Ciguatera fish poisoning outbreaks from 2012 to 2017 in Germany caused by snappers from India, Indonesia, and Vietnam

Ciguatera fish poisoning (CFP) is the most common fish intoxication worldwide. It is caused by ciguatoxins produced by tropical, benthic and epiphytic microalgae in the genera Gambierdiscus and Fukuyoa. These potent neurotoxins accumulate in the food chain reaching their highest concentration in tropical fish and invertebrates. In addition to gastrointestinal symptoms, cold allodynia and other neurologic signs are characteristic of ciguatera. In continental Europe, most cases were linked to vacation trips to tropical areas. The first outbreak in Germany was documented in 2012. The objective of this study is to document ciguatera outbreaks in Germany associated with imported tropical fish. Reports by physicians and the German Public Health Service to the German Federal Institute for Risk Assessment (BfR) were collated and evaluated for symptoms consistent with CFP. Data of molecular identification of the fish, as well as toxicity data from meal and batch remnants, were provided where possible to substantiate ciguatoxins as the causative agent. A series of six outbreaks were registered in Germany between 2012 and 2017. Fourteen of the 65 patients were hospitalised. All German outbreaks were caused by snappers (Lutjanidae) imported from India, Indonesia and Vietnam. Though ciguatera remains a rare disease in Germany, physicians should be aware of it, and appropriate preventive strategies should be established. Reporting of CFP in fish importing countries may contribute to improve regional public health strategies in the affected fish exporting countries and reduce chances of exporting ciguatoxic fish. This article proves that fish from the Indian Ocean can cause ciguatera, which has been poorly documented previously.