Wound Botulism Associated with Black Tar Heroin Among Injecting Drug Users

Wound Botulism Associated With Black Tar Heroin Among Injecting Drug Users

Douglas J. Passaro, MD, MPH; S. Benson Werner, MD, MPH; Jim McGee, MSPH; William R. Mac Kenzie, MD; Duc J. Vugia, MD, MPH

Context.—Wound botulism (WB) is a potentially lethal, descending, flaccid, pa- tiallylethalparalyticdiseasethatresults ralysis that results when spores of Clostridium botulinum germinate in a wound and from ingestion of preserved food con- elaborate neurotoxin. Since 1988, California has experienced a dramatic increase taining preformed botulinum toxin. in WB associated with injecting “black tar” heroin (BTH), a dark, tarry form of the Wound botulism is a clinically similar drug. syndrome of flaccid, symmetric, descending paralysis that results when Objective.—To identify risk factors for WB among injecting drug users (IDUs). spores of Clostridium botulinum, an ob- Design.—Case-control study based on data from in-person and telephone ligate anaerobe, are inoculated into a interviews. wound or other devitalized tissue.12 Af- Participants.—Case patients (n=26) were IDUs who developed WB from ter gaining access to this relatively an- January 1994 through February 1996. Controls (n=110) were IDUs newly enrolled aerobic environment, the spores germi- in methadone detoxification programs in 4 counties. nate and elaborate the most potent toxin Main Outcome Measures.—Factors associated with the development of WB. known.13 Historically, the implicated Results.—Among the 26 patients, the median age was 41.5 years, 15 (58%) wound has been a crush injury or other 14 were women, 14 (54%) were non-Hispanic white, 11 (42%) were Hispanic, and gross trauma to an extremity. The first none were positive for the human immunodeficiency virus. Nearly all participants reported case of WB associated with injecting drug use occurred in 1982 in New (96% of patients and 97% of controls) injected BTH, and the mean cumulative dose York City.15 of BTH used per month was similar for patients and controls (27 g and 31 g, All forms of botulism are reportable respectively; P=.6). Patients were more likely than controls to inject drugs subcu- diseases in California. Since 1988, the taneously or intramuscularly (92% vs 44%, PϽ.001) and used this route of drug year of California’s first reported WB administration more times per month (mean, 67 vs 24, PϽ.001), with a greater case associated with injecting drug use, cumulative monthly dose of BTH (22.3 g vs 6.3 g, PϽ.001). A dose-response re- the number of WB cases has increased lationship was observed between the monthly cumulative dose of BTH injected dramatically, totaling 49 from 1988 subcutaneously or intramuscularly and the development of WB (␹2 for linear trend, through 1995; 46 of these cases occurred 26.5; PϽ.001). In the final regression model, subcutaneous or intramuscular injec- in IDUs, nearly all of whom injected pri- tion of BTH was the only behavior associated with WB among IDUs (odds ratio, marily heroin. In each case, the same type of heroin was used: “black tar” 13.7; 95% confidence interval, 3.0-63.0). The risk for development of WB was not heroin (BTH), a black, gummy form of affected by cleaning the skin, cleaning injection paraphernalia, or sharing needles. the drug that usually is synthesized in Conclusions.—Injection of BTH intramuscularly or subcutaneously is the makeshift factories adjacent to opium primary risk factor for the development of WB. Physicians in the western United poppy fields in several Mexican states.16 States, where BTH is widely used, should be aware of the potential for WB to occur We performed a case-control study to among IDUs. compare IDUs who developed WB with JAMA. 1998;279:859-863 other heroin users to identify risk factors associated with the disease. From the Division of Communicable Disease Control, AN ESTIMATED 80 000 Americans, in- California Department of Health Services, Berkeley (Drs cluding 18 000 Californians, inject illicit METHODS Passaro, Werner, and Vugia and Mr McGee), and the 1 Division of Infectious Diseases and Geographic Medi- drugs. Compared with the general popu- Case patients (patients) were IDUs cine, Stanford University Medical School, Stanford, lation, injecting drug users (IDUs) are at who developed laboratory-confirmed Calif (Dr Passaro), and the Division of Field Epidemiol- increasedriskfordiseaseanddeath2-6 and WB from January 1, 1994, through ogy, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Ga (Drs Passaro and use a disproportionate amount of medical March 1, 1996. All CDHS case records Mac Kenzie). Dr Passaro is now with the Division of In- resources.7,8 Soft tissue infections are a since 1994 were reviewed, and current fectious Diseases and Geographic Medicine, Stanford particular problem.9-11 telephone numbers and addresses of pa- University Medical Center. Dr Mac Kenzie is now with the Division of Parasitic Diseases, Centers for Disease In 1994, the California Department of tients were obtained, generally through Control and Prevention. Health Services (CDHS) noted an in- hospital records or by contact tracing. Reprints: Douglas J. Passaro, MD, MPH, c/o Division creasing number of cases of wound botu- Telephone or in-person interviews were of Communicable Disease Control, California Depart- ment of Health Services, Berkeley, CA 94704 (e-mail: lism (WB), an unusual soft tissue infec- conducteddirectlywitheachpatient.Pa- [email protected]). tion. Botulism is best known as a poten- tients unable to speak because of ongo-

Downloaded From: https://jamanetwork.com/ on 09/29/2021 Table 1.—Baseline Characteristics of California Wound Botulism Patients, January 1994 Through February gression to all variables associated with 1996, Compared With Control and Reference Groups a significance level of PϽ.2 in the bivar- ␹2 Odds Ratio iate analysis; likelihood ratio statis- (95% Confidence tics were compared to assess the good- Case Group Control Group Reference Group Interval), Case vs ness of fit of increasingly parsimonious Characteristics (n = 26) (n = 110)* (n = 47 809)† Control Groups multivariable models.17 Because con- Median age, y (range) 41.5 (21-69) 40.5 (24-63) 38 (5-92) . . .‡ trols were clustered by county, robust Female sex, No. (%) 15/26 (58) 37/106 (35) 16 207/47 809 (34) 2.5 (1.0-6.7) (Huber/White/sandwich) estimators of Race/ethnicity, No. (%) Black 0/26 (0) 27/109 (25) 6844/46 841 (15) 0.0 (0.0-0.6) variance were used to calculate SEs in Hispanic 11/26 (42) 43/109 (39) 18 694/46 841 (40) 1.1 (0.4-2.9) the multivariable analyses (Stata 5.0, Non-Hispanic white 14/26 (54) 37/109 (34) 20 281/46 841 (43) 2.3 (0.9-5.9) Stata Corp, College Station, Tex). Analy- Other 1/26 (4) 2/109 (2) 1022/46 841 (2) 2.1 (0.0-32.0) ses involving needle-exchange pro- Body mass index, kg/m2 25 24 ...... grams were restricted to patients and controls from Alameda, Los Angeles, San *Controls were selected new enrollees of methadone detoxification programs in 4 California counties, March to Joaquin, and Santa Clara counties. All May 1996. Reference group members were all clients of methadone detoxification or maintenance programs in 17 California counties, 1994-1995. comparisons were 2-tailed. †Sex and race information was not available from all members of the control and reference groups. ‡Ellipses indicate not available. RESULTS ing mechanical ventilation provided purchasing, storing, and using practices A total of 35 cases of laboratory-con- written responses to in-person inter- in the month before developing WB; confirmed WB associated with injection views conducted by nursing staff. Pa- trols were asked identical questions drug use occurred in California during tientswithoutaccesstoatelephonewere aboutdrug-relatedpracticesinthemonth the 26-month study period. Of these 35 interviewed in person by staff of the Lo- before starting detoxification, including patients, all but 2 required lengthy hos- cal Assistance Branch, CDHS, Sacra- frequency and quantity of all drugs in- pitalization; all but 5 required mechani- mento, Calif. jected; frequency and method of cleaning cal ventilation. Of the 34 cases in which Controls were persons newly enrolled needlesandsyringes;frequencyofneedle botulinum toxin typing was performed, in 1 of 4 methadone detoxification pro- sharing; source of water or other solvent 30(88%)werecausedbybotulinumtoxin grams in geographically and ethnically used for dissolving heroin; type of appa- type A and 4 (12%) by type B. The case distinct cities in California (Oakland, Los ratus used for heating the heroin-water participation rate was 74%; 5 (45%) of 11 Angeles, San Jose, and Stockton) during mixture; whether cotton balls or ciga- patients diagnosed in 1994 and 21 March through May 1996. Recruitment rette filters (eg, “cottons”), through (87.5%) of 24 patients diagnosed after strategies for controls varied by clinic. At which the heroin mixture is drawn into January 1, 1995, were interviewed. the Los Angeles clinic, 25 consecutive pa- the syringe, were stored and reused; fre- Seven patients could not be located de- tients were enrolled in the study by the quency and type of skin cleansing before spite repeated attempts, and 2 refused clinic intake supervisor. At the Oakland, injection; which body sites were used for to participate. Control participation Stockton, and San Jose clinics, study in- injection; and injection technique (intra- rates varied by study site between 50% vestigators visited each of these 3 on 3 venous vs intramuscular vs subcutane- and 80% but were not precisely deter- nonconsecutive mornings. Each detoxifi- ous). Participants were also asked about mined because not all potential controls cation program patient who received their recent medical history and how fre- could be enumerated at all sites. methadone was asked to participate in quently they developed soft tissue ab- No blacks and no persons infected the study and was offered a meal voucher scesses. Each participant estimated the with the human immunodeficiency virus to encourage participation. Before inter- quantity of drugs he or she used by stated (HIV) developed WB during the study views, educational flyers about the study drug weight at point of purchase. When period; the HIV status of controls was and about WB associated with injecting this was not possible, quantities were es- not documented. Patients were less drug use (ie, “shooter’s botulism”) were timated by dollar amounts, which were likely than controls and the reference distributed at the clinics; these flyers convertedtoweightsusingthecostsmost grouptobenon-Hispanicblackandmore warned users of the local WB epidemic frequently cited by study participants: likely to be non-Hispanic white and to be among IDUs and explained warning $80 per gram of heroin and $100 per gram female, although these demographic symptomsbutdidnotdiscusshypotheses of cocaine. trends did not reach statistical signifi- about the causes of shooter’s botulism. Bivariateanalyseswereperformedby cance.Baselinecharacteristicswereoth- After each interview, participants were using the Fisher exact test or the Man- erwisesimilarbetweengroups(Table1). given verbal and written information tel-Haenszel ␹2 test (with the Yates cor- Of 34 drug purchasing, storing, and about shooter’s botulism. rection) for discrete variables and the using practices analyzed, the behavior Because our selection of methadone Student t test or the Wilcoxon 2-sample most strongly associated with the devel- clinic study sites was not random and to test for continuous variables. Since 34 opment of WB was injecting BTH sub- examine whether our control group was practices and characteristics were as- cutaneously or intramuscularly (skin- representative of California methadone sessedinthebivariateanalyses,theBon- popping) rather than intravenously clinic attendees, we also compared base- ferroni correction was used to provide a (Table 2). A total of 33 of 35 patients re- line patient characteristics of our con- stringent test of significance. Therefore, ported this route of BTH administration trol group with those of a reference bivariate associations were judged sig- at least occasionally. One of the 2 excep- group. The reference group consisted of nificantonlyifPϽ.002(ie,0.05/34).Dose- tions was an intravenous amphetamine allenrolleesinmethadonedetoxification response relationships were assessed user who insisted that she had never or maintenance programs during 1994 using the ␹2 test for linear trend (Epi skin-popped, never used BTH, and or 1995 from the 17 California counties Info 6.02, Centers for Disease Control never shared paraphernalia with BTH that have reported WB among IDUs. and Prevention, Atlanta, Ga). Multivari- users. The other exception was a patient Patients were questioned about base- able analyses were performed by apply- who reported injecting BTH but only in- line personal characteristics and 34 drug ing backwards-elimination logistic re- travenously.

Downloaded From: https://jamanetwork.com/ on 09/29/2021 Table 2.—Drug-Using Behaviors of California Wound Botulism Patients, January 1994 Through February 1996, Compared With Controls: Bivariate Analysis*

Odds Ratio (95% Confidence Interval), Case Group Control Group Case vs Control Behaviors (n = 26) (n = 110) Groups P Value Injection of BTH, No. (%) 25 (96) 107 (97) 0.7 (0.1-38.3) .6‡ No. of injections per month Mean (SD) 82 (39) 117 (63) . . . .01§ Median (IQR) 90 (60-150) 90 (60-300) . . . Dose of BTH per injection, g Mean (SD) 0.33 (0.21) 0.28 (0.14) . . . .6§ Median (IQR) 0.25 (0.25-0.5) 0.25 (0.25-0.31) . . . Dose of BTH injected per month, g Mean (SD) 27 (20) 31 (21) . . . .6§ Median (IQR) 22.5 (12.3-37.5) 28.1 (15.0-37.5) . . . Skin-pops† BTH, No. (%) 24 (92) 48 (44) 15.5 (3.5-139.5) Ͻ.001࿣ No. of skin-pops per month Figure 1.—Sex- and race-adjusted odds of being a “shooter’s botulism” patient, by cumulative monthly Mean (SD) 67 (51) 24 (45) . . . Ͻ .001§ dose of black tar heroin (BTH) injected subcutane- Median (IQR) 72 (16-112) 0 (0-28) . . . ously (quartiles). Participants were asked to esti- Dose of BTH per skin-pop, g mate the quantity of heroin used (injected subcuta- Mean (SD) 0.34 (0.22) 0.29 (0.14) . . . .5§ neously or intramuscularly) daily or weekly, by Median (IQR) 0.25 (0.25-0.5) 0.25 (0.13-31.3) . . . weight or by dollar amount. Weights were converted BTH dose skin-popped per month, g into monthly cumulative dollar amounts using the conversion ratio of $80 per gram of BTH.The refer- Mean (SD) 22.3 (20.5) 6.30 (12.5) . . . Ͻ .001§ ence category included those who did not inject Median (IQR) 20.0 (6.5-35.0) 0 (0.8-8) . . . BTH subcutaneously or intramuscularly. Bars rep- No. of persons sharing paraphernalia resent point estimates; error bars, upper 95% con- with user in most recent month fidence intervals. Mean (SD) 0.4 (. . .) 0.6 (. . .) . . . .04§ Median (IQR) 0 (0-0) 0 (0-1) . . . 6-fold higher among “occasional” subcu- Always or usually cleans paraphernalia 13 (50) 43 (39) 1.6 (0.6-4.0) .4࿣ taneousorintramuscularinjectionusers between injections, No. (%) (whose dosage was in the lowest quar- Always or usually cleans skin before 4 (16) 23 (21) 0.7 (0.2-2.3) .7࿣ injections, No. (%) tile, $20-$480 of BTH per month) and 25- No. of abscesses requiring medical fold higher among “heavy” users (whose attention or antibiotics in previous year dosage of drug injected subcutaneously Mean (SD) 3.0 (5.4) 0.6 (1.6) . . . Ͻ.001§ or intramuscularly was in the highest Median (IQR) 1 (0-3.5) 0 (0-0) . . . quartile,$2000-$6300ofBTHpermonth) No. of alcoholic drinks per month (Figure 1). Mean (SD) 7.3 (19.8) 14.4 (24.3) . . . .03§ Median (IQR) 0 (0-2) 2 (0-21) . . . COMMENT *Controls were selected new enrollees of methadone detoxification programs in 4 California counties, March to May From 1951 through 1995, 68 cases of 1996. IQR indicates interquartile range; BTH, black tar heroin; and ellipses, not applicable. WB were reported to CDHS. An aver- †Skin-popping is the practice of injecting drugs subcutaneously or intramuscularly.Askin-pop is a single subcutaneous or intramuscular injection. age of 0.49 WB cases per year were re- ‡P value obtained by Fisher exact test. ported from 1951 through 1987; 2.25 §P value obtained by the Wilcoxon 2-sample test. ࿣P value obtained by ␹2 test with Yates correction. cases per year were reported in 1988 through 1991, 3 cases in 1992, 4 in 1993, The total quantity of BTH used injections did not protect against devel- 11 in 1994, and 23 in 1995.18 From 1988 monthly by patients and controls was oping WB. Using needle-exchange pro- through 1995, only 2 WB cases among similar,buttheamountthatwasinjected grams did not protect against WB, and IDUs were reported from outside Cali- subcutaneously or intramuscularly was sharing injection paraphernalia was not fornia, and they occurred in Arizona greater among patients than among con- associated with the disease. (Foodborne and Diarrheal Disease trols (mean, 22.3 vs 6.3 grams; PϽ.001). In the final (parsimonious) multivari- Branch,CentersforDiseaseControland A dose-response relationship was ob- able model, injecting BTH subcutane- Prevention, unpublished data, 1996). served between the monthly dosage of ously or intramuscularly (odds ratio This study confirms that the ongoing BTH injected subcutaneously or intra- [OR], 13.7; 95% confidence interval [CI], epidemic of WB in California is strongly muscularly by quartile and the risk of 3.0-63.0; P=.001), sex, and race were the associated with subcutaneous or intra- developingWB(␹2 forlineartrend=26.5; only factors associated with WB. His- muscularinjection(skin-popping)ofBTH PϽ.001). This dose-response relation- panic and non-Hispanic whites had an and provides evidence to suggest that C ship remained when analysis was lim- increased risk of WB (OR, undefined; botulinum contamination of BTH is not ited to persons who reported injecting PϽ.001)andwomenhadanonsignificant theresultofspecificdrugstorageorother BTHsubcutaneouslyorintramuscularly increased risk of WB (OR, 2.2; 95% CI, using behaviors among IDUs. Although (␹2 for linear trend=4.1; P=.04). 0.8-5.9; P=.13). To better quantify the intravenous injection of heroin provides Patients reported having more ab- relationship between BTH dose and risk astrongerinitial“high,”“skinpopping”is scesses that received medical treatment for illness, race- and sex-adjusted ORs favored by users reluctant to inject intra- in the previous year than controls (Table were calculated for quartiles of cumula- venously, who desire to avoid telltale 2). Although cleaning the skin before in- tive BTH dose injected subcutaneously “track marks,” or for whom venous ac- jection may have protected against de- or intramuscularly per month. When cess is difficult because of obesity or the veloping soft tissue abscesses (P=.07, compared with IDUs who denied inject- scarring of veins from repeated use. datanotshown),cleaningtheskinbefore ing BTH subcutaneously or intramuscu- Black tar heroin was the only drug that injection or cleaning syringes between larly, the odds of developing WB were patientswithWBreportedskin-popping.

Downloaded From: https://jamanetwork.com/ on 09/29/2021 is unlikely to result in a contaminated finalproduct.Second,duringdetailedin- terviews, all 26 patients denied adding Cases per Million Inhabitants othersubstancesorsolventsorusingun- (1990 US Census Figures) usual water sources when preparing 0 drugs for injection (2 controls reported <2.5 occasionally using beer or wine as a solvent). Therefore, inadvertent contami- 2.5-4.99 nation of heroin by individual users ≥5.0 seemsunlikelytobethesourceofCbotu- linum spores. Third, frequency of skin Yolo cleansing before injection and the type of cleanser used were not associated 3 Sacramento with WB, and the quantity of BTH used 1 San Joaquin was a more important factor than the Lake 2 4 frequency of use. Therefore, skin con- Stanislaus tamination with C botulinum appears unlikely to be a major source of this epi- 2 Sonoma demic. Fourth, the frequency of using 2 San Francisco 2 3 new paraphernalia, the frequency and 2 method of cleaning old paraphernalia, Alameda 2 and the sharing of paraphernalia were Fresno not associated with WB. Therefore, Santa Clara spread of WB via fomites or blood is unlikely to be a factor in this epidemic. For 1 San these reasons, we suspect that BTH is Bernardino most likely being contaminated when di- Monterey luted (eg, possibly with soil) after manu- facture or during distribution. Fundamental questions about this 3 outbreak remain unanswered and prob- 1 ablyreflectincompleteunderstandingof 3 heroin distribution. For example, the 5 reason that the location of cases (Figure Santa Barbara 2) was spread throughout California yet Ventura 3 essentially spared the rest of the west- 7 Riverside Los Angeles ern United States (where BTH is also Orange distributed) is unexplained, although this pattern is consistent with contamination of BTH during in-state distribution. The lack of cases of WB occurring among black IDUs is also unclear. Drug Figure 2.—Cases of wound botulism among injecting drug users in California, by county, 1988 through 1995. enforcement officials hypothesize that Boldface numbers within each county represent the number of laboratory-conﬁrmed cases of wound botulism distrust between black IDUs and sup- associated with injecting drug use reported by county from 1988 through 1995.19 Unshaded areas indicate counties that reported no cases of wound botulism; green shading, counties that reported fewer than 2.5 cases pliers of BTH manufactured by smaller, per million inhabitants from 1988 through 1995; yellow shading, counties that reported 2.50 to 4.99 cases per lessexperiencedproducersanddistribu- million inhabitants; and red shading, counties that reported 5 cases or more per million inhabitants. tors (which might be more highly contaminated) has minimized the use of this Black tar heroin was introduced to US (inert materials, such as dextrose, that type of BTH among black IDUs. drugusersinthe1970sandslowlygained are used to “cut” heroin, providing bulk Reported cases of WB may represent market share from traditional white and weight and increasing the distribu- only a small fraction of this epidemic. heroin because Central and South tors’ profit margin). The tarry color and Nearly all patients diagnosed as having Americansupplierswereabletodevelop consistency of BTH has led to the use of botulism in California are described, dominant distribution networks and be- unusual diluents, including ground pa- because botulinum antitoxin is available cause initially BTH was cheaper and per fiber soaked in black shoe polish and, to California physicians only through more potent (up to 50% by weight diace- according to anecdotal reports, dirt. CDHS. However, botulism is a rapidly tylmorphine). Since the late 1980s, BTH Our study was not designed to deter- progressivediseaseandpersonswithlim- has become the predominant form of mine at which step in heroin production ited access to care or who delay seeking heroin in the United States west of the anddistributioncontaminationwasmost health care may be dying outside the hos- Mississippi River. In 1993, 20 of 21 likely to occur. However, there are sev- pital. In these circumstances, the diagno- samples of California heroin purchased eral reasons to suspect that contamina- sis of WB could be missed. For example, by undercover agents of the US Drug tion occurs during “cutting.” First, the if postmortem examination revealed de- Enforcement Agency were BTH.19 At last step in the conversion of opium to tectable serum opiate levels, an IDU present,heroinishighlyimpureandcon- BTH involves boiling the product with a might be presumed to have died from an tains contaminants (by-products of the strong acid at 150°C for several hours, overdose. In addition, there have been manufacturing process), adulterants which should destroy even heat-resis- several instances in which diagnosis of (chemicals such as methamphetamine, tant C botulinum spores. Therefore, WB has been delayed despite consulta- strychnine, or xylocaine), and diluents contamination before or during this step tion with neurologists and infectious dis-

Downloaded From: https://jamanetwork.com/ on 09/29/2021 ease specialists; a subset of persons with the internal surface of a syringe used by methadone clinics participating in this WB may have been diagnosed as having a patient with WB, and we have also cul- study. another neuromuscular disorder.19 tured related Clostridia species from Subcutaneous or intramuscular injec- Unlike the more widely publicized in- BTH samples belonging to other pa- tion of BTH is the primary risk factor for fectious complications of drug injection tients with WB.19 shooter’s botulism. In addition to coun- eg, HIV infection and viral hepatitis B, We do not know the source of C botu- seling IDUs to stop using BTH or, at WB is not contagious. In our study, risk linumsporescontaminatingBTH.How- least, to minimize the amount of BTH of disease was not associated with mark- ever, our findings suggest that BTH is that is injected, additional efforts are ers of exposure to other IDUs (eg, fre- contaminated before sale to IDUs and needed to increase awareness of WB quency of sharing needles). Although 3 that simple measures, such as cleaning among IDUs and health care workers clusters of WB involving pairs of “shoot- theskinbeforeinjectionandcleaningsy- who serve them and to increase access of ing partners” (persons that use drugs to- ringes, are unlikely to prevent WB. heroin users to methadone detoxifica- gether) have been reported, in all 3 epi- The CDHS has taken several steps to tion and maintenance programs. Physi- sodes the partners had used the same make drug users, public health officials, cians in the western United States heroin (S.B.W., unpublished data, 1996). and physicians aware of this growing should be alerted to the potential for WB TheCDHShasbeenunabletoprocure problem. In October 1995, informational occuring among IDUs. BTH samples large enough to ad- packets containing both technical and equately test for C botulinum. Further- lay fact sheets were sent to every public The authors acknowledge the work of the Local Assistance Branch, California Department of more, the samples obtained have not health jurisdiction in California for dis- Health Services, Berkeley; Sally Jew, California been closely linked to BTH samples tribution to emergency departments, Department of Alcohol and Drug Programs, Sacra- thought to have caused illness. Accord- needle-exchange programs, and metha- mento; Jeffrey Klausner, MD, MPH; and the assis- ingly, our suspicion that BTH contains done clinics. A report of the outbreak tance of staff at the East 14th Street Clinic, Oak- 16 land, the San Joaquin County Medical Center Clinic, botulism spores remains unproven. How- has been published. Education of IDUs Stockton, the Los Angeles Department of Health ever, we have cultured C botulinum from and clinic staff was also provided to the Services, and the South Valley Clinic, San Jose.

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