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American Journal of Epidemiology Copyright © 2002 by the Johns Hopkins Bloomberg School of Public Health All rights reserved

Vol. 155, No. 2 Printed in U.S.A.

Belgian Coca-Cola-related Outbreak Gallay et al.

Belgian Coca-Cola-related Outbreak: Intoxication, Mass Sociogenic Illness, or Both?

A. Gallay,1,2 F. Van Loock,1 S. Demarest,1 J. Van der Heyden,1 B. Jans,1 and H. Van Oyen1 An epidemic of health complaints occurred in five Belgian schools in June 1999. A qualitative investigation described the scenario. The role of soft drinks was assessed by using a case-control study. Cases were students complaining of headache, dizziness, nausea, vomiting, abdominal pain, diarrhea, or trembling. Controls were students present at school on the day of the outbreak but not taken ill. An analysis was performed separately for school A, where the outbreak started, and was pooled for schools B–E. In school A, the attack rate (13.2%) was higher than in schools B–E (3.6%, relative risk = 3.6, 95% confidence interval (CI): 2.5, 5.3). Exclusive consumption of regular Coca-Cola (school A: odds ratio (OR) = 29.7, 95% CI: 1.32, 663.6; schools B–E: OR = 7.3, 95% CI: 2.9, 18.0) and low mental health score (school A: OR = 16.1, 95% CI: 1.3, 201.9; schools B–E: OR = 3.1, 95% CI: 1.5, 6.6) were independently associated with the illness. In schools B–E, consumption of Fanta, consumption of Coca-Cola light, and female gender were also associated with the illness. It seems reasonable to attribute the first cases of illness in school A to regular Coca-Cola consumption. However, mass sociogenic illness could explain the majority of the other cases. Am J Epidemiol 2002;155:140–7. carbonated beverages; disease outbreaks; hydrogen sulfide; poisoning

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An epidemic of health complaints, including nausea, vomiting, abdominal pain, dizziness, and headache, potentially related to consumption of Coca-Cola Company soft drinks occurred in June 1999 in Belgium. The epidemic started on June 8 in one secondary school (school A). Two to 6 days later, students in four other secondary schools (schools B–E) complained of the same symptoms. During the same period, several complaints were reported in the Belgian and the French populations (1, 2). Between June 8 and June 20, the Belgian Poisoning Call Centre recorded over 1,400 telephone calls; 55 percent were complaints related to consumption of Coca-Cola soft drinks, and 45 percent of the callers asked for information about the quality of the soft drinks (1). The CocaCola-related calls constituted one third of all calls the Poisoning Call Centre received during this period. On June 15, The Coca-Cola Company announced that chemical analysis of the incriminated beverages had revealed very low concentrations of hydrogen sulfide in the glass bottles of Coca-Cola supplied to school A, and that 4chloro-3-methylphenol, applied to transport pallets, had contaminated the exterior surface of the cans delivered to
Received for publication February 26, 2001, and accepted for publication October 12, 2001. Abbreviations: CI, confidence interval; OR, odds ratio; RR, relative risk. 1 Unit of Epidemiology, Scientific Institute of Public Health, Brussels, Belgium. 2 European Programme for Intervention Epidemiology Training (EPIET), Brussels, Belgium. Reprint requests to Dr. Herman Van Oyen, Unit of Epidemiology, Scientific Institute of Public Health, J. Wytsmanstraat 16, 1050 Brussels, Belgium (e-mail: herman.vanoyen@iph.fgov.be). Coca-Cola, Coca-Cola light, and Fanta are manufactured by The Coca-Cola Company, Atlanta, Georgia.

schools B–E. In both cases, the company concluded that the very low concentration of these two substances could not have caused any toxicity. Still, The Coca-Cola Company withdrew 15 million crates of its soft drinks across Belgium, France, and Luxembourg and temporarily closed three of its factories in Europe. On June 23, the Belgian Ministry of Public Health commissioned the Unit of Epidemiology of the Scientific Institute of Public Health (Brussels) to investigate this outbreak and to identify the cause and mode of transmission. Epidemiologic and clinical information was collected on cases in the affected schools, and a case-control study was performed to determine the weight of evidence on both competing hypotheses—consumption of Coca-Cola Company products and mass sociogenic illness—as a risk factor for illness.
MATERIALS AND METHODS

It was decided to consider the outbreaks in school A and in schools B–E as two distinct incidents because 1) school A was supplied with glass bottles from an Antwerp (Belgium) plant, whereas the bottles and cans for schools B–E were supplied by plants in Gent (Belgium) and Dunkerque (France); 2) The Coca-Cola Company had identified a different toxicologic substance in the soft drinks delivered to school A and schools B–E; and 3) the events at school A and schools B–E occurred at different times.
Descriptive epidemiology

To obtain contextual information regarding the outbreaks, qualitative and open-ended telephone interviews were conducted with the school directors, and a self-administered
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Emergency room and hospital medical records were then checked for the symptoms and results of physical examinations. time of occurrence). In the afternoon of June 8. a possible link was made with consumption of this beverage. or trembling. 2.8.org/ by guest on April 29. and symptoms (type..m. The attack rate (3. the supplier of Coca-Cola removed most of the remaining crates from the school. 1999. time) and beverage consumption (place of purchase. the staff of school E had removed all cans stamped on the bottom with specific codes early on the morning of June 14 before the courses started. Information was gathered during a face-to-face interview in each school between June 25 and June 27. Following the hotline instructions of The CocaCola Company.. Chicago. With students reporting a “rotten” smell from Coca-Cola bottles.5 percent) was lower in schools B–E than in school A (relative risk (RR) 0. Centers for Disease Control and Prevention. Cases were identified according to a school register of illnesses filled out by a nurse.. the events were assumed to be related to consumption of Coca-Cola Company soft drinks. In school E. vomiting.m. In schools B–E.6) and schools B–E (RR 5. diarrhea. the attack rate was higher for girls than for boys in both school A (RR 1. particular taste or smell) on the day of the outbreak. In school A. water.9). and information was collected on demographics (gender. 2012 Crude and gender-specific attack rates in school A and schools B–E were calculated by dividing the number of cases by the number of students. students in school A complained of gastrointestinal symptoms with dizziness and headache shortly after consuming Coca-Cola from the school restaurant during the midday break. Case-control study logistic regression model by using a forward stepwise selection strategy (SPSS 8.2) were included in a Am J Epidemiol Vol. No. mental health status. Georgia).. 0. a sample size of 49 cases and 98 controls in each school group was required to detect an odds ratio of 3 or greater with 95 percent confidence and a power of 80 percent.001. two potential cases did not meet the eligibility criteria. several ambulances and a medical emergency team were sent to the school. 95 percent CI: 1. Between 12:30 and 1:00 p.19. these students were present at school on the first and the following day of the outbreak and had not been ill during the 2 weeks before the day of the outbreak up to the following day. 2002 In school A. A mental health score was calculated according to responses to the questions on mental health status on the SF36 Health Survey (3). 72 cases occurred on the first day of the outbreaks and three on the following day (figure 2).8. with onset of illness occurring before 2:10 p. Descriptive epidemiology Downloaded from http://aje.Belgian Coca-Cola-related Outbreak 141 questionnaire was distributed to the physicians in the emergency rooms. by 2:00 p. The first definition was consumption of regular Coca-Cola compared with any other consumption (other Coca-Cola Company products. three students reported to the secretarial office with health complaints. In schools B–E. the chief of police ordered all students reporting complaints to be sent to the hospital. 95 percent CI: 0. illness among friends.m. 17.oxfordjournals. and June 14 (schools D and E). Of the 33 students who went to the emergency unit on June 8. the courses started. In addition. a physician came on site to evaluate the situation. Exposure to Coca-Cola Company soft drinks was defined in two different ways. 12 were hospitalized overnight for observation.9. table 1). June 11 (school C). all ill students were transported to the local hospital either by ambulance or in staff members’ cars. SPSS Inc. At 1:10 p. package.7. Analysis On June 8. students complained of similar symptoms.—the first break period after the incident started—the first nine cases of illness occurred among students in six different classrooms (one to three cases per class). abdominal pain. On the basis of the number of students with health complaints. table 1). In school A. nausea. age). Six other students were taken to the same hospital on June 9. odds ratios and 95 percent confidence intervals were computed by using Epi Info software (version 6. 95 percent confidence interval (CI): 0. In one of the B–E schools. In school C. Exposures found by univariate analysis to be associated with the illness (p value < 0. Results of biologic and toxicologic tests of blood and urine samples were collected. 20 (71. On June 10 (school B). the exposure was exclusive consumption of a Coca-Cola Company product compared with water or no consumption at all. In schools . The mean ages of cases in school A and schools B–E were compared by using the Kruskal-Wallis test. RESULTS Scenario of the outbreaks Controls were students from the same class as the cases and were next on the alphabetic list. Following advice from the medical school inspector. place and time of consumption. According to the second definition. 155. dizziness.40. Atlanta. six more students from different classes complained of feeling ill.4 percent) ill students of the remaining 28 cases were grouped in four classrooms (four to six cases per class). or no consumption at all). A 50 percent prevalence of exposure to Coca-Cola Company soft drinks among healthy students and a 1:2 ratio of cases to controls were assumed. the cases were younger than those in schools B–E (p < 0.2 percent. Illinois). Because of extensive media attention given to the outbreak in school A. Cases were defined as students in school A or in schools B–E who suffered from at least one of the following complaints on the first day or on the second day after the onset of the outbreak in each school: headache.28. therefore.04.m. To compare exposures between cases and controls. 3. all ill students were taken to the local hospital. students were grouped and were assisted by an interviewer when completing the questionnaire. Thirtyone students became ill on the first day and six on the following day (figure 1). A structured questionnaire was used. non-Coca-Cola Company products.0. The overall attack rate was 13. food consumption (place.

Abdominal pain. respectively. cases also were more likely to consume regular Coca-Cola exclusively (OR 23. 12 students were hospitalized for a period of 1–3 days.5 hours). mental health status. Coca-Cola light. Number of cases of Coca-Cola-related illness.. 95 percent CI: 3. this information was available for 50 and 75 cases. 2012 . In school A.m. There was no difference in time of onset of symptoms between girls and boys in both schools.6 percent) blood samples and the seven (9.9) remained independently associated with the illness. 220. 3 hours) later. nausea.4) was similar in both school groups but was statistically significant for only schools B–E (table 5). school A.9). 95 percent CI: 3. Medical records could be checked for 32 of the 37 cases from school A and for 62 of the 75 cases from schools B–E.32. B–E. the age and gender of the 37 cases and 34 controls were similar. 1. 407. In schools B–E. 663. 95 percent CI: 1. The proportion of students that had bought and consumed regular Coca-Cola at school was higher among cases than controls in both school A (OR 36. In school A. 23. Headache. In school A. In schools B–E. 2002 Downloaded from http://aje.3 percent) of the patients from school A and schools B–E.2. cases were more likely to have a low mental health score. cases were more likely to exclusively consume regular Coca-Cola (OR 5.0.5 hours (median.8. Belgium. and dizziness were the main clinical symptoms reported on the medical charts (table 2). Georgia. 2. The following variables were included in the multivariate model: age.9). Fanta. About one third of the cases described the smell as nasty or rotten.5). Fanta (OR 3.8. Six students from school A and two students from the other schools relapsed within a couple of days. and dizziness were the main clinical symptoms reported by the first nine cases in school A. Exclusive consumption of other beverages (other Coca-Cola and non-Coca-Cola products) was similar among cases and controls (table 4). few cases and no controls noted a bad smell. 95 percent CI: 8. exclusive consumption of beverages (regular Coca-Cola. In school A. 95 percent CI: 2. and the reporting of a bad taste to soft drinks. No.8. In schools B–E. 1. Coca-Cola is manufactured by The Coca-Coca Company. two thirds (51/75) of the cases were clustered in 11 classrooms. fewer than one control per case in school A and fewer than two controls per case in schools B–E could be interviewed. cases were more likely to report an off-odor (OR 43. the delay between consumption of soft drinks and occurrence of symptoms ranged from 30 minutes to 7. Case-control study Because of practical constraints in schools to interviewing during the end-of-school examinations. 95 percent CI: 1. with onset of symptoms 30 minutes to 24.5. respectively. exclusive consumption of regular Coca-Cola (OR 29. Because school A did not provide food.7.7. gender. In schools B–E. In schools B–E. and respiratory troubles were reported more frequently by the later cases.4 percent) and 56 (90. the odds ratio (2.1. with consumption of water or no consumption at all as the reference.142 Gallay et al.0. 12. all but three cases drank beverages between 12:00 and 12:30 p. other soft drinks) as a set of dummy variables.2.oxfordjournals. 235.5. by gender and time of onset of illness.6). The number of cases per class ranged from three to nine. 95 percent CI: 1. In both school groups. abdominal pain.1) and schools B–E (OR 3. in schools B–E. 95 percent CI: 2. In school A.1. 77. nausea. 7.4) or a bad taste (OR 28.3 percent) urine samples taken from the 75 students from schools B–E were normal. the majority of students ate a homemade lunch. headache.7) to the regular Coca-Cola. Extreme pallor was noted for some of the first cases from school A. In schools B–E. The results of a range of routine biologic tests performed on the 56 (74. nausea. headache.7.7.9) (table 4). Although blood and urine samples were collected from students in school A. or Coca-Cola light (OR 12. 201. 155. no results from the routine biologic and toxicologic analysis could be obtained.3. 10. Am J Epidemiol Vol. In both school groups A and B–E.4. the 75 cases and 130 controls were similar in age. 1999. respectively.3.0) (table 3).206. time of beverage consumption and time of onset of symptoms were available for 31 and 37 cases.8. and few cases and one control reported a bad taste.org/ by guest on April 29. having a friend become ill was not associated with the disease. cases were less likely than controls to have eaten the food provided by the school (table 5). In each of the school groups A and B–E. FIGURE 1. In school A. 95 percent CI: 1.6) and having a low mental health score (OR 16.2. 95 percent CI: 7. Physical examination was normal for 27 (84. 95 percent CI: 1.5 hours (median.7 percent) students from schools B–E. but cases were more likely to be girls (odds ratio (OR) 4. In schools B–E. All symptoms disappeared spontaneously within several hours for the majority of patients. the reporting of an off-odor. and flushed skin and/or red eyes were noted for six (9.5. Atlanta.

No other soft drink or food item was associated with becoming ill. 18. by gender and time of onset of illness.org/ by guest on April 29.Belgian Coca-Cola-related Outbreak 143 Downloaded from http://aje. and Coca-Cola light (OR 15. 19.5) and students with a low mental health score (OR 3. 1999.8. 16. 95 percent CI: 1.oxfordjournals. Belgium. 155. 95 percent CI: 2.1. schools B–E.1.0. 95 percent CI: 1. The short interval between exposure to the soft drink and occurrence of symptoms favored a toxicologic cause (table 6).6) also were more likely to have reported the illness. No.2) remained independently associated with the illness. Fanta (OR 5. 95 percent CI: 1. Georgia.5).2.7. 95 percent CI: 3.0). Girls (OR 4. 2. 2012 FIGURE 2. 2002 DISCUSSION The epidemiologic investigation suggested that consumption of regular Coca-Cola was a strong determinant of illness in school A.3. Atlanta. 78. exclusive consumption of regular Coca-Cola (OR 7. Number of cases of Coca-Cola-related illness. 6. Coca-Cola is manufactured by The Coca-Coca Company. Am J Epidemiol Vol. Regular Coca-Cola was the .7.5.9.

9 83. a similar but weaker association with regular Coca-Cola consumption was observed. Exclusive exposure to specific beverages* in school A and schools B–E. TABLE 2.2 2 Asthenia Respiratory 7 30. 1999 Beverage School A (glass bottles) Regular Coca-Cola Fanta Coca-Cola light Other Coca-Cola Company products Non-Coca-Cola Company products Water/no drink Cases Controls (no.7 16.8 Coca-Cola light 2.7 0 22.5 (72/2.2 (37/280) 15. Exposure to regular Coca-Cola*. Coca-Cola light) were also identified as risk factors.7 (3/388) School A Yes No Total Schools B–E Yes No Total 34 3 37 31 44 75 91.9 Other Coca-Cola Company 5 5 4.0 18 11. The first cases may have been exposed to a higher concentration of carbonyl sulfide and hydrogen sulfide.1 8 26 34 22 108 130 23.org/ by guest on April 29. Descriptive epidemiology of Coca-Cola*-related illness.9 9 3 12. were compatible with the expected symptoms of exposure to carbonyl sulfide and hydrogen sulfide (4. although blood and urine samples were collected from school A students at the local hospital. † CI. typical of carbonyl sulfide and hydrogen sulfide contaminating the carbon dioxide used in the beverage.0 5 33. 3.3 Non-Coca-Cola Company 1 5 0. % Schools B–E (n = 62) Downloaded from http://aje.8 7. a clear off-odor was established. 17. 235.1 1 troubles 4.9 (9/101) 3. % Later cases (n = 23) No. if there were. confidence interval.8.8.9 1 4. CI.8 products 0. Atlanta.3 Symptom No. % Controls No. No. 13–15. ‡ OR.0 0 Reference 0. Belgium.9) Range.6) (95% CI: 1. Attack rate (%) Among girls Among boys Relative risk of being ill according to female gender.5 36.4 3 pain 62.0 2 2. school A and schools B–E. TABLE 3.0 * Coca-Cola is manufactured by The Coca-Cola Company.9.1. Coca-Cola and Fanta are manufactured by The Coca-Cola Company. Belgium.5 1 7. Georgia.9 8.7 8 0 Vomiting 12. 47. school A and schools B–E. 2. the results were unobtainable.) 31 0 0 1 0 2 8 9 0 3 2 12 OR† 95% CI† 3. Moreover.5 76. and the GC-MS technique (gas chromatography in combination with mass specAm J Epidemiol Vol. particularly among the first cases. confidence interval. Belgium.5 Regular Coca-Cola 2. 10.† in school A and schools B–E. 1999 Consumption of regular Coca-Cola Cases No.2 Schools B–E (cans and bottles) 26 20 5.4 3 /minute† 12. CI. 8. 77.5 0. Other CocaCola Company soft drinks (Fanta.4 36 66. and dizziness). Georgia.5 Fanta 1. Belgium.3 Heart rate ≥100 2 10. 50. Atlanta.6 0.4 4 Dizziness 30. It is very unfortunate that. the main symptoms observed (headache.9.8.4. Atlanta.3 7 0 Diarrhea 11.1 3. 12. there was no evidence that any analyses were conducted.1 1 Weakness 4.6 (28/179) 8.1 1 Trembling 29.3 (72/1. 1999 School A Schools B–E 1. In the sensory analysis conducted by The Coca-Cola Company’s Northwest Europe Division.oxfordjournals. Range 13–19. ‡ Fever was known for 7 of the first cases and 14 of the later cases in school A and for 37 cases in schools B–E. nausea.3 products 0.7 3 11.8 2 8. Symptoms of Coca-Cola*-related illness abstracted from the medical records.4 3 11.672) 0. 155. odds ratio.7 (95% CI†: 0. 5). Atlanta.7 6 Nausea 58.1 * Coca-Cola is manufactured by The Coca-Cola Company. 20. Age (years) median. 6).2 39 33.4 7 30. The sulfur-containing compound responsible for this off-odor was detected in the regular Coca-Cola consumed in school A by gas chromatography in combination with a sniffing technique (GC-SNIFF) (4).8 6 26.1 3 0 Fever ≥38˚C‡ 8.3 58.2 0 13 56.5 1.5 19 81 Reference Water/no drink * Beverages bought and consumed at school on the day of the outbreak. % OR‡ 95% CI‡ TABLE 1. % 23. 220.7.8 7 Headache 77. 1999 School A Cases with onset of illness before 14:10 (first cases) (n = 9) No. 7.1 41. Brief exposure to hydrogen sulfide can be sufficient to induce such symptoms (5. 2. while the later cases may have paid attention when opening and drinking the soft drink. 2012 TABLE 4.0 19 44.5 48 77.144 Gallay et al.8 5. † OR. In schools B–E. only soft drink that the students characterized as having a rotten smell. † Regular Coca-Cola bought and consumed at school on the day of the outbreak. 2002 . confidence interval. Georgia.9 5 21. odds ratio.1 3 13. 13 median. A sensory analysis of the outside of the cans from the production site supplying schools B–E detected a “medicine-like” odor. 8. Georgia. by school 13.6 Abdominal 15 65.) (no. † Pulse rate was known for the first cases and 20 of the later cases in school A and for 40 cases in schools B–E.9 9 11 3.7. 15 * Coca-Cola is manufactured by The Coca-Cola Company.060) 4.

Downloaded from http://aje. it is unlikely that such low concentrations of carbonyl sulfide. The beverages consumed in school A on the day of the outbreak had been produced just 4 days earlier. no evidence. The company submitted the results of chemical analyses to a laboratory for toxicologic advice (4). 155. becoming stronger and disappearing after a few days (7). or parasitologic investigations carried out by The Coca-Cola Company laboratory were all negative. However. None of these symptoms was reported by the students. § Refer to Ware et al. Am J Epidemiol Vol. 1999 Evidence for a School A Schools B–E Causal toxicity Consumption of soft drink associated with the illness (Regular Coca-Cola) (Several beverages) Short interval between exposure to soft drink and occurence of symptoms Typical odor (Regular Coca-Cola: typical of carbonyl sulfide and hydrogen sulfide) Toxicologic analyses Compatibility between observed and expected symptoms (of exposure to (of exposure to carbonyl sulfide and chlorocresol) hydrogen sulfide) Mass sociogenic illness Classic risk factors of mass sociogenic illness (occurence among adolescents.8 20¶ 27 17 6 65 11¶ 2 1 26 101 2.4 43. † Coca-Cola is manufactured by the Coca-Cola Company. trometry) revealed the presence of a very low concentration of chlorocresol (4-chloro-3-methylphenol) on the external surface of the cans from the French plant (Dunkerque) (4). hydrogen sulfide. According to the toxicologic reports. 2.206. † Cases. controls. the observed symptoms were not compatible with the expected symptoms (either eye and skin irritation as a result of dermal contact or severe effects on mucous membranes caused by ingestion) of the p-chloro-mcresol exposure (4. n = 75.7. Evidence* for a causal toxicity connection versus evidence for a mass sociogenic illness with Coca-Cola†-related illness in school A and schools B–E.Belgian Coca-Cola-related Outbreak 145 TABLE 5. n = 37. 2002 . 5). controls.9 0.5 * OR.2 1.8. No. 7.0. . all toxicologic analyses were performed only several days after the day of the outbreak. girls.7 0. in 1962. CI.) OR* 95% CI* School A† Food provided by school Having a friend be ill Mental SF-36 Health Survey score§ <median Bad smell Bad taste Schools B–E# Food provided by school Having a friend be ill Mental SF-36 Health Survey score§ <median Bad smell Bad taste —‡ 36 —‡ 30 4. unusual mental stress) Benign morbidity. Bacterial. ¶ 1 missing value among the cases and 2 missing values among the controls. 1. In addition. n = 34. viral. Hall noted that water carbonated with carbon-dioxidecontaining carbonyl sulfide produced detectable hydrogen sulfide some hours later. confidence interval.3. evidence.0 0. relapse of illness Rapid spread and dissolution Identification of a trigger: a bad odor No readily apparent environmental cause Person-to-person transmission by line-of-sight or audiovisual cues Role of the media in transmission * . odds ratio.4 1. strong evidence.4 22.4 3.oxfordjournals. clusters. It is unclear whether the beverages produced on June 4 were supplied to other places within the same time delay and whether the samples taken for analyses came from the lots suspected of causing the illness (4).) (no.1. the fact that these test results showed low or undetectable levels of gases may not be a meaningful indicator of a potential exposure. 0. 242.4 3. # Cases. no clinical or laboratory evidence. all laboratory results and physical examinations were normal (table 6). 961.org/ by guest on April 29. and 4-chloro-3methylphenol could have caused any toxicity.6 47 6 11 54 0 1 2. 2012 TABLE 6. However. Since carbonyl sulfide and hydrogen sulfide concentrations are known to decrease over time (7). in schools B–E.1. Georgia. n = 130.2 28.8. 4.2 8. 407. ‡ No food was provided at school A. Exposure to other risk factors in school A and schools B–E. Belgium. (3). 1999 Risk factor Cases Controls (no.8 0. Belgium.4. Atlanta. . 4.9 0.

with the highest proportion of Am J Epidemiol Vol. classic risk factors for mass sociogenic illness were identified in both school groups A and B–E (table 6). school lunch) by line-of-sight or audiovisual cues (16). This was not usual in previous outbreaks of mass sociogenic illness in which airborne substances were commonly incriminated with unspecific sources (14. Moreover.org/ by guest on April 29. public measures for withdrawing the implicated products were insufficient. a selection of cases on the exposure may have induced the association between consumption of regular Coca-Cola and symptoms. This information was probably more precise in school A. In both school groups. which had heightened anxiety in the population about food safety (22). 16. 2. conversely. it could be argued that in school A. which is typical of the odor of sulfide. lack of transparency about the safety of the Coca-Cola product and controversial information from officials intensified the community’s concern.146 Gallay et al. the associations with low mental health scores do not disprove chemical contamination as a cause of the outbreaks. and because the symbolic image of The Coca-Cola Company is so well known and is highlighted by extensive media coverage. the outbreak took place during the end-of-school examination period (11). regular Coca-Cola was clearly identified in school A as having a “rotten egg” odor. and communicating the diagnosis in order to stop the spread of the illness. The outbreak was characterized by occurrence among adolescents or preadolescents in a school setting. may have contributed further to the psychosocial distress of the general population (1. 10). 2. More complex instruments have been proposed to evaluate mass sociogenic illness (14). many vectors were incriminated (21). First. Second. In this outbreak. 17). and clear information from the different actors implicated. Nonetheless. a bad odor of a “gas” was identified by students and could have been a trigger (11–14. during the last week of end-of-school examinations. identifying the existence of an outbreak of mass sociogenic illness. 23–25). The proportion of cases that consumed regular Coca-Cola was 100 percent among the first nine cases compared with only 87 percent among cases whose onset of symptoms occurred after the afternoon break between classes. although the association was not statistically significant. if cases are told that their source of anxiety is a false belief. The high awareness and anxiety about the safety of modern food products. it would have been difficult to stop the process without a quick and complete analysis of the incriminated product and clear information about the safety of the soft drink. Nonetheless. Extensive nationwide radio and television media coverage of the first incident in school A probably played a substantial role in transmitting the outbreak from school to school and from school to the general population (11. relapse of illness. cases more often than controls had reported a friend being ill on the day of the outbreak (16). 22). that no toxicologic cause exists. combined with a very strong symbolic image of the incriminated product. propose that mass sociogenic illness be considered in any outbreak of acute illness thought to be caused by exposure to a toxic substance but with minimal physical findings and no environmental cause readily apparent to the investigator (17). Jones et al. In the present study. Previous papers have attributed. as quickly as possible. Similar to several outbreaks of mass sociogenic illness described previously. credibility of the results and the official information depends on the absence of a conflict of interest. without investigation. In this study. However. Even anxiety can cause real symptoms. several deficiencies in crisis management were identified. the outbreaks to episodes of mass sociogenic illness (9. objective features. No. resulting in the spread of symptoms (11. this explanation will not reduce their embarrassment and can exacerbate their condition (26). Because of the great distribution of the soft drinks. Under the hypothesis of a mass sociogenic illness. The SF-36 Health Survey scores addressed the feelings of the students during the previous 4 weeks and provided only an indicator of mental health status. a preponderance of illness among girls. Such outbreak investigations need transparency. because they felt bad since the incident had occurred. one would expect the opposite. and rapid spread and dissolution of the outbreak (11–15). These include ensuring. the Ministry of Public Health was already very involved in the dioxin crisis. In both school A and schools B–E. 155. clustering of cases in classrooms. If selection of cases would have occurred based on the exposure. 18–20) or. benign morbidity and no clinical or laboratory evidence of illness. evidence of unusual mental stress among those reporting illness. In schools B–E. 2012 . 16–19).oxfordjournals. which could have introduced recall errors that particularly affected time of beverage consumption and time of onset of illness. 16). This possibility seems highly unlikely. the survey was performed 2 weeks after the outbreak. a number of difficulties arise in balancing competing requirements. because of the lack of pathognomonic indicators of mass sociogenic illness and the difficulty in proving the presence of a toxicologic substance. the odor described varied. For example. which can increase stress (13. First. interrupting the transmission of symptoms by separating exposed groups and suppressing audiovisual transmission seemed practically impossible (16). When a possible outbreak of mass sociogenic illness is investigated. propagation of the illness accelerated with person-to-person transmission when students were grouped (during break periods. 2002 Downloaded from http://aje. Many students reported that it was difficult to answer this question. since mental health status could easily modify symptom severity or a person’s behavior. where all soft drinks were sold at noon break only. In addition. In such a situation. and The Coca-Cola Company performed nearly all soft drink analyses. investigations often have become extensive before a diagnosis can be stated. it is likely that friends consume similar products or even share them. belonging to a group having a low mental health score was independently associated with illness and could highlight a stressful situation being experienced by the ill students. several features enhanced contagion of the outbreak (table 6). the arrival of ambulances with emergency personnel and the police could have increased the general excitement and anxiety. In schools B–E. The findings of this study are subject to a number of limitations. However. Furthermore. as in many previous outbreaks. this outbreak occurred within the context of the recent Belgian general election and a dioxin crisis in Belgium 2 weeks earlier.

Mass psychogenic illness attributed to toxic exposure at a high school. Belgium: Centre Antipoisons. Epidemiology 1990. not the least of which was the end-of-year examinations. MA: The Health Institute. classic factors of mass sociogenic illness were present and could explain the majority of the later cases in both schools A and B–E. Mental health status at the time was influenced by many factors. No. Outbreak of psychosomatic illness at a rural elementary school. Borus JF. 22. Chorba TL. 8. Lancet 1989. Seydlitz R. 20. Gardner H. New England Medical Center. (Editorial). Int J Mass Emergencies Disaster 1991.3:711–16. Mass psychogenic illness attributed to toxic exposure at a high school. 2. Boogaerts M. Patterns of transmission of epidemic hysteria in a school. 1997. 19. 6. Biogeochemistry of dissolved hydrogen sulfide species and carbonyl sulfide in the western North Atlantic Ocean. Observations du Centre Antipoisons portant sur la période du 08/06/1999. Desenclos JC.19:233–43. Rifkin A.gov/sis1). Some limitations of this investigation were related to deficiencies in managing the crisis. The authors acknowledge the directors of the five schools (Bornem.40:201–8. Denmark: Dansk Toksikologi Center. et al. N Engl J Med 2000.342: 1673–5. et al. Radford-Knoery J. Exposure to carbonyl sulfide and hydrogen sulfide could explain the observed symptoms.58:269–78.58:5421–31. 3. 5. A sudden outbreak of illness suggestive of mass hysteria in schoolchildren. Outbreak of illness in a school chorus: toxic poisoning or mass hysteria? N Engl J Med 1983. Am J Psychiatry 1985. Mass sociogenic illness in a youth center. Romn FJ. 1999.342:96–100. Nemery B. Fort Lauderdale. but cannot always explain it. Copenhagen. Levine RJ. 12. Lancet 1974. Horan M. 155. 26. ACKNOWLEDGMENTS 16. Arch Fam Med 1994. (In French). Feinberg DT. SF-36 Health Survey: manual and interpretation guide. Coke adds life. 18. Ware J. Rev Epidemiol Sante Publique 1992. 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There also may have been an overestimation of a low mental health score among cases. 2012 Am J Epidemiol Vol. 1993. Spencer JW. et al. Small GW. 15. CocaCola. Factors that contribute to the possible existence and role of mass sociogenic illness are difficult to discern. N Engl J Med 2000. Van Oyen H. et al. Report on the analysis of the prod- 21.354:77.238:2373–6. Brussels. (http://sis. JAMA 1977.16:265–70. They also thank the physicians of the hospitals for providing the medical information.org/ by guest on April 29.53:744–5. 25. Goossens E. Lancet 1999. Cutter G. Geochimica et Cosmochimica Acta 1994. Small GW. Cole TB. Online carbonyl sulphide—HSDB-Hazardous Substances Data Bank. et al. Etude descriptive et surveillance des manifestations symptomatiques rapportées par les consommateurs de boissons commercialisées par la marque CocaCola en juin 1999. Epidemiol Rev 1997. 24. 7. Snow KK. 13. Smith HC. Paris. 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