Anthrax - Blackpool, England

I had no idea this news had broken when I made the earlier post, odd coincidence really. Sorry to "go on" about it ...

From BBC @ 15:00 today, HPA and NHS Blackpool :-

Anthrax Case in Blackpool Confirmed by HPA

The Health Protection Agency (HPA) and NHS Blackpool can confirm they are investigating the death of a drug injecting heroin user in Blackpool. The investigation has confirmed that the cause of death was anthrax following positive test results.

This is the second case of anthrax seen in an injecting drug user in England, the first announced in London on 5 February.  Similar cases have been seen in Scotland since December 2009 with nineteen cases having been confirmed and one in Germany. Similarities to the cases in Scotland suggest that the heroin, or a contaminated cutting agent mixed with the heroin, is the likely source of infection.

Dr Arif Rajpura, Director of Public Health from NHS Blackpool, said:” While public health investigations are ongoing, it must be assumed that all heroin in the North West carries the risk of anthrax contamination. I urge all heroin users to be extremely alert to the risks and to seek urgent medical advice if they experience signs of infection such as redness or excessive swelling at or near an injection site, or other symptoms of general illness such a high temperature, chills or a severe headache or breathing difficulties, as early antibiotic treatment can be lifesaving.

“Heroin users are strongly advised to cease taking heroin by any route, if at all possible, and to seek help from their local drug treatment services. This is a very serious infection for drug users and prompt treatment is crucial.

“Drug injecting is an extremely risky and dangerous practice and users are vulnerable to a wide range of infectious diseases, both from the action of piercing the skin, as well as contaminants in the drugs that they use.” 

Symptoms (from HPA) :-

What are the symptoms in humans?

There are two main forms of anthrax infection: cutaneous and inhalation.

In cutaneous (skin) anthrax, a lesion appears on the skin, often on the head, neck, forearms or hands. This lesion starts as a small bump and develops into a characteristic ulcer with a black centre. It is rarely painful, but if untreated the infection can spread to cause blood poisoning. If untreated, the disease can be fatal in 5% of cases, but with prompt antibiotic treatment recovery occurs.

Inhalation anthrax is normally much less common. Symptoms begin with a flu-like illness followed by respiratory difficulties and shock after 2-6 days.

Injection anthrax - since December 2009, a signficant number of drug users in Scotland have been found to have anthrax infection. it is thought that they contracted the infection from using heroin contaminated by anthrax spores. Further information

Intestinal anthrax is a very rare form of food poisoning, and results in severe gut disease, fever and blood poisoning.

Inhalation and intestinal anthrax are serious and can often be fatal. They can be treated effectively with antibiotics if identified early enough, but this can be difficult as the initial symptoms are similar to other illnesses.

and here, also from HPA :-

Anthrax in drug users appears to be very rare; prior to the current outbreak in Scotland, only one previous case had been reported in Norway in 2000.

Q5. How long can you have the infection before developing symptoms?

This is dependent on the dose and route of exposure and may vary from one day to eight weeks. However, symptoms usually develop within 48 hours with inhalation anthrax and 1-7 days with cutaneous anthrax. It is not known exactly how long symptoms can take to develop following the use of contaminated heroin, however in most cases during the current outbreak, symptoms started within 1 to 7 days of taking heroin.

Q6. What are the symptoms?

Early identification of anthrax can be difficult as the initial symptoms are similar to other illnesses.

Symptoms vary according to the route of infection:

Anthrax in drug users

Drug users may become infected with anthrax when heroin or the cutting agent mixed with heroin has become contaminated with anthrax spores. This could be a source of infection if injected, smoked or snorted. The clinical presentation is likely to vary according to the way in which the heroin is taken and might include:

• Swelling and redness at an injection site, which may or may not be painful
• Abscess or ulcer at an injection site often with marked swelling (oedema)
• Septicaemia (blood poisoning)
• Meningitis
• Symptoms of inhalational anthrax (see below)

Cutaneous anthrax - Local skin involvement after direct contact.

• Commonly seen on hands, forearms, head and neck. The lesion is usually single
• 1-7 days after exposure a raised, itchy, inflamed pimple appears followed by a papule that turns vesicular (into a blister). Extensive oedema or swelling accompanies the lesion – the swelling tends to be much greater than would normally be expected for the size of the lesion and this is usually PAINLESS
• The blister then ulcerates and then 2-6 days later the classical black eschar develops
• If left untreated the infection can spread to cause blood poisoning

Inhalation anthrax - symptoms begin with a flu-like illness (fever, headache, muscle aches and non-productive cough) followed by severe respiratory difficulties and shock 2-6 days later. Untreated disease is usually fatal, and treatment must be given as soon as possible to reduce mortality.

Intestinal anthrax is contracted by the ingestion of contaminated carcasses and results in severe disease which can be fatal. This is found in some parts of the world where the value of an animal dying unexpectedly outweighs any fears of contracting the disease.

Q7. Can anthrax be treated?

Cutaneous anthrax can be readily treated and cured with antibiotics. Mortality is often high with inhalation and gastrointestinal anthrax, since successful treatment depends on early recognition of the disease.

Prompt treatment with antibiotics and, where appropriate, surgery is important in the management of anthrax related to drug use.

Q8. How is anthrax spread?

A person can get anthrax if they inject, inhale, ingest or come into direct physical contact (touching) with the spores from the bacteria. These spores can be found in the soil or in contaminated drugs. It is extremely rare for anthrax to spread from person-to-person. Airborne transmission from one person to another does not occur; there have been one or two reports of spread from skin anthrax but this is very, very rare.

Q9. How do drug users become infected with anthrax?

Heroin or the cutting agent mixed with heroin may become contaminated with anthrax spores from the environment. This could be a source of infection if injected, smoked, or snorted.

(Q&As courtesy of Health Protection Scotland)

The swine flu hotline no longer exists.
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Anthrax - Europe

This is just a collection of odds and ends resulting from digging around the internet. These snippets, which are presented in no particular order and without much comment, have been sitting in isolated non-posts in the drafts folder. Haven't a clue if they're of any use, haven't a clue if they're relevant to anybody or not, but better out here than tucked away.

It seems that there was a problem in Germany in December. (from Reuters, 23rd January)

The eighth victim was a 42-year-old man in Germany who died of anthrax infection in mid-December after injecting drugs, authorities said.

"It is now suspected that heroin with infectious anthrax spores (and possibly other psychoactive substances that can be injected) is in circulation in Europe," the health ministry in Berlin said in a statement.

Anthrax infection occurs most often in wild and domestic animals in Asia, Africa and parts of Europe.

Humans are rarely infected but touching contaminated hides or hair can cause skin lesions. If the bacillus is inhaled, it can take hold quickly and by the time symptoms show up, it usually is too late for successful treatment with antibiotics.

The European Center for Disease Prevention and Control (ECDC), which monitors health in the European Union, said on its website that further anthrax cases were possible.

"The occurrence of 15 confirmed cases, including 8 deaths in a 5-week period is unusual and unexpected," it said.

"Considering the complex international distribution chain of heroin, and the clustering in time of cases in Scotland and Germany, the exposure to a contaminated batch of heroin distributed in several EU Member States is possible."

The ECDC reports (3rd February):

In Germany, an epidemiological investigation was launched by the Robert Koch Institute, which includes distribution of information to hospitals, GPs, emergency departments, microbiologists and low threshold facilities was launched in order to raise awareness, gain more thorough information and search for suspected cases.
The joint ECDC / EMCDDA risk assessment comes to the following conclusions:

• what is currently known is that there is likely a contaminated batch of heroin circulating in the MS.
• the anthrax contaminated batches of drugs are most likely due to accidental contamination and not deliberate release. There is a complex international distribution chain of heroin, and the clustering in time of cases in Scotland and Germany, the exposure to a contaminated batch of heroin distributed in several EU Member States is possible. Therefore, it is likely that additional cases will still be identified in the near future, in the UK and potentially in Germany and other Member States.
• It can also be assumed, that since anthrax infections in drug users is not a frequent event, persons who deal in the chain of procedures for drug analysis in laboratories may not suspect anthrax to be present in samples that they perform routine tests on.
• The epidemiological data suggests that infection via inhalational route with anthrax-contaminated material is possible.

ECDC and key partners have already identified steps to take to further monitor and act in this situation.

Another source locates the German case in North-Rhine-Westphalia.

Updates on the HPS Scotland site suggest no new cases, same with HPA - which can only be good news.

A piece, on a Biosecurity blog in USA The site is meant for "clinicians who are interested in biodefense" so it might not have been such a good idea to use the link, especially as none of the Rigbys are either clinicians or specialists, but no matter, it's still interesting.

Big Bear says France is worried by anthrax outbreak, the same is mentioned on Bio-prep watch, which is a Chicago based site.

"StoptheDrugWar" (US based) 22nd January (the whole article is worth reading).

drug reform and drug user activists are reporting a cluster of nine suspicious heroin-related deaths in Coimbra, Portugal, although it is unclear at this point whether they are linked to anthrax-tainted heroin.

Can't find out if these were linked to anthrax contamination or not, but this forum suggests it was overdose rather than contamination - so perhaps no need to panic.

Nothing at all on the EMCDDA (European Monitoring Centre for Drugs and Drug Addiction)
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Anthrax - in London

Quoted from HPA, and found by chance when looking at ambulance statistics :-

Anthrax alert for heroin users in London

5 February 2010

The Health Protection Agency (HPA) and NHS London can confirm that a drug injecting heroin user has tested positive for anthrax and is being treated in a London hospital.

This is the first case of anthrax seen in an injecting drug user in England since similar cases were first seen in Scotland in December 2009. Nineteen cases have so far been confirmed in Scotland. Similarities to the cases in Scotland suggest that the heroin, or a contaminated cutting agent mixed with the heroin, is the likely source of infection.

Dr Brian McCloskey, Director of the Health Protection Agency in London, said:

"We are working closely with NHS London to monitor the situation. There is no evidence of person to person transmission in this case and I'd like to reassure people that the risk to the general population, including close family members of the infected patient, is negligible. It is extremely rare for anthrax to be spread from person to person and there has been no evidence of a significant risk of airborne transmission associated with the current situation in Scotland.

"While public health investigations are ongoing, it must be assumed that all heroin in London carries the risk of anthrax contamination. Heroin users are advised to cease taking heroin by any route, if at all possible, and to seek help from their local drug treatment services. Heroin users in London are strongly encouraged, as soon as possible, to find out more about the support services in their area. They can be put in touch with local drug services and receive advice by contacting Talk to Frank."

Professor Lindsey Davies, Regional Director of Public Health from NHS London, said:

"I urge all heroin users in London to be extremely alert to the risks and to seek urgent medical advice if they experience signs of infection such as redness or excessive swelling at or near an injection site, or other symptoms of general illness such a high temperature, chills or a severe headache or breathing difficulties, as early antibiotic treatment can be lifesaving. This is a very serious infection for drug users and prompt treatment is crucial.

"Drug injecting is an extremely risky and dangerous practice and users are vulnerable to a wide range of infectious diseases, both from the action of piercing the skin, as well as contaminants in the drugs that they use.

"Health professionals and drug action teams in England had already been alerted to the situation in Scotland in December and we will continue to work closely with colleagues who work with drug users to monitor probable cases and raise awareness of the risks."

To the best of our knowledge, we Rigbys know nobody who uses heroin - but we hope those who do are careful with their sources.

It's at times like this when we wonder if legalising drugs would be sensible, as they have done in Portugal, and as reported by the Cato Institute.

Would legalising help stop contamination? - Discuss amongst yourselves.

Edit:
This item from Scientific American reports on the situation in Portugal 5 years after decriminalisation and

Walter Kemp, a spokesperson for the United Nations Office on Drugs and Crime, says decriminalization in Portugal "appears to be working."

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Anthrax

Eight people, including seven in Scotland, have died of anthrax infection from using suspected contaminated heroin, European health authorities said last night, and one expert advised users to stop taking the narcotic immediately.

So says the Indy.

We're reassured that those injecting themselves with heroin read the Independent, and will stop using the drug straight away thanks to advice from some un-named official somewhere in Europe.

No other papers appear to carry this news, although it is tucked away within BBC Scotland

A further case of anthrax has been confirmed in a drug user in Scotland bringing the total number of cases in this outbreak to 15.
The new case of the potential killer was confirmed to have taken place in the NHS Ayrshire and Arran area.
So far, the number of anthrax related deaths stands at seven with cases confirmed in six NHS boards.

The BBC reassures that we can't catch it :-

It normally infects humans when they inhale or ingest anthrax spores, but it cannot be passed from person to person.

Funny how they describe it as an "outbreak" if you can't catch it - a bit careless perhaps?

Apparently Anthrax is (quote HPA).

... a bacterial infection caused by Bacillus anthracis, spores of which can survive in the environment for years or decades. It is primarily a disease of herbivorous mammals, though other animals and some birds, particularly carrion birds, can also contract it.

There's a Q+A (FAQ) here and something on DEFRA wrt animals

HPA also says this

Anthrax became a notifiable industrial disease under the Factories Act in 1895, and in December 1960 became a notifiable disease under the Public Health Act. Information about the morbidity of the disease in the general population is available only since 1961.

The last reported case of anthrax in England and Wales occurred in October 2008  ... this was a fatal case of inhalation anthrax in a man whose exposure occurred during manipulation of animal hides while drum-making. This was the first death since 1974, when there were been two fatal cases, both believed to be associated with bonemeal fertilizer. One had haemorrhagic septicaemia and generalised infection with Bacillus anthracis, and the second had gastrointestinal and pulmonary anthrax. Prior to that, the last reported case of pulmonary anthrax had been in 1965.

A death from anthrax occurred in Scotland in 2006; this was a case of atypical inhalation anthrax which probably followed exposure as a result of playing/handling animal hide drums ... In December 2009 cases of anthrax were reported in injecting drug users in Scotland.

There's more information about the cases on HPA here

It's odd that these little spores, which apparently can't be (according to the BBC) "passed from one person to another", caused an island to be abandoned and sealed off about fifty or so years ago. There was some obscure reference to anthrax to do with doing up some of the tube stations too, because the old plaster contained dead anthrax spores from either horse hair or straw - can't find a reference.

Anyhow, here's a bit more, this time from  Wikipedia

Anthrax cannot be spread directly from person to person, but a patient's clothing and body may be contaminated with anthrax spores. Effective decontamination of people can be accomplished by a thorough wash down with antimicrobial effective soap and water. Waste water should be treated with bleach or other anti-microbial agent. Effective decontamination of articles can be accomplished by boiling contaminated articles in water for 30 minutes or longer. Chlorine bleach is ineffective in destroying spores and vegetative cells on surfaces, though formaldehyde is effective. Burning clothing is very effective in destroying spores.

Absolutely no idea if this is accurate or not, because sometimes Wikipedia seems to have been written by idiots, but the science stuff is usually quite good.

Does anybody out there know a bit more?