1. North Central District Health Department
Botulism
A Bioterrorism Agent
Presented by:
Donna Anderson, RN
Staff Epidemiologist
North Central District Health Department
April 6, 2006
Botulinum toxin poses a major bioweapon threat because of its extreme potency and lethality; its ease of production, transport, and misuse; and the need for prolonged intensive care among affected persons. An outbreak of botulism constitutes a medical emergency that requires prompt provision of botulinum antitoxin and, often, mechanical ventilation, and it constitutes a public health emergency that requires immediate intervention to prevent additional cases. Timely recognition of a botulism outbreak begins with an astute clinician who quickly notifies public health officials.

2. What is Botulism The Illness The Germ Clostridium botulinum
Therapeutic use of botulinum toxin
How common is botulism
Illness in US
Incidence<200 annual cases all forms
Disease: Botulinum toxin is a remarkably poisonous substance. While it has a variety of medical uses, it is also of interest and concern to physicians because of its involvement in food poisoning and its potential use as an agent of bioterrorism.
Agent: Botulinum toxin is an enzyme produced by Clostridium botulinum, a spore-forming bacillus. One gram of crystalline botulinum toxin is enough to kill 1 million people. The toxin blocks the neuromuscular junction which results in flaccid paralysis of muscles.
Source: Botulism is worldwide in distribution. The spores are ubiquitous; are found in soils, airborne dust, surfaces of raw fruits and vegetables and seafood throughout the world. Hardy and heat resistant.
Discovered bacterium in 1895 Belgium but the first complete description of the botulism was published in the mid 1800’s Germany, the toxin was linked to consumption of smoked sausage. It was named botulus, which means sausage in latin.
Therapeutic use of botulinum toxin: Botox frown lines. Packaged in dilute preparations so not feasible to weaponize 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
Cosmetic use
Sweating disorders
Sporadic cases, outbreaks in families, and general outbreaks occur when food products are not prepared or preserved using proper methods. An average of 9 or 10 outbreaks occur each year in the United States.
US Largest 20th Century outbreak of food-borne botulism. Michigan cases from home-preserved jalapeno peppers at a restaurant
Approx 9 annual outbreaks of food-borne with average of 24 cases
Mortality 25% prior to 1960
6% during the 90’s

3. Categories of Botulism
Foodborne botulism
Intestinal botulism (infant and child/adult)
Wound botulism
Inhalation botulism
Foodborne botulism
Caused by eating foods that contain botulism toxin
Intestinal botulism (infant and child/adult)
Caused by ingesting spores of the bacteria which germinate and produce toxin in the intestines
Wound botulism
C. botulinum spores germinate in the wound
Inhalation botulism
Aerosolized toxin is inhaled
Does not occur naturally and may be indicative of bioterrorism

4. Usually Seen Following….
Home-canned goods (foodborne)
Particularly low-acid foods such as asparagus, beets, and corn
Honey (ingestion)
Can contain C. botulinum spores
Not recommended for infants <12 month old
Crush injuries, injection drug use (wound)

5. Botulism Prevention Proper Canning Proper heating of home canned foods
No honey for < 1 year olds
Seek medical care for wounds
Avoid injectable street drugs
Botulism vaccine

6. Botulism: As a Weapon
Weaponized by several nations including the U.S., Japan, and Soviet Union, beginning in the 1930’s
Iraq (1980’s) produced 19,000 L of concentrated botulism toxin
Japan (1990’s) Aum Shinrikyo cult

7. What Makes Botulism Toxin a Good Weapon?
Extreme potency and lethality
Ease of production
Difficult to distinguish intentional exposures
Expensive, long-term care needed for recovery
Botulism toxin is the most poisonous substance known
High lethality: 1 aerosolized gram could potentially kill 1 million people
Isolated fairly easily from soil
Could be released as an aerosol or as a contaminant in the food supply
Ease of transport

8. What causes illness Incubation period varies with type of poisoning
Toxin enters bloodstream from mucosal surface or wound
Binds to peripheral nerve endings
Preventing muscles from contracting
Incubation period Depends on inoculated dose
Ingestion: unknown
Foodborne: 6 hours – 8 days
Wound: 4 – 14 days
Inhalation: (estimated) 24 – 36 hours
Toxin enters bloodstream from mucosal surface (gut or lungs) or wound (break in skin) Intact skin not penetrated
Binds to peripheral cholinergic nerve endings
Inhibits release of acetylcholine, preventing muscles from contracting
All forms of disease lead to same process

9. And then…….
Symmetrical, descending paralysis occurs beginning with cranial nerves and progressing downward
Can result from airway obstruction or paralysis of respiratory muscles
Secondary complications related to prolonged ventilatory support and intensive care
Symmetrical: Lose head control
Lose gag- require intubation
Lose diaphragm- require mechanical ventilation
Loss of deep tendon reflexes
Gastrointestinal/Urinary: N/V/D Abd pain, Intestinal ileus, urinary retention
Neurologic : Dry mouth, blurry vision, diplopia,dilated or unreactive pupils
dysphagia, decreased gag reflex
Muscular: Symmetrical skeletal muscle weakness, respiratory muscle paralysis, fatigue, dyspnea

10. Classic symptoms of botulism poisoning include:
Blurred/double vision
Muscle weakness
Drooping eyelids
Slurred speech
Difficulty swallowing
Patient is afebrile and alert
Infants with botulism will present with:
Weak cry
Poor feeding
Constipation
Poor muscle tone, “floppy” baby syndrome

11. How is it Diagnoses? Toxin neutralization mouse bioassay
Serum, stool, gastric aspirate, suspect foods
Isolation of C. botulinum or toxin
Feces, wound, tissue
Collect samples for diagnostic testing
Serum, vomit, gastric aspirate, suspect food , stool
Collect serum before antitoxin is given
If enema required, use sterile water
Refrigerate samples and suspect foods
Confirmation takes 1-4 days
Available at CEC and State Labs
Culture results in 7-10 days

12. Botulism Treatment Closely monitor known/suspected exposed
Treat with antitoxin at first sign of disease
Elimination
Induced vomiting
High enemas
Supportive care
Mechanical ventilation
Body positioning
Parenteral nutrition
Antitoxin adverse effects Serum sickness (2-9%),anaphylaxis (2 %)
Recovery takes weeks
Special groups-same treatment : children, pg. women, immunocompromised

13. Botulism Antitoxin Equine antitoxin
Effective in the treatment of foodborne, intestinal, and wound botulism
Effectiveness for inhalation botulism has not been proven
Does not reverse current paralysis, but may limit progression and prevent nerve damage if administered early
Trivalent and bivalent antitoxins available through the CDC
Licensed trivalent antitoxin neutralizes type A, B, and E botulism toxins

14. Call North Central District Health
What do I do now?
Immediately
Call North Central District Health
if during office hours
(208) or
State Communications Public Health Paging System (24/7) Public Health will be paged
What to do at first suspicion of a case
Immediately notify Public Health
Acquire therapeutic antitoxin
Get medication list to rule out anticholinsterases

15. Botulism Infection Control
Botulism cannot be transmitted person-to-person
Standard precautions should be taken when caring for botulism patients

16. Decontamination 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

17. Botulism Talk Takeaways
Disease caused by C. botulinum toxin
Most toxic substance ever identified
Known to be weaponized
Classic Signs and Symptoms
Symmetric, descending flaccid paralysis
No fever
Alert

18. Botulism Talk Takeaways
Clinical diagnosis
Report to State/Local Health Department ASAP
Start antitoxin ASAP
Supportive care
Recovery may take weeks