Transcript National Surveillance

Trends in wound botulism among injectors in
the United Kingdom, 2000-2004
Leah de Souza-Thomas, Vina Mithani, Jim McLauchlin,
Vivian D Hope*, Jeffrey Dennis & Fortune Ncube
Centre for Infections, Health Protection Agency, Colindale, London.
* Also at the Centre for Research on Drugs and Health Behaviour,
Imperial College London.
Bacterial infections among IDUs
The epidemiology of viral infections among injectors is
widely study
Many bacterial infections which can be acquired by
IDUs
Infections can be crudely split into hygiene or drug
contamination related.
Surveillance data currently only available on the most
severe infections i.e. Clostridia infections
Wound botulism
Wound botulism (WB) occurs when the spores of Clostridium
botulinum contaminate a wound, germinate and produce toxin
Symptoms are caused by the neurotoxin which blocks the release
of acetylcholine at the neuromuscular junction.
Symptoms include blurred
vision and difficulty in
swallowing and speaking, and
it can also result in paralysis
and death.
There is an effective
antitoxin.
Epidemiology of wound botulism
WB first described in the USA in 1951, reporting begun
in 1950 (Davis et al., 1951)
WB in IDUs first described in New York in 1982 (Weber et
al., 1993)
Cases in USA make up 90% of known cases worldwide,
75% of which occur in California (Werner et al., 2000)
Epidemiology of WB in the UK
Prior to 2000 no reported cases
Data to the end of 2004, 89 cases of suspected or
confirmed WB
Thirty-seven of the 89 (42%) cases were confirmed
Eighty-two per cent (70/85) in England, 15% (13/85) in
Wales, 2% (2/85) in Wales
Reported cases of wound botulism
among injecting drug users in the UK
Number of cases reported
Scotland
England
Wales
50
40
30
20
10
0
2000
2001
2002
Year
2003
2004
Number of cases
UK Cases 2004
10
9
8
7
6
5
4
3
2
1
case in England
case in Scotland
c confirmed case
c
c
c
c
c
c
c
c
c
c
c
52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54
Jan
Feb
March
April
May
Jun
July
2004
Week of reporting
Aug
Sep
Oct
Nov
Dec
Found geographical and
temporal clusters in
London, Yorkshire & Humberside
and East Midlands regions
WB cases in 2004
Median age 35 years (range 20-54)
Mean injecting duration 12.7 years (range 2-24)
Ventilation required for 18 cases
Deaths in 2 cases
Antitoxin administer to 22% (9/41) of cases
Skin abscesses not found in all cases
Injecting practises (2004)
Intravenous injection reported by 66% (10/15)
Muscle Popping reported by 40% (6/15)
Skin popping reported by 33% (5/15)
Drugs reported include heroin, crack, cocaine,
methadone, temazepam & temgesic. Poly drug use,
18% (3/17) heroin alone
Citric acid most common dissolvent (86%, 12/14), other
include jif, lemon juice, vinegar, vitamin C and water
Potential costs
Distressing and unpleasant
Health care costs: Surgery; Medication - Antibiotics &
Antitoxins; long stays in hospital including ITU / HDU; &
Laboratory work
Mortality
‘costs’ are likely to be very high per case.
Conclusions
Emerging problem of WB among injecting drug users.
Increased awareness and vigilance to reduce the
severity of morbidity and mortality.
Further research:
• What has caused the increase?
• How widespread is the problem overall?
• Analysis of drug related deaths?
• Investigation of risks of acquiring WB?
Further information on
infections among injecting
drug users can be found at:
http://www.hpa.org.uk/
Go to:
‘Topics A to Z’
and select:
‘Injecting drug users (IDUs)’