Resources & Publications

Resources

Clinical Guidelines for Diagnosis and Treatment of Botulism, 2021

These are the first comprehensive clinical care guidelines for botulism. They include

Best practices for diagnosing, monitoring, and treating botulism, including during outbreaks
Special considerations for infants, children, and people who are pregnant or breastfeeding
Recommendations for supportive care, including psychosocial support for patients and family members

“Botulism,” a CDC-sponsored supplement to Clinical Infectious Diseases

The supplement includes six systematic reviews and other articles that provided the evidence base for the clinical guidelines. Contents include reviews and articles on

Clinical presentation
Effectiveness of antitoxin
Antitoxin adverse reactions
Outbreaks
And more

Preparing and Administrating Heptavalent Antitoxin for the Treatment of Botulism

Preparing and Administrating Heptavalent Antitoxin for the Treatment of Botulism

Low Resolution Video

CDC created this video to guide healthcare professionals on preparing and administering antitoxin for the treatment of botulism. Refer to the FDA package insert for complete information.

Other Resources

Handbook for Epidemiologists, Clinicians, and Laboratory Workers – Botulism in the United States, 1899–1996 [PDF – 43 pages]
Botulism: Countering Common Clinical Misperceptions
Dr. Agam Rao discusses how to recognize and treat botulism and she addresses common clinical misperceptions about the illness. Read the transcript [PDF – 3 pages]

Publications

Clinical Characteristics and Ancillary Test Results Among Patients With Botulism—United States, 2002–2015. DOI PubMed
Rao AK, Lin NH, Jackson KA, Mody RK, Griffin PM. Clin Infect Dis. 2017 Dec 27; 66(Suppl 1): p. S4–S10.
Clinical Features of Foodborne and Wound Botulism: A Systematic Review of the Literature, 1932–2015. DOI PubMed
Chatham-Stephens K, Fleck-Derderian S, Johnson SD, Sobel J, Rao AK, Meaney-Delman D. Clin Infect Dis. 2017 Dec 27; 66 (Suppl 1): p. S11–S16.
Pediatric Botulism and Use of Equine Botulinum Antitoxin in Children: A Systematic Review. DOI PubMed
Griese SE, Kisselburgh HM, Bartenfeld MT, Thomas E, Rao AK, Sobel J, Dziuban EJ. Clin Infect Dis. 2017 Dec 27; 66(Suppl 1): p. S17–S29.
Botulism During Pregnancy and the Postpartum Period: A Systematic Review. DOI PubMed
Badell ML, Rimawi BH, Rao AK, Jamieson DJ, Rasmussen S, Meaney-Delman D. Clin Infect Dis. 2017 Dec 27; 66(Suppl 1): p. S30–S37.
Botulism mortality in the United States, 1975–2009. DOI PubMed PMC
Jackson KA, Mahon BE, Copeland J, Fagan R. The Botulinum J. 2016; 3(1): p. 6–17.
Botulism. In: Bacterial Infections of Humans. Springer
Yu PA, Maslanka SE, St Louis ME, Swerdlow DL. Editors: Evans AS, Brachman PS. New York: Springer; 2009. p. 159–176.
Long-term outcomes of 217 botulism cases in the Republic of Georgia. DOI PubMed
Gottlieb SL, Kretsinger K, Tarkhashvili N, Chakvetadze N, Chokheli M, Chubinidze M, et al. Clin Infect Dis. 2007 Jul 15; 45(2): p. 174–80.
Adult botulism type F in the United States, 1981–2002. DOI PubMed
Gupta A, Sumner CJ, Castor M, Maslanka S, Sobel J. Neurology. 2005 Dec 13; 65(11): p. 1694–700.
Botulism. DOI PubMed
Sobel J. Clin Infect Dis. 2005 Oct 15; 41(8): p. 1167–73.
Identification of the major steps in botulinum toxin action. DOI PubMed
Simpson LL. Annu Rev Pharmacol Toxicol. 2004 Feb 10; 44: p. 167–93.
Botulism in the United States: a clinical and epidemiologic review. DOI PubMed
Shapiro RL, Hatheway C, Swerdlow DL. Ann Intern Med. 1998 Aug 1; 129(3): p. 221–8.
Botulism. In: Bacterial Infections of Humans. Springer
Angulo FJ, St. Louis ME. Editors: Evans AS, Brachman PS. New York: Plenum; 1998. p. 131–3.

Foodborne botulism outbreaks in the United States, 2001–2017. DOI PubMed
Lúquez C, Edwards L, Griffin C, Sobel J. Front Microbiol. 2021 Jul; 12: 713101.
The Epidemiology of Foodborne Botulism Outbreaks: A Systematic Review. DOI PubMed
Fleck-Derderian S, Shankar M, Rao AK, Chatham-Stephens K, Adjei S, Sobel J, et al. Clin Infect Dis. 2017 Dec 27; 66 (Suppl 1): p. S73–S81.

Botulism linked to improperly home-canned, fermented, or preserved foods, including traditional Alaska Native foods

Notes from the Field: botulism Type E after consumption of salt-cured fish — New Jersey, 2018. MMWR PubMed
Ganapathiraju PV, Gharpure R, Thomas D, Millet N, Gurrieri D, Chatham-Stephens K, et al. MMWR Morb Mortal Wkly Rep. 2019 Nov; 68(44): p. 1008–09.
Botulism outbreak associated with home-canned peas—New York City, 2018. MMWR PubMed
Bergeron G, Latash J, Dacosta-Carter CA, Egan C, Stavinsky F, Kileci JA, et al. MMWR Morb Mortal Wkly Rep. 2019 Mar; 68(10): p. 251–52.
Large outbreak of botulism associated with a church potluck meal—Ohio, 2015. MMWR PubMed PMC
McCarty CL, Angelo K, Beer KD, Cibulskas-White K, Quinn K, de Fijter S, et al. MMWR Morb Mortal Wkly Rep. 2015 Jul 31; 64(29): p. 802–3.
Regional variations in home canning practices and the risk of foodborne botulism in the Republic of Georgia, 2003. DOI PubMed PMC
Tarkhashvili N, Chokheli M, Chubinidze M, Abazashvili N, Chakvetadze N, Imnadze P, et al. J Food Prot. 2015 Apr; 78(4): p. 746–50.
Botulism associated with home-fermented tofu in two Chinese immigrants—New York City, March–April 2012. MMWR PubMed PMC
Chai E, Choi E, Guitierrez C, Hochman M, Johnkutty S, Kamel W, et al. MMWR Morb Mortal Wkly Rep. 2013 July 5; 62(26): p. 529–32.
Three outbreaks of foodborne botulism caused by unsafe home canning of vegetables—Ohio and Washington, 2008 and 2009. DOI PubMed
Date K, Fagan R, Crossland S, MacEachern D, Pyper B, Bokanyi R, et al. J Food Prot. 2011; 74(12): p. 2090–6.
Outbreak of clinically mild botulism type E illness from home-salted fish in patients presenting with predominantly gastrointestinal symptoms. DOI PubMed
Sobel J, Malavet M, John S. Clin Infect Dis. 2007 Jul 15; 45(2): p. 14–6.
The need for global planned mobilization of essential medicine: lessons from a massive Thai botulism outbreak. PubMed PMC
Ungchusak K, Chunsuttiwat S, Braden CR, Aldis W, Ueno K, Olsen SJ, Wiboolpolprasert S. Bull World Health Organ. 2007 Mar; 85(3): p. 238–240.
Brief Report: Foodborne botulism from home-prepared fermented tofu—California. MMWR PubMed
Meyers H, Inami G, Rosenberg J, Mohle-Boetani J, Vugia D, Yuan J. MMWR Morb Mortal Wkly Rep. 2007 Feb 9; 56(5): p. 96–7.
Botulism type E outbreak associated with eating a beached whale, Alaska. DOI PubMed PMC
McLaughlin JB, Sobel J, Lynn T, Funk E, Middaugh JP. Emerg Infect Dis. 2004 Sep; 10(9): p. 1685–7.
Botulism among Alaska natives in the Bristol Bay area of southwest Alaska: a survey of knowledge, attitudes, and practices related to fermented foods known to cause botulism. DOI PubMed
Chiou LA, Hennessy TW, Horn A, Carter G, Butler JC. Int J Circumpolar Health. 2002 Feb; 61(1): p. 50–60.
Foodborne botulism from eating home-pickled eggs—Illinois, 1997. MMWR PubMed
Rifkin G, Sibounheuang K, Peterson L, Kelly K, Langkop C, Kauerauf D, et al. MMWR Morb Mortal Wkly Rep. 2000 Sep 1; 49(34): p. 778–80.

Botulism linked to pruno, a type of homemade alcohol

Mild botulism from illicitly brewed alcohol in a large prison outbreak in Mississippi. DOI PubMed
Marlow M, Edwards L, McCrickard L, Francois Watkins LK, Anderson J, Hand S, et al. Front Public Health. 2021 Aug; 9: 716615.
Notes from the field: botulism outbreak from drinking prison-made illicit alcohol in a federal correctional facility—Mississippi, June 2016. MMWR PubMed
McCrickard L, Marlow M, Self JL, Watkins LF, Chatham-Stephens K, Anderson J, et al. MMWR Morb Mortal Wkly Rep. 2017 Jan 6; 65(52): p. 1491–2.
A qualitative inquiry about pruno, an illicit alcoholic beverage linked to botulism outbreaks in United States prisons. DOI PubMed PMC
Walters MS, Sreenivasan N, Person B, Shew M, Wheeler D, Hall J, et al. Am J Public Health. 2015 Nov; 105(11): p. 2256–61.
Alcohol production, prevention strategies, and inmate knowledge about the risk for botulism from pruno consumption in a correctional facility—Arizona, 2013. DOI PubMed PMC
Adams LE, Yasmin S, Briggs G, Redden K, Silvas S, Anderson S, et al. J Correct Health Care. 2015 Oct; 21(4): p. 335–42.
Notes from the field: botulism from drinking prison-made illicit alcohol—Arizona, 2012. MMWR PubMed PMC
Briggs G, Anderson S, Komatsu K, Weiss J, Henke E, Tsang CA, et al. MMWR Morb Mortal Wkly Rep. 2013 Feb 8; 62(5): p. 88.
Botulism from drinking prison-made illicit alcohol—Utah, 2011. MMWR PubMed
Thurston D, Risk I, Hill MB, Vitek D, Bogdanow L, Robertson J, et al. MMWR Morb Mortal Wkly Rep. 2012 Oct 5; 61(39): p. 782–4.
Botulism from drinking pruno. DOI PubMed PMC
Vugia DJ, Mase SR, Cole B, Stiles J, Rosenberg J, Velasquez L, et al. Emerg Infect Dis. 2009 Jan; 15(1): p. 69–71.

Botulism linked to other foods

Notes from the field: botulism caused by consumption of commercially produced potato soups stored improperly—Ohio and Georgia, 2011. MMWR PubMed
Seaman MP, Sulka AC, Tobin-D’Angelo M, Blass MA, Mills RL, Carmean J, et al. MMWR Morb Mortal Wkly Rep. 2011 Jul 8; 60(26): p. 890.
International outbreak of severe botulism with prolonged toxemia caused by commercial carrot juice. DOI PubMed
Sheth AN, Wiersma P, Atrubin D, Dubey V, Zink D, Skinner G, et al. Clin Infect Dis. 2008 Nov 15; 47(10): p. 1245–51.
Botulism associated with commercially canned chili sauce—Texas and Indiana. MMWR PubMed
Ginsberg MM, Granzow L, Teclaw RF, Gaul LK, Bagdure S, Cole A, et al. MMWR Morb Mortal Wkly Rep. 2007 Aug 3; 56(30): p. 767–9.
Botulism associated with commercial carrot juice—Georgia and Florida, September 2006. MMWR PubMed
Shuler C, Drenzek C, Lance S, Gonzalez G, Miller J, Tobin-D’Angelo M, et al. MMWR Morb Mortal Wkly Rep. 2006 Oct 13; 55(40): p. 1098–9.
An outbreak of foodborne botulism associated with food sold at a salvage store in Texas. DOI PubMed
Kalluri P, Crowe C, Reller M, Gaul L, Hayslett J, Barth S, et al. Clin Infect Dis. 2003 Dec 1; 37(11): p. 1490–5.
A large outbreak of botulism: the hazardous baked potato. DOI PubMed
Angulo FJ, Getz J, Taylor JP, Hendricks KA, Hatheway CL, Barth SS, et al. J Infect Dis. 1998 Jul; 178(1): p. 172–7.
Foodborne botulism—Oklahoma, 1994. MMWR PubMed
Knubley W, McChesney TC, Mallonee J, Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 1995 Mar 24; 44(11): p. 200–2.
Epidemiologic notes and reports fish botulism—Hawaii, 1990. MMWR DOI PubMed
Kershaw P, Dioso M, Wong B, Ibara C, Robertson D, Tamao W, et al. MMWR Morb Mortal Wkly Rep. 1991 Jun 21; 40(24): p. 412–4.
Botulism from chopped garlic: delayed recognition of a major outbreak. DOI PubMed
St. Louis ME, Peck SHS, Bowering D, Morgan GB, Blatherwick J, Banerjee S, et al. Ann Intern Med. 1988 Mar; 108(3): p. 363–8.

Other foodborne botulism

Foodborne botulism in the United States, 1999–2000. DOI PubMed PMC
Sobel J, Tucker N, McLaughlin J, Maslanka S. Emerg Infect Dis. 2004 Sep; 10(9): p. 1606–11.
Foodborne botulism in the Republic of Georgia. DOI PubMed PMC
Varma JK, Katsitadze G, Moiscrafishvili M, Zardiashvili T, Chikheli M, Tarkashvili N, et al. Emerg Infect Dis. 2004 Sept; 10(9): p. 1601–5.
Signs and symptoms predictive of death in patients with foodborne botulism—Republic of Georgia, 1980–2002. DOI PubMed
Varma JK, Katsitadze G, Moiscrafishvili M, Zardiashvili T, Chokheli M, Tarkhashvili N, et al. Clin Infect Dis. 2004 Aug 1; 39(3): p. 357–62.

Botulism in Alaska: A Guide for Physicians and Health Care Providers. CDC Stacks PDF [32 pages]
Castrodale LJ (ed.). State of Alaska Department of Health and Social Services. 2011.
Endemic foodborne botulism among Alaska Native persons—Alaska, 1947–2007. DOI PubMed
Fagan RP, McLaughlin JB, Castrodale LJ, Gessner BD, Jenkerson SA, Funk EA, et al. Clin Infect Dis. 2011 Mar 1; 52(5): p. 585–92.
Botulism type E outbreak associated with eating a beached whale, Alaska. DOI PubMed PMC
McLaughlin JB, Sobel J, Lynn T, Funk E, Middaugh JP. Emerg Infect Dis. 2004 Sep; 10(9): p. 1685–7.
Botulism among Alaska Natives in the Bristol Bay area of southwest Alaska: a survey of knowledge, attitudes, and practices related to fermented foods known to cause botulism. DOI PubMed
Chiou LA, Hennessy TW, Horn A, Carter G, Butler JC. Int J Circumpolar Health. 2002 Feb; 61(1): p. 50–60.
Botulism among Alaska Natives. The role of changing food preparation and consumption practices. PubMed PMC
Shaffer N, Wainwright RB, Middaugh JP, Tauxe RV. West J Med. 1990 Oct; 153(4): p. 390–3.

Equine botulinum antitoxin for the treatment of infant botulism. DOI PubMed↗ PMC
Vanella de Cuetos EE, Fernandez RA, Bianco MI, Sartori OJ, Piovano ML, Lúquez C, de Jong LI. Clin Vaccine Immunol. 2011 Nov; 18(11): p. 1845–9.
Clostridial infections: botulism and infant botulism. In: The Red Book: 2009 Report of the Committee on Infectious Diseases. PDF [32 pages]
Arnon SS, Barzilay EJ. Editors: Pickering LK, Baker CJ, Kimberlin DW, Long SS. Elk Grove Village (IL): American Academy of Pediatrics; 2009. p. 259–62.
Intestinal botulism formerly infant botulism. In: Control of Communicable Disease Manual. 19^th ed. APHA
Barzilay E, Schlundt J, Toyofuku H. Editor: Heymann DL. Washington, D.C.: American Public Health Association. 2008. p. 79–87.
Global occurrence of infant botulism, 1976–2006. DOI PubMed
Koepke R, Sobel J, Arnon S. Pediatrics. 2008 Jul; 122(1): p. 72–82.
Human botulism immune globulin for the treatment of infant botulism. DOI PubMed
Arnon SS, Schechter R, Maslanka SE, Jewell NP, Hatheway CL. N Engl J Med. 2006 Feb 2; 354(5): p. 462–71.
Foodborne botulism in a six-month-old infant caused by home-canned baby food. DOI PubMed↗
Armada M, Love S, Barrett E, Monroe J, Peery D, Sobel J. Ann Emerg Med. 2003 Aug; 42(2): p. 226–9.
Infant botulism—New York City, 2001–2002. MMWR PubMed
Reddy V, Balter S, Weiss D, Layton M, Kornstein L, Friberg I, et al. MMWR Morb Mortal Wkly Rep. 2003 Jan 17; 52(2): p. 21–4.
Risk of infant botulism from corn syrup. Ovid PubMed
Olsen SJ, Swerdlow DL. Pediatr Infect Dis J. 2000 Jun; 19(6): p. 584–5.

Wound botulism among persons who inject black tar heroin in New Mexico, 2016. DOI PubMed
Middaugh N, Edwards L, Chatham-Stephens K, Arguello DF. Front Public Health. 2021 Dec; 9: 744179.
Notes from the field: Botulism Type B after intravenous methamphetamine use – New Jersey, 2020. MMWR PubMed
Waltenburg MA, Larson VA, Naor EH, Webster TG, Dykes J, Foltz V, et al. MMWR Morb Mortal Wkly Rep. 2020 Oct; 69(39): p. 1425–26.
Recurrent wound botulism among injection drug users in California. DOI PubMed
Yuan J, Inami G, Mohle-Boetani J, Vugia DJ. Clin Infect Dis. 2011 Apr 1; 52(7): p. 862–6.
Wound botulism acquired in the Amazonian rain forest of Ecuador. DOI PubMed
Reller ME, Douce RW, Maslanka SE, Torres DS, Manock SR, Sobel J. Am J Trop Med Hyg. 2006 Apr; 74(4): p. 628–31.
Wound botulism among black tar heroin users—Washington, 2003. MMWR DOI PubMed
Spitters C, Moran J, Kruse D, Barg N, Leslie M, Hoffman J, et al. MMWR Morb Mortal Wkly Rep. 2003 Sep 19; 52(37): p. 885–6.
Wound Botulism in California, 1951–1998: Recent Epidemic in Heroin Injectors. DOI PubMed Benson Werner S, Passaro D, McGee J, Schechter R, Vugia DJ. Clin Infect Dis. 2000 Oct 1; 31(4): p. 1018–24.
Wound botulism—California, 1995. MMWR PubMed
Gollober M, Beyer RA, Kwan S, Bates RO, Billimek M, Matson SE, et al. MMWR Morb Mortal Wkly Rep. 1995 Dec 8; 44(48): p. 889–92.

Efficacy of Antitoxin Therapy in Treating Patients With Foodborne Botulism: A Systematic Review and Meta-analysis of Cases, 1923–2016. DOI PubMed PMC
O'Horo JC, Harper EP, El Rafei A, Ali R, DeSimone DC, Sakusic A, et al. Clin Infect Dis. 2017 Dec 27; 66 (Suppl 1): p. S43–S56.
Safety and Improved Clinical Outcomes in Patients Treated With New Equine-Derived Heptavalent Botulinum Antitoxin. DOI PubMed PMC
Yu PA, Lin NH, Mahon BE, Sobel J, Yu Y, Mody RK, et al. Clin Infect Dis. 2017 Dec 27; 66 (Suppl 1): p. S57–S64.
Allergic Reactions to Botulinum Antitoxin: A Systematic Review. DOI PubMed PMC
Schussler E, Sobel J, Hsu J, Yu P, Meaney-Delman D, Grammer LC 3^rd, Nowak-Wegrzyn A. Clin Infect Dis. 2017 Dec 27; 66 (Suppl 1): p. S65–S72.
The eyes have it. DOI PubMed
Rao AK, Jackson KA, Mahon BE. N Engl J Med. 2013 Jan 24; 368(4): p. 392.
Initial recovery and rebound of type F intestinal colonization botulism after administration of investigational heptavalent botulinum antitoxin. DOI PubMed
Fagan RP, Neil KP, Sasich R, Luquez C, Asaad H, Maslanka S, Khalil W. Clin Infect Dis. 2011 Nov; 53(9): p. 125–8.
Utility of botulinum toxin ELISA A, B, E, F kits for clinical laboratory investigations of human botulism. DOI
Maslanka SE, Luquez C, Raphael BH, Dykes JK, Joseph, LA. Botulinum J. 2011; 2(1): p. 72–92.
Investigational heptavalent botulinum antitoxin (HBAT) to replace licensed antitoxin AB and investigational botulinum antitoxin E. MMWR PubMed
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2010 Mar 19; 59(10): p. 299.

Botulism. In: Beyond Anthrax: The Weaponization of Infectious Diseases. Springer
Sobel J. Editors: Lutwick LI, Lutwick SM. Towata (NJ): Humana Press. 2009. p. 85–105.
Botulinum toxin as a biological weapon: medical and public health management. DOI PubMed
Arnon SS, Schechter R, Inglesby TV, Henderson DA, Bartlett JG, Ascher MS, et al. JAMA. 2001 Feb 28; 285(8): p. 1059–70.
Botulism surveillance and emergency response: a public health strategy for a global challenge. DOI PubMed
Shapiro RL, Hatheway C, Becher J, Swerdlow DL. JAMA. 1997 Aug 6; 278(5): p. 433–5.

Clostridium botulinum type B isolated from a wound botulism case due to injection drug use resembles other local strains originating from Hawaii. DOI PubMed
Halpin JL, Foltz V, Dykes JK, Chatham-Stephens K, Lúquez C. Front Microbiol. 2021 Jul; 12: 678473.
Genomic characterization of strains from a cluster of infant botulism type A in a small town in Colorado, United States. DOI PubMed
Gladney L, Halpin JL, Lúquez C. Front Microbiol. 2021 Jul; 12: 688240.
Molecular characterization of Clostridium botulinum harboring the bont/B7 gene. DOI PubMed
Halpin JL, Dykes JK, Katz L, Centurioni DA, Perry MJ, Egan CT, Lúquez C. Foodborne Pathog Dis. 2019 Jun; 16(6): p. 428–33.
Draft genome sequences for dual-toxin-producing Clostridium botulinum DOI PubMed
Halpin JL, Dykes JK, Lúquez C. Microbiol Resour Announc. 2019 Jan; 8(4): e01152–18.
Draft genome sequence of a Clostridium botulinum isolate from Thailand harboring the subtype bont/B8 gene. DOI PubMed
Halpin JL, Wangroongsarb P, Jittaprasartsin C, Dykes JK, Lúquez C. Microbiol Resour Announc. 2019 Jan; 8(5): e01216–18.
Pulsotype diversity of Clostridium botulinum strains containing serotypes A and/or B genes. DOI PubMed
Halpin JL, Joseph L, Dykes JK, McCroskey L, Smith E, Toney D, et al. Foodborne Pathog Dis. 2017 Sep; 14(9): p. 494–501.
Finished whole-genome sequences of Clostridium butyricum toxin subtype E4 and Clostridium baratii toxin subtype F7 strains. DOI PubMed
Halpin JL, Hill K, Johnson SL, Bruce DC, Shirey TB, Dykes JK, Lúquez C. Genome Announc. 2017 Jul. 5(29): e00375–17.
Finished whole-genome sequences of two Clostridium botulinum type A(B) isolates. DOI PubMed
Halpin JL, Hill K, Johnson SL, Bruce DC, Shirey TB, Dykes JK, Lúquez C. Genome Announc. 2017 May; 5(21): e00381–17.
Finished whole-genome sequence of Clostridium argentinense producing botulinum neurotoxin type G. DOI PubMed
Halpin JL, Hill K, Johnson SL, Bruce DC, Shirey TB, Dykes JK, Lúquez C. Genome Announc. 2017 May; 5(21): e00380–17.

Notes from the Field: Intestinal colonization and possible iatrogenic botulism identified by mass spectrometry in mouse-bioassay-negative serum specimens—Los Angeles County, California, November 2017. MMWR PubMed
Halai U, Terashita D, Kim M, Green N, Kalb SR, Chatham-Stephens K, Balter S. MMWR Morb Mortal Wkly Rep. 2018 Nov; 67(43): p. 1221-22.

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Page last reviewed: June 16, 2022

Content source: Centers for Disease Control and Prevention , National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) , Division of Foodborne, Waterborne, and Environmental Diseases (DFWED)