On December 17th, Health Protection Scotland contacted the Bacterial Zoonosis Branch (BZB) to discuss 3 cases of anthrax in heroin users. They requested assistance with the epidemiologic investigation and patient treatment options, such as adjunctive therapy with anthrax immune globulin. Because immunotherapy is of potential benefit in anthrax, the U.S. Department of Health and Human Services and CDC provided immune globulin for patients with anthrax.
On December 19th, Senior Epidemiologist Dr. Sean Shadomy, Epidemic Intelligence Service Officer Dr. Kendra Stauffer, and I arrived in Scotland to assist with the epidemiologic investigation and to provide consultation on administration of the immune globulin. Several doses of anthrax immune globulin were delivered by the CDC Division of Strategic National Stockpile and arrived on December 19th as well. In Atlanta, Dr. Theresa Smith, Branch Chief, BZB, and Principal Investigator for anthrax immune globulin, led and coordinated support activities with the CDC Regulatory Affairs program.
Initial epidemiologic investigations and case identification revealed that anthrax cases associated with heroin use were confined to a limited area in Glasgow and Lanarkshire. As of February 3rd, Health Protection Scotland has confirmed 19 cases of anthrax with 9 deaths. Cases have been identified in health boards outside of the immediate area of Glasgow, including in Glasgow, Stirling, Kirkcaldy, Dundee, Airdrie, and Kilmarnock.
Investigation surrounding the source of contamination of heroin or a mixing substance continues. All patients report a recent history of heroin use, predominantly by injection (either intravenous injection or intramuscular injection intentionally or by accident) but also by other routes, including smoking and snorting. There have been a number of presentations among patients. Some have presented with severe localized infection at injection site, proceeding to necrotizing fasciitis requiring debridement. Others have had less severe tissue infections. A number have presented with more of a meningitis type pattern with headache and systemic illness. Our program continues to actively assist Health Protection Scotland in both its epidemiologic investigation and consultation on adjunctive therapy.
In 1990, it was estimated that there were 8500 intravenous drug users in Glasgow, Scotland. Several instances of infections resulting from injections into soft tissue associated with spore-forming bacilli are reported in the literature. In 2000, one case of anthrax associated with injecting heroin was reported in Oslo, Norway. Also in 2000, CDC provided assistance during an outbreak of Clostridium novyi resulting in severe illness among injecting drug users in Scotland. During that outbreak, 60 cases were identified—23 confirmed, 37 likely.
International collaborations on these types of outbreaks are providing CDC’s anthrax experts with important information on clinical presentation and course of illness in patients exposed to Bacillus anthracis spores through a rare and unusual exposure route. The IV drug-using community and the medical community are being informed about the potential risk of exposure to B. anthracis spores associated with heroin use. Clinical guidance on the need to initiate appropriate therapy with antimicrobial agents as quickly as possible is being emphasized.
For More Information
The Bacterial Zoonosis Branch continues to actively assist Health Protection Scotland in both its epidemiologic investigation and consultation on treatment. For updates on case counts, check out Health Protection Scotland’s website at www.hps.scot.nhs.uk. At this website, you’ll also find guidance documents developed to assist in the investigation and management of cases.
What Is Anthrax and How Do You Get It?
Anthrax is a serious disease caused by Bacillus anthracis, a bacterium that forms spores. Spores are cells that are dormant (asleep) but that can come to life with the right conditions. When people are exposed to Bacillus anthracis, they can develop three types of anthrax: skin (cutaneous), lungs (inhalation), and digestive (gastrointestinal).
Anthrax is not known to spread from one person to another, but it can be spread from animals. For example, people have been infected with anthrax when they handled products from infected animals or by breathing in anthrax spores from infected animal products (like wool or drums made from animal hides). People also can become infected with gastrointestinal anthrax by eating undercooked meat from infected animals.
Anthrax also has been used as a weapon, as we saw in 2001, when letters with powder containing anthrax were deliberately spread through the postal system. Twenty-two people got sick, and 5 of them died. For more information about anthrax, visit CDC’s website: http://www.bt.cdc.gov/agent/anthrax/needtoknow.asp.