FOODBORNE BOTULISMFOODBORNE BOTULISM

NYC Dept. of Health and Mental HygieneNYC Dept. of Health and Mental Hygiene

Office of Emergency Preparedness and ResponseOffice of Emergency Preparedness and Response

OBJECTIVESOBJECTIVES

Review DOHMH roles and responsibilities Review DOHMH roles and responsibilities during a foodborne botulism incidentduring a foodborne botulism incident

Discuss ways to address potential Discuss ways to address potential planning gaps and incident-related planning gaps and incident-related challengeschallenges

BOTULISM: BOTULISM: CLINICAL FEATURESCLINICAL FEATURES

GENERALGENERALBotulism is a paralytic illness caused by a neurotoxin that is produced by an Botulism is a paralytic illness caused by a neurotoxin that is produced by an anaerobic bacterium, anaerobic bacterium, Clostridium botulinumClostridium botulinum

Toxin absorbed in the digestive tract binds irreversibly to structures in Toxin absorbed in the digestive tract binds irreversibly to structures in voluntary/involuntary motor nerves, inhibiting secretion of a neurotransmitter and voluntary/involuntary motor nerves, inhibiting secretion of a neurotransmitter and transmission of nerve impulses transmission of nerve impulses – This leads to weakness or paralysis of affected motor nerves, including This leads to weakness or paralysis of affected motor nerves, including

those governing respiration those governing respiration

Botulinum toxin is heat-sensitive and is inactivated in food when the temperature Botulinum toxin is heat-sensitive and is inactivated in food when the temperature is kept above boiling for 10 minutes is kept above boiling for 10 minutes

Sensory nerves are unaffected.Sensory nerves are unaffected.

Human botulism is caused by toxin types A, B, E and F. Human botulism is caused by toxin types A, B, E and F.

Waterborne botulism has never been documentedWaterborne botulism has never been documented– Successful contamination of large water supplies is unlikely because of Successful contamination of large water supplies is unlikely because of

dilutional effectsdilutional effects

Aerosol release of botulinum toxin not considered very likelyAerosol release of botulinum toxin not considered very likely

ILLNESS TYPES AND SYMPTOMSILLNESS TYPES AND SYMPTOMS

All naturally occurring types of botulism (infant, food borne, wound and adult intestinal All naturally occurring types of botulism (infant, food borne, wound and adult intestinal colonization) result in the same illness. colonization) result in the same illness.

Early botulism: bilateral cranial nerve palsies and descending muscle weaknessEarly botulism: bilateral cranial nerve palsies and descending muscle weaknessSymptomsSymptoms: dry mouth; blurry or double vision; nausea, vomiting or constipation; and : dry mouth; blurry or double vision; nausea, vomiting or constipation; and difficulty speaking or swallowing.difficulty speaking or swallowing.

Late botulism: weakness or paralysis of respiratory muscles may require mechanical Late botulism: weakness or paralysis of respiratory muscles may require mechanical ventilation, which can last for monthsventilation, which can last for months

Incubation Period:Incubation Period:– Food borne botulism: 12 – 36 hoursFood borne botulism: 12 – 36 hours– Inhalational botulism (US primate studies): 12 – 80 hours Inhalational botulism (US primate studies): 12 – 80 hours

Case fatality rate: 5% - 10% for food borne botulism. Case fatality rate: 5% - 10% for food borne botulism.

Lethal Dose: LD50 (amount fatal to 50% of persons exposed) for 154lb person: ~70 Lethal Dose: LD50 (amount fatal to 50% of persons exposed) for 154lb person: ~70 microgramsmicrograms

INCIDENCEINCIDENCE

In the United States, an average of 145 cases of In the United States, an average of 145 cases of botulism are reported each yearbotulism are reported each year– 15% foodborne15% foodborne– 65% infant botulism65% infant botulism– 20% wound20% wound

Adult intestinal colonization and iatrogenic botulism also Adult intestinal colonization and iatrogenic botulism also occur, but rarely occur, but rarely

Outbreaks of foodborne botulism involving two or more Outbreaks of foodborne botulism involving two or more persons occur most years and are usually caused by persons occur most years and are usually caused by home-canned foodshome-canned foods

Most wound botulism cases are associated with black-tar Most wound botulism cases are associated with black-tar heroin injection, especially in California heroin injection, especially in California

TREATMENTTREATMENT

Adults/children:Adults/children: botulinum antitoxin botulinum antitoxin

IInfants:nfants: IV botulinum immune globulin (BIG-IV) antibody IV botulinum immune globulin (BIG-IV) antibody injectioninjection

Multiple administrations of antitoxin might be needed for Multiple administrations of antitoxin might be needed for persons exposed to higher doses of toxin.persons exposed to higher doses of toxin.

Supportive care, including mechanical ventilation – Supportive care, including mechanical ventilation – potentially for monthspotentially for months

NO PROPHYLAXIS AVAILABLENO PROPHYLAXIS AVAILABLE

BOTULISM: BOTULISM: PUBLIC HEALTH FEATURESPUBLIC HEALTH FEATURES

TRANSMISSION, TRANSMISSION, ISOLATION & QUARANTINEISOLATION & QUARANTINE

No person-to-person transmission. No person-to-person transmission. Isolation not required and quarantine Isolation not required and quarantine would not be used.would not be used.

ENVIRONMENTAL STABILITYENVIRONMENTAL STABILITY

Heating food/beverage to boiling for 10 minutes Heating food/beverage to boiling for 10 minutes inactivates toxin. Depending on concentration, inactivates toxin. Depending on concentration, pasteurization might inactivate most, but not all, pasteurization might inactivate most, but not all, toxintoxin

Toxin would be stable on countertops/other Toxin would be stable on countertops/other environmental surfaces that came in contact with environmental surfaces that came in contact with contaminated food item (e.g., spilled milk)contaminated food item (e.g., spilled milk)

Proper disposal of contaminated food item and Proper disposal of contaminated food item and decontamination of locations/surfaces where decontamination of locations/surfaces where contaminated food item was foundcontaminated food item was found

FOOD SAFETY, FOOD SAFETY, DECONTAMINATION & REMEDIATIONDECONTAMINATION & REMEDIATION

Once identified, the implicated food item would Once identified, the implicated food item would be collected, disposed and recalled by the be collected, disposed and recalled by the manufacturer. manufacturer.

Personal decontamination and bagging/disposal Personal decontamination and bagging/disposal of clothing would not be necessary. of clothing would not be necessary.

Goals and standards for environmental Goals and standards for environmental decontamination will be determined by decontamination will be determined by environmental hazard and risk assessments in environmental hazard and risk assessments in collaboration with other agencies.collaboration with other agencies.

RE-OCCUPANCYRE-OCCUPANCY

Limited evacuation, remediation Limited evacuation, remediation and re-occupancy may be and re-occupancy may be indicated.indicated.

PET & VETERINARYPET & VETERINARY

Dogs, cats and sheep: Dogs, cats and sheep: notnot susceptible to susceptible to toxins A, B, E or Ftoxins A, B, E or F

Horses/cattle: Susceptible to toxin BHorses/cattle: Susceptible to toxin B

Ferrets: Susceptible to toxins A and EFerrets: Susceptible to toxins A and E

Birds: Susceptible to toxin E Birds: Susceptible to toxin E

MENTAL HEALTH IMPACTMENTAL HEALTH IMPACT

Widespread anxiety and distressWidespread anxiety and distress

Fear driven behaviors (e.g., flight)Fear driven behaviors (e.g., flight)

Resistance to public health measuresResistance to public health measures

POTENTIAL CITYWIDE EFFECTSPOTENTIAL CITYWIDE EFFECTS

GENERAL CONSIDERATIONSGENERAL CONSIDERATIONS

Multiple attacks possibleMultiple attacks possible

Cross-contamination of persons, property, animals and Cross-contamination of persons, property, animals and food might occurfood might occur

Impacts will depend on the nature of the attack(s) and Impacts will depend on the nature of the attack(s) and targeted industry and/or populationstargeted industry and/or populations

Emergency responders who collect food from residences Emergency responders who collect food from residences will assume that the environment they are entering is will assume that the environment they are entering is contaminated and will require specific training and contaminated and will require specific training and equipmentequipment

Highly unlikely that MTA would suspend all or parts of Highly unlikely that MTA would suspend all or parts of service on rail and bus linesservice on rail and bus lines

HEATHCARE CONSIDERATIONSHEATHCARE CONSIDERATIONS

NYC has ~20,000 hospital beds; typically operating at NYC has ~20,000 hospital beds; typically operating at ~80% capacity. Surge in capacities will be needed within ~80% capacity. Surge in capacities will be needed within 2 days of a large release2 days of a large release

Botulism outbreaks have the potential to generate high Botulism outbreaks have the potential to generate high demand for ICU care (e.g., skilled nursing and demand for ICU care (e.g., skilled nursing and ventilators), other staffed beds and mental health ventilators), other staffed beds and mental health servicesservices– DOHMH and other ESF 8 partners may need to determine DOHMH and other ESF 8 partners may need to determine

resource allocation strategies and implementation. resource allocation strategies and implementation.

Initial symptoms may be vague (e.g., blurred vision). Initial symptoms may be vague (e.g., blurred vision). May need nurse’s hotline to triage calls from 311. May need nurse’s hotline to triage calls from 311.

HEATHCARE CONSIDERATIONS HEATHCARE CONSIDERATIONS (continued)(continued)

Many persons will go to outpatient offices and emergency Many persons will go to outpatient offices and emergency departments for evaluation and prophylaxisdepartments for evaluation and prophylaxis– Triage methods will be needed to distinguish between those who Triage methods will be needed to distinguish between those who

do and do not need evaluation in emergency departmentsdo and do not need evaluation in emergency departments

Limited supply of antitoxin in the SNSLimited supply of antitoxin in the SNS– In an event that involves a widely distributed food product, NYC In an event that involves a widely distributed food product, NYC

might be competing with other states for this and other resourcesmight be competing with other states for this and other resources

CA Department of Public Health is sole supplier of BIG-IVCA Department of Public Health is sole supplier of BIG-IV

Outreach will be needed to both pediatric and internal Outreach will be needed to both pediatric and internal medicine communities medicine communities

Past EventsPast Events1971 – Vichyssoise1971 – Vichyssoise

– New York man died and his wife became seriously ill due to botulism after eating a can of Bon Vivant vichyssoise soup New York man died and his wife became seriously ill due to botulism after eating a can of Bon Vivant vichyssoise soup – Company began a recall of 6,444 cans of vichyssoise soup made from the contaminated batch Company began a recall of 6,444 cans of vichyssoise soup made from the contaminated batch – FDA discovered that the company’s processing practices raised questions about all products packed by the company, FDA discovered that the company’s processing practices raised questions about all products packed by the company,

and subsequently shut down the Newark, NJ plant and subsequently shut down the Newark, NJ plant – Bon Vivant filed for bankruptcy within a month of the announcement of the recallBon Vivant filed for bankruptcy within a month of the announcement of the recall

1987 - Dried Fish1987 - Dried Fish – 8 cases of botulism (2 in New York City and 6 in Israel) from consumption of Kapchunka, an uneviscerated, dry-salted, 8 cases of botulism (2 in New York City and 6 in Israel) from consumption of Kapchunka, an uneviscerated, dry-salted,

air-dried, whole whitefishair-dried, whole whitefish– Product was made in New York City and some of it was transported by individuals to IsraelProduct was made in New York City and some of it was transported by individuals to Israel– All 8 patients with botulism developed symptoms within 36 hoursAll 8 patients with botulism developed symptoms within 36 hours– 1 died, 2 required breathing assistance, 3 treated with antitoxin, and 3 recovered spontaneously 1 died, 2 required breathing assistance, 3 treated with antitoxin, and 3 recovered spontaneously

1989 - Bottled Garlic1989 - Bottled Garlic– Bottled, chopped garlic-in-oil mix was responsible for three cases of botulism in Kingston, N.Y. Bottled, chopped garlic-in-oil mix was responsible for three cases of botulism in Kingston, N.Y. – Two men and a woman were hospitalizedTwo men and a woman were hospitalized

1992 – Whitefish 1992 – Whitefish – Four members of a Fort Lee family were stricken with botulism after eating fish bought in Jersey City Four members of a Fort Lee family were stricken with botulism after eating fish bought in Jersey City

2007 – Chili Sauce2007 – Chili Sauce– Botulism found in cans of Castleberry's, Austex and Kroger brands of chili sauce. Botulism found in cans of Castleberry's, Austex and Kroger brands of chili sauce. – Over 25 different brands of a variety of products were recalledOver 25 different brands of a variety of products were recalled

2010 – Frozen Fish2010 – Frozen Fish– A New York importer is recalling uneviscerated frozen fish from Vietnam after an inspection found that it might be A New York importer is recalling uneviscerated frozen fish from Vietnam after an inspection found that it might be

contaminated with botulismcontaminated with botulism

CITYWIDE RESPONSECITYWIDE RESPONSE

POTENTIAL DOHMH REQUESTS: POTENTIAL DOHMH REQUESTS: TREATMENT ASSETSTREATMENT ASSETS

Timing and quantity of botulinum anti-toxin Timing and quantity of botulinum anti-toxin

Mechanical ventilators and support Mechanical ventilators and support equipmentequipment

Assistance procuring BIG-IV from CA Assistance procuring BIG-IV from CA Department of Public Health (sole Department of Public Health (sole supplier)supplier)

POTENTIAL DOHMH REQUESTS: POTENTIAL DOHMH REQUESTS: Environmental Response Guidance & StandardsEnvironmental Response Guidance & Standards

Federal assistance in collecting and analyzing environmental Federal assistance in collecting and analyzing environmental samples in coordination with local environmental sampling efforts: samples in coordination with local environmental sampling efforts: – USDA/FSIS: meat, poultry and eggsUSDA/FSIS: meat, poultry and eggs– FDA: all other food itemsFDA: all other food items

Coordination of data sharing requirements Coordination of data sharing requirements

Federal (CDC NIOSH and EPA) and NYSDOH participation in Federal (CDC NIOSH and EPA) and NYSDOH participation in multiagency advisory group for environmental recovery, remediation multiagency advisory group for environmental recovery, remediation and re-occupancy issues and re-occupancy issues

Decontamination, remediation and re-occupancy standards and Decontamination, remediation and re-occupancy standards and guidelines for locations where contaminated food item was guidelines for locations where contaminated food item was manufactured, stored, prepared and consumed manufactured, stored, prepared and consumed

POTENTIAL DOHMH REQUESTS: POTENTIAL DOHMH REQUESTS: Public Health Surge CapabilitiesPublic Health Surge Capabilities

Laboratory sampling and analytical Laboratory sampling and analytical capacity, including staff, reagents and capacity, including staff, reagents and other laboratory supplies other laboratory supplies (e.g., bioassay, if needed)(e.g., bioassay, if needed)

POTENTIAL DOHMH REQUESTS:POTENTIAL DOHMH REQUESTS:Federal Health/Medical AssetsFederal Health/Medical Assets

Request from below or order per specific mission needs through ESF-8 via OEM to Request from below or order per specific mission needs through ESF-8 via OEM to NY State NY State

National Medical Response Team (medical care; biological incident specialty; mass National Medical Response Team (medical care; biological incident specialty; mass casualty decon; 50-person, 48 hours; currently one team available for deployment)casualty decon; 50-person, 48 hours; currently one team available for deployment)

Federal Medical Station (acute, non-trauma care; 250 beds scalable in 50 bed Federal Medical Station (acute, non-trauma care; 250 beds scalable in 50 bed increments, 48 hours, order with or without staff; 60 caches around country.)increments, 48 hours, order with or without staff; 60 caches around country.)

HHS Rapid Deployment Force (HHS Rapid Deployment Force (cancan staff medical station; staff medical station; clinical; mental health, clinical; mental health, public health; 105 members, 12 hours; only one available on eastern seaboard)public health; 105 members, 12 hours; only one available on eastern seaboard)

Pediatric intensivist strike teams (two persons/team; available through Public Health Pediatric intensivist strike teams (two persons/team; available through Public Health Service Tier III or NDMS.)Service Tier III or NDMS.)

Applied Public Health Teams (PHS officers w/ equipment to surge all key local health Applied Public Health Teams (PHS officers w/ equipment to surge all key local health department functions.)department functions.)

NDMS Disaster Medical Assistance Teams (Can be configured as needed; NDMS Disaster Medical Assistance Teams (Can be configured as needed; approximately six - 35 member teams within a 12 hour deployment zone.approximately six - 35 member teams within a 12 hour deployment zone.