Gastrointestinal Emergency Room Admissions and Florida Red Tide Blooms

Emerging Insights into Brevetoxicosis in Sea Turtles

This review summarizes the current understanding of how brevetoxins, produced by Karenia brevis during harmful algal blooms, impact sea turtle health. Sea turtles may be exposed to brevetoxins through ingestion, inhalation, maternal transfer, and potentially absorption through the skin. Brevetoxins bind to voltage-gated sodium channels in the central nervous system, disrupting cellular function and inducing neurological symptoms in affected sea turtles. Moreover, the current evidence suggests a broader and longer-term impact on sea turtle health beyond what is seen during stranding events. Diagnosis relies on the detection of brevetoxins in tissues and plasma from stranded turtles. The current treatment of choice, intravenous lipid emulsion therapy, may rapidly reduce symptoms and brevetoxin concentrations, improving survival rates. Monitoring, prevention, and control strategies for harmful algal blooms are discussed. However, as the frequency and severity of blooms are expected to increase due to climate change and increased environmental pollution, continued research is needed to better understand the sublethal effects of brevetoxins on sea turtles and the impact on hatchlings, as well as the pharmacokinetic mechanisms underlying brevetoxicosis. Moreover, research into the optimization of treatments may help to protect endangered sea turtle populations in the face of this growing threat.

The human health effects of harmful algal blooms in Florida: The importance of high resolution data

Harmful algal blooms (HABs) have been found to cause increases in healthcare visits for a variety of illnesses to humans if exposure and contact is sufficient. We use a more comprehensive dataset than previously implemented in prior literature to better isolate visits by healthcare facility type and proximity to bloom. Using a difference-in-differences model, our results suggest HABs cause an increase of 23.67 healthcare admissions per zip code per month across four HAB-related diagnoses. This impact is a 3,000% increase over baseline non-bloom times and an increase in monthly healthcare costs of about $250,000 for the entire impacted area. Our data include inpatient non-emergency and outpatient healthcare visits, which account for over 60% of all HAB-related healthcare visits, meaning that prior literature that has not measured those facilities has greatly underestimated HAB health impacts.

Harmful algal bloom aerosols and human health

Harmful algal blooms (HABs) are increasing across many locations globally. Toxins from HABs can be incorporated into aerosols and transported inland, where subsequent exposure and inhalation can induce adverse health effects. However, the relationship between HAB aerosols and health outcomes remains unclear despite the potential for population-level exposures. In this review, we synthesized the current state of knowledge and identified evidence gaps in the relationship between HAB aerosols and human health. Aerosols from Karenia brevis, Ostreopsis sp., and cyanobacteria were linked with respiratory outcomes. However, most works did not directly measure aerosol or toxin concentrations and instead relied on proxy metrics of exposure, such as cell concentrations in nearby waterbodies. Furthermore, the number of studies with epidemiological designs was limited. Significant uncertainties remain regarding the health effects of other HAB species; threshold dose and the dose-response relationship; effects of concurrent exposures to mixtures of toxins and other aerosol sources, such as microplastics and metals; the impact of long-term exposures; and disparities in exposures and associated health effects across potentially vulnerable subpopulations. Additional studies employing multifaceted exposure assessment methods and leveraging large health databases could address such gaps and improve our understanding of the public health burden of HABs.

Precipitation, submarine groundwater discharge of nitrogen, and red tides along the southwest Florida Gulf coast

Blooms of the dinoflagellate Karenia brevis occur almost every year along the southwest Florida Gulf coast. Long-duration blooms with especially high concentrations of K. brevis, known as red tides, destroy marine life through production of neurotoxins. Current hypotheses are that red tides originate in oligotrophic waters far offshore using nitrogen (N) from upwelling bottom water or, alternatively, from blooms of Trichodesmium, followed by advection to nearshore waters. But the amount of N available from terrestrial sources does not appear to be adequate to maintain a nearshore red tide. To explain this discrepancy, we hypothesize that contemporary red tides are associated with release of N from offshore submarine groundwater discharge (SGD) that has accumulated in benthic sediment biomass by dissimilatory nitrate reduction to ammonium (DNRA). The release occurs when sediment labile organic carbon (LOC), used as the electron donor in DNRA, is exhausted. Detritus from the resulting destruction of marine life restores the sediment LOC to continue the cycle of red tides. The severity of individual red tides increases with increased bloom-year precipitation in the geographic region where the SGD originates, while the severity of ordinary blooms is relatively unaffected.

Seafood consumption during harmful algal blooms: The impact of information regarding safety and health

Harmful algal blooms (HABs) can cause massive fish kills all over the world. However, some commercially caught species are safe to eat. The fish safe for consumption are vastly different from the fish that wash up on shore. Prior research finds this difference in edibility is mostly unknown by consumers, and that the misperception of unhealthy and unsafe fish is the dominant paradigm. To date, there has been minimal research on the effect of disseminating this information regarding seafood health to consumers, and how consumption habits would change during a bloom. We implement a survey that presents respondents with information explaining the health and safety of certain commercially caught seafood during a HAB, specifically red grouper. It is a particularly popular, large, deep-sea fish. Our results suggest that respondents receiving this information are 34 percentage points more likely to say that they would be willing to consume red grouper during a bloom, relative to consumers who were not provided this added information. Prior knowledge of this information suggests long-term outreach programs may be more effective than last minute "point of sale" information campaigns. The results demonstrated the importance of correct knowledge and awareness regarding HABs, as it pertains to efforts to stabilize local economies dependent on seafood harvesting and consumption.

Impact of climatic and non-climatic stressors on ocean life and human health: A review

Ocean life forms are fundamentally well adapted to natural environmental variations, and they can even tolerate extreme conditions for a short time. However, several anthropogenic stressors are causing such drastic changes in the ocean ecosystem. First, the review attempts to outline the impact of climatic and non-climatic stressors on ocean life, and it also outlines the synergistic impact of both stressors. Then the impact on human health caused by the damage of the marine ecosystem has been discussed. Furthermore, the type of prior studies and current mitigation adaptation programs have been presented. Finally, some perspectives about future research and mitigation adaptation are offered.

Florida’s Harmful Algal Bloom (HAB) Problem: Escalating Risks to Human, Environmental and Economic Health With Climate Change

Harmful Algal Blooms (HABs) pose unique risks to the citizens, stakeholders, visitors, environment and economy of the state of Florida. Florida has been historically subjected to reoccurring blooms of the toxic marine dinoflagellate Karenia brevis (C. C. Davis) G. Hansen & Moestrup since at least first contact with explorers in the 1500’s. However, ongoing immigration of more than 100,000 people year–1 into the state, elevated population densities in coastal areas with attendant rapid, often unregulated development, coastal eutrophication, and climate change impacts (e.g., increasing hurricane severity, increases in water temperature, ocean acidification and sea level rise) has likely increased the occurrence of other HABs, both freshwater and marine, within the state as well as the number of people impacted by these blooms. Currently, over 75 freshwater, estuarine, coastal and marine HAB species are routinely monitored by state agencies. While only blooms of K. brevis, the dinoflagellate Pyrodinium bahamense (Böhm) Steidinger, Tester, and Taylor and the diatom Pseudo-nitzschia spp. have resulted in closure of commercial shellfish beds, other HAB species, including freshwater and marine cyanobacteria, pose either imminent or unknown risks to human, environmental and economic health. HAB related human health risks can be classified into those related to consumption of contaminated shellfish and finfish, consumption of or contact with bloom or toxin contaminated water or exposure to aerosolized HAB toxins. While acute human illnesses resulting from consumption of brevetoxin-, saxitoxin-, and domoic acid-contaminated commercial shellfish have been minimized by effective monitoring and regulation, illnesses due to unregulated toxin exposures, e.g., ciguatoxins and cyanotoxins, are not well documented or understood. Aerosolized HAB toxins potentially impact the largest number of people within Florida. While short-term (days to weeks) impacts of aerosolized brevetoxin exposure are well documented (e.g., decreased respiratory function for at-risk subgroups such as asthmatics), little is known of longer term (>1 month) impacts of exposure or the risks posed by aerosolized cyanotoxin [e.g., microcystin, β-N-methylamino-L-alanine (BMAA)] exposure. Environmental risks of K. brevis blooms are the best studied of Florida HABs and include acute exposure impacts such as significant dies-offs of fish, marine mammals, seabirds and turtles, as well as negative impacts on larval and juvenile stages of many biota. When K. brevis blooms are present, brevetoxins can be found throughout the water column and are widespread in both pelagic and benthic biota. The presence of brevetoxins in living tissue of both fish and marine mammals suggests that food web transfer of these toxins is occurring, resulting in toxin transport beyond the spatial and temporal range of the bloom such that impacts of these toxins may occur in areas not regularly subjected to blooms. Climate change impacts, including temperature effects on cell metabolism, shifting ocean circulation patterns and changes in HAB species range and bloom duration, may exacerbate these dynamics. Secondary HAB related environmental impacts are also possible due to hypoxia and anoxia resulting from elevated bloom biomass and/or the decomposition of HAB related mortalities. Economic risks related to HABs in Florida are diverse and impact multiple stakeholder groups. Direct costs related to human health impacts (e.g., increased hospital visits) as well as recreational and commercial fisheries can be significant, especially with wide-spread sustained HABs. Recreational and tourism-based industries which sustain a significant portion of Florida’s economy are especially vulnerable to both direct (e.g., declines in coastal hotel occupancy rates and restaurant and recreational users) and indirect (e.g., negative publicity impacts, associated job losses) impacts from HABs. While risks related to K. brevis blooms are established, Florida also remains susceptible to future HABs due to large scale freshwater management practices, degrading water quality, potential transport of HABs between freshwater and marine systems and the state’s vulnerability to climate change impacts.

Essential components of the xanthophyll cycle differ in high and low toxin Karenia brevis

The dinoflagellate Karenia brevis, blooms annually in the Gulf of Mexico, producing a suite of neurotoxins known as the brevetoxins. The cellular toxin content of K. brevis, however, is highly variable between or even within strains. Herein, we investigate physiological differences between high (KbHT) and low (KbLT) toxin producing cultures both derived from the Wilson strain, related to energy-dependent quenching (qE) by photosystem II, and reduced thiol content of the proteome. We demonstrate that gene and protein expression of the xanthophyll cycle enzyme diadinoxanthin de-epoxidase (Dde) and monogalactosyldiacylglycerol (MGDG) synthase are not significantly different in the two cultures. Using redox proteomics, we report a significantly higher reduced cysteine content in the low toxin proteome, including plastid localized thioredoxin reductase (Trx) which can result in inactivation of Dde and activation of MGDG synthase. We also report significant differences in the lipidomes of KbHT and KbLT with respect to MGDG, which facilitates the xanthophyll cycle.

Red Tide: Overview and Clinical Manifestations

Harmful algal blooms occur when toxin-producing algae grow rapidly. These occur worldwide and have significant impacts on aquatic ecosystems and on human health. Specifically, the toxic blooms of Karenia brevis in Florida may affect humans via inhalation or ingestion. On retrospective reviews, health care costs appear to rise during these outbreaks because of respiratory and gastrointestinal manifestations. Treatment for exposure is supportive care, though traditional inhalers may help with respiratory complications.

Estimating the Health-Related Costs of 10 Climate-Sensitive U.S. Events During 2012

Climate change threatens human health, but there remains a lack of evidence on the economic toll of climate-sensitive public health impacts. We characterize human mortality and morbidity costs associated with 10 climate-sensitive case study events spanning 11 US states in 2012: wildfires in Colorado and Washington, ozone air pollution in Nevada, extreme heat in Wisconsin, infectious disease outbreaks of tick-borne Lyme disease in Michigan and mosquito-borne West Nile virus in Texas, extreme weather in Ohio, impacts of Hurricane Sandy in New Jersey and New York, allergenic oak pollen in North Carolina, and harmful algal blooms on the Florida coast. Applying a consistent economic valuation approach to published studies and state estimates, we estimate total health-related costs from 917 deaths, 20,568 hospitalizations, and 17,857 emergency department visits of $10.0 billion in 2018 dollars, with a sensitivity range of $2.7-24.6 billion. Our estimates indicate that the financial burden of deaths, hospitalizations, emergency department visits, and associated medical care is a key dimension of the overall economic impact of climate-sensitive events. We found that mortality costs (i.e., the value of a statistical life) of $8.4 billion exceeded morbidity costs and lost wages ($1.6 billion combined). By better characterizing health damages in economic terms, this work helps to shed light on the burden climate-sensitive events already place on U.S. public health each year. In doing so, we provide a conceptual framework for broader estimation of climate-sensitive health-related costs. The high health-related costs associated with climate-sensitive events highlight the importance of actions to mitigate climate change and adapt to its unavoidable impacts.

Neurological illnesses associated with Florida red tide (Karenia brevis) blooms

Human respiratory and gastrointestinal illnesses can result from exposures to brevetoxins originating from coastal Florida red tide blooms, comprising the marine alga Karenia brevis (K. brevis). Only limited research on the extent of human health risks and illness costs due to K. brevis blooms has been undertaken to date. Because brevetoxins are known neurotoxins that are able to cross the blood-brain barrier, it is possible that exposure to brevetoxins may be associated with neurological illnesses. This study explored whether K. brevis blooms may be associated with increases in the numbers of emergency department visits for neurological illness. An exposure-response framework was applied to test the effects of K. brevis blooms on human health, using secondary data from diverse sources. After controlling for resident population, seasonal and annual effects, significant increases in emergency department visits were found specifically for headache (ICD-9 784.0) as a primary diagnosis during proximate coastal K. brevis blooms. In particular, an increased risk for older residents (≥55 years) was identified in the coastal communities of six southwest Florida counties during K. brevis bloom events. The incidence of headache associated with K. brevis blooms showed a small but increasing association with K. brevis cell densities. Rough estimates of the costs of this illness were developed for hypothetical bloom occurrences.

A Prospective Study of Marine Phytoplankton and Reported Illness Among Recreational Beachgoers in Puerto Rico, 2009

BACKGROUND

Blooms of marine phytoplankton may adversely affect human health. The potential public health impact of low-level exposures is not well established, and few prospective cohort studies of recreational exposures to marine phytoplankton have been conducted.

OBJECTIVE

We evaluated the association between phytoplankton cell counts and subsequent illness among recreational beachgoers.

METHODS

We recruited beachgoers at Boquerón Beach, Puerto Rico, during the summer of 2009. We conducted interviews at three time points to assess baseline health, water activities, and subsequent illness. Daily water samples were quantitatively assayed for phytoplankton cell count. Logistic regression models, adjusted for age and sex, were used to assess the association between exposure to three categories of phytoplankton concentration and subsequent illness.

RESULTS

During 26 study days, 15,726 individuals successfully completed all three interviews. Daily total phytoplankton cell counts ranged from 346 to 2,012 cells/mL (median, 712 cells/mL). The category with the highest (≥ 75th percentile) total phytoplankton cell count was associated with eye irritation [adjusted odds ratio (OR) = 1.30; 95% confidence interval (CI): 1.01, 1.66], rash (OR = 1.27; 95% CI: 1.02, 1.57), and earache (OR = 1.25; 95% CI: 0.88, 1.77). In phytoplankton group-specific analyses, the category with the highest Cyanobacteria counts was associated with respiratory illness (OR = 1.37; 95% CI: 1.12, 1.67), rash (OR = 1.32; 95% CI: 1.05, 1.66), eye irritation (OR = 1.25; 95% CI: 0.97, 1.62), and earache (OR = 1.35; 95% CI: 0.95, 1.93).

CONCLUSIONS

We found associations between recreational exposure to marine phytoplankton and reports of eye irritation, respiratory illness, and rash. We also found that associations varied by phytoplankton group, with Cyanobacteria having the strongest and most consistent associations.

CITATION

Lin CJ, Wade TJ, Sams EA, Dufour AP, Chapman AD, Hilborn ED. 2016. A prospective study of marine phytoplankton and reported illness among recreational beachgoers in Puerto Rico, 2009. Environ Health Perspect 124:477-483; http://dx.doi.org/10.1289/ehp.1409558.

Marine harmful algal blooms, human health and wellbeing: challenges and opportunities in the 21st century

Microalgal blooms are a natural part of the seasonal cycle of photosynthetic organisms in marine ecosystems. They are key components of the structure and dynamics of the oceans and thus sustain the benefits that humans obtain from these aquatic environments. However, some microalgal blooms can cause harm to humans and other organisms. These harmful algal blooms (HABs) have direct impacts on human health and negative influences on human wellbeing, mainly through their consequences to coastal ecosystem services (fisheries, tourism and recreation) and other marine organisms and environments. HABs are natural phenomena, but these events can be favoured by anthropogenic pressures in coastal areas. Global warming and associated changes in the oceans could affect HAB occurrences and toxicity as well, although forecasting the possible trends is still speculative and requires intensive multidisciplinary research. At the beginning of the 21st century, with expanding human populations, particularly in coastal and developing countries, mitigating HABs impacts on human health and wellbeing is becoming a more pressing public health need. The available tools to address this global challenge include maintaining intensive, multidisciplinary and collaborative scientific research, and strengthening the coordination with stakeholders, policymakers and the general public. Here we provide an overview of different aspects of the HABs phenomena, an important element of the intrinsic links between oceans and human health and wellbeing.

Human responses to Florida red tides: policy awareness and adherence to local fertilizer ordinances

To mitigate the damages of natural hazards, policy responses can be beneficial only if they are effective. Using a self-administered survey approach, this paper focuses on the adherence to local fertilizer ordinances (i.e., county or municipal rules regulating the application of fertilizer to private lawns or facilities such as golf courses) implemented in jurisdictions along the Southwest Florida coast in response to hazardous blooms of Florida red tides (Karenia brevis). These ordinances play a role in the context of evolving programs of water pollution control at federal, state, water basin, and local levels. With respect to policy effectiveness, while the strength of physical linkages is of critical importance, the extent to which humans affected are aware of and adhere to the relevant rules, is equally critical. We sought to understand the public's depth of understanding about the rationales for local fertilizer ordinances. Respondents in Sarasota, Florida, were asked about their fertilizer practices in an area that has experienced several major blooms of Florida red tides over the past two decades. A highly educated, older population of 305 residents and "snowbirds" reported relatively little knowledge about a local fertilizer ordinance, its purpose, or whether it would change the frequency, size, or duration of red tides. This finding held true even among subpopulations that were expected to have more interest in or to be more knowledgeable about harmful algal blooms. In the face of uncertain science and environmental outcomes, and with individual motivations at odds with evolving public policies, the effectiveness of local community efforts to decrease the impacts of red tides may be compromised. Targeted social-science research on human perceptions about the risks of Florida red tides and education about the rationales for potential policy responses are warranted.

The human health effects of Florida red tide (FRT) blooms: an expanded analysis

Human respiratory and digestive illnesses can be caused by exposures to brevetoxins from blooms of the marine alga Karenia brevis, also known as Florida red tide (FRT). K. brevis requires macro-nutrients to grow; although the sources of these nutrients have not been resolved completely, they are thought to originate both naturally and anthropogenically. The latter sources comprise atmospheric depositions, industrial effluents, land runoffs, or submerged groundwater discharges. To date, there has been only limited research on the extent of human health risks and economic impacts due to FRT. We hypothesized that FRT blooms were associated with increases in the numbers of emergency room visits and hospital inpatient admissions for both respiratory and digestive illnesses. We sought to estimate these relationships and to calculate the costs of associated adverse health impacts. We developed environmental exposure-response models to test the effects of FRT blooms on human health, using data from diverse sources. We estimated the FRT bloom-associated illness costs, using extant data and parameters from the literature. When controlling for resident population, a proxy for tourism, and seasonal and annual effects, we found that increases in respiratory and digestive illnesses can be explained by FRT blooms. Specifically, FRT blooms were associated with human health and economic effects in older cohorts (≥55 years of age) in six southwest Florida counties. Annual costs of illness ranged from $60,000 to $700,000 annually, but these costs could exceed $1.0 million per year for severe, long-lasting FRT blooms, such as the one that occurred during 2005. Assuming that the average annual illness costs of FRT blooms persist into the future, using a discount rate of 3%, the capitalized costs of future illnesses would range between $2 and 24 million.

KARENIA: The biology and ecology of a toxic genus

Karenia is a genus containing at least 12 species of marine unarmored dinoflagellates. Species of the genus can be found throughout the world in both oceanic and coastal waters. They are usually sparse in abundance, but occasionally form large blooms in coastal waters. Most Karenia species produce a variety of toxins that can kill fish and other marine organisms when they bloom. In addition to toxicity, some Karenia blooms cause animal mortalities through the generation of anoxia. At least one species, K. brevis, produces brevetoxin that not only kills fish, marine mammals, and other animals, but also causes Neurotoxic Shellfish Poisoning and respiratory distress in humans. The lipid soluble brevetoxin can biomagnify up the food chain through fish to top carnivores like dolphins, killing them. Karenia dinoflagellates are slow growers, so physical concentrating mechanisms are probably important for the development of blooms. The blooms are highly sporadic in both time and space, although most tend to occur in summer or fall months in frontal regions. At the present time, our understanding of the causes of the blooms and ability to predict them is poor. Given the recent discovery of new species, it is likely that new Karenia species and toxins will be discovered in the future.

Review of Florida Red Tide and Human Health Effects

This paper reviews the literature describing research performed over the past decade on the known and possible exposures and human health effects associated with Florida red tides. These harmful algal blooms are caused by the dinoflagellate, Karenia brevis, and similar organisms, all of which produce a suite of natural toxins known as brevetoxins. Florida red tide research has benefited from a consistently funded, long term research program, that has allowed an interdisciplinary team of researchers to focus their attention on this specific environmental issue-one that is critically important to Gulf of Mexico and other coastal communities. This long-term interdisciplinary approach has allowed the team to engage the local community, identify measures to protect public health, take emerging technologies into the field, forge advances in natural products chemistry, and develop a valuable pharmaceutical product. The Review includes a brief discussion of the Florida red tide organisms and their toxins, and then focuses on the effects of these toxins on animals and humans, including how these effects predict what we might expect to see in exposed people.

Florida Red Tide Perception: Residents versus Tourists

The west coast of Florida has annual blooms of the toxin-producing dinoflagellate, Karenia brevis with Sarasota, FL considered the epicenter for these blooms. Numerous outreach materials, including Frequently Asked Question (FAQ) cards, exhibits for local museums and aquaria, public beach signs, and numerous websites have been developed to disseminate information to the public about this natural hazard. In addition, during intense onshore blooms, a great deal of media attention, primarily via newspaper (print and web) and television, is focused on red tide. However to date, the only measure of effectiveness of these outreach methods has been counts of the number of people exposed to the information, e.g., visits to a website or number of FAQ cards distributed. No formal assessment has been conducted to determine if these materials meet their goal of informing the public about Florida red tide. Also, although local residents have the opinion that they are very knowledgeable about Florida red tide, this has not been verified empirically. This study addressed these issues by creating and administering an evaluation tool for the assessment of public knowledge about Florida red tide. A focus group of Florida red tide outreach developers assisted in the creation of the evaluation tool. The location of the evaluation was the west coast of Florida, in Sarasota County. The objective was to assess the knowledge of the general public about Florida red tide. This assessment identified gaps in public knowledge regarding Florida red tides and also identified what information sources people want to use to obtain information on Florida red tide. The results from this study can be used to develop more effective outreach materials on Florida red tide.