Global & Disaster Medicine

Archive for the ‘Botulism’ Category

14 people, including four children, were hospitalized after a mass botulism food poisoning outbreak in southern Kyrgyzstan.


  •  3 are in a serious condition.
  • All patients have received the anti-botulinum serum.

Jars of canned vegetables

Researchers analyzing cow feces samples collected at a South Carolina farm discovered a strain of Enterococcus carrying a newtoxin similar to the one that causes botulism.


“……“BoNT-like gene clusters have not previously been identified in any bacterial species outside of Clostridium and no toxins of E. faecium have been reported before now,” the authors said. “It is disconcerting to find a member of potent neurotoxins in this widely distributed gut microbe, which is a leading cause of hospital-acquired infections.”…..”



CDC recommendations to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas during the period of September 2017 – March 2018.


Advice for Providers Treating Patients in or Recently Returned from Hurricane-Affected Areas, Including Puerto Rico and US Virgin Islands

Distributed via the CDC Health Alert Network
October 24, 2017, 1330 ET (1:30 PM ET)

The Centers for Disease Control and Prevention (CDC) is working with federal, state, territorial, and local agencies and global health partners in response to recent hurricanes. CDC is aware of media reports and anecdotal accounts of various infectious diseases in hurricane-affected areas, including Puerto Rico and the US Virgin Islands (USVI). Because of compromised drinking water and decreased access to safe water, food, and shelter, the conditions for outbreaks of infectious diseases exist.

The purpose of this HAN advisory is to remind clinicians assessing patients currently in or recently returned from hurricane-affected areas to be vigilant in looking for certain infectious diseases, including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. Additionally, this Advisory provides guidance to state and territorial health departments on enhanced disease reporting.


Hurricanes Irma and Maria made landfall in Puerto Rico and USVI in September 2017, causing widespread flooding and devastation. Natural hazards associated with the storms continue to affect many areas. Infectious disease outbreaks of diarrheal and respiratory illnesses can occur when access to safe water and sewage systems are disrupted and personal hygiene is difficult to maintain. Additionally, vector borne diseases can occur due to increased mosquito breeding in standing water; both Puerto Rico and USVI are at risk for outbreaks of dengue, Zika, and chikungunya.

Health care providers and public health practitioners should be aware that post-hurricane environmental conditions may pose an increased risk for the spread of infectious diseases among patients in or recently returned from hurricane-affected areas; including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. The period of heightened risk may last through March 2018, based on current predictions of full restoration of power and safe water systems in Puerto Rico and USVI.

In addition, providers in health care facilities that have experienced water damage or contaminated water systems should be aware of the potential for increased risk of infections in those facilities due to invasive fungi, nontuberculous Mycobacterium species, Legionella species, and other Gram-negative bacteria associated with water (e.g., Pseudomonas), especially among critically ill or immunocompromised patients.

Cholera has not occurred in Puerto Rico or USVI in many decades and is not expected to occur post-hurricane.



These recommendations apply to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas (e.g., within the past 4 weeks), during the period of September 2017 – March 2018.

  • Health care providers and public health practitioners in hurricane-affected areas should look for community and healthcare-associated infectious diseases.
  • Health care providers in the continental US are encouraged to ask patients about recent travel (e.g., within the past 4 weeks) to hurricane-affected areas.
  • All healthcare providers should consider less common infectious disease etiologies in patients presenting with evidence of acute respiratory illness, gastroenteritis, renal or hepatic failure, wound infection, or other febrile illness. Some particularly important infectious diseases to consider include leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza.
  • In the context of limited laboratory resources in hurricane-affected areas, health care providers should contact their territorial or state health department if they need assistance with ordering specific diagnostic tests.
  • For certain conditions, such as leptospirosis, empiric therapy should be considered pending results of diagnostic tests— treatment for leptospirosis is most effective when initiated early in the disease process. Providers can contact their territorial or state health department or CDC for consultation.
  • Local health care providers are strongly encouraged to report patients for whom there is a high level of suspicion for leptospirosis, dengue, hepatitis A, typhoid, and vibriosis to their local health authorities, while awaiting laboratory confirmation.
  • Confirmed cases of leptospirosis, dengue, hepatitis A, typhoid fever, and vibriosis should be immediately reported to the territorial or state health department to facilitate public health investigation and, as appropriate, mitigate the risk of local transmission. While some of these conditions are not listed as reportable conditions in all states, they are conditions of public health importance and should be reported.


For More Information

California: An outbreak of botulism linked to the consumption of ready-to-eat nacho cheese


California Department of Public Health

MEMORANDUM DATE: September 6, 2017
TO: Directors of Environmental Health
FROM: California Department of Public Health (CDPH), Food and Drug Branch (FDB)
SUBJECT: Nacho cheese warming units at retail locations


The CDPH Food and Drug Branch (FDB) and Sacramento County Environmental Management Department (SCEMD) recently investigated an outbreak of botulism linked to the consumption of ready to eat nacho cheese purchased at Valley Oak Food and Fuel in Walnut Grove, California. The nacho cheese was applied to chips by customers from a counter-top, self-service warming and dispensing unit supplied by the cheese manufacturer. These types of warming and dispensing units are typically designed to maintain the cheese at approximately 140 deg. F.

As of May 31, 2017, a total of 10 case-patients were laboratory-confirmed with C. botulinum toxin type A. All patients were hospitalized; nine were in an intensive care unit, seven required ventilator support, and one died. Leftover nacho cheese sauce collected from the gas station yielded C. botulinum toxin type A bacteria and toxin. Due to the extensive distribution of the same lot code of nacho cheese throughout the United States without additional botulism cases, internal testing conducted by the Wisconsin manufacturer of the nacho cheese, and only a single bag of cheese linked to human illness, FDB and SCEMD suspect the nacho cheese was likely contaminated at the retail location. A few items in particular were noted during the investigation that was concerning:

 The 5 pound bag of nacho cheese collected at the retail location on May 5, 2017 was being used past the “Best By” date.

 Records were not being maintained by the gas station employees indicating when the bag of nacho cheese was originally added to the warming unit.

 The plastic tool designed to open the bags of cheese (provided with the nacho cheese warming and dispensing unit) was not being used by employees.

FDB is aware that these types of nacho cheese warming and dispensing units are in use at many retail locations throughout California. These units generally provide safe, ready-to-eat foods without significant input from employees at each location. FDB would like to provide the following guidance regarding the use of nacho cheese warming and dispensing units in retail locations.

1. Management and employees should follow the instructions for each type of machine and product they use. Instructions for use may be included on the packaging of the


bagged nacho cheese or included on the interior panels of the warming and dispensing unit. These directions may include pre-heating and the length of time a product can remain at elevated holding temperatures. In some cases the product may only be held above 135 deg. F. for 4-6 days.

2. Management should ensure that records are maintained indicating when bagged cheese was last changed. This may be accomplished by writing the date the product was added to the warmer on the bag itself.

3. Management should ensure that the warming and dispensing units are not turned off at night or plugged into a timer. These types of machines need to remain “on” at all times. This will ensure that appropriate temperatures are maintained in this ready-to-eat food.

4. Management and employees should ensure that any supplied tools for opening the bags of cheese are used per the product directions. These devices need to be washed, rinsed, and sanitized between uses. In some cases these opening tools are only supplied with warming and dispensing unit.

5. Management and employees should verify on a regular basis that the internal temperature of the hot held cheese product is being held at the proper temperature. The internal temperature can be measured by placing the cheese product in a cup with a thermometer to verify the product is maintaining the minimum hot holding temperature of 135 deg. F as required under the California Retail Food Code Section113996 or hot holding temperature as recommended by the manufacturer.

CDPH hopes this information can be shared widely to ensure retail food facilities have current information and are taking appropriate measures to keep our food supply safe. Thank you for your consideration and ongoing collaboration with our Department


Botulism in Italy, 1986 to 2015


Eurosurveillance, Volume 22, Issue 24, 15 June 2017

Surveillance and outbreak report                                                                                                                                                                               Anniballi, Auricchio, Fiore, Lonati, Locatelli, Lista, Fillo, Mandarino, and De Medici:                                                                                 Botulism in Italy, 1986 to 2015

“…..From 1986 to 2015, 466 confirmed cases of botulism were recorded in Italy (of 1,257 suspected cases). Of these, 421 were food-borne (the most frequently seen form of botulism due to the consumption of improperly home-canned foods), 36 were infant botulism, which accounts for ca 50% of all these types of cases registered in Europe, six were wound-related and three were due to adult intestinal colonisation. ……”
Clinical signs and symptoms reported by patients with food-borne botulism, Italy, 1986–2015 (n=421)
Clinical sign/symptom Number of cases % of cases
Headache 28 6.6
Double vision 298 70.6
Drooping upper eyelid 43 10.2
Dilation of the pupil 88 20.9
Difficulty in swallowing 304 72.0
Dry mouth 278 65.9
Facial palsy 28 6.6
Respiratory failure 75 17.8
Constipation 209 49.5
Nausea 145 34.4
Vomiting 157 37.2
Abdominal pain 6 1.4
Diarrhoea 40 9.5
Urinary retention 20 4.7
Coma 9 2.1
Death 17 4.0
* Usually, patients presented mild symptomatology, with a clinical picture including diplopia (double vision), dysphagia (difficulty in swallowing), and dry mouth in ca 50% of the cases.
* Respiratory failure was reported in 17.8% (75/421) of patients.
* 16 deaths were recorded, giving a case-fatality rate of 3.8% (16/421), with four of the deaths occurring in elderly patients aged over 80 years who lived alone.

CDC: Summary of Botulism Cases Reported in 2015


Summary of Botulism Cases Reported in 2015

A total of 199 confirmed and 14 probable cases of botulism were reported to CDC in 2015.

Among confirmed cases, infant botulism accounted for 141 (71%) cases, foodborne botulism for 39 (20%) cases, wound botulism for 15 (8%) cases, and botulism of unknown or other transmission category for 4 (2%) cases (Table 1).

Among probable cases, foodborne botulism accounted for 6 (43%) cases and wound botulism for 8 (57%) cases.

The 141 cases of infant botulism were reported from 33 states and the District of Columbia. The median age of patients was 2.7 months with a range of 0 – 10 months; 70 (50%) were girls. Toxin type A accounted for 60 (43%), toxin type B accounted for 79 (56%), and toxin type Bf accounted for 2 (1%). No deaths were reported.

The 39 cases of confirmed foodborne botulism were reported from 7 states (Figure 1). The median age of patients was 59 years with a range of 9 – 92 years; 25 (64%) were women.

There were 5 outbreaks (events with two or more cases) accounting for 37 confirmed cases. One outbreak was associated with home-canned potatoes in a potato salad served at a church potluck (27 cases),† one was associated with fermented seal flipper (4 cases), and one was associated with beets roasted in aluminum foil and kept at room temperature for several days then made into a soup (2 cases). In addition, there were two outbreaks of two cases each living in the same household or facility in which the foodborne source was unknown (Table 2a).

Toxin type A accounted for 34 (87%), and toxin type E accounted for 5 (13%). One death was reported. The 6 cases of probable foodborne botulism (clinically compatible illness, not laboratory-confirmed, with an epidemiologic link to a suspect food) were reported from 3 states. The median age of patients was 53 years with a range of 23 – 73 years; 3 (50%) were women. No deaths were reported. Seal oil was the suspected food source for 2 of the 6 probable cases (Table 2b). There were 15 cases of confirmed wound botulism reported from 5 states. The median age of patients was 49 years with a range of 12 – 61 years; 2 (13%) were women. Toxin type A accounted for 14 (93%), and toxin type B accounted for 1 (7%). Fourteen (93%) were people who inject drugs (PWID). One death was reported.

The 8 cases of probable wound botulism (clinically compatible case who has no suspected exposure to contaminated food and who has a history in the 2 weeks before illness began of either a fresh wound or injection drug use) were reported from 3 states. The median age of patients was 59 years with a range of 28 – 78 years; 1 (12%) was a woman. All 8 were PWID. No deaths were reported. The 4 confirmed botulism cases of unknown etiology were reported from 3 states. The median age of patients was 47 years with a range of 27 – 71 years; 1 (25%) was a woman. Toxin type A accounted for all 4. No definitive route of transmission was identified for these cases.

Two cases were suspected to be adult intestinal colonization, a rare form of botulism thought to have a similar mechanism as infant botulism. The other two cases did not consume a suspect food, have any wounds, or have any known risk factors for adult intestinal colonization. How these persons were exposed to botulinum toxin is unknown. One patient developed botulism in 2015 and died in 2016 during a prolonged hospitalization.

The Ukraine’s Ministry of Health has said “as of July 18, 2017, 81 cases of botulism were reported in Ukraine, 90 people fell ill, nine of them fatally”.

Daily Express

“…..It is so far unclear how the Ukrainians contracted botulism ….”


Ukrainians receive first antitoxin against botulism since 2014


“….Over the last months, Ukraine faced an outbreak of botulism – 76 cases recorded since the beginning of the year, 8 of them fatal. Ministry of Health of Ukraine faced a serious challenge fighting the current outbreak, as there are no botulism antitoxins registered in Ukraine since 2014. Moreover, there was no budget funding allocated for procurement of this kind.

International organizations were asked to help resolve the issue. United Nations Development Program reacted and expressed readiness to provide humanitarian response.

The antitoxin, which is produced only by a few manufacturers around the world, was sourced by UNDP within the shortest possible period. High-quality medicine manufactured in Canada arrived to airport in Kyiv today, from where it is being transferred to the specialized warehouse of the Ministry of Health.

Current shipment will allow to form the essential stock, which will be used to immediately cover new cases that might occur. Serums will be urgently provided in case of need…..”

In 2014, 123 cases of botulism were reported by 16 EU/EEA countries, including 91 cases reported as confirmed.


Botulism -Europe_ Annual epidemiological report-2016:  Document

Key facts

  • In 2014, 123 cases of botulism were reported by 16 EU/EEA countries, including 91 cases reported as confirmed. Thirteen countries notified zero cases.
  • The notification rate was 0.02 cases per 100 000 population.
  • Romania notified the highest number of cases (N=31) and presented the highest rate (0.15 cases per 100 000 population
  • Methods

Click here for a detailed description of the methods used to produce this annual report

  • In 2014, 29 countries reported data, including 13 countries that reported zero cases.
  • Nine countries reported in accordance with the 2012 EU case definition, 13 countries used the 2008 EU case definition, and the remaining seven countries used other case definitions.
  • Botulism is a mandatorily notifiable disease in all reporting countries.


In 2014, 123 cases were reported, including 91 confirmed cases, by a total of 16 EU/EEA countries. Thirteen countries had no cases. Italy and Liechtenstein had not reported data for 2014 at the time of the data extraction. The EU/EEA notification rate was 0.02 cases per 100 000 population (Table 1).

Romania (31 confirmed cases), Poland (17) and Hungary (12) were the countries accounting for most of the confirmed cases. Twelve countries reported between one and six confirmed cases each.

Romania (0.15 cases per 100 000), Hungary (0.12 cases per 100 000) and Lithuania (0.10 cases per 100 000) reported the highest rates in 2014 (Table 1).

Threats description for 2014

An outbreak of botulism among injecting drug users in Norway and Scotland started in December 2014. By February 2015, 23 cases of botulism had been reported [1]. The source of the infection was assumed to be contaminated heroin.


Figure 3 shows an ascending trend in the rate of botulism notifications in the EU/EEA after July 2012. This observation is based on a small number of cases and does not necessarily represent a real increase in incidence.

The randomly occurring peaks may be explained by small-scale outbreaks due to locally produced food. Botulism cases are often detected as sporadic cases which may belong to household clusters. Case reports and retrospective analyses of cases are useful and complement the mandatory surveillance systems [2,3].

Public health conclusions

While the case definition for surveillance at the EU level focuses on C. botulinum as the etiological agent, sporadic clusters and cases due to type F toxin produced by C. baratii have been reported in recent years [4,5]. These botulism cases due to F toxin type are a cause of concern because the antitoxin is not readily available in Europe, and the commonly used antitoxins may not effectively neutralise toxin F. Preparedness plans may need to consider the timely access to antitoxins in order to cover a broad range of different toxin types, including toxin F [4,5]. In addition, subtyping of botulism neurotoxins is important to monitor the evolution of strains and its implications for public health as exemplified by the recent characterisation of a novel botulism neurotoxin subtype (BoNT/A8) in Germany [6].


  1. European Centre for Disease Prevention and Control. Wound botulism in people who inject heroin, Norway and the United Kingdom – 14 February 2015. Stockholm: ECDC; 2015. Available from: .
  2. Ambrožová H, Džupová O, Smíšková D, Roháčová H. Familial occurrence of botulism – A case report. Klinicka Mikrobiologie a Infekcni Lekarstvi. 2014;20(2):40-2.
  3. Lonati D, Flore L, Vecchio S, Giampreti A, Petrolini VM, Anniballi F, et al. Clinical management of foodborne botulism poisoning in emergency setting: An Italian case series. Clinical Toxicology. 2015;53(4):338.
  4. Castor C, Mazuet C, Saint-Leger M, Vygen S, Coutureau J, Durand M, et al. Cluster of two cases of botulism due to Clostridium baratii type F in France, November 2014. Euro Surveill. 2015;20(6):pii=21031.
  5. European Centre for Disease Prevention and Control. Scientific advice on type F botulism. Stockholm: ECDC; 2015. Available from:
  6. Kull S, Schulz KM, Weisemann J, Kirchner S, Schreiber T, Bollenbach A, et al. Isolation and functional characterization of the novel Clostridium botulinum neurotoxin A8 subtype. PLoS One. 2015;10(2):e0116381.


The number of botulism cases reported in Ukraine during the past three months has risen to 62

Outbreak News

  • 9 have died.
  • Dried fish, both home prepared and commercially prepared has been linked to most of the botulism cases
  • Officials say some cases have been linked to home prepared stew.
  • There is a lack of  anti-botulinum serum in Ukraine



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