Botulism

Emergency Response

  • Approach from Upwind, Uphill, or Upstream
  • Isolate Immediate Area in all directions distance of at least 300 feet
  • Keep Unauthorized Persons Away
  • Stay Upwind
  • Make Notifications
  • Decon with 5% bleach solution (for surface contamination if present) or soap and water (for personal contamination)
  • Obtain immediate medical treatment

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).

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