North West: Anthrax case confirmed by HPA in Blackpool

10 February 2010

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.

Professor Qutub Syed, Director of the Health Protection Agency in the North West, said: "We are working closely with NHS Blackpool to monitor the situation. I'd like to reassure people that the risk to the general population, including close family members of the deceased, 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 being passed associated with the current situation in Scotland."

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."

ENDS

Notes to Editors:

Further information about the cases of anthrax in Scotland is available at:
www.hps.scot.nhs.uk/anthrax
Heroin users in NW region are strongly encouraged to find out more about the support services in their area. They can find drug services or seek advice from Talk to Frank: 24-hour helpline: 0800 77 66 00 / website: www.talktofrank.com
The outbreak in Scotland began with the identification of cases in NHS Greater Glasgow & Clyde in December 20009, with cases now having been identified in six NHS board areas across the country, and represents the first known outbreak of anthrax to have occurred in conjunction with drug use. It is important to note that there is no evidence of person-to-person transmission in this outbreak.
The Health Protection Agency has produced advice for injecting drug users and guidelines on the clinical evaluation and management of people with possible cutaneous anthrax in England. These are available at: http://www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1191942145749/
Recent public health alerts issued by the Department of Health through the Central Alerting System are available at: https://www.cas.dh.gov.uk/Home.aspx

Media enquiries:
Health Protection Agency:
claire.rogers@hpa.org.uk 0151 482 5732 / 07827 954 768

Anthrax in drug users: Q&A

Q1. What is anthrax?
Anthrax is a very rare but serious bacterial infection caused by the organism Bacillus anthracis. The disease occurs most often in wild and domestic animals in Asia, Africa and parts of Europe; humans are rarely infected. The organism can exist as spores that allow survival in the environment, e.g. in soil, for many years.

Q2. How does anthrax usually affect humans?
There are three classical forms of human disease depending on how infection is acquired: cutaneous (skin), inhalation and ingestion. In over 95% of cases the infection is cutaneous, generally caught by direct contact with the skins or tissues of infected animals. Inhalation anthrax is rare and is caught by breathing in anthrax spores. Intestinal anthrax is very rare, and occurs from ingestion of contaminated meat or spores.

Q3. How has anthrax been affecting drug users?
There is an ongoing outbreak of anthrax among heroin users in the UK. Since December 2009, a number of heroin users have been found to have anthrax infection, and almost half of the infections have been fatal. It is thought that the people contracted anthrax from taking heroin contaminated by anthrax spores.

Q4. How common is anthrax?
The disease was also known as 'wool-sorters disease' and was a recognised occupational hazard for some workers, including woollen mill workers, abattoir workers, tanners, and those who process hides, hair, bone and bone products. However, anthrax is now uncommon in humans in the UK, only a handful of cutaneous cases have been notified over the last decade. 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. Human infections are more frequent in countries where the disease is common in animals, including countries in South and Central America, southern and eastern Europe, Asia and Africa.

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.

Last reviewed: 10 February 2010