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Final Issue: Volume 16 Number 51
Published on: 21 December 2006
Final Issue in PDF
Last updated: Volume 16, No. 13 (PDF file, 376 KB)
Wound botulism in injecting drug users in the United Kingdom Wound botulism was first reported in the United Kingdom (UK) among injecting drugs users (IDUs) in 2000 (1). Between 2000 and 2005, 112 cases of suspect wound botulism amongst IDUs were reported in the UK: five cases occurred in 2000, four in 2001, 20 in 2002, 15 in 2003, 40 in 2004 and 28 in 2005 (figure 1). Eighty per cent, (94) of cases occurred in England.
Figure. Cases of suspected wound botulism in injecting drug users: 2000 to 2005
All of the cases from England in 2005 for whom detailed information was available reported injecting heroin, and 64% reported also injecting methadone. All cases had used either vitamin C or citric acid for dissolving the drug. The duration of injecting ranged from one year to 30 years with an average of 10 years. Injection into skin (‘skin popping’) or muscle (‘muscle popping’) was reported by all the cases and in the previous month they had all noticed swelling and tenderness of an area of skin where they inject. The majority (75%) required ventilation during their hospital admission.
Forty-five (42%) of the 108 cases where material was submitted for laboratory examination were laboratory confirmed by either the detection of neurotoxin in serum or wound material, or by the detection of C.botulinum from material collected from infected. Among the laboratory confirmed cases, 39 were due to C.botulinum type A, four to type B and two to both types A and B. Wound botulism among IDUs is now the most common presentation of this disease in the UK, and despite drug using communities existing throughout the UK is largely confined to England. Seven suspect cases were reported during the first 13 weeks of 2006 (1January to 28 March): all occurred in England.
Injection practices amongst IDUs are likely to be important since a major risk factor for soft tissue wound infections is skin or muscle ‘popping’. Clinicians should suspect botulism in any patient with an afebrile, descending, flaccid paralysis. Botulinum antitoxin is effective in reducing the severity of symptoms for all forms of botulism if administered early in the course of the disease: this should not be delayed for the results of microbiological testing. In cases of wound botulism, antimicrobial therapy and surgical debridement are important to reduce the organism load and avoid relapse after antitoxin treatment. C. botulinum is sensitive to benzyl penicillin and metronidazole. Advice for responding to suspect wound botulism is available on the HPA website (2). As well as providing information for health professionals, the HPA website gives advice for preventative measures for IDUs including; smoking instead of injecting heroin; if injecting, to intravenously and not intramuscularly or subcutaneously inject; not to share needles, syringes, cookers, or spoons used for injection; to use as little citric acid as possible; if injecting more than one type of drug to inject in separate places; and if swelling, redness or pain occurs at injection sites to immediately seek medical advice (2).
With effect from March 2006, the oral typhoid vaccine, Vivotif® (Berna Products), has been re-introduced to the United Kingdom after it was removed from the market in 2002 (1).
Typhoid vaccine is recommended for:
Vivotif® is an oral vaccine that can be administered to persons aged six years and above as a course of three doses; one capsule taken on days 1, 3, and 5. Protection against typhoid fever commences approximately 7 to 10 days after ingesting the third dose. There are now five vaccines available in the UK for prevention of typhoid fever. The other (injectable) vaccines are Typhim Vi® and Viatim® (Sanofi Pasteur MSD), and Typherix® and Hepatyrix® (GlaxoSmithKline). Details of each can be found on the typhoid vaccine information sheet from the National Travel Health Network and Centre (NaTHNaC) at http://www.nathnac.org/pro/factsheets/typhoid_vaccine.htm.
Vaccination against typhoid fever provides only partial protection against the disease, and does not provide any protection against Salmonella Paratyphi. S. Paratyphi is increasingly a cause of enteric fever in UK travellers (3). All travellers should therefore take food and water hygiene precautions during their trip (see NaTHNaC information sheet http://www.nathnac.org/pro/factsheets/food.htm). Further information about typhoid and paratyphoid in travellers is available at http://www.nathnac.org/pro/factsheets/typhoid.htm.
The Health Protection Agency (HPA), working with the NHS and various voluntary organizations, is piloting the National Knowledge Service for TB (NKS-TB), and has recently launched the NKS-TB web pages <http://www.hpa.org.uk/tbknowledge/default.htm> . The aim of NKS-TB is to ensure that sources of information and knowledge on tuberculosis are brought together for healthcare professionals and patients. This will enable both professionals and patients to base their decisions on best current knowledge. Pilots are simultaneously also being conducted for oral health, diabetes, breast cancer and congestive heart failure.
Information outputs will be mapped onto the patient care pathway defined by the National Tuberculosis Action Plan (1) and National Institute for Health and Clinical Excellence (NICE) guidelines on tuberculosis (2), such that they can be used for clinical consultation or public health action. Emphasis will be on short, tailored and easily accessible information outputs. Much of the supporting technology that will be used to deliver these information outputs will be provided through the National Programme for Information Technology – particularly the Map of Medicine (3) or through the National Library for Health and its specialist libraries (4). In addition to developing information or resources relevant to NICE guidelines on TB, the pilot will identify gaps and important knowledge areas not addressed by the NICE guidelines.
The National Knowledge Service covers clinical practice, healthcare, social care, and public health; the users have been identified as being patients and the public, clinicians, managers, and public health professionals. The NKS commissioned the HPA to undertake the TB pilot, with Professor Mike Catchpole as project lead. The National Knowledge Service is part of the NHS National Programme for IT.
NKS has also been involved in developing information resources for staff working with the homeless sector staff, those working with children, and clinicians and public on ’Pregnancy and TB’.