It started in Tennessee: one patient with an unusual recurrence of meningitis. An infectious disease specialist at Vanderbilt University worked the case like a detective, tracking down a lead. When the detective work led to an unusual suspect – a possible contamination – the Tennessee Department of Health was promptly notified. And when Tennessee public health specialists feared the contamination might be widespread, they contacted the Centers for Disease Control and Prevention (CDC). In short order, a second federal agency, the Food and Drug Administration (FDA), and most states in the eastern half of the country were working to solve a puzzling fungal meningitis outbreak that affected thousands of people.
Although the outbreak continues, much has been accomplished thus far to protect the public’s health. The contaminated medicines have been recalled, the company that produced them has been closed down, and nearly all of the people who may have been infected have been contacted. The incident serves as a front-page reminder of the critical role that public health professionals play every day.
According to ABC News, the initial diagnosis came from April Pettit, MD, an infectious disease specialist at Vanderbilt University. A patient she treated for bacterial meningitis was readmitted to her hospital. Pettit ordered more exhaustive testing, which led to a rare diagnosis: aspergillus meningitis, which is caused by a type of fungus. Pettit talked with the patient’s family members to try to discover how such an infection could have taken place.
Soon, she found a possible answer. The patient had received a steroid shot four weeks earlier to relieve back pain. Sensing there could be a connection, Pettit contacted the Tennessee Department of Health.
That contact led to Marion Kainer, MD, MPH, who is in charge of the state’s health care-associated infections prevention efforts. She confirmed the details of Pettit’s patient just as other cases in the Nashville area were popping up. Three days after Pettit’s initial contact with Kainer, the state alerted its health care network about the potential outbreak. As CDC began to accelerate its role – it had been consulted since the beginning – the FDA also became actively involved in the investigation.
On September 27, the CDC – after putting out a nationwide alert – received a report of fungal meningitis from North Carolina. As the picture became clearer, more states became involved and CDC devoted more of its personnel to the investigation.
“In terms of ratcheting up the [CDC’s] response, several things became apparent fairly early on,” J. Todd Weber, MD, the CDC’s incident manager for the response, told Research!America. “One was that this was a true outbreak, not a unique patient experience. Among the possible sources of exposure were several products that had national or near-national distribution. Our investigation made it apparent that there were many thousands of doses of what turned out to be the implicated drug. As we learned more about the outbreak with each passing day, more and more people became involved as part of their daily work here at CDC.”
Because of the urgency of the situation and the large number of people at CDC focusing on the outbreak, the agency decided early on to activate its Emergency Operations Center (EOC). While some people may think such a facility is primarily for natural disasters, Weber said the outbreak certainly qualified as a man made disaster. Indeed, the EOC had a crucial role in CDC’s response during the H1N1 pandemic and, had it existed in 2001, would’ve been used for responding to the anthrax attacks, Weber said.
The EOC diverts CDC personnel from their normal duties, so Weber said the decision to activate it is not made lightly. But because of the demands of the outbreak – such as helping states with outreach to thousands of people, pulling together needed CDC experts into a centralized location – activating the EOC early in the fungal meningitis response made sense.
“At the time we activated it, there were over 10,000 people who had been potentially exposed to this infection,” Weber said. “And there was nothing we knew at that point that didn’t suggest that all 10,000 of those people might have become ill.”
Weber noted that one of CDC’s objectives was to support the states during the response, and he believes that mission has been achieved. As an example, CDC has facilitated daily conference calls with all of the 23 states that received shipments of the contaminated steroids, resulting in discussions and exchange of current information among state officials. And CDC supported the states’ efforts to reach hospitals, clinics, professionals and patients who were affected.
The reality is that such large-scale outbreaks are thankfully rare. But CDC collaborates with health departments from across the country on a daily basis. At points during the outbreak, agency officials were in contact with all 50 states to keep them up to date on developments.
There’s still more to be done. Because fungal meningitis was so rarely seen prior to the outbreak, Weber likened it to a new disease; there is virtually no historic clinical information to rely on. CDC continues to focus on learning more about the fungal meningitis and other illnesses linked to this outbreak, and providing interim guidance on how to treat those who have been affected.
“It was all the different parts of public health that really worked here,” Weber said. “It was the front line clinicians; it was the local and state health departments who recognized what was going on; it was them having a federal resource that could reach out across states to share information and coordinate activities in a really flexible manner that made such a difference.”
“We brought together many groups at CDC, including the division responsible for healthcare-associated infections and the division with experts in fungal infections. Our fungal infections laboratory – the mycotics laboratory – [is] normally not at the center of public health attention,” he added. “But if we had not had this specialized laboratory as a resource, our response would have not been as good as it was.”
On Public Health Thank You Day, the fungal meningitis outbreak reminds us of the invaluable contributions of those professionals working behind the scenes to ensure that Americans stay safe. Even if you’ve never heard the term “mycotics,” or “healthcare-associated infections”, it’s good to know that there are people who are experts in these infectious disease threats, and that they’re looking out for us every day.
Every year we celebrate Public Health Thank You Day the Monday before Thanksgiving day. Be sure and thank your local public health professional today and every day.
Learn more here: http://www.researchamerica.org/ph_thank_you
On October 31st, the Centers for Disease Control and Prevention reported new cases of fungal meningitis in Indiana, Maryland, Michigan and Virginia, bringing the total to 368 cases in the recent outbreak. This form of meningitis, which has been linked to contaminated steroid injections, is a serious disease that infects the brain and spinal cord. In the face of this tragedy, public health agencies and professionals have coordinated an excellent emergency response to the outbreak.
The CDC responded quickly, identifying possible sources of contamination, tracking cases and communicating updates to the nation. CDC experts and local public health workers have been working day and night to alert clinics and patients that may have received the contaminated medication. Through this diligence, over 97% of patients have already been contacted and experts are now working to identify individuals at greatest risk for infection. Because meningitis can be fatal, local public health workers are saving lives through early recognition of symptoms and appropriate treatment.
Despite the critical role played by CDC and the increasing demands it faces due to congressional mandates, funding for this agency has declined in recent years. And unless policymakers change course, CDC will be swept up in dramatic, across the board budget cuts known as “sequestration.” If these cuts go into effect, they will severely compromise CDC’s capacity to protect the public health. As it stands, limited funds make it far more difficult to respond to public health emergencies like the meningitis outbreak and mean that a majority of the work falls to smaller and smaller groups of dedicated individuals. These public health heroes must be recognized for their unflagging commitment to protecting the health of Americans. The Monday of Thanksgiving, Public Health Thank You Day, is the perfect opportunity to give thanks to these individuals and others around the nation. To learn more about PHTD, please visit http://www.researchamerica.org/ph_thank_you or like our PHTD Facebook page. And to join other advocates fighting against sequestration, visit http://www.saveresearch.org.