Skin infections in people who use drugs: Learnings from a mixed-methods survey in Wales, 2023

Author: Amy Plimmer, Christopher Roberts, Michelle Hughes, Dean Acerman, Rick Lines, Juliana Coelho, Yan Ryan, Clare Sawyer

Theme: Epidemiology & Public Health Research Year: 2023

Background: In September 2022, Public Health Wales (PHW) were notified of 8 Group A Streptococcus (GAS) infections in people who use drugs (PWUD), of which one case was invasive. All were typed emm 108.1, clustered within 0-3 single nucleotide polymorphisms. A high proportion of cases were crack cocaine smokers. We describe exposures amongst PWUDs with skin infections, to inform harm reduction interventions.

Methods: A case was defined as any PWUD with evidence of a skin infection compatible with GAS, identified on or after 01/09/2022. 10 cases were recruited, including 5 previously notified GAS cases. All completed a mixed-methods questionnaire, delivered by a substance misuse team member, who transcribed responses. Respondents were described in terms of demographics, infection history, drug use history and practices. Open-ended responses were reviewed for recurring themes.

Results: 70% of questionnaire respondents were female. Half had a confirmed GAS infection, others had no microbiological testing. 70% reported injecting drugs in the 4 weeks before infection and all reported smoking crack cocaine. Infections were on the legs (60%), hands (50%) and face (30%), sites where frequency of injection was proportionally lower (30% injected legs and/or arms). Whilst respondents reported knowledge of harm reduction practices for injecting drugs, 90% reported sharing crack pipes, and only 20% decontaminated pipes before use. Social pressure was associated with sharing pipes in groups.

Conclusions: We report a high prevalence of skin infections amongst crack smokers. Respondents had limited awareness of potential harms associated with sharing pipes, reflecting low awareness levels reported elsewhere. We recommend PHW and substance misuse teams raise awareness of the risks of sharing smoking paraphernalia to minimise health-related harms associated with smoking drugs, alongside current holistic harm reduction practices.

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