Download Actions requested of all clinicians

[Health Department Name]
[Unit Name]
[Street]
[City, State, Zip Code]
Phone: [insert number] Fax: [insert number]
[Email Address], [Website]
[Insert Logo]
BOTULISM HEALTH ALERT
[INSERT DATE]
[Insert short description why Health Alert is being released (e.g., Two cases of botulism have been identified)].
This Health Alert is posted on the [insert website name] at [insert web link].
ACTIONS REQUESTED OF ALL CLINICIANS:
1. Be alert for cases of botulism.
2. Report suspect cases to [insert unit/department name] at [insert phone number]. [Insert party responsible
for testing and release of antitoxin] can facilitate testing and release of antitoxin.
3. Consider Neurology and Infectious Disease consultation.
4. Obtain serum for toxin assays (in serum separator tubes).
INCIDENT SUMMARY
[Insert event-specific background information (e.g., Suspected aerosol release of botulism toxin)].
DESCRIPTION
Botulism is a muscle-paralyzing disease caused by a toxin made by a bacterium called Clostridium botulinum.
There are seven serotypes of the toxin, labeled A-G. Types A, B, and E (and rarely, F) cause natural diseases in
humans. C. botulinum can also release spores that are resistant to chemicals, heat, and drying, which allows
them to remain persistent in the environment even under the most unfavorable conditions. These spores can later
produce growing cells that are capable of making the botulism toxin.
There are three naturally occurring forms of botulism:
 Foodborne botulism: Occurs when a person ingests pre-formed toxin that leads to illness within a few
hours or a few days.
 Wound botulism: Occurs when wounds are infected with C. botulinum that secretes the toxin. Since 1988 it
has been predominantly associated with subcutaneous or intramuscular black tar heroin use.
 Intestinal botulism: Occurs in a small number of susceptible infants per year who harbor C. botulinum in
their intestinal tract. Rarely occurs in adults.
Additionally, there is a man-made form of botulism:
 Inhalation botulism: Results from the aerosolized botulism toxin, has been demonstrated experimentally in
primates, and has been attempted by bioterrorists.
Botulism toxin is considered a bioweapon because of its extreme potency, lethality, and the need for prolonged
intensive care among infected persons. This health alert focuses on foodborne and inhalational botulism because
they are the forms most likely to occur following a botulism release.
Categories of urgency levels
Health Alert: Conveys the highest level of importance; warrants immediate action or attention.
Health Advisory: Provides important information for a specific incident or situation; may not require immediate action.
Health Update: Provides updated information regarding an incident or situation; unlikely to require immediate action.
[Insert Health Department Name]
CASE DEFINITION
The following definitions should be used to identify exposed persons and cases. Testing, treatment, and
implementation of infection control measures should be based upon these definitions.
BOTULISM: CASE DEFINITION (Excluding Intestinal Botulism)
Categorization
Definition
Foodborne
1. Potentially
Exposed Person
2. Probable Case
4. Confirmed
Case
Inhalation
A person who [insert type of food consumed
A person in the proximity of [insert
/location present] during [insert timeframe
event/place] during [insert timeframe (note:
(note: incubation period is usually within 8
incubation period for aerosol release is
days)]
usually within 36 hours)].
Meets:
1) Potentially exposed person case definition; AND
2) Has clinical symptoms compatible with botulism:

Diplopia

Blurred vision

Bulbar weakness

Symmetric paralysis, which may progress rapidly
1) Clinical symptoms compatible with
botulism; AND
1) Clinical symptoms compatible with
botulism; AND
2a) Laboratory-confirmed
 Detection of botulinum toxin in serum,
stool, or patient's food, or
 Isolation of C. botulinum from stool
OR
2b) Occurs among persons who [ate the same
food/had the same exposure (insert specific
food or exposure)]as persons who have
laboratory-confirmed botulism.
2a) Laboratory-confirmed:
 Detection of botulinum toxin in clinical
specimen
 Isolation of C. botulinum from clinical
specimen
OR
2b) Occurs among persons [who had the same
exposure(insert exposure)] as persons who
have laboratory-confirmed botulism.
CLINICAL FEATURES
The disease manifestations of botulism are similar, regardless of botulism type. Botulism may be recognized by
its classic triad:
1) Symmetric descending flaccid paralysis with prominent bulbar palsies (diplopia, dysarthria,
dysphagia, and dysphonia), in
2) An afebrile patient, with
3) A clear sensorium
The following clinical features should be noted for suspected cases of botulism:
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[Insert Health Department Name]
BOTULISM: CLINICAL FEATURES
Incubation
Period§
Transmission
FOODBORNE
INHALATION
2 hours – 72 hours
(range 2 hrs – 8 days)
24-36 hours (aerosol*)
Ingestion of preformed toxin
Inhalation of preformed toxin
Early Presentation – cranial
nerve abnormalities
• Dysarthria
• Blurred and/or double vision
• Dry mouth
• Ptosis
• Symptoms may be slow in onset
or rapidly progressive (dosedependent)
Later Presentation – descending paralysis
Dysphonia, dysphagia
 Symmetrical, descending progressive muscular
weakness
 Dilated or fixed pupils
 Decreased gag reflex
Signs &
 Respiratory failure
Symptoms
 Autonomic nerve dysfunction; may include urinary
retention, orthostasis
 Normal mental status, though may appear lethargic
and have difficulty with
 communication
 Normal sensory nerve function
 Afebrile unless there is complicating infection
 Normal CSF glucose, protein, cell count
 Normal CBC
 Normal imaging of brain and spine (CT scan or MRI)
Laboratory
Characteristic EMG findings include:
Findings
 Incremental response (facilitation) to repetitive stimulation at 50 Hz
 Short duration of motor unit potentials
 Normal sensory nerve function
 Normal nerve conduction velocity
* Time to onset of inhalational botulism cannot be stated with certainty because so few cases are known.
Monkeys showed signs of botulism in 12-80 hours, and the 3 known human cases had an onset of symptoms at
approximately 72 hours.
§ Incubation period is dose-dependent
Differential Diagnosis
Botulism is frequently misdiagnosed, most often as a polyradiculoneuropathy (Guillain-Barré or Miller-Fisher
syndrome), myasthenia gravis, or disease of the central nervous system. Botulism differs from other flaccid
paralyses in its prominent cranial nerve palsies disproportionate to milder weakness and hypotonia below the
neck, in its symmetry, and in its absence of sensory nerve damage.
Note: A careful travel, activity, and dietary history should be taken in any suspected botulism outbreak. Patients
should also be asked if they know others with similar symptoms.
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[Insert Health Department Name]
REPORTING
Immediately report all cases of botulism (including suspect cases) to your facility’s infection control practitioner
AND to [Insert Unit/Department Name]: [Insert Phone Number]. The health department can authorize and
facilitate testing, and will initiate the public health response as needed. Please either ask family members and
close contacts of patients for their telephone contact information, or ask these individuals to stay at the hospital
for public health interview and potential intervention.
INFECTION CONTROL
Infection Control for Caregivers
Person-to-person transmission does not occur in botulism. Standard Precautions are adequate for the care of
patients with botulism. Patients do not require isolation.
See http://www.sfcdcp.org/document.html?id=317 for key features of standard infection control
precautions.
Decontamination
Botulism toxin is easily destroyed. Heating to an internal temperature of 85ºC for at least 5 minutes will detoxify
any contaminated food or drink. All suspected food or drink should be promptly removed from potential
consumers and submitted to public health authorities for testing. It is estimated that in the case of aerosolized
botulism, substantial inactivation of the toxin occurs by 2 days after aerosolization (although this is dependent
upon specific atmospheric conditions and particle size of the aerosol). Clothing and skin should be washed with
soap and water after exposure to botulism toxin. Contaminated objects or surfaces should be cleaned with a
0.1% hypochlorite bleach solution if they cannot be avoided for the hours or days required for natural
degradation. Spores are hardy, resistant to desiccation, heat, UV light, and alcohols, and can survive boiling up
to 4 hours. They are, however, readily killed by chlorine solutions.
LABORATORY & DIAGNOSTIC TESTING
Consider testing symptomatic persons. Asymptomatic persons need not be tested.
If you are testing or considering testing for botulism:
1. Immediately notify:
a. [Insert Unit/Department Name]: [Insert Phone Number]. The health department can authorize
and facilitate testing and will initiate the public health response as needed; AND
b. Your hospital laboratory and infection control practitioner that botulism is under suspicion;
AND
2. If testing is deemed necessary:
a. Use appropriate precautions when obtaining diagnostic specimens.
b. Specimens to be obtained should include:
i. Serum (Preferred specimen for food borne, wound botulism and intentional release):
Collect 30 cc whole blood as soon as possible after symptom onset and before antitoxin
administration). 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.
ii. Food: Generally, public health officials will obtain food specimens. Clinicians can
facilitate testing by asking patients not to throw away food from recent meals or to
empty garbage containing food items. Potentially contaminated food samples may be
collected (10-50 gm), sealed, and transported under refrigeration.
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[Insert Health Department Name]
iii. Stool: Stool specimens are rarely used and should only be collected if advised by your
health department.
c. Submit specimens to your hospital laboratory, and notify them to test for botulism. If needed,
your lab will submit specimens to the public health laboratory for testing.
i. Transport specimens at 4ºC immediately to the laboratory.
*Note: Diagnosis and appropriate treatment primarily depends on the basis of clinical presentation.
Laboratory confirmation often requires 1-4 days to complete and is performed only at reference laboratories.
Test results may be negative if the samples were collected late or the quantity of toxin is small; thus lack of
detection of botulinum toxin does not necessarily rule out the diagnosis of botulism.
TREATMENT AND PROPHYLAXIS
Supportive care is the mainstay of care for botulism, including:




Timely administration of botulinum antitoxin
Mechanical ventilation
Parenteral nutrition
Ventilatory support may be required for several weeks or more
Note: Aminoglycosides and clindamycin are contraindicated for treatment of secondary infections since they
may exacerbate the neuromuscular blockade.
Botulism Antitoxin Treatment
Botulinum toxin binds to cholergenic neurons and blocks acetylcholine release, which causes the affiliated
muscle to become paralyzed. Normal functioning resumes slowly, either through production of new
synapses or turnover of proteins, which can take up to a few months. Botulism antitoxin only binds to
toxin circulating in the blood, and does not affect toxin that has already bound to the neuron or
reverse existing paralysis.
 To obtain antitoxin, phone [Insert Health Department/Unit Name]: [Insert 24 hour phone number].
If the clinical picture is compatible with botulism, antitoxin may be released emergently (within 12
hours).
 Antitoxin is most effective when given within 24 hours after symptom onset.
 Antitoxin cannot reverse any existing paralysis, but can slow progression of further disease and potentially
decrease the duration of ventilatory support and increase the likelihood of survival.
 The supply of antitoxin is very limited. Decisions to release antitoxin will be made in consultation with
local and state public health authorities.
Antitoxin Type and Dose: The currently available formulation is botulinum antitoxin bivalent for types A and B
(licensed by FDA). Botulinum antitoxin type E is investigational. A trivalent preparation (types A, B, E) has
been discontinued. The military is testing a heptavalent antitoxin (type A through G). One 10-ml vial of each
preparation of antitoxin is sufficient to neutralize circulating toxin from most naturally occurring intoxications.
A repeat dose is not usually necessary.
Antitoxin Hypersensitivity: Since antitoxin is of equine origin, hypersensitivity reactions, including anaphylaxis,
serum sickness, and febrile reactions have occurred in up to 9% of patients receiving antitoxin. Skin testing for
hypersensitivity should be performed in all patients before administering antitoxin. If skin testing 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.
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[Insert Health Department Name]
No Prophylaxis of Exposed, Asymptomatic Persons
There is currently no available post exposure prophylaxis for asymptomatic exposed persons. Such
persons should be:
1. Educated regarding the signs and symptoms of clinical botulism
2. Instructed to seek medical care immediately if symptoms occur
Exposed persons and their families may experience anxiety and/or somatic symptoms that may include
neurologic symptoms. These patients should be carefully assessed. Antitoxin supplies are limited, and therapy
will be reserved for patients with compatible neurological findings. Pre-exposure immunization with botulinum
toxoid is restricted to certain laboratory and military personnel. Supplies are extremely limited and would not be
available for the public.
ADDITIONAL RESOURCES
 [Add your health department name and link.]
 CDC Emergency Preparedness & Response Bioterrorism Site: www.bt.cdc.gov/bioterrorism
 Working Group on Civilian Biodefense: http://jama.ama-assn.org/cgi/content/abstract/285/8/1059
 Health Protection Agency Deliberate Release:
www.hpa.org.uk/infections/topics_az/deliberate_release/menu.htm
REFERENCES
Arnon SS et al, for the Working Group on Civilian Biodefense. Botulinum toxin as a biological
weapon: medical and public health management. JAMA 2001;285(8):1059-81.
CIDRAP. Botulism: Current, comprehensive information on pathogenesis, microbiology, epidemiology,
diagnosis, treatment, and prophylaxis. June 16, 2005.(www.cidrap.umn.edu/cidrap/content/bt).
CDC. Case definitions for infectious conditions under public health surveillance. MMWR 1997;46(RR10):1-55
http://www.cdc.gov/mmwr/preview/mmwrhtml/00047449.htm.
CDC. Biosafety in microbiological and biomedical laboratories (BMBL). Ed 4, Apr 1999. Section VIIA:
Bacterial agents: Clostridium botulinum.
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