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A ProMED-mail post http://www.promedmail.org ProMED-mail is a program of the International Society for Infectious Diseases http://www.isid.org

[1] Date: Fri 1 Feb 2008 Source: Associated Press (AP) [edited] http://ap.google.com/article/ALeqM5hqaebpM28dOdHO2Fop0x-o06mxqQD8UHHT4O2

Investigators are closer to understanding a mysterious illness reported by pork plant workers in Minnesota (MN) and Indiana (IN) and now have pinned a name on it, officials said. CDC (US Centers for Disease Control and Prevention) issued a report on Thursday [31 Jan 2008] summarizing the investigation so far that gives the condition a name, progressive inflammatory neuropathy.

Minnesota officials said they were broadening their investigation to thousands of former employees at the Quality Pork Processors Inc plant in Austin, MN, going back a decade to when a powerful compressed air system was installed to remove brain tissue from pig heads.

Investigators have been trying to determine whether pig brain tissue, sprayed into the air as droplets during removal by the compressed air system, was inhaled by workers and made them sick. If further investigation proves their theories true, they will have identified a rare, new condition that could shed light on a whole family of poorly understood disorders in which the body's immune system attacks the nerves or the sheath that surrounds them, the Star Tribune reported.

This "could have far reaching applications in terms of our understanding of the mechanism of disease," said Ruth Lynfield, Minnesota's state epidemiologist, who is heading the investigation [in Minneapolis]. Since December 2007, 12 meatpackers in Austin and 2 at a plant in Indiana have reported fatigue, numbness, and tingling in their arms and legs. A few are severely disabled; others have returned to work. Indiana health officials have declined to discuss the conditions of the affected workers there or say where they were employed, citing patient privacy laws.

All 14 employees worked near powerful compressed air systems that blow brains out of pig heads at what is known as the head table. Both plants have stopped using the process.

Lynfield said investigators are now looking for anyone who has worked near Quality Pork's head table since 1997. That's difficult because the plant employs about 1200 workers, many of them immigrants, and turnover is high. "But we feel it's important to look for prior cases," she said.

Investigators say they've ruled out toxins as a cause, and viruses or bacteria are unlikely because none of the affected workers reported infectious disease symptoms, such as fever, before the onset of their neurological symptoms. That would leave the brain tissue itself. Experts said the foreign pig tissue may have triggered the workers' immune system, which then attacked their own neural tissue.

Experts at the Mayo Clinic and New York's Columbia University are now trying to devise ways to test pig brain tissue against the immune cells of the sick workers, Lynfield said. It could be months before results are in, she said.

-- communicated by: ProMED-mail promed@promedmail.org

[2] CDC Report Date: Thu 31 Jan 2008 Source: CDC. MMWR Morb Mortal Wkly Rep 2008;57 (early release): 1-3. [edited] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm57e131a1.htm?s_cidmm57e131a1_e

Investigation of progressive inflammatory neuropathy [PIN] among swine

slaughterhouse workers -- Minnesota, 2007-2008

On 29 Oct 2007, the Minnesota Department of Health (MDH) was notified by a tertiary care provider of unexplained neurologic illnesses among workers in a swine slaughterhouse (plant A) in south east Minnesota. As a result, MDH initiated a detailed investigation at plant A to characterize the outbreak. This report describes the ongoing investigation and outbreak-control measures undertaken by state public health officials and CDC.

Plant A, located in south eastern Minnesota, employs about 1200 workers and processes 18 000 pigs per day. After being notified of the illnesses, MDH investigators initiated active case finding, interviewed workers at plant A, and reviewed the plant's occupational health and employment records. As of 28 Jan 2008, a total of 12 workers at plant A had been identified with confirmed (8 workers), probable (2), or possible (2) progressive inflammatory neuropathy (PIN) [see 'Box' below.] Illness onset ranged from November 2006 through November 2007. Median age of the 12 patients was 31 years (range: 21-51); 6 patients were female. All 12 patients reported being healthy before the onset of neurologic symptoms.

Symptoms ranged from acute paralysis to gradually progressive symmetric weakness over periods ranging from 8 to 213 days. Severity ranged from minor weakness and numbness to paralysis predominantly in the lower extremities affecting mobility. 11 patients had evidence of axonal or demyelinating peripheral neuropathy by electrodiagnostic testing. Cerebrospinal fluid was obtained from 7 patients. All 7 had elevated protein levels (median: 125 mg/dL; range: 75-231 mg/dL [normal: 14-45 mg/dL]) with no or minimal pleocytosis (median: 1 cell/dL; range: 1-73 cells/dL in a nontraumatic tap); 5 patients had evidence of inflammation on spinal magnetic resonance imaging (4 patients in peripheral nerves or roots and one patient in the anterior spinal cord).

All 12 patients reported either working at or having regular contact with an area where swine heads were processed (known as the head table), which was located within a larger processing area in plant A known as the warm room. A case-control study was conducted among plant A workers to identify specific risk factors associated with illness. The 10 patients with confirmed or probable cases were included in the study, along with 2 stratified control groups: 1) a random selection of 48 healthy warm-room workers and 2) all 65 healthy head-table workers. Statistically significant (p less than 0.05) differences were calculated by chi-square test. Blood samples and throat swabs were collected from all consenting case-patients and controls. As of 30 Jan 2008, laboratory investigations had not identified any infectious agent from the blood and throat-swab specimens that would explain the occurrence of PIN.

Results of the case-control study indicated that case-patients (7 of 10, 70 per cent) were significantly more likely to have worked at the head table than the warm-room controls (12 of 48, 25 per cent) (odds ratio [OR]: 7.0; 95 per cent confidence interval [CI] = 1.3-42.2; p = 0.009). Case-patients also were more likely to have removed brains or remaining skeletal muscle from the pig head (a process known as backing heads) (4 of 10, 40 per cent) than controls (2 of 46, 4 per cent) (OR: 15.3; CI = 1.8-163.4; p = 0.006). Among head-table workers, case-patients were significantly more likely to have removed brains or skeletal muscle from the head (4 of 7, 57 per cent) than head-table controls (8 of 65, 12 per cent) (OR: 9.50; CI = 1.40-70.2; p = 0.01). Illness was not determined to be associated with previous travel outside or within the USA; exposure to chemicals, fertilizers, or insecticides; use of medications; or receipt of previous vaccinations.

An environmental assessment of the plant was conducted on 28 Nov 2007. Standard personal protective equipment (PPE) used by workers at plant A included hard hats, laboratory coats (including some that were short-sleeved), boots, hearing protection, eye protection, and specialized gloves that varied with the particular task of the worker. A compressed air device was used in the plant to harvest brain tissue from pig heads at the head table. The device was placed into the skull of the pig through the foramen magnum, and the force of the air disrupted the brain material into a liquefied form that made it easier to remove (a technique known as "blowing brains"). This technique caused generation of small droplets and splatter, possibly including aerosolized brain material, to which workers operating the device and others nearby might have been exposed. In response to the investigation, plant A voluntarily suspended harvesting of brains and instituted additional mandatory PPE on 28 Nov 2007, including face shields and long sleeves, for workers stationed at the head table and other workers who chose to use additional PPE.

Results of case-finding survey

A survey of the 25 federally inspected swine slaughterhouses with greater than 500 employees in the USA indicated that only 3 plants (plant A in Minnesota and plants in Nebraska and Indiana) reported recent use of compressed air to extract pig brains. To date, no cases of PIN have been identified in association with workers at the Nebraska plant. However, several workers at the Indiana plant have been preliminarily identified with neurologic illnesses and similar histories of exposure to head-processing activities at that slaughterhouse. Further assessments of these patients, and additional measures to identify other workers with illness, are being conducted in Indiana. As a result of this investigation, all three plants have stopped using compressed air to extract brain material.

[Reported by: Lachance D, Goyal S, Danila R, et al]

MMWR editorial note

This report summarizes an ongoing investigation of PIN, a syndrome that appears to be associated with swine slaughterhouse workers who process pig heads. Several clinical and laboratory features of this illness and the distinctive epidemiology associated with patients appear unique. Pigs slaughtered at plant A have passed inspection by the USA Department of Agriculture Food Safety and Inspection Service [USDA-FSIS], and the investigation has not identified any foodborne risk to the general population.

The investigation in Minnesota indicates that PIN appears associated with having worked at the head table, where a compressed-air device was used to extract pig brains. In the process of blowing compressed air into the pig skull, brain material might have been splattered or even aerosolized, and workers might have been exposed through inhalation or contact with mucous membranes. One hypothesis for development of PIN is that worker exposure to aerosolized pig neural protein might have induced an autoimmune-mediated peripheral neuropathy (1,2). Additional investigation of the characteristics and causes of PIN is under way.

Whether compressed-air devices are being used for pig-brain extraction in other slaughterhouses or processing facilities, in the USA or internationally, is unknown. Clinicians should provide CDC with information regarding swine slaughterhouse workers who might have illnesses similar to PIN, including patients with peripheral neuropathy, myelopathy, or features of both. Clinicians who identify such patients should report the cases to their state health department and contact CDC at 770-488-7100.

References

1. Quattrini A. Inflammatory neuropathies. Neurol Sci 2005; 26: S6.
2. Tatsumoto M, Koga M, Gilbert M, et al. Spectrum of neurological diseases associated with antibodies to minor gangliosides GM1b and GalNAc-GD1a. J Neuroimmunol 2006; 177: 201-8.

Box: Working case definition for PIN among swine slaughterhouse workers

Epidemiologic criterion: - participation in or close exposure to commercial or private swine slaughtering operations. Clinical criteria: - new onset of bilateral and relatively symmetric flaccid weakness/paralysis of the limbs, with or without involvement of cranial nerve innervated muscles. - new onset of decreased or absent deep tendon reflexes at least in affected limbs. Diagnostic criteria: - electrodiagnostic studies consistent with axonal or demyelinating peripheral neuropathic features in affected limbs and not attributed to an underlying chronic disease condition. - neuroimaging consistent with radiculitis, myelitis, or encephalitis. - cerebrospinal fluid protein level greater than 45 mg/dL (with or without pleocytosis). Exclusion criterion: - identification of an alternative etiology for clinical or diagnostic findings. Case classification: - confirmed case: meets epidemiologic criterion, meets both clinical criteria, and has electrodiagnostic studies consistent with axonal or demyelinating features. - probable case: meets epidemiologic criterion, at least one clinical criterion, and at least one diagnostic criterion. -possible case: meets epidemiologic criterion, and at least one clinical criterion.

-- communicated by: ProMED-mail rapporteur Brent Barrett

[The AP piece states that the compressed air system has been used for 10 years but previous posts have stated that the system was recently installed.

The CDC report, which gives a name to the process, clearly states that respiratory personal protective equipment was not used and also provides a working case definition and more specific information regarding the clinical cases and the case-control study.

No additional information is given regarding etiology, but it remains likely that this is not directly infectious in etiology. - Mod.LL]

[see also: Undiagnosed neuro. synd., porcine plant workers - USA (02): (IN, MN) 20080129.0366 Undiagnosed neuro. synd., porcine plant workers - USA: (IN, MN) 20080118.0226

2007

Undiagnosed neuro. synd., porcine plant workers - USA: (MN), RFI 20071204.3915]

.................ll/mj/sh