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Journal of Toxicology
Volume 2010, Article ID 313280, 7 pages
Research Article

An Outbreak of Hepatic Veno-Occlusive Disease in Western Afghanistan Associated with Exposure to Wheat Flour Contaminated with Pyrrolizidine Alkaloids

1Ministry of Public Health, Kabul, Afghanistan
2London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
3World Health Organisation, Geneva, Switzerland
4National Institute for Public Health & the Environment, RIVM, 3720 BA Bilthoven, The Netherlands

Received 16 November 2009; Revised 19 February 2010; Accepted 16 May 2010

Academic Editor: Peter John O'Brien

Copyright © 2010 Faizullah Kakar et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Pyrrolizidine alakloids (PAs) are known to cause hepatic veno-occlusive disease (VOD). Outbreaks have occurred in Western Afghanistan since 1974, the latest in February 2008. We conducted an outbreak investigation using a case-control design. Sixty-seven cases of VOD were compared with 199 community controls. Consumption of bread was strongly associated with disease (adjusted odds ratio: 35.8 [95%CI: 7.6–168.2]). Toxic doses of PA were found in plant extracts and in samples of wheat flour taken from the study area. Compared to wheat flour there was 1000 times less PA in milk and whey and in water samples the PA content was zero. Although direct analysis was not possible, contaminated wheat flour used to make bread was the likely source of PA causing the outbreak. Eating a more varied diet including meat and fruit may be protective. Prevention and control measures will rely on community awareness and agricultural interventions to ensure safety of the food supply.