National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion
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1 National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion
2 A Multistate Outbreak of Fungal Meningitis and Other Infections Associated with Contaminated Steroid Injections J. Todd Weber, MD Chief, Prevention and Response Branch, DHQP Incident Manager, CDC Response to Multistate Outbreak of Fungal Meningitis and Other Infections Healthcare Infection Control Practices Advisory Committee March 14 15, 2013 The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion
3 Major Outbreak Response Largest healthcare-associated infection outbreak reported in the United States Massive undertaking Response was a joint effort at CDC Division of Healthcare Quality Promotion Mycotic Diseases Branch Over 300 staff at CDC HQ Likely more than 1000 staff nationally State and local health departments Clinicians, nurses, administrative staff Collaborations State HDs, FDA, CMS, clinicians
4 Development of Clinical Guidance Engaged clinical expert mycologists with experience in fungal infections Best practices for diagnosis, treatment, and management Based on little to no data, but likely theoretical benefit Resulted in real-time development, dissemination of recommendations for patient care Able to evolve with the rapidly changing outbreak CMS CDC guidance used as the basis for modifying indications for diagnostic testing and treatment and eligibility for reimbursement
5 CDC Health Alert Network (HAN): Update: Notice to Clinicians: Continued Vigilance Urged for Fungal Infections Among Patients Who Received Contaminated Steroid Injections, March 4, 2013 Update: Multistate Outbreak of Fungal Infections among Persons Who Received Injections with Contaminated Medication, December 20, 2012 Update: Additional Contamination Identified in Medical Products from New England Compounding Center, December 3, 2012 Update: Multistate Outbreak of Fungal Meningitis and Other Infections Associated with Contaminated Steroid Medication, November 20, 2012 Contamination Identified in Additional Medical Products from New England Compounding Center, November 1, 2012 Voluntary Recall of All Ameridose Medical Products, November 1, 2012 Issuance of Guidance on Management of Asymptomatic Patients Who Received Epidural or Paraspinal Injections with Contaminated Steroid Products, October 23, 2012 Update: Multistate Outbreak of Fungal Meningitis and Joint Infections Associated with Contaminated Steroid Medications, October 17, 2012 Multistate Outbreak of Meningitis and Stroke Associated with Potentially Contaminated Steroid Medication, October 8, 2012 Meningitis and Stroke Associated with Potentially Contaminated Product, October 4, 2012
6 Laboratory Support Fungal diagnostics for CSF do not exist Novel PCR test developed in 2 days >1,000 specimens processed during outbreak Detection of fungal DNA in human body fluids and tissues during a multistate outbreak of fungal meningitis and other infections L Gade, et al., Eukaryotic Cell, 1 March 2013
7 Communications Integral component of outbreak response Website Media Publications HANs Blast s Widely lauded as best practices
8 OUTBREAK- CURRENT STATUS
9 Case Definitions Probable Case: Person who received injection with one of the 3 implicated lots of MPA from NECC and developed any of the following: Meningitis of unknown etiology following epidural or paraspinal injection Posterior circulation stroke without cardioembolic source or documentation of a normal CSF profile following epidural or paraspinal injection Osteomyelitis, abscess or other infection of unknown etiology, at or near the site of injection following epidural or paraspinal injection Osteomyelitis or worsening inflammatory arthritis of a peripheral join of unknown etiology diagnosed following joint injection Confirmed Case: Probable case with evidence (by culture, histopathology, or molecular assay) of a fungal pathogen associated with the clinical syndrome
10 Case Count as of March 11, 2013
11 Epidemic Curve as of March 4, 2013 DRAFT
12 Characteristics of Case-Patients (n=684) Characteristic Median Age 64 years (16-97 years) Sex, Female 411 (60%) State of Injection MI 238 (35%) TN 146 (21%) IN 80 (12%) Median Number of Injections 1 injection (1-6 injections) Laboratory Confirmed 190 (28%)
13 PUBLIC HEALTH IMPACT
14 Meningitis Cases Weekly 60-day CFR During the Outbreak DRAFT
15 THE FUTURE
16 The Outbreak Going Forward Cases continue to be reported (~5 / week) Long term follow up study planned to track clinical course of case-patients Possibility of case control study to address some unanswered questions: What are risk factors for infection among exposed? Why do some states/ clinics have high attack rates? Injection practice Vial life
17 THANK YOU
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