A pragmatic harm reduction approach to manage a large outbreak of wound botulism in people who inject drugs, Scotland 2015.

BACKGROUND: People who inject drugs (PWID) are at an increased risk of wound botulism, a potentially fatal acute paralytic illness. During the first 6 months of 2015, a large outbreak of wound botulism was confirmed among PWID in Scotland, which resulted in the largest outbreak in Europe to date. METHODS: A multidisciplinary Incident Management Team (IMT) was convened to conduct an outbreak investigation, which consisted of enhanced surveillance of cases in order to characterise risk factors and identify potential sources of infection. RESULTS: Between the 24th of December 2014 and the 30th of May 2015, a total of 40 cases were reported across six regions in Scotland. The majority of the cases were male, over 30 and residents in Glasgow. All epidemiological evidence suggested a contaminated batch of heroin or cutting agent as the source of the outbreak. There are significant challenges associated with managing an outbreak among PWID, given their vulnerability and complex addiction needs. Thus, a pragmatic harm reduction approach was adopted which focused on reducing the risk of infection for those who continued to inject and limited consequences for those who got infected. CONCLUSIONS: The management of this outbreak highlighted the importance and need for pragmatic harm reduction interventions which support the addiction needs of PWID during an outbreak of spore-forming bacteria. Given the scale of this outbreak, the experimental learning gained during this and similar outbreaks involving spore-forming bacteria in the UK was collated into national guidance to improve the management and investigation of future outbreaks among PWID.

Assessing the impact of a temporary class drug order on ethylphenidate-related infections among people who inject drugs in Lothian, Scotland: an interrupted time-series analysis.

BACKGROUND AND AIMS: In April 2015, the UK government enacted a temporary class drug order (TCDO) on ethylphenidate in response to reported harms associated with its use, in particular an outbreak of infections among people who inject drugs (PWID) in Lothian, Scotland. This study assesses the effect that the TCDO had on reducing the most common infections identified during the outbreak: Streptococcus pyogenes and Staphylococcus aureus. DESIGN: The outbreak was split into a pre-intervention period (35 weeks) and a post-intervention period (26 weeks) based around the date of the TCDO. Segmented negative binomial regression models were used to compare trends in weekly counts of infections between the pre- and post-intervention periods. SETTING AND PARTICIPANTS: PWID in the Lothian region of Scotland. MEASUREMENTS: Cases of S. pyogenes and S. aureus infections reported within the National Health Service, Lothian. FINDINGS: There were 251 S. pyogenes and/or S. aureus infections recorded among 211 PWID between February 2014 and December 2015: 171 infections in the pre-intervention period and 51 in the post-intervention period. Significant trend changes in weekly S. pyogenes and/or S. aureus infections following the TCDO were found [relative risk (RR) = 0.88, 95% confidence interval (CI) = 0.82-0.94]. PWID who self-reported using novel psychoactive substances (NPS) were at higher risk of acquiring these infections (RR = 1.81, 95% CI = 1.12-2.93), particularly when comparing the risk of infection with NPS use for a specific strain, S. pyogenes emm76.0, against the risk of infection with NPS use for S. pyogenes (emm types other than emm76.0) (RR = 3.49, 95% CI = 1.32-9.21). CONCLUSIONS: The UK government's 2015 temporary class drug order on ethylphenidate was effective in reducing infections among people who inject drugs during an outbreak situation in Lothian, Scotland.

Expansion of HCV treatment access to people who have injected drugs through effective translation of research into public health policy: Scotland's experience.

Seven years have elapsed since the Scottish Government launched its Hepatitis C Action Plan - a Plan to improve services to prevent transmission of infection, particularly among people who inject drugs (PWID), identify those infected and ensure those infected receive optimal treatment. The Plan was underpinned by industrial scale funding (around £100 million, in addition to the general NHS funding, will have been invested by 2015), and a web of accountable national and local multi-disciplinary multi-agency networks responsible for the planning, development and delivery of services. Initiatives ranged from the introduction of testing in specialist drug services through finger-prick blood sampling by non-clinical staff, to the setting of government targets to ensure rapid scale-up of antiviral therapy. The Plan was informed by comprehensive national monitoring systems, indicating the extent of the problem not just in terms of numbers infected, diagnosed and treated but also the more penetrative data on the number advancing to end-stage liver disease and death, and also through compelling modelling work demonstrating the potential beneficial impact of scaling-up therapy and the mounting cost of not acting. Achievements include around 50% increase in the proportion of the infected population diagnosed (38% to 55%); a sustained near two-and-a-half fold increase in the annual number of people initiated onto therapy (470 to 1050) with more pronounced increases among PWID (300 to 840) and prisoners (20 to 140); and reversing of an upward trend in the overall number of people living with chronic infection. The Action Plan has demonstrated that a Government-backed, coordinated and invested approach can transform services and rapidly improve the lives of thousands. Cited as "an impressive example of a national strategy" by the Global Commission on Drug Policy, the Scottish Plan has also provided fundamental insights of international relevance into the management of HCV among PWID.

Assessing the cost-effectiveness of treating chronic hepatitis C virus in people who inject drugs in Australia.

BACKGROUND AND AIM: To assess the cost-effectiveness of hepatitis C virus treatment with pegylated interferon alfa-2a and ribavirin in current and former people who inject drugs (PWID). METHODS: A decision analytic model simulated the lifetime costs and outcomes of four treatment options: early treatment with mild fibrosis, standard treatment with moderate fibrosis, late treatment with compensated cirrhosis, and no treatment. Treatment modalities were simulated across current, former, and never-injector cohorts of 1000 hypothetical patients with chronic hepatitis C virus. The main outcome measures were incremental costs ($AUD) per quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICERs) were calculated for each cohort. RESULTS: Treatment of current PWID during mild fibrosis resulted in a discounted average gain of 1.60 QALYs (95% confidence interval 0.93-2.26) for an added cost of $12,723 ($11,153-$14,396) compared with no treatment, yielding an ICER of $7941 per QALY gained ($6347-$12,017). Former PWID gained 1.80 QALYs (1.29-2.33) for $10,441 ($8843-$12,074) for early treatment compared with no treatment, resulting in an ICER of $5808 per QALY gained ($5189-$6849). Never-injectors gained 2.33 QALYs (1.87-2.80) for $9290 ($7642-$10,912) compared with no treatment-an ICER of $3985 per QALY gained ($3896-$4080). Early treatment was more cost-effective than late treatment in all cohorts. CONCLUSIONS: Despite comorbidities, increased mortality, and reduced adherence, treatment of both current and former PWID is cost-effective. Our estimates fall below the unofficial Australian cost-effectiveness threshold of $AUD 50,000 per QALY for public subsidies. Scaling up treatment for PWID can be justified on purely economic grounds.