Cuts threaten public health in wake of meningitis outbreak

None appreciate a safety net more than the one falling

By Gary Evans, Executive Editor

The history of public health has too often been told as a story of great heroism followed by benign neglect.

Beth Bell, MD, MPH

The best example in a single disease may be tuberculosis, which has resurged and been vanquished again so many times it inspired the term “the U-shaped curve of concern.” That is, as the disease declines due to public health interventions, funding for those very programs is subsequently cut. When both TB and “concern” about TB are sufficiently low, the disease invariably begins to rise again. As we previously reported in our HICprevent blog (http://ow.ly/hKg5T), a TB outbreak in Jacksonville, FL last year sounded like a report from a Third World country — 99 active cases of TB and 13 deaths in a population that was primarily homeless and in need of mental health care.

Now in the wake of last year’s inspired response from public health officers and clinicians to the massive national outbreak of fungal meningitis, we are reminded that we may be less lucky next time if budget cuts for these very programs continue. In particular, state and local health departments have lost more than 45,000 jobs and eliminated many important programs and services since 2008, the Centers for Disease Control and Prevention reports in a recently published summary of the outbreak.1

“Things are really stretched thin — public health has suffered a lot of critical losses over the last few years,” says Beth Bell, MD, MPH, lead author of the paper and director of the CDC National Center for Emerging and Zoonotic Infectious Diseases. “It is something I think people don’t recognize and sort of take for granted until something happens. This is something that we really do have to pay attention to and make sure that we don’t slip into a situation where the nation is not protected.”

The state budget cuts have resulted in greater reliance on CDC’s funding to state and local health departments to support core infectious disease programs. The country could ultimately lose its frontline defense of highly trained epidemiology and laboratory experts capable of detecting and responding to infectious threats, Bell warns.

“We really are dangerously close to not being able to do what we need to do,” she says.

In other words, the next outbreak due to some contaminated product, a new emerging infection or even a bioterrorist attack could spread rapidly and cause more infections if such programs continue to see eroding infrastructure and declining staff due to funding cuts. The meningitis outbreak showed the inherent value of such programs — wherein clinicians, infection preventionists and public health epidemiologists form partnerships and frequently communicate. “This was a picture of the power of public health,” Bell says. “We don’t like to overdramatize our work, but this showed we are saving lives. It also really does illustrate this point of the importance of doctors working in communities, so we all have to stay well connected.“

Largest fungal outbreak on record

Linked to injections of contaminated methylprednisolone acetate prepared by the New England Compounding Center (NECC) in Framingham, MA, the outbreak included 693 cases and 45 deaths as of January 28, 2013. That makes it the largest health care–associated fungal outbreak reported in U.S. history.

Cases are still being investigated and follow-up continues, as the outbreak diminishes down to “a very long tail,” says Marion Kainer, MD, director of the Healthcare Associated Infections & Antimicrobial Resistance Program at the Tennessee Department of Health in Nashville.

One of the key investigators in the case, Kainer worked with local epidemiologists and infection preventionists to track down the source and instigate the critical product recall after being alerted to the index case by an astute clinician at Vanderbilt University. Kainer and colleagues essentially solved the mysterious outbreak over 18 long days in September and October, prompting a national recall of NECC products.

“If the recall hadn’t happened the supplies that facilities still had on hand would have continued to be used,” Kainer say. “There was a lot still out there.”

Laboratory scientists at CDC identified the pathogen causing illness as Exserohilum rostratum, a fungal organism that rarely infects humans. Moreover, in just two days they developed assays to detect it in cerebrospinal fluid. In baseball parlance, it is fair to say the CDC has a deep bench.

“We have laboratory scientists that have worked for decades in this area of mycology,” Bell says. “Granted, this is an organism that almost never infects people, but these laboratory scientists know so much about fungi in general and about molds — and this exserohilum is a black mold — they were able to put all of this into context and move very quickly.”

The CDC subsequently convened an expert fungal panel to develop diagnostic and management guidance that was updated through the outbreak.

“This was very helpful to clinicians, many of whom have never treated fungal meningitis before. That guidance without a doubt saved a lot of lives,” Kainer said. “Of the 33 Tennessee patients who sought medical care before October 3, nine (27%) died. Of the 48 patients who sought medical care on or after October 3 — when the first CDC treatment guidance was issued — four (8%) died. We were identifying patients a lot earlier, so they were treated a whole lot earlier and they were given the appropriate treatment.”

The CDC underscored such findings, noting that the 30-day case-fatality rate among patients with meningitis — which reached the 50% level early on — fell sharply after the etiology of the infection was identified and a treatment protocol issued.

“In the weeks before the outbreak was detected, people clearly didn’t know what they were dealing with and patients had a very high likelihood of dying,” Bell says. “Once we were able to identify [the pathogen] and get the word out to people, get the product off the shelves — even though the number of cases diagnosed went up sharply, those patients were not dying.”

Follow-up a matter of life and death

But it wasn’t as easy as making a few phone calls. Public health officials like Kainer were working against the clock, knowing they had to rapidly notify potentially exposed patients before the infection progressed. She concedes she may have gotten one to three hours sleep – at the health department — some of those nights.

“In Tennessee we had over 1,000 people exposed and we did massive outreach with the health department partnering with the clinics,” she says. “We didn’t consider leaving a voice mail message a contact. Contact meant that people were spoken to face-to-face or on the telephone. If we couldn’t get them that way we sent out public health nurses to knock on doors, speak to neighbors. We traced one person to literally a tour operator at Yellowstone National Park.”

The effort was crucial because the onset of symptoms was surprisingly mild in many cases.

“These patients would not normally seek medical care and the clinicians at that time would certainly not even think about meningitis,” Kainer says. “Even though they may have complained of headache and fever and neck stiffness, only a very small portion actually had any objective signs of meningitis. I think only around 8% actually had fever.”

Thus it was highly unlikely that clinicians would do a lumbar puncture to detect the etiology of infection, nor were they going to be starting an empiric regimen of antifungal medication.

“It was really important to find these people out there, bring them in and make sure that clinicians had a very low threshold for performing lumbar punctures,” Kainer says.

Many lives were saved, but some of those infected early on — when clinicians were dealing with the virtually unseen scenario of infection from a rare fungus in cerebral spinal fluid – died without even knowing what had caused their infection.

“There were just devastating stories,” Kainer says. “Early on most of our patients who died had strokes involving the brain stem. Some had hemorrhages because they would have aneurysms.”

Many of the patients were elderly, partly explaining why they would be seeking pain relief from back pain in the form of a spinal injection.

“Their renal function was not that great to start with, and then you are giving them medications that are nephrotoxic,” Kainer says. “They definitely suffered. A lot of the patients are still on antifungal treatment [that may continue for six to 12 months.]”

Kainer’s program in Tennessee is a state-of-the-art collaborative between public health and clinicians, so it was no accident that the out-break was solved there. However, the program is dependent on federal and state funds that are not immune to budget cuts.

“We are concerned about reductions in funding,” she says. “We have invested tremendous resources in building up our infrastructure for health care associated infections in terms of training and the expertise the staff has developed on HAIs. We want to see that go on.”

Indeed, the program could probably easily justify its existence through reductions in costly HAIs involving multidrug resistant organism (MDROs) and Clostridium difficile.

“The investment in the HAI program means you are building up these relationships,” Kainer says. “I think one of the things we need to look at very carefully — especially in the control of C. diff and MDROs — are interventions across the spectrum of healthcare. We are looking at long term care, long term acute care, dialysis facilities as well as acute care hospitals. If we only focus our attention on one of these [sectors] we will never control MDROs or C. diff. You have to have a community approach across the health care spectrum.”

In doing so, you also end up with a safety net against emerging infections. Tennessee is one of 10 states that work with the CDC as members of its Emerging Infections Program. “The listeria cantaloupe outbreak last year was another situation in which one of our emerging infections program states — Colorado — played a similar role and sounded the alarm,” Bell says. “It is sort of an early warning system, which once again really saved lives.”

Thus the CDC is taking the unusual step of reminding all who will listen that such outbreak response relies on programs and infrastructure that could whither into ineffectiveness if funds are not forthcoming.

“The system did work this time, but the system is not as healthy as we would like it to be,” Bell says.

Thanks to public health programs in Tennessee and other states, the CDC was eventually able to identify some 14,000 potentially exposed patients in 23 states in the meningitis outbreak. CDC then served as the hub for guiding the response, activating its emergency operation center on Oct. 3, 2012.

“We had hundreds of people working on the response out of the emergency operation center,” Bell says. “We were essentially operating 24/7 and people were working all the time to get various jobs done. We activated that same emergency operation center during the [2009 H1N1] pandemic.”

Reference

  1. Bell BP, Khabbaz RF. Responding to the Outbreak of Invasive Fungal Infections: The Value of Public Health to Americans JAMA. 2013;1-2. doi:10.1001/jama.2013.526. http://jama.jamanetwork.com/article.aspx?articleid=1567243