Outbreak of Beriberi among African Union Troops in Mogadishu, Somalia

Abstract

Context and ObjectivesIn July 2009, WHO and partners were notified of a large outbreak of unknown illness, including deaths, among African Union (AU) soldiers in Mogadishu. Illnesses were characterized by peripheral edema, dyspnea, palpitations, and fever. Our objectives were to determine the cause of the outbreak, and to design and recommend control strategies.Design, Setting, and ParticipantsThe illness was defined as acute onset of lower limb edema, with dyspnea, chest pain, palpitations, nausea, vomiting, abdominal pain, or headache. Investigations in Nairobi and Mogadishu included clinical, epidemiologic, environmental, and laboratory studies. A case-control study was performed to identify risk factors for illness.ResultsFrom April 26, 2009 to May 1, 2010, 241 AU soldiers had lower limb edema and at least one additional symptom; four patients died. At least 52 soldiers were airlifted to hospitals in Kenya and Uganda. Four of 31 hospitalized patients in Kenya had right-sided heart failure with pulmonary hypertension. Initial laboratory investigations did not reveal hematologic, metabolic, infectious or toxicological abnormalities. Illness was associated with exclusive consumption of food provided to troops (not eating locally acquired foods) and a high level of insecurity (e.g., being exposed to enemy fire on a daily basis). Because the syndrome was clinically compatible with wet beriberi, thiamine was administered to ill soldiers, resulting in rapid and dramatic resolution. Blood samples taken from 16 cases prior to treatment showed increased levels of erythrocyte transketolase activation coefficient, consistent with thiamine deficiency. With mass thiamine supplementation for healthy troops, the number of subsequent beriberi cases decreased with no further deaths reported.ConclusionsAn outbreak of wet beriberi caused by thiamine deficiency due to restricted diet occurred among soldiers in a modern, well-equipped army. Vigilance to ensure adequate micronutrient intake must be a priority in populations completely dependent upon nutritional support from external sources.

Vitamin B1Deficiency Does not Affect the Liver Concentrations of the Other Seven Kinds of B-Group Vitamins in Rats

“…This implies that vitamin B 1 deficiency affects the contents of other B-group vitamins. The vitamin B 1 deficiency beriberi occurs even in recent years in poor countries that consume rice as their staple food 4–13. Vitamin B 1 deficiency manifests with a severe decrease in appetite, decrease in growth, and peripheral neurologic symptoms of paresthesias.…”

“…All of these reported that thiamin therapy produced complete, rapid clinical recovery in all cases. One paper stated: “the patient was administered intramuscular thiamin and this resulted in rapid and dramatic improvement of his condition within hours, including resolution of edema and cardiac symptoms.”13 These reports imply that the vitamin B 1 deficiency would not affect the other B-group vitamins, including vitamin B 12 4–13. We could not find papers examining the influence of vitamin B 1 -deficiency on the contents of other B-group vitamins.…”

“…Outbreaks of beriberi, a vitamin B 1 deficiency, have been reported even in recent years 4–13. All of these reported that thiamin therapy produced complete, rapid clinical recovery in all cases.…”

A diagnosis and treatment gap for thiamine deficiency disorders in sub‐Saharan Africa?

“…Epidemics of beriberi manifesting with sensory neuropathy and gait ataxia have been described in children and adults within segments of the African population subsisting on diets that provide marginal or submarginal intakes of thiamine in prison populations and in garrisoned troops …”

Nutritional and other types of oedema, albumin, complex carbohydrates and the interstitium – a response to Malcolm Coulthard's hypothesis: Oedema in kwashiorkor is caused by hypo-albuminaemia

“…142 Plasma albumin and globulin levels in wet beriberi are normal. [143][144][145] there is increased cardiac output despite a depression of left ventricular function; plasma renin, angiotensin II and aldosterone levels are lower than in patients with low output heart failure. 146 Although thiamine deficiency occurs much more frequently in malnourished children than in controls, Hailemariam et al could not relate this to the occurrence of oedema in malnutrition.…”