Abstract

Beriberi is the clinical manifestation of severe and prolonged thiamine (vitamin B1) deficiency. It is a neglected disease that affects low-income populations facing food and nutrition insecurity. The aim of this study was to compare cases of beriberi among indigenous and non-indigenous people in Brazil. We conducted a cross-sectional study using data on cases of beriberi during the period July 2013-September 2018 derived from beriberi notification forms available on the FormSUS platform. Cases in indigenous and non-indigenous patients were compared using the chi-squared test or Fisher’s exact test, adopting a significance level of 0.05. A total of 414 cases of beriberi were reported in the country during the study period, 210 of which (50.7%) were among indigenous people. Alcohol consumption was reported by 58.1% of the indigenous patients and 71.6% of the non-indigenous patients (p = 0.004); 71.0% of the indigenous patients reported that they consumed caxiri, a traditional alcoholic drink. Daily physical exertion was reported by 76.1% of the indigenous patients and 40.2% of the non-indigenous patients (p < 0.001). It is concluded that beriberi disproportionately affects indigenous people and is associated with alcohol consumption and physical exertion.

Key words:
Thiamine deficiency; Vulnerable populations; Disease notification; Poverty; Public health surveillance

Introduction

The term beriberi is derived from a Sinhalese word meaning “extreme weakness”, alluding to the debilitating nature of the disease. It is the clinical manifestation of severe and chronic thiamine (vitamin B1) deficiency and has multiple underlying causes. Although easily treatable, if left untreated it can lead to death¹1 Whitfield KC, Bourassa MW, Adamolekun B, Bergeron G, Bettendorff L, Brown KH, Cox L, Fattal-Valevski A, Fischer PR, Frank EL, Hiffler L, Hlaing LM, Jefferds ME, Kapner H, Kounnavong S, Mousavi MPS, Roth DE, Tsaloglou MN, Wieringa F, Combs Jr GF. Thiamine deficiency disorders: diagnosis, prevalence, and a roadmap for global control programs. Ann N Y Acad Sci 2018; 1430(1):3-43..

Thiamine is a heat-labile and water-soluble essential vitamin that acts in the metabolism of amino acids, fats, and carbohydrates, playing a vital role in the conversion of carbohydrate to energy (adenosine triphosphate) and ensuring the proper functioning of nerve and muscle cells²2 Maihara VA,Silva MG, Baldini VLS, Miguel AMR, Fávaro DIT. Avaliação nutricional de dietas de trabalhadores em relação a proteínas, lipídeos, carboidratos, fibras alimentares e vitaminas. Cienc Tecnol Aliment 2006; 26(3):672-677.. According to the World Health Organization (WHO), the Recommended Dietary Allowance for thiamine varies between 0.2 and 1.5 mg/day³3 Bellows L, Moore, R. Water-soluble vitamins: B-complex and vitamin C [Internet]. 2012. [cited 2020 out 20]. Available from: https://extension.colostate.edu/docs/foodnut/09312.pdf
https://extension.colostate.edu/docs/foo... , depending on sex, age, and physical activity. Body reserves of thiamine are completely depleted in 4 to 6 weeks in the absence of intake⁴4 Rodríguez-Pardo J, Puertas-Muñoz I, Martínez-Sánchez P, Terán JD, Pulido-Valdeolivas I, Fuentes B. Putamina involvement in Wernicke encephalopathy induced by Janus Kinase 2 inhibitor. Clin Neuropharmacol 2015; 38(3):117-118..

Clinical signs of beriberi range from weakness of the legs, paraesthesia, anorexia, indigestion, malaise, edema to peripheral neuropathy, lesions of the brain (Wernicke-Korsakoff syndrome), cardiac insufficiency (wet beriberi), and acute heart failure with cardiogenic shock (Shoshin beriberi)⁵5 World Health Organization (WHO). Thiamine deficiency and its prevention and control in major emergencies. Geneva: WHO; 1999.. Diagnosis is essentially clinical and performed by observing the response to the administration of thiamine⁶6 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Secretaria Especial de Saúde indígena. Secretaria de Vigilância em Saúde. Guia de consulta para vigilância epidemiológica, assistência e atenção nutricional dos casos de Beribéri. Brasília: MS; 2012..

Beriberi has been reported since the twentieth century as an endemic disease or in outbreaks, especially in developing and underdeveloped countries, in closed communities, and in populations affected by major emergencies, exposed to mycotoxin citreoviridin, or with a monotonous diet⁵5 World Health Organization (WHO). Thiamine deficiency and its prevention and control in major emergencies. Geneva: WHO; 1999.. However, information on thiamine status has not been well documented due to the dearth of population-level biomarker data, hampering the determination of the global and regional prevalence of thiamine deficiency disorders (TDDs)¹1 Whitfield KC, Bourassa MW, Adamolekun B, Bergeron G, Bettendorff L, Brown KH, Cox L, Fattal-Valevski A, Fischer PR, Frank EL, Hiffler L, Hlaing LM, Jefferds ME, Kapner H, Kounnavong S, Mousavi MPS, Roth DE, Tsaloglou MN, Wieringa F, Combs Jr GF. Thiamine deficiency disorders: diagnosis, prevalence, and a roadmap for global control programs. Ann N Y Acad Sci 2018; 1430(1):3-43..

It is worth highlighting that beriberi is a neglected disease and that causes are amplified in low-income areas and related to severe food and nutrition insecurity, poor sanitation and hygiene, and overconsumption of alcohol⁷7 Brasil. Ministério do Desenvolvimento Social e Combate à Fome (MDS). O Brasil sem miséria. Brasília: MDS; 2014.. The disease predominantly affects young men, prisoners, indigenous peoples, and vulnerable populations, which are priority groups for the National Food and Nutrition Security System (SISAN)⁶6 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Secretaria Especial de Saúde indígena. Secretaria de Vigilância em Saúde. Guia de consulta para vigilância epidemiológica, assistência e atenção nutricional dos casos de Beribéri. Brasília: MS; 2012..

The main policy addressing dietary patterns and nutrient intake in Brazil is the National Food and Nutrition Policy (PNAN), published in 1999 and updated in November 2011 by Ministerial Order 2,715. The policy aims to improve the population’s food, nutrition, and health status by promoting healthy eating habits and improving access to nutritional care services provided by the country’s public health system, the Sistema Único de Saúde (SUS) or Unified Health System⁶6 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Secretaria Especial de Saúde indígena. Secretaria de Vigilância em Saúde. Guia de consulta para vigilância epidemiológica, assistência e atenção nutricional dos casos de Beribéri. Brasília: MS; 2012., focusing on major nutritional problems: overweight and obesity at all life stages, iron deficiency anemia, vitamin A deficiency, and other emerging nutrient deficiencies such as thiamine deficiency⁸8 Coutinho JG, Cardoso AJC, Toral N, Silva ACF, Ubarana JA, Aquino KKNC, Nilson EAF, Fagundes A, Vasconcellos AB. A organização da Vigilância Alimentar e Nutricional no Sistema Único de Saúde: histórico e desafios atuais. Rev Bras Epidemiol 2009; 12(4):688-699..

It is also important to highlight food and nutrition surveillance directed at traditional peoples and communities and other vulnerable populations who experience nutritional inequities. The latter affects predominantly children and women living in pockets of poverty, with particularly high prevalence of chronic malnutrition being found among indigenous children (26%), Quilombolas (16%), people living in the country’s Northeast region (15%), and families receiving assistance from cash transfer programs (15%)⁹9 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Alimentação e Nutrição. Brasília: MS; 2013..

Thus, food security and nutrition status monitoring data provide a basis for the analysis and diagnosis of cases of beriberi and the formulation of criteria for the stratification of risk and vulnerability to identify the right level of care and services for distinct subgroups of patients¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Marco de referência da vigilância alimentar e nutricional na atenção básica. Brasília: MS; 2015..

Beriberi is an important public health issue because it is a debilitating and potentially lethal disease that can cause outbreaks and epidemics with rapid onset of symptoms and death often occurring within a few days⁷7 Brasil. Ministério do Desenvolvimento Social e Combate à Fome (MDS). O Brasil sem miséria. Brasília: MDS; 2014..

In 2006, an outbreak of beriberi in the southeast of the state of Maranhão affected 434 people and resulted in 40 deaths. Associated risk factors included alcohol abuse and physically demanding labor¹¹11 Padilha EM, Fujimori E, Borges ALV, Sato APS, Gomes MN, Branco MRFC, Santos HJ, Junior NL. Perfi l epidemiológico do beribéri notificado de 2006 a 2008 no estado do Maranhão, Brasil. Cad Saude Publica 2011; 27(3):449-459.. In 2008, there was an outbreak of beriberi in indigenous communities in the Municipality of Uiramutã in Roraima. The people affected belonged to the Ingaricó and Macuxí indigenous groups and had a history of low thiamine intake and overconsumption of caxiri, a traditional alcoholic drink¹²12 Cerroni MP, Barrado JCS, Nobrega AA, Lins ABM, Silva IP, Mangueira RR, Cruz RH, Mendes SMF, Sobel J. Outbreak of Beriberi in an Indian Population of the Upper Amazon Region, Roraima State, Brazil, 2008. Am J Trop Med Hyg 2010; 83(5):1093-1097..

Considering that a national epidemiological survey of beriberi has yet to be undertaken, the aim of this study was to analyze sociodemographic, clinical, and behavioral data of reported cases of beriberi in the country and compare cases in indigenous and non-indigenous people.

Methods

We conducted a cross-sectional study using time series data on cases of beriberi during the period July 2013-September 2018 derived from beriberi notification forms on the FormSUS platform, as described by Assunção et al.¹³13 Assunção AKM, Branco MRFC, Santos TS, Costa SSB, Dias JJ, Soeiro VMS, Araújo AS, Queiroz RCS, Frota MTBA, Caldas AJM, Oliveira BLCA, Santos AM. Beriberi in Brazil: a disease that affects Indigenous people. Food Nutr Bull 2021; 42(3):427-436..

The data were downloaded in Excel format from the platform in November 2018. The FormSUS was developed by the SUS’s Department of Informatics (DATASUS) for the creation of Web forms and follows all legal and regulatory norms and standards and the SUS’s information and information technology security policies¹⁴14 Brasil. Ministério da Saúde (MS). Ficha de investigação clínica e de notificação dos casos de beribéri [Internet]. FormSUS versão 3.0. [acessado 2020 out 20]. Disponível em: http://formsus.datasus.gov.br/site/default.php
http://formsus.datasus.gov.br/site/defau... .

The FormSUS beriberi form was designed by the Office for the Coordination of Food and Nutrition (CGAN) based on the items listed in the beriberi clinical investigation and notification form contained in the Reference Guide for Epidemiological Surveillance and Nutritional Care in Cases of Beriberi⁶6 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Secretaria Especial de Saúde indígena. Secretaria de Vigilância em Saúde. Guia de consulta para vigilância epidemiológica, assistência e atenção nutricional dos casos de Beribéri. Brasília: MS; 2012..

The definition adopted for notifiable cases was that proposed by the Ministry of Health: any individual in a situation of risk showing characteristic signs and symptoms of beriberi. Situations of risk include regular strenuous physical exertion (e.g., manual labor), excessive alcohol use, a monotonous diet, hyperemesis gravidarum, and diarrhea. Characteristic signs and symptoms include paraesthesia and/or leg pain, partial loss of sensation, reflexes, and muscle strength (difficulty walking), tachycardia (palpitations), divergent blood pressure, water hammer pulse, jugular venous distention, systolic heart murmurs, gallop rhythm, dyspnoea, leg swelling, sudden cardia arrest associated with lactic acidosis and shock, ophthalmoparesis, nystagmus, cerebellar ataxia, and memory deficit⁶6 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Secretaria Especial de Saúde indígena. Secretaria de Vigilância em Saúde. Guia de consulta para vigilância epidemiológica, assistência e atenção nutricional dos casos de Beribéri. Brasília: MS; 2012..

Cases of wet beriberi, dry beriberi, Shoshin beriberi, and Wernicke-Korsakoff syndrome were defined according to Ministry of Health criteria⁶6 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Secretaria Especial de Saúde indígena. Secretaria de Vigilância em Saúde. Guia de consulta para vigilância epidemiológica, assistência e atenção nutricional dos casos de Beribéri. Brasília: MS; 2012..

The study variables were taken from the latest version of the FormSUS beriberi form, which was updated in 2014. The outcome of interest was whether the patient was indigenous or not.

The study variables were as follows: 1) sociodemographic aspects: race/color, place of residence, sex, age, age group, education level, social program(s) beneficiary, monthly family income; 2) clinical, behavioral, and health service aspects: patient history of beriberi, family history of beriberi, daily physical exertion, whether the patient was a smoker or drinker, drinking frequency, consumption of caxiri, hospitalization, type of entry into the health service, signs and symptoms, type of comorbidities, case classification, treatment with thiamine, progression of the case; and 3) constructed variables: indigenous (yes, no); does manual labor. Given that manual labor is a risk factor for the disease, the dichotomous variable “does manual labor” was derived from the items “main occupation” and “main activity” in the FormSUS beriberi form, based on the Brazilian Classification of Occupations¹⁵15 Brasil. Ministério do Trabalho e Emprego (MTE). Classificação Brasileira de Ocupações: CBO. Brasília: TEM; 2010..

The prevalence (P) of cases of beriberi in the indigenous and non-indigenous population during the study period was calculated using the following formula:

The statistical analysis was performed using STATA® version 14.0 (Stata Corporation, College Station, Texas, USA). The qualitative variables were described using absolute frequencies and proportions. Measures of central tendency and dispersion were calculated for age. Possible risk factors were assessed using a 2 x 2 table. Differences between the indigenous and non-indigenous groups were analyzed using the chi-squared test or Fisher’s exact test, adopting a significance level of 0.05.

This research was conducted in accordance with the norms and standards set out in National Health Council Resolution 466/2012¹⁶16 Brasil. Ministério da Saúde (MS). Resolução n. 466, de 12 de dezembro de 2012. Aprova diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União 2012; 13 jun. and the study protocol was approved by Maranhão Federal University Hospital’s research ethics committee and the National Research Ethics Committee (reference numbers 2.888.343 and CAAE 83673418.7.0000.5086, respectively, 11 September 2018).

Results

A total of 414 cases of beriberi were reported in the country between 2013 and 2018, 210 of which (50.7%) were among indigenous people and 204 (49.3%) in non-indigenous people. Prevalence was 25 cases per 100,000 population among indigenous people and 0.10 cases per 100,000 population in non-indigenous people. The mean age of patients was 43.9 ± 0.7 years. Those affected by the disease were predominantly males aged between 18 and 59 years; however, this result was not statistically significant. In the majority of cases (69.0%), education level was either not informed or low.

With regard to patient history of beriberi, 102 (48.6%) of the indigenous patients reported having had beriberi at least once (p < 0.001), while 59 out of 177 (33.3%) mentioned that at least one family member had had the disease (p < 0.001). Seventy-one out of 138 indigenous patients (51.4%) had wet beriberi, while 23 (69.7%) out of 33 non-indigenous patients had dry beriberi (p < 0.001) (Table 1).

A total of 122 (58.1%) indigenous patients reported alcohol consumption, compared to 146 (71.6%) non-indigenous patients (p = 0.004). Forty-two out of 122 (34.4%) indigenous patients drank alcohol between 5 and 7 times a week, compared to 81 (55.5%) out of 146 non-indigenous patients (p < 0.001) (Table 2). Fifty-four out of 76 (71.0%) indigenous patients reported that they consumed caxiri.

Most indigenous patients (160 or 76.1%) reported daily physical exertion (p < 0.001), while 152 (72.4%) did manual labor (p < 0.001). The majority of non-indigenous patients (85.6%) needed to be admitted to hospital (p < 0.001) (Table 2).

The most common types of signs and symptoms were paresis (73.4%), edema (49.5%), paraesthesia in the arms and legs (44.4%), difficulty walking (51.4%), and loss of muscle strength (58.2%). The least common symptom was calf pain, followed by asthenia, dyspnoea, weight loss, nausea and vomiting, tachycardia, confusion, diplopia, and divergent blood pressure. Almost all cases (99%) were treated by administering oral doses of 300 mg thiamine.

Comorbidities were recorded in 102 out of 408 (25.0%) cases with information on this variable. The most common comorbidities were high blood pressure (9.4%) and severe liver disease (6.0%), while the least common were and diabetes mellitus, heart disease, anemia, chronic kidney disease, neurological sequelae, epilepsy, neoplasm, mental disorder, gastrointestinal surgery, tuberculosis, and leprosy, among others.

One of the cases, reported in 2015, was a pregnant woman in the third semester. The patient was a 24-year-old homemaker from the Karajá Xambioá indigenous group and lived in the Warylyty village in Santa Fé do Araguaia, Tocantins. She reported daily physical exertion and that she was a beneficiary of a food basket distribution program. She was admitted to hospital with classic signs of beriberi and hyperemesis gravidarum. She was classified as having dry beriberi and had not had the disease before.

There were three deaths over the study period (in 2014, 2015, and 2016): two men aged 30 and 42 years from Brasilândia do Tocantins and Palmas, Tocantins; and a 54-year-old woman from Tocantinópolis, also in Tocantins. They were all brown, smokers, and had a low education level and monthly income of up to one minimum wage. The woman was a homemaker, while the men were both laborers, had severe liver disease, and were alcoholics. One of the men was classified as having Shoshin beriberi and the other Shoshin beriberi and Wernicke-Korsakoff syndrome. The woman was classified as having dry beriberi.

Complete data at: https://doi.org/10.48331/scielodata.LB0VAV.

Discussion

More than half the cases of beriberi (50.7%) were among indigenous people, despite the fact that this group accounts for a mere 0.43% (896,000 people) of the country’s population¹⁷17 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Brasileiro de 2010. Rio de Janeiro: IBGE; 2012.. Prevalence among this group was 25 cases per 100,000 population.

The findings show the importance of information on patient or family history of the disease in indigenous beriberi patients to help identify the condition and ensure timely therapeutic testing¹⁸18 Latt N, Dore G. Thiamine in the treatment of Wernicke encephalopathy in patients with alcohol use disorders. Intern Med J 2014; 44(9):911-915., given that beriberi can result in death¹1 Whitfield KC, Bourassa MW, Adamolekun B, Bergeron G, Bettendorff L, Brown KH, Cox L, Fattal-Valevski A, Fischer PR, Frank EL, Hiffler L, Hlaing LM, Jefferds ME, Kapner H, Kounnavong S, Mousavi MPS, Roth DE, Tsaloglou MN, Wieringa F, Combs Jr GF. Thiamine deficiency disorders: diagnosis, prevalence, and a roadmap for global control programs. Ann N Y Acad Sci 2018; 1430(1):3-43.. Smith et al.¹⁹19 Smith TJ, Johnson CR, Koshy R, Hess SY, Qureshi UA, Mynak ML, Fischer PR. Thiamine deficiency disorders: a clinical perspective. Ann N Y Acad Sci 2020; 1498(1):9-28. suggest that a low threshold of clinical suspicion and early therapeutic thiamine is currently the best approach.

Drinking was more common in the non-indigenous group (71.6%) than the indigenous group (58.1%). This result was statistically significant (p = 0.004). The percentage of drinkers among the indigenous group is higher than the rate observed by the First National Survey on Alcohol and Drug Use Patterns among Indigenous Populations, performed in 2007. The survey showed that 38.4% of indigenous people drank, with 44.1% of drinkers reporting alcohol abuse and 22.9% dependence on alchool²⁰20 Brasil. Secretaria Nacional Antidrogas (SNA). I Levantamento Nacional sobre Padrões de Consumo de Álcool na População Brasileira. Brasília: MS; 2007..

Drinking 5 to 7 times a week was more frequent among the non-indigenous group (p < 0.001). The health effects of alcohol have been reported by Subramanian et al.²¹21 Subramanian VS, Subramanya SB, Tsukamoto H, Said HM. Effect of chronic alcohol feeding on physiological and molecular parameters of renal thiamin transport. Am J Physiol Renal Physiol 2010; 299(1):F28-F34. in an experiment with rats, which showed that chronic alcohol use causes inhibition in renal thiamin transport, negatively affecting renal thiamin metabolism at the transcriptional and macro level.

Some of the indigenous patients reported drinking caxiri. Souza and Garnelo²²22 Souza MLP, Garnelo L. Quando, como e o que se bebe: o processo de alcoolização entre populações indígenas do alto Rio Negro, Brasil. Cad Saude Publica 2007; 23(7):1640-1648. reported that cachaça (a liquor distilled from sugar cane) and caxiri were the most commonly abused alcoholic drinks by indigenous peoples in the upper Rio Negro region, Amazonas. More recently, in a study of the use of alcohol in the Sucuba indigenous community in Alto Alegre, Roraima/RR, Pereira and Robaina²³23 Pereira EB, Robaina JVL. O índice do uso de bebida alcoólica na região indígena comunidade do Sucuba em Alto Alegre/RR. Rev Interdiscip Sulear 2021; 11:46-56. reported that 71% of the sample drank alcohol and that the most popular drink was caxiri, being consumed by 40% of respondents.

Caxiri is drunk on special occasions, such as celebrations and sacred rituals and ceremonies²⁴24 Fernandes JA. Selvagens bebedeiras: álcool e contatos culturais no Brasil Colonial (séculos XVI-XVII) [tese]. São Paulo: Universidade Federal Fluminense; 2004.. However, changes in culture, traditions, and values resulting from contact and integration with non-indigenous society has led to the problem of excessive alcohol consumption in indigenous communities²⁵25 Branco FMFC, Vargas D. Alcoholization process: reflections on problems related to alcohol consumption in indigenous communities. J Nurs UFPE on line 2017; 11(2):718-723.^,2626 Langdon EJ. O que beber, como beber e quando beber: o contexto sociocultural no alcoolismo entre as populações indígenas. In: Coordenação Nacional de DST e AIDS, Secretaria de Políticas de Saúde, Ministério da Saúde, organizadores. Seminário sobre alcoolismo e DST/AIDS entre os povos indígenas; Brasília: MS; 2001. p. 83-97.. Historically consumed only by indigenous people, caxiri is now sold in local markets²³23 Pereira EB, Robaina JVL. O índice do uso de bebida alcoólica na região indígena comunidade do Sucuba em Alto Alegre/RR. Rev Interdiscip Sulear 2021; 11:46-56..

Alcohol is high in calories and has little nutritional value. The greater the abuse of alcohol (when alcohol makes up more than 30% of total caloric intake), the more it affects the metabolism and physiology of enzymes that control carbohydrate, protein, and fat metabolism²⁷27 Toffolo MCF, Aguiar-Nemera AS, Silva-Fonseca VA. Alcohol: effects on nutritional status, lipid profile and blood pressure. J Endocrinol Metab 2012; 2(6):205-211., undermining the absorption of nutrients, such as A, C, and B vitamins, including thiamine²⁸28 Lieber CS. Relationships between nutrition, alcohol use, and liver disease. Alcohol Res Health 2003; 27(3):220-231.^,2929 Chandrakumar A, Bhardwaj A, Jong GW. Review of thiamine deficiency disorders: Wernicke encephalopathy and Korsakoff psychosis. J Basic Clin Physiol Pharmacol 2019; 30(2):153-162..

A large percentage of the indigenous patients reported doing manual labor and daily physical exertion, which is consistent with the findings of studies of outbreaks of beriberi in Brazil¹¹11 Padilha EM, Fujimori E, Borges ALV, Sato APS, Gomes MN, Branco MRFC, Santos HJ, Junior NL. Perfi l epidemiológico do beribéri notificado de 2006 a 2008 no estado do Maranhão, Brasil. Cad Saude Publica 2011; 27(3):449-459. and Gambia³⁰30 Thurnham DI, Cathcart AE, Livingstone, BEM. A retrospective investigation of thiamin and energy intakes following an outbreak of beriberi in the Gambia. Nutrients 2011; 3(1):135-151.. Beriberi may be caused by a combination of chronic thiamine deficiency, elevated alcohol consumption, and manual labor, which requires high energy intake as minimum thiamine needs rise during periods of increased metabolism⁵5 World Health Organization (WHO). Thiamine deficiency and its prevention and control in major emergencies. Geneva: WHO; 1999..

Hospitalization was more frequent among the non-indigenous groups and patients with dry beriberi, suggesting that more severe cases are found in urban areas, possibly due to flaws in epidemiological surveillance and in the detection and follow-up of cases by health services. It is worth highlighting that after outbreaks, such as those in indigenous communities in Roraima and Maranhão reported by Cerroni et al.¹²12 Cerroni MP, Barrado JCS, Nobrega AA, Lins ABM, Silva IP, Mangueira RR, Cruz RH, Mendes SMF, Sobel J. Outbreak of Beriberi in an Indian Population of the Upper Amazon Region, Roraima State, Brazil, 2008. Am J Trop Med Hyg 2010; 83(5):1093-1097. and Padilha et al.¹¹11 Padilha EM, Fujimori E, Borges ALV, Sato APS, Gomes MN, Branco MRFC, Santos HJ, Junior NL. Perfi l epidemiológico do beribéri notificado de 2006 a 2008 no estado do Maranhão, Brasil. Cad Saude Publica 2011; 27(3):449-459., training courses and awareness raising campaigns were developed to help health workers working in indigenous and primary care services recognize signs and symptoms and promote early treatment⁶6 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Secretaria Especial de Saúde indígena. Secretaria de Vigilância em Saúde. Guia de consulta para vigilância epidemiológica, assistência e atenção nutricional dos casos de Beribéri. Brasília: MS; 2012..

Beriberi should be recognized as a problem associated with food insecurity and poverty, as well as a neglected disease related to alcoholism and disproportionately affecting indigenous peoples¹³13 Assunção AKM, Branco MRFC, Santos TS, Costa SSB, Dias JJ, Soeiro VMS, Araújo AS, Queiroz RCS, Frota MTBA, Caldas AJM, Oliveira BLCA, Santos AM. Beriberi in Brazil: a disease that affects Indigenous people. Food Nutr Bull 2021; 42(3):427-436..

Indigenous health has historically been overlooked in Brazil. It was only in the twentieth century (1957) that the Brazilian government officially began to provide indigenous health services on a more consistent basis. However, these services were poorly coordinated and characterized by lack of integration with Ministry of Health services and programs until the end of the 1990s³¹31 Kabad JF, Pícoli RP, Arantes R. A saúde da família indígena. In: Geniole LAI, Kodjaoglanian V L, Vieira CCA, organizadores. Saúde bucal por ciclos de vida. Campo Grande: Fiocruz; 2011. p. 22-90.. The enactment of the “Arouca Law” in 1999 (Law 9836) led to changes in the SUS, including the creation of the National Indigenous Health Care Policy (PNASPI) in 2002. Under this policy, indigenous health care services, including primary care, were administered and delivered by the National Health Foundation (FUNASA), until 2010, when Law 12.314/2010 and Decree 7.336/2010 transferred administration to the newly created Special Secretariat for Indigenous Health (SESAI)³²32 Altini E, Rodrigues G, Padilha L, Moraes PD, Liebgott RA, organizadores. A política de atenção à saúde indígena no Brasil. Breve recuperação histórica sobre a política de assistência à saúde nas comunidades indígenas. Conselho Indigenista Missionário; 2013..

This process took almost three years and the transfer of responsibilities created uncertainty over public health actions, leading to the deterioration of indigenous health services. Under this new model, the Ministry of Health’s Department of Indigenous Health (DESAI) is responsible for the administration of the Indigenous Health Care Subsystem and promotion of macroregional and national meetings to evaluate the implementation of the PNASPI, and private non-profit organizations are contracted to provide complementary health services³³33 Brasil. Fundação Nacional de Saúde (FUNASA). Lei Arouca - 10 anos de saúde indígena. Brasília: FUNASA; 2009..

The SESAI faces several major management challenges, including lack of consideration of traditional indigenous medicine by local health managers when developing care activities, in addition to the wielding of political influence in the management of the DSEI, resulting in manger and health staff instability³⁴34 Brasil. Ministério da Saúde (MS). Secretaria Especial de Saúde Indígena. Relatório da 5ª Conferência Nacional de Saúde Indígena. Brasília: MS; 2014..

In recent years, the SESAI and other government bodies and civil society organizations that work with indigenous health have not been able to meet the commitments set out in the legislation related to the provision of comprehensive health care to indigenous peoples. This situation has aggravated health risks associated with infant mortality, chronic diseases (obesity and diabetes), infectious diseases, malnutrition, and mental health problems, such as alcoholism and suicide. It is therefore evident that Brazil’s indigenous health policy remains largely ineffective³²32 Altini E, Rodrigues G, Padilha L, Moraes PD, Liebgott RA, organizadores. A política de atenção à saúde indígena no Brasil. Breve recuperação histórica sobre a política de assistência à saúde nas comunidades indígenas. Conselho Indigenista Missionário; 2013..

Deep socioeconomic inequalities in Brazil mean that certain groups are more exposed to intermediary determinants of health³⁵35 Ribeiro MCSA, Barata RB. Saúde: vulnerabilidade social, vizinhança e atividade física. Cad.Metrop 2016; 18(36):401-420., making them more vulnerable to health-compromising conditions³⁶36 Cidade LCF. Urbanização, ambiente, risco e vulnerabilidade: em busca de uma construção interdisciplinar. Cad Metrop 2013; 15(29):171-191.. Government interventions and policies and civil society action are therefore urgently needed to address social determinants of health, guarantee human rights, and help promote behavioral change towards a transformation of reality³⁷37 Ayres JR CM, Franca Junior I, Calazans GJ, Saletti Filho HC. O conceito de vulnerabilidade e as práticas de saúde: novas perspectivas e desafios. In: Czeresnia D, Freitas CM, organizadores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: Fiocruz; 2003. p. 171-191..

The right to adequate food is enshrined in the Universal Declaration of Human Rights, adopted in 1948. Fulfilling this right is the duty of the State, which should promote and provide regular and permanent access to quantitatively and qualitatively adequate food. Civil society has the right to demand that the government fulfils its duty and that food corresponds to the cultural traditions of the people to which the consumer belongs and is environmentally, culturally, economically, and socially sustainable³⁸38 Brasil. Ministério do Desenvolvimento Social e Combate à Fome (MDS). O direito humano à alimentação adequada e o sistema nacional de segurança alimentar e nutricional. Brasília: ABRANDH; 2013..

Strategies, tools, and techniques are necessary to analyze and monitor social conditions to reduce the vulnerability of these groups, who have been ill for some time and probably have other deficiencies associated with poverty and food insecurity.

The beriberi problem became more evident during the COVID-19 pandemic, which began in 2020. The FAO’s State of Food Security and Nutrition in the World 2021 shows that the number of people living in poverty increased during the pandemic and post-pandemic period. The organization estimates that 10% of the global population (around 768 million people) faced hunger in 2020 and more than 2.3 billion people did not have access to adequate food, representing a worrying increase in the prevalence of food insecurity³⁹39 Food and Agriculture Organization of the United Nations (FAO). World Health Organization (WHO). The State of Food Security and Nutrition in the World 2021. Transforming food systems for food security, improved nutrition and affordable healthy diets for all. Rome: FAO; 2021.. In Brazil, the National Survey of Food Insecurity in the Context of the Covid-19 Pandemic⁴⁰40 Rede Brasileira de Pesquisa em Soberania e Segurança Alimentar (REDE PENSSAN). VIGISAN: Inquérito Nacional sobre Insegurança Alimentar no Contexto da Pandemia da Covid-19 no Brasil. Rio de Janeiro: Rede Penssan; 2021. revealed that over half of households (55.2%) experienced food insecurity and 9% faced hunger, with prevalence rates being highest in the North and Northeast. It is worth noting that prevalence rates have been on the rise for some time and that this increase did not occur only during the pandemic.

Study limitations are related to the beriberi notification form. The form consists of an Excel worksheet without automated control of data entry errors and missing information and lacking a function preventing the finalization of completed forms due to inconsistencies.

Underreporting of cases of beriberi is a major challenge for epidemiological surveillance. Besides the fact that official figures are not representative of the full extent of the disease among the population, poor quality data hampers planning and decision-making regarding the government response to this public health problem⁴¹41 Melo MAS. Avaliação de aspectos organizacionais da vigilância sanitária em uma amostra de municípios goianos na perspectiva de seus trabalhadores [tese]. Goiânia: Universidade Federal de Goiás; 2012.. Quality data is a vital resource in the field of public health, contributing to the efficient allocation of resources and providing valuable inputs to inform strategies to promote the prevention and timely diagnosis and treatment of this neglected disease⁴²42 Santos RJ, Cruz JC, Moreira PA. Perfil epidemiológico e tendencia temporal da mortalidade por suicídio no estado de Sergipe, de 2006 a 2015. Braz J Healt ver 2019; 2(1):495-500..

It is worth mentioning the Ministry of Health recommendation to include severe and prolonged thiamine deficiency (beriberi) in the national list of notifiable diseases to promote the adoption of appropriate interventions by the government and health professionals and enable the wide-scale monitoring of disease characteristics. Cases of beriberi meet some of the criteria used to select notifiable diseases, including social and economic relevance and vulnerability⁴³43 Teixeira MG, Penna GO, Risi JB, Penna ML, Alvim MF, Moraes JC, Luna E. Seleção das doenças de notificação. compulsória: critérios e recomendações para as três esferas de governo. Inf Epidemiol Sus 1998; 7(1):8-28.. Special attention should be paid to priority regions for disease notification, based on current epidemiological knowledge, such as the findings presented in this article, with the aim of generating national databases that enable a more robust analysis, providing a solid basis for guidance, planning, and care response for vulnerable groups.

One of the strengths of this study is that it used a nationwide sample of reported cases of beriberi encompassing sociodemographic, behavioral, and clinical aspects.

The findings of this study provide important insights for health surveillance and the government agencies working with indigenous peoples, such as SESAI and the National Indian Foundation (FUNAI), as well as local, state, and federal governments, revealing priority groups (indigenous peoples and people who drink excessively) for health status monitoring, thiamine supplementation, food fortification, and dietary changes in both indigenous and non-indigenous populations. In addition, health professionals need to be trained in the detection, screening, and early treatment of beriberi⁴⁴44 Gomes F, Bergeron G, Bourassa MW, Fischer PR. Thiamine deficiency unrelated to alcohol consumption in high-income countries: a literature review. Ann N Y Acad Sci 2021; 1498(1):46-56..

The effective control of beriberi requires the involvement of all sectors of society in the formulation and implementation of prevention policies, programs, and actions aimed at promoting improvements in socioeconomic and nutritional status, care, and health monitoring, and the creation of cross-sector networks that ensure comprehensive care and tackle the conditions that lead to beriberi.

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