MDH Response to Fungal Meningitis Outbreak
MDH infectious disease staff race against time to notify patients of possible fungal infection from contaminated injections
In late September, the Tennessee Department of Health investigated fungal meningitis in a patient who had received epidural steroid injections at a surgical care center. This began one of the most unprecedented health events in U.S. history whereby over 14,000 patients in 23 states had received injections with a contaminated drug, methylprednisolone acetate (MPA), prepared by the New England Compounding Center (NECC), in Framingham, Massachusetts.
The MPA was contaminated with fungus and bacteria due to terrible lapses in safety and hygiene during production. NECC violated multiple federal and state laws. The Centers for Disease Control and Prevention (CDC) confirmed the predominant pathogen as Exserohilum rostratum, a plant fungus that rarely infects humans. To date, approximately 700 patients have developed meningitis, spinal infections, or joint infections with 45 of them having died of infections from the contaminated drug.
In Minnesota, one pain management clinic system had unknowingly used contaminated MPA, exposing approximately 1,000 of its patients. MPA and other steroids are often injected directly into spinal and joint spaces for relief of chronic pain. MDH staff in the Acute Disease Investigation and Control section were notified by CDC in early October on a Thursday of this affected Minnesota clinic. Recognizing that the clinic did not have enough staff to immediately notify all of the exposed patients, MDH staff from the Infectious Disease Investigation and Control Division worked Friday, through the weekend and through Monday to notify them as quickly as possible. Staff talked to patients by phone, evaluating any symptoms, and advised them to go to an emergency department or their physician if they were exhibiting certain symptoms that might indicate a fungal infection. These clinic patients were already fragile, suffering with pain, and the news they were being given was frightening. It was a dramatic race against time for MDH staff to locate and notify them, since Tennessee was reporting patients who quickly developed strokes or died within hours or days after first symptoms appeared.
In addition to contacting patients, MDH staff needed to alert the clinical community and pass on information that was being developed “on-the-fly” by CDC, including interim diagnostic and treatment guidelines. MDH also alerted other clinics about the discovery of additional contaminated medicines produced by NECC and its sister facility, warning them that they should immediately stop using the products. MDH sought and investigated disease cases, secured patient specimens for testing by the MDH Public Health Laboratory and at the CDC, ultimately finding 12 cases. Staff had to get rapidly changing information out to the public, affected patients, clinicians, laboratories, hospitals, and clinics. They kept abreast of the situation with many conference calls and webinars with CDC, other state health departments, the U.S. Food and Drug Administration, and the Minnesota Board of Pharmacy.
This was an unusual health emergency, and active participation by public health agencies was very valuable. CDC reports that there was a dramatic decrease in the 30-day case-fatality rate among meningitis patients diagnosed after the outbreak was recognized and public health action initiated. Outbreak of Fungal Meningitis infographic (CDC)
This event underscores the need for public health to be ready to respond to any emerging or novel threat, whether it is a massive failure in pharmaceutical safety, bioterrorism, or an emerging pathogen. It also shows that an adverse event occurring anywhere in the world can have major consequences to the health of Minnesotans and that extensive partnerships between public health, the medical community, media, regulators, and the public leads to successes such as this.