Compounding Pharmacies

The official case count is up to 105 in the largest outbreak of fungal meningitis in US history, but it will undoubtedly go higher as more cases are recognized as being connected to the contaminated medicine (CDC currently is updating the case counts once a day).

http://www.cdc.gov/HAI/outbreaks/meningitis.html

Fungal meningitis is the rarest form of meningitis and it is not contagious from one person to another. It usually occurs only in people who have a damaged immune system, like those with AIDS or undergoing chemotherapy. I heard a TV interview by a doctor, not a public health official, but an infectious disease specialist. He said we’ve never seen anything like this before. Well, he’s not exactly correct. A few years back there was an outbreak of Pseudomonas fluorescens traced to a compounding pharmacy in Texas. It involved kids with serious diseases, like cancer, who had indwelling catheters that required periodic flushing wit a heparin preparation to keep them from clogging.  See http://cid.oxfordjournals.org/content/47/11/1372.full.pdf

What are compounding pharmacies? They are a lot like the big factories that produce food for retail stores.  They buy large quantities of medication, like steroids, then mix them with sterile water or another solution and prepare vials for doctors. They exist because they can produce the drug at a cheaper price than pharmacies with more rigorously oversight. The problem is that organisms, mostly bacteria and fungi, have a way of getting everywhere. Unless you use high tech systems to ensure absolute sterility mistakes like this can happen. Just like one contaminated cow can be spread E. coli to a lot of ground beef one unsterile step in a compounding pharmacy can contaminate a lot of medicine.

What is odd and concerning is that the injections of steroids into the spinal column is resulting in meningitis. The goal of the procedure is to inject the medicine around the nerve root as it emerges from the spinal cord.  Decreasing inflammation by the use of steroids will reduce pain. Most of the time the placement of the needle is checked with fluoroscopy and dye. The spinal sac is not penetrated, which means that the infections in the outbreak are a result of direct fungal invasion though the spinal cord membrane or via the bloodstream. Both scary situations.

Dying to be beautiful

The quest for beauty and perfection will make people do strange things. Some might include cosmetic surgery on the list but I think most would agree that allowing a person who never attended medical school or any hospital training to operate on you is beyond strange if not foolhardy.

Back in 2010 we were called by an astute and thoughtful hospital doctor. He was treating a woman who had bilateral abscesses in her buttocks. When he asked her what had provoked the unusual infection she confided that she recently had liposuction. When the doctor asked who did the procedure he was surprised by what he heard. A local Spa operator. Thinking that a language barrier was preventing him from fully understanding what the woman was saying he probed deeper. No, she wasn’t a doctor, but had done these procedures many times before. The patient had allowed the Spa operator to remove fat cells from her abdomen and re-insert them into her derriere.

Along with detectives from the major case squad we raided the Queens Spa and confiscated records and drugs. We found a number of pharmaceuticals that require a license to prescribe, such as botox, and others that are illegal in the United States. We began calling the patrons to ask if they were well and to learn the scope of this illegal medical practice and the harm it might have caused. Five procedures were popular: liposuction, meso therapy, botox, injection of filler materials and intravenous vitamin infusions.  Bust, thigh and buttock augmentation with silicone or other industrial-use chemicals was the most common procedure performed. Meso therapy is the injection of chemicals under the skin to dissolve fat. It is unproven and can result in infection and scarring. Quite a few had complications such as scarring, discolored skin and wounds that didn’t heal. This past spring the Spa owner pleaded guilty and was slapped with a $400,000 dollar fine and two years jail time.  http://www.queensda.org/newpressreleases/2012/may/nieto_05_29_2012.con.pdf

The district attorney sent a message to others involved in the illegal practice of medicine that putting the public health in danger will not be tolerated in NYC. It is also a cautionary tale to people seeking affordable alternatives to plastic surgery.

Sadly plastic surgery by unlicensed practitioners of medicine is all too common as a simple Web search reveals. And these are just the people who got caught. Costing a fraction of what real doctors and hospitals charge it is most popular among Hispanic women.  This was our fourth investigation into illegal medical practice.  The woman who was dissatisfied with her figure learned of the Spa from a friend who informed her that she could get a procedure that usually costs over $10,000 dollars for $500. What she got for her money was pain, fever, a deep tissue infection and a several day stay in the hospital.

She was lucky, others have not been as fortunate suffering debilitating pain, chronic infections with mycobacteria, permanent disfigurement and even death. In 2009 a Bronx woman died of silicone pulmonary embolism from a filler injection.  The list of chemicals injected is appalling as is the lack of safe and sanitary practices. One women used Krazy Glue to seal a wound (see links below). Cheap cosmetic surgery by an unlicensed practitioner is dangerous and you get what you pay for. So if you are determined to improve your appearance save up for a real plastic surgeon or do it the old fashioned way. Tone those abs and butt at the gym.

Bronx woman dies

http://www.wpix.com/wpix-woman-dies-after-illegal-plast-257650,0,2530751.story

PR woman dies after lipo

http://news.google.com/newspapers?nid=1356&dat=19980904&id=nM0UAAAAIBAJ&sjid=QggEAAAAIBAJ&pg=5617,1611875

Miss Argentina

http://www.theplasticsurgerychannel.com/breaking-news/former-miss-argentina-dies-after-buttock-augmentation.html

UK woman dies

http://hellobeautiful.com/1659285/girl-dies-after-illegal-plastic-surgery/

Las Vegas crime
http://www.lvrj.com/news/pair-whose-illegal-plastic-surgery-led-to-woman-s-death-sentenced-132262758.html

Another Blog on dangers

http://www.plasticsurgeryinflorida.com/blog/2010/01/experts-say-large-volume-buttock.html

Deadly Virus Visits National Park

As scenic vacations go, Yosemite is spectacularly breathtaking. Whether you are viewing the awesome rock formations from an overlook or standing in the valley staring up at a waterfall. In the world of hantaviruses, Sin Nombre virus (SNV) is equally breathtaking. Literally. In the spring of 1993, in the Four Corners area of the US, the Sin Nombre virus killed two young, accomplished long distance runners. They died of sudden respiratory failure and the only clue was that the two victims were engaged to be married. A week later another couple became seriously ill with the same air gasping symptoms. One was a relative of the very first case.  The damage to the victim's lungs looked like they had inhaled World War I nerve gas. When investigators visited the home of the first two cases they found no obvious source, but noted that they place was heavily infested with rodents. El Nino’s rains resulted in a bumper crop of pine nuts, a staple for the white-footed deer mouse and their numbers had doubled since the previous year.

After an incubation period from one to five weeks the first symptoms to appear that aren’t much different from the flu and include fever, chills, headache and severe muscle aches. Sometimes stomach pain and dizziness occur.   Several days later respiratory symptoms appear.  The life sustaining oxygen membrane in the lungs no longer works. Fluid collects and patients die of oxygen starvation. Most hantavirus cases in the US have occurred in the southwest but another strain was discovered in Maryland and we have had two cases in New York, the latest was just last year: (http://abclocal.go.com/wabc/story?section=news/local/long_island&id=8211238)

Back in June of 1993 the CDC began testing serum from the Four Corners victims of SNV against a battery of viruses from across the world looking for cross-reactivity as a clue to Sin Nombre’s identity. They got reactions with two viruses from halfway across the world, Haantan and Seoul. These viruses were discovered during the Korean War and were known to cause kidney disease. Sin Nombre was their cousin and was uniquely adapted to survive in the urinary systems of mice, Peromyscus maniculatus to be exact, the white-footed deer mouse. Disturbing mouse nests or sweeping urine-laden dust aerosolizes the virus and brings it into contact with sensitive lung cells. To read the full Sin Nombre virus investigation story see CJ Peter's book, Virus Hunters, chapter 1.

Curry Village is a camp comprised of canvas tent-cabins in the valley of Yosemite. It is affordable and popular with families. Thus far six cases and two deaths from SNV have been confirmed in visitors to the park. Four were known to have stayed in Curry Village. Others are under investigation and an alert was sent to state health departments because an estimated 10,000 people from across the nation stayed at Curry Village from June to August this year.

Prevention begins with sealing your house to prevent mouse invasion, a difficult task. Even here in the Big Apple the industrious little critters routinely make there way into apartment buildings. Trapping (I use live, “green” mouse traps) and good food hygiene are the next steps, like disposing of trash in a receptacle that rodents can’t penetrate. That includes food in your home, using thick plastic, metal or glass canisters to store food.  Caution is advised when cleaning areas of mouse habitation. Ensure proper ventilation, spray the area first with a disinfectant, like dilute bleach. This will inactivate viruses and keep dust levels down. Wearing personal protective equipment to include a mask, goggles and gloves is also a good idea. See full CDC recommendations here: http://www.cdc.gov/rodents/cleaning/index.html

What is up with West Nile virus this year?

It has been a bad West Nile virus (WNV) season, the worst since the virus arrived on the continent in 1999, and it isn’t over yet. But why? Why Texas, and even more curious, why South Dakota? WNV is a mosquito-born virus, but so is malaria and we don’t have malaria in the US anymore.

To understand the epidemiology of WNV we have to look at nature. It turns out that humans are “dead end” hosts, meaning we aren’t the intended target. That’s because we don’t sustain a significant viremia (meaning there is lots of virus circulating in the blood as happens with malaria for instance). Mosquitoes don’t pick up virus from us to transmit it to others. WNV is a virus adapted for birds and the normal cycle is that an infected mosquito bites a bird. The bird becomes viremic, other mosquitoes bite the bird and perpetuate the cycle. This is how the virus “amplifies” over the summer months.   Most of these mosquitoes specifically feed on birds and don’t bite humans, but there are crossover mosquito species, omnivores if you will, with a taste for bird and human blood. They come into the picture late in the season when the cycle has amplified the virus to infect many birds. Crossover occurs, the omnivores bite birds, pick up the virus then bite humans.  This is why we see most of the cases of WNV in late August and September. Amplification takes time.

Believe it or not WNV mostly causes an inapparent human infection. Only two out of ten get sick, and most of those get a flu-like illness. About one in a hundred get the more serious version, called “neuroinvasive disease.” This is a brain infection that causes weakness, confusion, coma and even death.  Age is a risk factor with 55 years seemingly where the increased risk begins, but anyone with a health condition that impairs the immune system should consider themselves at risk and take precautions when outside during mosquito season.

Mosquito control includes the use of larvacides-chemicals that kill the non-flying stage of mosquito – early in the season and adulticides throughout the season. Adulticides are chemicals that kill the flying adults.  We all remember spraying from when we were kids and chased the fogger down the block on our bicycles (well, some of us remember.)

So what’s a person to do? If you own a home make sure there are no items in your yard that could collect water and serve as a breeding sites for mosquitoes. Ensure that all windows are secure and screens intact. Don’t leave your door open. Peak mosquito biting hours are dusk and dawn but also anytime in between. Permethrin-based repellents can be applied to clothing but not skin.  Long sleeved shirts and pants, if made of thick material can deter bites, but it has been really hot throughout most of the US this summer.  The best put-on-the-skin repellents are DEET and Picaridin and the duration of effectiveness depends on the concentration. DEET can be toxic to small kids, so apply with caution. Oil of lemon eucalyptus is another alternative. CDC’s advice on mosquito repellent use is here: 

http://www.cdc.gov/ncidod/dvbid/westnile/qa/insect_repellent.htm

Back to why is Texas and South Dakota having so much West Nile? The answer is nature. The right combination of rain and sun increases food supply for birds. If there are more birds, there is more food for mosquitoes and then more mosquitoes. Amplification of the virus is increased. The weather and rain also impact on mosquito breeding and hot weather means a higher amount of WNV in mosquitoes. If there are a lot of juvenile birds of the right species, birds that haven’t had been infected with the virus before, then that is the perfect storm. I haven’t been to Texas or South Dakota but I bet there has been an increase in young, naïve birds capable of sustaining the WNV and a bumper crop of all mosquitoes, including the crossover biting ones.

The fallacy of IT security

Forgive me readers for it has been many weeks since I have last written. It is not because infectious diseases have gone away. To the contrary, there is a new new flu virus, H3N2v that has emerged again in pigs and has caused some recent furor though thus far the illness is mild. There have been more iatrogenic outbreaks related to poor infection control and there's even an Ebola outbreak in Uganda with 23 cases and 16 deaths. No info on how the outbreak began though. The reason I have taken a hiatus from the blog is to focus on the new novel and it occupies all of my writing hours.

But when something sticks in my craw I just have to get it down on cyber paper. At work, the latest bureaucratic brainstorm is to require password changes for the application we use to log our time every three months. I want to know if anyone had ever suffered a breach. Really, who would want to crack into this system? Perhaps to steal some sick days? I bet they go for a few hundred apiece on the black and blue market.

Let's see, now I have at least three or four other work related passwords, all of which expire far too frequently, then there's email, twitter, bank accounts... soo many that I've had to write them all down.  In the same location in fact, so that I have them handy in case I forget. Check that multiple locations. But wait, doesn't that defeat the purpose of having expiring passwords?

Yes, it most certainly does. WTF?

Not AGAIN! Hepatitis C caused by a medical procedure

The New Hampshire Department of Health is reporting ten cases of nosocomial hepatitis C associated with a cardiac cath lab. What is unusual about this outbreak is that it is in a hospital where infection control is generally more rigorously practiced. While the exact route of transmission in this outbreak has yet to be determined, public health enemy number one has to be suspected.

http://www.fosters.com/apps/pbcs.dll/article?AID=/20120606/GJNEWS_01/120609858

In May of 2001 we did our very first hepatitis C outbreak investigation. A doc in Brooklyn reported himself after he found four of his own patients hospitalized with acute hepatitis C while on hospital rounds. He had done endoscopy on all four within the recent past. Endoscopy, more specifically colonoscopy, is recommended for screening and prevention of a big killer, colon cancer.  It is an important medical procedure, but it has risks. One of which shouldn’t be a risk, hepatitis C. When performing colonoscopy the physician reuses the equipment. That was our first suspicion and while the steps to clean the instruments didn’t follow the exact manufacturer’s instructions, we quickly ruled out the scopes as the cause. We had uncovered twelve patients over a five day period, many of who had their procedures back-to-back. There simple wasn’t time to reuse the scopes. We next zeroed in on the other invasive part of the procedure, anesthesia. We quickly discovered that all the patients had received the same drugs in about the same quantities, but what really stood out was the vials. They weren’t single use and thrown away. Meet the multi-dose vial (MDV). Intended for a single patient, these are often used for multiple patients. Why? They cost less. But it shouldn’t be a problem. As long as they are always entered with a clean needle, that is. Unfortunately, that isn’t what happens. The medical literature is littered with outbreaks traced to MDVs. We determined that a patient known to be infected with hepatitis C underwent colonoscopy. He woke up during the procedure. The anesthesiologist removed the needle and syringe that had been bathing in the patient’s blood and reinserted this into a MDV. The bottle was then used for the next fifteen or so patients, infecting twelve of them with the virus.

So, what’s the answer? For the consumer ask your doctors if they use MDVs and request that you get a fresh vial and it is thrown away when done. For us doctors, don’t use MDVs. For the FDA prohibit MDV use without appropriate engineering controls which eliminate the possibility of  accidental needle reuse. Hepatitis C is preventable. 

Mycobacterium chelonae outbreak

A cluster of infections due to Mycobacterium chelonae have been diagnosed in individuals who patronized the same upstate NY tattoo parlor. The outbreak was traced to a bottle of pre-mixed ink and the FDA is issuing a recall. 

For information on tattoos and mycobacteria infections see:

http://findarticles.com/p/articles/mi_hb4393/is_1_42/ai_n56785728/

and

http://www.ncbi.nlm.nih.gov/pubmed/19733936