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On July 26, 2022, a pediatric kidney specialist at the Edward Francis Small Teaching Hospital in Banjul — the only teaching hospital in The Gambia, a West African country — warned the Ministry of Health about a cluster of acute kidney injury (AKI) in young children. The Gambia doesn't routinely track AKI, so there was no baseline, but the numbers were alarming: by August 12, 30 of 37 children with AKI reported nationwide had died.
On August 23 the ministry asked CDC for help. A team — an epidemiologist, an anthropologist, an infectious disease physician and an environmental health scientist — arrived on September 16 to work with the ministry and The Gambia's Field Epidemiology Training Program. The ministry separately worked with the World Health Organization (WHO) to test medicines.
Image from CDC's report on acute kidney injury in The Gambia.
The outbreak
As of September 29, 2022:
- 78 suspected cases had been identified, and 66 (85%) of the children had died;
- 75% were under 2 years old, and 60% were boys;
- cases came from six of the country's seven health regions.
Investigators reviewed medical records for 52 children and interviewed caregivers of 27 in their homes, in local languages; 56 children met the confirmed case definition — no urine output of unknown cause, for at least 24 hours, in a child aged 8 or younger, between June 21 and September 29. More than half first had fever (54%), and half had vomiting. Abnormal lab results — impaired kidney and liver function, high platelet counts, and mild to moderate anemia — were found in 66% to 100% of patients.
Tracing the source
- Every one of the 26 included children whose caregivers were interviewed had taken a prescription or over-the-counter syrup medicine before their kidneys stopped working — including paracetamol (acetaminophen), commonly given for fever. Twelve had taken four or more medicines before hospitalization.
- Caregivers of 14 children could name at least one manufacturer, and 8 of those 14 named the same international manufacturer.
- Doctors had reported that children received paracetamol and promethazine before falling ill, so the ministry told the public to stop using paracetamol syrups on September 7 and promethazine syrups on September 16.
- WHO and the ministry tested 23 medication samples: four products from Maiden Pharmaceuticals Limited of Haryana, India, contained diethylene glycol (DEG) and ethylene glycol (EG). All the contaminated products had been imported on June 21, 2022 — shortly before the first cases, which is why the case definition starts that day.
The response
| Date | Action |
|---|---|
| October 4, 2022 | The ministry suspends imports from the manufacturer and tells providers to stop prescribing, dispensing and using its products |
| October 5, 2022 | WHO issues a worldwide medical product alert for four of the company's syrups |
| Following weeks | A house-to-house recall, with WHO, UNICEF, ChildFund The Gambia and The Gambia Red Cross Society, of the manufacturer's products and all paracetamol, promethazine and cough syrups; public messaging on radio, TV, social media and in places of worship; pharmacy spot checks; training for surveillance officers in case finding and follow-up |
Why DEG poisoning keeps happening
DEG-contaminated medicines have caused AKI outbreaks in Panama, Nigeria, India and Haiti. Poisoning can bring confusion, headache and stomach symptoms, but the most consistent sign is kidney injury: little or no urine, progressing over 1–3 days to kidney failure. In past outbreaks, manufacturers were suspected of substituting DEG for more expensive pharmaceutical-grade solvents.
Several things pointed to a poison rather than an infection here: cases spread across almost the whole country, many children had taken products from the same manufacturer, and there was little spread within households. Only children were affected — likely because syrups are mostly given to children in The Gambia.
This is one of the first documented DEG outbreaks in which the contaminated medicines were imported rather than made in the country. Medicines made for export may face less rigorous regulation, and low-resource countries may lack the people and money to test imported drugs.
Caregivers' recall was limited: many assumed medicines couldn't hurt their children, grieving parents were interviewed an average of 33 days after a death, and health alerts may have made some reluctant to report.
Lessons
- Strengthen international pharmaceutical regulation and quality control, especially for exports to low-resource countries.
- Build event-based surveillance, which picks up unstructured signals — reports, rumors — of unusual events, complementing routine disease reporting so outbreaks of unknown cause are caught faster. Field epidemiology–trained experts can help.
Sources
Based on Bastani P, Jammeh A, Lamar F, et al., "Acute Kidney Injury Among Children Likely Associated with Diethylene Glycol–Contaminated Medications — The Gambia, June–September 2022," Morbidity and Mortality Weekly Report 72(9), Centers for Disease Control and Prevention; a work of the United States government in the public domain. Original report.
Licencia: CC0 1.0 (dominio público) · Adaptado de www.cdc.gov
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