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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 neuro-transmitter (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 outbreaks, 1950-1996
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%)*
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 B (59%)
Type E (84%)
Type A (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%)
MMWRs
Other Risk Factors
• Uneviscerated, Salt-Cured Fish Product
• Home-pickled eggs
• Home-canned bamboo shoots
• Black tar heroin (wound botulism)
• Fermented beaver
• Beached whale
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
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