### Bureau of· Environmental Haalt

. h HealthAsseasmentSection

"To proiBct and Improvethe health ofallOhloana"

### The**~** 

# Publil c H l ealth**ssu:e:** This summer Ohio's local health departments, local physician offices, Poison Control Centers and the state health department have received reports of illness from people who have claimed to have had contadwith HAS-contaminated water. Several ofOhio's inland lakes have experienced cyanobaderia blue-green algae blooms, commonly referred to as Harmful Algal Blooms (HABs). Depending on the genera, water conditions, and otherfaders, neurotoxins, hepatotoxins, cytotoxins, dermatotoxins and gastrointestinal toxins can be produced by cyanobacteria. These toxins are released to the water as the bacteria die. Water samples from various Ohio lakes have detected the presence ofmicrocystin, anatoxin-a, cylindrospermopsin and saxitoxin. Both humans and animals can experience illness from exposure to these toxins during recreational activities and otherwater uses.

with cyanobacteria ortoxins

Skin contact 'With water contaminated with cyanobacteria ortoxins
orcontact with animals contaminated with (microcystins, cylindrospermopsin) Elevated AST/AL T, GGT Gastroenter1tls Acute hepatitis Kidney damage Malaise Headache Anorexia
(anatoxin-a, anatoxin-a{s), saxitoxin) Paresthesia Tremor Fasciculations Hypersalivation Dlarrttea Ataxia Motorweakness

Dennaltoxlna (Lyngbyatoxins, lipopolysaccharide endotoxins) Rash, hives Skin blistering Minutes to hours other microbial infections/toxins

Viral hepatitis

Viral Gastroenteritis
Hepatotoxic drug ingestion (acetaminophen)

poisoning

otherdermal allergens. non-allergic urticaria, photosensitivity reactions

Upper respiratory initation UnknOYm, but otherairborne allergens, upper Rhinitis likelyan acute respiratory infection, flu
ortoxins Possible reaction reaction * Symptom onsettimes are primarilyextrapolations from laboratoryanimal data and events.

# Dil a.gnosi:s a.nd L

. ab 

# Testi:ng: Currently there is no laboratory diagnostic testing which can confirm the presence ofcyanotoxins in human clinical specimens. In the absence of laboratory confirmation, presumptive diagnosis can be made based upon exposure history, clinical signs and symptoms, and ruling out other diagnoses. In
cases where exposure to hepatotoxins is suspected, a standard liver panel is recommended (AST (SGOT), AL T, ALP, GGT, albumin and bilirubin). Tests for ruling out other diagnoses should also be performed. 

# Ca

. se Defin1 i:ti:on: CDC case definition summaryforselectedtoxins (for complete description see CDC Proposed Case Definitions forAlgal Toxin-related Diseases)

• SuspectCase Exposure to waterwith a confirmed algal bloom AND onset ofassociated signs and symptoms within a reasonable time after exposure AND without identification ofanother
cause ofillness.

• Probable Case Meets criteria for Suspect Case AND there is laboratory documentation ofa HAB toxin(s) in the water.

• Confirmed Case Meets criteria for a Probable Case combined with professional judgment based on medical review.

Freshwater TypeofToxin Causative organism Vector Cyanotoxins Anatoxin-a Neurotoxin Anabaena spp. Contaminated Aphanizomsnonspp. fresh water Planktothrixspp. Anatoxin-a(s) Neurotoxin Anabaena t1os-aquae Contaminated fresh water Cylindrospermopsin Hepatotoxin Cylindrospermopsis Contaminated fresh water and raciborskii, Aphanizomenon possibly fish ova/isporum Lyngbyatoxin Dermal toxin Lyngbya spp. Contaminated fresh or marine waters Microcystins Hepatotoxin M. aeruginosa Contaminated Anabaena spp. fresh water Planktothrixspp. Saxitoxins Neurotoxin Anabaena circinalis Contaminated fresh water Lvnabva wollei 

# Treatment and Patient M J anagement: Symptomatic, supportive care. There are currently no known antidotes for exposures to the group of toxins associated with cyanobacteria. Follow-up laboratory testing as indicated.

# Pati: ant Educatlon1 : Community education outreach efforts are currently being pursued by the state agencies involved addressing Ohio HABs. Please referto the following links for more information regarding Harmful Algal Blooms:


## > Ohio Department of Health (ODH) Bureau ofEnvironmental Health (BEH) Blue-Green Algae Fact Sheet: www.odh.ohio.gov/ASSETS/5C9F74E704F5459885200FC9A1EBDOD8/Biue%20Green%20AI gae%20HABs.pdf 

## > Ohio Department of Health Odors and Your Health Fact Sheet: www.odh.ohio.gov/ASSETS/64E05559F9AE4A3786CFC4EE9DCBE5E2/0dorsFS.pdf 

## > Ohio Environmental Protection Agency Grand Lake St. Marys Harmful Algal Bloom Website: www.epa.ohio.gov/pic/glsm algae.aspx 

## > Centers for Disease Control and Prevention, Environmental Hazards 

### &Health Effects, Harmful Algal Blooms HABs http://wNw.cdc.gov/hab/cyanobacterialfacts.htm#treat 

# H

J AB Case 

# Reoort

. ln1 glRaqulram; an1 ts: Pursuant to Ohio Administrative Code (OAC) Chapter 3701-3-02 and the ODH Infectious Disease Control Manual ( www.odh.ohio.gov/pdflidanlintro1.pdf) healthcare providers are required to submit reports of

### human illness related to exposure

### to HABs to the local health district where the ill individual resides. Reports are to be made underClass C -

..waterborne disease outbreaks; report single cases oftoxin poisoning associated with exposure to waterwith a confirmed algal bloom bythe end ofthe next business day to the local public health department where the patient resides.•• WHO must report? Healthcare providers (physicians, hospitals, infection control professionals, local public health providers) with knowledge of

### a case or suspect case of 

### HAB exposure and illness are required to report. WHAT must be reported? Healthcare providers must submitthe HAB-related human illness form to the local health districtwhere the ill individual resides. WHEN must a report be made? Class C - must 

### be sent by the end ofthe next business dayto the local public health department. WHERE mustthe report be made? Healthcare providers should send the case information to the local healthjurisdiction where the patient resides. A listing oflocal health departments may be found at: http://odhlogin.sso.odh.ohio.gov/LHDdirectory/NetMgr/ODHList.aspx
ODH, with assistance from the Centers for Disease Control and Prevention, has developed case definitions and the following human illness reporting form for HAS-related illnesses:

HAB-related human illness report: www.odh.ohio.gov/ASSETSn3AB58EA30EB4F28944F96211 EOE6905/HABRelated%20Human%20111ness%20Form-%2008-06-201O.pdf

Animal Illness: Reports of

### suspected domestic animal illness associated with exposure to HAB should 

### be reported to the Local Health District. Local health districts receiving reports from veterinarians should contact the ODH Zoonotic Disease Program (ZDP) at 614-752-1029, select option 

### two (2). Completed animal illness report forms can be faxed to the ODH ZDP at 614-644-1057.

HAB-related animal Illness report:www.odh.ohio.gov/ASSETS/F142B8DFD67B4855B71650062F4F72C6/Animai%20HABRelated%20111ness%20Form.pdf

# Addit.iona

. l Resources: Centers for Disease Control and Prevention http:/fw.Nw.cdc.gov/hab/cyanobacteria/default.htm CDC Facts About Cyanobacteria and Cyanobacterial Harmful Algal Blooms www.cdc.gov/hab/cyanobacteria/pdfs/facts.pdf CDC, Environmental Hazards 

### &Health Effects, Harmful Algal Blooms (HABs) www.cdc.gov/hab/cyanobacteria/facts.htm#treat

U.S. EPA International Symposium on Cyanobacterial Harmful Algal Blooms (ISOC-HAB) http://WNW.epa.gov/cyano habs symposium/monograph.html Toxicological Reviews of Cyanobacterial Toxins: Microcystins LR, RR, YR and LA (External Review Draft) http://cfpub2.epa.gov/ncea/cfm/recordisplay.cfm?deid=160548

World Health Organization Toxic cyanobacteria in water: A guide to their public health consequences, monitoring and management http:/fw.Nw.who.intlwater sanitation health/resourcesgualitv/toxicyanbact/en/index.html Cyanobacteria and cyanotoxins in drinking-water http:/fw.Nw.who.intlwater sanitation health/dwg/cyanobactox/en/index.html

Global Water Research Coalition- Water Quality Research ofAustralia International Guidance Manual for the Management ofToxic Cyanobacteria
Canadian Drinking Water Guidance Federal-Provincial-Territorial Committee on Drinking Water http:/fw.Nw.hc-sc.gc.ca/ewh-semt/alt formats/hecs-sesc/pdf/pubs/watereau/cyanobacterial toxins/cyanobacterial toxins-eng.pdf

State Guidance Vermont http:/fw.Nw.anr.state.vt.us/DEC/watersup/forms/AigaiToxinDetections 2009.pdf Washington http:/fw.Nw.doh.wa.gov/ehp/oehas/pubs/334177recauide.pdf http://WNW.doh.wa.gov/ehp/algae/faqs.htm Wisconsin Department of Health Services, Blue-Green Algae www.dhs.wisconsin.gov/eh/bluegreenalgae/ Florida http:/fw.Nw.doh.state.fl.us/environment/medicine/aguatic/pdfs/BG algae FAQ.pdf http://research.myfwc.com/support/view faqs.asp?id=45 Wisconsin Department of Natural Resources http:/fw.Nw.uwsp.edu/cnr/uwexlakes/ecology/Biue-green%20FAQ%202.pdf http://dnr.wi.gov/lakes/bluegreenalgae!WisconsinLakesBGA.pdf 

# Where can 1

.gat m

. ora i:nform

. ati' on?
Ohio Department of Health Bureau of Environmental Health 246 N. High Street Columbus, Ohio 43215 Phone: (614) 466-1390 Fax: {614) 466-4556

Revised 08116/10