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Meningitis Outbreak Grows

The number of people sickened by a nationwide meningitis outbreak has risen to at least 91 patients in nine states, with seven deaths, health officials said Sunday, and potentially hundreds more could be affected.

Tennessee, Virginia, Maryland, Florida, North Carolina and Indiana had previously reported cases. This weekend, Michigan, Minnesota and Ohio joined the list. Tennessee has been hardest hit, with 32 cases and three deaths.

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 Framingham, Mass., New England Compounding Center, and recalled Sept. 26.

The Centers for Disease Control and Prevention website lists the names of about 75 clinics in 23 states that received the injections. Nearly 17,700 vials of the steroids were shipped.

The CDC said Sunday that "Clinicians should actively contact patients" who received potentially contaminated injections starting May 21, 2012.

"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 anti-fungal therapy, lives may be saved."

The pharmacy on Saturday announced a voluntary recall of all of its products
as a precautionary measure. It said there is no indication that any other products have been contaminated. The pharmacy has voluntarily shut down. The Food and Drug Administration had previously told health professionals not to use any products distributed by the center.

This type of meningitis is not contagious and can't be spread from person to person, Park said.

Meningitis is an inflammation of the lining of the brain and spinal cord. 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 said that anyone who had an epidural injection since May 21 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. At a press conference last week, officials said they found foreign material in other products as well, but had not yet had time to test what that material was.

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, said 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, said 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," he said.

Steroids decrease inflammation, which can ease pain. Injections are a mainstay of pain management, used for decades. They're a good alternative to narcotics for people with chronic pain, because they are very safe, effective and pose no risk of addiction, said David Zvara, chair of anesthesiology at UNC-Chapel Hill.

The risk of complications is a fraction of 1%, Blau said. "We give about three
injections a day, and we're just one clinic," said Blau, who added that people with
long-term pain may need two or three injections a year.

Steroid injections "dramatically and immediately decrease inflammation around irritated nerve roots," Zvara said. "Getting an injection like this hastens the healing process and can mean the difference between several lost days of work with back pain and returning to normal functioning within a day or two for many people."

Pain specialists can help people decide if an injection is the best therapy, Zvara said. "In most cases, an irritated nerve root will heal on its own over several days or weeks, he said. "The steroid injection hastens this process dramatically. For some, back pain can be debilitating resulting in lost work and suffering. Seeing a physician and potentially receiving a steroid injection in conjunction with other analgesics and muscle relaxants can be enormously beneficial. Importantly, patients must determine if the back pain is due to a surgical problem such as a herniated disc or a tumor as the steroid injection may reduce some of the discomfort, but it will not reverse the underlying cause."

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 said. 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

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 said. 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 said the outbreak highlights stress in the pharmaceutical industry,
which sometimes can't produce enough of certain medications.

Companies that 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 said.

The fungus blamed for the outbreak, Aspergillus, is very common and found in leaf
mold, according to 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

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 AIDS; 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 and The (Nashville) Tennessean