Outbreak of micronutrient deficiency disease: did we respond appropriately?

By Dianne Stevens, Patricia Araru and Buwa Dragudi, Save the Children (UK)

Dianne Stevens is a nutritionist with a Masters in Public Health and Tropical Medicine. She has been working for SC (UK) for the past two years in the nutrition and food security sector and has most recently been a nutrition advisor in Wajir.

Buwa Dragudi took over from Patricia as Programme Manager. Both were involved in addressing these outbreaks.

Patricia Araru worked as Programme Manager for Health during the start-up phase of the SCF response to this emergency.

In September 2000 there was an outbreak of scurvy and what appeared to be dry beriberi in the west of Wajir District, North Eastern Kenya. This article sets out to describe the outbreak and the response by the international community and the government of Kenya. Lessons learnt from the experience are drawn out so we can better respond in the future to prevent and control micronutrient deficiencies in emergencies.

Background

Since 1990 Wajir has suffered from a succession of disasters with droughts in 1992 and 1996/97, El Nino floods in 1997/98 and ongoing tribal conflicts. With no significant rain since the El Nino rains the area is experiencing yet another drought. The majority of the population of Wajir are nomadic pastoralists of the Somali ethnic group. In February 2000 many pastoralists were forced to migrate long distances with their herds in search of water and pasture. Those who could not travel the long distances, mostly women, children and the elderly, were left behind. Many other pastoralists have been made destitute through loss of livestock as a result of the El Nino floods, drought and conflict. This is particularly so in the west of Wajir where there is a large displaced population from the Bagalla massacre of 1998. Since March 2000 there has been an influx of people into the west displaced from the conflict in the north of the district. Those left behind when herds migrate and the displaced have settled in peri-urban areas to benefit from relief and are dependent on food aid for their survival. All are at risk of food insecurity and malnutrition. A nutrition survey in late September in the west and north of Wajir District found high levels of malnutrition in children with a prevalence of 21.2% global acute malnutrition and 5.8% severe malnutrition¹.

The Outbreak

In early September 2000 there were reports from the west of Wajir that people had been experiencing symptoms of weakness and pain in the lower limbs and joints and in some cases peripheral neuritis and immobility. A rapid assessment by the Ministry of Health (MoH) and Save the Children, UK (SC(UK)) with technical advice from the Centre for Disease Control and Prevention (CDC) identified suspected vitamin deficiencies.

Discussions with the community revealed that the signs and symptoms observed had never been experienced before in this population. Interviews and clinical examination of 23 people affected found that the symptoms developed gradually and the duration of symptoms was from one to four months preceding the visit. All sexes and ages were affected.

Symptoms experienced

Most individuals affected experienced weakness, nonspecific weight loss, peripheral oedema and an inability to stand from a squatting position. These symptoms could be attributed to protein energy malnutrition (PEM), vitamin C or thiamine deficiency. PEM was ruled out as all but one of the adults examined had mid upper arm circumferences greater than 18.5cm, the suggested cut off for moderate malnutrition in adults².

Seventeen people experienced symptoms of scurvy - specifically bleeding gums and swollen leg muscles or knees. Seven people experienced symptoms specific to dry beriberi including stocking and glove sensory changes, loss of reflexes, and in two cases, foot drop. Five experienced symptoms of both scurvy and dry beriberi.

Access to food sources

Those affected had typically lost their animals and hence their livelihoods because of drought, conflict or the El Nino floods. All were living on the periphery of town centres and the majority were displaced. All had been eating an extremely limited diet of Government of Kenya relief maize and black tea from February to June and had no milk or meat (their usual diet) since the herds had migrated away in February. Relief maize provided by the government provided only 9% of energy needs. Donor response to the emergency was slow³ and a World Food Programme (WFP) general food ration (GFR) was not introduced until June. Pulses and oil were only added in July. Even with the GFR the diet remained deficient in energy, protein and micronutrients. The food aid allocation was not based on any assessment of the food security situation of the population.

Until the introduction of pulses to the GFR the typical diet contained no vitamin C and even with the introduction of pulses, the dietary intake of vitamin C was insufficient to prevent scurvy. The August dietary intake of vitamin C was 1 mg whereas 6.5-10mg per day is required to prevent scurvy⁴. Thiamine intake was only 22% of the Recommended Daily Allowance until the introduction of the GFR and did not meet requirements until pulses were introduced in July.

Blanket SFP

In early September, a blanket supplementary feeding programme (SFP) was introduced providing a monthly ration of fortified corn soya blend (CSB) to all children under five and pregnant and lactating women. The inadequate GFR meant that the CSB was consumed by the entire household, and not just the intended beneficiaries, and as such only lasted for two weeks rather than one month. With the CSB the vitamin C content of the diet jumped from 5% to 185% of the recommended intake. The thiamine content of the diet was not significantly increased. All those with symptoms reported an improvement after the first distribution of CSB e.g. those previously bed-ridden were now at least able to walk a little.

The above estimates of nutrient intake assume that the whole general ration is consumed by the recipient and there are minimal losses with food preparation. However in Wajir, food preferences and preparation methods would have further reduced the intake of both vitamin C and thiamine.

Being water soluble, vitamin C is susceptible to destruction by heat. Much of the small amounts provided by the pulses in the general ration would therefore have been lost in cooking. Recipients were also wary of consuming pulses complaining of gastrointestinal problems.

The people of Wajir are unfamiliar with maize as a food and are unsure of how best to prepare it. Thiamine intake from the maize ration would have been reduced for a number of reasons:

• the practice of dehusking or milling the maize (most of the thiamine resides in the outer layers of the grain)
• loss in cooking (both thiamine and vitamin C are water-soluble)
• the widespread practice of drinking large amounts of tea (the tannin in tea is a thiamine antagonist and interferes with the absorption and digestion of thiamine⁵)
• lack of vitamin C in the diet (Vitamin C, when consumed together with thiamine, increases thiamine bio-availability)
• A preference for tea meant that many households exchanged some of their ration for tea or sugar (3 kg of maize was typically exchanged for 250g of sugar).

There is no doubt that most of the symptoms reported and observed were attributable to scurvy. Outbreaks of scurvy have occurred regularly in similar populations in the Horn of Africa⁶.

Reaction to findings

There was some scepticism about an outbreak of thiamine deficiency as in recent history outbreaks of beriberi have been limited largely to rice eating populations⁷. Yet thiamine deficiency has occurred on some occasions in non-rice eating populations and given the extremely limited diet over several months it could not be ruled out in Wajir. The level of uncertainty meant that questions were raised about whether this was a more complex picture of multiple micronutrient deficiencies.

It was time to call in the experts to confirm the diagnosis, develop case definitions, determine the public health significance of the outbreak and advise on appropriate treatment and control of the outbreak.

The Response

While CDC (Centre for Disease Control) were initially considered for the assessment, concerns around an onslaught of technical teams and the need to allow national teams to gain experience led to the Ministry of Health (MoH) combining with the African Medical and Education Research Foundation (AMREF) to field an assessment team at the end of September. CDC offered support to AMREF if needed.

This assessment involved extensive investigation of 59 people who showed symptoms of micronutrient deficiency. Blood and urine samples were taken for micronutrient analysis. Initial impressions of the team based on clinical examination were of a multiple vitamin deficiency syndrome - predominantly vitamin C and B-complex deficiency. However, the symptom profile had changed significantly since the initial rapid assessment by the Ministry of Health and SC(UK) team. The sensory changes associated with dry beriberi were no longer evident and the team attributed this to improvements resulting from the introduction of a general food ration and blanket supplementary feeding.

Because of the complexity of the presentation of symptoms, case definitions for specific deficiencies were not possible. A broader case definition of "ascending or descending pain of the lower limbs (joints and or muscles) and difficulty walking within the last 3-5 months" was used by the team. An assessment of prevalence based on this case definition was not undertaken. This case definition was used to identify people with possible micronutrient deficiency disease in a nutrition survey conducted by MoH and SC(UK) in the north and west of Wajir in October. Out of 3380 people interviewed 27 cases were identified, the majority of which were in the west of Wajir. The low prevalence of 0.8% indicates that the outbreak was small and localised.

Recommendations

Recommendations by the MoH/AMREF team included:

• house to house vitamin supplementation
• an increase in the general food ration
• GFD should include a fortified blended cereal.

These recommendations were not circulated widely and the Ministry of Health was not pro-active in advocating for their implementation. Unfortunately the blood and urine samples were not analysed, probably because of a lack of technical capacity, and no confirmation of diagnosis of specific deficiencies has been made.

Response taken

Save the Children (UK) responded to the initial rapid assessment by:

• recommending an increase in the general food ration
• inclusion of a fortified blended cereal into the ration
• grinding of the maize prior to distribution
• treatment of those affected with vitamin supplements
• Admitting anyone presenting with symptoms into the SC(UK)/MoH targeted SFP. They would then receive a weekly ration of fortified CSB.

SC(UK) were successful in securing a donation of thiamine tablets and negotiated with WFP to grind the maize as well as consulting USAID to ensure CSB was fortified. Logistical problems meant that the thiamine did not arrive until well after the symptoms of beriberi resolved. To this day the general food ration has not been increased, the maize has not been ground and CSB has not been added to the general ration. It is fair to say that problems in the food pipeline and the extent of the food aid requirements across the country rather than a disinterest by WFP was the reason nothing was done. Fortified CSB did arrive in the country and because of the outbreak of vitamin deficiency, Wajir was one of the districts targeted to benefit from the CSB which was channelled into blanket supplementary feeding programmes rather than the general ration. At the time of writing the blended food pipeline was once again in jeopardy. Despite the confusion in the diagnosis, little understanding of the extent and public health significance of the outbreak and both late and inadequate response, those affected improved simply by providing them with a nutritionally balanced diet in the form of a fortified cereal blend. Nothing more needed to be done.

Lessons

Micronutrient deficiencies in emergency situations may well appear as a complex picture of multiple deficiencies. Deficiencies of one nutrient are unlikely to occur in isolation. This complicates assessment and looking for specific signs and symptoms can lead to delays in arriving at a firm diagnosis. A diagnosis and case definition (possibly covering multiple deficiencies) are required to determine the extent and public health significance of the problem. This will help determine and advocate for the most appropriate public health intervention.

Assessment and diagnosis of multiple micronutrient deficiencies is a specialised field and requires the input from experts to arrive at a rapid assessment and response. Most field personnel are unlikely to recognise that a deficiency exists in the early stages of presentation. Diagnosis by biochemical analysis requires the technical know-how and resources found only in specialised laboratories. There may therefore be a tension between bringing in outside expertise and utilising and strengthening local professional capacity. We need the experts but must ensure that they work with governments and leave some capacity behind when they leave.

Nutritional surveys are a common assessment tool used in emergencies and yet generally they do not give enough attention to the assessment of micronutrient deficiencies. By training field personnel in the signs and symptoms of micronutrient deficiency diseases (by including a few questions in the survey to help identify the onset of deficiencies) and through actively seeking cases, nutritional assessments could be better used to identify that a problem exists.

*% RDA is based on daily mean population requirements of 2100 kcal, 58 gm protein, 0.9 mg of thiamine and 28 mg of vitamin C (WHO, 1997).

Prevention of deficiency outbreaks

Micronutrient deficiencies can be easily prevented by the provision of a balanced diet and yet outbreaks of deficiency diseases have regularly occurred in refugee populations dependent on food aid. Years of experience and expert consultation over the past two decades have led to several initiatives to reduce the likelihood of micronutrient deficiency outbreaks occurring during emergency programmes. Perhaps the most significant initiative has been the introduction of a stipulation in the WFP/UNHCR Guidelines for estimating food and nutritional needs in emergencies (1997) whereby a fortified blended cereal should be included in the ration of all food aid dependent populations unless other appropriate commodities can be provided.

However, in the case of Wajir, food aid arrived too late and when it did arrive, the GFR did not meet the nutritional needs of the population. It appears that there was insufficient awareness of the risks of micronutrient deficiency disease in populations dependent on food aid.

We recommend that key humanitarian agencies should, with the support of the RNIS monitoring system⁸, take steps to raise awareness among their staff of the important risk of micronutrient deficiencies and better co-ordinate food aid to ensure that it is prompt, adequate and appropriate.

There is no excuse for what happened in Wajir. The problem is understood and the solution is simple. Outbreaks of micronutrient deficiency disease in food aid dependent populations should be a thing of the past and not of the 21st century.

View the postscript that this article relates to

¹Save the Children (UK) and Ministry of Health, Kenya, Nutrition Survey in North and West Wajir District, Kenya, October, 2000

²Collins, S., Duffield, A., and Myatt, M. Assessment of nutritional status in emergency-affected populations: adults., 2000, UN ACC/Sub- Committee on Nutrition

³The Kenyan government's economic and political performance has been a factor in donor reluctance to respond

⁴WHO, Scurvy and its prevention and control in major emergencies, 1999

⁵WHO, Thiamine deficiency and its prevention and control in major emergencies, 1999

⁶WHO, Scurvy and its prevention and control in major emergencies, 1999

⁷WHO, Thiamine deficiency and it prevention and control in major emergencies, 1999

⁸RNIS, ACC/Sub-Committee on Nutrition (V222), 20, avenue Appia, 1211 Geneva 27, Switzerland. Email: accscn@who.ch