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Published Date: 2011-12-31 10:51:11
Subject: PRO/AH/EDR> Anthrax, human - UK, Germany 2010: heroin users, final report
Archive Number: 20111231.3712

ANTHRAX, HUMAN - UK, GERMANY 2010: HEROIN USERS, FINAL REPORT
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Date: 28 Dec 2011
Source: Health Protection Scotland [edited]
http://www.documents.hps.scot.nhs.uk/giz/anthrax-outbreak/anthrax-outbreak-report-2011-12.pdf

An Outbreak of Anthrax Among Drug Users in Scotland, December 2009 to
December 2010. A report on behalf of the National Anthrax Outbreak
Control Team.
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Summary

Outbreak Characteristics
- An outbreak of anthrax was identified starting in Glasgow in
December 2009, when cases of serious soft tissue infection (SSTI)
among drug users were confirmed as being due to infection with
_Bacillus anthracis_, the 1st such outbreak formally recorded. A local
outbreak investigation began, which became a national investigation in
January 2010 coordinated by Health Protection Scotland (HPS), when
cases were identified in multiple NHS board areas.

- Cases were also investigated over the same period in England and
Germany, with 5 anthrax cases confirmed in England and 2 in Germany.

[cut]
6.1. Key Conclusions
6.1.1. Outbreak Genesis
The outbreak was the largest single common source, non-occupational
human anthrax outbreak recorded in the UK since systematic
notification of non-occupational cases began in 1960 and was
associated with the use of illicit heroin, which probably originated
in Afghanistan or Pakistan.

6.1.2. Source of Anthrax Spores
The spores from which the anthrax organisms originated came from a
single common source, probably a single infected animal or hide. The
anthrax organisms were all identified as being of a single, novel
anthrax strain not seen before in the UK or elsewhere but closely
related to strains seen previously in goats in Turkey.

6.1.3. Heroin Contamination
The contamination of heroin with anthrax spores probably occurred as a
result of contact between heroin and a source of spores somewhere in
the drug distribution network close enough to the country of origin to
enable heroin from a single contaminated batch to be imported by drug
dealers to all of the countries where anthrax cases occurred
(Scotland, England and Germany).

6.1.4. Distribution networks
Heroin users in the West of Scotland, especially Glasgow and
Lanarkshire, and in Dundee were at increased risk of anthrax infection
compared to others living in Lothian (Edinburgh), Grampian (Aberdeen),
the Highlands and Islands, probably as a result of the differing
distribution networks for illicit heroin in Scotland but possibly also
related to unknown underlying factors associated with the general
health status of heroin users living in the more heavily affected
areas, including their use of alcohol.

6.1.5. Contaminated Heroin Exposure
Infection occurred mainly between December 2009 and March 2010,
indicating that the peak exposure to contaminated heroin also occurred
just before and during this period then remained in circulation within
Scotland (and England) for almost a year. However, the possibility
that anthrax-contaminated heroin had been imported to Scotland prior
to December 2009 cannot be completely excluded only on the basis that
no cases were detected earlier.

6.1.6. Drug User History
Drug users with a longer history of heroin use appeared to be more at
risk of infection, possibly associated with their increased likelihood
of taking heroin by injection methods.

6.1.7. Control Measures
Options for control measures to prevent infection among drug users
were limited and relied on police action to reduce the amount of
heroin in circulation and curtail heroin dealing, and public health
action to advise drug users and others of the risks of continued
heroin use. Other control options were considered but were assessed as
being impractical.

6.1.8. Advice to drug users
The NAOCT (National Anthrax Outbreak Control Team)issued advice to
drug users not to take any heroin based on the evidence available at
the time. Evidence from the subsequent retrospective case-control
study suggests that there may have been an increased risk of infection
associated with injecting heroin in particular. However, given the
limitations of the study method, this evidence has to be interpreted
with caution.

6.2. Summary Conclusion
The epidemiological and microbiological evidence supports a conclusion
that heroin was the vehicle for transmission of anthrax spores to
cases and that exposure was by a variety of routes, particularly by
injection but also by smoking (inhalation). The mechanism for and the
location of spore contamination are not known; however, genotyping
evidence strongly suggests that infection was due to a single, novel,
anthrax strain related to Trans-Eurasian (TEA) anthrax strains
previously identified in goats in Turkey. This and other intelligence
on the heroin trafficking trade support a conclusion that the
contaminated heroin imported to Scotland was from a single batch
contaminated with anthrax spores via contact with a single infected
animal or contaminated hide, somewhere in transit between
Afghanistan/Pakistan and Scotland, probably in Turkey.

--
Communicated by:
ProMED-mail
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[This is an admirable report and needs to be read by all. There is
much to be learnt from it. For readers' convenience we have posted
only the author's key comments. Thanks to the number of cases
presented, an effective and successful method of treatment emerged.
But at the same time, medical miracles are rare, and already moribund
cases cannot be saved. Persuading drug addicts to present themselves
as soon as they begin to feel ill is a challenge.

However, I have some problems with the mode of contamination. To quote
pp 22-23: "The overall conclusion from this work is, therefore, that
the isolates of _B. anthracis_ grown from the heroin-associated
anthrax outbreak cases in Scotland were most closely related to
strains previously found in infected animals in Turkey. This finding
provides additional support for the favoured outbreak hypothesis; that
the heroin implicated as the vehicle for transmitting the anthrax
identified in Scottish drug users was probably contaminated in transit
between the source country (probably Afghanistan or Pakistan) and
final destination (Europe/UK/Scotland) and that a likely locus of this
contamination was in Turkey, possibly via contact with a contaminated
animal, carcass or hide. Police intelligence also supports the
plausibility of such a link, in that Turkey is a known staging post in
the distribution of illegal heroin between Afghanistan and Pakistan
and the UK."

A question: Why would a shipment of heroin from Afghanistan/Pakistan
be shifted in mid-stream, after traveling some thousands of miles,
from whatever packaging it came out of in Afghanistan/Pakistan and be
repackaged into a Turkish goatskin? It makes little sense. A more
probable explanation might be that if the bulk came from Afghanistan
and Pakistan, someone added either Turkish heroin to it to make up the
volume or added some diluent that had been stored in this Turkish
goatskin, though it is hard to think of what this might be and that it
would [have been] stored in a goatskin.

Also, the report does not give the key SNP (single nucleotide
polymorphism) identification values for the singular strain involved,
other than to say it was a Trans-Eurasian strain and a close match to
2 cultures in Keim's collection corresponding to Central Turkey. The
rest of the world needs those SNP values. Why not give them?

[1] There are a number of equally competent genomic laboratories in a
number of countries ... the NAU (Northern Arizona University at
Flagstaff) expertise is not unique. We need to maximise that global
opportunity of expertise.

[2] Such SNP identifications are like fingerprints. If such an event
occurs again, a check must be run fast. The SNP values are like a key
to a door to a specific cabinet. Open it, and there is more
information revealed; it is not just the genome. And no one has all
that information; in fact, some have little beyond the information on
their vial label. Sharing literally opens doors. Rethink it as
Interpol sharing criminal fingerprints and DNA.

[3] Everybody's culture collection is different, though some have
significant overlaps with others, and with regional pluses and minuses
with more or less insight and detail. By publicly providing the SNP
values, others can see whether they have something similar, thereby
better defining the possible source area and possible origins.

[4] Many countries -- such as India and Russia, to pick but 2 from an
unfortunately not short list -- refuse to share cultures, either
through paranoia or individual concerns; this is similar to the
problems we have seen with H5N1 avian flu isolates in Asia. But some
of these recusants have a national SNP identification capacity and
could check if asked. A "TEA" [Trans-Eurasian] designation does not
solve that. We need information leverage to get better answers from
reluctant collaborators.

[5] We are beginning to realise that some countries are actively
exporting [contaminated] bone meals, for example, and as a result,
strains which are enzootic in one area of a country can be seen
popping up in various distant places (plural) elsewhere. This is a
repeat of the old trade patterns but with a contemporary twist. But it
is an emerging pattern with more suspicions than hard data. Some
strains are not as "unique" as some might think. - Mod.MHJ

A HealthMap/ProMED-mail map can be accessed at:
http://healthmap.org/r/1h2A]

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