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Anthrax Cases Among Heroin Users in Europe Illustrate Novel Risk

By Amesh A. Adalja, MD, January 22, 2010

Bacillus anthracis, a ubiquitous but deadly pathogen found in soil, has been primarily an occupational disease. Notable exceptions include cases caused by the Amerithrax attacks and by exposure through animal drum skins (see CBN, Jan. 8, 2010). However, recent cases of anthrax, some fatal, in Scotland and Germany highlight a new risk—recreational heroin use.

Only 1 prior case of anthrax infection in a heroin user has been reported: in 2000, a team in Norway described a fatal case in a user who had “skin-popped” the drug. No contamination source was ever elucidated.

Eight Deaths To Date

Since December 16, 2009, 8 heroin users have died from anthrax (7 in Scotland; 1 in Germany). In Scotland, 7 known nonfatal cases also have occurred. All patients were heroin users who presented with soft tissue infections, and all injected heroin subcutaneously or intramuscularly and/or smoked or snorted it. Severe cases have progressed to septic shock and meningitis. Treatment regimens have included antibiotics and anthrax immunoglobulin.

Speculation on the Source

The source of anthrax contamination is believed to be animal products that may have been present in cutting agents used to dilute the heroin. Early speculation has focused on bone meal, a known source of anthrax contamination, particularly in heroin from anthrax endemic regions such as Afghanistan—a major exporter of heroin to the UK. Contamination in the purification of heroin could also have occurred if it was done in proximity to animal products.

More Cases Expected; Risk to U.S. Minimal

Because of the black market-like nature of drug distribution networks, it will be difficult to anticipate future cases caused by contaminated heroin. Details of the case of the deceased German patient, who had no travel to Scotland, may indicate the risk of infection outside of Scotland and the point of origin of contamination (source, dealer, etc.).

Heroin users in the U.S. are at much lower risk of anthrax given that most heroin in this country originates in South America and Mexico, neither of which have a rate of anthrax endemicity as great as that of Afghanistan.

More Details Sought

Several pieces of information that may solve the epidemiological puzzles posed by these cases have not been but should be made available, including:

  • results of any investigation into cutting agents present in the case patients’ heroin supply;
  • details on the local and international supply chain known for the case patients’ heroin; and
  • serotype of the anthrax strains isolated from the patients.
         

Thank you to Leigh Henderson, PhD, for her insight into the illicit drug market.

References

  1. Ramsay CN, Stirling A, Smith J, et al., on behalf of the NHS GGC, on behalf of the Scottish National Outbreak Control Teams. An outbreak of infection with Bacillus anthracis in injecting drug users in Scotland. Euro Surveill. 2010. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19465. Accessed January 15, 2010.
  2. Ringertz SH, Hoiby EA, Jensenius M, et al. Injectional anthrax in a heroin skin-popper. Lancet. 2000;356(9241):1574-5.
  3. Radun D, Bernard H, Altmann M, et al. Preliminary case report of fatal anthrax in an injecting drug user in North-Rhine-Westphalia, Germany, December 2009. Euro Surveill. 2010; http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19464. Accessed January 15, 2010.
  4. Heroin. U.S. Drug Enforcement Agency website. http://www.justice.gov/dea/concern/heroin.html. Accessed January 15, 2010.
  5. Countering Narcotics website. Foreign and Commonwealth Office, UK in Afghanistan, British Embassy. http://ukinafghanistan.fco.gov.uk/en/working-with-afghanistan/counter-narcotics. Accessed January 15, 2010.
  6. Davies DG, Harvey RW. Anthrax infection in bone meal from various countries of origin. J Hyg (Lond). 1972;70(3):455-7.
  7. ProMed-mail. Anthrax, Human – United Kingdom (03): (Scotland). December 22, 2009. http://www.promedmail.org/pls/otn/f?p=2400:1001:565224337543627::::F2400_
    P1001_BACK_PAGE,F2400_P1001_ARCHIVE_NUMBER,F2400_P1001_USE_ARCHIVE:
    1001,20091222.4317,Y
    . Accessed January 15, 2010.