As infectious disease doctors, we routinely care for patients with meningitis, but never have we treated a case of aspergillus meningitis, the type of fungal infection that has caused more than a dozen deaths and sickened nearly 200 people in Tennessee and other states.
Vigilance on the part of an astute physician identified the first case of fungal meningitis, and then well-trained epidemiologists at the Tennessee Department of Health discovered additional cases, identified the causative agent and alerted the Centers for Disease Control and Prevention.
This outbreak of meningitis is an opportunity for us to recognize the importance of our public health infrastructure and explore ways to further improve it.
When an infectious outbreak occurs in a health-care facility, state and federal health officials -- like crime detectives -- search for a possible culprit: a product, a procedure, or a person. In this case, the contaminated product, the methyprednisalone, a steroid injection, was the cause. The contamination likely occurred at the compounding pharmacy that distributed the medicines.
In other outbreaks, the culprit has been poor technique in a procedure or a lack of proper hand hygiene. For example, in Nevada, an endoscopy clinic reusing syringes led to the transmission of hepatitis C to eight patients and placed 50,000 patients at risk. And in Georgia, five patients developed joint infections from MRSA, an antibiotic-resistant staph bacterium, in part due to poor hand-washing among health-care staff at a primary care clinic.
Such infections are a stark reminder of the cat-and-mouse game that humans and pathogens play in our complex health-care settings. So how can we get the upper hand?
First and foremost, we need to bolster our surveillance of both rare and common diseases. For example, we need to hardwire our communication among providers and the health department through laboratory systems and electronic medical records.
Secondly, regulations and guidelines related to potential infections need to be enforced. Last year, the CDC developed a detailed checklist for both administrators and frontline personnel to prevent infections in outpatient settings, yet no one knows if the recommendations are being followed.
Lastly, transparency and public reporting of infections from hospitals and outpatient settings is necessary to reduce infection rates. For example, in 2008 after Tennessee's legislature mandated that hospital infections due to central lines (catheters that go into the patients' veins) be publicly reported, we experienced a nearly 40 percent drop in our central line infection rates in intensive care units. State legislatures around the country can demand public reporting of other health-care setting infections.
Recently, much of the upgrade at the state health departments has been possible due to the Affordable Care Act, aka Obamacare, which allocated $270 million for public health infrastructure training as well as research and tracking.
We worked with the Tennessee Department of Health, which has received part of this funding over the past two years, and believe it has undoubtedly strengthened Tennessee's infection control infrastructure and allowed for a rapid and meticulous response to this fungal meningitis outbreak. Unfortunately, such support for state health departments is often inaccurately called a "slush fund," and is at risk of being cut.
We, as infectious disease doctors and as epidemiologists, are confident that the fungal meningitis outbreak will be contained and eliminated -- yet unquestionably, other infections and potential outbreaks are lurking.
We must use this opportunity to recognize the success of our public health infrastructure, which saves countless lives every day. Ironically, we only recognize this when an outbreak occurs.
Manoj Jain MD MPH
Infectious-diseases specialist and adjunct assistant professor at the Rollins School of Public Health at Emory University
William Schaffner MD MPH
Professor and chairman of the department of preventive medicine, Vanderbilt University School of Medicine.
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