In early September, an alert healthcare worker in Tennessee discovered that her ill patient had fungus in their spinal fluid. Within a matter of days, the Centers for Disease Control (CDC) and the Food and Drug Administration (FDA) were involved, and an unprecedented public health crisis began sweeping the nation and dominating media headlines. Patients were becoming sick with fungal meningitis, an uncommon infection, people were dying, and authorities were racing against the clock to discover the outbreak’s cause and prevent additional infections and deaths.
Today, as this article is being written, the number of patients presenting symptoms and the number of fatalities has slowed significantly from the outbreak’s early stages, but no one can accurately predict when the crisis will end as the timeframe for the onset of symptoms can vary and because investigations are still ongoing. The CDC is directing healthcare providers and patients to remain vigilant in looking for symptoms of the disease in at-risk patients. These symptoms typically take one to four weeks from the time of the injection to appear, but they can appear in shorter or longer timeframes as well.
Already, more than 500 cases of fungal meningitis and nearly 40 deaths across 19 states have occurred as a result of the outbreak. Virginia has the fourth highest number of cases linked to the outbreak, with Southwest Virginia being hit particularly hard.
Gary Winfield, M.D., the Chief Medical Officer for LewisGale Regional Health System, says that the Roanoke area was highly studied by the CDC because it was one of the “hotspots” in the outbreak.
“Southwest Virginia had a high number of patients – nearly 700 people – who were exposed to the tainted steroid medication,” Dr. Winfield explains.
The CDC traced the outbreak’s origin to three lots of contaminated methylprednisolone and estimates that 14,000 patients received injections with the contaminated medication.
“New England Compounding Center (NECC), in Framingham, MA, shipped tainted medication to two facilities [in Virginia] and those facilities unknowingly injected their patients with the medication,” says Dr. Winfield.
Regionally, neither LewisGale Regional Health System nor Carilion Clinic used NECC as a supplier for the steroid medication linked to the fungal meningitis outbreak.
Jean Smith, M.D., an infectious disease physician at Carilion Clinic who sees patients at her office on Crystal Spring Avenue in Roanoke and is also an associate professor at the Virginia Tech Carilion School of Medicine, further explains the outbreak’s origins.
“The recent fungal meningitis outbreak has been associated with the injections of a compounded steroid product that has been shown to have been contaminated with fungus, and particularly shown to have a specific fungus,” Dr. Smith says. “And we believe those individuals got injections into their epidural space, which is just above the dura or lining of the spinal cord, and developed an infection in that area which extended into the meninges.” The meninges aremembranes that surround the brain and spinal cord.
In addition to Virginia, NECC’s contaminated medication was injected into patients in 18 other states. A complete list by state of healthcare providers who received and used the contaminated steroid, as well as up-to-date information, is available at www.cdc.gov.
Only patients who received the injection in their back – commonly referred to as an epidural injection and often used for pain management – of the recalled steroid medication are at risk of contracting fungal meningitis or other infections. In addition to the fungal meningitis, these patients are also at risk of developing spinal epidural abscesses and arachnoiditis as a result of receiving the contaminated steroid injections. Arachnoiditis is pain caused by swelling of the arachnoid – a membrane that surrounds the spinal cord and is one of the three meninges.
Patients who received an injection in a joint, rather than an epidural injection, with the contaminated steroid are at risk of developing a joint infection, but not necessarily fungal meningitis. The outbreak is not related to any vaccines or to the epidural injections that somewomen receive during labor and delivery, and fungal meningitis is not contagious.
What is Meningitis and How Do Fungal, Viral, and Bacterial Meningitis Differ?
“Meningitis is an inflammation of the meninges which are the lining of the brain and spinal cord,” explains Dr. Smith. “It can be due to a variety of things, including bacterial, fungal and viral infections. Everybody hears the term ‘meningitis’ and immediately thinks of meningococcal meningitis, which is bacterial meningitis and very severe with a high mortality rate and transferable from person to person.”
“Viral [meningitis] is generally self-limited and people generally get over it with no specific treatment. Fungal is much less common and can be life-threatening but it is not contagious,” Dr. Smith notes.
Both Carilion Clinic and LewisGale Regional Health System, as well as countless other healthcare providers, played an important role in helping diagnose and treat patients who had been infected. Dr. Winfield says that a lot of great work went into getting ahead of the outbreak once it was recognized and that there was great cooperation among LewisGale Regional Health System, Carilion Clinic, and the healthcare providers in Roanoke to ensure that patients were informed.
“I’m very proud of the physicians, ER, labs, pharmacy, nurses and others who worked around the clock to serve the people affected and make sure we did all we could,” Dr. Winfield says.
Despite the fear surrounding the recent outbreak, patients shouldn’t avoid obtaining necessary medical treatment – whether it’s for pain management or other symptoms – because they’re worried about another outbreak.
“This is the first time that anything like this has happened,” explains Dr. Winfield. “The history is that people have done well (with epidural steroid injections) and that is probably the best indicator. It comes down to a rare event involving contaminated products.”
At the same time, Dr. Winfield cautions patients not to ignore meningitis symptoms simply because they know they weren’t exposed to the contaminated medication.
“People that didn’t get the injection can still get meningitis,” Dr. Winfield states. “People get it every day in this state. If you have symptoms, seek treatment.”
In the case of a patient who didn’t receive the contaminated injection but still contracted meningitis, that patient would most likely have viral or bacterial meningitis as opposed to the uncommon fungal meningitis.