Transcript Slide 1

Botulism Associated with
Commercial Carrot Juice --Georgia and Florida,
September 2006
David Kirschke, MD
Northeast Regional Office
Epi Meeting 11/16/06
Setting
• September 8: Georgia Division of
Public Health notified of 3 suspected
cases of foodborne botulism
• Three patients admitted to local
hospital with cranial nerve palsies and
progressive descending flaccid
paralysis resulting in respiratory failure
• Patients had shared meals on
September 7
Outbreak
• Three patients consumed
juice from same 1-liter bottle
of Bolthouse Farms carrot
juice
• Bottle had "best if used by"
date of September 18, 2006
• Botulinum toxin type A was
identified in serum and stool
of all 3 patients
• Leftover carrot juice also
tested positive for botulinum
toxin type A
FDA Investigation
• Bolthouse Farms, Inc., manufacturing
plant in Bakersfield, California
• Tested other bottles of implicated brand
of carrot juice, including bottles from
different lots
• All were negative for botulinum toxin
FDA Consumer Advisory
• Lapse in refrigeration during transport
or storage was suspected
• September 17, FDA issued consumer
advisory on importance of keeping
carrot juice refrigerated
•
“However, information obtained from patient interviews regarding storage and
transport of the carrot juice did not confirm mishandling by the patients.”
Outbreak
• September 25: Florida Department of Health notified
of patient hospitalized with respiratory failure and
descending paralysis
• Botulinum toxin type A was identified in serum
• 450-mL bottle of Bolthouse Farms carrot juice was
found by family member in hotel room where patient
had been staying
• No refrigerator
• “Best if used by" date of September 19 and different
lot number than Georgia cases
• Botulinum toxin type A was identified in carrot juice
Recall
• Bolthouse Farms Carrot Juice
distributed in all 50 states, Mexico,
Canada, and Hong Kong
• September 29, FDA warned consumers
not to drink Bolthouse Farms carrot
juice with "best if used by" dates of
November 11, 2006
• Bolthouse Farms issued a voluntary
recall
Syndromes
• Foodborne botulism
– Ingestion of foods contaminated with toxin
• Wound botulism
– Wound colonization and toxin production
• Infant botulism
– Intestinal colonization and toxin production
• Adult intestinal toxemia botulism
– Intestinal colonization and toxin production
Differential Diagnosis
• Includes Guillian-Barré Syndrome,
myasthenia gravis, stroke, tick
paralysis
• Outbreak setting diagnosis more
evident
Toxin Effect
• Block neurotransmitter
(acetylcholine)
• Neuromuscular
junction
• Blockade result in
flaccid paralysis
• Most potent toxins
known (lethal oral
dose = 70µg)
Clinical Manifestations
• All cause same
clinical syndrome
– Symmetric cranial
nerve palsies
– Descending,
symmetric flaccid
paralysis
– Respiratory
compromise
– Death
Ptosis and facial paralysis
Foodborne Botulism
• Uncommon disease
– 9 foodborne outbreaks / yr with 2.5 cases /
ob
– 23 cases / yr
• Caused by several types of Clostridium
botulinum
• Type A (56%), B (21%), E (22%), F (1%)*
Foodborne botulism outbreaks, 1950-1996
Toxin Production
• C botulinum forms heat-resistant
spores
• Spores germinate and produce toxin:
– Anaerobic milieu
– Non-acidic pH
– Low salt / sugar
– Temperature 4°C-121°C
Geographic Distribution of Foodborne
Botulism by Type, 1950-1996
Type A
(59%)
Type E
(84%)
Type B
(59%)
Foodborne Botulism
• Named for association with home-made
sausage (botulus in Latin)
• Associated with home-canned foods
including green beans, asparagus, beets,
and corn
• Toxin produced in food before consumption
• Toxin inactivated by heating to 85°C x 5 min
• Spores heat resistant and commonly
ingested without causing illness
Risk Factors for Foodborne
Botulism
• Home-canned foods (65%)
– Vegetables, fruits, meat products
• Commercially processed foods (7%)
– Pot pies, restaurant food
• Unknown source (28%)
Other Risk Factors
• Uneviscerated, SaltCured Fish Product
• Home-pickled eggs
• Home-canned bamboo
shoots
• Black tar heroin (wound
botulism)
• Fermented beaver
• Beached whale
MMWRs
Infant Botulism
• Most common form (~80-100 cases / yr)
• Children aged <1 year
• Normal competing bowel flora not fully established
• C botulinum colonization of intestines with toxin
production
• Honey a risk factor (≤ 20%)
• Newly licensed human-source antitoxin
– Avoid hypersensitivity to equine serum
– Efficacy of equine antitoxin not proven in infants
• With appropriate care survival ~100% (+/- antitoxin)
Wound Botulism
• Contamination of wounds with C
botulinum
• Toxin produced in anaerobic wound
• Wound often unimpressive (boil)
• Associated with Western US and IVDU
(skin-popping and black-tar heroin)
• Syndrome similar to foodborne
Other Syndromes
• Inhalational – intentional release of
aerosolized toxin
• Iatrogenic – injection of toxin for
cosmetic / therapeutic indications
Protocols for clinicians
evaluating suspected cases
of botulism
• For suspected foodborne botulism, wound
botulism, or botulism of unknown source,
health department should be contacted via
24-h emergency telephone number;
– If no response, CDC’s Emergency Operations
Center should be contacted (770-488-7100)
• For suspected infant botulism occurring in
any state, the California Department of
Health Services, Infant Botulism Treatment
and Prevention Program should be contacted
(510-540-2646)
Laboratory Confirmation
• Demonstration of toxin in serum,
gastric contents, stool, or food
– Bioassay (injected into mice)
• C botulinum in stool or wound for
wound / infant botulism
• Clinical / public health management
based on clinical diagnosis
Treatment
• Supportive intensive care
– Mortality rate decreased from 70% to 5%
• Botulinum antitoxin
– Neutralizes only unbound toxin
– Arrests but does not reverse paralysis
Thank You