Politzer, W.M.

Sherman, Y.

Stewart, T.H.

English

AJOL - African Journals Online

200 S.A. TYDSKRIF VIR GENEESKUNDE 22 Februarie 1969AN OUTBREAK OF FOOD·POISONING DUE TO A FLOUR IMPROVER,POTASSIUM BROMATE*T. H. STEWART, M.B., B.CH., D.P.H., City Health Department, Y. SHERMAN, B.Sc. (HONS), M.B., B.CH., TransvaalMemorial Hospital for Children, AND W. M. POLITZER, M.D., South African Institute for Medical Research,JohannesburgTABLE I. BREAD MADE IN 1966'Date received: 6 November 1968.tExtracts from Food, Drugs and Disinfectants Act reproduced underGovernment Printer's Copyright Authority No. 4086 of 28 November 1968.Various improvers in the bread-making industry havebeen so authorized: t12(1) Flour.(a) No person shall import into the Union any flour towhich any foreign substance, other than a substance mentionedor referred to in clause (2) hereof, has been added, or whichhas been subjected to any artificial bleaching process, and noperson shall import into the Union, have in his possession, orsell any chemical bleaching agent or so-called 'improver'intended for the treatment of or mixing with flour.(b) Before importing into the Union any consignment ofThe Food, Drugs and Disinfectants Act: No. 13 of 1929,has as its object 'to consolidate and amend the laws forregulating the labelling and preventing the importation orsale of food and drugs which are unwholesome or adul-terated or incorrectly or falsely described and for regula-ting the labelling and preventing the importation or sale ofdisinfectants which are incorrectly or falsely described'.This Bill was passed by Parliament in 1928 and becamelaw in 1929. The Act was needed as it had become neces-sary to protect the public from adulteration and sophistica-tion of articles of food. The Minister of Health and hisdepartment were made responsible for its administration.Unlike the earlier Public Health Act, which is concernedwith the fitness of food for human consumption due tobacterial contamination, the Food, Drugs and DisinfectantsAct aims primarily at the prevention of fraud and mis-representation and the prevention of harmful adulterationof food of a chemical nature.Amendments to parliamentary legislation are oftendifficult and cumbrous to negotiate. This is taken care ofby regulations which may be promulgated in terms ofthe Act, a step which must be taken before the introduc-tion of anything new in the food processing industry.Had this been done, the accident due to the overdosingof a batch of bread with a flour improver, potassiumbromate, might have been prevented.As reported in the Annual Report of th:: Wheat IndustryControl Boardz for 1966. the bread-making industry inSouth Africa used 551,477 tons of wheat for bread-making in that year. In an industrial undertaking of thismagnitude the use of flour improvers is approved by theMinister of Health 'provided he authorises it' (Section13(3)(a) of the Food, Drugs and Disinfectants Act).flour intended for sale or use in the Union, the importer orhis agent shall produce to the collector of customs at theport of entry, a certificate by the head of the department ofagriculture or other responsible officer of the Government ofthe exporting country stating that the flour is entirely freefrom any foreign substance, other than a substance mentionedor referred to in clause (2) hereof, and has not been subjectedto any artificial bleaching process. Samples of the flour mayalso be taken and transmitted to an analyst.(c) No person shall add to any flour any foreign substance,other than a substance mentioned or referred to in clause (2)hereof, or similar substance or shall subject any flour eitherduring or after milling to any artificial bleaching process, savethat flour milled in the Union may during milling be treatedwith peroxide of nitrogen generated by electricity, the treat-ment being regulated and restricted so that the total nitrites(calculated as sodium nitrite) in the treated flour shall notexceed six parts per million.(2) Self-raising flour is flour to which baking powder orother leavening substances have been added. The label ofevery package containing flour to which acid phosphate hasbeen added shall state, in type H, 'Prepared with acid phos-phate baking powder'.(8) Wholesome natnral substances of animal or vegetableorigin may be added to meal or flour or maize meal for thepurpose of increasing its nutritional value. The addition ofsynthetic vitamins is prohibited. The addition of 14 ouncescalcium acetate to 200 lb. meal to prevent the formation ofrope is permitted.(9) Meal or flour or maize meal to which wholesome sub-stances have been added as permitted by sub-regulation (8)hereof, and bread made from such meal or flour shall belabelled in type G with the word 'enriched' and the name andbusiness address of the manufacturer.13(1) Bakin.g powder is the leavening agent produced bymixing an acid-reacting material, with sodium bicarbonate,with or without starch. It shall contain not more than 1·5 percent of sulphates calculated as calcium sulphate (CaSO.),. ormore than 0·1 per cent of aluminium compounds calculatedas alumina (AI,03), and shall yield not less than 10 per centby wei.eht, of carbon dioxide, and shall not contain fluorine.(2) Cream of tartar shall contain not less than 95 per centof acid tartrates calculated as potassium acid tartrate(KHC.H.O.) and not more than 2 per cent of sulphates cal-culated as calcium sulphate (CaSO.).(3) 'Acid phosphate' powder is an acid phosphate which,with or without starch or other wholesome farinaceous sub-stance, may be used to replace cream of tartar in the prepara-tion of chemical leaven for baking purposes. It shall notcontain more than 2 per cent of sulphates calculated ascalcium sulphate (CaSO.), nor more than 0·3 per cent of anycompound of aluminium calculated as alumina (Al,03). Everypackage containing acid phosphate for use in food, or con-taining any baking powder of which acid phosphate is aningredient, shall be labelled with the words 'acid phosphate',in type E. The words 'cream of tartar' or any lettering sug-gesting cream of tartar or tartaric acid shall not appear onany such label.The bread-making industry is higWy competitive andsales acceptance depends on many factors-whiteness,lightness, freshness and keeping quality, among others.Freshly milled flour is always under-oxidized, and toensure the desired dough-handling characteristics and toobtain baked products with the best volume, grain andtexture, it is common 'practice for millers and bakers toadd oxidizing agents to flour and dough. For many yearsyeast 'foods' containing potassium bromate, ammoniumWeight in lb.1,031,860,533450.998.02849,981;45677,014,0341,609,854,051 (804,927 tons)TypeWhiteBrownWholewheat'Compound'Total22 February 1969 S.A. MEDICAL JOUR 'AL 201TABLE H. ANALYSIS OF PATlE TSRace Adlllts Children Adlllts Children TotalColoured 40 638 9 40 727Bantu 5 5White 2 63 2 17 84816CLI ICAL FI Dl 'csIn all, 68 cases were admitted to ho pital and 481 ca ewere seen as outpatients. At 2 Coloured schools, a further290 children were seen by a medical team sent fromTransvaal Memorial Hospital for Children. Of these, 31children were removed to hospital by ambulance and 8were admitted. Ages varied from under 1 year to 48years.. A sample of bread contained I· I 'Yo by weight of pota -SlUm bromate. The bakery concerned wa revisited and anacknowledgement obtained that a single batch of doughhad been accidentally gros ly overdo ed with a flour im-prover, potassium bromate (40 p.p.m. i apparently theusual amount used where it is the practice to usepotassium bromate as a flour improver).'All hospitals in the Johannesburg area were notified thatthe poisoning was due to potas ium bromate and a furtherbulletin was broadca t to the effect that bread producedin Johannesburg was once again safe and that only onesmall batch produced by one bakery on 14 Augu t 1968had been involved in the food-poisoning outbreak.InpatientsOlltpatientsThese patients presented with the following clinical signsand symptoms: abdominal pain, vomiting, diarrhoea,headache, dryness of mouth, weakness and dizziness.The abdominal pain varied from mild epigastric dis-comfort to severe stabbing pains. The time of on et ofthis pain after eating the bread depended on the amountswallowed-which was seldom more than a mouthful, dueto the bad taste-and it varied from about 2 hours to 6hours or longer.Vomiting was invariable and ranged from mild nauseato copious vomiting. Several patients stated that they hadactually vomited blood but no blood was reported invomitus of any of the cases hospitalized.Diarrhoea was not invariable and, when it occurred.varied from 1 to 5 watery stools. In only one case wasdehydration severe enough to warrant intravenous fluidtherapy, and in one case only was there a report of darkred blood in the stool.Ingested bromate may cause methaemoglobinaemia withconsequent cyanosis and central nervous system and kidneydamage. No cases in this series showed these equelae.Full blood counts on 10 children admitted to TransvaalMemorial Hospital for Children were done. The e werenormal in all but 4. who showed mild eosinophilia. Threeout of 10 urine specimens submitted showed albumin. Tillproteinuria cleared up within 48 hour. No cyano i wasnoted in any of the cases seen either as outpatient orin the wards.Physical examination revealed little except mild epi-gastric tenderness. Pulse rates, temperature, re pirationTHE OUTBREAKAt 2.30 p.m. on 15 August 1968, a report was receivedat the City Health Department that 3 cases of vomitingand abdominal pain had been seen following the eatingof bread purchased that day. These cases, plus 4 otherswhich had occurred since the report was received, werevisited.The history was the same: the eating of bread purchasedthat day, followed within a few hours by abdominal painand vomiting. Questioning revealed that the bread eatenhad not smelt or tasted 'too good'.Clinically the patients, both adults and children, werenot very ill. There was no pyrexia, pulses were slow andstrong, no vomiting occurred during physical examination,and there was only a mild degree of epigastric tenderness.Bread which had apparently caused the trouble was re-trieved. This had a peculiar dryish smell which was notidentified, and a greyish look. The loaf was rather blownand friable.A hospital where 3 further adult cases had been admittedwas visited. Here the story was the same: the eating ofbread, followed within an hour or two by abdominal painand vomiting. One man, in no distress, stated that he hadvomited clots of blood. (All bed letters of cases whichwere subsequently admitted to various hospitals in thecity were later perused; a few mentioned the vomiting ofblood before admission, but there was no confirmation thatvomiting of blood had occurred in hospital.)A common factor had been determined, the eating ofbread supplied by a specific bakery. The Managing Direc-tor stated that an excess of an ingredient had been acci-dentally added to a batch of 288 loaves which were laterdelivered to 5 dealers in the western part of the city. Assoon as the error was noted, the bakery concerned hadretrieved all the unsold loaves. With this assurance, nofurther action was taken that evening.By 16 August 1968 an epidemic of abdominal pain,vomiting and diarrhoea had broken out in the suburbssupplied by bread from the 5 bread retailers concerned.Cases started flooding into 2 regional hospitals and aspecial message was broadcast not to eat any breadoriginating in Johannesburg the day before.cWoride and calcium sulphate' have been in use. Recentlypotassium iodate was added to this list. These themicals,singly or in combination, are used in many countries toimprove bread quality. There is a rapid 'proofing' of dough,especially when' ferment-yeasts are used; gas-retention inthe dough is increased, giving a 'nice light texture'. Thereis also a great saving in space that would otherwise benecessary for slow proofing of dough.With the increase in bread sales, interest in quick pro-cesses for dough maturation has become widespread andmany bakers are now using these processes regularly, somefor whole and others for part of their daily production.Conditions which may influence quality range widely indifferent bakeries, and new processes introduced mayovertake legislation in this regard.In the baking process bromate is reduced to bromideand therefore any direct toxicity can be based on thebromide content. At normal 40 p.p.m. there is no inter-ference with the nutritional quality of the bread!6202 S.A. TVDSKRIF VIR GENEESKUNDE 22 Februarie 1969blood pressure, etc., were normal. (Hypotension has beenreported in potassium bromate poisoning.)The duration of hospital admission in 90% of caseswas 24 hours only and varied from a few hours' obser-vation to 5 days. There were no fatalities and no sequelaehave been reported. Treatment was purely symptomatic.A few children at Transvaal Memorial Hospital for Child-ren had stomach wash-outs performed and in these cases5 - 20 G of sodium thiosulphate, depending on age, wasgiven by mouth.POTASSIUM BROMATE POISONINGWhen potassium bromate is brought into contact with anacid, such as gastric hydrochloric acid, hydrogen bromateis released.A fatal dose has been estimated at 60 G, and 10fatalities have been reported in the medical literature dueto the ingestion of potassium bromate in hair cold-waveneutralizing solutions. No other potassium bromate fata-lities from any other source have been recorded.Ingestion is followed by nausea, vomiting, severe ab-dominal pain and diarrhoea. The patient becomes apatheticbut irritable, and there is central nervous depression withloss of tendon reflexes and even loss of consciousness;however, convulsions may occur. Kidney damage with al-buminuria and subsequent anuria may arise. Respirationbecomes shallow. and rapid, pulse rate increases and thereis a fall in blood pressure. Body temperature is low.ered.Hepatitis, pulmonary oedema and toxic myocarditis havebeen reported.'As 'potassium bromate is an oxidizing agent, the ferrousiron of the haemoglobin may be oxidized to ferric ironwhich may lead to methaemoglobinaemia, cyanosis andkidney damage.'In the blood, bromate is reduced to bromide withinBOOK REVIEWSMULTIPLE SCLEROSISThe Epidemiology of Multiple Sclerosis. Ed. by M. Alter,M.D., Ph.D., and J. F. Kurtzke, M.D. Pp. xiv + 204.lIIustrated. $10.50.' Springfield, Ill.: Charles C. Thomas.1968. . .Multiple sclerosis, which was a rare disease 30 years ago, hasbecome relatively common in South Africa in recent years.Although some neurologists- believe that this increase is moreapparent than real, I am of the opinion that the disease is onthe increase. If this is so, it may be of great aetiological signi-ficance.The timeous appearance of this book may stimulate furtherstudies in this field. It describes epidemiological methods whichcould be applied in South Africa and possibly lead to a betterunderstanding· of the condition-perhaps even its elucidation.A.V.B.SUDDEN DEATH IN INFANCYSudden Death in Infancy. By P. Geertinger, M.D. Pp. xv +107. I1lustrated. $6.75. Springfield, Ill.: Charles C. Thomas.1968.This short monograph in the American Lecture Series is writtenb.y a Scandinavian who· is a forensic pathologist. He puts for-ward a tenable thesis to account for an important problemin the more higWy civilized countries. The arguments thathe uses to account for sudden unexplained death are con-vincing, ...though in some aspects the investigations are incom-a few hours." The normal blood bromide level on theWitwatersrand is very low, usually less than 1 mg.l100 ml.In 5 cases in this series blood bromides were done onoutpatients who had certainly ingested some bromate andwere eXhibiting symptoms of an acute gastritis. The methodused was that described by Barbour et al.9 The serumbromide levels of these 5 patients were 3'0, 3'0, 3'1, 3·4and 3·6 mg./100 ml., respectively. These low findingssuggest that the amount of bromate ingested was verysmall or that most of the bromate ingested was lost byvomiting.SUMMARYAn outbreak of food-poisoning due to a chemical flour im-prover, potassium bromate, is reported. This chemical wasaccidentally added in an excess amount to a batch of 'doughand resulted in 816 persons seeking medical attention; 68persons, mainly children, were admitted to hospital. Fortu-nately the resulting illness was not serious and no sequelae.have been reported or are expected.We wish to thank Prof. A. H. Smith, Medical Officer ofHealth, Johannesburg, for permission to publish, and theMedical Superintendents of the 5 hospitals which handledcases, for permission to make use of hospital records.REFERENCESL Cluver, E. H. (1960): Medical and Health Legislation ill the Unionof South Africa. Cape Town: Central News Agency.2.' Wheat Industries Control Board (1966): Annual Report.3. American Bakery Engineers (1967): Report of 43rd Annual GeneralMeeting, Chicago.4. WHO Expert Committee (1964): Wld Hlth Org. Techn. Rep. SeL. No.281, p. 164.5. Dreisbach, R. H. (1966): Handbook of Poisoning, 5th ed., p. 208. LosAltos, Calif.: Lange Medical Publications.6. Todd, R. G., ed. (1967): Martindale's Extra Pharmacopoeia, 25th ed..p. 1543. London: Pharmaceutical Press.7. Merck & Co. Inc. (1960): The Merck Index of Chemicals and Drugs,p. 838.' Rahway, NJ: Merck & Co.8. Spector, W. S. (1956): Handbook of Biological Data, p. 241. Philadel-phia: W. B. Saunders.9. Barbour, R. F., Pilkington. F. and Sargenl. W. (1936): Brit. Med. J ..2, 957.BOEKBESPREKINGSplete and merit further study. Understandably, he freely ad-mits to a limited knowledge in the fields of biochemistry,endocrinology and embryology.The book is concise and written in simple language makingit easy to .read, though grammatical errors (which shouldhave been eliminated by the editor) are too frequent. It is,however, an essential addition to the medical literature andis recommended to all forensic and paediatric pathologistsas well as clinical paediatricians. R.O.C.K.GENEESKUNDIGE ETIEKPhilosophy and Elhics of Medicine. By M. Gelfand, C.B.E.,M.D., ER.C.P., D.P.H., D.M.R. Pp. viii + 174. £1.2.6.Edinburgh and London: E. & S. Livingstone. 1968.Die era van hernieude besinning oor die geneeskundige etiekis pas ingelui. Net voor die hartoorplanting en dus aan dievooraand van hierdie era, skryf Ge1fand 'n boek wat raakaan die praktyksprobleme van elke dag.Dit is op die man at en in 'n geselstrant wat die boekie 'nplek op die kassie langs die bed laat verdien. Die waardedaarvan is veral in die paar hoofstukke wat oor die dokter-skap handel. Dit lewer die riglyne hoe om te antwoord opdie vrae wat in elkeen van ons se bepeinsinge hul verskyningmaak.'n Pragwerk deur·'n bekende outeur-iemand wat oordertig jaar die moderne en die primitiewe heelkuns met mekaarkon vergelyk. H.B.

An outbreak of food-poisoning due to a flour improver, potassium bromate

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An outbreak of food-poisoning due to a flour improver, potassium bromate

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