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Legionella discovered in water system at VA Loma Linda, testing ordered for pneumonia patients

March 9, 2025

The VA Loma Linda Healthcare System has ordered precautionary testing for all pneumonia patients following the recent discovery of Legionella bacteria at various locations within the Jerry L. Pettis Memorial Veterans’ Hospital.

In an email last week to clinical personnel, Dr. V. Franklin Sechriest II, the VA Loma Linda’s chief of staff, said Legionella was found during routine water testing.

“Until further notice, all clinical staff at the VA Loma Linda Healthcare System should remain vigilant and ensure that Legionella testing is ordered for all patients exhibiting signs and symptoms of pneumonia,” Sechriest said in the email obtained by the Southern California News Group. “It is crucial to order these clinical tests as soon as pneumonia is suspected or diagnosed to avoid delays in necessary treatment and case investigation.”

VA Loma Linda’s Water Safety Committee is initiating remediation steps to address the Legionella.

“The safety of veteran patients and employees is a top priority at Loma Linda Health Care System,” VA Loma Linda officials said in an email to the Southern California News Group. “We are addressing this situation with the utmost caution to ensure the well-being of veterans, their families and caregivers.”

Legionnaires’ disease, a severe and potentially fatal form of pneumonia caused by the Legionella bacteria, can be contracted by inhaling microscopic drops in mist or water vapor. The bacteria thrive in freshwater, but can multiply in indoor water systems such as hot tubs and air conditioners, according to the Centers for Disease Control and Prevention.

Legionella is not spread through person-to-person contact. Those at higher risk for infection are people 50 or older and those who have smoked or currently smoke, have chronic lung disease or a weakened immune system. Symptoms can include diarrhea, high fever, cough, chest pain and shortness of breath.

VA Loma Linda officials did not disclose whether any patients have tested positive for Legionnaires’ disease.

Testing report

Legionella pneumophila, the primary pathogen responsible for the majority of Legionnaires’ cases and the type of Legionella more likely to cause severe pneumonia, and non-pneumophila Legionella, which produces minor symptoms, were found in varying levels in five sinks, a shower, a backflow and two water cooling towers on Jan. 30, according to a testing report obtained by the Southern California News Group.

Non-pneumophila Legionella was detected in three samples at levels greater than or equal to 1 colony-forming unit at VA Loma Linda in two different locations, the test results state.

According to the CDC, a high level of non-pneumophila Legionella in potable water is generally considered 1 CFU or greater, meaning the sample should be considered concerning and may warrant further investigation and corrective actions.

Legionella pneumophila, the most common organism in Legionnaires’ disease, was not found in any samples above 1 CFU at VA Loma Linda.

There is no known safe level or type of Legionella, and testing alone can’t predict if people will get Legionnaires’ disease.

If Legionella is detected during quarterly inspections, advanced Legionella-specific filters are installed on impacted fixtures such as sinks, bottle fill stations, drinking fountains and showers, VA Loma Linda officials said.

“We also ensure that clear signage is placed in affected areas and that email notifications are sent to all potentially impacted individuals, advising them of the precautions in place,” the officials said.

Legionella remediation follows VA directives and includes a “full water loop” remedy for a complete, self-contained system in which water circulates through a closed circuit and “point-of-use remediation” for a localized issue, officials said.

“After implementing these measures, we conduct resampling to confirm the effectiveness of the remediation on water quality,” officials said. “We continue this testing and remediation cycle until tests confirm that the fixtures no longer test positive for Legionella, ensuring the safety and well-being of everyone at our facility.”

History of Legionella problems

VA Loma Linda has a lengthy history of grappling with Legionella.

In 2018, two VA Loma Linda doctors and six nurses filed a federal whistleblower complaint alleging officials covered up a Legionella bacteria outbreak for months. The complaint alleged the medical center did not notify its staff of the outbreak, denied it existed, failed to correct the problem and was not forthcoming with the California Department of Public Health.

“Public health investigators were told by Loma Linda VA officials that there was no Legionella exposure to report, there was no verified index case and that the water testing was negative,” the complaint stated.

A few weeks after the whistleblowers filed their complaint, federal officials converged on Pettis Memorial and collected hundreds of pages of patient records.

An ensuing federal investigation found VA Loma Linda officials concealed the Legionella discovery, posing a public health danger and possibly causing at least one doctor to contract Legionnaires’ disease.

“We found violations of Veterans Affairs and Veterans Health Administration policy, and note that a substantial and specific danger to public health and safety existed at Loma Linda,” says the November 2018 report from the U.S. Department of Veterans Affairs.

According to the report, federal investigators reviewed data from Pettis Memorial for 2017 and 2018 and found 33 positive results for Legionella, the report says.

The report acknowledges that, despite evidence in 2017 of Legionella in Pettis Memorial’s water system, VA officials did not develop an effective strategy to deal with the problem until contacted in June 2018 by the Southern California News Group.

Pettis Memorial has 162 acute-care beds and a 108-bed community living center. It is the cornerstone of the VA Loma Linda Healthcare System, which has more than 2,400 employees and 1,300 volunteers who serve more than 76,000 veterans.

One of the whistleblowers who sparked the federal investigation said last week they never drank from the medical center’s water fountains and, as a safety precaution, only consumed bottled water.

The recent water testing results are similar to others that have been sent to clinical staff from 2022 to 2025, said the whistleblower, who asked not to be identified because they are not authorized to speak about the Legionella issue.

“This type of email communication which I have received before is exactly what should have been happening back in 2016-18, when the executive leadership was not being transparent about higher figures of Legionella testing in our water system,” the whistleblower said.

Orange County Register

News Details

Legionella discovered in water system at VA Loma Linda, testing ordered for pneumonia patients

Testing report

History of Legionella problems

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