Disease detectives curbed spread of meningitis

• Information from Tennessee helped limit outbreak
• Meningitis cases on decline in Tennessee
• 29 deaths reported; 19 states affected

NASHVILLE -- It was just an e-mail about a single case of illness, but a gut instinct developed through years of disease detective work made Dr. Marion Kainer sense a bigger danger.

Kainer, the director of health care-associated infections for the Tennessee Department of Health, started investigating the day she got that e-mail and hasn't stopped since. She camped out in her office for three weeks, leading a team of state workers as they traced the source of what would become a national outbreak of fungal meningitis.

Within the first three days, they had enough evidence to alert federal officials of the burgeoning crisis. They had pain clinics removing suspect medicine from shelves before other states had even determined who had it in stock. Those actions kept the outbreak from affecting more Tennesseans.

The outbreak that they identified, linked to contaminated epidural steroid injections from a specialty pharmacy in Massachusetts, has sickened 404 people nationwide, killing 29 of them. The toll would be higher -- with a high potential for public panic -- had it not been for Tennessee, said Dr. Paul Jarris, executive director of the Association of State and Territorial Health Officials.

"By the time we learned this was a problem around the country, the information from Tennessee had already narrowed it down to what the problem was," Jarris said. "Imagine how frightening it would have been if 23 states had a meningitis outbreak and we didn't know what caused it."

He called the actions of the Tennessee Department of Health "a textbook case of how to do it right."

Tennessee cases on the decline

Although Tennessee received more contaminated medicines than other states, illnesses here are on the decline as they rise elsewhere -- a trend that could have been different with a slower response.

Michigan, for example, continued giving the tainted shots into early October, while Tennessee halted them before the end of September.

In the early stages of the outbreak, Tennessee had more cases of fungal meningitis than any other state, but by Oct. 24, Michigan had overtaken that spot.

"Even though a recall was issued at the end of September, by the time we were able to identify all the facilities in Michigan -- there were four of them -- it was the beginning of October before these injections were no longer being given," said Angela Minicuci, public information officer for the Michigan Department of Community Health. "From the beginning of last month, October, we were still giving out the injections of this steroid."

With its longer exposure window, Michigan now has the most cases in the nation. It had 112 as of Friday, compared with 78 in Tennessee.

Doctor's expertise was key

An e-mail from a Vanderbilt University Medical Center physician that a patient had tested positive for a rare form of fungal meningitis after receiving a steroid epidural at Saint Thomas Outpatient Neurosurgery Center started Tennessee's work.

The Vanderbilt doctor who sent that e-mail, Dr. April Pettit, received a phone call the same day. That e-mail might have been ignored had it not been for Kainer's expertise and diligence, said state epidemiologist Dr. Tim F. Jones.

Kainer, who has completed fellowships in infectious diseases, microbiology and clinical epidemiology, served a two-year stint with the U.S. Centers for Disease Control and Prevention.

Pettit questioned whether the epidural might have caused her patient's illness. Kainer recognized this single illness could be the harbinger of something bigger.

"One case isn't an outbreak," said Jones. "We see oddball cases of things all the time."

Kainer did not wait to see whether another report came in, but had the "innate sense" that something was amiss.

Long hours

By the time a representative of the CDC arrived in Nashville, Kainer had already identified methylprednisolone acetate from New England Compounding Center as the leading suspect in the illnesses.

Jones, who was doing field work in Ethiopia the first week of the crisis, returned to Nashville to find Kainer still sleeping on a mat in her office.

About 170 employees of the health department have worked on the crisis, Jones said, putting in such long hours that he worried about losing them to exhaustion.

"Some of our folks we practically had to to drag out and throw in their cars," Jones said.

Tennessee department among best

Jarris compares public health workers to police officers and firefighters.

"People expect the fire department and the police department to be there 24 hours a day," Jarris said. "What they don't realize is their health department is there 24 hours a day, seven days a week."

Dr. William Schaffner, a Vanderbilt professor who is president of the National Foundation for Infectious Diseases, said Tennessee's epidemiology department had a reputation as being among the best in the nation before the outbreak.

"So many of these people in the Tennessee Department of Health have had training at the CDC," Schaffner said. "They have national reputations in many areas. ... We are kind of the envy of many others."

But an irony of the job is that public health workers are largely forgotten when their behind-the-scenes work prevents outbreaks and other illnesses.

Said Jones: "You can't measure what you have prevented."