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UNITED
NATIONS
S

        Security Council
Distr.
GENERAL
S/15756
10 May 1983

ORIGINAL: ENGLISH

REPORT OF THE SECRETARY-GENERAL

On 4 April 1983, the following statement was issued by the President of the Security Council (S/15680):
Immediately after the issuance of this statement, the Secretary-General, who had already been in touch on this matter with Dr. Halfdan Mahler Director-General of the World Health Organization (WHO) , contacted him again and, requested that an independent inquiry be conducted by WHO in pursuance of the wishes of the Security Council. Dr. Mahler agreed to do so.

On 10 May the Secretary-General received Dr. Mahler's report on this subject which is transmitted herewith to the Security Council.

HEALTH CONDITIONS OF THE ARAB POPULATION IN THE OCCUPIED
ARAB TERRITORIES, INCLUDING PALESTINE

Report by the Director-General on a health emergency of an
ill-defined nature on the West Bank, March-April 1983

Introduction

1. From the last week of March 1983, the news media reported the occurrence of ill-defined illnesses among the Palestinian population of the West Bank, mostly among schoolgirls. A number of media releases ascribed these illnesses to "mass poisoning".

2. During the latter part of March and early April, several Member States of WHO and the Secretary-General of the United Nations separately requested the Organization to assess the situation on the West Bank. At the same time, fulfilling its responsibility as the directing and co-ordinating authority on international health work, WHO was already initiating action. WHO's initiative coincided with informal consultations of the Secretary-General of the United Nations with members of the United Nations Security Council on the same subject, which resulted in members of the Security Council, requesting the Secretary-General "to conduct independent inquiries concerning the causes and effects of the serious problem of the reported cases of poisoning . ..". The WHO action therefore constituted the independent inquiry which several Member States had requested of WHO and that members of the Security Council had requested of the Secretary-General.

3. The Special Committee of Experts established by the Twenty-sixth World Health Assembly in 1973 to study the health conditions of the Arab population in the occupied Arab territories, including Palestine, included this health emergency among the factors affecting the health situation,that it considered during its visit from 6 to 14 April 1983. The observations of the Special Committee are recorded in its report to the Thirty-sixth World Health Assembly (document A36/14).

WHO's independent inquiry

4. A WHO team composed of an epidemiologist and a toxicologist from the headquarters staff left Geneva for the West Bank on 4 April 1983. The team enjoyed full independence in its work. It visited each of the three districts in which cases were reported to have occurred. In each district the team:

5. In addition to the above, discussions were held with a large number of persons, including:

6. For further environmental investigations, the independent WHO team was strengthened by two further members of the headquarters staff: a sanitary engineer, who joined the team on the West Bank on 13 April 1983, and, later, an air pollution monitoring expert , who joined the team on 27 April 1983.

7. At the beginning of the stay of the WHO team on the West Bank, another team, consisting of the Director, Division of Surveillance, Hazard Evaluations, and Field Studies, of the National Institute foe Occupational Safety and Health, Centers for Disease Control (CDC), Atlanta, Georgia, USA, and a medical epidemiologist from the Center for Infectious Diseases, CDC, was carrying out clinical, epidemiological and environmental investigations. Their investigations were distinct from the inquiry made by the WHO team; however, the WHO and CDC experts met and the CDC team discussed its approach with the WHO team. Since then, the CDC team's report has been made public.

8. Serum specimens from acute cases (7 specimens), from convalescent and recovered patients (22 specimens) and from controls (21 specimens) were sent to WHO collaborating centres in Europe for toxicological and biological investigations. Environmental specimens, including sludge from a septic tank, were likewise sent to WHO collaborating centres in Europe for investigation.

9. The WHO team received the full support of the United Nations Truce Supervision Organisation (UNTSO), which kindly provided secretarial, transport, telephone and all other necessary facilities.

Summary account of events

10. The health emergency comprised three successive episodes during the period 21 March to 4 April 1983. The first episode occurred on 21 March and involved the elementary, primary and secondary classes of a girls' school in the northern part of the West Bank. The majority of the cases occurred on 21 March but some cases continued to occur during the next few days. The cases occurred mostly among schoolgirls, but: three teachers, a worker in the school, and a person living near the school were also involved. All cases (more than 60) were hospitalised. The school was closed on 21 March and remained closed until 2 May 1983. The senior medical officer of the district and members of his staff arrived at the school within less than two hours of the time of onset of the first cases. The Director of the Public Health Division, West Bank, and the Chief Area Supervising Nurse, West Bank, visited .the school on the evening of the same day. On both occasions the health teams were aware of an unpleasant smell and a transient irritation of the eyes and throat. Environmental investigations were carried out two days later, on 23 March, by the Research Institute for Environmental Health, Tel Aviv University.

11. The second episode, affecting over 300 persons, occurred mainly during the period 26-28 March and involved six girls' schools in the same district as the first episode. The cases presented the same clinical picture as had been noted in the first school. However, in contrast to the first episode, a relatively large number of adults of both sexes and not connected with the affected schools were taken ill. Cases also occurred in the schools and outside them on 29-31 March. Almost all cases were hospitalised and schools were closed.

12. The third episode, on 3 April, involved girls from two schools in another district in the northern part of the West Bank and two schools in one district in the southern part. A relatively small number of individuals not connected with the schools, the majority of them adults, also fell ill. A few cases also occurred in the southern part of the West Bank on 4 April. Again, almost all the cases (over 500) were admitted to hospital.

13. Following the third episode , all elementary, primary and secondary schools on the West Bank were closed. By 19 April 1983 they,were all open again, except for the schools directly involved in the health emergency , which reopened in the first week of May 1983. No further cases have been reported.

Summary findings

14. On the basis of the inquiries made by the independent WHO team and of the information made available to it, the clinical manifestations, epidemiological observations, environmental investigations , and laboratory findings may be summarised as follows.

15. Most of the cases had one or more of the following signs and symptoms: headache, dizziness, cyanosis of the extremities, myoriasis, myalgia, abdominal pain, vertigo or ataxia, tremors or twitches, nausea and vomiting, tachycardia, and general weakness. No fever was noted. The stay in hospital was usually between 4 and 5 days. A large proportion of patients experienced a recurrence of signs or symptoms, and some had persistent symptoms for 2-3 weeks. All cases were admitted to hospitals on the West Bank, but some of those considered severe were transferred to hospitals in Israel. All cases have now been discharged from hospital. No deaths were reported.

16. Clinical laboratory investigations were conducted in hospitals on the West Bank and in Israel. The hospital records show an occasional proteinuria,
transient alterations in serum electrolytes or alkalosis, and in one case anaemia; otherwise the hospital laboratory findings fell within the normal ranges.

17. In the schools, cases occurred in all classes (l-12; elementary through secondary), but there were only a few cases in classes l-4. In general, the highest incidence was observed in classes 9, 10 and 11. Cases occurred in persons ranging in age from below 10 years to 20 years, but in general the highest incidence was in the 13-17-year age range. A number of teachers and workers in the schools fell ill at the same time as the students.

18. Most cases outside the schools occurred in persons over 16 years old, the highest age recorded being 40 years. One third of these cases were in males.

19. The epidemiology of the episode in the first school was analysed in particular detail. The incidence rate by classroom showed a clustering in a few classrooms. The onset was marked by the occurrence of a few cases in the first hour of entry into class, of still fewer cases during the second hour, and of the majority of cases during the third hour. Cases among students and among adults connected with the school continued to occur after the closure of the school.

20. In the course of the investigations made on 23 March, hydrogen sulfide was detected in a classroom of the school where the first cases occurred. This suggested the possibility that gases from the decomposition of organic wastes may have emanated from the leaching pits connected to the school toilets.

21. The WHO team investigated this possibility. The results of this work, which was carried out on 1 May 1983, indicated that the toilets produce a certain amount of hydrogen sulfide but the concentrations encountered did not seem unusual for this type of facility under the climatic conditions that prevailed at the time and given the fact that the school had been closed since 21 March 1983. No hydrogen sulfide could be detected in the classrooms by the WHO team.

22. Sanitary facilities at all the other schools where outbreaks had occurred, and at nine schools from which no outbreaks had been reported, were carefully inspected. No features were found that would suggest that the sanitary conditions in the schools where outbreaks had occurred were significantly different from those in the other schools.
23. The blood specimens tested at the WHO collaborating centres were subjected to solvent extraction and processed by gas chromatography and scanning mass spectrometry. No differences between samples from cases and samples from controls were observed. The environmental specimens did not reveal abnormal findings.

Conclusions

24. The independence of the WHO inquiry was not affected by any authority or in any other way.

25. The epidemiological inquiry was, to a great extent, impaired by having to rely on a largely retrospective approach. This affected both the case investigations and the environmental investigations, but it particularly limited the usefulness of the biological and environmental samples taken retrospectively for the identification of toxic and microbiological substances. With the conditions prevailing during and after these outbreaks of ill-defined clusters of symptoms, the value of any structured or unstructured retrospective interviews of persons who had experienced various combinations of symptoms with varying degrees of intensity was also affected. For the same reason WHO cannot vouch for the correctness of the clinical findings made at the time the cases occurred, but the WHO team found no reason whatsoever to challenge the findings reported to it.

26. Within the above limitations, the WHO inquiry has not been able to indicate any specific cause or causes of this ill-defined health emergency. However, the initial medical records and interviews with cases in the first outbreak and with local health and other authorities suggest that an environmental agent could have provoked at least some cases in the first outbreak.

Recommendation

27. In view of the anxiety under which the population lives in these occupied territories, and given the susceptibility of girls during the stressful
transitional period of adolescence, it is the Director-General's opinion that everything possible should be done to protect the local population from unnecessary alarm. For that purpose WHO's presence should be made available in the event of any suspected recrudescence of this ill-defined health emergency. This would not interfere with the normal activities of the local population. On the contrary, individuals, families, communities and the authorities should feel reassured by the knowledge that WHO could be mobilized in any case of need. Although it appears unlikely that the patients in this ill-defined health emergency will suffer any significant sequelae, there should also be provision foe clinical follow-up by WHO should any of them or their families so request.
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