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Case study

A large-scale outbreak of botulism associated with a traditional celebratory Egyptian fish dish in five governorates - Lower Egypt, 2019: a teaching case-study

A large-scale outbreak of botulism associated with a traditional celebratory Egyptian fish dish in five governorates - Lower Egypt, 2019: a teaching case-study

Sherif Shamseldein1,2,&, Mahmoud Azqul1,2, Sahar Samy1,2, Hanem Abdelraoof2


1Egypt Field Epidemiology Training Program (FETP), Cairo, Egypt, 2Ministry of Health and Population, Cairo,Egypt



&Corresponding author
Sherif Shamseldein, Egypt Field Epidemiology Training Program (FETP), Ministry of Health and Population, Cairo, Egypt




Botulism is a potentially fatal illness caused by the botulinum toxin. Foodborne Botulism is characterized by symmetric descending paralysis of voluntary muscles that can progress to respiratory failure and death. On September 24, 2019, a large Botulism outbreak of 92 cases took place in five governorates in Lower Egypt and was associated with a traditional meal (Feseekh). Feseekh is celebratory Egyptian dish consisting of fermented salted fish that is kept under anaerobic conditions for a long period of time. Case series study was conducted with the sensitive case definition of anyone having neurological or gastrointestinal symptoms and a history of eating Feseekh in the last 10 days. The goal of this case study is to build the capacity of trainees in investigating outbreaks. This case study stimulates students to analyse surveillance data, critically appraise an epidemic report, and assess the epidemic contingency plan. The case study is designed for training Novice field epidemiology trainees and can be administered in 3-4 hours. Used as adjunct training material, the case study provides the trainees with competencies in analysing available data in order to identify triggering factors for Botulism outbreaks in Egypt and using information to develop a risk map using relevant software.



How to use this case study    Down

General instructions: this case study should be used as adjunct training material for novice epidemiology trainees to reinforce the concepts taught in prior lectures. The case study is ideally taught by a facilitator in groups of about 20 participants. Participants are to take turns reading the case study, usually a paragraph per student. The facilitator guides the discussion on possible responses to questions. The facilitator may make use of flip charts to illustrate certain points. Additional instructor´s notes for facilitation are coupled with each question in the instructor´s guide to aid facilitation.

Audience: this case study was developed for novice field epidemiology students. These participants are commonly health care workers working in the county departments of health whose background may be as medical doctors, nurses, environmental health officers or laboratory scientists who work in public health-related fields. Most have a health science or biology background.

Prerequisites: before using this case study, participants should have received lectures on disease surveillance and outbreak investigation.

Level of training and associated public health activity: Novice - Outbreak Investigation

Time required: 3-4 hours

Language: English



Case study material Up    Down



Competing interest Up    Down

The authors declare no competing interests.



Acknowledgement Up    Down

We wish to acknowledge the Eastern Mediterranean Public Health Network (EMPHNET) for their support to develop this case study.



References Up    Down

  1. CDC. Botulism Webpage. Last reviewed October 2018.

  2. Weber JT, Richard Hibbs Jr G, Ahmed Darwish, Ban Mishu, Andrew Corwin L, Magda Rakha et al. A Massive Outbreak of Type E Botulism Associated with Traditional Salted Fish in Cairo Published by: Oxford University Press Stable. Fish in Cairo A Massive Outbreak of Type E Botulism Associated with Traditiona. 2020;167:451-454.

  3. DHSS. Botulism in Alaska. November 2017.