Europe - Several die as anthrax infects heroin users

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Re: Europe - Several die as anthrax infects heroin users

http://www.promedmail.org/pls/apex/f?p=2400:1001:398147634441175::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,83381

Archive Number 20100625.2119
Published Date 25-JUN-2010
Subject PRO/AH/EDR> Anthrax, human - UK (19): (Scotland)


ANTHRAX, HUMAN - UNITED KINGDOM (19): (SCOTLAND)
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Date: 25 Jun 2010
Source: Health Protection Scotland
<http://www.hps.scot.nhs.uk/anthrax/index.aspx>


Date / Confirmed Cases / Deaths
25 Jun 2010 / 46 / 13

Cumulative Scottish Total by NHS Board, 25 Jun 2010
NHS Board / Confirmed Cases / Deaths
Ayrshire and Arran / 1 / 0
Dumfries and Galloway / 6 / 0
Fife / 3 / 1
Forth Valley / 1 / 1
Greater Glasgow & Clyde / 19* / 7
Lanarkshire / 9 / 2
Lothian / 2 / 0
Tayside / 5 / 2

[Deleted expletive! One new case reported in Greater Glasgow and
Clyde. This is 20 days since the last report. This moderator had been
hoping that this epidemic was over. It has lasted quite long enough,
and it was time to expect to be reading an authoritative HPS report
explaining everything. Not to be for the moment. Obviously with
heroin based epidemics it lasts until the contaminated batch is
finally used up and not a grain wasted. - Mod.MHJ]

[Shiloh]

Re: Europe - Several die as anthrax infects heroin users

Source: http://www.eht-forum.org/news.html?f...from=home&id=0

Friday 24 September 2010
UK investigators puzzled by anthrax outbreak
Ongoing anthrax outbreak raises concerns the disease could become endemic in drug users


Heroin laced with anthrax has killed 16 people in the UK over the past nine months. The ongoing outbreak is the largest the country has seen for decades, and the first ever recorded in injecting drug users.

With cases still turning up, questions linger as to whether the infection will persist in this population, and how the drug became contaminated in the first place...

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Re: Europe - Several die as anthrax infects heroin users

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Subject: PRO/AH> Anthrax, human - UK: (Scotland) heroin users case control study
Archive Number: 20120525.1143693

ANTHRAX, HUMAN - UK: (SCOTLAND) HEROIN USERS CASE CONTROL STUDY
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Date: 22 May 2012
Source: Clinical Infectious Diseases (Advanced Access) [edited]

http://cid.oxfordjournals.org/content/early/2012/05/21/cid.cis511.abstract?sid=71d13f70-fe13-4fe2-9d21-ddc89b40eee7

Anthrax infection among heroin users in Scotland during 2009-2010: a case-control study by linkage to a national drug treatment database. Palmateer NE, Ramsay CN, Browning L, Goldberg DJ, Hutchinson SJ . Clin Infect Dis. 2012 May 22. [Epub ahead of print] PMID: 22618565 [PubMed - as supplied by publisher]

Abstract
Using a data-linkage approach, we conducted a case-control study to investigate risk factors in an outbreak of anthrax infection among Scottish heroin users. Factors associated with an increased risk of infection included longer injecting history, receiving opioid substitution therapy, and alcohol consumption. Smoking heroin was associated with lower risk of infection [But not without risk - Mod.MHJ].

Corresponding author: Norah Palmateer, Meridian Court, 4th floor, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom; .

Discussion
By using a record-linkage approach to generate case-control data, we have identified selected risk factors for anthrax infection in the recent Scottish outbreak. This approach was used because it was not possible to undertake a traditional case-control study due to logistic constraints, and because the information collected during the anthrax outbreak investigation did not have controls for comparison. We found that longer injecting history, receiving OST, and alcohol consumption were positively associated with anthrax infection. We also found that only smoking heroin was associated with lower risk of infection. The risk factors identified in this study are consistent with the hypotheses developed, but not formally confirmed, in the investigation of the anthrax outbreak.

Notably, we did not find an association between sharing injecting equipment and anthrax infection. This is consistent with other evidence, described in the outbreak report, which strongly points to the heroin itself as the source of infection. The latter is also supported by the observed correlation between length of injecting and infection: whereas we might have expected younger, less experienced drug users -- who tend to engage in riskier behaviour -- to have a greater burden of infection, the opposite was observed. Older age/longer injecting career have previously been implicated in bacterial soft tissue infections among injectors, which may have been explained by the higher propensity for older individuals to inject into the skin/muscle, an anaerobic environment in which _Clostridia_ species proliferate. Since _B. anthracis_ is aerobic, this is perhaps less likely to be the case here.

The association between anthrax and longer injecting career may reflect the poorer health and, therefore, greater susceptibility to infection of long-term drug users. Similarly, the association between alcohol and anthrax may reflect higher susceptibility to infection due to alcohol's immuno-suppressive effects.

With regard to route of heroin administration and risk of infection, it is conceivable that the intravenous administration of heroin is more conducive to the germination of spores and proliferation of vegetative organisms than smoking/inhaling heroin. However, inhalation of anthrax spores via heroin inhalation/smoking is a biologically plausible route of infection, and evidence from the outbreak case histories verified that infection did occur in non-injecting heroin users, including at least one fatal case.

The finding that those who were currently receiving OST were more likely to have had anthrax was significant, even after adjustment for time since onset of injecting. Nevertheless, there may still be residual confounding, and this association may simply reflect the more problematic and long-standing drug use of the anthrax cases, since the likelihood of being in treatment for drug use increases with increasing length and severity of drug use.

This study has a number of limitations. Firstly, because the linked data was from a preexisting source (i.e. it was not collected with the specific purpose of investigating the anthrax outbreak), we were limited to examining the data that are collected for drug misuse treatment.

Secondly, there was a long time delay between SDMD registration and anthrax onset for many of the cases. Thus, the behaviour that was recorded during an individual's historical attendance at a treatment facility may not be representative of his/her behaviour in the period immediately preceding onset of anthrax illness. Nevertheless, studies have demonstrated that drug-taking behaviour can be consistent over time, particularly among long-term heroin users, who are highly represented among our linked anthrax cases.

Thirdly, there was a large amount of missing data in the drug treatment records; thus, the current study was likely underpowered to detect some associations.

Fourthly, 17 anthrax cases did not link to the SDMD. Plausible reasons for this could be: incomplete coverage of drug treatment services by the SDMD; that the cases had never received treatment for drug misuse; or inaccuracies in the identifying information used for record linkage. The predominance of non-linkers from the West of Scotland, and Glasgow in particular (9 of the non-linkers), likely reflects an issue with completeness of reporting of data to the SDMD in this area since mid-2009 due to the introduction of an electronic system (Andrew Deas, ISD, personal communication, 2012). To verify whether the exclusion of these cases would bias our findings, we compared data on injecting/smoking heroin in the week prior to anthrax onset and found no statistically significant difference between the linkers and nonlinkers (5 percent of linkers vs. 0 percent of non-linkers had only smoked heroin, P=0.64).

In conclusion, we have demonstrated a method of using routinely collected data to enable a case-control analysis where otherwise this would not be possible, which can be used to support hypotheses and/or corroborate the findings of other investigations (e.g. epidemiological, clinical, microbiological, criminal justice). Understanding the risk factors for anthrax infection may help to inform risk communication in future outbreaks of anthrax or other bacterial infections affecting drug users.

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[For those wanting the full details of this valuable study, access to the full article is limited, unfortunately, to subscribers or via PubMed.

A valuable commentary in parallel with the findings of this Scottish group can be found in The Lancet Infectious Diseases: "Anthrax -- where does the real threat lie?" http://dx.doi.org/10.1016/S1473-3099(12)70128-7. - Mod.MHJ

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1h2A.]

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Re: Europe - Several die as anthrax infects heroin users

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shed Date: 2012-06-12 19:35:06
Subject: PRO/AH/EDR> Anthrax, human - Germany: (Bavaria) fatal, heroin user
Archive Number: 20120612.1165823

ANTHRAX, HUMAN - GERMANY (BAVARIA) FATAL, HEROIN USER
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Date: Tue 12 Jun 2012 16:16:34 +0200
From: Thomas Holzmann



Please find the following brief report of a human anthrax case from Regensburg (Germany). Bacillus anthracis was found in a dead heroin user. This case reminds us of the cases reported 2 years ago from Scotland. We think it is highly important to inform physicians.

Report: Anthrax found in an dead heroin user from Regensburg, Germany
---------------------------------------------------------------------
Blood cultures from a drug injecting heroin user who died last week [5 Jun 2012] at a hospital in Regensburg have shown the presence of _Bacillus anthracis_. The patient was hospitalized due to acute septic disease and died on the day of admission. Initial diagnostics tests were performed using PCR targeting the rpoB-, pagA-, and capC-genes at the Institute of Medical Microbiology and Hygiene, University of Regensburg pointing to _Bacillus anthracis_ as the causative agent. The results were confirmed using additional chromosomal markers by the Bundeswehr Institute of Microbiology in Munich. Further molecular typing of the strain is in progress.

The responsible Bavarian health authorities are involved in the management of the case in close contact with the diagnostic institutions and the police authorities. Health officials believe that contaminated heroin or a contaminated cutting agent mixed with the heroin may be responsible for the infection. Investigations by the German police authorities are in progress.

Doctors and diagnostic laboratories should consider anthrax as a possible disease in injecting heroin users presenting with fever or sepsis at the emergency room.

--
Dr. Thomas Holzmann, M.D.
University of Regensburg
Faculty of Medicine
Institute of Medical Microbiology and Hygiene Franz-Josef-Strauss-Allee 11
D-93053 Regensburg
Germany

http://www.uni-regensburg.de

http://www.rimmh.de

[Our heartfelt thanks to Dr. Holzmann for this report. This is a typical history of a heroin drug addict coming in when definitely ill and dying virtually on arrival. One of the problem with heroin associated (injection) anthrax is to get the affected addicts to come in promptly and not delay. Early and they can be successfully treated. Delayed and they are soon dead.

Also the Scottish experience pointed up the need to keep the injection site as drained of fluids as possible thereby minimising the impacts of the toxins (oedema toxin and lethal toxin) on the patient. This is very important.
- Mod.MHJ

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1zJl.]

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Re: Europe - Several die as anthrax infects heroin users - new fatality reported in Bavaria

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Published Date: 2012-06-21 18:37:51
Subject: PRO/AH/EDR> Anthrax - Germany (02): (BY) 2nd heroin case, RFI
Archive Number: 20120621.1175326

ANTHRAX - GERMANY (02): (BAVARIA) SECOND HEROIN CASE, REQUEST FOR INFORMATION
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Date: Wed 20 Jun 2012
From: Thomas Holzmann [edited]


Please find the following brief report of the 2nd case of human anthrax from Regensburg (Germany).

2nd case of anthrax found in a heroin user from Regensburg, Germany
-------------------------------------------------------------------
A 40-year old female drug injecting heroin user presented at the emergency department of the University Medical Centre Regensburg with fever and a purulent infection of the neck [18 Jun 2012]. She had injected heroin into the jugular vein 3 days before. One day later she developed a necrosis on the left upper limb.

She is now being treated in the ICU with antibiotic triple therapy (vancomycin, clindamycin, ciprofloxacin). Blood cultures turned positive showing Gram positive bacilli growing in chains [20 Jun 2012]. PCR targeting the rpoB-, pagA-, and capC-genes at the Institute of Medical Microbiology and Hygiene, University of Regensburg confirmed _Bacillus anthracis_ as the causative agent. Further confirmation will be performed by the Bundeswehr Institute of Microbiology in Munich.

The responsible Bavarian health and police authorities were informed immediately. Investigations by the German police authorities are in progress.

Although contaminated heroin or a contaminated cutting agents mixed with the heroin may be responsible for the infection, the exact source could not yet be identified.

This is the 2nd case within a month from the Region of Regensburg, Bavaria. All health professionals and health authorities across Europe should be aware of the possible beginning of a new outbreak of anthrax among heroin users.

It is of great interest to know whether other countries currently have cases of anthrax or suspected anthrax, especially in injecting drug users. The Robert Koch Institute (RKI) in Berlin is promoting the regional and international public health investigations as the coordinating German health authority.

--
Dr Thomas Holzmann MD
University of Regensburg
Faculty of Medicine
Institute of Medical Microbiology and Hygiene
Franz-Josef-Strauss-Allee 11
D-93053 Regensburg
Germany

http://www.uni-regensburg.de

http://www.rimmh.de

[Our thanks to Thomas for this report. We are doubly in debt to him because, though we may well have missed it, we have not seen any reports in the European press and TV news of these events. He is our singular reporter on these cases.

The last time, the German case was just an incidental as the heroin shipment made its way to the UK and Scotland. So far this time there have been no other reports of contaminated heroin. We must all be on the alert for them, especially as heroin addicts have an unfortunate tendency to present themselves too late for successful treatment. Logically there is a large shipment of lethally contaminated heroin out there in the process of being broken up and sold.

Also, in the Scottish series no contaminated heroin was interrupted and therefore the nature of the contamination could not be defined. This is very important to do so that the intermediate processors can be identified and the cause(s) for this contamination described. - Mod MHJ

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/2BZj.]

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Re: Europe - Several die as anthrax infects heroin users - new fatality reported in Bavaria

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Published Date: 2012-06-23 19:58:11
Subject: PRO/AH/EDR> Anthrax, human - Denmark: German heroin associated RFI
Archive Number: 20120623.1178659

ANTHRAX, HUMAN - DENMARK: GERMAN HEROIN ASSOCIATED REQUEST FOR INFORMATION
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Sent: Fri 22 Jun 2012
From: Robert Spencer [edited]



I understand that there is a probable case of cutaneous anthrax in Jutland, Denmark, in a 69-year-old injection drug user (IDU), who is said to have purchased heroin in Germany 3 weeks ago.

I also understand that the 2 German strains of _Bacillus anthracis_ are most likely identical by genotyping.

These are unconfirmed reports.

--
Robert Spencer, MB,BS,MSc,FRCPath
Consultant Medical Microbiologist
University Hospital Bristol NHS Foundation Trust
Queen's Building, Bristol Royal Infirmary
Bristol, BS2 8HW, UK


[We would appreciate getting an independent confirmation from our Danish members in regard to Bob's communication. He is sound and in a position to be privy to such information, but confirmation is needed.

Thanks to Bob for this heads up. - Mod.MHJ

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1ZJN.]

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Re: Europe - Several die as anthrax infects heroin users - new fatality reported in Bavaria

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Published Date: 2012-06-24 19:05:51
Subject: PRO/AH/EDR> Anthrax, human - Denmark (02): NOT
Archive Number: 20120624.1179204

ANTHRAX, HUMAN - DENMARK (02): NOT
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Date: 24 Jun 2012
From: Kare Molbak [edited]


The mentioned case was not confirmed to be anthrax, but rather a streptococcal infection. Furthermore, investigations of the origin of the heroin did not confirm a link with Germany but suggested that the heroin was bought in Copenhagen. Hence, there is not a confirmed "Danish link" to the 2 German cases.

--
Kare Molbak
Director, Department of Infectious Disease Epidemiology
State Epidemiologist for Denmark
Statens Serum Institut
Artillerivej 5
2300 Copenhagen S
Denmark


[I am very grateful to our Danish colleagues for clarifying this so quickly and authoritatively. Instead of being _Bacillus anthracis_, it is a haemolytic Group A streptococcus. According to the Danish police, this heroin has been circulating in the Copenhagen area for the last 3 months. - Mod.MHJ

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1ZJN.]

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Re: Europe - Several die as anthrax infects heroin users - new fatality reported in Bavaria

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Published Date: 2012-06-24 21:57:16
Subject: PRO/AH/EDR> Anthrax - Germany (03): strain identified
Archive Number: 20120624.1179225

ANTHRAX - GERMANY (03): STRAIN IDENTIFIED
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Date: 22 Jun 2012
Source: Robert Koch Institute [in German, trans. Sabine Zentis, edited]

http://www.rki.de/DE/Content/Service/Presse/Pressemitteilungen/2012/09_2012.html

In the Regensburg area, there are 2 recent cases of anthrax in drug users (heroin), one fatal, and the current anthrax strain has been confirmed to be identical to the 2009/2010 outbreak strain associated with cases in the UK.

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Communicated by:
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[The German press has been quick to say that this contaminated heroin came from the UK. I suspect that the genesis of this latest contaminated batch may be more complicated. But for those interested, here are some links to the German press:
http://web.de/magazine/gesundheit/ps...er-bayern.html, http://web.de/magazine/gesundheit/ps...en-europa.html. - Mod.MHJ

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1zJl.]

[Giuseppe]

Re: Europe - Several die as anthrax infects heroin users - new fatality reported in Bavaria

[Source: European Centre for Disease Prevention and Control, full text: (LINK).]

Anthrax cases among injecting drug users: ECDC and EMCDDA updated risk assessment


09 Jul 2012 / ECDC



In June, ECDC and EMCDDA jointly assessed the risk associated with two cases of anthrax among injecting drug users (IDU) in Regensburg (Bavaria, Germany).
Another case of anthrax in a injecting drug user has been reported from Berlin. The first two cases, one of which was fatal, are likely linked through exposure to heroin contaminated by a most likely identical Bacillus anthracis strain. The link with the third case, though probable, needs to be confirmed.

The geographical distribution of the contaminated heroin is unknown at this time, but it is possible that the batch has the same source as the contaminated heroin incriminated in the 2009/2010 outbreak in Scotland, with cases also reported from Germany and England.

The risk of exposure for heroin users in Germany and other countries is still present and therefore additional cases among IDUs may occur in the future.

As anthrax has rarely been associated with severe infection among drug users, clinicians may not consider anthrax in the differential diagnosis of severe infections in this population and this consequently may result in undiagnosed cases. Clinical awareness in healthcare settings of the risk of injection-related infection with rare pathogens among the IDU population is therefore crucial.

ECDC and EMCDDA will continue to monitor the evolution of this situation in terms of the epidemiological information available.

Read full joint rapid risk assessment: Anthrax cases among injecting drug users - Germany, June-July 2012 - Update, 6 July 2012



Read more on ECDC website:

Anthrax health topic page

European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) website

Robert Koch Institute: Dritter Milzbrandfall bei Heroinkonsument (Berlin) (in German)

-
------

[alert]

Re: Europe - Several die as anthrax infects heroin users - new fatality reported in Bavaria

Published Date: 2012-09-07 14:03:11
Subject: PRO/AH/EDR> Anthrax, human - UK (06): (Wales) new heroin case
Archive Number: 20120907.1285521

ANTHRAX, HUMAN - UK (06): (WALES) NEW HEROIN CASE
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Date: Thu 6 Sep 2012
Source: Public Health Wales [edited]

http://www.wales.nhs.uk/news/24028

Public Health Wales can confirm that a Gwynedd man who has injected drugs is currently an inpatient in a hospital in the North West of England with confirmed anthrax infection. The patient's condition is stable. [This is north west Wales. - Mod.MHJ] It is not yet clear whether this case is linked to recent cases of anthrax infection in people who inject drugs in Blackpool [England] and Scotland.

Public Health Wales and Health Boards have issued alerts to local substance misuse groups across Wales to warn them of the danger of contaminated heroin. Alerts have also been sent to health professionals to remind them of the symptoms of anthrax infection.

There is an ongoing outbreak of anthrax in intravenous drug users in Europe. A total of 8 cases have been identified since early June [2012]. The source is presumed to be contaminated heroin.

The Rare and Imported Pathogens Laboratory at Health Protection Agency, Porton Down (Salisbury, England), is providing diagnostic support to clinical teams to assist them with the handling of anthrax incidents.

Dr Chris Whiteside, Consultant in Communicable Disease Control for Public Health Wales, said: "It's likely that further cases among people who inject drugs will be identified as part of the ongoing outbreak in EU countries. The Department of Health has alerted the NHS of the possibility of drug users presenting to Emergency Departments and Walk-in Clinics, with symptoms suggestive of anthrax.

"Although a very serious disease, anthrax responds to antibiotics and patients have a better chance of recovery if treatment is started early. It is therefore important for medical professionals to know the signs and symptoms to look for, so that there are no delays in providing the necessary treatment."

People can become infected with anthrax through either the skin, inhalation, injection, or by ingestion of anthrax spores. The symptoms of anthrax vary depending on the route of infection. Anthrax in drug users was considered to be very rare -- prior to the 2009-2010 outbreak in Scotland, only one previous case had been reported in Norway in 2000. Drug users may become infected with anthrax when heroin is contaminated with anthrax spores. This could be a source of infection if injected, smoked or snorted -- there is no safe route for consuming heroin or other drugs that may be contaminated with anthrax spores.

Further information about anthrax is available from http://www.wales.nhs.uk/sites3/page....=457&pid=25408.

--
Communicated by:
Sabine Zentis
Castleview Pedigree English Longhorns
Gut Laach
52385 Nideggen
Germany


[There is a BBC Wales report but it is essentially just a rewrite of the NHS news release and adds nothing of relevance:
http://www.bbc.co.uk/news/uk-wales-n...wales-19510933.

An inquest on the Blackpool case was called and then postponed for another day. Hopefully this Welsh addict can provide some useful information on the source of his heroin. Presently these cases are presenting more questions than answers, though if the affected addicts present themselves early their chances of survival are much greater because of the knowledge gained from previous cases. One of which is the aggressive draining of the lesion to remove the anthrax toxins there. Antibiotics by themselves are insufficient.- Mod.MHJ]

[Also see http://www.flutrackers.com/forum/sho...290#post467290 for more on this latest case. - alert]

[alert]

Re: Europe - Several die as anthrax infects heroin users

Published Date: 2012-09-18 13:04:05
Subject: PRO/AH> Anthrax, human - UK (09): (England) addict experience
Archive Number: 20120918.1298718

ANTHRAX, HUMAN - UK (09): (ENGLAND) ADDICT EXPERIENCE
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Date: Fri 14 Sep 2012
Source: The Guardian [edited]

http://www.guardian.co.uk/world/2012/sep/14/anthrax-heroin-blackpool

'Having anthrax didn't make me think I should stop taking heroin'
-----------------------------------------------------------------
As a 2nd drug user dies of anthrax in Blackpool, a former addict explains why warnings about the disease are ignored. [C.], a former addict injected herself with anthrax, at the Pierpoint addiction centre in St Annes-on-Sea, Lancashire.

When she injected herself with heroin, unaware it had been contaminated by anthrax, her wrist immediately began to swell and turn red. The pain was shocking. But she felt only anger and irritation. "I wanted my usual buzz," she said. "I'd been a heroin addict for 23 years. I knew I'd spiked my vein properly. I couldn't understand why the gear wasn't working."

So she injected herself a 2nd time. This time her entire arm swelled up. The red turned to purple. It spread up towards her elbow and down towards her fingers. The pain intensified but the drug high still didn't come.

It was 2010 and [C.] had infected herself with anthrax at the height of the largest single common-source outbreak of human anthrax in the UK in more than 50 years. The deaths spread across Europe: 126 cases were eventually identified, including 119 in the UK. At least 14 people died. This week [week of 10 Sep 2012] health experts said a 2nd drug user had died of anthrax in Blackpool, weeks after the 1st such death in the town.

[snip, but read the whole article!!!]

[Byline: Amelia Hill]

--
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[For those of us with drug addictions no worse than for nicotine or caffeine, it is puzzling why these heroin addicts put themselves at risk. This article begins to explain the problems that Public Health officers face when the heroin is contaminated. Let us learn from it.

And frankly C. was very lucky to have been treated successfully with just antibiotics after 3 i.v. injections of contaminated heroin. - Mod.MHJ]