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    NewsLatin AmericaAn outbreak of aseptic meningitis sets off alarm bells in Durango

    An outbreak of aseptic meningitis sets off alarm bells in Durango

    The Durango Health Secretary, Irasema Kondo, in front of an information module on meningitis.SSDURANGO (RR.SS.)

    Durango is on alert for an outbreak of aseptic meningitis. At least 12 people, 11 women and one man, have died in the last month in four private state hospitals due to a fungus present in four batches of bupivacaine, a local anesthetic. There are more than 60 confirmed positive cases, the vast majority of them young women, according to the Durango Health Secretariat (SSD). Despite the fact that the authorities have set up special areas in two public centers to treat the infection, the situation has not yet stabilized and the numbers continue to rise slowly.

    “It will easily reach about 100 infections. The fungus is very aggressive despite treatment, mortality can exceed up to 50% of cases. It is a tragedy, it will go down in the history of medicine”, explains Dr. Eder Zamarron, specialist in intensive care at the MAC Tampico Hospital and scientific disseminator. Experts agree that the most probable hypothesis is that the medicine was contaminated by mishandling in health centers, although no one has so far taken responsibility and there have been no arrests. “It would be speculative to attribute the cases to the bottles manufactured, stored, or to the use of the anesthetic in patients,” defended the Undersecretary of Health, Hugo Lopez-Gatell, in a statement.

    The disease is not contagious, but there is no record of how many patients received the anesthetic and were exposed to the fungus. The health authorities are monitoring all the people who have received the medicine since March in any of the four affected hospitals —Parque, Sante, Dikcava and San Carlos, all in the city of Durango and temporarily closed—, for that the number could be in the hundreds. This newspaper has requested an interview with those responsible for the SSD, but at the close of this article it has not received a response. “The investigation to determine the causes of meningitis will take time and will be focused on determining at what point in the process the contamination occurred,” Lopez-Gatell Ramirez declared in the statement, which specified that another 12 women are in serious condition. Although one of the deaths has been registered in a hospital in Torreon, in Coahuila, the victim had also been operated on in Durango.

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    The alarm with meningitis, a disease that inflames the tissues that cover the brain and spinal cord, went off in early November. At that time, the origin of the disease was still unclear. Although it is normally transmitted by direct contact with an infected person, medical tests revealed that in the case of Durango the cause was a fungus —scientific name Fusarium solani— present in batches of bupivacaine and heavy bupivacaine. The drug is a local anesthetic used for short surgeries, lasting around two hours. The contaminated batches were manufactured by Pisa, a pharmaceutical company based in Mexico, although the experts consulted agree that the fungus was present in the drug since its production. On the contrary, they point out that it was most likely compromised in the four hospitals where infections have been registered, since the company supplies the same medicine to the entire country and some hospitals in South America.

    “One of the most likely hypotheses is that to save resources they have reused the needles”

    Consuelo Tinajero, an anesthesiologist at the General Hospital of Silao, Guanajuato, has closely followed the outbreak from the beginning: “As anesthesiologists, we were notified that cases of meningitis were occurring in the city of Durango and it was being associated with the use of bupivacaine, we were notified of the specific lots that were used and we were advised of the risk that existed if we were to give an anesthesia. What strikes me is that Pisa distributes to the entire country and this type of case has not been reported anywhere else. In the hospital where I am, we perform a minimum of 12 to 15 neuraxial anesthesias a day because we work with a lot of pregnant patients and for a cesarean section it is the ideal anesthesia”.

    The vast majority of patients are young women who have given birth in the last few months and have undergone caesarean sections. Dr. Alejandro Macias, one of the leading infection specialists in Mexico, points out: “In men it is used less, for example, in hemorrhoid operations, which explains why women with cesarean sections are basically affected.” “We can practically rule out that the drug is contaminated, unless it was contaminated at the site of use. One of the most probable hypotheses is that to save resources they have reused the needles”, says the infectologist.

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    The needles, Macias explains, are disposable and are inserted into the syringe through a plastic part that cannot be disinfected while hot because the material melts. “There is something called cold sterilization, but it is a pipe dream, the false idea that you can sterilize something outside of the autoclave [maquina para esterilizar a altas temperaturas]. Many times they use disinfectants and then cold disinfection systems, believing that it will leave the needle sterile, and it is not true, these systems do not sterilize the inside of the needle. If it was contaminated and had that fungus, they have injected the painkiller into the central nervous system.”

    Tinajero agrees with him, explaining that in the type of anesthesia for which bupivacaine is used, the medication is inserted directly into the central nervous system with a “very thin” needle. “I am suspicious of the syringes, before they were made of glass, they were not discarded, and they were sterilized, sometimes with heat or with other substances, including alcohol. I think these hospitals are still using these types of reusable glass syringes.”

    The experts consulted reject that, despite the fact that most of those affected are women, it is a case of obstetric violence — “violence exercised by health professionals towards pregnant women during childbirth and the postpartum period”, according to the World Organization for Health (WHO). “I would not judge it as obstetric violence, I think the doctors who administered the anesthesia were correct and did not know the risk they were subjecting to the patients,” says Tinajero.

    “Few types of procedures are given this type of anesthesia that is injected into the cerebrospinal fluid. Pregnant women with a cesarean section are the most exposed because the anesthetic effect wears off quickly, their immune system is affected and their defenses are low due to the physiological change of pregnancy itself. The direct inoculation of a fungus, no matter how good your defense system is, will affect you”, adds Zamarron.

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    “The responsibility lies with the hospital managers”

    “Another hypothesis,” Macias points out, “is that they had bought the medicine on the black market, and there they even prepare the medicines in a garage. If they bought it there to save resources, they may have falsified labels or put in complete batches”, continues the expert. Is it medical negligence? “Absolutely. It is a problem in medicine that happens a lot in developing countries to save resources. If that was what happened, this is one of the worst cases that I have seen of failing in the most elementary care measures, ”he says.

    Tinajero, however, qualifies: “I would not call it medical negligence because we as doctors and anesthesiologists have no way of knowing if the medicine is contaminated or the needles sterilized, although we can tell if they give us reusable syringes, if they are made of glass and not plastic. The responsibility lies with the hospital managers, they know that they are not sterilizing properly, or re-sterilizing single-use material, or that they bought apocryphal medicine. The provider of that hospital should know that, he is the one who should be investigated ”.

    Macias takes stock: “I don’t want to be alarmist and you have to be very careful, but it is a fungus that is very resistant to existing drugs. The problem is going to carry over for months, it is a slow evolution meningitis. Some cases take weeks to manifest. There are dozens of women who may have many problems, they are having the best treatment available, but efficacy cannot be guaranteed. The infections are no longer going to spread, but the problem that exists at the moment is still lurking.”

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