Botulism In The Alaska Botulism In The Alaska BushBush

““A Public Health Emergency” A Public Health Emergency” CDC (2009)CDC (2009)

By Deborah ForchtBy Deborah ForchtMPH Student MPH Student

Walden UniversityWalden UniversityAugust 2, 2009August 2, 2009

Learning ObjectivesLearning Objectives What is Botulism?What is Botulism? Alaska Public Health Department reporting listAlaska Public Health Department reporting list Types of BotulismTypes of Botulism

– WoundWound– InfantileInfantile– FoodborneFoodborne

Incubation periodIncubation period OccurrenceOccurrence Signs and symptomsSigns and symptoms TreatmentTreatment Alaska health care providers awarenessAlaska health care providers awareness 2002 Outbreak2002 Outbreak Delivery of botulism antitoxinDelivery of botulism antitoxin

Clostridium Botulinum ToxinClostridium Botulinum Toxin

A neurotoxin that A neurotoxin that originates in soiloriginates in soil

Prevalent along the Prevalent along the coastline of Alaskacoastline of Alaska

Found in marine Found in marine mammalsmammals

Anaerobic sporesAnaerobic spores– Survive w/o oxygenSurvive w/o oxygen– Low PH (4.6)Low PH (4.6)– High moistureHigh moisture– 39 degrees Fahrenheit39 degrees Fahrenheit

(Moeller 2005 p138)(Moeller 2005 p138)

State of Alaska EpidemiologyState of Alaska EpidemiologyTracking of Reportable Conditions of Public Health ConcernTracking of Reportable Conditions of Public Health Concern

Outbreak surveillance and responseOutbreak surveillance and response– Notation of trendsNotation of trends– Monitoring of new infectious diseasesMonitoring of new infectious diseases

MeaslesMeaslesBotulismBotulismRabiesRabiesParalytic shellfish poisoningParalytic shellfish poisoningFood borne and waterborne diseasesFood borne and waterborne diseasesTuberculosisTuberculosisTo report Public Health Emergencies call (907) 269-8000or after hours To report Public Health Emergencies call (907) 269-8000or after hours

(800) 478-0084(800) 478-0084

(State of Alaska Public Health Epidemiology 2009)(State of Alaska Public Health Epidemiology 2009)

Food Types of BotulismFood Types of Botulism

Wound Wound Infantile Infantile FoodborneFoodborne

(Angulo 2005)(Angulo 2005)

Photo: Courtesy of HHS Public Health State of AlaskaPhoto: Courtesy of HHS Public Health State of Alaska

Wound BotulismWound Botulism

Botulism infection Botulism infection in open woundsin open wounds

Signs & symptoms Signs & symptoms are the sare the same as with ame as with food botulismfood botulism

Risky behavior Risky behavior Intravenous drug useIntravenous drug use

Dirty needlesDirty needles Black tar Heroin useBlack tar Heroin use

Poor wound care Poor wound care

(Sobel 2005)(Sobel 2005)

Infantile BotulismInfantile Botulism Ingestion of honey Ingestion of honey

– Children under 1 year of Children under 1 year of age age (WHO 2009)(WHO 2009)

Signs & symptomsSigns & symptoms ConstipationConstipation AnorexiaAnorexia MalaiseMalaise Change in their cryChange in their cry Loss of muscle tone most Loss of muscle tone most

noticeable in the ability to noticeable in the ability to move their head and neckmove their head and neck

(Heymann 2004 p.70)(Heymann 2004 p.70)

OccurrenceOccurrence Fermented foodsFermented foods

Muktuk-fermented Muktuk-fermented whale whale

Beaver tailBeaver tail Typically found atTypically found at

PotlatchesPotlatches Group Gatherings with Group Gatherings with

Foods Foods Single or multiple Single or multiple

victims, dependent victims, dependent upon the number of upon the number of persons who ingest the persons who ingest the food sourcefood source

(State of Alaska Public Health 2009) (State of Alaska Public Health 2009)

Photo: Courtesy of HHS Public Health State of Alaska

Incubation PeriodIncubation Period Incubation PeriodIncubation Period

– 12-24 hours12-24 hours– Onset of symptoms Onset of symptoms

may occur up to 2 may occur up to 2 weeks after weeks after ingestions of food ingestions of food sourcesource

– 2 week food history 2 week food history required for required for investigation of investigation of botulismbotulism

(Jong & Sanford 2008).(Jong & Sanford 2008).

Signs & SymptomsSigns & Symptoms General malaiseGeneral malaise Decreased muscle Decreased muscle

strengthstrength DizzinessDizziness LightheadednessLightheadedness Blurred visionBlurred vision NauseaNausea VomitingVomiting Diarrhea or Diarrhea or

constipationconstipation Abdominal bloatingAbdominal bloating Respiratory Respiratory

depressiondepression

(WHO 2009)(WHO 2009)

Treatment of BotulismTreatment of Botulism

Oxygen therapy and support Oxygen therapy and support for patients demonstrating for patients demonstrating respiratory distress from respiratory distress from decrease in muscle strengthdecrease in muscle strengthIntravenous delivery of Intravenous delivery of antitoxin: equine antitoxin: equine botulinumbotulinum

““Dilute 10-ml vial, 1:10 in Dilute 10-ml vial, 1:10 in 0.9% saline solution: deliver 0.9% saline solution: deliver IV slowly”IV slowly”(Veenema, T. 2006 p.116)(Veenema, T. 2006 p.116)

Available through the State Available through the State of Alaska Public Health of Alaska Public Health DepartmentDepartment

Public Health Emergencies Public Health Emergencies

call (907) 269-8000 orcall (907) 269-8000 or

after hours (800) 478-0084after hours (800) 478-0084

(State of Alaska Public Health 2009)(State of Alaska Public Health 2009)

C. Botulinum Type EC. Botulinum Type E

Prevalent along the Prevalent along the coastline of Alaskacoastline of Alaska

Found in marine Found in marine mammalsmammals

Can be killed if Can be killed if boiled for more boiled for more than 10 minutes than 10 minutes

(MMWR 2003)(MMWR 2003)

Cluster OutbreakCluster Outbreak July 13-15, 2002July 13-15, 2002 Muktuk (fermented whale) is Muktuk (fermented whale) is

eaten during a potlatch in a eaten during a potlatch in a western Alaskan fishing village western Alaskan fishing village

Estimated death of whale Estimated death of whale several weeks priorseveral weeks prior

14 persons aged 13-83 years14 persons aged 13-83 yearsare suspected of botulism are suspected of botulism poisoningpoisoning

57% of these are confirmed with 57% of these are confirmed with botulism poisoningbotulism poisoning

5 hospitalized5 hospitalized 4 receive antitoxin4 receive antitoxin 2 require ventilator assistance in 2 require ventilator assistance in

the ICUthe ICU

(MMWR 2003)(MMWR 2003)

Delivery of Botulism antitoxinDelivery of Botulism antitoxin BotulinumBotulinum antitoxin is antitoxin is

available in the United available in the United States through the States through the public health system public health system

Report all suspected Report all suspected casescases

Rapid treatment of Rapid treatment of Botulism is essentialBotulism is essential

To report: To report: Public Health Public Health Emergencies in Alaska call Emergencies in Alaska call (907) 269-8000or after hours (907) 269-8000or after hours (800) 478-0084(800) 478-0084

(State of Alaska Public Health 2009)(State of Alaska Public Health 2009)

ReviewReview What is Botulism?What is Botulism? Alaska Public Health Department reporting listAlaska Public Health Department reporting list Types of BotulismTypes of Botulism

– WoundWound– InfantileInfantile– FoodborneFoodborne

Incubation periodIncubation period OccurrenceOccurrence Signs and symptomsSigns and symptoms TreatmentTreatment Alaska health care providers awarenessAlaska health care providers awareness 2002 outbreak2002 outbreak Delivery of botulism antitoxinDelivery of botulism antitoxin

REFRENCES:REFRENCES: Angulo, F. (2005) Botulism. Angulo, F. (2005) Botulism. Clinical Infectious Diseases Clinical Infectious Diseases 41(8)1167-117341(8)1167-1173

CDC (2009) Center for Disease Control and Prevention: “Botulism” Division of CDC (2009) Center for Disease Control and Prevention: “Botulism” Division of Foodborne, Bacterial and Mycotic Disease. Retrieved from the internet on July Foodborne, Bacterial and Mycotic Disease. Retrieved from the internet on July 6, 2009 at: http://www.cdc.gov/nczved/dfbmd/disease_listing/botulism_gi.html6, 2009 at: http://www.cdc.gov/nczved/dfbmd/disease_listing/botulism_gi.html

Cox, N., Hinkle, R. (2002) Infant Botulism. Cox, N., Hinkle, R. (2002) Infant Botulism. American Family PhysicianAmerican Family Physician. 65(7) . 65(7) 1388-1392.1388-1392.

Heymann, D. (2004) Control of Communicable Diseases 4Heymann, D. (2004) Control of Communicable Diseases 4thth ed. Washington ed. Washington D.C. American Public Health Association.D.C. American Public Health Association.

MMWR (2003) Morbidity & Mortality Weekly: Outbreak of Botulism Type E MMWR (2003) Morbidity & Mortality Weekly: Outbreak of Botulism Type E Associated with Eating a Beached Whale--- Western Alaska, July 2002. MMWR Associated with Eating a Beached Whale--- Western Alaska, July 2002. MMWR 52(02)24-26. Retrieved from the internet on July 10,2009 52(02)24-26. Retrieved from the internet on July 10,2009 at:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5202a2.htmat:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5202a2.htm

Moeller, D. (2005) Environmental health 3Moeller, D. (2005) Environmental health 3rdrd. Ed. Cambridge, MA. Harvard . Ed. Cambridge, MA. Harvard University PressUniversity Press

References Continued:References Continued: State of Alaska Public Health Epidemiology (2009). Conditions State of Alaska Public Health Epidemiology (2009). Conditions

Reportable to Public Health in Alaska. Retrieved from the internet Reportable to Public Health in Alaska. Retrieved from the internet on July 19, 2009 at: on July 19, 2009 at: http://www.epi.hss.state.ak.us/pubs/conditions/default.stmhttp://www.epi.hss.state.ak.us/pubs/conditions/default.stm

Veenema, T. (2006) 3Veenema, T. (2006) 3rdrd ed. Ready RN: Handbook for Disaster ed. Ready RN: Handbook for Disaster Nursing and Emergency Preparedness. St. Louis, MO. Mosby.Nursing and Emergency Preparedness. St. Louis, MO. Mosby.

WHO (2009) World Health Organization: Botulism retrieved from WHO (2009) World Health Organization: Botulism retrieved from the internet on July 9,2009 at: the internet on July 9,2009 at: http://www.who.int/mediacentre/factsheets/fs270/en/http://www.who.int/mediacentre/factsheets/fs270/en/

Sources for Further ReadingSources for Further Reading Angulo, F. (2005) Clinical Infectious Diseases. Angulo, F. (2005) Clinical Infectious Diseases. Cox, N., Hinkle, R. (2002) Infant Botulism. Cox, N., Hinkle, R. (2002) Infant Botulism. American Family American Family

PhysicianPhysician. 65(7) 1388-1392. 65(7) 1388-1392 Drexler, M. (2002). Secret Agents: The Menace of Emerging Drexler, M. (2002). Secret Agents: The Menace of Emerging

Infections. Infections. Jong, E., Sandord, C. (2003) 3Jong, E., Sandord, C. (2003) 3rdrd ed. Travel and Tropical Medicine ed. Travel and Tropical Medicine

Manual.Manual. Melnick, D., Rouse, B. (2001). Portrait of Health in the United Melnick, D., Rouse, B. (2001). Portrait of Health in the United

States: Major Statistical Trends and Guide to Resources 2001.States: Major Statistical Trends and Guide to Resources 2001. Rhoades, M. Everett, R. (2000). American Indian Health: Rhoades, M. Everett, R. (2000). American Indian Health:

Innovations in Health Care, Promotion, and Policy. Innovations in Health Care, Promotion, and Policy. State of Alaska Epidemiology. Botulism in Alaska: State of Alaska Epidemiology. Botulism in Alaska:

http://www.epi.hss.state.ak.us/pubs/botulism/bot_01.hthttp://www.epi.hss.state.ak.us/pubs/botulism/bot_01.ht Tayfun, A., Sencan,A.,Aksun,M. (2007). A Food Borne Botulism May Tayfun, A., Sencan,A.,Aksun,M. (2007). A Food Borne Botulism May

Cause Unnecessary Operation: A Case Report.Cause Unnecessary Operation: A Case Report. Veenema, T. (2006). Ready RN: Handbook for disaster Nursing and Veenema, T. (2006). Ready RN: Handbook for disaster Nursing and

Emergency Preparedness.Emergency Preparedness.