Beriberi (thiamine hypovitaminosis) outbreak investigation among male prisoners in a state public jail, Brazil, 2020

Background:
In early May 2020, an outbreak of unknown etiology was reported among male prisoners in a public state jail, Brazil. Initial diagnostic hypotheses included leptospirosis, exogenous intoxication, and water/foodborne diseases; Beriberi hypothesis (thiamine hypovitaminosis) was considered during fieldwork. We investigated the outbreak to confirm the disease etiology, identify risk factors associated to illness, and recommend control measures.

Methods:
We conducted a descriptive followed by case-control study (1:1.5 ratio) based on medical records, available laboratory results and standardized interview questionnaire. Neither thiamine dosage nor therapeutic testing were possible; cases were defined as inmates who met Beriberi suspected clinical criteria between January 1st and June 15th, 2020. Control was any inmate who did not meet case definition. We also described environments/routines related to etiological hypotheses, based on official jail documents.

Results:
Among 656 inmates, 262 cases of the unknown disease were identified, which only 2% (1/66) were confirmed for leptospirosis. Jail’s environments and routines description removed initial hypotheses
by plausibility and temporality criteria, while we identified a menu with characteristics of food monotony, 15 hours intermittence between dinner and breakfast, a diet rich in simple carbohydrates and interruption in food remittance by relatives due to the Covid-19 pandemic. 199 (76%) sick inmates met case definition of suspected Beriberi, of which 56 (28%) were hospitalized and six (3%) died. Paresthesia (n=120; 60%), edema (n=113; 57%) and numbness (n=98; 49%) were the most frequent signs and symptoms. Physical exercise (OR 0.3; 95%CI 0.1-0.9; p=0.03) and detention time longer than six months (OR 5.1; 95%CI 1.4-21.7; p=0.02) were associated with illnesses.

Conclusions:
Hypovitaminosis was the outbreak’s probable etiology, especially by thiamine deficiency. We recommend diversifying prisoners’ diet, including vitamin-rich foods; thiamine administration for all
prisoners; clinical monitoring to check prognostic improvement and final classification of suspected beriberi cases; and offering rehabilitation when necessary.

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