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Outbreak Investigation: Meningitis

Posted on by CDC's Safe Healthcare Blog
Carol Bolden

One Case Sparks National Action

Imagine… A patient goes to the doctor for a routine steroid injection.   A couple weeks later, the patient feels sick – headache, fever and suddenly uncomfortable in bright light.  Within days, the patient is admitted to the local hospital’s intensive care unit.  Doctors discover that the patient has a life-threatening disease they’ve never treated before. 

The medical team immediately calls the state health department to alert them of this rare illness.  A short time later, public health is spurred into action, sparking a national investigation of tainted medication given to thousands of Americans. 

No one ever knows when the next outbreak will hit.  The keys to catching outbreaks fast are astute clinical teams, a strong state and federal public health system, and strong collaboration with a range of national and local organizations. 

Current Fungal Meningitis Investigation

CDC and the Food and Drug Administration (FDA) are investigating fungal infections among patients who received epidural steroid injections (medication injected into the spine) with contaminated medication. CDC believes that approximately 14,000 patients may have been exposed to this medication. Most patients who have become sick have developed a rare type of meningitis, fungal meningitis, which is not contagious.  As of October 22, 2012, a total of 297 cases, including 23 deaths and 3 peripheral joint infections, have been reported in 16 states. Patients who become sick  can develop symptoms including fever, new or worsening headache, sensitivity to light, stiff neck, new weakness or numbness, slurred speech, and/or increased pain, redness, and swelling at the injection site.

The medication in question came from the New England Compounding Center (NECC) in Framingham, Massachusetts. NECC has stopped all production and initiated a recall of the manufactured lots of steroid medication in question, preservative-free methylprednisolone acetate (80mg/ml), and other products.  More information.  

What’s Making People Sick?

CDC and FDA recently connected the fungus found in patients with fungus found in unopened steroid vials. The fungus Exserohilum rostratum  was present in unopened vials of a steroid medication called methylprednisolone acetate that was manufactured by NECC.  This fungus has also been found in all but two of the patients with laboratory-confirmed fungal meningitis.

CDC’s Role

Working closely with the FDA and state health departments, CDC is trying to better understand the nature of these fungal infections and how best to stop them. At the same time, experts at CDC are helping physicians understand how to approach and treat patients who may have been exposed (resources for physicians).  Our labs are hard at work analyzing samples from states, and we have sent teams of epidemiologists into states affected by the outbreak.

Important Facts

  • Those people injected in joints only are not believed to be at risk for fungal meningitis, but could be at risk for joint infection.
  • The epidural steroid medication associated with this outbreak is not the same as the epidural injections given to pregnant women during childbirth.
  • Patients who believe they might have received a contaminated medication should contact the physician who performed their procedure.
  • Patients who received a contaminated medication should seek medical attention if they have any symptoms. Symptoms may include: fever, new or worsening headache, sensitivity to light, stiff neck, new weakness or numbness in any part of the body, slurred speech, or increased pain, redness, and swelling at the injection site.  Patients might have just one or two of these symptoms, and they may take several weeks to appear.

More Information

For patients: http://www.cdc.gov/hai/outbreaks/patients/faq-meningitis-outbreak-patients.html

For clinicians: http://www.cdc.gov/hai/outbreaks/clinicians/index.html

For a list of facilities that received the contaminated medicine visit: http://www.cdc.gov/hai/outbreaks/meningitis-facilities-map.html

General information: http://www.cdc.gov/hai/outbreaks/meningitis.html

FDA Updates: http://www.fda.gov/Drugs/DrugSafety/FungalMeningitis/ucm322734.htm

Posted on by CDC's Safe Healthcare Blog

20 comments on “Outbreak Investigation: Meningitis”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    Dear Terri,

    Thank you for your comments on CDC’s Safe Healthcare Blog. Please accept our sincere apologies for our delayed response. We have received a lot of emails from patients and families and are working quickly to try to get back to people.

    We appreciate your concern for the patients affected by this outbreak. It is a tragic situation. Be assured that we are taking this outbreak with the utmost seriousness, even going so far as to engage the CDC Emergency Operations Center in order to most effectively respond to clinicians, patients, and public health officials. We appreciate your comments and recommendations and have passed them along to our clinical team, which is responsible for making recommendations and following the outbreak long-term.

    Dear Ms. DeGennaro,

    Thank you for writing to CDC’s Safe Healthcare Blog. Please accept our sincere apologies for our delayed response. We have received a lot of emails from patients and families and are working quickly to try to get back to people.

    We can certainly understand that this is a worrisome situation. First, we encourage you to determine if you were injected with a recalled product. If so, you should have an in-depth discussion with your doctor about diagnostic and treatment options. Information detailing recalled lots of steroids, symptoms of meningitis (including headache), typical timing of symptom onset, and diagnostic/treatment options can be found on this webpage: http://www.cdc.gov/hai/outbreaks/patients/faq-meningitis-outbreak-patients.html#symptoms.

    We trust you will find the answers to your questions there. If you are still concerned, please follow up with your medical team, or consider consulting an infectious disease specialist. Again, thank you for writing to CDC.

    Dear Marcia,

    Thank you for writing to CDC’s Safe Healthcare Blog. Please accept our sincere apologies for our delayed response. We have received a lot of emails from patients and families and are working quickly to try to get back to people.

    We can certainly understand that this is a worrisome situation. First, we encourage you to determine if you were injected with a recalled product. If so, you should have an in-depth discussion with your doctor about diagnostic and treatment options. Information detailing recalled lots of steroids, symptoms of meningitis (including light sensitivity), typical timing of symptom onset, and diagnostic/treatment options can be found on this webpage: http://www.cdc.gov/hai/outbreaks/patients/faq-meningitis-outbreak-patients.html#symptoms.

    We trust you will find the answers to your questions there. If you are still concerned, please follow up with your medical team, or consider consulting an infectious disease specialist. Again, thank you for writing to CDC.

    Dear Dena,

    Thank you for sharing your story on the CDC Safe Healthcare Blog. Please accept our sincere apologies for our delayed response. We have received a lot of emails from patients and families and are working quickly to try to get back to people.

    We can certainly understand that this is a worrisome situation. First, we encourage you to determine if you were injected with a recalled product. If so, you should have an in-depth discussion with your doctor about diagnostic and treatment options. Information detailing recalled lots of steroids, symptoms of meningitis, and diagnostic/treatment options can be found on this webpage: http://www.cdc.gov/hai/outbreaks/patients/faq-meningitis-outbreak-patients.html#symptoms. If you are still concerned after these discussions, you might consider consulting with an infectious disease specialist.

    Again, thank you for writing to CDC.

    Dear A.C. Rabito,

    Thank you for contacting CDC through the Safe Healthcare Blog and for your question on the difference between bacterial meningitis and fungal meningitis.

    Meningitis is a disease caused by the inflammation of the protective membranes covering the brain and spinal cord known as the meninges. The inflammation is usually caused by an infection of the fluid surrounding the brain and spinal cord.

    Meningitis may develop in response to a number of causes, usually bacteria or viruses, but meningitis can also be caused by physical injury, cancer or certain drugs.

    The five “types” of meningitis are:
    • Bacterial Meningitis
    • Viral Meningitis
    • Fungal Meningitis
    • Parasitic Meningitis
    • Non-infections Meningitis

    For more information about the different types of meningitis, please see: http://www.cdc.gov/meningitis/index.html.

    We hope your family is well.

    Dear Mr. Mullikin,

    Thank you for commenting on CDC’s Safe Healthcare Blog. Please accept our sincere apologies for our delayed response. We have received a lot of emails from patients and families and are working quickly to try to get back to people.

    We hope you are continuing to feel well and are without symptoms. We can appreciate how concerned you must be – this is a very unfortunate situation. In this outbreak, symptoms typically have appeared 1 to 4 weeks following injection, but it’s important to know that longer and shorter periods of time between injection and onset of symptoms have been reported. Although it sounds like you are continuing to feel well, you should closely watch for symptoms for several months after the injection and see a doctor if you have any of the symptoms, even if they have been previously evaluated.

    Importantly, CDC’s investigation suggests that patients are most at risk for developing fungal meningitis within the first 6 weeks (42 days) after receiving their last injection in the back (epidural or paraspinal) with contaminated steroid medication from the New England Compounding Center. CDC continues to emphasize it is important for all patients who received epidural or paraspinal infections to watch closely for symptoms of illness. Among patients who received an epidural or paraspinal injection and have no symptoms, the risk of fungal meningitis is estimated to be very low and will continue to decrease as more time elapses since their last injection. However, it’s possible that additional monitoring strategies could reduce the risk further. In an effort to help patients and physicians make decisions on how to minimize their risk, CDC has advised that clinicians consider the option of performing a lumbar puncture in patients who received their last injection with contaminated steroid within the past 6 weeks (42 days) to look for evidence of meningitis. For all patients, the best approach is to continue to watch closely for onset of symptoms for several months after the injection and seek medical care if symptoms appear.

    Please see this webpage for information about symptoms, guidance for patients and clinicians, and recent news: http://www.cdc.gov/hai/outbreaks/patients/faq-meningitis-outbreak-patients.html#symptoms.

    Dear Michele,
    Thank you for your comment on the CDC Safe Healthcare Blog. My apologies for the delay in responding to you. The Methylprednisolone Acetate (PF) involved in the meningitis outbreak is administered either in the spine or in a joint space. To find out if facilities in your area received contaminated steroids, please see this page: http://www.cdc.gov/hai/outbreaks/meningitis-facilities-map.html. CDC has worked diligently to ensure all healthcare providers have been alerted to this outbreak. If you have questions about your local healthcare facilities, please do contact them directly. Or, contact your health department.

    Dear Ms. Lopez,

    Thank you for your comment on CDC’s Safe Healthcare Blog. Please accept our sincere apologies for our delayed response. We have received a lot of emails from patients and families and are working quickly to try to get back to people.

    We understand that this is a very difficult and worrisome situation. Please review this web page http://www.cdc.gov/hai/outbreaks/meningitis-facilities-map.html to see whether the facility that administered your injection received contaminated steroids. If so, please contact your physician to discuss your potential treatment options, especially if you are having symptoms of meningitis (please see this page for symptoms: http://www.cdc.gov/hai/outbreaks/patients/faq-meningitis-outbreak-patients.html#symptoms). Also, please be aware that all products produced by NECC were recalled. No anesthetics or antiseptics associated with the steroid injections have been associated with the fungal infections.

    We hope this information is helpful to you and wish you well.

    Dear Mr. Seymour,

    Thank you for writing to us via the CDC Safe Healthcare Blog. Please accept our sincere apologies for our delayed response. We have received a lot of emails from patients and families and are working quickly to try to get back to people.

    I am very sorry to hear of your wife’s death. Patients deserve to be safe wherever they receive healthcare. This outbreak is a tragic reminder that we need to ensure that all medical procedures, devices, and medications are safe. We know that you and your wife put your faith in our healthcare system. We want to ensure there is a safety net in place to prevent tragedies like this in the future.

    We hope that you have been able to get in touch with your doctor. Unfortunately, we cannot intervene in clinician communication, however, you might consider discussing your case with your local or state department of health. Please let us know if you need a contact.

    Our most sincere wishes for healing for you and your family.

    Folks,

    I collaborate with a group of persons who have been spine injured through a variety of pathways, but all of whom have developed arachnoiditis. I am a Phd level Rehabilitation specialist, a social scientist, and parent of a young adult with arach. We want to help you.

    The expression of arach amounts to a significant turn of events that will have lifetime consequences for persons who turned to support for chronic or chronic intractable pain. This disease process will require a variety of supports – social, mental health, rehabilitation technologies. We know a great deal about this entirely predictable turn of events.

    Please, please, let us help you.

    Terri Lewis PhD
    Rehabilitation Institute
    Southern Illinois University Carbondale
    Carbondale, ILL
    931-267-3532
    tlm7291@siu.edu
    tal7291@yahoo.com

    In the 1930s a group of black Americans were inoculated with syphilis without their knowledge or consent. The inoculations were performed as an experiment to see what would happen. In 2012 14,000
    Americans who are disabled with chronic pain were inoculated with fungus without their knowledge or consent. In the inoculations with both substances, the future clinical course was unknown. For the disabled pain sufferers in 2012, at least 30 have paid with their lives, and there is no way to predict the ultimate death toll, nor the extent of severe further disability to be caused by the inoculation. It is only clear that the inoculation of fungus will cause untold death and destruction for those disabled Americans who have been targeted.
    The Federal Government, and the United States Public Health Service did little for the victims of the syphilis inoculation experiment (also known as the Tuskegee Experiment because of where it was done)until at least 75 years later. Such a delay for the victims of the fungal inoculation experiment will be woefully to little, too late.
    To date the Center for Disease Control and Prevention (CDCP) has essentially adopted a plan of “wait and see”, recommending further diagnosis only AFTER symptoms of meningitis or other focal infection have occurred. Too often we are seeing pain clinics take an “hands off” approach to follow up on the victims. Primary care doctors are too often asked to manage the patients with no concrete steps to take except to wait for the signs of meningitis.
    Syphilis can be a silent killer and if untreated lead to central nervous system can damage that is irreversible. It can be diagnosed with blood, and if needed CNS, laboratory testing. However, neurosyphilis is a late and IRREVERSIBLE effect of an underlying smoldering disease. Similarly, fungal meningitis is a late and IRREVERSIBLE effect of fungal destruction of brain tissue. Diagnosis BEFORE the onset of clinical neurologic signs is the ONLY way to prevent irreversible destruction of brain tissue. The “wait and see” approach if applied to syphilis would be considered gross medical negligence. In today’s world of high tech laboratory diagnostics, we, the undersigned, believe the “wait and see” approach to fungal inoculation will be even more damaging and even lethal than the “wait and see” approach to syphilis. We believe a more PROACTIVE approach to earliest possible diagnosis of fungal infestation of the inoculated people is desperately needed.
    Amazingly the doctors at the CDCP and infectious disease experts who have been interviewed in some news media seem “surprised” that inoculation victims who have been treated for meningitis are developing abscesses at the inoculation site, specifically epidural abscesses! They seem to have labeled them as “late complications of the meningitis!” They should not be surprise about the existence of these abscesses. A much more plausible clinical scenario it that the epidural infestation was the PRIMARY source of infection, and that the invading organism spread via the venous and sinus paths in the arachnoid layer and adjacent spaces, where it gained access by its ability to be “angio invasive” in the words of the CDCP. These channels are well known routes of communication from the lower spine and the brain. These channels are the ones that carry spinal fluid back to the brain from the flow downward in the spinal canal.
    And always keep in mind that the epidural space in these victims was inoculated with an invasive and locally destructive fungus. It destroys the very blood supply that would deliver the anti-fungal medication to the infected site. The inoculation was also accompanied by super high local doses of immune suppressing steroid that further compromises the body’s ability to effectively fight the infection. It is also known that the underlying musculoskeletal disease that causes (or at least accompanies) back pain destroys the normal anatomy of the tissues around the epidural space. It is alarming the CDCP seems to be ignoring basic clinical pathophysiology of how the spine and the body work!
    But the issue at hand is not the underlying pathophysiology, but that the people at risk are being left in the dark to simply “wait and see” while doctors seem to be dismissing potential victims who are presenting with non-specific symptoms, such as complaints of nausea, mild headache, increased back pain, fatigue, etc. They are left to suffer the sever psychologic trauma of wondering, “Will I be the next one to die? Will I be the next to get a stroke and be a vegetable even if I live?” This hands off, “wait and see” form of medicine is inhumane and unacceptable.
    We believe that you, as Surgeon General of ALL the people of the United States – including those who are among the protected class of people disabled by chronic pain and who are victims of this unprecedented experiment of what will happen as a result of this mass fungal inoculation.
    We ask, or demand, that you take the following steps regarding the immediate risk posed to victims of the mass fungal inoculation:
    1. Declare this event a Public health Emergency
    2. Establish a CLINCAL team to guide the frontline clinical diagnosis of the full extent of fungal infestation of the people who have been inoculated. The purpose will be to guide local physicians in the diagnostic steps to take, and to provide that diagnostic intervention for those victims who are unable to obtain it through normal medical channels.
    3. Establish federal funding to pay for all costs of the diagnostic efforts, including transportation and housing costs of those who need to travel distances for full and ongoing diagnostic efforts…and to pay for all treatment related costs if those arise as consequence of the inoculation.
    4. Immediately begin a program of public AND physician education about the full range of available medial diagnostic options that can be taken BEFORE the onset of very late clinical signs!
    5. We believe that such diagnostic tests should include but may not be limited to the following:
    a. Immediate serum PCR for presence of fungus, especially since to date the PCR has been the most sensitive confirmatory test used by CDCP. PCR should then be measured weekly for at least 4 weeks and then monthly for 12 months. After all serial inoculation is a risk factor for serious infection, and serial testing may be the most sensitive way to provide surveillance for active infection.
    b. Immediate imaging with the highest resolution MRI available to be done at the site of inoculation to look for infiltrated tissue or micro abscess.
    c. MR Angiogram of the inoculated area to look for vascular deformities caused by invading fungi.
    d. MRI with Contrast to look for evidence of evolution of ARACHNOIDITIS, that could create a safe harbor for fungus to lie dormant for years, as well as cause other severe symptoms and limitations in mobility.
    e. Possible use of PET scan to look for altered metabolic activity in the inoculated tissue.
    f. Transportation and housing and meals should be paid for by the Federal government for those who have to travel long distances for these tests.
    g. Collection of accessible fluids (sputum, blood, urine, feces) for future analysis as further tests are developed and knowledge of the disease progresses.
    h. Other imaging tests such as bone scan and even the old “tagged white cell scan” for detecting occult abscess formation should be utilized.
    i. Serial measurement of PCR and other tests as well as serial MRI and MRA imaging since these tests are safe and do not have the risks seen with X-Ray imaging.
    j. Measurement of Fungus Specific Antigen, chemicals that trigger immune response and that come only from fungus that is viable. Given the lack of knowledge of this disease, this test should be done serially over the next year.
    k. Testing for fungus specific antibody that would indicate the presence of the body’s immune response to fungus.
    l. Develop guidelines for CLINCIL management of people who DEVELOP positive test for Fungal Specific Antibody. We know that treatment of people who convert to positive tests in syphilis and Tuberculosis have lower risk for late devastating complications. Enough is known about this fungal invasion to believe that, out of an abundance of caution, people who convert to positive for Fungal Specific antigen or antibody will probably do better in the long run.
    m. Serial monitoring on traditional serum markers of infection and inflammation: White blood count and differential, Erythrocyte Sedimentation Rate (ESR) and C-reactive protein.
    The above tests are a minimum that should be undertaken until a better diagnostic and treatement protocol is developed. The above tests are safe and do not add any clinical risk to the victims. Failure to do the above tests does add to the risk of physical and psychologic harm to the victims. There is no evidence that the above tests will work to save lifes or limit disease effects. However, there is evidence that ignoring these tests, and continuing with the currently recommended “wait and see” approach is causing serious harm and it has done nothing to stem the slow increase in the death toll.
    This is a call to action. We ask that you take immediate steps to make at least all of the above tests available immediately to all victims of inoculation with fungal contaminated steroid. We ask that you make immediately available the diagnostic evaluations that are rightfully due to the protected class of people disabled by chronic pain who have received these potentially contaminated and deadly or disabling injections.
    We also ask that you establish an agency that is responsible for the long term monitoring and management of people who are inoculated but do not develop meningitis. As with syphilis and tuberculosis, there is the potential for late activation of fungal growth to occur years later. The current inoculation will likely affect future management in those who develop other diseases such as cancer or various autoimmune diseases. Indeed the chronic presence of fungal antigen has at least the potential to increase the risk of some autoimmune diseases. We ask that you establish an agency that will coordinate the long term monitoring of the future clinical manifestations of this tragic inoculation.

    Respectfully submitted,
    Terri Lewis
    Tal7291@yahoo.com

    My name is
    Rose Ann I received a shot on July 24 and then another nurve shot on Sept 19 two week after the shot my face got
    numbness I felt very strange trough my body now its Nov 2 and my face is still getting numbness I went to the hospital three times for pressure in my head they are saying there is nothing wrong please someone blog about this if it happened to you. I am wondering if it another symptom from this outbreak .

    I have complained to my doctors after experiencing these symptoms and they don’t take me seriously. I had 2 steriod injections. May 24 in my neck for pinched nerve and one on june 8 in my wrist for carpal tunnel. Became very ill on juy 4 and eventually blinded by the bright sun. As of now my neck feels very stiff. I was told your fine or you would be deadby now if I had it.

    I had gotten a shot Qct. 2nd and got it at Hendersonville Tn, I fainted or black out Oct 17th and fell and broke my back, prior to that my right side of my neck down into my shoulder started hurting,I had mild headace with it but the pain was really bad, I had this before I fell, I am still worried because the dr. said I didnt have it, my question is don’t you have to have a spinal tap for being tested for this, I want to know if I am safe from this and why did I pass out, they say thats not a symptom, I don’t know but it still worries me, my dr. is wanting me to have another shot, but, I am worried about this………

    what is the different from bacteria meningitis in fungal meningitis my wife has injections then got bacteria in was sick as a dog

    I would like to know whan I can stop worring about this. I had a shot june 22 that they said was the bad stuff.
    My next shot was July 13 2012 and they tell me that one was from the bad batch. I had my 3ed shot Oct 1 2012
    witch they said was good. The bad one was July 13 2012 so how much longer do I have th worrie. My shots were from Rochester Brain and Spine Rochester,N.Y

    When referring to steroid injections, are they limited to only those administered in the spine, and other joints? Is this steroid medication the same used to treat patients suffering with severe asthma, and administered I.V. or injected right into the vein? Does the steroid also include the ones that hospital use, that can be an oral liquid dose, or the same one can be administered by injection, as some hospitals use, I gather to cut costs?
    Are there any New York Area Hospitals or other facilities that have received this product or other products from NECC, but haven’t had any further cases reported? And does that include emergency personal, EMT that administers medications from NECC, have they been included in
    trying to identify providers that could have administered these drugs?

    As a healthcare consumer I am grateful to the CDC for the abundance of public information related to the tragic Meningitis outbreak. Just 2 weeks before the rash of fatalities, I received the precise procedure responsible for these deaths. By CDC calculations I received the steroid injection at the same time as those who have been injured or killed by the tainted material. My fears were immediately assuaged by the CDC’s Internet service that provided specific, state-by-state information, detailing healthcare providers which had accessed the harmful substance. The U.S. map as site locator is a tool that most anyone with Internet access could easily use. Fortunately, I found that my Anesthesiologist had not received the deadly medication. A few days later a nurse from my facility phoned to assure me that the steroid used was acquired directly from Pfizer Pharmaceuticals: clearly Pfizer was not responsible and not the focus of any CDC investigation. Worth commenting: Government regulations and agencies are vital to every American. It’s unfortunate we have a political climate that insists these agencies and employees require substantial reduction, if not complete elimination. The folks at CDC are heroes.

    I just had cervical injections n since Sept 2012 I have had three treatments.,
    In Torrance CA
    I am curious if Any medicaton might have been double brokered out to supply Los Angeles area? Or smaller compound pharmicutical areas? What about the Anestetic and or antiseptics used with these procedures? Any routine investigations on that ? What about all medications that were produced and processed or outsourced from New England CC or NECC?
    Thank you
    Concerned Patient Alejandra Lopez
    Since I get migraines its a lil hard to tell when or if I would have a symptom?
    If I take headache meds and I wouldnt get fevers but I will look out for symptoms if any. My doctors office has told me we shouldn’t worry about meds they used. But I do.

    My wife Darlene received a steroid injection on July 2, 2012, of Methylprdnisolone Acetate 40 mg. and died on July 7, 2012. Her blood pressure shot up from 135 to 197 within hours of the shot and never came down below 170. I can’t get the doctor to respond to my calls in their office. And they wonder why we end up in attorneys offices asking for answers. She had never had a blood pressure problem prior to getting the shot. I have left 3 messages at the doctor’s office to have the doctor call me but no one calls…..

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