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Case Study: Clostridium botulinum
Teacher Version
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?
Answer: Effects to neurological system including paralysis, blurred vision, difficulty breathing and swallowing
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?
Answer: Yes, one case of botulism is considered an outbreak due to the severity of illness and mortality. For other illnesses, an outbreak is defined as 2 or more affected persons from the same source.
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.
Answer: Data are provided in Table 1. Suspect foods are low-acid and originally packaged anaerobically. If inadequate processing or temperature abuse occurred (example, unrefrigerated vacuum-packaged meat), these foods could have supported C. botulinum growth and toxin production. Unsuspected foods are either naturally high acid, acidified, high salt/sugar, and/or stored aerobically, characteristics that do not readily support the germination of C. botulinum spores and growth of vegetative cells.
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.
Answer:
Health conditions/symptoms recently?
When did symptoms begin?
Where did they eat in the past 8 days?
With whom have you shared meals in the past 8 days?
What foods have you consumed in the past 8 days?
Have you traveled in the past 8 days?
Prior health conditions?
Do you can your own foods at home?
What specific question(s) might you ask in light of the case in Texas?
Answer:
Were any of the above food items tested in the Texas case also consumed by the patients in Ohio?
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?
Answer: Canned chili. Other low-acid, anaerobically-stored products are most likely eliminated from consideration due to consumption patterns of family members. For example, canned corn was consumed by only one of the children, and chicken noodle soup was consumed by the parents who did not fall ill.
Do the data suggest any similarities with the case in Texas?
Answer: Yes, consumption of canned chili.
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
Answer: To determine adequacy of processing conditions to kill C. botulinum spores in product that could support their outgrowth
Maintenance, repair, and calibration records for the cooker equipment (a.k.a. retorts)
Answer: To determine adequacy of equipment to deliver process necessary to kill C. botulinum spores
Distribution records for the product made under the production lot codes on the cans recovered from the victims homes
Answer: To determine distribution of potentially defective product
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?
Answer: Stop production. Retain all product not yet shipped made on that equipment from installation date. Recall all products in commerce made on equipment from installation date to present (consumer, retail, food service). Also possibly open 24-hr consumer hot-line, refunds, etc. Equipment repair and validation are essential prior to use.
Prepare a 60-second television news piece that informs the public of the critical information related to the cases.
Answer: Suggested for inclusion: source of contamination (brands, products, time period), how to discard product, relevant time exposures, number individuals affected, region individuals affected, basic facts about botulism, symptoms, treatment, what to do if concerned about exposure or if develop some symptoms, and reliable resources for more information (FDA, CDC, etc.). No sensationalism.
Prepare a 10-minute presentation for the class giving an overview of case study.
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)YesAnaerobic, low-acid, if stored at improper temperatureStrawberries
Plastic clamshellRefrigerated3.40.98Yes
(trash)NoAcidityPineapple chunks Canned Shelf stable3.50.97No
(cupboard)NoAcidityChili beans, meat, seasoningCannedShelf stable6.50.95Yes
(recycle bin)YesAnaerobic, low-acidKetchup Plastic bottleRefrigerated3.60.92Yes (refrigerator)NoAcidityMilk Plastic jugRefrigerated6.60.98Yes (refrigerator)NoAerobic Orange juice Paperboard cartonRefrigerated3.80.98Yes
(refrigerator)NoAcidityGrape jellyPlastic jarRefrigerated3.10.68Yes
(refrigerator)NoAcidity, low awVegetable soupCannedShelf stable6.30.96No
(cupboard)YesAnaerobic, low-acidDried spaghettiBoxShelf stable6.50.50Yes (cupboard)NoLow aw. aerobicTomato sauce Glass jarShelf stable4.10.95No
(cupboard)NoAciditySoda Plastic bottleShelf stable3.40.98Yes (refrigerator)NoAcidity
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
Background information:
Clostridium botulinum is a sporeforming bacterium. Spores may be found in the environment; the spore state of metabolic dormancy protects the bacterium from environmental stresses. C. botulinum that is actively growing, known as the vegetative state, produces a potentially-fatal neurotoxin. Botulism intoxication is characterized by constipation, dizziness, blurred vision, difficulty breathing, slurred speech, and paralysis (IAFP, 1999). Immediate diagnosis is critical; treatment involves administration of botulinum antitoxin and management of symptoms. A vaccine is available for C. botulinum toxin, but is administered to individuals considered at risk for exposure such as laboratory workers and military personnel (Arnon et al., 2001).
Control of C. botulinum in foods is by heat inactivation of both vegetative cells and spores, or with conditions that prevent germination of spores. Heat inactivation is achieved by high temperature treatment, under pressure, of containers with foods that could support the outgrowth of C. botulinum. The process is used for canned foods in processing equipment known as retorts. Germination and outgrowth of spores is inhibited by high acidity, defined as having a pH less than 4.6 (either naturally or by acidification), water activity below 0.9, and/or aerobic conditions. Refrigeration will slow growth. Canned low-acid foods are considered at risk for supporting C. botulinum growth; however, strict adherence to low-acid, canned food regulations which require processing conditions in excess of those necessary to inactivate C. botulinum spores has provided an excellent safety record for these foods. Failures in temperature/time treatment of canned foods could lead to germination and outgrowth of surviving C. botulinum spores and subsequent toxin production. The integrity of hermetically sealed cans is critical because a small opening could permit the introduction of contaminating spores or vegetative cells. The product may reseal the opening effectively maintaining anaerobic conditions throughout the can. Other foods associated with C. botulinum include improperly home-canned low-acid foods, smoked fish, and low-acid foods left unrefrigerated that establish anaerobic conditions such as cooked potatoes and stews (IAFP, 1999). More recently, the use of oils with inclusions led to the requirement for acidification of these products due to intrinsic conditions which could support C. botulinum growth.
This case study was based on a 2007 outbreak of botulism associated with commercially-canned chili sauce. It was the first botulism outbreak in the United States attributed to commercially-canned foods since 1974. The majority (92%) of botulism cases in the period from 1950 to 2000 were associated with home-processed foods. The implicated chili was processed on new equipment that was flawed, leaving the product undercooked. The actual outbreak involved 8 cases of botulism and one death allegedly attributed to the product (case pending at writing). The first suspected case was reported July 7, 2007. A recall was initiated July 18, 2007. The canning facility closed July 21, 2007 and reopened September 18, 2007. More than 90 different items amounting to tens of millions of cans over 49 states were recalled during the actual outbreak. The company reported $78 million in recall-related costs. By May 2008, the company reported resumed distribution of their products to 85% of stores that previously purchased their products. Widespread distribution and the long-shelf life of canned foods decrease potential for full success of their recall. Even discarded cans may be used if recovered by food-insecure individuals. A follow-up inspection by the North Carolina Department of Agriculture and Consumer Services reported in 2008 the results of 250 site visits to evaluate effectiveness of this particular recall. Thirty-eight percent of all stores that handled the product still had some recalled product on the shelf after the recall. More than 5,000 cans were embargoed or retained and removed. (The Food Industry Center, 2008)
References
Arnon, S. S., R. Schechter, T. V. Inglesby, D. A. Henderson, J. G. Bartlett, M. S. Ascher, E. Eitzen, A. D. Fine, J. Hauer, M. Layton, S. Lillibridge, M. T. Osterholm, T. OToole, G. Parker, T. M. Perl, P. K. Russell, D. L. Swerdlow, and K. Tonat. 2001. Botulinum toxin as a biological weapon. Journal of the American Medical Association 285:10592081.
Centers for Disease Control and Prevention (CDC). 2007. Botulism associated with commercially canned chili sauce Texas and Indiana, July 2007. Morbidity and Mortality Weekly Report 56(30): 767-769.
International Association for Food Protection (IAFP). 1999. Procedures to investigate foodborne illness, 5th edition. IAFP. Des Moines, IA, USA. Page 129.
The Food Industry Center, Univ. Minnesota, National Center for Food Protection and Defense, Castleberrys: 2007 Botulism Recall, A Case Study by the Food Industry Center August 2008.
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.
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