CHARLOTTE, N.C. (AP) - Days after investigators linked a deadly cluster of rare fungal meningitis cases in Tennessee to tainted back pain medication, North Carolina officials received an urgent email from the Centers for Disease Control and Prevention.The federal health agency said North Carolina had a possible fungal meningitis case with links to the Tennessee outbreak. If true, the CDC said it would confirm a "broader contamination issue."
That was Sept. 27. But it wasn't until five days later that the North Carolina Department of Health and Human Services notified the public about the threat, according to documents obtained by The Associated Press.
Hundreds of emails obtained through a public records request show how North Carolina health officials handled the fast-moving crisis.
Working with the CDC, the state health agency wrestled with what to tell the public, including whether to name the clinics suspected of administering the contaminated medication.
Health department spokeswoman Julie Henry said officials wanted to have all the facts before releasing information because it would have raised more questions than answers.
"We were trying hard not to promote hysteria in the general public," she said.
But she said officials also weighed the impact of waiting.
"So the other part of that is if we wait another day, are we going to put somebody at risk because they haven't recognized their symptoms soon enough?" she said.
A tainted steroid made by the New England Compound Center has been linked to a fungal meningitis outbreak that has killed 40 people nationwide and sickened more than 600.
The Framingham, Mass.-based company has been shut down since the outbreak was discovered in September.
When it comes to informing the public about health threats, North Carolina doesn't have a protocol, Henry said. Like many states, decisions about when to publicly release information are made on a case-by-case basis.
In Indiana, the AP found that health officials waited nearly a week before disclosing that six clinics had received the tainted back pain medication.
The CDC warned North Carolina of the meningitis threat by email on Thursday, Sept. 27.
The agency said a doctor called because he suspected a patient -- a 77-year-old North Carolina woman -- had meningitis-like symptoms after receiving an epidural injection "likely from the lots of interest." The clinic that administered the shot told the CDC that 120 doses of the lot were given out to about 60 patients.
The CDC said other patients from the clinic needed to be "contacted ASAP."
State health agency officials and the CDC continued to exchange emails that night about what to do, and scheduled a conference call for the following morning.
Meanwhile, Zack Moore, an epidemiologist with the state health agency, suggested the state at least provide health providers with information sent out by the state of Tennessee, which said it was notified Sept. 18 that a patient developed the fungal meningitis after the epidural steroid injection.
Such warnings are distributed through the N.C. Health Alert Network (HAN), which goes out to doctors, hospitals and other critical health care providers.
But Moore expressed concerns about timing.
"I could send it now, but doubtful many would see it before tomorrow morning, and we might have other pertinent info to share after the call," he wrote.
After Moore's email, Megan Davies, chief of North Carolina's epidemiology section, asked questions about where the North Carolina patient was admitted and, when they found out, to inform the local health director. She also said they would need to send out an alert.
By the next morning, North Carolina officials knew three clinics had received the tainted medicine.
On Friday, the state agency sent out a HAN message, warning providers to be on the lookout for fungal meningitis cases.
It's unclear how many people actually saw it because it was sent late Friday afternoon and went out as a "low priority" health alert, according to an email.
Over the weekend, state health officials exchanged emails with the CDC -- including an ominous one. CDC's Rachel Smith asked if public health officials in North Carolina had the power to request an autopsy and examination if the 77-year-old woman died. "Something to think about pending the outcome of this case," she wrote.
By that Monday, state health officials knew they had to publicly address the emerging crisis.
At 10:32 a.m., Davies sent an email to several agency officials saying director Laura Gerald wanted to send out a news release.
"She is concerned that we need to make every effort to communicate to people potentially exposed," Davies said.
She added one more thing: Tennessee health officials would be releasing more information that day -- but this time they would mention the North Carolina case.
In the afternoon, Davies informed Gerald they were still working on the news release, but said the number of possible patients exposed was up to 94.
North Carolina hospital was bracing for negative publicity.
Rita Bunch, senior director at the High Point Regional Health System, wrote that word was beginning to spread that the meningitis outbreak had spread to North Carolina. The 77-year-old woman, who later died, was a patient at the High Point, N.C., hospital.
"Not sure where you are on the release from N.C. but I think we want to get in front of this before someone finds out it (was) HP and we are behind it," Bunch wrote an email sent at 5:39 p.m.
The state agency released the information to the public later that Monday, saying it was assisting the CDC in its meningitis investigation, and that one case had been identified in North Carolina. Officials also warned people who had received injections to be on the lookout for symptoms, which included headache, stiff neck and fatigue.