Global Occurrence of Infant Botulism: 2007-2021

We sought to summarize the worldwide occurrence and epidemiology of infant botulism (IB) from 2007 to 2021. Data were collected through active and passive surveillance, via hospital inquiries to the Infant Botulism Treatment and Prevention Program regarding Human Botulism Immune Globulin Intravenous for patients with suspected IB, by contact with epidemiologists in countries with historically high case counts and by searching the medical literature. A case was defined as an infant with laboratory-confirmed botulism that was not due to ingestion of food containing botulinum toxin. Eighteen countries reported their first cases between 2007 and 2021. Of the 2943 cases recognized from 2007 to 2021, 1587 were type A, 6 type Ab or A&B, 1 type Af, 1254 type B, 9 type Ba, 26 type Bf, 1 type Bh, 8 type E, 15 type F, and 36 of unknown toxin type. Median age at onset was 16.8 weeks and 48.4% of patients were female. Patients in the rest of the world (ROW) were more likely to be intubated than US patients (50.3% ROW vs 21.2%), have longer hospital stays (median 27.0 days ROW vs 12.0 days), and have consumed honey (19.7% ROW vs 3.8%). In conclusion, the distribution of IB cases worldwide does not reflect the detection of Clostridium botulinum spores in soil, suggesting IB is underrecognized in certain countries. To improve recognition of IB, physicians should consider IB when an infant presents with cranial nerve palsies, hypotonia, constipation, and/or poor feeding. Pediatricians globally should continue to educate parents about honey ingestion as one risk factor for IB.