Dr. Robert Jesse, VA Principal Deputy Undersecretary for Health, is VA's latest point person on Gulf War veterans' health issues. He continues to ignore Gulf War veterans' detailed written requests for action on a litany Gulf War veterans' health issues.
SOURCE: Pittsburg (Pa.) Tribune-Review TribLIVE, Mike Wereschagin and Adam Smeltz reporting, May 10, 2014.
VA records contradict testimony by agency leaders to Congress
By Mike Wereschagin and Adam Smeltz
Published: Saturday, May 10, 2014, 11:00 p.m.
Internal emails and documents contradict testimony given by Department of Veterans Affairs leaders to a congressional subcommittee investigating a Legionnaires' disease outbreak that left at least six dead and 16 sickened in two Pittsburgh area hospitals.
The contradictions emerge from nearly 7,000 pages of internal VA emails and documents sent during and shortly after the outbreak that the agency and federal health investigators suspect began in February 2011 and ended in November 2012. The Tribune-Review obtained the emails and records through a Freedom of Information Act request filed more than a year ago.
Shortly after announcing the outbreak, former regional VA director Michael Moreland described the aftermath as “a good learning event for all of us — going well so far,” in a Nov. 21, 2012, email to VA Pittsburgh associate director Lovetta Ford.
Two days later, the outbreak's last known victim, William Nicklas, died in the VA's University Drive hospital in Oakland.
Neither Moreland nor Ford could be reached for comment.
Other emails between VA officials:
• The director of VA Pittsburgh learned in November 2012 that a water system shut down when workers tried to super-heat water to kill Legionella, the bacteria behind a severe pneumonia that can be fatal in people with weakened immune systems. A national VA executive testified before a House VA subcommittee hearing in Washington on Feb. 5, 2013, that the super-heating worked.
• VA Pittsburgh workers rarely and inconsistently collected water samples to check for bacteria, according to two internal emails that contradict Moreland's testimony during that hearing.
• An internal investigation found in December 2012 that VA Pittsburgh workers did not properly operate a water disinfection system, a discovery that leaders did not disclose when Congress and others asked what went wrong.
VA officials in Washington and Pittsburgh said in response that the agency “cooperated fully” with investigations into the outbreak, but declined to address some of the discrepancies. The federal Centers for Disease Control and Prevention blamed the outbreak on Legionella-tainted water at VA hospital campuses in Oakland and in O'Hara.
“Employees and executives who allowed patients to slip through the cracks must be held accountable, as should anyone who intentionally misled the public, their superiors at VA or the Congress of the United States,” U.S. Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans' Affairs, told the Trib.
Terry Gerigk Wolf, director of VA Pittsburgh, learned in a Nov. 30, 2012, meeting that the Oakland hospital's water system “simply shuts down” when the temperature reaches 154 degrees — six degrees shy of the minimum temperature recommended to control Legionella, according to one email. Similar problems appeared as early as 2010, according to an investigation report by the VA's Office of Inspector General.
During the February 2013 congressional hearing in Washington, however, Dr. Robert Jesse, the VA's principal deputy undersecretary of health, told lawmakers: “Pittsburgh promptly implemented an aggressive, multi-phase remediation effort including, again, super-heating the water supply to 160 to 170 degrees, followed by hyperchlorination of the hot water distribution system.”
National VA spokeswoman Ramona Joyce refused to say whether Jesse knew about the system's problems. Jesse was not on the email chain about the water heating failure.
VA Pittsburgh spokesman Mark Ray said the system could superheat water but could not maintain a 160-degree temperature everywhere in its pipes. VA workers flushed the lines with chlorine, Ray said.
VA leaders, including former regional director Moreland, repeatedly claimed VA Pittsburgh exceeded Legionella testing standards set by the CDC and VA.
“The system of control for Legionella, as CDC said, at Pittsburgh is very comprehensive,” Moreland testified during the February 2013 hearing. “And so you have the engineering department who's looking at the water and managing the water; then you have a group of infectious disease professionals who are reviewing the copper-silver ionization levels. They're reviewing the water samples, and they're looking at that.”
But workers rarely collected water samples, according to internal VA emails. Instead, they usually swabbed the insides of faucets and tested those swabs for Legionella, according to emails exchanged two months before the hearing.
“We had not collected water samples in the past, however, since the CDC visit we have been collecting 1L (one liter) water samples and swabs,” infection prevention nurse Patricia Harris wrote to Dr. Robert Muder, the former head of infection control, and others.
Moreland was not on that email chain. He and Muder retired in the months after the outbreak and investigations became public. Phoenix House, a New York-based nonprofit that runs 120 drug and alcohol programs in 11 states, hired Moreland as its senior vice president and chief operating officer. A spokeswoman would not put the Trib in touch with Moreland and referred questions to the VA.
Ray said swabs count as water samples under VA guidelines. But experts, including former VA microbiologist Janet Stout, say swabs alone can miss bacteria.
“Water collected from the fixture may be positive when the swab is negative,” said Stout, who resigned her VA post and runs the Special Pathogens Laboratory in Uptown.
Two weeks after VA Pittsburgh disclosed the outbreak, Dr. Robert Petzel, undersecretary of the Veterans Health Administration, dispatched engineers from Washington to investigate what went wrong.
The head of the investigating team, Oleh Kowalskyj, told Moreland and others on Dec. 10, 2012, that he found poor record-keeping, lack of oversight and documentation, and failure to test the hospital water's pH level, among other “gaps” in protecting the safety of veterans and hospital workers.
High pH and low ion levels make copper-silver systems less effective, according to research conducted by Dr. Victor Yu, the former head of the VA Pittsburgh laboratory. Yu was fired in 2006 by Moreland when the latter was director of the VA Pittsburgh system.
An internal VA memo on Dec. 13, 2012, marked “For Official Use Only,” said the “copper-silver ionization system's effectiveness was significantly impacted by fluctuation in pH levels.”
VA Pittsburgh leaders suggested early that the system failed.
When executives in Pittsburgh were crafting the news release to divulge the outbreak, someone in Moreland's office — it's unclear who from the emails — added a paragraph stating that the system “may not be as effective as previously thought, as is the case in other health systems using this method.”
“It was NOT included in the draft that you sent to Mr. Moreland (I just checked),” Bethany Miga, an aide to VA Pittsburgh director Wolf, wrote to her boss on Nov. 24, 2012.
The “sentence is just tacked on very awkwardly at the bottom of the press release, and — surprise, surprise — it's the sentence that has garnered the most attention because ... well, it is open to attack relative to everything else in the release,” Miga wrote.
Ray, the Pittsburgh VA spokesman, declined to say who added the sentence to the news release.
“Releases of this nature go through a multilevel vetting process,” he said.
Pittsburgh VA never identified the copper-silver system as the primary cause of the outbreak, he said.
“However, the CDC review detected Legionella growing in water samples with adequate concentrations of copper and silver ions,” Ray wrote in response to Trib questions.
Copper and silver ions take time to reach nooks in a plumbing system, so if VA workers turned up the disinfection systems shortly before the CDC arrived, the ions might not have had time to work, Stout said.
“Any disinfectant, whether it's ions or other (chemicals), takes time to kill,” Stout said.
The VA emails show some leaders did not seem to fully grasp the magnitude of the outbreak months after it was believed to have ended.
Moreland, who received lavish praise and tens of thousands of dollars in bonuses from VA leaders in 2011 and 2012, wrote to top Pittsburgh officials on Jan. 29, 2013: “We had 0 cases in the summer of 2012.”
The VA's internal tally listed three Legionnaires' patients in the summer of 2012 who probably contracted the disease in the hospital, and two who definitely did. One of the four, Lloyd Wanstreet, died on July 4, 2012.
Editor's note: This story is the first in a two-part series.