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CLOSTRIDIUM BOTULINUM

PATHOGEN SAFETY DATA SHEET - INFECTIOUS SUBSTANCES

SECTION I - INFECTIOUS AGENT

NAME: Clostridium botulinum.

SYNONYM OR CROSS REFERENCE: BotulismFootnote 1-3, allantiasisFootnote 2, and botulinum toxinFootnote 4.

CHARACTERISTICS: A gram-positive (at least in early stage of growth), anaerobic, rod- shapedFootnote 3, spore-forming bacillusFootnote 1-3. Seven types of C. botulinum toxins exist (A-F)Footnote 1 Footnote 2 Footnote 5.Types A, B, E, and rarely F can cause human botulism. Strains consistent with type G were assigned to C. argentinense in 1993. Botulinum neurotoxin is produced when, under anaerobic conditions, C. botulinum spores germinateFootnote 3 Footnote 5 Footnote 6. In addition to C. botulinum, C. argentinense (formerly C. botulinum type G), C. butyricum, and C. baratii can also produce botulinum neurotoxin.

C. botulinum (botulinum toxin) is defined as a biothreat level A organism by the Centers for Disease Control and PreventionFootnote 7. Category A organisms are considered to pose the greatest threat to national security.

SECTION II - HAZARD IDENTIFICATION

PATHOGENICITY: Rare but serious paralytic diseaseFootnote 1 Footnote 6, caused by a neurotoxin formed during the growth of the spore-forming bacterium C. botulinum (or rarely, C. argentinense, C. butyricum, or C. baratii )Footnote 3 Footnote 5. This neurotoxin binds to the neuromuscular junction and blocks excitatory synaptic transmission by inhibiting acetylcholine releaseFootnote 2 Footnote 8, causing (flaccid) paralysisFootnote 1 Footnote 5 Footnote 6, and sometimes fatal respiratory failureFootnote 1 Footnote 2 Footnote 5 Footnote 8. The fatality rate of botulism is 5 to 10%Footnote 8.

Food-borne botulism: The classic form of botulism is caused by the ingestion of preformed toxin in contaminated foodFootnote 1 Footnote 2 Footnote 5 Footnote 8. Symptoms include double vision, drooping eyelids (ptosis), slurred speech, difficulty swallowing and muscle weakness that is symmetric and descends through the body (first shoulders are affected, then upper arms, lower arms, thighs, calves, etc.)Footnote 1. Death is usually due to respiratory failureFootnote 1 Footnote 2 Footnote 6 Footnote 8 and may occur as soon as 24 hours after onset of symptomsFootnote 8.

Wound botulism: Occurs by contamination of a wound with spores from neurotoxin-producing Clostridium species in the environment and subsequent germination of these spores and production of toxin in the anaerobic milieu of an abscessFootnote 1 Footnote 5 Footnote 4. The toxin is released into the bloodstreamFootnote 1 Footnote 6 and symptoms may take up to 2 weeks to appearFootnote 4.

Intestinal (infant) botulism: Results almost exclusively from spore ingestion and subsequent growth and toxin production in the intestineFootnote 1 Footnote 2 Footnote 5, affecting infants under 1 year oldFootnote 1 Footnote 5 Footnote 9. The first clinical sign is usually constipationFootnote 1 Footnote 2, but this disease has a wide spectrum of clinical severity, ranging from mild illness with gradual onset, to sudden infant death due to respiratory failureFootnote 1 Footnote 2. With appropriate intensive care, almost 100% of infants with botulism make a full recoveryFootnote 5. Infants with botulism are lethargic, feed poorly, have a weakened cry, exhibit ptosis, and floppy neck, and may progress to generalised flaccidity and respiratory compromiseFootnote 2 Footnote 4.

Adult infectious botulism: RareFootnote 5. Caused by the intestinal colonization of C. botulinum / other neurotoxin producing species, followed by in vivo toxin production in a manner similar to infant botulismFootnote 1 Footnote 2 Footnote 5. Patients often have a history of immunocompromise, abdominal surgery, bowel disease, or recent antibiotic therapy.

Inhalational botulism: Is not a naturally occurring diseaseFootnote 5, but has occurred in laboratory workers due to inhalation of aerosolized toxinFootnote 1. Inhalational botulism leads to neurological symptoms similar to those of food-borne botulism, but with a longer incubation periodFootnote 5 Footnote 6.

Iatrogenic botulism: Side effects resulting from the therapeutic intramuscular injection of Botox (purified, diluted A neurotoxin)Footnote 5. Characterized by clinical weakness and electrophysiological abnormalitiesFootnote 10 Footnote 11.

EPIDEMIOLOGY: Sporadic. Family and general outbreaks occur worldwide in association with food products prepared or preserved by means that do not destroy spores and permit the formation of toxinFootnote 1 Footnote 2 Footnote 5.

HOST RANGE: Humans, and various animals, e.g., fowl, fish, cows, dogs, and minksFootnote 1 Footnote 2.

INFECTIOUS DOSE: Cells/spores are not normally toxic for healthy adultsFootnote 2. Botulinum toxin is the most potent toxin known, with an estimated oral or injected toxic dose (serotype A) of 0.001 μg/kg body weight, and an estimated lethal dose by inhalation exposure in humans of approximately 0.07 μg/kg body weightFootnote 5 Footnote 6. Type A toxin is more potent than types B and E and causes the longest lasting diseaseFootnote 9.

MODE OF TRANSMISSION: Food borne botulism: Ingestion of contaminated food containing toxinFootnote 1 Footnote 2 Footnote 5. Infection is commonly associated with commercially processed foods that had undergone poor processing, storage, and improper preservationFootnote 12.

Wound botulism: Contamination of wounds with spores of neurotoxin producing Clostridium speciesFootnote 1 Footnote 2 Footnote 5 and is seen almost exclusively in injection drug users, particularly those who partake in injection of black-tar heroin into skin tissueFootnote 5 Footnote 13.

Intestinal (infant) botulism: Ingestion of spores. Sources include honey and infant milk powderFootnote 1 Footnote 5 Footnote 9.

Adult infectious botulism: Ingestion of clostridial spores, rather than toxin, which then colonize the gut to produce their neurotoxin directly in the gutFootnote 1 Footnote 5 Footnote 9.

Iatrogenic botulism: Side effect of injection of purified toxinFootnote 5.

Inhalational botulism: Occurs due to absorption of botulinum toxin by the mucous membrane of the noseFootnote 5 Footnote 6.

INCUBATION PERIOD: The shorter the incubation period, the more severe the disease and the higher the case fatality rateFootnote 1.

Food-borne botulism: Usually 12 to 72 hrs after ingestion of toxin, depending on the doseFootnote 9.

Wound botulism: The median period is 7 daysFootnote 9.

Adult infectious botulism: UnknownFootnote 1.

Intestinal botulism: UnknownFootnote 1.

Inhalational botulism: Not well defined, but it is longer than for food borne botulismFootnote 1 Footnote 6, and is estimated at 12-80 hoursFootnote 14.

COMMUNICABILITY: No evidence of person-to-person transmissionFootnote 1 Footnote 5.

SECTION III - DISSEMINATION

RESERVOIR: Spores are found in soil, aquatic sediments, the intestinal tract of birds, animals and fish, and agricultural products, including honey and vegetablesFootnote 1 Footnote 2 Footnote 13.

ZOONOSIS: No epidemiological relationship between human and animal botulism has been establishedFootnote 2.

VECTORS: None.

SECTION IV - STABILITY AND VIABILITY

DRUG SUSCEPTIBILITY: Susceptible to penicillin, metronidazole, clindamycin, cephalothin, cefoxitin, cefotaxime, chloramphenicol, tetracycline, erythromycin, rifampin, and vancomycin (with some strain variation)Footnote 15 Footnote 16.

DRUG RESISTANCE: Usually resistant to the aminoglycosidesFootnote 3, and may be resistant to tetracyclines and cephalosporins (with some strain variation)Footnote 16 Footnote 17. Also resistant to nalidixic acid and sulphamethoxazole-trimethoprim (SMX-TMP)Footnote 18.

SUSCEPTIBILITY TO DISINFECTANTS: The vegetative state is susceptible to disinfectants such as 70% ethanol, 0.1% sodium hypochlorite, and 0.1N NaOHFootnote 19. Spores may be resistant to disinfectants. Toxins are inactivated (more than 99.7%) by 20 minutes exposure to 3 mg/L free available chlorine (FAC; similar to the military disinfection procedure), and 84% inactivated by a treatment of 20 minutes at 0.4 mg/L FAC (similar to municipal water treatment procedures)Footnote 6.

PHYSICAL INACTIVATION: Toxin is destroyed after heating for 5 minutes at greater than 85°CFootnote 1 Footnote 8 Footnote 9. Toxins are detoxified in air within 12 hours and following exposure to sunlight within 1 to 3 hoursFootnote 9. Spores are highly resistant to heatFootnote 2 and desiccationFootnote 2; therefore, it is recommended to sterilize with dry heat (2 hours at 160°C) by autoclaving (20 minutes at 121°C, 1 atm pressure) and/or by irradiationFootnote 9.

SURVIVAL OUTSIDE HOST: Survives well in soil, water and agricultural productsFootnote 2 Footnote 5.

SECTION V - FIRST AID / MEDICAL

SURVEILLANCE: Since botulism is a life threatening condition, a rapid diagnosis is essentialFootnote 9and may require testing to differentiate botulism from other neurological diseasesFootnote 6.

Food borne botulism: Can be diagnosed by demonstration of toxin in serumFootnote 1 Footnote 2 Footnote 5 Footnote 8 Footnote 15, stoolFootnote 1 Footnote 2 Footnote 6 Footnote 8, gastric aspirateFootnote 1 Footnote 2 Footnote 5 or implicated foodFootnote 1 Footnote 2 Footnote 5, or by culture of C. botulinum from a patient's gastric aspirate or stool in a clinical caseFootnote 1 Footnote 5. The mouse bioassay is the most reliable method for detection of botulinumFootnote 5 Footnote 6 Footnote 8.

Wound botulism: Can be diagnosed by demonstration of toxin in serum, or by positive wound cultureFootnote 1 Footnote 2.

Adult infectious botulism: Can be diagnosed by demonstration of C. botulinum (or other neurotoxin producing species) and/or toxins in a patient's faeces or in autopsy specimensFootnote 1.

Intestinal (infant) botulism: Since the toxin is rarely found in the sera of infantsFootnote 1 Footnote 2, faeces should be examinedFootnote 1. An ELISA has been developed for the detection of A and B toxins in children's faecal samplesFootnote 2.

Inhalational botulism: Aerosolized toxin can not usually be identified in serum or faeces, but may be detected by ELISA from nasal swabsFootnote 8.

Iatrogenic botulism: Should be suspected if patient has recently received BotoxFootnote 10 Footnote 11. An immuno-PCR assay capable of detecting neurotoxin type A in the femtogram range has been developedFootnote 20.

Note: All diagnostic methods are not necessarily available in all countries.

FIRST AID/TREATMENT:

Foodborne botulism: Within 1 hour of ingestion of suspected food, the recommended course of action is a gastric lavageFootnote 1 Footnote 2, or enemasFootnote 1, and the administration of a cathartic (sorbitol)Footnote 1. In some cases intravenous administration of AB or ABEFootnote 1 Footnote 2 Footnote 6 Footnote 8 botulinum antitoxinFootnote 1 Footnote 2 Footnote 5 Footnote 6 Footnote 8 is required, and assisted ventilation if respiratory failure occurs. Treatment may be required for weeks or monthsFootnote 5.

Wound botulism: AntitoxinFootnote 1 Footnote 5, wound debridement, drainage and irrigationFootnote 1 Footnote 5 Footnote 13, and antibiotic treatmentFootnote 1.

Infant botulism: Requires meticulous supportive careFootnote 1. Instead of antitoxin which can cause sensitization and anaphylaxisFootnote 1 Footnote 6 Footnote 8, an investigational human-derived botulinal immunoglobulin (BIG) is available for the treatmentFootnote 1 and assisted respiration is given if requiredFootnote 1 Footnote 5.

Intestinal botulism: Repeated administration of ABE antitoxinFootnote 6 and assisted respiration is given, if requiredFootnote 1 Footnote 5.

IMMUNISATION: NoneFootnote 5.

PROPHYLAXIS: Individuals known to have eaten contaminated food should be purged with catharticsFootnote 1, given a gastric lavage and high enemasFootnote 1, and may be given equine botulinum AB or ABE antitoxinFootnote 1 Footnote 6.

SECTION VI - LABORATORY HAZARDS

LABORATORY-ACQUIRED INFECTIONS: Rarely reportedFootnote 5.

SOURCES/SPECIMENS: Food products, and clinical materials such as serum/blood, stool, vomit, and gastric aspiratesFootnote 5. For wound botulism: wound exudates, debrided tissue, or swab sample. Other sources include, nasal swabs from inhalational botulism patients, and environmental samples (soil, surface water)Footnote 1 Footnote 2 Footnote 6 Footnote 9.

PRIMARY HAZARDS: Exposure to the toxin. The toxin may be absorbed after ingestion, or following contact with the non-intact skin, the eyes, or mucous membranes, including the respiratory tractFootnote 5. Inhalation of the toxin has occurred under laboratory conditionsFootnote 5 Footnote 6.

SPECIAL HAZARDS: None.

SECTION VII - EXPOSURE CONTROLS / PERSONAL PROTECTION

RISK GROUP CLASSIFICATION: Risk Group 2Footnote 21.

CONTAINMENT REQUIREMENTS: Containment Level 2 facilities, equipment, and operational practices for work involving infectious or potentially infectious materials, animals, or cultures.

PROTECTIVE CLOTHING: Lab coat. Gloves when direct skin contact with infected materials or animals is unavoidable. Eye protection must be used where there is a known or potential risk of exposure to splashesFootnote 19.

OTHER PRECAUTIONS: All procedures that may produce aerosols, or involve high concentrations or large volumes should be conducted in a biological safety cabinet (BSC). The use of needles, syringes, and other sharp objects should be strictly limited. Additional precautions should be considered with work involving animals or large scale activitiesFootnote 19.

SECTION VIII - HANDLING AND STORAGE

SPILLS: Allow aerosols to settle, and, while wearing protective clothing, gently cover the spill with paper towels and apply appropriate disinfectant starting at the perimeter, working inwards towards the centre. Allow sufficient contact time before clean upFootnote 19.

DISPOSAL: Decontaminate before disposal, using steam sterilisation, incineration, or chemical disinfectionFootnote 19.

STORAGE: In locked, leak-proof containers that are appropriately labelled and securedFootnote 19.

SECTION IX - REGULATORY AND OTHER INFORMATION

REGULATORY INFORMATION: The import, transport, and use of pathogens in Canada is regulated under many regulatory bodies, including the Public Health Agency of Canada, Health Canada, Canadian Food Inspection Agency, Environment Canada, and Transport Canada. Users are responsible for ensuring they are compliant with all relevant acts, regulations, guidelines, and standards.

UPDATED: September 2010.

PREPARED BY: Pathogen Regulation Directorate, Public Health Agency of Canada.

Although the information, opinions and recommendations contained in this Pathogen Safety Data Sheet are compiled from sources believed to be reliable, we accept no responsibility for the accuracy, sufficiency, or reliability or for any loss or injury resulting from the use of the information. Newly discovered hazards are frequent and this information may not be completely up to date.

Copyright ©
Public Health Agency of Canada, 2010
Canada

REFERENCES:


Footnote 1
An Official Report of the American Public Health Association. (2004). In D. L. Heymann (Ed.), Control of Communicable Diseases Manual. (pp. 69-74). Washington, DC, USA: American Public Health Association.
Footnote 2
Acha, P. N., & Szyfres, B. (2001). Bacterial Infection and Mycoses. Zoonoses and Communicable Diseases Common to Man and Animals. (pp. 3-283, 28-40). Washington, D.C, USA: Pan American Health Organization.
Footnote 3
Johnson, E. A., Summanen, P., & Finegold, S. M. (2007). Clostridium. In P. R. Murray, E. J. Baron, J. H. Jorgensen, M. L. Landry & M. A. Pfaller (Eds.), Manual of Clinical microbiology (9th ed., pp. 889-910). Washington, DC: ASM press.
Footnote 4
Davis, L. E. (1993). Botulinum toxin: From poison to medicine. Western Journal of Medicine, 158 (1), 25-29.
Footnote 5
Sobel, J. (2005). Botulism. Clinical Infectious Diseases, 41 (8), 1167-1173.
Footnote 6
US Army Medical Research Institute of Infectious Diseases. (2004). Medical Management of Biological Casualties Handbook. Medical Management of Biological Casualties Handbook. (5th ed., ). USA: US Army Medical Research Institute of Infectious Diseases.
Footnote 7
Humes, R., & Snyder, J. W. (2007). Laboratory Detection of Potential Agents of Bioterrorism. In P. R. Murray, E. J. baron, J. H. Jorgensen, M. L. Landry & M. A. Pfaller (Eds.), Manual of Clinical Microbiology (9th ed., pp. 107-117). Washington, D.C.: ASM Press.
Footnote 8
Franz, D. R., Jahrling, P. B., McClain, D. J., Hoover, D. L., Byrne, W. R., Pavlin, J. A., Christopher, G. W., Cieslak, T. J., Friedlander, A. M., & Eitzen E.M., J. (2001). Clinical recognition and management of patients exposed to biological warfare agents. Clinics in Laboratory Medicine, 21 (3), 435-473.
Footnote 9
Lindstr*m, M., & Korkeala, H. (2006). Laboratory diagnostics of botulism. Clinical Microbiology Reviews, 19 (2), 298-314.
Footnote 10
Bakheit, A. M., Ward, C. D., & McLellan, D. L. (1997). Generalized botulism-like syndrome after intramuscular injections of botulinum toxin type A: a report of two cases J. Neurol. Neurosurg. Psychiatry, 62 (2), 198.
Footnote 11
Cheng, C. M., Chen, J. S., & Patel, R. P. (2006). Unlabeled uses of botulinum toxins: A review, part 2. American Journal of Health-System Pharmacy, 63 (3), 225-232.
Footnote 12
McLauchlin, J., Grant, K. A., & Little, C. L. (2006). Food-borne botulism in the United Kingdom. Journal of Public Health (Oxford, England), 28 (4), 337-342. doi:10.1093/pubmed/fdl053
Footnote 13
Reller, M. E., Douce, R. W., Maslanka, S. E., Torres, D. S., Manock, S. R., & Sobel, J. (2006). Wound botulism acquired in the Amazonian rain forest of Ecuador. American Journal of Tropical Medicine and Hygiene, 74 (4), 628-631.
Footnote 14
Project Tripwire. (2007). Botulism. Retrieved 11/24, 2010, from American Journal of Tropical Medicine and Hygiene
Footnote 15
Swenson, J. M., Thornsberry, C., & McCroskey, L. M. (1980). Susceptibility of Clostridium botulinium to thirteen antimicrobial agents. Antimicrobial Agents and Chemotherapy, 18 (1), 13-19.
Footnote 16
Dezfulian, M., & Dowell Jr., V. R. (1980). Cultural and physiological characteristics and antimicrobial suspectibility of Clostridium botulinum isolates from foodborne and infant botulism cases. Journal of Clinical Microbiology, 11 (6), 604-609.
Footnote 17
Boyanova, L., Kolarov, R., & Mitov, I. (2007). Antimicrobial resistance and the management of anaerobic infections. Expert Review of Anti-Infective Therapy, 5 (4), 685-701.
Footnote 18
Fenicia, L., Ferrini, A. M., Anniballi, F., Mannoni, V., & Aureli, P. (2003). Considering the antimicrobial sensitivity of the intestinal botulism agent Clostridium butyricum when treating concomitant infections. European Journal of Epidemiology, 18 (12), 1153-1154.
Footnote 19
Public Health Agency of Canada. (2004). In Best M., Graham M. L., Leitner R., Ouellette M. and Ugwu K. (Eds.), Laboratory Biosafety Guidelines (3rd ed.). Canada: Public Health Agency of Canada.
Footnote 20
Chao, H. -., Wang, Y. -., Tang, S. -., & Liu, H. -. (2004). A highly sensitive immuno- polymerase chain reaction assay for Clostridium botulinum neurotoxin type A. Toxicon, 43 (1), 27-34.
Footnote 21
Human pathogens and toxins act. S.C. 2009, c. 24, Second Session, Fortieth Parliament, 57- 58 Elizabeth II, 2009. (2009).