NASHVILLE, Tenn. (AP) -- Tennessee health officials report four more people have been sickened by an outbreak of fungal meningitis.
State Health Commissioner John Dreyzehner said in a press conference Friday that there are 29 cases in the state and three deaths.
The new cases raise the total to 39 people in six states who contracted the rare meningitis after receiving steroid injections for back pain. Five have died.
The commissioner repeated three times that "the evidence indicates this is a product issue." He said the clinics administering the shots had no way of knowing the injections were contaminated.
The Massachusetts pharmacy that supplied the steroid has recalled nearly 17,000 lots of the medical while federal officials have warned health care providers not to use any products from the New England Compounding Center.
By Tom Wilemon, Nicole Young, Brian Haas and Walter F. Roche Jr. The Tennessean
All of the patients who received epidural steroid injections at three Tennessee pain clinics from July 1 to Sept. 28 are believed to have been treated with recalled medicine, state health officials said Thursday.
However, that does not mean every vial of medicine was contaminated or that all of the more than 1,000 Tennessee patients who received the pain treatment will get sick, said Dr. John Dreyzehner, state health commissioner.
The recalled medicine included 17,676 single-dose vials, distributed to about 75 facilities in 23 states, officials said.
So far, 35 people who got the possibly contaminated injections from those vials have come down with the rare fungal meningitis, with a total of five deaths in Tennessee, Virginia and Maryland.
Dreyzehner said the "attack rate" -- the actual percentage of epidural patients who have gotten sick thus far -- is "far less than 100 percent ... actually in the single digits."
On Thursday, federal officials announced they had found fungal contaminants in an unopened vial of steroid medicine at the Massachusetts compounding laboratory that has been linked to the national outbreak.
The toll is highest in Tennessee, where 25 people have gotten sick and three have died.
The first, a 78-year-old man, died Sept. 17 at Vanderbilt University Medical Center, according to Vanderbilt spokeswoman Melissa Stamm. The Tennessean was unable to obtain his name Thursday night.
Less than two weeks later, 55-year-old Thomas Warren Rybinski of Smyrna died at Vanderbilt. Rybinski worked at General Motors for more than 35 years, according to his obituary. His brother in Michigan, Bob Rybinski, said the death was too fresh to talk about when reached by phone Thursday evening. He is survived by his wife, Colette, a daughter and two sons.
Stamm confirmed that Rybinski died of aspergillus meningitis on Sept. 29. Aspergillus is a mold commonly found in the environment.
The third to die was Diana Reed, 56, of Brentwood, whose family confirmed through attorneys Thursday that Reed was told she had meningitis.
She was admitted to Saint Thomas Hospital with severe headaches during the weekend of Sept. 23 and died there around 2:30 p.m. on Wednesday, said Bill Lassiter and John Belcher of the law firm of Lassiter, Tidwell and Davis.
Saint Thomas spokeswoman Amanda Anderson confirmed that Reed died while she was being treated at the hospital.
The lawyers also confirmed that Reed had undergone a series of injections for neck pain at the Saint Thomas Outpatient Neurosurgery Center, which has closed its doors since the outbreak. An autopsy was scheduled Thursday morning.
Reed was the wife of Wayne Reed, namesake of The Wayne Reed Christian Childcare Center on Lindsley Avenue in Nashville.
Her friend Pat Ward of Brentwood said Reed was devoted to her husband, who has been battling amyotrophic lateral sclerosis, also known as Lou Gehrig's disease, for the past 20 years.
"She was his rock," said Ward, who spent every day with Reed in the hospital while she fought meningitis. "They worked together three days a week, and she would get him up every morning, put him in the wheelchair and take him to work."
More cases likely
Nationwide, the number of sickened will rise, said Dr. Benjamin Park with the U.S. Centers for Disease Control and Prevention.
"However, it is possible that if patients are identified soon and started on appropriate antifungal therapy, some of the unfortunate consequences may be avoided," Park said.
One antifungal is voriconazole, but it has severe toxic side effects that can damage the kidney and liver. And officials with the CDC continue testing to determine the exact contaminants, which can make a difference in what medicine is prescribed.
All those sickened received epidural steroid injections, a treatment for pain. In Tennessee, three sites -- Saint Thomas in Nashville, the Specialty Surgery Center in Crossville and PCA Pain Care Center of Oak Ridge -- had vials of the recalled medicine.
Dr. Marion Kainer, director of health-care-associated infections for the state Department of Health, said all the patients treated at those three clinics during the "window of concern" from July 1 to Sept. 28 are believed to have received injections from medicines with recalled lot numbers.
Fungal meningitis is not contagious. Its symptoms include headaches, fever, numbness, stiff neck, slurring of speech and confusion. Unlike bacterial meningitis, the symptoms manifest themselves slowly.
Investigators began inspections Monday at the New England Compounding Center in Massachusetts, which was the source of the recalled medicine, and observed "foreign particulate matter" in an unopened vial, said Mutahar Shamsi, the New England district director for the U.S. Food and Drug Administration.
The material was identified as a fungal contaminant, said Ilisa Bernstein, director of the office of compliance for the FDA.
"For the sake of time, because everything is unraveling and unfolding very quickly, we have not been able to do further microbial testing of additional vials," Bernstein said.
More tests are under way to identify the specific type of fungus.
At a news conference in Boston, Dr. Madeleine Biondolillo, director of the Bureau of Healthcare Safety for the Massachusetts Health Department, said that 17,676 single-dose vials were included in the three recalled lots. They were distributed by the company between July and late September.
"Hundreds have been returned," she said, adding that she did not have an exact number.
She said that as a precautionary measure and to be "abundantly cautious," the company was recalling all similar drugs it had issued. The FDA advised health facilities across the nation to discard all products from the Massachusetts compounding pharmacy.