Third Vet’s Death Tied to Legionnaires’

His wife blames water from VA hospital in Oakland

The wife of a Vietnam War Army veteran who died Oct. 23 in Erie believes her husband may have died after contracting Legionnaires’ disease from the water system at the VA hospital in Oakland.

If John McChesney, 63, did die after contracting the pneumonia-like disease at the University Drive facility, that potentially makes him the third patient in the past two years to die after getting Legionnaires’ disease there.

It also makes Mr. McChesney part of an expanding investigation into the Legionnaires’ outbreak at the hospital that has caught national attention in part because the hospital used to be home to researcher Victor Yu, who in 1982 first confirmed the connection between the spread of the disease and water systems.

Part of that expanding inquiry is looking into whether Legionnnaires’ cases also originated at the VA’s H.J. Heinz campus near Aspinwall, a site that contains a nursing home for veterans.

VA spokesman David Cowgill on Monday confirmed the VA has detected Legionella, the bacterium that causes the disease, in the water system at Heinz, and that facility still has water restrictions in effect while the water system is being treated with chlorine. Water restrictions were finally lifted at University Drive on Friday after two weeks of cleaning.

Mr. Cowgill said in an email that one of the five cases of Legionnaires’ disease that originated at the VA may have originated at Heinz, though there is a “high probability” that it began at University Drive for that patient.

Mr. Cowgill said he could not comment on Mr. McChesney’s case, though Mr. McChesney’s wife, Evelyn, said she has been contacted three times in the past five days by officials from the VA about her husband’s death and requests to test the water in her Columbus, Warren County, home to see if that was the source of the Legionnaires’ disease he contracted.

“I think he got it at the VA,” she said Monday. “I don’t believe there’s anything wrong with my water.”

Mr. McChesney had suffered from kidney and heart trouble that resulted from contact with the chemical defoliant Agent Orange during his 18-month stint in the infantry in Vietnam.

He died after his wife of 18 years took him to St. Vincent Health Center in Erie on Oct. 1 because he was coughing and wheezing badly. She said an emergency room doctor there said Mr. McChesney tested positive for Legionnaires’ disease.

That was less than 14 days after he had spent six days over two visits to the University Drive facility in late September, where he was being seen for heart problems. Legionnaires’ disease typically has up to a 14-day incubation period.

Mrs. McChesney, who has been following the stories about the outbreak over the past two weeks, was incensed by what she has read.

“Whoever was responsible for this, they should be held accountable,” she said. “I mean, the suffering my husband went through for 3 1/2 weeks [before he died] was needless and it was because they just neglected things.”

“I feel my husband and other soldiers served their country and they deserve the best care possible,” she added.

The outbreak was first revealed by the VA Pittsburgh Healthcare System on Nov. 16, when it said that it had confirmed just four cases of the disease linked to the University Drive hospital, and it said all four patients had recovered.

It later said on Nov. 22 that a fifth person had contracted the disease from the hospital, though it omitted from the news release that the fifth patient had died. It wasn’t until Friday that the VA told the Allegheny County Health Department that that person — whom the VA refuses to identify — had died after contracting the disease.

In addition, the children of a second veteran, John Ciarolla, 83, told the Pittsburgh Post-Gazette that he died last year after contracting the disease following stays at both University Drive and the VA’s H.J. Heinz nursing home.

The U.S. Centers for Disease Control and Prevention is investigating how the outbreak occurred, and U.S. Sen. Bob Casey, D-Pa., has asked Veterans Affairs Secretary Eric Shinseki for a report on why the outbreak occurred.

Dr. Yu and his research colleague, Janet Stout, who both left the VA after a dispute with management in 2006 and 2007, respectively, believe that the outbreak is due to the VA’s failure to properly manage and maintain the water treatment system they first installed at the hospital in 1993. The VA believes the treatment system is what failed.

U.S. Rep. Brad Miller, D-N.C., was chairman of the House Investigations and Oversight Subcommittee in 2008 when it held a hearing into the way that Dr. Yu and Dr. Stout were pushed out of the hospital, and how the VA destroyed 30 years worth of frozen isolates of Legionnaires’ disease that the researchers had collected.

Mr. Miller believed then that the VA seriously erred in forcing Dr. Yu and Dr. Stout out and destroying their isolate collection. Now the actions look even worse, he said, since it was Dr. Stout who oversaw the water treatment system at the hospital.

“At the very least, [losing Dr. Yu and Dr. Stout] compromised that hospital’s ability to deal” with the outbreak, Mr. Miller said Monday. “And they may have lost the people who were best at handling [the water treatment] system.”

Another part of the story that has bothered Mrs. McChesney and others is that the VA knew as early as June that it had a problem with the water treatment system — known as a copper-silver ionization system. The VA called in a consultant then, who recommended in July a series of steps to make it work properly.

But the VA did not do anything in response to the recommendations until sometime in October, when it called the consultant back in and asked the consultant to adjust the copper-silver system to work properly.

“I mean, for them to be that negligent,” Mrs. McChesney said. “They never even warned their patients.”

Because the Legionella bacterium must get into a patient’s lungs, one of the most common ways it infects a person is while taking a shower, when the moist mist from a shower is inhaled. Mrs. McChesney believes her husband took at least two showers during a four-day stay at the hospital from Sept. 18 to Sept. 21. He returned for a two-day visit at the VA Sept. 26 and 27 and then went home after a procedure.

About 8,000 to 10,000 people each year are hospitalized with the disease. But the Centers for Disease Control and other experts believe many more cases occur each year that go undiagnosed as simple pneumonia or other afflictions. Legionnaires’ disease can be fatal in 5 percent to 30 percent of cases, depending on who it strikes and where it is acquired.

After Mr. McChesney was admitted to St. Vincent on Oct. 1, his condition got worse, and it was the heart and kidney conditions he had suffered from for much of his life that were the official causes of death on Oct. 23. But his wife said his doctors acknowledged to her that it was the Legionnaires’ disease that exacerbated them, leading to his death.

Mrs. McChesney said VA officials told her in late October that they would send bottles to her to collect samples of her home water to test.

But she never got the bottles and no one followed up until the past five days, after the outbreak had been publicly revealed.

On Thursday, a VA official called and asked if she could send Mrs. McChesney a kit to test her home’s water. Then, on Friday, Robert Muder, director of the infectious disease section at University Drive, called her and left a message that he wanted to talk to her. And finally, on Monday, another VA official called and asked if the VA could send a social worker to her home to test her water.

“I’m not sure I want them to come, or if I want to talk to them,” Mrs. McChesney said.

Now, she said, she’s focused on getting to the bottom of what caused her husband’s death, to honor his memory.

“I do know that he would not want me to just let this go,” she said.

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