The need for global planned mobilization of essential medicines: lessons from a massive Thai motulism outbreak

Abstract

Introduction A massive outbreak of botulism in northern Thailand in March 2006 tested international capacity to respond to a public health emergency. Botulism poisoning due to contaminated home-canned bamboo shoots caused illness in 209 villagers, of whom 134 persons were hospitalized and 42 required mechanical ventilation. A global search for Botulinum antitoxin began, involving international agencies, embassies, national laboratories, airlines and commercial organizations in seven countries. Sufficient antitoxin was obtained from four sources for treatment of 90 patients, but with delays in treatment of 5 to 9 days from time of exposure. Rapid local outbreak detection and an effective international response likely prevented mortality and additional morbidity. However, the international response to this public health emergency was informal and conducted through professional relationships rather than through predefined protocol for antitoxin acquisition. Stronger commitment through formal international agreements, including creation of global and regional stockpiles of critical medicines and supplies, is urgently needed. The outbreak On Wednesday, 15 March 2006, several patients sought treatment at Ban Luang district hospital with reports of gastroenteritis starting at 13:00. An outbreak of botulism was suspected, and an investigation was begun when another 10 patients presented to the emergency unit, some with bulbar palsies and respiratory compromise. (1) All patients had eaten home-canned bamboo shoots one day earlier, when approximately 330 villagers attended an annual religious rite in a small village in this district, during which home-canned bamboo shoots from two 20-litre cans were served without heating in small plastic bags for lunch. Over the following week, a total of 209 villagers had the onset of symptoms compatible with botulism. Among the affected villagers, 134 (64%) were hospitalized with paralysis ranging from minor bulbar palsies to quadraparesis; 42 (20%) of patients required mechanical ventilation for respiratory depression. There were no deaths. The epidemiological investigation of this outbreak has been reported previously. (2) The response Authorities in the province declared a public health emergency on Thursday 16 March. Immediately upon establishing a presumptive diagnosis of botulism poisoning, efforts were begun to obtain Botulinum antitoxin, which is life-saving if given within 48 hours. (3) The total number of cases and those with severe neuromuscular impairment requiring ventilatory support increased over the next several days, to 19 patients on ventilators by the third day and 39 by day six. Numbers of patients requiring ventilator support and times of request and deliveries of antitoxin are shown in Fig. 1. The process of obtaining antitoxin was difficult. Telephone and email contacts were established between the Thai public health ministry in Bangkok; embassies in Bangkok, Geneva and London; the World Health Organization in Geneva; the United States Centers for Disease Control and Prevention (CDC) in Atlanta; the National Laboratory in the United Kingdom; and the Japan National Institute of Infectious Disease (NIID) in Tokyo. [FIGURE 1 OMITTED] Ultimately it was possible to obtain 93 vials (treatment courses) of antitoxin from the CDC, the United Kingdom's National Laboratory and NIID in Tokyo. An additional 10 vials were purchased from a commercial source in Canada. The first 20 patients with most severe neurological impairment received antitoxin on day five, and 70 more patients were treated by the ninth day after the exposure. Table 1 shows time intervals from the original exposure, initiation of requests for antitoxin, initiation of procurement from various sources and delivery to the hospital. If Thai authorities had not been able to mobilize 42 ventilators and staff to manage the most severely affected patients, these delays would have certainly resulted in significant mortality. …