CDC Helps Solve Panama Mystery Illness
Outbreak in Panama
|Martín Torrijos, President of the Republic of Panama, receives a briefing on the progress of the International Interagency Working Group from LCDR Joshua Schier, MD, CDC team lead, shortly before midnight on Tuesday, October 10 2006. Behind President Torrijos and Dr. Schier is a map depicting the government health facilities in Panama.|
Scientists at the Centers for Disease Control and Prevention's (CDC) National Center for Environmental Health (NCEH) have identified the cause of nearly two-dozen mysterious deaths over the last month in the Republic of Panama, according to LTCDR Joshua Schier, MD, the NCEH medical toxicologist heading the agency's investigative team in Panama. Somehow, diethylene glycol (DEG) was introduced into government-made, generic-label sugar-free cough and anti-allergy syrups. DEG is a water-soluble, clear liquid commonly found in brake fluids, antifreeze, and fuel additives. It is also used to retain moisture in the industrial processing of tobacco products; in the treatment of corks, glue, paper and cellophane; and in the manufacture of unsaturated polyester resins, polyurethanes and plasticizers. Exposure to large amounts of DEG can damage the kidneys, heart, and nervous system.
Panamanian health authorities quickly withdrew the contaminated medications as well as those potentially contaminated by DEG from clinics, and people have been notified to immediately discontinue their use. The medications were all compounded in a production laboratory operated by the Panamanian Social Security hospital system. Government officials are investigating how contaminated ingredients came to be included in these common medications.
CDC Director Julie Gerberding, M.D., M.P.H., echoes the sense of relief felt by all involved and praises the international and agency-wide effort leading to this point: "First and foremost, I am incredibly relieved that we have been able to identify the toxin and hopefully avoid any additional loss of life, and I am also immensely proud of the role CDC played in getting us here." Recalling the rapid containment of the recent E. coli outbreak, Gerberding adds, "This is science in action—this is what we do."
A Pattern Emerges, A Partnership is Formed
Beginning in late September, media headlines declared a "mystery illness" responsible for numerous deaths and almost two-dozen seriously ill patients in the Latin American nation. As Panama's Minister of Health, Camilo Alleyne, worked to keep people informed and calm, officials from his ministry and the Gorgas Memorial Institute of Health Research (GMIHR) in Panama City requested assistance from the CDC, Pan American Health Organization (PAHO), and U.S. FDA in tracking the unknown killer.
"From the start, this has taken a lot of effort from a lot of people," says Dr. Carol Rubin, chief of the Health Studies Branch, NCEH. "This amazing collaboration identified the probable cause of this syndrome within a remarkable 11 days of the initiation of the investigation by the Ministry of Health (MOH)."
Less than a month ago, there were far more questions than answers: Is it contagious? Is it somehow related to West Nile Virus? Dengue fever? Influenza? No one knew for sure. What was known was this: by September 20, doctors working in the Social Security hospital had recognized a pattern of cases and began to track, diagnose, and report them. Then, on September 28, the Social Security health care system reported the suspicious pattern to the Ministry of Health, which began coordinating a national response and requested international assistance. The illness—which started with diarrhea and fever and progressed to acute kidney failure, paralysis, and death—seemed to be striking mostly men over 60 whose only significant common denominators were standard treatments for high blood pressure, diabetes, or kidney disorders.
Closing in on a Killer
When Dr. Jorge Motta, director of GMIHR, first contacted CDC's Coordinating Office for Global Health (COGH) on October 2, the origin of the outbreak was unknown. COGH's Global Disease Detection (GDD) division immediately began coordinating CDC's response. A team was assembled pulling expertise from across the agency: NCEH; National Center for Zoonotic, Vector-Borne, and Enteric Diseases (NCZVED); and the Regional Office in Guatemala.
|As the CDC jet landed in Panama City, Panama, LT Jacob Wamsley III (l) was at the airport with packaged samples and specimens, collected by staff working through the night at Panama City hospitals. LCDR Eduardo Azziz Baumgartner, MD, MPH, from NCEH’s Division of Environmental Hazards and Health Effects, was on board to receive the samples and ensure their immediate delivery to CDC laboratories as soon as the plane returned to Atlanta.|
Dr. Schier led CDC's deployment team, which included two medical epidemiologists (one from CDC's Guatemala field station), an EIS-1 officer, a laboratorian, a neuro-epidemiologist, a bi-lingual epidemiologist, a risk communication specialist, a trainee from the Field Epidemiology Training Program, and an NCEH staff member already in Panama for a PAHO training course. They hit the ground running in Panama, quickly gathering medical samples from patients—as well as a variety of suspected sources for the possible poisoning—and sending them back to the agency's infectious-disease and environmental laboratories in Atlanta—sometimes within eight hours because of immediate access to CDC's own dedicated airplane. (Just a few years ago, shipment of SARS specimens on commercial carriers required 72-96 hours due to international clearances, paperwork required to ship specimens, and availability—all of which can contribute to delays or even failed receipt of specimens.)
Early evidence such as no clustering of illness within families and no healthcare providers getting sick suggested the event was not contagious. CDC's team and laboratories still tested specimens of kidney and nerve tissue for infectious diseases while simultaneously conducting urgent laboratory examinations of products such as high blood pressure medication and simple cough syrup found in patients' homes. Just nine days after the CDC team landed in Panama, DEG was isolated as the culprit.
Detective Work, Cooperation Solve the Riddle
So how had these patients come into contact with a substance associated with brake fluid and polyester resins? Thanks to solid epidemiological detective work and round-the-clock evidence gathering on the ground in Panama, the answer was found. Among the many anecdotal leads being pursued and household items being sent off to Atlanta and FDA labs, an epidemiologist from the Health Ministry first noted that cough syrup was another common factor among patients affected by what news reports were calling a "mystery illness."
|Camilo Alleyne, MD, Minister of Health for the Republic of Panama, and Jana Telfer, associate director for communication for NCEH/ATSDR and CDC risk communication advisor, discuss risk communication strategies to help the Panamanian community and news media better respond to the uncertainty of a developing outbreak with no known cause.|
"This incident amplifies the importance of international cooperation," says Jana Telfer, associate director for communication science, NCEH, who was on the ground in Panama to assist officials there with communications efforts. "The Ministry has done all the right things in this truly multi-national, multi-jurisdictional effort—first and foremost by requesting assistance from the international community."
Questions Yet to Be Answered, Parallels to the Past
The combined Health and Human Services (HHS) team now in Panama continues to investigate the source of the DEG contamination. This scenario is similar to the deadly DEG event that took place in Haiti between November 1995 and June 1996. In that episode, 109 children sustained a variety of toxic effects including acute renal failure. Of 87 children who stayed in Haiti, 85 died—a death toll of 98%. Of the 11 children evacuated to the United States, eight survived. An investigation initiated by Haiti's Ministry of Health, the University General Hospital in Port-au-Prince, PAHO, the Caribbean Epidemiology Center, and CDC determined that this outbreak was associated with DEG-contaminated glycerin in acetaminophen syrup. The investigation determined that roughly 80% of the children had consumed one of two locally produced preparations, which were found to contain DEG. The trace-back investigation, conducted in collaboration with U.S. FDA, found the contaminated glycerin in these syrups was imported from China. (For more on the Haiti outbreak, see www.cdc.gov/mmwr/preview/mmwrhtml/00043194.htm and http://jama.ama-assn.org/cgi/content/full/279/15/1175.)
Authorities at both FDA and CDC hope that the trace-back investigation now underway will ultimately reveal the origin of the DEG. Meanwhile, CDC's team in Panama continues to assist with ongoing surveillance for any new cases. While the agency is prepared to remain in Panama as long as necessary to help to fully contain and control the situation, team members are beginning to plan the transition process. This DEG investigation illustrates the value of international cooperation and partnership in addressing emerging health threats. Team members believe that both the science that created a breakthrough in the investigation and the quality of the international partnership will advance the practice of public health around the world.