1. 2012 Fungal Meningitis Outbreak Associated With
Contaminated Steroid Injections
Dr. Joan Duwve
Chief Medical Officer
Indiana State Department of Health
April 12, 2013

2. Outbreak Identified
Sept 18: TN receives alert of fungal meningitis/stroke case following ESI.
Sept 20: Methylprednisolone acetate (MPA) from New England Compounding Center identified;
Sept. 26: NECC recalls 3 lots of MPA and distributes list of clinics receiving product to CDC.
Sept 28: CDC notifies IN of six clinics receiving NECC MPA (1,502 patients)

3. Outbreak Unfolds
Oct 1: ISDH notifies clinics, provides CDC talking points to notify patients; CDC begins daily conference calls, case counts
Oct 3: NECC recalls all MPA lots
Oct 4: First Indiana case identified; press release issued
Oct. 6: NECC recalls all products

4. ISDH Response Clinic notification/assessment
Case investigation/reporting
Advising clinicians
Messaging and media
Laboratory testing
Participating in calls
Requesting CDC Epi-Aid team

5. CDC Case Definition Meningitis: mild symptoms
Posterior circulation stroke
Joint infections
Localized injection site infections
Epidural abscess
Osteomyelitis
Arachnoiditis/discitis
Stress atypical, mild symptoms of meningitis—slightly more than normal, especially difficult to distinguish in chronic pain patients

6. and parameningeal infections in the spine (1b)
Illustrations of location and approaches of epidural injection (1a) and location of CNS
and parameningeal infections in the spine (1b)
CDC

7. Thecal Sac with phlegmon
Operative Findings
Thecal Sac with phlegmon
This is an intraoperative image from a patient with a similar presentation, showing a thecal sac with visible phlegmon
Photo credit: St. Joseph Mercy Health Systems CDC 7

12. 11 Total 4 Out of State Date range from October 2012 to January 2013
Indiana Deaths
11 Total
4 Out of State
Date range from October 2012 to January 2013

13. Exserohilum rostratum
Main outbreak organism
Found in soil and plants
Warm, humid climates
Rarely causes infection
Sinusitis
Skin
Eye
Endocarditis
Osteomyelitis
Those at greatest risk are immunocompromised.
Photo courtesy of CDC

14. Challenges Rapidly evolving situation
CDC case definition evolved with Outbreak
Unique, little known clinical course
Clinical guidelines were unknown
Harsh treatment regimens
Uncertain disease progression

15. National Total - 730 cases with 51 deaths
As of 3/28/13

16. National Data As 3/4/13

18. Team Work Hospitals, IPs and ID Physician CDC ISDH and LHD CLINIC
Patient
Hospitals, IPs and
ID Physician
CDC
ISDH
and
LHD
CLINIC

19. Chief Medical Officer, ISDH jduwve@isdh.in.gov Tina Feaster, MS
Joan Duwve, MD MPH
Chief Medical Officer, ISDH
Tina Feaster, MS
Invasive Disease Epidemiologist, ISDH
Jean Svendsen, RN BS
Chief Nurse Consultant, ISDH