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Archives | News Archives 2004: Page 1 | News Archives 2005 Page 2 | News 26 August 2004

News Archives: | 2006 | 2005 | 2004 | 2003

• Increased reports of suspected cases of wound botulism among injecting drug users during 2004
• Shigella sonnei outbreak: update
  

Increased reports of suspected cases of wound botulism among injecting drug users during 2004

Twenty-seven suspected cases of wound botulism in injecting drug users (IDUs) have been reported to the HPA between 1 January and 25 August 2004.  Twenty-five of these were in England, and six were laboratory confirmed.  Of the confirmed cases, three occurred in London region during January and February, and the remaining three in Yorkshire and Humberside during June and July.  Reports of suspect cases continue to be received, especially from Yorkshire and Humberside and the North West regions.  These reports exceed the number for the whole of 2003.  There were 14 reports of suspected cases of wound botulism among IDUs reported in 2003, seven of which were confirmed by laboratory tests

Between March 2000 and the end of 2002 there were 33 clinically diagnosed cases in IDUs in the United Kingdom and Republic of Ireland: none had been reported prior to this period (1).  Twenty of these 33 cases were confirmed in the laboratory by either detection of Clostridium botulinum neurotoxin in serum, or by the isolation of C. botulinum from wound tissue or pus (1). Among these 33 cases, 23 occurred in 2002, 20 of which were in England and Wales (1).   During September and October 2002 there was an outbreak of eight cases possibly related to a contaminated batch of heroin (2). 

Wound botulism occurs when spores of C. botulinum contaminate a wound, germinate and produce botulinum neurotoxin in vivo.  All of the wound botulism cases detected so far in the UK have been among illegal injecting drugs users (IDUs) (1).  The symptoms of botulism are caused by the neurotoxin, which blocks the release of acetycholine at the neuromuscular junction resulting in a descending flaccid paralysis.  Patients with botulism may present with blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle weakness. There is usually no fever, no loss of sensation and no loss of awareness.  If untreated, paralysis may progress to the arms, legs, trunk, and respiratory muscles.  If onset is very rapid, there may be no symptoms before sudden respiratory paralysis occurs. Clinicians should suspect botulism in any patient with an afebrile, descending, flaccid paralysis.

Botulinum antitoxin is effective in reducing the severity of symptoms if administered early in the course of the disease for all forms of botulism and 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.  Further advice for injecting drug users and for microbiological investigations is available on the Health Protection Agency website at <http://www.hpa.org.uk/infections/topics_az/botulism/menu.htm>.  Information on the supply of botulinum antitoxin is available from the Health Protection Agency's Communicable Disease Surveillance Centre (CDSC) duty doctor, tel: 020 8200 6868 (24 hours)

Consultants in Communicable Disease Control (CCDCs) are asked to report any suspected cases of wound botulism to the CDSC duty doctor, tel: 020 8200 6868, or to Jim McLauchlin, at the HPA Food Safety Microbiology Laboratory (tel: 020 8200 4400 ext 7117).

Samples for the laboratory investigation of cases of botulism (detection of neurotoxin and isolation of C. botulinum) should be sent to HPA Food Safety Microbiology Laboratory Specialist and Reference Microbiology Division, Central Public Health Laboratory, 61 Colindale Ave, London NW9 5HT. 0208 200 4400.

References


1. Brett MM, Hallas G, Mpamugo O. Wound botulism in the UK and Ireland. J Med Microbiol 2004; 53: 555-61.

2. PHLS.  Cluster of wound botulism cases in injecting drug users in England - update.  Commun Dis Rep CDR Wkly [serial online] 2002 [cited 26 August 2002] : 12(46): news.  Available at  <http://wwww.hpa.org.uk/cdr/archives/2002/cdr4602.pdf>.

Shigella sonnei outbreak: update

An outbreak of Shigella sonnei infection in nursery and primary school pupils and staff of a religious community was reported in summer 2004 (1).   Laboratories were requested to send isolates for typing to the Health Protection Agency's Laboratory of Enteric Pathogens (LEP). As of 25 August 2004, LEP has received 63 isolates possibly linked to the outbreak, of which 61 comprised two new, but distinguishable (similar novel), phage types, provisionally designated as phage type (PT) P (34 isolates, from laboratories in Leeds, Manchester, and London) and PT6A (27 isolates from laboratories in London and Manchester).  The remaining two isolates were phage type 13.  All isolates have the same antimicrobial resistance pattern and appear to be linked to the community. The two new phage types were also distinguishable from each other by plasmid profile analysis and pulsed field gel electrophoresis.

No increase has been detected in national laboratory reports of Shigella sonnei to the Health Protection Agency's Communicable Disease Surveillance Centre (CDSC) in 2004 (see table and figure), although caution is always required in interpreting recent surveillance trends because of reporting delays.

Table Laboratory reports to CDSC of Shigella Sonnei England and Wales 2000-2004 by specimen date

Figure Laboratory reports to CDSC of Shigella sonnei by specimen date of report: 2002-2004



Consultants in Communicable Disease Control (CCDCs) and local authorities should remain vigilant for Shigella sonnei infection and its prevention as children return to school after the summer holidays (2).


References

1. HPA.  Outbreak of Shigella sonnei in north London.  Commun Dis Rep CDR Wkly [serial online] 2004 [cited 26 August 2004]; 14(30): News.  Available at <http://wwww.hpa.org.uk/cdr/archives/2004/cdr3004.pdf>.

2. A Working Party of the PHLS Salmonella Committee.  The prevention of human transmission of gastro-intestinal infections, infestations and bacterial intoxications:  a guide for public health physicians and environmental health officers in England and Wales. Commun Dis Rep CDR Rev 1995; 5(11): R157-72.