Tainted drugs threat lingers
Dr. Jose Montero, state director of public health, Department of Health and Human Services. Shawne K. Wickham/Sunday News
It's been five months since injectable medications made by now-shuttered New England Compounding Center were first implicated in a deadly, multistate outbreak. To date, 14 cases of illness in New Hampshire have been linked to the outbreak: nine patients with meningitis and five others who got joint infections.
But the state Division of Public Health Services continues to monitor 752 patients for possible illness, according to Dr. Sharon Alroy-Preis, state epidemiologist. Because this kind of fungal infection has never before been seen, even the medical experts don't know what to expect, she said.
"They're not out of the woods because ... we see from other states that some people continue to have complications from the infection," she said. "We're still learning what are the long-term effects of this previously unknown infection."
A look back
The first warning about potentially contaminated drugs came from the Centers for Disease Control and Prevention last Sept. 28, recalled Alroy-Preis.
The CDC was asking state health departments to find out which clinics and hospitals had gotten the suspect medications from NECC "and then reach out to patients to notify them and ask about symptoms that they might have," she said. The agency also asked states to put systems in place to evaluate those patients.
"This is a serious situation that may require urgent attention over the coming days," the CDC warned.
"We didn't have a clear picture at that time of the magnitude of this," recalled Dr. Jose Montero, state public health director. "(We knew) this doesn't look good, but it was not clear how many hundreds or thousands of patients or facilities we actually had to deal with at that time."
That weekend, top epidemiologists from the Northeast region happened to be in Meredith for an annual conference. Officials here quickly scrambled to set up a room with phone lines so those experts could call in to a CDC conference call scheduled for the next day.
Montero remembers "a sense of disbelief."
"The first question you ask is: Why? How did it happen?"
It was the second time in four months that state health officials were asking that very question.
The public health lab was still testing thousands of patients of Exeter Hospital's cardiac catheterization lab for hepatitis C.
A former medical technician at the hospital, David Kwiatkowski, who has the chronic liver disease, had been arrested in July, accused of stealing syringes of painkillers meant for patients, injecting himself, and refilling the contaminated syringes with saline solution before returning them.
Back on May 15, Exeter Hospital had notified the state that it had an unusual cluster of four hepatitis C cases. Epidemiologist Alroy-Preis had just returned from maternity leave a day earlier.
Two weeks later, tests confirmed the four cases shared a common source and the state announced the outbreak.
From the start, drug diversion by a hospital employee was at the top of the list of possible causes, Montero said.
"That's what science tells us," he said. "We need to look at how it has happened in other places."
Still, he said, "We needed time to prove that. We needed to be sure."
In previous hepatitis C outbreaks caused by health care workers in Colorado, Florida and Nevada, thousands of patients had to be tested for the virus, he said, so local officials knew what New Hampshire was facing.
"We knew that the size of the investigation was going to grow exponentially as new information was going to come in," Montero said.
They also knew that an Exeter Hospital employee, Kwiatkowski, was one of the first four patients diagnosed with hepatitis C. Without more information from him, however, they had no idea how long the potential exposure period for other patients was.
Since someone can have the virus for six months before testing positive, officials had to keep pushing back the time frame to test patients each time an earlier case was diagnosed. And as that time period lengthened, it increasingly pointed to a health care worker as the source.
That's because the virus cannot live on equipment for more than five days, Alroy-Preis explained. "The only way we can explain this over months and months and months is by (drug) diversion," she said.
But the uncertainty over how many patients were at risk made for a "tricky message" to deliver to an anxious public, Montero said.
"And when you're frail, you're ill, you have a really severe condition, you went through a procedure, being called back for a test ... it's really hard to explain to people they shouldn't worry until they get the results," he said.
The state did come under fire from the public for its handling of the hepatitis C testing, and Montero said he understands that. "People want answers and we don't always have the answers that they want."
And while he declined to criticize how Exeter Hospital officials handled the crisis, Montero did say, "I know that the public expected more, and that is clear."
Did the public deserve more? "Absolutely," he said.
The unprecedented back-to-back crises shook the public's confidence in our hospitals and the drugs people take, state experts agreed.
Montero said both outbreaks also highlight the need for continued vigilance. "People can grow complacent, and that's an enormous mistake that we cannot afford to do," he said.
It also revealed "how interrelated and outsourced health care is," he said.
Still, officials say they're proud of the state's response to both crises. And they're ready if it happens again.
Over the years, New Hampshire had developed an incident command system to respond to public health crises. Created after the 2001 anthrax attacks, it had been tested by EEE, the H1N1 flu and, in 2009, a case of anthrax in Durham traced to an animal-skin drum.
When the NECC crisis hit, "We pulled everybody in to help," Montero said. The state also turned to the health departments in Manchester and Nashua to do some of its ongoing disease surveillance work.
The outbreaks underscore the importance of keeping a strong public health system, Montero said. "We need to make sure that that system provides the health care quality the public needs, deserves and pays for, and that's our job," he said.
Meanwhile, the immediate crises may be over, but the work - and worry - is not.
About 200 patients who underwent early rounds of testing for hepatitis C still need to be retested to make sure they didn't contract the virus.
And the state is working with the physicians of those 752 patients who received NECC injections to monitor them for symptoms, Alroy-Preis said.
She said she believes New Hampshire is safer after what happened last year. The state's health care quality commission is reviewing best practices to prevent drug diversion, and new rules are being written for compounding pharmacies.
The best way to restore public trust is to make sure proper regulations are in place to minimize risk, Alroy-Preis said.
"I don't think people will be able to live in a society where they can't trust their medication, they can't trust their hospitals," she said. "So you need to see that someone is doing something about that to prevent the next time."
"It's not the Wild West and everyone can do whatever they want," she said. "Someone is protecting me."
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