1. Trends in wound botulism among injectors in the United Kingdom, 2000-2004 Leah de Souza-Thomas, Vina Mithani, Jim McLauchlin, Vivian D Hope*, Jeffrey Dennis & Fortune Ncube Centre for Infections, Health Protection Agency, Colindale, London. * Also at the Centre for Research on Drugs and Health Behaviour, Imperial College London.

2. Bacterial infections among IDUs The epidemiology of viral infections among injectors is widely study Many bacterial infections which can be acquired by IDUs Infections can be crudely split into hygiene or drug contamination related. Surveillance data currently only available on the most severe infections i.e. Clostridia infections

3. Wound botulism Wound botulism (WB) occurs when the spores of Clostridium botulinum contaminate a wound, germinate and produce toxin acetylcholine Symptoms are caused by the neurotoxin which blocks the release of acetylcholine at the neuromuscular junction. Symptoms include blurred vision and difficulty in swallowing and speaking, and it can also result in paralysis and death. There is an effective antitoxin.

4. Epidemiology of wound botulism WB first described in the USA in 1951, reporting begun in 1950 (Davis et al., 1951) WB in IDUs first described in New York in 1982 (Weber et al., 1993) Cases in USA make up 90% of known cases worldwide, 75% of which occur in California (Werner et al., 2000)

5. Epidemiology of WB in the UK Prior to 2000 no reported cases Data to the end of 2004, 89 cases of suspected or confirmed WB Thirty-seven of the 89 (42%) cases were confirmed Eighty-two per cent (70/85) in England, 15% (13/85) in Wales, 2% (2/85) in Wales

6. Reported cases of wound botulism among injecting drug users in the UK

7. UK Cases 2004 Found geographical and temporal clusters in London, Yorkshire & Humberside and East Midlands regions

8. WB cases in 2004 Median age 35 years (range 20-54) Mean injecting duration 12.7 years (range 2-24) Ventilation required for 18 cases Deaths in 2 cases Antitoxin administer to 22% (9/41) of cases Skin abscesses not found in all cases

9. Injecting practises (2004) Intravenous injection reported by 66% (10/15) Muscle Popping reported by 40% (6/15) Skin popping reported by 33% (5/15) Drugs reported include heroin, crack, cocaine, methadone, temazepam & temgesic. Poly drug use, 18% (3/17) heroin alone Citric acid most common dissolvent (86%, 12/14), other include jif, lemon juice, vinegar, vitamin C and water

10. Potential costs Distressing and unpleasant Health care costs: Surgery; Medication - Antibiotics & Antitoxins; long stays in hospital including ITU / HDU; & Laboratory work Mortality ‘costs’ are likely to be very high per case.

11. Conclusions Emerging problem of WB among injecting drug users. Increased awareness and vigilance to reduce the severity of morbidity and mortality. Further research: What has caused the increase? How widespread is the problem overall? Analysis of drug related deaths? Investigation of risks of acquiring WB?

12. Further information on infections among injecting drug users can be found at: http://www.hpa.org.uk/ Go to: ‘Topics A to Z’ and select: ‘Injecting drug users (IDUs)’