The Value of Public Health to America – Responding to the Outbreak of Fungal Infections
Centers for Disease Control and Prevention (CDC) sent this bulletin at 01/31/2013 03:10 PM ESTThe ongoing outbreak of fungal meningitis and other infections has highlighted the importance of a strong public health infrastructure. Being able to rapidly respond to this widespread outbreak helped save lives and prevent additional illness among thousands of exposed patients. A CDC article about the outbreak response and the impact of public health was published today in the Journal of the American Medical Association, read more here: http://jama.jamanetwork.com/article.aspx?articleid=1567243
ONLINE FIRST Responding to the Outbreak of Invasive Fungal InfectionsThe Value of Public Health to Americans FREE ONLINE FIRST
Published online January 30, 2013
The outbreak of invasive fungal infections among patients who received injections of contaminated methylprednisolone acetate prepared by the New England Compounding Center (in Framingham, Massachusetts) is a disturbing tragedy, already the largest health care–associated fungal outbreak reported in the United States, with 693 cases and 45 deaths reported as of January 28, 2013.1 Effectively responding to this catastrophic event required rapid actions by clinical and public health practitioners who worked to ensure discontinued use of the suspect medication, notify at-risk patients and their physicians, and decipher the many unknowns about the outbreak to provide the best guidance for minimizing harm.
In the United States, public health is a distributed system, with critical responsibilities at local, state, and federal levels. The fungal infections outbreak underscores the pivotal detection and response roles of state health departments, working with local clinical and public health colleagues. In this outbreak, the Tennessee Department of Health (TDOH) sounded the alarm based on a telephone call from an alert clinician treating a patient with an unusual form of meningitis.2 The clinician had not only asked about a broad range of possible patient exposures, but also recognized the potential public health implications and knew to contact the health department. This well-established linkage reflects long-term efforts of the TDOH to establish partnerships and work collaboratively with clinicians, hospitals, and other health care facilities to implement measures to reduce health care–associated infections.
With information rapidly communicated from the TDOH, the Centers for Disease Control and Prevention (CDC) reached out to state and local health departments and took collective action. Within days, the source of the outbreak was identified and a massive effort was undertaken to identify and contact the nearly 14 000 potentially exposed patients and their physicians across 23 states.3 State and local health departments remained in close contact with treating physicians, reporting surveillance and other information to CDC in near real time to help validate and improve interim guidance. CDC served as a hub for characterizing and sharing clinical information and experiences, repeatedly convening leading mycology experts and treating physicians to ensure the quality and effectiveness of evolving diagnostic and treatment guidance.
Laboratory scientists at CDC confirmed the predominant pathogen-causing illness as Exserohilum rostratum, a fungal organism rarely infecting humans, and in just 2 days developed assays for its detection in cerebrospinal fluid. CDC laboratories also assisted the US Food and Drug Administration (FDA) by identifying the specific organisms found in the contaminated medication vials and mobilized surge capacity to support state health department and clinical laboratories, rapidly testing more than 800 specimens from 26 states. Longer-term investments in training proved important as well: using expertise gained through earlier CDC training, the Virginia Department of Health laboratory was the first to identify Exserohilum, which had been cultured from an autopsy specimen.
The potential extent and severity of the outbreak and the many unknowns surrounding the unusual infections demanded rapid, broad, and frequent communications. CDC sent regular updates to more than 240 clinical and professional organizations; held clinician conference calls including more than 5000 participants; partnered with Medscape to release a clinical video,4 which was viewed nearly 40 000 times; and released multiple health advisories through its Health Alert Network. CDC's meningitis and fungal infections outbreak web pages were accessed more than 1 million times.
Public health preparedness is vital for detecting and responding to emerging infections. In this outbreak, effective implementation of its essential components—from detection of the cluster, to identification of the rare pathogen, then to rapid implementation of multiple response components—yielded clear results, including a dramatic decrease in the 30-day case-fatality rate among patients with meningitis diagnosed after the outbreak was recognized and public health action initiated (Figure). Beyond highlighting issues surrounding safe compounding practices, the outbreak also reminds us that despite our prevention efforts everyday systems malfunction and cause harm, new infections emerge, and unforeseen illnesses arise. Other recent examples of complex disease outbreaks in the United States include listeriosis from cantaloupes and other new vehicles of food-borne disease transmission, pandemic influenza originating in the Western hemisphere, a resurgence of West Nile virus infections, outbreaks of pertussis and other vaccine-preventable diseases, and outbreaks of highly resistant organisms in health care settings. Although such events cannot be fully predicted, they should be expected, and effective responses to routine health events strengthen our ability to prevent, detect, and respond to the unusual.
Figure. Meningitis Cases and 30-Day Case-Fatality Rate by Week of Diagnosis (August 13–December 23, 2012)
Each 30-day case-fatality rate is calculated for patients diagnosed during the corresponding week. TDOH indicates Tennessee Department of Health; NECC, New England Compounding Center; CDC, Centers for Disease Control and Prevention; FDA, US Food and Drug Administration.
Despite the strength of the response, the outbreak also exposed vulnerabilities in the nation's public health systems. Since 2008, state and local health departments have lost more than 45 000 jobs and eliminated many important programs and services.5- 6 These reductions have resulted in even greater reliance on CDC's funding to state and local health departments to support core infectious disease program functions.7 The country could lose its frontline defense of highly trained, flexible epidemiology and laboratory experts capable of effectively detecting and responding to infectious threats.
There is also a need to modernize public health systems at all levels with the best available technologies. Public health has yet to benefit adequately from advances in information technology and molecular technologies, from electronic health records to rapid genetic sequencing of pathogens and enhanced bioinformatics capacities. As the use of culture-independent diagnostic tests expands in the clinical sector, laboratory-based surveillance systems that rely on cultures must be transformed to ensure their continued ability to detect and prevent clusters of illness. Further, public health needs to reach more broadly in its efforts to reduce infectious diseases and protect health—building and strengthening relationships with partners such as clinical networks, insurance companies and other payers, the media, industry, and consumer groups.
From the first recognition of signs pointing to a potential outbreak, hundreds of public- and private-sector workers across health care, public health, industry, and academia joined forces to reduce the number of serious illnesses and deaths. Each public health event brings lessons and opportunities to improve future responses. Clearly, an important lesson from this outbreak is the critical need for strong and sustained public health systems engaged with their many essential partners.
AUTHOR INFORMATION
Published Online: January 30, 2013. doi:10.1001/jama.2013.526
Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Additional Contributions: We gratefully acknowledge Robin Moseley, MAT, Office of Infectious Diseases, CDC, for her editorial assistance in preparation of the manuscript. She did not receive compensation for her contribution.
REFERENCES
Multistate fungal meningitis outbreak: current case count. Centers for Disease Control and Prevention. http://www.cdc.gov/HAI/outbreaks/meningitis-map.html#casecount_table. Accessed January 28, 2013
Kainer MA, Reagan DR, Nguyen DB, et al; Tennessee Fungal Meningitis Investigation Team. Fungal infections associated with contaminated methylprednisolone in Tennessee. N Engl J Med. 2012;367(23):2194-2203
PubMed | Link to Article
PubMed | Link to Article
Smith RM, Schaefer MK, Kainer MA, et al. Fungal infections associated with contaminated methylprednisolone injections: preliminary report [published online December 19, 2012]. N Engl J Meddoi: 10.1056/NEJMoa1213978
PubMed
PubMed
Multistate fungal meningitis outbreak investigation: clinician guidance. Centers for Disease Control and Prevention. http://www.cdc.gov/hai/outbreaks/clinicians/index.html. Accessed January 22, 2013
Budget cuts continue to affect the health of Americans: update August 2012. Association of State and Territorial Health Officials. http://www.astho.org/Research/Data-and-Analysis/ASTHO-Budget-Cuts-Impact-Research-Brief-Update-(August-2012)/. Accessed January 17, 2013
Local health department job losses and program cuts: findings from the January 2012 survey [research brief]: May 2012. National Association of County and City Health Officials. http://www.naccho.org/topics/infrastructure/lhdbudget/upload/Research-Brief-Final.pdf. Accessed January 17, 2013
The CDC and public health response to the 2012 fungal meningitis and other infections outbreak: statement of Beth Bell, MD, MPH: testimony before the Health, Education, Labor and Pensions Committee, US Senate, November 15, 2012. http://www.cdc.gov/washington/testimony/pdf/testimony_20121115.pdf. Accessed January 17, 2013
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