Epidemiology

Cases of botulism are more common in the US than in the UK.

Spores of Clostridium botulinum are ubiquitous. In the US, 60% of cases east of the Mississippi river are due to B toxin, while west of the river, 85% of cases are due to A toxin.[1] Infant botulism, the most common form, occurs with toxin types A, B, or F. In 2017 there were 141 confirmed or probable paediatric cases in the US. CDC: national botulism surveillance Opens in new window A total of 2419 infant cases were reported in the US from 1976 to 2006.[2] Over this time span, an additional 524 cases of infant botulism were identified globally.[2] Rare cases of infant botulism due to toxin E production by Clostridium butyricum, or toxin F production by Clostridium baratii, have also been reported.[3][4] In England and Wales between 1975 and 2013, 16 cases of infant botulism were reported.[5]

Foodborne botulism, attributed to A, B, or E toxin, is most frequently seen in an outbreak setting. Although commercially tinned foods were commonly the source of foodborne illness in the early 1900s, home-preserved vegetables, fruits, and fish products are now the most common sources.[6] In some cultures, such as among the indigenous people of Alaska, preferred food preparation practices involving fish fermentation commonly lead to botulism.[7] In China, homemade fermented beans are the leading cause.[8] Commercial foods and restaurants are still occasional sources.[9] In the US, 263 cases of foodborne botulism occurred from 1990 to 2000 (17-43 cases per year).[10] In 2017, 19 cases of foodborne intoxication were reported in the US. CDC: national botulism surveillance Opens in new window Foodborne illness has been reported throughout the US, but over half of cases (54%) have occurred in just 5 western states (California, Washington, Oregon, Colorado, and Alaska).[1]

Foodborne botulism is uncommon in the UK; only 62 cases were reported from 1922 to 2005.[11] More cases are seen in southern and eastern Europe, where it is more common to preserve foods at home.[12][13] In England and Wales between 1980 and 2013, there were 36 reported cases of foodborne botulism, with 3 reported as resulting in deaths. Of these cases, in 1989 an outbreak of 26 cases were due to contaminated hazelnut yoghurt.[14] 

Wound botulism is due to A or B toxin and is the result of wound contamination by C botulinum spores. It has been associated almost exclusively with injection drug users of 'black tar' heroin.[15][16][17] In England and Wales from 2000 to 2013, 147 suspected cases of wound botulism were reported. Eight deaths were recorded between 2003 and 2013.[18]

Inhalational botulism does not occur in nature; an unusual toxin type (i.e., C, D, F, or G) or symptoms among patients with a common geographical factor may suggest an act of bioterrorism.

Botulinum toxin types A and B have been approved by the US Food and Drug Administration for cosmetic and therapeutic purposes (e.g., blepharospasm, strabismus, cervical dystonia). Iatrogenic botulism cases have been reported with the therapeutic and unlicensed cosmetic use of botulinum toxin A.[19][20][21][Figure caption and citation for the preceding image starts]: Six-week-old infant with botulismCenters for Disease Control and Prevention (CDC) [Citation ends].com.bmj.content.model.Caption@290da207[Figure caption and citation for the preceding image starts]: Wound botulism involvement of compound fracture of right armCenters for Disease Control and Prevention (CDC) [Citation ends].com.bmj.content.model.Caption@4e99a30c

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