Ciguatera fish poisoning: Incidence, health costs and risk perception on Moorea Island (Society archipelago, French Polynesia)

Ciguatera poisoning in French Polynesia: A review of the distribution and toxicity of Gambierdiscus spp., and related impacts on food web components and human health

Ciguatera Poisoning (CP) is a seafood poisoning highly prevalent in French Polynesia. This illness results from the consumption of seafood contaminated with ciguatoxins (CTXs) produced by Gambierdiscus, a benthic dinoflagellate. Ciguatera significantly degrades the health and economic well-being of local communities largely dependent on reef fisheries for their subsistence. French Polynesia has been the site of rich and active CP research since the 1960's. The environmental, toxicological, and epidemiological data obtained in the frame of large-scale field surveys and a country-wide CP case reporting program conducted over the past three decades in the five island groups of French Polynesia are reviewed. Results show toxin production in Gambierdiscus in the natural environment may vary considerably at a temporal and spatial scale, and that several locales clearly represent Gambierdiscus spp. "biodiversity hotspots". Current data also suggest the "hot" species G. polynesiensis could be the primary source of CTXs in local ciguateric biotopes, pending formal confirmation. The prevalence of ciguatoxic fish and the CTX levels observed in several locales were remarkably high, with herbivores and omnivores often as toxic as carnivores. Results also confirm the strong local influence of Gambierdiscus spp. on the CTX toxin profiles characterized across multiple food web components including in CP-prone marine invertebrates. The statistics, obtained in the frame of a long-term epidemiological surveillance program established in 2007, point towards an apparent decline in the number of CP cases in French Polynesia as a whole; however, incidence rates remain dangerously high in some islands. Several of the challenges and opportunities, most notably those linked to the strong cultural ramifications of CP among local communities, that need to be considered to define effective risk management strategies are addressed.

A Case of Ciguatera Fish Poisoning in South Georgia

Ciguatera fish poisoning (CFP) is a seafood-associated non-infectious condition, caused by Ciguatoxins. It is known to be the most frequently reported cause of seafood-toxin-related illness in the world. CFP can cause a wide range of gastrointestinal, neurological, and cardiovascular symptoms which can last from a few days to a few months. We describe a case of ciguatera fish poisoning (CFP) in South Georgia after ingestion of a fish from the Caribbean Sea. This case report brings the attention of clinicians for early recognition of the condition and appropriate treatment.

Estimating the Number of Illnesses Caused by Agents Transmitted Commonly Through Food: A Scoping Review

Estimates of the overall human health impact of agents transmitted commonly through food complement surveillance and help guide food safety interventions and regulatory initiatives. The purpose of this scoping review was to summarize the methods and reporting practices used in studies that estimate the total number of illnesses caused by these agents. We identified and included 43 studies published from January 1, 1995, to December 31, 2019, by searching PubMed and screening selected articles for other relevant publications. Selected articles presented original estimates of the number of illnesses caused by ≥1 agent transmitted commonly through food. The number of agents (species or subspecies for pathogens) included in each study ranged from 1 to 31 (median: 4.5; mean: 9.2). Of the 40 agents assessed across the 43 studies, the most common agent was Salmonella (36; 84% of studies), followed by Campylobacter (33; 77%), Shiga toxin-producing Escherichia coli (25; 58%), and norovirus (20; 47%). Investigators used a variety of data sources and methods that could be grouped into four distinct estimation approaches-direct, surveillance data scaled-up, syndrome or population scaled-down, and inferred. Based on our review, we propose four recommendations to improve the interpretability, comparability, and reproducibility of studies that estimate the number of illnesses caused by agents transmitted commonly through food. These include providing an assessment of statistical and nonstatistical uncertainty, providing a ranking of estimates by agent, including uncertainties; describing the rationale used to select agents and data sources; and publishing raw data and models, along with clear, detailed methods. These recommendations could lead to better decision-making about food safety policies. Although these recommendations have been made in the context of illness estimation for agents transmitted commonly through food, they also apply to estimates of other health outcomes and conditions.

Improving in vitro ciguatoxin and brevetoxin detection: selecting neuroblastoma (Neuro-2a) cells with lower sensitivity to ouabain and veratridine (OV-LS)

Marine biotoxins accumulating in seafood products pose a risk to human health. These toxins are often potent in minute amounts and contained within complex matrices; requiring sensitive, reliable, and robust methods for their detection. The mouse neuroblastoma (Neuro-2a) cytotoxicity assay (N2a-assay) is a sensitive, high-throughput, in vitro method effective for detecting sodium channel-specific marine biotoxins. The N2a-assay can be conducted to distinguish between specific effects on voltage-gated sodium (Na_V) channels, caused by toxins that activate (e.g., ciguatoxins (CTXs), brevetoxins (PbTxs)) or block (e.g., tetrodotoxins, saxitoxins) the target Na_V. The sensitivity and specificity of the assay to compounds activating the Na_V are achieved through the addition of the pharmaceuticals ouabain (O) and veratridine (V). However, these compounds can be toxic to Neuro-2a cells and their application at insufficient or excessive concentrations can reduce the effectiveness of this assay for marine toxin detection. Therefore, during growth incubation, Neuro-2a cells were exposed to O and V, and surviving cells exhibiting a lower sensitivity to O and V (OV-LS) were propagated. OV-LS Neuro-2a cells were selected for 60-80% survival when exposed to 0.22/0.022 mM O/V during the cytotoxicity assay. At these conditions, OV-LS N2a cells demonstrated a 3.5-fold higher survival rate 71% ± 7.9 SD (n = 232), and lower sensitivity to O/V, compared to the original Neuro-2a cells 20% ± 9.0 SD (n = 16). Additionally, OV-LS N2a cells were 1.3-2.6-fold more sensitive for detecting CTX3C 1.35 pg/ml, CTX1B 2.06 pg/ml, and PbTx-3 3.04 ng/ml compared to Neuro-2a cells using 0.1/0.01 mM O/V. Detection of CTX3C in a complex fish matrix using OV-LS cells was 0.0048 pg CTX3C/mg fish tissue equivalent. This work shows the potential for a significant improvement in sensitivity for CTX3C, CTX1B, and PbTx-3 using the OV-LS N2a-assay.

Ciguatera poisonings: A global review of occurrences and trends

Ciguatera Poisoning (CP) is the most prevalent, phycotoxin related seafood poisoning across the globe, affecting between 10,000 and 50,000 people annually. This illness results from the consumption of seafood contaminated with lipid soluble toxins known as ciguatoxins (CTXs) that are produced by benthic dinoflagellates in the genera Gambierdiscus and Fukuyoa. The present work reviews the global occurrence of CP events and outbreaks, based on both scientific and gray literature. Ciguatera prevalence is significantly underestimated due to a lack of recognition of ciguatera symptoms, limited collection of epidemiological data on a global level, and reticence to report ciguatera in CP-endemic regions. Analysis of the time-series data available for a limited number of countries indicates the highest incidence rates are consistently reported from two historical CP-endemic areas i.e., the Pacific and Caribbean regions, a situation due in part to the strong reliance of local communities on marine resources. Ciguatera-related fatalities are rare (<0.1% of reported cases). The vast majority of outbreaks involve carnivorous fish including snappers, groupers, wrasses, and barracudas. Since 2000, an expansion of the geographical range of CP has been observed in several areas like Macaronesia and east and southeast Asia. In some of these locales, random surveys confirmed the presence of CTXs in locally sourced fish, consistent with the concurrent report of novel CP incidents (e.g., Canary Islands, Madeira, Selvagens Islands, New South Wales). One characteristic of outbreaks occurring in Asia is that they often present as large disease clusters due to group consumption of a single contaminated fish. Similar observations are reported from the Indian Ocean in the form of shark poisoning outbreaks which often lead to singular types of CP characterized by a high fatality rate. Other atypical forms of CP linked to the consumption of marine invertebrates also have been documented recently. Owing to the significant health, socioeconomic and socio-cultural impacts of ciguatera, there is an urgent need for increased, standardized, coordinated efforts in ciguatera education, monitoring and research programs. Several regional and international initiatives have emerged recently, that may help improve patients' care, data collection at a global scale, and risk monitoring and management capabilities in countries most vulnerable to CP's toxic threat.

Evidence for the Range Expansion of Ciguatera in French Polynesia: A Revisit of the 2009 Mass-Poisoning Outbreak in Rapa Island (Australes Archipelago)

Ciguatera poisoning (CP) results from the consumption of seafood contaminated with ciguatoxins (CTXs). This disease is highly prevalent in French Polynesia with several well-identified hotspots. Rapa Island, the southernmost inhabited island in the country, was reportedly free of CP until 2007. This study describes the integrated approach used to investigate the etiology of a fatal mass-poisoning outbreak that occurred in Rapa in 2009. Symptoms reported in patients were evocative of ciguatera. Several Gambierdiscus field samples collected from benthic assemblages tested positive by the receptor binding assay (RBA). Additionally, the toxicity screening of ≈250 fish by RBA indicated ≈78% of fish could contain CTXs. The presence of CTXs in fish was confirmed by liquid chromatography tandem mass spectrometry (LC-MS/MS). The potential link between climate change and this range expansion of ciguatera to a subtropical locale of French Polynesia was also examined based on the analysis of temperature time-series data. Results are indicative of a global warming trend in Rapa area. A five-fold reduction in incidence rates was observed between 2009 and 2012, which was due in part to self-regulating behavior among individuals (avoidance of particular fish species and areas). Such observations underscore the prominent role played by community outreach in ciguatera risk management.

Global impact of ciguatoxins and ciguatera fish poisoning on fish, fisheries and consumers

Ciguatera fish poisoning (CFP) is one of the most devastating food-borne illnesses caused by fish consumption. Ciguatoxins (CTXs) are potent neurotoxins synthesized by the benthic microalgae Gambierdiscus spp. and Fukuyoa spp. that are transmitted to fish by grazing and predation. Despite the high incidence of CFP, affecting an estimated number of 50,000 persons per year in tropical and subtropical latitudes, the factors underlying CTXs occurrence are still not well understood. Toxin transfer and dynamics in fish and food-webs are complex. Feeding habits and metabolic pathways determine the toxin profile and toxicity of fish, and migratory species may transport and spread the hazard. Furthermore, CTX effect on fish may be a limiting factor for fish recruitment and toxin prevalence. Recently, new occurrences of Gambierdiscus spp. in temperate areas have been concomitant with the detection of toxic fish and CFP incidents in non-endemic areas. CFP cases in Europe have led to implementation of monitoring programs and fisheries restrictions with considerable impact on local economies. More than 400 species of fish can be vectors of CTXs, and most of them are high-valued commercial species. Thus, the risk uncertainty and the spread of Gambierdiscus have serious consequences for fisheries and food safety. Here, we present a critical review of CTXs impacts on fish, fisheries, and humans, based on the current knowledge on CFP incidence and CTXs prevalence in microalgae and fish.

Climate change and harmful benthic microalgae

Sea surface temperatures in the world's oceans are projected to warm by 0.4-1.4 °C by mid twenty-first century causing many tropical and sub-tropical harmful dinoflagellate genera like Gambierdiscus, Fukuyoa and Ostreopsis (benthic harmful algal bloom species, BHABs) to exhibit higher growth rates over much of their current geographic range, resulting in higher population densities. The primary exception to this trend will be in the tropics where temperatures exceed species-specific upper thermal tolerances (30-31 °C) beyond which growth slows significantly. As surface waters warm, migration to deeper habitats is expected to provide refuge. Range extensions of several degrees of latitude also are anticipated, but only where species-specific habitat requirements can be met (e.g., temperature, suitable substrate, low turbulence, light, salinity, pH). The current understanding of habitat requirements that determine species distributions are reviewed to provide fuller understanding of how individual species will respond to climate change from the present to 2055 while addressing the paucity of information on environmental factors controlling small-scale distribution in localized habitats. Based on the available information, we hypothesized how complex environmental interactions can influence abundance and potential range extensions of BHAB species in different biogeographic regions and identify sentinel sites appropriate for long-term monitoring programs to detect range extensions and reduce human health risks.

Intraspecific Variability in the Toxin Production and Toxin Profiles of In Vitro Cultures of Gambierdiscus polynesiensis (Dinophyceae) from French Polynesia

Ciguatera poisoning (CP) is a foodborne disease caused by the consumption of seafood contaminated with ciguatoxins (CTXs) produced by dinoflagellates in the genera Gambierdiscus and Fukuyoa. The toxin production and toxin profiles were explored in four clones of G. polynesiensis originating from different islands in French Polynesia with contrasted CP risk: RIK7 (Mangareva, Gambier), NHA4 (Nuku Hiva, Marquesas), RAI-1 (Raivavae, Australes), and RG92 (Rangiroa, Tuamotu). Productions of CTXs, maitotoxins (MTXs), and gambierone group analogs were examined at exponential and stationary growth phases using the neuroblastoma cell-based assay and liquid chromatography–tandem mass spectrometry. While none of the strains was found to produce known MTX compounds, all strains showed high overall P-CTX production ranging from 1.1 ± 0.1 to 4.6 ± 0.7 pg cell⁻¹. In total, nine P-CTX analogs were detected, depending on strain and growth phase. The production of gambierone, as well as 44-methylgamberione, was also confirmed in G. polynesiensis. This study highlighted: (i) intraspecific variations in toxin production and profiles between clones from distinct geographic origins and (ii) the noticeable increase in toxin production of both CTXs, in particular CTX4A/B, and gambierone group analogs from the exponential to the stationary phase.

Economic impact of harmful algal blooms on human health: a systematic review

Harmful algal blooms (HABs) damage human activities and health. While there is wide literature on economic losses, little is known about the economic impact on human health. In this review, we systematically retrieved papers which presented health costs following exposure to HABs. A systematic review was conducted up to January 2019 in databases such as ScienceDirect and PubMed, and 16 studies were selected. Health costs included healthcare and medication expenses, loss of income due to illness, cost of pain and suffering, and cost of death. Two categories of illness (digestive and respiratory) were considered for health costs. For digestive illness cost, we found $86, $1,015 and $12,605, respectively, for mild, moderate and severe cases. For respiratory illness, costs were $86, $1,235 and $14,600, respectively, for mild, moderate and severe cases. We used Quality-Adjusted Life Years (QALYs) to access the loss of well-being due to illness caused by HABs. We found that breathing difficulty causes the most loss of QALYs, especially in children, with a loss of between 0.16 and 0.771 per child. Having gastroenteritis could cause a loss of between 2.2 and 7.1 QALYs per 1,000 children. Misleading symptoms of illness following exposure to HABs could cause bias in health costs estimations.

Application of solid phase adsorption toxin tracking (SPATT) devices for the field detection of Gambierdiscus toxins

Ciguatera fish poisoning is a food-borne illness caused by the consumption of seafood contaminated with ciguatoxins (CTXs) produced by dinoflagellates in the Gambierdiscus genus. Since most surveillance programs currently rely on the survey of Gambierdiscus cell densities and species composition, supplementary toxin-based methods allowing the time- and spatially integrated sampling of toxins in ciguateric environments are needed for a more reliable assessment and management of the risks associated with Gambierdiscus proliferation. Solid Phase Adsorption Toxin Tracking (SPATT) filters use porous synthetic resins capable of adsorbing toxins directly from the water column. To assess the ability of these passive monitoring devices to retain Gambierdiscus toxins, SPATT bags filled with 10g of HP20 resin were deployed for 48h in two French Polynesian locations at high (Nuku Hiva Island) vs. low to moderate (Kaukura Atoll) risk of ciguatera. CTXs could be detected in SPATT bags extracts from Nuku Hiva Island, as assessed by the mouse neuroblastoma cell-based assay (CBA-N2a) and liquid chromatography - tandem mass spectrometry (LC-MS/MS) analyses. Results of in vitro experiments suggest that the saturation limit of CTXs on HP20 resin, for a deployment time of 48h, is ≃ 55ng P-CTX-3C equiv. g^-1 resin. Despite the non detection of maitotoxin (MTX), LC-MS/MS analyses showed that two other compounds also produced by Gambierdiscus species were retained on SPATT bags, i.e. iso-P-CTX-3B/C and a putative MTX analogue, known as MTX-3. This study, the first to demonstrate the suitability of SPATT technology for the in situ monitoring of Gambierdiscus toxins, highlights the potential application of this tool for routine ciguatera risk assessment and management programs.