Collaborative Public Health Investigation of Clenbuterol-Adulterated Heroin Outbreak-Richmond, Virginia, March-April 2015.

CONTEXT: In March 2015, the Virginia Department of Health (VDH) was alerted by the Virginia Poison Center of a 6-patient cluster treated for severe clinical presentations after using heroin. Patients' symptoms were atypical for heroin use, and concern existed that patients were exposed to heroin that had been adulterated with or replaced by another substance.

OBJECTIVE

To understand the extent and characterization of the outbreak and implement response measures to prevent further cases. The purpose of this report is to highlight the collaborative nature of a public health investigation among a diverse group of stakeholders.

DESIGN

Active surveillance and retrospective case finding.

SETTING

Richmond metro area community and hospitals.

PARTICIPANTS

Regional poison centers, the Division of Consolidated Laboratory Services, the Department of Behavioral Health and Developmental Services, community partners, local law enforcement, and multiple VDH divisions.

INTERVENTION: Outbreak investigation, communication to public health professionals, clinicians, and the community, and liaising with the local law enforcement.

MAIN OUTCOME MEASURES: Outbreak control.

RESULTS

Laboratory confirmation of clenbuterol in clinical specimens implicated it as the heroin adulterant. Thirteen patients met clinical and epidemiologic criteria for exposure to clenbuterol-adulterated heroin. All patients were associated with a localized area within Richmond, and patient interviews elucidated heroin supplier information. VDH collaborated with local law enforcement agents who investigated and arrested the supplier, leading to cessation of the outbreak.

CONCLUSION

This outbreak highlights the value of policies and practices that support an integrated outbreak response among public health practitioners, poison center staff, laboratorians, clinicians, law enforcement agents, community groups, and other agencies. Collaboration enabled implementation of effective control measures-including those outside the purview of the health department-and should be standard practice in future outbreaks involving illicit substances.