title: Collaborative Public Health Investigation of Clenbuterol-Adulterated Heroin Outbreak-Richmond, Virginia, March-April 2015.
abstract: 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.
  
  
  
  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.
  
  
  
  Active surveillance and retrospective case finding.
  
  
  
  Richmond metro area community and hospitals.
  
  
  
  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.
  
  
  
  Outbreak investigation, communication to public health professionals, clinicians, and the community, and liaising with the local law enforcement.
  
  
  
  Outbreak control.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Centers for Disease Control and Prevention, Richmond, Virginia (Dr Gleason); Virginia Department of Health, Richmond, Virginia (Drs Gleason and Forlanoand and Ms West); Richmond City Health District, Richmond, Virginia (Dr Avula and Mr Utah); Chesterfield Health Department, Chesterfield, Virginia (Mr Vogt); Virginia Poison Center, and Section of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia (Dr Cumpston); Richmond Cardiology Consultants, Richmond, Virginia (Dr Kelly); Bon Secours Health System, Richmond, Virginia (Mr Brasler); and Division of Consolidated Laboratory Services, Richmond, Virginia (Mr Wyatt).
authors.forename: Brigette
authors.initials: B
authors.lastname: Gleason
authors.forename: Angela
authors.initials: A
authors.lastname: West
authors.forename: Danny
authors.initials: D
authors.lastname: Avula
authors.forename: Okey
authors.initials: O
authors.lastname: Utah
authors.forename: Marshall
authors.initials: M
authors.lastname: Vogt
authors.forename: Kirk
authors.initials: K
authors.lastname: Cumpston
authors.forename: Michael
authors.initials: M
authors.lastname: Kelly
authors.forename: Paul
authors.initials: P
authors.lastname: Brasler
authors.forename: Shane
authors.initials: S
authors.lastname: Wyatt
authors.forename: Laurie
authors.initials: L
authors.lastname: Forlano
mesh_terms: D002976:Clenbuterol / Q000009:adverse effects*; D004340:Drug Contamination / Q000706:statistics & numerical data; D003932:Heroin / Q000009:adverse effects*; D006801:Humans; D011634:Public Health / Q000379:methods*; D012189:Retrospective Studies; D019966:Substance-Related Disorders / Q000453:epidemiology; D014768:Virginia / Q000453:epidemiology
chemical_list: D003932:Heroin; D002976:Clenbuterol