BIODEFENSE

Epidemiology of
Botulism
Shahid Beheshti University of
medical sciences, April 2005
By: Vahdani P. MD. MPH, Hatami H. MD. MPH
 Definition
Disease botulism
Agent botulinum toxin
Source of toxin - Clostridium
botulinum

((Botulinum
))Botulinum







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 History
Therapeutic use of botulinum toxin
FDA approved for neuromuscular disorders
Blepharospasm
Strabismus
Torticollis
Many other unapproved uses
Packaged in dilute preparations
Not feasible to use licensed toxin for weapon

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 Therapeutic Uses of Botulism Toxin
Focal dystonias - involuntary, sustained, or
spasmodic patterned muscle activity
Spasticity - velocity-dependent increase in muscle
tone
Nondystonic disorders of involuntary muscle activity
Strabismus (disorder of conjugate eye movement)
and nystagmus
Disorders of localized muscle spasms and pain
Smooth muscle hyperactive disorders
Cosmetic use
Sweating disorders
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 Bioweapon Potential
Known unsuccessful uses as weapon
1990 -1995 aerosol releases by Aum Shinrikyo
Downtown Tokyo, Japan
3 times at US Military bases in Japan
Weapons Programs
1930s Japanese fed C. botulinum to prisoners
U.S. produced botulinum toxin during WWII
Soviet Union spliced genome into other bacteria
1991 Iraq weaponized 19,000L during Persian
Gulf War

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 Bioweapon Potential
Botulinum toxin a major threat because:
Extreme potency and lethality
Ease of production
Ease of transport
Need for prolonged intensive care
Top 6 potential biological warfare agents
Listed as Category A agent: High priority

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Critical Biological Agents

Category A
Variola major
Bacillus anthracis
Yersinia pestis
Clostridium botulinum
Francisella tularensis
Ebola hemorrhagic fever
Marburg hemorrhagic fever
Lassa & Junin
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 Bioweapon Potential
Factors suggesting intentional release
Large # cases
Acute flaccid paralysis with bulbar palsies
Unusual botulinum toxin type
Type C, D, F, or G
Type E not acquired from aquatic food
Common geographic factor among cases
No common dietary exposure - Suggests aerosol
Multiple simultaneous outbreaks without common
source

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 Bioweapon Potential
Estimated Effect
Most toxic substance known
1 gram crystalline toxin can kill > 1
million people if dispersed and inhaled
evenly
Point source aerosol release
Incapacitate/kill 10% of people downwind
within 500 meters

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Bioweapon Potential
Naturally occurring botulism
1. Foodborne (preserved or non-preserved)
2. Wound
3. Intestinal
Bioterrorism routes of intoxication
Aerosol (inhaled into lungs)
Foodborne
Waterborne ???

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 Bioweapon Potential
Inhalational exposure
One documented accidental
outbreak
Germany 1962
3 laboratory workers
Exposed to re-aerosolized toxin type
A
Confirms that aerosol route is
effective means of intoxication
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Bioweapon Potential
Food-borne botulism
Foods that are higher pH
corn, pepper, carrots, beans,
Contaminated condiments
Commercial foods
Difficult to distinguish intentional

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Bioweapon Potential
Water-borne botulism
No instances of water-borne botulism
have ever been reported
Contamination of water supply is
possible
Toxin would be rapidly inactivated by
the chlorine used to purify drinking
water
Harrison 2005 pp. 1286 13
Bioweapon Potential
Municipal water plants unlikely source
Botulinum toxin inactivated by standard
potable water treatments (chlorination,
aeration)
Slow turnover time of large-capacity
reservoirs
However, in untreated water or beverages
the toxin may be stable for several days

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 Epidemiology
U.S. incidence
< 200 annual cases of all forms
Approx 9 annual outbreaks of food-borne
median of 24 cases
Recent trend toward restaurant rather than home-
preserved foods
All ages and genders equally susceptible
Mortality
25% prior to 1960
6% during 1990s

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 Epidemiology








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 Epidemiology
Incubation period
Depends on inoculated dose
Inhalational
12-18 hours in primate studies
72 hours in 3 known inhalational cases
True incubation period is unknown
Foodborne
6 hours to 8 days
Wound
7.5 days (range 4-18 days) after injury

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 Microbiology
C. Botulinum
Gram-positive obligate anaerobic bacillus
Spore-forming
Produces botulinum toxin
Heat sensitive as bacillus
Prefers low acid environment

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 Microbiology
C. Botulinum spores
Ubiquitous
Soil
Airborne dust
Surfaces of raw fruits and vegetables
Seafood
Heat resistant, hardy

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 Microbiology
Botulinum toxins
Consist of light and heavy chains
Light chain zinc endopeptidase
The bioactive component
Colorless, odorless
Environmental survival
Inactivated by heat >85C for 5 min
pH <4.5

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 Microbiology
Toxin Classification
All have same clinical effect
Types A-G, antigenically distinct
Type A- 54%, Type B- 15%, Type E- 27%
Type A- Western U.S., Type B- Eastern
Types C, D reported in animals only
Type G in soil samples only
Humans likely susceptible to all types

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 Pathogenesis
Possible routes of exposure
Inhalation of toxin (in a biological
attack)
Food or water toxin contamination
Wound infected with C. Botulinum
Ingestion of C. botulinum

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Botulism Toxin Mechanism

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 Pathogenesis
Estimated lethal human dose
Crystalline type A toxin
0.09-0.15 g given iv or im
0.70-0.90 g inhalationally
70 g given po

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 Pathogenesis
Toxin must enter body
Direct toxin absorption from mucosal surface
Gut foodborne
Lungs inhalational
Via toxin produced by infection with C.botulinum
Skin breaks wound botulism after trauma, IV drugs
Gut intestinal botulism
Would not be seen in BT event, as toxin would be used
Does not penetrate intact skin

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 Pathogenesis
All forms of disease lead to same process
Toxin absorbed into bloodstream
Irreversibly binds peripheral cholinergic synapses
Cleaves fusion proteins used by neuronal vesicles to
release acetylcholine into neuromuscular junction
Blocks Acetylcholine release permanently
Results in paralysis of that muscle
Reinnervation via regeneration of axon twigs
Takes weeks to months

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 Clinical Features
Symptoms
All forms same neuro symptoms
Diplopia / blurred vision
Ptosis
Slurred speech
Dysphagia / dry mouth
Muscle weakness

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 Infant Botulism
Most common form in U.S.
Spore ingestion
Germinate then toxin released and
colonize large intestine
Infants < 1 year old
94% < 6 months old
Spores from varied sources
Honey, food, dust, corn syrup

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 Infant Clinical Signs
Constipation
Lethargy
Poor feeding
Weak cry
Bulbar palsies
Failure to thrive

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 Clinical Features
Classic Triad
Symmetric, descending flaccid paralysis
with prominent bulbar palsies
Afebrile
Clear sensorium
Bulbar palsies summarized as "4 Ds"
Diplopia, dysarthria, dysphonia, dysphagia

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 Clinical Features

Patient at rest, bilateral mild Requested to perform max.

ptosis, disconjugate gaze, smile. Ptosis, disconjugate gaze,
symmetric facial muscles. mild asymmetric smile.

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 Clinical Features
Symptom progression
Descending paralysis
Lose head control
Lose gag require intubation
Lose diaphragm mechanical
ventilation
Loss of deep tendon reflexes

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 Clinical Features
Gastrointestinal/ Neurologic Muscular
Urinary
Nausea Dry Mouth Symmetrical skeletal
Muscle weakness
Vomiting Blurry vision Respiratory muscle
paralysis
Diarrhea Diplopia Fatigue
Abdominal Pain Dilated or Dyspnea
unreactive pupils
Intestinal ileus Dysphagia

Urinary retention Decreased gag

reflex
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 Clinical Features
4 clinical forms of botulism
1)Food-borne (first described in
1897)
2)Wound (1943)
3)Infant (1976)
4)Indeterminate (1977)

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 Clinical Features
Infant
Occurs in children < one year old
Ingests spores, grows in bowel &
release toxin
Intestinal colonization of organisms
Normal intestinal flora not
developed

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 Clinical Features
Indeterminate
No specific food or wound source
identified
Similar to infant but occurs only in
adults
Risk factor: surgical alterations of the
GI tract and/or antibiotic therapy
Leads to colonization

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 Diagnosis
Clinical diagnosis
Diagnostic tests help confirm
Toxin neutralization mouse bioassay
Serum, stool, or suspect foods
Infant botulism
C botulinum organism or toxin in feces

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 Diagnosis
What to do at first suspicion of a case
Immediately notify public health dept
Acquire therapeutic antitoxin
Send samples for diagnostic testing
Serum, vomit, gastric aspirate, suspect food, stool
Collect serum before antitoxin given
If enema required, use sterile water
Refrigerate samples and suspect foods
Get medication list to rule out anticholinesterases

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 Diagnosis
Confirmation
Takes 1-4 days
Available only at CDC and state public health labs
Mouse Bioassay
Type-specific antitoxin protects vs. toxin in sample
The assay can detect at minimal 0.03ng of toxin.
Culture
Fecal and gastric specimens cultured anaerobically
Results in 7 to 10 days

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 Diagnosis
Differential diagnosis
Guillain-Barre, myasthenia gravis
Unique features to help in diagnosis
Disproportionate cranial nerve palsies
More hypoxia in facial muscles than below neck
Lack of sensory changes

The diagnosis is suspected on clinical grounds

and confirmed by a mouse bioassay or toxin
immunoassay. HA 2005

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 Botulism Differential
Diagnoses
Guillain-Barr Psychiatric illness
syndrome Poliomyelitis
Myasthenia Diabetic
gravis Complications
Stroke Drug intoxication
Tick paralysis CNS infection
Lambert-Eaton Overexertion
syndrome 43
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 Treatment
Supportive care
Enteral tube feeding or parenteral
nutrition
Mechanical ventilation
Treatment of secondary infections
Avoid aminoglycosides and
clindamycin
Worsens neuromuscular blockade

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Do not give aminoglycosides and clindamycin

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 Treatment
Passive immunization - equine
antitoxin (5000-9000 IU)
Antibodies to Types A, B and E toxins
Binds and inactivates circulating toxin
Stops further damage but doesnt reverse
Administer ASAP for best outcome
Dose per package insert
Heptavalent antitoxin
Investigational
Effective against all toxins

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 Treatment
Antitoxin action
Food-borne botulism
Neutralizing antibody levels exceed toxin levels
Single dose adequate
Large exposure (e.g. biological weapon)
can confirm adequacy of neutralization
recheck toxin levels after treatment
Antitoxin adverse effects
Serum sickness (2-9%), anaphylaxis (2%)

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 Treatment
Recovery takes weeks
Until motor axon twigs regenerate
Special groups - same treatment
strategy
Children
Pregnant women
Immunocompromised

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 Levels of Prevention
Primary Prevention:
Prevention of disease in well
individuals
Secondary Prevention:
Identification and intervention in
early stages of disease
Tertiary Prevention:
Prevention of further deterioration,
reduction in complications
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 Post Exposure Prophylaxis
2 possibilities
Antitoxin
Prevents disease if start prior to
symptom onset
Specific human hyperimmune
globulin

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 Post Exposure Prophylaxis
Antitoxin not recommended for PEP
Limited supply
Substantial adverse effects
Exposures have variable clinical effects
Recommendation
Closely monitor known/suspected exposed
treat with antitoxin at first sign of disease

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 Prevention
Natural disease
Boil home-canned foods 10 minutes
Follow USDA instructions on home-
canning
Restrict honey from < 1 year old
Seek medical care for wounds
Avoid injectable street drugs

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 Prevention
Vaccine
Botulinum pentavalent toxoid
Not available to general public
Limited supply provided by CDC
In use for laboratory workers, military
Protects vs. types A-E
Long-lasting immunity
Prohibits future therapeutic use of toxin
Onset too slow to be effective PEP

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 Infection Control
Standard precautions only
No person-to-person transmission

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 Decontamination
Heat all food 85C x 5 min
Aerosolized toxin viability
Inactivate by 2 days in optimal conditions
Re-aerosolization a theoretical concern
Mask over the face may be protective
Exposed clothing and surfaces
Wash with 1:10 hypochlorite solution

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References:
1) Botulism, bioterrorism : Center for the study of
bioterrorism and emerging infections, Saint Louis
University School of Public Health.
2) Hatami H. : Clinical Epidemiology and Control of
Infectious Diseases related to Bioterrorism,
Second edition.(http://www.elib.hbi.ir/persian/library.htm)
3) Glenda Dvorak,Botulism, the center for food
security & public health, Iowa state university.
4) Vahdani P. Botulism & food borne disease, Shahid
Beheshti University of Medical Sciences,
5) Mandell 2000
6) Harrison 2005
7) CDC Internet site
8) WHO Internet site 58