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Wound botulism among people who inject heroin in Norway, 31 October 2013 (ECDC, extract)

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  • Wound botulism among people who inject heroin in Norway, 31 October 2013 (ECDC, extract)

    [Source: European Centre for Disease Prevention and Control (ECDC), full PDF document: (LINK). Extract.]

    Rapid Risk Assessment

    Wound botulism among people who inject heroin in Norway, 31 October 2013

    Main conclusions and recommendations
    • As of 28 October 2013, six cases of wound botulism have been reported in Norway among people who had injected heroin.
    • The reported onset of symptoms was between 10 and 25 October.
    • Two cases have been confirmed through mice inoculation and four are suspected cases with laboratory results pending.
    • Ages range from 35 to 55 years; four of the cases are male and all cases have been hospitalised.
    • All cases reside in the Oslo area or in neighbouring municipalities.
    • All reported heroin use and most reported intramuscular injection of heroin.
    • The source of infection is thought to be a batch of contaminated heroin.
    • The geographical distribution of the potentially contaminated heroin is unknown at this time, as is the distribution stage at which the heroin may have been contaminated.

    People who inject drugs (PWID) are known to be at risk of wound botulism. Guidance on drug treatment and prevention and control of infections among people who inject drugs has recently been issued by ECDC and the EMCDDA [1]. No person-to-person transmission has ever been reported.

    Based on current information (cases clustered in time and space), it is very likely that the two confirmed and the four suspected cases of wound botulism among PWID in Norway are linked through exposure to contaminated heroin. The ubiquity of Clostridium botulinum makes contamination of heroin possible at any stage. Therefore, it is important to ensure epidemiological investigation to relate cases with the same source of heroin.

    As this is an ongoing problem, the following measures are relevant for consideration in other EU/EEA Member States:
    • increase awareness in hospitals and other healthcare settings to support prompt diagnosis and treatment as well as reporting to appropriate public health authorities;
    • increase awareness among heroin users, their social networks and drug treatment and harm reduction services regarding the signs and symptoms of wound botulism infection and of the importance of seeking medical treatment immediately;
    • encourage heroin users to reduce or eliminate heroin use by promoting access to appropriately-dosed opiate substitution treatment;
    • encourage the exchange documents useful for investigation and control, such as case definitions, educational material, investigation questionnaires, protocols for treatment and documents useful to develop a strategy to address communication among vulnerable groups (including materials already developed by Public Health England [2,3]);
    • continue forensic investigations at the national and EU/EEA level to identify contaminated batches of heroin, and limit the occurrence of additional cases;
    • ensure availability of anti-toxin vials for possible future cases. As large clusters of cases could eventually occur, mechanisms facilitating the mobilisation of anti-toxin across EU/EEA countries should be considered.

    Public health issue

    Cluster of wound botulism among people who inject drugs (PWID) in Norway.

    Source and date of request

    The European Commission requested a rapid risk assessment on this event on 28 October 2013.

    Consulted experts

    ECDC internal response team: Paloma Carrillo-Santisteve, Juliana Reyes-Uruena, Ettore Severi, Anastasia Pharris, Elisabeth Bancroft, Lara Tavoschi, Johanna Takkinen, Denis Coulombier.

    EMCDDA experts: Lucas Wiessing, Julian Vicente.

    External experts consulted and acknowledged: Norwegian Institute of Public Health: Karin Nygard, Emily MacDonald, Hans Blystad, Karin Rønning. Public Health England: Vivian Hope.