Outbreak of mass sociogenic illness in a school feeding program in northwest Bangladesh, 2010.
BACKGROUND
In 2010, an acute illness outbreak was reported in school students eating high-energy biscuits supplied by the school feeding programme in northwest Bangladesh. We investigated this outbreak to describe the illness in terms of person, place and time, develop the timeline of events, and determine the cause and community perceptions regarding the outbreak.


METHODS
We defined case-patients as students from affected schools reporting any two symptoms including abdominal pain, heartburn, bitter taste, and headache after eating biscuits on the day of illness. We conducted in-depth interviews and group discussions with students, teachers, parents and community members to explore symptoms, exposures, and community perceptions. We conducted a questionnaire survey among case-patients to determine the symptoms and ascertain food items eaten 12 hours before illness onset, and microbiological and environmental investigations.


RESULTS
Among 142 students seeking hospital care, 44 students from four schools qualified as case-patients. Of these, we surveyed 30 who had a mean age of 9 years; 70% (21/30) were females. Predominant symptoms included abdominal pain (93%), heartburn (90%), and bitter taste (57%). All students recovered within a few hours. No pathogenic Vibrio cholerae, Shigella or Salmonella spp. were isolated from collected stool samples. We found no rancid biscuits in schools and storage sites. The female index case perceived the unusually darker packet label as a "devil's deed" that made the biscuits poisonous. Many students, parents and community members reported concerns about rumors of students dying from biscuit poisoning.


CONCLUSIONS
Rapid onset, followed by rapid recovery of symptoms; female preponderance; inconsistent physical, microbiological and environmental findings suggested mass sociogenic illness rather than a foodborne or toxic cause. Rumours of student deaths heightening community anxiety apparently propagated this outbreak. Sharing investigation results and reassuring students and parents through health communication campaigns could limit similar future outbreaks and help retain beneficiaries' trust on nutrition supplementation initiatives.
Centre for Communicable Diseases (CCD), icddr,b, Dhaka, Bangladesh ; Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka, Bangladesh.
Farhana
F
Haque
Subodh Kumar
SK
Kundu
Md Saiful
MS
Islam
S M Murshid
SM
Hasan
Asma
A
Khatun
Partha Sarathi
PS
Gope
Zahid Hayat
ZH
Mahmud
A S M
AS
Alamgir
M Sirajul
MS
Islam
Mahmudur
M
Rahman
Stephen P
SP
Luby
D001459:Bangladesh / Q000453:epidemiology; D002648:Child; D004196:Disease Outbreaks; D005260:Female; D006801:Humans; D007046:Hysteria / Q000453:epidemiology; D008297:Male; D008399:Mass Behavior; D012574:Schools / Q000706:statistics & numerical data; D013334:Students / Q000523:psychology* / Q000706:statistics & numerical data*