Meningitis Cases Rise Amid Hunt for Victims

The number of people sickened with fungal meningitis from tainted epidural steroid injections has now risen to 91 in nine states, including seven deaths, federal officials said Sunday, as investigators try to home in on the precise source of contamination at a compounding pharmacy tied to the widespread outbreak.

Investigators from the U.S. Food and Drug Administration and state officials are probing the Framingham, Mass., facility where the New England Compounding Center made the 17,676 potentially tainted steroid injections, which were then shipped to 75 clinics in 23 states, according to federal and state officials.

A Centers for Disease Control and Prevention spokesman said it isn't possible to know how many cases there will be. The CDC and state health officials scrambled last week and over the weekend to track down patients who received the shots to see if they had been sick and to warn them to watch for possible symptoms.

The numbers of cases are rising sharply now not necessarily because people are continuing to get sick, but because investigators are pinpointing more illnesses among those who already received the injections of methylprednisolone acetate for relief of back and neck pain.

The injections were given between July and September. So far, those who have been infected developed symptoms between one and four weeks after receiving their injections.

"There's no evidence that new infections are occurring at a more rapid rate," said John Jernigan, medical epidemiologist at the CDC who is involved in the investigation.

It is too early to know how many people ultimately will be affected. Federal and state investigators must determine how many people received potentially contaminated injections, then track down each one. They must then confirm that those who have subsequently become ill actually had fungal meningitis and not another disease. There are "too many variables to speculate on the number of possible cases," said a CDC spokesman.

The compounding pharmacy that produced the injections in question issued a recall Saturday of all products made at its compounding center. "This action is being taken out of an abundance of caution due to the potential risk of contamination," the New England Compounding Center said in a statement. The company has said it is cooperating with investigators. It had no further comment Sunday.

The FDA had already advised medical professionals last week not to use NECC-made products.

Meningitis is a potentially deadly inflammation of the brain or central nervous system. It is usually caused by viruses or bacteria, but can also be brought on by fungi. The two fungi found thus far in some patients—known as aspergillus and exserohilum—are commonly found in the air and soil.

The fungal form of meningitis is particularly difficult to diagnose because the symptoms can be vague and mild initially, including fever, headache, nausea and stiffness of the neck, according to the CDC. People with fungal meningitis can also experience dizziness and confusion. Several of the patients in the current outbreak have had strokes.

Most of the people who have been sickened had normal immune systems, Dr. Jernigan said, meaning they weren't at particular risk of infections. While the investigation into how patients became infected is ongoing, there is some evidence to suggest that the fungi in the medication penetrated the lining protecting the central nervous system after being injected epidurally, Dr. Jernigan said.

While the fungi aren't harmful in the environment, they can become deadly when they flourish in a medication and are then injected directly into a part of the body that should not have germs, Dr. Jernigan said.

One possible victim, 56-year-old Tennessee resident Diana Reed, died Wednesday; she got meningitis after receiving steroid injections, says a lawyer for her family. She had received the injections at a facility that has since been closed because of a meningitis outbreak, according to its Web site.

Ms. Reed underwent an autopsy; the lawyer said he didn't yet know the results.

The outbreak has drawn renewed attention to the little-regulated world of compounding pharmacies. The FDA is hampered by federal law and conflicting federal court decisions over its authority to regulate compounding pharmacies. Current and former senior FDA officials said the agency has sought greater authority over the past decade, but so far has been stymied.

Government officials say the FDA is especially concerned about large compounding pharmacies that send out large amounts of drugs across the country—as opposed to a small pharmacy that may compound a medication three or four times a year.

In particular, the agency hasn't been able to take the normal steps it would take to ensure the safety of a drug produced at a compounding pharmacy. That includes requiring and evaluating clinical trials, and inspection of manufacturing facilities.

Attempts in the past by the agency to regulate more strenuously have been challenged in court.

Syria, Turkey Trade Fire; Blast Hits Damascus Police

Turkish troops guard a border crossing in Akcakale, across from Syrian rebel-controlled Tel Abyad, on Sunday.

Syria and Turkey exchanged artillery fire for a fifth straight day on Sunday, while insurgents struck police headquarters in Damascus, in the third high-profile attack in the Syrian capital in recent weeks.

The escalating pressure in the capital and along the border present a rising pair of challenges for the Assad regime, which already accuses outside forces, including Turkey, of working with the rebels to destabilize the country.

A bomb in the Damascus police headquarters' parking lot caused the powerful blast that killed a police officer, said an official at the interior ministry.

In Turkey, there were no immediate reports of casualties in the early afternoon after a shell landed close to a grain-storage facility, witnesses said, several hundred yards from the town center in Akçakale, the border town where Syrian artillery killed five Turkish citizens on Wednesday.

Turkey's military fired artillery on targets inside Syria in response, Turkey's state-run news agency reported.

It has fired artillery shells across the border every day since Wednesday in response to Syrian artillery hitting towns along its border.

Syria's government, despite international condemnation, has held back from apologizing to Turkey while it investigates the source of the fire from its territory, which it says could be from antigovernment fighters who control large parts of the border territory.

U.S. Defense Secretary Leon Panetta warned over the weekend that the continued exchange of fire across the Syrian-Turkish border raises concerns that the conflict could spread to neighboring countries.

Mr. Panetta, in a news conference in Peru on Saturday, said that the U.S. is using its diplomatic channels to relay worries about the fighting, the Associated Press reported.

Still, regional diplomats and analysts say the risk of a full-blown confrontation between Syria and Turkey, former allies whose leaders were personal friends before Syria's crisis erupted last year, is limited.

Cross-border incidents are likely to continue, however, analysts say, as President Bashar al-Assad's forces pursue rebel fighters leading an insurgency against his rule.

"The risks of miscalculation are considerable," Ayham Kamel and Naz Masraff, analysts with political-risk firm Eurasia Group, wrote in a recent note.

"Ankara and Damascus no longer share a direct and open military or political communication channel. During potential clashes, miscommunication is probable and both sides could misinterpret their respective intentions," they wrote.

Mr. Assad can't afford to give up control of the border area, a lifeline for rebels, and has delegated military decision-making to local commanders, the analysts said. That raises the risk of knee-jerk responses and potential mistakes that could escalate, they added.

Turkey's leadership has made clear that it has no intention to go to war with Syria but that it would respond to violations of its sovereignty.

Turkish Prime Minister Recep Tayyip Erdogan has raised doubts over whether the frequent cross-border fire from Syria is an accident but has refrained from further comment on the Syrian government's intentions.

In Syria's al-Raqqa province, just across the border from Akçakale, rebel fighters said the source of the shelling on Sunday that struck Turkish territory was government tanks in the village of Ain Arous, about seven miles from the border.

The nearby city of Tal Abyad was still being shelled by Syrian army positions in the area, residents said.

Syrian rebels have voiced frustration with what they see as a restrained response from Turkey, but rejected accusations that they might be instigating border tensions to push Turkey toward an armed confrontation with Syrian regime forces of the sort that rebels have long advocated.

"The Free Syrian Army in Tal Abyad doesn't have tanks or missiles to launch these kind of attacks anyway," said Ayham al-Khalaf, an activist with the local activist media council in al-Raqqa.

In Damascus, security checkpoints cordoned off the Fahama district in the capital's center after the bombing occurred shortly after 7:15 p.m. local time.

A few reporters were later allowed into the compound where cleaning crews were sweeping up the debris and distraught members of the police force were comforting each other.

The facade of the two-story building was torn away and more than 20 vehicles were either incinerated or badly damaged. The stench of gasoline from ruptured fuel tanks filled the air.

Several police officers said a driver for one of the senior officers placed the bomb inside his boss's car, detonated it, and fled.

"He blew up the car and ran away to Deraa,"—the city in southern Syria where antigovernment protests first erupted last year—said a young officer with a bandaged arm and blood-covered T-shirt.

The bombing is the latest in a string of apparent rebel victories in the heart of Damascus, signaling how precarious security has become in the once-calm capital even as fighting between government and rebel forces has been focused farther north in Aleppo.

Sunday's attack came after several bombings last week in Aleppo that appeared to target hotels housing military officers, and blasts that rocked the headquarters of the armed forces in central Damascus on Sept. 26.

Police chief Maj. Gen. Ibrahim Ibrahim sat on a lawn chair at the scene of the blast in Damascus but refused to speak to the media.

An hour after the first explosion, two other explosions were heard in the city, but their cause wasn't immediately known.