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San Diego Union-Tribune

“……They were hospitalized after experiencing a range of symptoms including double vision, drooping eyelids, difficulty swallowing, slurred speech and generalized weakness.

All three have required intensive care treatment with an anti-toxin that counteracts the effects of a neurotoxin produced by clostridium botulinum….”

Xinhua

•  3 are in a serious condition.
• All patients have received the anti-botulinum serum.

CELL

“……“BoNT-like gene clusters have not previously been identified in any bacterial species outside of Clostridium and no toxins of E. faecium have been reported before now,” the authors said. “It is disconcerting to find a member of potent neurotoxins in this widely distributed gut microbe, which is a leading cause of hospital-acquired infections.”…..”

CDC

Advice for Providers Treating Patients in or Recently Returned from Hurricane-Affected Areas, Including Puerto Rico and US Virgin Islands

(https://emergency.cdc.gov/han/index.asp)

Distributed via the CDC Health Alert Network
October 24, 2017, 1330 ET (1:30 PM ET)
CDCHAN-00408

Summary
The Centers for Disease Control and Prevention (CDC) is working with federal, state, territorial, and local agencies and global health partners in response to recent hurricanes. CDC is aware of media reports and anecdotal accounts of various infectious diseases in hurricane-affected areas, including Puerto Rico and the US Virgin Islands (USVI). Because of compromised drinking water and decreased access to safe water, food, and shelter, the conditions for outbreaks of infectious diseases exist.

The purpose of this HAN advisory is to remind clinicians assessing patients currently in or recently returned from hurricane-affected areas to be vigilant in looking for certain infectious diseases, including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. Additionally, this Advisory provides guidance to state and territorial health departments on enhanced disease reporting.

 

Background
Hurricanes Irma and Maria made landfall in Puerto Rico and USVI in September 2017, causing widespread flooding and devastation. Natural hazards associated with the storms continue to affect many areas. Infectious disease outbreaks of diarrheal and respiratory illnesses can occur when access to safe water and sewage systems are disrupted and personal hygiene is difficult to maintain. Additionally, vector borne diseases can occur due to increased mosquito breeding in standing water; both Puerto Rico and USVI are at risk for outbreaks of dengue, Zika, and chikungunya.

Health care providers and public health practitioners should be aware that post-hurricane environmental conditions may pose an increased risk for the spread of infectious diseases among patients in or recently returned from hurricane-affected areas; including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. The period of heightened risk may last through March 2018, based on current predictions of full restoration of power and safe water systems in Puerto Rico and USVI.

In addition, providers in health care facilities that have experienced water damage or contaminated water systems should be aware of the potential for increased risk of infections in those facilities due to invasive fungi, nontuberculous Mycobacterium species, Legionella species, and other Gram-negative bacteria associated with water (e.g., Pseudomonas), especially among critically ill or immunocompromised patients.

Cholera has not occurred in Puerto Rico or USVI in many decades and is not expected to occur post-hurricane.

 

Recommendations

These recommendations apply to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas (e.g., within the past 4 weeks), during the period of September 2017 – March 2018.

• Health care providers and public health practitioners in hurricane-affected areas should look for community and healthcare-associated infectious diseases.
• Health care providers in the continental US are encouraged to ask patients about recent travel (e.g., within the past 4 weeks) to hurricane-affected areas.
• All healthcare providers should consider less common infectious disease etiologies in patients presenting with evidence of acute respiratory illness, gastroenteritis, renal or hepatic failure, wound infection, or other febrile illness. Some particularly important infectious diseases to consider include leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza.
• In the context of limited laboratory resources in hurricane-affected areas, health care providers should contact their territorial or state health department if they need assistance with ordering specific diagnostic tests.
• For certain conditions, such as leptospirosis, empiric therapy should be considered pending results of diagnostic tests— treatment for leptospirosis is most effective when initiated early in the disease process. Providers can contact their territorial or state health department or CDC for consultation.
• Local health care providers are strongly encouraged to report patients for whom there is a high level of suspicion for leptospirosis, dengue, hepatitis A, typhoid, and vibriosis to their local health authorities, while awaiting laboratory confirmation.
• Confirmed cases of leptospirosis, dengue, hepatitis A, typhoid fever, and vibriosis should be immediately reported to the territorial or state health department to facilitate public health investigation and, as appropriate, mitigate the risk of local transmission. While some of these conditions are not listed as reportable conditions in all states, they are conditions of public health importance and should be reported.

 

For More Information

• General health information about hurricanes and other tropical storms: https://www.cdc.gov/disasters/hurricanes/index.html
• Information about Hurricane Maria: https://www.cdc.gov/disasters/hurricanes/hurricane_maria.html
• Information for Travelers:
  • Travel notice for Hurricanes Irma and Maria in the Caribbean: https://wwwnc.cdc.gov/travel/notices/alert/hurricane-irma-in-the-caribbean
  • Health advice for travelers to Puerto Rico: https://wwwnc.cdc.gov/travel/destinations/traveler/none/puerto-rico?s_cid=ncezid-dgmq-travel-single-001
  • Health advice for travelers to the U.S. Virgin Islands: https://wwwnc.cdc.gov/travel/destinations/traveler/none/usvirgin-islands?s_cid=ncezid-dgmq-travel-leftnav-traveler
  • Resources from CDC Health Information for International Travel 2018 (the Yellow Book):
    • Humanitarian Aid Workers: https://wwwnc.cdc.gov/travel/yellowbook/2018/advising-travelers-with-specific-needs/humanitarian-aid-workers
• Post-travel Evaluation: https://wwwnc.cdc.gov/travel/yellowbook/2018/post-travel-evaluation/general-approach-to-the-returned-traveler
• Information about infectious diseases after a disaster: https://www.cdc.gov/disasters/disease/infectious.html
  • Dengue: https://www.cdc.gov/dengue/index.html
  • Hepatitis A: https://www.cdc.gov/hepatitis/HAV/index.htm
  • Leptospirosis: https://www.cdc.gov/leptospirosis/
  • Typhoid fever: https://www.cdc.gov/typhoid-fever/index.html
  • Vibriosis: https://www.cdc.gov/vibrio/index.html
• Information about other infectious diseases of concern:
  • Conjunctivitis: https://www.cdc.gov/conjunctivitis/
  • Influenza: https://www.cdc.gov/flu/index.htm
  • Scabies: https://www.cdc.gov/parasites/scabies/index.html
  • Tetanus and wound management: https://www.cdc.gov/disasters/emergwoundhcp.html
    • Tetanus in Areas Affected by a Hurricane: Guidelines for Clinicians https://emergency.cdc.gov/coca/cocanow/2017/2017sept12.asp

California Department of Public Health

The CDPH Food and Drug Branch (FDB) and Sacramento County Environmental Management Department (SCEMD) recently investigated an outbreak of botulism linked to the consumption of ready to eat nacho cheese purchased at Valley Oak Food and Fuel in Walnut Grove, California. The nacho cheese was applied to chips by customers from a counter-top, self-service warming and dispensing unit supplied by the cheese manufacturer. These types of warming and dispensing units are typically designed to maintain the cheese at approximately 140 deg. F.

As of May 31, 2017, a total of 10 case-patients were laboratory-confirmed with C. botulinum toxin type A. All patients were hospitalized; nine were in an intensive care unit, seven required ventilator support, and one died. Leftover nacho cheese sauce collected from the gas station yielded C. botulinum toxin type A bacteria and toxin. Due to the extensive distribution of the same lot code of nacho cheese throughout the United States without additional botulism cases, internal testing conducted by the Wisconsin manufacturer of the nacho cheese, and only a single bag of cheese linked to human illness, FDB and SCEMD suspect the nacho cheese was likely contaminated at the retail location. A few items in particular were noted during the investigation that was concerning:

 The 5 pound bag of nacho cheese collected at the retail location on May 5, 2017 was being used past the “Best By” date.

 Records were not being maintained by the gas station employees indicating when the bag of nacho cheese was originally added to the warming unit.

 The plastic tool designed to open the bags of cheese (provided with the nacho cheese warming and dispensing unit) was not being used by employees.

FDB is aware that these types of nacho cheese warming and dispensing units are in use at many retail locations throughout California. These units generally provide safe, ready-to-eat foods without significant input from employees at each location. FDB would like to provide the following guidance regarding the use of nacho cheese warming and dispensing units in retail locations.

1. Management and employees should follow the instructions for each type of machine and product they use. Instructions for use may be included on the packaging of the

bagged nacho cheese or included on the interior panels of the warming and dispensing unit. These directions may include pre-heating and the length of time a product can remain at elevated holding temperatures. In some cases the product may only be held above 135 deg. F. for 4-6 days.

2. Management should ensure that records are maintained indicating when bagged cheese was last changed. This may be accomplished by writing the date the product was added to the warmer on the bag itself.

3. Management should ensure that the warming and dispensing units are not turned off at night or plugged into a timer. These types of machines need to remain “on” at all times. This will ensure that appropriate temperatures are maintained in this ready-to-eat food.

4. Management and employees should ensure that any supplied tools for opening the bags of cheese are used per the product directions. These devices need to be washed, rinsed, and sanitized between uses. In some cases these opening tools are only supplied with warming and dispensing unit.

5. Management and employees should verify on a regular basis that the internal temperature of the hot held cheese product is being held at the proper temperature. The internal temperature can be measured by placing the cheese product in a cup with a thermometer to verify the product is maintaining the minimum hot holding temperature of 135 deg. F as required under the California Retail Food Code Section113996 or hot holding temperature as recommended by the manufacturer.

CDPH hopes this information can be shared widely to ensure retail food facilities have current information and are taking appropriate measures to keep our food supply safe. Thank you for your consideration and ongoing collaboration with our Department

Eurosurveillance

Eurosurveillance, Volume 22, Issue 24, 15 June 2017

CDC

Summary of Botulism Cases Reported in 2015

A total of 199 confirmed and 14 probable cases of botulism were reported to CDC in 2015.

Among confirmed cases, infant botulism accounted for 141 (71%) cases, foodborne botulism for 39 (20%) cases, wound botulism for 15 (8%) cases, and botulism of unknown or other transmission category for 4 (2%) cases (Table 1).

Among probable cases, foodborne botulism accounted for 6 (43%) cases and wound botulism for 8 (57%) cases.

The 141 cases of infant botulism were reported from 33 states and the District of Columbia. The median age of patients was 2.7 months with a range of 0 – 10 months; 70 (50%) were girls. Toxin type A accounted for 60 (43%), toxin type B accounted for 79 (56%), and toxin type Bf accounted for 2 (1%). No deaths were reported.

The 39 cases of confirmed foodborne botulism were reported from 7 states (Figure 1). The median age of patients was 59 years with a range of 9 – 92 years; 25 (64%) were women.

There were 5 outbreaks (events with two or more cases) accounting for 37 confirmed cases. One outbreak was associated with home-canned potatoes in a potato salad served at a church potluck (27 cases),† one was associated with fermented seal flipper (4 cases), and one was associated with beets roasted in aluminum foil and kept at room temperature for several days then made into a soup (2 cases). In addition, there were two outbreaks of two cases each living in the same household or facility in which the foodborne source was unknown (Table 2a).

Toxin type A accounted for 34 (87%), and toxin type E accounted for 5 (13%). One death was reported. The 6 cases of probable foodborne botulism (clinically compatible illness, not laboratory-confirmed, with an epidemiologic link to a suspect food) were reported from 3 states. The median age of patients was 53 years with a range of 23 – 73 years; 3 (50%) were women. No deaths were reported. Seal oil was the suspected food source for 2 of the 6 probable cases (Table 2b). There were 15 cases of confirmed wound botulism reported from 5 states. The median age of patients was 49 years with a range of 12 – 61 years; 2 (13%) were women. Toxin type A accounted for 14 (93%), and toxin type B accounted for 1 (7%). Fourteen (93%) were people who inject drugs (PWID). One death was reported.

The 8 cases of probable wound botulism (clinically compatible case who has no suspected exposure to contaminated food and who has a history in the 2 weeks before illness began of either a fresh wound or injection drug use) were reported from 3 states. The median age of patients was 59 years with a range of 28 – 78 years; 1 (12%) was a woman. All 8 were PWID. No deaths were reported. The 4 confirmed botulism cases of unknown etiology were reported from 3 states. The median age of patients was 47 years with a range of 27 – 71 years; 1 (25%) was a woman. Toxin type A accounted for all 4. No definitive route of transmission was identified for these cases.

Two cases were suspected to be adult intestinal colonization, a rare form of botulism thought to have a similar mechanism as infant botulism. The other two cases did not consume a suspect food, have any wounds, or have any known risk factors for adult intestinal colonization. How these persons were exposed to botulinum toxin is unknown. One patient developed botulism in 2015 and died in 2016 during a prolonged hospitalization.