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Suspected toxic ingestion outbreak in central Afghanistan

By Gerald Martone, International Rescue Committee (IRC)

Gerald Martone is the Director of Emergency Response at the International Rescue Committee's Headquarters in New York. Gerald is responsible for implementing emergency start-up operations, maintaining the agency's readiness to respond rapidly, and conducting assessments of complex humanitarian emergencies. During the past nine years at IRC, Gerald has overseen the start-up of programs in over 20 emergency affected countries. This article arises out of his experience in Central Afghanistan.

Humanitarian assistance operations in Afghanistan are only just beginning to reach beyond major towns and cities. There remain, however, many inaccessible and isolated rural communities. This is particularly true in the remote and mountainous areas of central Afghanistan.

In the highland areas of Afghanistan where the northern, eastern, and western regions intersect, impassable snowdrifts and freezing temperatures limit access to a fairly restricted time of year. The terrain is inhospitable with dangerously deep crevasses, insurmountable rocky slopes and steep ravines. No motor vehicles are capable of reaching many of these places. The only way to penetrate these mountains is by an arduous journey for several days, usually on horseback, donkeys, or by foot.

Due to a shorter growing season in the higher altitudes, agricultural livelihoods above the tree line are particularly vulnerable to even minor climatic changes. The recent drought has resulted in depletion of household assets, complete loss of agricultural self-reliance, and significant food scarcity. Hundreds of thousands of internally displaced Afghans have migrated from their ancestral homes in these rural communities towards larger towns and cities in the hope of receiving some external assistance.

Village elder in Chimtal holding a "Tartran" root.

While conducting field assessments and food surveys in remote areas, International Rescue Committee (IRC) staff member, engineer Hamidullah Hamidi, visited the remote village of Abdulgan and its neighbouring sub-villages in Zari District on December 2 and 3, 2001. Hamidi reported agonising food shortages and 'starvation' of villagers as a result of the drought.

In response, the IRC Northern Afghanistan program organised a caravan of 400 donkeys to try to move relief assistance up the mountain to Abdulgan. From January 5-21, 2002, IRC transported and distributed over 3,000 metric tons of wheat. During the arduous journey up and down the mountain footpaths, four men and one donkey died from hypothermia and exposure.

It was during the return mission that the field staff reported an unusually high prevalence of illness and death due to conditions that the villagers were unfamiliar with. IRC staff reported that food was so scarce that villagers were foraging for wild plants, grass, and roots that were not normally part of their diet.

On recalling the toxico-nutritional state, 'Konzo', seen occasionally in sub-Saharan Africa during drought or extended dry seasons, we felt it was critical to arrange a return investigation to the region. The plan was to conduct follow-up interviews of villagers and explore the status of their coping strategies, and determine if toxic ingestions of wild foods were, in fact, occurring.

Measuring arm circumference with MUAC strip in Abdulgan during investigation.

The etiology of Konzo is presumed to be the consumption of improperly prepared cassava root (Manihot Esculenta), particularly the bitter variety. This toxic state occurs in communities that consume cassava root that has not been boiled and washed sufficiently. The hasty preparation of cassava root is sometimes seen during acute food shortages and drought. Some observers have regarded Konzo as an early famine warning sign or even as a crude proxy of pre-famine conditions.

Investigation

From February 15-18, 2002, the IRC Northern Afghanistan Program conducted a follow-up field assessment to Bini Gaw sub-village, Babah Ali village of Abdulgan, District of Zari, Balk Province, departing from Mazar-I-Sharif.

Abdulgan is among some of the most remote communities in Afghanistan. It is located about 150 miles south of the city of Mazar-I-Sharif in the Mushkel-Hal Mountains. The altitude of Abdulgan is approximately 2,800 meters above sea level. There are no roads, no electricity, and no indigenous water sources beyond the capture of surface run-off from rain in underground stone cisterns.

Children haul water for great distances as a result of the drought: Sakkhi IDP camp in Mazar-i-Sharif.

Abdulgan is divided into four main villages; Baya, Fulad, Babah Ali, and Dawlat Muhamad. The total population at the time of this assessment was 1,407 families with approximately five persons per family. The people of this central region are ethnic Hazara, hence they refer to the area as Hazarajat.

The rapid assessment was conducted through key informant interviews, focus group discussion, and a brief household survey. The primary informant was Atahullah Kashifi, Chief of Abdulgan, now living in Bini Gaw sub-village. The interviews were conducted in Dari and translated into English by the field mission staff.

MUAC (Mid-Upper Arm Circumference) measurements were obtained on eight children under 5 years old. Two children were identified with moderate malnutrition (110-124mm circumference) and no cases of severe malnutrition (less than 110mm) were noted. Villagers anecdotally describe the main causes of illness and death as acute respiratory illness, measles, and diarrhoea. The nearest health facility is in Zari town. This very basic health unit is a six and a half hour walk from Abdulgan on a treacherous and icy mountain trail.

As an indication of the level of food insecurity that had developed, almost all villagers have had to sell some of their personal possessions, roof timbers from their houses, and draught animals to cope with the loss of their livelihood. Many villagers explained that they had eaten their seeds and were unable to plant for the next season when they hoped the rains would finally come. There is no agricultural irrigation and the steep mountain fields are entirely rain-fed.

Wet-feeding programme with Corn-Soya Blend porridge in Herat IDP camp.

Villagers recounted the occasional consumption of wild plants and atypical roots as a coping strategy to expand their dwindling food reserves. One particular food that was described was a starchy white tuber referred to as 'tartran.'

Tartran is the root of a wild plant. It vaguely resembles parsnips in appearance. People report that tartran grows in the higher altitudes on mountain slopes. In fact no samples were available in villages at lower altitudes that were surveyed in Faryab Province, although people reported climbing the mountains in search of the root during past food shortages. The grassy part of the plant is traditionally used as animal fodder for the winter. The leaves are sun-dried and stored and then fed to domesticated animals when they are no longer able to graze as a result of snow cover.

Several dried root samples were obtained and brought back from a villager's food stores in the hope that an analysis might be conducted at a later date. A sample of round bread containing wild grass (used to expand the grain content) was also given to the team to take back for examination.

In the focus group discussion, people reported that tartran was last consumed 30 years ago during the severe drought of 1972 when people discovered that you could eat this root. To prepare the root, it is first peeled and then the starchy interior is boiled at least three times, each time discarding the water. According to all accounts, tartran tastes very, very bitter. Some people offered that the taste is so disagreeable that it is almost inedible, especially if it has not been triple-boiled.

Times of extreme nutritional distress seem to promote short cuts in the processing of the root. One woman described how over the last several months she would not wait for the thorough preparation of tartran and would on occasion prematurely serve the root after only one boiling. The scarcity of firewood in these areas contributes to the rushed and insufficiently prepared tuber.

Very few Afghans outside of remote and isolated areas have ever known of this root or its name. The guides that accompanied us on the mission had never heard of it. One sixty-year old man from Aque Kupruk town recognised the root and confirmed that it was something that was rarely eaten except in times of food scarcity, such as the drought of 1972. On later investigation, a former rural resident from as far away as the highlands of Badakhshan Province confirmed his knowledge of the use of tartran root during the previous and current drought. He referred to it as "tartrene."

One mother in Babah Ali village described the sudden death of her three-year old child. The child had eaten tartran only two days before. The mother reported that the child "could not walk" after eating tartran. The mother also reported abdominal distention and coughing.

This winter in Bandicheep sub-village, a mother reported that her unattended 4-year old boy pulled a tartran root out of the pot before the boiling was complete and ate it. The mother reported that her child developed abdominal distention, gastritis, and "white water coming from his mouth." He died one day later.

In the sub-village of Bini Gaw (population 65 families) several people reported that nine months ago, five children were foraging together in the mountains for food. They recounted that these children came back to Bini Gaw and were acting "mad." The children were described as aggressive and repeatedly running away from the home without direction or destination. Approximately five days later, the children were reportedly returned to normal. The villagers believed that this behaviour was the result of a mythical spirit. Some villagers suspect, however, that the children had eaten tartran, among other wild plants, that they may have discovered. This description was later verified by Chief Kashifi.

A Toxic State?

When the symptoms of paraparesis or sudden difficulty with walking were described, several villagers responded that there had been "many cases" in Abdulgan. The descriptions consistently fit the abrupt onset and rapid deterioration typically ascribed to the Konzo syndrome.

During the time of this assessment, however, we were unable to observe any active cases of this suspected toxicity. Since we were unable to observe an active case, the team could not test for lower limb hyperreflexia, observe spastic abnormality of gait while walking, nor could we check for impaired eye movements and/or blurred vision. It would also have been useful to obtain a urine sample from an active case for later analysis for the presence of thiocyanate.

The symptoms of Konzo have been attributed to dietary cyanide exposure. If the tuber is prepared without sufficient maceration/grinding, drying, fermentation, soaking, and/or cooking, the toxin will not be liberated from the plant's cells and converted to hydrogen cyanide, which then evaporates and renders the food safe to eat. Typically cassava root should soak in water for at least 3 nights. The soaking time must be extended much longer if the water is cold.

Further complicating the toxicity of dietary cyanide is a diet low in protein. Without adequate protein intake there is insufficient dietary sulfur amino acids. These sulfur substrates are the major metabolic detoxification pathway for cyanide, converting it to thiocyanate.

The word Konzo means "tired legs" in the indigenous language of the people in Zaire where the disease was first recorded. One of the more noticeable signs of dietary cyanide poisoning is the spastic gait. Many sufferers describe weakness, trembling, and heaviness in the legs. There is a tendency to fall while walking as well as an inability to stand. Some afflicted people are even bedridden for several days. These symptoms have sometimes been confused with polio infection.

Most documented outbreaks of Konzo were confined to areas of Africa that were rural, poor, and remote. The majority of described cases occurred during dry seasons, particularly in times of drought.

Conclusion

As this analysis and survey were informal, anecdotal, and unscientific, definitive interpretation of the findings would be premature. However, considering the potential impact that this unconfirmed toxic ingestion might have on distressed rural communities, a methodical and scientifically rigorous investigation of potentially poisonous 'famine foods' in Afghanistan should be conducted. An investigation by a follow-up research mission should include a qualified toxicologist as well as provision of appropriate assay methods that could more adequately investigate the existence of a toxiconutritional syndrome.

Active cases of recent ingestions as well as old cases with persistent upper motor neuron symptoms should be examined for neurological sequelae. Fresh samples of the tartran root should be collected for later analysis for cyanide derivatives. These specimens must be prevented from drying out during transport, as evaporation of hydrogen cyanide would reduce the detectable levels of cyanide compounds during the assay. It is advisable to also collect specimens of other "famine foods" or wild plants for later analysis should there be a toxic state where tartran was in fact not the causative agent.

An additional toxic nutritional condition known as Lathyrism has been described in India and Bangladesh. The symptoms result from the excess consumption of peas of the Lathyrus family otherwise known as chickling peas. The amino acid Beta-N-oxalyamino-L-alanine in some strains of chickling peas is a known neurotoxin. This toxin affects the central nervous system and produces an untreatable slowly progressive paraparesis.

If further investigation strengthens the suspicion of a disease condition with a dietary etiology, a widespread information campaign should immediately be instituted about the dangers of these foods as well as instruction in the correct method of preparation.

In the meantime, we must proceed with a rapid response to food deficits and other public health problems in these difficult-to-access communities. In past outbreaks of Konzo in sub-Saharan Africa, even a modest amount of food relief was able to diversify the caloric intake enough to substantially reduce the impact of the disease.

The villagers of Abdulgan suggest that hundreds of lives were saved as a result of the original field survey and the subsequent emergency food distribution. Moreover, the people of Abdulgan are no longer resorting to the consumption of the tartran root.

The IRC Northern Afghanistan program is building on the successful experience of this mission and has expanded its survey work with the creation of the REACH Project (Remote Emergency Assessments of Communities and Households). This project aims to further investigate some of the most inaccessible and isolated areas of central Afghanistan.

The REACH Project will also disseminate accurate, timely, and objective assessment findings and survey data about vulnerable communities through bimonthly reports to central and regional governmental authorities, national and international NGOs, UNOCHA, WFP/VAM, UNHCR, and other relevant institutions. Any change or unusual movement of populations to or from these rural areas will also be provided to the humanitarian community. This data will serve both as an early warning indicator as well as status monitoring of humanitarian events in these remote communities.

References Cliff et al, Konzo associated with War in Mozambique: Tropical Medicine and International Health, Volume 2, Number 11, pages 1068-1074 Tylleskar, T., Banea, M., Bikangi, N., Fresco, L., Persson, L., Rosling, H., Epidemiological evidence from Zaire for a dietary aetiology of konzo, an upper motor neuron disease. Bulletin of the World Health Organisation, 1991; 69: pages 581-590 Cassava Cyanide Diseases Network (CCDN), Towards the elimination of Konzo, TAN and other cassava cyanide disease.

For further information contact: Gerald Martone, R.N., M.S., Director of Emergency Response International Rescue Committee,122 East 42nd Street, New York, NY 10168, email: gerald@theIRC.org

 

Konzo: A distinct type of upper motorneuron disease

Definition

Konzo is characterised by the abrupt onset of an isolated and symmetric spastic (increased muscle tone) paraparesis (weakness of both lower limbs), which is permanent but nonprogressive.

Aetiology

An association between konzo and dietary cyanide exposure (from consumption of insufficiently processed bitter cassava) has been linked with the onset of konzo in several epidemiological surveys. A combined high cyanide/low sulfur (low protein) intake has also been implicated. Despite its epidemic occurrence and familial clustering, konzo patients show no signs of infection and outbreaks tend to be restricted to remote rural areas.

Clinical manifestations

The onset of konzo is sudden, in 90% of cases less than 1 day. The initial symptoms, often triggered by a long walk or hard work, include trembling or cramping in the legs, heaviness or weakness of the legs, and a tendency to fall. The severity of konzo varies between individuals but ranges from hyperreflexia in the lower limbs to a severely disabled, bedridden patient. Associated signs include weakness of the trunk and arms, impaired eye movements, dysarthria (disordered articulation) and possibly visual impairment. Intellectual capacity, hearing, coordination, sensory function as well as urinary, bowel and sexual functions are all normal. While typically the condition remains stable, some patients may suffer a sudden and permanent worsening of the spastic paraparesis (second onset).

Treatment

There is no known cure for konzo. Immediate treatment with high doses of multivitamins (especially B vitamins) has been suggested, to avoid possible increased neurodamage due to concurrent vitamin B deficiency. A good and varied diet with adequate protein is essential. Physical rehabilitation has proven successful in achieving independent locomotion.

Prevention

Konzo is not a major public health problem in populations as a whole, but is so in affected communities. There is a risk of konzo epidemics where agro-ecological problems turn bitter cassava into the major source of calories and where food and/or fuel shortage may lead to short-cuts in cassava preparation. Konzo can likely be prevented by applying effective processing of the cassava root.

Adapted from WHO WEEKLY EPIDEMIOLOGICAL RECORD, No. 30, 26 July 1996 (Based on a report from the Department of Nutrition, Uppsala University, Sweden).

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Gerald Martone (2002). Suspected toxic ingestion outbreak in central Afghanistan. Field Exchange 16, August 2002. p6. www.ennonline.net/fex/16/suspected

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