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Mold that led to patients' deaths may have come from linens, UPMC report says

Darrell Sapp/Post-Gazette

Mold that led to patients' deaths may have come from linens, UPMC report says

An internal UPMC report filed Thursday in a civil lawsuit says an investigation found mold at a Clearfield County laundry facility that washes all of its 22 hospitals’ linens, including for UPMC Presbyterian and Montefiore hospitals where five transplant patients were infected with mold and later died.

The mold the investigation found at the laundry facility in DuBois, as well as in a Montefiore laundry storage area, was similar to the types that infected the patients in an outbreak that led to a federal investigation and temporary shutdown of UPMC’s solid organ transplant program in 2015.

That finding may finally offer a connection between the five patients and the mold infections that led to their deaths. The federal Centers for Disease Control and Prevention said it was unable to find a source of the mold that infected the patients when it investigated the mold outbreak in September, 2015, though it cast some blame at UPMC’s use of negative pressure rooms at the time.

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The CDC apparently never investigated the laundry facility itself during its investigation. But after being made aware of the internal report this week, a CDC spokesman said that “it’s safe to say we’ll take a look at the new report you mention and if necessary we’ll follow up with the state and” UPMC.

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UPMC had resisted releasing the internal report – which was completed in May 2016 by noted mold expert Andrew Streifel - to the attorneys for two of the patients’ families, said Brendan Lupetin, an attorney for the families of Che DuVall and David Krieg.

“I didn’t think UPMC would ever let us get this” report, Mr. Lupetin said Thursday.

He said his office only knew about it because of a tip that came in to their office that proved to be accurate that after an initial investigation in the fall of 2015, UPMC had later called back Mr. Streifel to investigate the hospital laundry and the location where it is cleaned, Paris Healthcare Linen Services in Dubois, in February, 2016.

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In response today, UPMC said in statement it posted on its blog, in part, that: “We continue to be transparent with federal and state health regulators and we shared all our findings with them.”

“Despite the lack of a definitive source, UPMC still went above and beyond state and federal recommendations in order to implement changes to protect our patients. One of the many changes includes the provision of specially treated bioburden-reduced linens to our highest risk transplant patients.”

A spokeswoman for Paris Healthcare did not return an emailed request for comment.

But in October 2015, the spokeswoman said in an emailed reply to questions: “UPMC’s Infection Prevention department visited Paris Companies. They toured the facility and tested air and surfaces. They were quite impressed with the facility and its cleanliness. They did not take any linen samples. There was no mold found.”

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UPMC would not answer any questions beyond the statement.

UPMC’s hired investigator, Mr. Streifel – who could not be reached for comment Thursday - was suspicious of the laundry from the beginning.

In an interview with the Post-Gazette in September 2015, before he was hired by UPMC to investigate the outbreak for them, Mr. Streifel said based on what he knew from initial reports about the infections the patients contract, the laundry was a possible culprit.

Because the first three patients’ infections began on the outside of their bodies, he said then, “that makes me suspicious of the laundry.”

Not only that, but 15 years before he came to Pittsburgh to investigate the Presbyterian and Montefiore mold outbreak, he had investigated an outbreak at Mercy Hospital (before UPMC owned it).

His conclusion in that investigation?

“I traced it back to dust stirred up by jack-hammering not far from the laundry area,” he said in 2015. “Laundry is usually clean when it’s done, but it can get contaminated after it is washed.”

Sean D. Hamill: shamill@post-gazette.com or 412-263-2579 or Twitter: @SeanDHamill.

First Published: January 27, 2017, 12:00 a.m.
Updated: January 27, 2017, 3:42 a.m.

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