Epidemic of pediatric deaths from acute renal failure caused by diethylene glycol poisoning. Acute Renal Failure Investigation Team.

CONTEXT: Contaminated pharmaceutical products can result in substantial morbidity and mortality and should be included in the differential diagnosis of deaths of unknown origin. OBJECTIVE: To investigate an outbreak of deaths among children from acute renal failure in Haiti to determine the etiology and institute control measures. DESIGN: Case-control study, cohort study, and laboratory toxicologic evaluation. SETTING: Pediatric population of Haiti. PARTICIPANTS: Cases were defined as Haitian residents younger than 18 years with idiopathic anuria or severe oliguria for 24 hours or longer. Febrile hospitalized children without renal failure were enrolled as control subjects. MAIN OUTCOME MEASURE: The odds of exposure to suspected etiologic agents among cases and controls. RESULTS: We identified 109 cases of acute renal failure among children. The clinical syndrome included renal failure, hepatitis, pancreatitis, central nervous system impairment, coma, and death. Of 87 patients with follow-up information who remained in Haiti for treatment, 85 (98%) died; 3 (27%) of 11 patients transported to the United States for intensive care unit management died before hospital discharge. A locally manufactured acetaminophen syrup was highly associated with disease (odds ratio, 52.7; 95% confidence interval, 15.2-197.2). Diethylene glycol (DEG) was found in patients' bottles in a median concentration of 14.4%. The median estimated toxic dose of DEG was 1.34 mL/kg (range, 0.22-4.42 mL/kg). Glycerin, a raw material imported to Haiti and used in the acetaminophen formulation, was contaminated with 24% DEG. CONCLUSIONS: An epidemic of severe systemic toxicity and deaths from DEG-contaminated acetaminophen syrup occurred in Haiti. Good manufacturing practice regulations should be used by all pharmaceutical manufacturers to prevent such tragedies.

Heat-related deaths during the July 1995 heat wave in Chicago.

BACKGROUND: During a record-setting heat wave in Chicago in July 1995, there were at least 700 excess deaths, most of which were classified as heat-related. We sought to determine who was at greatest risk for heat-related death. METHODS: We conducted a case-control study in Chicago to identify risk factors associated with heat-related death and death from cardiovascular causes from July 14 through July 17, 1995. Beginning on July 21, we interviewed 339 relatives, neighbors, or friends of those who died and 339 controls matched to the case subjects according to neighborhood and age. RESULTS: The risk of heat-related death was increased for people with known medical problems who were confined to bed (odds ratio as compared with those who were not confined to bed, 5.5) or who were unable to care for themselves (odds ratio, 4.1). Also at increased risk were those who did not leave home each day (odds ratio, 6.7), who lived alone (odds ratio, 2.3), or who lived on the top floor of a building (odds ratio, 4.7). Having social contacts such as group activities or friends in the area was protective. In a multivariate analysis, the strongest risk factors for heat-related death were being confined to bed (odds ratio, 8.2) and living alone (odds ratio, 2.3); the risk of death was reduced for people with working air conditioners (odds ratio, 0.3) and those with access to transportation (odds ratio, 0.3). Deaths classified as due to cardiovascular causes had risk factors similar to those for heat-related death. CONCLUSIONS: In this study of the 1995 Chicago heat wave, those at greatest risk of dying from the heat were people with medical illnesses who were socially isolated and did not have access to air conditioning. In future heat emergencies, interventions directed to such persons should reduce deaths related to the heat.