DEG-contaminated cough syrups led to AKI and death in many children in Gambia

Key findings from the analysis were as follows:

• A confirmed case of pediatric AKI was defined as anuria (no urine output) of unknown etiology in a child aged eight years and younger, persisting for 24 hours or more, from June 21 to September 29; 56 of the 59 patients met the case definition.
• Of these 56, 54% experienced fever as their first symptom, 50% experienced vomiting, and 34% had diarrhea or loose stools. All patients experienced anuria and fever; 95% had vomiting, 73% had diarrhoea, and 48% had anorexia or reduced feeding.
• The median interval from symptom onset to anuria was five days, and among the patients who died, the median interval from onset of anuria to death was six days.
• Abnormal lab results occurred in 66% to 100% of patients, including impaired renal and liver function, thrombocytosis, and mild to moderate anaemia.
• Among 26 caregivers interviewed, all reported that the children had taken over-the-counter or prescription syrup-based medications, including acetaminophen, before the onset of anuria. 
• In eight of the 14 interviews where caregivers identified the manufacturer name of at least one medication the child had taken, one international manufacturer that produced a syrup-based medication was identified.

The import of all medications from the manufacturers was suspended by the Gambia's MoH on Oct. 4, 2022, and all healthcare providers were alerted of the possible contamination. On October 5, the WHO issued a worldwide medical product alert for the four medications. In collaboration with other organizations, the MoH conducted a house-to-house recall collection of these products and all promethazine, paracetamol, and cough syrups. 

Joshua Schier of CDC and colleagues wrote, "such poisonings are nothing new; more than 14 mass poisonings with DEG have been reported in 14 countries over the last 80 years, often affecting children." The perspective was published in the New England Journal of Medicine. 

"There is no clarity on the root causes of medication-associated diethylene glycol mass poisonings (MDMPs). However, DEF continues to sporadically appear in medications that normally contain appropriate excipients, such as pharmaceutical grade glycerin and propylene glycol," they stated. 

DEG has many industrial uses because it is an effective solvent for water-soluble chemicals and is commonly used in antifreeze, brake fluid, fuel, lubricant, and wallpaper stripper. It is odourless, colourless, clear, viscous, and sweet. 

Bastani's group noted that "inadequate regulatory structures make the sale of medications from international markets an especially high-risk activity in low-resource settings." 

"MDMPs are a recurring public health problem, but guidance already exists regarding the identification of affected ingredients and final products that are likely to cause a mass poisoning," Schier and team concluded. "Following this guidance is critical to preventing MDMP-associated illnesses and deaths."

Reference:

1) Bastani P, Jammeh A, Lamar F, et al. Acute Kidney Injury Among Children Likely Associated with Diethylene Glycol–Contaminated Medications — The Gambia, June–September 2022. MMWR Morb Mortal Wkly Rep 2023;72:217–222. DOI: http://dx.doi.org/10.15585/mmwr.mm7209a1