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Ex-state health director dismissed need to alert CDC early in Legionnaires’ outbreak that eventually killed a dozen people

The audit of the state’s handling of Legionnaire’s cases at the Civil War-era home found that Shah dismissed the need for having the CDC visit the facility on the eighth day of the outbreak that began Aug. 21, 2015. In an email at the time, Shah said he didn’t “think it’s necessary right now” despite two deaths and dozens of illnesses already having occurred, the audit found.

The audit said that by the time Shah relented to have the CDC called in, the agency didn’t arrive on site until the outbreak’s 12th day. By then, seven people had died and 37 others had become ill.

Auditor General Frank Mautino’s review also found that the nursing staff was given limited notification on procedures to protect residents and staff until six days into the outbreak and said there was no documentation that staff provided additional monitoring of patients susceptible to or exhibiting potential illness from Legionella bacteria.

According to the audit, on the outbreak’s fifth day, veterans home officials wrote an email to staff saying: “I want to reassure all staff that if we truly felt there was an issue with Legionella we would not put the Residents or Staff at risk. I ask that you please not panic and do not discuss this with the residents. The last thing we need is for the residents to get worried and upset.”


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