Source: http://www.tbo.com, November 22, 2015
By: Howard Altman
Late last year, the bacteria that can cause the potentially fatal Legionnaire’s disease was found in half the sites tested in the mental health treatment building at the Bay Pines VA Medical Center.
No patients or staff in the building contracted the disease and tests after cleanup efforts showed only three of the sites tested positive for Legionella pneumophila, according to records obtained by the Tribune.
But the results show the challenges hospitals face in dealing with a bacteria that’s commonly found in water supplies. And experts contacted by the Tribune say the test results show the hospital is doing a good job handling a problem that led to the death of a patient at Bay Pines 10 months earlier and vexes medical centers around the country.
The quarterly tests for Legionella pneumophila bacteria in September and December of 2014 were the first conducted at Bay Pines in Pinellas County following sweeping new Department of Veterans Affairs regulations on Legionnaire’s disease.
The September 2014 tests showed nine of 19 sites in Building 1 had the Legionella pneumophila bacteria. The next round of testing, in December, found 11 out of 20 sites tested positive for the bacteria.
After the hospital learned of the findings, officials conducted two “full building remediations” by flushing the water systems with high levels of chlorine, according to Heather Brauer, assistant chief of engineering. The results of two subsequent tests obtained by the Tribune found two sites tested positive for the bacteria in June and one in March.
In August, the Tribune filed a Freedom of Information Act request for the information. The request was made following a patient death from hospital-acquired Legionnaire’s disease in February and a lawsuit and other claims that the hospital retaliated against safety employees concerned about the bacteria.
The testing at Bay Pines began a month after the VA instituted a new policy, called Directive 1061, that required greater review and remediation nationwide for Legionella pneumophila. The directive was issued after six people died and more than 20 contracted the disease at a VA hospital in Pittsburgh in spring 2014. It requires the closer scrutiny at buildings where patients have overnight stays.
The testing at Bay Pines began in September 2014 and is now being performed quarterly. Results obtained by the Tribune were for testing through June.
There were 462 sites tested in six buildings on the Bay Pines campus. A lab in Pittsburgh found some form of the Legionella bacteria in 76 locations. Of those, 34 tested positive for the pneumophila strain — the most dangerous. In addition to Building 1, Legionella pneumophila was found in Buildings 100, 101 and 102 and the Fisher House. Other strains of the bacteria also were found in those buildings as well as in Building 71.
The tests were in addition to those initiated after a veteran being treated in Building 100 tested positive for Legionella pneumophila and died in February from resulting medical complications.
After confirming the Legionnaire’s disease case, “we restricted the use of showers in building 100 and also completed water testing” after the hospital found “a minor presence” of Legionella pneumophila in an ice machine in one of 13 areas tested Feb. 21 and 23, said Bay Pines spokesman Jason Dangel.
The VA, Dangel said then, “has a zero tolerance for any level of Legionella pneumophila.”
The level of the bacteria detected was 4.1 units per milliliter, well below the 10 units per milliliter allowed in potable water by the federal Occupational Safety and Health Administration, Dangel noted.
By comparison, the testing in Building 1 from September and December of 2014 found levels ranging from 20 units per milliliter to one unit per milliliter.
Since then, the highest level of Legionella pneumophila found at Bay Pines was once again in Building 1 — 90 units per milliliter found in June in a cold shower. Tests also found a level of 21 units per milliliter in a hot shower.
Quarterly testing began at Tampa’s James A. Haley Veterans’ Hospital in November 2014, says spokeswoman Karen Collins.
“Our water safety committee was formed in April of 2014 and prior to that we had a Legionella prevention program in place,” Collins says. “There have been no deaths due to hospital acquired Legionnaire’s disease in the last 24 months. In fact I am not aware of any instances of any hospital acquired Legionnaire’s here during that time frame.”
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Two workers fired from the Bay Pines hospital safety team earlier this year say that they lost their jobs after pushing for tests on whether Legionnaires’ disease was present and that VA officials covered up the high levels of contamination in an area where the veteran who died of the disease was staying.
The two workers, Keith Litchfield and Narciso Martinez, make those allegations in individual claims filed to the Merit Systems Protection Board, an agency designed to protect federal workers, and in a federal lawsuit filed in April against the Department of Veterans Affairs.
Three other VA employees, including two still on the safety team, also are plaintiffs in the lawsuit, saying they were harassed by unit supervisor Darlene Powell. Two of the three employees filed affidavits with the protection board backing up Litchfield and Martinez.
The lawsuit accuses the VA of intentional infliction of emotional distress; defamation; negligent hiring, retention and supervision of their supervisor; and failure to train the supervisor.
Dangel declined to comment on the allegations because VA policy precludes commenting on pending legal matters.
However, water test results are provided to the hospital’s Water Safety Committee and to the regional and national VA offices, Dangel says.
After the patient died in Building 100, the hospital’s main center, test results obtained by the Tribune show that out of about 40 sites tested, only one showed a slight trace of the Legionella pneumophila bacteria — less than one tenth of the standard set by OSHA.
Still, Lee Blais, the attorney representing those suing the VA, said in an interview Thursday that the presence of Legionella pneumophila is “concerning, because it is an integrated water system and the bacteria could easily move from one building to another.”
Brauer, with Bay Pines engineering, disputes that, saying bacteria cannot travel between buildings because the system does not allow water to reenter the system from each individual building.
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Legionnaire’s disease has been on the rise across the U.S. for the last decade, according to the Centers for Disease Control.
An estimated 8,000 to 18,000 people are hospitalized because of Legionnaires’ disease each year, according to the CDC, and that figure may be low because many infections are not diagnosed or reported. Each year between 2008 and 2012, 3,000 to 4,000 cases were reported to the CDC.
A number of possible reasons may explain the increase, including an older U.S. population, more at-risk individuals, aging plumbing infrastructure and climate, the CDC says. It may also arise from greater use of diagnostic testing or more reliable reporting.
As of last month, the most recent reporting period, the Pinellas County Department of Health reported 14 cases of legionellosis countywide, all of them caused by the Legionella bacteria, and 269 in Florida. That includes Bay Pines. In 2014, 13 legionellosis cases were reported in Pinellas.
Legionella is commonly found in water supplies in all buildings, not just hospitals, says Thomas Klein, emeritus professor of immunology at the University of South Florida Morsani College of Medicine.
The levels reported in the tests obtained by the Tribune “don’t sound particularly high to me,” Klein says. “They have tested positive, but they are not grossly contaminated.”
The fact there has been no spike in patients dying from the disease or even contracting it is a good sign, he says, adding that the VA’s new directive means the hospital “is doing what it should be doing.”
Klein, however, says he is “generally surprised” it wasn’t until after the deaths in Pittsburgh that the VA moved to require more stringent testing measures. The VA has decades of experience with Legionnaire’s disease, dating back to an outbreak in 1997 at a hospital in Los Angeles that killed more than 40, he said, leaving him “befuddled that it’s taken this long.”
The new VA program “is probably one of most stringent Legionella prevention programs in the nation,” says Janet Stout of the private Special Pathogens Laboratory in Pittsburgh, which conducted the Bay Pines testing.
The findings of the first two tests on Building 1 showed a greater risk for disease, Stout says. But those at the greatest risk are older patients, smokers, those with chronic lung diseases, diabetes and transplant patients.
The pneumophila species of the bacteria poses the most significant health concern because it can cause Legionella pneumonia or Pontiac Fever, says Dangel, the Bay Pines spokesman. “Legionella disease occurs after inhalation or aspiration of contaminated water. Most people who are exposed to the bacteria never become ill,” Dangel says.
Some sources of water send greater doses directly to the lungs than others and are harmful at lower levels, says Maggie Hall, spokeswoman for the Pinellas health department.
These include humidifiers and other misters producing aerosol that is directly inhaled into the lungs. A cooling tower, on the other hand, has much higher unsafe levels, measured in colony-forming units — a measure of microorganisms present in a sample.
“We recommend prompt cleaning and/or biocide when cooling towers have 100 CFU per milliliter and humidifiers have 1 CFU per milliliter,” Hall said.
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Before the new VA directive, officials at Bay Pines only tested for Legionella once a year, or after an incident such as an illness or system malfunction. After learning about the tests results in Building 1, the hospital “spent a lot of time investigating the infrastructure,” says Brauer, with Bay Pines engineering.
One of the problems, she said, was aging systems a change in use of some areas. Patient rooms, for example, became exam rooms where less water was used and higher levels of the bacteria could form.
The staff did two complete building remediations, including a robust system flush and higher chlorination levels to eradicate the bacteria, Brauer says.
In 2015 alone, Bay Pines performed full building remediation seven times and engineering employees put in more than 660 overtime hours to complete remediation-related work, Dangel says.
“As you can see, we take this issue very seriously. A tremendous amount of time and effort is dedicated to monitoring and maintenance of our water systems.”
It’s a never-ending battle, Dangel adds. Staff conducts regular surveillance of water temperature and oxidant residual levels in all patient care buildings.
Legionella “is something we constantly have to keep our finger on because there is a zero tolerance policy to ensure the safety of our patients.”