Published Date: 2004-01-24 23:50:00
Subject: PRO/EDR> Tetanus, parenteral drug users - UK
Archive Number: 20040124.0277
TETANUS, PARENTERAL DRUG USERS UK
A ProMED-mail post
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International Society for Infectious Diseases
Date: Fri, 23 Jan 2004
From: ProMED-mail <firstname.lastname@example.org>
Source: Eurosurveillance Weekly Vol 8 / Issue 4 22 Jan 2004 [edited]
Ongoing outbreak of tetanus in injecting drug users in the UK
The outbreak of tetanus in injecting drug users (IDUs) in England 1st
reported in Nov 2003 (1) is ongoing and has spread to Scotland and
Wales. Since the last update (2), 2 more cases* have been reported, giving
a total of 14 cases in the United Kingdom (UK) between Jul 2003 and 21 Jan
2004 [See figure 1 at the Eurosurveillance web site Mod.LL]. The most
recent onset date was 19 Jan 2004.
The majority of cases had generalized tetanus, and one case is known to
have died. 9 cases were in females and 5 in males. 7 out of 9 cases for
whom information on the method of injection was available, reported
subcutaneous injection of heroin ("skin popping"). All cases with
information on the type of drug injected (8 cases) reported heroin
injection. Information on tetanus immunization status was available for 8
cases. Of these, only one was reported as having been immunized in the past
10 years, and 3 had probably never been immunized. 4 of the cases have been
tested for tetanus IgG, and all had levels below the minimum protective
level, which supports the claim that they may not have had a full course of
tetanus vaccination. _Clostridium tetani_ was isolated from one case; in
another case tetanus toxin was detected in a serum sample. The age of cases
ranged between 20 and 53 years, with female cases being younger than male
cases (median age 27 and 46 years, respectively). 11 cases were reported
from England, of which 8 were from the west of the country. 2 cases have
been reported from Scotland, and one from Wales.
In addition to these 14 cases, 2 potentially relevant reports were received
of an IDU with trismus, and the isolation of _C. tetani_ from an abscess of
an IDU in England. These reports do not fit the case definition, but are
likely to be associated with the same source as that which is causing the
cases in this outbreak. To our knowledge, no cases of tetanus in IDUs have
been reported from elsewhere in Europe.
The current cluster of tetanus in IDUs can be explained by contamination
with tetanus spores at any stage during the production, distribution,
storage, cutting, or injecting of heroin. The observation that no cases
have been reported from elsewhere in Europe, however, is consistent with
contamination occurring within the UK. The widespread distribution of cases
within the UK suggests contamination relatively high in the supply chain.
The peak in the number of cases in week 45 may indicate a point source
rather than ongoing contamination. Descriptive information on the cases so
far suggests that subcutaneous injection of heroin is a contributing
factor, which is consistent with previous reports on _Clostridium_
infections in IDUs (4, 5). The predominance of women and older injectors
among our cases was also found in the cluster of severe illness and death
among IDUs which occurred in England in 2000, and could be explained by
these being more likely to have difficulties accessing veins and,
therefore, to inject subcutaneously or intramuscularly (4, 6). Waning or
incomplete immunity is an additional factor.
Continued vigilance for early signs and symptoms of tetanus in IDUs is
important, since early treatment with intravenous tetanus immunoglobulin,
antibiotics, and wound debridement can be life-saving.
Tetanus can present with local fixed muscle rigidity and painful spasms
confined to the area close to the site of injury or injection. Although
localized tetanus can last weeks or months, it is more commonly a precursor
to generalized tetanus. The illness can progress for about 2 weeks.
Generalized tetanus can present with symptoms ranging from mild trismus
(lockjaw), neck stiffness and/or abdominal rigidity to generalized tetanus,
which includes general spasticity, severe dysphagia, respiratory
difficulties, severe and painful spasms, opisthotonus, and autonomic
dysfunction. So far, the presentation of the cases has ranged from mild
trismus to generalized tetanus with respiratory arrest.
Tetanus is a vaccine-preventable disease. In the UK [and elsewhere
Mod.LL], 5 doses of tetanus toxoid containing vaccine at the appropriate
intervals are considered sufficient for lifelong protection as long as
tetanus-prone wounds are treated with prophylactic tetanus immunoglobulin
(TIG) (3). The information obtained so far on vaccination status of the
cases is consistent with this, in that none of the cases has reported to
have received all 5 doses.
Health professionals in regular health care settings and drug services
should ask IDUs about their tetanus immunization status. IDUs who have not
received 5 doses of tetanus-containing vaccine or are unsure about their
vaccination status, should be offered additional tetanus-low dose
diphtheria (Td) vaccination. Many IDUs will require at least one booster.
Unvaccinated IDUs should be encouraged to complete a primary course of Td
vaccination followed by 2 further boosters.
Even individuals who have received 5 doses of tetanus vaccine in childhood
may eventually have insufficient antibody levels to protect against heroin
or a wound heavily contaminated with _C. tetani_. Generally, those who are
exposed to risk of tetanus through injury are recommended to receive TIG
even if fully vaccinated (3). This recommendation is impracticable for IDUs
who may be at recurrent risk through regular injection. The question
remains unanswered whether IDUs might benefit from regular boosters to
ensure protection from ongoing contamination of heroin and/or from exposure
to other sources.
1. Hahne, S, Crowcroft N, White J, et al.Cluster of cases of tetanus in
injecting drug users in England: European alert Eurosurveillance Weekly
2003; 7, Nov
2. HPA. Cluster of cases of tetanus in injecting drug users in England:
update. Commun Dis Rep CDR Wkly 2003; 13 (48) [accessed 21 Jan 2004]
3. Salisbury D, Begg N. Immunisation against infectious disease (The
Green Book). London: HMSO, 1996.
4. Jones J, Salmon J, Djuretic T, et al. An outbreak of serious illness
and death among injecting drug users in England during 2000. J Med
Microbiol 2002, 51:978-84.
5. Abrahamian F, Pollack C, LoVecchio F, et al. Fatal tetanus in a drug
abuser with protective antitetanus antibodies. J Emerg Med, 2000, 18:189-93.
6. Bellis M et al. Unexplained illness and deaths among injecting drug
users in England: a case control study using Regional Drug Misuse
Databases. J Epidemiol Comm Health 2001; 55:843-44.
[Reported by: Susan Hahne (<email@example.com>), Natasha Crowcroft,
Joanne White, Fortune Ncube, Vivian Hope, Leah de Souza, Moira Brett,
Kirsty Roy, and David Goldberg.