Purpose
To
recommend procedures for handling potential biological threats of Botulism
exposure. This policy and procedure will address foodborne and possible
terrorist threat.
1. Botulism
is an infection caused by the bacteria, Clostridium
botulinum, a gram positive rod, commonly found in the soil. The bacteria
forms spores which allows them to survive in a dormant state until exposed to
conditions that can support their growth. There are seven types of botulism
toxins designated by the letters A through G. Only types A, B, E and F are
capable of causing illness in humans.
2. Botulism
is a muscle paralyzing disease, described as three types:
a) Foodborne
botulism: Occurring when a person ingests preformed toxin that leads to
illness within a few hours to days. Foodborne botulism is a public health
emergency since the contaminated source may be available for other persons
besides the patient.
b) Infant
botulism: Occurring in a small number of susceptible infants each who
harbor the organism in the intestinal tract
c) Wound
Botulism: Occurring when wounds are infected with the organism that
secretes the toxin.
3. Possible
terrorist threat:
a) Inhalation
b)
Waterborne
No instances of waterborne botulism have ever been
reported. It is unlikely for at least 2 reasons. First, botulinum toxin is
rapidly inactivated by standard potable water treatments (e.g., chlorination,
aeration). Second, because of the slow turnover time of large-capacity
reservoirs, a comparably large (and technically difficult to produce and
deliver) inoculum of botulinum toxin would be needed. In contrast with treated
water, botulinum toxin may be stable for several days in untreated water or
beverages. Hence, such items should be investigated in a botulism outbreak if
no other vehicle for toxin can be identified.
Transmission
1. Inhalation
2. Ingestion
of contaminated food or water
Incubation
1. Foodborne -
Neurologic symptoms of foodborne botulism
begin 12—36 hours after ingestion
2. Inhalation -
Neurologic symptoms of inhalational botulism begin 24—72
hours after aerosol exposure
Signs and Symptoms
1. Double
vision
2. Blurred
vision
3. Drooping
eyelids
4. Slurred
speech
5. Difficulty
swallowing
6. Dry
mouth
7. Muscle
weakness that always descends through the body: first shoulders are affected,
then upper arms, lower arms, thighs, calves, etc. Paralysis of breathing
muscles can cause the person to stop breathing and die unless mechanical
ventilation is provided.
Diagnosis
Physicians
may consider the diagnosis of botulism if the patient’s history and physical
examination are consistent with the disease. However, these clues are generally
not enough to allow for the diagnosis since other conditions including
Guillain-Barre syndrome, stroke, and myasthenia gravis can have similar
symptoms. Testing should be done to exclude these conditions, including brain
scan, CSF examination, nerve conduction studies and a tensilon test to rule out
myasthenia gravis. Stool samples can be tested for botulinum toxin at some
state health departments or through the CDC. The local health department should
be contacted to coordinate this testing.
Treatment
If
diagnosed early, botulism can be treated with an antitoxin that blocks the
action of the toxins circulating in the blood. This can prevent the patient
from worsening, but recovery will still take several weeks. The CDC has a
supply of antitoxin. If antitoxin is needed, it can be delivered to a physician
anywhere in the country. Local health departments should be contacted regarding
this. Most patients generally recover after weeks to months of supportive care.
Ventilatory support may be necessary if respiratory paralysis occurs.
Supportive medical and nursing care are dependent on the individual symptoms.
Prophylaxis
There
is no prophylaxis for botulism. Preventative measures for foodborne
cases are widely published, however, the concern for a terrorist event deals
with protecting the water supply of a community for extrinsic contamination.
Standard
Precautions are sufficient for patient care since person-to-person transmission
has not been shown to occur. Patients with suspected botulism do not need to be
isolated, but those with flaccid paralysis from suspected meningitis require
droplet precautions. Routine decontamination of environmental surfaces is
appropriate.
Notification
Internal: At hospital
notify______________________________
External: All suspected cases of suspected botulism
exposure are Class Al Reportable and should be reported immediately to the
Local Health Department who will then contact the State Health Department
and/or CDC.
Lab
Due
to potential risks associated with handling infectious materials, laboratory
testing should be the minimum necessary for diagnostic evaluation and patient
care. Laboratory specimens should be placed in plastic bags that are sealed,
and then transported in clearly labeled, durable, leak-proof containers directly
to the specimen handling area of the laboratory. Care should be taken not to
contaminate the external surfaces of the container. Lab personnel should be
notified of what they are handling. Bio-Safety Level 2 should be used for
handling specimens.
SPECIMENS
|
BOTULISM (Clostridium
botulinum) |
Red-Top or Gold-Top tubes
(for serology) |
Stool (not in transport
medium) |
Gastric aspirate |
CSF (if meningeal signs
are present) |
ID Consult |
Note on requisition |
|
Possible C. botulinum exposure
in an asymptomatic patient |
No |
No |
No |
No |
No |
Not applicable |
|
Botulism – symptomatic |
Yes 3 tubes (10cc blood/tube) |
Yes >25 g stool |
Yes |
Not recommended. CSF will be normal; help R/O other causes |
Yes |
R/O Botulism |
References
Final
Bioterrorism Readiness Plan 4/13/99
2001
American Medical Association. All rights reserved.
(Reprinted)
JAMA, February 28, 2001-Vol 285, No. 8
CDC
Website
http://www.cdc.gov/ncidod/diseases/submenus/sub_botulism.htm
Note: These are guidelines that have been developed with data
available as of 3/13/02.
Initially Prepared by
The Akron Regional Hospital
Association
Emergency Preparedness
Subcommittee
August 20, 2002