By Tom Wilemon
| The Tennessean
It was just an email 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.
the director of health care associated infections for the Tennessee
Department of Health, started investigating the day she got that email
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.
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
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
He called the actions of the Tennessee Department of Health "a textbook case of how to do it right."
Tenn. acted early
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.
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.
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
With its longer exposure window, Michigan now has the
most cases in the nation. It had 112 as of Friday, compared to 78 in
Tennessee's work began Sept. 18,
when the state Health Department received an email 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.
Dr. April Pettit,
the Vanderbilt doctor who sent that email, got a phone call back the
same day. That email might have been ignored had it not been for
Kainer's expertise and diligence, said state epidemiologist Dr. Tim F.
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.
questioned whether the epidural might have caused her patient's
illness. Kainer recognized this single illness could be the harbinger of
"One case isn't an outbreak," said Jones. "We see oddball cases of things all the time."
did not wait to see if another report came in, but had the "innate
sense" that something was amiss. Nurses at surgery centers and hospitals
answered telephone calls fromKainer asking questions.
Her questions started the ball rolling in Tennessee, Jones said.
Tracking the victims
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.
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
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.
assisted the three surgery centers in Tennessee that used the tainted
medicines in locating 1,009 people potentially exposed.
the nightmare for our folks was tracking these people down," Jones said.
"We were phoning people in other states. We were driving to their
houses, talking to their neighbors who would tell us they were on
vacation on the other side of the country, calling someone else to get
their cellphone, talking to them and saying, 'If you are having this and
this symptom, go to the nearest emergency room.'"
Always on the job
Jarris compares public health workers to police officers and firefighters.
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."
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."
Contact Tom Wilemon at firstname.lastname@example.org or 615-726-5961.