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Kastango offered additional possible scenarios, related to the large volume produced: Making thousands of doses at a time can take many hours or days. It’s possible that a batch could sit for hours or even a day or so before being placed in vials, making it vulnerable to contamination, he said.

It’s also likely a pharmacy worker would take a break to get a snack or cup of coffee, to go to the bathroom or to step outside for a smoke, Kastango explained. If the person hurried back and didn’t properly wash up or put on new gowns, masks and other safety garb, that could introduce contamination.

Faulty or misused sterilizing equipment is also a possibility. After a 2002 fungal meningitis outbreak linked to a South Carolina compounding pharmacy, investigators discovered that a piece of sterilizing equipment called an autoclave had been improperly used by the staff.

The types of fungus in the latest outbreak are ubiquitous: The first to be identified was Aspergillus, commonly found indoors and outdoors. As more testing of patients was completed, it became clear that another fungus _ a black mold called Exserohilum _ caused most of the illnesses. Exserohilum is common in dirt and grasses.

Most people do not get sick from ordinary exposure to these kinds of fungus, but spinal injections can provide them a pathway into the brain. Doctors are generally leery of using spinal steroid injections that contain preservatives because of fears the preservatives themselves can cause side effects.

Whatever happened at New England Compounding, it probably wasn’t unique.

Just last year, there were at least three apparently similar incidents: At least 33 patients suffered fungal eye infections traced to products made by a compounding pharmacy in Ocala, Fla.; at least a dozen Florida patients were blinded or damaged in an outbreak linked to a compounder in Hollywood, Fla.; and the deaths of nine Alabama patients were attributed to tainted intravenous nutritional supplement provided by a compounder in Birmingham.

“These events have been happening once or twice a year for the last 15 years,” Kastango said. “We wouldn’t tolerate this if a plane crashed once or twice a year. But in health care, we’ve grown desensitized to these kinds of problems.”

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Online:

CDC outbreak information: http://www.cdc.gov/HAI/outbreaks/meningitis.html