9. METHODS OF CONTROL

A. Preventive measures:

1) Ensure effective control of processing and preparation of commercially canned and preserved foods.

2) Educate those concerned with home canning and other food preservation techniques regarding the proper time, pressure and temperature required to destroy spores, the need for adequately refrigerated storage of incompletely processed foods, and the effectiveness of boiling, with stirring, home canned vegetables for at least 10 minutes to destroy botulinum toxins.

3) C. botulinum may or may not cause container lids to bulge and the contents to have "off-odors." Other contaminants can also cause cans or bottle lids to bulge. Bulging containers should not be opened, and foods with off-odors should not be eaten or "taste tested." Commercial cans with bulging lids should be returned unopened to the vendor.

4) Although C. botulinum spores are ubiquitous, identified sources such as honey, should not be fed to infants.

B. Control of patient; contacts and the immediate environment:

1) Report to local health authority: Case report of suspected and confirmed cases obligatory in most states and countries, Class 2A (see Communicable Disease Reporting); immediate telephone report indicated.

2) Isolation: Not required, but handwashing is indicated after handling soiled diapers.

3) Concurrent disinfection: The implicated food(s) should be detoxified by boiling before discarding, or the containers broken and buried deeply in soil to prevent ingestion by animals. Contaminated utensils should be sterilized by boiling or by chlorine disinfection to inactivate any remaining toxin. Usual sanitary disposal of feces from infant cases. Terminal cleaning.

4) Quarantine: None.

5) Management of contacts: None for simple direct contacts. Those who are known to have eaten the incriminated food should be purged with cathartics, given gastric lavage and high enemas and kept under close medical observation. The decision to provide presumptive treatment with polyvalent (equine AD or ABE) antitoxin to asymptomatic exposed individuals should be weighed carefully: balance the potential protection when antitoxin is administered early (withIn 1-2 days after eating the implicated meal) against the risk of adverse reactions and sensitization to horse serum.

6) Investigation of contacts and source of toxin: Study recent food history of those ill, and recover all suspected foods for appropriate testing and disposal. Search for other cases of botulism to rule out foodborne botulism.

7) Specific treatment: Intravenous administration as soon as possible of 1 vial of polyvalent (AD or ABE) botulinum antitoxin, available from CDC, Atlanta, through state health departments is considered a part of routine treatment (the emergency telephone number at CDC for botulism calls during regular office hours is 404-639-2206; and after hours and on weekends is 404-639-2888). Serum should be collected to identify the specific toxin before antitoxin is administered, but antitoxin should not be withheld pending test results. Most important is immediate access to an intensive care unit so that respiratory failure, the usual cause of death, can be anticipated and managed promptly. For wound botulism, in addition to antitoxin, the wound should be debrided and/or drainage established, and appropriate antibiotics (e.g., penicillin) administered.

In intestinal botulism, meticulous supportive care is essential. Equine botulinum antitoxin is not used because of the hazard of sensitization and anaphylaxis. An investigational human derived botulinal immune globulin (BIG) is currently available for the treatment only of infant botulism patients under an FDA approved open-label Treatment Investigational New Drug protocol from the California Department of Health Services. Information on BIG for the "empiric" treatment of suspected intestinal botulism in infants can be obtained from the California Department of Health Services at 510-540-2646 (24-hour line). Antibiotics do not improve the course of the disease, and aminoglycoside antibiotics in particular may worsen it by causing a synergistic neuromuscular blockade. Thus, antibiotics should be used only to treat secondary infections. Assisted respiration may be required.

C. Epidemic measures:

Suspicion of a single case of botulism should immediately raise the question of a group outbreak involving a family or others who have shared a common food. Home preserved foods should be the prime suspect until ruled out, although restaurant foods or widely distributed commercially preserved foods are occasionally identified as the source of intoxication and pose a far greater threat to the public health.

In addition, because recent outbreaks have implicated unusual food items, even theoretically unlikely foods should be considered. When any food is implicated by epidemiologic or laboratory findings, immediate recall of the product is necessary, as is immediate search for people who shared the suspected food and for any remaining food from the same source. Any remaining food may be similarly contaminated; such food, if found, should be submitted for laboratory examination. Sera, gastric aspirates and stool from patients and (when indicated) from others exposed but not ill should be collected and forwarded immediately to a reference laboratory before administration of antitoxin.

D. Disaster implications: None.

E. International measures: 

Commercial products may have been distributed widely; international efforts may be required to recover and test implicated foods. International common source outbreaks have occurred.

F. Bioterrorism measures: 

Botulinum toxins can be easily used by terrorists. Although the greatest threat may be via aerosol use, the more common threat may be via its use in food and drink. The occurrence of even a single case of botulism, especially if there is no obvious source of an improperly preserved food should raise the possibility of deliberate use of botulinum toxin. All such cases should be reported immediately so that appropriate investigations can be initiated without delay.