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BACKGROUND: In 2013, a Pennsylvania childcare center reported a suspected outbreak of scombrotoxic fish poisoning, or scombroid, among students and staff members. Sombroid occurs after consuming finfish, including tuna, which are not properly refrigerated after they are caught. Bacterial spoilage causes a breakdown of tissue and resultant histamine buildup. Eating fish containing high levels of histamine can cause symptoms within 2 minutes to 2 hours after consumption. Symptoms can include rash, diarrhea, flushing, sweating, headache, vomiting, burning/swelling of the mouth, abdominal pain or a metallic taste.
METHODS: The childcare center collected and summarized symptom information for all ill students and staff. Epidemiologic data were summarized. Leftover food samples were requested for laboratory testing.
RESULTS: The childcare center consists of six age-grouped classes, ranging from infants to kindergarten. The childcare center served tuna salad sandwiches made with commercially pouched tuna and mayonnaise to approximately 30 students and staff members. Within 5-15 minutes of consumption, 6 students and 3 staff members presented with symptoms of scombroid. A seventh student reported symptoms after 7 hours and visited the emergency department complaining of hives and diarrhea, was diagnosed with scombroid, but was not admitted. The most commonly reported symptoms were redness/swelling around the mouth (70%) and facial flushing (40%). All patients recovered; none died or were hospitalized. The childcare center immediately recognized the outbreak and prevented further service of the associated lot of tuna. No illness was reported among students in unexposed classes. The chunk light tuna in water was sold in 2.1lb pouches, 6 pouches to a case, and was a product of Ecuador. No leftover tuna from the pouch suspected of causing illness was available for testing. One remaining unopened pouch from the case was submitted to the supplier for testing. Analysis found < 5 ppm histamine in the unopened pouch of tuna. The United States Food and Drug Administration reported that regulatory action can be taken at a level of 200 ppm for pouched tuna products or 50 ppm for whole fish.
CONCLUSIONS: This report summarizes a suspected outbreak of scombrotoxic fish poisoning in an unusual setting, with a relatively high attack rate of 30%. Though laboratory results were inconclusive, the symptoms reported by affected students and staff are consistent with scombroid. Proper post-harvest refrigeration and time/temperature holding of finfish can prevent bacterial spoilage and scombroid.