Date: Tue, 20 Jan 2004 12:20:16 -0500 (EST)
From: ProMED-mail
Subject: PRO> Botulism, fish-related 2003 - Norway, Germany
BOTULISM, FISH-RELATED 2003 - NORWAY, GERMANY
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Date: Fri, 16 Jan 2004 11:51:21 -0500
From: ProMED-mail
Source: Eurosurveillance Weekly Vol. 8 Issue 3, 15 Jan 2004 [edited]
Botulism infection after eating fish in Norway and Germany
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Norway:
Helgeland Hospital admitted 4 patients for botulism infection after they
had eaten homemade oerakfisk in late 2003 (1). Oerakfisk is
semi-fermented fish often prepared at home in Norway and eaten
traditionally around Christmas. Salt and sugar are added to a gutted fish,
which is put into a pressurized container and stored for several weeks at
5-8 deg C before being eaten without cooking. Should the temperature during
fermentation be higher than 8 deg C and/or the salt added be less than 5
percent of the weight of the fish, _C. botulinum_ may germinate and produce
toxin.
The first patient was a woman who was admitted to the hospital in Mosjoen
in northern Norway after she could not get out of bed. The patient had had
a stroke in 2001, with resulting paresis and speech difficulties, but not
swallowing difficulties. Her new illness was also initially diagnosed as a
stroke. The patient continually asked for water but could not swallow.
Her pupils were non-reactive and dilated, and initially there was no
explanation for this. One of the patient's sons later informed physicians
that the patient's husband, a 2nd son, and a friend of his were also ill,
after they and the patient had all eaten homemade oerakfisk 3 days previously.
These people were contacted and it appeared that they all had a very
similar illness. The day after the meal they had all vomited and had had
stomach pain. After this, they experienced an increasing dryness of mouth,
difficulties in swallowing, general lethargy, and low energy. In addition,
one patient had especially pronounced accommodation difficulties. All
patients experienced progression of neurological symptoms until they were
hospitalized, but the stomach pain disappeared within the first 24 hours.
The eldest patient also had problems passing urine. All patients had been
constipated after the oerakfisk meal. 2 other people had eaten the fish
without developing severe illness.
Botulism was diagnosed clinically. The Norwegian Institute of Public Health,
() provided the botulism antitoxin, which was
administered on the following day. All the patients have now recovered.
Germany:
Botulism outbreak in a family after eating dried fish from the Elbe river.
In week 42 of 2003, 3 suspected cases of botulinum poisoning were notified
to local public health authorities in Northern Germany. On 10 Oct 2003, a
father, mother, and son in the same family became ill with nausea. The next
day, the 14-year-old boy developed typical clinical signs and symptoms of
botulism. He was immediately admitted to hospital where he required
controlled ventilation. He was reported to have had a good recovery.
The source of the outbreak was identified as a home-cooked meal of fish
that all of the patients had eaten. The fish was a sea bream caught from
the Elbe River. It had been gutted, salted in brine, pressed and dried in
the open air for a few days, and then eaten without further preparation.
The remains of the fish were tested in the microbiology department at the
Hamburg-Eppendorf University Clinic. Botulinum toxin was found in a sample
from the fish. Results of a mouse bioassay showed that a serum sample taken
from the boy also contained the toxin. Subtyping at testing laboratories in
Erfurt identified the toxin as Subtype E. For notification purposes, the
boy was found to have both clinically and laboratory diagnosed botulism,
and the parents were notified as having had clinical-epidemiological botulism.
Commentary
Few doctors have seen cases of botulism, and the symptoms can often be
confused with other neurological syndromes.
35 cases of foodborne botulism have been reported in Norway since 1975.
There were 2 outbreaks of botulism after the consumption of oerakfisk in
2003, with a total of 6 people affected. It was important to the diagnosis
that information was received about the other ill people and the oerakfisk
meal.
Botulinum toxins are produced by the spore-generating anaerobic bacteria
_Clostridium botulinum_, which are normally found ubiquitously in soil, sea
sediments, and the intestinal tract of animals. Therefore, contamination of
fish with _C. botulinum_, especially home-caught and -prepared fish, can
easily occur. The most important preventative measure in Norway is a high
standard of hygiene in the preparation of oerakfisk, other preserved fish,
tinned food, and cured ham.
In the German cases, it seems that the air-drying of the salted fish
without further preparation enabled bacteria to survive. If _C. botulinum_
survive, reproduction of the bacteria and formation of botulinum toxin E is
prevented only at comparatively low temperatures (under 3 deg C) (4).
Typical incubation periods are between 12 and 36 hours, but can vary
between 6 hours and 10 days. The most common symptoms are dry mouth,
constipation, double vision, speech difficulties, and progressive
paralysis, including respiratory weakness. At onset, vomiting and diarrhea
may occur. Case history is important for diagnosis, which can be verified
by tests for the toxin in blood, vomit, feces or food samples. There are 7
types of toxin, of which types A, B, and E (very rarely also F) cause
intoxications in humans.
Treatment for foodborne botulism is by administration of the antitoxin. It
is important to detect, by careful observation, respiratory difficulties
that could require ventilation. After having diagnosed a case of botulism,
it is important to determine quickly whether others could also have been
exposed, in order to expedite diagnosis and treatment.
1. Eriksen T, Broch Brantsæter A. Botulisme og Rakfisk. MSIS-Rapport; 31:
16 Dec 2003.
2. Robert Koch-Institut. Botulismus: Anmerkungen zu einer aktuellen
Familien Erkrankung nach Fischverzehr. Epidemiologisches Bulletin 45: 368, 2003
3. Kuusi M, Hasseltvedt V, Aavitsland P. Surveillance Report: Botulism in
Norway. Euro Surveill 1999; 4: 11-2.
4. Robert Koch-Institut. Fallbericht: Botulismus nach Verzehr von rohem
Lammschinken. Epidemiologisches Bulletin 2003; 3 17-9.
[Byline: Torfinn Eriksen, Arne Broch Brantsæter, Wolfgang Kiehl and Ines
Steffens. Translations by the editorial team, Eurosurveillance editorial
office]
- ---
ProMED-mail
[Botulinum toxin is considered one of the category A biowarfare agents by
the US CDC. In the past a number of governmental military programs,
including those of the former Soviet Union, Nazi Germany, imperial Japan,
and the US all extensively weaponized the toxin. Indeed, even after the
1992 Biological and Toxin Weapons Convention, the Soviet Union and Iraq
allegedly continued large-scale production of the toxin for offensive
warfare purposes, and the USSR was reported to have spliced the toxin gene
into other bacterial species (1).
Classically, botulism is a food-borne disease caused by the ingestion of
preformed toxin, although there also exist wound botulism (in which _C.
botulinum_ spores germinate in a wound) and infant botulism (in which the
spores germinate in the intestinal tract). In the USA, infant botulism is
the most common. Inhalation botulism or food/water deliberate
contamination may be biowarfare events. An accidental exposure of lab
workers to aerosolized toxin occurred in the early 1960s in Germany (2)
- -- the clinical symptoms were mild with complete recovery, probably in
part due to a sublethal dose. Lethal disease has been caused in primates
exposed to a botulinum toxin aerosol (3). Aun Shinrikyo, the Japanese
cult, unsuccessfully attempted to aerosolize the toxin in Tokyo and against
US military installations in Japan in the 1990s (4, 5). Although considered
by some military experts to be an inefficient military weapon (only a 10
percent casualty rate), large-scale water exposures are unlikely, since
standard water treatment methodology will inactivate the toxin.
1. Alibek K, Handleman S. Biohazard. 1999, New York, Random House.
2. Holzer, VE. Botulismus durch inhalation. Med Klin 1962;41:1735-1738.
3. Franz DR, Pitt LM, Clayton MA, et al. Efficacy of prophylactic and
therapeutic administration of antitoxin for inhalation botulism, in
Botulism and Tetanus Neurotoxoins: Neurotransmission and Biomedicine
Aspects. Das Gupta BR (ed), 1993, Plenum Text, New York, pp 473-476.
4. Tucker J. Toxic terror: Assessing the Terrorist Use of Chemical and
Biological Weapons, 2000, MIT Press, Cambridge.
5. WuDunn S, Miller J, Broad WJ. How Japan Germ Terror Alerted the World.
In New York Times 1998, New York, p A1, A10.
- - Mod.LL]
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