Botulism epidemiology and demographics

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2], Keanu Ngo[3]

Overview

Botulism is a rare, reportable disease that occurs worldwide. In the United States, an average of roughly 200 cases are reported annually, of which approximately three-fourths are infant botulism; foodborne, wound, and "other" (iatrogenic, adult intestinal colonization, and unknown-route) cases make up the remainder.[1][2] Since 1973 the CDC, with the Council of State and Territorial Epidemiologists, has maintained the National Botulism Surveillance System, which classifies laboratory-confirmed cases as foodborne, wound, infant, or other. Because botulism antitoxin in the United States is available only through the CDC, the Alaska Division of Public Health, and (for infants) the California-based Infant Botulism Treatment and Prevention Program, nearly all recognized cases are captured, although mild or misdiagnosed cases are under-ascertained.[3] Case counts differ by ascertainment system: the ~200 cases/year figure derives from CDC National Botulism Surveillance, whereas the ~130–159 infant cases/year figure derives from Infant Botulism Treatment and Prevention Program BIG-IV request data; both are subject to under-ascertainment.[4]

Incidence by transmission category (United States)

Historical baseline surveillance (since 1973) recorded medians of approximately 24 foodborne, 3 wound, and 71 infant cases per year.[5] Contemporary data show infant botulism has risen substantially while foodborne and wound botulism have remained lower or event-driven.

  • Infant botulism (most common form). From 2007–2021, 1947 U.S. cases were recognized (an average of ~130 cases/year), with a statistically significant upward linear trend and a 5-year average of 159 cases/year for 2017–2021. National incidence was 3.3 cases per 100,000 live births.[6]
  • Foodborne botulism. Roughly 15%–25% of annual cases historically; the 2006–2010 annual average was ~17 cases. From 1990–2000, 263 cases occurred in 160 events, with 39% of cases in Alaska.[7][8]
  • Wound botulism. Historically only a few cases per year, but sharply increased since the mid-1990s because of injection drug use. More than 350 U.S. wound botulism cases were reported to the CDC during 2001–2016, of which 292 (>80%) occurred in California.[9]
  • Other (iatrogenic, adult intestinal colonization, unknown route). Adult intestinal colonization botulism is very rare, typically following intestinal surgery or antimicrobial exposure. Cosmetic/therapeutic iatrogenic botulism is an emerging category (below).[10]

Demographics

Age

  • Infant botulism occurs in infants younger than 12 months; in 40-year California surveillance (1345 cases, 1976–2016), 88% were ≤6 months of age, and breastfed infants presented later (median 4.4 months) than formula-fed infants (median 1.7 months).[11]
  • Foodborne and wound botulism occur across all ages; foodborne median age is ~48–53 years. In Alaska Native persons, foodborne incidence is highest in those aged ≥60 years.[12][13]

Sex

Overall, men and women are affected approximately equally. Infant botulism shows no male predominance (51.2% male nationally, 2007–2021; 51% female in California). Foodborne cases have shown a female majority (~59%). Wound botulism among injection drug users has occurred disproportionately in women and Hispanic persons in California.[14][15]

Race/ethnicity

No intrinsic racial predilection is established for botulism overall. Distribution reflects exposure: in California infant botulism, 84.2% of cases were white and 29.4% Hispanic; endemic foodborne botulism in Alaska is concentrated among Alaska Native persons because of traditional food practices.[16][17]

Geographic distribution

  • Infant botulism clusters in the arid West/Southwest and in a temperate mid-Atlantic band. State incidence per 100,000 live births (2007–2021) far exceeds the national rate of 3.3 in Delaware (20.4), Pennsylvania (12.1), New Jersey (7.5), Maryland (6.7), Utah (7.5), California (7.7), and New Mexico (4.7).[18]
  • Foodborne botulism concentrates in the West and in Alaska; historically, more than 50% of U.S. foodborne outbreaks since 1950 have been reported from California, Washington, Colorado, Oregon, and Alaska. Alaska incidence among Alaska Native persons (~6.9/100,000/year) is more than 800 times the overall U.S. rate.[19][20]
  • Wound botulism is overwhelmingly concentrated in California among people who inject black tar heroin.[21]

Toxin-type distribution

  • Foodborne (U.S.): type A ~50–51%, types B and E ~25% each; type E predominates in Alaska (90% of Alaska cases) and the Great Lakes region and is associated with fish/aquatic foods. Type A predominates in western states, type B in eastern states.[22][23]
  • Infant (U.S., 2007–2021): type B 58.3%, type A 39.4%.[24]

Case-fatality

Mortality has fallen markedly with modern intensive care and timely antitoxin. Foodborne case-fatality decreased from ~25% (1950–1959) to ~6% (1990–1996); contemporary overall mortality is approximately 5%. Alaska foodborne case-fatality was 8.2% overall (1947–2007) but ≤4% since 1980, with misdiagnosis associated with higher mortality and delayed antitoxin.[25][26][27]

Emerging iatrogenic (cosmetic) botulism

Iatrogenic botulism from therapeutic and, increasingly, cosmetic botulinum toxin injection is a growing epidemiologic category, driven by counterfeit/unlicensed products, unlicensed practitioners, and off-label high-dose use (e.g., injections for weight loss/gastric procedures). Large single-center series have reported dozens to >160 cosmetic iatrogenic cases, with clusters in 2023–2024; severe cases have required prolonged mechanical ventilation.[28][29][30]

Notable foodborne outbreaks

Country (region) Year Source Affected
United States (California) 2017 Nacho cheese sauce (gas-station) 10 (1 death)
United States (Mississippi) 2016 Prison-made "pruno" 31
United States (Ohio) 2015 Home-canned potatoes (church potluck) 29 (1 death)
United States (multiple) 1994–2021 Inadequately refrigerated commercial foods (13 events) 37 (4 deaths)
China (Hebei) 2010 Contaminated sausage 66
Thailand (Nan) 2006 Home-canned bamboo shoots 209
United States/Canada 2006 Commercial carrot juice ≥3 (US/Canada)
United States (Texas) 1994 Baked potatoes in dip 23

[31][32][33]

Global occurrence

C. botulinum spores are present in soil on all continents except Antarctica, and foodborne botulism occurs worldwide. Infant botulism, however, is reported very unevenly: incidence is high in Argentina (~7.0/100,000 live births) and parts of the western United States, but low in Europe (0.1–0.4) and Canada (0.5), rare in China (~0.014), and essentially unreported in Russia and most of Africa. Case clustering in arid, desert, and Mediterranean-climate regions is a recurring global pattern.[34]

Clinically actionable points

  • Infant botulism is the dominant U.S. form and is increasing; suspect it in any afebrile hypotonic infant <12 months regardless of honey exposure.[35]
  • Ask about injection drug use (black tar heroin, skin popping) in any adult with descending paralysis, especially in California.[36]
  • Consider cosmetic/therapeutic iatrogenic botulism in patients with recent botulinum toxin injection, particularly from unlicensed sources.[37]
  • Any cluster of cases mandates immediate health-department notification.[38]

References

  1. ↑ Jin J (2023). "What Is Botulism?". JAMA. 330 (1): 90. doi:10.1001/jama.2023.8085.
  2. ↑ Berkwitt A; El Saleeby CM; Murphy SA (2024). "Case 3-2024: An 8-Week-Old Male Infant with Inconsolable Crying and Weakness". The New England Journal of Medicine.
  3. ↑ Carrillo-Marquez MA (2016). "Botulism". Pediatrics in Review. 37 (5): 183–192. doi:10.1542/pir.2015-0018.
  4. ↑ Dabritz HA; Chung CH; Read JS; Khouri JM (2025). "Global Occurrence of Infant Botulism: 2007–2021". Pediatrics. 155 (4): e2024068791. doi:10.1542/peds.2024-068791.
  5. ↑ Shapiro RL; Hatheway C; Swerdlow DL (1998). "Botulism in the United States: A Clinical and Epidemiologic Review". Annals of Internal Medicine. PMID 9696731.
  6. ↑ Dabritz HA; Chung CH; Read JS; Khouri JM (2025). "Global Occurrence of Infant Botulism: 2007–2021". Pediatrics. 155 (4): e2024068791. doi:10.1542/peds.2024-068791.
  7. ↑ Carrillo-Marquez MA (2016). "Botulism". Pediatrics in Review. 37 (5): 183–192. doi:10.1542/pir.2015-0018.
  8. ↑ Sobel J; Tucker N; Sulka A; McLaughlin J; Maslanka S (2004). "Foodborne Botulism in the United States, 1990-2000". Emerging Infectious Diseases. PMID 15498163.
  9. ↑ Kuehn B (2019). "Wound Botulism Outbreak". JAMA. 321 (6): 534. doi:10.1001/jama.2019.0006.
  10. ↑ American Academy of Pediatrics (2024). Botulism and Infant Botulism (Clostridium botulinum). Red Book: 2024–2027 Report of the Committee on Infectious Diseases.
  11. ↑ Panditrao MV; Dabritz HA; Kazerouni NN; et al. (2020). "Descriptive Epidemiology of Infant Botulism in California: The First 40 Years". The Journal of Pediatrics. PMID 32800814 Check |pmid= value (help).
  12. ↑ Sobel J; Tucker N; Sulka A; McLaughlin J; Maslanka S (2004). "Foodborne Botulism in the United States, 1990-2000". Emerging Infectious Diseases. PMID 15498163.
  13. ↑ Fagan RP; McLaughlin JB; Castrodale LJ; et al. (2011). "Endemic Foodborne Botulism Among Alaska Native Persons—Alaska, 1947-2007". Clinical Infectious Diseases. PMID 21292663.
  14. ↑ Dabritz HA; Chung CH; Read JS; Khouri JM (2025). "Global Occurrence of Infant Botulism: 2007–2021". Pediatrics. 155 (4): e2024068791. doi:10.1542/peds.2024-068791.
  15. ↑ Werner SB; Passaro D; McGee J; Schechter R; Vugia DJ (2000). "Wound Botulism in California, 1951-1998: Recent Epidemic in Heroin Injectors". Clinical Infectious Diseases. PMID 11049786.
  16. ↑ Panditrao MV; Dabritz HA; Kazerouni NN; et al. (2020). "Descriptive Epidemiology of Infant Botulism in California: The First 40 Years". The Journal of Pediatrics. PMID 32800814 Check |pmid= value (help).
  17. ↑ Fagan RP; McLaughlin JB; Castrodale LJ; et al. (2011). "Endemic Foodborne Botulism Among Alaska Native Persons—Alaska, 1947-2007". Clinical Infectious Diseases. PMID 21292663.
  18. ↑ Dabritz HA; Chung CH; Read JS; Khouri JM (2025). "Global Occurrence of Infant Botulism: 2007–2021". Pediatrics. 155 (4): e2024068791. doi:10.1542/peds.2024-068791.
  19. ↑ Carrillo-Marquez MA (2016). "Botulism". Pediatrics in Review. 37 (5): 183–192. doi:10.1542/pir.2015-0018.
  20. ↑ Fagan RP; McLaughlin JB; Castrodale LJ; et al. (2011). "Endemic Foodborne Botulism Among Alaska Native Persons—Alaska, 1947-2007". Clinical Infectious Diseases. PMID 21292663.
  21. ↑ Werner SB; Passaro D; McGee J; Schechter R; Vugia DJ (2000). "Wound Botulism in California, 1951-1998: Recent Epidemic in Heroin Injectors". Clinical Infectious Diseases. PMID 11049786.
  22. ↑ Sobel J; Tucker N; Sulka A; McLaughlin J; Maslanka S (2004). "Foodborne Botulism in the United States, 1990-2000". Emerging Infectious Diseases. PMID 15498163.
  23. ↑ Carrillo-Marquez MA (2016). "Botulism". Pediatrics in Review. 37 (5): 183–192. doi:10.1542/pir.2015-0018.
  24. ↑ Dabritz HA; Chung CH; Read JS; Khouri JM (2025). "Global Occurrence of Infant Botulism: 2007–2021". Pediatrics. 155 (4): e2024068791. doi:10.1542/peds.2024-068791.
  25. ↑ Arnon SS; Schechter R; Inglesby TV; et al. (2001). "Botulinum Toxin as a Biological Weapon: Medical and Public Health Management". JAMA. 285 (8): 1059–1070. doi:10.1001/jama.285.8.1059.
  26. ↑ Jin J (2023). "What Is Botulism?". JAMA. 330 (1): 90. doi:10.1001/jama.2023.8085.
  27. ↑ Fagan RP; McLaughlin JB; Castrodale LJ; et al. (2011). "Endemic Foodborne Botulism Among Alaska Native Persons—Alaska, 1947-2007". Clinical Infectious Diseases. PMID 21292663.
  28. ↑ Qiu H; Shen J; Tang Y; et al. (2025). "A Retrospective Case Series Study of Illegal Cosmetic Iatrogenic Botulism: Outbreak Analysis and Response Lessons". Aesthetic Surgery Journal. PMID 40391523 Check |pmid= value (help).
  29. ↑ Dressler D; Frevert J; Johnson EA; et al. (2026). "Iatrogenic botulism: a risk for botulinum toxin's medical use?". Journal of Neural Transmission.
  30. ↑ Yang P; Du Y; He S; et al. (2026). "Iatrogenic Botulism Induced by Cosmetic Injection Requiring Mechanical Ventilation". Clinical Toxicology.
  31. ↑ Edmunds S; Vugia DJ; Rosen HE; et al. (2022). "Inadequate Refrigeration of Some Commercial Foods Is a Continued Cause of Foodborne Botulism in the United States, 1994-2021". Foodborne Pathogens and Disease. PMID 35713923 Check |pmid= value (help).
  32. ↑ McCrickard L; Marlow M; Self JL; et al. (2017). "Botulism Outbreak from Drinking Prison-Made Illicit Alcohol—Mississippi, June 2016". MMWR. PMID 28056003.
  33. ↑ McCarty CL; Angelo K; Beer KD; et al. (2015). "Large Outbreak of Botulism Associated with a Church Potluck Meal—Ohio, 2015". MMWR. PMID 26225479.
  34. ↑ Dabritz HA; Chung CH; Read JS; Khouri JM (2025). "Global Occurrence of Infant Botulism: 2007–2021". Pediatrics. 155 (4): e2024068791. doi:10.1542/peds.2024-068791.
  35. ↑ Dabritz HA; Chung CH; Read JS; Khouri JM (2025). "Global Occurrence of Infant Botulism: 2007–2021". Pediatrics. 155 (4): e2024068791. doi:10.1542/peds.2024-068791.
  36. ↑ Kuehn B (2019). "Wound Botulism Outbreak". JAMA. 321 (6): 534. doi:10.1001/jama.2019.0006.
  37. ↑ Qiu H; Shen J; Tang Y; et al. (2025). "A Retrospective Case Series Study of Illegal Cosmetic Iatrogenic Botulism". Aesthetic Surgery Journal. PMID 40391523 Check |pmid= value (help).
  38. ↑ Kuehn BM (2021). "Botulism Guidelines Aim to Help Prepare Clinicians for Outbreaks". JAMA. 325 (24): 2428. doi:10.1001/jama.2021.8969.


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