Department of Veterans Affairs 

Office of Inspector General 

Assessment of Legionnaire's Disease Risk 

in Veterans Health Administration 

Inpatient Facilities 

Report No. 07-00029-151 June 20, 2007

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

Executive Summary 

The Veterans Health Administration (VHA) has taken a number of steps to reduce the 

risk of Legionnaire’s Disease (LD) in its hospitals, but little information is available 

regarding current environmental conditions, prevention strategies, and clinical practices 

in hospitals across the VA system. The Office of Inspector General, Office of Healthcare 

Inspections, therefore conducted a survey of VHA’s inpatient facilities to characterize 

risks to patients at individual facilities and suggest where prevention strategies might best 

be focused. 

We obtained detailed information from 159 acute-care and extended-care inpatient 

facilities. Nine facilities reported being a site for bone marrow or solid organ 

transplantation, and five of these had no explicit plan for LD prevention. One hundred 

and forty-five of the facilities reported obtaining water from municipal sources, 30 of 

which use disinfection systems believed to confer decreased risk of LD. Twenty-five 

facilities reported that they conduct routine periodic environmental surveillance and 12 

have specific disinfection systems in place. Eighteen acute-care facilities reported no 

recent diagnostic testing of patients and could be categorized as being at relatively 

increased risk. We concluded that a prioritized approach to amelioration of LD risk at a 

system level is possible. 

We recommended that the Under Secretary for Health take the required actions to ensure 

that inpatient facilities where transplants are performed have a written plan which 

addresses the prevention of Legionnaire’s Disease and that all inpatient facilities 

periodically assess local risk for Legionnaire’s Disease using specific guidelines 

developed by VHA experts. 

VA Office of Inspector General 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Under Secretary for Health, Department of Veterans Affairs (10) 

SUBJECT: Assessment of Legionnaire's Disease Risk in Veterans Health 

Administration Inpatient Facilities 

Introduction 

Purpose 

The Veterans Health Administration (VHA) has taken a number of steps to reduce the 

risk of Legionnaire’s Disease (LD) in its hospitals, achieving a significant decline in 

cases between fiscal years (FY) 1992 and 1999.1

 However, little information is available 

regarding current environmental conditions, prevention strategies, and clinical practices 

in hospitals across the VA system. Because the degree of risk to patients may vary 

considerably, the Office of Inspector General (OIG), Office of Healthcare Inspections 

(OHI), conducted a survey of inpatient facilities. The purposes of this review were to 

characterize risks to patients at individual facilities and suggest where prevention 

strategies might best be focused. 

Background 

LD has been the subject of numerous media reports since 1976, when it was responsible 

for 34 deaths among delegates to an American Legion convention in Philadelphia.2

 

Because LD is both preventable and treatable and because outbreaks are often described 

in hospitals and nursing homes, LD is relevant to the VHA and its inpatient facilities. 

 

1

 Kelly AA, Danko LH, Kralovic SM, Simbartl LA, Roselle GA. Legionella in the veterans healthcare 

 system: report of an eight-year survey. Epidemiol Infect. 2003;131:835-9. 2

 Stout JE, Yu VL. Legionellosis. N Engl J Med. 1997;337:682-687. Examples of recent media attention include 

reports of an outbreak in a Toronto nursing home (Washington Post, October 6, 2005), and reports of several 

outbreaks in hospitals and nursing homes in New York (New York Times, July 19, 2005; Associated Press, August 

31, 2006) and in Texas (San Antonio Express-News, June 26, 2006). 

VA Office of Inspector General 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

LD accounts for approximately five percent of community-acquired pneumonia, but is 

much more frequent in hospitalized patients.3

 Among Intensive Care Unit (ICU) patients 

with pneumonia, it is second only to S. pneumoniae as an etiologic agent. Legionella, the 

genus of the group of organisms which cause LD, colonizes hot water distribution 

systems in many medical facilities, but it is by no means ubiquitous.4,5

 Factors that 

enhance colonization include warm temperatures (25–42◦

C), stagnation, scale and 

sediment, and the presence of other commensal organisms. VA hospitals where 

municipal water is treated with monochloramine seem to have a significantly reduced 

incidence of LD.6

 

For the prevention of hospital-associated LD, routine culturing of the hot water supply 

has been advocated by investigators in Pittsburgh.7

 However, this approach has not been 

favored by the Healthcare Infection Control Practices Advisory Committee of the Centers 

for Disease Control and Prevention, which advocates clinical laboratory surveillance. 

Routine environmental cultures are considered an “unresolved issue” but are suggested as 

an option for institutions with transplant programs.8

 Unfortunately, LD is difficult to 

distinguish from pneumonias of other etiologies9

 and less intensive clinical testing may 

be appropriate in hospitals with a water supply known to be free of Legionella. 

If LD prevention is to depend on the identification of cases through clinical testing, 

medical treatment facilities should be able to demonstrate that clinicians routinely test for 

LD in patients with pneumonia. In VA hospitals, however, preliminary data suggest a 

wide range in the use of the most common test for LD (urinary antigen), with numerous 

facilities testing very infrequently.10 

Although routine environmental sampling has been adopted in several states,11 five 

European countries, and in Taiwan, there is little consensus about the utility of this 

 

3

 Pedro-Botet ML, Yu VL. Epidemiology and pathogenesis of Legionella infection. In: Up-To-Date, Rose, BD 

(Ed), Up-To-Date, Waltham, MA, 2004. 4 Goetz AM, Stout JE, Jacobs SL, Fisher MA, Ponzer RE, Drenning S, Yu VL. Nosocomial Legionnaires’ disease 

discovered in community hospitals following cultures of the water system: seek and ye shall find. Am J Infect 

Control. 1998 Feb;26(1):8-11. 5

 Stout, JE, et al. Endemic Legionellosis uncovered in a prospective study of hospital acquired Legionnaires’ 

disease: value of environmental monitoring. Abstract No. 22187. 31st Annual Meeting of the Association for 

Professionals in Infection Control, 2004; Phoenix, AZ. 6

 Heffelfinger JD, et al. Risk of hospital-acquired Legionnaire’s Disease in cities using monochloramine versus other 

water disinfectants. Infect Control Hosp Epidemiol. 2003;24:569-74. 7

 Yu VL. Resolving the controversy on environmental cultures for Legionella: a modest proposal. Infect Control 

Hosp Epidemiol. 1998;19:893-897. 8

 Tabian OC, et al; Healthcare Infection Control Practices Advisory Committee. Guidelines for Preventing 

Healthcare-Associated Pneumonia, 2003. MMWR. 53(RR03):1-36 (March 26, 2004). 

9 Edeltsein PH, Cianciotta NP. Legionella. In: Mandell GL, et al., Eds. Principles and Practice of Infectious 

Diseases, 6th Ed. Philadelphia: Elsevier Churchill Livingstone, 2005:2716. 10 Data on file, Office of Healthcare Inspections, VA Office of Inspector General, 2005. 11 State of Maryland Department of Health and Mental Hygiene. Report of the Maryland Scientific Working Group 

to Study Legionella in Water Systems in Healthcare Institutions, June 14, 2000. 

VA Office of Inspector General 2 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

approach in general settings in the United States. Much greater agreement exists in favor 

of sampling in facilities housing severely immunocompromised persons.12

For eradication in situations where Legionella has been isolated, many approaches have 

been described, but only copper-silver ionization has been rigorously evaluated.13 

Chlorine dioxide, ultraviolet light, and point-of-use filters also seem to be effective but 

have not been carefully studied.14,15 Other methods, particularly super-heating and 

hyper-chlorination, provide only temporary disinfection, are ineffective, or are associated 

with health risks and unacceptable corrosive damage to water systems. 

Scope and Methodology 

Identification of Facilities and Facility Characteristics

We identified inpatient treatment facilities from VHA’s Master Treatment File. We 

incorporated both acute care and extended care facilities (including nursing homes and 

inpatient rehabilitation facilities), but excluded domiciliaries. For the purpose of this 

review, geographically discrete facilities were analyzed separately irrespective of 

administrative designation. For example, an acute care hospital with a nursing home on 

the same campus was evaluated as a single unit, while facilities in different locations 

were analyzed separately. Type of care provided by facilities was derived from VHA 

program officials and gleaned from facility web sites. The number of active operating 

beds at each facility as of December 31, 2006, was obtained from managers at each of 

VHA’s 21 Veterans Integrated Service Networks. Facility teaching status was based on 

membership in the Association of American Medical Colleges’ Council of Teaching 

Hospitals and Health Systems (COTH),16 and characterization as urban or rural was 

derived from U.S. census data17 and the VA Office of Policy and Planning.18 

Survey Design and Administration

After review of the medical literature relevant to prevention of healthcare-associated LD 

and consultation with experts, we developed an internet-based questionnaire to be 

completed by facility infection control practitioners, engineers, and laboratory staff. We 

 

12 Edeltsein PH, Cianciotta NP. Legionella. In: Mandell GL, et al., Eds. Principles and Practice of Infectious 

Diseases, 6th Ed. Philadelphia: Elsevier Churchill Livingstone, 2005:2711-2724. 13 Stout JE, Yu VL. Experiences of the first 16 hospitals using copper-silver ionization for Legionella control: 

implications for the evaluation of other disinfection modalities. Infect Control Hosp Epidemiol. 2003;24:563-8. 14 Craven DE. Progress in the battle against nosocomial Legionnaire’s disease: shedding light on shades of gray. 

Infect Control Hosp Epidemiol. 2003;24:560-2. 15 Sheffer PJ, Stout JE, Wagener MM, Muder RR. Efficacy of new point-of-use water filter for preventing exposure 

to Legionella and waterborne bacteria. Am J Infect Control. 2005 Jun;33(5 Suppl 1):S20-5 16 http://www.aamc.org/members/coth. 

17 http://factfinder.census.gov. “Download Center,” Census Summary File 1, Table P2 (Urban & Rural). 18 vaww.pssg.med.va.gov. (Note that this is an internal VA website not publicly available.) 

VA Office of Inspector General 3 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

modified the questionnaire after discussions with VHA’s consultant for Infectious 

Diseases and pilot testing at two sites. 

Risk Stratification

Based on available literature, we made several a priori assumptions. We assumed that 

facilities at highest risk for hospital-acquired LD would be those with transplantation 

programs but no explicit plan for LD prevention. We also assumed that facilities at lower 

risk would have one or more of the following characteristics: periodic surveillance 

cultures of potable water, evidence to suggest routine clinical diagnostic testing, and 

potable water from a municipal system which employs treatment with monochloramine. 

Since extended care facilities routinely transfer patients with pneumonia to acute care 

hospitals, we considered minimal clinical testing to be an indication of increased risk 

only for acute care facilities. 

This review was conducted in accordance with Quality Standards for Inspections 

published by the President’s Council on Integrity and Efficiency. 

VA Office of Inspector General 4 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

Findings 

Responses were received from all facilities from which they were requested. After 

completion of survey administration, we discovered that several facilities had been 

inadvertently omitted – one teaching facility with acute and extended care components, 

and seven extended care facilities. Characteristics of responding facilities are outlined in 

Table 1. 

Facility Number

Characteristics (percent)

Distinct Facilities Surveyed

 Total 159 (100)

 Acute Care only 34 (21)

 Extended Care only 34 (21)

 Acute and Extended care 91 (57)

Number of Active Operating Beds

 <100 33 (21)

 100–200 54 (34)

 >200 72 (45)

Locale 

 Rural 32 (20)

Teaching Status 

 Teaching (COTH) 77 (48)

Source of Potable Water

 Municipal 145 (91)

 Well or Other 14 (9)

Treatment of municipal water

 Chlorine 115 (79)

 Monochloramine 30 (21)

Table 1. Characteristics of 159 surveyed facilities. 

VA Office of Inspector General 5 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

Nine hospitals reported being a site for bone marrow or solid organ transplantation. Most 

(145) of the facilities reported obtaining water from municipal systems, and of these 30 

use water treated with monochloramine. Five cases of hospital-acquired LD were 

reported from three facilities in FY 2006. The figure depicts the geographic distribution 

of facilities described in this report.

VA Office of Inspector General 6 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

Nine facilities provided evidence of an explicit plan for routinely testing pneumonia 

patients for LD, and 69 indicated that their clinicians requested urinary antigen testing for 

Legionella fewer than 10 times in FY 2006 (see Table 2). At the same time, 25 facilities 

reported that they conduct routine periodic environmental surveillance for Legionella, 12 

have specific disinfection systems in place, and almost all facilities have urinary antigen 

testing available without prior approval. 

Prevention Practices Number 

(percent) 

Facility Measures 

Routine periodic potable water cultures 25 (16) 

Specific Legionella-specific disinfection system 12 (8) 

Clinical Practices 

Urinary antigen testing available without prior approval 150 (94) 

Clinical testing results available within 24 hours 48 (30) 

Ten or more urinary antigen tests performed in FY 2006 90 (57) 

Protocol for routinely testing patients with pneumonia for LD 9 (6) 

Table 2. Legionnaire’s Disease Prevention Practices. 

We found that five of VHA’s nine hospitals which manage acute transplant patients 

lacked an explicit plan for LD prevention (Table 3). Further, none of these five facilities 

routinely test potable water for Legionella, and none derives water from a municipal 

system which uses monochloramine. Fortunately, these facilities all provide clinical 

testing without prior approval and at each there is evidence that clinicians regularly test 

patients for LD. 

Twenty medical facilities in our survey perform periodic environmental surveillance and 

show evidence that their clinicians routinely test patients for LD. In addition, 8 of these 

facilities have specific disinfection systems in place. As a group these facilities comprise 

a system-wide resource for best practices. 

As anticipated, most facilities (134, 84 percent) were found to have characteristics 

placing them at an intermediate degree of risk for hospital-acquired LD. Within this 

large group; however, it is possible to discriminate smaller numbers of facilities which 

might warrant relatively more or less attention. In particular, 18 acute care hospitals 

reported no clinic testing in FY 2006 and do not have water supplies which would place 

them at relatively low risk. These facilities may therefore be considered at somewhat 

increased risk and probably warrant focused risk mitigation efforts. On the other hand, 

an additional 18 facilities (both acute and extended care) have both monochloraminetreated municipal water and clinicians who order clinical testing for LD on a regular 

basis. These latter facilities may be considered to be at lower risk. 

VA Office of Inspector General 7 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

Legionnaire’s Disease Number

Risk Stratification (percent)

Higher Risk Facilities 5 (3)

Transplant centers with no explicit plan addressing LD prevention

Intermediate Risk Facilities 134 (84)

Acute care facilities without monochloramine-treated water and which

 reported no clinical testing for LD (probably higher risk) .... 18 (11)

Facilities with monochloramine-treated water and clinicians testing

 more frequently for LD (probably lower risk) .... 18 (11)

Lower Risk Facilities 20 (13)

Facilities performing periodic environmental surveillance and

 whose clinicians tested more frequently for LD

Table 3. Legionnaire’s Disease Risk at 159 Surveyed VHA Facilities. 

VA Office of Inspector General 8 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

Conclusion 

A relatively uncommon illness overall, Legionnaire’s Disease is an important cause of 

pneumonia among compromised hospitalized patients. Because outbreaks have been 

linked to colonization of hospital water and because risk of disease can be reduced with 

established amelioration methods, health care systems are compelled to determine at 

which facilities focused interventions are warranted. 

A carefully implemented program of periodic sampling of potable water is probably the 

most accurate way to evaluate risk to patients, but this approach remains controversial. 

In particular, despite recent evidence demonstrating the utility of surveillance cultures, 

uncertainty persists and no standard-setting organization has endorsed them. 

Nevertheless, the predictable occurrence of hospital-acquired infection and the large 

population of vulnerable hospitalized veterans warrant a strategic plan. Fortunately, an 

assessment of patient characteristics, clinician practice behavior, and the nature of 

hospital water supplies suggest that resources can be directed at a limited number of 

facilities with high-risk characteristics. 

Our review reveals a wide range of practices and of estimated risk, and several findings 

merit emphasis. 

• Five teaching facilities where transplants are performed had no explicit plan for LD 

prevention, and none conduct routine environmental surveillance. 

• Twenty facilities demonstrated management and clinical practice characteristics 

which could offer lessons for the feasibility of system-wide implementation. 

• Although most facilities were predictably considered to be at an intermediate level of 

risk, within this group a relatively small number (22 percent) could be categorized as 

being at relatively lower or higher risk. A prioritized approach to amelioration of risk 

at a system level is therefore possible. 

VA Office of Inspector General 9 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

Recommendations 

Recommendation 1. We recommend that the Under Secretary of Health take the 

required actions to ensure that inpatient facilities where bone marrow or organ transplants 

are performed have a written plan which addresses the prevention of Legionnaire’s 

Disease. 

Recommendation 2. We recommend that the Under Secretary of Health take the 

required actions to ensure that all inpatient facilities periodically assess local risk for LD 

using specific guidelines developed by VHA experts. 

Comments 

The Acting Under Secretary for Health agreed with the findings and recommendations 

and provided acceptable improvement plans. (See Appendix A, pages 10–13, for the full 

text of comments.) We will follow up on the planned actions until they are completed. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 10 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

Appendix A 

Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum

Date: May 25, 2007 

From: Acting Under Secretary for Health, Department of Veterans 

Affairs (10) 

Subject: Assessment of Legionnaire’s Disease Risk in VHA Inpatient 

Facilities, Project No.: 2007-00029-HI-0010, (WebCIMS 

379169)

To: Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report and I concur with the 

recommendations. I appreciate your acknowledgement that 

VA has taken a number of steps to reduce the risk of 

Legionnaire’s Disease (LD) in our inpatient facilities. This 

assessment will help to further prevent the risk of LD in our 

facilities. 

2. Although your evaluation appears to be primarily based on 

the web-based survey of VHA medical facilities, rather than 

in-depth analysis, your assessment emphasizes the importance 

of prevention measures at higher risk inpatient facilities, 

where bone marrow or organ transplants are performed. The 

Office of Patient Care Services will convene a work group 

within VHA to develop a written plan, guidance and 

prevention strategies for such facilities. In addition, the work 

group’s guidance will include scientific and clinical evidence, 

and recommendations that will aid each facility in 

establishing a process for periodic risk assessment and 

prevention of Legionella. Periodic assessments will help to 

maintain information on existing environmental conditions 

concerning LD in VA facilities. 

VA Office of Inspector General 11 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

3. Thank you for the opportunity to review the report. If you 

have any questions, please contact Margaret M. Seleski, 

Director, Management Review Service (10B5) at (202) 565-

7638. 

Michael J. Kussman, MD, MS, MACP 

VA Office of Inspector General 12 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

Under Secretary for Health’s Comments 

to Office of Inspector General’s Report 

The following Under Secretary for Heath’s comments are 

submitted in response to the recommendations in the Office 

of Inspector General’s report: 

OIG Recommendations

We recommend that the Under Secretary for Health, 

Department of Veterans Affairs, take the required actions to 

ensure that: 

Recommendation 1. Inpatient facilities where bone 

marrow or organ transplants are performed have a written 

plan which addresses the prevention of LD. 

Concur Target Completion Date: October 30, 2007 

The Infectious Diseases Program Office of Patient Care 

Services will convene a work group to develop guidance 

regarding Legionella. The work group will consist of 

representatives from the Office of the Deputy Under 

Secretary for Health for Operations and Management and the 

Office of Public Health and Environmental Hazards, VHA 

field experts, and field transplant units. As the transplant 

recipient population may have a higher risk of acquisition of 

Legionella infection, a component of this process will be to 

ensure that a written plan which addresses the prevention of 

Legionella infection will be generated at inpatient facilities 

where bone marrow and solid organ transplants are 

performed. This expert work group will convene by June 30, 

2007, with a draft Directive submitted for concurrence by 

August 31, 2007. We anticipate that the concurrence process 

will be completed by September 30, 2007, with subsequent 

anticipation that facilities where bone marrow and solid organ 

transplantation are performed will be given 30 days from 

publication to review the document(s) and incorporate 

appropriate components into a written plan. 

VA Office of Inspector General 13 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

Recommendation 2. All inpatient facilities periodically 

assess local risk for LD using specific guidelines developed 

by VHA experts. 

Concur Target Completion Date: November 30, 2007 

The expert work group referred to in response to 

recommendation 1 will develop recommendations and written 

guidance that will include scientific and clinical evidence that 

can be used by each facility for establishing their own process 

for periodic risk assessment and prevention of Legionella. 

The guidance to be developed will allow each facility to best 

determine how those risk assessments should be conducted 

based on the facility’s unique patient population and physical 

plant. The expert work group will complete their 

recommendations and proposed guidance no later than 

September 30, 2007, with the understanding that each facility 

will be expected to complete their first Legionella risk 

assessments within 60 days of the publication of the 

guidance. 

VA Office of Inspector General 14 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities 

Appendix B 

OIG Contact and Staff Acknowledgments 

OIG Contact Karen Moore, Associate Director 

Dallas Office of Healthcare Inspections 

(214) 253-3332 

Acknowledgments Jerome E. Herbers, Jr., M.D., Associate Director 

Medical Consultation and Review 

Marilyn Barak 

Shirley Carlile 

Linda DeLong 

Marnette Dhooghe 

Gilbert Melendez 

Rayda Nadal 

VA Office of Inspector General 15 
Assessment of Legionnaire's Disease Risk in Veterans Health Administration Inpatient Facilities

Appendix C 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Under Secretary for Health, Department of Veterans Affairs (10) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction and Veterans Affairs 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction and Veterans Affairs 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp

VA Office of Inspector General 16