Botulism from instant soup in Italy

Posted on March 25, 2014 by Douglas Powell

A 33-year old man hospitalized in Camposampiero remains in critical condition, but is showing signs of recovery following botulism poisoning after eating an instant soup.

Though the young man remains intubated in intensive care, he is slowly regaining mobility of his limbs, after the paralysis caused by the intoxication. Meanwhile, the medical director of Local Health Unit 15 Sandro Artosi stated that he had immediately alerted the Ministry of Health (which was sent a sample of the soup eaten by the 33 year-old).

The Ministry of Health has initiated the emergency food alert procedure and ordered the seizure of the minestrone from retailers. The young man had eaten a pre-cooked instant soup of the company Buonaterra during his lunch break. The Local Health Unit of Alessandria, where the soup manufacturer is located, was also immediately alerted and a Food Alert was started, with the publication on the website of the Ministry of Health.

Botulinum toxin type B has been analytically confirmed in soup by the laboratories of the Istituto Zooprofilattico delle Venezie, Legnaro (Padova). The young man, who had eaten the pre-cooked soup on March 19, is still hospitalized in the intensive care unit of the hospital in Camposampiero Friday. On Saturday March 22 he was treated with antibotulin serum.

(Thanks to Luca Bucchini for the story and translation.)

Botulism in Australia: Lucas Whitelegg is going home after 241 days at Monash Children’s Hospital

Posted on January 10, 2014 by Douglas Powell

Lucas Whitelegg is finally ready to embrace the world with both arms after spending 10 months with his entire body paralysed by botulism.

Three days after celebrating his first birthday, Lucas will on Friday wave goodbye to the Monash Children’s Hospital staff who helped him through 241 days in intensive care and the gradual return of his movement from the pure form of Botox. For Lucas’ mother Bree Bailey it will mark the end of nightmare that began when he was 8 1/2 weeks old and ingested a spore that sprouted botulism in his belly, which then spread through his bloodstream and paralysed his entire body.

One of only 13 cases of botulism in Victoria in the last five years, doctors had to retrieve a $100,000 antitoxin from the US to save Lucas and then wait for the paralysis to wear off.

It was weeks before Lucas could even open his eyes, three months before his fingers and toes wiggled, and eight months before his lungs and diaphragm freed up allowing him to breath without a ventilator.

Texas botulism cases linked to home fermented turshi

Posted on December 18, 2013 by Ben Chapman

Botulism isn’t always pruno-related, the most common source of botulism in North America is improperly canned home preserves. Usually the illnesses are from low acid foods being placed into a jar and then heating enough to seal – but not enough to inactivate the C. botulinum spores. In 2012, a few unlucky folks attending a Oregon family gathering ate some beets that had been boiling-water-bathed, reaching just 212F instead of the needed 240F. Sometimes, if folks are home fermenting stuff, they can create the exact same conditions. Amarillo News reports that a cluster of four botulism cases were likely caused by an amateur fermenter.

The apparent cause of the botulism cases is homemade food called turshi, a traditional Middle Eastern dish of fermented vegetables.

“Investigators believe that during the fermentation phase of preparation lasting several weeks, conditions were ideal for bacteria growth and botulinum toxin production,” according to a news release.

“No commercial food product or restaurant has been linked to the outbreak. No new cases have been added to the outbreak of four and there is no reason to believe this contaminating product is a threat to the general public.”

Health care workers reported the first case Dec. 9, and an investigation found the other victims who knew each other.

Two patients are still in a local hospital.

“One remained on a ventilator this afternoon,” Duke said. “My understanding is it will be removed in the near future.”

Experimentating with pruno leads to 8 cases of botulism in Utah

Posted on December 14, 2013 by Ben Chapman

The first case of food-related botulism recorded in the medical literature occurred in Germany in 1735 and was traced to uncooked fermented blood sausage. Food safety history guru (and pretty decent margarita recipe developer) Carl Custer pointed out in an IAFP workshop that botulism concerns (and regulatory responses) go back further than that. In the 10th century, Emperor Leo VI of Byzantium prohibited the manufacture of blood sausage because of repeated illnesses leaving folks paralyzed and dying not too long after exposure. Botulism (derived from botulus, the latin word for sausage) is a pretty nasty old-world illness. Clostridium botulinum spores are fairly common in soil and can germinate and outgrow into vegetative cells in anaerobic, low acid conditions. A byproduct of the cells’ multiplication is the toxin.

Mrs. Kalisz, my family studies teacher warned of the dangers of botulism by showing a bulging can of beans. She didn’t mention anything about partially-fermented sausages, under processed home-canned food, packaged seafood, foil-wrapped baked potatoes – or a homemade prison alcohol called pruno.

To make pruno, a sugar source (like fruit acquired from a prison lunch) is put into in a bottle or bag, the naturally occurring yeast should convert the carbs into alcohol – creating some low-cost wine. If the sugar source is acidic fruit the low pH will suppress the germination of C. bot spores. If a potato (also full of carbs) is added by the amateur microbiologist it can raise the pH enough to allow for outgrowth. According to a paper published by Williams and colleagues in the Annals of Emergency Medicine, this is likely what happened in a 2011 botulism outbreak traced to a Utah prison.

Twelve prisoners consumed pruno, a homemade alcoholic beverage made from a mixture of ingredients in prison environments. Four drank pruno made without potato and did not develop botulism. Eight drank pruno made with potato, became symptomatic, and were hospitalized. The prune recipe involved in this outbreak (see right) was provided by patient 4, who reportedly had cooked this recipe approximately 20 times previously without a potato. The prisoner’s rationale behind using a potato was that he thought it would “accelerate fermentation,” and he was “experimenting.”

Pruno or prison wine: old potato led to botulism outbreak in Utah prison

Posted on December 14, 2013 by Douglas Powell

Who hasn’t tried to make hooch from old produce while in prison.

I have.

It’s so boring in jail people will try anything, usually experimenting with creative ways to bring in drugs, and becoming better criminals upon release.

I had a basic understanding of microbiology and fermentations.

The Salt Lake Tribune reports that the inmate who cooked up some botulism-tainted jailhouse wine at the Utah State Prison in 2011 had brewed homemade alcohol before. But he made one — nearly fatal — mistake in October 2011.

He used a potato.

Pruno, or “prison wine” is an alcoholic liquid made from apples, oranges, fruit cocktail, ketchup, sugar, milk, and possibly other ingredients, including crumbled bread to ferment the beverage.

According to a study about the botulism outbreak published this week in the Annals of Emergency Medicine, the inmate’s experimentation in putting an old potato among other ingredients in the plastic bag hidden in his cell led to the sickening of 12 inmates at the prison. The potato allowed botulism to develop, according to the article.

The 2011 incident was highlighted in the peer-reviewed journal for the American College of Emergency Physicians in an article entitled, “Emergency Department Identification and Critical Care Management of a Utah Prison Botulism Outbreak.”

In the Utah case, researchers said eight of the 12 inmates who were sickened by the bad brew were diagnosed with “acute botulism poisoning.” This incident is one of the largest foodborne botulism outbreaks since 2006, according to researchers.

The inmate who made the so-called “pruno” told medical officials that he had made the brew — which contained a two-week old baked potato, powdered juice mix and several types of fresh and canned fruit — about 20 times before. But this was the first time he had added a potato, thinking it would “accelerate fermentation.”

4 in hospital; possible botulism outbreak in Texas

Posted on December 12, 2013 by Douglas Powell

The city of Amarillo Department of Public Health is investigating four botulism cases after four people have been hospitalized with symptoms of the bacteria.

All four people in the cases are hospitalized at this time, two patients have received the antitoxin and are improving slowly. All of the patients know one of the other patients but DPH has yet to find a definitive link between the cases and a specific restaurant, food, school, workplace or church.

At this time officials are asking doctors and patients to watch for these symptoms so health officials can respond to the cases quickly. DPH and the City of Amarillo Environmental Health are working with the Texas Department of State Health Services and Centers for Disease Control. Food samples have been submitted for testing and results are expected within the next two days.

A fresh perspective on alleged pesto outbreak in Italy

Posted on July 23, 2013 by Douglas Powell

It’s better to rely on locals who know their stuff, so I turned to our Italian food safety friend, Luca Bucchini to clarify the alleged-botulism-in-pesto story. He writes:

There was probably no botulin toxin in the Italian basil pesto that sent more than 100 people to the emergency departments across Italy. Of the 100, 10 have been initially hospitalised, but 8 were later sent home: none had symptoms which suggested botulism. While tests on products and humans are still pending, the toxin has yet to be found in any sample.

The company, Bruzzone and Ferrari, which has been producing basil for pesto for two centuries, had identified a “potentially pathogenic microorganism” in a lot of its pesto: it is widely believed that the organism was C. botulinum, the bacterium which can, under certain conditions, produce the lethal toxin. The product, which is a fresh sauce requiring refrigeration, was already on the market: when the shelf life of a product is relatively short and time required for testing is relatively long, products are shipped before the results of the testing are known. This procedure is often required by retailers. When Bruzzone and Ferrari realised that they had a positive finding for the pathogen, though not for the toxin, they decided to issue a recall; a public recall is uncommon in Italy.

Italy’s Ministry of Health, usually stingy with information, issued a Press Release (http://www.salute.gov.it/portale/news/p3_2_4_1_1.jsp?lingua=italiano&menu=salastampa&p=comunicatistampa&id=4053) on July 20, 2013, calling the incident an “alarm” and explained that the botulin toxin is potentially fatal. However, it failed to mention the retail brands under which the product was sold, and did not offer advice to consumers, for example on when to seek medical care. Only the lot, the sell-by date and the producer’s name were mentioned; it was assumed that consumers are able to scan the back of the label and identify the small print needed to identify the producer. The press release also suggested that products were mostly off the shelf and the recall was limited. Ministry of Health press releases are immediately taken up by the main press agencies, and automatically become major news.

It soon became apparent that 15,000 jars were affected, and that many consumers had eaten the product, which had been on the market for at least a week; there was no information for them in the official communication. Panic ensued. Officials communicated sparingly, with the exception of Liguria, the region where the company is based. Hospitals were slow to explain that no cases were confirmed and that people without symptoms did not need hospitalisation; the Facebook site of Bruzzone & Ferrari was the only formal source of information, with only a few independent media outlets providing further details. The affected lot had been sold under several brands, including those of Italy’s top supermarket chains. The supermarket chains posted alert signs in shops and frantically e-mailed and phoned customers with loyalty cards to inform them of the recall; they probably hoped to avoid going public. As consumers reported about the calls received on Facebook and on other sites, some eventually capitulated and published on their website a recall notice, while others are still silent.

At this point in time, it seems likely that there was no toxin in most or all jars, and that people sought medical attention for reasons unrelated to product content. Some suspect that other pathogens may be present; however, no specific information supports this, and reported symptoms by few patients (vomit, diarrhea) may be unrelated to the exposure.

Nevertheless, the presence of the toxin in some jars cannot be excluded. The product does not appear to be heat-treated; it is part of a broad global trend to produce raw, semi-raw fresh products which require refrigeration. The pH of the product is permissive for growth of botulin (specifications: 4.8-5.8); it is rich in oil providing anaerobic conditions; it is used on pasta as a sauce without cooking; it has a shelf life of 30 days. While the product is to be refrigerated, the cold chain, especially in summer, with ambient temperatures above 30 C, is often not reliable: retailers often don’t prioritise temperature control. Consumers may not understand the difference between shelf-stable pesto (which is more common) and the refrigerated variety, or underestimate the importance of refrigeration.

Though food safety officials praised the company for not hesitating to issue a public recall, magistrates, as it is usual in Italy, were quick to start a criminal investigation for alleged unintentional injuries. In Italy, companies fear issuing precautionary recalls as magistrates generally try and convict in criminal court those who publicly confess to the mere presence of a pathogen in their products. This has been a factor in the hesitation of businesses to embrace European food law which requires issuing immediate recalls.

Overall, it is early to draw final conclusions from this episode. Hopefully, the results of the testing will be made public and confirm that there was no outbreak (incidentally, Italy has an ongoing foodborne Hepatitis A outbreak with hundreds of cases of which were little is being said). It is perhaps time to question products which, while nicely fresh, depend on the cold chain for being safe from botulin. It is quite clear that the authorities, and particularly the Ministry of Health, need risk communication training: consumers need to reliably identify products, get quickly rid of them, and not rush to the ER if they don’t need to.

50 sick: the link between Simon Cowell, botox and pesto?

Posted on July 23, 2013 by Douglas Powell

Food poisoning can be caused by Clostridium botulinum, a bacteria that can form spores which require extra processing or careful control of temperature. Botox, derived from botulinum, is used by vain people.

UK’s Daily Mail, you are a gift that keeps giving, after reporting “dozens of people have been hospitalized in Italy after eating pesto sauce contaminated with Botox. … Tests on the pesto showed the presence of the bacteria Clostridium botulinum, which produces the toxin Botulinum, used cosmetically by television personalities such as Simon Cowell. When ingested the toxin causes a life-threatening kind of food poisoning.”

The local producer responsible for the outbreak has been growing the area’s renowned basil for almost two centuries, but only recently started selling pre-prepared jars of the sauce.

The company said, “We made the discovery during our own tests and analysis of our fresh product, non-pasteurized product, which contains no preservatives.”

Refrigeration would help.

30 hospitalized from botulism in pesto in Italy

Posted on July 22, 2013 by Douglas Powell

At least 30 people were admitted to Italian hospitals for suspected botulism poisoning after eating pesto produced by Bruzzone and Ferrari. All reported having consumed the same pesto. Samples of blood, urine, feces and pesto same were sent to the Ministry of Health, Rome, for analysis.

In 2012, the UK Food Standards Agency identified an outbreak of botulism linked to olives from Italy.

Stories, not just statistics, matter in food safety

Posted on April 29, 2013 by Ben Chapman

Back in grad school Doug told me how to give a successful talk: Present in a series of stories; get those stories right; be passionate; and, end early (because everyone goes over time).

Storytelling in food safety matters. Folks aren’t compelled by the fancy facts and figures that all of us nerds have access to. What connects are the weird stories about symptoms, contamination and tragedy of outbreaks. And there’s some stuff in the literature to back this up. Morgan and colleagues (2002) evaluated various safety messages targeted at farmers regarding the use of personal protective structures for vehicles by presenting combinations of different message delivery methods. Participants reported that messages based on stories, and those that were meant to elicit fear about individual practices, had more impact on their desire to use safe practices than presenting consequence-based statistics alone. Slater and Rouner (1996) found that folks rate messages with narratives as higher quality and perceived them to be the most persuasive when looking at alcohol risks.

A couple of my colleagues who are designing a course on acidified foods processing for regulatory folks asked me for some help in identifying stories to supplement the technical information they were teaching about. I went back through barfblog and FSNet files and pulled up some nice ones. Like the restaurant-linked botulism cases linked to a chopped-garlic-in-soybean-oil that was held at room temp for several months before being used on a sandwich. Or the home pickled eggs that lead to a 68-year-old man acquiring bot intoxication. The eggs were boiled, peeled and punctured with toothpicks and placed into a jar with beets, hot peppers and vinegar – and then held at room temperature for a week. While the pickling liquid had a pH of 3.5, bot toxin was detected in both the liquid and the yolks. Although the yolks had 1000x greater concentration. Best guess is that C. botulinum spores were driven into the yolk during the puncturing and the liquid never made it in to acidify.

Add stories on fermented seal flipper and native Alaskan meat preservation to the list. According to Discover Magazine’s Rebecca Kreston, many of the botulism intoxication cases seen in the U.S. annually are linked to changing processes for fermenting meat. She relates a story told to her in an bacterial pathogenesis class and goes on to investigate the anecdote.

[O]ur professor noted that several cases of botulism in Alaskan Natives occurred as a result of changing methods of fermenting meat. Professor, you had me at “fermenting meat”.

Investigating the veracity of this anecdote I found that tried and true Alaskan Native methods of burying meat underground to ferment had been modified by the introduction of Western conveniences. Tupperware containers and sealable plastic bags were now being used to create a meaty, anaerobic environment that C. botulinum was happy to vacation in. Oh plastics, you synthetic polymers, what have you wrought!

I also discovered the staggering statistic that Alaska ranks among the highest incidence of foodborne botulism in the world. Indeed, nearly half of all cases of foodborne botulism cases in the United States occur in that icy Northern state; the incidence of botulism in Alaska is 8.46 cases per 100,000 compared to Washington’s paltry 0.43 per 100,000 (see here, and here).

This is truly a public health dilemma! Botulism has been repeatedly referred to as an endemic “hazard of the North” but typically occurs in western Eskimo coastal villages and Native Americans regions in the southwestern region of Alaska due to their proximity to aquatic foodstuffs

The term “fermented” might be putting it kindly – many ethnographers have described these prepared foods as intentionally putrefied. And, in fact, the fermentation process cannot occur without a carbohydrate substance and these meats aren’t technically “fermented”. The researcher Nelson reported the preparation process quite evocatively in 1971:

“Meat is frequently kept for a considerable length of time and sometimes until it becomes semiputrid. This meat was kept in small underground pits, which the frozen subsoil rendered cold, but not cold enough to prevent the bluish fungus growth which completely covered the carcasses of the animals and the walls of the storerooms”.

The customary preparation process has since been modified from fermenting food in a buried clay pit, enclosed in a woven basket or sewn seal skin (known as a “poke”) for weeks or months at a time. Food is now stored in airtight, Western consumer goods such as plastic or glass jars, sealable plastic bags or even plastic buckets, and eaten shortly after in a week or month. Additionally, the food many be stored indoors, above ground or in the sun at milder, less optimal temperatures. This move towards storing meat in warmer, anaerobic settings for shorter lengths of time may expedite the fermentation process and, subsequently, enhance the risk of botulinum toxin production.

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