Strategies to Control Botulism in Alaska - Case Study Example

Food Safety Management Introduction: The bacterium Clostridium botulinum produces a toxic compound called Botulin. It is one of the most deadly neurotoxins known. Its chemical structure is a double polypeptide chain consisting of a light 50kDa, and a heavy 100kDa chain linked by disulphide bonds. Clostridium spores are found all over the world, in the soil, in vegetables, meat, ocean water, and sediment, and even marine mammals. As the spores can multiply rapidly without air, poorly preserved or canned food become ideal mediums for proliferation. Human botulism is the result of eating improperly stored foods that contains A and B type botulism toxin. While boiling for 30 minutes can destroy the spores, its toxins have to be subjected to moist heat at 80C for the same time It was the German physician and poet Justinus Kerner who first developed the idea of a possible therapeutic use of botulinum toxin, which he called "sausage poison." In 1870, Muller, another German physician coined the name botulism. The Latin form is botulus, which means sausage. In 1895, Emile Van Ermengem first isolated the bacterium Clostridium botulinum. In 1944, Edward Schantz cultured Clostridium botulinum and isolated the toxin” Seven types of Clostridium botulinum, are identified so far, of these the type A, B, E and F are known to cause human botulism. (Botulism). General Details of the Case and Causative Agents: In the village of Manokotak, in Southwest Alaska, in the winter of 2001, a break out of botulism was reported. The preformed bacteria were traced to contaminated, fermented beaver tail and feet. Traditionally Alaskans prepare and preserve their native food by fermenting and storing it in pits. The more recent practice of storing in airtight plastic bags and containers does not prevent the growth of bacteria, as they can multiply in anaerobic environments too. Clostridium botulinum rides on improperly preserved food, and in this case it was beaver tail and paws that were fermented, and stored for over 3 months. The toxic intensity of Botulin is 200-300 pg/kg meaning that a dose of 100 grams could kill the entire human population in the world. The toxins that enter the bloodstream accumulate at the neuromuscular junctions. When this protease (toxin) acts upon one of the fusion proteins at the neuromuscular junctions, the vesicles are inhibited from adhering to the membrane that releases acetylcholine. This lack of acetylcholine leads to muscular and respiratory paralysis. When the nerves that run to the diaphragm are affected, Botulism interferes with the person’s breathing and causes respiratory distress. Antitoxins hamper the binding property of Botulin. In the illustrated case, fourteen persons were admitted with poisoning. They showed typical botulism symptoms of dry throat, difficulty in breathing, slurred speech, double vision, general weakness, and breathing difficulties. Out of them eleven had mild symptoms. Four were admitted for overnight observation, and seven were discharged after 48 hours observation. One person stayed in hospital for ten days, because a tracheotomy had to be done due to complications arising from an earlier attack of botulism. Three patients were more seriously affected with botulism, and were put on the ventilator due to respiratory distress. One of them deteriorated further had a cardiac arrest, but was successfully resuscitated. They were also administered the A, B, and E botulism antitoxin after six hours, and admitted to the ICU of Anchorage. Of the fourteen who reported ill, clinical tests revealed the presence of toxin type E in blood serum and stool samples of the ICU patients, and not in the other eleven patients. (Botulism Outbreak Associated With Eating Fermented Food – Alaska, 2001). Critical Examination of the Incident: Alaska rates the highest in botulism outbreaks in the world. Food borne Botulism in Alaska is widespread, as it is closely related to the food culture of its natives – the consumption of dried/fermented food and cooking condiments, such as seal oil. The traditional method of fermentation involves keeping the food in a barrel beneath the ground, or in a grass-lined hole. It can also be placed in a shady area above the ground, and left to ferment for many weeks. The oxygen less condition encourages the growth of toxin producing bacteria. As in the January 2001 incident, food borne botulism needs to be quickly assessed at clinics, as the after effects are quick and fatal. The laboratory tests (of blood serum, stool, and implicated food) often take more than four days, so treatment must begin immediately. Type E botulism is most common in Alaska, and sometimes type B. This was confirmed in the findings that this outbreak was related to Type E botulism, as was demonstrated by the stool examinations. It is important that the related antitoxin be readily administered to arrest the toxin’s binding process, as was done in this outbreak. Early detection and treatment are vital for recovery. Intubations and assisted ventilation help reduce fatality. Another precaution is to understand that in food borne botulism, there will always be more than one case, when reported. Therefore it is important to investigate and bring under observation/possible treatment, asymptomatic persons who maybe at risk, i.e. been exposed to fermented food in the past twelve days or so. Severity of symptoms is often directly related to amount of ingested, contaminated food. Outbreak severity is also related to how soon medical attention is received and the quick diagnosis. Mild cases may often not get the required medical attention. Physicians, health workers, and the public have the need to understand botulism, as a near fatal disease. Early and correct diagnosis is vital and the disease is preventable. (Botulism in Alaska). An Attempt to Assess the Cost of the Outbreak to both Industry and Public Service: In every emergency, there is a call for additional resources, and therefore a rise in unforeseen costs. The cost of an outbreak, such as the botulism outbreak in Alaska in January 2001, covers a whole range of socio-economic factors, its variance depends on the measure of impairment, a change in status of well being, and also on certain intangible factors, such as grief and suffering. To value the costs of such incidents, one must understand what kinds of costs are involved. Primarily three different costs are considered: 1. Direct costs include three elements – the casualty costs that cover the cost of human injuries and damages to physical assets. Medical costs that include emergency care, tests, treatment, facilities, physician care, therapy, medication and aids and appliances. The non-medical costs include rehabilitation, special transportation, vocational rehabilitation, home adaptations, and so on. The greatest disadvantage in assessing direct costs is the wide variation between the charged, and the actual health care costs. 2. Indirect costs- relate to costs due to loss relating to morbidity, mortality viz. reduced performance and participation in employment, job changes, and lost prospects. An issue that is debatable under estimating indirect costs is whether the loss of the employee has a direct impact on the economic state of the organization. 3. Intangible costs – reduction in physical and mental welfare, deteriorating mutual relationships, and social problems like divorce, addiction, violence, and so on. As intangible costs are borne by the individual while assessing these costs, an interesting concept was revealed i.e. the employees “willingness to pay (WTP)”. The different assessment methods used to gauge the cost of the outbreak, include: 1. Direct cost method, that could employ either the incidence method or the prevalence method. 2. Indirect costs can be measured using the Human Capital Method (HCM). The Human Capital Method (HCM) is the traditional valuation method used to measure the indirect cost of injury events. The approach emphasizes that people are valuable resources. It also explains that the loss due to injury is not fully replaceable and therefore production costs are implicated. It calculates the indirect costs of production that are comparable if the person was not injured, and adds the costs relating to loss of productive years of life. “These production losses are measured as the discounted stream of future income foregone by the individual. This future income is discounted because the future value of capital is less than the current value, and because of time preference” (Goodchild, M., Sanderson, K., & Nana, G., 2002). For a cost benefit and impact analysis, the estimates as determined by the Economic Research Service (ERS) for illness cost/death relating to food – borne diseases, are used. For such cost analysis, the ERS uses assumptions of outcome severity, disease numbers, medical costs, non-medical costs and disability costs. A food-borne illness cost calculator provides details on the assumptions, thereby enabling users to make case specific assumptions that help calculate costs of food borne illnesses in a specific region or for a particular outbreak. (Foodborne Illness Cost Calculator). The labor market approach in the calculation of costs due to food borne illnesses “values the economic cost of premature deaths based on the risk premium revealed by the higher wages paid for dangerous jobs”. This approach makes an assumption that the risk preferences observed in job choices are a reflection of the risk preferences in food safety. ERS has modified this approach by adding the factor of age distribution of deaths with relation to each of the pathogens, and thus treating the value of life as an annuity that is paid over the average life span at an interest rate of three percent. This would mean that in the ERS calculations of the cost of death using the labor market approach, each death would be five times higher for individuals who passed away before their first birthday, than in the case of individuals who died at an age of eighty five or over that. (Economics of Foodborne Disease: Overview). Cost Calculations: HCM Approach: The HCM approach uses the following factors in the calculation of costs based on severity: No Medical Care – Physician Visit Only – Hospitalized – Died – Total LM Approach: The LM approach uses the following factors in the calculations of costs based on type of costs: Medical Costs – Hospital Care – Other Medical Services – Lost Productivity – Total ERS has provided for cost calculations for Salmonella, E.coli, Campylobacter, and Listeria monocytogenes. Cost factors for Clostridium botulinum have not been provided. Assumptions in the data could lead to false computations of costs for both the HCM approach and the LM approach. (Economics of Foodborne Disease: Overview). Account of the Relevant Legislation at the Time of the Incident: In an effort to improve the safety of food supplies the Clinton Administration had expanded the investment in ensuring food safety and introduced measures to ensure early warning on the outbreak of food borne diseases. The budgets for the financial years 2000 and 2001 for the food safety initiatives were $ 109 million and $ 149 million respectively. Starting from 1993 onwards the Clinton Administration initiated several significant steps to expand the food safety programs and response to food borne illnesses. One of these significant steps was the creation of the Foodborne Illness Surveillance Network in 1995. Through the coordinated efforts of the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and the US Department of Agriculture (USDA), the Foodborne Illness Active Surveillance became a reality in 1996. Since then the network has been responsible for not just identifying the common cause of food borne diseases, and the burden of these diseases, it has also provided the infrastructure for the responding quickly to new and emerging food borne diseases and investigations into them. Another major initiative was the Comprehensive Food Safety Initiative in 1997. Under this initiative was a key component in the form of the Early Warning System. As a part of this Early Warning System, the CDC, FDA and the USDA have by working in tandem with the state and local agencies have created epidemiological and laboratory capacity to respond to food borne diseases. The PulseNet forms the first component of the Early Warning System and the national computer network of the CDC in the public health laboratories contribute to this by passing on early warning of the likelihood of food borne illnesses across the country, and cause investigations into the cause of it, so that the cause can be identified, and the necessary steps be taken to contain it. The second element of the early warning system is the FoodNet, whereby the CDC, FDA and USDA have caused eight sentinel sites across the country. Using these active sentinel sites for surveillance of food borne diseases and other related epidemiological studies it is expected that there would be a better understanding of the epidemiology of food borne diseases and provided valuable data for providing a scientific basis to the hazard prevention programs. Yet another significant initiative was the “Fight BAC!” public education campaign that was initiated in 1997 by the HHS, USDA and Department of education to improve the awareness of safe food practices. This has significant importance in the containing botulism in Alaska, as it is unsafe food practices that have cause the outbreak of botulism, including the outbreak in 2001. The objective of this campaign is the education of the public on the problems associated with food borne diseases, and providing them with information on proper sanitation and safe food handling. It is expected that these education programs on sanitation and safe food handling methods would assist in the reduction of risk factors associated with food borne diseases. In 1998 a Presidential executive order created the President’s Council on Food Safety that was responsible for the development of a comprehensive, and strategic plan for federal food safety activities and making sure that the federal agencies worked in tandem in the creation of food safety budgets. It also had the function of overseeing the Joint Institute for Food Safety Research that was accord the highest priority to research requirements. (HHS INITIATIVES TO REDUCE FOODBORNE ILLNESS). Recommendations for Practical Steps Necessary to Avoid a Future Outbreak with Reference to Current Legislation: The prevention and control of Botulism in Alaska is challenging. Although a toxoid for type A, B, and E is available, the thought of immunizing the whole population is daunting. The two possible strategies to address botulism include – hampering the spread of spores as well as early identification of botulism infection. In addition the following practical steps could be taken: 1. Primary awareness must be built across all economic sections of society on the threat of botulism. Educating people on the risks of eating inappropriately fermented food, assessing the symptoms and seeking medical attention is vital to keep a check on future outbreaks. 2. The people should be educated on the importance of careful preservation of food, adhering to requirements of temperature, pressure, humidity etc 3. Where unsure about the quality of the preserved food, boiling for ten minutes will reduce possible risk of the toxin. 4. Where infected food is seen, it needs to be located and recalled at the earliest to the Alaska Division of Public Health, Section of Epidemiology. Legislation needs to be passed to grant FDA and USDA mandatory recall authority. 5. The press should immediately and widely publicize any information on outbreaks, with specific details such as location, extent of poisoning etc. People need to be adequately warned about the health risks related to botulism; as such infections are rarely limited to one or two cases. 6. The government needs to set aside funds to support victims of food borne botulism, financially, emotionally and legally. 7. The number of pathogen testing facilities needs to be increased. (Why Are People Still Dying From Contaminated Food). Literary References ‘Botulism’. 2002. World Health Organization. Fact Sheet, [Online]. Available at: http://www.who.int/mediacentre/factsheets/who270/en/. ‘Botulism in Alaska’. 2005. Department of Health and Social Services, [Online]. Available at: http://www.epi.hss.state.ak.us/pubs/botulism/Botulism.pdf. ‘Botulism Outbreak Associated With Eating Fermented Food – Alaska, 2001’. MMWR, 2001, vol. 50, no. 32, pp. 680-682. ‘Economics of Foodborne Disease: Overview’. Economic Research Service. USDA, [Online]. Available at: http://www.ers.usda.gov/Briefing/FoodborneDisease/overview.htm. ‘Foodborne Illness Cost Calculator’. Economic Research Service. USDA, [Online]. Available at: http://www.ers.usda.gov/data/Foodborneillness/. Goodchild, M., Sanderson, K., & Nana, G. 2002. ‘MEASURING THE TOTAL COST OF INJURY IN NEW ZEALAND: A REVIEW OF ALTERNATIVE COST METHODOLOGIES’. Business and Economic Research Limited, [Online]. Available at: http://www.dol.govt.nz/PDFs/COI-ReviewCostMethods.pdf. ‘HHS INITIATIVES TO REDUCE FOODBORNE ILLNESS’. 2000. U.S. Department of Health and Human Services, [Online]. Available at: http://www.cfsan.fda.gov/~lrd/hhsfsi2.html. ‘Why Are People Still Dying From Contaminated Food?’ S.T.O.P., [Online]. Available at: http://www.safetables.org/pdf/STOP_Report.pdf. Read More