Missouriwatcher
Editor, Senior Moderator
MMWR Weekly
February 1, 2013 / 62(04);61-65
During August 2010–July 2011, the New York City Department of Health and Mental Hygiene (DOHMH) received reports of six outbreaks and one single case of ciguatera fish poisoning (CFP), involving a total of 28 persons. CFP results from consumption of certain large, predatory, tropical reef fish that have bioaccumulated ciguatoxins (CTX). CFP is characterized by various gastrointestinal, cardiovascular, and neurologic symptoms. A prolonged period of acute illness can result, and the neurologic symptoms can last months, with variable asymptomatic and symptomatic periods...DOHMH's investigation revealed that 13 persons became ill after eating barracuda, and 15 became ill after eating grouper. Although specific and highly sensitive laboratory analyses can detect and confirm CTX in fish, no practical field tests are available for fish monitoring programs. CFP prevention depends on educating the public, seafood suppliers, and distributors about known CFP endemic areas and high-risk fish species...
...experienced abdominal cramps, dizziness, headache, faintness, nausea, and vomiting. Hypotension and bradycardia persisted, despite volume resuscitation with normal saline. The treating physician suspected a link between the barracuda consumption and neurologic and gastrointestinal symptoms, subsequently diagnosed CFP, and contacted the NYC Poison Control Center (PCC). The PCC reported the incident to DOHMH, and a DOHMH inspector collected samples of barracuda from the fish market and the patients' home. The inspector also embargoed barracuda sale at the fish market...
On August 6, 2010, an adolescent female aged 16 years, and her mother aged 47 years went to a hospital emergency department (ED) with diarrhea, light-headedness, and perioral tingling after eating barracuda purchased at a fish market in Queens, New York. Hours later, an additional four family members (three males and one female) who had eaten the same fish, reported tingling in their extremities. Two of the four also visited the ED. Later, the four who had gone to the ED experienced abdominal cramps, dizziness, headache, faintness, nausea, and vomiting...
During August–September 2010, an additional seven CFP cases were reported to DOHMH. These consisted of two outbreaks (outbreaks 2 and 3) and a single case. All patients experienced symptoms consistent with CFP after eating barracuda purchased from fish markets in three different NYC boroughs and one restaurant...
On July 12, 2011, two separate outbreaks and an additional four cases that were associated with eating grouper at Manhattan restaurants were reported to DOHMH. One of the patients was a physically active man who swam >2 miles per day before his illness. After the onset of acute CFP symptoms, he had difficulty walking that persisted for several months. A sample of leftover fish was confirmed by FDA to contain 1.9 µg/kg total C-CTX-1 equivalents, exceeding the FDA guidance level by almost 20 times.
Reported by
Nathan Graber, MD, Faina Stavinsky, MS, Robert Hoffman, MD, Jessica Button, Nancy Clark, MA, New York City Dept of Health and Mental Hygiene; Scott Martin, MD, Stony Brook Univ Medical School, Stony Brook, New York. Alison Robertson, PhD, Food and Drug Administration. John Hustedt, MPH, Public Health Prevention Svc, CDC.
CTX are naturally occurring toxins that can accumulate in commonly consumed coral reef fish (e.g., barracuda, grouper, snapper, amberjack, and surgeonfish). Precursors of CTX are derived from marine dinoflagellates (microalgae) that live on the surfaces of seaweeds and denuded corals. These microalgae are consumed by herbivorous fish and undergo bioconversion to the more potent CTX as they move through the food chain. CTX can accumulate in reef fish that eat other fish, reaching levels that can cause CFP among humans when consumed. The toxins are colorless, odorless, tasteless, and temperature-stable, making them difficult to detect or destroy. Consequently, CFP occurrence is not attributable to incorrect food handling, storage, preparation, or procurement methods. The attack rate can be 80%–90%..
Initial treatment options for CFP are limited and supportive only. The majority of patients experience symptoms within 6–48 hours after eating contaminated fish...
This report reflects the importance of surveillance and outreach networks in responding to patients' histories, including food consumption, that are indicative of CFP, and highlights prevention challenges... As a result of considerable education and outreach efforts by the Florida Department of Health during the past decade, accuracy of CFP diagnosis in that state has improved. However, in other nonendemic regions, diagnostic recognition remains low...
CFP is considered a highly underreported illness, with only an estimated 10% of cases reported to health authorities...However, CFP prevention is complicated by difficulty in identifying high-risk fishing grounds and inadequate industry knowledge and compliance with the FDA seafood Hazard Analysis and Critical Control Point (HACCP) regulations. Premarket testing of fish for CTX is not feasible because of the lack of rapid field methods and the sporadic distribution of toxic fish, even in endemic areas...
...Reports indicate that 20%–25% of all seafood products are mislabeled... Until accurate and cost-effective means of premarket testing become available, prevention of additional cases will continue to be dependent on HACCP compliance by the seafood industry and CFP diagnosis and reporting by health-care providers, warranting additional outreach and education.
Acknowledgment
Munerah Ahmed, MPH, New York City Dept of Health and Mental Hygiene, New York.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6204a1.htm?s_cid=mm6204a1_w
February 1, 2013 / 62(04);61-65
During August 2010–July 2011, the New York City Department of Health and Mental Hygiene (DOHMH) received reports of six outbreaks and one single case of ciguatera fish poisoning (CFP), involving a total of 28 persons. CFP results from consumption of certain large, predatory, tropical reef fish that have bioaccumulated ciguatoxins (CTX). CFP is characterized by various gastrointestinal, cardiovascular, and neurologic symptoms. A prolonged period of acute illness can result, and the neurologic symptoms can last months, with variable asymptomatic and symptomatic periods...DOHMH's investigation revealed that 13 persons became ill after eating barracuda, and 15 became ill after eating grouper. Although specific and highly sensitive laboratory analyses can detect and confirm CTX in fish, no practical field tests are available for fish monitoring programs. CFP prevention depends on educating the public, seafood suppliers, and distributors about known CFP endemic areas and high-risk fish species...
...experienced abdominal cramps, dizziness, headache, faintness, nausea, and vomiting. Hypotension and bradycardia persisted, despite volume resuscitation with normal saline. The treating physician suspected a link between the barracuda consumption and neurologic and gastrointestinal symptoms, subsequently diagnosed CFP, and contacted the NYC Poison Control Center (PCC). The PCC reported the incident to DOHMH, and a DOHMH inspector collected samples of barracuda from the fish market and the patients' home. The inspector also embargoed barracuda sale at the fish market...
On August 6, 2010, an adolescent female aged 16 years, and her mother aged 47 years went to a hospital emergency department (ED) with diarrhea, light-headedness, and perioral tingling after eating barracuda purchased at a fish market in Queens, New York. Hours later, an additional four family members (three males and one female) who had eaten the same fish, reported tingling in their extremities. Two of the four also visited the ED. Later, the four who had gone to the ED experienced abdominal cramps, dizziness, headache, faintness, nausea, and vomiting...
During August–September 2010, an additional seven CFP cases were reported to DOHMH. These consisted of two outbreaks (outbreaks 2 and 3) and a single case. All patients experienced symptoms consistent with CFP after eating barracuda purchased from fish markets in three different NYC boroughs and one restaurant...
On July 12, 2011, two separate outbreaks and an additional four cases that were associated with eating grouper at Manhattan restaurants were reported to DOHMH. One of the patients was a physically active man who swam >2 miles per day before his illness. After the onset of acute CFP symptoms, he had difficulty walking that persisted for several months. A sample of leftover fish was confirmed by FDA to contain 1.9 µg/kg total C-CTX-1 equivalents, exceeding the FDA guidance level by almost 20 times.
Reported by
Nathan Graber, MD, Faina Stavinsky, MS, Robert Hoffman, MD, Jessica Button, Nancy Clark, MA, New York City Dept of Health and Mental Hygiene; Scott Martin, MD, Stony Brook Univ Medical School, Stony Brook, New York. Alison Robertson, PhD, Food and Drug Administration. John Hustedt, MPH, Public Health Prevention Svc, CDC.
CTX are naturally occurring toxins that can accumulate in commonly consumed coral reef fish (e.g., barracuda, grouper, snapper, amberjack, and surgeonfish). Precursors of CTX are derived from marine dinoflagellates (microalgae) that live on the surfaces of seaweeds and denuded corals. These microalgae are consumed by herbivorous fish and undergo bioconversion to the more potent CTX as they move through the food chain. CTX can accumulate in reef fish that eat other fish, reaching levels that can cause CFP among humans when consumed. The toxins are colorless, odorless, tasteless, and temperature-stable, making them difficult to detect or destroy. Consequently, CFP occurrence is not attributable to incorrect food handling, storage, preparation, or procurement methods. The attack rate can be 80%–90%..
Initial treatment options for CFP are limited and supportive only. The majority of patients experience symptoms within 6–48 hours after eating contaminated fish...
This report reflects the importance of surveillance and outreach networks in responding to patients' histories, including food consumption, that are indicative of CFP, and highlights prevention challenges... As a result of considerable education and outreach efforts by the Florida Department of Health during the past decade, accuracy of CFP diagnosis in that state has improved. However, in other nonendemic regions, diagnostic recognition remains low...
CFP is considered a highly underreported illness, with only an estimated 10% of cases reported to health authorities...However, CFP prevention is complicated by difficulty in identifying high-risk fishing grounds and inadequate industry knowledge and compliance with the FDA seafood Hazard Analysis and Critical Control Point (HACCP) regulations. Premarket testing of fish for CTX is not feasible because of the lack of rapid field methods and the sporadic distribution of toxic fish, even in endemic areas...
...Reports indicate that 20%–25% of all seafood products are mislabeled... Until accurate and cost-effective means of premarket testing become available, prevention of additional cases will continue to be dependent on HACCP compliance by the seafood industry and CFP diagnosis and reporting by health-care providers, warranting additional outreach and education.
Acknowledgment
Munerah Ahmed, MPH, New York City Dept of Health and Mental Hygiene, New York.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6204a1.htm?s_cid=mm6204a1_w