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The Role of a Poison Control Center in Identifying and Limiting an Outbreak of Foodborne Botulism
The Role of a Poison Control Center in Identifying and Limiting an Outbreak of Foodborne Botulism Jennifer Brown, MD, Mark E. Sutter, MD, D. Adam Algren, MD, Jerry D. Thomas, MD, Sean Ragone, MD, Joshua G. Schier, MD, Robert J. Geller, MD Abstract: Many poison control centers partner with public health agencies to handle weekend and after-hours consultations and emergencies. This event describes the effective use of poison control center capabilities in identifying and limiting an outbreak of foodborne botulism. On September 8, 2006, the poison control center received a call regarding a man aged 77 years admitted to a hospital neurology service with dysarthria, dysphagia, and weakness. The poison control center was contacted regarding a concern for botulism. Further information revealed that the patient’s wife and a friend had similar symptoms and had eaten together on the previous night. All three sought treatment at different hospitals. The poison control center successfully located the other two patients and provided information regarding the treatment of botulism. In addition, the poison control center notifıed the on-call local public health offıcial and the CDC for the release of botulinum antitoxin. Public health offıcials were informed of our concerns for a foodborne outbreak given the common meal. Their investigation determined that the source of botulism was carrot juice. (Am J Prev Med 2010;38(6):675– 678) Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
T
his outbreak illustrates the important role that poison control centers can play in the public health. Although only one case was called into the poison control center, the other two cases were located, care was coordinated, and antitoxin release was initiated. By identifying a common encounter, a starting point for the epidemiologic investigation was identifıed. This report highlights the capabilities of poison control centers in public health and prevention. Increased collaboration and utilization of poison control center capabilities should be explored.
Introduction Poison control centers are unique entities that have developed their reputation around poison prevention, education, and providing a 24-hour telephone assistance line. Research1,2 shows that poison control centers are effective in limiting both medical expenses and healthcare
From the Georgia Poison Center, Education Department (Brown, Sutter, Algren, Thomas, Ragone, Schier, Geller); and the National Center for Environmental Health (Brown, Sutter, Algren, Thomas, Schier), CDC, Atlanta, Georgia Address correspondence to: Joshua G. Schier, MD, CDC/NCEH/ EHHE/HSB MS F-57, 4770 Buford Highway NE, Chamblee GA 30341. E-mail: [email protected]. 0749-3797/00/$17.00 doi: 10.1016/j.amepre.2010.02.007
resource utilization. For example, more than 70% of callers with exposures to poisons and who are in need of assistance are able to remain at home rather than seek medical attention in clinics and hospitals.3 In addition, studies1,2 have demonstrated that for every $1 spent on poison control centers, $7 is saved on long-term medical expenditures. Despite this evidence, fınancial support for poison control centers at the federal and state levels is often tenuous. Similar fınancial challenges are often faced by other public health agencies, such as local and state public health departments. With such limited fınancial support for public health measures, numerous agencies are asked to expand services. As a result, several states have developed mutually benefıcial partnerships between poison control centers and other public health agencies. In these innovative alliances, some poison control centers now respond to after-hours and weekend emergency calls, addressing rabies inquiries and performing other statespecifıc duties. This report describes a successful collaboration between a poison control center and local, state, and federal public health agencies. To increase the awareness and effective utilization of a poison control center, this report highlights the poison control center’s capabilities in identifying, treating, and limiting an outbreak of foodborne botulism. In addition, this report illustrates the importance of developing stronger
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
Am J Prev Med 2010;38(6)675– 678 675
676
Brown et al / Am J Prev Med 2010;38(6):675– 678
collaborations between poison control centers and public health agencies.
Outbreak Description On September 8, 2006, the poison control center received a call regarding a man aged 77 years who was admitted to a hospital neurology service with dysarthria, dysphagia, and generalized weakness. Within hours he developed respiratory failure and required intubation. The primary neurologist was skeptical Figure 1. Outbreak timeline regarding the diagnosis of a stroke and called the poison control center to disIn addition to the three index cases in Georgia, three cuss other potential etiologies. After a discussion between other people developed foodborne botulism as a result of the poison control center’s on-call toxicologist and the consuming the carrot juice. The patients included one neurologist, it was agreed that botulism was a likely cause person from Florida and two people from Canada. Each for the patient’s illness. patient purchased the contaminated carrot juice locally; Further information provided to the toxicologist by however, it originated from a single distribution center in the patient’s family and friends revealed that the patient’s California. wife had a similar illness, but was admitted to a different hospital. In addition, an acquaintance of this couple also felt ill and was en route to a third hospital. It was also Discussion disclosed that these three patients ate dinner together the The response to this outbreak of foodborne botulism previous night. underscores the value of collaborations between poison Poison control center personnel used their resources to control centers and other public health entities. Outside immediately locate the hospitals and the physicians who of the mandatory reportable diseases that lead to highly were caring for these patients. The toxicologist spoke variable amounts of collaboration, there are no requiredirectly with each physician and learned that all three ments for standardized working relationships between patients had similar symptoms and clinical fındings. Bestaff at poison control centers and local and state public cause of the possibility that botulinum toxin was the health departments. The Medicine and Public Health cause of their illnesses, the toxicologist immediately conInitiative (MPHI), which was developed by the American tacted local public health offıcers to obtain botulinum Medical Association and the American Public Health antitoxin for each patient. (Botulism is classifıed as a Association, has resulted in benefıcial partnerships beCategory A bioterrorism threat; therefore, public health tween medicine and public health.5 The experiences with notifıcation is mandated for antitoxin release.) In addithis outbreak of foodborne botulism suggest that the lestion to providing information about the clinical manifessons learned from the MPHI could also be applied to the tations and locations of each patient, the toxicologist institutions of poison control centers and public health relayed the history of the patients’ common meal. Further agencies. Effective collaborations between poison control discussions between staff members at the poison control centers and public health agencies may further bolster center, the state public health department, and the CDC public health endeavors. ensured that antitoxin was released and administered to As this outbreak of botulism demonstrates, the fırst each patient. contact in a public health outbreak may be a regional Within 5 days, serum and stool samples obtained from poison control center and not a public health agency. This all three patients on admission to the hospital were found disparity is consistent with those described by several to be positive for botulinum toxin type A (Figure 1). Two studies6,7 that found calls into poison control centers days later, botulinum toxin type A was also identifıed in a overlap only partially with calls into local public health sample of store-bought carrot juice, which had been condepartments. The fact that the initial request for assissumed by all three patients on the evening prior to their tance came through the normal poison control center call illnesses. Within 3 weeks, state epidemiologists traced the lines rather than the designated public health telephone contaminated carrot juice to its source and a voluntary recall was announced.4 line is important. The fırst patient’s physician called the www.ajpm-online.net
Brown et al / Am J Prev Med 2010;38(6):675– 678
poison control center rather than a public health agency to discuss the possible etiologies of his patient’s abnormal neurologic fındings. Likewise, hospital personnel caring for each of the patients with botulism did not initiate contact with local and state public health departments. The poison control center had a preexisting agreement with the state to cover after-hours and weekend public health assistance calls and other emergencies. Therefore, protocols were in place and the hospital personnel were prepared to deal with an outbreak of this nature. This protocol included the real-time notifıcation of the state epidemiologist as well as the CDC. Because the poison control center territory covers the entire state, immediate access to resources for the entire state were available and it was possible to rapidly link the three patients who presented to hospitals in three different local public health jurisdictions. Poison control centers have readily available and accessible contact information for every hospital in their region. This capability was invaluable in this situation; it facilitated the ability to rapidly pinpoint the locations of the three patients, compare clinical manifestations, and initiate the proper steps for antitoxin release and outbreak containment. Such knowledge is also helpful in cases when an uncommon antidote is required. Poison control center staff is able to direct treating physicians to those facilities that are likely to stock the required antidote. In this outbreak of botulism, the three patients were admitted to three different regional hospitals, and all cases would not have been reported to the same local public health offıcial if they had been called in according to geographic boundaries. As a result, the correlation among these patients may have been more challenging. Nevertheless, the partnership between staff at the poison control center and local and state public health agencies, and the CDC was ultimately vital for the treatment of these patients and for limiting the morbidity of this outbreak to six people. Physicians and the general public may initiate contact with a poison control center rather than a public health agency for a variety of reasons. One explanation for this phenomenon could be the rapid, real-time availability of on-call toxicologists to discuss cases with treating physicians. The poison control center toxicologists are able to provide immediate recommendations to facilitate and to improve the care of poisoned patients. As this outbreak of botulism illustrates, a physician may suspect that a patient’s clinical symptoms are due to a toxin or poisoning and not necessarily a reportable public health disease. According to the National Poison Data System, healthcare professionals consult poison control center experts 1400 times a day seeking treatment recommendations for their patients.8 The general public may also initiate conJune 2010
677
tact with a poison control center for several reasons. Owing to a variety of public education efforts, the general public may be more familiar with poison control center services and not necessarily public health agency services. Currently, most poison control centers have several mechanisms in place that could enable the formation of stronger partnerships to promote public health measures. For example, poison control centers are staffed 24 hours a day and are supported by physicians with subspecialty knowledge in medical toxicology. This allows for real-time, direct communication among staff members and physicians caring for patients with toxic exposures. Recently, these poison control center attributes have been exploited through several novel collaborations with public health agencies in response to the H1N1 influenza outbreak. For example, poison control centers have partnered with public health agencies to create H1N1 influenza telephone hotlines that are manned by poison control center personnel, thus reducing the burden of calls coming into public health departments. Poison control centers have also been monitoring for adverse reactions to the H1N1 vaccination and helping to manage emergency stockpiles of personal protective equipment.9 Similar to the collaborative efforts described in this outbreak of botulism, these novel partnerships demonstrate the public health successes that can be achieved through collaborations between poison control centers and public health agencies.
Conclusion In conclusion, poison control centers have many capabilities that make them effective entities for promoting public health. Poison control centers provide a 24-hour service that is supervised by medical toxicologists, and they have the ability to coordinate patient care at multiple medical facilities. These features allowed the poison control center to partner with local, state, and federal public health organizations to identify and limit this outbreak of botulism. Collaborations between poison control centers and public health agencies have the potential to improve public health measures and should be explored. No fınancial disclosures were reported by the authors of this paper.
References 1. Miller TR, Lestina DC. Costs of poisoning in the U.S. and savings from poison control centers: a benefıt– cost analysis. Ann Emerg Med 1997;29(2):239 – 45. 2. IOM, Committee on Poison Prevention and Control, B Geyer, JA Alexander, P Blanc, D Emerson, JR Hedges, MS Kamlet, A Mickalide, BH
678
Brown et al / Am J Prev Med 2010;38(6):675– 678
Rumack, DP Schor, DA Spyker, A Stergachis, DJ Tollerud, DK Walker; Board on Health Promotion and Disease Prevention. Forging a poison prevention and control system. IOM of the National Academies, 2004. www.nap.edu/catalog/10971.html. 3. Bronstein AC, Spicer DA, Cantilena LR, Green J, Rumack BH, Heard SE. 2006 annual report of the American Association of Poison Control Centers’ National Poison Data System. Clin Toxicol 2007;45:815–917. 4. CDC. Botulism associated with commercial carrot juice—Georgia and Florida, September 2006. MMWR Morb Mortal Wkly Rep 2006; 55(40):1098 –9. 5. Beitsch LM, Brooks RG, Glasser JH, Coble YD Jr. The medicine and public health initiative ten years later. Am J Prev Med 2005;29(2): 149 –53.
6. Derby MP, McNally J, Ranger-Moore J, et al. Poison control center– based syndromic surveillance for foodborne illness. MMWR Morb Mortal Wkly Rep 2005;54(Suppl):S35– 40. 7. Kay RS, Blackmore C, Johnson D, et al. Monitoring poison control center data to detect health hazards during hurricane season—Florida 2003–2005. MMWR Morb Mortal Wkly Rep 2006;55(15);425– 8. 8. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffın SL. 2008 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 26th annual report. Clin Toxicol (Phila) 2009;47(10):911–1084. 9. American Association of Poison Control Centers: Count U.S. poison centers among fırst responders in H1N1 flu pandemic. www.aapcc. org/dnn/NewsandEvents/NewsMediaResources/tabid/131/Default.aspx.
Did you know? You can personalize the AJPM website to meet your individual needs. Visit www.ajpm-online.net today!
www.ajpm-online.net
T
his outbreak illustrates the important role that poison control centers can play in the public health. Although only one case was called into the poison control center, the other two cases were located, care was coordinated, and antitoxin release was initiated. By identifying a common encounter, a starting point for the epidemiologic investigation was identifıed. This report highlights the capabilities of poison control centers in public health and prevention. Increased collaboration and utilization of poison control center capabilities should be explored.
Introduction Poison control centers are unique entities that have developed their reputation around poison prevention, education, and providing a 24-hour telephone assistance line. Research1,2 shows that poison control centers are effective in limiting both medical expenses and healthcare
From the Georgia Poison Center, Education Department (Brown, Sutter, Algren, Thomas, Ragone, Schier, Geller); and the National Center for Environmental Health (Brown, Sutter, Algren, Thomas, Schier), CDC, Atlanta, Georgia Address correspondence to: Joshua G. Schier, MD, CDC/NCEH/ EHHE/HSB MS F-57, 4770 Buford Highway NE, Chamblee GA 30341. E-mail: [email protected]. 0749-3797/00/$17.00 doi: 10.1016/j.amepre.2010.02.007
resource utilization. For example, more than 70% of callers with exposures to poisons and who are in need of assistance are able to remain at home rather than seek medical attention in clinics and hospitals.3 In addition, studies1,2 have demonstrated that for every $1 spent on poison control centers, $7 is saved on long-term medical expenditures. Despite this evidence, fınancial support for poison control centers at the federal and state levels is often tenuous. Similar fınancial challenges are often faced by other public health agencies, such as local and state public health departments. With such limited fınancial support for public health measures, numerous agencies are asked to expand services. As a result, several states have developed mutually benefıcial partnerships between poison control centers and other public health agencies. In these innovative alliances, some poison control centers now respond to after-hours and weekend emergency calls, addressing rabies inquiries and performing other statespecifıc duties. This report describes a successful collaboration between a poison control center and local, state, and federal public health agencies. To increase the awareness and effective utilization of a poison control center, this report highlights the poison control center’s capabilities in identifying, treating, and limiting an outbreak of foodborne botulism. In addition, this report illustrates the importance of developing stronger
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
Am J Prev Med 2010;38(6)675– 678 675
676
Brown et al / Am J Prev Med 2010;38(6):675– 678
collaborations between poison control centers and public health agencies.
Outbreak Description On September 8, 2006, the poison control center received a call regarding a man aged 77 years who was admitted to a hospital neurology service with dysarthria, dysphagia, and generalized weakness. Within hours he developed respiratory failure and required intubation. The primary neurologist was skeptical Figure 1. Outbreak timeline regarding the diagnosis of a stroke and called the poison control center to disIn addition to the three index cases in Georgia, three cuss other potential etiologies. After a discussion between other people developed foodborne botulism as a result of the poison control center’s on-call toxicologist and the consuming the carrot juice. The patients included one neurologist, it was agreed that botulism was a likely cause person from Florida and two people from Canada. Each for the patient’s illness. patient purchased the contaminated carrot juice locally; Further information provided to the toxicologist by however, it originated from a single distribution center in the patient’s family and friends revealed that the patient’s California. wife had a similar illness, but was admitted to a different hospital. In addition, an acquaintance of this couple also felt ill and was en route to a third hospital. It was also Discussion disclosed that these three patients ate dinner together the The response to this outbreak of foodborne botulism previous night. underscores the value of collaborations between poison Poison control center personnel used their resources to control centers and other public health entities. Outside immediately locate the hospitals and the physicians who of the mandatory reportable diseases that lead to highly were caring for these patients. The toxicologist spoke variable amounts of collaboration, there are no requiredirectly with each physician and learned that all three ments for standardized working relationships between patients had similar symptoms and clinical fındings. Bestaff at poison control centers and local and state public cause of the possibility that botulinum toxin was the health departments. The Medicine and Public Health cause of their illnesses, the toxicologist immediately conInitiative (MPHI), which was developed by the American tacted local public health offıcers to obtain botulinum Medical Association and the American Public Health antitoxin for each patient. (Botulism is classifıed as a Association, has resulted in benefıcial partnerships beCategory A bioterrorism threat; therefore, public health tween medicine and public health.5 The experiences with notifıcation is mandated for antitoxin release.) In addithis outbreak of foodborne botulism suggest that the lestion to providing information about the clinical manifessons learned from the MPHI could also be applied to the tations and locations of each patient, the toxicologist institutions of poison control centers and public health relayed the history of the patients’ common meal. Further agencies. Effective collaborations between poison control discussions between staff members at the poison control centers and public health agencies may further bolster center, the state public health department, and the CDC public health endeavors. ensured that antitoxin was released and administered to As this outbreak of botulism demonstrates, the fırst each patient. contact in a public health outbreak may be a regional Within 5 days, serum and stool samples obtained from poison control center and not a public health agency. This all three patients on admission to the hospital were found disparity is consistent with those described by several to be positive for botulinum toxin type A (Figure 1). Two studies6,7 that found calls into poison control centers days later, botulinum toxin type A was also identifıed in a overlap only partially with calls into local public health sample of store-bought carrot juice, which had been condepartments. The fact that the initial request for assissumed by all three patients on the evening prior to their tance came through the normal poison control center call illnesses. Within 3 weeks, state epidemiologists traced the lines rather than the designated public health telephone contaminated carrot juice to its source and a voluntary recall was announced.4 line is important. The fırst patient’s physician called the www.ajpm-online.net
Brown et al / Am J Prev Med 2010;38(6):675– 678
poison control center rather than a public health agency to discuss the possible etiologies of his patient’s abnormal neurologic fındings. Likewise, hospital personnel caring for each of the patients with botulism did not initiate contact with local and state public health departments. The poison control center had a preexisting agreement with the state to cover after-hours and weekend public health assistance calls and other emergencies. Therefore, protocols were in place and the hospital personnel were prepared to deal with an outbreak of this nature. This protocol included the real-time notifıcation of the state epidemiologist as well as the CDC. Because the poison control center territory covers the entire state, immediate access to resources for the entire state were available and it was possible to rapidly link the three patients who presented to hospitals in three different local public health jurisdictions. Poison control centers have readily available and accessible contact information for every hospital in their region. This capability was invaluable in this situation; it facilitated the ability to rapidly pinpoint the locations of the three patients, compare clinical manifestations, and initiate the proper steps for antitoxin release and outbreak containment. Such knowledge is also helpful in cases when an uncommon antidote is required. Poison control center staff is able to direct treating physicians to those facilities that are likely to stock the required antidote. In this outbreak of botulism, the three patients were admitted to three different regional hospitals, and all cases would not have been reported to the same local public health offıcial if they had been called in according to geographic boundaries. As a result, the correlation among these patients may have been more challenging. Nevertheless, the partnership between staff at the poison control center and local and state public health agencies, and the CDC was ultimately vital for the treatment of these patients and for limiting the morbidity of this outbreak to six people. Physicians and the general public may initiate contact with a poison control center rather than a public health agency for a variety of reasons. One explanation for this phenomenon could be the rapid, real-time availability of on-call toxicologists to discuss cases with treating physicians. The poison control center toxicologists are able to provide immediate recommendations to facilitate and to improve the care of poisoned patients. As this outbreak of botulism illustrates, a physician may suspect that a patient’s clinical symptoms are due to a toxin or poisoning and not necessarily a reportable public health disease. According to the National Poison Data System, healthcare professionals consult poison control center experts 1400 times a day seeking treatment recommendations for their patients.8 The general public may also initiate conJune 2010
677
tact with a poison control center for several reasons. Owing to a variety of public education efforts, the general public may be more familiar with poison control center services and not necessarily public health agency services. Currently, most poison control centers have several mechanisms in place that could enable the formation of stronger partnerships to promote public health measures. For example, poison control centers are staffed 24 hours a day and are supported by physicians with subspecialty knowledge in medical toxicology. This allows for real-time, direct communication among staff members and physicians caring for patients with toxic exposures. Recently, these poison control center attributes have been exploited through several novel collaborations with public health agencies in response to the H1N1 influenza outbreak. For example, poison control centers have partnered with public health agencies to create H1N1 influenza telephone hotlines that are manned by poison control center personnel, thus reducing the burden of calls coming into public health departments. Poison control centers have also been monitoring for adverse reactions to the H1N1 vaccination and helping to manage emergency stockpiles of personal protective equipment.9 Similar to the collaborative efforts described in this outbreak of botulism, these novel partnerships demonstrate the public health successes that can be achieved through collaborations between poison control centers and public health agencies.
Conclusion In conclusion, poison control centers have many capabilities that make them effective entities for promoting public health. Poison control centers provide a 24-hour service that is supervised by medical toxicologists, and they have the ability to coordinate patient care at multiple medical facilities. These features allowed the poison control center to partner with local, state, and federal public health organizations to identify and limit this outbreak of botulism. Collaborations between poison control centers and public health agencies have the potential to improve public health measures and should be explored. No fınancial disclosures were reported by the authors of this paper.
References 1. Miller TR, Lestina DC. Costs of poisoning in the U.S. and savings from poison control centers: a benefıt– cost analysis. Ann Emerg Med 1997;29(2):239 – 45. 2. IOM, Committee on Poison Prevention and Control, B Geyer, JA Alexander, P Blanc, D Emerson, JR Hedges, MS Kamlet, A Mickalide, BH
678
Brown et al / Am J Prev Med 2010;38(6):675– 678
Rumack, DP Schor, DA Spyker, A Stergachis, DJ Tollerud, DK Walker; Board on Health Promotion and Disease Prevention. Forging a poison prevention and control system. IOM of the National Academies, 2004. www.nap.edu/catalog/10971.html. 3. Bronstein AC, Spicer DA, Cantilena LR, Green J, Rumack BH, Heard SE. 2006 annual report of the American Association of Poison Control Centers’ National Poison Data System. Clin Toxicol 2007;45:815–917. 4. CDC. Botulism associated with commercial carrot juice—Georgia and Florida, September 2006. MMWR Morb Mortal Wkly Rep 2006; 55(40):1098 –9. 5. Beitsch LM, Brooks RG, Glasser JH, Coble YD Jr. The medicine and public health initiative ten years later. Am J Prev Med 2005;29(2): 149 –53.
6. Derby MP, McNally J, Ranger-Moore J, et al. Poison control center– based syndromic surveillance for foodborne illness. MMWR Morb Mortal Wkly Rep 2005;54(Suppl):S35– 40. 7. Kay RS, Blackmore C, Johnson D, et al. Monitoring poison control center data to detect health hazards during hurricane season—Florida 2003–2005. MMWR Morb Mortal Wkly Rep 2006;55(15);425– 8. 8. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffın SL. 2008 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 26th annual report. Clin Toxicol (Phila) 2009;47(10):911–1084. 9. American Association of Poison Control Centers: Count U.S. poison centers among fırst responders in H1N1 flu pandemic. www.aapcc. org/dnn/NewsandEvents/NewsMediaResources/tabid/131/Default.aspx.
Did you know? You can personalize the AJPM website to meet your individual needs. Visit www.ajpm-online.net today!
www.ajpm-online.net