This article, which was written by Lawrence F Muscarella PhD, focuses on an outbreak of Legionella in Pennsylvania that was reported by several news sources, including CNN.

This April, 2013, the Veterans Affairs Office of Inspector General issued its report about this outbreak.

  • Entitled “Healthcare Inspection: Legionnaires’ Disease at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,” this report can be read by <CLICKING HERE>.
  • To read the specific recommendations that the VA’s Office of Inspector General Recommendations is currently providing to prevent these types of outbreaks, <CLICK HERE>.
  • To read the report “Highlights of the VA inspector general report on Pittsburgh Legionnaires’ outbreak,” <CLICK HERE>.

And, to read Dr. Muscarella’s article “Prevention of Legionnaires’ Disease in Healthcare Settings,” <CLICK HERE>.


The evening of December 13, 2012, CNN aired a story about the Veterans Health Administration (VHA), its transparency, and its management of health care and patient safety.

Entitled “VA under scrutiny after Legionnaires’ cases in Pittsburgh,” CNN reported that 29 cases of Legionnaires’ disease have been diagnosed at the Pittsburgh (PA) Veterans Administration Medical Center (VAMC) since January 2011 (almost two years ago). Of these 29 cases, at least 5 patients were reportedly infected with this disease while receiving treatment at this VAMC.

Click here to read the written transcript of this CNN report discussing this bacterial outbreak.

As a result of another incident, I previously wrote and published an article/blog entitled “Prevention of Legionnaires’ Disease in Healthcare Settings,” which can be read by clicking here. In that blog I discuss the contribution of a hospital’s water supply, including of contaminated decorative water falls, to healthcare-associated outbreaks of Legionella, the causative agent of Legionnaires’ disease. (Click here to view a listing of most of my recently posted blogs.)

Possible Causes of Infection

According to this CNN report about infections of Legionella at this VAMC in Pittsburgh:  (1) “records indicate this hospital’s water systems were not properly maintained”;  (2) “hospital officials knew they had a problem with the water system as far back as last December, but chose not to reveal that until a month ago”; and that (3) the hospital’s water “over the past year did not contain enough disinfectant to prevent Legionnella bacteria from reaching dangerous levels.”


When CNN’s correspondent visited this VAMC in Pittsburgh (PA) to ask its officials:  (1) about these cases of Legionella infection (click here to view footage of the confrontation between this news correspondent and federal law enforcement officials guarding the VAMC); (2) when officials first learned about the potential for the transmission of Legionella at this VAMC, and (3) what measures officials have taken at this VAMC to prevent further cases of infection, this reporter was met by 4 armed federal officers who sternly instructed him and his camera crew to leave the premises promptly.

Other Breaches at VAMCs

In the medical literature (click here) and in some of my other blogs, I have written about other identified infection-control breaches within the VHA, questioning whether the VHA’s actions are consistent with its published commitment to transparency and to the full disclosure of infection-control breaches to affected patients. For more about my perspectives about transparency within the VHA, please refer to: (a) my blog “San Juan’s VAMC: A Faulty Assessment of the Risk of Disease Transmission?,” which can be read here; and (b) my comments on the front page of a newspaper, which can be read here.

Final Remarks

A system that lacks transparency and disclosure in health care is one that is bereft of the necessary quality to ensure patient safety. Therefore, a commitment to quality and to patient safety would seemingly require the VHA (perhaps, with few reasonably exceptions and certainly consistent with its own directives – refer to the VHA’s “Disclosure of Adverse Events to Patients“) to inform affected patients of a potentially significant infection-control breach, whether the breach is identified at a VA medical facility in Pittsburgh (PA), in San Juan (PR), or in any other city. Concerns about the inadequate notification of patients have been discussed vis-a-vis the recent spread of a resistant “superbug” at a hospital in Maryland; click here to read more about this incident.

In closing, the failure to disclose to affected patients an infection-control breach associated with an increased risk of infection – for example, a medical facility’s failure to properly disinfect or sterilize a potentially contaminated reusable, semi-critical (or critical) medical instrument – not only would lack quality (and transparency), but also walks a slippery slope, and, as I have previously written, implies that the proper, rigorous and thorough reprocessing of the instrument is “superfluous and unnecessary.”

Article by: Lawrence F. Muscarella, Ph.D. posted on 12-14-2012 (Updated: 12-17-2012)

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