US - CDC reports 63 dead, 749 infected with fungal meningitis in 20 states (Update Aug 5, 2013)

[Treyfish]

Re: US - 12 dead, 119 sick from suspected fungal meningitis as outbreak worsens

Deaths rise to 12 in rare meningitis outbreak
At least 119 sickened


Florida recorded its first death connected to the outbreak of a rare, noncontagious form of meningitis, raising the toll Tuesday to a total of 12 fatalities nationwide.
Earlier in the day, federal authorities reported 11 deaths and 119 persons becoming ill in the outbreak, the Centers for Disease Control and Prevention announced Tuesday. Those figures were an increase from Monday's count of eight deaths and 105 illnesses.

Florida health officials also reported a total of six cases connected to the outbreak -- all in Marion County.

That figure -- one more than federal officials have so far counted in Florida -- means that a total of 120 persons nationwide have become ill, according to state officials.

The outbreak is linked to contaminated steroid injections, and as many as 13,000 people may have received the medicine between May 21 and September 24, the CDC said.

The death of a 70-year-old Florida man occurred in July, prior to the discovery of the contamination, the state's health department said.

"Our disease investigation process di



Read more: http://www.wcvb.com/health/Deaths-ri...#ixzz28r4bWCaG

[Pathfinder]

Re: US - 11 dead, 119 sick from suspected fungal meningitis as outbreak worsens

<TABLE border=0 cellSpacing=0 cellPadding=5 width="100%"><TBODY><TR bgColor=#cccccc><TD vAlign=top align=left>PO Box 360
Trenton, NJ 08625-0360
For Release:
10/09/2012

</TD><TD vAlign=top align=right>Mary E. O'Dowd, M.P.H.
Commissioner

For Further Information Contact:
Office of Communications
(609) 984-7160


</TD></TR></TBODY></TABLE>

NJ Reports First Case Associated With Potentially Contaminated Steroid Medication

Today, the New Jersey Department of Health reported to the U.S. Centers for Disease Control and Prevention (CDC) its first case linked to an ongoing, multi-state outbreak of fungal meningitis associated with potentially contaminated steroid medication.

A 70-year-old Cumberland County man is hospitalized with presumptive fungal meningitis and is recovering. He received an injection with medication from one of the lots recalled by New England Compounding Center (NECC) located in Framingham, Mass. He developed headaches and went to the emergency room with fever and continued headaches. He is being treated with anti-fungal medication at South Jersey Healthcare Regional Medical Center at Vineland.

"Due to the fact that this is an ongoing investigation, physicians need to closely monitor patients who were administered steroid injections from the three recalled lots," said Health Commissioner Mary E. O'Dowd. "Symptoms include headaches, fever, nausea, neck stiffness, confusion and/or dizziness. Any patient who has had a steroid injection and is experiencing symptoms should seek immediate medical attention."
...
DOH has been in contact with six facilities that received the affected product and requested that they reach out to all patients who received injections of the recalled steroid medication (methylprednisolone actetate). Almost all of the approximately 650 affected patients in New Jersey have been notified.

"Affected health care facilities have been working diligently to respond to this recall," the Commissioner said. "I thank them for their efforts to offer assistance to their patients as quickly and effectively as possible during this ongoing investigation and response."

On September 25, 2012, NECC voluntarily recalled the following lots of methylprednisolone acetate (PF) 80mg/ml:. PF) 80 mg/ml Injection, Lot #05212012@68, BUD 11/17/2012 Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #06292012@26, BUD 12/26/2012. Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #08102012@51, BUD 2/6/2013.


Health care facilities in New Jersey that received this medication have removed the product from inventory. Those facilities are:

• Central Jersey Orthopedics Specialists, PC in South Plainfield
• Edison Surgical Center, Edison
• IF Pain Associates/Isaiah Florence, Teaneck
• Premier Orthopedics Surgical Assoc, LLC, Vineland
• Comprehensive Pain Management, Sparta
• South Jersey Healthcare, Elmer and Vineland

...
Full text:

http://www.state.nj.us/health/news/2012/approved/20121009a.html

[Giuseppe]

Re: US - 12 dead, 119 sick from suspected fungal meningitis as outbreak worsens

[Source: Michigan Department of Health, full text: (LINK).]

Michigan Confirms 25 Meningitis Cases, Including Three Deaths

Contact: Angela Minicuci (517) 241-2112 / FOR IMMEDIATE RELEASE: October 9, 2012



UPDATE: Additional information regarding the three Michigan deaths has become available.

The locations of residence for the three deaths are as follows:

• Genesee County - 56 year old woman
• Livingston County - 67 year old woman
• Washtenaw County - 78 year old woman

Aside from age, gender, and location of residence, the Michigan Department of Community Health cannot release any additional information regarding the three deaths in Michigan because of Health Information Protection laws.

*** Beginning tomorrow, Oct. 10, the Michigan Department of Community Health will be updating the fungal meningitis case count associated with the Centers for Disease Control and Prevention's multistate investigation at 3 p.m. daily online at http://www.michigan.gov/emergingdiseases/0,4579,7-186--287628--,00.html. ***



LANSING - The Michigan Department of Community Health (MDCH) is coordinating with the Centers for Disease Control and Prevention (CDC) and Food and Drug Administration on a multi-state investigation of cases of fungal meningitis among patients who received steroid injections. Michigan currently has 25 confirmed meningitis cases associated with this outbreak, including three deaths. As of Oct. 9, 119 cases and 11 deaths have been reported from 10 states.

As this is a developing investigation, the number of cases is expected to increase. The age range of current identified cases is 46-89 years old. Of the three deaths, all were females ages 56, 67, and 78. An individual with a joint infection was incorrectly reported yesterday and is no longer counted as a case. All cases are linked to the four facilities in Michigan that received a potentially contaminated product, suspected to be the cause of the outbreak.

Interim data show that infected patients received an injection with one of three lots of preservative-free methylprednisolone acetate prepared by the New England Compounding Center (NECC), located in Framingham, Mass. The four Michigan facilities that received shipments of these recalled lots are working with MDCH to notify patients who may have received this product between May and October and may be at risk for developing illness.

The facilities are:

• Michigan Neurosurgical Institutes in Grand Blanc
• Michigan Pain Specialists in Brighton
• Neuromuscular and Rehabilitation in Traverse City
• Southeast Michigan Surgical Hospital in Warren

These fungal infections are not transmitted person-to-person.

Infected patients have become ill approximately one to four weeks following their injection with a variety of symptoms.

Patients who received epidural injections have presented with symptoms including fever, new or worsening headache, neck stiffness, sensitivity to light, and/or a new neurological deficit such as weakness or numbness, consistent with deep brain stroke. Those receiving joint injections may present with increasing pain, redness or swelling at injection site. Some patients' symptoms were very mild in nature.

Any individual who received a steroid injection at one of the four Michigan facilities and is experiencing the symptoms described above should immediately contact their physician or seek medical attention.

Additional information about the Michigan investigation can be found at www.michigan.gov/mdch.


For more information about the CDC investigation, visit www.cdc.gov/hai/outbreaks/meningitis.html.

-
-------

[Giuseppe]

Re: US - 12 dead, 119 sick from suspected fungal meningitis as outbreak worsens

[Source: Florida Department of Health, full PDF document: (LINK). Edited.]


Rick Scott, Governor / John H. Armstrong, MD, State Surgeon General - Office of the State Surgeon General, 4052 Bald Cypress Way, Bin A00 ? Tallahassee, Florida 32399-1701, Phone: (850) 245-4444 ? Fax: (850) 922-9453 ? http://www.floridashealth.com

FOR IMMEDIATE RELEASE

Contact: DOH Communications, Jessica Hammonds, (850) 245-4111
October 9, 2012

FIRST CONFIRMED DEATH IN FLORIDA

~Review of case linked to meningitis~



TALLAHASSEE ? The Florida Department of Health (DOH) has confirmed that a 70-year old male has died as a result of the fungal meningitis outbreak currently being investigated.

The individual died in July, prior to the discovery of the contaminated lots of New England Compounding Center (NECC) methylprednisolone acetate used for epidural back injections.

A 78-year-old man has also been identified with fungal meningitis related to a contaminated back steroid injection.

Taken together, there are six cases to date in Florida, all in Marion County, with one death.

"We are saddened by this news and share our condolences with his family and friends," said State Surgeon General and Secretary of Health Dr. John Armstrong.

"Our disease investigation process discovered the link between this individual's death and a contaminated steroid injection. We will continue to work closely with our health partners to ensure that individuals who may have received the contaminated medicine are treated, and we have ensured that no medications from NECC, steroid or otherwise, are available in Florida."

The Department has visited all 78 facilities in the state to urge them to stop using any product from NECC since January 1, 2012.

The contaminated methylprednisolone lots from NECC are 05212012@68, 06292012@26 and 08102012@51.

All contaminated lots and NECC products should be returned in accordance with FDA recall procedures.

We will continue to update our websites at http://newsroom.doh.state.fl.us/ or http://www.myfloridalicense.com/dbpr/ .

We have set up a toll-free hotline at 1-866-523-7339 for those who may have additional questions.

To view FDA?s product list as of Oct. 9, please visit: http://www.fda.gov/DRUGS/DRUGSAFETY/ucm322752.htm.

To view the CDC?s list of Florida facilities involved, please visit http://newsroom.doh.state.fl.us/wp-content/uploads/newsroom/2012/10/10-06-12-FLORIDA-LIST-WITH-NECC.pdf.

The Florida Department of Health works to protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts.


###



-
-------

[Treyfish]

Re: US - 12 dead, 119 sick from suspected fungal meningitis as outbreak worsens

Meningitis outbreak: Incubation period is longer than first thought
New cases may show up through early November
2:51 AM, Oct 10, 2012

The incubation period for some patients who received tainted epidural steroid injections is longer than doctors initially realized, which means new cases of fungal meningitis may continue to appear through early November, state health officials said Tuesday.

And a recently identified fungus, exserohilum, is now indicated as the cause of nearly all of the fungal meningitis cases in Tennessee ? a number that rose to 39, including six deaths, on Tuesday.

Based on analysis of Tennessee patients, a range for development of symptoms is six to 42 days ? and ?some experts believe vigilance for up to three months will be necessary,? Health Commissioner John Dreyzehner said.

That recommendation comes out of an ?abundance of caution,? he said.

Previously, the incubation period had been estimated at two to 28 days. An initial case appeared to have a two-day incubation period, but that was misleading because the patient had multiple epidural injections and probably was infected before the most recent shot, Dreyzehner said.

To this point, the average time between epidurals and appearance of symptoms for Tennessee patients has been 16 days.

?We are investigating this carefully and will be keeping in touch with those patients who may be at risk for infection,? Dreyzehner said.

?Until we have evidence that the incubation period has passed, it?s important to understand the incubation period is an outer limit based on the best available science.

?Opinions and science could change as more information is gathered.?

Dreyzehner also said that patients exposed to the potentially tainted steroid can?t rely on a spinal tap to indicate they will remain free of meningitis because infection could develop later.

Normal results from a diagnostic lumbar puncture ? which is being used to identify fungal meningitis cases ? ?is an indication of the (patient?s) status at that point in time, but not going forward,? Dreyzehner said. ?Certainly, if they worsen, another lumbar puncture might be indicated.?

New fungus at fault
Exserohilum ? a mold found in soil and on plants, especially grasses and rotting wood ? has now been identified as the primary cause of infections in Tennessee patients. Another fungal species, aspergillus, has been confirmed in only one Tennessee case, Dreyzehner said.

Exserohilum infections are ?so rare that most physicians never see it in a lifetime of practicing medicine,? Dreyzehner said.

Nationally, the number of epidural steroid reported deaths is 12 and the total meningitis cases climbed to 121.

The Centers for Disease Control and Prevention reported 119 cases and 11 deaths midday Tuesday, but late in the day the Florida Department of Health confirmed two more cases and said a 70-year-old man there has died of fungal meningitis. His death, the first to be reported from Florida, occurred in July but is believed to be linked to the current outbreak, the state said.

Ten states are now reporting cases, including a new case in previously unaffected New Jersey. Tennessee still leads the country in the total number of cases and deaths. Michigan is second with 25 cases and three deaths; Virginia is next with 24 cases and one death.

In all, about 1,000 Tennessee patients are believed to be at risk, but health officials have said most will not develop fungal meningitis. The attack rate is estimated at slightly less than 5 percent, said David Reagan, chief medical officer for the Tennessee Department of Health ? though that number changes slightly as case analysis continues.

However, officials said there is no way to exclude a patient from the risk pool based on age, illnesses or any demographic characteristic.

Any patient who received epidural steroid injections of methylprednisolone acetate for back or neck pain at Saint Thomas Outpatient Neurosurgery Center from June 27 to Sept. 28 is potentially at risk. So are patients receiving the injection at the PCA Pain Care Center of Oak Ridge or Specialty Surgery Center in Crossville from July 1 to Sept. 28.

They should continue to watch for symptoms including a stiff neck, worsening headache or fever, Dreyzehner said.http://www.tennessean.com/article/20...101/1969/NEWS?

[sharon sanders]

Re: US - 11 dead, 119 sick from suspected fungal meningitis as outbreak worsens

Join us for an upcoming COCA Conference Call, where CDC subject matter experts will discuss topics of interest to clinicians. If you have questions or trouble accessing this COCA Call/Webinar, please
e-mail coca@cdc.gov.

Multistate Meningitis Outbreak Investigation: Information and Guidance for Clinicians

= No Continuing Education

Date: Wednesday, October 10, 2012 - TOMORROW
Time: 2:00 - 3:00 pm (Eastern Time)
Join by Phone:
Dial-In Number: 888-790-6180
Passcode: COCA
Overview:

The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) continue to work closely with state public health departments on a multistate investigation of fungal meningitis among patients who received an epidural steroid injection. These cases are associated with a potentially contaminated steroid medication prepared by New England Compounding Center (NECC), located in Framingham, Mass. During this COCA Call, CDC subject matter experts will review current epidemiology of the outbreak, describe clinical presentation and features of fungal meningitis, and review CDC?s recommended treatment guidance.

Presenter(s):

Melissa K. Schaefer, MD
Medical Officer
Division of Healthcare Quality Promotion
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease and Control and Prevention

Tom Chiller, MD, MPH
Medical Epidemiologist
Division of Foodborne, Waterborne & Environmental Diseases
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease and Control and Prevention

This is an audio only call. There are no slides or handouts for this call. The recorded call audio and transcript will be available a few days after the live call. To view the record call materials please visit the call webpage at http://emergency.cdc.gov/coca/calls/...nfo_101012.asp

Notes from conference:


On CDC conferece call now regarding #USA recalled steroid injections. Now speaking: Melissa K. Schaefer, MD - #meningitis #stroke #fb

About 13,000 injections from 3 recalled lots. As of now there are 12 known deaths & 137 cases. #meningitis #stroke #fb

Referring everyone to CDC website http://www.cdc.gov/hai/outbreaks/meningitis.html ? #meningitis #stroke #fb

All patients who received injection from any of 3 recalled lots after May 21 should b contacted 2 determine status #meningitis #stroke #fb

Investigation is evolving. Please check website frequently for most recent guidance etc. http://www.cdc.gov/hai/outbreaks/meningitis.html ? #meningitis #stroke #fb

New Update re: Case Definitions for #Meningitis and Septic Arthritis here: http://www.cdc.gov/HAI/outbreaks/cli..._outbreak.html ? #stroke #fb

Now speaking: Tom Chiller, MD, MPH Medical Epidemiologist Division of Foodborne, Waterborne & Environmental Diseases #meningitis #stroke #fb

Clinical info is being evolved as patients are being discovered. Most patients presenting w/headache. #meningitis #stroke #fb

1/3 w/neck stiffness & pain Many cases r "mild".Anyone who has abnormal white blood csf count >5 is to b evaluated. #meningitis #stroke #fb

Updated Clinician Guidance here: http://www.cdc.gov/hai/outbreaks/clinicians/index.html ? #meningitis #stroke #fb

Interim Treatmnt 4 CNS &/or Parameningeal Infections Assoc w/Injection of Contaminated Steroid http://www.cdc.gov/hai/outbreaks/cli...dance_cns.html ? #meningitis #stroke #fb

At this time, CDC does not recommend initiation of antifungal prophylaxis in exposed patients who are asymptomatic. #meningitis #stroke #fb

Now discussing meds: voriconazole, liposomal amphotericin B, Please see site: http://www.cdc.gov/hai/outbreaks/cli...dance_cns.html ? #meningitis #stroke #fb

Adequate duration of antifungal treatment is unknown but likely will require prolonged therapy (e.g., months). #meningitis #stroke #fb

Incubation period appears to be 1-4 weeks, but also shorter & longer too. Patients are not "safe" after 4 weeks. #meningitis #stroke #fb

Exserohilum is a black mold and evaluating further for recommendations for treatment. #meningitis #stroke #fb

Most deaths were from stroke. In 1 case exserohilum was directly invading into tissue causing stroke. #meningitis #stroke #fb

Some reports of incubation of 40 days and beyond. Still an unknown. #meningitis #stroke #fb

1 emergency room doctor n Tenn reports that he has seen 65 patients in last few days-all have presented w/headaches. #meningitis #stroke #fb

This concludes today's COCA conference with over 2000 listeners.

[Treyfish]

Re: US - 12 dead, 137 sick from suspected fungal meningitis as outbreak worsens

Multistate Outbreak of Meningitis Associated with Injection of Potentially Contaminated Steroid Products
Case Definitions for Meningitis and Septic Arthritis
October 10, 2012 12:00 PM EDT

A person who received an injection with methylprednisolone acetate produced by the New England Compounding Center (NECC) who has developed any of the following:

Fungal meningitis or non-bacterial and non-viral meningitisa of sub-acute onset, following epidural injection on and after May 21, 2012.
Basilar stroke following epidural injection after May 21, 2012b, who has not received a diagnostic lumbar puncture.
Evidence of spinal osteomyelitis or epidural abscess at the site of injection following epidural or sacroiliac injection after May 21, 2012.
Septic arthritisc or osteomyelitis of a peripheral joint (e.g., knee) diagnosed following joint injection after May 21, 2012.

a Clinically diagnosed meningitis meaning one or more of the following symptoms: headache, fever, stiff neck, or photophobia and a cerebrospinal fluid (CSF) profile showing pleocytosis (>5 white blood cells, adjusting for presence of red blood cells) regardless of glucose or protein levels.

b These people, if possible, should have a lumbar puncture.

c Clinically diagnosed septic arthritis meaning new or worsening pain with presence of effusion or new or worsening effusion.

Suspect Case:
A person who has developed an infection of a normally sterile site (e.g., blood, CSF, pleural fluid, peritoneal fluid, pericardial fluid, surgical aspirate, bone, joint fluid, or internal body site [e.g., lymph node, brain]) following use of a product labeled as sterile prepared by the New England Compounding Center (NECC).http://www.cdc.gov/hai/outbreaks/cli..._outbreak.html

[Emily]

Re: US - 12 dead, 137 sick from suspected fungal meningitis as outbreak worsens

http://mynorthwest.com/?nid=789&sid=1231727

Source: Health News
Originally published: Oct 5, 2012 - 3:20 pm
Intense pain, confusing diagnosis mark meningitis

Associated Press

NASHVILLE, Tenn. (AP) - A week after her annual steroid shot for back pain, Janet Russell began getting unbearable headaches. A fever followed. Doctors admitted her to the hospital, but couldn't say what was wrong.

"She is screaming and nothing is helping. They have already given her medication, but nothing is helping," said Russell's daughter, Tracy Barreiro. "It continually escalated."
[snip]
Russell's husband, Robert, said his wife's doctor told him early on, "`You can call it meningitis, you can call it anything you want to, but quite frankly, nobody, not anybody in this country, knows what it is at this point because we have never seen it.'"

"They didn't really tell us it was a fungal meningitis until the CDC told them," he said....

[Catbird]

Re: US - 12 dead, 137 sick from suspected fungal meningitis as outbreak worsens

I posted a few days back about the business relationship between Ameridose and NECC. So, I've been keeping an eye out for reports that the investigation is widening to include looking at Ameridose.

"2nd firm agrees to temporary shutdown in outbreak"

"A Massachusetts company run by the same executives who operated a specialty pharmacy linked to a fatal meningitis outbreak has agreed to temporarily shut down for inspection by state and federal regulators.

Ameridose is located in Westborough, Mass. The New England Compounding Center, which produced a steroid linked to the outbreak, is in Framingham. Both firms are run by Barry Cadden and Greg Conigliaro.

Ameridose provides sterile medication in prefilled oral syringes to about 3,000 hospitals nationwide. It opened its doors in 2006, eight years after NECC opened.

The Massachusetts Department of Public Health says Ameridose agreed to the shutdown until inspections by state regulators and the U.S. Food and Drug Administration are completed.

There is no recall of Ameridose products."

[sharon sanders]

Re: US - 12 dead, 137 sick from suspected fungal meningitis as outbreak worsens

Unfortunately it appears we need to open a separate forum for this developing situation:

1) The CDC recommendation is that anyone with a headache who had an inoculation from any of the 3 recalled lots should be evaluated for fungal meningitis,

2) It appears meningitis caused by exserohilum fungus can be a chronic illness scenario,

3) With 13,000 inoculations there could be hundreds of cases developing over the next months as the fungus presents itself.

[Catbird]

Re: US - 12 dead, 137 sick from suspected fungal meningitis as outbreak worsens

Unfortunately it appears we need to open a separate forum for this developing situation:

1) The CDC recommendation is that anyone with a headache who had an inoculation from any of the 3 recalled lots should be evaluated for fungal meningitis,

2) It appears meningitis caused by exserohilum fungus can be a chronic illness scenario,

3) With 13,000 inoculations there could be hundreds of cases developing over the next months as the fungus presents itself.

Something that isn't getting much publicity is that the case definition now also includes septic arthritis.

CDC Case Definition as of Oct. 10:

"Septic arthritisc or osteomyelitis of a peripheral joint (e.g., knee) diagnosed following joint injection after May 21, 2012."


This could have a significant effect on the numbers.

[sharon sanders]

Re: US - 12 dead, 137 sick from suspected fungal meningitis as outbreak worsens

We are going to start a thread per state to better keep track of local news and health department notices.

Here is the new Tennessee thread:

Tennessee - Outbreak of fungal meningitis: 6 deaths, 39 cases

[Catbird]

Re: US - 12 dead, 137 sick from suspected fungal meningitis as outbreak worsens

I'm not trying to sensationalize or politicize this, as the situation is already bad enough, but I think this info is important enough to post. I have not found confirmation from other sources yet but I suspect it's out there and just needs a little digging.

From a CNN article "Meningitis outbreak highlights failed oversight efforts":

"...At the same time, the FDA lacks clear authority for ensuring the safety of these products and last updated its guidance for (the) industry in 2002."

The FDA has been working on new guidelines since at least 2006, but the effort is "still in progress," FDA spokeswoman Erica Jefferson said.

Currently, the FDA does not have jurisdiction over compounding pharmacies until there is a problem. FDA officials say they have been fighting to change that for more than 20 years.

The compounding pharmacy industry has challenged those efforts, and courts have ruled that individual state health departments are in charge.

"These facilities are inspected upon initial licensure and in response to complaints," said Alec Loftus of the Massachusetts Department of Public Health.

...The center's building in Framingham is also home to a garbage compactor and recycling center. CNN observed a medical waste truck making a drop, as well as piles of garbage, boxes, and old mattresses on the back side of the pharmacy compound building. Both companies are owned by the same people.

If the site had been accredited, officials would have examined the facilities and considered whether there are concerns about the site sharing space with a garbage facility, Gupta said."

[sharon sanders]

Re: US - 12 dead, 138 sick from suspected fungal meningitis as outbreak worsens

Idaho announces 1 case. US total now 138.

Please see:

Idaho - Outbreak of fungal meningitis - 1 case

[Catbird]

Re: US - 12 dead, 138 sick from suspected fungal meningitis as outbreak worsens

Confirmation of the placement of the waste facility.

This Reuters article also has a lot of further detail on the business relationship between NECC, Ameridose and the distributing company Alaunus Pharmaceutical which is also owned by the same people.


"...Ameridose LLC agreed to close down for 12 days while state and federal officials investigate the New England Compounding Center, which distributed thousands of vials of a contaminated steroid made at a shabby brick complex next to a waste and recycling operation in a western suburb of Boston.

The pharmacies are owned by Gregory Conigliaro, an engineer, and his brother-in-law, Barry Cadden, a pharmacist who was in charge of pharmacy operations at NECC. The waste and recycling facility is another of Conigliaro's business interests."