INDIANAPOLIS (AP) — Indiana heath officials say four people have now died from fungal meningitis linked to injections of a recalled back pain medication.

State Department of Health spokesman Ken Severson also said Monday Indiana now has 51 cases of the rare disease.

Officials didn’t say where the fourth death occurred. Severson says officials can’t discuss individual cases due to privacy laws.

Elkhart County’s health officer has said three deaths are linked to the northern Indiana county.

The state health agency has said six Indiana clinics received the tainted steroids, including the OSMC Outpatient Surgery Center in Elkhart. The tainted medication also went to clinics in Columbus, Evansville, Fort Wayne, South Bend and Terre Haute.

The tainted steroids have been traced to the New England Compounding Center of Framingham, Mass.