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" @ " 9 {oS / d J" % % 0 & V" x 3* 3* " 3* ] " q q q q q q q % % q q q & q q q q 3* q q q q q q q q q # : Foodborne Illness Outbreak Investigation
Case Study: Clostridium botulinum
A physician in Texas suspects one of his patients has botulism, a potentially fatal and notifiable illness. The physician reports the suspect case to the Texas Department of State Health Services who in turn notify the United States Centers for Disease Control and Prevention (CDC). As the CDC epidemiologist assigned to the case, it is your responsibility to determine the source of illness and to suggest means to prevent others from becoming ill. This involves interviewing the patient, determining potential exposure sources, determining what should be tested, interpreting laboratory results, helping to determine necessary actions to prevent others from becoming ill, and helping to determine actions necessary to prevent future occurrences.
The physician suspects the patient is suffering from botulism, an intoxication associated with certain foods. What symptom(s) distinguishes botulism from other microbiological foodborne illnesses?
Tests of the patients stool sample confirm the presence of Clostridium botulinum spores, and botulinum toxin is detected in serum samples. A search of networked CDC databases for reportable illnesses yields no other cases in the same time frame to-date. Does this Texas case constitute an outbreak?
You travel to the hospital to interview the patient to gather more information. By the time you arrive, the patients condition has worsened dramatically such that he is unable to communicate. He lives alone and works from home; and consequently, there are no close contacts available to provide information about his eating habits. Credit card records show no restaurant charges in the past two weeks. Dishes in the dishwasher are clean. Inspection of his home refrigerator, cupboards, trash and recycle bin yields various items listed in Table 1. Using data provided, complete Table I by indicating whether or not the foods found in this patients home have the potential to support C. botulinum growth and toxin production. Provide explanations for your determinations.
You collect samples of the suspect food(s) and/or container(s) from the Texas victims home and send them to the laboratory for testing. In the meantime, two cases of botulism are reported in Ohio. The victims are siblings, ages 4 and 5. They are responsive and their parents are available for interview.
Prepare a list of interview questions for their parents.
What specific question(s) might you ask in light of the case in Texas?
None of the containers and foods collected from the Texas victims home tested positive for C. botulinum spores. Interviews with parents of the victims in Ohio yield food consumption information presented in Table 1.
What foods do you suspect as potential vehicles in the Ohio cases?
Do the data suggest any similarities with the case in Texas?
There are no remaining food samples to test in the Ohio cases; and, as in the Texas case, rinse samples of empty containers yield negative results for C. botulinum and its toxin. However, containers from the suspect food are also coded to identify the facility where the product was manufactured. A comparison of containers reveals a common production facility for the suspect food despite different brand labels. The facility is visited by inspectors from government agencies. Review of operational quality assurance, production, and distribution records ensues. Why do the inspectors review the following records?
Time and temperature cook profiles for the production lot codes on the cans recovered from the victims homes
Maintenance, repair, and calibration records for the cooker equipment (a.k.a. retorts)
Distribution records for the product made under the production lot codes on the cans recovered from the victims homes
A comprehensive review reveals critical problems on one production line with new equipment installed 5 days prior to the production date of the product consumed by the victims. The production lines are running right now. What actions do you think should be taken?
Prepare a 60-second television news piece that informs the public of the critical information related to the cases.
Prepare a 10-minute presentation for the class giving an overview of case study.
This case study was prepared by the 91ԭ. This material is based upon work supported by the Cooperative State Research, Education, and Extension Service, U. S. Department of Agriculture, under Award No. 2009-38414-19698. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the U.S. Department of Agriculture.
Table I. Food and Containers from Texas Residence of First Case Patient
Food/ContainerPackagingStoragepHWater activity (aw)Container opened?Suspected Food?Why or why not?Ground meat
Vacuum packaged in trayRefrigerated6.70.96Yes
(trash)Strawberries
Plastic clamshellRefrigerated3.40.98Yes
(trash)Pineapple chunks Canned Shelf stable3.50.97No
(cupboard)Chili beans, meat, seasoningCannedShelf stable6.50.95Yes
(recycle bin)Ketchup Plastic bottleRefrigerated3.60.92Yes (refrigerator)Milk Plastic jugRefrigerated6.60.98Yes (refrigerator)Orange juice Paperboard cartonRefrigerated3.80.98Yes
(refrigerator)Grape jellyPlastic jarRefrigerated3.10.68Yes
(refrigerator)Vegetable soupCannedShelf stable6.30.96No
(cupboard)Dried spaghettiBoxShelf stable6.50.50Yes (cupboard)Tomato sauce Glass jarShelf stable4.10.95No
(cupboard)Soda Plastic bottleShelf stable3.40.98Yes (refrigerator)
Table II. Intake History of Ohio Case Patients
PatientFood/Beverage ConsumedOthers who consumed same?4 yr oldOrange juiceParentsChili (canned)Hot dog CarrotsMacaroni and cheese (boxed)Chicken patty (frozen, precooked)MilkParentsCereal (dry)Scrambled eggsParentsPeaches (canned)Applesauce (homemade)ParentsPopcornParents5 yr oldOrange juiceParentsChili (canned)Corn (canned)Macaroni and cheese (boxed)Chicken pattyMilkBananaScrambled eggsParentsPears (canned)Applesauce (homemade)Parents Peanuts Chicken noodle soup (canned)Parents
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