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MYCOTOXINS Children's Health and the Environment WHO Training Package for the Health Sector World Health Organization www.who.int/ceh October 2011 TRAINING.

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Presentation on theme: "MYCOTOXINS Children's Health and the Environment WHO Training Package for the Health Sector World Health Organization www.who.int/ceh October 2011 TRAINING."— Presentation transcript:

1 MYCOTOXINS Children's Health and the Environment WHO Training Package for the Health Sector World Health Organization October 2011 TRAINING FOR THE HEALTH SECTOR [Date …Place …Event…Sponsor…Organizer] [Date …Place …Event…Sponsor…Organizer] 1

2 Mycotoxins 2  To understand that exposure to mycotoxins is associated with some diseases in children  To describe routes of exposure to mycotoxins  To consider some of the options for prevention of diseases associated with these toxins LEARNING OBJECTIVES

3 Mycotoxins 3 OUTLINE  Case study  Routes of exposure  Toxin-related diseases  Diagnosis and treatment  The role of climate change  Prevention, remediation, education  Role of the health care provider

4 Mycotoxins of 452 elementary school children in USA became ill 15 minutes after eating school lunch Predominant symptoms: abdominal cramps in 88% vomiting in 62% headache in 62% nausea in 39% WHO CASE STUDY: SCHOOL OUTBREAK

5 Mycotoxins CASE STUDY: HISTORY OF PRESENT ILLNESS  Who else is ill? Many classmates  When did symptoms begin? 12:30 pm today  Where did symptoms start? In cafeteria 5

6 Mycotoxins 6  Illness linked to eating burritos for lunch  What would you do next? ? ? ? CASE STUDY: SCHOOL OUTBREAK

7 Mycotoxins : Because of the short incubation period, each of the following should be considered:  Staphylococcus aureus (preformed toxins)  Bacillus cereus (emetic toxin)  Heavy metals (copper, tin, cadmium, iron, zinc)  Natural toxins (vomitoxin =deoxynivalenol (DON) CASE STUDY: DIFFERENTIAL DIAGNOSIS

8 Mycotoxins 8  Burritos also implicated in 15 other outbreaks in 6 different states  2 million pounds of burritos recalled from two companies CASE STUDY: SCHOOL OUTBREAK

9 Mycotoxins  1700 primary schoolchildren in 6 states developed vomiting 15 minutes to 2 hours after eating lunch at the school cafeteria  Lunch food (burritos) contained 0.3 ppm vomitoxin 9

10 Mycotoxins 10  Both are fungi  Both include some poisonous varieties  Example: Species of Amanita produce poisonous toxins Death may occur 4-7 days after ingestion Mortality rate 5-10% Halshka Graczyk MOLDS AND MUSHROOMS

11 Mycotoxins 11  Myco: fungus  Toxin: naturally-produced poison  Natural products produced by fungi that evoke a toxic response when introduced in low concentrations to higher vertebrates by a natural route  known mycotoxins MYCOTOXINS

12 Mycotoxins 12  Probably a means of protection from insects, microorganisms, nematodes, grazing animals and humans  “Chemical defense system” of the fungi or mold EPA EVOLUTION OF MYCOTOXINS

13 Mycotoxins 13 CHEMICAL AGENTS PRODUCED BY MOLDS Mycotoxins are associated with human disease and cause acute and chronic effects  Mycotoxins  Aflatoxins  Tricothecenes  Ochratoxins and citrinin  Hundreds of others  Glucans (cell wall components)  Volatile organic compounds (irritating) EPA

14 Mycotoxins 14 ROUTES OF EXPOSURE  Eating food or drink containing toxins  Breathing moldy air in damp indoor areas  Dermal absorption EPA Mold growing on a wooden headboard in a room with high humidity

15 Mycotoxins 15 HOW CHILDREN ARE DIFFERENT Short stature Breathe closer to the ground Increased air intake Ongoing lung development WHO

16 Mycotoxins 16  Food poisoning and vomiting (vomitoxin)  Aflatoxicosis (aflatoxin)  Aplastic anemia (bone marrow failure) and bleeding (trichothecenes)  Acute pulmonary hemorrhage  Cancer (aflatoxins)  Birth defects (fumonisins) CONDITIONS LINKED TO MYCOTOXIN EXPOSURES CONDITIONS LINKED TO MYCOTOXIN EXPOSURES

17 Mycotoxins 17 AFLATOXICOSIS  Acute high exposures (Africa, Asia): Vomiting Abdominal pain Hepatitis Death  Lethal dose for adults: mg  Chronic low-dose exposures: Impaired growth

18 Mycotoxins 18 ADVERSE HEALTH EFFECTS Deaths Hospitalizations Visits to Clinic Symptoms Annoyance, Discomfort WHO

19 Mycotoxins 19  Mycotoxicosis in horses first reported in 1931 (Ukraine)  Massive numbers of horses died with gastrointestinal bleeding  Horses ate hay heavily contaminated with Stachybotrys mold ANIMAL EXAMPLE: BLEEDING FROM TRICHOTHECENES

20 Mycotoxins 20 Alimentary Toxic Aleukia (ATA) First appeared in 1913 in far eastern Siberia Responsible for the death of at least 100,000 Russian people between 1942 and 1948 Necrotic ulcers in the mouth, throat, nose, stomach and intestines Bleeding from the nose, mouth, GI tract, and kidneys Associated with eating grains (wheat and corn) which had been under snow the previous winter Grains contaminated with Fusarium and Stachybotrys ANIMAL EXAMPLE: BLEEDING FROM TRICHOTHECHENES

21 Mycotoxins 21 INFANT ACUTE PULMONARY HEMORRHAGE  Emerging data show an association with indoor exposure to moldy home environments  Mycotoxins on surface of spores may lead to capillary fragility  Additional research ongoing Etzel

22 Mycotoxins 22 CANCER  Aflatoxin is a carcinogen (Group 1) Increases risk of hepatocellular cancer  Fumonisins linked to oesophageal cancer International Agency for Research on Cancer Group B2

23 Mycotoxins 23 BIRTH DEFECTS Fumonisins linked to neural tube defects Finding emerged from studies of women who consumed tortillas in Mexico WHO

24 Mycotoxins 24 TOXICITY & BIOLOGICAL EFFECTS OF MYCOTOXINS IN FOODS MycotoxinMajor FoodsSpeciesHealth effectsLD 50 (mg/kg) AflatoxinsMaize, groundnuts, figs, tree nuts (Aflatoxin M 1 (secreted by cow after metabolism of aflatoxin B 1 ), milk, milk products Aspergillus flavus Aspergillus parasiticus Hepatotoxic, carcinogenic 0.5 (dog) 9.0 (mouse) Cyclopiazonic acidCheese, maize, groundnuts, Rodo millet Aspergillus flavus Penicillium aurantiogriseum Convulsions36 (rat) DeoxynivalenolCerealsFusarium graminearum Vomiting, food refusal 70 (mouse) T-2 toxinCerealsFusarium sporotrichioides Alimentary toxic aleukia 4 (rat) ErgotamineRyeClaviceps purpurea Neurotoxin-

25 Mycotoxins 25 TOXICITY & BIOLOGICAL EFFECTS OF MYCOTOXINS IN FOODS MycotoxinMajor FoodsSpeciesHealth effectsLD 50 (mg/kg) FumonisinMaizeFusarium moniliformeEsophageal cancer? OchratoxinMaize, cereals, coffee beans Penicillium verrucosum Aspergillus ochraceus Nephrotoxic20-30 (rat) PatulinApple juice, damaged apples Penicillium expansumEdema, hemorrhage, possibly cancer 35 (mouse) PenitremWalnutsPenicillum aurantiogriseum Tremors1.05 (mouse) SterigmatocystinCereals, coffee beans, cheese Aspergillus versicolorHepatotoxic, cancer 166 (rat)

26 Mycotoxins 26 TOXICITY & BIOLOGICAL EFFECTS OF MYCOTOXINS IN FOODS MycotoxinMajor FoodsSpeciesHealth EffectsLD 50 (mg/kg) Tenuazonic acid Tomato pasteAlternaria tenuisConvulsions, hemorrhage 81 (female mouse) 186 (male mouse) ZearolenoneMaize, barley, wheatFusarium graminearum OestrogenicNot acutely toxic

27 Mycotoxins 27 OTHER CONDITIONS UNDER STUDY  Sick Building Syndrome: Living in moldy indoor environments. Symptoms include:  Fatigue  Headache  Difficulty in concentrating  Many pure microbial toxins have been shown to be neurotoxic in vitro and in vivo such as the products of:  Fusarium (fumonisin B1, deoxynivalenol)  Stachybotrys (satratoxin G)  Aspergillus (ochratoxin A)  Penicillium (ochratoxin A, verrucosidin)

28 Mycotoxins 28 CLIMATE CHANGE AND MYCOTOXINS  Aflatoxins are expected to become more prevalent as climate continues to change  Young children among most vulnerable WHO Enrique Montenegro

29 Mycotoxins 29  Extreme precipitation, storms and floods cause moist conditions that promote fungal growth  Drought weakens seed kernels of plants, allowing greater fungal contamination  Increased temperatures promote fungal growth WHO CLIMATE CHANGE MANY INCREASE EXPOSURE TO MYCOTOXINS

30 Mycotoxins OTHER TOXICANTS OF BIOLOGICAL ORIGIN Ciguatera Shellfish toxins: paralytic neurotoxic diarrhoeic amnesic Pyrrolizidine alkaloids Histamine Toxicant dinoflagellates various toxic plants spoilage bacteria tropical fish shellfish cereals, honey fish, cheese SourceAssociated food

31 Mycotoxins 31 EXAMPLE OF OTHER TOXINS: INCREASE IN SHELLFISH POISONINGS  Heat-resistant toxins produced by algae  Sudden increase ("bloom") in an area  Four distinct syndromes: Paralytic (saxitoxin, gonyautoxin) Diarrhetic (okadaic acid, inophysistoxin) Neurotoxic (brevetoxins) Amnesic (domoic acid)  Paralytic poisoning has high mortality rate

32 Mycotoxins 32 ALGAL INTOXICATIONS ASSOCIATED WITH SHELLFISH SyndromeSymptomsToxinAlgal Species Amnesic shellfish poisoning Choking, vomiting, diarrhoea, incapacitating headaches, seizures, short-term memory loss Domoic acidPseudonitzschia pungens Diarrheic shellfish poisoning Diarrhoea, vomiting, abdominal pain, nausea (may persist for several days) Okadaic acidDynophysis acuta Dynophysis acuminata Dynophysis fortii Neurotoxic shellfish poisoning Paresthesia, reversal of hot and cold temperature sensitivity, myalgia and vertigo (generally mild) brevetoxinsPtychodiscus brevis Paralytic shellfish poisoning Tingling, numbness in fingertips and lips, giddiness, staggering, incoherent speech, respiratory paralysis Saxitoxin gonyautoxin Alexandrium (Gonyaulux) catenella Alexandrium tamarensis

33 Mycotoxins 33 INTERVENTIONS  To reduce airborne exposures to molds: Keep indoor areas dry Fix all leaks and clean up flooding within 24 hours Do not smoke indoors  To reduce foodborne exposure to aflatoxin: Protect agricultural crops from moisture during both growth and post-harvest storage Do not eat grains with visible mold Computer models to predict mycotoxin levels

34 Mycotoxins 34 INTERVENTIONS AFTER FLOODS  Tetanus booster  Food & water safety  Sanitation & hygiene  Power outages  Carbon monoxide  Animal & insects  Cleanup  Mold and mycotoxins  Electrical hazards  Reentering flooded buildings Centers for Disease Control and Prevention

35 Mycotoxins 35 PREVENTION, REMEDIATION & EDUCATION  Protect child and pregnant woman from ingesting or inhaling mycotoxins  Foods (especially grains)  Water-damaged, moldy homes  Folic acid supplements for women  Protect agricultural crops  Growth  Post-harvest  Education  Community leaders  Consumer knowledge WHO

36 Mycotoxins 36 HEALTH BENEFITS OF MYCOTOXIN REDUCTION Aflatoxin Reduction Trichothecenes Reduction Fusarium Reduction Cancer+++ RespiratoryDiseases++ Birth defects + Mental Health + Gastrointestinal Diseases very good evidence, ++ good evidence, + some evidence

37 Mycotoxins 37 OUTCOME EFFECTS Gastrointestinal disease Lung Disease Multi-system illnesses Death or Survival SUSCEPTIBILITIES Critical windows/timing Age Nutritional status Poverty CHILD'S AND ADOLESCENT'S COMPLEX ENVIRONMENTS HAZARDS Biological MEDIA Air - Food SETTINGS Rural/Urban Home School Field Street Workplace ACTIVITIES Eating, Breathing WHO

38 Mycotoxins 38  Do research and publish results  Detect sentinel cases  Inspire community-based interventions  Take history of childhood exposures  Diagnose and treat  Educate  Patients and families  Colleagues and students  Advocate  Provide good role model CRITICAL ROLE OF HEALTH PROFESSIONALS WHO

39 Mycotoxins 39 HISTORYTAKING: POSSIBLE QUESTIONS HISTORY TAKING: POSSIBLE QUESTIONS Foods, home and habits -Eating moldy grains? - Eating shellfish? - Do mother or father smoke tobacco? -Is the home water damaged or moldy? Cultural history Cultural practices Parental work -What is the occupation of mother and father? - Any work with agriculture? Does family grow and store their own grain?

40 Mycotoxins 40 POINTS FOR DISCUSSION

41 Mycotoxins 41 WHO is grateful to the US EPA Office of Children’s Health Protection for financial support that made this project possible and for some of the data, graphics and text used in preparing these materials for a broad audience. Further support was kindly provided by the UK Department of Health. First draft prepared by Ruth A. Etzel, MD PhD (WHO) With the advice of the Working Group Members on the Training Package for the Health Sector: Cristina Alonzo MD (Uruguay); Yona Amitai MD MPH (Israel); Stephan Boese-O’Reilly MD MPH (Germany); Stephania Borgo MD (ISDE, Italy); Irena Buka MD (Canada); Ernesto Burgio (ISDE, Italy); Lilian Corra MD (Argentina); Ligia Fruchtengarten MD (Brazil); Amalia Laborde MD (Uruguay); Jenny Pronczuk MD (WHO) Christian Schweizer TO (WHO/EURO); Kathy Shea MD (USA). Reviewers: Dr Huw Brunt (UK), Prof Gary Coleman (UK), Dr Raquel Duarte-Davidson (UK), Dr Elaine Lynch Farmery (UK), Alison M Good BSc Dip Med Tox MSc (UK), Dr Mark Griffiths (UK), Dr John Thompson (UK), Dr Laura Yates (UK) WHO Project coordination: Ruth A. Etzel, MD PhD Marie-Noël Bruné, MSc Latest update: October 2011 (H. Graczyk, L. Tempesta) ACKNOWLEDGEMENTS

42 Mycotoxins 42 DISCLAIMER  The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.  The opinions and conclusions expressed do not necessarily represent the official position of the World Health Organization.  This publication is being distributed without warranty of any kind, either express or implied. In no event shall the World Health Organization be liable for damages, including any general, special, incidental, or consequential damages, arising out of the use of this publication  The contents of this training module are based upon references available in the published literature as of its last update. Users are encouraged to search standard medical databases for updates in the science for issues of particular interest or sensitivity in their regions and areas of specific concern.  If users of this training module should find it necessary to make any modifications (abridgement, addition or deletion) to the presentation, the adaptor shall be responsible for all modifications made. The World Health Organization disclaims all responsibility for adaptations made by others. All modifications shall be clearly distinguished from the original WHO material.


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