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 acetylcholineacetylcholine 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

0

10

20

30

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50

2000 2001 2002 2003 2004

Year

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Scotland England Wales

UK Cases 2004

Found geographical and temporal clusters in London, Yorkshire & Humberside and East Midlands regions

109 case in England c confirmed case8 case in Scotland765432 c c

1 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

Sep Oct Nov Dec

Week of reporting

Aug2004

April May Jun July

Num

ber o

f cas

es

Jan Feb March

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)’