Taiwan: Woman dies of botulism; mother-in-law on ventilator

[alert]

http://hisz.rsoe.hu/alertmap/woalert_read.php?glide=EH-20100418-25751-TWN&cat=dis&lang=eng

The Centers for Disease Control (CDC) under the Department of Health confirmed Sunday that a woman who died April 14 after eating dried beancurd and preserved oysters had a botulism infection. CDC Deputy Director Lin Ting said lab tests confirmed that the 44-year-old woman from Miaoli County had a botulism infection, which is usually caused by a nerve toxin produced by clostridium botulinum bacteria. Several mice were injected with the woman's blood serum and they died within 24 hours, Lin added. However, further lab tests will be required to determine what type of botulism caused the woman's death, he said. It was also still not known whether it was the dried beancurd or the preserved oysters which the woman and her mother-in-law ate that caused the fatal botulism infection, Lin said. The woman's 71-year-old mother-in-law has been on intubation at Taichung Veterans General Hospital in central Taiwan since she fell ill after eating the beancurd and oysters. Lab tests have confirmed that she also has a botulism infection. She has received two doses of botulismus-antitoxin that were rushed to the hospital by the CDC and which saved her life, according to Lin. However, the daughter-in-law was not that lucky, as she was rushed to a different hospital in Taoyuan County, northern Taiwan which was not alert enough to seek emergency assistance from the CDC for the treatment of botulism, Lin said.

Samples of two packs of dried beancurd and a can of salted oysters that were found in the women's home in Miaoli were retrieved by the Food and Drug Administration for testing, but the lab reports will not be available for two weeks, the CDC said. The two Miaoli women were the third and fourth botulism cases this year, following a mother and daughter in Taoyuan County who were diagnosed in early April, the CDC said. The Taoyuan mother and daughter were treated with botulismus-antitoxin. Meanwhile, the Taoyuan County Public Health Bureau on Friday closed operations for two weeks at the two companies where the dried beancurd was made and ordered that the products be pulled from the shelves of major grocery stores. However, the companies have complained of mistreatment, saying that their products were safe and were made in line with government standards. They complained that the two-week suspension will cost them hundreds of thousands of New Taiwan dollars. "I hope the relevant tests will be completed soon so that my company's name can be cleared, " said Tseng Fan-Hsiang, owner of Cheng Hsiang Foods Co. The latest incident has also resulted in declining business in Taoyuan County's Dasi township -- the center of dried beancurd production in Taiwan. Huang Chien-chia, president of Tafang Foods, a well-established manufacturer of dried beancurd and related products in Dasi, said his store's business has shrunk by one-third this weekend. Chiang Chiu-yun, the owner of another company known as Wan Li Hsiang which was established in 1921, said business at her store has also been affected by the incident, but added that her faithful customers were not at all fazed.

[alert]

Re: Taiwan: Woman dies of botulism; mother-in-law on ventilator

http://www.promedmail.org/pls/otn/f?p=2400:1001:946137375285229::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1040,82310

Archive Number 20100418.1257
Published Date 18-APR-2010
Subject PRO/MBDS> Botulism - Taiwan: Taoyuan, Miaoli, RFI

BOTULISM - TAIWAN: TAOYUAN, MIAOLI, REQUEST FOR INFORMATION
************************************************** *********
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International Society for Infectious Diseases
<http://www.isid.org>

In this posting:
[1] Taoyuan - 2 cases, packaged foods suspected
[2] Miaoli - 2 cases (1 fatal), dried bean curd or preserved oysters suspected

******
[1] Taoyuan - 2 cases, packaged foods suspected
Date: Wed 14 Apr 2010
Source: The China Post [edited]
<http://www.chinapost.com.tw/taiwan/national/national-news/2010/04/14/252415/DOH-urges.htm>


Department of Health (DOH) officials urged consumers to cook their
food and dishes well after 3 residents in Taoyuan County fell ill
after eating packaged foodstuffs contaminated by botulinum toxin.

In the 1st reported botulinum toxin case in Taiwan this year [2010],
a 61-year-old woman and her daughter, 41, are still under intensive
medical care while the woman's son-in-law also showed moderate
symptoms, said DOH officials yesterday [13 Apr 2010].

The DOH has started tracing the sources of the packaged vegetarian
foods mainly imitation dried meat, pig legs, and preserved bean curd
for vegetarians the 3 purchased on their trip to southern Chiayi and
Tainan districts during the Tomb Sweeping Festival holidays in late
March (2010).

The mother and daughter were hospitalized on [1 Apr 2010] after
showing symptoms like vomiting, muscle spasms, and blurred eyesight.
The son-in-law said they purchased the vegetarian food with vacuum
packing at different markets on the trip.

DOH officials said vacuum packing is a modern method of storing food
in an airless environment. But the food items can still be
contaminated during packing, delivery or storage. They said consumers
should choose products from credible food companies. But the most
important step is to cook or boil the ready-to-eat foods well to
eliminate bacteria that cannot survive high heat. The same practice
should be also applied to other packaged foodstuffs and frozen foods,
including the popular frozen dumplings with meat stuffing, the officials said.

Botulinum toxin has deadly toxic effect in foodstuffs, although
Botox, the trade name for botulinum toxin cosmetic procedures, has
been increasingly used to treat muscle spasms and has won over many
people who care for good looks in Taiwan.

A total of 9 people in Taiwan were poisoned by botulinum toxin and 2
died in 1986 after eating brine cured peanuts from a local supplier.

There were 12 confirmed cases in Taiwan area during the past 2 years,
the officials said.

--
Communicated by:
ProMED-mail Rapporteur Angela Huang

******
[2] Miaoli - 2 cases (1 fatal), dried bean curd or preserved oysters suspected
Date: Fri 16 Apr 2010
Source: The China Post [edited]
<http://focustaiwan.tw/ShowNews/WebNews_Detail.aspx?ID=201004160008&Type=aLIV>


A 45-year-old woman living in Miaoli County who died 2 days ago is
suspected of having died from botulism growing on dried bean curd or
preserved oysters that she had eaten, Department of Health (DOH)
officials said Friday [16 Apr 2010].

The woman's 72-year-old mother-in-law, who had also eaten the 2
suspicious items, was on intubation in the Taichung Veterans General
Hospital intensive care unit, said Feng Jun-lan, an official with the
Food and Drug Administration (FDA) under the DOH.

The suspect dried bean curd was bought from a store in their
neighborhood in Miaoli, while the oysters were bought recently in
Yunlin, Feng said.

No symptoms were reported among the other members of the family,
including a grandfather and son, who did not eat the dried bean curd
at all, and a grandson who only consumed a little of the food,
according to Feng.

Lin Ting, deputy director of the DOH's Centers for Disease Control
(CDC), said that although it would take 2 days to find out the
results of tests, their symptoms suggested serious paralytic illness
caused by a nerve toxin produced by the bacterium clostridium botulinum.

The CDC has rushed antiviral agents to the hospital in the hope that
the 72-year-old's life can be saved, Lin said.

Samples of the dried bean curd and salted oyster were also retrieved
by the FDA, but lab reports are not expected to be available for 2
weeks, Feng said.

She described the bacteria as anaerobic, gram-positive, spore-forming
rods that produce a potent neurotoxin and grow best in low oxygen
conditions. She suggested that all home-canned foods, vegetables and
meats should be boiled for at last 10 minutes before consumption.

According to DOH tallies, Taiwan's botulism mortality rate averages
between 5 and 10 percent. The illness was declared by the CDC as a
notifiable disease in 2007.

A total of 12 botulism cases were reported in 2007-2008, with one
67-year-old man dying of the disease.

The 2 Miaoli women were the 3rd and 4th cases this year [2010]
following a mother and daughter in Taoyuan County who were diagnosed
as victims of botulism in early April [2010], the CDC said.

[Byline: Chen Ching-fang; Deborah Kuo]

--
Communicated by:
ProMED-mail Rapporteur Angela Huang

[Botulism is a muscle-paralyzing disease caused by a toxin made by a
bacterium called _Clostridium botulinum_. With foodborne botulism,
symptoms begin within 6 hours to 10 days (most commonly between 12
and 36 hours) after eating food that contains the toxin. Symptoms
include double vision, blurred vision, drooping eyelids, slurred
speech, difficulty swallowing, dry mouth and muscle weakness that
moves down the body. Paralysis of breathing muscles can cause a
person to stop breathing and die unless mechanical ventilation is provided.

The antitoxin is most effective in reducing the severity of symptoms
if administered early in the course of the disease. Most patients
eventually recover after weeks to months of supportive care.
Foodborne botulism is a public health emergency because the
contaminated food may still be available to other persons besides the
patient (see <http://www.bt.cdc.gov/agent/botulism/factsheet.asp>).

More details on laboratory criteria for diagnosis and case
classification is available at
<http://www.cdc.gov/ncphi/disss/nndss/casedef/botulism_current.htm>).

The severity of foodborne botulism seems to be associated with toxin
type. Toxin type A produces a more severe illness than type B, which
in turn is more severe than type E. The case-fatality rate for type A
botulism is 10 percent, twice that of type B. While European cases
most commonly are associated with type B contamination of
home-processed meats, Alaskan, Canadian, and Japanese outbreaks often
involve type E toxin in preserved seafood. Chinese cases involve type
A toxin in home-processed bean products. A recently described case in
Thailand was associated with ingestion of home-preserved bamboo
shoots (see < http://emedicine.medscape.com/article/829125-overview>).

Cases attributable to botulism in Taiwan from the GIDEON (Global
Infectious Disease and Epidemiology Network
<http://www.gideononline.com>) database (note that no information is
available for 2004):

Year: cases
1992: 3
1993: 2 (one case from Miaoli and another one from Changhua)
1994: 1 (case from Taipei)
1995: 3 (cases from Taoyuan, Changhua and Nantou)
1996: 4
1997: 4
1998: 0
1999: 1
2000: 5
2001: 6
2002: 3
2003: 1
2005: 1
2006: 2
2007: 8
2008: 11

Notes: Cases for 1995, 1996, 1997, 1999 and 2000 were 'not confirmed'.

In Taiwan, an outbreak of type A foodborne botulism resulted in 9
cases, 2 of them fatal in 1986. Commercially canned peanuts processed
by an unlicensed cannery were identified as the vehicle of in this
outbreak. Clinical manifestations of cases were general malaise,
ptosis, double vision, dysarthria, dysphagia and proximal limb weakness (1,2).

In 1987, the 1st case of infantile botulism in Taiwan was reported.
The laboratory confirmed type B toxin in serum and stool specimen
whereas the vehicle of transmission was not identified. In 1990, an
outbreak of type B botulism was reported in 11 cases. The vehicle of
transmission was fermented food. Cases were presented with
gastrointestinal symptoms (i.e., dysphagia, ileus).

In 2006, there were 5 cases reported in an outbreak of type B
botulism in Taiwan. Cases presented with ileus and acute cranial
nerve dysfunction including dysphagia and blurred vision. One of them
had severe neurologic impairment and required mechanical ventilatory
support. No patient received antitoxin administration because of
delayed diagnosis, however, there were no fatalities. The food
specimen (fermented food) revealed positive botulism toxin B (3).

According to the above 2 newswires, there were total 4 botulinum
toxin cases and one fatality reported in Taiwan in 2010. The
suspected food that would be the vehicles of transmission of this
outbreak were packaged vegetarian foods (mainly imitation dried meat,
pig legs and preserved bean curd for vegetarians), dried bean curd
and salted oyster. These suspected foods were bought from different counties.

Laboratory investigation from suspected food and palpable cases are
under the process to confirm etiological agent responsible for this
outbreak. Information from reliable sources on the results of
investigations for the above mentioned botulism outbreak would be
highly appreciated by PRO/MBDS.

References
----------
1. Chou JH, Hwang PH, Malison MD. An outbreak of type A foodborne
botulism in Taiwan due to commercially preserved peanuts. Int J
Epidemiol. 1988 Dec;17(4):899-902.
2. Tsai SJ, Chang YC, Wang JD, Chou JH. Outbreak of type A botulism
caused by a commercial food product in Taiwan clinical and
epidemiological investigations. Zhonghua Yi Xue Za Zhi (Taipei). 1990
Jul;46(1):43-8.
3. Tseng CK, Tsai CH, Tseng CH, Tseng YC, Lee FY, Huang WS. An
outbreak of foodborne botulism in Taiwan. Int J Hyg Environ Health.
2009 Jan;212(1):82-6.