Liz Szabo, USA TODAY
The number of people sickened by a nation-wide meningitis outbreak has grown to 47 patients in seven states, health officials said Friday, but potentially hundreds more could be affected.
The number of deaths - five - has remained the same. Tennessee, Virginia, Maryland, Florida, North Carolina and Indiana had previously reported cases. On Friday, Michigan joined the list, with four cases.
The outbreak of fungal meningitis has been tied to steroid shots used to treat back pain. The steroid was custom-made by a specialty pharmacy in Massachusetts, New England Compounding Center. The Centers for Disease Control and Prevention on Friday also published the names of clinics that received the injections on its website.
"All patients who may have received these medications need to be tracked down immediately,"said Benjamin Park, medical officer, at the CDC's mycotic diseases branch. "It is possible that if patients with infection are identified soon and put on appropriate antifungal therapy, lives may be saved."
Infected patients have developed a variety of symptoms, which have set in one to four weeks after their injections. These include fever, a new or worsening headache, nausea and problems similar to those seen in a stroke.
CDC officials say anyone who had an epidural injection since July should contact a doctor if they have these symptoms, and also if they have a stiff neck, sensitivity to light, slurred speech or newly developed weakness in any part of the body.
Health inspectors found fungus in at least one sealed vial of the steroid at the company's facility, according to the Food and Drug Administration.
The Massachusetts pharmacy has voluntarily shut down. The company has recalled the steroid which was sent to clinics in 23 states. The government urged doctors not to use any of the company's products.
Impact on medical care
The outbreak is already interrupting medical care for some patients.
Anders Cohen, chief of neurosurgery and spine surgery at the Brooklyn Hospital Center in New York, says he advises patients in pain to wait until the CDC's investigation is completed before getting steroid injections.
Steroid injections are an "extremely common" treatment for lower back pain, such as sciatica caused by a herniated disk, says William Blau, a professor of anesthesiology at the University of North Carolina's School of Medicine. "I'm guessing there are hundreds or thousands every day," Blau says.
Steroids decrease inflammation, which can ease pain.
Injections are a good alternative to narcotics for people with chronic pain, because they are very safe, effective and pose no risk of addiction, Blau says. The risk of complications is a fraction of 1%, he says. "We give about three injections a day, and we're just one clinic," says Blau, who says people with long-term pain may need two or three injections a year.
Epidural steroid injections are administered somewhat like the epidural pain relievers given to many women in labor, injected at the base of the spine near the spinal fluid, Blau says. Women in labor, however, receive continuous pain relief through a catheter, rather than a one-time steroid shot.
In some ways, epidurals have advantages over taking steroid pills. Because they're shot directly into the spinal area, they tend to cause fewer side effects than oral medications, which circulate throughout the body. Some of the main side effects from long-term steroid use are immune suppression and a worsening of osteoporosis, which can increase the risk of bone fractures, Blau says.
The tainted steroids "are such a potential health hazard for patients because the medication is site specific, delivered to the spinal canal, and nerves in the spinal cord," Cohen says. Patients who choose to skip epidural medications for now "can ask their physicians about other alternatives such as oral pain medications. I've received calls from several patients, including one who came into the office to check his lot number. I advise patients to call their physicians to make sure their lots are cleared."
Cohen says the outbreak highlights stress in the pharmaceutical industry, which sometimes can't produce enough of certain medications.
Companies who can't keep up with demand may turn to compounding pharmacies, which make their own medications from basic ingredients.
"Due to the high demand of certain medications, pharmaceutical companies are outsourcing production, which sometimes leads to problems, because compounders are not under the same stringent regulatory guidelines as the pharmaceutical companies," Cohen says.
Tennessee has been hit the hardest in the meningitis outbreak. The number of Tennesseans affected has risen from 25 to 29, John Dreyzehner, the state's commissioner of health, said Friday.
Aspergillus fungus at center of outbreak
The fungus blamed for the outbreak, Aspergillus, is very common and found in leaf mold, says William Schaffner, an infectious disease expert at the Vanderbilt University School of Medicine in Nashville.
The fungus floats in the air, indoors and outdoors - and only very rarely makes people sick.
People inhale Aspergillus fungus spores all the time without any problem. It's nearly impossible to avoid, because it is found in such places as decaying leaves, trees, grain, soil, household dust, heating ducts and building materials. The fungus can also cause skin infections if it enters a break in the skin.
It's being blamed for meningitis that occurred after a steroid contaminated with it was injected into the spinal column of some patients. That provides a rapid way for the fungus to cause a serious infection. It's not clear how the fungus got into the medication.
Usually, after somebody inhales Aspergillus spores, they're destroyed by the body. But people with cystic fibrosis or asthma may have problems with it, wheezing and coughing. A more severe infection can arise in people with weakened immune systems, like those with HIV, the virus that causes AID; those who've had transplant surgery; or patients getting chemotherapy for cancer. This invasive infection can cause fever, chest pain and shortness of breath.
It's hard to tell exactly how common Aspergillus infections are, but one study suggests it may affect just one or two people per 100,000 every year.
Contributing: The Associated Press, The (Nashville) Tennessean