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Eurosurveillance Weekly: Thursday 11 October 2001. Volume 5, Issue 41
Contents:
1.
2.
3.
4.
Salmonella Stanley and Salmonella Newport in imported peanuts
Wound botulism in an injecting drug user in Scotland
Severe systemic sepsis in injecting drug users in Scotland: report published
Outbreak of serious illness related to contaminated heroin: European network helps improve
surveillance of acute serious health events
5. Management of possible exposure to CJD through medical procedures
Salmonella Stanley and Salmonella Newport in imported peanuts
Following an international outbreak of Salmonella Stanley associated with consumption of a specific
brand of imported peanuts in Australia (1,2) and Canada (3), a request for information was sent via Enternet on 8 October 2001 to ascertain whether any other countries had any cases that may be associated
with this product. To date, seven cases have been identified in Australia and Canada; no other countries
have reported cases associated with this product. S. Stanley has been isolated from an unopened packet
of this product in Australia, whereas in Canada both S. Stanley and S. Newport have been isolated from
unopened packets. The peanuts originate from and are produced in China, and are distributed via
Singapore. If found in the United Kingdom (UK) these peanuts are more likely to be sold through
specialist stores. At the request of the Food Standards Agency (FSA), local sampling was undertaken by
the Public Health Laboratory Service (PHLS) and environmental health departments of local authorities in
London and the north west to determine whether any of these imported peanuts, on sale, are
contaminated with Salmonella spp. To date, three samples of garlic flavoured in-shell peanuts from the
same batch with a best before date of 28 June 2003 have been found positive for S. Newport or S.
Stanley by the PHLS London Food, Water and Environmental Laboratory and Preston PHL. A further two
samples of the same product and batch have been found positive for Salmonella spp. by Chester PHL.
Molecular typing of these food isolates together with recent human isolates is in progress in the PHLS
Laboratory of Enteric Pathogens (LEP).
The UK importer has initiated a recall of the product. As a protective measure, the FSA has advised
consumers of what products to avoid, and has issued a food hazard warning asking local authority
enforcement officers to ensure that these products are removed from sale (4,5).
From 1 January 2001 to 30 September 2001, LEP has reported on 78 and 138 human isolates of S.
Stanley and S. Newport, respectively, in England and Wales.
References:
1.
2.
3.
4.
5.
Australia New Zealand Food Authority. Shandong peanuts – Salmonella contamination - 10 September 2001.
<http://www.anzfa.gov.au/recallssafety/foodrecalls/currentconsumerlevelrecalls/shandongpeanutssalmo1036.cfm>
Salmonella Stanley, peanuts – Australia: Recall. ProMED-mail 2001; 11 September.
(http://www.promedmail.org/pls/promed/promed.searchhtml.showmail?p_filename=20010911.2189&p_year=2001&p_mo
nth=09)
Canada Food Inspection Agency. Health hazard alert. Imported Farmer Brand peanuts may contain dangerous bacteria,
September 18, 2001. (http://www.inspection.gc.ca/english/corpaffr/recarapp/20010918e.shtml)
Food Standards Agency. Food hazard warning. Withdrawal of 'Farmer Brand' garlic flavour peanuts (in shells), 10 October
2001.
Food Standards Agency. Some garlic flavoured peanuts found to be contaminated with salmonella. Press release
2001/0154, 10 October 2001. (http://www.foodstandards.gov.uk/press_releases/uk_press/2001/pr011010peanuts.htm)
Reported by Christine Little ([email protected]), Public Health Laboratory Service Communicable
Disease Surveillance Centre, London, England.
Wound botulism in an injecting drug user in Scotland
A case of presumptive wound botulism has been diagnosed in a 33 year old male injecting drug user
(IDU) in Glasgow, Scotland. The man presented to hospital on 28 September and, shortly after
admission, was admitted to the intensive therapy unit with respiratory failure. Clinical features are
consistent with infection due to Clostridium botulinum.
In the context of last year’s outbreak of severe illness and death among injecting drug users (see below)
– mainly from Glasgow, Dublin, and parts of England (1-4) – which arose as a consequence of injecting
heroin contaminated with C. novyi and other similar organisms, it seems likely that this latest infection
was acquired in the same way. Prior to this outbreak, in February and May 2000, Eurosurveillance
Weekly reported on clinical cases of wound botulism in IDUs diagnosed in Switzerland and England,
respectively (5-7).
Accident and emergency departments, general practitioners, and microbiologists have been informed
about the latest case in Glasgow, which, at present, seems to be a sporadic one. Nevertheless, it is
important that relevant clinical and public health professionals remain vigilant about recognising and
reporting other cases, as it is possible that a batch of contaminated heroin is in circulation.
References:
1.
2.
3.
4.
5.
6.
7.
Maagaard A, Hermansen N, Heger B, Bruheimand M, Meidell NK, Hoel T, et al. Serious systemic illness among injecting
drug users in Europe: new case in Oslo. Eurosurveillance Weekly 2000; 4: 000914.
(http://www.eurosurv.org/2000/000914.htm)
Andraghetti R, Twisselmann B. Severe systemic sepsis in injecting drug users – Scottish outbreak control team sets up
website. Eurosurveillance Weekly 2000; 4: 000824. (http://www.eurosurv.org/2000/000824.htm)
Greater Glasgow Health Board, Scottish Centre for Infection and Environmental Health, 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)
CDC. Unexplained illness and death among injecting-drug users – Glasgow, Scotland; Dublin, Ireland; and England, AprilJune 2000. MMWR Morb Mortal Wkly Rep 2000; 49(22); 489-92.
(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4922a2.htm)
Brett M. Clinical case of wound botulism in a drug user. Eurosurveillance Weekly 2000; 4: 000525.
(http://www.eurosurv.org/2000/000525.htm)
Athwal B, Gale A. Wound botulism in injecting drug user in London. Eurosurveillance Weekly 2000; 4: 000518.
(http://www.eurosurv.org/2000/000518.htm)
Burnens A. Cases of wound botulism in Switzerland. Eurosurveillance Weekly 2000; 4: 000203.
(http://www.eurosurv.org/2000/000203.html)
Reported by David Goldberg ([email protected]), Scottish Centre for Infection and
Environmental Health, Glasgow, Scotland.
Severe systemic sepsis in injecting drug users in Scotland in 2000: final report
published
Last year, Eurosurveillance Weekly covered an outbreak of severe systemic sepsis in injecting drug users
(IDUs) in Norway, Scotland, Ireland, and England (1-14). A report into the deaths of 23 drug users who
died after injecting contaminated heroin has now been published by a multidisciplinary team in Glasgow
(15,16) and is available at <http://www.show.scot.nhs.uk/ggnhsb/>. Doctors investigating the outbreak,
which also affected drug users in the north west of England and in the city of Dublin in Ireland, have
drawn up 12 recommendations to prevent further deaths.
The report describes an unprecedented outbreak of severe illness among 60 IDUs in Scotland, mostly in
Glasgow, between April and August 2000. It said that 23 IDUs died as a result of taking the drug, some
within hours of presenting to hospitals. All victims developed a serious abscess after they had injected
into muscle or accidentally outside a vein. But it is still not known how the heroin was contaminated.
Most addicts inject into their veins, and the oxygen in their blood does not facilitate the growth of
anaerobic bacteria present in the heroin. In these cases, the acid solution of heroin is believed to have
killed the muscle tissue into which it was injected, depriving it of oxygen and providing ideal conditions for
anaerobic bacteria to grow. Greater Glasgow Health Board (GGHB) investigated the outbreak, identifying
the bacterium Clostridium novyi as the causative agent in many of the cases.
GGHB is hoping that this discovery may help earlier recognition of the organism in future cases. In many
cases the C. novyi infection caused untreatable multiple organ failure, according to the clinical analysis of
the outbreak which affected 109 addicts in Scotland, England, and Ireland.
GGBH said it could happen again, underlining the vulnerability of street heroin users and the need for
effective treatments. The 12 recommendations made include improving communications between doctors
and hospitals dealing with any further outbreak, and also the flow of information to users.
The recommendations are as follows.
1. When there is no obvious cause of death in a known drug user, pathologists should be told
immediately to enable necessary specimens to be taken.
2. When there is a risk of serious or unusual infection, doctors should inform clinical microbiologists
that patients are known drug users and discuss what specimens should be taken.
3. Information about any unusual infection in a drug user should be given to the local public health
consultant, who should inform the relevant national centre for communicable disease
surveillance.
4. Tissue samples from living and deceased cases involving severe tissue infection should receive
additional treatment to facilitate the growth of strict anaerobes.
5. Steps should be taken to ensure hospital laboratories are maintained with qualified staff to enable
them to cope with such outbreaks.
6. A properly funded prospective research study should be undertaken to ascertain the underlying
incidence and nature of soft tissue infection.
7. Drug action teams should review arrangements for communicating information for those at risk
from future outbreaks.
8. Health boards should review arrangements for receiving and treating drug users.
9. Drug action teams should continue efforts to make drug users aware of the dangers of injecting.
10. In future similar outbreaks, there should be proactive, consistent, and open communication with
the media.
11. The coordinating health board should use a pre-existing outbreak website to disseminate
information, available, and publicised on commonly used search engines.
12. An international meeting should be convened to consider what lessons should be learnt from the
outbreak and what could be done to prevent future incidents.
A fatal accident inquiry is due to open at Glasgow Sheriff Court next month into the deaths of 18 men and
women from Glasgow who died from the apparently contaminated drug batch.
An international scientific meeting about the outbreaks of illness among IDUs is being held on 15 and 16
October 2001 at the Royal College of Physicians and Surgeons in Glasgow. Topics will include the
identification and investigation of the outbreaks, the epidemiological, microbiological, pathological, and
toxicological findings, outbreak management, and public health implications. The meeting is being
convened by GGBH, in collaboration with SCIEH, the Public Health Laboratory Service (England and
Wales), the Eastern Regional Health Authority (Ireland), and the Centers for Disease Control and
Prevention (Atlanta). Places are still available. For further details, click here.
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Maagaard A, Hermansen N, Heger B, Bruheimand M, Meidell NK, Hoel T, et al. Serious systemic illness among injecting
drug users in Europe: new case in Oslo. Eurosurveillance Weekly 2000; 4: 000914.
(http://www.eurosurv.org/2000/000914.htm)
Andraghetti R, Twisselmann B. Severe systemic sepsis in injecting drug users – Scottish outbreak control team sets up
website. Eurosurveillance Weekly 2000; 4: 000824. (http://www.eurosurv.org/2000/000824.htm)
CDC. Update: Clostridium novyi and unexplained illness among injecting-drug users – Scotland, Ireland, and England,
April-June 2000. MMWR Morb Mortal Wkly Rep 2000; 49(24): 543-5.
(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4924a6.htm)
Jones J, Gill N, Djuretic T, Greater Glasgow Health Board, Scottish Centre for Infection and Environmental Health, Murray
K, et al. ‘Serious unexplained illness’ among injecting drug users in Britain and Ireland. Eurosurveillance Weekly 2000; 4:
000622. (http://www.eurosurv.org/2000/000622.htm)
Khan M, Chay S, Bonner S, Brett M. Wound botulism in injecting drug user: second case in England. Eurosurveillance
Weekly 2000; 4: 000615. (http://www.eurosurv.org/2000/000622.htm)
Greater Glasgow Health Board, Scottish Centre for Infection and Environmental Health, 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)
CDC. Unexplained illness and death among injecting-drug users – Glasgow, Scotland; Dublin, Ireland; and England, AprilJune 2000. MMWR Morb Mortal Wkly Rep 2000; 49(22); 489-92.
(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4922a2.htm)
Greater Glasgow Health Board, Scottish Centre for Infection and Environmental Health. 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)
Djuretic T, Gill N. Serious unexplained illness among injecting drug users in England. Eurosurveillance Weekly 2000; 4:
000608. (http://www.eurosurv.org/2000/000608.htm)
10. Eastern Regional Health Authority, National Disease Surveillance Centre Dublin, Ireland. Deaths from unexplained illness
in heroin users in Dublin. Eurosurveillance Weekly 2000; 4: 000601. (http://www.eurosurv.org/2000/000601.htm)
11. Ahmed S, Gruer L, Goldberg D. Serious unexplained illness among injecting drug users in Scotland and the Republic of
Ireland – update. Eurosurveillance Weekly 2000; 4: 000601. (http://www.eurosurv.org/2000/000601.htm)
12. Greater Glasgow Health Board, Scottish Centre for Infection and Environmental Health. Unexplained illness among drug
injectors in Glasgow. Eurosurveillance Weekly 2000; 4: 000518. (http://www.eurosurv.org/2000/000518.htm)
13. Høiby EA, Caugant DA, Ringertz SH, Jensenius M, Fossum K, Hoel T, et al. Systemic anthrax in an injecting drug user:
Oslo, Norway April 2000. Eurosurveillance Weekly 2000; 4: 000511. (http://www.eurosurv.org/2000/000511.htm)
14. Killer heroin report published. BBC News Online, 18 September 2001.
(http://news.bbc.co.uk/hi/english/uk/scotland/newsid_1550000/1550241.stm)
15. Unexplained deaths, drug addicts – UK: report. ProMED mail, 3 October 2001.
(http://www.promedmail.org/pls/promed/promed.searchhtml.showmail?p_filename=20011003.2398&p_year=2001&p_mo
nth=10)
Reported by Greater Glasgow Health Board and Scottish Centre for Infection and Environmental Health,
Glasgow, Scotland. Further enquiries to Syed Ahmed ([email protected]).
Outbreak of serious illness related to contaminated heroin: European network
helps improve surveillance of acute serious health events
During July 2001, new warnings were issued in Britain about the possibility that a batch of contaminated
heroin was back on the market in England and Scotland. The European Monitoring Centre for Drugs and
Drug Addiction (EMCDDA) in Lisbon, Portugal, alerted by the Public Health Laboratory Service (PHLS)
for England and Wales, passed on these new warnings to the Reitox network of national focal points for
immediate dissemination to professionals in contact with drug users throughout the European Union (1).
By the end of August, nine potential cases of serious illness (including necrotising fasciitis) had occurred
in Scotland, but these were less severe than in 2000. It is suspected that, unlike last year's outbreak, they
represent a cluster of mixed infection comprising group A streptococcus and Clostridium perfringens.
Additionally, in the last week, the Scottish surveillance network has also reported an isolated case of
wound botulism (C. botulinum) in an IDU (see above).
At present, there is no evidence that the outbreak of heroin related serious illness in Scotland is related to
last year's outbreak, but continued vigilance is needed. In England, there have been two reports of
Clostridium novyi isolated from injecting drug users in 2001, one at the beginning of the year and the
second recently.
The incidents illustrate the value of the European infrastructure for rapidly alerting professionals in the
drug field. Furthermore, they show that improved surveillance of acute serious health events among
injecting drug users is warranted.
Reference:
1.
McMenamin J, Goldberg D, Gill N, Wiessing L. Outbreak of serious illness related to contaminated heroin: less severe
illness, different bugs. Drugnet Europe 2001; (31): 6. (http://www.emcdda.org/infopoint/publications/drugnet.shtml)
Reported by Jim McMenamin and David Goldberg, Scottish Centre for Infection and Environmental
Health, Glasgow, Scotland; Noel Gill, Public Health Laboratory Service Communicable Disease
Surveillance Centre, London, England; and Lucas Wiessing ([email protected]), European
Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal.
Management of possible exposure to CJD through medical procedures
The Department of Health in the United Kingdom is seeking views on this consultation paper produced by
the CJD Incidents Panel (1). This expert advisory group was set up in August 2000 by the chief medical
officer to advise on issues relating to the possible transmission of Creutzfeldt-Jakob disease (CJD) and
variant CJD from person to person through healthcare. Such CJD ‘incidents’ can arise when a patient
found to have CJD has previously had surgery, or donated blood, organs, or tissues.
There is considerable scientific uncertainty about the transmission risk in such circumstances. In sporadic
CJD, abnormal prion protein and experimental infectivity have been demonstrated in brain, spinal cord,
and parts of the eye. Rare episodes of transmission have been documented through neurosurgical
procedures and in recipients of human pituitary derived gonadotrophins and growth hormone.
Person to person transmission of vCJD has not been documented. The distribution of abnormal prion
protein in the body in vCJD, however, is wider than in sporadic CJD. This leads to the unquantifiable, but
theoretically possible, risk that vCJD may be transmissible through surgical procedures, especially those
involving lymphoreticular tissues as well as tissues of the central nervous system, and through donations
of blood, organs, and tissues. Normal decontamination and sterilisation procedures do not destroy
abnormal prion protein.
The proposals put forward by the CJD Incidents Panel to support health authorities and trusts in
managing CJD incidents acknowledge the uncertainties and ethical dilemmas posed by the limited
scientific knowledge of these risks and their possible consequences.
Four main actions are proposed.
1. Provide advice on when instruments or blood products should be removed from use.
2. Establish a confidential database of all possibly exposed people, who would not be routinely
informed about their possible exposure. This database, which would be maintained by the Public
Health Laboratory Service Communicable Disease Surveillance Centre (CDSC), would be used
to increase the knowledge of the risk of transmission.
3. Inform a small group of possibly exposed people where the panel considers there is sufficient risk
to warrant public health action (advising people not to donate blood or organs and special
precautions should surgery be needed).
4. Publicise the database to enable people to find out if they have been possibly exposed, or to
choose to remove their names without learning whether they may have had an exposure.
The consultation paper is available electronically at http://www.doh.gov.uk/cjd/consultation. The views of
a wide range of healthcare professionals, patient support groups, and other interested people are sought
to address a series of questions highlighted within the document. Responses can be returned
electronically or by post.
Reference:
1.
Management of possible exposures to CJD through medical procedures. A consultation paper. CJD Incidents Panel.
Department of Health, October 2001, London. http://www.doh.gov.uk/cjd/consultation
Reported by Gerry Bryant ([email protected]), Public Health Laboratory Service Communicable
Disease Surveillance Centre, London, England.