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Nicotine Poisoning After Ingestion of Contaminated Ground Beef --- Michigan, 2003
On January 3, 2003, the Michigan Department of Agriculture's (MDA) Food and Dairy Division and the U.S. Department of Agriculture (USDA) were notified by a supermarket of a planned recall of approximately 1,700 pounds of ground beef because of customer complaints of illness after eating the product. On January 10, the supermarket notified MDA that their laboratory had determined that the contaminant in the ground beef returned by customers with reported illness was nicotine. This report summarizes the investigation of these cases, which identified approximately 100 affected persons, and discusses actions taken to prevent additional illness, including the arrest of a person charged with deliberately poisoning the ground beef at the supermarket.
The recall was prompted by complaints from four families comprising 18 persons who became ill immediately after eating product sold on December 31 or January 1. Reported symptoms included burning of the mouth, nausea, vomiting, and dizziness. One person reported having been seen in the emergency department (ED) and treated for atrial fibrillation. The recalled product had been ground in the store using ground beef purchased from an out-of-state processor inspected by USDA, Food Safety Inspection Service. MDA made routine notifications about the recall to local and state health departments. The product recall was issued on January 3 for beef with a sell-by date of January 1 and January 2, followed by a press release on January 8, which expanded the recall to beef with a sell-by date of January 3. After the initial recall notices, approximately 36 persons reported to the supermarket that they or their families had experienced illness after eating the product, and approximately 120 persons returned recalled product.
Company officials submitted samples of ground beef provided by the ill families to a private laboratory, where product testing for foodborne pathogens was negative. Additional testing for chemical contamination was conducted at a large regional medical center. On January 10, company officials notified MDA and USDA that nicotine had been presumptively identified in the ground beef samples tested by the second laboratory, which reported an assay result 1 week later of approximately 300 mg/kg nicotine in the submitted samples. The high nicotine concentrations found in the tested meat products prompted concerns of intentional contamination with a pesticide, which sometimes contain nicotine as an additive. USDA and the Federal Bureau of Investigation joined the investigation because interstate commerce could have been involved and intentional contamination was suspected. Because a legal investigation was initiated, federal authorities requested that information be released to the public only as necessary to avoid compromising any future criminal case. On January 17, the supermarket issued another press release and recall notice stating the implicated product contained an unspecified, nonbacterial contaminant that could not be made safe by cooking.
Contamination of the product was believed to have occurred at a single store rather than the meat processing plant. The product was distributed directly from the plant to many other stores, including other stores in the supermarket chain; neither the processing plant nor any other store in the supermarket chain received complaints of illness. No nicotine-containing pesticides were reportedly used or sold in the store where the recalled product was sold.
On January 23, the local health department alerted hospital EDs and selected medical practices serving the area where the store was located. On January 24, after receiving confirmatory test results, the company issued another press release naming nicotine as the contaminant. This announcement was published and broadcast by local media.
The local health department conducted an epidemiologic investigation, including interviews of persons reporting illness, to assess the consistency of the clinical presentation and to establish a case definition. A case was defined as one or more symptoms (i.e., burning sensation to lips, mouth or throat, dizziness, nausea, vomiting, abdominal pain, diarrhea, sweating, blurred vision, headache, body numbness, unusual fatigue or anxiety, insomnia, tachypnea or dyspnea, and tachycardia or tachyarrythmias) in persons who ate ground beef product purchased from the supermarket on either December 31, 2002, or January 1, 2003, with symptom onset occurring within 2 hours of eating the product.
A total of 148 interviews were conducted with persons who reported they had experienced illness after eating the product and of family members and friends who also might have eaten the contaminated meat. Of those interviewed, 92 persons had illness consistent with the case definition. Patients had a median age of 31 years (range: 1--76 years), and 46 (50%) were female; 65% of the patients lived in the town where the implicated store was located. The majority of illness occurred during the time that the contaminated product was sold. Cases were identified as late as 49 days after the last date of potential sale, indicating that some persons froze and then ate the contaminated product after the first recall was issued. Of the 92 patients, four (3%) sought medical treatment, including two who reported to their personal physicians with complaints of vomiting and stomach pains and two who were evaluated in EDs. The two who were treated in the EDs included a man aged 39 years with atrial fibrillation and a woman aged 31 years who had nausea, vomiting, and complaint of rectal bleeding. Information is being collected on an additional 16 persons to assess whether their illnesses are consistent with the case definition, including a pregnant woman aged 24 years who was hospitalized for 1 day with episodic vomiting.
On February 12, a grand jury returned an indictment for arrest of a person accused of poisoning 200 pounds of meat at the supermarket with an insecticide called Black Leaf 40, which has a main ingredient of nicotine. The person was an employee of the supermarket at the time of the contamination.
Reported by: M Boulton, MD, M Stanbury, MSPH, D Wade, PhD, Michigan Dept of Community Health; J Tilden, DVM, Michigan Dept of Agriculture; D Bryan, MPA, J Payne, MPH, Kent County Health Dept; B Eisenga MD, DeVos Children's Hospital, Regional Poison Control Center, Grand Rapids, Michigan.
Deliberate contamination of food during its production and preparation has been reported infrequently (1,2). Unintentional contamination of food by chemicals occurs sporadically, including reports of contamination by pesticides (3,4). Unintentional poisoning by nicotine has been reported, usually among children who eat cigarettes (5), in suicide attempts (6), or among tobacco workers who experience "green tobacco sickness" (7). One homicide by nicotine was reported to have occurred in Eastern Europe (8).
Acute nicotine toxicity is associated with overstimulation of nicotinic receptors. Burning in the throat with nausea and vomiting occurs quickly after ingestion. More toxic manifestations include cardiac tachyarrythmias, seizures, and hypertensive crisis. The lethal dose of nicotine in adults is from 0.5 to 1.0 mg/kg of body weight or a total dose of 30--60 mg. Toxic symptoms might been seen at doses as low as 2--5 mg of nicotine; however, persons might have widely different levels of tolerance to the toxic effects of nicotine. Small children might develop symptoms after exposure to as little as 1 mg of nicotine. Nicotine is used in a limited number of pesticides because of its toxic properties; nine nicotine-containing pesticides are registered for use in Michigan, and none of the product labels list nicotine at more than 14%. Black Leaf 40 contained 40% nicotine, and the EPA canceled its product registration in 1992 because of its toxicity.
This investigation involved the private sector (i.e., the food retailer) and five government agencies, including local and state public health departments, the state agriculture department, and two federal agencies. Public health officials undertook an epidemiologic investigation that involved contacting affected persons and providing information to the public and clinicians about the health threat. It also was necessary to conduct a legal investigation in a rapid and relatively closed manner. Frequent contacts among the parties allowed for negotiation and consensus around most issues.
This incident underscores the importance of ensuring the safety and security of food supplies. Vigilance and heightened awareness for human poisonings caused by hazardous levels of chemical in the food supply are essential. Clinicians should immediately report clusters of poisonings to public health officials, especially when presenting symptoms are unusual. Public health response capabilities addressing hazardous chemicals in food and other media need to be strengthened. Multiple agency coordination and cooperation between health, agriculture, and law enforcement officials at the local, state, and federal levels are critical for the detection and response to similar events, whether they are intentional or unintentional (9).
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