Toxic shock syndrome: B.C. teen's death revives an '80s anxiety

For women living in the 21st century, toxic shock syndrome can feel like a bit of a bogeyman — an ominous warning on your tampon package about a threat that almost never materializes.

16-year-old Sara Manitoski was likely killed by a toxin tied to a bacteria found on her tampon

Sixteen-year-old Sara Manitoski's death from toxic shock syndrome may have been linked to her tampon use. (George Dolgikh/Shutterstock)

For women living in the 21st century, toxic shock syndrome can feel like a bit of a bogeyman — an ominous warning on your tampon package about a threat that almost never materializes.

But this week, the Coroners Service of British Columbia revealed that a 16-year-old Comox Valley student who died in her sleep while on a class trip last year was likely killed by toxic shock — possibly linked to her tampon.

Toxic shock syndrome is a serious infection that occurs naturally when toxins made by certain strains of Staphylococcus aureus bacteria get into the bloodstream, Health Canada says.  

Scientists have not been able to figure out exactly why tampons are linked to toxic shock — but leaving a tampon in place for too long may increase the risk. 

These days, toxic shock is rare, though it's difficult to say exactly how rare. Health Canada says there have only been a few cases in recent years, but the B.C. Centre for Disease Control doesn't track the illness, and the coroners service didn't have readily available statistics on recent deaths.

Even so, it's a serious illness that progresses quickly, and can lead to death or require amputation of limbs. It can be triggered by infections from multiple sources, but a surge in cases in the 1970s and '80s has left toxic shock forever tied to tampon use.

Teen died in her sleep

According to the coroner's report, 11th-grader Sara Manitoski was on Hornby Island taking part in an outdoor education program when she began complaining to her friends about cramps. She had very little for dinner on the night of March 14, and after she missed breakfast the next morning, a classmate discovered her lying in bed, unresponsive.

Investigators believe Manitoski was killed by toxins released by the bacteria, Staphylococcus aureus, a microbe that was found on her tampon.

Manitoski, a Grade 11 student from the Comox Valley, died in her sleep while on a school trip to Hornby Island, B.C., on March 15, 2017. (CHEK News)

Staph. aureus is one of two bacteria known to cause toxic shock, according to Dr. Anthony Chow, professor emeritus in infectious diseases at the University of B.C. 

Tampons are often associated with that microbe, but there are other sources.

"It could be due to a wound infection, for example, or a bite," Chow said. "The bacteria itself is all around us. It could be on our body already. It could be on our skin."

The night before Manitoski died, other girls in the cabin heard her breathing become fast and shallow, and then stop, according to the coroner's report. An autopsy revealed that her skin was red on the neck, upper arms, upper chest, lower abdomen and thighs.

All of these are typical symptoms of toxic shock.

"It's a fairly rapid progression," Chow said. "Usually people, just all of a sudden, feel hot, have a high fever, maybe vomiting, and then they develop a rash like a sunburn, and then right after that — within hours — could go into shock, and that's when things really go haywire."

It's essential to get to a hospital immediately when symptoms of toxic shock appear, he added. If someone gets to the ER in time, and enough fluids are pumped into the body to counteract the toxin, then it's possible to recover.

The toxic shock scare

Toxic shock syndrome was named in 1978, and soon gained worldwide attention as reported cases began piling up.

Between 1976 and 1981, there were 53 cases of toxic shock reported in Canada, including three deaths. Thirty-six of those cases were connected to tampon use.

The U.S. saw close to 1,200 cases in the same time period, many of which were linked to a specific brand of tampons — Proctor & Gamble's Rely line, which was marketed as so absorbent, "it even absorbs the worry."

While most tampons are made from cotton or rayon, Rely used foam cubes made from polyester and an edible thickening agent known as carboxymethylcellulose.

Doctors recommend changing tampons every four to eight hours to avoid toxic shock syndrome. (Rich Pedroncelli/Associated Press)

The tampons were on the market for just two years before they were recalled in 1980, after the U.S. Centre for Disease Control revealed that Rely was connected to more cases of toxic shock than any other tampon brand.

"The particular brand of tampon was withdrawn from the market, and there was a fairly rapid decline in the incidence of toxic shock," Chow recalled.

Still, the illness can be associated with any brand of tampon.

According to Health Canada, younger women are more at risk because they have yet to develop antibodies to the toxin that causes the illness. 

Today, doctors recommend that girls and women avoid super-absorbent tampons, and use the lowest absorbency possible. Tampons should be changed every four to eight hours and should not be used overnight.

Anyone who has ever been diagnosed with toxic shock should not use tampons again.

With files from Deborah Goble

About the Author

Bethany Lindsay

Journalist

Bethany Lindsay has more than a decade of experience in B.C. journalism, with a focus on the courts, health and social justice issues. She has also reported on human rights and crimes against humanity in Cambodia. Questions or news tips? Get in touch at bethany.lindsay@cbc.ca or on Twitter through @bethanylindsay.

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