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Date: Thu 7 Jun 2012
Source: Eurosurveillance Edition 2012; 17(23) [edited] <http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20188>

Outbreak of ciguatera food poisoning by consumption of amberjack (_Seriola_ spp.) in the Canary Islands, May 2012
[authors: Nunez D, Matute P, Garcia A, Garcia P, Abadia N]

In May 2012 a family outbreak of ciguatera food poisoning, affecting 4 people, was detected in Tenerife, Canary Islands. The outbreak was caused by eating amberjack fish (_Seriola_ spp.) bought in a local market. This is the 3rd outbreak of ciguatera food poisoning in the Canary Islands in 2012. We describe the epidemiology of this outbreak.

Outbreak description
In mid-May 2012, a primary health care center in Tenerife reported a case compatible with ciguatera food poisoning, according to the criteria established by the Epidemiological Surveillance System for Ciguatera poisoning in the Canary Islands (SVEICC) (1). The next day, a primary health care centre in a different town notified a 2nd compatible case. The 2nd case belonged to the same family as the index case. An investigation was initiated, and 2 more cases were subsequently found, also with symptoms consistent with ciguatera poisoning. The 4 cases consisted of a man and 3 women, aged in their mid-30s to early 60s. The symptoms presented by the cases are detailed in table 1 [for tables, see source URL above. - Mod.LL]. Although 3 cases were treated, none required hospitalization.

Food investigation
Questioning cases about their food history revealed that all had shared a common meal. The onset of symptoms had occurred between 5 and
36 hours after ingestion of a food item served during this meal.

The food eaten by all cases was made with fish of the species amberjack (_Seriola_ spp.), which had been bought 2 months earlier in a local market, and frozen until the date of consumption. It was a 2 kg piece of fish, the origin of which is currently being sought. The only remains of the consumed meal was a soup made with the fish in question, which is being analyzed to confirm the presence of ciguatoxin, the toxin responsible for ciguatera poisoning.

Ciguatera is a type of food poisoning caused by eating fish contaminated with ciguatoxin. Typically the implicated fish are large predator species that have accumulated toxin provided by herbivore fish that feed on algae and toxic dinoflagellates found on coral reefs (such as _Gambierdiscus toxicus_). The toxin is concentrated through the food chain, ultimately reaching the human consumer. Larger and older fish are often more toxic (2). People who have ciguatera may experience nausea, vomiting, and neurologic symptoms such as tingling fingers or toes; they also may find that cold things feel hot and hot things feel cold. Onset usually occurs within 10 minutes to 24 hours after ingestion of toxic fish. Symptoms usually go away in days or weeks but can last for years. People who have ciguatera can be treated for their symptoms. Ciguatera has no cure (3).

Situation in Europe
In Europe, there have been reports of ciguatera poisoning related to travel to endemic countries boarding the Caribbean Sea or the Red Sea (2). No indigenous cases have been reported in Spain but an outbreak occurred in 2004 associated with consumption of amberjack fish (_Seriola_ spp.) captured in Canarian waters (4). In 2008, an outbreak of ciguatera in Madeira, Portugal, was reported, due to consumption of amberjack fish caught in local waters (5). Furthermore, some studies have identified the presence of _Gambierdiscus_ spp. in waters surrounding the Canary Islands and Madeira (6), but there are still many gaps in knowledge regarding their prevalence, how long they have been present, the type(s) of toxin they produce, and the accumulation of toxins in the surrounding marine life (7).

An autochthonous outbreak of ciguatera food poisoning occurred in the Canary Islands in 2008 and was associated with consumption of fish purchased in the local market (8,9).

Surveillance initiatives in the Canary Islands
Following this outbreak [in 2008], which affected 25 people, the SVEICC was launched in 2009. The SVEICC is based on urgent and compulsory notification of all cases that are treated in the health care system with symptoms consistent with ciguatera (suspected cases), and the collection of basic data on a case-specific epidemiological questionnaire. The "suspected case" definition includes a history of consuming fish from any of the varieties considered at risk (amberjack, abbot, grouper, silverside, barracuda, moray eel, wahoo, and Atlantic bonito) and the presence of clinical symptoms. Both the SVEICC and the specific epidemiological questionnaire are available on the Canary Islands Health Service website (1).

The food research done for each case of suspected ciguatera poisoning includes information on the date and place of capture of fish, their origin, weight and size, and place of distribution or sale. It also gives priority to location and collection of a sample of the product consumed (for laboratory confirmation) and the destruction of the remains of involved fish to avoid its consumption.

Epidemiological surveillance results
In addition to the most recent outbreak reported here, the SVEICC recorded 8 indigenous outbreaks of ciguatera food poisoning between November 2008 and April 2012, according to data from the Epidemiology and Prevention Service of de General Directorate of Public Health. The total number of people who have been affected up to now is 68. Table 2 [see source URL above. - Mod.LL] contains information broken down for each of the outbreaks: date of onset, number of cases, species of fish associated with the outbreak, weight and their origin. In 3 of the outbreaks, presence of ciguatoxin in the food eaten was confirmed.

Epidemiological surveillance activities indicate that ciguatera food poisoning occurs in the Canary Islands. All documented outbreaks since
2004 have been associated with the consumption of large amberjack. To date, no other species has been identified in relation to outbreaks.
Most of the outbreaks are linked to sport fishing activities.

Ciguatera poisoning is an emergent process in the Canary Islands, with a persistent incidence of outbreaks and an impact on public health.
However, the number of cases remains lower than an average of 12 cases per year, so the risk of contracting the disease in the Canary Islands is very low. Moreover there are still many unknowns regarding the origin of the problem and the real meaning of the presence of _Gambierdiscus_ spp. (producers of ciguatoxin) (5-7) in our marine environment.

1. Servicio de Epidemiologia y Prevencion. Direccion General de Salud Publica. Gobierno de Canarias. Protocolo de actuacion para la vigilancia epidemiologica de la intoxicacion por ciguatera en Canarias [Protocol for the epidemiological surveillance of ciguatera poisoning in the Canary Islands]. [Accessed 6 Jun 2012]. Spanish. Available from <http://www2.gobiernodecanarias.org/sanidad/scs/contenidoGenerico.jsp?idDocument=bb1799ed-b4c0-11de-ae50-15aa3b9230b7&idCarpeta=1f358add-07f8-11de-8a2d-f3b13531fc76>.
2. Food and Agriculture Organization of the United Nations (FAO). FAO food and nutrition papers v 80. Marine biotoxins. Rome: FAO. 2004.
Available from
3. Centers for Disease Control and Prevention (CDC): National Center for Environmental Health. Ciguatera fish poisoning. Atlanta: CDC.
[Accessed 6 Jun 2012]. Available from
4. Perez-Arellano JL, Luzardo OP, Perez Brito A, et al. Ciguatera fish poisoning, Canary Islands. Emerg Infect Dis. 2005; 11(12): 1981-2.
[Available from
5. European Food Safety Authority (EFSA): EFSA Panel on Contaminants in the Food Chain. Scientific opinion on marine biotoxins in shellfish
- emerging toxins: ciguatoxin group. EFSA Journal 2010; 8: 1627.
Available from
6. Fraga S, Rodriguez F, Caillaud A, et al. Ciguatera y _Gambierdiscus_ en la Macaronesia [Ciguatera and _Gambierdiscus_ in Macaronesia]. XI Reunion Iberica sobre Microalgas Nocivas y Biotoxinas; 2011 30 May-2 June; Bilbao, Spain. Spanish. [Accessed 6 Jun 2012]. Available from <http://www.ehu.es/reunioniberica/images/stories/Resmenes_final.doc>.
7. Caillaud A, Canete E, Fraga S, et al. Toxicidad de la dinoflagelada _Gambierdiscus_ sp. aislada de las Islas Canarias [Toxicity of the dinoflagellate _Gambierdiscus_ spp. isolated from the Canary Islands].
IX Reunion Iberica del grupo de Trabajo multidisciplinar sobre fitoplancton toxico y biotoxinas; 2007 May 7-10; Cartagena, Spain.
8. Matute P, Nunez D, Abadia N. Caracterizacion de dos brotes autoctonos de intoxicacion alimentaria por ciguatera ocurridos en Tenerife en noviembre de 2008 y enero de 2009 [Characterisation of two indigenous outbreaks of ciguatera food poisoning which occurred in Tenerife in November 2008 and January 2009]. XXXVII Reunion de la Sociedad Espanola de Epidemiologia; 2009 Oct 28-30; Zaragoza, Spain.
9. Boada LD, Zumbado M, Luzardo OP, et al. Ciguatera fish poisoning on the West Africa Coast: An emerging risk in the Canary Islands (Spain).
Toxicon. 2010; 56(8): 1516-9. Available from <http://www.ncbi.nlm.nih.gov/pubmed/20692274>.

communicated by:

[The following is taken from CDC: Cluster of ciguatera fish poisoning
- North Carolina, 2007. MMWR 2009; 58: 283-5
(<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5811a3.htm>) (original citation numbering retained):

Ciguatoxins are lipid-soluble cyclic polyether compounds and are the most potent sodium channel toxins known (3). Carnivorous tropical and semitropical fish, such as barracuda, amberjack, red snapper, and grouper, become contaminated with ciguatoxins by feeding on plant-eating fish that have ingested _Gambierdiscus toxicus_ or another member of the _Gambierdiscus_ genus, a group of large dinoflagellates commonly found in coral reef waters (4). Gambiertoxins from _Gambierdiscus_ spp. are converted into more potent lipid-soluble ciguatoxins. Spoilage of fish that have been caught is not a factor in toxin development, and cooking does not deactivate the toxin. Humans who eat contaminated predatory fish are exposed to variable concentrations of ciguatoxin, depending on the fish size, age, and part consumed (toxins concentrate more in the viscera, especially liver, spleen, gonads, and roe). The attack rate can be as high as 80 to 90 per cent in persons who eat affected fish, depending on the amount of toxin in the fish.

Persistence or recurrence of neurologic symptoms are hallmarks of CFP [ciguatera fish poisoning]. 3 of the 9 patients in this cluster had recurrences of one or more symptoms for more than 6 months after their initial illness. If these patients are again exposed to fish (either ciguatoxin-contaminated or even noncontaminated fish), their symptoms likely will be more severe than those experienced with their initial episodes of CFP (3).

Variations in the geographic distribution of the various ciguatoxins might explain regional differences in symptom patterns. CFP symptoms associated with eating fish from the Pacific Ocean are primarily neurologic, and symptoms associated with eating fish from the Caribbean Sea are more commonly gastrointestinal (4). Amberjack often is linked to CFP cases in the Caribbean. Although the amberjack fish responsible for this cluster of CFP cases tested positive for C-CTX-1, it was not tested for the presence of other ciguatoxins, which also might have been present and could have altered disease presentation (7).

CFP has been associated almost exclusively with eating fish caught in tropical or semitropical waters, but increased global marketing of these species has increased the possibility that persons in temperate zones might become ill with CFP (4). Moreover, warming seawaters might expand the ranges of ciguatoxin-contaminated fish (8). In the USA, such fish have been found as far north as the coastal waters of North Carolina. Despite underreporting, CFP now is considered one of the most common illnesses related to fish consumption in the United States (9).

Any level of Caribbean ciguatoxin 0.1 ppb or more of fish tissue is thought to pose a health risk (3). As this illness becomes more common in nontropical areas of the world, clinicians need to be aware of its manifestations and how to manage it. Although opinions vary on the most effective course of treatment, intravenous mannitol has been a mainstay of management of neurologic symptoms for more than 20 years.
Early mannitol treatment is considered more effective, but anecdotal evidence suggests that even delayed therapy benefits some patients.
Amitriptyline also has been useful in relieving some of the neurologic symptoms of CFP (10). If evaluating a possible case, clinicians should consult their local poison control center for the latest treatment guidelines.

3. Pearn J. Neurology of ciguatera. J Neurol Neurosurg Psychiatry 2001; 70(1): 4-8 [available at <http://jnnp.bmj.com/content/70/1/4.long>].
4. Lewis RJ. The changing face of ciguatera. Toxicon 2001; 39(1):
97-106 [abstract available at
5. Lange WR, Lipkin KM, Yang GC. Can ciguatera be a sexually transmitted disease? Clin Toxicol 1989; 27(3): 193-7 [abstract available at <http://www.ncbi.nlm.nih.gov/pubmed/2810444>].
7. Lewis RJ, Jones A. Characterization of ciguatoxins and ciguatoxin congeners present in ciguateric fish by gradient reverse-phase high-performance liquid chromatography/mass spectrometry. Toxicon 1997; 35(2): 159-68 [abstract available at <http://www.ncbi.nlm.nih.gov/pubmed/9080572>].
8. Chateau-Defat ML, Chinain M, Cerf N, et al. Seawater temperature, _Gambierdiscus_ spp. Variability and incidence of ciguatera poisoning in French Polynesia. Harmful Algae 2005; 4: 1053-62 [abstract available at <http://www.ilm.pf/node/1356>].
9. CDC. Surveillance for foodborne-disease outbreaks - United States, 1998-2002. MMWR 2006; 55(SS-10): 1-34 [available at <http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5510a1.htm>].
10. Lewis R, Ruff T. Ciguatera: ecological, clinical, and socioeconomic perspectives. Crit Rev Environ Sci Technol 1993; 23(2):
137-56 [abstract available at
<http://www.tandfonline.com/doi/abs/10.1080/10643389309388447>]. - Mod.LL

A HealthMap/ProMED-mail map can be accessed at:

[see also:
Ciguatera fish poisoning - China: (HK) 20120329.1084658 2010
Ciguatera, fish poisoning - Philippines 20100627.2147
Ciguatera toxin, 2007 - USA: (NC), unusual symptoms 20090402.1273
Foodborne illness, fish - China (Guangdong): ciguatera susp.
Ciguatera fish poisoning - China (Hong Kong): alert 20061206.3437
Food poisoning - Australia (VIC): RFI 20041113.3077 Ciguatera fish poisoning - China (Hong Kong): alert 20040401.0888
Ciguatera fish poisoning, human - USA (Florida) 19991212.2153
Ciguatera fish poisoning, human - Canada (Quebec) 19971019.2147] .................................................ll/mj/sh
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