Ongoing outbreak of invasive and non-invasive disease due to group A Streptococcus (GAS) type emm66 among homeless and people who inject drugs in England and Wales, January to December 2016

Bundle, Nick; Bubba, Laura; Coelho, Juliana; Kwiatkowska, Rachel; Cloke, Rachel; King, Sarah L.; Rajan-Iyer, J; Courtney-Pillinger, Max; Beck, Charles R.; Hope, Vivian; Lamagni, Theresa; Brown, Colin S; Jermacane, Daiga; Glass, Rachel; Desai, Monica; Gobin, Maya; Balasegaram, Sooria; Anderson, Charlotte

doi:10.2807/1560-7917.es.2017.22.3.30446

Cited by 43 publications

(35 citation statements)

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“…This mixed method study generated questionnaire with urinalysis (n = 455) and qualitative interview (n = 32) data with PWID in London, UK, between October 2017 and March 2019. The aim of Care & Prevent is twofold: (1) to explore associations between SSTI and the renal disease, AA amyloidosis, including though risk screening and specialist referral and (2) to explore the risk factors and contexts related to SSTI among PWID. This paper will present findings pertaining to the latter aim, primarily drawing on qualitative accounts of injection preparation practices.…”

Section: Methodsmentioning

confidence: 99%

“…Keywords: Water for injection, Injection preparation, People who inject drugs, Homelessness, Skin and soft tissue infections, Crack cocaine, heroin Background Health harms are increasing among the estimated 200,000 people who inject drugs (PWID) in the United Kingdom (UK). Since 2012, there has been a steady increase in hospitalisations for serious bacterial infections [1], a doubling of opioid-related deaths [2], and outbreaks of invasive and infectious diseases among PWID, particularly among those who are homeless [1][2][3]. The recent outbreak of coronavirus (COVID-19) is of particular concern, given vulnerability to respiratory problems among PWID in the UK, many of whom also smoke (crack cocaine, heroin, tobacco) and have a much higher incidence of chronic obstructive pulmonary disease (COPD) than the general population [4].…”

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confidence: 99%

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Navigating environmental constraints to injection preparation: the use of saliva and other alternatives to sterile water among unstably housed PWID in London

et al. 2020

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Background: The United Kingdom is experiencing an increase in drug-related deaths and serious bacterial infections among its most vulnerable citizens. Cuts to essential services, coupled with a growing homeless population, create a challenging environment to tackle this public health crisis. In this paper, we highlight an underexplored environmental constraint faced by people living and injecting drugs on the streets. Access to water for injection is restricted in the UK, due to legislative and financial barriers. Austerity measures, such as public toilet closures, further restrict the ability of people made homeless to access clean water and protect themselves from health harms. Methods: We generated questionnaire (n = 455) and in-depth qualitative interview (n = 32) data with people who inject drugs in London for the Care and Prevent study. Participants provided detail on their life history; drug use, injecting and living environments; health conditions and care seeking practices. Findings: A high proportion of the survey sample reported lifetime history of street homelessness (78%), bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts highlight unsafe, potentially dangerous, injection practices in semi-public spaces. Multiple constraints to sourcing sterile water for injection preparation were reported. Alternatives to sterile water included puddle water, toilet cistern water, whisky, cola soda and saliva. Participants who injected heroin and crack cocaine together unanimously reported adding water at two stages during injection preparation: first, adding water as a vehicle for heroin (which was then heated); second, adding cold water to the heroin mixture prior to adding the crack cocaine. This new finding of a stage addition of solvent may represent an additional risk of infection.(Continued on next page)

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Section: Methodsmentioning

confidence: 99%

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confidence: 99%

Navigating environmental constraints to injection preparation: the use of saliva and other alternatives to sterile water among unstably housed PWID in London

et al. 2020

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“…Recent reports have described GAS outbreaks affecting homeless populations that were caused by strains of emm types 82, 83, 87, 101, and 114 in Canada [7], 44 in France [34], and 32 and 66 in Great Britain [35, 36]. One common theme between the current emm74 and prior emm59 epidemics, as well as in these other reports, is that the offending GAS strains belong to emm types of pattern D (skin tropism) or E (generalist, ie, both throat and skin tropism) [37, 38].…”

Section: Discussionmentioning

confidence: 99%

Canada-Wide Epidemic of emm74 Group A Streptococcus Invasive Disease

Teatero

McGeer

Tyrrell

et al. 2018

Open Forum Infectious Diseases

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BackgroundThe number of invasive group A Streptococcus (iGAS) infections due to hitherto extremely rare type emm74 strains has increased in several Canadian provinces since late 2015. We hypothesized that the cases recorded in the different provinces are linked and caused by strains of an emm74 clone that recently emerged and expanded explosively.MethodsWe analyzed both active and passive surveillance data for iGAS infections and used whole-genome sequencing to investigate the phylogenetic relationships of the emm74 strains responsible for these invasive infections country-wide.ResultsGenome analysis showed that highly clonal emm74 strains, genetically different from emm74 organisms previously circulating in Canada, were responsible for a country-wide epidemic of >160 invasive disease cases. The emerging clone belonged to multilocus sequence typing ST120. The analysis also revealed dissemination patterns of emm74 subclonal lineages across Canadian provinces. Clinical data analysis indicated that the emm74 epidemic disproportionally affected middle-aged or older male individuals. Homelessness, alcohol abuse, and intravenous drug usage were significantly associated with invasive emm74 infections.ConclusionsIn a period of 20 months, an emm74 GAS clone emerged and rapidly spread across several Canadian provinces located more than 4500 km apart, causing invasive infections primarily among disadvantaged persons.

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“…However, recent outbreaks of both noninvasive and invasive GAS disease have been reported in community settings, often in marginalized populations. For example, there have been reports of GAS outbreaks in a homeless shelter in Toronto, Ontario (18), a homeless population in Alaska, United States (US) (19), persons who use drugs (PWUD) in England and Wales (20), and a population with a high prevalence of PWUD, alcohol abuse and homelessness in Thunder Bay, Ontario (21).…”

Section: The Public Health Agency Of Canada's 2006 Guidelines For Thementioning

confidence: 99%

Community outbreak of invasive group A streptococcus infection in Ontario, Canada

Dickson¹,

Pham²,

Nguyen³

et al. 2018

CCDR

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Background: Outbreaks of invasive group A streptococcal infection (iGAS) have historically occurred in institutional settings. Increasingly, community-based outbreaks have been reported, often among marginalized populations, yet few guidelines exist for managing iGAS outbreaks in such settings. Objective: To describe the ongoing outbreak of iGAS in Middlesex-London, Ontario, and the challenges that arose while applying current guidelines to a marginalized population in a community setting. Methods: The outbreak investigation included all iGAS cases in Middlesex-London with an onset date from April 1, 2016 to February 28, 2018. Clinical specimens were submitted to provincial and federal laboratories for typing. Public health management of the outbreak involved environmental health inspections, contact tracing, chemoprophylaxis of close contacts, swabbing to determine colonization rates of Streptococcus pyogenes, and communicating with stakeholders and the public. Results: A total of 156 confirmed cases of iGAS corresponding to 147 individuals were reported in less than two years. More than 60% of cases occurred in men (n=91) and almost half (n=71) of the total number of cases were persons who used drugs (PWUD) and/or were under-housed. Of the PWUD cases, 58 of 65 (89%) used injection drugs. Key challenges in controlling this outbreak included reaching PWUD and under-housed people; completing a case history and contact list; facilitating completion of treatment; dealing with concurrent infections such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV); and optimizing environmental health conditions. Guidelines were adapted so contacts who shared drugs or injection drug equipment with a known iGAS case would be offered chemoprophylaxis regardless of the clinical severity of the case. To optimize treatment completion, a single-dose of azithromycin for individuals in close contact with PWUD and/or under-housed cases was given. Cases with macrolide-resistant strain emm9 have recently emerged. Conclusion: The application of institution-based guidelines for iGAS outbreaks has been ineffective in controlling this particular community outbreak. There is a need for guidelines on managing outbreaks of iGAS in the community especially when an outbreak involves marginalized populations.

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Ongoing outbreak of invasive and non-invasive disease due to group A Streptococcus (GAS) type emm66 among homeless and people who inject drugs in England and Wales, January to December 2016

Cited by 43 publications

References 11 publications

Navigating environmental constraints to injection preparation: the use of saliva and other alternatives to sterile water among unstably housed PWID in London

Navigating environmental constraints to injection preparation: the use of saliva and other alternatives to sterile water among unstably housed PWID in London

Canada-Wide Epidemic of emm74 Group A Streptococcus Invasive Disease

Community outbreak of invasive group A streptococcus infection in Ontario, Canada

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