A Hybrid Strategy for Surveillance of Individuals Exposed to Potentially Contaminated Methylprednisolone Acetate – Virginia, 2012

BACKGROUND:  In the fall of 2012, the Virginia Department of Health (VDH) began investigating cases of fungal meningitis and other illnesses in patients who had received potentially contaminated preservative-free methylprednisolone acetate (MPA) steroid injections from a compounding pharmacy in Massachusetts. This product was distributed to two facilities in southwest Virginia, resulting in 680 exposed individuals. VDH and clinical partners used a unique active surveillance system to follow this exposed cohort and monitor for the onset of concerning signs and symptoms. 

METHODS: Surveillance of exposed individuals was divided between clinicians and public health; clinical partners followed individuals who entered clinical care and received a lumbar puncture (LP), while staff at local health districts (LHDs) followed patients who were not under clinical surveillance. Public health surveillance consisted of weekly phone calls to individuals from October 1^st to November 26^th, 2012 to ensure that people were aware of their exposure, to address any questions and provide them with contact information for the LHD and to assess for the development of relevant signs and symptoms and refer to care if necessary.

RESULTS: VDH and clinical partners followed up on all 680 exposed individuals. Two hospitals in southwest Virginia provided the bulk of clinical follow-up and ten LHDs conducted surveillance on exposed residents of their districts. The number of exposed residents per district ranged from one to 355 patients. All exposed individuals were contacted at least once, and the majority was contacted multiple times by the LHDs. Many individuals who were exhibiting concerning symptoms were referred to clinical care. Fifty-one of Virginia’s cases were identified during this active surveillance period, although not all entries in to clinical care can be attributed to public health follow-up.

CONCLUSIONS: During the 2012 fungal meningitis outbreak associated with steroid injections, VDH used a unique method of active surveillance to monitor individuals who had been exposed to the potentially contaminated product. The hybrid system had distinct roles for public health and clinicians in order to provide patients with the most appropriate form of follow-up. In addition to performing their normal job duties, VDH epidemiologists conducting the public health surveillance of these individuals adopted more of a case management type role as part of this follow-up than is typical during day-to-day operations. During the surveillance period, multiple patients sought clinical care, some of whom may not have done so in the absence of public health intervention.