Description of a mass poisoning in a rural district in Mozambique: The first documented bongkrekic acid poisoning in Africa

Abstract

Background

On January 9, 2015, in a rural town in Mozambique, over 230 people became sick and 75 died from an illness linked to drinking pombe, a traditional alcoholic beverage.

Methods

An investigation was conducted to identify cases and determine the cause of the outbreak. A case was defined as any resident of Chitima who developed any new or unexplained neurologic, gastrointestinal, or cardiovascular symptom from January 9 at 6:00 a.m. through January 12. We conducted medical record reviews; healthcare worker and community surveys; anthropological and toxicological investigations of local medicinal plants and commercial pesticides; and laboratory testing of the suspect and control pombe.

Results

We identified 234 cases; 75 (32%) died and 159 recovered. Overall, 61% of cases were female (n=142), and ages ranged from 1–87 years (median: 30 years). Signs and symptoms included abdominal pain, diarrhea, vomiting, and generalized malaise. Death was preceded by psychomotor agitation and abnormal posturing. The median interval from pombe consumption to symptom onset was 16 hours. Toxic levels of bongkrekic acid (BA) were detected in the suspect pombe but not in the control pombe. Burkholderia gladioli pathovar cocovenenans, the bacteria that produces BA, was detected in the flour used to make the pombe.

Conclusions

We report for the first time an outbreak of a highly lethal illness linked to BA, a deadly food-borne toxin in Africa. Given that no previous outbreaks have been recognized outside of Asia, our investigation suggests that BA might be an unrecognized cause of toxic outbreaks globally.