Scurvy outbreak in Afghanistan: an investigation by Action Contre la Faim (ACF) and WHO

By Philipe Leborgne, Caroline Wilkinson, Sylvie Montembaut, and Mija Tesse Ververs

Dr Philippe Leborgne has been Head of the ACF Medical Department since 1994. Before this he worked with a French NGO in primary health care in Equatorial Guinea and in Rwanda with MSF.

Caroline Wilkinson has been a nutrition advisor in the Paris headquarters of ACF since 2000. Before this she spent five years working as an ACF field nutritionist in Africa, Kosovo and Central Asia.

Sylvie Montembaut is an argronomist and has been ACF Head of Food Security Department since 2001. Before this, she was a field worker and consultant for different humanitarian agencies in China, Sri Lanka, Bosnia, Armenia, Georgia, Burundi & Chechnya.

Mija Tesse Ververs is the ACF Technical Director.

The support of Dr. Sylvie Goosens (ACF Taywara) and WHO, especially Dr Yon Fleerackers (WHO Afghanistan) in preparation of this article is acknowledged and appreciated.

Taywara district is located in the south of Ghor province, Western Afghanistan. The area is mountainous and access between the main town, Taywara Centre, and the villages is very limited. The population of Taywara district numbers approximately 79,000 people. The nearest hospital to Taywara Centre is located in Chaghcharan (provincial capital), a one day car journey from the town during the summer, and an often inaccessible route during the winter. Throughout the remainder of the district, very few dispensaries are functional.

In early March 2002, whilst establishing a nutrition programme in the area, an ACF field team came across twenty deaths and forty seven suspected cases of scurvy in four villages.

The main symptoms described were:

• pain in the joints leading to inability to walk
• gingivitis, with bleeding gums and loss of teeth
• oedema of the lower limbs, and of the knees
• haematoma and ecchimosis (black spots) on the legs.

Displaced person camp Mazar.

Subsequently, on the 6th March 2002, these suspected scurvy cases were reported by ACF to the WHO Sub-Office in Herat. In response, an investigation team was sent on 12th March from Herat (including a WHO epidemiologist and Ministry of Health staff) to join the ACF doctors in Taywara Centre.

Outbreak investigation

The case definition of scurvy used by the investigating team was painful legs and/or joints and hemorrhagic gingivitis (bleeding gums) and/or ecchimosis on the legs. The geographical location of the investigation was confined to the Taywara district and the time frame restricted to after the beginning of Eid Ramazan (16 December 2001).

The identified priorities of the investigation were to:

• Confirm the outbreak.
• Evaluate the district scurvy case fatality rate during the last 3 months.
• Evaluate the district scurvy attack rate during the last 3 months through village interviews by community health workers.
• Evaluate the district scurvy prevalence (from the number of scurvy cases diagnosed at the time of the visits by community health workers).
• Treat confirmed cases.
• Make recommendations adapted to the local context.

Between 14th to 20th March, vitamin C tablets provided by UNICEF and WHO were distributed to all of the 242 villages in Taywara district through the trained community health workers. Until that time, vitamin C had only been available in pharmacies in Taywara Centre.

To facilitate this operation, twenty-five village health workers received training by the investigation team on the symptoms and signs of scurvy, treatment protocols, and scurvy morbidity and mortality data collection.

Confirmed cases of scurvy

Nutritional Surveillance - Kabul.

Eighteen suspected cases were investigated in Zardbid village, of which twelve were clinically diagnosed with scurvy on the day of the visit. For accessibility reasons, case identification could only be carried out in this village. Regarding the twelve confirmed cases, 83% had first developed symptoms in January and February 2002. The median age for this caseload was 30 years, ranging from 7 to 50 years.

In addition six deaths (that were locally attributed to scurvy) had occurred between January and February 2002. The mean time between the onset of symptoms and death was 16 days, ranging from 6 to 31 days. Death occurred in all those with the condition who were over fifty years of age.

Among the eighteen suspected cases, eight (44%) were male and ten (56%) were female. The median age was 35 years.

During field trips by the teams between 5 and 14 March 2002, four children aged between 3 and 5 years old had been seen in two villages close to Taywara Centre, who were suffering from painful joints which prevented them from standing up or walking.

Case attack and fatality rates

A questionnaire was used by the community health workers to collect data on the number of cases and deaths in the village. From this it was calculated that over a period of 3 months, the district scurvy attack rate was 6.3% (corresponding to 4588 cases). Such an epidemic is classified as severe according to the WHO criteria "attack rate more than 5%".

Amongst those affected, there was a 7% case fatality rate (corresponding to 323 deaths) and a 20% proportional mortality rate (0.4% scurvy mortality rate out of a 2.1% global mortality rate). At the time of the survey, scurvy prevalence was estimated at 3.9%.

Trend of Epidemic

Waiting room in medical structure.

The first scurvy cases were reported in November 2001. Based on village reports, it is estimated that the epidemic peaked between January and February 2002. The vitamin C distribution in March was therefore too late to meet the needs of the majority of those affected.

At the time of the investigation, the number of cases was falling in the district as people began to eat "seech" (a green plant which starts to grow in March). Seech is typically boiled and then fried in oil for a few minutes, and is usually eaten from April to June. All persons who died in Zardbid village had not eaten "seech" whereas half of those cases that survived reported eating this plant.

Seasonal outbreaks of scurvy

Scurvy is endemic in this region of Afghanistan during winter and cases normally occur in Taywara district every year. The disease is well known by the population and called "siah lengi "(black leg) in local language. However, even in the absence of baseline data from previous years, anecdotally this year was considered unusually bad by local health staff and the population in terms of the number of cases and deaths.

There have been a number of recent comparable outbreaks of scurvy in the region. In Chaghcharan district (which borders Taywara) during the same period, hundreds of cases have been declared (there were more cases reported this year than during the last two years). According to WHO/Médecins du Monde who investigated the Chaghcharan epidemic, scurvy prevalence was beginning to decline compared to the previous month mainly due to the availability of wild plants ("sheresh") from which tea is prepared by families to treat scurvy.

In bordering Faryab province where in 2001 an outbreak was documented¹, most of the scurvy cases occurred between mid-December and mid- February and incidence began to decrease once wild leaves became available.

Why was this year particularly bad? The basic diet of the population consists of bread (wheat), rice, tea, small amounts of dairy products and wild green leaves. As fresh fruit and vegetables are only consumed during spring and summer, people are largely deprived of the main sources of vitamin C during winter.

Three consecutive droughts have seen a reduction in cultivable lands affecting agricultural production and reducing food resources, particularly vegetables such as potatoes and carrots. Wheat is given priority over vegetable cultivation when maximising on what limited water resources are available. Animal husbandry has been affected as well, resulting in less available animal traction to cultivate land, and a reduction in dairy and meat product consumption.

The last food distribution took place in November 2001, where rations consisted of rice, split peas and vegetable oil and were aimed at covering the needs of all district households for a period of 3 months. At the time of the investigation in March 2002, village elders reported that most families in the villages were consuming only bread and tea.

Recommendations

In order to prevent a recurrence of the outbreak of scurvy in Western Afghanistan, a series of short term measures need to be implemented in conjunction with longer term strategies aimed at strengthening food security and promoting dietary diversity.

Immediate and medium-term measures

• Improve the quality of the food aid rations distributed, to cover the micronutrient needs of the population. The majority of the population are fully dependent on the food received and have little potential to vary their diet through fortified food or durable vegetable supplies containing vitamin C.
• Promote the germination of cereals (wheat grains) or pulses and the consumption of the germinated sprouts. The sprouts that contain vitamin C should be consumed raw or with very little cooking so that all the vitamin C is not lost. Germination would have to take place at the community or household level rather than centrally.
• Establish surveillance systems to detect scurvy and other micronutrient deficiencies. Early warning for the main micronutrient deficiency diseases, as well as epidemic preparedness for associated diseases, should be strengthened in the region through appropriate coordination mechanisms at various levels (region, province, district). These should be adapted appropriately for those regions with very few functional health facilities.
• Carry out systematic surveys on the health and nutritional status of the people living in Ghor Province (and in neighbouring provinces of Badghis and Faryab) using standardised assessment methods.

Long-term measures

• Promote and support household production of fruits, vegetables and tubers. In particular, local cultivation of vegetables such as tomatoes, peppers, and leafy green vegetables and tubers, such as potatoes, should be strongly promoted as a long-term strategy to address the problem of micronutrient deficiencies.
• Initiate a range of food security-related initiatives. These would include income generating projects, construction or rehabilitation of flood protection walls, rehabilitation of drainage channels and irrigation dividers, reforestation and subsidised sale of animals (particularly animal traction).

Finally, any agencies embarking on these interventions in the area should be aware and prepared for next winter when the distribution of foods fortified with micronutrients (especially vitamin C) may be a priority to prevent a recurrence of this scale of outbreak.

For further information, contact Dr. Phillipe Leborgne, Medical Department, Action Contre le Faim (ACF), 4 Rue Niepce, 75014 Paris, France. Tel: +1 433 58822. E-mail: phl@acf.imaginet.fr

¹Assefa, F. Scurvy outbreak and erosion of livelihoods masked by low levels in drought affected Northern Afghanistan, Field Exchange, 2001; 13: 14-16.