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> From: Liz Brown <bfeab@uaf.edu>
> Date: 2004/01/21 Wed AM 11:44:49 EST
> To: seafood@ucdavis.edu
> Subject: [Fwd: PRO> ProMED Digest V2004 #30]
>
>
>
> 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
> ********************************
> A ProMED-mail post
>
> ProMED-mail is a program of the
> International Society for Infectious Diseases
>
>
> 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
> - -----------------------------------------------------------
> 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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