ProMED: Angola, Poss. Mass Psychogenic Illness, multi-focal

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FOR YOUR INFORMATION...Date: August 29, 2011 1:50:02 PM GMT+03:00Subject: ProMED: Angola, Poss. Mass Psychogenic Illness, multi-focalReply-To: Greenberg UNDIAGNOSED OUTBREAK, SCHOOLS - ANGOLA (02): MASS HYSTERIA SUSPECTED********************************************************************A ProMED-mail post <http://www.promedmail.org>ProMED-mail is a program of the International Society for InfectiousDiseases <http://www.isid.org>[1]Date: Wed 17 Aug 2011 [edited]There is a possibility of mass psychogenic illness [MPI]. Onlyvomiting is unusual in mass psychogenic illness and all other featurescorrespond to MPI. Always exclude other causes before diagnosis ofMPI.--Dr. Jahangir HossainAssociate ScientistHead, Outbreak investigation clusterDhakaBangladesh******[2]Date: Wed 17 Aug 2011 [edited]Following the latest ProMED-mail communication (20110816.2486) of theWHO outbreak report in Angola, suspected currently for exposure toirritant chemicals, I would like to comment that although it should beprimarily a diagnosis by exclusion only, an outbreak of "masshysteria", also known as "epidemic hysteria" or "mass sociogenicillness", could eventually make another possible etiology for thiskind of outbreak and its unique characteristics, as preliminaryreported.Sudden onset with rapid (and complete) resolution within a few hoursof several symptoms, all of which could have had a psychogenic origin(such as, vomiting, breathing difficulties, fainting), andparticularly in school children (no other population, such as schoolteachers, was mentioned in the initial WHO report), was also reportedbefore in numerous outbreaks of epidemic hysteria [1].A literature review [1] has found that about 50 percent of thereported past 20th century epidemic hysteria outbreaks were associatedwith schools, mostly with schoolchildren and with higher femaleprevalence. The trigger of such outbreaks was often reported to beassociated with an environmental event or even a rumor of such anevent (such as, water supply contamination, a gas odor or perceptionof such odor).Reference---------1. Boss LP: Epidemic hysteria: a review of the published literature.Epidemiol Rev 1997; 19(2): 233-43 [available at<http://epirev.oxfordjournals.org/content/19/2/233.full.pdf>].--Eran Kopel MDTel Aviv, Israel[ProMED-mail thanks Drs Hossain and Kopel for their timely comments.This moderator also considered MPI in the differential diagnosis inthis situation in Angola but was awaiting more information. Acommission in Angola has also suggested the diagnosis as well as seenbelow. - Mod.LL]******[3]Date: Thu 4 Aug 2011Source: Daily Monitor (Uganda) [edited]<http://www.monitor.co.ug/News/World/-/688340/1213862/-/11gql3e/-/index.html>A commission set up by the Angolan government to probe mass faintingin schools in the country has denied that toxic gas was responsibleand instead blamed "mass hysteria" for the phenomenon.More than 500 pupils have allegedly fainted in 7 provinces includingthe capital Luanda since April 2011, allegedly due to intoxicationwith an unidentified gas. The fainting wave has affected mainlyfemales and speculation had earlier centered on criminals supposedlysighted launching toxic gas in the institutions.But on Wednesday, 3 Aug 2011, the deputy commander of the NationalPolice, o de Almeida, dismissed the existence of such a gas."Tests do not confirm any toxic substance causing the faintingregistered in several schools in the country," he said at a newsconference. "The tests were done and the results are negative," hesaid, adding that the samples had also been sent to foreignlaboratories. The officer however admitted that some gangs wereseeking to capitalize on the public's panic and confirmed the forcehad made some arrestsAnother member for the commission, Luanda psychiatric hospitaldirector Dr Rui Pires, said that no syndrome of any sort had beenconfirmed and alluded to "psychological" problems instead.Dr Adelaide de Carvalho the national director of public health, saidnone of the teenagers had spent more than 5 days in hospitals, andsome of them were asthmatics.[byline: Arnaldo Vieira]--[Additional references on mass hysteria cited in a previous ProMED-mail posting:1. Govender I: Mass hysteria with possible pseudoseizures at a primaryschool. S Afr Med J. 2003; 93(1): 10 (available at<http://www.samj.org.za/index.php/samj/article/viewFile/2025/1283>).2. Small GW, Feinberg DT, Steinberg D, MT: A sudden outbreakof illness suggestive of mass hysteria in schoolchildren. Arch FamMed. 1994; 3(8): 711-6 (available at<http://archfami.ama-assn.org/cgi/content/abstract/3/8/711>).3. Mkize DL, Ndabeni RT: Mass hysteria with pseudoseizures at a SouthAfrican high school. S Afr Med J. 2002; 92(9): 697-9.4. Roach ES, Langley RL: Episodic neurological dysfunction due to masshysteria. Arch Neurol. 2004; 61(8): 1269-72 (available at<http://archneur.ama-assn.org/cgi/content/full/61/8/1269>).5. Pastel RH: Collective behaviors: mass panic and outbreaks ofmultiple unexplained symptoms. Mil Med. 2001; 166(12 Suppl): 44-6(available at<http://findarticles.com/p/articles/mi_qa3912/is_200112/ai_n9008773/>).6. CDC: Rashes Among Schoolchildren: 14 States, October 4,2001-February 27, 2002. MMWR 2002: 51(8); 161-4; available at<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5108a1.htm>.7. Bartholomew RE: Re: "Epidemic hysteria: a review of the publishedliterature". Am J Epidemiol. 2000; 151(2): 206-7 (available at<http://aje.oxfordjournals.org/content/151/2/206.full.pdf>).8. Cole TB, Chorba TL, Horan JM: Patterns of transmission of epidemichysteria in a school. Epidemiology. 1990; 1(3): 212-8 (available at<http://www.jstor.org/pss/25759800>).9. P, Szewczyk M, Haddy L, P, Harvey W: Outbreak ofitching and rash. Epidemic hysteria in an elementary school. ArchIntern Med. 1984; 144(10): 1959-62 (abstract available at<http://www.ncbi.nlm.nih.gov/pubmed/6486980>).10. Dhadphale M, Shaikh SP: Epidemic hysteria in a Zambian school:"the mysterious madness of Mwinilunga". Br J Psychiatry. 1983; 142:85-8 (abstract available at<http://bjp.rcpsych.org/content/142/1/85.abstract>).11. TF, Craig AS, Hoy D, et al: Mass psychogenic illnessattributed to toxic exposure at a high school. N Engl J Med. 2000;342(2): 96-100 (available at<http://www.nejm.org/doi/full/10.1056/NEJM200001133420206>. - Mod.LL][The curiosity here is the occurrence of these events in multipleschools located in 7 different provinces. We have not seeninformation on the time line (epidemic curves) of each of theseoutbreaks, but one wonders if there has been media coverage of eachoutbreak and that subsequent outbreaks occurred following the mediacoverage. A review of the literature revealed reports of illnesseslabeled as "mass hysteria" were overwhelmingly from a singlegeographic location (a school, a single town, a single village). Ofinterest, there was an incident associated with vaccine administrationin Jordan where day one, there was a mass hysteria event leading to 80students from one school being hospitalized that day, with thefollowing day up to 122 students country-wide were hospitalized. Acontributing factor seemed to be the media coverage of the initialmass hysteria event. (see Kharabsheh S, Al-Otoum H, Clements J, AbbasA, Khuri-Bulos N, Belbesi A, Gaafar T, Dellepiane N. Mass psychogenicillness following tetanus-diphtheria toxoid vaccination in Jordan.Bull World Health Organ. 2001;79(8):764-70. Epub 2001 Oct 24.available at <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2566491/pdf/11545334.pdf>).Given the unusual geographic distribution of these events, we awaitfurther information on the results of the investigation underway asmentioned in the WHO report in the earlier post on this outbreak(Undiagnosed outbreak, schools - Angola: WHO, RFI 20110816.2486). -Mod.MPP][The HealthMap/ProMED-mail interactive map of Angola can be seen at<http://healthmap.org/r/18AP>. - Sr.Tech.Ed.MJ]Date: Mon 15 Aug 2011Source: WHO Global Alert and Response (GAR) [edited]<http://www.who.int/csr/don/2011_08_15/en/index.html>Outbreak of illness in schools in Angola----------------------------------------An outbreak of an unknown illness has been reported among children andstudents in schools in Angola. In most cases, the illness has occurredsuddenly, followed by the resolution of symptoms within a few hours.No deaths have been reported. The typical symptoms reported include:vomiting, headache, sore throat, eye irritation, coughing, breathingdifficulties, and fainting in some cases. The outbreaks have beenreported in schools of the capital, Luanda, and in a number of otherprovinces.Although the cause of these outbreaks still remains unknown, this maybe related to exposure to irritant chemicals. WHO has sent a team toAngola to assist the Government in investigating these outbreaks andto suggest measures for preventing further occurrences. The WHO teamincludes an epidemiologist, laboratory specialists, and apharmacologist/toxicologist who are providing technical support to thenational intersectoral committee created for this purpose. This iscomplex work and WHO is consulting with experts and specializedinstitutions from other countries to explore ideas on appropriatelines of investigation.--Communicated by:ProMED-mail Rapporteur nne Hopp[indeed, the symptom complex described is compatible with a chemicalirritant. It is difficult to explain the apparent widespread nature ofthe outbreak involving schools in multiple provinces. A time curve ofwhere and when each school was affected would be instructive to see ifa pattern can be found. Hopefully, WHO can contribute to finding theetiology of these outbreaks. - Mod.LL][The HealthMap/ProMED-mail interactive map of Angola can be seen at<http://healthmap.org/r/18AP>. - Sr.Tech.Ed.MJ]SOURCE: OCC-ENV-MED-L Digest for Monday, August 29, 2011