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.
Highlights
Since 1991, Somalia has lacked a functioning central government, resulting in extreme, longstanding insecurity
Because the syndrome was clinically compatible with wet beriberi, thiamine was administered to ill soldiers, resulting in rapid and dramatic resolution
An outbreak of wet beriberi caused by thiamine deficiency due to restricted diet occurred among soldiers in a modern, well-equipped army
Summary
Since 1991, Somalia has lacked a functioning central government, resulting in extreme, longstanding insecurity. In February 2007, the UN Security Council approved a peace support mandate (Resolution 1863) for the African Union Mission in Somalia (AMISOM). AMISOM soldiers are headquartered at the Base Camp adjacent to the Mogadishu airport. The activity of AMISOM soldiers in Mogadishu is limited; repeated violent attacks, including mortar fire, gunfire, and roadside and suicide bomb attacks have made movement around the city difficult and dangerous [2]. Security constraints in Mogadishu severely limit the local procurement of fresh foods for the 5750 soldiers, limiting fruit, vegetable and meat consumption. On February 22, 2009, an attack in Mogadishu (at the time the worst attack to date) killed 11 AMISOM soldiers and injured 15, and resulted in a further tightening of security measures [3]. Interaction with the surrounding community, including formal and informal procurement of fresh food, declined even further
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