Botulism Associated with Commercial Carrot Juice --- Georgia and Florida, September 2006 David Kirschke, MD Northeast Regional Office Epi Meeting 11/16/06.

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