Aflatoxin contamination of commercial maize products during an outbreak of acute aflatoxicosis in eastern and central Kenya

In April 2004, one of the largest aflatoxicosis outbreaks occurred in rural Kenya, resulting in 317 cases and 125 deaths. Aflatoxin-contaminated homegrown maize was the source of the outbreak, but the extent of regional contamination and status of maize in commercial markets (market maize) were unknown. We conducted a cross-sectional survey to assess the extent of market maize contamination and evaluate the relationship between market maize aflatoxin and the aflatoxicosis outbreak. We surveyed 65 markets and 243 maize vendors and collected 350 maize products in the most affected districts. Fifty-five percent of maize products had aflatoxin levels greater than the Kenyan regulatory limit of 20 ppb, 35% had levels > 100 ppb, and 7% had levels > 1,000 ppb. Makueni, the district with the most aflatoxicosis case-patients, had significantly higher market maize aflatoxin than did Thika, the study district with fewest case-patients (geometric mean aflatoxin = 52.91 ppb vs. 7.52 ppb, p = 0.0004). Maize obtained from local farms in the affected area was significantly more likely to have aflatoxin levels > 20 ppb compared with maize bought from other regions of Kenya or other countries (odds ratio = 2.71; 95% confidence interval, 1.12-6.59). Contaminated homegrown maize bought from local farms in the affected area entered the distribution system, resulting in widespread aflatoxin contamination of market maize. Contaminated market maize, purchased by farmers after their homegrown supplies are exhausted, may represent a source of continued exposure to aflatoxin. Efforts to successfully interrupt exposure to aflatoxin during an outbreak must consider the potential role of the market system in sustaining exposure.

Ciguatera fish poisoning: treatment, prevention and management

Ciguatera Fish Poisoning (CFP) is the most frequently reported seafood-toxin illness in the world, and it causes substantial physical and functional impact. It produces a myriad of gastrointestinal, neurologic and/or cardiovascular symptoms which last days to weeks, or even months. Although there are reports of symptom amelioration with some interventions (e.g. IV mannitol), the appropriate treatment for CFP remains unclear to many physicians. We review the literature on the treatments for CFP, including randomized controlled studies and anecdotal reports. The article is intended to clarify treatment options, and provide information about management and prevention of CFP, for emergency room physicians, poison control information providers, other health care providers, and patients.

Plasma 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (DDE) levels and immune response

For determination of whether plasma 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (DDE) pesticide levels (< or =1-32 ppb) are associated with immune suppression or DNA damage in lymphocytes, 302 individuals residing in Moore County, North Carolina, in 1994-1996 provided a blood specimen, underwent a skin test, and answered a questionnaire concerning factors affecting plasma organochlorine pesticide levels and the immune system. The blood specimens were analyzed for levels of plasma DDE (a metabolite of 1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane), numbers and types of blood cells, immunoglobulin levels, mitogen-induced lymphoproliferative activity, and lymphocyte micronuclei. When DDE levels were categorized as 1 or less, more than 1 to 2, more than 2 to 4.3, more than 4.3 to 7.6, and more than 7.6 ppb, individuals with higher plasma DDE levels had lowered mitogen-induced lymphoproliferative activity (concanavalin A, range: 74,218 dropping to 55,880 counts per minute, p = 0.03) and modestly increased total lymphocytes (range: 2.0-2.3 x 10(3)/microl, p = 0.05) and immunoglobulin A levels (range: 210-252 mg/dl, p = 0.04). There were no consistent differences in response to the skin tests by plasma DDE levels. Plasma DDE levels were not associated with a higher frequency of micronuclei. The authors conclude that relatively low levels of plasma DDE are associated with statistically significant changes in immune markers, although the magnitude of the effects are of uncertain clinical importance.

Ackee fruit poisoning: an outbreak investigation in Haiti 2000-2001, and review of the literature

The Centers for Disease Control and Prevention (CDC) provided technical assistance to the Ministry of Health of Haiti during an outbreak of over 100 cases of acute illness and death in the northern region of Haiti during a 4-month period beginning in November 2000. The epidemiologic, clinical, and laboratory findings in this investigation indicated the ingestion of unripe ackee fruit as the most likely cause of this outbreak. This report describes the CDC field investigation in Haiti and gives a brief overview of the current state of knowledge about ackee poisoning.

Effects on the immune system associated with living near a pesticide dump site

In this paper, we report results of the second phase of a larger study designed to evaluate the effects on the immune system of living near a Superfund site containing organochlorine pesticides, volatile organic compounds, and metals. Phase II was conducted to determine whether living near the site, consisting of six locations in Aberdeen, North Carolina, is associated with higher plasma organochlorine levels, immune suppression, or DNA damage. Each of 302 residents of Aberdeen and neighboring communities provided a blood specimen, underwent a skin test, and answered a questionnaire. Blood specimens were analyzed for organochlorine pesticides, immune markers, and micronuclei. Of 20 organochlorines tested, only DDE was detected in the blood of participants (except for one individual). Age-adjusted mean plasma DDE levels were 4.05 ppb for Aberdeen residents and 2.95 ppb (p = 0.01) for residents of neighboring communities. Residents of 40-59 years of age who lived within a mile of any site, but particularly the Farm Chemicals site, had higher plasma DDE levels than residents who lived farther away. Residents who lived near the Farm Chemicals site before versus after 1985 also had higher plasma DDE levels. Overall, there were few differences in immune markers between residents of Aberdeen and the neighboring communities. However, residents who lived closer to the dump sites had statistically significantly lower mitogen-induced lymphoproliferative activity than residents who lived farther away (p < 0.05). Residential location was not consistently associated with frequency of micronuclei or skin test responses. Although some statistically significant differences in immune markers were noted in association with residential location, the magnitude of effects are of uncertain clinical importance.

Ciguatera and scombroid fish poisoning in the United States

BACKGROUND

Ciguatera and scombroid fish poisonings are common causes of fish-related foodborne illness in the United States; however, existing surveillance systems underestimate the overall human health impact.

OBJECTIVES

This study aimed to describe existing data on ciguatera and scombroid fish poisonings from outbreak and poison control center reports and to estimate the overall number of ciguatera and scombroid fish-poisoning illnesses, hospitalizations, and deaths in the United States.

METHODS

We analyzed outbreak data from the Foodborne Disease Outbreak Surveillance Systems (FDOSS) from 2000 to 2007 and poison control center call data from the National Poison Data System (NPDS) from 2005 to 2009 for reports of ciguatera and scombroid fish poisonings. Using a statistical model with many inputs, we adjusted the outbreak data for undercounting due to underreporting and underdiagnosis to generate estimates. Underreporting and underdiagnosis multipliers were derived from the poison control call data and the published literature.

RESULTS

Annually, an average of 15 ciguatera and 28 scombroid fish-poisoning outbreaks, involving a total of 60 and 108 ill persons, respectively, were reported to FDOSS (2000-2007). NPDS reported an average of 173 exposure calls for ciguatoxin and 200 exposure calls for scombroid fish poisoning annually (2005-2009). After adjusting for undercounting, we estimated 15,910 (90% credible interval [CrI] 4140-37,408) ciguatera fish-poisoning illnesses annually, resulting in 343 (90% CrI 69-851) hospitalizations and three deaths (90% CrI 1-7). We estimated 35,142 (90% CrI: 10,496-78,128) scombroid fish-poisoning illnesses, resulting in 162 (90% CrI 0-558) hospitalizations and 0 deaths.

CONCLUSIONS

Ciguatera and scombroid fish poisonings affect more Americans than reported in surveillance systems. Although additional data can improve these assessments, the estimated number of illnesses caused by seafood intoxication illuminates this public health problem. Efforts, including education, can reduce ciguatera and scombroid fish poisonings.

The impact of excess heat events in Maricopa County, Arizona: 2000--2005

Exposure to excess heat is preventable yet it is the primary weather-related cause of mortality in the United States. In the Southwest United States, high temperatures are common and indoor environments often have cooling devices. In summer 2005, Maricopa County, Arizona experienced a 182% increase in reported heat-related deaths in comparison to 2000--2004. We examined at-risk populations and excess mortality. We characterized heat-related deaths using descriptive and multivariate time-series analyses of county vital record data from June-September 2000--2005. Dose-response relationships for heat-related mortality and heat index were evaluated using linear and quadratic splines. From June-September, 2000--2005, 136 heat-related deaths (0.68 per 100,000) were reported; 49 (36%) occurred in 2005. In July 2005, a 14-day heat wave resulted in 28 (57%) reported deaths--a 102% increase in comparison to the same time period in 2000--2004. Decedent demographics in 2005 did not differ from previous years. The mean age of all 136 deaths was 56 years (range: 7-92 years). Of those with discernable reported injury locations, 62 (66%) were identified outdoors. Forty-eight (77%) decedents identified outdoors were < 5 years; conversely, 26 (82%) decedents who were found indoors were > or = 65 years. A 6% (95% CI: 1.00-1.13) increase in mortality risk was observed for each degree (F) increase in heat index. Excess heat impacted a younger population in Maricopa County and many deaths occurred outdoors. Consecutive days of heat exposure--even among a heat-acclimated population--can increase mortality risk. Public health response activities guided by locally obtained data will better target those at risk.

Neuropsychological study of ciguatera fish poisoning: a longitudinal case-control study

PURPOSE

The purpose of the study was to evaluate the neuropsychological effects of ciguatera fish poisoning (CFP).

METHOD

In a longitudinal matched cohort study, 12 CFP cases and 12 matched friend-controls received baseline neuropsychological evaluations within one month after intoxication and follow-up evaluations approximately six months after baseline.

RESULTS

Only one case received intravenous mannitol treatment, which occurred 10 or more days after intoxication. At baseline and follow-up evaluations, there were no statistically significant differences between CFP cases and controls on cognitive measures. At baseline, however, CFP cases endorsed significantly greater subjective toxicity symptoms (e.g. fatigue, tingling sensations) and greater anxiety symptoms than controls. Follow-up evaluations suggested resolution of all symptoms after six months. Subsequent analyses, in which data from this study were pooled with data from an earlier pilot study, supported these results.

CONCLUSION

Untreated ciguatera was associated acutely with significant subjective neurotoxicity symptoms and anxiety which were transient, but not with objectively measured cognitive changes. Future investigation with a larger sample size is warranted.

Estimated burden of disease from arsenic in drinking water supplied by domestic wells in the United States

Well water around the world can be contaminated with arsenic, a naturally occurring geological element that has been associated with myriad adverse health effects. Persons obtaining their drinking water from private wells are often responsible for well testing and water treatment. High levels of arsenic have been reported in well water-supplied areas of the United States. We quantified - in cases and dollars - the potential burden of disease associated with the ingestion of arsenic through private well drinking water supplies in the United States. To estimate cancer and cardiovascular disease burden, we developed a Monte Carlo model integrating three input streams: (1) regional concentrations of arsenic in drinking water wells across the United States; (2) dose-response relationships in the form of cancer slope factors and hazard ratios; and (3) economic cost estimates developed for morbidity endpoints using 'cost-of-illness' methods and for mortality using 'value per statistical life' estimates. Exposure to arsenic in drinking water from U.S. domestic wells is modeled to contribute 500 annual premature deaths from ischemic heart disease and 1,000 annual cancer cases (half of them fatal), monetized at $10.9 billion (2017 USD) annually. These considerable public health burden estimates can be compared with the burdens of other priority public health issues to assist in decision-making.

Evaluation of harmful algal bloom outreach activities

With an apparent increase of harmful algal blooms (HABs) worldwide, healthcare providers, public health personnel and coastal managers are struggling to provide scientifically-based appropriately-targeted HAB outreach and education. Since 1998, the Florida Poison Information Center-Miami, with its 24 hour/365 day/year free Aquatic Toxins Hotline (1-888-232-8635) available in several languages, has received over 25,000 HAB-related calls. As part of HAB surveillance, all possible cases of HAB-related illness among callers are reported to the Florida Health Department. This pilot study evaluated an automated call processing menu system that allows callers to access bilingual HAB information, and to speak directly with a trained Poison Information Specialist. The majority (68%) of callers reported satisfaction with the information, and many provided specific suggestions for improvement. This pilot study, the first known evaluation of use and satisfaction with HAB educational outreach materials, demonstrated that the automated system provided useful HAB-related information for the majority of callers, and decreased the routine informational call workload for the Poison Information Specialists, allowing them to focus on callers needing immediate assistance and their healthcare providers. These results will lead to improvement of this valuable HAB outreach, education and surveillance tool. Formal evaluation is recommended for future HAB outreach and educational materials.

Reduction in drinking water arsenic exposure and health risk through arsenic treatment among private well households in Maine and New Jersey, USA

Over 2 million mostly rural Americans are at risk of drinking water from private wells that contain arsenic (As) exceeding the U.S. Environmental Protection Agency (USEPA) Maximum Contaminant Level (MCL) of 10 micrograms per liter (μg/L). How well existing treatment technologies perform in real world situations, and to what extent they reduce health risks, are not well understood. This study evaluates the effectiveness of household As treatment systems in southern-central Maine (ME, n = 156) and northern New Jersey (NJ, n = 94) and ascertains how untreated well water chemistry and other factors influence As removal. Untreated and treated water samples, as well as a treatment questionnaire, were collected. Most ME households had point-of-use reverse-osmosis systems (POU RO), while in NJ, dual-tank point-of-entry (POE) whole house systems were popular. Arsenic treatment systems reduced well water arsenic concentrations ([As]) by up to two orders of magnitude, i.e. from a median of 71.7 to 0.8 μg/L and from a mean of 105 to 14.3 μg/L in ME, and from a median of 8.6 to 0.2 μg/L and a mean of 15.8 to 2.1 μg/L in NJ. More than half (53%) of the systems in ME reduced water [As] to below 1 μg/L, compared to 69% in NJ. The treatment system failure rates were 19% in ME (>USEPA MCL of 10 μg/L) and 16% in NJ (>NJ MCL of 5 μg/L). In both states, the higher the untreated well water [As] and the As(III)/As ratio, the higher the rate of treatment failure. POE systems failed less than POU systems, as did the treatment systems installed and maintained by vendors than those by homeowners. The 7-fold reduction of [As] in the treated water reduced skin cancer risk alone from 3765 to 514 in 1 million in ME, and from 568 to 75 in 1 million in NJ.

Investigation of the relation between self-reported food consumption and household chemical exposures with urinary levels of selected nonpersistent pesticides

Concerns about pesticide exposure through food consumption have increased during the past several years. The main objective of our study was to determine whether we could use data from the Third National Health and Nutrition Examination Survey (NHANES III) to detect a relation between self-reported food consumption--particularly consumption of fruits, vegetables, and bread products--and urinary levels of pesticides or their metabolites in a population of 978 adults living in the US. A secondary objective was to investigate whether these urine levels differed for people who reported exposure to selected common household chemicals including bug or insect spray, weed killer, and mothballs or crystals. We used monthly food frequency data from the NHANES III, 1988-1994. Urinary pesticide/metabolite levels and information about chemical exposures were taken from the Priority Toxicant Reference Range Study (a component of the NHANES III). Six pesticides or their metabolites were detected in at least 50% of the sample, three of which--1-naphthol (86.4%), pentachlorophenol (62.5%), and 3,5,6-trichloro-2-pyridinol (82.0%)--were possibly related to food consumption. We were unable to detect a relation between self-reported food consumption and their urinary levels. This may be due more to the limitations of the datasets than to a lack of a relation between food consumption and urine pesticide/metabolite levels. We did find that people who reported recently using selected common chemicals had higher geometric mean urine pesticide/metabolite levels than did people who reported not recently using these chemicals.

State-Level Policies Concerning Private Wells in the United States

Currently, no federal policies exist in the United States regarding private wells; this authority is devolved to states. This study inventoried state-level policies governing private wells in the United States in order to identify the topics addressed by each state, division of responsibilities across state agencies, and geographic differences in policy comprehensiveness. From May to August 2016, two independent reviewers conducted an online search followed by directly contacting state agencies (98% response) to identify all state-level policies in the United States that directly reference private wells. The search, updated in April 2018, confirmed the existing water policy list and identified 23 additional policies. Policies were then coded according to nine not-mutually-exclusive classifications. The results indicate that all states had at least one policy addressing private well drilling or construction. Significant geographic differences exist in maintenance-related policies. In conclusion, although drilling and construction safety are addressed by each state, some policy domains are addressed inconsistently across states, and other policy domains are absent in most states.

Exposure assessment of a mercury spill in a Nevada school -- 2004

BACKGROUND

Although mercury is toxic, few studies have measured exposure in children who handled elemental mercury briefly. In 2004, a student spilled approximately 60 milliliters of mercury at a Nevada school. Within 12 hours, all students were removed from the source of exposure. We conducted an exposure assessment at the school.

METHODS

We administered questionnaires and obtained urine samples from students. Using two-sample t-tests, we compared urine mercury levels from students who self-reported exposure to mercury levels of other students.

RESULTS

Two-hundred students participated, including 55/62 (89%) who were decontaminated. The students' geometric mean urine mercury level was 0.36 microg/L (95% confidence interval 0.32-0.40 microg/L). The student who brought the mercury to school was the only one to have an elevated urine mercury level (11.4 microg/L).

CONCLUSION

Despite environmental contamination, mercury exposure may have been minimized because of rapid identification of the elemental mercury spill and decontamination.

Urolithiasis, Urinary Cancer, and Home Drinking Water Source in the United States Territory of Guam, 2006-2010

We reviewed patient records with a first-listed diagnosis of urolithiasis-also known as urinary tract or kidney stone disease, nephrolithiasis-upon discharge from Guam's sole civilian hospital during 2006 to 2010 and urinary cancer mortality records from the Guam Cancer Registry for 1970 to 2009 to determine the source of municipal water supplied to the patients' residence. The objective was to investigate a possible relationship between the sources of municipal water supplied to Guam villages and the incidence of urolithiasis and urinary cancer. We analyzed hospital discharge diagnoses of urolithiasis or renal calculi by calculating the incidence of first-mentioned discharge for urolithiasis or renal calculi and comparing rates across demographic or geographic categories while adjusting by age, sex, and ethnicity/race. We reviewed cancer registry records of urinary cancer deaths by patient residence. The annual incidence of hospitalization for urolithiasis was 5.22 per 10,000. Rates adjusted for sex or age exhibited almost no change. The rate of 9.83 per 10,000 among Chamorros was significantly higher (p < 0.05) than the rates among any other ethnic group or race. When villages were grouped by water source, rates of patients discharged with a first-listed diagnosis of urolithiasis, adjusted for ethnicity/race, were similar for villages using either well water (5.44 per 10,000) or mixed source water (5.39 per 10,000), and significantly greater than the rate for villages using exclusively reservoir water (1.35 per 10,000). No statistically significant differences were found between the water source or village of residence and urinary cancer mortality. Some Guam residents living in villages served completely or partly by deep well water high in calcium carbonate may be at increased risk for urolithiasis compared with residents living in villages served by surface waters. Although the risk appears to be highest in villagers of Chamorro ethnicity, residents should be aware of other contributing risk factors and steps to take to avoid developing this health problem.

Fish bioassay and toxin induction experiments for research on Pfiesteria piscicida and other toxic dinoflagellates: workshop summary

In late January 2000, the Centers for Disease Control and Prevention sponsored a workshop to discuss standardizing the laboratory materials and methods used for in vivo fish bioassays and toxin induction experiments. Representatives from six laboratories using these assays to conduct research on Pfiesteria piscicida Steidinger & Burkholder, similar organisms (i.e., members of the toxic Pfiesteria complex) or their toxins were invited to attend. The workshop objectives were a) to discuss the need for uniform quality assurance for fish bioassays and toxin induction, b) to encourage publishing the relevant materials and methods in the literature, c) to foster communication among the laboratories conducting this work, and d) to respond to requests from state health and environmental protection agencies for guidance in interpreting the results from fish bioassays conducted in different laboratories. To facilitate discussion at the workshop, researchers conducting Pfiesteria research completed a detailed questionnaire in advance about fish bioassays and toxin production assays. Workshop participants discussed experimental factors that might influence the reproducibility or interpretation of fish bioassays and toxin-induction experiments. The experimental factors were categorized into physical, chemical, and biological parameters. In addition, participants ranked experimental factors by their relative importance in conducting these assays as a) factors that are critically important and should be maintained within a recommended range, b) factors that are important in conducting the assays but that may be variable among laboratories or within experiments and whose values should be recorded and reported by investigators, and c) factors of unknown importance that should be considered important research questions. This article summarizes results obtained from the questionnaire and workshop discussions.

Algal bloom-associated disease outbreaks among users of freshwater lakes--United States, 2009-2010

Harmful algal blooms (HABs) are excessive accumulations of microscopic photosynthesizing aquatic organisms (phytoplankton) that produce biotoxins or otherwise adversely affect humans, animals, and ecosystems. HABs occur sporadically and often produce a visible algal scum on the water. This report summarizes human health data and water sampling results voluntarily reported to CDC's Waterborne Disease and Outbreak Surveillance System (WBDOSS) via the National Outbreak Reporting System (NORS) and the Harmful Algal Bloom-Related Illness Surveillance System (HABISS)* for the years 2009-2010. For 2009-2010, 11 waterborne disease outbreaks associated with algal blooms were reported; these HABs all occurred in freshwater lakes. The outbreaks occurred in three states and affected at least 61 persons. Health effects included dermatologic, gastrointestinal, respiratory, and neurologic signs and symptoms. These 11 HAB-associated outbreaks represented 46% of the 24 outbreaks associated with untreated recreational water reported for 2009-2010, and 79% of the 14 freshwater HAB-associated outbreaks that have been reported to CDC since 1978. Clinicians should be aware of the potential for HAB-associated illness among patients with a history of exposure to freshwater.

Abstract P5-02-02: Improving efficiency of breast MRI utilization by coordinating primary care, breast imaging and surgeons

Introduction: Breast MRI in the workup of a new breast cancer diagnosis is both a valuable and costly imaging study. The decision to obtain a breast MRI is often made by the surgeon who is referred the newly diagnosed breast cancer patient. That is followed by a delay in their management due to scheduling the MRI. Our breast center program leadership developed a protocol to move the time of MRI prior to the surgeon's evaluation while avoiding unnecessary breast MRIs ordered by some well-intentioned primary care providers. Coordinating a breast MRI protocol can optimize timely performance of breast MRI, guiding primary care to become the ordering clinician while avoiding unnecessary breast MRIs.

Methods: Recognizing a delay in the journey of newly diagnosed breast cancer patients that have their breast MRI ordered only after the multidisciplinary conference or surgical consultation, we developed a protocol to improve timeliness of care. Guidelines were identified by our breast program leadership when a newly diagnosed breast cancer patient would warrant a breast MRI. Agreed upon indicators included dense breast tissue, invasive lobular breast cancer, patients typically under 50 years old, and vague imaging of primary lesions. When these findings were identified, the radiologist included a statement with the core needle biopsy report. It stated that our breast program leadership identified this patient as benefiting from a breast MRI ordered soon after the positive biopsy. This avoided the issue of self-referral since our breast leadership created the guidelines. The message went to the primary care provider who now ordered the breast MRI prior to conference or surgical consultation. We examined sixty consecutive patients from two time periods, half before and half after institution of the MRI protocol.

Results: Prior to this policy, patients who needed breast MRI would obtain the study on average 12 days after our multidisciplinary breast conference (MDC), while after institution of the policy breast MRI was obtained 3 days PRIOR to conference. Before only 43% of necessary breast MRIs were ordered prior to surgical consultation while after the protocol 100% of breast MRIs were ordered PRIOR to surgical consultation. Before the protocol rarely did primary care order breast MRIs. After the protocol primary care providers ordered 80% of all breast MRIs. While ordering more breast MRIs, primary care ordered less unnecessary studies. After the protocol was instituted, inappropriate studies as determined by the MDC decreased from 21% deemed unnecessary to only 10%.

Conclusions: Institution of a breast MRI ordering guideline by the breast program leadership with participation of primary care had the benefits of obtaining the breast MRI before the multidisciplinary conference and/or surgical consultation while avoiding unnecessary breast MRI orders. Institution of a breast MRI protocol enhances patient care, eliminates delays in treatment, avoids unnecessary tests, shifts appropriate care to primary care providers and allows initial surgical consultation to have all the data necessary to make definitive decisions. This quality improvement effort via program leadership improved comprehensive care.

Citation Format: Kaufman CS, Behrndt VS, Hall W, Moses K, Wolgamot GM, Crabo L, Backer L, Carpenter K, Smits S. Improving efficiency of breast MRI utilization by coordinating primary care, breast imaging and surgeons [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-02-02.

Evaluation of Electronic Health Records to Monitor Illness From Harmful Algal Bloom Exposure in the United States

Harmful algal blooms (HABs) are the rapid growth of algae that can produce toxic or harmful effects in people and animals. Potential health effects include respiratory illness, gastrointestinal illness, skin and eye irritation, and sometimes more severe toxic effects such as liver damage. Defining HAB exposure and related illness is challenging for many reasons, including characterizing the exposure. Large electronic health record databases present an opportunity to study health encounters specifically related to HAB exposure through querying medical diagnostic codes. We queried the MarketScan Research Databases between January 2009 and April 2019 for use of the International Classification of Diseases (ICD) codes for HAB exposure. We found a total of 558 records that used either the ICD-9 or ICD-10 code for HAB exposure. Respiratory illness was most commonly reported along with the HAB exposure code. Use of HAB exposure codes showed seasonal fluctuations during 2012-2019. We found that although the HAB-related ICD-9 and ICD-10 codes were used infrequently, they were most often recorded during bloom seasons in warmer months. This analysis is the first that utilizes a large-scale national database of de-identified health records to understand the use of medical diagnostic codes related to algae exposure.

Assessing the relationship between cyanobacterial blooms and respiratory-related hospital visits: Green bay, Wisconsin 2017-2019

Potential acute and chronic human health effects associated with exposure to cyanobacteria and cyanotoxins, including respiratory symptoms, are an understudied public health concern. We examined the relationship between estimated cyanobacteria biomass and the frequency of respiratory-related hospital visits for residents living near Green Bay, Lake Michigan, Wisconsin during 2017-2019. Remote sensing data from the Cyanobacteria Assessment Network was used to approximate cyanobacteria exposure through creation of a metric for cyanobacteria chlorophyll-a (ChlBS). We obtained counts of hospital visits for asthma, wheezing, and allergic rhinitis from the Wisconsin Hospital Association for ZIP codes within a 3-mile radius of Green Bay. We analyzed weekly counts of hospital visits versus cyanobacteria, which was modelled as a continuous measure (ChlBS) or categorized according to World Health Organization's (WHO) alert levels using Poisson generalized linear models. Our data included 2743 individual hospital visits and 114 weeks of satellite derived cyanobacteria biomass indicator data. Peak values of ChlBS were observed between the months of June and October. Using the WHO alert levels, 60% of weeks were categorized as no risk, 19% as Vigilance Level, 15% as Alert Level 1, and 6% as Alert Level 2. In Poisson regression models adjusted for temperature, dewpoint, season, and year, there was no association between ChlBS and hospital visits (rate ratio [RR] [95% Confidence Interval (CI)] = 0.98 [0.77, 1.24]). There was also no consistent association between WHO alert level and hospital visits when adjusting for covariates (Vigilance Level: RR [95% CI] 0.88 [0.74, 1.05], Alert Level 1: 0.82 [0.67, 0.99], Alert Level 2: 0.98 [0.77, 1.24], compared to the reference no risk category). Our methodology and model provide a template for future studies that assess the association between cyanobacterial blooms and respiratory health.

Status of state cyanoHAB outreach and monitoring efforts, United States

A widespread effort is underway to improve awareness of cyanobacteria harmful algal blooms (cyanoHABs) across the United States using a variety of monitoring programs and public health outreach measures to protect people, pets, and livestock. To determine the status of cyanoHAB outreach and monitoring efforts, 2 questionnaires were distributed to health/environmental departments in 50 states and the District of Columbia (DC). One questionnaire focused on cyanoHAB exposure to humans from drinking water and the second targeted exposure through recreational activities. All states plus DC responded to the recreational survey; 46 states plus DC responded to the drinking water survey. All states except Alaska answered that microcystins were the cyanotoxins of greatest concern for recreational exposure; microcystins were also of greatest concern for drinking water with the exception of Utah (anatoxin-a in reservoirs was greatest concern) and Rhode Island (microcystins and anatoxin-a in reservoirs/ponds were greatest concern). Regional comparisons disclosed a lack of cyanoHAB programs in southern states relative to northern states that may be related to the higher percentage of water surface area in northern states. Interestingly, recreational outreach is more extensive than drinking water outreach (only 16 states reported having some type of drinking water outreach program, compared with 35 states with recreational outreach), and preferred outreach methods are websites and press releases. Additionally, respondents reported very limited funding for outreach and monitoring programs. Our results establish baseline information to help determine what future direction cyanoHAB outreach and monitoring programs can take at local, regional, and national levels.

Emerging areas of research reported during the CDC National Conference on Pfiesteria: from biology to public health

Since its identification in 1996, the marine dinoflagellate Pfiesteria piscicida Steidinger & Burkholder has been the focus of intense scientific inquiry in disciplines ranging from estuarine ecology to epidemiology and from molecular biology to public health. Despite these research efforts, the extent of human exposure and the degree of human illness directly associated with Pfiesteria is still in the process of being defined. Unfortunately, during this same time Pfiesteria has also stimulated media coverage that in some instances jumped ahead of the science to conclude that Pfiesteria presents a widespread threat to human health. Political and economic forces also came into play when the tourism and seafood industries were adversely impacted by rumors of toxin-laden water in estuaries along the east coast of the United States. Amid this climate of evolving science and public concern, Pfiesteria has emerged as a highly controversial public health issue. In October 2000 Centers for Disease Control and Prevention sponsored the National Conference on Pfiesteria: From Biology to Public Health to bring together Pfiesteria researchers from many disparate disciplines. The goal of this meeting was to describe the state of the science and identify directions for future research. In preparation for the conference an expert peer-review panel was commissioned to review the existing literature and identify research gaps; the summary of their review is published in this monograph. During the meeting primary Pfiesteria researchers presented previously unpublished results. The majority of those presentations are included as peer-reviewed articles in this monograph. The discussion portion of the conference focused upon researcher-identified research gaps. This article details the discussion segments of the conference and makes reference to the presentations as it describes emerging areas of Pfiesteria research.