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VA Pittsburgh often delayed reporting Legionnaires’ cases to state, records show

Pittsburgh VA officials delayed notifying the state Department of Health’s reporting system about veterans sickened with Legionnaires’ disease in at least one-third of the 21 cases during a deadly outbreak between February 2011 and November 2012, the Tribune-Review has learned.

State health guidelines require most public hospitals to electronically report Legionnaires’ and other major infectious diseases within 24 hours of diagnosis. Compliance by Department of Veterans Affairs is voluntary, however, and the VA Pittsburgh Healthcare System waited two or more days before reporting in at least seven cases, according to hospital records obtained under the Freedom of Information Act.

The VA Pittsburgh took two weeks to report one of those seven delayed cases. In the worst example, nearly four months and two weeks passed.

“We regret these delays” in reporting, Pittsburgh VA spokesman David Cowgill wrote in an email. He emphasized, however, that VA physicians did not delay treating affected patients.

In seven of the 21 cases the VA reported veterans with Legionnaires’ to the state system the next day, but it is unclear whether that was within 24 hours of diagnosis because the records don’t include reporting times. One case involved a veteran believed to have contracted the disease at the VA Pittsburgh hospital, but it wasn’t reported until after he was discharged and later went to St. Vincent Health System in Erie for treatment.

“The question for VA right now is, ‘Where is the accountability?’ Without meaningful accountability for the employees who allowed this outbreak to fester, the facility may never regain the trust of the veterans it is charged with serving,” said Rep. Jeff Miller, the Florida Republican who chairs the House Committee on Veterans’ Affairs.

Miller and Pennsylvania lawmakers said the records obtained by the Trib show why legislation is needed to force the VA to report infectious diseases to state and county health agencies. The VA Pittsburgh with certainty met Pennsylvania’s standard in just six of the 21 Legionnaires’ cases the Centers for Disease Control and Prevention identified.

Cowgill acknowledged some reporting lagged behind the state standard but said VA officials are improving disclosure processes. He blamed some delays during the Legionnaires’ outbreak on the timing of test results on weekends or federal holidays. He said two delays happened because of data-entry errors but were corrected promptly.

In some cases, Cowgill said, VA workers might have discussed a Legionnaires’ case with state or county health officials before filing the electronic report.

Regulating action

The VA in Washington issued an internal directive last week instructing its hospitals nationwide to follow the reporting rules in their states. But congressional leaders have expressed conern about the VA’s ability to police itself without penalties.

“In the midst of a disease outbreak, every moment wasted exposed patients to dangerous conditions and potentially deadly infections,” said Rep. Tim Murphy, R-Upper St. Clair. He and Rep. Mike Doyle, D-Forest Hills, introduced one of two House bills that would require immediate disease reporting by the VA. Sen. Bob Casey Jr., D-Scranton, introduced a similar bill in the Senate. Proposed punishments include fines like those other hospitals face and suspension of regional VA directors whose hospitals do not comply.

“Human nature being what it is, and government being what it is, you need to have deadlines. You need to have reporting periods,” Casey said. “A voluntary system, in my judgment, will not work.”

A Trib investigation in March exposed the double-standard that allows the VA to escape enforcement of state reporting requirements, a discrepancy that medical experts said can inhibit how public health agencies detect and control disease outbreaks.

‘Public health risk’

Dr. Paul Etkind, a senior director at the National Association of County and City Health Officials, said incomplete and slow reporting contributes to “significant barriers to appropriate and effective disease-specific control measures.”

“Timely disease surveillance is critical to preventing infectious disease morbidity and mortality,” he said at a June 19 congressional hearing.

Phenelle Segal, a former infection prevention analyst for the Pennsylvania Patient Safety Authority, said irregular reporting of diseases “places a public health risk upon others.” She praised the bills that would force VA hospitals to disclose cases of Legionnaires’ and other major diseases within 24 hours.

“Due to the inconsistency of the reporting and the seriousness of the Legionnaires’ outbreak, I believe it would be in the best interest of public health overall to have those standards imposed,” said Segal, now president of Infection Control Consulting Services in Blue Bell, Montgomery County, and Delray Beach, Fla.

The CDC traced the Legionnaires’ outbreak to contaminated water at the Oakland and O’Hara VA campuses. A Trib investigation found Legionella bacteria in significant concentrations in water samples at the Oakland campus as early as 2007, leaving open the possibility that earlier patients might have contracted the ailment without having been documented as Legionnaires’ cases.

In Monroeville, Maureen Ciarolla said it’s distressing that lawmakers have to force transparency on the VA. Her family has begun civil action against the VA for the death of her father, Navy veteran John Ciarolla, 83, of North Versailles. He died during the Pittsburgh outbreak, which remains under investigation by federal authorities.

“The public deserves better by their medical community, and our veterans deserve a whole lot better than what they get from this Pittsburgh hospital,” Ciarolla said.

Adam Smeltz is a Trib Total Media staff writer. He can be reached at 412-380-5676 or [email protected].


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