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close this bookScurvy and its Prevention and Control in Major Emergencies (WHO; 1999; 70 pages)
View the documentAcknowledgements
View the documentScurvy: definition
close this folderIntroduction
View the documentScope
View the documentBackground
View the documentRecent outbreaks of scurvy
View the documentRisk factors
open this folder and view contentsScurvy
open this folder and view contentsVitamin C
open this folder and view contentsRecommended Daily Allowance (RDA)
open this folder and view contentsSources of vitamin C
open this folder and view contentsStrategies to prevent scurvy in large refugee populations
View the documentCosts
open this folder and view contentsConclusions and recommendations
View the documentReferences
View the documentAnnex 1
View the documentAnnex 2
View the documentAnnex 3
View the documentBack Cover
 

Recent outbreaks of scurvy

Except for infantile scurvy, which was a well-recognised public health problem during the period 1945-65, particularly in Canada (Severs et al., 1961) and Australia (Turner et al., 1959), scurvy has been an extremely rare disease since the late 1940s. The problem was confined to infants that were not breast-fed and whose substitute food-most commonly evaporated cow's milk contained little vitamin C. Scurvy was also reported in selected communities in South Africa, e.g. among mine labourers and chronically malnourished urban populations (Grusin & Kincaid-Smith, 1954) whose diet consisted mainly of maize porridge, bread, small quantities of meat, and vegetables which were usually so overcooked that they were virtually devoid of vitamin C. More recently, scurvy has been reported in groups consuming a monotonous diet, e.g. soldiers and prisoners (Mardel et al., 1995), and among alcoholics, people on fad diets (Sherlock & Rothschild, 1967), widowers living alone and unaccustomed to cooking (Reuler et al., 1985), and even hospital patients.

The most recent epidemic occurred in 1982 among Ethiopian refugees in Somalia as a result of problems associated with providing an adequate diet for a large population in inaccessible areas where local food supplies were limited. Magan et al., (1983) reported that the most prominent symptoms were pain in the joints of the lower extremities and bleeding gums. Most of those affected were pastoral nomads whose main traditional source of vitamin C was camel's milk. This population's total dependency on donated rations inadequate in vitamin C, and with no access to local markets, resulted in a high prevalence of clinical signs of vitamin C deficiency. Table 1 summarises the daily ration supplied to this group.

Table 1. Daily rations supplied to Ethiopian refugees in Somalia in 1982

 

Amount
(g)

Vitamin C content
(mg)

Maize/sorghum

300

-

Wheat flour

75

-

Oil

30

-

Dried skimmed milk

40

2.8

Beans

40

-

Source: USAID, 1993

The daily requirement of vitamin C is estimated at 30 mg (FAO/WHO, 1970), although much lower daily doses of 6.5-10 mg have been found to be sufficient to prevent scurvy (G.B. Medical Research Council, 1953, Hodges et al., 1969, Hodges et al., 1971, Irwin & Hutchins, 1976).

With a diet completely lacking in vitamin C, body stores of vitamin C will last only about 2-3 months (Hodges et al., 1969; Carpenter, 1986). Although the refugees involved in the outbreak in Somalia had been in the camps for as long as 3 years, they had been supplementing their general rations with food (e.g. camel's milk, tomatoes, onions, sweet potatoes) purchased in the local markets in and around the camps (Magan et al., 1983). Six months prior to the scurvy outbreak, however, the Government of Somalia ordered the closure of all local markets. As a result poorer refugees were unable to purchase sufficient amounts of camel's milk or other vitamin C containing foods due to a sharp rise in price. Vitamin C tablets were distributed weekly to all refugees, and increased surveillance measures were instituted. More in-depth studies (of the interaction between socioeconomic factors and local food supplies) are required to explain the outbreak of scurvy in other camps not affected by the closure of markets.

Means of providing natural sources of vitamin C regularly to refugees are being explored but local sources are usually unable to deliver in required quantities. The importation of appropriate foods is costly and subject to the problems associated with transport and storage. Vitamin C is very unstable, easily oxidized, and destroyed by heat and sunlight (Marks, 1968). Since 1982, scurvy outbreaks have frequently been reported in other refugee areas, mainly in long-stay refugee camps on the Horn of Africa (Ethiopia, Kenya, Somalia and Sudan) where dwellers have not had access to fresh fruit and vegetables. Prevalence rates for scurvy in some camps for Ethiopian refugees have been among the highest recorded this century (see Table 2).

Desenclos et al., (1989) reported that in all camps cases of scurvy began to be reported within 3-10 months (median 4 months) of the refugees' arrival. The highest incidences occurred during and immediately after the dry season, February to May in Eastern Sudan and July to October in Northern Somalia. The risk of developing scurvy increased with the length of time that refugees had been in the camps and was higher among those who were older and among women of reproductive age. The prevalence of scurvy was similar irrespective of whether the refugees had participated in supplementary feeding programmes. Outbreaks occurred after 3-4 months consumption of relief food containing no more than 2 mg of vitamin C per day (WHO, 1989). No fresh food in significant quantities was available for purchase. Depending on the camp, vitamin C tablets, fresh food (lemons, onions) and/or corn soya milk (CSM) powder (40 mg vitamin C per 100 g (UNHCR, 1986)) were distributed.

Table 2. Prevalence rates of scurvy among refugees in the Horn of Africa

Year

Location

Population

Prevalence (%)

1982a

Southern Somalia

150 000

1-5

1984b

Eastern Sudan

50 000

22

1985c

North-West Somalia

160 000

7-44

1989c

Hartisheik Ethiopia

170 000

1-2

1991d

Kassala Sudan

20 000

15

a Magan et al. 1982; b Desenclos et al. 1989; c CDC, 1989; d Toole, 1992

Attendance at supplementary feeding centres and distribution of cooked rations prepared with CSM were not associated with any preventive effect. This may be due to the low concentration of vitamin C in CSM, and to the vitamin's poor heat and storage stability (Hallberg et al., 1982). The weekly distribution of vitamin C tablets to all children less than 5 years of age and to pregnant and lactating women, and the active enrolment of malnourished children in supplementary feeding programmes was instituted in June 1989 (Centers for Disease Control, 1989). Vitamin C tablets have only limited success because of problems with distribution and compliance. The only effective solution is to provide a complete general ration by distributing additional commodities or by fortifying existing ones (Seaman & Rivers, 1989). Mid- and long-term solutions need to be based on developing refugees' self-reliance through education campaigns and by encouraging home gardening efforts.

The extent to which scurvy contributes to mortality is uncertain. However, because vitamin C is associated with protection against infection and increased iron absorption (WHO, 1976), scurvy might well have had a role to play in the very high mortality and morbidity rates reported in the region (Toole et al., 1988). This underscores the need, and importance, of determining feasible interventions which will help to prevent vitamin C deficiency in refugee populations.

More recently, scurvy was reported at clinics in camps in Eastern Ethiopia with incidences as high as 3.5/1000/month in November 1993 and 12.8/1000/month in January 1994 (ACC/SCN, RNIS reports No. 3,4). Throughout 1993 food distribution to the camps was erratic and inadequate, there was little progress in developing self-sufficiency through rehabilitation programmes, and there were few opportunities for refugees to supplement their rations.

Persistent outbreaks of scurvy among Somali and Ethiopian refugees have occurred in Kenya; for example, there were reports of renewed outbreaks of scurvy in late 1994 (ACC/SCN, RNIS report No. 8). Shortages of fruit and vegetables in the markets because of drought, over-cooking of CSM, and seasonal factors affecting food availability were associated with the emergence of scurvy in Kenya (ACC/SCN, RNIS report No. 8).

In January 1994, the first cases of scurvy were reported among Bhutanese refugees in Nepal, mainly in the 10-30 year age group, with an incidence rate of 0.7/10000/day (ACC/SCN, RNIS Report No. 5). Throughout the first half of 1994, incidence rates were of the order of 0.5-0.7/10000/day. while in October 1995 the incidence was 0.12/10000/day (ACC/SCN, RNIS Report No. 13). Continued low levels of scurvy, despite inclusion of fresh vegetables and corn soya blend (CSB) in the general ration, suggests that entire households, or at least some members, lacked access to fresh vegetables and/or CSB, or had additional nutritional requirements.

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