CDC Update Of Fungal Meningitis Cases

 

# 6717

 

The CDC - which now issues updates on Mondays, Wednesday, and Friday - indicates that 23 new cases of fungal infection from contaminated steroids have been identified since last Friday’s report (Monday was a Federal Holiday).

 

*451 cases of fungal meningitis, stroke due to presumed fungal meningitis, or other central nervous system-related infection meeting the outbreak case definition, plus 10 peripheral joint infections (e.g., knee, hip, shoulder, elbow). No deaths have been associated with peripheral joint infections.

 

The bulk of these newly identified cases (20) are listed as coming from Michigan, although no details are given.  A quick check of the Michigan Department of Health’s website still shows case counts current as of November 9th.

 

As of November 9, 2012, Michigan's case count associated with the Centers for Disease Control and Prevention multi-state meningitis investigation is 128 total cases and eight deaths [64 cases of meningitis, eight deaths*, 57 epidural abscess, one stroke and six joint infections].

 

Since these reports don’t tell us the date of onset of symptoms, we really can’t tell how many of these cases are `new’ in the past couple of weeks, and how many are older, but just now being identified. 

 

The assumption is that no contaminated steroids were administered to patients after the recall notice was announced in late September.

 

The danger of developing meningitis is believed greatest during the first six weeks after injection, so there is some hope that the number of new cases will begin to decline soon.

 

We’ve also seen reports of epidural abscesses and arachnoiditis among some of these patients. These are localized pockets of fungal infection that are slow to grow, difficult to identify, and even more difficult to treat.

 

The CDC updated their Frequently Asked Questions for Clinicians late last week, with the following information.

Epidural Abscess and Arachnoiditis

There have been media reports of spinal epidural abscesses and arachnoiditis among patients who received treatment for meningitis. What are these conditions and their symptoms?

CDC has received preliminary reports of spinal epidural abscesses and arachnoiditis occurring among a portion of patients undergoing treatment for fungal meningitis due to this outbreak. CDC does not know at this time how many patients developed these disorders or why they occurred.  Both conditions are rare but serious disorders in the general population that require prompt medical attention. 

• A spinal epidural abscess is characterized by inflammation and a collection of pus around the spine. Spinal epidural abscesses sometimes result in swelling in the affected area (e.g., near the site where contaminated steroid mediation was injected).
  • Common symptoms can include fever, headache, back pain, and neurological problems (e.g., weakness, unusual changes in sensation)
• Arachnoiditis is a disorder caused by the inflammation of the arachnoid, one of the membranes that surrounds and protects the nerves of the spinal cord. The condition can be caused by irritation from chemicals, infection, or direct injury to the spine.
  • Symptoms can include numbness, tingling, and a characteristic stinging and burning pain in the lower back or legs.  Some people with arachnoiditis may have debilitating muscle cramps, twitches, or spasms.  The condition may also affect the bladder, bowel, and sexual function.  In severe cases, arachnoiditis may cause paralysis of the lower limbs. 
  • For more information about arachnoiditis, see the National Institute of Neurological Disorders and Stroke’s website.

 

The emergence of these new syndromes linked to fungal tainted steroid injections adds yet another level of uncertainty for those who are waiting to see if they will develop symptoms.

 

And finally, the head of the embattled pharmacy that created and distributed these steroid products appeared before a congressional committee today, but declined to testify.   This from the Boston Globe.

 

 

Pharmacy head pleads Fifth at meningitis outbreak hearing

WASHINGTON Barry Cadden, the owner and director of the specialty pharmacy tied to deadly fungal meningitis outbreak declined to testify Wednesday morning before a congressional committee investigating the matter.

»» Read More

CDC HAN Advisory: Additional NECC Products Found Contaminated

# 6690

 

 

Last night the CDC – as part of their investigation into the multistate fungal meningitis outbreak linked to contaminated steroid products distributed by the New England Compounding Center (NECC) -  issued a pair of HAN Advisories. 

 

• The first, is a notification that two additional products produced by NECC (betamethasone and cardioplegia solution) have tested positive for bacterial contamination.  
• The second advisory is essentially a HAN version of the FDA’s announcement on Wednesday of a total recall of all Ameridose products.  Ameridose is a a sister company to NECC.

 

The CDC’s Health Alert Network (HAN) is designed to ensure that communities, agencies, health care professionals, and the general public are able to receive timely information on important public health issues.

 

You can sign up for HAN messages, and scores of other CDC and HHS email notifications, by going to the CDC - Quick Subscribe GovDelivery page

 

There are 4 types of HAN releases, starting from the highest priority to the lowest.

 

• Health Alert - Conveys the highest level of importance; warrants immediate action or attention.
• Health Advisory - Provides important information for a specific incident or situation; may not require immediate action.
• Health Update - Provides updated information regarding an incident or situation; unlikely to require immediate action.
• Info Service -Provides general information that is not necessarily considered to be of an emergent nature.

 

Yesterday, the CDC also updated the number of confirmed infections due to these contaminated pharmaceuticals, which now total 377 cases of fungal meningitis, and 9 peripheral joint infections.

 

 

 

The following are excerpts from last night’s HAN Advisory on NECC contamination issues.

 

Contamination Identified in Additional Medical Products from New England Compounding Center

Summary: As part of the ongoing investigation of the multistate outbreak of fungal meningitis and other infections, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) continue to test medical products from the New England Compounding Center (NECC) in Framingham, Mass.

NECC is the firm that distributed and recalled injectable steroid medications implicated in the current outbreak of fungal meningitis and other infections. CDC and FDA are reporting today that product testing has identified bacterial contamination with several Bacillus species and closely related bacterial organisms in unopened vials of betamethasone and cardioplegia solution that were distributed and later recalled by NECC on October 6, 2012. These bacteria are commonly found in the environment and have been rarely reported as a cause of human disease; it is not known how product contamination with these species might affect patients.

Although clinical infection is possible, CDC has not received reports of laboratory-confirmed cases of infection due to Bacillus or closely related organisms linked to these products. CDC’s recommendations to healthcare providers for diagnosing and treating symptomatic patients who have received NECC products have not changed as a result of these findings. Additional microbial organisms may be identified in recalled NECC products as additional laboratory testing is completed.

<SNIP>

As part of the ongoing investigation, FDA and CDC have been testing various NECC products for evidence of contamination. Laboratory testing at CDC and FDA has found multiple species of Bacillus and closely related bacterial organisms in unopened vials of betamethasone and cardioplegia solution, as shown in the table below.

Medication
Lot number
Microbial contamination

Betamethasone
08202012@141
Paenibacillus pabuli/amolyticus, Bacillus idriensis, Bacillus flexus, Bacillus simplex, Lysinibacillus sp.

Betamethasone
07032012@22
Bacillus niabensis, Bacillus circulans

Betamethasone
07302012@52
Bacillus lentus, Bacillus circulans

Cardioplegia solution
09242012@55
Bacillus halmapalus, Brevibacillus choshinensis

Other cultures for these products, including fungal cultures, are pending.

Recommendations to Healthcare Providers
CDC and FDA have previously advised that healthcare professionals should cease use of any product produced by NECC. On October 15, FDA issued a MedWatch Safety Alert advising clinicians to follow-up with patients who received any injectable NECC product, including betamethasone or cardioplegia solution purchased from or distributed by NECC after May 21, 2012. Clinicians were also requested to report any suspected adverse events following use of these products to FDA's MedWatch program.

 

CDC continues to investigate reports of potential infections in patients receiving other NECC products. As of November 1, CDC has received no reports of confirmed infections resulting from injection of any NECC product except those from the three recalled lots of preservative-free methylprednisolone acetate.^[1]

 

CDC’s recommendations to healthcare providers for diagnosing and treating symptomatic patients who have received NECC products have not changed as a result of these findings. CDC continues to recommend routine laboratory and microbiologic tests, including bacterial and fungal cultures, deemed necessary by treating clinicians.

 

These bacteria have been rarely reported as a cause of human disease. Nevertheless, clinicians should consider these product findings when reviewing laboratory results from patients who have been exposed to a NECC product, since Bacillus and related bacteria are often considered in clinical results to be possible skin contaminants. Physicians should continue to report infections potentially related to NECC products to FDA’s MedWatch and to state health departments.

---

1. NECC lots of methylprednisolone acetate (PF) 80mg/ml:

• Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #05212012@68, BUD 11/17/2012
• Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #06292012@26, BUD 12/26/2012
• Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #08102012@51, BUD 2/6/2013

»» Read More

CDC: Update On Fungal Meningitis Outbreak – Oct 10th

 

 

# 6623

 

We’ve updated numbers from the CDC this afternoon on the cases of meningitis across the country linked to potentially contaminated injectable steroids, along with an updated Q&A sheet for patients and revised case definitions for clinicians.

 

 

While the numbers continue to climb, it is important to note that this type of meningitis is not contagious. All of these cases received an epidural injection from a potentially contaminated steroid.

 

 

I’ve only excerpted the opening of the FAQ page for Patients below, follow the link to read it in its entirety.

 

Frequently Asked Questions For Patients: Multistate Meningitis Outbreak Investigation

October 10, 2012 12:45 PM EDT

About the Outbreak

Background
The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) are currently coordinating a multistate investigation of fungal meningitis among patients who received an epidural steroid injection with a potentially contaminated product. Several of these patients also suffered strokes that are believed to have resulted from their infection.

 

How many cases have been reported?
Updates about the investigation, including case counts, are available at http://www.cdc.gov/hai/outbreaks/meningitis.html.

 

Is the source of the outbreak known?
CDC is investigating medications and products that are associated with this outbreak of meningitis. At this point, the original source of the outbreak has not been determined. However, injectable steroid medication has been linked to the outbreak. The lots of medication that were given to patients have been recalled by the manufacturer.

 

The type of epidural medication given to patients affected by this outbreak is not the same type of medication as that given to women during childbirth.

(Continue . . . .)

 

Of interest primarily to clinicians, here is a link to the updated case definitions.

 

Multistate Outbreak of Meningitis Associated with Injection of Potentially Contaminated Steroid Products

 

 

And finally, a report from Maggie Fox of NBC News on the growing controversies surrounding compounding pharmacies.

 

Compounding pharmacies -- heroes or outlaws?

By Maggie Fox, NBC News

A single compounding pharmacy, one that mixes up drugs to order, appears to be the source of contamination that has killed 12 people and made more than 100 sick with a rare form of fungal meningitis. Some consumer advocates want the Food and Drug Administration to crack down harder on such pharmacies, but the legal battle for regulate them has been long and convoluted.

(Continue . . . )

»» Read More

HPA Updates The Stoke-On-Trent Legionella Outbreak

 

Legionella Bacteria - Photo Credit CDC PHIL

# 6450

 

Yesterday Crof reported on the UK: Legionnaires' disease outbreak in Stoke-on-Trent that involved 7 patients hailing from that city in Staffordshire, England.

 

Today, we’ve an update from the HPA indicates that two more cases have been identified, and that early microbiology testing is consistent with there being an (as yet, unidentified) common source.

 

 

3.00pm update on Legionnaires' disease in Stoke-on-Trent

25 July 2012

Two further case of Legionnaires' disease have been confirmed in the Stoke-on-Trent outbreak bringing the total number of cases to nine. All those affected are between their late 40s and mid 70s and are being treated at University Hospital of North Staffordshire. The Health Protection Agency (HPA) is also investigating two cases identified in early summer as being possibly linked to the current cluster.

 

Professor Harsh Duggal, Director of the Health Protection Unit in Stafford, said: “Early microbiology typing results back from the HPA laboratories show that samples taken from some of the patients look very similar so far and this is consistent with the cases having caught their infection from the same environmental source. We are taking detailed histories of the movements of the patients to see if there are similar patterns which would indicate a local source of infection.

(Continue . . . )

 

 

While an infectious pneumonia, Legionella is not a contagious disease.  It is transmitted environmentally, usually through water.

 

Legionella got it’s name after it was identified as the bacterial cause of a large pneumonia outbreak at Philadelphia’s Bellevue Stratford Hotel during an American Legion convention in 1976.

 

During this outbreak, 221 people were treated and 34 died.

 

We now know Legionella to be a major cause of infectious pneumonia, and that it can sometimes spark large outbreaks of illness.  According to the CDC between 8,000 and 18,000 Americans are hospitalized with Legionnaire's Disease each year, although many more milder cases likely occur.

 

For more information on the disease, the CDC maintains a fact sheet at Patient Facts: Learn More about Legionnaires' disease.

The bacteria thrives in warm water, such as is often found in air-conditioning cooling towers, hot tubs, and even ornamental water fountains. Improper maintenance or poor design can lead to the bacteria blooming.

 

When water is sprayed into the air the bacteria can become airborne, and if inhaled by a susceptible host, can cause a serious (and sometimes fatal) form of pneumonia.

 

While large outbreaks of Legionella are often traced to specific causes, quite often the source of the infection for sporadic cases remains a mystery.  

 

Today’s HPA announcement stresses that these cases are not hospital acquired, and that the authorities are working to identify the source.

»» Read More

That Duck May Look Clean, But . . .

 

 

# 6410

 

The CDC is investigating an outbreak of Salmonella Montevideo involving 66 persons across 20 states linked to the handling of live poultry (baby chicks or ducklings or both) sold via mail-order hatcheries and  agricultural feed stores.

 

You may recall that similar warnings have gone out in the past regarding Human Salmonella Infections Linked to Small Turtles.   Like turtles, poultry can sometimes carry and spread the salmonella bacteria, which makes good hand hygiene particularly important after touching these birds. 

 

In this case, the CDC’s investigation has traced the infected birds to a Hatchery in Springfield, Missouri.  You can read the details at:

 

 

Multistate Outbreak of Human Salmonella Montevideo Infections Linked to Live Poultry

Highlights

• Read the Advice to Consumers »
• A total of 66 persons infected with the outbreak strain of Salmonella Montevideo have been reported from 20 states.
  • The number of ill persons identified in each state is as follows: Alaska (1), California (2), Colorado (1), Georgia (1), Illinois (1), Indiana (8), Iowa (2), Kansas (10), Kentucky (1), Massachusetts (1), Missouri (22), Nebraska (5), Nevada (1), New York (1), North Carolina (1), Ohio (1), Oklahoma (4), South Dakota (1), Vermont (1), and Wyoming (1).
  • 16 ill persons have been hospitalized.  One death was reported in Missouri, but Salmonella infection was not considered a contributing factor in this person’s death.
  • 35% of ill persons are children 10 years of age or younger.
• Epidemiologic, laboratory, and traceback findings have linked this outbreak of human Salmonella infections to contact with chicks, ducklings, and other live baby poultry from Estes Hatchery in Springfield, Missouri.
• Mail-order hatcheries, agricultural feed stores, and others that sell or display chicks, ducklings, and other live poultry should provide health-related information  [PDF - 1 page] to owners and potential purchasers of these birds prior to the point of purchase. This should include information about the risk of acquiring a Salmonella infection from contact with live poultry.

 

 

There are over 2,500 serotypes of Salmonella, and . Salmonella Montevideo ranks among the 10 most common strains.  According to the CDC, the Clinical Features/Signs and Symptoms of infection are:

 

Most persons infected with Salmonella develop diarrhea, fever, and abdominal cramps 12-72 hours after infection. Infection is usually diagnosed by culture of a stool sample. The illness usually lasts from 4 to 7 days. Although most people recover without treatment, severe infections may occur. Infants, elderly persons, and those with weakened immune systems are more likely than others to develop severe illness. When severe infection occurs, Salmonella may spread from the intestines to the bloodstream and then to other body sites and can cause death unless the person is treated promptly with antibiotics.

 

 

For more  information about Salmonella, you may wish to check out the CDC’s Salmonella FAQ.

»» Read More

More Tales From The Crypto

 

 

# 6375

 

 

A little more than a week ago, in Tales From The Crypto, I wrote about an HPA (Health Protection Agency) investigation into an unusually large number of gastrointestinal illnesses being reported across England due to the Cryptosporidium parasite, or as it is commonly called, “Crypto”.

 

Over the past 7 days another 60 people have been diagnosed with this (generally) waterborne illness from the four regions of the North East, Yorkshire, West Midlands and East Midlands, bringing the total since early May to 327 (compared to 82 during the same period in 2011).

 

While still elevated above normal, the number of new cases over the past week is less than was seen during the previous two weeks, and not all of these may be attributed to this outbreak.

 

It is too soon to know if this outbreak has peaked.

 

The source of infection has yet to be identified. Local water authorities reassure that there is no evidence of contamination of the public water supply.

 

While generally thought of a waterborne illness, Crypto may be found in soil, food, water, or on surfaces that have been contaminated with the feces from infected humans or animals.

 

Photo Credit CDC PHIL

 

Here is the latest Health Protection Agency update on the Crypto outbreak, followed by some prevention advice from the CDC.

 

Update 8 June: Increase in cases of cryptosporidiosis

8 June 2012

The Health Protection Agency (HPA) continues to lead a multi-agency investigation to determine whether recent cases of cryptosporidiosis are linked to a common source.

 

The English regions most affected by the increase in cases continue to be the North East, Yorkshire, West Midlands and East Midlands. An additional 60 cases of cryptosporidiosis have been confirmed across the four regions between 01 June and 07 June 2012, taking the total number of cases confirmed in these regions since 11 May 2012 to 327. This compares to 82 cases of the infection confirmed across the four regions within the same period the previous year (11 May 2011 to 07 June 2011).

 

Most people affected had a mild to moderate form of illness and the HPA is not aware that any cases reported in the past week (since 1 June) have been hospitalised.

 

So far investigations have not identified a likely source of infection. The Drinking Water Inspectorate has confirmed that there is currently no evidence that public water supplies are implicated.

 

Cryptosporidiosis is caused by an organism called Cryptosporidium, which is found in soil, food, water or surfaces that have been contaminated with infected human or animal droppings. People can become infected by consuming contaminated water or food, by swimming in contaminated water, for example in lakes or rivers, or through contact with infected animals. The most common symptom is diarrhoea, which can range from mild to severe.

 

Dr Stephen Morton, who is leading the investigation for the HPA, said: “The latest figures show that the sudden upturn in cases seen in May 2012 has not continued into the first week of June. The majority of cases became ill between 11 and 18 May. Whilst the increase is higher than we might expect at this time of year, it is not unusual to see an increase in cryptosporidiosis cases in the early summer and not all of the cases reported since 11 May are likely to be linked.

(Continue . . . )

 

Crypto infections occur around the globe, and according to an EID Journal study published last year, there are estimated to be nearly 750,000 Crypto infections in the United States each year (see Foodborne Illness Acquired in the United States—Major Pathogens).

 

For most healthy individuals, a Crypto infection is an unpleasant, but not life threatening illness.  The most common symptoms (which generally last 1 to 2 weeks) are:

 

• Watery Diarrhea
• Stomach cramps or pain
• Dehydration
• Nausea
• Vomiting
• Fever
• Weight loss

 

Although rarely fatal in healthy individuals, `Crypto’ can be deadly for the very young, the very old, and those with compromised immune systems.

 

 

All of which makes prevention key.  The CDC gives the following advice to reduce exposure to Crypto.

 

Practice Good Hygiene

Everywhere

• Wash hands with soap and water for at least 20 seconds, rubbing hands together vigorously and scrubbing all surfaces:
  • Before preparing or eating food
  • After using the toilet
  • After changing diapers or cleaning up a child who has used the toilet
  • Before and after tending to someone who is ill with diarrhea
  • After handling an animal or animal waste

At child care facilities

• To reduce the risk of disease transmission, children with diarrhea should be excluded from child care settings until the diarrhea has stopped.

At recreational water venues (pools, interactive fountains, lakes, ocean)

• Protect others by not swimming if you are experiencing diarrhea (this is essential for children in diapers). If diagnosed with cryptosporidiosis, do not swim for at least 2 weeks after diarrhea stops.
• Shower before entering the water.
• Wash children thoroughly (especially their bottoms) with soap and water after they use the toilet or their diapers are changed and before they enter the water.
• Take children on frequent bathroom breaks and check their diapers often.
• Change diapers in the bathroom, not at the poolside.

Around animals

• Minimize contact with the feces of all animals, particularly young animals.
• When cleaning up animal feces, wear disposable gloves, and always wash hands when finished.
• Wash hands after any contact with animals or their living areas.

Outside

• Wash hands after gardening, even if wearing gloves.

»» Read More

Uganda Outbreak Identified As Plague: Officials

 

 

UPDATED:  This story has been updated, and the diagnosis remains in doubt.   See OCHA: The Ugandan Outbreak By The Numbers

# 5123

 

After more than a month of speculation by local health officials and the media, we are seeing reports that officials have tentatively identified the outbreak of disease in the northern Ugandan district of Kitgum as pneumonic plague.

 

Previous blog entries on this outbreak include:

Updating Uganda’s Mystery Outbreak

Uganda: Unidentified Hemorrhagic Outbreak

 

 

A link to the Reuters report (h/t Shiloh on FluTrackers):

 

Pneumonic plague outbreak in Uganda: officials

 

Tue Dec 7, 2010 10:19am EST

KAMPALA (Reuters) - Pneumonic plague has broken out in northern Uganda, killing 38 people and putting dozens in hospital, a senior health official said Tuesday.

(Continue . . . )

 

 

Treyfish, posting on this FluTrackers thread, has another report from the Newvision website.

 

Mysterious Acholi disease is plague

By Conan Businge
and Chris Ocowun

PLAGUE, a disease that affects rodents but can be spread to humans and other animals by infected fleas, has hit the northern Ugandan district of Kitgum, the health ministry has confirmed.

(Continue . . .)

 

 

Although few people are aware of it, plague cases still occur and claim lives every year around the world. Even on rare occasions, in the United States.

 

In 1975, after completing my paramedic training in Florida, I was offered an ALS (Advance Life Support) ambulance job in Phoenix, Arizona.

 

On my first day there, I was given an orientation, which included information about threats I hadn't dealt with in my home state of Florida: Scorpion stings, Gila Monster bites, and bubonic plague.

 

This map, from the CDC, shows areas of the world where plague is endemic, mostly in rodents.

 

 

The last major urban outbreak of plague in the United States occurred in 1924-25 in Los Angeles.  Since then, only scattered cases have been reported, with about 10-15 cases each year.

 

Worldwide, on average, anywhere between 1,000 and 3,000 cases are reported each year.

 

Bubonic Plague (Yersinia Pestis) is a bacterial infection transmitted by fleas, carried by infected rats.   The infection generally sets up in the lymphatic system, resulting in the tell-tale buboes, or swollen lymph glands in the the groin, armpits, and neck.

 

In rare cases, however, Pneumonic Plague may develop.  Here the infected person develops a severe pneumonia, with coughing and hemoptysis (coughing up of blood), and may spread the disease from human-to-human.

 

Luckily modern antibiotics are pretty good at treating bubonic plague. Without treatment, however, mortality rates run 40%-60%.  Untreated, pneumonic plague is almost always fatal.

 

In 1994, the last big plague year, 5000 suspected cases of bubonic plague and pneumonic plague occurred in Surat, India, with 100 deaths. 

»» Read More