Haff Disease in Salvador, Brazil, 2016-2021: Attack rate and detection of toxin in fish samples collected during outbreaks and disease surveillance

Cristiane Wanderley Cardoso; Monaise Madalena Oliveira E Silva; Antônio Carlos Bandeira; Renan Bispo Silva; Ana Paula Pitanga Barbuda Prates; Ênio Silva Soares; José Jorge Moreno Silva; Lázaro José Rodrigues de Souza; Mirela Maisa da Silva Souza; Marcela Almeida Muhana; Rosildete Silva Santos Pires; José Fernando Araujo Neto; Manuela Sampaio Souza Santos; Luiz Laureno Mafra Junior; Thiago Pereira Alves; Mathias Alberto Schramm; Guilherme Sousa Ribeiro

doi:10.1016/j.lana.2021.100092

Haff Disease in Salvador, Brazil, 2016-2021: Attack rate and detection of toxin in fish samples collected during outbreaks and disease surveillance

Lancet Reg Health Am. 2021 Nov 1:5:100092. doi: 10.1016/j.lana.2021.100092. eCollection 2022 Jan.

Authors

Cristiane Wanderley Cardoso¹, Monaise Madalena Oliveira E Silva², Antônio Carlos Bandeira³, Renan Bispo Silva², Ana Paula Pitanga Barbuda Prates¹, Ênio Silva Soares¹, José Jorge Moreno Silva¹, Lázaro José Rodrigues de Souza¹, Mirela Maisa da Silva Souza¹, Marcela Almeida Muhana¹, Rosildete Silva Santos Pires¹, José Fernando Araujo Neto³, Manuela Sampaio Souza Santos³, Luiz Laureno Mafra Junior⁴, Thiago Pereira Alves⁵, Mathias Alberto Schramm⁵, Guilherme Sousa Ribeiro^{2

6}

Affiliations

¹ Secretaria Municipal de Saúde de Salvador, Salvador, Brazil.
² Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.
³ Secretaria de Saúde do Estado da Bahia, Salvador, Brazil.
⁴ Centro de Estudos do Mar, Universidade Federal do Paraná, Pontal do Paraná, Brazil.
⁵ Instituto Federal de Santa Catarina, Campus Itajaí, Itajaí, Brazil.
⁶ Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.

Abstract

Background: From late 2016 to early 2021, cases of Haff disease, a rare cause of rhabdomyolysis, possibly due to poisoning by palytoxin-like compounds in seafood, were detected in Salvador, Brazil. Surveillance was established to detect additional cases aiming at describing the clinical characteristics of the cases, identifying associated factors, estimating disease attack rate, and investigating the presence of biotoxins and trace metals in selected fish specimens obtained from cases.

Method: Between December/2016-January/2021, surveillance investigated Haff disease suspected cases, and obtained clinical and fish samples to test.

Findings: Of 65 cases investigated during the 2016-2017 outbreak, 43 (66%) had high creatine phosphokinase (CPK) levels. Among those with laboratory-confirmed rhabdomyolysis, 38 (88%) were hospitalized, 11 (26%) required intensive care, and three (7%) dialysis. Ingestion of marine fish 24h before disease onset was reported by 74% of the cases with elevated CPK and by 41% of those without CPK measurement (P=0·02). Attack rate for individuals who ate fish related to the outbreak was 55%. Following this outbreak, surveillance identified 12 suspected cases between 2017-2019, and a second outbreak in 2020-2021, with 16 laboratory-confirmed rhabdomyolysis patients (five required intensive care; one died). No traces of ciguatoxins and metals were detected in fish specimens obtained in 2016, found to be Seriola rivoliana. Some fish samples from 2020 were screened for palytoxin (PlTX)-like compounds and contained detectable levels of molecule fragments characteristics of isobaric PlTX, ovatoxin-a (OVTX-a), OVTX-b and OVTX-d.

Interpretation: These findings support the hypothesis that compounds related to PlTX accumulated in marine fish may be the toxic agent causing the disease. Haff disease is a life-threatening condition, requiring clinical suspicion for patients with sudden-onset myalgia following fish ingestion. Suspected cases should be reported to health authorities for investigation.

Keywords: Haff disease; Rhabdomyolysis; epidemiology; foodborne disease; global health; outbreak; palytoxin; public health; surveillance.