The food aid incident was the largest known outbreak of tropane alkaloids

Researchers have provided more details about an outbreak traced to tainted food aid in Uganda in 2019 that killed five people.

This was the largest documented outbreak caused by food contamination with tropane alkaloids, according to the study published in the journal BMC Public Health.

Jimsonweed, also known as Datura stramonium, contains toxic alkaloids that cause gastrointestinal and central nervous system symptoms when ingested and can be fatal in high doses. The plant may grow with some crops and mix with them during harvest. In March 2019, more than 200 patients were admitted to several health centers due to acute gastrointestinal and neurological symptoms.

Scientists reviewed medical records and inspected all eight affected sub-district villages to identify cases. In a retrospective study in 17 villages reporting early cases, researchers interviewed 211 residents about their dietary history from March 11 to 15.

The team identified 293 suspected cases and five deaths. Symptoms included confusion, dizziness, diarrhea, nausea or vomiting, convulsions, and hallucinations. The outbreak began on March 12, two to 12 hours after a batch of fortified corn and soybean blend (CSB+) was distributed by the World Food Program. In the retrospective cohort study, 66 percent of the 134 people who took CSB+, compared to 2.2 percent of the 75 people who did not, developed the disease.

Lab test results
Samples of the infected batch distributed from March 11 to 15 contained 14 tropane alkaloids, including atropine at 25 to 50 parts per million (ppm) and scopolamine at 1 to 10 ppm. Solanaceae seed proteins and Jimsonweed DNA have been identified.

Samples were shipped to Intertek in South Africa, Mérieux Nutrisciences in Italy, and the Center for Food Safety and Applied Nutrition (CFSAN) at the US Food and Drug Administration. CFSAN identified atropine and scopolamine in the samples. Levels of atropine and scopolamine were hundreds of times higher than the permissible limits set by the European Food Safety Authority (EFSA).

The outbreak occurred in Nabak and Amodat districts of Karamoja district, northeastern Uganda. In total, 215 cases were in Nabak and 78 in Amudas. Four deaths occurred in Nabak and one in Amudat. Two children died, ages 2 and 10.

The high number of deaths could be due to the multiple tropane alkaloids in the batch involved, along with the high prevalence of malnutrition among children in Karamoja, researchers said.

For most patients, symptoms disappear within 24 hours after treatment with intravenous fluids, activated charcoal, and sedatives. No antibiotics were given. Females were more likely to contract the disease than males. People under the age of five were the most affected.

The outbreak subsided after CSB+ was withdrawn. However, some community members did not return CSB+ despite efforts by the World Food Program to withdraw the food. In late March and mid-April, two smaller outbreaks occurred after people started taking CSB+ and did not return to WFP.

Turkish origin
Two contracting companies transported the contaminated batch from a central distribution point in Tororo, Uganda, to Moroto, where the food was sent to health facilities. It was imported to Uganda from Mombasa, Kenya.

Records show that this batch came from Turkey but the researchers were unable to determine the exact location in the country where CSB+ was produced or how it was processed. Another study found deficiencies in the Turkish plant providing nutritional assistance implicated.

Batch numbers were associated with the donation shipment and not the production date, raw material source, or plant, which is contrary to documented best practices and CSB+ packaging lacks unique serial numbering.

Identification of proteins from eggplant seeds and DNA isolation of Jimson grass in the batch indicated contamination in the harvest and production stages due to a failure of quality control along the supply chain, according to the study.

However, CSB+ control samples taken from unaffected households and a central repository also contained low levels of atropine, suggesting that contamination may be widespread.

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