“It's not just a disease of the past”: the return of scurvy in France, more than 100 cases per year among children

Citrus fruits are the best-known source of vitamin C. Midi Libre – MICHAEL ESDOURRUBAILH

A worrying number of 888 cases between 2015 and 2023, and a significant incidence in 2020, 26.6 cases per 100,000 children, compared to 8.2 in 2016: Zein Assad, pediatrician and researcher at Inserm, first author of the French study published last December in The Lancet on the return of scurvy in France, explains the situation.

Forgotten and relegated, in the collective imagination, to the ailments of another time, when sailors on expeditions were deprived of vitamin C, scurvy is making a comeback in France, warns a French study published in The Lancet last December.

Zein Assad is the lead author of the study published in The Lancet.

Dr. Zein Assad led the study, which recorded 888 pediatric cases of scurvy between 2015 and 2023 in France. The increase in the incidence of this disease, which had been “regular” since 2015 (+0.05% per month), accelerated significantly from March 2020 (+1.9% per month). A pediatrician, Zein Assad is also an Inserm researcher in the Infection, Antimicrobials, Modeling, Evolution (IAME) laboratory.

What alerted you to the scurvy situation in France? ?

We started from a clinical observation, as is often the case in epidemiological studies. At the Robert-Debré hospital, we had the feeling of seeing children from increasingly precarious families, sometimes living on the street, it was not really measurable.

And at the same time, we observed a few cases of scurvy, which is a disease linked to a profound vitamin C deficiency, due to a lack of fresh fruit and vegetable intake (broccoli, cabbage, citrus fruits, pineapple, etc.). We therefore wanted to check whether this signal of an increase in cases was observed on a national scale, and whether there was a link with precariousness.

Were you surprised by the result?

Nearly 900 cases in 9 years is still rare for such a disease. But the upward trend observed in recent years is worrying. In the collective imagination, scurvy is a disease of the past, which affected 15th century sailors during their long sea expeditions without access to fresh produce.

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Why scurvy ? Midi Libre – SOPHIE WAUQUIER

Have other epidemics been observed since ?

Scurvy usually accompanies poverty and malnutrition and is therefore often found in displaced populations exposed to famine and refugee camps. Since malnutrition does not necessarily mean undernutrition, scurvy also reappeared among infants of wealthy and educated families in late 19th century France and the United States. This infant scurvy was linked to the abandonment of breastfeeding for industrial cow's milk treated at high temperatures and therefore devoid of vitamin C.

In our study carried out in France, we observed a gentle and constant increase in the number of cases since 2015, and, from 2020, in the midst of the Covid epidemic, an acceleration.

Why Covid ?

We used the Covid-19 pandemic as a marker of a new period that, from our point of view, was an accelerator of precariousness. We were also able to correlate the increase in the number of cases of scurvy with food inflation without demonstrating a causal link. Several factors can contribute to the increase in these cases of scurvy: we can cite precariousness, both economic and social, which can limit access to certain types of food, the lack of information on what a varied and balanced diet is, but also the change in the ultra-selective eating behaviors of some children.

No one is immune ?

It is important to understand that scurvy manifests itself from the moment when the vitamin C deficiency is profound and prolonged.
Vitamin C is a water-soluble vitamin, it is not stored in the body. The intake must therefore be regular and daily to avoid being deficient.

You need a lot of it ?

Less than 10 milligrams per day. An orange is 100 milligrams of vitamin C!

Can vitamin C tablets be an alternative, or is there a risk of overdose ?

Vitamin C tablets are the curative treatment for deficiency. Despite the absence of toxicity or disease linked to an overdose, vitamin C tablets should not replace foods whose nutritional qualities exceed those of the tablets!

The most obvious symptom is bleeding gums ? What are the other symptoms of scurvy ?

Vitamin C allows the synthesis of collagen, itself essential for the renewal of connective tissue, cartilage, blood vessels which must be elastic and flexible. It also promotes the absorption of iron, and participates in the immune response. The deficiency can therefore lead to healing problems, bone pain, muscle weakness, fatigue, weight loss, etc., which are not in themselves symptoms specific to scurvy, hence the importance of thinking about the disease and asking patients about their diet.

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