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London: Second anthrax case confirmed in London

1 March 2010

The Health Protection Agency (HPA) and NHS London can confirm that an injecting heroin user has tested positive for anthrax and is being treated in a London hospital.

This is the third case of anthrax seen in an injecting drug user in England since similar cases were first seen in Scotland in December 2009. Twenty-four cases have so far been confirmed in Scotland and one in Germany. Similarities to the cases in Scotland suggest that the heroin, or a contaminated cutting agent mixed with the heroin, is the likely source of infection.

Dr Rachel Heathcock, from the Health Protection Agency in London, said:
"We are working closely with NHS London to monitor the situation. There is no evidence of person-to-person transmission with any of the recent cases and I'd like to reassure people that the risk to the general population, including close family members of the infected patient, is negligible. It is extremely rare for anthrax to be spread from person-to-person."

"While public health investigations are ongoing, it must be assumed that all heroin in London carries the risk of anthrax contamination. Heroin users are advised to cease taking heroin by any route, if at all possible, and to seek help from their local drug treatment services. Heroin users in London are strongly encouraged, as soon as possible, to find out more about the support services in their area. They can be put in touch with local drug services and receive advice by contacting Talk to Frank."

Professor Lindsey Davies, Regional Director of Public Health from NHS London, said:
"I urge all heroin users in London to be extremely alert to the risks and to seek urgent medical advice if they experience signs of infection such as redness or swelling at or near an injection site or other symptoms of general illness such a high temperature, chills or a severe headache, as early antibiotic treatment can be lifesaving. This is a very serious infection for drug users and prompt treatment is crucial.

"Drug injecting is an extremely risky and dangerous practice and users are vulnerable to a wide range of infectious diseases, both from the action of piercing the skin, and from contaminants in the drugs that they use.

"Health professionals and drug action teams in England had already been alerted to the situation in Scotland in December and we will continue to work closely with colleagues who work with drug users to monitor probable cases and raise awareness of the risks."

Notes to Editors:

Cumulative National Total in England

Date Confirmed cases Deaths
1 March 2010 3 1

Cumulative Total by region, 1 March 2010

Region Confirmed cases Deaths
London 2 0
North West 1 1

1. Further information about the cases of anthrax in Scotland is available at:

2. Heroin users in London are strongly encouraged to find out more about the support services in their area. They can find drug services or seek advice from Talk to Frank:
24-hour helpline: 0800 77 66 00 / website:

3. The outbreak in Scotland began with the identification of cases in NHS Greater Glasgow & Clyde in December 2009, with cases now having been identified in seven NHS board areas across the country, and represents the first known outbreak of anthrax to have occurred in conjunction with drug use. It is important to note that there is no evidence of person-to-person transmission in this outbreak.

4. The Health Protection Agency has produced advice for injecting drug users and guidelines on the clinical evaluation and management of people with possible cutaneous anthrax in England. These are available at:

5. Recent public health alerts issued by the Department of Health through the Central Alerting System are available at:

Media enquiries:

Health Protection Agency:
020 7759 2834
020 7759 2824

NHS London:
020 7932 3911. Out of office hours, please call 0844 822 2888 and ask for pager number LON01.

Anthrax in drug users: Q&A

Q1. What is anthrax?

Anthrax is a very rare but serious bacterial infection caused by the organism Bacillus anthracis. The disease occurs most often in wild and domestic animals in Asia, Africa and parts of Europe; humans are rarely infected. The organism can exist as spores that allow survival in the environment, e.g. in soil, for many years.

Q2. How does anthrax usually affect humans?

There are three classical forms of human disease depending on how infection is acquired: cutaneous (skin), inhalation and ingestion. In over 95% of cases the infection is cutaneous, generally caught by direct contact with the skins or tissues of infected animals. Inhalation anthrax is rare and is caught by breathing in anthrax spores. Intestinal anthrax is very rare, and occurs from ingestion of contaminated meat or spores.

Q3. How has anthrax been affecting drug users in Scotland?

There is an ongoing outbreak of anthrax in heroin users in Scotland. Since December 2009, a significant number of heroin users have been found to have anthrax infection. Sadly, a number of these people have died. It is thought that they contracted anthrax from taking heroin contaminated by anthrax spores.

Q4. How common is anthrax?

The disease was also known as 'wool-sorters disease' and was a recognised occupational hazard for some workers, including woollen mill workers, abattoir workers, tanners, and those who process hides, hair, bone and bone products. However, anthrax is now uncommon in humans in the UK, only a handful of cutaneous cases have been notified over the last decade. A death from anthrax occurred in Scotland in 2006 and London in 2007; these were cases of atypical inhalation anthrax which probably followed exposure as a result of playing/handling animal hide drums.  Human infections are more frequent in countries where the disease is common in animals, including countries in South and Central America, southern and eastern Europe, Asia and Africa.
Anthrax in drug users appears to be very rare; prior to the current outbreak in Scotland, only one previous case had been reported in Norway in 2000.

Q5. How long can you have the infection before developing symptoms?

This is dependent on the dose and route of exposure and may vary from one day to eight weeks. However, symptoms usually develop within 48 hours with inhalation anthrax and 1-7 days with cutaneous anthrax. It is not known exactly how long symptoms can take to develop following the use of contaminated heroin, however in most cases during the current outbreak, symptoms started within 1 to 7 days of taking heroin.

Q6. What are the symptoms?

Early identification of anthrax can be difficult as the initial symptoms are similar to other illnesses.
Symptoms vary according to the route of infection:

Anthrax in drug users

Drug users may become infected with anthrax when heroin or the cutting agent mixed with heroin has become contaminated with anthrax spores. This could be a source of infection if injected, smoked or snorted. The clinical presentation is likely to vary according to the way in which the heroin is taken and might include:

  • Swelling and redness at an injection site, which may or may not be painful
  • Abscess or ulcer at an injection site often with marked swelling (oedema)
  • Septicaemia (blood poisoning)
  • Meningitis
  • Symptoms of inhalational anthrax (see below)

Cutaneous anthrax - Local skin involvement after direct contact.

  • Commonly seen on hands, forearms, head and neck. The lesion is usually single
  • 1-7 days after exposure a raised, itchy, inflamed pimple appears followed by a papule that turns vesicular (into a blister). Extensive oedema or swelling accompanies the lesion - the swelling tends to be much greater than would normally be expected for the size of the lesion and this is usually PAINLESS
  • The blister then ulcerates and then 2-6 days later the classical black eschar develops
  • If left untreated the infection can spread to cause blood poisoning
    Inhalation anthrax - symptoms begin with a flu-like illness (fever, headache, muscle aches and non-productive cough) followed by severe respiratory difficulties and shock 2-6 days later. Untreated disease is usually fatal, and treatment must be given as soon as possible to reduce mortality.
    Intestinal anthrax is contracted by the ingestion of contaminated carcasses and results in severe disease which can be fatal. This is found in some parts of the world where the value of an animal dying unexpectedly outweighs any fears of contracting the disease.

Q7. Can anthrax be treated?

Cutaneous anthrax can be readily treated and cured with antibiotics. Mortality is often high with inhalation and gastrointestinal anthrax, since successful treatment depends on early recognition of the disease.
Prompt treatment with antibiotics and, where appropriate, surgery is important in the management of anthrax related to drug use.

Q8. How is anthrax spread?

A person can get anthrax if they inject, inhale, ingest or come into direct physical contact (touching) with the spores from the bacteria. These spores can be found in the soil or in contaminated drugs. It is extremely rare for anthrax to spread from person-to-person. Airborne transmission from one person to another does not occur; there have been one or two reports of spread from skin anthrax but this is very, very rare.

Q9. How do drug users become infected with anthrax?

Heroin or the cutting agent mixed with heroin may become contaminated with anthrax spores from the environment. This could be a source of infection if injected, smoked, or snorted.

Last reviewed: 1 March 2010