Scurvy outbreak among South Sudanese adolescents and young men – Kakuma refugee camp, Kenya, 2017-2018

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Summary of research¹

Background

Scurvy is a relatively rare micronutrient-deficiency disease that can occur among refugees dependent on food assistance due to inadequate access to fresh fruits and vegetables. Kakuma refugee camp in Kenya’s Turkana district is home to 148,000 refugees, mostly from Somalia and South Sudan, who receive food assistance. In August 2017, a number of South Sudanese adolescent and young adult male refugees were evaluated for calf pain, chest pain and gingival (gum) swelling. No diagnosis was initially made due to non-specific symptoms and some patients received antibiotics and analgesics. All were managed as outpatients, but symptoms did not improve. During subsequent months, more young men reported similar symptoms. On 20 January 2018, the United Nations High Commissioner for Refugees (UNHCR) was informed and conducted clinical examinations. Signs and symptoms included lower limb pain and swelling, lethargy, fatigue, gingival swelling and pain, hyperkeratotic skin changes and chest pain. Based on these clinical findings, an outbreak of micronutrient deficiency, particularly vitamin C deficiency (scurvy) was suspected. Vitamin C treatment was given to those affected and, in February 2018, UNHCR requested assistance from Centers for Disease Control and Prevention (CDC) to carry out an investigation. This article summarises the findings.

Investigation and findings

Two health specialists from CDC and UNHCR conducted an outbreak investigation from 11 to 17 March 2018. A suspected scurvy case was defined as the occurrence of lower limb, knee joint or ankle swelling, and at least two of the fol­lowing: calf pain, shin pain, knee-joint pain, or gingivitis in a person of any age. Because the South Sudanese frequently have very dark skin, the typical dermato­logic symptom of petechial haemorrhage was not included in the case definition. Forty-five patients with suspected scurvy were identified and interviewed using a questionnaire developed by investi­gators to obtain information on symptoms and diet, with a recall period of six months. For a subset of 14 patients, the age structure of the household was analysed. Additional interviews were conducted with staff members from UNHCR, World Food Programme (WFP), the non-governmental organisation responsible for healthcare in the camp, community health volunteers, community leaders and food-shop owners who interacted with the patients. Dietary intake was estimated using WFP’s information on provided food rations and NutVal 4.1, a free software programme for calculating the nutritional content of food rations.²

At the time of this investigation, all refugees in Kakuma received food assistance, consisting of cereal, pulses, fortified corn-soy blend (CSB+) and vitamin A-fortified oil. By WFP standards, a food ration should provide 2,100 kcal per person per day (pppd) but, after 2015, a part of the cereal compo­nent of the ration was replaced by electronic cash (e-cash) to provide dietary diversification and choice. In 2017 and 2018, one-person households received a 500 Kenyan Shillings (KSh)/pppd and food ration of 900-1,400 kcal/pppd. Households of ≥2 persons received 300 KSh/pppd and a food ration of 900-1,700 kcal/pppd. The variations in the food assistance from 2015 onwards resulted from shortages of commodities and funding shortfalls. Among the 45 patients with suspected scurvy, date of symptom onset was known for 44. Among these, 29 (66%) reported onset between August and November 2017.

All 45 patients with suspected scurvy were adolescent and young adult male refugees from South Sudan who had arrived in Kakuma between 2012 and 2017; 33 (73%) had arrived in 2014 or later. The median age was 19 years (range = 12-32 years). Approximately 58% of patients reported swelling of the lower limb, 53% ankle swelling, and 42% lower-limb pain. Interviews with health personnel and patients found that approximately seven to 10 patients had been unable to walk. Forty of the 45 patients with suspected scurvy were treated with vitamin C. The median household size of patients with suspected scurvy was five persons (range = one to 15 persons). Among the subset of 14 households for which age was collected, nine (64.3%) included only adolescents and young men aged 13-22 years; only five households included a female, only one of whom was an adult.

All patients with suspected scurvy reported that they ate one meal per day. None had income from work or received any remittances and all reported that, rather than using the e-cash to diversify their diets, they used the full e-cash amount to purchase staple foods (e.g., cereals and pulses) and sometimes salt. Forty-three patients (96%) reported that they had not purchased vegetables, fruits or potatoes since their arrival in Kakuma and used the e-cash to supplement their diet with cereals and pulses, which provided an additional 870-1,450 kcal/pppd. All patients who received treatment with vitamin C noted improvement of symptoms within less than one week, particularly reduc­tion in swelling of knee and ankle joints and shin pain. All patients who previously had been unable to walk were able to do so after treatment.

In response to this outbreak, in April 2018 WFP tested the amount of vitamin C in CSB+ after simulating the CSB+ preparation in a laboratory setting. The raw product contains 90 mg vitamin C per 100g, and each refugee received 40g CSB+ per day (equivalent to 36 mg vitamin C per day). The cooking simulation demonstrated that vitamin C retention after preparation was <16%; thus, intake through consump­tion would be <6 mg vitamin C per day, which is insufficient to prevent deficiency.

Discussion

Scurvy is not new to refugee settings in which a limited amount of fresh foods is available or affordable and has previously been documented in Kakuma refugee camp, with outbreaks reported during 1995-1997 (Verdirame and Harrell-Bond, 2005) and 2003 (UNHCR, 2003). Vitamin C defi­ciency has also been described among refugees and imprisoned male populations in similar geographic areas (Desenclos et al, 1989; Seaman and Rivers, 1989; Bennett and Coninx, 2002). The energy requirements for males aged 14-18 years and 18-30 years are 3,000-3,400 kcal per day and 2,550-3,900 kcal per day, respectively (FAO/WHO/UNU, 2001), based on moderate physical activ­ity (males aged 14-18 years) and active-to-moderately-active physical activity (men aged 18-30 years). The food ration provided in the camp supplied 900-1,700 kcal/pppd; if all e-cash was used to purchase sorghum and split peas, an additional 870-1,450 kcal/pppd was potentially available, for a maximum theoretical intake of 1,800-2,900 kcal/pppd, depending on household size. Thus, the food ration met only half of the required caloric needs. Because the e-cash intended for dietary diversification was not used to purchase fresh foods, such as vitamin C-rich fruits and vegetables, but rather to comple­ment the food rations with more calorie-dense and cheaper staple foods to secure the missing calories, vitamin C deficiency resulted. The diet of patients with suspected scurvy contained, on average, <10 mg vitamin C per day; the minimum daily requirement to prevent scurvy is 10 mg (WHO, 1999). Despite previous assumptions, the fortified commodity, CSB+, was not a sufficient source of vitamin C as losses during preparation were much higher than initially estimated. The geographic clustering of suspected cases likely resulted from the relatively higher number of young men living and cooking together in one area of the camp and sharing their limited food rations and e-cash.

Provision of food assistance in refugee settings is often based on average household composition, factoring in age, sex and caloric needs. In this investigation, the adolescent and young males had very high nutritional needs compared with persons in an average household. These differences in household demographics demonstrate that simply providing an average amount of calories calculated on assumed household demo­graphics is inadequate to meet nutritional requirements. In addition to food rations, refugees were provided with e-cash to purchase their own food to add diversity and choice to their diet. However, this investigation indicated that for adolescent and young adult male refugees, both forms of assistance were inadequate to allow access to sufficient calories and the dietary diversification needed for intake of sufficient micronutrients, such as vitamin C. It is important to consider these needs when determining the amount of food or cash assistance provided to adolescents and young adult male refugees.

Endnotes

¹Ververs, M., Wambugu Muriithi, J., Burton, A., Wagacha Burton, J., Oman Lawi, A. (2019). Scurvy outbreak among South Sudanese adolescents and young men – Kakuma refugee camp, Kenya, 2017-2018. Morbidity and Mortality Weekly Report (MMWR) US Department of Health and Human Services/Centers for Disease Control and Prevention, January 25, 2019. Vol. 68/ No. 3.

²www.nutval.net

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