Legionnaire’s Outbreak at Pittsburgh VA Hospital Kills 5; Director Awarded $63k Bonus

Posted by Jason Van Steenwyk

legionnaire’s diseaseWhat happens to Veterans Administration employees when they decide close the VA Special Pathogens Laboratory and sack two of the leading experts on legionnaire’s disease mitigation and eradication in 2006 when six years later there’s a legionnaire’s disease outbreak at the hospital they oversee that kills five people?

Well, apparently, in Shinseki’s world, they get a bonus. $62,895 bonus, to be exact. Michael Moreland received the bonus, along with a Distinguished Rank Award, given to just one percent of senior federal employees, in a black-tie banquet last week. 

On April 23rd, three days before Moreland received the bonus, the VA’s Inspector General published this report, which found that while there were some solid efforts underway to mitigate the spread of legionnaire’s bacteria in the hospital water supply (an ongoing challenge for any health care facility), the Pittsburgh VA had not followed through adequately on them.

The findings in the VA report are rather tame. But the VA IG doesn’t go into the backstory with the Special Pathogens lab, documented here.

In 2006, the efforts of Lab director Dr. Victor Yu, chief of Infectious Disease Prevention at the VA, and and Dr. Janet Stout, the director of at the Special Pathogens lab in pioneering legionnaire’s disease prevention techniques were lauded in the Pittsburgh press. Yu, Stout and the other clinical staff were getting noticed in the medical community nationwide for their work.

Nevertheless, just three days after the Pittsburgh Tribune Review published this laudatory article about the lifesaving contributions of the Special Pathogens Laboratory, VA officials in the Bush Administration abruptly shut down the Special Pathogen Laboratory for reasons that are still unclear. Five clinical staff were terminated immediately, while another, Dr. Janet Stout, was demoted to bench technician. The Lab’s director, Dr. Victor Yu, appealed to Michael Moreland’s office, but Moreland affirmed the decision to shutter the lab. 

“This absolutely will jeopardize lives,” Dr. Yu told press at the time. “Outbreaks will be missed; we can’t do testing for any more hospitals. We have been given 48 hours.”

According to correspondence from the last days of the Lab’s operation, Moreland was an obstacle to the orderly closing of the lab and the processing of remaining samples for legionnaire’s bacteria testing. Dr. Yu wrote at the time:

You promised the Special Pathogens Lab personnel 14 days to process clinical and lab specimens. While you have kept your promise, Moreland and the administration have initiated a series of actions that have proven extraordinarily disruptive.  They are now locked out of the lab. The security guard is stationed there today ostensibly to prevent the lab personnel from entering.

Yesterday, a security guard sabotaged Sue Meitzner’s cultures on patient respiratory samples by refusing her to complete her work. The fact that Mr Moreland and his staff walked through the lab before the guard appeared suggests that they ordered the security guard to force her out of the lab.

We insist that two patient specimens be re-processed since they have been ordered by VA physicians for their patients. Unfortunately we need the original sputum specimen and those two specimens were taken by Cheryl Wanzie. We also need the microscopes which were removed from the

lab without our permssion. In addition, there are at least 200 environmental samples that require processing. The samples are from Johns Hopkins University, NY Alice Hyde Hospital, Erie St Vincent Hospital, Bayview Medical Center, SUNY-Buffalo, Phoenix VAMC. These specimens must be performed for humanitarian reasons.

I will not accept the suggestion that these specimens be processed in the clinical microbiology lab. No more disruptions. Let them finish their job in the lab that they have worked in for 10 years.

Finally, let us both agree to assist the laboratory personnel so they can conclude their work. Bureaucratic politics is taking too much of their time and yours. 

Dr. Stout likewise documented several instances of Moreland’s employees interfering with her work, “bordering on harassment.”

On Wednesday and Thursday, at least 14 different individuals paraded unannounced through the lab performing walk-throughs. This included a 5 member labor crew who removed clinical specimens,microscopes, all of the diagnostic test kits, and supplies during while the lab personnel were trying to conclude their work. When Dr Melhelm came, she was accompanied by 2 security guards.

On July 12, 2006, Dr. Yu, still smarting from the closure (he uses the term “destruction”) of the Special Pathogens Laboratory, Dr. Yu requested to be allowed to interview applicants for the Clinical Microbiology Lab directorship position. Moreland and his staff refused the request. When they hired someone who had not been active in the field for many years, Dr. Yu emailed Both Michael Moreland and Dr. Rajiv Jain:

Dear Dr Jain and Mr Moreland

Given our record of clinical excellence, it seemed reasonable for me to interview the new supervisor of the Clinical Microbiology Lab.  However, this reasonable request was denied, and an unqualified individual was hired.?? 

It took over 20 years to raise the VA Special Pathogens Lab to a lab of excellence that was self-sufficient and internationally-recognized.  Similarly, we elevated the VA Clinical Microbiology Lab to be the most responsive lab to clinicians at this hospital. However, the lab also became a lab of excellence as documented below.??

In a period of 2 weeks, both of you took part in the destruction of 2 great labs in the US because of a presumed bureaucratic issue.?? 

In sadness,

Victor L Yu MD 

In early 2007, Yu continued to press the VA over the destruction of numerous samples and cultures that were vital to continued research.

The closure led to Congressional hearings in 2008, however.

Melhem insisted repeatedly that she did not know the thousands of vials — each marked with letters and numbers and placed in racks — were being used for research when she ordered staff to toss them…

Michael Moreland, who headed the VA Pittsburgh Healthcare System at the time, said he was unaware of the collection’s significance. 

Although the VA Inspector General’s report does not directly reference the closure of the Special Pathogen Laboratory in 2006, and only mentions Moreland once, they do cite Yu and Stout’s research in legionnaire’s disease pathogen control within the report’s footnotes.

Meanwhile, in addition to the finding published last week, the Veterans Affairs Inspector General’s office is conducting a criminal probe into the way senior VA managers in Pittsburgh handled the legionnaire’s outbreak. The U.S. Attorney’s office is also conducting its own criminal investigation, according to reporting from the Pittsburgh Tribune. According to reporting from the Pittsburgh Post-Gazette, “The Pittsburgh VA first publicly revealed it had an outbreak on Nov. 16, 2012, even though officials, including Mr. Moreland, knew they had a serious problem as early as July 2011.”

Nevertheless, none of the information from the VA Inspector General’ report, nor the background story involving the dismantling of the VA Special Pathogens Laboratory, nor the congressional hearings establishing the reckless disregard for clinical procedure under Moreland’s direction, nor even the fact that Moreland’s operation is under two separate ongoing criminal probes from the VA’s own IG and by the local U.S. Attorney, was enough to slow-track Moreland’s bonus, equal to 35 percent of his $179,000+ annual salary 

Note: the occasional typographical error in quoted correspondence was intentionally retained for accuracy’s sake.

 

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