Investigation of Fungal Infections Associated with Contaminated Steroid Injections, A State Perspective, New Jersey 2012

BACKGROUND: In September 2012, the New Jersey Department of Health (NJDOH) was notified of 6 facilities that received 1443 vials of contaminated methylprednisolone acetate (MPA) from the New England Compounding Company (NECC), associated with fungal infections.  To manage the scope of this outbreak, NJDOH formed an outbreak investigation team and initiated the Incident Command Structure (ICS) with section leads (ie clinical, surveillance, logistics) to manage identification of persons potentially exposed to MPA and to perform surveillance for associated infections.

METHODS: NJDOH reached out to facilities that received MPA along with local health departments (LHDs) and epidemiologists. Facilities were asked to account for all vials of MPA received, and to identify and notify exposed patients with assistance of LHDs. NJDOH provided line-lists, data-collection templates and talking points to facilitate notification, symptom assessment, and patient tracking.  NJDOH provided written guidance and hosted conference calls to address patient follow-up, case identification, and Centers for Disease Control and Prevention (CDC) recommendations. Clinical records were reviewed and symptomatic patients classified using the CDC case definitions. The NJ Communicable Disease Reporting and Surveillance System (CDRSS) was adapted to track exposed patients seeking medical care and to facilitate LHD, NJDOH and providers to review real-time data. Clinical specimens on case-patients were sent to CDC for testing.

RESULTS: Within NJ, 705 people were potentially exposed to contaminated MPA, which included additional patients identified well into the investigation, resulting in further patient notifications and case identification.  Among those exposed, 46 cases were identified; 35 cases with meningitis, 6 cases with meningitis plus abscess/osteomyelitis, and 5 cases with abscess/osteomyelitis only. Six (13%) cases were laboratory confirmed. Four patients were injected with product after the September 26, 2012 recall date.

CONCLUSIONS: Initiating ICS greatly assisted the public health response of this multi-faceted investigation.  Another success included adaptation of CDRSS facilitating the tracking of patient information from various sources.  However, the investigation into cases relied heavily on private-healthcare partners and several challenges were encountered.  One facility had difficulty reconciling vials received, removing the product, and identifying all those exposed which resulted in administration of contaminated product after the recall date and late identification of exposed patients.  Additional challenges included timely communication with providers regarding changing clinical recommendations, the ability of public health to ensure the adequacy of symptom assessment by facility staff, difficulty in ensuring timely access to skilled care for all symptomatic patients, and differing interpretation of clinical information among public health and private partners.