously noted, the performance of this system, its maintenance and monitoring, is complex and may have failed to consistently prevent Legionella growth.
VAPHS has also chartered a water safety committee, which will be charged with the oversight of efforts to maintain effective communication about water safety and oversight of monitoring and remediation efforts throughout the facility. The chairperson is the associate director and the group will have representation from facilities management, infection prevention, and laboratory service. The committee will report to the medical center’s executive leadership board.
VAPHS proactively contacted local media and provided a brief summary of the findings, the status of remediation efforts, the number of confirmed hospital-acquired cases of Legionella at VAPHS to date (5), and the number of probable cases to date (16). On November 16, 2012, VAPHS leadership activated an incident command center and tasked this center with clarifying facts and communicating news and updates to Veterans and employees. A call center was established to answer questions from Veterans, staff, and family members. All inquiries were addressed by the call center staff or referred to the Director of Infectious Disease for resolution. In addition, VAPHS leadership held Town Hall meetings with employees at all three VAPHS campuses. VAPHS public affairs department also notified local congressional offices, union partners, and the media about the presence of Legionella in the VAPHS water system and the identification of patients with Legionella pneumonia. VAPHS has identified and attempted to contact all known Veterans diagnosed with Legionella pneumonia, but whose source of infection is unknown. For patients where community acquired Legionnaires’ disease was suspected, VAPHS proactively offered to test the water systems in the homes of these individuals and access to our medical experts in order to determine if the source of infection was in their home. To date, in response to this request, no samples were received. Finally, the VAPHS public affairs department has been posting pertinent updates and information in various places on VAPHS’ internal and external websites, http://www.pittsburgh.va.gov. The designated call center remains open and Veterans can contact the call center at (412) 360-1199. Any employees with questions relating to Legionella have access to an e-mail group that will address their questions and concerns. Legionella updates were provided at recent employee town hall meetings and a Veteran roundtable event.
VAPHS is following the recommendations of the numerous external and internal review teams, such as superheating and hyper-chlorinating the water system among other remediation efforts. These efforts have successfully reduced Legionella in the water supply. Our ability to provide the best care to our Veteran patients improves through this expert consultation and analysis. VHA is committed to the prevention of Legionella and is continually looking to update best practices for prevention.
Chairman Coffman and Ranking Member Kirkpatrick, VA is committed to providing the highest quality of care that our Veterans have earned and deserve and continues to take appropriate actions to ensure the safety and protection of our patients. We deeply regret that any Veteran was exposed to Legionella bacterium at VAPHS.
We appreciate the opportunity to appear before you today. My colleagues and I are now prepared to answer your questions.