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• Ongoing national outbreak of tetanus in injecting drug users
  

Ongoing national outbreak of tetanus in injecting drug users

The national outbreak of tetanus in injecting drug users (IDUs) previously reported in CDR Weekly is continuing (1-3).  Ten further cases have been reported since the last update (3), giving a total of 20 cases since July 2003 (figure 1). The most recent onset date was 20 February 2004. Cases are spread across England, Scotland, and Wales, with some clustering in the north west and midlands of England (figure 2).  Four of the cases reported that they obtained their heroin through a dealer from Liverpool. Twelve cases are in females, and eight in males; the median age is 33 years. All but two cases had severe tetanus (grade 3; table 1); one patient is known to have died.

Figure 1 Cases of tetanus in injecting drug users by week of onset, England, Wales, and Scotland: 1/7/2003-26/2/2004

Figure 2 Cases of tetanus in injecting drug users, England, Wales, and Scotland: 1/7/2003-26/2/2004

Table 1 Severity grading of tetanus*

*Reference (7).

To date, information on the tetanus immunisation status is available for ten cases. Of these, three cases reported not to have been immunised at all, and five had had less than the recommended five doses. For two cases, both with severe disease, parental recall suggested that they had received five doses of tetanus in their lifetime. Levels of tetanus immunity are available for eight cases, of which seven had non-protective levels at the onset of their illness consistent with the diagnosis and with their reported immunisation status. The single case with tetanus who had protective antibody levels, had mild disease (severity 1; table 1). Clostridium tetani was isolated from one case and tetanus toxin detected in two others.

The current cluster of tetanus in IDUs could be explained by contamination of heroin with tetanus spores at any stage during the production, distribution, storage, cutting, or injecting. The observation that no cases have been reported from elsewhere in Europe is consistent with contamination occurring within the United Kingdom (UK). The widespread distribution of cases within the UK suggests that contamination is occurring relatively high up the heroin supply chain. Current descriptive information on the cases 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 cases in the current outbreak was also found in the cluster of severe illness and death among IDUs that occurred in England in 2000. This pattern can be explained by such individuals being more likely to inject subcutaneously or intramuscularly, due to difficulties in accessing veins (4, 6). Information for injecting drug users on how to prevent clostridium infections is available on <http://www.hpa.org.uk/infections/topics_az/tetanus/advice_to_idu_271103.pdf> and <http://www.iduoutbreak.abelgratis.com/>.

Prior to this incident, tetanus infection in IDUs was uncommon in the UK, with only two cases reported between 1984 and 2000 (7). It is too soon to conclude whether the current cluster is an isolated incident, or reflects a genuine change in the UK epidemiology of tetanus as occurred in the United States, where the proportion of IDUs among cases of tetanus increased from 2-5% between 1982 and 1994 to 15-18% between 1995 and 2000 (8).

Two of the cases in the current cluster were reported to have received five doses of vaccine, suggesting that despite this their antibody levels were insufficient to protect against the amount of toxin produced. Generally, those who are exposed to the risk of tetanus through injury are recommended to receive tetanus immunoglobulin (TIG) even if fully vaccinated (9). 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. Despite this, it is of prime importance that IDUs who have not received five doses of tetanus-containing vaccine or are unsure about their vaccination status, should be offered additional tetanus-low dose diphtheria (Td) vaccination. Health professionals in regular health care settings and drug services should therefore ask IDUs about their tetanus immunisation status. Many IDUs will require at least one booster. Unvaccinated IDUs should be encouraged to complete a primary course of Td vaccination followed by two further boosters.

Information for health professionals (including testing of heroin and paraphernalia) is available at <http://www.hpa.org.uk/infections/topics_az/tetanus/menu.htm>.  Complete documentation and diagnosis of all cases of tetanus is necessary to inform future prevention strategies. The Health Protection Agency's Communicable Disease Surveillance Centre (HPA-CDSC) has alerted accident and emergency (A&E) departments, infectious disease units, microbiologists and intensive therapy units (ITUs), and would welcome reports of any person with clinical evidence of tetanus. (Clinical evidence of tetanus infection is defined as mild to moderate trismus and one or more of the following: spasticity, dysphagia, respiratory embarrassment, spasms, autonomic dysfunction.)

Please report cases using the surveillance form that can be downloaded from the HPA website at <http://www.hpa.org.uk/infections/topics_az/tetanus/tetanus_idu_quest.pdf> to Joanne White, CDSC, email: <joanne.white@hpa.org.uk>, tel: 020 8200 6868 ext 4446, fax: 020 8200 7868).  Please note that in addition to national reporting, clinicians are required by law to notify the case to the proper officer of the local authority (usually the consultant in communicable disease control [CCDC]) if they suspect tetanus.

References

1.HPA. Cluster of cases of tetanus in injecting drug users in England. Commun Dis Rep CDR Wkly [serial online] 2003 [cited 26 February 2004]; 13 (47): news.  Available at
<http://wwww.hpa.org.uk/cdr/archives/2003/cdr4703.pdf>.

2.HPA. Cluster of cases of tetanus in injecting drug users in England: update. Commun Dis Rep
CDR Wkly [serial online] 2003 [cited 26 February 2004]; 13 (48): news.  Available at
<http://wwww.hpa.org.uk/cdr/archives/2003/cdr4803.pdf>.

3.HPA. Ongoing outbreak of tetanus in injecting drug users. Commun Dis Rep CDR Wkly [serial online] 2004 [cited 26 February 2004]; 14 (3): news.  Available at <http://wwww.hpa.org.uk/cdr/archives/2004/cdr0304.pdf>.

4.Jones J, Salmon J, Djuretic T, Nichols G, George R, Gill O, 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, Nanda R, Carlson R. Fatal tetanus in a drug abuser with "protective" antitetanus antibodies. J Emerg Med 2000, 18:189-93.

6.Bellis M, Beynon C, Millar T, Ashton JR, Thomson R, Djuretic T, Taylor A. 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.

7.Rushdy AA, White JM, Ramsay ME, Crowcroft NS. Tetanus in England and Wales 1984 - 2000. Epidemiol Infect 2003; 130(1): 71-7.

8.Pascual FB, Emily L. McGinley EL, Zanardi LR, Cortese MM, Murphy TV.  Tetanus Surveillance - United States, 1998-2000.  Morbid Mortal Wkly Rep MMWR: 52 (SS03): 1-8. 
Available at <http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5203a1.htm>.

9.Salisbury D, Begg N. Immunisation against infectious disease (The Green Book). London: HMSO, 1996. Available at <http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance /PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4072977&chk=87uz6M>.