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Lessons for Control of Heroin-Associated Anthrax in Europe from 2009–2010 Outbreak Case Studies, London, UK - Volume 20, Number 7—July 2014 - Emerging Infectious Disease journal - CDC

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Lessons for Control of Heroin-Associated Anthrax in Europe from 2009–2010 Outbreak Case Studies, London, UK - Volume 20, Number 7—July 2014 - Emerging Infectious Disease journal - CDC


Volume 20, Number 7—July 2014


Lessons for Control of Heroin-Associated Anthrax in Europe from 2009–2010 Outbreak Case Studies, London, UK

Aula Abbara, Tim Brooks, Graham P. Taylor, Marianne Nolan, Hugo Donaldson, Maribel Manikon, and Alison HolmesComments to Author 
Author affiliations: Imperial College Healthcare National Health Service Trust, London, UK (A. Abbara, G.P. Taylor, M. Nolan, H. Donaldson, M. Manikon, A. Holmes)Public Health England, Porton Down, UK (T. Brooks)


Outbreaks of serious infections associated with heroin use in persons who inject drugs (PWIDs) occur intermittently and require vigilance and rapid reporting of individual cases. Here, we give a firsthand account of the cases in London during an outbreak of heroin-associated anthrax during 2009–2010 in the United Kingdom. This new manifestation of anthrax has resulted in a clinical manifestation distinct from already recognized forms. During 2012–13, additional cases of heroin-associated anthrax among PWIDs in England and other European countries were reported, suggesting that anthrax-contaminated heroin remains in circulation. Antibacterial drugs used for serious soft tissue infection are effective against anthrax, which may lead to substantial underrecognition of this novel illness. The outbreak in London provides a strong case for ongoing vigilance and the use of serologic testing in diagnosis and serologic surveillance schemes to determine and monitor the prevalence of anthrax exposure in the PWID community.
Heroin-associated anthrax resulting from direct injection or injection under the skin, or “skin popping,” among persons who inject drugs (PWIDs) is a distinct form of anthrax seen during a 2009–2010 outbreak in Scotland and England and again during 2012–2013 in northern Europe and Germany. There are an estimated 281,000 heroin users in England and >50,000 in Scotland (1), suggesting that the cases recognized and diagnosed during the outbreaks are the tip of the iceberg.
The first 2 cases of heroin-associated anthrax occurred in the Greater Glasgow and Clyde area of Scotland and were reported on December 10, 2009. By July 2010, there were 47 confirmed case-patients in Scotland, of whom 13 (28%) died (2). In January 2010, the first cases outside Scotland were described in England and Germany (3); the final outbreak total in England was 6, with 4 deaths (4). The last case from this outbreak occurred in October 2010, and Health Protection Scotland declared the UK outbreak over on December 23, 2010; no active surveillance was established afterward (4,5).
In June 2012, 21 months after the last reported case in the United Kingdom, a fatal case was reported in Regensburg, Bavaria, Germany. As of March 2013, 7 more cases had occurred in the United Kingdom, including 5 in England; 4 patients died during this outbreak: 2 in England, 1 in Scotland, and 1 in Wales. Another 6 cases occurred in Germany, Denmark, and France, bringing the total to 14 as of (March 2013) (68), which suggests that contaminated heroin remains in circulation and that vigilance should be maintained.
The only reported case of heroin-associated anthrax before this outbreak was during 2000 in an injecting drug user in Norway in whom fatal hemorrhagic encephalitis developed. Although anticipated, no outbreak emerged (9).

Dr Abbara is an infectious diseases and general medicine registrar in London. Her research interests include infections among vulnerable groups including refugees and tuberculosis.


A.H. is supported by the United Kingdom Clinical Research Council and the Imperial NIHR Biomedical Research Centre.


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Suggested citation for this article: Abbara A, Brooks T, Taylor GP, Nolan M, Donaldson H, Manikon M, et al. Lessons for control of heroin-associated anthrax in Europe from 2009–2010 outbreak case studies, London, UK. Emerg Infect Dis. 2014 Jul [date cited].
DOI: 10.3201/eid2007.131764

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