Abstract
BackgroundIn 2010, an acute illness outbreak was reported in school students eating high-energy biscuits supplied by the school feeding programme in northwest Bangladesh. We investigated this outbreak to describe the illness in terms of person, place and time, develop the timeline of events, and determine the cause and community perceptions regarding the outbreak.MethodsWe defined case-patients as students from affected schools reporting any two symptoms including abdominal pain, heartburn, bitter taste, and headache after eating biscuits on the day of illness. We conducted in-depth interviews and group discussions with students, teachers, parents and community members to explore symptoms, exposures, and community perceptions. We conducted a questionnaire survey among case-patients to determine the symptoms and ascertain food items eaten 12 hours before illness onset, and microbiological and environmental investigations.Results Among 142 students seeking hospital care, 44 students from four schools qualified as case-patients. Of these, we surveyed 30 who had a mean age of 9 years; 70% (21/30) were females. Predominant symptoms included abdominal pain (93%), heartburn (90%), and bitter taste (57%). All students recovered within a few hours. No pathogenic Vibrio cholerae, Shigella or Salmonella spp. were isolated from collected stool samples. We found no rancid biscuits in schools and storage sites. The female index case perceived the unusually darker packet label as a “devil’s deed” that made the biscuits poisonous. Many students, parents and community members reported concerns about rumors of students dying from biscuit poisoning.ConclusionsRapid onset, followed by rapid recovery of symptoms; female preponderance; inconsistent physical, microbiological and environmental findings suggested mass sociogenic illness rather than a foodborne or toxic cause. Rumours of student deaths heightening community anxiety apparently propagated this outbreak. Sharing investigation results and reassuring students and parents through health communication campaigns could limit similar future outbreaks and help retain beneficiaries’ trust on nutrition supplementation initiatives.
Highlights
Outbreaks of mass sociogenic illness (MSI) known as epidemic hysteria or mass psychogenic illness (MPI) have been reported in schools worldwide [1,2,3]
In Bangladesh, the World Food Programme (WFP) provides a daily snack of eight fortified high-energy biscuits (HEBs) in a single packet to primary school students in foodinsecure areas [14]
Rapid onset of symptoms followed by rapid recovery, female preponderance together with physical, laboratory and environmental findings inconsistent with a diagnosis of microbial contamination or toxicity suggested that mass sociogenic illness rather than a food-borne illness following school meals was the primary cause of this outbreak [1,3,5,18,32]
Summary
Outbreaks of mass sociogenic illness (MSI) known as epidemic hysteria or mass psychogenic illness (MPI) have been reported in schools worldwide [1,2,3]. Rapid onset and quick spread of symptoms among members of a cohesive group without any organic basis tends to signal mass sociogenic illness These are frequently characterized by a rapid recovery, a higher tendency of affecting females, and transmission through visual or oral communication channels [4,5,6]. In 2010, an acute illness outbreak was reported in school students eating high-energy biscuits supplied by the school feeding programme in northwest Bangladesh. We investigated this outbreak to describe the illness in terms of person, place and time, develop the timeline of events, and determine the cause and community perceptions regarding the outbreak. Sharing investigation results and reassuring students and parents through health communication campaigns could limit similar future outbreaks and help retain beneficiaries’ trust on nutrition supplementation initiatives
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