Botulism: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, and treatment

Last updated February 5, 2009

Agent
Pathogenesis
Epidemiology
—Foodborne Botulism
—Wound Botulism
—Infant Botulism
—Adult Intestinal Toxemia Botulism
—Inhalational Botulism
—Iatrogenic Botulism
—Botulinum Toxin as a Biological Weapon
—Use of Therapeutic Botulinum Toxin
Clinical Features
Pediatric Considerations
Differential Diagnosis
Laboratory Diagnosis
—Specimen Collection and Transport
—Laboratory Biosafety
—Laboratory Response Network
—Diagnostic Tests for Detection of Botulinum Toxin and C botulinum
Prevention and Treatment Issues
—Therapy for Botulism
—Botulinum Toxoid
—Research on New Therapies and Vaccines
Emergency Response
Infection Control
Issues Related to Autopsies and Burial
Case Definitions and Public Health Reporting
References

Agent

Botulinum Toxin

Botulism is an intoxication caused by botulinum toxin, which is produced by Clostridium botulinum and, rarely, by other Clostridium species. Seven antigenically distinct toxin types (A, B, C, D, E, F, G) have been identified.

The following are key characteristics of botulinum toxins (see References: CDC 1998: Botulism in the United States, 1899-1996; Hatheway 1998; Lacy 1998; Schiavo 1994; Sneath 1986).

Botulinum toxins are the most lethal toxins known. For type A toxin, the toxic dose is estimated at 0.001 mcg/kg (see References: Franz 1997); the lethal dose for a 70-kg person by the oral route is estimated at 70 mcg, by the inhalational route 0.80 to 0.90 mcg, and by the intravenous route 0.09 to 0.15 mcg (see References: Sobel 2005). The toxins are identified by neutralization with type-specific antitoxin; minor cross-neutralization between types C and D and between types E and F has been observed (see References: Smith 1988).
The toxins are produced by vegetative cells (ie, germination of spores) and released by cell lysis.
Some toxins are fully activated by the bacteria that produce them (proteolytic strains of type A, B, and F), and some require exogenous proteolytic activation (types E and non-proteolytic types B and F).
Types A, B, E, and F cause natural disease in humans. The vast majority of disease is caused by types A, B, and E; type F rarely occurs (ie, about 1% of US cases [see References: Gupta 2005]).
In a recent study, a novel in vivo mouse assay was used to correlate toxin type and dosage with the duration of muscle paralysis for types A, B, and E (see References: Keller 2006).

Botulinum toxin A produced longer paralysis than botulinum toxin B, consistent with human observations.
For type A, duration of paralysis was exponentially related to toxin dose; the paralysis time doubled with every 25% increase of the toxin concentration.
For type B, the duration of paralysis was linear relative to the toxin dose.
Type E toxin had the shortest duration of action, but unlike the other two toxins, the dose of toxin did not influence recovery time.

Types C and D cause natural disease in birds, horses, and cattle; strains that produce these types reside in the intestinal tract of certain animals. Contaminated silage has been reported to cause botulism outbreaks among cattle (see References: Myllykoski 2008).
Toxin type G has never clearly been shown to cause human disease.
Toxin types C, D, and G cause botulism in primates when administered through aerosol challenge (see References: Middlebrook 1997). As a result of these experiments, experts generally believe that humans also are susceptible to these types.
Botulinum toxins are colorless, odorless, and presumably tasteless.
Aerosolized particles of toxin are approximately 0.1 to 0.3 mcm in size (see References: Shapiro 1997).
The toxins are inactivated by heating (>85°C for 5 minutes) (see References: Siegel 1993).
In the event of an intentional release of botulinum toxin, the causative organisms may or may not be present.

Clostridium botulinum

The following are key microbiologic characteristics of C botulinum (see References: CDC 1998: Botulism in the United States, 1899-1996; Hatheway 1998; Smith 1988; Sneath 1986).

Gram-positive spore-forming bacillus (may stain poorly)
Somewhat varying strain sizes but generally in the range of 0.5 to 2.0 mcm in width and 1.6 to 22.0 mcm in length (see References: CDC 1998: Botulism in the United States, 1899-1996)
Straight to slightly curved, with a peritrichous flagellum
Spores are oval, eccentric to subterminal, and usually swell the bacterial cell
Strict anaerobe
"Sluggishly" motile
Produce lipase on egg-yolk agar
Ferment glucose and liquefy gelatin (all strains)
Commonly isolated from soil and marine and lake sediments

The classification of C botulinum strains is based on metabolic activity (groups I to IV) and on toxin types (types A to G) (see References: Hatheway 1998, Sneath 1986, Smith 1988):

Group I includes type A strains and proteolytic strains of types B and F.
Group II includes type E strains and nonproteolytic strains of types B and F
Group III includes nonproteolytic strains of types C and D.
Group IV includes only strains that produce type G.
Strains that produce more than one toxin type or have genetic sequences encoding more than one toxin have been identified (see References: Barash 2004, Fathalla 2008, Kirma 2004).
Each group has a different optimal growth temperature, but there are no colonial morphology features that allow distinction between groups or antigenic types.
Genetic homology has been demonstrated within antigenic groups of C botulinum, and there is minimal antigenic cross-reactivity between groups.
Antimicrobial susceptibilities of C botulinum strains vary somewhat by group, but most strains are susceptible to penicillin, metronidazole, rifampin, and erythromycin (see References: Smith 1988).

C botulinum spores have the following features (see References: Smith 1988):

Spores may survive boiling for up to 3 to 4 hours or temperatures of 105^oC for 100 minutes.
Spores are readily killed by chlorine (either as chlorinated water or as diluted solutions of hypochlorite).
Spores undergo maximum germination when activated by heat. For example, type A strains undergo maximum germination by heat treatment (or "heat shocking") at 80°C for 10 to 20 minutes.
Spores are resistant to desiccation and can survive in the dry state for 30 years or more.
Spores are resistant to ultraviolet light, alcohols, and phenolic compounds. They are relatively resistant to irradiation.

Other Neurotoxin-Producing Clostridium Species

Clostridium butyricum–producing type E toxin has been reported to cause intestinal botulism in infants and young adults in Italy and foodborne botulism in Asia (see References: Aureli 1986, Fenicia 1999, Schecter 1999).
Clostridium baratii producing type F toxin has caused intestinal botulism in infants and adults; in the latter it is usually associated with gastrointestinal pathology, recent gastrointestinal surgery, or recent use of antimicrobial agents (see References: Barash 2005, Gupta 2005, McCroskey 1991, Schecter 1999).

Pathogenesis

Exposure to botulinum toxin occurs through the following mechanisms (toxin is not absorbed through intact skin):

Ingestion of preformed toxin
Inhalation of preformed toxin
Local production of toxin by C botulinum organisms in the gastrointestinal tract
Local production of toxin by C botulinum organisms in devitalized tissue at the site of a wound

Following exposure, pathogenesis includes the following steps (see References: Arnon 2001; CDC 1998: Botulism in the United States, 1899-1996; Halpern 1995; Schiavo 1995; Simpson 2004):

Botulinum toxin is activated by proteolytic cleavage; the activated structure is a 150-kd polypeptide comprising two chains (a heavy chain [100 kd] and a light chain [50 kd]) that are connected by a single disulfide bond.
Botulinum toxin enters the circulation and is transported to the neuromuscular junction.
At the neuromuscular junction, the heavy chain of the toxin binds to the neuronal membrane on the presynaptic side of the peripheral synapse.
The toxin then enters the neuronal cell via receptor-mediated endocytosis.
The light chain of the toxin crosses the membrane of the endocytic vesicle and enters the cytoplasm.
Once inside the cytoplasm, the light chain of the toxin (which is a zinc-containing endopeptidase) cleaves some of the proteins that form the synaptic fusion complex. The synaptic proteins, referred to as SNARE proteins, include synaptobrevin (cleaved by toxin types B, D, F, and G), syntaxin (cleaved by toxin type C), and synaptosomal-associated protein (SNAP-25; cleaved by toxin types A, C, E) (see References: Arnon 2001). The clostridial neurotoxin apparently first binds to the SNARE complex before cleavage occurs (see References: Breidenbach 2004).
The synaptic fusion complex allows the synaptic vesicles (which contain acetylcholine) to fuse with the terminal membrane of the neuron. Disruption of the synaptic fusion complex prevents the vesicles from fusing with the membrane, which in turn prevents release of acetylcholine into the synaptic cleft.
Without neuronal acetylcholine release, the affiliated muscle is unable to contract and becomes paralyzed.
The blockade of acetylcholine release lasts up to several months; normal functioning slowly resumes either through turnover of SNARE proteins within the cytoplasm or through production of new synapses.
Death from botulism results acutely from airway obstruction or paralysis of respiratory muscles. Death also can result from complications related to prolonged ventilatory support and intensive care.
Botulinum toxin apparently does not cross the blood-brain barrier; therefore, central nervous system functions remain intact.

Epidemiology

Foodborne Botulism

Foodborne botulism is caused by ingestion of food contaminated with preformed botulinum toxin and subsequent absorption of toxin through the gastrointestinal tract. The following steps are necessary for a food item to cause botulism (see References: CDC 1998: Botulism in the United States, 1899-1996):

The food item must be contaminated with C botulinum spores, which are normally found in soil.
The spores must survive food preservation methods.
Adequate conditions for spore germination and neurotoxin production must be present (see next bullet).
The food must not be reheated adequately (>85°C for 5 minutes) to inactivate the heat-labile toxin before the food is consumed (see References: Siegel 1993).

Generally, adequate conditions for germination and neurotoxin production include the following, although various caveats exist (see References: CDC 1998: Botulism in the United States, 1899-1996; Solomon 2001, Smith 1988):

An anaerobic environment
Nonacidic pH (generally 4.6 to 4.8; pockets of different pH may be present within a single food source and allow toxin to be produced in a food that overall has an acidic pH)
Minimum temperature of 10°C (the optimum temperature for growth of proteolytic strains is close to 35°C; some nonproteolytic strains of types B, E, and F can produce toxin at refrigeration temperatures [3°C to 4°C])
Availability of water with limited solute concentration

Toxin types A, B, and E account for most cases of foodborne botulism, and toxin types tend to be geographically distributed within the United States. The outbreaks reported to the CDC between 1950 and 1996 (see References: CDC 1998: Botulism in the United States, 1899-1996) were distributed as follows:

144 (86%) of 167 type A outbreaks occurred west of the Mississippi River
37 (61%) of 61 type B outbreaks occurred east of the Mississippi River
56 (84%) of 67 type E outbreaks occurred in Alaska

Type F foodborne botulism has rarely been reported in humans (see References: CDC 1998: Botulism in the United States, 1899-1996; Midura 1972).
A case of recurrent type B botulism has recently been reported in the United States. The case arose from repeated ingestion of home-prepared hot chili pepper sauce. Only two other cases have been reported in the United States and only three elsewhere in the world (see References: Bilusic 2008).
The median number of cases of foodborne botulism reported to the CDC annually between 1973 and 1996 was 24 (range, 8 to 86 cases) (see References: Shapiro 1998).
The mean number of foodborne botulism outbreaks per year between 1950 and 1996 was 9.4, with a mean number of 2.5 cases per outbreak (see References: CDC 1998: Botulism in the United States, 1899-1996).
Between 1990 and 2000, the median number of botulism events per year was 14 (range, 9 to 24) and the median number of cases per event was 1 (range, 1-17) (see References: Sobel 2004). During this time period, the highest incidence rates were in Alaska (19 per million population), Idaho (0.6 per million population), and Washington (0.3 per million population).
Improperly home-canned or home-prepared foods (particularly vegetables) continue to account for most of the food vehicles associated with foodborne botulism in the United States (see References: Sobel 2004).
Over the past 20 years, a wide variety of commercially produced (preserved and nonpreserved) foods have caused botulism outbreaks. Examples include foil-wrapped baked potatoes, sauteed onions held under a layer of butter, garlic in oil, commercially produced cheese sauce, commercially prepared chili, hazelnut yogurt, jarred peanuts, matambre (Argentine meat roll) sealed in heat-shrinked plastic wrap, commercially prepared carrot juice, and canned chili sauce (see References: Angulo 1998; CDC 2007: Botulism associated with canned chili sauce, July-August 2007; Chou 1988; Kalluri 2003; MacDonald 1985: Type A botulism from sauteed onions; O'Mahony 1990; St Louis 1988; Steth 2008; Townes 1996; Villar 1999).
A variety of salted, fermented, smoked, and canned fish sources have been implicated in type E botulism outbreaks in the United States and worldwide (see References: Lindstrom 2006, Sobel 2007, Telzak 1990).
Foodborne botulism is a significant public health problem among Alaskan natives and is usually associated with consumption of fermented meat from aquatic mammals and fish (see References: McLaughlin 2004; Shaffer 1990, Wainwright 1988).
Occasionally, unusual food preparation methods (particularly for home-prepared products) can lead to botulism. For example, an outbreak in Turkey (eastern Anatolia) in 2005 was associated with eating suzme (yogurt buried under soil) (see References: Akdeniz 2007).
Sales of minimally heated, chilled foods have grown recently in Western countries, such as the United States and the United Kingdom, and have raised concerns about the potential for foodborne botulism (see References: Peck 2006).
Waterborne botulism has not been reported , most likely for the following reasons (see References: Arnon 2001, Siegel 1993):

Botulinum toxin is rapidly inactivated by standard treatment of potable water.
A very large amount of toxin would be needed to contaminate a water supply on account of the dilution factor.

Wound Botulism

Wound botulism is caused by infection of a contaminated wound with C botulinum and subsequent absorption into the circulation of locally produced toxin.
C botulinum is a natural contaminant of soil throughout the United States (see References: Smith 1978).
Wound botulism has been recognized with increasing frequency among injecting drug users, particularly in California, where the disease has been associated with use of black tar heroin (see References: Davis 2008; MacDonald 1985: Botulism and botulism-like illness in chronic drug users; Passaro 1998; Werner 2000). Similarly, in the United Kingdom, bacterial infections (particularly wound botulism) have increased markedly since 2000 among injecting heroin users (see References: Brett 2005: Soft tissue infections caused by spore-forming bacteria in injecting drug users in the United Kingdom). The authors of this study observed that the major risk factor was skin- or muscle-popping. Cases also have been reported in Germany (see References: Preuss 2006) and in Sweden, where real-time PCR was used to diagnose a case of type wound E botulism (see References: Artin 2007).
Wound botulism in drug abusers can be misdiagnosed as drug intoxication (see References: Royl 2007); presenting features can alert physicians to the correct diagnosis (see References: Wenham 2008). It should be considered in injecting drug users who present with dysarthria and dysphagia (see References: Preuss 2006).
Wound botulism may occur following traumatic injury to an extremity, such as a compound fracture, laceration, puncture wound, gunshot wound, severe abrasion ("road rash"), or crush injury (see References: Merson 1973, Werner 2000).
Sinusitis associated with intranasal cocaine use has been the source of wound botulism in a few cases (see References: Kudrow 1988; MacDonald 1985: Botulism and botulism-like illness in chronic drug users; Roblot 2006, Werner 2000).
A few cases have occurred postoperatively (usually following intra-abdominal procedures) and an abscessed tooth was the source of C botulinum infection in one case (see References: Weber 1993).
Between 1943 (when the condition was first recognized) and 1985, 33 cases of wound botulism were reported to the CDC. Between 1986 and 1996, 78 cases were reported and most were associated with injecting drug use (see References: CDC 1998: Botulism in the United States, 1899-1996).

Infant Botulism

Infant botulism is caused by ingestion of C botulinum spores. The spores subsequently colonize the gastrointestinal tract, germinate, and produce toxin, which is absorbed into the circulation.
Most infants are well before illness onset (see References: Wigginton 1993). The disease characteristically begins with lethargy and poor feeding (with or without constipation), followed by neuromuscular paralysis, hypotonia, or weakness (see References: Clemmens 2007). Constipation may be subtle or overt.
The source of spores for most cases remains unknown, although the most common sources of infection for infants appear to be honey and environmental exposure (see References: Arnon 1979, Brook 2007, Nevas 2005). Infant formula was postulated to be the source for one case (see References: Brett 2005: A case of infant botulism with a possible link to infant formula milk powder). Other risk factors identified in one study for infants 2 months of age and older included breast-feeding, less than one bowel movement per day in the 2 months before illness onset, and ingestion of corn syrup (see References: Spika 1989). In that study, the only identified risk factor among infants less than 2 months old was living in a rural area or on a farm.
Between 1976 (when infant botulism was first recognized) and 1996, 1,442 cases were reported to CDC (see References: CDC 1998: Botulism in the United States, 1899-1996).

Cases were reported from 46 states, with Delaware, Hawaii, Utah, and California having the highest incidence rates (9.0, 8.8, 6.3, and 5.7 per 100,000 live births, respectively).
Almost half of all cases were reported from California (680 cases; 47.2%).
The mean age at onset was 13 weeks (range, 1 to 63 weeks).

Analysis of infant botulism cases occurring globally from 1996 through 2008 revealed 524 cases in 26 countries representing five continents. The fact that most countries have not reported cases of infant botulism suggests that the disorder is underreported, underrecognized, or both, because the organism is present worldwide and cases of foodborne botulism have been reported in many of these countries (see References: Koepke 2008).
Five cases of infant botulism caused by C baratii type F have been identified; the youngest patient was just 38 hours old at presentation (see References: Barash 2005).
A review of charts of infant patients in California who were treated with the orphan drug Human Botulism Immune Globulin on the basis of clinical presentation but did not ultimately have laboratory-confirmed botulism (32 of the 681 who were treated) demonstrated that these patients fell into five categories: spinal muscular atrophy type I (five patients), metabolic disorders (eight patients), infectious diseases (three patients), miscellaneous (seven patients; includes Miller Fisher variant of Guillain-Barre syndrome, neuroblastoma stage III, and cerebral infarctions, among others), and probable infant botulism lacking laboratory confirmation (nine patients) (see References: Francisco 2007).

Adult Intestinal Toxemia Botulism

The pathogenesis of intestinal botulism in adults is similar to that of infant botulism. Disease is caused by ingestion of C botulinum spores, with subsequent colonization of the gastrointestinal tract. Spores germinate and produce toxin, which is then absorbed into the circulation.
Only a few cases have been recognized, and most have occurred postoperatively or in adults with underlying pathology of the gastrointestinal tract such as Crohn's disease (see References: Bartlett 1986, Chia 1986, Griffin 1997, Shapiro 1998).
Several cases caused by type F toxin produced by C baratii have been reported to the CDC (see References: McCroskey 1991) and cases caused by C butyricum producing type E toxin also have been recognized (see References: Fenicia 1999).

A recently published review of type F adult botulism in the United States between 1981 and 2002 demonstrated the following findings (see References: Gupta 2005):

Thirteen cases of adult type F botulism were reported to CDC during the study period, representing 1% of US cases.
A toxigenic C baratii organism producing type F toxin was isolated in 8 (80%) of 10 positive stool cultures. Type F toxin was identified in serum for nine of the cases.
In 5 (42%) of 12 cases, a history of gastrointestinal disease or an invasive gastrointestinal procedure was present before illness onset. Also in 5 (42%) of 12 cases, antimicrobials were reportedly taken before illness onset. A possible food source was only identified in one instance.

Inhalational Botulism

Disease is caused by inhalation of aerosolized preformed botulinum toxin with subsequent absorption through the lungs into the circulation.
Three cases of inhalational botulism were reported in 1962 in veterinary technicians in Germany who were working with aerosolized botulinum toxin in animals (see References: Arnon 2001). Symptoms occurred about 72 hours after exposure.
Inhalational disease also has been produced experimentally in animals. One study, involving primates, demonstrated that illness occurred 12 to 80 hours after exposure (see References: Franz 1993). Another study, involving mice, demonstrated that following inhalational challenge, the maximum concentration of botulinum toxin in blood occurred at 2 hours postexposure (see References: Park 2003).
A more recent mouse study characterized the pathological consequences of inhalational botulinum toxin exposure in mice given prophylactic pentavalent (ABCDE) toxoid. The authors found that the mice sustained severe histopathological lung damage despite protection from the lethal neurotoxic effects. Signs included "thickening of the alveolar septa and perivascular areas with a generalized spreading interstitial edema and a moderate intra-alveola/intrabronchiola hemorrhage" (see References: Taysse 2005). These findings suggest a direct toxic affect of botulinum toxin on lung tissues; however, more research is needed to better define this potential effect.

Iatrogenic Botulism

Iatrogenic botulism is caused inadvertently by injection of botulinum toxin for therapeutic or cosmetic reasons (see References: Sobel 2005).
Four cases of iatrogenic botulism occurred in December 2004 in Florida following cosmetic injection with a botulinum toxin that was not approved for use in humans (see Dec 15, 2004, CIDRAP News story). The injections contained much higher concentrations of botulinum toxin than the FDA-approved product Botox. A research firm in Arizona sold the raw botulinum toxin to healthcare practitioners as a Botox substitute.

Botulinum Toxin as a Biological Weapon

Past efforts to weaponize botulinum toxin include the following:

The United States produced botulinum toxin as a potential biological weapon beginning in World War II; however, the US offensive biological weapons program ended after the 1972 Biological and Toxin Weapons Convention (BTWC).
The former Soviet Union conducted research on use of botulinum toxin as a biological weapon as late as the early 1990s, despite having signed the BTWC.
At the time of the Gulf War, Iraq had produced 19,000 L of concentrated botulinum toxin, some of which was loaded into military weapons (see References: Zilinskas 1997).
The Japanese cult Aum Shinrikyo attempted to use aerosolized botulinum toxin in Japanese cities on at least three occasions between 1990 and 1995. Fortunately, these efforts were not successful.

The two most likely mechanisms for use of botulinum toxin as a terrorist weapon include deliberate contamination of food or beverages or via an aerosol release (see References: Villar 2006).

Because food products are often widely distributed, contamination of a commercially produced food or beverage product could result in a high number of casualties and fatalities across the country. In addition, such a bioterrorist act would produce severe civic disruption, economic loss, and social anxiety. Any food or beverage item that is not heat-processed at 85°C (185°F) for 5 minutes prior to consumption or is potentially contaminated following sufficient temperature processing must be considered a possible vehicle for botulinum toxin. For example, typical temperatures employed for pasteurization of commercially available beverage products will not sufficiently denature all botulinum toxin in the product. Mathematical modeling suggests that 1 g of botulinum toxin added to commercially distributed milk consumed by 568,000 people could result in 100,000 cases of botulism (see References: Wein 2005). Ten grams of toxin added to the same quantity of milk could result in over 500,000 cases in the exposed population.
An aerosol release could also lead to high numbers of casualties, although the event would be more localized. Experts have estimated that 1 g of aerosolized botulinum toxin could kill up to 1.5 million people (see References: Shapiro 1997). Aerosolized particles of botulinum toxin are approximately 0.1 to 0.3 mcm in size (see References: Shapiro 1997).

Although contamination of a water supply is feasible, this approach is unlikely since a large amount of toxin would be needed to initially contaminate water. In general, deliberated contamination of water with potential bioterrorism agents may not be very effective for the following reasons: dilution of the agent in a large body of water; direct inactivation from chlorine or other disinfectants; nonspecific inactivation by other mechanisms (such as hydrolysis, sunlight, or microbes); filtration; and the relatively small amount of water that is actually ingested from the source (see References: Kahn 2001).

Botulinum toxin is naturally inactivated in fresh water within 3 to 6 days, and toxin is rapidly (within 20 minutes) inactivated by standard potable water treatment (see References: Siegel 1993).
A 2005 study found that two of seven small-scale water purification devices tested were able to effectively eliminate botulinum toxin from water. Those based on filtration (pore size 0.2 to 0.4 mcm) or irradiation from a UV-lamp (254 nm) failed toremove the toxin from inoculated water. Reverse osmosis and experimental sand filtration effectively eliminated the toxin (see References: Horman 2005).

The following features of a botulism outbreak would suggest deliberate toxin release (see References: Arnon 2001).

An outbreak involving a larger number of cases than previous outbreaks
An outbreak caused by an unusual toxin type (ie, C, D, F, or G) or an outbreak involving type E toxin without an apparent aquatic source
Multiple simultaneous outbreaks with or without an apparent source
For aerosol release, cases would not have a common food exposure but would have been in a common geographic location during the week before symptom onset

Use of Therapeutic Botulinum Toxin

Patients with a range of spastic or autonomic neuromuscular disorders may benefit from small amounts of purified botulinum toxin injected into affected muscles (see References: Schantz 1992): Examples include:

Spasmodic torticollis
Strabismus
Blepharospasm
Laryngeal dystonia
Focal dystonias of the hand
Limb spasticity
Hemifacial spasm
Cerebral palsy
Migraine headache
Hyperhydrosis
Post-stroke spasticity

Purified botulinum toxin type A (Botox, produced by Allergan, Inc) was originally approved by the Food and Drug Administration (FDA) in 1989 to treat blepharospasm and strabismus and was approved in December 2000 to treat cervical dystonia (see References: Allergan, Inc). In a recent report, botulinum type A toxin injections produced functional improvement in spastic diplegia among children with cerebral palsy (see References: Bjornson 2007, Willis 2007).
Purified botulinum toxin type B (Myobloc, produced by Elan Pharmaceuticals, Inc) was approved by the FDA in 2000 for treatment of patients with cervical dystonia to reduce the severity of abnormal head position and neck pain (see References: FDA: Myobloc labeling information).
In April 2002, the FDA approved use of botulinum toxin type A for cosmetic purposes (see References: Allergan, Inc; FDA: Botox Cosmetic labeling information).
Therapeutic botulinum toxin contains about 0.3% of the estimated lethal human inhalational dose and only 0.005% of the estimated lethal human oral dose; therefore, this form of toxin is not likely to be used as a bioterrorist weapon (see References: Arnon 2001).
An unlicensed, highly concentrated preparation of botulinum toxin caused botulism in four adult patients undergoing cosmetic procedures. Affected patients may have received doses 2,857 times the estimated human lethal dose by injection. Pretreatment serum levels in three of the four patients were between 21 to 43 times the estimated human lethal dose (see References: Chertow 2006).

Clinical Features

Botulism is characterized by acute afebrile descending symmetric paralysis. Recovery occurs over weeks to months and often requires extensive supportive care.
Disease generally begins with evidence of cranial nerve dysfunction and then progresses to muscle weakness (proximal muscle groups are affected first and may be more severely involved).
Severity of disease ranges from mild cranial nerve dysfunction to complete flaccid paralysis. Paralysis of pharyngeal or respiratory muscles may result in the need for prolonged mechanical ventilation.

Severity of disease correlates with the amount of toxin absorbed into the circulation.
Several studies have shown that a shorter incubation period correlates with more severe disease (see References: MacDonald 1985: Type A botulism from sauteed onions; Tacket 1984). Similarly, a study of botulism cases in Japan revealed that patients who had shorter incubation periods had a significantly higher risk of death (see References: Nishiura 2007).
Disease caused by toxin type A tends to be more severe than disease caused by toxin type B or E (see References: Shapiro 1998).
Among more than 200 patients in an outbreak in Thailand, respiratory failure was less likely to develop in those who did not manifest nausea or vomiting and did not have urinary retention requiring catheterization. Nausea or vomiting and any cranial neuropathy with urinary retention or difficulty swallowing were symptoms most predictive of respiratory failure (see References: Wongtanate 2007).

Death can result from airway obstruction or paralysis of respiratory muscles. Death also can result from complications related to prolonged ventilatory support and intensive care, such as aspiration pneumonia and other infectious conditions.

Before mechanical ventilation was widely available, the case-fatality rate was about 60% (see References: Shapiro 1998).
The case-fatality rate currently is low owing to adequate supportive care; overall the rate is 5% to 10% for foodborne disease and somewhat higher for wound botulism (see References: Shapiro 1998, Werner 2000).
In the event of a mass exposure (such as a bioterrorism attack), clinical resources could be overwhelmed rapidly and the case-fatality rate could be much higher.
A recent retrospective study of hospitalized foodborne botulism cases in the Republic of Georgia, 1980-2002, found that patients with shortness of breath and impaired gag reflex and without diarrhea were 23 times more likely to die than were patients without this syndrome (see References: Varma 2004). In this case series, the incubation period was similar among those who died and those who survived, as was the likelihood of receiving antitoxin.

Clinical features are outlined in the table below.

Clinical Features of Foodborne and Wound Botulism
Note: Information presented is for foodborne and wound botulism; infant botulism is not included, since that condition is distinct from what would be expected in a bioterrorism attack. The presenting features of inhalational botulism likely would be comparable to those of foodborne and wound botulism.
Characteristic	Features
Incubation period^a	—Dependent on level of toxin exposure —For foodborne botulism, 2 hr–8 days —For wound botulism, 4-14 days —Unknown for inhalational botulism; estimated to be 24-36 hr; the only three reported cases in humans had an incubation period of 72 hr
Symptoms (compiled from reports of foodborne botulism outbreaks caused by toxin types A, B, and E)^b	—Nausea (88%)^c —Dry mouth (82%) —Blurred vision (78%) —Dysphonia (76%) —Dysphagia (75%) —Weakness (72%) —Fatigue (69%) —Dyspnea (65%) —Dysarthria (63%) —Double vision (60%) —Dizziness (56%) —Vomiting (52%)^c —Constipation (related to autonomic dysfunction) (45%) —Sore throat (40%) —Abdominal cramps or abdominal pain (40%)^d —Diarrhea (35%)^c —Paresthesias (29%)
Signs (compiled from cases of types A and B botulism reported to CDC in 1973 and 1974)^d	—Alert mental status (90%) —Weakness of upper extremities (75%) —Ptosis (73%) —Weakness of lower extremities (69%) —Extraocular muscle weakness (65%) —Diminished gag reflex (65%) —Facial nerve dysfunction (63%) —Dilated or fixed pupils (44%) —Diminished or absent deep tendon reflexes in affected groups (40%) —Nystagmus (22%) —Ataxia (17%) —Other considerations: ~Patients generally afebrile ~Mental status generally intact, although patients may appear lethargic or have difficulty communicating because of bulbar dysfunction ~Sensory exam generally normal
Laboratory features	—Normal CSF glucose, protein, cell count —Normal CBC —Normal imaging of brain and spine (ie, CT scan or MRI) —Characteristic EMG findings^e: ~Incremental response (facilitation) to repetitive stimulation (not always present and often seen only at 50 Hz) ~Short duration of motor unit potentials (MUPs); polyphasic MUPs ~Decreased amplitude of compound muscle action potentials (CMAPs) after a single nerve stimulus (most prominent in proximal muscle groups) ~Normal sensory nerve function ~Normal nerve conduction velocity (motor and sensory)
Complications	—Respiratory failure (which may require prolonged ventilatory support); in some outbreak settings, up to 30%-40% of patients required mechanical ventilation —Aspiration pneumonia (among patients with respiratory failure)^f —Residual fatigue, dry mouth or eyes, dyspnea on exertion up to several years after initial presentation^g
Case-fatality rate^h	—5%-10% for foodborne botulismⁱ —15%-44% for wound botulism^j
Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography; MRI, magnetic resonance imaging; CBC, complete blood count. ^aSee References: Arnon 2001, Franz 1997. ^bThe percentages were derived from compiling information available from published reports of large foodborne outbreaks caused by toxin type A, B, or E. The number of cases in each denominator ranged from 30 to 180. See References: Angulo 1998; from s 1985: Type A botulism; St Louis 1988; Wainwright 1988; Weber 1993. ^cGastrointestinal symptoms are uncommon in patients with wound botulism (see References: Merson 1973) and likely would be uncommon in the setting of inhalational exposure. ^dSee References: Hughes 1981. ^eSee References: Cherington 1998, Maselli 2000. ^fSee References: Schmidt-Nowara 1983. ^gSee References: Mann 1981, Mann 1983, Wilcox 1989. ^hBefore mechanical ventilation was widely available, the case-fatality rate was much higher (about 60%). In the setting of a mass exposure, where intensive-care resources could rapidly be overwhelmed, the case-fatality rate may be higher than that currently observed. ⁱSee References: Shapiro 1998. ^jSee References: Merson 1973, Shapiro 1998, Werner 2000.

Pediatric Considerations

Most pediatric cases of botulism occur in infants (ie, infant botulism), although foodborne and wound botulism also can affect the pediatric population.
In the event of an aerosol release of botulinum toxin, children may be at an even greater level of risk than adults, since children have a higher number of respirations per minute and consequently could have an increased level of exposure to toxin (see References: AAP 2000).
Signs and symptoms of botulism in children following a bioterrorist attack (ie, aerosol or foodborne exposure) would be similar to those seen in adults.
Assuring adequate intensive care resources for the pediatric population in the event of a bioterrorism attack involving an agent such as botulinum toxin should be an important priority in bioterrorism preparedness planning.

Differential Diagnosis

Differential Diagnosis of Botulism
Note: This differential diagnosis applies to botulism in adults and older children; infant botulism is not included, since that condition is distinct from what would be expected during a bioterrorism attack.
Condition	Features that distinguish each condition from botulism^a
Guillain-Barre syndrome (GBS) (particularly Miller Fisher variant)	—Classic GBS results in ascending paralysis —Miller Fisher variant may be descending and may have pronounced cranial nerve involvement; it usually includes a triad of ophthalmoplegia, ataxia, and areflexia (5% of GBS cases are of the Miller Fisher variant)^b —Abnormal CSF protein 1-6 wk after illness onset (although may be normal early in clinical course) —Paresthesias commonly occur (often stocking/glove pattern) —EMG shows abnormal nerve conduction velocity; facilitation with repetitive nerve stimulation does not occur (as with botulism) —History of antecedent diarrheal illness (suggestive of Campylobacter infection, which accounts for about one third of GBS cases) —Outbreaks of GBS do not occur (unlike botulism)
Myasthenia gravis	—Dramatic improvement with edrophonium chloride (ie, a positive Tensilon test), although some botulism patients may exhibit partial improvement following administration of edrophonium chloride (ie, a borderline Tensilon test) —EMG shows decrease in muscle action potentials with repetitive nerve stimulation
Tick paralysis^c	—Ascending paralysis —Paresthesias are common —Careful examination reveals presence of tick attached to skin —Recovery occurs within 24 hr after tick removal —EMG shows abnormal nerve conduction velocity and unresponsiveness to repetitive stimulation —Usually does not involve cranial nerves
Lambert-Eaton syndrome	—Commonly associated with carcinoma (often oat cell carcinoma of lung) —Although EMG findings are similar to those in botulism, repetitive nerve stimulation shows much greater augmentation of muscle action potentials, particularly at 20-50 Hz —Increased strength with sustained contraction —Deep tendon reflexes often absent; ataxia may be present —Usually does not involve cranial nerves
Stroke or CNS mass lesion	—Paralysis usually asymmetric —Brain imaging (CT or MRI) usually abnormal —Sensory deficits common —Altered mental status may be present
Poliomyelitis	—Febrile illness —CSF shows pleocytosis and increased protein —Altered mental status may be present —Paralysis often asymmetric
Paralytic shellfish poisoning or ingestion of puffer fish	—History of shellfish (ie, clams, mussels) or puffer fish ingestion within several hours before symptom onset —Paresthesias of mouth, face, lips, extremities commonly occur
Belladonna toxicity	—History of recent exposure to belladonna-like alkaloids —Fever —Tachycardia —Altered mental status
Aminoglycoside toxicity	—History of recent exposure to aminoglycoside antibiotics —More likely to occur in the setting of renal insufficiency —Most commonly seen with neomycin —Most commonly associated with other neuromuscular blocking agents such as succinylcholine and paralytics
Other toxicities (hypermagnesemia, organophosphates, nerve gas, carbon monoxide)	—History of exposure to toxic agents —Carbon monoxide toxicity: altered mental status may occur, cherry-colored skin —Hypermagnesemia: history of use of cathartics or antacids may be present, elevated serum magnesium level —Organophosphate toxicity: fever, excessive salivation, altered mental status, paresthesias, miosis
Other conditions	—CNS infections (particularly brainstem infections) —Inflammatory myopathy —Hypothyroidism —Diabetic neuropathy —Viral infections —Streptococcal pharyngitis (pharyngeal erythema and sore throat can occur in botulism owing to dryness caused by parasympathetic cholinergic blockade)
Abbreviations: CSF, cerebrospinal fluid; EMG, electromyogram; CT, computed tomography; MRI, magnetic resonance imaging. ^aSee References: Arnon 2001, Campbell 1981, Cherington 1998, Werner 2000. ^bSee References: Sobel 2005, Dorr 2006. ^cSee References: Felz 2000.

Laboratory Diagnosis

Specimen Collection and Transport

Specimen collection and transport procedures for testing related to diagnosing botulism are outlined in the following table.

Collection and Transport of Laboratory Specimens for the Diagnosis of Botulism
Note: A list of patient medications should accompany specimens, since some medications may be toxic to mice and can be removed by dialysis before testing is performed.^a
Specimen	Clinical Indication	Collection and Transport
Serum	Intentional release, foodborne botulism, autopsy specimens	—Collect >20 mL whole blood before administration of antitoxin using red-top or separator tube (no anticoagulant) —Ship >10 mL serum at 4^oC —Do not ship whole blood, which tends to become hemolyzed during transit —Notify testing lab if patient has received "stigmine drugs" or a Tensilon test —Keep specimen refrigerated at all times
Serum	Wound botulism (critical specimen for confirmation)	—Collect 30 cc whole blood (before antitoxin administration) —Ship at 4^oC —Sera submitted for toxin detection should not be hemolyzed —Notify testing lab if patient has received "stigmine drugs" or a Tensilon test —Keep specimen refrigerated at all times
Wound/tissue	Wound botulism	—Collect exudate, tissue, or swabs —Ship at room temperature in anaerobic transport system
Stool, enema fluid, intestinal fluid	Intentional release, foodborne botulism, infant botulism, wound botulism^b	—Obtain 10-50 g of stool (as little as "pea-size" for infant botulism); transport at 4^oC —Enema fluid (20 cc) can be collected as an alternative to stool, using minimal amount of sterile nonbacteriostatic water; ship at 4^oC —Intestinal fluid collected at autopsy (20 cc); ship at 4^oC
Gastric fluid, vomitus	Foodborne botulism, intentional release	—Collect within 72 hr of symptom onset —Obtain 20 cc of vomitus; ship at 4^oC —Obtain 20 cc of gastric fluid (living cases or at autopsy); ship at 4^oC
Specimens to collect at autopsy	Intentional release, foodborne botulism, infant botulism	—Serum, according to methods outlined above —Contents from different sections of small and large intestines (10 g per sample in separate containers) —Gastric contents as indicated, according to methods outlined above —Tissue samples as indicated, according to methods outlined above
Food samples (epidemiologically implicated)	Intentional release, foodborne botulism, infant botulism	—Obtain 10-50 g of implicated or suspect food; ship at 4^oC in original container —Place individually in leak-proof sealed transport devices
Nasal swab	Intentional release^c	—Obtain anaerobic swab; ship at room temperature
Environmental sample	Intentional release, infant botulism	—Collect as appropriate: ~Environmental swab; ship at room temperature ~Soil (50-100 g) ~Water (>100 mL)
^aSee References: Arnon 2001. ^bA wound may not be the actual source of infection/intoxication. ^cToxin may be present on nasal mucosa for up to 24 hr after inhalational exposure (see References: Franz 1997). Adapted from the following sources (see References): ASM 2003: Sentinel laboratory guidelines for suspected agents of bioterrorism: botulinum toxin; CDC 1998: Botulism in the United States, 1899-1996; CDC: Specimen selection table.

Guidelines have been published for packing and shipping of infectious substances, diagnostic specimens, and biological agents from suspected bioterrorism (see References: ASM: Sentinel laboratory guidelines for suspected agents of bioterrorism: packing and shipping infectious substances, diagnostic specimens, and biological agents). C botulinum is classified under World Health Organization (WHO) risk group 4. Cultures that are reasonably suspected to contain C botulinum must be transported as "infectious substances." International Air Transport Association (IATA) rules require training of all individuals involved in the transport of dangerous goods, including infectious substances. Once botulinum toxin is identified, samples may be regulated as select agents and subject to additional transport requirements (see below). Chain of custody should be documented for material that may constitute evidence of criminal activity.

Laboratory Biosafety and Biosecurity

Botulinum toxin and Clostridium species that produce botulinum toxin are classified as select agents and therefore are regulated under 42 CFR part 73 (Possession, Use, and Transfer of Select Agents and Toxins), which was published in final form in the Federal Register in March 2005 (see References: HHS). As specified in the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, 42 CFR part 73 provides requirements for laboratories that handle select agents (including registration, security risk assessments, safety plans, security plans, emergency response plans, training, transfers, record keeping, inspections, and notifications).
C botulinum toxin detection should be performed only by trained individuals at laboratory response network (LRN) reference or higher laboratories.
Sodium hypochlorite (0.1%) or sodium hydroxide (0.1 N) inactivate the toxin and are recommended by CDC for decontaminating work surfaces and spills of cultures or toxin (see References: CDC 2007: Biosafety in microbiological and biomedical laboratories).
Biosafety recommendations from the Food and Drug Administration (FDA) for laboratories that test for C botulinum include the following (see References: Solomon 2001):

Place biohazard signs on doors to restrict entrance and keep the number of people in the laboratory to a minimum.
All workers should wear laboratory coats and safety glasses.
Never pipette anything by mouth; use mechanical pipettes.
Use a biohazard hood for transfer of toxic material if possible.
Centrifuge toxic materials in a hermetically closed centrifuge with safety cups.
Personally take all toxic material to the autoclave and see that it is sterilized immediately.
Do not work alone in the laboratory or animal rooms after hours or on weekends.
Have an eye wash fountain and foot-pedaled faucet available for hand washing.
Allow no eating or drinking in the laboratory.
In a very visible location, list phone numbers where therapeutic antitoxin can be obtained.
Reduce clutter in the laboratory to a minimum and keep all equipment and other materials in their proper place.

Laboratory Response Network

The Laboratory Response Network (LRN) is a national network of approximately 150 laboratories. The network includes the following types of labs: federal, state and local public health, military, food testing, environmental, veterinary, and international (located in Canada, the United Kingdom, and Australia) (see References: CDC: Facts about the Laboratory Response Network).

The LRN structure for bioterrorism designates laboratories as either national, reference, or sentinel. Designation depends on the types of tests a laboratory can perform and how it handles infectious agents to protect workers and the public.

National laboratories have unique resources to handle highly infectious agents and the ability to identify specific agent strains.
Reference laboratories, sometimes referred to as "confirmatory reference," can perform tests to detect and confirm the presence of a threat agent. These laboratories ensure a timely local response in the event of a terrorist incident. Rather than having to rely on confirmation from laboratories at CDC, reference laboratories are capable of producing conclusive results; this allows local authorities to respond quickly to emergencies. These are mostly state or local public health laboratories with BSL-3 containment facilities that have been given access to nonpublic testing protocols and reagents.
Sentinel laboratories represent the thousands of hospital-based labs that are on the front lines. Sentinel laboratories have direct contact with patients. In an unannounced or covert terrorist attack, patients provide specimens during routine patient care. Sentinel laboratories could be the first facility to spot a suspicious specimen. A sentinel laboratory’s responsibility is to refer a suspicious sample to the right reference laboratory. These laboratories generally have at least BSL-2 containment

Diagnostic Tests for Detection of Botulinum Toxin and C botulinum

The mouse bioassay is currently the only diagnostic method used for detection and identification of botulinum toxin. Other methods (see below) are still considered investigational.

Mice are injected intraperitoneally with the patient sample, stool or food extract, culture filtrate, or other sample and observed for up to 4 days.
Control mice are injected with a mixture of the sample combined with neutralizing antibody to different toxin types.
Signs of botulism intoxication usually are evident in 6 to 24 hours.
As little as 0.03 ng of toxin can be detected by this method (see References: CDC 1998: Botulism in the United States, 1899-1996; Shantz 1992).

Culture for C botulinum in addition to toxin testing for stool or gastric specimens has been used for diagnosis (see References: CDC 1998: Botulism in the United States, 1899-1996). Isolates are tested for neurotoxin by the mouse bioassay. An activation step with trypsin is required to detect toxin from some group II strains. Isolation of C botulinum from stool or a wound is considered diagnostic in patients with signs and symptoms of botulism.
Nasal swabs may be collected in the event of an aerosol exposure (see References: CDC: Specimen selection table; Franz 1997). As with other types of potential bioterrorism exposures, the sensitivity and diagnostic value of nasal culture is unknown. Nasal swabs should only be used as part of an epidemiologic investigation or on the basis of recommendations made by the CDC in the event of a bioterrorist attack.
Serological assays for botulinum toxin antibody are not useful as a measure of exposure, which does not typically induce an antibody response (see References: Middlebrook 1997).
Detailed methods for testing food samples have been published by the FDA's Center for Food Safety and Applied Nutrition (CFSAN) (see References: Solo mon 2001). Detection of botulinum toxin in an epidemiologically implicated food item confirms the diagnosis of botulism. Since C botulinum is widely distributed in nature, the organism may be present in food without producing toxin or causing disease. Therefore, positive culture results from food, in the absence of detectable toxin, must be interpreted within the context of other epidemiological findings.
Pulsed-field gel electrophoresis (PFGE), randomly amplified polymorphic DNA analysis, and automated ribotyping methods have been compared for epidemiological typing of C botulinum type E using clinical and food isolates associated with four botulism outbreaks that occurred in the Canadian Artic. A modified PFGE protocol was judged to be the most useful method for typing epidemiologically related type E strains, based on its ability to type all strains reproducibly and with an adequate level of discrimination (see References: Leclair 2006).
Other tests for botulinum toxin:

Enzyme-linked immunoassays (ELISA) (see References: Dezfulian 1991, Ferreira 2001, Ferreira 2003, Stanker 2008, Wictome 1999)
An immuno-PCR assay that measures antigen-antibody reactions using a conjugated reporter DNA molecule followed by PCR amplification (see References: Chao 2004)
Time-resolved fluorescence assays for C botulinum A/B neurotoxin (see References: Peruski 2002)
Matrix-assisted laser desorption/ionisation-time of flight mass spectrometry (MALDI-TOF MS) (see References: Barr 2005, Cruzan 2006, Darby 2001, Wilkes 2006)
An optical immunoassay for rapid detection of neurotoxins A, B, E, and F (see References: Ganapathy 2008)
A micromechanosensor for detection of botulinum toxin type B (see References: Liu 2003)
Lateral flow devices for environmental testing (see References: Alexeter Technologies, New Horizon Diagnostics, Osborn Scientific Group).
A botulinum neurotoxin serotype A assay with a large immuno-sorbent surface area (BoNT/A ALISSA) that captures a low number of toxin molecules and measures their intrinsic metalloprotease activity with a fluorogenic substrate (see References: Bagramyan 2008)

Other tests for C botulinum (organism)

Polymerase chain reaction (PCR) assays have been used for the detection of C botulinum toxin genes in animal, food, and fecal samples (see References: Craven 2002, Dahlenborg 2001, Fenicia 2007, Franciosa 1994, Lindstrom 2001). A "ruggedized" real-time PCR assay called R.A.P.I.D. for use by first-responders and in military field hospitals and other rough environments is commercially available but not FDA-approved (see References: Idaho Technology). PCR-based assays detect genetic sequences of the organism, not the toxin molecule itself. This is important to consider, since the organism may not be present in clinical specimens or may not be involved in an intentional release of botulinum toxin.
Subtyping methods for C botulinum, such as ribotyping, have been described (see References: Skinner 2000).
An amplification method that analyzes variable number tandem repeat regions in C botulinum has been shown to be capable of discriminating among type A strains and may provide laboratories with a rapid, highly discriminatory diagnostic tool for use in botulism outbreaks (see References: Macdonald 2008).
Additional information about genetic testing methods and future perspectives can be found in recent reviews (see References: Lindstrom 2006: Laboratory diagnosis of botulism).

Prevention and Treatment Issues

Therapy for Botulism

Supportive care is the mainstay for treatment of botulism; prolonged intensive care, mechanical ventilation, and parenteral nutrition may be required.
Botulinum antitoxin can be administered to treat forms of botulism other than infant botulism and is most effective if given early in the clinical course. Although antitoxin will not reverse existing paralysis, it will prevent additional nerve damage if given before all circulating toxin is bound at the neuromuscular junction.
In cases of wound botulism, the wound should be surgically debrided and antibiotics should be administered (usually penicillin).
Botulism immune globulin–intravenous (human) (BIG-IV) for treatment of infant botulism was licensed by the FDA in October 2003 as BabyBIG.

A recent 5-year randomized, double-blind, placebo-controlled trial of BIG-IV treatment for infant botulism in California demonstrated that it significantly: (1) shortened duration of hospitalization (from a mean of 5.7 weeks to 2.6 weeks), (2) shortened time spent in intensive care (from 5.0 weeks to 1.8 weeks), and (3) decreased mean hospital costs per patient by $88,000 (see References: Arnon 2006).
BIG-IV is available as a public-service orphan drug and may be obtained by contacting the California Department of Human Services, Infant Botulism Treatment and Prevention Program (see References: California Department of Health Services, Arnon 2006). The circumstances that enabled the creation of BIG-IV have been presented as a possible paradigm for development of other "orphan" drugs (drugs used to treat relatively few patients) (see References: Arnon 2007).

Availability of botulinum antitoxin

Antitoxin should be requested as soon as the diagnosis of botulism is suspected, since confirmation of botulism may take several days and antitoxin is most effective if given within 24 hours after symptom onset (see References: Tacket 1984).
Antitoxin for use in the United States is of equine origin and only available through the CDC via state and local health departments (except in California and Alaska, where antitoxin release is controlled by the state health departments).
In addition to resources at the state level, epidemiologists at CDC are available 24 hours a day to provide advice regarding use of antitoxin.
Antitoxin (supplied by CDC) is maintained at quarantine stations located in airports in various metropolitan areas (eg, New York, Chicago, Atlanta, Miami, Los Angeles, San Francisco, Seattle, Honolulu). Once antitoxin is requested for a patient with suspected botulism, it generally can be delivered within 12 hours (see References: Shapiro 1997).
The CDC formulary includes botulinum antitoxin bivalent (equine) for types A and B (produced by Aventis Pasteur and licensed by the FDA) and botulinum antitoxin (equine) type E (an investigational product). In the past, CDC released trivalent ABE antitoxin for treatment of suspected or confirmed botulism cases in the United States; however, the trivalent product is currently not available (see References: CDC: Drug Service: Formulary).
The US army has developed an investigational heptavalent botulinum antitoxin (types A, B, C, D, E, F, G). This product could potentially be used during a bioterrorist attack involving aerosolized botulism; however, its efficacy in humans is not yet known (see References: Arnon 2001, Franz 1997).
In May 2006, Cangene Corporation was awarded a 5-year development and supply contract by the US Department of Health and Human Services for 200,000 doses of a heptavalent botulism antitoxin (BAT). Cangene announced a substantial delivery of the antitoxin in 2008 (see References: Cangene 2008).

Recommended therapy with botulinum antitoxin

If the type of botulinum toxin is not known, all three types of antitoxin should be administered. If the toxin type is known (ie, in an outbreak setting where the toxin type has been previously identified), then either bivalent AB antitoxin or type E antitoxin should be administered on the basis of the identified toxin type.
According to the package inserts, each vial of bivalent AB antitoxin contains 7,500 IU of type A antitoxin and 5,500 IU of type B antitoxin. Each vial of type E antitoxin contains 5,000 IU of type E antitoxin. One IU neutralizes 1,000 mouse LD50 of toxin E or 10,000 mouse LD50 of toxins A and B.
These amounts are more than adequate to neutralize the amount of toxin likely to be present in the circulation for naturally occurring botulism cases (see References: Hatheway 1984).
The circulating equine antitoxins have a half-life of 5 to 8 days (see References: Hatheway 1984).
In the setting of a bioterrorist attack, where cases may have been exposed to unusually large amounts of toxin, additional doses of antitoxin may be necessary. According to the package inserts, additional doses may be given (at least 2 to 4 hours after an initial dose or between doses) if the patient's condition continues to deteriorate. Alternatively, the patient's serum could be retested for the ongoing presence of circulating toxin (see References: Arnon 2001); however, this process would take time. The scarcity of antitoxin limits the capacity to provide additional doses.

Administration of botulinum antitoxin

The vial(s) should be diluted in 0.9% saline for intravenous infusion at a 1:10 dilution.
The preparation should be at ambient temperature before infusion and each diluted vial should be infused slowly (ie, over a minimum of 2 minutes) according to the manufacturer's instructions.

Hypersensitivity reactions to antitoxin

According to the package inserts, the following reactions can occur:

Anaphylaxis
Thermal reactions (usually occurring 20 minutes to 1 hour after administration and characterized by chills, slight dyspnea, and then a rapid rise in temperature)
Serum sickness (occurring within 14 days after administration and characterized by fever, urticaria or a maculopapular rash, arthritis or arthralgias, and lymphadenopathy)

In one series of 268 patients who received antitoxin between 1967 and 1977 (when the recommended dose of antitoxin was 2 to 4 times higher than it is currently), 24 (9%) had acute (13 patients) or delayed (11 patients) hypersensitivity reactions (see References: Black 1980).
Of patients treated with one vial of antitoxin (the current recommended dose), fewer than 1% experienced hypersensitivity reactions (see References: Sobel 2005).
Skin testing for sensitivity should be performed on all patients before they receive antitoxin (even if they have received the product at some point in the past). The best method is through a scratch test (outlined in the package insert). If the scratch test is positive, the patient can be desensitized over several hours before the full dose of antitoxin is administered.
Diphenhydramine and epinephrine should be available during administration of antitoxin, and the patient should be kept under careful observation for 1 to 2 hours after administration (then under close surveillance for a full 24 hours).
A case-control study of 217 botulism patients has provided details about long-term outcome of treated patients. Of the 211 patients who survived, 68% reported having worse health at the time of interview than 6 years earlier, compared with 17% of 656 controls (matched odds ratio, 17.6; 95% confidence interval, 10.9-28.4). Nearly twice as many patients as controls (49% vs 25%) reported their current health as fair or poor. Significantly more botulism patients than controls reported fatigue, dizziness, dry mouth, and difficulty lifting objects. In addition, botulism patients were significantly more likely than controls to report difficulty breathing with moderate exertion and were also more likely to report being limited in vigorous activities, walking 3 blocks, and climbing 3 flights of stairs (see References: Gottlieb 2007).

Botulism immune globulin

Isolation of plasma from donors immunized with pentavalent (ABCDE) botulinum toxoid yields botulism immune globulin (BIG). A 2005 hospital-based study in Utah demonstrated that BIG-IV could shorten hospital course and reduce disease complications in patients with infant botulism (see References: Thompson 2005).

Botulinum Toxoid

Immunization with botulinum toxoid is recommended for:

Laboratory personnel who work with cultures of C botulinum or its toxins (see References: CDC 1999: Biosafety in microbiological and biomedical laboratories; CDC 1999: Pentavalent [ABCDE] Botulinum Toxoid)
Military personnel who may be at risk of exposure to botulinum toxin

A pentavalent (ABCDE) botulinum toxoid is available through the CDC as an investigational new drug (IND) by calling the CDC Drug Service at 404-639-3670 (see References: CDC: Drug Service: General information; CDC 1999: Pentavalent [ABCDE] Botulinum Toxoid).
Botulinum toxoid is administered deep subcutaneously as a 0.5-mL dose at 0, 2, and 12 weeks, with a booster dose at 1 year.
Antitoxin titers should be measured by CDC every 2 years after the booster dose, and additional doses of toxoid should be administered as needed. A serum titer of 1:16 or 0.15 to 0.30 IU of antitoxin per mL is considered adequate evidence of immunity (see References: CDC 1999: Pentavalent (ABCDE) Botulinum Toxoid).
After a primary series, 91% of vaccinated persons in one study had an adequate response to type A toxin and 78% had an adequate response to type B toxin. All vaccinated persons had detectable antibody titers to both A and B toxins after the first annual booster (see References: Siegel 1988).
Toxoid immunization precludes its recipient from showing a response to treatment with medicinal botulinum toxin.
Pentavalent botulinum toxoid is not recommended for the general public since botulism is a rare condition and the toxoid is not widely available.

Research on New Therapies and Vaccines

Antibody therapeutics.

Humanized monoclonal antibodies, small peptides, peptide mimetics, receptor mimics, and small molecules targeting active sites are candidates for inhibiting botulinum toxin and may eventually be used in treatment strategies (see References: Adekar 2008,Cai 2007 Nowakowski 2002).

Protein and peptide vaccines

Various recombinant vaccines are currently under investigation in animal models (see References: Baldwin 2008, Boles 2006, Lee 2007, Pier 2008, Webb 2007, Yu 2008).

Viral vector vaccines

Vectored vaccines also have been studied; one report involved Venezuelan equine encephalitis virus as the vector (see References: Lee 2006) and others have involved adenovirus (see References: Xu 2009, Zeng 2007).

Emergency Response

Botulism Surveillance

CDC maintains an intensive surveillance system for botulism in the United States.
Cases are identified through follow-up of requests for botulinum antitoxin.
All suspect cases in which treatment is being considered are reported, since CDC is the only source of antitoxin and all requests for antitoxin must first be approved by a CDC epidemiologist before release (except in California and Alaska, where the state health departments control the release of antitoxin) (see References: Shapiro 1997).
Cases also may come to detection through requests for laboratory testing of food or clinical specimens. Arrangements for laboratory testing are made through state public health laboratories. These laboratories either have the capability to test specimens directly or they collect and submit specimens to another laboratory for testing (usually at CDC). All positive specimens identified through state public health laboratories are reported to CDC on at least an annual basis.
All state health departments have 24-hour emergency phone lines for reporting cases of botulism (see References: CDC: Emergency response). Requests to CDC for antitoxin are usually made through the state epidemiology offices, although some requests are made directly to CDC by clinicians caring for suspect botulism patients.

Botulism Outbreak or Intentional Dissemination

A single case of foodborne botulism (or botulism from an unknown source) is considered an outbreak (see References: MacDonald 1986) and is a public health emergency. Suspected cases should be reported immediately to state or local public health officials.
Public health officials will: (1) assist with appropriate laboratory testing to confirm the diagnosis, (2) authorize use of antitoxin, (3) conduct aggressive surveillance for other cases, and (4) immediately begin an epidemiologic investigation to identify the source or vehicle (such as a contaminated commercial product) or to determine if there is evidence to suggest a bioterrorism-related event.
Original specimens should be preserved and their custody documented, pursuant to public health and regulatory investigation procedures as well as potential criminal investigation procedures (see References: ASM 2003: Sentinel laboratory guidelines for suspected agents of bioterrorism: botulinum toxin).
Public health officials will coordinate notification of local FBI agents as appropriate.
If available evidence suggests the potential for a continued increase in cases while the investigation proceeds, involved hospitals should establish communication networks between the emergency department, the intensive care unit, and those services likely to be involved in managing cases (eg, infectious disease, pulmonary, respiratory therapy, critical care, neurology). These networks should focus on establishing policies and procedures for handling large numbers of patients (see below).

Emergency Response to a Mass Exposure

In the event of a mass exposure, such as a widespread aerosol release of botulinum toxin, the following steps would be necessary.

Rapid administration of antitoxin to ill persons: Although antitoxin does not reverse existing paralysis, once administered it binds to any toxin remaining in the circulation and, therefore, can mitigate progression of disease, increase the likelihood of survival, and decrease the duration of mechanical ventilatory support (if respiratory failure occurs). Release of antitoxin and coordination of administration would be performed by local/state public health officials in conjunction with CDC.
Rapid mobilization of mechanical ventilators: Adequate supportive care resources, including those for infants and children, would be critical to successful management of any mass-exposure botulism outbreak.

International Public Health Concerns

A recent large outbreak in Thailand (209 cases) emphasized the need for addressing global policy issues concerning outbreaks in developing countries, including health infrastructure, communication and response systems, stockpiles of medication and supplies, decision algorithms for notification, and international response to public health emergencies (see References: Ungchusak 2007).

Infection Control

Isolation Precautions

In the hospital setting, Standard Precautions are adequate for patients with botulism, since person-to-person transmission does not occur.
In the laboratory setting, sodium hypochlorite (0.1%) or sodium hydroxide (0.1 N) inactivate the toxin and are recommended by CDC for decontaminating work surfaces and spills of cultures or toxin (see References: CDC 1999: Biosafety in microbiological and biomedical laboratories).

Issues Related to Autopsies and Burial

Recent guidelines from CDC indicate that Standard Precautions should be used for postmortem care. These include using a surgical scrub suit, surgical cap, impervious gown or apron with full sleeve coverage, a form of eye protection (eg, goggles or face shied), shoe covers, and double surgical gloves with an interposed layer of cut-proof synthetic mesh (see References: CDC 2004: Medical examiners, coroners, and biologic terrorism: a guidebook for surveillance and case management).
In addition, autopsy personnel should wear N-95 respirators during all autopsies, regardless of suspected or known pathogens. Powered air-purifying respirators (PAPRs) equipped with N-95 or high-efficiency particulate air (HEPA) filters should be considered.
Bodies infected with biological terrorism agents should not be embalmed (see References: CDC 2004: Medical examiners, coroners, and biologic terrorism: A guidebook for surveillance and case management).

Case Definitions and Public Health Reporting

Botulism Case Definitions

The following case definitions were published in CDC's Morbidity and Mortality Weekly Report in 1997 (see References: CDC 1997: Case definitions for infectious conditions under public health surveillance).

Foodborne botulism

Clinical description: Ingestion of botulinum toxin results in an illness of variable severity. Common symptoms are diplopia, blurred vision, and bulbar weakness. Symmetric paralysis may progress rapidly.
Laboratory criteria for diagnosis:

Detection of botulinum toxin in serum, stool, or patient's food or
Isolation of C botulinum from stool

Probable case: A clinically compatible case with an epidemiologic link to a food source (eg, ingestion of a home-canned food within the previous 48 hours)
Confirmed case: A clinically compatible case that is laboratory-confirmed or that occurs among persons who ate the same food as persons who have laboratory-confirmed botulism

Infant botulism

Clinical description: An illness of infants, characterized by constipation, poor feeding, and "failure to thrive" that may be followed by progressive weakness, impaired respiration, and death.
Laboratory criteria for diagnosis:

Detection of botulinum toxin in stool or serum or
Isolation of C botulinum from stool

Confirmed case: A clinically compatible case that is laboratory-confirmed, occurring in a child less than 1 year of age

Wound botulism

Clinical description: An illness resulting from toxin produced by C botulinum that has infected a wound. Common symptoms are diplopia, blurred vision, and bulbar weakness. Symmetric paralysis may progress rapidly.
Laboratory criteria for diagnosis:

Detection of botulinum toxin in serum or
Isolation of C botulinum from a wound

Confirmed case: A clinically compatible case that is laboratory confirmed in a patient who has no suspected exposure to contaminated food and who has a history of a fresh, contaminated wound during the 2 weeks before onset of symptoms.

Public Health Reporting

According to state disease-reporting requirements, all confirmed and suspected cases of botulism must be reported immediately to state or local public health officials, even after normal working hours. Public health officials will then contact CDC through the CDC Emergency Operations Center (telephone number: 770-488-7100) to arrange for clinical consultation if necessary and for the release of botulinum antitoxin (see References: CDC 2003: Notice to Readers: New telephone number to report botulism cases and request antitoxin).

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