Scurvy — vitamin C deficiency — is rare, but it can strike refugees who depend on food aid and cannot get fresh fruit and vegetables. Kakuma Refugee Camp, in Kenya's Turkana District, is home to 148,000 refugees, mostly from Somalia and South Sudan, who receive food assistance. In 2017 and 2018 scurvy broke out there among adolescent and young adult men from South Sudan.
A puzzling illness
In August 2017, several young South Sudanese men came to a camp clinic with pain in their calves and chest and swollen gums. The symptoms were nonspecific, so no diagnosis was made; some were given antibiotics and painkillers as outpatients, and none improved. More young men with the same complaints followed over the next months.
On January 20, 2018, the United Nations High Commissioner for Refugees (UNHCR) was informed and examined patients. They had pain and swelling in the legs, sometimes involving the joints, lethargy and fatigue, sore swollen gums, hyperkeratotic skin changes and chest pain. Vitamin C deficiency was suspected. All the cases were young men who lived and cooked together in one section of the camp. Blood from three patients on January 26 showed vitamin C at 2.89, 3.06 and 2.71 mg/L — in the low-normal range (normal is 2–14 mg/L; deficiency is below 2) — while their B vitamins were normal. With their symptoms, this pointed to scurvy, and in February UNHCR asked CDC for help.
The investigation
CDC and UNHCR specialists investigated from March 11 to 17, 2018. A suspected case was swelling of the lower limb, knee or ankle plus at least two of calf pain, shin pain, knee pain or gingivitis. Petechial hemorrhage, the typical skin sign, was left out of the definition because many South Sudanese have very dark skin.
Suspected scurvy cases by month of symptom onset, Kakuma Refugee Camp, May 2017–March 2018. CDC, MMWR.
- 45 suspected cases, all adolescent and young men from South Sudan who had arrived in Kakuma between 2012 and 2017 (33 of them in 2014 or later). Their median age was 19, ranging from 12 to 32.
- Timing: of 44 with a known onset date, 29 (66%) fell ill between August and November 2017. The outbreak was still going in early March 2018, though cases had declined.
- Symptoms: about 58% had lower-leg swelling, 53% ankle swelling and 42% leg pain. Roughly seven to 10 could not walk.
- Households: the median household had five people. Of 14 households whose ages were recorded, nine held only adolescents and young men aged 13–22; only five included a female, and only one an adult woman.
Age distribution of patients with suspected scurvy. CDC, MMWR.
Why it happened
All refugees in Kakuma received cereal, pulses, a fortified corn-soy blend (CSB+) and vitamin A–fortified oil. The World Food Programme's standard is 2,100 kcal per person per day, but after 2015 part of the cereal ration was replaced with electronic cash ("Bamba Chakula," or "get your food") so refugees could buy a more varied diet. In 2017–2018, one-person households received 500 Kenyan shillings (100 shillings is about US$1) per person per day and 900–1,400 kcal of food; larger households received 300 shillings and 900–1,700 kcal. Commodity and funding shortfalls caused the variation.
Every patient ate one meal a day, had no work income or remittances, and spent all the e-cash on staples — cereals, pulses, sometimes salt. Forty-three (96%) had bought no vegetables, fruit or potatoes since arriving. The staples added 870–1,450 kcal a day.
The numbers show why. Young men aged 14–18 need 3,000–3,400 kcal a day and those aged 18–30 need 2,550–3,900. The ration supplied 900–1,700 kcal, and even with every shilling spent on sorghum and split peas the most they could reach was 1,800–2,900 kcal — so the ration itself met only half their needs. Spending the e-cash on cheap calories instead of fresh food left their diets with, on average, less than 10 mg of vitamin C a day, too little to prevent scurvy.
The fortified corn-soy blend did not make up the difference. In April 2018 WFP tested it: the raw product holds 90 mg of vitamin C per 100 g, so each refugee's 40 g daily share held 36 mg, but less than 16% survived cooking — under 6 mg a day. The cases clustered because many young men lived and cooked together in one area, sharing limited rations and cash.
Reported symptoms among patients with suspected scurvy. CDC, MMWR.
Treatment
Forty of the 45 were treated with vitamin C, and all who were treated improved within a week, especially the swelling of knees and ankles and the shin pain; everyone who had been unable to walk walked again. The local clinic had been giving 200–300 mg a day for one to three weeks; the investigation changed this to 600 mg a day for three days followed by 200 mg a day for 11 days.
Chest pain is not often described in scurvy at this age, but it was common here, believed to come from scurvy's effect on the collagen-containing cartilage at the ends of the ribs (the costochondral junctions).
Lessons
Scurvy is not new to Kakuma — outbreaks were reported in 1995–1997 and 2003 — or to refugee and prison populations in the region. Food aid is usually sized for an average household, but young men living together need far more calories than that. For them, neither the rations nor the cash was enough to cover both calories and a varied diet with enough vitamin C, and aid for adolescent and young adult male refugees needs to take that into account.
The investigation relied on self-reported symptoms and took place after the outbreak had peaked.
Sources
- Ververs M, Muriithi JW, Burton A, Burton JW, Lawi AO. "Scurvy Outbreak Among South Sudanese Adolescents and Young Men — Kakuma Refugee Camp, Kenya, 2017–2018." MMWR 68(3). CDC.
Licence: CC0 1.0 (public domain) · Adapted from www.cdc.gov
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