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 Foodborne Disease
Handbook
Second Edition, Revised and Expanded

Volume 3: Plant Toxicants

edited by
Y. H. Hui
Science Technology System
West Sacramento, California

R. A. Smith
University of Kentucky
Lexington, Kentucky

David G. Spoerke, Jr.

Bristlecone Enterprises
Denver, Colorado

MARCEL

MARCEL DEKKER, INC. NEWYORK BASEL

D E K K E R
ISBN: 0-8247-0343-X

This book is printed on acid-free paper.

Headquarters
Marcel Dekker, Inc.
270 Madison Avenue, New York, NY 10016
tel: 2 12-696-9000; fax:2 12-685-4540

Eastern Hemisphere Distribution

Marcel Dekker AG
Hutgasse 4, Postfach 812, CH-4001 Basel, Switzerland
tel: 41-61-261-8482; fax: 41-61-261-8896

World Wide Web

http://www.dekker.conl

The publisher offers discountson this book when ordered in bulk quantities. Formore information,
write to Special Sales/Professional Marketing at the headquarters address above.

Copyright 0 2001 by Marcel Dekker, Inc. All Rights Reserved.

Neither this book nor any part may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, microfilming, and recording, by or any infornla-
tion storage and retrieval system, without permission in writing from the publisher.

Current printing (last digit):

1 0 9 8 7 6 5 4 3 3 1

PRINTED IN THE UNITED STATES OF AMERICA

Introduction to the Handbook

The Foodbome Disease Handbook, Second Edition,Revised am?Expanded, could not be

appearing at a more auspicious time. Never before has the campaign for food safety been
pursued so intensely on so many fronts in virtually every country around the world. This
new edition reflects at least one of the many aspects of that intense and multifaceted
campaign: namely, that research on food safety has been very productive in the years
since the first edition appeared. The Handbook is now presented in four volumes instead
of the three of the 1994 edition. The four volumes are composed of 86 chapters, a 22%
increase over the 67 chapters of the first edition. Much of the information in the first
edition has been carried forward to this new edition because that information is still as
reliable and pertinent as it was in 1994. This integration of the older data with the latest
research findings gives the reader a secure scientific foundation on which to base important
decisions affecting the public's health.
We are not so naive as to think that only scientific facts influence decisions affecting
food safety. Political and economic factors and compelling national interests may carry
greater weight in the minds of decision-makers than the scientific findings offered in this
new edition. However, if persons in the higher levels of national governments and interna-
tional agencies, such as the Codex Alimentarius Commission, the World Trade Organiza-
tion, the World Health Organization, and the Food and Agriculture Organization, who
must bear the burden of decision-making need and are willing to entertain scientific find-
ings, then the infomation in these four volumes will serve them well indeed.
During the last decade of the previous century, we witnessed an unprecedentedly
intense and varied program of research on food safety, as we have already noted. There
are compelling forces driving these research efforts. The traditional food-associated patho-
gens, parasites, and toxins of forty years ago still continue to cause problems today, and
newer or less well-known species and strains present extraordinary challenges to human
health.
These newer threats may be serious even for the immunocompetent, but for the
inlmunocompromised they can be devastating. The relative numbers of the immunocom-
promised in the world population are increasing daily. We include here not just those
affected by the human immunodeficiency virus (HIV), but also the elderly; the very young;
the recipients of radiation treatments, chemotherapy, and immunosuppressive drugs:

iii
iv to Introduction the Handbook

patients undergoing major invasive diagnostic or surgical procedures: and sufferers of

debilitating diseases such as diabetes. To this daunting list of challenges must be added
numerous instances of microbial resistance to antibiotics.
Moreover, it is not yet clear how the great HACCP experiment will play out on the
worldwide stage of food safety. Altruism and profit motivation have always made strange
bedfellows in the food industry. It remains to be seen whether HACCP will succeed in
wedding these two disparate motives into a unifying force for the benefit of all con-
cerned-producers, manufacturers, retailers, and consumers. That HACCP shows great
promise is thoroughly discussed in Volume 2, with an emphasis on sanitation in a public
eating place.
All the foregoing factors lend a sense of urgency to the task of rapidly identifying
toxins, species, and strains of pathogens and parasites as etiologic agents, and of determin-
ing their roles in the epidemiology and epizootiology of disease outbreaks, which are
described in detail throughout the Foodborne Disense Hmdbook.
It is very fortunate for the consumer that there exists in the food industry a dedicated
cadre of scientific specialists who scrutinize all aspects of food production and bring their
expertise to bear on the potential hazards they know best. A good sampling of the kinds
of work they do iscontained in these four new volumes of the Handbook. And the benefits
of their research are obvious to the scientific specialist who wants to learn even more
about food hazards, to the scientific generalist who is curious about everything and who
will be delighted to find a good source of accurate, up-to-date information, and to consum-
ers who care about what they eat.
We are confident that these four volumes will provide competent, trustworthy, and
timely information to inquiring readers, no matter what roles they may play in the global
campaign to achieve food safety.

Y. H. Hui
J. Richard Gorham
Dcrvid Kitts
K. D. Murre11
Wai-Kit Nip
Merle D. Pierson
Sved A. Suttar
R. A. Smith
David G. Spoerke, Jr.
Peggv S. Stanjield
Preface

The world ofnature offers many pleasant attractions. Concurrent with theincreased crowd-
ing ofurban areas inmuchof the developed world, there is a growing tendency for
stressed-out city dwellers to seek peace in the wilderness, the more or less easily accessi-
ble natural areas, both terrestrial and aquatic. Much of the fauna and flora of these nat-
ural areas are quite innocuous-for the most part, only specialists are aware of excep-
tions. And even some of the specialists might be unaware of hazards originating outside
their own sphere of expertise. Among consumers, mushroom hunters and fishermen are
probably the best informed about potential hazards in their favored haunts. However,
without access to specialized equipment and laboratory protocols, even the most compe-
tent specialist may be quite as unable to detect a hazard in food as the most naive con-
sumer.
While poisonous mushrooms figure prominently in this volume of the Foodborne
Diseuse Handbook, other dangerous botanicals are by no means neglected. By “danger-
ous,” we refer to a very broad range of effects on human and animal health. The poisonous
plants, their toxins, and the symptoms they cause are all discussed in detail, but more than
that, the reader will find current and helpful information on methods of chemical analysis
and recommendations for the medical management of poisoning episodes.
Mushrooms are enormously popular around the world as a food item. Fortunately
for the average consumer, grocery stores and restaurants get their mushrooms from com-
mercial growers. Such mushrooms have no inherent toxic properties and thus are consid-
ered safe to eat and, in fact, are safe to eat. However, even with commercially produced
mushrooms, the potential for microbial and insecticidal contamination should not be ig-
nored.
In the category of organisms known as fungi, mushrooms and toadstools are rela-
tively large and easy to recognize for what they are. There are other fungi, however, that
most of us will never see and that many consumers do not even know exist. Yet they, or
the toxins they elaborate, may be just as dangerous as the much more obvious poisonous
mushrooms. These are the fungi that produce mycotoxins (e.g., aflatoxin). For example,
edible plant foods may contain natural poisons. We have heard about molds in peanut,
which are a form of fungi-and contain aflatoxin. Poisons in cotton seed, cabbage, and

V
vi Preface

potatoes are usually either removed during processing or destroyed during cooking. Plant
toxins are described in great detail-detection, identification, effects on human and animal
health, epidemiology-in this volume.

Y. H. Hui
R. A. Snzith
David G. Spoerke, JK
Contents

htroduction to the Handbook ...

111
Preface V
Corn-ibutors i.x
Colttents of Other Volumes xi

I. Poison Centers

1. U.S. Poison Centers for Exposures to Plant and Mushroom Toxins 1

David G. Spoerke, Jr.

11. Selected Plant Toxicants

2. Toxicology of Naturally Occurring Chemicals in Food 37

Ross C. Beier and Herbert N. Nigg

3. Poisonous Higher Plants 187

Doreell Grace Lnng and R. A. Smith

4. Alkaloids 247
R. A. Smith

5. Antinutritional Factors Related to Proteins and Amino Acids 257

Irvin E. Liener

6. Glycosides 299
Walter Majak and Michael H. Benn

vii
viii Contents

7. Analytical Methodology for Plant Toxicants 351

Alister David Muir

8. Medical Management and Plant Poisoning 413

Robert H. Poppenga

9. Plant Toxicants and Livestock: Prevention and Management 44 1

Michael H. RnIphs

111. Fungal Toxicants

10. Aspergillus 47 1
ZoJin Kozakiewicz

11. Claviceps and Related Fungi 503

Gretchen A. Kuldau and Charles W. Bacon

12. Fusarium 535

Walter F. 0. Marasas

13. Penicillium 581

John I. Pitt

14. Foodborne Disease and Mycotoxin Epidemiology 593

S a m Hale Herwy and F. Xavier Bosch

15. Mycotoxicoses: The Effects of Interactions with Mycotoxins 627

Heather A. Koshinshy, Adrienne Woytowich, and
George G. Khnchntourians

16. Analytical Methodology for Mycotoxins 653

James K. Porter

17. Mycotoxin Analysis: Immunological Techniques 683

Fun S. Chu

18. Mushroom Biology: General Identification Features 715

David G. Spoerke, Jr.

19. Identification of Mushroom Poisoning (Mycetismus), Epidemiology,

and Medical Management 739
David G. Spoerke, Jr.

20. Fungi in Folk Medicine and Society 78 1

David G. Spoerke, Jr.

Index 803
Contributors

Charles W. Bacon Toxicology and Mycotoxin Research Unit, Russell Research Center,
Agricultural Research Service, U.S. Department of Agriculture, Athens, Georgia
Ross C. Beier Southern Plains Agricultural Research Center, Agricultural Research Ser-
vice, U.S. Department of Agriculture, College Station, Texas
Michael H. Benn Chemistry Department, University of Calgary, Calgary, Alberta,
Canada
F. Xavier Bosch Epidemiology Unit, Institute of Oncology, Llobregat Hospital, Barce-
lona, Spain
Fun S. Chu Department of Food Microbiology and Toxicology, Food Research Insti-
tute, University of Wisconsin-Madison, Madison, Wisconsin
Sara Hale Henry Center for Food Safety and Applied Nutrition, U.S. Food and Drug
Administration, Washington, D.C.
George G. Khachatourians Department of Applied Microbiology and Food Science,
University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Heather A. Koshinsky Investigen, Alameda, California
ZofiaKozakiewicz Biotechnology and Utilization of Biodiversity, CAB1 Bioscience,
Egham, Surrey, England
Gretchen A. Kuldau Department of Plant Pathology, Pennsylvania State University,
University Park, Pennsylvania
Doreen Grace Lang Department of Veterinary Science, University of Kentucky, Lex-
ington, Kentucky
Irvin E. Liener Department of Biochemistry, Molecular Biology, and Biophysics, Uni-
versity of Minnesota, St. Paul, Minnesota
WalterMajak Range Research Unit, Agriculture and Agri-Food Canada, Kamloops,
British Columbia, Canada

ix
X Contributors

Walter F. 0. Marasas Programme on Mycotoxins and Experimental Carcinogenesis,

Medical Research Council, Tygerberg, South Africa
Alister David Muir Crop Utilization, Agriculture and Agri-Food Canada, Saskatoon,
Saskatchewan, Canada
Herbert N. Nigg University of Florida, Lake Alfred, Florida
John I. Pitt Food Science Australia, North Ryde, New South Wales, Australia
Robert H. Poppenga New Bolton Center, School of Veterinary Medicine, University
of Pennsylvania, Kennett Square, Pennsylvania
James K. Porter Toxicology and Mycotoxin Research Unit, R. B. Russell Agricultural
Research Center, Agricultural Research Service, U.S. Department of Agriculture, Athens,
Georgia
Michael H. Ralphs Poisonous Plant Research Lab, Agriculture Research Service, U.S.
Department of Agriculture, Logan, Utah
R.A.Smith Department of Veterinary Science, University of Kentucky, Lexington,
Kentucky
David G. Spoerke, Jr. Bristlecone Enterprises, Denver, Colorado
Adrienne Woytowich Department of Applied Microbiology and Food Science, Univer-
sity of Saskatchewan, Saskatoon, Saskatchewan, Canada
Contents of Other Volumes

VOLUME 1: BACTERIAL PATHOGENS

I. Poison Centers

1. The Role of U.S. Poison Centers in Bacterial Exposures

David G. Spoerke, Jr.

11. Bacterial Pathogens

2. Bacterial Biota (Flora) in Foods

James M. Jay

3. Aeromonns hydrophila
Carlos Abeyta, Jr., Samuel A. Palumbo, and Gerard N. Stelma, Jr.

4. Update: Food Poisoning and Other Diseases Induced by Bacillus cereus

Kathleerl T. Rnjkowski and James L. Smith

5. Brucella
Shirley M. Hallirzg and Edward J. Young

6. Campylobucter jejuni
Don A. Franco and Charles E. Williams

7. Clostridium botulirzum
John W. Austift and Karerl L. Dodds

8. Clostridium yel@irzgerzs
Dorothy M. Wrigley

xi
xii Contents of Other Volumes

9. Escherichia coli
Marguerite A. Neill, Phillip I. Tarr, David N. Taylor, and Marcia Wolf

10. Listeria nzonocytogenes

Catherine W. Donnelly

11. Bacteriology of Salmonella

Robin C. Arzderson and Richard L. Ziprirl

12. Salmonellosis in Animals

David J. Nisbet and Richard L. Ziprin

13. Human Salmonellosis: General Medical Aspects

Richard L. Ziprin and Michael H . Hume

14. Shigella
Anthony T. Mnurelli crnd Keith A. Lnmpel

15. Stuphylococcus aureus

Scott E. Martin, Eric R. Myers, and John J. Inndolo

16. Vibrio cholerae

Charles A, Kaysner and June H. Wetherington

17. Vibrio yarahaernolyticus

Tm-jyi Chai and John L. Pace

18. Vibrio vulnificus

Anders Dalsgaard, Lise H@i, Debi Lirlkous, and James D. Oliver

19. Yersinia
Scott A. Minnich, Michael J. Smith, Steven D. Weagant, and Peter Feng

111. Disease Surveillance, Investigation, and Indicator Organisms

20. Surveillance of Foodborne Disease

Ewen C. D. Todd

21. Investigating Foodborne Disease

Dale L. Morse, Guthrie S. Birkhead, crnd Jack J. Guzewich

22. Indicator Organisms in Foods

James M. Jay

Index
Contents of Other Volumes

VOLUME 2: VIRUSES, PARASITES, PATHOGENS, AND HACCP

I. Poison Centers

1. The Role of Poison Centers in the United States

David G. Spoerke, Jr.

11. Viruses

2. Hepatitis A and E Viruses

Theresa L. Cromeam, Michael 0. Favorov, Ornana V. Nainan, and
Harold S. Margolis

3. Norwalk Virus and the Small Round Viruses Causing Foodborne Gastroenteritis
Hazel Appleton

4. Rotavirus
Syed A. Sattar, V. Susan Springthorpe, and Jason A. Tetro

5. Other Foodborne Viruses

Syed A. Sattar and Jason A. Tetro

6. Detection of Human Enteric Viruses in Foods

Lee-Ann Jaykus

7. Medical Management of Foodborne Viral Gastroenteritis and Hepatitis

Suzanne M. Mntsui and Ramsey C. Chemg

8. Epidemiology of Foodborne Viral Infections

Thomas M. Liithi

9. Environmental Considerations in Preventing the Foodborne Spread of Hepatitis A

Syed A. Sattnr and Sabah Bidawid

111. Parasites

10. Taeniasis and Cysticercosis

ZbignieMt S. Pawlowski and K. D. Murre11

11. Meatborne Helminth Infections: Trichinellosis

William C. Campbell

12. Fish- and Invertebrate-Borne Helminths

John H. Cross

13. Waterborne and Foodborne Protozoa

Ronald Fayer
xiv Contents of Other Volumes

14. Medical Management

Paul Prociv

15. Immunodiagnosis of Infections with Cestodes

Bruno Gottsteirr

16. Immunodiagnosis: Nematodes

H. Ray Ganlble

17. Diagnosis of Toxoplasmosis

Alan M. Johnson and J. P. Dubey

18. Seafood Parasites: Prevention, Inspection, and HACCP

Arm M. A d a m and Debra D. DeVlieger

IV. HACCP and the Foodservice Industries

19. Foodservice Operations: HACCP Principles

0. Peter Snyder, Jr.

20. Foodservice Operations: HACCP Control Programs

0. Peter Srlyder, Jr.

Irzdex

VOLUME 4: SEAFOOD AND ENVIRONMENTAL TOXINS

I. Poison Centers

1. Seafood and Environmental Toxicant Exposures: The Role of Poison Centers

Dmid G. Spoerke, Jr.

11. Seafood Toxins

2. Fish Toxins
BrmP W. Hulstend

3. Other Poisonous Marine Animals

Bruce W. Hdstend

4. Shellfish Chemical Poisoning

Ljwdolz E. Llewellyn

5. Pathogens Transmitted by Seafood

Russell P. Herwig
Contents of Other Volumes xv

6. Laboratory Methodology for Shellfish Toxins

David Kitts

7. Ciguatera Fish Poisoning

Yoshitsugi Hokcrrna and Joanrle S. M. Yoshih-awa-Ebesu

8. Tetrodotoxin
Joanne S. M. Yoshikawa-Ebesu, Yoshitsugi Hokanln, and Tarnno Noguchi

9. Epidemiology of Seafood Poisoning

Lora E. Flemit1g, Dolores Kat:, Judv A. Bean, and Roberta Hammond

10. The Medical Management of Seafood Poisoning

Donna Glad Blvthe, Eileerl Hack, Giavnnni Wnshington, and Lorn E. Fleming

11. The U.S. National Shellfish Sanitation Program

Rebecca A. Reid m d Timothv D. Durance

12. HACCP, Seafood, and the U.S. Food and Drug Administration
Kim R. Young, Miguel Rodrigues Kanznt, arrd George Perly Hoskin

111. Environmental Toxins

13. Toxicology and Risk Assessment

Donuld J. Ecobichorr

14. Nutritional Toxicology

David Kitts

15. Food Additives

Laszlo P. Somogyi

16. Analysis of Aquatic Contaminants

Joe W. Kiceniuk

17. Agricultural Chemicals

Debra L. Browning and Carl K. Winter

18. Radioactivity in Food and Water

Hank Kocol

19. Food Irradiation

Hank Kocol

20. Drug Residues in Foods of Animal Origin

Austin R. Long and Jose E. Roybnl
xvi Contents of Other Volumes

21. Migratory Chemicals from Food Containers and Preparation Utensils

Yvonne V. Yuan

22. Food and Hard Foreign Objects: A Review

J. Richard Gorhnm

23. Food, Filth, and Disease: A Review

J. Richard Gorhnrn

24. Food Filth and Analytical Methodology: A Synopsis

J. Richard Gorham
1
U S . Poison Centers for Exposures
to Plant and Mushroom Toxins

David G. Spoerke, Jr.

Bristlecorte Enterprises, Denver, Colorado

Epidemiology
I. 1
A. AAPCC 2
B. Staffingpoison
a center 4
C. Types of calls received 5
D. How calls
arehandled 6
E. References
used 7
F. How poisoncentersaremonitoredforquality 7
G. Professionalandpubliceducationprograms 8
H. Related
toxicology
organizations 8
1. International affiliations 10
J. Toxicology and poisoncenterWeb sites 11
K. North American mycologicalassociation 11
11. PoisonInformationCenters intheUnited States 12
111. National and InternationalMycologicalAssociations/Clubs/
Organizations 23
References 36

1. EPIDEMIOLOGY

Epidemiological studies aid treatment facilities in determining risk factors, determining

who may become exposed, and establishing the probable outcomes of various treatments.
A few organizations have attempted to gather such information and organize it into yearly
reports. The American Associations of Poison Control Centers (AAPCC), North American
Mycological Association (NAMA), and some federal agencies all work toward obtaining
epidemiological information, while the AAPCC has an active role in assisting with the
treatment of exposures. Epidemiological studies assist government and industry in de-
termining package safety, effective treatment measures, conditions of exposure, and fre-
quency of exposure. In 1987 there were 7023 cases of mushroom poisoning reported to
the AAPCC. In 1988, that figure increased to 7,834 (1). These numbers were approxi-

f
2 Spoerke

mately 0.6% of the total cases called to poison centers. The NAMA mushroom poisoning
case registry was provided with 156 reports (4.6% of reported mushroom cases), and, in
1988, 116 cases (3.4%) were registered (1).
Studies on mushroom poisonings provide information on the type of people most
commonly involved in exposures. Are these patients children experimenting in the back-
yard, hikers, or mycophiles looking for dinner? Studies can also tell us which species are
most commonly involved and what species were being sought. What types of symptoms
are seen first, onset of symptoms, and any sequelae may also be determined and compared
to accepted norms.

A. AAPCC
1. What Are Poison Centers and the AAPCC?
The group in the United States most concerned on a daily basis with poisonings due to
household agents, industrial agents, and biologics (including plants and mushrooms) is
the AAPCC. This is a national resource that provides information concerning all aspects
of poisoning and often refers patients to treatment centers. This group of loosely affiliated
centers is often supported by both government and industrial sources.
Poison centers were started in the late 1950s, the first thought to be in the Chicago
area. The idea caught on quickly and at the peak of the movement there were hundreds
of centers throughout the United States. Unfortunately, there were little or no standards
to define what might be called a poison center, the type of staff, hours of operation, or
information resources. One center may have had a dedicated staff of doctors, pharmacists,
and nurses trained specifically in handling poison cases: the next center may just have
had a book on toxicology in the emergency room or hospital library. In 1993, the Health
and Safety Code (Sec. 777.002) specified that a poison center provide a 24-hr service for
public and health care professionals and meet requirements established by the AAPCC.
This action helped the AAPCC to standardize activities and staffing of the various poison
centers.
The federal government does not fund poison centers, even though for every dollar
spent on poison centers there is a savings of $2-9 in unnecessary expenses (2, 3). The
federal agency responsible for the Poison Prevention Packaging Act is the U.S. Consumer
Product Safety Commission (CPSC). The National Clearinghouse for Poison Control Cen-
ters initially collected data on poisonings and information on commercial product ingredi-
ents and biologic toxic agents. For several years the National Clearinghouse provided
product and treatment information to the poison centers that handled the day-to-day man-
agement of the centers.
At first most poison centers were funded by the hospital in which they were located.
As the centers grew in size and number of calls being handled, both city and state govern-
ments took on the responsibility of contributing funds. In recent years, the local govern-
ments have found it very difficult to fund such operations and centers have had to look
to private industry for additional funding. Government funding may take several forms,
either as a line-item on a state’s budget, as a direct grant, or as moneys distributed on a
per call basis. Some states with fewer residents may contract with a neighboring state to
provide services to its residents. Some states are so populous that more than one center
is funded by the state. Industrial funding also varies, sometimes as a grant, sometimes as
 Poison Centers for Plant Toxin Exposure 3

Table 1 AAPCC MushroomExposures

~ ~ ~~~ ~

Year # of exposures % accidental % of total AAPCC calls

1989 9388 95 5.9

1990 9570 95 5.7

payment for handling the company’s poison or drug information-related calls, sometimes
as payment for collection of data regarding exposure to the company’s product.
Every year the AAPCC reports a summary of plant and mushroom exposures. As
an example, data on mushroom exposures from 1989 and 1990 are listed in Tables 1 and 2.
The totals do not equal loo%, as not everyone who was exposed to a mushroom
went to anemergency department, and not all calls concerning mushroom exposures were
due to poisonings. As can be seen by these statistics, there are a large number of exposures,
but very few serious outcomes due to mushroom exposures.
The same type of information is available for plant exposures. Each plant and mush-
room has its own code number in the POISINDEX‘ reference system, which is entered
by the poison center specialist taking the call. Thus, if the plant or mushroom is known
at the time of exposure and the right code is entered, the database will describe ages,
sexes, signs and symptoms, treatment, and outcomes for any particular plant or mushroom.
2. RegionalCenters
The number of listed centers has dropped significantly since its peak of 600 plus. Many
centers have been combined into regional centers. These regional poison centers provide
poison information and telephone management and consultation, collect pertinent data,
and deliver professional and public education. Cooperation between regional poison cen-
tersand poison treatment facilities is crucial. The regional poison information center
should work with various hospitals to determine the capabilities of the treatment facilities
of the region and to identify and have a working relationship with analytical toxicology
laboratories, emergency departments, critical care wards, medical transportation systems,
and extracorporeal elimination methods availability. This should be done for both adults
and children.
A “region” is usually determined by state authorities in conjunction with local
health agencies and health care providers. Documentation of these state designations must
be in writing unless a state chooses (in writing) not to designate any poison center or
accepts a designation by other political or health jurisdictions. Regional poison infomation
centers should serve a population base of greater than one million people and must receive
at least 10,000 human exposure calls per year.
The number of certified regional centers in the United States is now under SO. Certi-
fication as a regional center requires the following (4):

Table 2 Outcomes of AAPCC Mushroom Exposures-% of Total Calls: ED Visits and

Outcomes
Tx EDYear SxNo or
minor Death
Mod
Sx
Major
Sx
1989 24.4% 78.5% 2.5% 0.16% 3 cases
1990 24.8% 76.1% 2.0% 0.10% 1 case
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