Outbreak of Type E Foodborne Botulism Linked to Traditionally Prepared Salted Fish in Ontario, Canada

On April 17, 2012, two adult females presented to the hospital with symptoms of botulism. Patient A displayed shortness of breath, increasing lethargy, ptosis, and fixed and dilated pupils, and was intubated after admission. Patient B presented with shortness of breath, vomiting, and stridor. Both patients consumed a meal consisting of a traditionally prepared salted fish, fesikh, on the evening of April 16 during a gathering to celebrate Sham el-Nessim, an Egyptian holiday marking the beginning of spring. Foodborne botulism was suspected based on symptoms and consumption of potentially hazardous food. Antitoxin was administered to both patients on April 18. Another attendee of the Sham el-Nessim gathering (patient C), who also consumed the implicated food, developed symptoms consistent with botulism on April 18. Clinical specimens from all three symptomatic attendees tested positive for either Clostridium botulinum or type E botulinum neurotoxin. Fesikh remaining from the shared meal contained both type E botulinum neurotoxin and C. botulinum type E organisms. Unsold fesikh shad and fesikh sardines tested positive for C. botulinum type E, while unsold fesikh mullet pieces in oil tested positive for both C. botulinum type E and type E botulinum neurotoxin. After consultation with public health investigators, all fesikh products were voluntarily withheld from sale by the manufacturer prior to laboratory confirmation of contamination. Additional illnesses were likely prevented by these precautionary holds, which underscores the importance of timely public health action based on epidemiological evidence available in advance of laboratory results. This is the first documented outbreak of foodborne botulism associated with fesikh to occur in Canada.