Large outbreak of Jimsonweed (Datura stramonium) poisoning due ... - BMC Public Health

Our investigation revealed an outbreak of tropane alkaloid poisoning. Identifying atropine and scopolamine in a ratio of roughly 10:1 suggested a potential botanical source for the contamination; Jimsonweed (Datura stramonium) was identified as a contaminant of corn-soy-based humanitarian relief food distributed to the affected population. The outbreak occurred in a food-insecure region in northeastern Uganda, where relief food has been distributed for many years. This was the largest such outbreak recorded in the published literature [4].

Symptoms reported by patients during this outbreak, particularly neurologic symptoms, were consistent with other studies of tropane alkaloid poisoning [2, 5, 19, 20]. Consistent with other food poisoning incidents involving tropane alkaloids [21, 22], many patients, especially children, developed aggressive behavior resulting in skin injuries such as bruises and cuts. Symptoms started within 2 h of eating CSB + food, which is consistent with poisoning; fever among some case-patients was consistent with the pharmacokinetic effects of atropine following quick absorption from the gastrointestinal tract [23]. The absence of jaundice and bleeding made aflatoxicosis unlikely as an etiology [24].

This outbreak caused five deaths. Previous outbreaks of unintentional tropane alkaloid poisoning have rarely resulted in death [5, 21, 25]. The deaths in this outbreak are likely associated with the high concentrations of tropane alkaloids in the implicated batch of CSB + . Levels of atropine and scopolamine in this outbreak were hundreds of times higher than those reported in other domestic food poisoning cases and the allowable levels set by the European Food Safety Authority [4, 26]. As with all toxins, tropane alkaloid toxicity is dose dependent. The toxic doses for individual tropane alkaloids have been previously estimated based upon human case reports. More than 10 mg of atropine in adult humans is expected to cause significant toxicity. In contrast, more than 50 mg, or 1-2 mg/kg, may be fatal. Data for scopolamine toxicity is scarce; however, doses of 78–435 mg have been reported to cause significant toxicity in adults, and as little as 10 mg may be fatal in children [27]. The high number of deaths could also be due to multiple tropane alkaloids in Batch X, coupled with the high prevalence of malnutrition among children aged 6–59 years (stunting 45% and underweight at 31.9%) in the Karamoja Region [28]. Autopsy conducted on three of the five decedents did not find any evidence of the cause of death. The limitted scope of tissue examination could explain this.

The contaminated corn-soy relief food in our study was sourced from Turkey. Jimsonweed, which favors growth in fields of leguminous crops, has long been known to exist in Turkey [29]. Soy contamination with toxic weed seeds, including jimsonweed, has long been recognized [30]. Physically, jimsonweed seeds are similar to some varieties of soy seeds in color and size, making it possibly difficult to separate the two during processing [31]. Identification of proteins from Solanaceae seeds and isolation of DNA of jimsonweed in Batch X suggested the possibility of contamination at harvesting and production stages due to failure of quality control mechanisms along the value chain [32]. This has also been the commonest route of contamination by tropane alkaloids in previous incidents of unintended food poisoning [5, 21, 25]. The finding that 'control' CSB + samples sourced from un-affected households and central warehouse also contained low levels of atropine (< 50 ppb) indicates that low-level atropine contamination could be widespread [33].

During this investigation, tracking Batch X back to the point of manufacture proved difficult as batch numbers were related to donation consignment and not related to production date, source of raw materials, or machine plant. This is contradictory to documented best practices [34,35,36]. Furthermore, the packaging of CSB + lacked unique serial numbering that could have aided sequential tracking of the individual food sacks distributed. These factors made it difficult to establish possible contamination points along the supply chain beyond the production stage. Labeling such shipments in the future should maintain a coding system that enables tracking back to the source of the product to allow efficient trace-back. Lotome and Karita subcounties were the most affected of the 12 subcounties evaluated. Health facilities serving these sub-counties were the first to run out of Batch W and began distributing Batch X, the implicated food; this further accounts for the clustering of cases around these health facilities and the absence of cases in areas that had not distributed the food. The reasons for the higher attack rates among females over five years of age was likely due to differences in gender roles in this community; males spend most of their time away from home in dry seasons, searching for greener pastures to feed their cattle, while women primarily stay at home [37].

Our investigation had three major strengths. First, we conducted a rigorous and thorough epidemiologic investigation, closely following the standard steps of an outbreak investigation [38], making results reliable. Second, the FDA/CFSAN of United States and Mérieux Nutrisciences Laboratories in Italy, both world-renowned laboratories, conducted independent testing of the food samples; the corroboration of results further eliminated incidental laboratory findings. Third, the clinical presentations of patients were consistent with both the identified chemical agent (tropane alkaloids) and the plant source (Datura stramonium), further elaborating the biological plausibility of the results. However, we could not confirm the etiologic agent in human samples. Due to logistical limitations, we could not trace the food to its origin to determine precisely how the corn and soy were contaminated with jimsonweed. This trace-back investigation would have aided in identifying the source and mechanism of contamination.

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