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Eurosurveillance Weekly: Thursday 22 June 2000. Volume 4, Issue 25
Contents:
1. Infectious disease surveillance in Belgium during the Euro 2000 football tournament
2. ‘Serious unexplained illness’ among injecting drug users in Britain and Ireland
3. Wound botulism in injecting drug user: second case in England
4. Promotion of condom use in high risk setting
Infectious disease surveillance in Belgium during the Euro 2000 football
tournament
Mass gatherings increase the potential for transmission of infectious diseases (1,2).
Contributory factors include the setting up of itinerant food catering installations, the possible
carriage of infections by people from different countries, and increased contact between
people. The Euro 2000 football competition, taking place in the Netherlands and Belgium
between 10 June and 2 July 2000, is an event likely to carry some risk of infectious disease.
Footballers from 16 European countries and an expected 1 200 000 visitors have gathered for
the tournament in the two countries.
A surveillance system based on daily reporting has been set up throughout Belgium in order to
detect and investigate infectious events that require immediate action. Local public health
authorities (Commission Communautaire Commune (Brussels), Communauté française and
Vlaamse Gemeenschap), and the Federal Ministry of Public Health are working together to
define the extent of the response, coordinate actions, and collate notifications.
The list of priorities drawn up during preparatory meetings includes legionellosis, foodborne
diseases, measles, pertussis, diphtheria, meningococcal meningitis, and rare imported
diseases. The surveillance system implemented has four components:
 remind all general practitioners to notify
 ask all hospital emergency units to notify
 activate the sentinel laboratory network (national coverage >70%)
 ask the European infectious diseases networks (European Working Group on Legionella
Infections and Enter-Net) for information about infections possibly linked to Euro2000.
All incoming data are being sent to the National Institute of Public Health (Institut Scientifique
de la Santé Publique/Wetenschappelijk Instituut Volksgezondheid -IPH-), where they are
collated, interpreted, and reported to the authorities by electronic mail each day. Information is
being exchanged with Dutch medical authorities. All European national institutes for
communicable disease surveillance are invited to report relevant information about infectious
diseases that may have been acquired during the event to the IPH ([email protected]).
References:
1.
Handysides S. Medical care at special events. Eurosurveillance Weekly 2000; 2: 980603
(http://www.eurosurv.org/1998/980603.html)
2.
Coulombier D. Surveillance for the World Cup, France, 1998. Eurosurveillance Weekly 2000; 2: 980611
(http://www.eurosurv.org/1998/980611.html)
Reported by Olivier Ronveaux ([email protected]), Sophie Quoilin, Frank Van Loock,
Epidemiology Section, Scientific Institute of Public Health, Brussels, Belgium.
‘Serious unexplained illness’ among injecting drug users in Britain and
Ireland
A syndrome of soft tissue inflammation associated with sites used for injecting drugs,
circulatory collapse, leucocytosis, pleural effusions, and soft tissue oedema and necrosis (1)
has affected at least 88 injecting drug users (IDUs) in Britain and Ireland since 1 April and
caused the deaths of 40. Clostridium novyi type A has been identified in tissue from several
cases (1). Cases continue to be identified through a process of active case ascertainment. A
case definition has been agreed by representatives of the several nations investigating the
incident:
International specific case definition: an injecting drug user who has been admitted to
hospital or found dead since 1 April 2000 with soft tissue inflammation (abscess, cellulitis,
fasciitis, or myositis) at an injection site, and with (i) severe systemic toxicity (sustained
systolic blood pressure <90 mm Hg despite fluid resuscitation and total peripheral white blood
cell count >30 x 109/L), or (ii) postmortem evidence of a diffuse toxic or infectious process
including pleural effusions and soft tissue oedema or necrosis.
Injecting drug user on England’s south coast dies with Clostridium novyi infection
The first case of ‘serious unexplained illness’ among IDUs in England to have been confirmed
outside the north west has been identified in Brighton, on the south coast (2). This brings the
total in England and Wales since 1 April to 21 cases, 12 of whom have died. Eleven (10
fatal) of the 21 meet the specific case definition drawn up by representatives of several
countries (3). Clostridium novyi type A has been isolated from tissue specimens from two
cases, the case from Brighton (fatal; onset in mid May) who fulfils the case definition (3), and
one who had severe local but not systemic features.
Two cases have been reported who fulfil the specific case definition (3) apart from having
become ill before 1 April, the start of the period in which cases have been sought actively.
The earlier case, from whom an uncharacterised Clostridium species was isolated from tissue,
was admitted to hospital on 25 February 2000. The second case is being investigated
microbiologically, but positive identification is unlikely given the age of specimens. These
reports suggest that the association of injecting drug use with this syndrome (3) has existed
longer than initially thought.
Update from Scotland
By 19 June, a total of 48 cases had been identified in Scotland, six more than reported on 12
June (1). Using the local, as opposed to the international case definition, the total number of
definite cases is now 19, and there are 29 probable cases. Sixteen of the 19 cases identified
as definite using the local case definition, also meet the international case definition (1). A
case control study is being conducted in Glasgow; many of the cases and 70 controls have
now been interviewed.
Unexplained illness and death among injecting drug users in Dublin, Ireland – update
Further to earlier reports in Eurosurveillance Weekly (4,5), there are currently 19 cases of
unexplained illness and death among IDUs in Dublin, Ireland. Eight of these cases, all of
whom have died, meet the international specific case definition (3). Eleven cases meet the
local probable case definition, characterised by severe unexplained illness in an IDU who is
admitted to hospital with extensive local inflammation with induration at the injection site. The
11 probable cases are all alive and recovering, four in hospital. Twelve of the 19 cases are
male, seven female. The most recent case became ill on 7 June and was admitted to hospital
on 17 June. Active and passive surveillance is continuing among area hospitals, general
practitioners, and coroners' offices in Dublin, where all the cases have arisen. A case control
study began on 19 June, to assess risk factors for illness among IDUs. No definitive laboratory
results to date clearly identify a cause for these illnesses.
References:
1.
2.
3.
4.
5.
Greater Glasgow Health Board, SCIEH, Djuretic T. Clostridium novyi is likely cause of ‘serious unexplained
illness’ as cases continue to be reported. Eurosurveillance Weekly 2000; 4: 000615.
(http://www.eurosurv.org/2000/000615.htm)
Brighton Hove and East Sussex Health Authority. Advice to heroin users following Brighton death. Press
release, 19 June 2000
(http://www.esbhhealth.ndirect.co.uk/Publications%20and%20Reports/Press%20releases/2000/PR%20-%20Ad
vice%20.htm)
CDC. Unexplained illness and death among injecting drug users – Glasgow, Scotland; Dublin, Ireland; and
England, April-June 2000. MMWR Morb Mortal Wkly Rep 2000; 49: 489-92.
(http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4922a2.htm)
Barry J, O’Flanagan D. Deaths from unexplained illness in heroin users in Dublin. Eurosurveillance Weekly
2000; 4: 000601. (http://www.eurosurv.org/2000/000601.htm)
Greater Glasgow Health Board and SCIEH. Serious unexplained illness among injecting drug users in Scotland
and the Republic of Ireland – update. Eurosurveillance Weekly 2000; 4: 000608.
(http://www.eurosurv.org/2000/000608.htm)
Reported by Jane Jones, Noel Gill, Tamara Djuretic, Public Health Laboratory Service
Communicable Disease Surveillance Centre; Greater Glasgow Health Board and Scottish
Centre for Infection and Environmental Health; Kristy Murray ([email protected]), Joe Barry
([email protected]), Darina O’Flanagan (darina.oflanagan.ndsc.ie), Eastern Regional Health
Authority and National Disease Surveillance Centre Dublin, Ireland.
Wound botulism in injecting drug user: second case in England
Wound botulism is rare in Europe (1), but a second case has been reported in England, only a
month after the first (1,2). Wound infection with Clostridium botulinum may be underdiagnosed
in injecting drug users (IDUs) and C. novyi appears to have been responsible for some of the
recent deaths reported in IDUs (3).
A 27 year old heroin addict was admitted to a hospital in the north east of England with fever
(38°C), a painful groin swelling with cellulitis, which had developed after an unsuccessful
attempt at intravenous injection two days earlier. His white cell count on admission was 16.7 x
109/L. Ultrasonography of the groin revealed no evidence of an abscess. The patient was
treated with intravenous cefuroxime and metronidazole for 24 hours, followed by oral
cephalexin and rectal metronidazole.
The patient presented three days later after discharge with progressive dysphasia, dysphagia,
and generalised flaccid limb weakness. Twelve hours after admission he suffered a
respiratory arrest, and required intubation and artificial ventilation in the intensive care unit. He
exhibited generalised muscle weakness, particularly of bulbar and proximal muscles.
Computed tomography of brain, lumbar puncture, and magnetic resonance imaging of brain
and brainstem were normal, as was the patient’s serum creatine phosphokinase.
Electromyography yielded results suggestive of botulism, which was confirmed by the
detection of C. botulinum toxin type A in serum from the patient by the Food Safety
Microbiology Laboratory (FSM) at the PHLS Central Public Health Laboratory (CPHL).
References:
1. Athwal B, Gale A. Wound botulism in an injecting drug user in London. Eurosurveillance Weekly 2000; 4:
000518. (http://www.eurosurv.org/2000/000518.htm)
2. Brett M. Clinical case of wound botulism in a drug user. Eurosurveillance Weekly 2000; 4: 000525.
(http://www.eurosurv.org/2000/000525.htm)
3. Greater Glasgow Health Board and SCIEH; Djuretic T. Clostridium novyi is likely cause of ‘serious unexplained
illness’ as cases continue to be reported. Eurosurveillance Weekly 2000; 4: 000615.
(http://www.eurosurv.org/2000/000615.htm)
Reported by Mohammad Khan ([email protected]), Stephen Chay, Stephen Bonner,
South Cleveland Hospital, Middlesbrough, England, Moira Brett (mbrett.phls.nhs.uk), PHLS
Central Public Health Laboratory, London, England.
Promotion of condom use in high risk setting
In the absence of an effective vaccine for HIV/AIDS, behavioural change is a vital means of
preventing infection. A randomised controlled trial reported in the Lancet investigated the
impact of providing health education material and condoms on condom use in a central district
of Managua, the capital of Nicaragua (1).
Rates of infection with HIV-1 in Nicaragua are rising rapidly, and the prevalence of sexually
transmitted infections is high. As elsewhere in Latin America, motels, boarding houses, and
hotels rent rooms for short times for discreet commercial and non-commercial sex. In
Managua, a substantial proportion of all sexual encounters – commercial and non-commercial
– probably takes place in motels, which are therefore key locations for promoting the use of
condoms. The trial was conducted in 19 motels between 31 July and 4 October 1997, and
data were collected on the three busiest days of the week. Condoms were given out on
request, made available in rooms, or given directly to couples, with and without the presence
of health education material in the rooms. Condom use was assessed directly by searching
the rooms after couples had left, and the number and characteristics of condoms recorded.
Leaflets and posters were found not to increase condom use in the study, and for commercial
sex, the presence of health education material seemed to reduce the frequency of condom
use. This was an unexpected finding, and further trials are recommended. Provision of
condoms in rooms – which meant that couples did not have to ask for them – was found to
increase condom use substantially.
The study had several limitations. Firstly, only short term effects were assessed, and exposure
to educational material over a longer period might increase condom use. Secondly, only 19
out of 36 motel owners agreed to take part. Thirdly, although estimates of condom use are
probably accurate for commercial sex, numbers may have been underestimated for
non-commercial sex.
Improving the provision of condoms could have a substantial effect. This study suggests that
making condoms available in hotel rooms increase their use by an average of about 8% in the
19 motels studied. More than 6000 sexual encounters were recorded. Extrapolating these
findings to include sexual encounters in all of Managua’s motels could mean that, if the effect
of condom provision in rooms were constant, this intervention could protect another 80 000
sexual acts every year in Managua.
Reference:
1. Egger M, Pauw J, Lopatatzidis A, Medrano D, Paccaud F, Davey Smith G. Promotion of condom use in a
high-risk setting in Nicaragua: a randomised controlled trial. Lancet 2000; 355: 2101-5.
(http://www.thelancet.com/newlancet/reg/issues/vol355no9221/menu_NOD999.html)
Reported by Birte Twisselmann ([email protected]), PHLS Communicable
Disease Surveillance Centre, London, England.