Casey Calls on VA To Make CDC Report on Pittsburgh Legionnaires’ Outbreak Public

In Letter to Secretary Shinseki, Casey Calls for Reform of VA’s Public Notification Protocols

Senator Asks for Update on Implementation of Recommended Reforms

Washington DC- U.S. Senator Bob Casey (D-PA) today  announced that he has sent a letter to U.S. Department of Veteran’s Affairs (VA) Secretary Eric Shinseki urging him to make public the Centers for Disease Control (CDC) report on the legionnaires’ outbreak at the Pittsburgh VA. In his letter, Senator Casey also urged reform of the agency’s protocols for public notification and asked for a status update on the reforms recommended by the CDC’s report.

“The public still has legitimate questions about how the legionnaires’ outbreak occurred and what is being done to prevent it from ever happening again. One way to begin to answer those questions is to release the full CDC report to the public,” Senator Casey said. “During this outbreak the public was clearly not adequately informed. Changes are needed to ensure there is better notification in the future and that steps are being taken right now to make sure veterans being treated at this facility can be safe.”

The full text of Senator Casey’s letter to Secretary Shinseki is below:

The Honorable Eric K. Shinseki


U.S. Department of Veterans Affairs

Dear Secretary Shinseki:

I am writing to express my continued concern with the response to the recent outbreak of Legionnaires’ Disease at the VA Pittsburgh Healthcare System (VAPHS). Effective communication, both internal and external, is critical. There is more that the VA can do to provide pertinent information to the public about the outbreak and response.

As you know, the House Committee on Veterans Affairs’ Subcommittee on Oversight and Investigations held a hearing on February 5, 2013 about the Legionnaires’ Disease outbreak and response at the VAPHS. The testimony raised many questions about events leading up to the outbreak and how the VAPHS handled the outbreak once it occurred. The testimony by the Centers for Disease Control and Prevention (CDC) covered their investigation of the outbreak and the subsequent January 25, 2013 report.

I ask that the VA publically release the January 25, 2013 CDC report about the VAPHS Legionnaires’ Disease outbreak. Understandably, any patient sensitive information in the report should be redacted in advance. A public report would provide valuable information about the outbreak and the VA’s response to the families who have been impacted by this tragedy. Also, the people of southwestern Pennsylvania have a right to know what happened.

The CDC testimony and report indicated several specific areas for improvement. I ask for your assurance that the following actions have or will be taken:

  1. VAPHS follows best practices for maintaining any Legionella control system as recommended by public health agencies and manufacturers;
  2. VAPHS is now following the water sampling protocol discussed and recommended by the CDC in their report and that VA water sampling policy has been modified to reflect that such best practices will be used going forward in all VA facilities that are prone to Legionella infection;
  3. Internal VA communications plans between the pathology labs, prevention team, providers, and patients will be revised and improved based on the feedback from the CDC and lessons learned from this recent outbreak; and
  4. External communications plans between the VAPHS, Pennsylvania Department of Health and the Allegheny County Health Department regarding Legionnaires’ Disease surveillance and outbreak response be revised and improved based on the feedback from the CDC and lessons learned from this recent outbreak.

In addition to these recommendations, I ask that you outline for me the specific protocols you expect to put in place to inform the CDC, other stakeholders and the public in the future. Appropriate reporting requirements are essential to keep people safe and informed.

I know that both you and I share a commitment to the men and women of our Armed Forces who have made such extraordinary sacrifices for our nation. Please know that I will continue to give this issue my personal attention until I am confident that all questions have been answered and that a tragedy like this will never happen again.


Robert P. Casey, Jr.

United States Senator

Press Contact

April Mellody 202-228-6367