Pellagra in Angola
Pellagra Sophie Baquet 21.12.99
Pellagra -Reply Rita Bhatia 21.12.99
pellagra in Angola Mike Golden 21.12.99
Re: FW: pellagra in Angola Don McCormick 26.12.99

Date: Tue, 21 Dec 1999 15:06:49 +0000


Subject: Pellagra


Dears all,

I would like to ask your opinion and your advice on the following problem :

A pellagra epidemic is occurring in Kuito (Angola). The diagnosis of the cases is based on typical dermatological presentation of the pellagra (a dermatitis on two different and symmetrical sites exposed to sunlight or with a typical casal's necklace).

A total number of 616 cases have been diagnose since July 1999. (attack rate in town estimated 2.6/1000 inhabitants.) The disease is occurs particularly in woman (83 %) and among the over 15 years old (85%). 66 % of the cases come from the displaced population.

All patients have been treated with Nicotinamide and Vitamin B complex + a food diet with high content of niacin and protein. (CSB, dry fish). Cure is usually successful within 3 weeks.

We think that a strong emphasis should be placed on the prevention by the provision of an adequate nutrients rations.

The niacin content of the actual daily ration distributed is +/- 8 mg. A solution could be to enrich the actual ration with blended food, peanuts or other sources of Niacin. An other method could be the local fortification of food as it was done in Malawi.

A routine tablets supplementation to the entire population seems not be a solution (difficult to organise, expensive and probably infective in the long term)

I would appreciate any advice, technical information on fortification or experience dealing with pellagra.

Thanks. Regards,


Sophie Baquet

Medecins Sans Frontières, Bruxelles

Date: Tue, 21 Dec 1999 16:30:56 +0100

From: Rita Bhatia <>

Subject: Pellagra -Reply



This message takes me back to 1989-1990 Out break of Pellagra in Malawi among the Mozambican Refugees. MSF France was very active in the epidemiological surveillance and intervention.

Forti cation of Maize Flour at Blantyre was one of the intervention and local production of CSB with specific premix for fortification. Ground nuts were added into the food basket.

Date: Tue, 21 Dec 1999 19:42:50 +0000

From: Michael Golden <>

Subject: pellagra in Angola


Dear Ngonuts,

The message by Sophie Baquet about pellagra in Angola is important and deserves comment at a number of levels. There is a report in Word (131Kb) which I'm sure that Sophie will make available to anyone with a professional interest. There is clearly a great urgency to mobilise the resources necessary to properly deal with this situation, even at this late stage.

Jeya Henry and other NGONUTS have previous experience of the epidemic in Malawi and I hope that their help will be offered and accepted.

There is a major problem with case definition so that the true extent of the problem is normally underestimated. The rash starts as a sensation of burning in light exposed areas, followed by slight oedema of the skin which then blisters and develops dark patches: it progresses to scaling with fissures in between which may bleed. The lesions are symmetrical - and usually quite sharply demarcated on the hands, feet, face or neck. The Casal's necklace are classical, but also "boot and glove" lesions with sharp demarcation and a dark butterfly rash on the cheeks occur. These classical features are diagnostic and no other disease seems to give this pattern; this is strongly supported by the diet history where the affected population has been subsisting on maize, beans, sugar and oil, with the purchase of wheat in the previous week being a protective feature in the epidemiology and indeed, could have been predicted for any population living on this ration. We can be confident that this is indeed pellagra and the cause is the restricted diet.

However, these classical signs only seem to occur in older persons - children do not seem to get the skin lesions - and those that do not go out of doors do not get the skin lesions either.

However, the first signs of pellagra are usually diarrhoea (which is usually diagnosed as an infection) and is probably the main presenting feature in children although the research on this is not clear. Older patients experience a reduction in mental acuity and may have weakness, tremor, anxiety and depression. In severe cases there can be delirium - which is easily confused with other diagnoses such as cerebral malaria - also chronic deficiency can lead to dementia. Patients with these features will not be identified with any of the usual case definitions. There are usually features of other deficiency diseases as well. Thus, although with the strict case definition we can be confident that there is pellagra the true extent of the clinical illness caused by niacin deficiency is probably underestimated, potentially to a very great extent if the under 15s half the population. Furthermore, niacin deficiency will impair functioning and cause ill health at levels that are not low enough to generate the classical skin lesions. So this is the tip-of the iceberg and most of the population will be suffering from various degrees of niacin deficiency.

Niacin in maize is tightly bound and is much less available than from other grains so that when maize is the source a much higher amount is required and the maize niacin should not be added to the rest of the dietary intake without an adjustment for availability. Alkalinisation by addition of lime makes the niacin much more available, as used culturally in Central America, this may be a partial strategy to explore.

There is also not much tryptophan in maize - much of the niacin in the body is made from the amino acid tryptophan. This conversion is dependent upon another B vitamin - pyridoxine - and if the diet is low in pyridoxine as well as niacin then this will greatly exacerbate the deficiency. Pyridoxine should usually also be given to the patients as well as niacin as pellagra is much more commonly seen with the combined deficiency than with the single deficiency.

Note that patients on INH for Tuberculosis are particularly vulnerable as the drug interferes with pyridoxine and hence niacin metabolism.

Niacin is the precursor for NAD which is critical in energy metabolism and also for NADPH which is a central component of protection against free radicals. It may be for this reason that pellagra and kwashiorkor share so many common features. Nevertheless, one would expect any illness that causes an oxidative stress - malaria, diarrhoea, sepsis, pneumonia etc to be much more severe and have a much higher case fatality rate in patients that are on a marginal niacin containing diet - for this reason many deaths that would not have occurred if the subjects were not on a low niacin diet (and other deficiencies as well from a maize-beans-oil-sugar diet such as vitamin C and zinc etc) will be ascribed to the infection and not to the underlying cause of death with the disease.

There have been numerous other outbreaks of overt classical micronutrient deficiency in refugees and IDPs. That they still occur and are entirely predictable by any student of nutrition from consideration of the diet is a cause of shame for the whole world community. At the meeting in Machakos is was agreed that, as an expedient, that a small amount of CSB (40g per person per day) would be included in the food basket for refugees and IDPs.

Groundnuts are a rich source of niacin and the strategies that were used in Malawi are available if the resources can be mobilised. The logistic problems in Angola are immense and the agency staff are trying their best - but many hundreds of thousands of people are at great risk in this emergency, not only in the town served by MSF(B).

To a casual observer it would seem that politicians, donors, agency chiefs and other decision makers have concentrated their efforts and funds on the crisis in the Balkans, and withdrawn commitment from the mass of humanity in places like Angola. The result is yet another epidemic of an easily preventable nutritional deficiency.


Mike Golden

Date: Sun, 26 Dec 1999 18:41:49 -0500

From: Don McCormick <>

Subject: Re: FW: pellagra in Angola


Dear Joan,

I note one apparent oversite in Dr. Michael Golden's discussion. He mentioned the biochemically well-known relationship of vitamin B6 (pyridoxine) to niacin, but not that of riboflavin. This latter functions as FAD in the essential hydroxylase along the tryptophan to NMN (niacin equivalent) pathway, and is also necessary in the conversion of B6 (as pyridoxine 5'-phosphate and pyridoxamine 5'-phosphate) to coenzymic pyridoxal 5'-phosphate essential in the tryptophan to NMN pathway. This latter conversion (of B6 to its functional coenzyme) requires riboflavin (as FMN) too.Hence, riboflavin is a critical partner is the niacin story and, indeed, was often low and probably a complicating deficiency in the reports by Goldwater et al. on pellagra in the southeast of the U.S.A. For these reasons, namely that a mixed B-vitamin deficiency of niacin, B6, and riboflavin are common to pellagrins, it would seem best, if possible, to supplement with concern for all.


Don McCormick, F.E. Callaway Prof. of Biochemistry, Emory University, School of Medicine, Atlanta, GA 30322-3050