Centers for Disease Control and Prevention

The two molds that have caused meningitis in 203 people and killed 15 of them. Left is Aspergillus; on the right is Exserohilum

More than 200 people in 14 states have either died or shown symptoms in an outbreak of rare fungal meningitis linked to contaminated pain injections, federal health officials said Sunday. Fifteen people have died.

The Centers for Disease Control and Prevention said 203 people had meningitis, while two had infections in their joints.

The CDC has also published its first case report of the outbreak, which began when a Tennessee doctor diagnosed a patient with fungal meningitis on Sept. 18, nearly six weeks after getting a steroid injection for back pain.

The CDC says 26 of the patients have a confirmed fungal infection, and all but one are infected with a type of black mold called Exserohilum. It’s never been known to cause meningitis before, although it’s common in the environment and can cause sinus and eye infections. One patient has Aspergillus, another fungus that occasionally can cause meningitis if injected into the spine, as well as other infections.

Both grow slowly and don’t cause the classic symptoms of meningitis. “Early in this outbreak, many patients with meningitis had only a few mild symptoms,” the CDC and state health offficials say in their report.

Worse, treatment can last months and requires infusions of two strong antifungal drugs, the CDC says. Right now, no one knows how long patients will have to be treated, and the drugs themselves can cause severe side effects such as kidney damage. As many as 14,000 patients may have been given the tainted steroids.

“Early identification and treatment of patients with fungal infections might reduce the risk for serious complications, such as stroke or death,” CDC says.

Meningitis is an inflammation of the spinal cord or the membrane surrounding the brain. It's extremely serious when caused by bacteria; viruses can also cause meningitis. Fungi and parasites cause it more rarely. Most of the patients in this outbreak have complained of headaches.

"FDA urges patients who believe they received an injection or other product compounded by NECC to remain vigilant for the signs and symptoms of infection, including meningitis. The signs and symptoms of meningitis include fever, headache, stiff neck, nausea and vomiting, photophobia (sensitivity to light) and altered mental status," the Food and Drug Administration said in a statement.

State and federal health officials are trying to find out how and why a Massachusetts pharmacy, the New England Compounding Center, managed to distribute so many vials of the steroid, called methylprednisolone. It can be injected into the spine or joints such as the knee or ankle to treat pain.

Massachusetts state health authorities say it appears NECC broke regulations in distributing the high volume of drugs. All of the cases so far have been linked to three affected batches of the steroid, although all of NECC’s products have been recalled.

A sister company, Ameridose, is also being investigated. "Based on the business relationship between NECC and Ameridose, FDA and the Massachusetts Board of Pharmacy launched a joint inspection at the Ameridose facility in Westborough, Massachusetts on October 10, 2012," the FDA said in a statement.

"As part of our efforts to protect the public health, FDA is investigating whether certain aspects of compounding practices and facility conditions observed at NECC may be present at the Ameridose facility. FDA will review whether Ameridose has procedures and facilities necessary to safely produce and provide sterile drug products. At this time, there is no known contamination of products produced by Ameridose."

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At least 91 people have been infected with an unusual type of meningitis caused by contaminated steroid injections, federal health officials said Sunday, with seven deaths. The drugs were given starting May 21, much earlier than previously suspected, officials with the Centers for Disease Control and Prevention said.

They are urging anyone who has had an injection for lower back pain to watch for symptoms of meningitis, which include a stiff neck and balance problems.

Cases have been identified in nine states and health officials fear the numbers will rise as doctors check patients for the symptoms. Doctors and patients alike may not know to look for the unusual infection, which can take weeks to develop after an injection.

"Several of these patients have had strokes related to the meningitis," the CDC said in a statement posted on its website. "In several patients, the meningitis was found to be caused by a fungus that is common in the environment but rarely causes meningitis. This form of meningitis is not contagious. The source of the fungus has not yet been identified, and the cause of infections in the other patients is still being assessed."

The drug in question is called methylprednisone and is used mostly to treat older patients for lower back pain.

The contaminated drugs have been traced to a single pharmacy in Massachusetts, the New England Compounding Center. The pharmacy has closed voluntarily and recalled its products, which include steroids, painkillers and dozens of other drugs. At least one sealed vial of drug has been found to have fungus growing in it, the Food and Drug Administration said. The FDA does not regulate pharmacies like the one in Massachusetts but can be called in when contamination is suspected.

Compounding pharmacies usually make drugs to order, and the steroids suspected of causing the infections did not contain preservatives that can keep fungi and bacteria from growing.

The pharmacy sent products to clinics in California, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Maryland, Michigan, Minnesota, North Carolina, New Hampshire, New Jersey, Nevada, New York, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Virginia, Texas, and West Virginia, the CDC says.

In this case, the patients appear to have had contaminated drugs injected directly into their spinal fluid. CDC says the clinics do not appear to be to blame. The CDC said it has found fungus, including Aspergillus and Exserohilum, in specimens from nine patients.

Meningitis is an inflammation of the protective membranes covering the brain and spinal cord. Bacteria or viruses are the usual cause, but meningitis can also be caused by fungi and parasites. "In addition to typical meningitis symptoms, like headache, fever, nausea, and stiffness of the neck, people with fungal meningitis may also experience confusion, dizziness, and discomfort from bright lights. Patients might just have one or two of these symptoms," CDC said.

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Only a quarter of Americans infected with the AIDS virus are getting effective treatment, according to a U.S. government report released Friday -- and the youngest patients are the worst off.  The numbers could worsen if states don’t broaden health care as called for under the 2010 health reform law, scientists worry.

It’s the first comprehensive look by the Centers for Disease Control and Prevention at who is getting effective care, and it doesn’t paint a promising picture. The findings raise even more alarm bells as study after study presented at the International AIDS Conference in Washington this week show that treatment can help stop the spread of HIV.

“The majority of people living with HIV in the United States are not on antiretroviral treatment, not in stable care,” Dr. Kenneth Mayer of The Fenway Institute and Harvard Medical School in Boston told a news conference. “They need to be in care first and then able to get treatment.”

The study finds that just over a third of  HIV patients have steady care -- 34 percent  of African-Americans, 37 percent of Latinos and 38 percent of whites.

Younger patients are the least likely to be getting the cocktails of drugs that can keep them healthy and help keep them from infecting others. Just 15 percent of those aged 25-34 had the virus suppressed to desired levels, compared to 36 percent of those aged 55-64. Only 22 percent of young adults were even getting HIV drugs to treat their infection, the CDC found.

There’s no cure for the human immunodeficiency virus that causes AIDS and no vaccine. HIV has killed 25 million since it first started spreading globally in the early 1980s, and more than 33 million people are infected worldwide. About 1.1 million people in the United States have HIV, and the CDC estimates that 20 percent of them don’t even know it.

“We have to continue to raise the alarm,” CDC’s top AIDS official, Dr. Kevin Fenton, said in an interview. “We have to find that sense of outrage.”

The same factors are driving high transmission and poor treatment rates among some U.S. groups: poverty, a lack of access to medical care, and a lack of education about what causes HIV and what people can do about it. Policymakers need to understand that treating people with HIV saves money, Fenton said. 

“What we now know is that treating HIV is cost-effective. For every dollar spent, you save $2,” Fenton said.

Fenton said the U.S. should pull out the stops on providing condoms, counseling, testing and treatment.

“We need to ensure that states have policies that support routine HIV testing,” Fenton said. “Clearly, this is going to be more challenging in some states than in others.”

Top AIDS experts in the U.S. say no matter what people may think about the moral implications of some of the behavior that leads to HIV infection, it will benefit everyone to get people tested, treated and counseled about controlling their infection.

“Every state really must enact the Affordable Care Act,” said Dr. Judith Aberg, president of the HIV Medicine Association and an AIDS expert at New York University. “States need to fund HIV treatment and prevention. We need to continue this fight.”

Governors of several states have said they will not expand Medicaid, required by the health care law, because they cannot afford it. The U.S. Supreme Court ruled last month that states can decide whether to abide by that provision. States refusing expansion now include Texas, Florida, South Carolina and Louisiana. Medicaid, the state-federal health insurance plan for the poor, currently does not cover most low-income adults with HIV. AIDS activists say it’s essential to controlling the epidemic to get coverage for young adults with HIV, and at risk for HIV.

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Whooping cough is causing the worst epidemic seen in the United States in more than 50 years, health officials said Thursday, and they’re calling for mass vaccination of adults.

The epidemic has killed nine babies so far and babies are by far the most vulnerable to the disease, also known as pertussis, the U.S. Centers for Disease Control and Prevention says. The best way to protect them is to vaccinate the adults around them, and to vaccinate pregnant women so their babies are born with some immunity.

“As of today, nationwide nearly 18,000 cases have been reported to the CDC,” the CDC’s Dr. Anne Schuchat told reporters in a conference call. “That is nearly twice as many as reported last year. We may be on track for a record high pertussis rate this year,” she added.

“We may need to go back to 1959 to find as many cases. I think there may be more coming to a place near you.”

The last record year was 2010, when 27,000 cases were reported and 27 people died. In 1959, 40,000 cases were reported.

In 2008, whooping cough killed 195,000 people globally, according to the World Health Organization.

Whooping cough is caused by a bacterial infection. It gets its name from the nagging cough it causes that can make children breathless. They often gasp for air, making a distinctive whooping sound. But it’s not so serious in adults and they may not realize that a persistent cough is being caused by pertussis.

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Washington state is having an especially bad time with whooping cough this year, with 3,000 cases so far, compared to 20 at the same time last year, said Mary Selecky, secretary of the Washington State Department of Health.  “For every case that we know about, we suspect that there are many people out there who have pertussis and don’t know it,’ Selecky said.

“In many cases, babies get this illness from their mothers or others close to them. It’s absolutely tragic.”

The state has distributed 27,000 doses of a booster vaccine for uninsured adults and has ordered more.  “This disease is very easy to catch,” Selecky said. “It has certainly gotten hold of our population in Washington state.”

The CDC is trying to figure out what's going on, but Schuchat said a couple of factors are clearly at work. The formulation for the whooping cough vaccine was changed in 1997, and kids hitting age 13 and 14 now are the first to have been fully vaccinated with five doses of the new vaccine. The new formulation causes less of a reaction, but it may also wear off sooner, Schuchat said.

The older vaccine was made using a whole pertussis bacterium. It was very effective, but it did cause swelling in some kids who got it, and sometimes caused a fever -- something that scared parents. It also was widely blamed for causing rare but serious neurological reactions, although Schuchat said studies have not confirmed this.

“Vaccines have done a good job of reducing the incidence of pertussis but our vaccines aren’t perfect,” Schuchat said. “We wish we had better ways of controlling pertussis. Given how dangerous pertussis is for babies, preventing infection in babies is our priority.”

Schuchat says people who are not vaccinated have eight times the risk of infection compared to people who are fully vaccinated against whooping cough. And if someone who’s been vaccinated does get whooping cough, the disease is usually less serious and they are far less likely to infect someone else.

The CDC says 95 percent of toddlers aged up to three years have received at least three doses of the vaccine and 84 percent have four doses. And in 2010 69 percent of 13- to 17-year-olds got a fifth booster dose. Kids should get five doses to be fully protected.

And while adults are supposed to have at least one dose of whooping cough vaccine, only 8.2 percent of U.S. adults have done so.

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