The press in Pittsburgh has been following an attack of Legionaire’s disease at a local VA Hospital last winter that caused an estimated 16 to 21 deaths. The latest article is a nice one that shouts “doesn’t anyone care”, but the answer is that yes, we do care, and the CDC did intervene to find the cause and the solution of the problem.

The fact is that this disease does occur sporadically, and it took awhile for the CDC to be notified that there was an outbreak, not just the usual cases that we docs see now and then.

But the real cause of the anger is that the outbreak revealed real problems in monitoring the water supply in quite a few VA hospitals.

 Trib article here:

It’s not just Pittsburgh.
Department of Veterans Affairs hospitals across the country failed to follow policies designed to stop the spread of Legionnaires’ disease, according to a VA Office of Inspector General’s report released on Thursday.
More than one-third of VA hospitals and clinical care facilities did not conduct proper planning and risk assessment required by a 2008 national VA directive to control the Legionella bacteria. If inhaled in water mist, the bacteria can become a potentially deadly form of pneumonia known as Legionnaires’ disease.
“The report shows a clear lack of understanding at VA facilities across the country about proper protocol when testing for Legionella,” Sen. Bob Casey Jr., D-Scranton, wrote in an email to the Tribune-Review.
Well, after years of working in the federal IHS system, I know that following rules and taking forever to get around to do things is part of the problem of government medicine.
So yes,when the news paper editorial pages go balistic after the guy who dropped the ball in keeping the water clean got an award is understandable: but hey, that’s how the government works. He probably filled out the paperwork correctly and kept within the budgetary limitations, which is what his job was.
If I am being sarcastic, it is because I worked for the feds (IHS) and once got into a fight with a big shot visitor who told us our duty was to give care within the restraints of the budget, and I kept correcting her that our duty was to give good care, period, and although non urgent problems were sometimes delayed or denied, that we doctors kept submitting the paper work to get our patient’s care anyway. Needless to say, I was not popular with the area office.
However, in this case, the problem also happened to be a germ that wasn’t killed by the usual methods that should have killed it.
Let’s start at the beginning.
Usually Legionaire’s disease is spread when water droplets carrying the germ get sprayed into the air, for example in a shower or hot tub, or a water fountain, or in a humidifier or air conditioning sytem.

The disease got it’s name from an outbreak in the 1970’s, among men attending an American Legion convention, ergo the name. A lot of men died, many of whom were smokers, so when they died of pneumonia it wasn’t noticed right away. But the pneumonia looked funny on the x-ray, and it didn’t respond to ordinary antibiotics.  Soon a pattern was noticed, and the investigators went to work.

They finally found it was not a virus, as first believed, but a bacteria without a different type of cell wall.  This meant that ordinary laboratory “stains” didn’t make it easy to identify under a microscope, and to make it worse, it didn’t grow easily in the lab either. Later, they found silver would stain it, and now they use an antibody to identify the germ, but during the 1976 outbreak, there was a lot of confusion about what was causing these veterans to die.

The second problem is that the common antibiotics we used for people with bad lungs who got pneumonia (the penicillin and cephalosporin families) didn’t work.

Luckily, erythromycin works for the disease, and as the reports came in and this was noticed, we switched to this antibiotic even before we knew why it was working.

Erythromycin is a common antibiotic used for people who can’t take Penicillin, and we also use it for mycoplasm pneumonia, aka “walking pneumonia. But before this outbreak, we rarely used it severe pneumonia.  Since 1976, several antibiotics have been found to work, so fewer people die.

Preferred antibiotics include doxycycline, tigecycline, and azithromycin
because of their activity and pharmacokinetic properties (eg, better
bioavailability, better penetration into macrophages, longer half-life).

The real problem is figuring out what is causing your patient to get sick. As I mentioned before, not only is this a germ you have to do special tests to identify, but it happens in people who are prone to get sick anyway, either from bad lungs or immune problems.

So what happened in the Pittsburgh cases? I googled and found the CDC report on the VA problems. A very interesting report.

Yes, the water systems at the VA Hospital were contaminated. But the report has a lot of data that may not be in the “ain’t it awful” news reports.

Fact number one:: they have a lot of Legionaire’s disease in Pittsburgh,

You can get it from taking a shower if your hot water tank has the germ in it, and you have chronic lung disease or a problem with your immune system.  But Western Pennsylvania used to be an industrial area, and so there are a lot of retired older men who were heavy smokers, and a lot of men with black lung, so it took awhile for the public health dept to recognize that the cases were from a cluster of VA patients, not just the usual cases.

Fact number two: (from the CDC report)

a sample from the sand filter of the decorative fountain at the entrance
showed growth of the outbreak strain; therefore the fountain cannot be
ruled out as a potential source of exposure for some cases.

Translation: not only were the water tanks in the hospital found to have the germ, they even found Legionella bacteria in the decorative fountain in the entrance of the hospital.

Well, there goes all your pretty fountains.

Fact number three: The ordinary methods of superheating, chlorine treatment, and using the silver/copper ions used to keep the water clear that worked for ordinary legionella bacteria didn’t work here….a resistant strain had popped up.

Fact number four: The outbreak started at the time they were doing upgrading/construction in the area. The Legionella bacteria lives in soil, so this might be the source of the germ: it floated from the dust, settled into the water systems, and voila, a slow spread of germs.

Result of all this: The CDC upgraded the water cleansing system and so far things look clear, with no new cases at this VA.

But of course, it won’t be the last time this problem pops up in nursing homes, public fountains,  hotels, restaurants, etc.

So problem solved…at least this time. But it will happen again.

And when it does, the CDC folks will be there to check what’s causing the problem and telling you how to fix it, while the local newspapers will be shouting and pointing fingers and trying to make a scandal to sell newspapers.

So kudos to the CDC folks, who don’t get no respect for protecting us from diseases that threaten us and our loved ones.


Nancy Reyes is a retired physician living in the rural Philippines.




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