At the time of writing this there have been 7 deaths and 14 people are in hospital with infections related to anthrax in Scotland. The current official advice from Health Protection Scotland's Dr Colin Ramsey has been "... I would urge all users to stop using heroin immediately and contact local drug support services for help in stopping.", which as advice goes has been less than helpful. But what (if any) are the messages that should be given out, and just how worried should we be?

What is anthrax?

Anthrax is an acute disease caused by the bacteria bacillus anthracis that can be fatal. The bacteria can effect you via inhalation (breathing in), ingestion (eating) or, as with the current cases in Scotland - by infecting a wound.

The risk of anthrax infection becoming fatal depends on both the way you become infected and how soon you get treatment. Cutaneous (wound) anthrax is actually the least fatal and responds really well to treatment. The problem though is that you NEED early treatment and as the symptoms of anthrax are almost the same as everyday injecting infections people are unlikely to get the treatment.

Anthrax symptoms

• Cutaneous (wound) anthrax: all the current infections fit into this category. A boil develops about 2-5 days after initial infection which develops into a black necrotic ulcer/scab (eschar). Unlike other bruises and infections this may be painless. Cutaneous anthrax is rarely fatal, but untreated it can cause death in 20% of cases.
• Pulmonary (inhaled) anthrax: Respiratory infection in humans initially presents with cold or flu-like symptoms for several days, followed by severe (and often fatal) respiratory collapse. Even with treatment risk of death can be as high as 45%.
• Gastrointestinal anthrax: commonly comes from eating infected meat and can cause vomiting of blood, severe diarrhoea, acute inflammation of the intestinal tract, and loss of appetite. Sometime lesions have been found in the intestines, mouth and throat. Can be treated, fatality rates are 25% to 60% depending on how soon you get treatment.

Harm reduction

To be perfectly honest I've been putting off writing this article for the last couple of weeks. With previous bacterial infections affecting heroin injectors the harm reduction has been obvious; smoke rather than inject. But with anthrax this isn't as simple, we know a major route of infection is via inhalation, in fact this is the most deadly form. Although only theoretical, the risk from smoking seems likely. Anthrax spores would need to be heated above 90c for a significant time to kill them off (thanks to Tom Ward for this info).  Even if your heroin gets hotter than this it doesn't do so straight away so spores may be inhaled early in the smoking session (and maybe even all through it).

So the usual advice is no good. And neither is swallowing or snorting heroin an option, which brings us back to the 'stop using heroin' message. Great, but according to Sara McGrail on her fantastic blog post waiting times in Scotland for substitute prescribing currently range from 8 to 52 weeks.  Leaving the only current options as either continue using or self detox.

We need faster scripting

What is needed is rapid prescribing to any and all heroin users who want it. There are services in the UK that have same day prescribing and it is possible to do this on a simple basis. I remember talking to workers who had been getting 40ml scripts of methadone to street sex workers on the basis of self declared heroin use and a positive urine sample. Yes full information gathering would be best practice, a series of in depth one to one sessions would be great, but keeping people alive should be the first priority!

Heroin is mobile

And don't think that just because your service is in Birmingham, London or Devon that none of this applies to you. At the moment police attention on the dealer in the area will be intense, which means one of two things are likely to happen. Either the infected heroin will be vac-packed and buried for a year or so (anthrax spores can survive for decades) or it will be moved and the problem will move with it. We all need to be ready. (At the time of writing there is also an unconfirmed case in Germany, which may be a sign this is a big batch.)

Where did this come from?

We don't know. Microbiologist, Professor Hugh Pennington has said:

"You can’t completely rule out maliciousness as theoretically – people would be able to get hold of anthrax in the UK, although you’d need a specialist microbiological knowledge to do so"

Personally I think you can rule this out; in no way does it make business sense to kill your customers.

The most likely option is that the bacteria got there by accident either somewhere during manufacture/cutting (unlikely as this would probably have resulted in people becoming infected at this stage) or during transportation. Anthrax can be found on animal skins and in the meat of infected animals and it's possible that the heroin came into contact with these in some way during storage or shipping.

What to look out for.

All workers and injectors should become hyper aware of injecting infections and strongly encourage people to seek medical attention as soon as possible, the longer an anthrax infected wound is left the less likely it is that treatment will be effective. Anyone with flu like symptoms followed by signs of coughing up blood or intestinal problems should also seek medical attention.  Although none of the current cases are inhalation or gastrointestinal anthrax we can assume this is a risk factor. The Health Protection agency has produced some anthrax algorithms that should help (cutaneous anthrax, inhalation anthrax).

Why is so little being done?

There have been some angry reactions from the community over the lack of any real response to this situation and you can't help but wonder what the reaction would be if this was hitting any other social group. Remember the panic in America over anthrax a few years ago? Granted this is a normal (although sad) reaction to any stigmatised group (just think back to the early days of HIV). But in this case there is also a misunderstanding of the situation from the general public, clearly the answer is simple as Dr Ramsey said "...stop using heroin immediately". To Joe Bloggs public it must seem insane that a heroin injector carries on in the face of this.

But heroin users also face overdose, hepC, hepB, HIV, septicaemia, tetanus etc etc (the list goes on, and on) as Jolene Crawford, of Transform Drug Policy Foundation Scotland has said:

“It is accepted that some heroin will be lethal because by prohibiting it we gift control to criminals. Were opium and heroin to be legally available via regulated pharmacies and doctors’ surgeries, we would not have to see our children, mothers, fathers, brothers and sisters die unnecessarily in this way.”

Related links

Health Protection Agency anthrax page
Health Protection Scotland anthrax page
National Users Network Facebook page
Sara McGrail's anthrax article
Anthrax page on wikipedia
Self detox handout

Update

The Scottish Drugs Forum as released guidance for workers on how to deal with the Anthrax outbreak, this is essential reading for all workers (and users).