Clinical Criteria to Trigger Suspicion for Botulism: An Evidence-Based Tool to Facilitate Timely Recognition of Suspected Cases During Sporadic Events and Outbreaks.

Effective treatment for botulism requires early clinical recognition. Diagnosis of botulism, including during outbreaks, can be challenging. We assessed combinations of signs and symptoms among confirmed cases and identified sensitive clinical criteria to trigger suspicion. We produced a tool that may facilitate rapid identification of sporadic and outbreak-associated cases.

Safety and Improved Clinical Outcomes in Patients Treated With New Equine-Derived Heptavalent Botulinum Antitoxin.

Background: Botulism is a rare, life-threatening paralytic illness. Equine-derived heptavalent botulinum antitoxin (HBAT), the only currently available treatment for noninfant botulism in the United States, was licensed in 2013. No reports have systematically examined safety and clinical benefit of HBAT among botulism patients. Methods: From March 2010 through March 2013, we collected data prospectively and through medical record reviews of patients with confirmed or suspected botulism who were treated with HBAT under an expanded-access Investigational New Drug program. Results: Among 249 HBAT-treated patients, 1 (<1%) child experienced an HBAT-related serious adverse event (hemodynamic instability characterized by bradycardia, tachycardia, and asystole); 22 (9%) patients experienced 38 nonserious adverse events reported by physicians to be HBAT related. Twelve (5%) deaths occurred; all were determined to be likely unrelated to HBAT. Among 104 (42%) patients with confirmed botulism, those treated early (≤2 days) spent fewer days in the hospital (median, 15 vs 25 days; P < .01) and intensive care (10 vs 17 days; P = .04) than those treated later. Improvements in any botulism sign/symptom were detected a median of 2.4 days and in muscle strength a median of 4.8 days after HBAT. Conclusions: HBAT was safe and provided clinical benefit in treated patients. HBAT administration within 2 days of symptom onset was associated with shorter hospital and intensive care stays. These results highlight the importance of maintaining clinical suspicion for botulism among patients presenting with paralytic illness to facilitate early HBAT treatment before laboratory confirmation might be available. Clinical consultation and, if indicated, HBAT release, are available to clinicians 24/7 through their state health department in conjunction with CDC.

Clinical Characteristics and Ancillary Test Results Among Patients With Botulism-United States, 2002-2015.

Background: Botulism is classically described as a bilateral, symmetric, descending flaccid paralysis in an afebrile and alert patient without sensory findings. We describe the reported spectrum of clinical findings among persons >12 months of age in the United States during 2002-2015. Methods: The Centers for Disease Control and Prevention collects clinical findings reported by physicians treating suspected cases of botulism nationwide. We analyzed symptoms and signs, and neuroimaging and cerebrospinal fluid (CSF) results. A case was defined as illness compatible with botulism with laboratory confirmation or epidemiologic link to a confirmed case, and presence or absence of at least 1 sign or symptom recorded. Physicians' differential diagnoses were evaluated. Results: Clinical information was evaluated for 332 botulism cases; data quality and completeness were variable. Most had no fever (99%), descending paralysis (93%), no mental status change (91%), at least 1 ocular weakness finding (84%), and neuroimaging without acute changes (82%). Some had paresthesias (17%), elevated CSF protein level (13%), and other features sometimes considered indicative of alternative diagnoses. Five of 71 (7%) cases with sufficient information were reported to have atypical findings (eg, at least 1 cranial nerve finding that was unilateral or ascending paralysis). Illnesses on the physician differential included Guillain-Barré syndrome (99 cases) and myasthenia gravis (76 cases) and, rarely, gastrointestinal-related illness (5 cases), multiple sclerosis (3 cases), sepsis (3 cases), and Lyme disease (2 cases). Conclusions: Our analysis illustrates that classic symptoms and signs were common among patients with botulism but that features considered atypical were reported by some physicians. Diagnosis can be challenging, as illustrated by the broad range of illnesses on physician differentials.

Outbreak of Botulism Due to Illicit Prison-Brewed Alcohol: Public Health Response to a Serious and Recurrent Problem.

Background: Botulism is a rare, sometimes lethal neuroparalytic illness. On 2 October 2011, an inmate at prison A developed symptoms compatible with botulism after drinking pruno, an illicit, prison-brewed alcoholic beverage. Additional illnesses were identified within several days. We conducted an investigation to determine the cause and extent of the outbreak. Methods: A case was defined as signs or symptoms of botulism in a prison A inmate with onset during 30 September-9 October 2011. Cases were identified through medical evaluations and interviews with inmates about recent pruno consumption. Laboratory testing was performed for Clostridium botulinum and botulinum neurotoxin. Ingredients, preparation, and sharing of the implicated pruno were investigated. Results: Eight prisoners developed botulism; all drank pruno made with a potato. Three received mechanical ventilation. Culture of fluid from a sock that inmates reported using to filter the implicated pruno yielded C. botulinum type A. The implicated batch may have been shared between cells during delivery of meal trays. Challenges of the investigation included identifying affected inmates, overcoming inaccuracies in histories, and determining how the illicit beverage was shared. Costs to taxpayers were nearly $500000 in hospital costs alone. Conclusions: Pruno made with potato has emerged as an important cause of botulism in the United States. This public health response illustrates the difficulties of investigating botulism in correctional facilities and lessons learned for future investigations.

Spatial-temporal patterns of dengue in areas at risk of dengue hemorrhagic fever in Kaohsiung, Taiwan, 2002.

OBJECTIVE: This study aimed to examine whether spatial-temporal patterns of dengue can be used to identify areas at risk of dengue hemorrhagic fever (DHF). METHODS: Three indices - probability of case-occurrence, mean duration per wave, and transmission intensity - were used to differentiate eight local spatial-temporal patterns of dengue during the 2002 epidemic in Kaohsiung, Taiwan. DHF densities (DHF cases/km(2) per 100 dengue cases) in each spatial-temporal typed area were compared. RESULTS: Areas with three high indices correlated with the highest DHF density: (1) high transmission intensity only; (2) long duration of wave only, and (3) high transmission intensity plus long duration of wave. However, cumulative incidences of dengue cases were not correlated with DHF densities. CONCLUSION: Three spatial-temporal indices of dengue could provide useful information to identify areas at high risk of DHF.

Two clustering diffusion patterns identified from the 2001-2003 dengue epidemic, Kaohsiung, Taiwan.

This study analyzed the spatio-temporal patterns of 4,587 (94% of the total) confirmed dengue cases in Kaohsiung and Fengshan Cities (a two-city area) that occurred in Taiwan from 2001 to 2003. The epidemic had two simultaneous distinct diffusion patterns. One was a contiguous pattern, mostly limited to 1 km from an initial cluster, reflecting that there was a rapid dispersal of infected Aedes aegypti and viremic persons. The second followed a relocation pattern, involving clusters of cases that diffused over 10 weeks starting from the southern and moving to the northern parts of the two-city area. The virus from one clustering site jumped to several distant areas where it rapidly dispersed through a series of human-mosquito transmission cycles to several localities. In both patterns, transmission of disease quickly enlarged the epidemic areas. Future dengue control efforts would benefit from a timely syndromic surveillance system plus extensive public education on how to avoid further transmission.

Spatial mapping of temporal risk characteristics to improve environmental health risk identification: a case study of a dengue epidemic in Taiwan.

Mapping uneven events, such as disease cases or pollutants, is a basic but important procedure for analyzing regional relationships and variation in public health and environmental agencies. The purpose of mapping is to find out the spatial clustering of uneven events and identify spatial risk areas, which could lead to potential environmental hazards or epidemics. Meanwhile, more hypotheses could be generated through mapping process for further investigations. This paper proposed a novel spatial-temporal approach to focusing on: (1) how often these uneven cases occur, (2) how long these cases persist and (3) how significant cases occur in consecutive periods across the study area. The proposed model was applied to the dengue fever epidemic in Taiwan in 2002 as a case study, which was the worst epidemic in the last 60 years. This approach provides procedures to identify spatial health risk levels with temporal characteristics and assists in generating hypothesis that will be investigated in further detail.