title: Concurrent outbreaks of cholera and peripheral neuropathy associated with high mortality among persons internally displaced by a volcanic eruption.
abstract: BACKGROUND
  In October 2004, Manam Island volcano in Papua New Guinea erupted, causing over 10 000 villagers to flee to internally displaced person (IDP) camps, including 550 from Dugulaba village. Following violence over land access in March 2010, the IDPs fled the camps, and four months later concurrent outbreaks of acute watery diarrhea and unusual neurological complaints were reported in this population.
  
  
  METHODS
  A retrospective case-control study was conducted to identify the risk factors for peripheral neuropathy. Rectal swabs were collected from cases of acute watery diarrhea. Hair and serum metals and metalloids were analyzed by Inductively Coupled Plasma-Mass Spectrometry (ICP-MS).
  
  
  RESULTS
  There were 17 deaths among the 550 village inhabitants during the outbreak period at a crude mortality rate 21-fold that of a humanitarian crisis. Vibrio cholerae O1 El Tor Ogawa was confirmed among the population. Access to community-level rehydration was crucial to mortality. Peripheral neuropathy was diagnosed among cases with neurological symptoms. A balanced diet was significantly protective against neuropathy. A dose-response relationship was seen between peripheral neuropathy and a decreasing number of micronutrient- rich foods in the diet. Deficiencies in copper, iron, selenium and zinc were identified among the cases of peripheral neuropathy.
  
  
  CONCLUSIONS
  Cholera likely caused the mostly preventable excess mortality. Peripheral neuropathy was not caused by cholera, but cholera may worsen existing nutritional deficiencies. The peripheral neuropathy was likely caused by complex micronutrient deficiencies linked to non-diversified diets that potentially increased the vulnerability of this population, however a new zinc-associated neuropathy could not be ruled out. Reoccurrence can be prevented by addressing the root cause of displacement and ensuring access to arable land and timely resettlement.
authors.affiliation: World Health Organization, Port Moresby, National Capital District (NCD), Papua New Guinea ; School of Public Health and Community Medicine, The University of New South Wales, New South Wales, Sydney, NSW, Australia.
authors.forename: Alexander
authors.initials: A
authors.lastname: Rosewell
authors.forename: Geoff
authors.initials: G
authors.lastname: Clark
authors.forename: Paul
authors.initials: P
authors.lastname: Mabong
authors.forename: Berry
authors.initials: B
authors.lastname: Ropa
authors.forename: Enoch
authors.initials: E
authors.lastname: Posanai
authors.forename: Nicola W Y
authors.initials: NW
authors.lastname: Man
authors.forename: Samir R
authors.initials: SR
authors.lastname: Dutta
authors.forename: Wasa
authors.initials: W
authors.lastname: Wickramasinghe
authors.forename: Lixia
authors.initials: L
authors.lastname: Qi
authors.forename: Jack C
authors.initials: JC
authors.lastname: Ng
authors.forename: Glen
authors.initials: G
authors.lastname: Mola
authors.forename: Anthony B
authors.initials: AB
authors.lastname: Zwi
authors.forename: C Raina
authors.initials: CR
authors.lastname: MacIntyre
mesh_terms: D016022:Case-Control Studies; D002771:Cholera / Q000453:epidemiology*; D005260:Female; D006801:Humans; D008297:Male; D010219:Papua New Guinea / Q000453:epidemiology; D010523:Peripheral Nervous System Diseases / Q000453:epidemiology*; D012189:Retrospective Studies; D012307:Risk Factors; D018707:Volcanic Eruptions
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