Outbreak of type A botulism and development of a botulism surveillance and antitoxin release system in Argentina

Toxemia in Human Naturally Acquired Botulism

Human botulism is a severe disease characterized by flaccid paralysis and inhibition of certain gland secretions, notably salivary secretions, caused by inhibition of neurotransmitter release. Naturally acquired botulism occurs in three main forms: food-borne botulism by ingestion of preformed botulinum neurotoxin (BoNT) in food, botulism by intestinal colonization (infant botulism and intestinal toxemia botulism in infants above one year and adults), and wound botulism. A rapid laboratory confirmation of botulism is required for the appropriate management of patients. Detection of BoNT in the patient's sera is the most direct way to address the diagnosis of botulism. Based on previous published reports, botulinum toxemia was identified in about 70% of food-borne and wound botulism cases, and only in about 28% of infant botulism cases, in which the diagnosis is mainly confirmed from stool sample investigation. The presence of BoNT in serum depends on the BoNT amount ingested with contaminated food or produced locally in the intestine or wound, and the timeframe between serum sampling and disease onset. BoNT levels in patient's sera are most frequently low, requiring a highly sensitive method of detection. Mouse bioassay is still the most used method of botulism identification from serum samples. However, in vitro methods based on BoNT endopeptidase activity with detection by mass spectrometry or immunoassay have been developed and depending on BoNT type, are more sensitive than the mouse bioassay. These new assays show high specificity for individual BoNT types and allow more accurate differentiation between positive toxin sera from botulism and autoimmune neuropathy patients.

Assessment of the risk of botulism from chilled, vacuum/modified atmosphere packed fresh beef, lamb and pork held at 3 °C-8 °C

The safety of current UK industry practice (including shelf-life) for chilled, vacuum/modified atmosphere-packed fresh red meat (beef, lamb and pork) held at 3°C-8°C has been evaluated with respect to non-proteolytic Clostridium botulinum. UK industry typically applies a retail pack shelf-life at 3°C-8°C to 13 days for fresh red meat, with a maximum of 23 days for beef, 27 days for lamb, and 18 days for pork. An exposure assessment established that current commercial practice for fresh red meat provided strong protection with more than 10¹⁰ person servings marketed in the UK without association with foodborne botulism. A challenge test demonstrated that spores of non-proteolytic C. botulinum inoculated on chilled vacuum-packed fresh red meat did not lead to detectable neurotoxin at day 50 for beef, day 35 for lamb, or day 25 for pork (i.e. <40 pg type B toxin and type E toxin g^-1 of meat). The products were visually spoiled many days before these end points. The exposure assessment and challenge test demonstrated the safety of current UK industry practices for the shelf-life of fresh, vacuum-packed beef, lamb and pork held at 3°C-8°C with respect to C. botulinum, and that botulinum neurotoxin was not detected within their organoleptic shelf-life.

Efficacy of Antitoxin Therapy in Treating Patients With Foodborne Botulism: A Systematic Review and Meta-analysis of Cases, 1923-2016

Background

Botulism is a rare, potentially severe illness, often fatal if not appropriately treated. Data on treatment are sparse. We systematically evaluated the literature on botulinum antitoxin and other treatments.

Methods

We conducted a systematic literature review of published articles in PubMed via Medline, Web of Science, Embase, Ovid, and Cumulative Index to Nursing and Allied Health Literature, and included all studies that reported on the clinical course and treatment for foodborne botulism. Articles were reviewed by 2 independent reviewers and independently abstracted for treatment type and toxin exposure. We conducted a meta-analysis on the effect of timing of antitoxin administration, antitoxin type, and toxin exposure type.

Results

We identified 235 articles that met the inclusion criteria, published between 1923 and 2016. Study quality was variable. Few (27%) case series reported sufficient data for inclusion in meta-analysis. Reduced mortality was associated with any antitoxin treatment (odds ratio [OR], 0.16; 95% confidence interval [CI], .09-.30) and antitoxin treatment within 48 hours of illness onset (OR, 0.12; 95% CI, .03-.41). Data did not allow assessment of critical care impact, including ventilator support, on survival. Therapeutic agents other than antitoxin offered no clear benefit. Patient characteristics did not predict poor outcomes. We did not identify an interval beyond which antitoxin was not beneficial.

Conclusions

Published studies on botulism treatment are relatively sparse and of low quality. Timely administration of antitoxin reduces mortality; despite appropriate treatment with antitoxin, some patients suffer respiratory failure. Prompt antitoxin administration and meticulous intensive care are essential for optimal outcome.

A botulism outbreak from roasted canned mushrooms

Food-borne botulism is a rare disease that results from ingestion of the toxins produced by Clostridium botulinum. The most common cause of the disease is the consumption of home-canned foods prepared under inappropriate conditions, especially in rural environments. In this report, a food-borne botulism outbreak potentially caused by roasted home-canned mushrooms is evaluated and the major reasons for delayed diagnosis are emphasized. The clinical features, symptoms and prognosis of the five botulism patients involved in this outbreak are presented. The clinical progressions, treatments, durations of mechanical ventilation, intensive care unit stays and hospital stays of the three patients admitted to Akdeniz University Hospital are reported.

Two-family outbreak of botulism associated with the consumption of smoked ribs in Sichuan Province, China

BACKGROUND

On September 22, 2013, two patients from Sichuan Province, China presented with symptoms of food-borne botulism, a rare but fatal illness caused by the consumption of foods containing Clostridium botulinum neurotoxins.

METHODS

Investigators reviewed the medical charts and food consumption histories, and interviewed patients and family members. Food samples and clinical specimens were tested for botulinum toxin and neurotoxin-producing Clostridium species by standard methods.

RESULTS

The first two index cases presented with cranial neuropathies and flaccid paralysis, and required mechanical ventilation. There were 12 confirmed outbreak-associated cases. Botulinum toxin type A was identified in the smoked ribs, and all of the patients had consumed the smoked ribs from the same local restaurant. The smoked ribs contained no added salt, sugar, or preservative. Botulinum toxin production likely resulted from the cold-smoking preparation method and inappropriate refrigeration.

CONCLUSIONS

Smoked ribs produced by a local restaurant, contaminated with type A botulism, was the contributor to this outbreak. The supervision of food safety should be strengthened to prevent future outbreaks in China.

National outbreak of type a foodborne botulism associated with a widely distributed commercially canned hot dog chili sauce

BACKGROUND

On 7 and 11 July 2007, health officials in Texas and Indiana, respectively, reported 4 possible cases of type A foodborne botulism to the US Centers for Disease Control and Prevention. Foodborne botulism is a rare and sometimes fatal illness caused by consuming foods containing botulinum neurotoxin.

METHODS

Investigators reviewed patients' medical charts and food histories. Clinical specimens and food samples were tested for botulinum toxin and neurotoxin-producing Clostridium species. Investigators conducted inspections of the cannery that produced the implicated product.

RESULTS

Eight confirmed outbreak associated cases were identified from Indiana (n = 2), Texas (n = 3), and Ohio (n = 3). Botulinum toxin type A was identified in leftover chili sauce consumed by the Indiana patients and 1 of the Ohio patients. Cannery inspectors found violations of federal canned-food regulations that could have led to survival of Clostridium botulinum spores during sterilization. The company recalled 39 million cans of chili. Following the outbreak, the US Food and Drug Administration inspected other canneries with similar canning systems and issued warnings to the industry about the danger of C. botulinum and the importance of compliance with canned food manufacturing regulations.

CONCLUSIONS

Commercially produced hot dog chili sauce caused these cases of type A botulism. This is the first US foodborne botulism outbreak involving a commercial cannery in >30 years. Sharing of epidemiologic and laboratory findings allowed for the rapid identification of implicated food items and swift removal of potentially deadly products from the market by US food regulatory authorities.

Overview of the impact of epidemic-assistance investigations of foodborne and other enteric disease outbreaks, 1946-2005

Epidemic-assistance investigations (Epi-Aids) in response to outbreaks of foodborne and other enteric pathogens have identified novel pathogens, clinical syndromes, and sequelae; described new reservoirs and vehicles of transmission; evaluated existing prevention strategies; and identified deficiencies in the food safety systems on local, national, and international levels. Since the first Epi-Aid was issued in 1946, approximately 23% (1,023 of 4,484 for which investigations were initiated) of all Epi-Aids have been related to foodborne or other enteric diseases. Epi-Aid results have yielded valuable insights into the epidemiology of these pathogens and have molded prevention strategies for detecting, responding to, and preventing future outbreaks. New challenges, brought about in part by centralization and globalization of the food supply, will continue to emerge. The need for Epi-Aids of such outbreaks undoubtedly will persist as an integral part of future public health response efforts, prevention strategies, and training programs.

Clostridium botulinum and the safety of minimally heated, chilled foods: an emerging issue?

Foodborne botulism is caused by consumption of preformed botulinum neurotoxin, with as little as 30 ng of neurotoxin being potentially lethal. Consumption of minute quantities of neurotoxin-containing food can result in botulism. In view of the severity of foodborne botulism, it is essential that new foods be developed safely without an increase in incidence of this disease. Minimally heated, chilled foods are a relatively new type of food, sales of which are currently increasing by about 10% per annum. These products meet consumer demand for high-quality foods that require little preparation time. Their safety and quality depends on mild heat treatment, chilled storage, restricted shelf life and sometimes on intrinsic properties of the foods. The principal microbiological hazard is nonproteolytic Clostridium botulinum, and there is a concern that this may become an emerging issue. A considerable amount of research and development over the last 15 years has underpinned the safe production of commercial, minimally heated, chilled foods with respect to foodborne botulism, and it is essential that safe food continues to be developed. In particular, the desire to use lighter heat processes and a longer shelf life presents a challenge that will only be met by significant developments in quantitative microbiological food safety.

Management of botulism

OBJECTIVE

To provide a concise review of the presentation and treatment of botulism.

DATA SOURCES

Searches of MEDLINE (1966-November 2001), tertiary references, and public and government Internet sites were conducted.

STUDY SELECTION

All articles and additional references from those articles were thoroughly evaluated.

DATA SYNTHESIS

Clostridium botulinum toxin blocks acetylcholine release in a dose-dependent fashion, resulting in acute symmetric diplopia, dysarthria, dysphonia, dysphagia, and possible neurologic sequelae despite the route of exposure (i.e., food-borne, wound, intestinal, inhalation). Disease secondary to genetically engineered C. botulinum may differ from that of inadvertent exposure. Present treatment is primarily supportive care, respiratory support, rapid decontamination, and antitoxin administration (i.e., trivalent, pentavalent, heptavalent antitoxin). Early initiation of antitoxin limits the extent of paralysis, but does not reverse it.

CONCLUSIONS

Supportive care and the use of antitoxin have been effective in the treatment of botulism from food-borne, intestinal, and wound exposure. However, the effectiveness of antitoxin in the treatment of inhaled C. botulinum has not been proven.

Clostridium botulinum and the ophthalmologist: a review of botulism, including biological warfare ramifications of botulinum toxin

The anaerobic bacterium Clostridium botulinum causes disease by elaborating an extremely potent neurotoxin that inhibits release of acetylcholine at presynaptic nerve endings, thereby resulting in a descending flaccid paralysis and autonomic nervous system dysfunction. Possible ophthalmological effects of this neurotoxin are many and typically constitute the earliest manifestations of botulism. This review summarizes the medical literature on botulism with regard to historical perspective, epidemiology, clinical manifestations, and treatment. Ophthalmological findings of botulism are tabulated and their frequencies are provided. Finally, the bioterrorism/biologic warfare ramifications of botulinum toxin are briefly discussed.

Revival of the use of botulinum toxin: application in dermatology

Botulinum toxins (BTXs) comprise a family of neurotoxins designated as types A-G, which are produced by the anerobic bacterium Clostridium botulinum. BTX-A blocks the cholinergic transmission resulting in flaccid paralysis and autonomous nerve dysfunction. It has become a powerful therapeutic tool in a variety of conditions over the last decades. Primarily used in the treatment of strabismus, blepharospasm and hemifacial spasms, BTX has only recently been recognized in dermatology. The use of BTX in dermatology includes the treatment of focal hyperhidrosis, hyperfunctional facial lines as well as paralysis of the anal sphincter in the therapy of anal fissures. The mechanism of action is described and the current literature is reviewed.