1. 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

2. 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

3. 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

4. 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

5. 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.”

6. 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

7. 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

8. Syndromes Foodborne botulism Wound botulism Infant 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

9. Differential Diagnosis
Includes Guillian-Barré Syndrome, myasthenia gravis, stroke, tick paralysis
Outbreak setting diagnosis more evident

10. Toxin Effect Block neuro-transmitter (acetylcholine)
Neuromuscular junction
Blockade result in flaccid paralysis
Most potent toxins known (lethal oral dose = 70µg)

11. Clinical Manifestations
All cause same clinical syndrome
Symmetric cranial nerve palsies
Descending, symmetric flaccid paralysis
Respiratory compromise
Death
Ptosis and facial paralysis

12. Foodborne botulism outbreaks, 1950-1996
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,

13. 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

14. Geographic Distribution of Foodborne Botulism by Type, 1950-1996
Type B (59%)
Type E (84%)
Type A (59%)

15. 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

16. Risk Factors for Foodborne Botulism
Home-canned foods (65%)
Vegetables, fruits, meat products
Commercially processed foods (7%)
Pot pies, restaurant food
Unknown source (28%)

17. Other Risk Factors Uneviscerated, Salt-Cured Fish Product
Home-pickled eggs
Home-canned bamboo shoots
Black tar heroin (wound botulism)
Fermented beaver
Beached whale
MMWRs

18. 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)

19. 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

20. Other Syndromes
Inhalational – intentional release of aerosolized toxin
Iatrogenic – injection of toxin for cosmetic / therapeutic indications

21. 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 ( )
For suspected infant botulism occurring in any state, the California Department of Health Services, Infant Botulism Treatment and Prevention Program should be contacted ( )

22. 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

23. Treatment Supportive intensive care Botulinum antitoxin
Mortality rate decreased from 70% to 5%
Botulinum antitoxin
Neutralizes only unbound toxin
Arrests but does not reverse paralysis

24. Thank You