Meningitis Outbreak Spreading

Federal health officials say the death toll in an outbreak of meningitis has risen to seven, with more than 60 people sickened in nine states. The outbreak has been been linked to a steroid used in epidural injections to control back pain.

Ohio and Minnesota reported their first cases Saturday, joining Michigan, Tennessee, Virginia, Indiana, Florida, Maryland and North Carolina on the list of impacted states.

Meningitis is an inflammation of the spinal cord, usually caused by bacteria or viruses.

The steroid — methylprednisolone acetate – has been recalled by its manufacturer, the New England Compounding Center in Framingham, Massachusetts.  Federal inspectors found fungus in an unopened vial during an inspection at the company’s plant. Tests are underway to determine the exact type of fungus and if it is related to the meningitis outbreak.

The Centers for Disease Control and Prevention says 75 pain clinics in 23 states are known to have received shipments of methylprednisolone acetate from the pharmacy. The CDC and the Food and Drug Administration are advising doctors to avoid all products made by the company.

A CDC map of pain clinics in 23 states that received a recalled steroid suspected in the meningitis outbreak.

Meanwhile, the American Academy of Pain Medicine released a statement urging anyone who has been treated with spinal injections for back pain within the last four weeks to contact their doctor if they have symptoms such as a fever, headache, nausea or neurological problems.

“We urge patients who have received these treatments to err on the side of caution if they have new or worsening symptoms since their injection.  They should contact the medical expert, health clinic or hospital where they received their injection, even if the symptoms are very mild in nature,” said Dr. Martin Grabois, President of the Academy

This form of meningitis is not contagious and does not appear related to the spinal procedure involved. However, the outbreak is bringing new attention to epidural steroid injections, which are increasingly being used to control back pain. Critics say spinal injections are too often performed by untrained personnel and in unsanitary conditions that can lead to complications.

This week two medical associations, the American Society of Interventional Pain Physicians (ASIPP) and the North American Neuromodulation Society, announced their opposition to plans by Medicare & Medicaid Services (CMS) to allow nurse anesthetists to receive coverage for epidural steroid injections and other interventional treatments for chronic pain.

“This disregard to the education, board certifications, and training of medical physicians will be detrimental to patients, causing undue hardship and putting an increased financial burden on the healthcare system as poor results proliferate,” said Dr. Laxmaiah Manchikanti, chair and CEO of the ASIPP. “CMS is in essence saying that it doesn’t matter who performs these treatments - ‘no training required.'”

Manchikanti said nurses should not be allowed to diagnose complex conditions, order expensive tests or provide complex treatment for a field of medicine in which they have no formal training.

Authored by: Pat Anson, Editor

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It is disturbing that CMS and the government in general support the dumbing-down of medicine by allowing personnel with abbreviated training to practice on patients in the misguided effort to “improve access” to care. In some cases, such as with a nurse anesthetist instead of an anesthesiologist, there is absolutely no cost savings to the government as payor, as they pay the same amount whether a service is provided by an anesthesiologist (who is an MD or a DO) alone, an anesthesia nurse/crna alone, or an anesthesia nurse/crna supervised by an anesthesiologist; in the latter case, the payment is split 50-50 between nurse and doctor. I think the article above nicely addresses the absurdity of equating qualifications of physician extenders with their abbreviated training with those of fully trained physicians.

That said, I do NOT know of any evidence that implicates blocks being done by nurses in this recent fungal meningitis outbreak. Rather, it to be related to conditions at the place of manufacture of the steroid medications used. This does, however, also seem likely to be a symptom of misguided efforts to cut costs by using a less-regulated (and likely therefore lower-cost) purveyor of injectable medications.

The government is also promoting the use of nurse practitioners and physician assistants as equivalent to physicians in other areas, notably primary care. I think this is all very short-sighted, and fueled largely by the lobbying efforts of physician extenders.

Rebecca Roberts

It does matter who preforms these injections. In my opinion it should only be done by neurologist or anesthesiologist. These two professions are familiar with the nervous system and the spine. Not anyone can do these injections, I have had them before from an ortho. I ended up with a very painful spinal cord disease, called Arachnoiditis b/c of this..The ESI’s I had were also done without xray. How do they know where they are sticking that needle? Especially when the spinal area is full of scar tissue. The comment from CMS really scares me, this way of thinking. There should be adequate training in this area of pain management..