1. Gleason, Brigette MD, MPH
  2. West, Angela MPH
  3. Avula, Danny MD, MPH
  4. Utah, Okey MBBS, MPH
  5. Vogt, Marshall MPH
  6. Cumpston, Kirk DO, FACEP, FACMT, FAACT
  7. Kelly, Michael MD, FACC
  8. Brasler, Paul MA, MSW, LCSW
  9. Wyatt, Shane BS
  10. Forlano, Laurie DO, MPH


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.