This document is a review of pellagra. Pellagra results from a niacin and/or tryptophan deficient diet. Earliest recorded reports of pellagra were made almost 250 years ago. The condition quickly became associated with maize-based diets and was seen to spread throughout Europe following the introduction of maize as a staple crop from its original home in the New World.

The disease was still considered a public health problem in many maize-consuming African and Asian countries throughout the 1960s and 1970s. In South Africa more than 100 000 cases were reported each year during the 1970s. More recently, apart from sporadic cases reported in rural health centres during times of drought and food shortage, the condition has only been observed as a significant problem among food-aid dependent populations during food emergency and refugee programmes.

Numerous outbreaks of pellagra have occurred among refugees (see Table 1). More than 22 000 cases have been reported among 900 000 Mozambican refugees in southern Malawi since 1989. In 1990 alone, at least 18 000 cases were reported and attack rates in certain camps were as high as 13% (Centers for Disease Control, 1991). Cases of pellagra were also reported among refugees in Zimbabwe (1988 and 1989), Swaziland (1989), the former Zaire (1989), Angola and Nepal (1994) (Toole, 1994; ACC/SCN, RNIS Report Nos 5 & 8, 1994).

Large-scale outbreaks have also occurred among refugee returnee populations. This occurred in Mozambique where in one location in Tete province the prevalence of pellagra at the end of 1995 was estimated at 1.4%. This outbreak followed a large influx of refugees from Malawi whereby the population of Mutarara district increased from 50 000-200 000 (ACC/SCN, RNIS Report No.14, 1996). The most recent large-scale outbreak occurred among conflict-affected populations in Angola at the end of 1999 (ACC/SCN, RNIS Report No. 30, 2000).

The focus of this review will be on the occurrence of pellagra during emergencies with an analysis of risk factors and preventive and alleviation measures. It will begin with an historical overview of pellagra outbreaks leading up to the most recent outbreaks in refugee and emergency programmes. The next section will review the signs and symptoms of the disease and means of diagnosis. A subsequent section will detail the role of niacin in the etiology of pellagra and current consensus on RDAs of niacin. This will be followed by a section on sources of niacin. The final two sections of the review will provide detailed information on recent pellagra outbreaks, remedial strategies employed during these emergency programmes, and recommendations on strategies to prevent and combat future outbreaks of pellagra.

Table 1. Pellagra outbreaks in emergency-affected populations

^a Berry-Koch et al. Alleviation of nutritional deficiency diseases in refugees. Food and Nutrition Bulletin, 12 (2):106-112.

^b Moren A, Le Moult D. Pellagra cases in Mozambican refugees [Letter]. Lancet 1990, 335:1403-1404.

^c Centers for Disease Control. Outbreak of pellagra among Mozambican refugees, Malawi, 1990. MMWR 1991, 40:209-213.

^d UNHCR, unpublished report.

^e RNIS Report Nos 5 & 8. ACC/SCN News. June 1994, December 1994.

^f RNIS February 1996, Report No. 14.

^g MSF/ICRC Rapid NutritionalAssessment, Kuito province of Bie, Angola. December 1999.