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Eduardo Azziz-Baumgartner,¹ Kimberly Lindblade,² Karen Gieseker,³ Helen Schurz Rogers,¹ Stephanie Kieszak,¹ Henry Njapau,⁴ Rosemary Schleicher,¹ Leslie F. McCoy,¹ Ambrose Misore,⁵ Kevin DeCock,⁶ Carol Rubin,¹ Laurence Slutsker,⁷ and the Aflatoxin Investigative Group*

¹National Center for Environmental Health, ²National Center for Infectious Diseases, and ³Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; ⁴Food and Drug Administration, Washington, DC, USA; ⁵Preventive and Promotive Health Services, Kenya Ministry of Health, Nairobi, Kenya; ⁶Centers for Disease Control and Prevention, Kenya Field Office, Nairobi, Kenya; ⁷Centers for Disease Control and Prevention, Kenya Field Office, Kisumu, Kenya

Abstract
Objectives: During January-June 2004, an aflatoxicosis outbreak in eastern Kenya resulted in 317 cases and 125 deaths. We conducted a case-control study to identify risk factors for contamination of implicated maize and, for the first time, quantitated biomarkers associated with acute aflatoxicosis.
Design: We administered questionnaires regarding maize storage and consumption and obtained maize and blood samples from participants.
Participants: We recruited 40 case-patients with aflatoxicosis and 80 randomly selected controls to participate in this study.
Evaluations/measurements: We analyzed maize for total aflatoxins and serum for aflatoxin B₁-lysine albumin adducts and hepatitis B surface antigen. We used regression and survival analyses to explore the relationship between aflatoxins, maize consumption, hepatitis B surface antigen, and case status.
Results: Homegrown (not commercial) maize kernels from case households had higher concentrations of aflatoxins than did kernels from control households [geometric mean (GM) = 354.53 ppb vs. 44.14 ppb ; p = 0.04]. Serum adduct concentrations were associated with time from jaundice to death [adjusted hazard ratio = 1.3 ; 95% confidence interval (CI) , 1.04-1.6]. Case patients had positive hepatitis B titers [odds ratio (OR) = 9.8 ; 95% CI, 1.5-63.1] more often than controls. Case patients stored wet maize (OR = 3.5 ; 95% CI, 1.2-10.3) inside their homes (OR = 12.0 ; 95% CI, 1.5-95.7) rather than in granaries more often than did controls.
Conclusion: Aflatoxin concentrations in maize, serum aflatoxin B₁-lysine adduct concentrations, and positive hepatitis B surface antigen titers were all associated with case status.
Relevance: The novel methods and risk factors described may help health officials prevent future outbreaks of aflatoxicosis.
Key words: albumin adducts, aflatoxicosis, aflatoxin, Kenya, lysine, maize. Environ Health Perspect 113: 1779-1783 (2005) . doi:10.1289/ehp.8384 available via http://dx.doi.org/ [Online 9 August 2005]

Address correspondence to E. Azziz-Baumgartner, Centers for Disease Control and Prevention, Mailstop F46, 4770 Buford Hwy NE, Atlanta, GA 30341-3717 USA. Telephone: (770) 488-3412. Fax: (770) 488-3450. E-mail: eha9@cdc.gov

*Members of the Aflatoxin Investigative Group include J. Nyamongo, C. Njuguna, E. Muchiri, J. Njau, S. Maingi, J. Njoroge, J. Mutiso, J. Onteri, A. Langat, I.K. Kilei, G. Ogana, B. Muture, J. Nyikal (Kenya Ministry of Health) ; P. Tukei, C. Onyango, W. Ochieng (Kenya Medical Research Institute) ; I. Mugoya, P. Nguku, T. Galgalo, S. Kibet, A. Manya, A. Dahiye, J. Mwihia, S. Likimani, C. Tetteh (Kenya Field Epidemiology and Laboratory Training Program/Kenya Ministry of Health) ; J. Onsongo, A. Ngindu (World Health Organization, Kenya Country Office) ; P. Amornkul, D. Rosen, D. Feiken, T. Thomas (CDC Kenya) ; P. Mensah, N. Eseko, A. Nejjar (World Health Organization, Regional Office for Africa) ; M. Onsongo, F. Kessel (Foreign Agricultural Service, U.S. Department of Agriculture) ; D.L. Park (Center for Food Safety and Applied Nutrition, Food and Drug Administration) ; C. Nzioka (Office of Global Health, CDC) ; L. Lewis, G. Luber, L. Backer, C.D. Powers, C. Pfeiffer (National Center for Environmental Health, CDC) ; W. Chege, A. Bowen (Epidemiology Program Office, CDC) .

The use of trade names is for identification only and does not imply endorsement by the Centers for Disease Control and Prevention, the Agency for Toxic Substances and Disease Registry, the Public Health Service, or the U.S. Department of Health and Human Services.

The authors declare they have no competing financial interests.

Received 6 June 2005 ; accepted 9 August 2005.

Correction: The AGD data for control females were incorrect in Table 3 of the original manuscript published online, but they have been corrected here.

An erratum was published in Environ Health Perspect 114:A90 (2006) .