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Date:	November 7, 2018
To:	Medical Care Providers
From:	Julie Vaishampayan, MD, MPH, Health Officer

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Health Alert

Wound Botulism in People Who Inject Black Tar Heroin

Situation: Two Stanislaus County residents have been diagnosed with wound botulism in the past month. Both injected black tar heroin prior to symptom onset and tested positive for Clostridium botulinum toxin, type A.

Symptoms of wound botulism occur within days or weeks of injecting contaminated drug and may be mistaken for drug overdose. Symptoms can include weak or drooping eyelids, blurred or double vision, dry mouth, sore throat, slurred speech, trouble swallowing, difficulty breathing, and a progressive symmetric paralysis that begins at the face and head and travels down the body. If left untreated, symptoms may lead to paralysis of the respiratory muscles, arms, legs and trunk, and can cause death. Prompt diagnosis and treatment are critical to decreasing the severity and duration of illness. Antitoxin administration should be initiated based upon presumptive diagnosis and should not be delayed pending laboratory confirmation.

ACTIONS REQUESTED OF CLINICIANS:

• Think about botulism when evaluating a person with neurologic symptoms, especially if they inject black tar heroin.
• Report suspected botulism immediately by calling the Stanislaus County Public Health Communicable Disease
  Program at (209) 558-5678. After hours, weekends, and holidays, please call (209) 664-6032.
• Test and Treat: Stanislaus County Public Health will facilitate testing and antitoxin acquisition. Call the
  Stanislaus County Public Health at the number listed above to request testing and antitoxin.

Additional Information:
Centers for Disease Control and Prevention:
https://www.cdc.gov/botulism/index.html.
California Department of Public Health:
https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Botulism.aspx.
Public Health Communicable Disease Program: (209) 558-5678.