Proposed alert
Action by recipients:
- NHS Trusts - Medical Directors (England)
- NHST/FT/007 - NHS FOUNDATION TRUSTS (ENGLAND) - MEDICAL DIRECTOR
- Primary Care Trusts - Directors of Public Health
- Primary Care Trusts - Medical Directors
- Regional Directors of Public Health
- Strategic Health Authorities (England) - Directors of Public Health
Information to recipients:
- Consultants in Communicable Disease
- MHRA Drug Alerts
- NHS Trust Chief Executives
- NHST/FT/001 - NHS FOUNDATION TRUSTS (ENGLAND) - CHIEF EXECUTIVE
- PCT Chief Executives
- Public Health Link
- SHA Chief Executives
Action category: Urgent (cascade within 48 hours)
Title: POSSIBLE CONTAMINATED HEROIN AT RISK OF CAUSING WOUND BOTULISM IN INJECTING DRUG USERS
Broadcast content:
To: Directors of Public Health of PCTs to forward to: All general practitioners - and all practice nurses and non-principals and for the`locum information pack' Primary Care Medical Advisers Medical Directors in all NHS Trusts (including ambulance trusts) Staff in Accident and Emergency departments Intensive care units, high dependency units and trust microbiologists. It is also advised that where possible this alert and the attached information is cascaded to: Services dealing with drug misuse Services for drug misusers run by voluntary or other agencies
POSSIBLE CONTAMINATED HEROIN AT RISK OF CAUSING WOUND BOTULISM IN INJECTING DRUG USERS
The Health Protection Agency (HPA) has advised the Department of Health that in the week between 22/02/09 and 02/03/09, five heroin injecting drug users (IDUs) (four males and one female) have been reported to the Health Protection Agency Centre for Infections (HPA CfI), from London, East of England and the South Eastwith clinically diagnosed wound botulism.
Laboratory confirmation of Clostridium botulinum Type B has been reported in three of the cases, two males aged 30 and 45 years old and a female aged 35 years. C. botulinum Type A has been laboratory confirmed in one case - a male aged 38 years old reported to the HPA CfI on 11/01/09. These cases raise the possibility that a batch of heroin is contaminated with the anaerobic bacterium clostridium botulinum.
The HPA has also advised that there has also been a laboratory confirmed case (reported on 26/02/09) of, Clostridium novyi Type A in a Berkshire resident admitted to Hospital on 30/01/2009 with a perineal abscess who later died on 01/02/2009. This individual was injecting heroin into the perineum.
In IDUs, C.novyi and wound botulism result from common problems to do with what they inject and how they inject it. Specifically the use of contaminated heroin, skin popping (injecting into muscle) and heroin that requires the use of more citric acid than usual to dissolve it. All these factors increase the risks of anaerobic growth.
Taken together, the cluster of wound botulism cases in one week and the C.novyi case, are of significance and suggest that IDUs are at potentially increased risk of bacterial infection from a possibly contaminated batch of heroin that is in circulation.
Botulinum antitoxin is effective in reducing the severity of symptoms if administered early in the course of the disease. C. botulinum is sensitive to benzyl penicillin and metronidazole. In cases of wound infection, antimicrobial therapy and surgical debridement should reduce the organism load and therefore toxin production, but circulating toxin can only be neutralised by the early administration of antitoxin. The HPA has advised that where there is definite clinical suspicion of botulism,treatment with antitoxin should not be delayed for microbiological testing.
The Department of Health will be making information directly available through the National Treatment Agency for Substance Misuse and drug user networks, shortly after this alert has been sent to the NHS. The Home Office is also alerting police networks in the UK of the current position.
For further information please contact Dr Mark Prunty, Tel: 0207 972 3986, Email: This document has been authorised by the Department of Health: Gateway reference no: 11484. Further information attached: Links to the HPA website for information on wound botulism cases in injecting drug users, Clostridium novyi which include guidelines for their diagnosis and treatment.
Links: Wound botulism cases in injecting drug users
Severe systemic sepsis in injecting drug users