Question

Foodborne botulism is a severe illness that results from the ingestion of a preformed toxin produced by a bacterium, Clostridium botulinum, in contaminated food. Death can occur in up to 60% of untreated cases; supportive care and prompt administration of antitoxin have reduced mortality in the United States to less than 10%. Outbreaks of botulism have been linked to improperly preserved vegetables, fruits, and meats including fermented fish products, sausages, smoked meat, and seafood.

On January 12, 1994, an infectious diseases physician at a Montevideo-area hospital telephoned the Directorate of Epidemiology of the Uruguayan Ministry of Health (MoH) to report two possible cases of botulism. The patients, both male, presented with drooping eyelids, double vision, difficulty swallowing, and respiratory problems. One patient had onset of symptoms on January 5 and the other one on January 6. The physician had drawn sera and collected stool specimens from the men to test for botulinum toxin but no results were available.

The directors of the National Laboratory and the Environmental Health and Sanitation Program were notified of the possible cases of botulism. The two patients, still in the hospital, were interviewed by a MoH epidemiologist. Upon questioning, it was learned that both of the patients were drivers for the same bus company and drove the same route and shift. The patients knew each other but worked on different days of the week. They had not eaten together in more than a month.

To find additional cases, the MoH contacted all employees of the bus company with the ill drivers to see if any had symptoms suggestive of botulism. Hospitals in the area of Montevideo, where the cases occurred, were asked to report any patients with acute neurologic illnesses that could be botulism. Family members of cases were questioned about whether they also had symptoms of botulism. Additionally, the MoH developed a press release for distribution to the local news media.

Based on the results of the case finding efforts, seven additional patients with neurologic signs consistent with botulism were identified. Five of the patients had sought medical attention and four were hospitalized. Working diagnoses for these patients at the time the initial two cases were discovered included myasthenia gravis (1), Guillain-Barré syndrome (2), stroke (1), and diabetic complications (1). Botulinum toxin was identified in sera and/or stool from three patients, including one of the original cases reported on January 13.

All patients were drivers from the same bus company as the original cases and drove the same route. From initial reports, all had eaten at a home located at the terminal stop of the bus route where the drivers stopped during their breaks. Approximately 58 bus drivers worked this route; 27 in the morning shift, 16 in the afternoon shift, and 15 in the evening shift.

Would you initiate any control measures at this time? What criteria would you consider in implementing control measures so early in an investigation?

Answer 1

Food borne botulism is a paralytic disease/illness caused by a nerve toxin produced by the bacterium Clostridium botulinum.Here the cases discussed Montevideo-area hospital are suffering with food-borne botulism according t their history revealed.

*Food borne botulism may result from eating food contaminated with the toxins produced by organism Clostridium botulinum.This may be from poorly processed canned or bottled low acid foods,fermented foods or lightly preserved foods.

The botulism is a fatal condition where it should be considered as an medical emergency.

$\rightarrow$ The main fact is that there is no cure for botulism food poisoning and is a lethal or fatal condition if not managed properly

If treated and managed properly the symptoms may go away

With proper medical attention,the effects of botulism food poisoning subside after a few weeks or months

Medications can be used to stop the botulism toxin that may damaging the body

The other more fact is that it is a non-reversible condition,if the damage that already occurred.

*The trivalent antitoxins is effective against the three neurotoxin :A,B,E.

The antitoxin that blocks the action of neurotoxin that circulating the patient blood.

The antitoxins can be dispensed from the quarantine stations by the U.S governments CDC.

The recovery of the disease may takes weeks to months.

*Heptavalent antitoxin effective against the seven neurotoxins A,B,C,D,E F are available from U.S FEMA

$\rightarrow$ Other than medicines the control measures the physicians are followed such as :

Remove the contaminated food from the patient gut by inducing vomiting or by using enemas for unabsorbed toxins

If any wounds are present it should be treated as surgically such as surgical debridement,to remove the source of toxin producing bacteria.

Supportive care such as administration with IV fluid therapy,breathing support,In sever botulism,respiratory failure and paralysis may require to be on a ventilator for weeks.

In the treatment protocol of food borne botulism antibiotics therapy are not following.

While implementing the control measures we have to kept in mind that

$\rightarrow$ The patient suffering with severe botulism can manage not only with the breathing support measures but also need a intensive medical and nursing care with breathing support and fluid management measures.

The earlier diagnosis and treatment of the disease,get a better outcome

Sometimes outcomes may be considered only fair in some patients who develop chronic fatigue and shortness of breath for many years after a initial diagnosis and treatment of botulism.

This is better to keep in mind that implementing control measures will be so early in an investigation to prevent the mortality rate and aids in recovery