Bureau of· 

Environmental Haalt.h 

Health Asseasment Section 

"To proiBct and Improve the health of all Ohloana" 

The~ Publilc Hlealth 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 

contad with HAS-contaminated water. Several of Ohio'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 other faders, 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 of microcystin, anatoxin-a, cylindrospermopsin and saxitoxin. Both humans and animals can 

experience illness from exposure to these toxins during recreational activities and other water uses. 

with cyanobacteria or toxins 

Skin contact 'With water 

contaminated with 

cyanobacteria or toxins 

or contact 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 

Motor weakness 

Dennal toxlna 

(Lyngbyatoxins, lipopolysaccharide 

endotoxins) 

Rash, hives 

Skin blistering 

Minutes to hours 

other microbial infections/toxins 

Viral hepatitis 

Viral Gastroenteritis 

Hepatotoxic drug ingestion 

(acetaminophen) 

poisoning 

other dermal allergens. 

non-allergic urticaria, 

photosensitivity reactions 

Upper respiratory initation UnknOYm, but other airborne allergens, upper 

Rhinitis likely an acute respiratory infection, flu 

or toxins Possible reaction reaction 

* Symptom onset times are primarily extrapolations from laboratory animal data and events. 
Dila.gnosi:s a.nd L.ab Testi:ng: 

Currently there is no laboratory diagnostic testing which can confirm the presence of cyanotoxins 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 Defin1i:ti:on: 

CDC case definition summary for selected toxins (for complete description see CDC Proposed 

Case Definitions for Algal Toxin-related Diseases) 

• Suspect Case Exposure to water with a confirmed algal bloom AND onset of associated signs 

and symptoms within a reasonable time after exposure AND without identification of another 

cause of illness. 

• Probable Case Meets criteria for Suspect Case AND there is laboratory documentation of a 

HAB toxin(s) in the water. 

• Confirmed Case Meets criteria for a Probable Case combined with professional judgment 

based on medical review. 

Freshwater Type of Toxin Causative organism Vector 

Cyanotoxins 

Anatoxin-a Neurotoxin Anabaena spp. Contaminated 

Aphanizomsnon spp. fresh water 

Planktothrix spp. 

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 

Planktothrix spp. 

Saxitoxins Neurotoxin Anabaena circinalis Contaminated fresh water 

Lvnabva wollei 

Treatment and Patient MJanagement: 

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 refer to the following links for more information regarding Harmful 

Algal Blooms: 

> Ohio Department of Health (ODH) Bureau of Environmental Health (BEH) Blue-Green Algae 

Fact Sheet: 

www.odh.ohio.gov/ASSETS/5C9F74E704F5459885200FC9A 1 EBDOD8/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 

HJAB Case Reoort.ln1gl Raqulram;an1ts: 

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 under Class C - .. waterborne disease outbreaks; report 

single cases of toxin poisoning associated with exposure to water with a confirmed algal bloom by the 

end of the 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 submit the HAB-related human illness 

form to the local health district where the ill individual resides. 

WHEN must a report be made? Class C - must be sent by the end of the next business day to 

the local public health department. 

WHERE must the report be made? Healthcare providers should send the case information to 

the local health jurisdiction where the patient resides. A listing of local 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-%2008-06-201 O.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 of Australia 

International Guidance Manual for the Management of Toxic 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