Botulism Type E after consumption of salt-cured fish—New Jersey, 2018

The U.S. Centers for Disease Control reports on October 25, 2018, at 2:15 a.m., a woman aged 30 years and her mother, aged 55 years, both of Egyptian descent, arrived at an emergency department in New Jersey in hypotensive shock after 16 hours of abdominal pain, vomiting, and diarrhea. The daughter also reported blurry vision and double vision (diplopia), shortness of breath, chest pain, and difficulty speaking. She appeared lethargic and had ophthalmoplegia and bilateral ptosis. Both women were admitted to the hospital. The mother improved after fluid resuscitation, but the daughter required vasopressor support in the intensive care unit. Although the mother did not have evidence of cranial nerve involvement on admission, during the next 24 hours, she developed dysphagia and autonomic dysfunction with syncope and orthostasis and was transferred to the intensive care unit as her symptoms progressively worsened similar to those of her daughter.

Two days before admission, both women had eaten fesikh, a traditional Egyptian fish dish of uneviscerated gray mullet that is fermented and salt-cured. Fesikh has been linked to foodborne botulism, including a large type E outbreak in Egypt in 1993 (1). The Egyptian Ministry of Health has since issued public health warnings regarding fesikh before Sham el-Nessim, the Egyptian holiday commemorating the beginning of spring, during which fesikh is commonly prepared and eaten.* Foodborne botulism outbreaks associated with fesikh and similar uneviscerated salt-cured fish have also occurred in North America (2); two outbreaks occurred among persons of Egyptian descent in New Jersey in 1992 (3) and 2005 (4).

Botulism, a paralytic illness caused by botulinum neurotoxin (BoNT), was suspected because of the reported exposure to fesikh along with symptoms of ophthalmoplegia, bilateral ptosis, dysarthria, and autonomic dysfunction. Per New Jersey Reporting Regulations (NJAC 8:57), these suspected illnesses were immediately reported to the New Jersey Department of Health. After consultation with CDC, heptavalent botulism antitoxin was released by CDC and administered to both patients within approximately 24 hours of arrival at the hospital. The daughter’s symptoms improved, and she was weaned off vasopressors. Both patients survived following intensive care for 2 days and total hospitalization of 7 days each.

CDC tested serum obtained before antitoxin administration. Serum from the daughter tested positive for BoNT type E by the BoNT Endopep-MS assay (5); the mother’s serum tested negative. A leftover sample of the consumed fesikh also tested positive for BoNT type E and Clostridium botulinum type E.

Interviews conducted by the Communicable Disease Service at the New Jersey Department of Health revealed that two fresh mullets purchased by the patients’ neighbor at a local Asian market were used to prepare the fesikh. The mother salt-cured and fermented the mullet, leaving the fish uneviscerated and wrapped in plastic in the kitchen for 20 days at ambient temperature. The mother confirmed that she previously used the same method of preparation in Egypt with no deviation in techniques or steps.

These cases illustrate the importance of early recognition and treatment of botulism. Botulism can be fatal, typically from respiratory failure, and treatment delays can result in increased mortality and worsened overall outcomes (6). These cases also highlight the role of uneviscerated, salt-cured fish dishes as potential vehicles for foodborne botulism. C. botulinum spores are ubiquitous in marine environments, and traditional methods of home preparation for these dishes might support conditions that are favorable for toxin production (i.e. anaerobic conditions) (2). Neither of these patients had previously heard of botulism. Risk communication via public awareness campaigns, as has been conducted by the Egyptian Ministry of Health to discourage fesikh consumption, might be indicated in the United States; engagement with Egyptian communities in the United States might provide insights into additional prevention strategies to decrease the risk for foodborne botulism from fesikh and other uneviscerated, salt-cured fish products.

We all need someone to love: Foodborne Diseases Active Surveillance Network

FoodNet Fast provides online access to information reported to the Foodborne Diseases Active Surveillance Network (FoodNet). FoodNet’s surveillance area includes about 15% of the U.S. population.

You can use FoodNet Fast tools to search data and see results displayed on interactive graphs and charts.

Pathogen Surveillance Tool: See how rates of illness have changed in FoodNet’s surveillance area since 1996 for nine pathogens transmitted commonly through food: CampylobacterCryptosporidium *, Cyclospora, ListeriaSalmonella, Shiga toxin-producing Escherichia coli (STEC), ShigellaVibrio, and Yersinia.

Diagnostic Laboratory Practices Tool: Find out how diagnostic testing practices in FoodNet’s surveillance area have changed over time for 10 pathogens: Campylobacter, Cryptosporidium *, Cyclospora, Listeria, norovirus, Salmonella, STEC, Shigella, Vibrio, and Yersinia.

Hemolytic Uremic Syndrome (HUS) Surveillance Tool: HUS is a life-threatening condition, most often triggered by STEC infection. See how rates of pediatric HUS and STEC infection have changed in FoodNet’s surveillance area since 1997.

23 sick from Romaine lettuce: Was FDA’s outbreak announcement delay inexcusable or sensible

I love Mondays in Australia because it’s Sunday in the U.S., football and hockey are on TV for background, the kid is at school when not in France, and I write (Sorenne painting in France).

Fourteen years ago, me and Chapman went on a road trip to Prince George (where Ben thought he would be eaten by bears) to Seattle, then to Manhattan, Kansas, where in the first week I met a girl, got a job, and then spinach happened.

Leafy greens are still covered in shit.

I am drowning in nostalgia, but things haven’t changed, and, as John Prine wrote, all the news just repeats itself.

Same with relationships.

Former U.S. Food and Drug Administration food safety chief, David Acheson, writes that on October 31, 2019, FDA announced a romaine lettuce E. coli O157:H7 outbreak for which the active investigation had ended and the outbreak appeared to be over. As such FDA stated there was no “current or ongoing risk to the public” and no avoidance of the produce was recommended.

Since that announcement, however, I have seen a number of articles condemning FDA and CDC. Why? Because the traceback investigation of the outbreak began in mid-September when CDC notified FDA of an illness cluster that had sickened 23 people across 12 states. So why the delay in announcing it to the public?

Despite the critical (and rather self-serving; always self-serving) stance on the “inexcusable” delay taken by a prominent foodborne illness attorney and his Food Safety “News” publication – which blasted a headline FDA “hid” the outbreak – my stance, having been an FDA official myself involved in outbreak investigations, is that the delay was practical and sensible.

Why? As FDA states right in its announcement:

When romaine lettuce was identified as the likely source, the available data indicated that the outbreak was not ongoing and romaine lettuce eaten by sick people was past its shelf life and no longer available for sale.

Even once romaine was identified as the likely cause, no common source or point of contamination was identified that could be used to further protect the public.

During the traceback investigation, the outbreak strain was not detected in any of the samples collected from farms, and there were no new cases.

Thus, neither FDA nor CDC identified any actionable information for consumers.

So, if it is not in consumers’ best interest to publicize an issue that no longer exists, why should they be driven away from a healthy food alternative? Why should unfounded unease be generated that will damage the industry, providing no benefit for consumers but ultimately impacting their pockets? There is just no upside to making an allegation without information. We’ve seen the impact on consumers and the industry when an announcement of a suspected food turns out to be incorrect; specifically “don’t eat the tomatoes” when it turned out to be jalapeno and serrano peppers. Having learned from such incidents, FDA’s approach is: If we don’t have a message that will help protect the public, then there is no message to be imparted.

So, rather than condemn FDA and CDC, I would commend them for getting the balance correct. And, perhaps, instead of any condemning, we should be working together to get the answers faster, to get outbreak data through better, faster, more efficient and coordinated traceability. Our entire system is too slow – a topic we have discussed many times in these newsletters.

I disagree.

The public and the scientific community need to be informed to prevent additional people from barfing.

I also rarely eat lettuce of any sort because it is overrated and the hygiene controls are not adequate.

Greek salad without lettuce is my fave.

Going public: Early disclosure of food risks for the benefit of public health

Mar.17

NEHA, Volume 79.7, Pages 8-14

Benjamin Chapman, Maria Sol Erdozaim, Douglas Powell

http://www.neha.org/node/58904

Often during an outbreak of foodborne illness, there are health officials who have data indicating that there is a risk prior to notifying the public. During the lag period between the first public health signal and some release of public information, there are decision makers who are weighing evidence with the impacts of going public. Multiple agencies and analysts have lamented that there is not a common playbook or decision tree for how public health agencies determine what information to release and when. Regularly, health authorities suggest that how and when public information is released is evaluated on a case-by-case basis without sharing the steps and criteria used to make decisions. Information provision on its own is not enough. Risk communication, to be effective and grounded in behavior theory, should provide control measure options for risk management decisions. There is no indication in the literature that consumers benefit from paternalistic protection decisions to guard against information overload. A review of the risk communication literature related to outbreaks, as well as case studies of actual incidents, are explored and a blueprint for health authorities to follow is provided.

A tale of two antimicrobial resistance reports

I’ll leave the summary of two antimicrobial resistance reports to my friend and hockey colleague (and he’s a professor/veterinarian) Scott Weese of the Worms & Germs Blog (he’s the semi-bald dude behind me in this 15-year-old pic; I’m the goalie; too many pucks to the head):

 Two reports came out this week, both detailing the scourge of antibiotic resistance.

In Canada, the Canadian Council of Academies released “When antibiotics fail: the expert panel on the potential socio-economic impacts of antimicrobial resistance in Canada.

Not to be outdone, the CDC released Antibiotic Resistance Threats in the United States, 2019.

They’re both comprehensive, with a combined >400 pages explaining that this is a big problem.

I’m not going try to summarize the reports. I’ll just pick out a few interesting tidbits.

From the CCA report (Canada):

According to their modelling, first-line antimicrobials (those most commonly used to treat routine infections) helped save at least 17,000 lives in 2018 while generating $6.1 billion in economic activity in Canada. “This contribution is at risk because the number of effective antimicrobials are running out.”

Antimicrobial resistance was estimated to reduce Canada’s GDP by $2 billion in 2018. That’s only going to get worse unless we get our act together. It’s estimated that by 2050, if resistance rates remain unchanged, the impact will be $13 billion per year. If rates continue to increase, that stretches to $21 billion. Remember, that’s just for Canada, a relatively small country from a population standpoint.

Healthcare costs due to resistance (e.g. drugs, increased length of stay in hospital) accounted for $1.4 billion in 2018.  But remember that people who die from resistant infections can actually cost less. If I get a serious resistant infection and die quickly, my healthcare costs are pretty low since I didn’t get prolonged care. All that to say that dollar costs alone don’t capture all the human aspects. Regardless, this cost will likely increase to $20-40 billion per year by 2050.

In terms of human health, resistant infections were estimated to contribute to 14,000 deaths in Canada in 2018, with 5,400 of those directly attributable to the resistant infection (i.e. those deaths would not have occurred if the bug was susceptible to first line drugs). That makes resistance a leading killer, and it’s only going to get worse.

I’ll stop there. The document has a lot of good information and it’s worth reading if you’re interested in the topic.  They also provided a handy 2-page “infographic” summary if you can’t quite stomach the complete 268-page report (also see image below).

From the CDC report (US):

The document’s dedication says a lot. “This report is dedicated to the 48,700 families who lose a loved one each year to antibiotic resistance or Clostridioides difficile, and the countless healthcare providers, public health experts, innovators, and others who are fighting back with everything they have.”

The forward has some great messages too:

To  stop antibiotic resistance, our nation must:

Stop referring to a coming post-antibiotic era—it’s already here. You and I are living in a time when some miracle drugs no longer perform miracles and families are being ripped apart by a microscopic enemy. The time for action is now and we can be part of the solution.

Stop playing the blame game. Each person, industry, and country can affect the development of antibiotic resistance. We each have a role to play and should be held accountable to make meaningful progress against this threat.

Stop relying only on new antibiotics that are slow getting to market and that, sadly, these germs will one day render ineffective. We need to adopt aggressive strategies that keep the germs away and infections from occurring in the first place.

Stop believing that antibiotic resistance is a problem “over there” in someone else’s hospital, state, or country—and not in our own backyard. Antibiotic resistance has been found in every U.S. state and in every country across the globe. There is no safe place from antibiotic resistance, but everyone can take action against it. Take action where you can, from handwashing to improving antibiotic use.

Some might say it’s alarmist. However, I don’t think it’s alarmist when someone really should be raising the alarm. We need to talk about it more, not less. We need to get people (including the general public, healthcare workers, farmers, veterinarians, policymakers) on board, to realize it’s a big issue that needs to be addressed now. “Short term pain for long-term gain” certainly applies here. We can keep delaying and the numbers will keep going up, or we can invest in solutions.

The numbers are scary but specific numbers don’t really matter in many ways. “Lots” is all we should have to know to get motivated. However, decision-makers like numbers, so these numbers hopefully will be useful to show the impact and potential benefits of investing in this problem, and motivate them to put money into antimicrobial stewardship. Saving lives should be enough, but that often doesn’t cut it. Antibiotic resistance doesn’t have a good marketing campaign. Everyone knows why people were wearing pink last month and why there are some pretty dodgy moustaches this month. Those are important issues, for sure. However, considering the overall impact, antibiotic stewardship needs to get more people behind it if we’re going to effect change.

Salmonella, E. coli O157, Listeria, Campy: 1.9 million foodborne illnesses in US per year

In an ongoing effort to understand sources of foodborne illness in the United States, the Interagency Food Safety Analytics Collaboration (IFSAC) collects and analyzes outbreak data to produce an annual report with estimates of foods responsible for foodborne illnesses caused by pathogens. The report estimates the degree to which four pathogens – Salmonella, E. coli O157, Listeria monocytogenes, and Campylobacter – and specific foods and food categories are responsible for foodborne illnesses.

The Centers for Disease Control and Prevention (CDC) estimates that, together, these four pathogens cause 1.9 million foodborne illnesses in the United States each year. The newest report (PDF), entitled “Foodborne illness source attribution estimates for 2017 for Salmonella, Escherichia coli O157, Listeria monocytogenes, and Campylobacter using multi-year outbreak surveillance data, United States,” can be found on the IFSAC website.

The updated estimates, combined with other data, may help shape agency priorities and inform the creation of targeted interventions that can help to reduce foodborne illnesses caused by these pathogens. As more data become available and methods evolve, attribution estimates may improve. These estimates are intended to inform and engage stakeholders and to improve federal agencies’ abilities to assess whether prevention measures are working.

Foodborne illness source attribution estimates for 2017 for salmonella, Escherichia coli O157, listeria monocytogenes, and campylobacter using multi-year outbreak surveillance data, United States, Sept.2019

CDC, FDA, USDA-FSIS

https://www.cdc.gov/foodsafety/ifsac/pdf/P19-2017-report-TriAgency-508.pdf?deliveryName=DM10264

Size does not matter: 21 sick from Salmonella linked to pet turtles

I want a new drug, or approach or message, rather than CDC sending out yet another warning about yet another Salmonella outbreak from kids kissing their pet turtles.

(And I can’t believe I’m quoting Huey Lewis and the News, one of my 1982 university room mates’ favorite bands, along with Hall and Oates).

The U.S. Centers for Disease Control reports:

21 people infected with the outbreak strain of Salmonella Oranienburg have been reported from 13 states.

7 hospitalizations have been reported. No deaths have been reported.

Epidemiologic and traceback evidence indicate that contact with pet turtles is the likely source of this outbreak.

In interviews, 12 (71%) of 17 ill people reported contact with a turtle.

This investigation is ongoing and CDC will provide updates when more information is available.

Turtles can carry Salmonella germs in their droppings while appearing healthy and clean. These germs can easily spread to their bodies, tank water, and habitats. People can get sick after they touch a turtle or anything in their habitats.

People who own or come in contact with turtles should take steps to stay healthy around their pet:

Wash your hands.

Always wash hands thoroughly with soap and water right after touching, feeding, or caring for a turtle or cleaning its habitat.

Adults should supervise handwashing for young children.

Play safely.

Don’t kiss or snuggle turtles, because this can spread Salmonella germs to your face and mouth and make you sick.

Don’t let turtles roam freely in areas where food is prepared or stored, such as kitchens.

Clean habitats, toys, and pet supplies outside the house when possible.

Avoid cleaning these items in the kitchen or any other location where food is prepared, served, or stored.

Pick the right pet for your family.

CDC and public health officials in several states are investigating a multistate outbreak of human Salmonella Oranienburg infections linked to contact with pet turtles.

Public health investigators are using the PulseNet system to identify illnesses that may be part of this outbreak. PulseNet is the national subtyping network of public health and food regulatory agency laboratories coordinated by CDC. DNA fingerprinting is performed on Salmonella bacteria isolated from ill people by using a standardized laboratory and data analysis method called whole genome sequencing (WGS). CDC PulseNet manages a national database of these sequences that are used to identify possible outbreaks. WGS gives investigators detailed information about the bacteria causing illness. In this investigation, WGS showed that bacteria isolated from ill people were closely related genetically. This means that people in this outbreak are more likely to share a common source of infection.

Ill people reported contact with red-eared sliders and other turtles that were larger than four inches in length. Previous Salmonella outbreaks have been linked to turtles with a shell length less than four inches. Due to the amount of Salmonella illnesses related to these small turtles, the U.S. Food and Drug Administration banned the sale and distributionexternal icon of turtles with shells less than four inches long as pets.

Regardless of where turtles are purchased or their size, turtles can carry Salmonella germs that can make people sick. Pet owners should always follow steps to stay healthy around their pet.

This investigation is ongoing, and CDC will provide updates when more information becomes available.

Norovirus most common foodborne pathogen in 2017

This is the CIDRAP summary of the latest CDC number crunching on microorganisms that lead to barfing.

The Centers for Disease Control and Prevention (CDC) late last week released a summary of foodborne illnesses in 2017 based on an annual analysis of data from the Foodborne Disease Outbreak Surveillance System, and norovirus was the most common pathogen reported, responsible for 46% of illnesses. Salmonella and Shiga toxin–producing Escherichia coli were also linked to a substantial number of outbreaks.  

In 2017, the CDC tracked 841 foodborne outbreaks, which included 14,481 illnesses, 827 hospitalizations, 20 deaths, and 14 food product recalls. A single etiologic agent was confirmed in 395 outbreaks (47%), which are defined as two or more related cases.

Tainted seafood and poultry were tied with causing the most outbreaks, with mollusks (41 outbreaks), fish (37), and chicken (23) the specific food items most often implicated. The most outbreak-associated illnesses were from turkey (609 illnesses), fruits (521), and chicken (487), the CDC said.

California had the most outbreaks (107), followed by Ohio (69), and Washington state (67). 

As in past years, restaurants with sit-down dining were the most commonly reported locations for food preparation associated with outbreaks (366).

The complete report is available at: https://www.cdc.gov/fdoss/pdf/2017_FoodBorneOutbreaks_508.pdf

And here:

 

TB in deer hunters

For a country that still proclaims, we enjoy the safest food supply in the world in U.S. Department of Agriculture missives, when we’ve been arguing reduced risk is a better message for 25 years and that there are so many countries with the self-proclaimed title of safest food in the world they can’t all be right – it’s alarming that Mycobacterium bovis has been transmitted from deer to a human.

Hello zoonoses.

Deer hunting season in Ontario (that’s in Canada) begins about today.

I never had any interest.

Not a Bambi thing, just thought it was boring.

My dad went a few times but I’m not sure if he enjoyed it or not.

Whatever.

The U.S. Centers for Disease Control reports that in May 2017, the Michigan Department of Health and Human Services was notified of a case of pulmonary tuberculosis caused by Mycobacterium bovis in a man aged 77 years. The patient had rheumatoid arthritis and was taking 5 mg prednisone daily; he had no history of travel to countries with endemic tuberculosis, no known exposure to persons with tuberculosis, and no history of consumption of unpasteurized milk. He resided in the northeastern Lower Peninsula of Michigan, which has a low incidence of human tuberculosis but does have an enzootic focus of M. bovis in free-ranging deer (Odocoileus virginianus). The area includes a four-county region where the majority of M. bovis–positive deer in Michigan have been found.

Statewide surveillance for M. bovis via hunter-harvested deer head submission has been ongoing since 1995; in 2017, 1.4% of deer tested from this four-county region were culture-positive for M. bovis, compared with 0.05% of deer tested elsewhere in Michigan. The patient had regularly hunted and field-dressed deer in the area during the past 20 years. Two earlier hunting-related human infections with M. bovis were reported in Michigan in 2002 and 2004. In each case, the patients had signs and symptoms of active disease and required medical treatment.

Whole-genome sequencing of the patient’s respiratory isolate was performed at the National Veterinary Services Laboratories in Ames, Iowa. The isolate was compared against an extensive M. bovis library, including approximately 900 wildlife and cattle isolates obtained since 1993 and human isolates from the state health department. This 2017 isolate had accumulated one single nucleotide polymorphism compared with a 2007 deer isolate, suggesting that the patient was exposed to a circulating strain of M. bovis at some point through his hunting activities and had reactivation of infection as pulmonary disease in 2017.

Whole-genome sequencing also was performed on archived specimens from two hunting-related human M. bovis infections diagnosed in 2002 (pulmonary) and 2004 (cutaneous) that were epidemiologically and genotypically linked to deer (3). The 2002 human isolate had accumulated one single nucleotide polymorphism since sharing an ancestral genotype isolated from several deer in Alpena County, Michigan, as early as 1997; the 2004 human isolate shared an identical genotype with a grossly lesioned deer harvested by the patient in Alcona County, Michigan, confirming that his infection resulted from a finger injury sustained during field-dressing. The 2002 and 2017 cases of pulmonary disease might have occurred following those patients’ inhalation of aerosols during removal of diseased viscera while field-dressing deer carcasses.

In Michigan, deer serve as maintenance and reservoir hosts for M. bovis, and transmission to other species has been documented. Since 1998, 73 infected cattle herds have been identified in Michigan, resulting in increased testing and restricted movement of cattle outside the four-county zone. Transmission to humans also occurs, as demonstrated by the three cases described in this report; however, the risk for transmission is understudied.

Similar to Mycobacterium tuberculosis, exposure to M. bovis can lead to latent or active infection, with risk for eventual reactivation of latent disease, especially in immunocompromised hosts. To prevent exposure to M. bovis and other diseases, hunters are encouraged to use personal protective equipment while field-dressing deer. In addition, hunters in Michigan who submit deer heads that test positive for M. bovis might be at higher risk for infection, and targeted screening for tuberculosis could be performed. Close collaboration between human and animal health sectors is essential for containing this zoonotic infection.

Notes from the Field: Zoonotic mycobacterium bovis disease in deer hunters—Michigan, 2002-2017

James Sunstrum, MD1; Adenike S hoyinka, MD2; Laura E. Power, MD2,3; Daniel Maxwell, DO4; Mary Grace Stobierski, DVM5; Kim Signs, DVM5; Jennifer L. Sidge, DVM, PhD5; Daniel J. O’Brien, DVM, PhD6; Suelee Robbe-Austerman, DVM, PhD7; Peter Davidson, PhD5

https://www.cdc.gov/mmwr/volumes/68/wr/mm6837a3.htm

North Carolina man dies from Vibrio lined to undercooked seafood

 The North Carolina Department of Health and Human Services has confirmed man from Cary died from Vibrio vulnificus, apparently linked to raw oysters.

The Center for Disease Control says it is impossible to tell that an oyster is bad by looking at it.

“An oyster that contains harmful bacteria doesn’t look, smell, or even taste different from any other oyster,” the CDC’s website says.

Most Vibrio infections can be prevented by ensuring your seafood is thoroughly cooked, especially oysters.

33 sick: Outbreak of E. coli infections linked to ground bison

According to the U.S. Centers for Disease Control (CDC) an outbreak of Shiga toxin-producing Escherichia coli (STEC) — E. coli O103 and E. coli O121 — linked to ground bison appears to be over.

CDC, several states, the U.S. Food and Drug Administration, and the Canadian Food Inspection Agency investigated a multistate outbreak of infections.

On July 16, 2019, Northfork Bison Distributions, Inc., in Saint-Leonard, Quebec, Canada, recalled external icon ground bison produced between February 22, 2019, and April 30, 2019. Recalled ground bison was sold to distributors as ground bison and bison patties, referred to as Bison Burgers and/or Buffalo Burgers. Recalled ground bison was also sold to retailers in 4-ounce burger patties.

Do not eat, sell, or serve recalled Northfork Bison products.

As of September 13, 2019, this outbreak appears to be over.

A total of 33 people infected with the outbreak strain of STEC O103 and STEC O121 were reported from eight states.

Eighteen people were hospitalized. No cases of hemolytic uremic syndrome, a type of kidney failure, were reported. No deaths were reported.

When ordering at a restaurant, ask that ground bison burgers be cooked to an internal temperature of at least 160°F.