A Series of Unfortunate Events – How One Company’s Mishandling of Vaccine Led to a Mycobacterium fortuitum Outbreak in Three U.S. States (TED-style talk)

  • During this investigation of a multi-state outbreak of non-tuberculous mycobacterium (NTM) infections, we identified numerous issues with vaccine handling and storage at one company, which ultimately led to over 100 injection-site infections among vaccine recipients in three states. During the investigation, additional evidence was found to support the Kentucky Department for Public Health making a public recommendation that anyone who received a vaccination from this company be revaccinated, which was estimated to affect more than 1,000 people.
  • This investigation took place during flu season and during an on-going hepatitis A outbreak, which both needed widespread vaccination efforts. Not only were the reported NTM infections serious, requiring multiple medical treatments such as incision and drainage or surgeries, but it is also very likely that all of the vaccine administered by this company was ineffective and did not provide any protection to the recipients.
  • This investigation highlights the need for continued provider education and stricter requirements regarding who can administer vaccines. It also brings attention to the unique laws in each state that regulate vaccines and the administration of vaccines. Following the investigation, our primary focus is to propose and advocate for policies that support continued vaccine access AND increased vaccine safety.
Quote from the Disease Detective

“The infections people experienced during this outbreak were unacceptable and serve as a reminder that we can and must do more to prevent the mishandling of one of the most important inventions in modern history – vaccines. Given the nature of this investigation and potential legal implications, we faced a lot of challenges that we don’t usually face during outbreak investigations. We had to be creative and persistent in our efforts to understand how the outbreak happened and make sure affected people and their doctors had the information they needed.”

– Erin Blau, DNP, EIS Class of 2018

EIS officer collects environmental samples from a clinic[JPG - 68 KB]

EIS officer Erin Blau, DNP, MSN (right), collects environmental samples from a clinic during an investigation of an outbreak of non-tuberculous mycobacterium infections

EIS officer Erin Blau, DNP, MSN, collects environmental samples[JPG - 86 KB]

Erin Blau 2: EIS officer Erin Blau, DNP, MSN, collects environmental samples from a clinic during an investigation of an outbreak of non-tuberculous mycobacterium infections

Contact Information

CDC Media Relations
(404) 639-3286

Conference Information
Erin Blau


Erin Blau, DNP, MSN,
EIS Class of 2018
Kentucky Department of Public Health

Education: DNP: University of Colorado, Denver, 2017
MPH: University of Colorado, Denver, 2015
BSN: Saint Olaf College, 2013

Work Experience: Registered Nurse – Study Coordinator, Denver Public Health, Denver,CO, 2017-Present
Public Health Nurse – HIV Coordinator, Jefferson County Public Health,Lakewood, Colorado, 2014-2017
Clinical Nurse Scholar, University of Colorado, Aurora, Colorado, 2016-2016
Teaching Assistant, University of Colorado, Aurora, Colorado, 2016-2016
Research Assistant, Denver Public Health, Denver, Colorado,2014-2015
Registered Nurse, Professional Pediatric Home Care, Centennial, Colorado, 2013-2015
Community Health and Wellness Intern, Centura Health, Englewood, Colorado, 2014-2015
Registered Nurse, Kaiser Permanente