View source for Botulism

{{Short description|Human and animal disease}}
{{Use dmy dates|date=May 2025}}
{{cs1 config|name-list-style=vanc|display-authors=6}}
{{Infobox medical condition (new)
| name            = Botulism
| image           = Botulism1and2.JPG
| caption         = A 14-year-old boy with botulism, characterised by weakness of the eye muscles and the [[ptosis (eyelid)|drooping eyelids]] shown in the left image, and dilated and non-moving pupils shown in the right image. This [[adolescent|youth]] was fully conscious.
| field           = [[Infectious disease]], [[gastroenterology]]
| pronounce       = {{IPAc-en|ˈ|b|ɒ|tj|ʊ||l|ɪ|z|əm|}}
| symptoms        = Weakness, trouble seeing, [[Fatigue (medical)|feeling tired]], trouble speaking
| complications   = [[Respiratory failure]]
| onset           = 12 to 72 hours
| duration        = Variable
| types           = Foodborne, wound, infant, adult intestinal toxemia, inhalational, iatrogenic<ref name="CDCtypes">{{cite web |title=About Botulism |url=https://www.cdc.gov/botulism/about/index.html |website=Centers for Disease Control and Prevention |date=18 April 2024 |access-date=12 June 2025}}</ref>
| causes          = ''[[Clostridium botulinum]]''
| risks           = Improperly canned, preserved or fermented foods; injection drug use (e.g. black-tar heroin); honey consumption in infants &lt;1 year; contaminated wounds; high-dose cosmetic/therapeutic botulinum-toxin injections<ref name="CDCrisk">{{cite web |title=People at Increased Risk for Botulism |url=https://www.cdc.gov/botulism/risk-factors/index.html |website=Centers for Disease Control and Prevention |date=9 May 2024 |access-date=12 June 2025}}</ref>
| diagnosis       = Finding the bacteria or their toxin
| differential    = [[Myasthenia gravis]], [[Guillain–Barré syndrome]], [[Amyotrophic lateral sclerosis]], [[Lambert Eaton syndrome]]
| prevention      = Proper food preparation, no honey for children younger than one
| treatment       = [[Antitoxin]], antibiotics, [[mechanical ventilation]]
| medication      =
| prognosis       = ~7.5% risk of death
| frequency       = Worldwide: ''c.'' 1 000 reported cases per year; United States: 273 cases in 2021<ref name="MOHLOnt">{{cite web |title=Botulism |url=http://www.health.gov.on.ca/en/public/publications/disease/botulism.aspx |publisher=Ontario Ministry of Health and Long-Term Care |access-date=12 June 2025 |archive-date=17 October 2017 |archive-url=https://web.archive.org/web/20171017005607/http://www.health.gov.on.ca/en/public/publications/disease/botulism.aspx |url-status=bot: unknown }}</ref><ref name="CDC2021">{{cite web |title=National Botulism Surveillance Summary, 2021 |url=https://www.cdc.gov/botulism/php/national-botulism-surveillance/2021.html |publisher=Centers for Disease Control and Prevention |date=21 May 2025 |access-date=12 June 2025}}</ref>
| deaths          = Global case-fatality rate 5–10 % (≈50–100 deaths annually)<ref name="WHO2023">{{cite web |title=Botulism – Key facts |url=https://www.who.int/news-room/fact-sheets/detail/botulism |publisher=World Health Organization |date=25 September 2023 |access-date=12 June 2025}}</ref>
}}

'''Botulism''' is a rare and potentially fatal [[illness]] caused by [[botulinum toxin]], which is produced by the bacterium ''[[Clostridium botulinum]]''. The disease begins with weakness, blurred vision, [[Fatigue (medical)|feeling tired]], and trouble speaking. This may then be followed by weakness of the arms, chest muscles, and legs. Vomiting, swelling of the abdomen, and diarrhea may also occur. The disease does not usually affect [[consciousness]] or cause a [[fever]].

Botulism can occur in several ways. The [[bacterial spores]] which cause it are common in both soil and water and are very resistant. They produce the [[botulinum toxin]] when exposed to low oxygen levels and certain temperatures. Foodborne botulism happens when food containing the toxin is eaten. Infant botulism instead happens when the bacterium develops in the [[intestine]]s and releases the toxin. This typically only occurs in children less than one year old, as protective mechanisms against development of the bacterium develop after that age. Wound botulism is found most often among those who [[drug injection|inject street drugs]]. In this situation, spores enter a wound, and in the absence of oxygen, release the toxin. The disease is not passed directly between people. Its diagnosis is confirmed by finding the toxin or bacteria in the person in question.

Prevention is primarily by proper food preparation. The toxin, though not the spores, is destroyed by heating it to more than {{convert|85|°C|°F}} for longer than five minutes. The clostridial spores can be destroyed in an autoclave with moist heat (120°C/ 250°F for at least 15 minutes) or dry heat (160°C for 2 hours) or by irradiation. The spores of group I strains are inactivated by heating at 121°C (250°F) for 3 minutes during commercial canning. Spores of group II strains are less heat-resistant, and they are often damaged by 90°C (194°F) for 10 minutes, 85°C for 52 minutes, or 80°C for 270 minutes; however, these treatments may not be sufficient in some foods.<ref>{{Cite web |last=Center for Food Security and Public Health Iowa State University |date=19 February 2024 |title=Botulism |url=https://www.cfsph.iastate.edu/Factsheets/pdfs/botulism.pdf }}</ref> [[Honey]] can contain the organism, and for this reason, honey should not be fed to children under 12 months. Treatment is with an [[Heptavalent botulism antitoxin|antitoxin]]. In those who lose their ability to breathe on their own, [[mechanical ventilation]] may be necessary for months. [[Antibiotic]]s may be used for wound botulism. Death occurs in 5 to 10% of people. Botulism also affects many other animals. The word is from [[Latin]] {{lang|la|botulus}}, meaning 'sausage'.
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== Signs and symptoms ==
The muscle weakness of botulism characteristically starts in the muscles supplied by the [[cranial nerves]]—a group of twelve nerves that control [[eye movement (sensory)|eye movements]], the [[facial muscles]] and the muscles controlling [[chewing]] and [[swallowing]]. [[Diplopia|Double vision]], [[Ptosis (eyelid)|drooping of both eyelids]], loss of facial expression and swallowing problems may therefore occur. In addition to affecting the [[Somatic nervous system|voluntary muscles]], it can also cause [[Dysautonomia|disruptions in the autonomic nervous system]]. This is experienced as [[xerostomia|a dry mouth and throat]] (due to decreased production of saliva), [[postural hypotension]] (decreased blood pressure on standing, with resultant lightheadedness and risk of blackouts), and eventually [[constipation]] (due to decreased [[peristalsis|forward movement of intestinal contents]]).<ref name=Sobel2005/> Some of the toxins (B and E) also precipitate [[nausea]], [[vomiting]],<ref name=Sobel2005/> and [[dysarthria|difficulty with talking]]. The weakness then spreads to the arms (starting in the shoulders and proceeding to the forearms) and legs (again from the thighs down to the feet).<ref name=Sobel2005>{{cite journal | vauthors = Sobel J | title = Botulism | journal = Clinical Infectious Diseases | volume = 41 | issue = 8 | pages = 1167–73 | date = October 2005 | pmid = 16163636 | doi = 10.1086/444507 | doi-access = free }}</ref>

Severe botulism leads to reduced movement of the [[muscles of respiration]], and hence problems with [[gas exchange]]. This may be experienced as [[dyspnea]] (difficulty breathing), but when severe can lead to [[respiratory failure]], due to the buildup of unexhaled [[hypercapnia|carbon dioxide]] and its resultant depressant effect on the brain. This may lead to respiratory compromise and death if untreated.<ref name=Sobel2005/>

Clinicians frequently think of the symptoms of botulism in terms of a classic triad: [[bulbar palsy]] and descending paralysis, lack of fever, and clear senses and mental status ("clear sensorium").<ref name=outreakid>{{cite web|url=http://www.outbreakid.com/bioterrorism.htm |url-status=dead |archive-url=https://web.archive.org/web/20120402234631/http://www.outbreakid.com/bioterrorism.htm |archive-date=2 April 2012 |title=Botulism |website=OutbreakID.com}}</ref>

=== Infant botulism ===
[[File:Infant botulism patient.jpeg|thumb|upright|An infant with botulism. Despite not being asleep or sedated, he cannot open his eyes or move; he also has a weak cry.]]

Infant botulism (also referred to as [[floppy baby syndrome]]) was first recognized in 1976, and is the most common form of botulism in the United States. Infants are susceptible to infant botulism in the first year of life, with more than 90% of cases occurring in infants younger than six months.<ref name="SSAIBchap">{{cite book | vauthors = Arnon SS |chapter-url=http://www.infantbotulism.org/readings/ibchap.pdf |chapter=Infant Botulism | veditors = Feigin RD, Cherry JD, Demmler GJ, Kaplan SL |title=Textbook of Pediatric Infectious Diseases |edition=5th |location=Philadelphia |publisher=WB Saunders |date=2004 |pages=1758–66 |url-status=live |archive-url=https://web.archive.org/web/20110726180149/http://www.infantbotulism.org/readings/ibchap.pdf |archive-date=26 July 2011 }}</ref> Infant botulism results from the ingestion of the [[Clostridium botulinum|''C. botulinum'']] spores, and subsequent colonization of the small intestine. The infant gut may be colonized when the composition of the [[gut flora|intestinal microflora]] (normal flora) is insufficient to competitively inhibit the growth of ''C. botulinum'' and levels of bile acids (which normally inhibit [[Clostridia|clostridial]] growth) are lower than later in life.<ref name=Caya2004>{{cite journal |last1=Caya |first1=James G. |last2=Agni |first2=Rashmi |last3=Miller |first3=Joan E. |title=Clostridium botulinum and the Clinical Laboratorian: A Detailed Review of Botulism, Including Biological Warfare Ramifications of Botulinum Toxin |journal=Archives of Pathology & Laboratory Medicine |date=June 2004 |volume=128 |issue=6 |pages=653–662 |doi=10.5858/2004-128-653-CBATCL |pmid=15163234 }}</ref>

The growth of the spores releases [[botulinum toxin]], which is then absorbed into the bloodstream and taken throughout the body, causing paralysis by blocking the release of [[acetylcholine]] at the [[neuromuscular junction]]. Typical symptoms of infant botulism include constipation, lethargy, weakness, difficulty feeding, and an altered cry, often progressing to a complete descending [[flaccid paralysis]]. Although constipation is usually the first symptom of infant botulism, it is commonly overlooked.<ref name="Infant Botulism">{{cite web|url=http://kidshealth.org/en/parents/botulism.html|title=Infant Botulism|website=kidshealth.org|access-date=28 September 2016|url-status=live|archive-url=https://web.archive.org/web/20161007110000/http://kidshealth.org/en/parents/botulism.html|archive-date=7 October 2016}}</ref>

[[Honey]] is a known dietary reservoir of ''[[Clostridium botulinum|C. botulinum]]'' spores and has been linked to infant botulism. For this reason, honey is not recommended for infants less than one year of age.<ref name=Caya2004 /> Most cases of infant botulism, however, are thought to be caused by acquiring the spores from the natural environment. ''[[Clostridium botulinum]]'' is a ubiquitous soil-dwelling bacterium. Many infant botulism patients have been demonstrated to live near a construction site or an area of soil disturbance.<ref name="Infant botulism literature review">{{cite journal | vauthors = Domingo RM, Haller JS, Gruenthal M | title = Infant botulism: two recent cases and literature review | journal = Journal of Child Neurology | volume = 23 | issue = 11 | pages = 1336–46 | date = November 2008 | pmid = 18984848 | doi = 10.1177/0883073808318200 }}</ref>

Infant botulism has been reported in 49 of 50 US states (all except for Rhode Island),<ref name="SSAIBchap" /> and cases have been recognized in 26 countries on five continents.<ref name="globalIB">{{cite journal | vauthors = Koepke R, Sobel J, Arnon SS | title = Global occurrence of infant botulism, 1976-2006 | journal = Pediatrics | volume = 122 | issue = 1 | pages = e73-82 | date = July 2008 | pmid = 18595978 | doi = 10.1542/peds.2007-1827 }}</ref>

=== Complications ===
Infant botulism has no long-term side effects.{{citation needed|date=December 2022}}

Botulism can result in death due to [[respiration (physiology)|respiratory]] failure. However, in the past 50 years, the proportion of patients with botulism who die has fallen from about 50% to 7% due to improved supportive care. A patient with severe botulism may require [[mechanical ventilation]] (breathing support through a ventilator) as well as intensive medical and nursing care, sometimes for several months. The person may require rehabilitation therapy after leaving the hospital.<ref>{{cite web |url=https://www.cdc.gov/foodsafety/diseases/clostridium-perfringens.html|title=Prevent Illness From ''C. perfringens'' |access-date=14 June 2016 |publisher=U.S. Centers for Disease Control and Prevention |url-status=live |archive-url=https://web.archive.org/web/20160616152125/http://www.cdc.gov/foodsafety/diseases/clostridium-perfringens.html |archive-date=16 June 2016 }}</ref>

== Cause ==
[[File:Clostridium botulinum.jpg|thumb|A photomicrograph of ''[[Clostridium botulinum]]'' bacteria.]]

''[[Clostridium botulinum]]'' is an [[Anaerobic organism|anaerobic]], [[Gram-positive bacteria|Gram-positive]], spore-forming rod. [[Botulinum toxin]] is one of the most powerful known toxins: about one [[microgram]] is lethal to humans when inhaled.<ref name="Emmeluth2010">{{cite book | first = Donald | last = Emmeluth |title=Botulism|url=https://books.google.com/books?id=3fzYL6virMQC&pg=PA38|year=2010|publisher=Infobase Publishing|isbn=978-1-60413-235-9|page=38|url-status=live|archive-url=https://web.archive.org/web/20170101014327/https://books.google.com/books?id=3fzYL6virMQC&pg=PA38|archive-date=1 January 2017}}</ref> It acts by blocking [[nerve]] function ([[neuromuscular blockade]]) through inhibition of the excitatory [[neurotransmitter]] [[acetylcholine]]'s release from the [[presynaptic]] membrane of [[neuromuscular junction]]s in the [[somatic nervous system]]. This causes paralysis. Advanced botulism can cause [[respiratory failure]] by paralysing the muscles of the chest; this can progress to [[respiratory arrest]].<ref name="Arnon">{{cite journal | vauthors = Arnon SS, Schechter R, Inglesby TV, Henderson DA, Bartlett JG, Ascher MS, Eitzen E, Fine AD, Hauer J, Layton M, Lillibridge S, Osterholm MT, O'Toole T, Parker G, Perl TM, Russell PK, Swerdlow DL, Tonat K | title = Botulinum toxin as a biological weapon: medical and public health management | journal = JAMA | volume = 285 | issue = 8 | pages = 1059–70 | date = February 2001 | pmid = 11209178 | doi = 10.1001/jama.285.8.1059 }}</ref> Furthermore, acetylcholine release from the presynaptic membranes of [[muscarinic acetylcholine receptor|muscarinic]] nerve synapses is blocked. This can lead to a variety of autonomic signs and symptoms described above.{{citation needed|date=December 2022}}

In all cases, illness is caused by the botulinum toxin which the bacterium ''C. botulinum'' produces in anaerobic conditions and not by the bacterium itself. The pattern of damage occurs because the toxin affects nerves that fire (depolarize) at a higher frequency first.<ref>''Oxford Textbook of Medicine'', 4th Ed., Section 7.55</ref>

Mechanisms of entry into the human body for botulinum toxin are described below.{{citation needed|date=December 2022}}

=== Colonization of the gut ===
The most common form in Western countries is infant botulism. This occurs in infants who are [[Colonization (biology)|colonized]] with the bacterium in the small intestine during the early stages of their lives. The bacterium then produces the toxin, which is absorbed into the bloodstream. The consumption of [[honey]] during the first year of life has been identified as a risk factor for infant botulism; it is a factor in a fifth of all cases.<ref name=Sobel2005/> The adult form of infant botulism is termed ''adult intestinal toxemia'', and is exceedingly rare.<ref name=Sobel2005/>

=== Food ===
Toxin that is produced by the bacterium in containers of food that have been improperly preserved is the most common cause of food-borne botulism. Fish that has been pickled without the salinity or acidity of brine that contains [[acetic acid]] and high [[sodium]] levels, as well as smoked fish stored at too high a temperature, presents a risk, as does improperly canned food.<ref>{{cite journal |last1=Dolman |first1=Claude E. |title=Type E (fish-borne) botulism: a review |journal=Japanese Journal of Medical Science and Biology |date=1957 |volume=10 |issue=6 |page=383-395 |doi=10.7883/yoken1952.10.383}}</ref>

Food-borne botulism results from contaminated food in which ''[[Clostridium botulinum|C. botulinum]]'' spores have been allowed to germinate in low-oxygen conditions. This typically occurs in improperly prepared home-canned food substances and fermented dishes without adequate salt or acidity.<ref>{{cite web |title=About Botulism |url=https://www.cdc.gov/botulism/about/index.html |website=CDC |access-date=5 January 2025 |language=en-us |date=16 May 2024}}</ref> Given that multiple people often consume food from the same source, it is common for more than a single person to be affected simultaneously. Symptoms usually appear 12–36 hours after eating, but can also appear within 6 hours to 10 days.<ref>{{cite web | title = Facts About Botulism | url = http://www.bt.cdc.gov/agent/botulism/factsheet.asp | work = Emergency Preparedness and Response | publisher = [[Centers for Disease Control and Prevention]] | date = 14 October 2001 | access-date = 2 July 2011 | url-status = dead | archive-url = https://web.archive.org/web/20110705125238/http://www.bt.cdc.gov/agent/botulism/factsheet.asp | archive-date = 5 July 2011 }}</ref>

No withdrawal periods have been established for cows affected by Botulism. Lactating cows injected with various doses of Botulinum toxin C have not resulted in detectable Botulinum [[neurotoxin]] in milk produced.<ref>{{Cite journal |last1=Moeller |first1=Robert B. |last2=Puschner |first2=Birgit |last3=Walker |first3=Richard L. |last4=Rocke |first4=Tonie |last5=Galey |first5=Frank D. |last6=Cullor |first6=James S. |last7=Ardans |first7=Alex A. |date=November 2003 |title=Determination of the Median Toxic Dose of Type C Botulinum Toxin in Lactating Dairy Cows |journal=Journal of Veterinary Diagnostic Investigation |volume=15 |issue=6 |pages=523–526 |doi=10.1177/104063870301500603 |pmid=14667014 |doi-access=free }}</ref> Using [[mouse bioassay]]s and [[immunostick ELISA test]]s, botulinum toxin was detected in whole blood and serum but not in milk samples, suggesting that botulinum type C toxin does not enter milk in detectable concentrations.<ref>{{Cite journal |last1=Moeller |first1=R.B. |last2=Puschner |first2=B. |last3=Walker |first3=R.L. |last4=Rocke |first4=T.E. |last5=Smith |first5=S.R. |last6=Cullor |first6=J.S. |last7=Ardans |first7=A.A. |date=June 2009 |title=Short communication: Attempts to identify Clostridium botulinum toxin in milk from three experimentally intoxicated Holstein cows |journal=Journal of Dairy Science |language=en |volume=92 |issue=6 |pages=2529–2533 |doi=10.3168/jds.2008-1919|pmid=19447984 |doi-access=free }}</ref> Cooking and pasteurization denatures botulinum toxin but does not necessarily eliminate spores. Botulinum spores or toxins can find their way into the dairy production chain from the environment.<ref>{{cite journal |last1=Lindström |first1=Miia |last2=Myllykoski |first2=Jan |last3=Sivelä |first3=Seppo |last4=Korkeala |first4=Hannu |title=Clostridium botulinum in Cattle and Dairy Products |journal=Critical Reviews in Food Science and Nutrition |date=19 March 2010 |volume=50 |issue=4 |pages=281–304 |doi=10.1080/10408390802544405 |pmid=20301016 }}</ref> Despite the low risk of milk and meat contamination, the protocol for fatal bovine botulism cases appears to be incineration of carcasses and withholding any potentially contaminated milk from human consumption. It is also advised that raw milk from affected cows should not be consumed by humans or fed to calves.<ref>{{Cite journal |last1=Frye |first1=Elisha A. |last2=Egan |first2=Christina |last3=Perry |first3=Michael J. |last4=Crouch |first4=Esther E. |last5=Burbank |first5=Kyle E. |last6=Kelly |first6=Kathleen M. |date=September 2020 |title=Outbreak of botulism type A in dairy cows detected by MALDI-TOF mass spectrometry |journal=Journal of Veterinary Diagnostic Investigation |volume=32 |issue=5 |pages=722–726 |doi=10.1177/1040638720943127 |pmid=32715936 |pmc=7488966 }}</ref>

There have been several reports of botulism from [[pruno]] wine made of food scraps in prison.<ref>{{cite journal |last1=Adams |first1=Laura E. |last2=Yasmin |first2=Seema |last3=Briggs |first3=Graham |last4=Redden |first4=Kore |last5=Silvas |first5=Suzanne |last6=Anderson |first6=Shoana |last7=Weiss |first7=Joli |last8=Tsang |first8=Clarisse A. |last9=Henke |first9=Evan |last10=Francies |first10=Jessica |last11=Herrick |first11=Kristen |last12=Lira |first12=Rosa |last13=Livar |first13=Eugene |last14=Thompson |first14=Gerald |last15=Sunenshine |first15=Rebecca |last16=Robinson |first16=Byron F. |last17=Bisgard |first17=Kristine M. |last18=Komatsu |first18=Kenneth K. |title=Alcohol Production, Prevention Strategies, and Inmate Knowledge About the Risk for Botulism From Pruno Consumption in a Correctional Facility—Arizona, 2013 |journal=Journal of Correctional Health Care |date=October 2015 |volume=21 |issue=4 |pages=335–342 |doi=10.1177/1078345815599763 |pmid=26285594 |pmc=5549268 }}</ref><ref>{{cite journal |last1=Williams |first1=Benjamin T. |last2=Schlein |first2=Sarah M. |last3=Caravati |first3=E. Martin |last4=Ledyard |first4=Holly |last5=Fix |first5=Megan L. |title=Emergency Department Identification and Critical Care Management of a Utah Prison Botulism Outbreak |journal=Annals of Emergency Medicine |date=July 2014 |volume=64 |issue=1 |pages=26–31 |doi=10.1016/j.annemergmed.2013.10.027 |pmid=24331717 }}</ref><ref>{{cite journal |last1=Rao |first1=Agam K. |last2=Walters |first2=Maroya |last3=Hall |first3=Julia |last4=Guymon |first4=Colleen |last5=Garden |first5=Richard |last6=Sturdy |first6=Pauline |last7=Thurston |first7=Diana |last8=Smith |first8=Lori |last9=Dimond |first9=Melissa |last10=Vitek |first10=Dagmar |last11=Bogdanow |first11=Linda |last12=Hill |first12=Mary |last13=Lin |first13=Neal H. |last14=Luquez |first14=Carolina |last15=Griffin |first15=Patricia M. |title=Outbreak of Botulism Due to Illicit Prison-Brewed Alcohol: Public Health Response to a Serious and Recurrent Problem |journal=Clinical Infectious Diseases |date=2018 |volume=66 |issue=suppl_1 |pages=S85–S91 |doi=10.1093/cid/cix936 |jstor=26524925 |pmid=29293937 |doi-access=free }}</ref> In a Mississippi prison in 2016, prisoners illegally brewed alcohol that led to 31 cases of botulism. The research study done on these cases found the symptoms of mild botulism matched the symptoms severe botulism though the outcomes and progression of the disease were different.<ref>{{cite journal |last1=Marlow |first1=Mariel |last2=Edwards |first2=Leslie |last3=McCrickard |first3=Lindsey |last4=Francois Watkins |first4=Louise K. |last5=Anderson |first5=Jannifer |last6=Hand |first6=Sheryl |last7=Taylor |first7=Kathryn |last8=Dykes |first8=Janet |last9=Byers |first9=Paul |last10=Chatham-Stephens |first10=Kevin |title=Mild Botulism From Illicitly Brewed Alcohol in a Large Prison Outbreak in Mississippi |journal=Frontiers in Public Health |date=24 August 2021 |volume=9 |doi=10.3389/fpubh.2021.716615 |doi-access=free |pmid=34504830 |pmc=8421542 }}</ref>

=== Wound ===
Wound botulism results from the contamination of a wound with the bacteria, which then secrete the toxin into the bloodstream. This has become more common in [[Intravenous drug use (recreational)|intravenous drug users]] since the 1990s, especially people using [[black tar heroin]] and those [[skin popping|injecting heroin into the skin]] rather than the veins.<ref name=Sobel2005/> Wound botulism can also come from a minor wound that is not properly cleaned out; the skin grows over the wound thus trapping the spore in an anaerobic environment and creating botulism. One example was a person who cut their ankle while using a weed eater; as the wound healed over, it trapped a blade of grass and spec of soil under the skin that led to severe botulism requiring hospitalization and rehabilitation for months. Wound botulism accounts for 29% of cases.{{citation needed|date=December 2022}}

=== Inhalation ===
Isolated cases of botulism have been described after [[inhalation]] by laboratory workers.<ref>{{cite web | url= https://www.lecturio.com/concepts/botulism/ | title= Botulism | website= The Lecturio Medical Concept Library | access-date= 5 July 2021 | archive-date= 9 July 2021 | archive-url= https://web.archive.org/web/20210709190757/https://www.lecturio.com/concepts/botulism/ | url-status= live }}</ref>

=== Injection (iatrogenic botulism) ===

Symptoms of botulism may occur away from the injection site of [[botulinum toxin]].<ref name=Product2019/> This may include loss of strength, blurred vision, change of voice, or trouble breathing which can result in death.<ref name=Product2019/> Onset can be hours to weeks after an injection.<ref name=Product2019>{{cite web |title=Botox |url=https://media.allergan.com/actavis/actavis/media/allergan-pdf-documents/product-prescribing/20190620-BOTOX-100-and-200-Units-v3-0USPI1145-v2-0MG1145.pdf |access-date=6 December 2019 |archive-date=5 December 2019 |archive-url=https://web.archive.org/web/20191205180954/https://media.allergan.com/actavis/actavis/media/allergan-pdf-documents/product-prescribing/20190620-BOTOX-100-and-200-Units-v3-0USPI1145-v2-0MG1145.pdf |url-status=live }}</ref> This generally only occurs with inappropriate strengths of botulinum toxin for cosmetic use or due to the larger doses used to treat movement disorders.<ref name=Sobel2005/> However, there are cases where an off-label use of botulinum toxin resulted in severe botulism and death.<ref>{{cite journal |last1=You |first1=Geoffrey |last2=Khan |first2=Ahmed |last3=Shor |first3=Julia |last4=Forester |first4=Gary P. |title=Rapidly Progressive Muscle Paralysis and Acute Respiratory Failure Following Endoscopic Botulinum Toxin Injection |journal=ACG Case Reports Journal |date=2016 |volume=3 |issue=1 |pages=e166 |doi=10.14309/crj.2016.139 |pmid=27921065 |pmc=5126502 }}</ref> Following a 2008 review the FDA added these concerns as a [[boxed warning]].<ref>{{cite web |title=Update of Safety Review of OnabotulinumtoxinA (marketed as Botox/Botox Cosmetic), AbobotulinumtoxinA (marketed as Dysport) and RimabotulinumtoxinB (marketed as Myobloc) |website=[[Food and Drug Administration]] |url=https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/ucm174959.htm |access-date=29 December 2019 |date=15 November 2017|archive-url=https://web.archive.org/web/20171115034159/https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/ucm174959.htm |archive-date=15 November 2017 }}</ref> An international grassroots effort led by NeverTox to assemble the people experiencing Iatrogenic Botulism Poisoning (IBP) and provide education and emotional support serves 39,000 people through a Facebook group who believe themselves to be suffering from adverse events from botulinum toxin injections.<ref>{{cite web | url=https://www.toxsafety.com/resources | title=Resources }}</ref>

=== Lawsuits about botulism against pharmaceuticals ===
Prior to the boxed warning labels that included a disclaimer that botulinum toxin injections could cause botulism, there were a series of lawsuits against the pharmaceutical firms that manufactured injectable botulinum toxin. A Hollywood producer's wife brought a lawsuit after experiencing debilitating adverse events from migraine treatment.<ref>{{cite web | url=https://www.vanityfair.com/style/2003/05/celebrity-dermatologist-200305 | title=The Botoxed and the Boldfaced | website=[[Vanity Fair (magazine)|Vanity Fair]] | date=May 2003 }}</ref> A lawsuit on behalf of a 3-year-old boy who was permanently disabled by a botulinum toxin injection was settled in court during the trial.<ref>{{cite web | url=https://www.biospace.com/allergan-inc-settles-oklahoma-botox-case-during-trial | title=Allergan Inc. Settles Oklahoma Botox Case During Trial | date=27 February 2013 }}</ref> The family of a 7-year-old boy treated with botulinum toxin injections for leg spasms sued after the boy almost died.<ref>{{cite web | url=http://www.burlingtonfreepress.com/story/news/local/2014/11/22/couple-says-botox-almost-killed-boy/19365363/ | title=NY couple: Son almost died from Botox treatment }}</ref> Several families of people who died after treatments with botulinum toxin injections brought lawsuits.<ref>{{Cite web|url=https://www.findlaw.com/legalblogs/personal-injury/botox-death-suit-reaches-settlement/|title=Botox Death Suit Reaches Settlement|first=Aleksandr|last=Mashnitski|date=20 September 2010|website=FindLaw}}</ref><ref>{{cite web|url=https://www.reuters.com/article/us-allergan-botox-trial/allergan-wins-new-trial-in-big-botox-damages%20case-idUSBRE85019Y20120601/|title=Allergan wins new trial in big Botox damages case}}</ref><ref>{{cite web | url=https://www.burlingtonfreepress.com/story/news/local/2015/04/14/second-vermont-botox-lawsuit/25737279/ | title=Second Botox lawsuit filed in Vermont }}</ref><ref>{{cite web | url=https://abcnews.go.com/Health/Wellness/botox-led-daughters-death-mother-claims/story?id=9680014 | title=Could Alleged Botox Death Scare Patients? | website=[[ABC News (United States)|ABC News]] }}</ref> One lawsuit prevailed for the plaintiff who was awarded compensation of  million; the plaintiff was a physician who was diagnosed with botulism by thirteen neurologists at the NIH.<ref>{{cite web | url=https://kfor.com/news/health/investigation-allergan-botox/ | title=INVESTIGATION: What many don't know about popular wrinkle drug | date=4 May 2013 }}</ref> Deposition video from that lawsuit quotes a pharmaceutical executive stating that "Botox doesn't cause botulism."<ref>{{cite web | url=https://www.youtube.com/watch?v=e8wfajAovto&t=212s | title=16x9 - Worry Lines: Botox investigation | website=[[YouTube]] | date=25 August 2012 }}</ref>

== Mechanism ==
The toxin is the protein [[botulinum toxin]] produced under anaerobic conditions (where there is no oxygen)<ref>{{Cite web |date=1 June 2021 |title=About Botulism {{!}} Botulism {{!}} CDC |url=https://www.cdc.gov/botulism/general.html |access-date=18 May 2023 |website=www.cdc.gov |language=en-us}}</ref> by the bacterium ''[[Clostridium botulinum]]''.<ref>{{Cite web |title=Botulism |url=https://www.who.int/news-room/fact-sheets/detail/botulism |access-date=18 May 2023 |website=www.who.int |language=en}}</ref>

''[[Clostridium botulinum]]'' is a large anaerobic Gram-positive bacillus that forms subterminal [[endospores]].<ref name="ic.ucsc.edu">{{cite web |url=http://ic.ucsc.edu/~flegal/etox80e/SpecTopics/botulism.html |title=ETOX 80E -Botulism |publisher=University of California, Santa Cruz |access-date=12 February 2014 |url-status=live |archive-url=https://web.archive.org/web/20130509030327/http://ic.ucsc.edu/~flegal/etox80e/SpecTopics/botulism.html |archive-date=9 May 2013 }}</ref>

There are eight serological varieties of the bacterium denoted by the letters A to H. The toxin from all of these acts in the same way and produces similar symptoms: the motor nerve endings are prevented from releasing acetylcholine, causing flaccid paralysis and symptoms of blurred vision, ptosis, nausea, vomiting, diarrhea or constipation, cramps, and respiratory difficulty.{{citation needed|date=December 2022}}

Botulinum toxin is broken into eight neurotoxins (labeled as types A, B, C [C1, C2], D, E, F, and G), which are [[antigenic variation|antigenically]] and [[serological]]ly distinct but structurally similar. Human botulism is caused mainly by types A, B, E, and (rarely) F. Types C and D cause toxicity only in other animals.<ref>{{EMedicine|article|325451|Botulinum Toxin}}</ref>

In October 2013, scientists released news of the discovery of type H, the first new botulism neurotoxin found in forty years. However, further studies showed type H to be a chimeric toxin composed of parts of types F and A (FA).<ref name="Maslanka_2016">{{cite journal | vauthors = Maslanka SE, Lúquez C, Dykes JK, Tepp WH, Pier CL, Pellett S, Raphael BH, Kalb SR, Barr JR, Rao A, Johnson EA | title = A Novel Botulinum Neurotoxin, Previously Reported as Serotype H, Has a Hybrid-Like Structure With Regions of Similarity to the Structures of Serotypes A and F and Is Neutralized With Serotype A Antitoxin | journal = The Journal of Infectious Diseases | volume = 213 | issue = 3 | pages = 379–85 | date = February 2016 | pmid = 26068781 | pmc = 4704661 | doi = 10.1093/infdis/jiv327 }}</ref>

Some types produce a characteristic putrefactive smell and digest meat (types A and some of B and F); these are said to be [[proteolytic]]; type E and some types of B, C, D and F are nonproteolytic and can go undetected because there is no strong odor associated with them.<ref name="ic.ucsc.edu" />

When the bacteria are under stress, they develop spores, which are inert. Their natural habitats are in the soil, in the silt that comprises the bottom sediment of streams, lakes, and coastal waters and ocean, while some types are natural inhabitants of the intestinal tracts of mammals (e.g., horses, cattle, humans), and are present in their excreta. The spores can survive in their inert form for many years.<ref>{{cite journal | vauthors = Ward BQ, Carroll BJ, Garrett ES, Reese GB | title = Survey of the U.S. Gulf Coast for the presence of Clostridium botulinum | journal = Applied Microbiology | volume = 15 | issue = 3 | pages = 629–36 | date = May 1967 | pmid = 5340653 | pmc = 546991 | doi = 10.1128/aem.15.3.629-636.1967 }}</ref>

Toxin is produced by the bacteria when environmental conditions are favourable for the spores to replicate and grow, but the gene that encodes for the toxin protein is actually carried by a virus or [[bacteriophage|phage]] that infects the bacteria. Little is known about the natural factors that control phage infection and replication within the bacteria.<ref>{{cite book |chapter-url=http://www.nwhc.usgs.gov/publications/field_manual/chapter_38.pdf |title=Field Manual of Wildlife Disease |chapter=38: Avian Botulism |access-date=14 June 2016 |publisher=U.S. Geological Survey |vauthors=Franson JC, Friend M |isbn=978-0-607-88096-0 |url-status=live |archive-url=https://web.archive.org/web/20160809134547/http://www.nwhc.usgs.gov/publications/field_manual/chapter_38.pdf |archive-date=9 August 2016 |year=1999 }}</ref>

The spores require warm temperatures, a protein source, an anaerobic environment, and moisture in order to become active and produce toxin. In the wild, decomposing vegetation and invertebrates combined with warm temperatures can provide ideal conditions for the botulism bacteria to activate and produce toxin that may affect feeding birds and other animals. Spores are not killed by boiling, but botulism is uncommon because special, rarely obtained conditions are necessary for botulinum toxin production from C. botulinum spores, including an anaerobic, low-salt, low-acid, low-sugar environment at ambient temperatures.<ref>{{cite book |author=International Commission on Microbiological Specifications for Foods |year=1996 |chapter=Clostridium botulinum |pages=66–111 |chapter-url=https://books.google.com/books?id=lxycHnaPfCYC&pg=PA66 |title=Microorganisms in Foods 5: Characteristics of Microbial Pathogens |publisher=Springer |isbn=978-0-412-47350-0 |access-date=3 August 2015 |archive-date=28 November 2015 |archive-url=https://web.archive.org/web/20151128145935/https://books.google.com/books?id=lxycHnaPfCYC&pg=PA66 |url-status=live }} quoted in {{cite journal | title = Botulism from drinking prison-made illicit alcohol - Utah 2011 | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 61 | issue = 39 | pages = 782–4 | date = October 2012 | pmid = 23034585 | url = https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6139a2.htm | archive-url = https://web.archive.org/web/20170606173113/https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6139a2.htm | url-status = live | archive-date = 6 June 2017 | author1 = Centers for Disease Control Prevention (CDC) }}</ref>

Botulinum inhibits the release within the nervous system of [[acetylcholine]], a neurotransmitter, responsible for communication between motor neurons and muscle cells. All forms of botulism lead to [[paralysis]] that typically starts with the muscles of the face and then spreads towards the limbs.<ref name=Sobel2005/> In severe forms, botulism leads to paralysis of the breathing muscles and causes [[respiratory failure]]. In light of this life-threatening complication, all suspected cases of botulism are treated as [[medical emergency|medical emergencies]], and public health officials are usually involved to identify the source and take steps to prevent further cases from occurring.<ref name=Sobel2005/>

Botulinum toxin A and E specifically cleave the SNAP-25, whereas serotype B, D, F and G cut synaptobrevin. Serotype C cleaves both SNAP-25 and syntaxin. This causes blockade of neurotransmitter [[acetylcholine]] release,<ref>{{cite journal |last1=Tighe |first1=Ann P. |last2=Schiavo |first2=Giampietro |title=Botulinum neurotoxins: Mechanism of action |journal=Toxicon |date=June 2013 |volume=67 |pages=87–93 |doi=10.1016/j.toxicon.2012.11.011 |pmid=23201505 |bibcode=2013Txcn...67...87T }}</ref> ultimately leading to paralysis.

== Diagnosis ==
For botulism in babies, diagnosis should be made on signs and symptoms. Confirmation of the diagnosis is made by testing of a [[stool test|stool]] or [[enema]] specimen with the mouse [[bioassay]].

In people whose history and physical examination suggest botulism, these clues are often not enough to allow a diagnosis. Other diseases such as [[Guillain–Barré syndrome]], [[stroke]], and [[myasthenia gravis]] can appear similar to botulism, and special tests may be needed to exclude these other conditions. These tests may include a [[brain scan]], [[cerebrospinal fluid]] examination, nerve conduction test ([[electromyography]], or EMG), and an [[edrophonium]] chloride (Tensilon) test for [[myasthenia gravis]]. A definite diagnosis can be made if botulinum toxin is identified in the food, stomach or intestinal contents, vomit or feces. The toxin is occasionally found in the blood in [[peracute]] cases. Botulinum toxin can be detected by a variety of techniques, including [[enzyme-linked immunosorbent assay]]s (ELISAs), [[electrochemiluminescent]] (ECL) tests and mouse inoculation or feeding trials. The toxins can be typed with neutralization tests in mice. In toxicoinfectious botulism, the organism can be cultured from tissues. On egg yolk medium, toxin-producing colonies usually display surface iridescence that extends beyond the colony.<ref>{{cite book| vauthors = Weber JT |chapter=Botulism |title=Infectious Diseases |edition=5th | veditors = Hpeprich PD |publisher=[[J. B. Lippincott & Co.|J. B. Lippincott Company]] |date=1994 |pages=1185–94}}</ref>

== Prevention ==
Although the vegetative form of the bacteria is destroyed by boiling,<ref name="whodestroy">{{cite web |url=https://www.who.int/mediacentre/factsheets/fs270/en/ |title=Botulism |publisher=WHO |access-date=12 February 2014 |url-status=live |archive-url=https://web.archive.org/web/20140216031452/http://www.who.int/mediacentre/factsheets/fs270/en/ |archive-date=16 February 2014 }}</ref><ref>{{cite web |url=http://www.fsai.ie/faqs/botulism.html |title=Foodborne Botulism FAQ |publisher=Food Safety Authority of Ireland |date=15 November 2011 |access-date=20 May 2014 |url-status=dead |archive-url=https://web.archive.org/web/20140521032214/http://www.fsai.ie/faqs/botulism.html |archive-date=21 May 2014 }}</ref> the spore itself is not killed by the temperatures reached with normal sea-level-pressure boiling, leaving it free to grow and again produce the toxin when conditions are right.<ref>{{cite news |url=https://www.thestar.com/news/gta/2008/02/21/couple_suing_over_tainted_juice.html |title=Couple suing over tainted juice |newspaper=Toronto Star |first1=Isabel |last1=Teotonio |date=21 February 2008 |url-status=live |archive-url=https://web.archive.org/web/20160304062530/http://www.thestar.com/news/gta/2008/02/21/couple_suing_over_tainted_juice.html |archive-date=4 March 2016 }}</ref><ref>{{cite web |url=https://www.fda.gov/food/guidanceregulation/guidancedocumentsregulatoryinformation/ucm072481.htm |date=June 2007 |title=Guidance for Industry: Refrigerated Carrot Juice and Other Refrigerated Low-Acid Juices |publisher=FDA |url-status=dead |archive-url=https://web.archive.org/web/20150924165600/https://www.fda.gov/food/guidanceregulation/guidancedocumentsregulatoryinformation/ucm072481.htm |archive-date=24 September 2015 }}</ref><ref>{{cite web|url=https://www.byoulaserclinic.com/what-is-the-difference-and-similarity-between-botox-and-dysport/|date=August 2021|title=Similarities Between Botox and Dysport|url-status=live|archive-url=https://web.archive.org/web/20210820180909/https://www.byoulaserclinic.com/what-is-the-difference-and-similarity-between-botox-and-dysport/|archive-date=20 August 2021|access-date=20 August 2021}}</ref>

A recommended prevention measure for infant botulism is to avoid giving honey to infants less than 12 months of age, as botulinum spores are often present. In older children and adults the normal intestinal bacteria suppress development of ''C. botulinum''.<ref name="honey-risk">{{cite journal | vauthors = Arnon SS, Midura TF, Damus K, Thompson B, Wood RM, Chin J | title = Honey and other environmental risk factors for infant botulism | journal = The Journal of Pediatrics | volume = 94 | issue = 2 | pages = 331–6 | date = February 1979 | pmid = 368301 | doi = 10.1016/S0022-3476(79)80863-X }}</ref>

While commercially canned goods are required{{Citation needed|reason=Critical health related fact, probably right, but citation to an authoritative source should be added|date=August 2022}} to undergo a "botulinum cook" in a pressure cooker at {{convert|121|°C|°F}} for 3 minutes,<ref>{{cite web |title=Importance Of F0 Value In Sterilization {{!}} TERRA Food-Tech |url=https://www.terrafoodtech.com/en/importance-of-f0-value-in-sterilization/ |website=www.terrafoodtech.com |date=24 May 2022}}</ref> and thus rarely cause botulism, there have been notable exceptions. Two were the 1978 Alaskan salmon outbreak and the 2007 [[Castleberry's Food Company]] outbreak. Foodborne botulism is the rarest form, accounting for only around 15% of cases (US)<ref name="cdc.gov" /> and has more frequently resulted from [[Home canning|home-canned]] foods with low acid content, such as [[carrot juice]], [[asparagus (vegetable)|asparagus]], green [[bean]]s, [[beet]]s, and [[maize|corn]]. However, outbreaks of botulism have resulted from more unusual sources. In July 2002, fourteen [[Alaska]]ns ate ''muktuk'' ([[whale meat]]) from a [[beached whale]], and eight of them developed symptoms of botulism, two of them requiring [[mechanical ventilation]].<ref>{{cite journal | title = Outbreak of botulism type E associated with eating a beached whale--Western Alaska, July 2002 | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 52 | issue = 2 | pages = 24–6 | date = January 2003 | pmid = 12608715 | url = https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5202a2.htm | archive-url = https://web.archive.org/web/20170625130732/https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5202a2.htm | url-status = live | archive-date = 25 June 2017 | author1 = Centers for Disease Control Prevention (CDC) }}</ref>

Other, much rarer sources of infection (about every decade in the US<ref name="cdc.gov" />) include [[garlic]] or herbs<ref name="Infusions">{{cite web|url=http://www.ext.colostate.edu/safefood/newsltr/v2n4s08.html |title=Oil Infusions and the Risk of Botulism |publisher=Colorado State University Cooperative Extension |website=Safefood News |date=1998 |volume=2 |issue=4 |url-status=dead |archive-url=https://web.archive.org/web/20130404000129/http://www.ext.colostate.edu/safefood/newsltr/v2n4s08.html |archive-date=4 April 2013}}</ref> stored covered in [[Cooking oil|oil]] without [[Souring|acidification]],<ref>{{cite journal | title = Update: international outbreak of restaurant-associated botulism--Vancouver, British Columbia, Canada | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 34 | issue = 41 | page = 643 | date = October 1985 | pmid = 3930945 | url = https://www.cdc.gov/mmwr/preview/mmwrhtml/00000627.htm | archive-url = https://web.archive.org/web/20170625230758/https://www.cdc.gov/mmwr/preview/mmwrhtml/00000627.htm | url-status = live | archive-date = 25 June 2017 | author1 = Centers for Disease Control (CDC) }}</ref> [[capsicum|chili peppers]],<ref name="cdc.gov">{{cite web |url=https://www.cdc.gov/ncidod/aip/research/bot.html |title=Arctic Investigations Program – DPEI |publisher=Centers for Disease Control and Prevention (CDC) |date=1 April 2011 |access-date=12 February 2014 |url-status=dead |archive-url=https://web.archive.org/web/20101016104945/http://www.cdc.gov/ncidod/aip/research/bot.html |archive-date=16 October 2010 }}</ref> improperly handled baked potatoes wrapped in [[aluminum]] foil,<ref name="cdc.gov" /> tomatoes,<ref name="cdc.gov" /> and home-canned or [[fermented fish]].

When canning or preserving food at home, attention should be paid to hygiene, pressure, temperature, refrigeration and storage. When making home preserves, only acidic fruit such as apples, pears, stone fruits and berries should be used. Tropical fruit and tomatoes are low in acidity and must have some acidity added before they are canned.<ref>{{cite web |url=http://www.public.health.wa.gov.au/2/594/2/botulism_fact_sheet.pm |title=Botulism fact sheet |publisher=Department of Public Health, Western Australia |access-date=12 February 2014 |url-status=dead |archive-url=https://web.archive.org/web/20131230234538/http://www.public.health.wa.gov.au/2/594/2/botulism_fact_sheet.pm |archive-date=30 December 2013 }}</ref>

Low-acid foods have pH values higher than 4.6. They include red meats, seafood, poultry, milk, and all fresh vegetables except for most tomatoes. Most mixtures of low-acid and acid foods also have pH values above 4.6 unless their recipes include enough lemon juice, citric acid, or vinegar to make them acidic. Acid foods have a pH of 4.6 or lower. They include fruits, pickles, sauerkraut, jams, jellies, marmalades, and fruit butters.<ref name="usda-canning-guide1"/>

Although tomatoes usually are considered an acid food, some are now known to have pH values slightly above 4.6. Figs also have pH values slightly above 4.6. Therefore, if they are to be canned as acid foods, these products must be acidified to a pH of 4.6 or lower with lemon juice or citric acid. Properly acidified tomatoes and figs are acid foods and can be safely processed in a boiling-water canner.<ref name="usda-canning-guide1">{{cite web |url=https://nchfp.uga.edu/publications/usda/GUIDE01_HomeCan_rev0715.pdf |title=Complete Guide to Home Canning; Guide 1: Principles of Home Canning |publisher=United States Department of Agriculture |access-date=15 August 2018 |url-status=live |archive-url=https://web.archive.org/web/20180127101352/https://nchfp.uga.edu/publications/usda/GUIDE01_HomeCan_rev0715.pdf |archive-date=27 January 2018 }}</ref>

Oils infused with fresh garlic or herbs should be acidified and refrigerated. Potatoes which have been baked while wrapped in aluminum foil should be kept hot until served or refrigerated. Because the botulism toxin is destroyed by high temperatures, home-canned foods are best boiled for 10 minutes before eating.<ref>{{cite web|last=U.S. Food and Drug Administration|title=Bad Bug Book: Foodborne Pathogenic Microorganisms and Natural Toxins Handbook Clostridium botulinum|website=[[Food and Drug Administration]]|url=https://www.fda.gov/food/foodsafety/foodborneillness/foodborneillnessfoodbornepathogensnaturaltoxins/badbugbook/ucm070000.htm|access-date=12 January 2013|url-status=dead|archive-url=https://web.archive.org/web/20121129060830/https://www.fda.gov/Food/FoodSafety/FoodborneIllness/FoodborneIllnessFoodbornePathogensNaturalToxins/BadBugBook/ucm070000.htm|archive-date=29 November 2012}}</ref> Metal cans containing food in which bacteria are growing may bulge outwards due to gas production from bacterial growth or the food inside may be foamy or have a bad odor; cans with any of these signs should be discarded.<ref name="IFAS">{{cite web|last1=Schneider|first1=Keith R.|last2=Silverberg|first2=Rachael|last3=Chang|first3=Alexandra|last4=Goodrich Schneider|first4=Renée M. |title=Preventing Foodborne Illness: Clostridium botulinum|url=http://edis.ifas.ufl.edu/fs104|website=edis.ifas.ufl.edu|publisher=University of Florida IFAS Extension|access-date=7 February 2017|language=en|date=9 January 2015|url-status=live|archive-url=https://web.archive.org/web/20170208133143/http://edis.ifas.ufl.edu/fs104|archive-date=8 February 2017}}</ref><ref name="HGIC">{{cite web|title=Botulism Factsheet (HGIC 3680)|url=https://hgic.clemson.edu/factsheet/botulism/|publisher=Clemson Cooperative Extension - College of Agriculture, Forestry and Life Sciences - Home & Garden Information Center (HGIC)|access-date=9 February 2022|language=en|date=13 May 2020|url-status=live|archive-url=https://web.archive.org/web/20210123173114/https://hgic.clemson.edu/factsheet/botulism/|archive-date=23 January 2021}}</ref>

Any container of food which has been heat-treated and then assumed to be airtight which shows signs of not being so, e.g., metal cans with pinprick holes from rust or mechanical damage, should be discarded. Contamination of a canned food solely with ''C. botulinum'' may not cause any visual defects to the container, such as bulging. Only assurance of sufficient thermal processing during production, and absence of a route for subsequent contamination, should be used as indicators of food safety.

The addition of [[Nitrite#Nitrite in food preservation and biochemistry|nitrites]] and [[nitrates]] to processed meats such as ham, bacon, and sausages reduces growth and toxin production of ''C. botulinum''.<ref>{{cite journal | vauthors = Christiansen LN, Johnston RW, Kautter DA, Howard JW, Aunan WJ | title = Effect of nitrite and nitrate on toxin production by Clostridium botulinum and on nitrosamine formation in perishable canned comminuted cured meat | journal = Applied Microbiology | volume = 25 | issue = 3 | pages = 357–62 | date = March 1973 | pmid = 4572891 | pmc = 380811 | doi = 10.1128/AEM.25.3.357-362.1973 }}</ref><ref>{{Cite journal |last1=Lee |first1=Soomin |last2=Lee |first2=Heeyoung |last3=Kim |first3=Sejeong |last4=Lee |first4=Jeeyeon |last5=Ha |first5=Jimyeong |last6=Choi |first6=Yukyung |last7=Oh |first7=Hyemin |last8=Choi |first8=Kyoung-Hee |last9=Yoon |first9=Yohan |date=August 2018 |title=Microbiological safety of processed meat products formulated with low nitrite concentration — A review |journal=Asian-Australasian Journal of Animal Sciences |volume=31 |issue=8 |pages=1073–1077 |doi=10.5713/ajas.17.0675 |pmc=6043430 |pmid=29531192}}</ref> Other food additives (such as [[Lactic acid|lactate]] and [[sorbate]]) provide similar protection against bacteria, but do not provide a desirable pink color.<ref>{{cite journal | vauthors = Seward RA, Deibel RH, Lindsay RC | title = Effects of potassium sorbate and other antibotulinal agents on germination and outgrowth of Clostridium botulinum type E spores in microcultures | journal = Applied and Environmental Microbiology | volume = 44 | issue = 5 | pages = 1212–1221 | date = November 1982 | pmid = 6758699 | pmc = 242170 | doi = 10.1128/AEM.44.5.1212-1221.1982 | bibcode = 1982ApEnM..44.1212S}}</ref><ref>{{cite journal | vauthors = Sofos JN, Busta FF, Bhothipaksa K, Allen CE, Robach MC, Paquette MW |title=Effects of various concentrations of sodium nitrite and potassium sorbate on Clostridium botulinum toxin production in commercially prepared bacon |journal=Journal of Food Science |date=September 1980 |volume=45 |issue=5 |pages=1285–1292 |doi=10.1111/j.1365-2621.1980.tb06539.x}}</ref><ref>{{cite journal |last1=Linton |first1=Mark |last2=Connolly |first2=Malachy |last3=Houston |first3=Laurette |last4=Patterson |first4=Margaret F. |title=The control of Clostridium botulinum during extended storage of pressure-treated, cooked chicken |journal=Food Control |date=March 2014 |volume=37 |pages=104–108 |doi=10.1016/j.foodcont.2013.09.042}}</ref><ref>{{cite journal |last1=Alnoman |first1=Maryam |last2=Udompijitkul |first2=Pathima |last3=Paredes-Sabja |first3=Daniel |last4=Sarker |first4=Mahfuzur R. |title=The inhibitory effects of sorbate and benzoate against Clostridium perfringens type A isolates |journal=Food Microbiology |date=June 2015 |volume=48 |pages=89–98 |doi=10.1016/j.fm.2014.12.007}}</ref>

=== Vaccine ===
A [[vaccine]] for botulism exists, but it is rarely used.<ref name=WHO2018>{{cite web|title=Fact sheets - Botulism|url=https://www.who.int/news-room/fact-sheets/detail/botulism|work=World Health Organization|access-date=23 March 2019|date=10 January 2018|archive-date=23 March 2019|archive-url=https://web.archive.org/web/20190323162924/https://www.who.int/news-room/fact-sheets/detail/botulism|url-status=live}}</ref> The US CDC discontinued use of the vaccine in 2011 when the available product showed declining potency and an increase in moderate local reactions to booster shots.<ref>{{cite web |title=Notice of CDC's Discontinuation of Investigational Pentavalent (ABCDE) Botulinum Toxoid Vaccine |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6042a3.htm |work=CDC|access-date=5 May 2025|date=28 October 2011}}</ref> As of 2017 work to develop a better vaccine was being carried out, but the US FDA had not approved any vaccine against botulism.<ref>{{cite journal |last1=Webb |first1=Robert P |last2=Smith |first2=Leonard A |title=What next for botulism vaccine development? |journal=Expert Review of Vaccines |date=May 2013 |volume=12 |issue=5 |pages=481–492 |doi=10.1586/erv.13.37 |pmid=23659297 }}</ref><ref>{{cite journal | vauthors = Sundeen G, Barbieri JT | title = Vaccines against Botulism | journal = Toxins | volume = 9 | issue = 9 | page = 268 | date = September 2017 | pmid = 28869493 | pmc = 5618201 | doi = 10.3390/toxins9090268 | doi-access = free }}</ref>

== Treatment ==
Botulism is generally treated with botulism [[antitoxin]] and supportive care.<ref name=WHO2018/>

Supportive care for botulism includes monitoring of respiratory function. Respiratory failure due to [[paralysis]] may require [[mechanical ventilation]] for 2 to 8 weeks, plus intensive medical and nursing care. After this time, paralysis generally improves as new [[neuromuscular junction|neuromuscular connections]] are formed.<ref name=CDCClinicians>{{cite web |title=Botulism: Treatment Overview for Clinicians |publisher=U.S. Centers for Disease Control and Prevention (CDC) |date=2006 |url=http://emergency.cdc.gov/agent/Botulism/clinicians/treatment.asp |access-date=13 January 2016 |url-status=live |archive-url=https://web.archive.org/web/20160304104042/http://emergency.cdc.gov/agent/Botulism/clinicians/treatment.asp |archive-date=4 March 2016 }}</ref>

In some abdominal cases, physicians may try to remove contaminated food still in the digestive tract by inducing vomiting or using [[enema]]s. Wounds should be treated, usually surgically, to remove the source of the toxin-producing bacteria.<ref>{{cite journal | vauthors = Brook I | title = Botulism: the challenge of diagnosis and treatment | journal = Reviews in Neurological Diseases | volume = 3 | issue = 4 | pages = 182–9 | year = 2006 | pmid = 17224901 }}</ref>

=== Antitoxin ===
Botulinum {{anchor|antitoxin}}antitoxin consists of [[Antibody|antibodies]] that neutralize botulinum toxin in the [[circulatory system]] by [[passive immunity|passive immunization]].<ref name="O'HoroHarper2018">{{cite journal | vauthors = O'Horo JC, Harper EP, El Rafei A, Ali R, DeSimone DC, Sakusic A, Abu Saleh OM, Marcelin JR, Tan EM, Rao AK, Sobel J, Tosh PK | title = Efficacy of Antitoxin Therapy in Treating Patients With Foodborne Botulism: A Systematic Review and Meta-analysis of Cases, 1923-2016 | journal = Clinical Infectious Diseases | volume = 66 | issue = suppl_1 | pages = S43–S56 | pmid = 29293927 | pmc = 5850555 | doi = 10.1093/cid/cix815 | year = 2018 }}</ref> This prevents additional toxin from binding to the neuromuscular junction, but does not reverse any already inflicted paralysis.<ref name="O'HoroHarper2018"/>

In adults, a trivalent antitoxin containing antibodies raised against botulinum toxin types A, B, and E is used most commonly; however, a [[heptavalent botulism antitoxin]] has also been developed and was approved by the U.S. [[FDA]] in 2013.<ref name="Arnon" /><ref name=FDA2013>{{cite web|title=FDA approves first Botulism Antitoxin for use in neutralizing all seven known botulinum nerve toxin serotypes|date=22 March 2013|url=https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm345128.htm|website=FDA News Release|publisher=U.S. FDA|access-date=14 January 2016|url-status=dead|archive-url=https://web.archive.org/web/20160101121905/https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm345128.htm|archive-date=1 January 2016}}</ref> In infants, horse-derived antitoxin is sometimes avoided for fear of infants developing [[serum sickness]] or lasting [[hypersensitivity]] to horse-derived proteins.<ref name=deCuetos2011>{{cite journal | vauthors = Vanella de Cuetos EE, Fernandez RA, Bianco MI, Sartori OJ, Piovano ML, Lúquez C, de Jong LI | title = Equine botulinum antitoxin for the treatment of infant botulism | journal = Clinical and Vaccine Immunology | volume = 18 | issue = 11 | pages = 1845–9 | date = November 2011 | pmid = 21918119 | pmc = 3209035 | doi = 10.1128/CVI.05261-11 }}</ref> To avoid this, a human-derived antitoxin has been developed and approved by the U.S. FDA in 2003 for the treatment of infant botulism.<ref name=Arnon2006>{{cite journal | vauthors = Arnon SS, Schechter R, Maslanka SE, Jewell NP, Hatheway CL | title = Human botulism immune globulin for the treatment of infant botulism | journal = The New England Journal of Medicine | volume = 354 | issue = 5 | pages = 462–71 | date = February 2006 | pmid = 16452558 | doi = 10.1056/NEJMoa051926 | doi-access = free }}</ref> This human-derived antitoxin has been shown to be both safe and effective for the treatment of infant botulism.<ref name=Arnon2006 /><ref name=":0">{{cite journal |last1=Chalk |first1=Colin H |last2=Benstead |first2=Tim J |last3=Pound |first3=Joshua D |last4=Keezer |first4=Mark R |title=Medical treatment for botulism |journal=Cochrane Database of Systematic Reviews |date=17 April 2019 |volume=4 |issue=4 |pages=CD008123 |doi=10.1002/14651858.CD008123.pub4 |pmid=30993666 |pmc=6468196 }}</ref> However, the danger of equine-derived antitoxin to infants has not been clearly established, and one study showed the equine-derived antitoxin to be both safe and effective for the treatment of infant botulism.<ref name=deCuetos2011 />

Trivalent (A,B,E) botulinum antitoxin is derived from equine sources utilizing whole [[Antibody|antibodies]] (Fab and Fc portions). In the United States, this antitoxin is available from the local health department via the [[Centers for Disease Control|CDC]]. The second antitoxin, [[Heptavalent botulism antitoxin|heptavalent (A,B,C,D,E,F,G) botulinum antitoxin]], is derived from "despeciated" equine [[Immunoglobulin G|IgG]] antibodies which have had the Fc portion cleaved off leaving the F(ab')2 portions. This less immunogenic antitoxin is effective against all known strains of botulism where not contraindicated.<ref name="Yu2018">{{cite journal | vauthors = Yu PA, Lin NH, Mahon BE, Sobel J, Yu Y, Mody RK, Gu W, Clements J, Kim HJ, Rao AK | title = Safety and Improved Clinical Outcomes in Patients Treated With New Equine-Derived Heptavalent Botulinum Antitoxin | journal = Clinical Infectious Diseases | volume = 66 | issue = suppl_1 | pages = S57–S64 | pmid = 29293928 | pmc = 5866099 | doi = 10.1093/cid/cix816 | year = 2018 }}</ref>

== Prognosis ==
The paralysis caused by botulism can persist for two to eight weeks, during which supportive care and ventilation may be necessary to keep the patient alive.<ref name=CDCClinicians /> Botulism can be fatal in five to ten percent of people who are affected.<ref name=WHO2018/> However, if left untreated, botulism is fatal in 40 to 50 percent of cases.<ref name=":0" />

Infant botulism typically has no long-term side effects but can be complicated by treatment-associated adverse events. The [[case fatality]] rate is less than two percent for hospitalized babies.<ref>{{cite web |title=Botulism Prognosis |url=https://www.news-medical.net/health/Botulism-Prognosis.aspx |website=Medical Life Sciences |access-date=8 February 2019 |date=2 December 2009 |archive-date=9 February 2019 |archive-url=https://web.archive.org/web/20190209123901/https://www.news-medical.net/health/Botulism-Prognosis.aspx |url-status=live }}</ref>

== Epidemiology ==
Globally, botulism is fairly rare,<ref name=WHO2018/> with approximately 1,000 identified cases yearly.<ref>{{cite web|url=http://www.health.gov.on.ca/en/public/publications/disease/botulism.aspx|title=Botulism - Diseases and Conditions - Publications - Public Information - MOHLTC|publisher=Government of Ontario, Ministry of Health and Long-Term Care|website=www.health.gov.on.ca|language=en|access-date=29 October 2017|archive-date=17 October 2017|archive-url=https://web.archive.org/web/20171017005607/http://www.health.gov.on.ca/en/public/publications/disease/botulism.aspx|url-status=live}}</ref>

=== United States ===
In 2021, health departments reported 273 confirmed and probable cases of botulism in the United States. Of these, 66% were infant botulism, 24% wound botulism, 8% food-borne botulism, and 2% were of other or unknown etiology.<ref name=CDCsurv2021>{{cite web |title=National Botulism Surveillance Summary, United States, 2021 |url=https://www.cdc.gov/botulism/php/national-botulism-surveillance/2021.html |publisher=Centers for Disease Control and Prevention |access-date=12 June 2025}}</ref>  Infant botulism is still predominantly sporadic rather than epidemic, but marked geographic variability persists; California accounted for 45 cases (25%) and Pennsylvania for 21 cases (12%) of the 2021 infant total.<ref name=CDCsurv2021 />

Between 1990 and 2000, the [[Centers for Disease Control and Prevention]] (CDC) recorded 263 individual food-borne cases from 160 botulism events in the United States, with a case-fatality rate of 4%. Thirty-nine percent (103 cases and 58 events) occurred in Alaska, all attributable to traditional Alaska Native foods. In the lower 49 states, home-canned food was implicated in 70 events (~69%), with canned asparagus being the most frequent source. Two restaurant-associated outbreaks affected 25 people. The median number of cases per year was 23 (range 17–43) and the median number of events per year was 14 (range 9–24). The highest incidence rates occurred in Alaska, Idaho, Washington, and Oregon; all other states had an incidence rate of ≤1 case per ten million population.<ref>{{cite journal |vauthors=Sobel J, Tucker N, Sulka A, McLaughlin J, Maslanka S |title=Foodborne botulism in the United States, 1990–2000 |journal=Emerging Infectious Diseases |volume=10 |issue=9 |pages=1606–1611 |date=September 2004 |pmid=15498163 |pmc=3320287 |doi=10.3201/eid1009.030745 |publisher=Centers for Disease Control and Prevention}}</ref>

The number of food-borne and infant botulism cases has remained relatively stable in recent years, but wound botulism continues to rise—largely linked to injection-drug use, particularly black-tar heroin in California.<ref>{{cite journal |vauthors=Passaro DJ, Werner SB, McGee J, Mac Kenzie WR, Vugia DJ |title=Wound botulism associated with black tar heroin among injecting drug users |journal=JAMA |volume=279 |issue=11 |pages=859–863 |date=March 1998 |pmid=9516001 |doi=10.1001/jama.279.11.859}}</ref>

All data regarding botulism antitoxin releases and laboratory confirmation of cases in the US are recorded annually by the Centers for Disease Control and Prevention and published on their website.<ref name="CDCsurv">{{cite web |url=https://www.cdc.gov/nationalsurveillance/botulism_surveillance.html |title=National Case Surveillance: National Botulism Surveillance &#124; CDC National Surveillance |publisher=Centers for Disease Control and Prevention |date=25 June 2013 |access-date=12 February 2014 |url-status=live |archive-url=https://web.archive.org/web/20140130152612/http://www.cdc.gov/nationalsurveillance/botulism_surveillance.html |archive-date=30 January 2014 }}</ref>
* On 2 July 1971, the [[U.S. Food and Drug Administration]] (FDA) released a public warning after learning that a New York man had died and his wife had become seriously ill due to botulism after eating a can of [[Bon Vivant Soup Company|Bon Vivant]] [[vichyssoise]] soup.
* Between 31 March and 6 April 1977, 59 individuals developed type B botulism. All who fell ill had eaten at the same Mexican restaurant in [[Pontiac, Michigan]], and had consumed a hot sauce made with improperly home-canned jalapeño peppers, either by adding it to their food, or by eating [[nachos]] that had been prepared with the hot sauce. The full clinical spectrum (mild symptomatology with neurologic findings through life-threatening ventilatory paralysis) of type B botulism was documented.<ref>{{cite journal | vauthors = Terranova W, Breman JG, Locey RP, Speck S | title = Botulism type B: epidemiologic aspects of an extensive outbreak | journal = American Journal of Epidemiology | volume = 108 | issue = 2 | pages = 150–6 | date = August 1978 | pmid = 707476 | doi = 10.1093/oxfordjournals.aje.a112599 }}</ref>
* In April 1994, the largest outbreak of botulism in the United States since 1978 occurred in [[El Paso, Texas]]. Thirty people were affected; 4 required mechanical ventilation. All ate food from a Greek restaurant. The attack rate among people who ate a potato-based dip was 86% (19/22) compared with 6% (11/176) among people who did not eat the dip. The attack rate among people who ate an eggplant-based dip was 67% (6/9) compared with 13% (24/189) among people who did not. Botulism toxin type A was detected in patients and in both dips. Toxin formation resulted from holding aluminum foil-wrapped baked potatoes at room temperature, apparently for several days, before they were used in the dips. Food handlers should be informed of the potential hazards caused by holding foil-wrapped potatoes at ambient temperatures after cooking.<ref>{{cite journal | vauthors = Angulo FJ, Getz J, Taylor JP, Hendricks KA, Hatheway CL, Barth SS, Solomon HM, Larson AE, Johnson EA, Nickey LN, Ries AA | title = A large outbreak of botulism: the hazardous baked potato | journal = The Journal of Infectious Diseases | volume = 178 | issue = 1 | pages = 172–7 | date = July 1998 | pmid = 9652437 | doi = 10.1086/515615 | doi-access = free }}</ref>
* In 2002, fourteen [[Alaska]]ns ate ''[[muktuk]]'' (whale blubber) from a beached whale, resulting in eight of them developing botulism, with two of the affected requiring [[mechanical ventilation]].<ref>{{cite journal | title = Outbreak of botulism type E associated with eating a beached whale--Western Alaska, July 2002 | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 52 | issue = 2 | pages = 24–6 | date = January 2003 | pmid = 12608715 | url = https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5202a2.htm | author1 = Centers for Disease Control and Prevention (CDC) | access-date = 8 September 2017 | archive-date = 25 June 2017 | archive-url = https://web.archive.org/web/20170625130732/https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5202a2.htm | url-status = live }}</ref>
* Beginning in late June 2007, 8 people contracted botulism poisoning by eating canned food products produced by [[Castleberry's Food Company]] in its [[Augusta, Georgia]] plant. It was later identified that the Castleberry's plant had serious production problems on a specific line of retorts that had under-processed the cans of food. These issues included broken cooking alarms, leaking water valves and inaccurate temperature devices, all the result of poor management of the company. All of the victims were hospitalized and placed on mechanical ventilation. The Castleberry's Food Company outbreak was the first instance of botulism in commercial canned foods in the United States in over 30 years.<ref>{{cite journal |title=Botulism associated with commercially canned chili sauce--Texas and Indiana, July 2007 |journal=MMWR. Morbidity and Mortality Weekly Report |volume=56 |issue=30 |pages=767–9 |date=3 August 2007 |pmid=17673898 |author=Centers for Disease Control and Prevention (CDC) |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5630a4.htm }}</ref>
* One person died, 21 cases were confirmed, and 10 more were suspected in [[Lancaster, Ohio]] when a botulism outbreak occurred after a church potluck in April 2015. The suspected source was a salad made from home-canned potatoes.<ref>{{cite news|title=1 dead in botulism outbreak linked to Ohio church potluck|url=http://fox8.com/2015/04/28/contaminated-potato-salad-to-blame-for-deadly-botulism-at-ohio-church-potluck-dinner/|publisher=CNNWIRE|access-date=19 July 2015|agency=CNN|date=28 April 2015|url-status=live|archive-url=https://web.archive.org/web/20150722103827/http://fox8.com/2015/04/28/contaminated-potato-salad-to-blame-for-deadly-botulism-at-ohio-church-potluck-dinner/|archive-date=22 July 2015}}</ref>
* A botulism outbreak occurred in Northern California in May 2017 after 10 people consumed nacho cheese dip served at a gas station in Sacramento County. One man died as a result of the outbreak.<ref>{{cite news|title=Man dies in Sacramento county botulism outbreak from nacho cheese|url=http://www.kcra.com/article/man-dies-in-sacramento-county-botulism-outbreak-from-nacho-cheese/9909013|publisher=KCRA|access-date=22 May 2017|date=22 May 2017|url-status=live|archive-url=https://web.archive.org/web/20170523000126/http://www.kcra.com/article/man-dies-in-sacramento-county-botulism-outbreak-from-nacho-cheese/9909013|archive-date=23 May 2017}}</ref>

=== United Kingdom ===
The largest recorded outbreak of foodborne botulism in the United Kingdom occurred in June 1989. A total of 27 patients were affected; one patient died. Twenty-five of the patients had eaten one brand of hazelnut yogurt in the week before the onset of symptoms. Control measures included the cessation of all yogurt production by the implicated producer, the withdrawal of the firm's yogurts from sale, the recall of cans of the hazelnut conserve, and advice to the general public to avoid the consumption of all hazelnut yogurts.<ref>{{cite journal | vauthors = O'Mahony M, Mitchell E, Gilbert RJ, Hutchinson DN, Begg NT, Rodhouse JC, Morris JE | title = An outbreak of foodborne botulism associated with contaminated hazelnut yoghurt | journal = Epidemiology and Infection | volume = 104 | issue = 3 | pages = 389–95 | date = June 1990 | pmid = 2347382 | pmc = 2271776 | doi = 10.1017/s0950268800047403 }}</ref>

=== China ===
From 1958 to 1983 there were 986 outbreaks of botulism in China involving 4,377 people with 548 deaths.<ref>{{cite journal |last1=Ying |first1=S. |last2=Shuyan |first2=C. |title=Botulism in China |journal=Clinical Infectious Diseases |date=November 1986 |volume=8 |issue=6 |pages=984–990 |doi=10.1093/clinids/8.6.984 }}</ref>

====Qapqal disease====
After the [[Chinese Communist Revolution]] in 1949, a mysterious plague (named '''Qapqal disease''') was noticed to be affecting several [[Sibe people|Sibe villages]] in [[Qapqal Xibe Autonomous County]]. It was endemic with distinctive epidemic patterns, yet the underlying cause remained unknown for a long period of time.<ref name="nat_med_j_chin">{{cite journal| vauthors = Wu CR, Lian EH, Chen WJ, Liu YZ |title=Botulism: A report for Qapqal disease|journal=National Medical Journal of China|date=1958|volume=44|issue=10|pages=932–942}}</ref> It caused a number of deaths and forced some people to leave the place.<ref name="BMEnvS">{{cite journal | vauthors = Fu SW, Wang CH | title = An overview of type E botulism in China | journal = Biomedical and Environmental Sciences | volume = 21 | issue = 4 | pages = 353–6 | date = August 2008 | pmid = 18837301 | doi = 10.1016/S0895-3988(08)60054-9 | bibcode = 2008BioES..21..353F }}</ref>

In 1958, a team of experts were sent to the area by the Ministry of Health to investigate the cases. The epidemic survey conducted proved that the disease was primarily type A botulism,<ref name="PD">{{cite news|url=http://english.people.com.cn/102759/7567650.html|title=The Xibe ethnic minority|date=12 November 2011|access-date=29 January 2018|newspaper=People's Daily|editor=Huang Beibei|archive-date=24 October 2012|archive-url=https://web.archive.org/web/20121024013056/http://english.people.com.cn/102759/7567650.html|url-status=live}}</ref> with several cases of type B.<ref name="nat_med_j_chin"/> The team also discovered that the source of the botulinum was local fermented grain and beans, as well as a raw meat food called ''mi song hu hu''.<ref name="BMEnvS"/> They promoted the improvement of fermentation techniques among local residents, and thus eliminated the disease.

=== Canada ===
From 1985 to 2005 there were outbreaks causing 91 confirmed cases of foodborne botulism in [[Canada]], 85% of which were in [[Inuit]] communities, especially [[Nunavik]], as well as  [[First Nations in Canada|First Nations]] of the coast of [[British Columbia]], following consumption of traditionally prepared marine mammal and fish products.<ref>{{cite journal | vauthors = Leclair D, Fung J, Isaac-Renton JL, Proulx JF, May-Hadford J, Ellis A, Ashton E, Bekal S, Farber JM, Blanchfield B, Austin JW | title = Foodborne botulism in Canada, 1985-2005 | journal = Emerging Infectious Diseases | volume = 19 | issue = 6 | pages = 961–8 | date = June 2013 | pmid = 23735780 | pmc = 3713816 | doi = 10.3201/eid1906.120873 }}</ref>

=== Ukraine ===
In 2017, there were 70 cases of botulism with 8 deaths in Ukraine. The previous year there were 115 cases with 12 deaths. Most cases were the result of dried fish, a common local [[bar food|drinking snack]].<ref>{{Cite news|url=https://en.lb.ua/news/2017/06/14/3936_eight_ukrainians_died_botulism.html|title=Eight Ukrainians died of botulism in 2017|work=LB.ua|access-date=29 October 2017|archive-date=29 October 2017|archive-url=https://web.archive.org/web/20171029172901/https://en.lb.ua/news/2017/06/14/3936_eight_ukrainians_died_botulism.html|url-status=live}}</ref>

===Vietnam===
In 2020, several cases of botulism were reported in [[Vietnam]]. All of them were related to a product containing contaminated vegetarian [[pâté]]. Some patients were put on life support.<ref>{{cite web|url=https://vnexpress.net/doc-to-trong-pate-minh-chay-duoc-phat-hien-cach-nao-4156196.html|title=Độc tố trong pate Minh Chay được phát hiện cách nào?|access-date=4 September 2020|archive-date=4 September 2020|archive-url=https://web.archive.org/web/20200904001043/https://vnexpress.net/doc-to-trong-pate-minh-chay-duoc-phat-hien-cach-nao-4156196.html|url-status=live}}</ref><ref>{{cite web|url=https://ampe.vnexpress.net/news/news/lethal-bacteria-in-vegan-pate-puts-seven-people-on-life-support-4154479.html|title=Lethal bacteria in vegan pate puts seven people on life support|access-date=4 September 2020|archive-date=22 July 2021|archive-url=https://web.archive.org/web/20210722080831/https://ampe.vnexpress.net/news/news/lethal-bacteria-in-vegan-pate-puts-seven-people-on-life-support-4154479.html|url-status=live}}</ref>

== Other susceptible species ==
Botulism can occur in many [[vertebrate]]s and [[invertebrate]]s. Botulism has been reported in species such as rats, mice, chicken, frogs, toads, goldfish, [[aplysia]], squid, crayfish, [[drosophila]] and leeches.<ref name="pmid10865130">{{cite journal | vauthors = Humeau Y, Doussau F, Grant NJ, Poulain B | title = How botulinum and tetanus neurotoxins block neurotransmitter release | journal = Biochimie | volume = 82 | issue = 5 | pages = 427–46 | date = May 2000 | pmid = 10865130 | doi = 10.1016/S0300-9084(00)00216-9 }}</ref>

Death from botulism is common in waterfowl; an estimated 10,000 to 100,000 birds die of botulism annually. The disease is commonly called "limberneck". In some large outbreaks, a million or more birds may die. Ducks appear to be affected most often. An [[enzootic]] form of duck botulism in the Western US and Canada is known as "western duck sickness".<ref>W.B. Gross (1984), Botulism, in "Diseases of poultry", ed. by M.S. Hofstad, Iowa State University Press, Ames, Iowa, USA; {{ISBN|0-8138-0430-2}}, 8th ed., p. 257</ref> Botulism also affects commercially raised poultry. In chickens, the mortality rate varies from a few birds to 40% of the flock.

Botulism seems to be relatively uncommon in domestic mammals; however, in some parts of the world, epidemics with up to 65% mortality are seen in cattle. The prognosis is poor in large animals that are recumbent.

In cattle, the symptoms may include drooling, restlessness, incoordination, urine retention, [[dysphagia]], and sternal recumbency. Laterally recumbent animals are usually very close to death. In sheep, the symptoms may include drooling, a serous nasal discharge, stiffness, and incoordination. Abdominal respiration may be observed and the tail may switch on the side. As the disease progresses, the limbs may become paralyzed and death may occur. Phosphorus-deficient cattle, especially in southern Africa, are inclined to ingest bones and carrion containing clostridial toxins and consequently develop ''lame sickness'' or ''lamsiekte''.

The clinical signs in horses are similar to cattle. The muscle paralysis is progressive; it usually begins at the hindquarters and gradually moves to the front limbs, neck, and head. Death generally occurs 24 to 72 hours after initial symptoms and results from respiratory paralysis. Some foals are found dead without other clinical signs.

''[[Clostridium botulinum]]'' type C toxin has been incriminated as the cause of [[grass sickness]], a condition in horses which occurs in rainy and hot summers in [[Northern Europe]]. The main symptom is [[pharynx]] paralysis.<ref>{{cite book | vauthors = Blood DC, Henderson JA, Radostits OM | title = Veterinary Medicine | publisher = Baillière Tindall | location = London | edition = 5th | year = 1979 | isbn = 978-0-7020-0718-7 | pages = 1060 (Grass sickness)}}</ref>

[[Domestic dog]]s may develop systemic toxemia after consuming ''C. botulinum'' type C exotoxin or spores within bird carcasses or other infected meat<ref>{{cite web |url=http://www.vetbook.org/wiki/dog/index.php/Botulism |title=Dogs / Botulism |publisher=Vet Book |date=12 August 2012 |access-date=23 August 2013 |url-status=live |archive-url=https://web.archive.org/web/20140221092822/http://www.vetbook.org/wiki/dog/index.php/Botulism |archive-date=21 February 2014 }}</ref> but are generally resistant to the more severe effects of ''C. botulinum'' type C. Symptoms include flaccid muscle paralysis, which can lead to death due to cardiac and respiratory arrest.<ref>{{cite web|url=http://www.merckmanuals.com/vet/poultry/botulism_limberneck_western_duck_sickness/overview_of_botulism_in_poultry.html|title=Overview of botulism in poultry|publisher=Merck Manuals|date=31 March 2012|access-date=23 August 2013|url-status=live|archive-url=https://web.archive.org/web/20140204022428/http://www.merckmanuals.com/vet/poultry/botulism_limberneck_western_duck_sickness/overview_of_botulism_in_poultry.html|archive-date=4 February 2014}}</ref>

Pigs are relatively resistant to botulism. Reported symptoms include anorexia, refusal to drink, vomiting, pupillary dilation, and muscle paralysis.<ref>{{cite book|chapter=Botulism |title=Merck Veterinary Manual |edition=8th | veditors = Aiello SE, Mays A |location=Whitehouse Station, NJ |publisher=Merck and Co. |date=1988 |pages=442–44}}</ref>

In poultry and wild birds, [[flaccid paralysis]] is usually seen in the legs, wings, neck and eyelids. Broiler chickens with the toxicoinfectious form may also have diarrhea with excess [[urate]]s.

=== Prevention in non-human species ===
[[File:Waarschuwingsbord tegen botulisme bij Noordhollandskanaal, Bestanddeelnr 928-7134.jpg|thumb|Sign on the [[Noordhollandsch Kanaal]] in 1976, warning bathers of the presence of ''C. botulinum'' in the water.]]
One of the main routes of exposure for botulism is through the consumption of food contaminated with ''C. botulinum''. Food-borne botulism can be prevented in domestic animals through careful inspection of the feed, purchasing high quality feed from reliable sources, and ensuring proper storage. Poultry litter and animal carcasses are places in which ''C. botulinum'' spores are able to germinate so it is advised to avoid spreading poultry litter or any carcass containing materials on fields producing feed materials due to their potential for supporting ''C. botulinum'' growth.<ref>{{cite journal |last1=Rasetti-Escargueil |first1=Christine |last2=Lemichez |first2=Emmanuel |last3=Popoff |first3=Michel R. |title=Public Health Risk Associated with Botulism as Foodborne Zoonoses |journal=Toxins |date=30 December 2019 |volume=12 |issue=1 |pages=17 |doi=10.3390/toxins12010017 |pmid=31905908 |pmc=7020394 |doi-access=free }}</ref> Additionally, water sources should be checked for dead or dying animals, and fields should be checked for animal remains prior to mowing for hay or silage. Correcting any dietary deficiencies can also prevent animals from consuming contaminated materials such as bones or carcasses.<ref name=":2">{{Cite web |title=Botulism in Animals - Generalized Conditions |url=https://www.merckvetmanual.com/generalized-conditions/clostridial-diseases/botulism-in-animals |access-date=5 May 2023 |website=Merck Veterinary Manual |language=en-US}}</ref> Raw materials used for silage or feed mixed on site should be checked for any sign of mold or rotten appearance. Acidification of animal feed can reduce, but will not eliminate, the risk of toxin formation, especially in carcasses that remain whole.<ref name=":3">{{cite journal |last1=Anniballi |first1=Fabrizio |last2=Fiore |first2=Alfonsina |last3=Löfström |first3=Charlotta |last4=Skarin |first4=Hanna |last5=Auricchio |first5=Bruna |last6=Woudstra |first6=Cédric |last7=Bano |first7=Luca |last8=Segerman |first8=Bo |last9=Koene |first9=Miriam |last10=Båverud |first10=Viveca |last11=Hansen |first11=Trine |last12=Fach |first12=Patrick |last13=Åberg |first13=Annica Tevell |last14=Hedeland |first14=Mikael |last15=Engvall |first15=Eva Olsson |last16=De Medici |first16=Dario |title=Management of Animal Botulism Outbreaks: From Clinical Suspicion to Practical Countermeasures to Prevent or Minimize Outbreaks |journal=Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science |date=September 2013 |volume=11 |issue=S1 |pages=S191–S199 |doi=10.1089/bsp.2012.0089 |pmid=23971806 |url=https://backend.orbit.dtu.dk/ws/files/59874124/bsp_2E2012_2E0089.pdf }}</ref>

==== Vaccines in animals ====
Vaccines have been developed for use in animals to prevent botulism. The availability and approval of these vaccines varies depending on the location, with places experiencing more cases generally having more vaccines available and routine vaccination is more common.<ref name=":3" />

A variety of vaccines have been developed for the prevention of botulism in livestock. Most initial vaccinations require multiple doses at intervals from 2–6 weeks, however, some newer vaccines require only one shot. This mainly depends on the type of vaccine and manufacturers recommendations. All vaccines require annual boosters to maintain immunity. Many of these vaccines can be used on multiple species including cattle, sheep, and goats with some labeled for use in horses and mules as well as separate vaccines for mink. Additionally, vaccination during an outbreak is as beneficial as therapeutic treatment in cattle, and this method is also used in horses and pheasants.<ref name=":3" />

The use of region specific toxoids to immunize animals has been shown to be effective. Toxoid types C and D used to immunize cattle is a useful vaccination method in South Africa and Australia. Toxoid has also been shown to be an appropriate method of immunizing minks and pheasants. In endemic areas, for example Kentucky, vaccination with type B toxoid appears to be effective.<ref name=":2" />

== Use in biological warfare and terrorism ==

=== United States ===
Based on CIA research in [[Fort Detrick]] on [[biological warfare]], [[Anthrax weaponization|anthrax]] and botulism were widely regarded as the two most effective options.<ref name=":1">{{Cite book |last1=Miller |first1=Judith |author-link1=Judith Miller |last2=Engelberg |first2=Stephen |last3=Broad |first3=William |author-link3=William Broad |title=[[Germs: Biological Weapons and America's Secret War]] |publisher=Simon & Schuster |year=2001 |isbn=0-684-87158-0 |language=en}}</ref> During the 1950s, a highly lethal strain was discovered during the biological warfare program.<ref name=":1" /> The [[Central Intelligence Agency|CIA]] continued to hold 5 grams of ''[[Clostridium botulinum]]'', even after [[Statement on Chemical and Biological Defense Policies and Programs|Nixon's ban on biological warfare]] in 1969.<ref name=":1" /> During the [[Gulf War]], when the United States were concerned with a potential biowarfare attack, the efforts around botulism turned to prevention.<ref name=":1" /> However, the only way to make antitoxin in the U.S. until the 1990s was by drawing antibodies from a single horse named [[First Flight (medical research horse)|First Flight]], raising much concern from Pentagon health officials.<ref name=":1" /><ref>{{cite book |last1=Ni |first1=Samantha A. |last2=Brady |first2=Mark F. |title=StatPearls |date=2024 |publisher=StatPearls Publishing |url=https://www.ncbi.nlm.nih.gov/books/NBK534807/ |chapter=Botulism Antitoxin |pmid=30521228 }}</ref>

=== Iraq ===
Iraq has historically possessed many types of germs, including botulism.<ref name=":1" /> The [[ATCC (company)|American Type Culture Collection]] sold 5 variants of botulinum to the [[University of Baghdad]] in May 1986.<ref name=":1" /> 1991 CIA reports also show Iraqis filled shells, warheads, and bombs with biological agents like botulinum (though none have been deployed).<ref name=":1" /> The Iraqi air force used the code name "tea" to refer to botulinum, and it was also referred to as bioweapon "A."<ref name=":1" />

=== Japan ===
A Japanese cult called [[Aum Shinrikyo]] created laboratories that produced biological weapons, specifically botulinum, [[Anthrax weaponization|anthrax]], and [[Q fever]].<ref name=":1" /> From 1990 to 1995, the cult staged numerous unsuccessful bioterrorism attacks on civilians.<ref name=":1" /> They sprayed botulinum toxin from a truck in downtown Tokyo and in the Narita airport, but there are no reported cases of botulism as a result.<ref name=":1" />

== See also ==
* [[List of foodborne illness outbreaks]]
* [[Botulinum toxin]]

== References ==
{{reflist}}

== Further reading ==
* {{cite journal |vauthors=Rao AK, Sobel J, Chatham-Stephens K, Luquez C |title=Clinical Guidelines for Diagnosis and Treatment of Botulism, 2021 |journal=MMWR Recomm Rep |volume=70 |issue=2 |pages=1–30 |date=May 2021 |pmid=33956777 |pmc=8112830 |doi=10.15585/mmwr.rr7002a1 |doi-access=free }}

== External links ==
{{offline|med}}

* [https://www.who.int/news-room/fact-sheets/detail/botulism WHO fact sheet on botulism]
* [https://www.cdc.gov/ncidod/dbmd/diseaseinfo/files/botulism.PDF Botulism in the United States, 1889–1996. Handbook for Epidemiologists, Clinicians and Laboratory Technicians. Centers for Disease Control and Prevention. National Center for Infectious Diseases, Division of Bacterial and Mycotic Diseases 1998.]
* [http://www.nhs.uk/conditions/Botulism/Pages/Introduction.aspx NHS choices] {{Webarchive|url=https://web.archive.org/web/20171012085617/http://www.nhs.uk/conditions/Botulism/Pages/Introduction.aspx |date=12 October 2017 }}
* [http://emergency.cdc.gov/agent/Botulism/clinicians/control.asp CDC Botulism: Control Measures Overview for Clinicians]
* [http://ic.ucsc.edu/~flegal/etox80e/SpecTopics/botulism.html University of California, Santa Cruz Environmental toxicology – Botulism] {{Webarchive|url=https://web.archive.org/web/20130509030327/http://ic.ucsc.edu/~flegal/etox80e/SpecTopics/botulism.html |date=9 May 2013 }}
* [https://www.cdc.gov/nczved/divisions/dfbmd/diseases/botulism/ CDC Botulism FAQ]

{{Medical resources| DiseasesDB = 2811
| ICD11 = {{ICD11|1A11}}
| ICD10 = {{ICD10|A|05|1|a|00}}
| ICD9 = {{ICD9|005.1}},{{ICD9|040.41}},{{ICD9|040.42}}
| ICDO =
| OMIM =
| MedlinePlus = 000598
| eMedicineSubj =article
| eMedicineTopic =213311
| MeshID =D001906
}}
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[[Category:Botulism| ]]
[[Category:Biological agents]]
[[Category:Conditions diagnosed by stool test]]
[[Category:Foodborne illnesses]]
[[Category:Myoneural junction and neuromuscular diseases]]
[[Category:Poultry diseases]]
[[Category:Wikipedia infectious disease articles ready to translate]]
[[Category:Wikipedia medicine articles ready to translate]]