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

full-text ►

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

CME ACTIVITY

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

On This Page

• Medscape CME Activity
• Bacillus anthracis
• International Heroin Production and Transportation
• Clinical Cases
• Discussion
• Lessons from the 2009–2010 Outbreak
• Conclusion
• Suggested Citation

Figures

• Figure 1
• Figure 2

Tables

• Table

Downloads

• PDF[449 KB - 8 pgs]

Aula Abbara, Tim Brooks, Graham P. Taylor, Marianne Nolan, Hugo Donaldson, Maribel Manikon, and Alison Holmes 

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)

Suggested citation for this article

Abstract

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) (6–8), 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.

Acknowledgment

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

References

1. Reuter P, Stevens A. An analysis of UK drug policy: executive summary. United Kingdom Drug Policy Commission, 2007 [cited 2014 May 15].http://www.ukdpc.org.uk/docs/UKDPC%20drug%20policy%20review%20exec%20summary.pdf
2. Health Protection Scotland. News release. Final tally of anthrax cases announced. 2010 Dec 23 [cited 2014 May 15].http://www.documents.hps.scot.nhs.uk/news/anthrax-closure-press-release-2010-12-23.pdf
3. Radun D, Bernard H, Altmann M, Schonberg I, Bocht V, van Treeck U, Preliminary case report of fatal anthrax in an injecting drug user in North-Rhine-Westphalia, Germany, December 2009. Euro Surveill. 2010;15:19464.PubMed
4. National Anthrax Outbreak Control Team. An outbreak of anthrax among drug users in Scotland, December 2009 to December 2010. Health Protection Scotland, 2011 [cited 2014 May 15]. http://www.documents.hps.scot.nhs.uk/giz/anthrax-outbreak/anthrax-outbreak-report-2011-12.pdf
5. Palmateer NE, Ramsay CN, Browning L, Goldberg DJ, Hutchinson S. Anthrax infection amongst heroin users in Scotland during 2009–2010: a case-control study by linkage to a national drug treatment database. Clin Infect Dis. 2012;55:706–10. DOIPubMed
6. Grunow R, Klee SR, Beyer W, George M, Grunow D, Barduhn A, Anthrax among heroin users in Europe possibly caused by same Bacillus anthracisstrain since 2000. Euro Surveill. 2013;18:28.PubMed
7. Health Protection Agency. News release. Case of anthrax confirmed in Oxford. 2012 Feb 11 [cited 2014 May 15].http://www.hpa.org.uk/NewsCentre/NationalPressReleases/2012PressReleases/121102AnthraxinOxford/
8. Russell L, Pedersen M, Jensen AV, Soes LM, Hansen AB. Two anthrax cases with soft tissue infection, severe oedema and sepsis in Danish heroin users. BMC Infect Dis. 2013;13:408. DOIPubMed
9. Caugrant DA, Fossum K, Hoel T, Høiby EA, Iversen BG, Jensenius M, Systemic anthrax in an injecting drug user: Oslo, Norway April 2000. Euro Surveill. 2000;4:1605.
10. Dixon TC, Meselson M, Guillemin J, Hanna P. Anthrax. N Engl J Med. 1999;341:815–26. DOIPubMed
11. Tonello F, Zornetta I. Bacillus anthracis factors for phagosomal escape. Toxins (Basel). 2012;4:536–53.
12. Beaumont G. Anthrax in a Scottish intravenous drug user. J Forensic Leg Med. 2010;17:443–5. DOIPubMed
13. Health Protection Agency, Public Health England. Anthrax, hides and drums: Q&As. 2010 May 24 [cited 2014 May 15].http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733752819
14. Bartlett JG, Inglesby TV, Boriol L. Management of anthrax. Clin Infect Dis. 2002;35:851–8 . DOIPubMed
15. Greene CM, Reefhuis J, Tan C, Fiore A, Goldstein S, Beach MJ, Epidemiologic Investigations of bioterrorism-related anthrax, New Jersey, 2001.Emerg Infect Dis. 2002;8:1048–55. DOIPubMed
16. United Nations Office on Drugs and Crime. Afghanistan opium survey 2007, executive summary [cited 2014 May 15].http://www.unodc.org/pdf/research/AFG07_ExSum_web.pdf
17. Department for Environment. Food and Rural Affairs. Zoonoses report, UK 2009 [cited 2014 May 15].http://www.defra.gov.uk/publications/files/pb13571-zoonoses2009-110125.pdf
18. Price EP, Seymour ML, Sarovich DS, Latham J, Wolken SR, Mason J, Molecular epidemiologic investigation of an anthrax outbreak among heroin users, Europe. Emerg Infect Dis. 2012;18. DOIPubMed
19. Prince AS. The host response to anthrax lethal toxin: unexpected observations. J Clin Invest. 2003;112(5):656–658.
20. Booth MG, Hood J, Brooks T, Hart A. Anthrax infection in drug users. Lancet. 2010;375:1345–6. DOIPubMed
21. Knox D, Murray G, Millar M, Hamilton D, Connor M, Ferdinand RD, Subcutaneous anthrax in three intravenous drug users: a new clinical diagnosis. J Bone Joint Surg Br. 2011;93:414–7. DOIPubMed
22. Lalitha MK, Anandi V, Walter N, Devadatta JO, Pulimood BM. Primary anthrax presenting as an injection “abscess.” Indian J Pathol Microbiol.1988;31:254–6 .PubMed
23. Ramsay CN, Stirling A, Smith J, Hawkins G, Brooks T, Hood J, An outbreak of infection with Bacillus anthracis in injecting drug users in Scotland.Euro Surveill. 2010;15:14.PubMed
24. Nabavi-Tabrizi A, Soteriou M, Williams R. A case of cutaneous anthrax managed operatively. The Internet Journal of Surgery. 2000;1 [cited 2014 May 15]. http://ispub.com/IJS/1/1/8434
25. Powell AG, Crozier JE, Hodgson H, Galloway DJ. A case of septicaemic anthrax in an intravenous drug user. BMC Infect Dis. 2011;11:21.DOIPubMed
26. Batchelor L. Brain haemorrhage in a young adult. J Infect. 2011;63:498. DOI
27. Johns N, Cooper D, Terrace J. An unusual case of peritonitis in an intravenous drug user. Gastroenterology. 2011;141:435–6, 780–1.DOIPubMed
28. Health Protection Scotland. Interim clinical guidance for the management of suspected anthrax in drug users. Version 12.1, Appendix 1: Clinical guidelines for use of anthrax immune globulin intravenous (human) (AIGIV) in Scotland [cited 2014 May 15].http://www.documents.hps.scot.nhs.uk/giz/anthrax-outbreak/clinical-guidance-for-use-of-anthrax-immune-globulin-v12-1-2010-03-19.pdf
29. Stevens DL, Bisno A, Chambers H, Everett ED, Delling P, Goldstein EJC, Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41:1373–406. DOIPubMed
30. Health Protection Agency, Public Health England. Laboratory investigation of possible anthrax in heroin users. HPA v2.1. 2010 Dec 23 [cited 2014 May 15]. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1265296979282
31. Health Protection Agency, Public Health England. Clinical algorithm: clinical evaluation and management of drug users with possible anthrax.2010 Jan 15[cited 2014 May 15]. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1259152399460
32. Mytle N, Hopkins RJ, Malkevich NV, Basu S, Meister GT, Sanford DC, Evaluation of intravenous anthrax immune globulin for treatment of inhalational anthrax. Antimicrob Agents Chemother. 2013;57:5684–92. DOIPubMed
33. Holzmann T, Frangoulidis D, Simon M, Noll P, Schmoldt S, Hanczaruk M, Fatal anthrax infection in a heroin user from southern Germany, June 2012. Euro Surveill. 2012;17:26 http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20204.PubMed
34. Sobel J. Botulism. Clin Infect Dis. 2005;41:1167–73. DOIPubMed

Figures

• Figure 1. Manifestation of heroin-associated anthrax in patient 1, who injected heroin under the skin of her left thighPanel A demonstrates substantial edema and blistering of skinManifestation is more pronounced in...
• Figure 2. Manifestation of heroin-associated anthrax in patient 1, who injected heroin under the skin of his left buttock 1 week before seeking treatmentPanel A demonstrates severe edema with poorly demarcated...

Table

• Table. Details of 3 heroin-associated anthrax patients from the 2009–2010anthraxoutbreak, London, United Kingdom

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].http://dx.doi.org/10.3201/eid2007.131764

DOI: 10.3201/eid2007.131764

Related Links

• More Medscape CME Articles