Julie Cliff

Persistent konzo and cyanogen toxicity from cassava in northern Mozambique

We aimed to detect new cases of konzo and monitor cyanogen exposure from cassava flour in communities previously affected by konzo epidemics in Nampula Province, northern Mozambique. Other objectives were to detect subclinical upper motor neuron damage in schoolchildren and test a new kit to measure urinary thiocyanate concentration. In 1999 and 2000, we carried out active and passive case detection for konzo in Memba and Mogincual Districts. In July and October, 1999, we collected cassava flour from 30 houses in three communities and measured cyanogen concentrations with a picrate kit. In October 1999, we examined all schoolchildren in three communities for ankle clonus and measured urinary thiocyanate concentration in thirty schoolchildren in each of five communities with a picrate kit. We found 27 new cases of konzo in Mogincual District. Mean total cyanogen concentrations in cassava flour varied between both seasons and years, but were always high, ranging from 26 to 186 ppm. Very high mean levels at three sites in November 1998 and July 1999 were probably due to low rainfall in the 1997-1998 season. The proportion of schoolchildren with ankle clonus varied from 8 to 17%. The new picrate kit for urinary thiocyanate worked well; mean concentrations in schoolchildren ranged from 225 to 384 micromol x l(-1). Konzo and sub-clinical upper motor neuron damage persist in poor rural communities in northern Mozambique, associated with high cyanogen concentrations in cassava flour and high urinary thiocyanate concentrations in schoolchildren.

Konzo and continuing cyanide intoxication from cassava in Mozambique

In Mozambique, epidemics of the cassava-associated paralytic disease, konzo, have been reported in association with drought or war: over 1100 cases in 1981, over 600 cases in 1992-1993, and over 100 cases in 2005. Smaller epidemics and sporadic cases have also been reported. Large epidemics have occurred at times of agricultural crisis, during the cassava harvest, when the population has been dependent on a diet of insufficiently processed bitter cassava. Konzo mostly affects women of child-bearing age and children over 2 years of age. When measured, serum or urinary thiocyanate concentrations, indicative of cyanide poisoning, have been high in konzo patients during epidemics and in succeeding years. Monitoring of urinary thiocyanate concentrations in schoolchildren in konzo areas has shown persistently high concentrations at the time of the cassava harvest. Inorganic sulphate concentrations have been low during and soon after epidemics. Programmes to prevent konzo have focused on distributing less toxic varieties of cassava and disseminating new processing methods, such as grating and the flour wetting method. Attention should be given to the wider question of agricultural development and food security in the regions of Africa where dependence on bitter cassava results in chronic cyanide intoxication and persistent and emerging konzo.

Konzo: from poverty, cassava, and cyanogen intake to toxico-nutritional neurological disease.

Konzo is a distinct neurological entity with selective upper motor neuron damage, characterized by an abrupt onset of an irreversible, non-progressive, and symmetrical spastic para/tetraparesis. Despite its severity, konzo remains a neglected disease. The disease is associated with high dietary cyanogen consumption from insufficiently processed roots of bitter cassava combined with a protein-deficient diet. Epidemics occur when these conditions coincide at times of severe food shortage. Up to 1993, outbreaks in poor rural areas in Africa contributed to more than 3,700 cases of konzo. The number of affected people is underestimated. From unofficial reports, the number of cases was estimated to be at least 100,000 in 2000, in contrast to the 6,788 cases reported up to 2009 from published papers.

Translating research into policy: lessons learned from eclampsia treatment and malaria control in three southern African countries.

BackgroundLittle is known about the process of knowledge translation in low- and middle-income countries. We studied policymaking processes in Mozambique, South Africa and Zimbabwe to understand the factors affecting the use of research evidence in national policy development, with a particular focus on the findings from randomized control trials (RCTs). We examined two cases: the use of magnesium sulphate (MgSO4) in the treatment of eclampsia in pregnancy (a clinical case); and the use of insecticide treated bed nets and indoor residual household spraying for malaria vector control (a public health case).MethodsWe used a qualitative case-study methodology to explore the policy making process. We carried out key informants interviews with a range of research and policy stakeholders in each country, reviewed documents and developed timelines of key events. Using an iterative approach, we undertook a thematic analysis of the data.FindingsPrior experience of particular interventions, local champions, stakeholders and international networks, and the involvement of researchers in policy development were important in knowledge translation for both case studies. Key differences across the two case studies included the nature of the evidence, with clear evidence of efficacy for MgSO4 and ongoing debate regarding the efficacy of bed nets compared with spraying; local researcher involvement in international evidence production, which was stronger for MgSO4 than for malaria vector control; and a long-standing culture of evidence-based health care within obstetrics. Other differences were the importance of bureaucratic processes for clinical regulatory approval of MgSO4, and regional networks and political interests for malaria control. In contrast to treatment policies for eclampsia, a diverse group of stakeholders with varied interests, differing in their use and interpretation of evidence, was involved in malaria policy decisions in the three countries.ConclusionTranslating research knowledge into policy is a complex and context sensitive process. Researchers aiming to enhance knowledge translation need to be aware of factors influencing the demand for different types of research; interact and work closely with key policy stakeholders, networks and local champions; and acknowledge the roles of important interest groups.

Konzo associated with war in Mozambique

We report an epidemic of konzo, symmetric spastic paraparesis associated with cassava consumption and cyanide exposure: 384 patients were treated in rehabilitation centres; the prevalence rate in a badly affected area was 30/1000. Most patients were children over 3 and women. Owing to war, communities turned to bitter cassava as their staple and took shortcuts in its processing. When the war ended, they continued to depend on inadequately processed bitter cassava. The epidemic lasted 2 years (the last year of war and the first of peace) with peaks each year during the cassava harvest. Although most cases were reported from rural inland areas, patients also came from small towns and the coast. School children had raised urinary thiocyanate and linamarin and low inorganic sulphate concentrations. Urinary thiocyanate values were lower than those previously reported in konzo epidemics, probably because we collected specimens before the cassava harvest and epidemic peak. The necessary conditions for konzo were present: intensive cultivation of bitter cassava, insufficient processing, a probable high cyanide intake, and a low intake of protein‐rich foods.

Cyanogenic potential of cassava flour: field trial in Mozambique of a simple kit

The cyanogenic potential (ppm HCN equivalents) of 80 samples of cassava flour (obtained from the Mujocojo and Terrene-A areas of Nampula Province and the markets of Nampula City in Mozambique) were determined using a new simple kit, based on the use of picric acid paper (Egan et al., 1997). The kit is compact, requires only a small amount of water and is very simple to use in the field. Comparison with the results of a semi-quantitative method shows a mean deviation between the two methods of 20% (SD 12%). All samples fitted a single population distribution with a mean value of 45 ppm HCN equivalents (SD 37). Two maxima were observed in the distribution curve at 11-20 and 41-50 ppm. Five samples exceeded 100 ppm with two values of 200 ppm. The WHO safe level for cyanogens in cassava flour is 10 ppm. The lowest levels (2 and 6 ppm) were obtained from cassava flour prepared from sweet cassava. Over 76 samples the mean value of the cyanogenic potential of cassava flour produced by heap fermentation is only one half as large as that produced by sun-drying (P < 0.005). Interventions needed to reduce cyanogen levels are (1) improvements in processing methods, such as replacement of sun-drying by heap fermentation, (2) introduction of additional vegetables, pulses and fruit to alleviate the monotonous cassava diet of the people and (3) introduction of high-yielding, disease-resistant, low-cyanide cultivars.

System and market failures: the unavailability of magnesium sulphate for the treatment of eclampsia and pre-eclampsia in Mozambique and Zimbabwe.

Low cost and effective drugs, such as magnesium sulphate, need to be included in initiatives to improve access to essential medicines in Africa Ensuring the availability of effective drugs for priority health problems remains a key public health issue in many African countries.1 Market deficiencies in ensuring drug development for “neglected” diseases affecting developing countries are well described,2 3 w1 and several global initiatives are attempting to tackle this.4 w2 Even when low cost, effective treatments exist, however, drug availability for many common health problems remains poor in many settings, limiting progress towards achieving the millennium development goals.5 One such health problem is the management of pre-eclampsia and eclampsia, important causes of maternal and infant morbidity and mortality. Over 63 000 women die annually after eclamptic convulsions, with 99% of these deaths occurring in low and middle income countries.6 7 w3 Evidence is strong for the effectiveness of magnesium sulphate in treating and preventing eclampsia.8–10 w4 w5 Magnesium sulphate costs

The impact of war on children's health in Mozambique

0.35 (£0.19; €0.29) per ampoule (40 ml of 10% magnesium sulphate; Central Medical Stores, Mozambique, April 2005) and has appeared on the World Health Organizations essential medicines list since 1996.11 It is of great concern that this effective and low cost drug is still unavailable in many countries.12 13 w6 w7 We describe problems with the registration, approval, acquisition, and distribution of magnesium sulphate, and hence its availability to clinicians, in Mozambique and Zimbabwe, two countries with high maternal mortality ratios (table).14–16 We draw on a range of sources, including a bibliographical review of policies concerning magnesium sulphate over the past 25 years and qualitative data collected as part of a case study of policy making and procurement for magnesium sulphate in the two countries (box …

Policy challenges facing integrated community case management in Sub‐Saharan Africa

Since 1982, South African destabilization of Mozambique has caused childrens health to deteriorate. Destabilization has functioned through support of a surrogate movement and economic pressure. Attacks on economic and civilian targets have included the health services, leading to closure of 48% of the primary health care network. The war has caused displacement of over 3,000,000 persons and an estimated 494,000 excess childhood deaths between 1981 and 1988. An estimated 200,000 children have been separated from their families or orphaned; many children have also witnessed atrocities and suffered violence. A deepening economic crisis has been followed by an economic structural adjustment programme. Responses to the war include changes in vaccination strategy and programmes to reunite families and heal psychological trauma.

The burden of disease in Maputo City, Mozambique: registered and autopsied deaths in 1994

To report an in‐depth analysis of policy change for integrated community case management of childhood illness (iCCM) in six sub‐Saharan African countries. We analysed how iCCM policies developed and the barriers and facilitators to policy change.