Cold indoor temperatures and their association with health and well-being: a systematic literature review.

OBJECTIVE: The study aimed to identify, appraise and update evidence on the association between cold temperatures (i.e. <18°C) within homes (i.e. dwellings) and health and well-being outcomes. STUDY DESIGN: This study was a systematic review. METHODS: Seven databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, CINAHL, APA PsycInfo, Applied Social Sciences Index and Abstracts, Coronavirus Research Database) were searched for studies published between 2014 and 2022, which explored the association between cold indoor temperatures and health and well-being outcomes. Studies were limited to those conducted in temperate and colder climates due to the increased risk of morbidity and mortality during winter in those climatic zones. Studies were independently quality assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. RESULTS: Of 1209 studies, 20 were included for review. Study outcomes included cardiovascular (blood pressure, electrocardiogram abnormalities, blood platelet count), respiratory (chronic obstructive pulmonary disease symptoms, respiratory viral infection), sleep, physical performance and general health. Seventeen studies found exposure to cold indoor temperatures was associated with negative effects on health outcomes studied. Older individuals and those with chronic health problems were found to be more vulnerable to negative health outcomes. CONCLUSION: Evidence suggests that indoor temperatures <18°C are associated with negative health effects. However, the evidence is insufficient to allow clear conclusions regarding outcomes from specific temperature thresholds for different population groups. Significant gaps in the current evidence base are identified, including research on the impacts of cold indoor temperatures on mental health and well-being, studies involving young children, and the long-term health effects of cold indoor temperatures.

Adverse childhood experiences during childhood and academic attainment at age 7 and 11 years: an electronic birth cohort study.

OBJECTIVES: Adverse childhood experiences (ACEs) have a negative impact on childhood health, but their impact on education outcomes is less well known. We investigated whether or not ACEs were associated with reduced educational attainment at age 7 and 11 years. STUDY DESIGN: The study design used in the study is a population-based electronic cohort study. METHODS: We analysed data from a total population electronic child cohort in Wales, UK. ACEs (exposures) were living with an adult household member with any of (i) serious mental illness, (ii) common mental disorder (CMD), (iii) an alcohol problem; (iv) child victimisation, (v) death of a household member and (vi) low family income. We used multilevel logistic regression to model exposure to these ACEs and not attaining the expected level at statutory education assessments, Key Stage (KS) 1 and KS2 separately, adjusted for known confounders including perinatal, socio-economic and school factors. RESULTS: There were 107,479 and 43,648 children included in the analysis, with follow-up to 6-7 years (KS1) and 10-11 years (KS2), respectively. An increased risk of not attaining the expected level at KS1 was associated with living with adult household members with CMD (adjusted odds ratio [aOR]: 1.13 [95% confidence interval [CI]: 1.09-1.17]) or an alcohol problem (adjusted odds ratio [aOR]: 1.16 [95% confidence interval [CI]: 1.10-1.22]), childhood victimisation (adjusted odds ratio [aOR]: 1.58 [95% confidence interval [CI]: 1.37-1.82]), death of a household member (adjusted odds ratio [aOR]: 1.14 [95% confidence interval [CI]: 1.04-1.25]) and low family income (adjusted odds ratio [aOR]: 1.92 [95% confidence interval [CI]: 1.84-2.01]). Similar results were observed for KS2. Children with multiple adversities had substantially increased odds of not attaining the expected level at each educational assessment. CONCLUSION: The educational potential of many children may not be achieved due to exposure to adversity in childhood. Affected children who come in to contact with services should have relevant information shared between health and care services, and schools to initiate and facilitate a coordinated approach towards providing additional support and help for them to fulfil their educational potential, and subsequent economic and social participation.

Health and mass unemployment events-developing a framework for preparedness and response.

BACKGROUND: Mass unemployment events are not uncommon yet the impact on health is not well recognised. There is a need for a preparedness and response framework, as exists for other events that threaten population health. METHODS: Framework informed by a narrative review of the impact of mass unemployment on health (studies published in English from 1990 to 2016), and qualitative data from 23 semi-structured interviews with individuals connected to historical national and international events, addressing gaps in published literature on lessons learnt from past responses. RESULTS: Economic and employment shock triggered by mass unemployment events have a detrimental impact on workers, families and communities. We present a public health informed response framework which includes (i) identify areas at risk, (ii) develop an early warning system, (iii) mobilise multi-sector action including health and community, (iv) provision of support across employment, finance and health (v) proportionate to need, (vi) extend support to family members and (vii) communities and (viii) evaluate and learn. CONCLUSION: Mass unemployment events have an adverse impact on the health, financial and social circumstances of workers, families, and communities. This is the first framework for action to mitigate and address the detrimental impact of mass unemployment events on population health.

Measuring the relationships between adverse childhood experiences and educational and employment success in England and Wales: findings from a retrospective study.

OBJECTIVES: Educational and employment outcomes are critical elements in determining the life course of individuals, yet through health and other mechanisms, those who suffer adverse childhood experiences (ACEs) may experience barriers to achieve in these domains. This study examines the association between ACEs and poor educational outcomes, before considering the impact of ACEs and education on employment in adulthood. STUDY DESIGN: Retrospective cross-sectional surveys were conducted in England and Wales using a random stratified sampling methodology. METHODS: During face-to-face household interviews (n = 2881), data were collected on demographic factors, ACEs, self-rated childhood affluence, the highest qualification level attained and the current employment status. RESULTS: While respondents with ≥4 ACEs were significantly more likely to have no formal qualifications (adjusted odds ratio [AOR] = 2.18; P < 0.001), among those who did achieve secondary level qualifications, the presence of ACEs did not further impact subsequent likelihood of going on to attain college or higher qualifications. However, results suggest a persisting independent impact of high (≥4) ACEs, which were found to be significantly associated with both current unemployment (AOR = 2.52, P < 0.001) and long-term sickness and disability (AOR = 3.94, P < 0.001). Modelled levels of not being in employment ranged from as little as 3% among those with 0 or 1 ACE and higher qualifications to 62% among those with no qualifications and ≥4 ACEs (adjusted for age, gender and childhood affluence effects). CONCLUSIONS: Compulsory education may play a pivotal role in mitigating the effects of adversity, supporting the case for approaches within schools that build resilience and tackle educational inequalities. However, adults with ACEs should not be overlooked and efforts should be considered to support them in achieving meaningful employment.

Measuring mortality and the burden of adult disease associated with adverse childhood experiences in England: a national survey.

BACKGROUND: ACE (adverse childhood experience) studies typically examine the links between childhood stressors and adult health harming behaviours. Using an enhanced ACE survey methodology, we examine impacts of ACEs on non-communicable diseases and incorporate a proxy measure of premature mortality in England. METHODS: A nationally representative survey was undertaken (n = 3885, aged 18-69, April-July 2013). Socio-demographically controlled proportional hazards analyses examined the associations between the number of ACE categories (<18 years; e.g. child abuse and family dysfunction such as domestic violence) and cancer, diabetes, stroke, respiratory, liver/digestive and cardiovascular disease. Sibling (n = 6983) mortality was similarly analysed as a measure of premature mortality. RESULTS: Of the total, 46.4% of respondents reported ≥1 and 8.3% ≥4 ACEs. Disease development was strongly associated with increased ACEs (e.g. hazard ratios, HR, 0 versus ≥4 ACEs; cancer, 2.38 (1.48-3.83); diabetes, 2.99 (1.90-4.72); stroke, 5.79 (2.43-13.80, all P < 0.001). Individuals with ≥4 ACEs (versus no ACEs) had a 2.76 times higher rate of developing any disease before age 70 years. Adjusted HR for mortality was strongly linked to ACEs (≥4 versus 0 ACEs; HR, 1.97 (1.39-2.79), P < 0.001). CONCLUSIONS: Radically different life-course trajectories are associated with exposure to increased ACEs. Interventions to prevent ACEs are available but rarely implemented at scale. Treating the resulting health costs across the life course is unsustainable.

Views and experiences of hepatitis C testing and diagnosis among people who inject drugs: systematic review of qualitative research.

BACKGROUND: Many developed countries are facing a major challenge to improve identification of individuals acutely and chronically infected with hepatitis C virus (HCV) infection. We explored the views and experiences of people who inject drugs (PWID) in relation to HCV testing, and diagnosis through a review and synthesis of qualitative research. METHODS: Based on the thematic synthesis of qualitative research. Searches were conducted in 14 databases and supplemented by reference checking, hand searching of selected journals, and searches of relevant websites. Studies of any qualitative design that examined the views and experiences of, and attitudes towards, HCV testing and diagnosis among PWID or practitioners involved in their care were included. Key themes and sub-themes were systematically coded according to the meaning and content of the findings of each study which proceeded to the preparation of a narrative account of the synthesis. RESULTS: 28 qualitative studies were identified. We identified a number of overarching descriptive themes in the literature, finding overall that PWID hold complex and differing views and experiences of testing and diagnosis. Three major themes emerged: missed opportunities for the provision of information and knowledge; shifting priorities between HCV testing and other needs; and testing as unexpected and routine. Evidence of missed opportunities for the provision of knowledge and information about HCV were clear, contributing to delays in seeking testing and providing a context to poor experiences of diagnosis. Influenced by the nature of their personal circumstances, perceptions of the risk associated with HCV and the prioritisation of other needs acted both to encourage and discourage the uptake of HCV testing. Undergoing HCV testing as part of routine health assessment, and an unawareness of being testing was common. An unexpected positive diagnosis exacerbated anxiety and confusion. CONCLUSION: This review has identified that there are modifiable factors that affect the uptake of HCV testing and experiences of HCV diagnosis among PWID. Intervention development should focus on addressing these factors. There is a need for further research that engages PWID from a diverse range of populations to identify interventions, strategies and approaches that they consider valuable.

Nightlife, verbal and physical violence among young European holidaymakers: what are the triggers?

OBJECTIVES: There is an established relationship between nightlife, substance use and violence. This study investigated this relationship when people are on holiday, and explored the differences in experiences between physical and verbal violence. STUDY DESIGN: A survey of young tourists at seven airport departure areas in Southern European resorts. METHODS: Questionnaires from 6502 British and German tourists were analysed exploring demographics, violence (verbal and physical), substance use, and reasons for resort and venue selection. RESULTS: Over two-thirds of respondents reported being drunk on their holiday, 12.4% had been involved in arguments and 2.9% had been involved in fights. Logistic regression highlighted more violence amongst visitors to Mallorca [arguments: adjusted odds ratio (AOR) 2.7; fights: AOR 2.0] compared with those visiting Portugal, males (arguments: AOR 1.3; fights: AOR 1.7), those who had used illicit drugs (arguments: AOR 1.5; fights: AOR 2.9), those who had been in fights at home in the last 12 months (arguments: AOR 2.2; fights AOR 2.9), and those who had frequently been drunk abroad (arguments: AOR 2.4; fights: AOR 2.5). Those aged 16-19 years, visiting Italy or Crete, who were drunk for fewer than half of the days of their stay, and who chose bars because they were frequented by drunk people were more likely to report having an argument. Fights were associated with cannabis use and were negatively associated with choosing bars with a friendly atmosphere. Economic status or frequency of visiting bars had no relationship with arguments or fights. CONCLUSIONS: Understanding and addressing the variables involved in violence when holidaying abroad is critical in targeting appropriate health promotion and harm reduction measures.

Access to HIV community services by vulnerable populations: evidence from an enhanced HIV/AIDS surveillance system.

HIV disproportionately affects vulnerable populations such as black and minority ethnic groups, men who have sex with men (MSM) and migrants, in many countries including those in the UK. Community organisations in the UK are charitable non-governmental organisations with a proportion of the workforce who volunteer, and provide invaluable additional support for people living with HIV (PLWHIV). Information on their contribution to HIV care in vulnerable groups is relatively sparse. Data generated from an enhanced HIV surveillance system in North West England, UK, was utilised for this study. We aimed to determine the characteristics of individuals who chose to access community services in addition to clinical services (1375 out of 4195 records of PLWHIV in clinical services). Demographic information, risk factors including residency status, uniquely gathered in this region, and deprivation scores were examined. Multivariate logistic regression modelling was conducted to predict the relative effect of patient characteristics on attendance at community services. Attendance at community services was highest in those living in the most, compared with least, deprived areas (p<0.001), and was most evident in MSM and heterosexuals. Compared to white UK nationals attendance was significantly higher in non-UK nationals of uncertain residency status (Adjusted odds ratio [AOR] = 21.91, 95% confidence interval [CI] 10.48-45.83; p<0.001), refugees (AOR = 5.75, 95% CI 3.3-10.03; p<0.001), migrant workers (AOR = 5.48, 95% CI 2.22-13.51; p<0.001) and temporary visitors (AOR = 3.44, 95% CI 1.68-7.05; p<0.001). Community services, initially established predominantly to support MSM, have responded to the changing demography of HIV and reach the most vulnerable members of society. Consequent to their support of migrant populations, community services are vital for the management of HIV in black and minority groups. Paradoxically, this coincides with increasing funding pressures on these services.

The sexual behaviour of British backpackers in Australia.

OBJECTIVES: To explore sexual behaviour and risk-taking among British backpackers in Australia and to investigate the influence of substance use and social settings on sexual behaviour abroad. METHODS: A cross-sectional design was used. The questionnaire gathered information on sexual and substance use behaviour in the 12 months prior to leaving the UK and during backpackers' stays in Australia. A total of 1008 backpackers, recruited in hostels in Sydney and Cairns, were included in the study. RESULTS: In total, 73.2% had sex during their stay in Australia, including 68.9% of those who arrived without a partner. Across all backpackers, mean number of sexual partners increased from 0.3 per 4-week period in the UK in the 12 months prior to the trip to 1.0 per 4-week period spent in Australia. Over a third (39.7%) had multiple partners in Australia, increasing to 45.7% in those arriving single. Of those arriving single and having sex, 40.9% reported inconsistent condom use and 24.0% had unprotected sex with multiple partners. Number of sexual partners in the UK, length of stay in Australia at time of interview, planned length of stay, frequent visits to bars/clubs, high frequency of alcohol intake and use of illicit substances in Australia were indicators for risky sexual behaviour. CONCLUSIONS: Backpackers are at high risk of sexually transmitted infections and other negative sexual health outcomes. Multi-agency sexual health promotion strategies that address the relationship between sex, drugs and alcohol should be targeted at backpackers prior to, and during, their travels.

Traffic risk behaviors at nightlife: drinking, taking drugs, driving, and use of public transport by young people.

UNLABELLED: Road traffic crashes associated with nightlife alcohol and recreational drug use are a major health problem for young people. OBJECTIVES: This study explores use of different forms of transport to and from nightlife environments and the relationships between traffic risk behaviors, drunkenness, and drug consumption. METHODS: 1363 regular nightlife users from nine European cities in 2006 completed a self-administered and anonymous questionnaire. Sampling utilized a variation of respondent-driven sampling. RESULTS: Private car was the most frequent form of transport used when going out, especially by males and older individuals. Drug use was related to crashes and traffic risk behaviors, including having a lift from someone drunk or driving drunk or driving having taken drugs; drunkenness was related to risk behaviors but not to crashes (possibly because drunk people tend to use the private car less). Males showed higher levels of drunkenness and drug consumption, traffic risk behaviors, and traffic crashes. Age is not related to the traffic risk behaviors, but older individuals had less crashes. CONCLUSIONS: There are serious health problems related to transport and recreational nightlife activities. It is necessary to improve later public transport services, complemented by actions that deter the use of private cars. The relationships of both drunkenness and cannabis/cocaine use with traffic risk behaviors should be addressed and programs implemented to change risk perceptions on the effects of illegal drugs on driving.

Contribution of violence to health inequalities in England: demographics and trends in emergency hospital admissions for assault.

INTRODUCTION: Violence is increasingly recognised as a major public health issue yet health data are underutilised for describing the problem or developing responses. We use English emergency hospital admissions for assault over four years to examine assault demography and contribution to health inequalities. METHODS: Geodemographic cross-sectional analyses utilising records of all individuals in England (n = 120 643) admitted between 1 April 2002 and 31 March 2006. RESULTS: Over 4 years, rates of admission increased by 29.56% across England. Admissions peaked on Saturdays (22.34%) and Sundays (20.38%). Higher rates were associated with deprivation across all ages, including those <15 years, with a sixfold increase in admission rates between the poorest and wealthiest quintiles of residence. Logistic regression analyses indicate males are 5.59 times more likely to be admitted to hospital for assault and such admissions peak in those aged 15-29 years. Modelling based on national assault admissions and limited Accident and Emergency (A&E) data suggest that while more serious assaults requiring hospital admission have increased, assault attendances at A&Es have fallen. DISCUSSION: Hospital admission and A&E data identify a direct contribution made by violence to health inequalities. Levels of violence inhibit other interventions to improve people's health through, for instance, outdoor exercise or delivery of health-related services in affected areas. With disproportionate exposure to violence in poorer areas even in those under 15, early life primary prevention initiatives are required in disadvantaged communities to reduce childhood harm and the development of adult perpetrators and victims of violence.

The ability of two commercially available quick test kits to detect drug-facilitated sexual assault drugs in beverages.

AIMS: Assessment of the sensitivity and specificity of two commercially available 'drug-facilitated sexual assault' drug detector kits, Drink Guard and Drink Detective. DESIGN: Experimental. SETTING: Laboratory. MEASUREMENTS: Gamma hydroxybutyrate (GHB) sodium salt, ketamine hydrochloride, temazepam, flunitrazepam and diazepam were dissolved (Tween added to benzodiazepine solutions) as separate stock solutions and added to 330 ml samples of cola (Pepsi Max), beer (Stella Artois), 'alcopop' (Bacardi Breezer) and placebo (distilled water). The doses used are reported to be common in cases of intoxication. Each kit was tested 10 times for each drink/drug combination. Two blind, independent observers scored each test (presence/absence of drug) in accordance with kit instructions; chi 2 was used to compare the proportion of times raters scored tests correctly and incorrectly. Sensitivity and specificity were calculated overall, for each drink, and sensitivity was calculated for each drug. Inter-observer agreement was evaluated using the kappa statistic. FINDINGS: While both raters were able to score significantly more tests correctly than incorrectly using Drink Detective, and one rater scored similarly using Drink Guard, the overall sensitivity of Drink Detective and Drink Guard was 69.0% (95% CI 64.2-73.5%) and 37.5% (95% CI 30.1-45.5%), respectively. Sensitivity was drink-dependent. Drink Detective was unable to detect our dose of GHB in water, with all tests scored negatively by both raters for this drink/drug combination (n = 20 negative scores). Overall, specificity was 76.6% (95% CI 71.5-81.0%) and 87.9% (95% CI 83.0-91.6%) for Drink Guard and Drink Detective, respectively, but was affected by the beverage. Inter-rater agreement was poor for Drink Guard (kappa = 0.278 +/- 0.069) but excellent for Drink Detective (kappa = 0.894 +/- 0.245). Inter-observer agreement was drug-dependent. CONCLUSIONS: Use of drug detector kits by the public in the night-time environment needs further investigation and may create a false sense of security (false negatives) and undue concern (false positives) among kit users.

Elevated mortality following diagnosis with a treatable disease: tuberculosis.

OBJECTIVE: To determine whether previous diagnosis with tuberculosis (TB) increases the risk of mortality. DESIGN: A retrospective survey of 439 TB patients in the city of Liverpool, population 439500, over an 8-year period. OUTCOMES: Mortality compared with the general population; cause of death as identified from death certificates. RESULTS: A total of 104 (23.7%) TB cases had died within the follow-up period. For 45-54 year olds, the standardised mortality ratio (SMR) was 1101, an 11-fold higher mortality than expected from the Liverpool population. The SMR then declined with age, but remained higher in males than in females. Death certificates showed that 34 (30.8%) died from TB and 26 (21%) from bronchopneumonia. Malignancy was the cause of death in 24 cases (28%), including 16 with lung tumours, all in patients aged under 75 years. This gave a 30-fold greater mortality from lung cancer compared with the general population aged under 75. CONCLUSIONS: TB increases the risk of mortality compared with the general population, with unexpectedly high mortality from lung cancer in cases aged under 75. Older patients die from TB itself or other chest diseases. Common risk factors for the Liverpool population probably contribute to elevated mortality from all chest-related diseases, including TB.

Effects of nightlife activilty on health.

This article aims to increase understanding of nightlife health and the potential for nurses to reduce some of the negative health consequences associated with nightlife activity.

Sexual behaviour of young people in international tourist resorts.

BACKGROUND/OBJECTIVES: Increasingly, young people travel abroad to experience nightlife in international resorts. Although media coverage of such resorts suggests high levels of sexual activity, little empirical data are currently available. We have measured: 3 year trends in sexual behaviour of young people visiting Ibiza, levels of sexual risk taking, and their relation to substance use. Additionally, in 2002 we identified levels of homosexual sex and sexual interactions between UK residents and individuals from other countries. METHODS: Data were collected from visitors to Ibiza between 2000 and 2002 just before they left the island. Information on sexual health was surveyed using a short anonymous questionnaire. RESULTS: Over half of individuals (56.0%) visiting Ibiza had sex with at least one person, with 26.2% of males and 14.5% of females having sex with more than one individual. However, of those arriving without sexual partners (75.5%) just under half (47.5%) have sex in Ibiza and most of these (62.4%) always used condoms. Having any sex abroad was associated with using illicit drugs and having more sexual partners in the 6 months before visiting Ibiza. However, having unprotected sex or sex with more than one person was associated with smoking as well as having higher numbers of sexual partners before their visit. Overall, 8.6% of individuals had sex with a non-UK resident in Ibiza although such individuals were no more likely to have sex without condoms. CONCLUSIONS: Substantial numbers of individuals visiting international nightlife resorts have unprotected sex with people they meet while abroad. This poses an increasing threat to the sexual health of UK residents but as yet little attention has been paid to developing interventions that might reduce sexual risk taking among young people holidaying abroad.

Relationship between the use of hospital services and deprivation score of place of residence among HIV-positive individuals in the north west of England.

We used routine surveillance data to investigate whether deprivation relates to hospital admission in a HIV-positive population. HIV-positive individuals living in the poorest areas were more likely to have spent one or more nights in hospital for HIV-related care (adjusted odds ratio = 1.6, p = 0.009, after controlling for infection route, disease stage and demographic variables). This implies that healthcare networks in poorer areas may incur disproportionately greater costs.

Behind the mask. Journey through an epidemic: some observations of contrasting public health responses to SARS.

SARS has been called the first global epidemic of the 21st century and has been the cause of a massive and varied public health response in many countries of the world. This report describes observations made by two authors on a journey from Manchester in the United Kingdom to Chiang Mai in Thailand during the peak of global transmission. The public response to SARS, particularly characterised by the wearing of face masks, seemed to outstrip official guidance. Though of uncertain protective benefit, the wearing of masks may have contributed to the awareness of the collective and personal responsibility in combating infectious disease. Active and empowered involvement of the general public in implementing and cooperating with public health control measures supported by national and international authorities has clearly helped to bring SARS under control. The public health significance of such potent symbols as the face mask may be considered in strategies to tackle other emerging infections.

An investigation into the microflora of heroin.

In 2000, an unusual increase of morbidity and mortality among illegal injecting drug users in the UK and Ireland was reported and Clostridium novyi was identified as the likely source of the serious infection, although infections due to C. botulinum and Bacillus cereus were also reported. Because heroin was a possibile source of infection, this study investigated the microflora of heroin samples seized in England during 2000 and 2002. Two methods were developed for the examination of the microflora of heroin. The first consisted of suspension of the drug in maximum recovery diluent (MRD) which was inoculated directly into Clostridium Botulinum Isolation Cooked Meat Broth (CBI). The second method rendered the heroin soluble in citric acid, concentrated particulate material (and bacterial cells) by filtration and removed heroin residues by washing with citric acid and phosphate-buffered saline before placing the filter in CBI broth. Duplicate CBI broths from both methods were incubated without heating and after heating at 60 degrees C for 30 min. Subcultures were made after incubation for 7 and 14 days on to eight different solid media. The methods were evaluated with heroin samples spiked with either C. botulinum or C. novyi spore suspensions; recovery of 10 spores in the original sample was demonstrated. Fifty-eight heroin samples were tested by citric acid solubilisation and 34 by the MRD suspension technique. Fifteen different gram-positive species of four genera were recognised. No fungi were isolated. Aerobic endospore-forming bacteria (Bacillus spp. and Paenibacillus macerans) were the predominant microflora isolated and at least one species was isolated from each sample. B. cereus was the most common species and was isolated from 95% of all samples, with B. licheniformis isolated from 40%. Between one and five samples yielded cultures of B. coagulans, B. laterosporus, B. pumilus, B. subtilis and P. macerans. Staphylococcus spp. were isolated from 23 (40%) samples; S. warneri and S. epidermidis were the most common and were cultured from 13 (22%) and 6 (10%) samples respectively. One or two samples yielded cultures of S. aureus, S. capitis and S. haemolyticus. The remainder of the flora detected comprised two samples contaminated with C. perfringens and two samples with either C. sordellii or C. tertium. Multiple bacterial species were isolated from 43 (74%) samples, a single species from the remaining 15. In 13 samples B. cereus alone was isolated, in one B. subtilis alone and in one sample B. pumilus alone. C. botulinum and C. novyi were not isolated from any of the heroin samples. Recommendations for the optimal examination of the microflora of heroin are given.