Vibrio and Aeromonas species isolated form marine mammals, seabirds found sic on the beaches alond the coast of Rio de Janeiro state, southeastern Brazil.
\r\n\tIn sum, the book presents a reflective analysis of the pedagogical hubs for a changing world, considering the most fundamental areas of the current contingencies in education.
",isbn:"978-1-83968-793-8",printIsbn:"978-1-83968-792-1",pdfIsbn:"978-1-83968-794-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"b01f9136149277b7e4cbc1e52bce78ec",bookSignature:"Dr. María Jose Hernandez-Serrano",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10229.jpg",keywords:"Teacher Digital Competences, Flipped Learning, Online Resources Design, Neuroscientific Literacy (Myths), Emotions and Learning, Multisensory Stimulation, Citizen Skills, Violence Prevention, Moral Development, Universal Design for Learning, Sensitizing on Diversity, Supportive Strategies",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 14th 2020",dateEndSecondStepPublish:"October 12th 2020",dateEndThirdStepPublish:"December 11th 2020",dateEndFourthStepPublish:"March 1st 2021",dateEndFifthStepPublish:"April 30th 2021",remainingDaysToSecondStep:"4 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Phil. Maria Jose Hernandez Serrano is a tenured lecturer in the Department of Theory and History of Education at the University of Salamanca, where she currently teaches on Teacher Education. She graduated in Social Education (2000) and Psycho-Pedagogy (2003) at the University of Salamanca. Then, she obtained her European Ph.D. in Education and Training in Virtual Environments by research with the University of Manchester, UK (2009).",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"187893",title:"Dr.",name:"María Jose",middleName:null,surname:"Hernandez-Serrano",slug:"maria-jose-hernandez-serrano",fullName:"María Jose Hernandez-Serrano",profilePictureURL:"https://mts.intechopen.com/storage/users/187893/images/system/187893.jpg",biography:"DPhil Maria Jose Hernandez Serrano is a tenured Lecturer in the Department of Theory and History of Education at the University of Salamanca (Spain), where she currently teaches on Teacher Education. She graduated in Social Education (2000) and Psycho-Pedagogy (2003) at the University of Salamanca. Then, she obtained her European Ph.D. on Education and Training in Virtual Environments by research with the University of Manchester, UK (2009). She obtained a Visiting Scholar Postdoctoral Grant (of the British Academy, UK) at the Oxford Internet Institute of the University of Oxford (2011) and was granted with a postdoctoral research (in 2021) at London Birbeck University.\n \nShe is author of more than 20 research papers, and more than 35 book chapters (H Index 10). She is interested in the study of the educational process and the analysis of cognitive and affective processes in the context of neuroeducation and neurotechnologies, along with the study of social contingencies affecting the educational institutions and requiring new skills for educators.\n\nHer publications are mainly of the educational process mediated by technologies and digital competences. Currently, her new research interests are: the transdisciplinary application of the brain-based research to the educational context and virtual environments, and the neuropedagogical implications of the technologies on the development of the brain in younger students. Also, she is interested in the promotion of creative and critical uses of digital technologies, the emerging uses of social media and transmedia, and the informal learning through technologies.\n\nShe is a member of several research Networks and Scientific Committees in international journals on Educational Technologies and Educommunication, and collaborates as a reviewer in several prestigious journals (see public profile in Publons).\n\nUntil March 2010 she was in charge of the Adult University of Salamanca, by coordinating teaching activities of more than a thousand adult students. She currently is, since 2014, the Secretary of the Department of Theory and History of Education. Since 2015 she collaborates with the Council Educational Program by training teachers and families in the translation of advances from educational neuroscience.",institutionString:"University of Salamanca",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Salamanca",institutionURL:null,country:{name:"Spain"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"23",title:"Social Sciences",slug:"social-sciences"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"301331",firstName:"Mia",lastName:"Vulovic",middleName:null,title:"Mrs.",imageUrl:"https://mts.intechopen.com/storage/users/301331/images/8498_n.jpg",email:"mia.v@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"6942",title:"Global Social Work",subtitle:"Cutting Edge Issues and Critical Reflections",isOpenForSubmission:!1,hash:"222c8a66edfc7a4a6537af7565bcb3de",slug:"global-social-work-cutting-edge-issues-and-critical-reflections",bookSignature:"Bala Raju Nikku",coverURL:"https://cdn.intechopen.com/books/images_new/6942.jpg",editedByType:"Edited by",editors:[{id:"263576",title:"Dr.",name:"Bala",surname:"Nikku",slug:"bala-nikku",fullName:"Bala Nikku"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophanides",surname:"Theophile",slug:"theophanides-theophile",fullName:"Theophanides Theophile"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"38588",title:"Marine Environment and Public Health",doi:"10.5772/48412",slug:"marine-environment-and-public-health",body:'The oceans represent a significant source of biological diversity, water, biomass, oxygen, and other important aspects to human health [1-3]. The quality of the ocean is essential for maintaining the planet, and thus to public health. However, the complex and fragile evolutionary stabilization of the ocean and coastal regions has been disrupted by human activities in a short time scale [4]. The vast majority of waste produced by human activities for centuries has reached the oceans, even over long distances and in inhospitable places [3, 5]. In recent decades there have been evident the vast scope of the changes of the marine environment caused by anthropogenic activities, as well as the many responses to these changes that tend to impact ecological processes, putting endangered species susceptible and producing various diseases in the human population [3, 6]. These changes are not restricted to oceanic scale, but are strongly associated with the continents, consequently, strong pressure on the health of terrestrial ecosystems, with impacts on socioeconomic and cultural activities and, finally, to public health. Recently, the trend has grown to incorporate the term health within the definitions of environmental health. The term health of the oceans, the second definition of the Panel on Health of the Oceans (HOTO/GOOS), refers to the condition of the marine environment from a perspective of adverse effects caused by anthropogenic activities, in particular: habitat destruction, changes in the proportion of sedimentation, mobilization of contaminants and climate changes [7, 8].
Indeed, the human utilization of ocean environment has negatively and extensively impacted the ecological system that people are connected. The human activities in coastal zones, such as agricultures, urban development, fisheries, coastal industries and aquacultures, have contributed to chemical, physical and ecological impacts that may be interconnected [8, 9]. For example, the human activities cited generate a significant input of chemical pollutants (e.g. metals, persistent organic pollutants, nanoparticles, radionuclides and nutrients) that is known to impact the biodiversity and the marine ecological system [3, 10].
Marine microbiological pollution represents an expressive impact on biodiversity and human health. The microbiological activity in coastal environment can result in direct impact in human health, but can trigger the biodiversity loss, degradation of ecosystem function and impact in recreation, tourism and human wellbeing [1, 2, 6, 11, 12]. Marine pollution, such as nutrients input, runoffs, and regional and international navigation by ships can load new pathogens to the environment, and the climate change may exacerbate their effects and establishment in an area. For example, the oceans have been identified as the source of introduction of Vibrio cholerae that resulted in outbreaks in South America [11, 13]. Potential pathogens from the Family Vibrionaceae and Aeromonadaceae have been frequently identified in coastal humans and marine top predators. It is important to highlight that pathogens of these families are not associated with fecal contamination [1, 3].
The current scenario on the conservation of the oceans has been reflected in numerous human diseases related to marine life. The relationships of the oceans to human activities and public health is already consensus; however, its mechanisms are not well understood due to its complexity. These relationships include the focus on climate change, toxic algae poisoning and chemical and microbial contamination of marine waters and fish (Figure 1) [4, 14, 15].
The marine environment provides valuable benefitsfor human activities, including protein sources and economic activity through fisheries, aquaculture and navigation. Furthermore, there are the economic benefits from tourism, culture, biomedicine, recreation activities and renewable energy [4, 16]. The oceans represent a great source of biodiversity and play a vital role in water and biogeochemistry cycle. Other human benefits from the oceans are clear, and important for human wellbeing, such as artistic inspiration, increased physical activity and therefore fitness, reduced levels of stress and simply the harmony as a result of healthy oceans and their stable biodiversity [3].
The relationship between public health and the health of the oceans are also growing due to increasing number of people living in coastal areas, mainly in tropical and subtropical regions [1, 3, 4]. In these regions, increases vulnerability to social and environmental stability resulting from natural disasters that involve the ocean and health. It is estimated that world population has reached 6.6 billion in 2007, with a projected growth to 9.3 billion by 2050, developing countries are primarily responsible for this increase [17]. Approximately 65% of the human population lives within 159 km of shoreline with growth estimated at 75% for 2025. In coastal regions the oceans remain an important source of protein, quality of life, recreation, and are an integral part of economic activities in various localities [6, 18].
Coastal residents are highly vulnerable to climate variability and extreme events. As an example, the event of a tsunami in Indonesia has caused at least 175,000 deaths in 2005. In addition to the physical impacts on the health effects of these events, epidemics occur frequently due to the favorable conditions that follow extreme phenomena, and that end up being magnified by the conditions of social and environmental vulnerability of affected populations [4]. Various infectious agents found in marine hosts including bacterial, viral and protozoan result in infectious diseases in humans [19]. The effects of climate and temperature on disease vectors, such as the growing prevalence of malaria following El Niño events also have been suggested [20].
Schematic illustration of the anthropogenic pressures impacts (A) of the marine environment (B) and the subsequent result of the marine biodiversity alterations (e.g. pathogens, HABs) (C) on human health and biodiversity, wellbeing and socioeconomic relationships.
The oceans play an extreme important role in the climate by the storage and transportation of heat around the globe. The interaction of the ocean currents and atmospheric winds operate regulating the climate. The marine ecological processes are dependent of the variation of the temperature, as the availability of nutrients that is associated with this factor, and tend to maintain the ecologic stability [4]. An example of an extreme inter-annual variability is the El Niño Southern Oscillation (ENSO).
ENSO is a semi-periodic variability of the inter-annual climate cycle that occurs in intervals of 2-7 years as a result of the discontinuity of the up-welling system in the eastern Equatorial Pacific, forced by the change in wind pattern [20, 21]. The ENSO results in changes in the oceanic temperature and in the atmospheric pressure in the Pacific basin. However, the impacts of the ENSO are not limited to the Pacific Basin, but can influence many continental and marine regions around the globe by changing the atmospheric circulation that disturb temperature and precipitation pattern, resulting in extreme periods and intensity of drought and heavy rains in different areas [20].
Climatic variations triggered by El Niño events are associated with ecosystem changes that results in impact on public health. These climate variations influence the population density and dispersal pattern of vectors, for example, mosquitoes and rodents, which tend to cause infectious diseases in epidemic proportions, such as malaria, dengue and hantavirus[20, 22, 23]. In addition, other diseases such as leishmaniasis and cholera outbreaks have often been associated with this climatic event [23].
Besides the problems related to ENSO events, other extremes events such as drought, have more insidious effects on health for the loss in agricultural production and, consequently, for severe nutritional disorders [4]. Therefore, it is not only direct impacts, but also because it tends to aggravate the socioeconomic structure of the societies affected, causing an amplification of the impacts on public health. In cases of drought triggered by climate variations associated with ENSO forests tend to become more vulnerable to fires, resulting in the massive loss of biodiversity and respiratory diseases linked to poor air quality [22].
The occurrence of El Niño in 1997-1998 resulted in the deaths of more than 21,000 people in 27 countries around the world. Altogether, 117 million people were affected. The occurrence of morbidities as a result of the pressures of these phenomena have affected around 540,000 people, while 4.9 million people were displaced from their homes, becoming homeless [24].
Like the variations, understood as an intrinsic property of the climate system, responsible for natural variations in the patterns observed in geographical scales, global climate changes occur due to temperature rise caused by anthropogenic emissions of greenhouse gases during decades.
Global climate change may have both direct and indirect effects on public health [1, 25]. The greenhouse gases, naturally present in low concentrations in the atmosphere keep the earth’s average temperature around 15°C. Without this mechanism of regulation of the global atmospheric temperature, the Earth\'s average could be -18°C and the planet would freeze, preventing the extensive existing biodiversity [26]. However, the anthropogenic release of greenhouse gases has increased the global temperature resulting in catastrophic effects on human and environmental health, while causing socioeconomic and cultural upheavals [27].
Focusing on disorders caused by the effects of climate change in the long term in the oceans, the Intergovernmental Panel on Climate Change (IPCC) points as main influences the level rise of the oceans, the global temperature increase, the varying levels of salinity, the changes in the circulation of water masses, the decreasing concentration of oxygen, the sea level rise, and probable increase in intensity and frequency of hurricanes and cyclones [28].
One of the most discussed of global warming on the oceans is increasing the sea level. This can have catastrophic effect of introducing salt water into fresh water systems in the continent, affecting the quality and availability of this for consumption [1]. Moreover, according to the fourth IPCC report [28], there is observational evidence that an increase in the number of tropical cyclones in the North Atlantic, which began around 1970, is associated with increased surface temperature of the sea. Global warming may also promote changes in the general pattern of fecal-oral infections and foodborne illness. It is hoped that the wide geographic distribution (by both the altitude and latitude) of organisms that transmit disease (vectors) not only increase the potential for transmission, but also change the dynamics of the life cycle (e g, reproduction, survival and potential of infection) of vectors of parasitic infectious organisms [23, 25, 26, 29].
The imbalance in ecological relationships, due to climate change may alter the natural mechanisms of control of vectors and their host organisms, and populations of parasites. In addition, more frequent droughts and rising sea levels may force human populations to migrate to areas where infectious organisms are located, but that currently produce little impact on people. Additional effects include impacts of global change on agriculture, reductions in the ozone layer, economic impacts and increased vulnerability to disease and malnutrition. The many effects of climate change will affect all life forms on Earth, including all its biodiversity and ecological processes.
Due to the increasingly human populations residing on coastal regions, extreme events such as tsunamis, tornadoes, cyclones, storms and floods tend to mobilize international public attention due to increased social vulnerability [18, 30, 31]. Extreme events of the same magnitude and similar characteristics, impact differentially the different population groups depending on their level of vulnerability [1, 3, 4, 32]. While the rich industrialized nations suffer most from economic loss as a consequence to natural disasters, the poor and developing countries often suffer from extensive loss of life, incidence of diseases, and loss of social and physical structures [30]. An example is the Indian Ocean tsunami event in 2004, which triggered a series of tsunamis responsible for approximately 220,000 deaths, Indonesia being one of the countries most affected with more than 400,000 homeless.
Natural disasters force a temporary condition of people living in crowded conditions with poor sanitation, poor management of human waste, impoverished nutrition, and incidence of waterborne diseases, low immunity and susceptibility to infectious diseases such as pneumonia, cholera, dengue, malaria, addition of trauma resulting from the magnitude of the events [32]. In addition, extreme events can also interfere in the continuity of health services due to impacts on infrastructure, or force changes of priority in health policies. Some infectious diseases may be aggravated by malnutrition or hunger-related as a result of human migration. Recent studies show that the destructive power of hurricanes has grown around the world, dramatically raising its frequency in the last two decades in the Atlantic [33, 34]. Often the ability to anticipate and respond to natural disasters is based on understanding of climate systems, which depend on the complex interaction of the atmosphere, the continents and oceans. However, usually the main importance is focused on developing and improving measures to prevent population to environmental extremes, there is a need to improve the socioeconomic conditions in order to reduce these impacts.
The Brazilian coast present 8,698 kilometers long of extension, covering about 514,000 square kilometers. The heterogeneity and vulnerability of this coastal region is obstacle for environmental management, principally due to the proportion of the population living in this environment (18%). As an example, 16 out of 28 metropolitan regions in Brazil are located along the coast. Coastal erosion is particularly a phenomenon that results in an elevated risk to the large number of people inhabiting coastal areas along the Brazilian coast [35, 36]. Despite of the widespread range or coastal eroded regions, the configuration of the magnitude of the disasters are not equally distributed. Environmental influences (e.g. wind, wave and wave partners and trends) have been identified as the developer to seashore erosion, but human intervention in the morphodynamic of river mouth or sedimentary flux has influenced such disasters. In Atafona beach, São João da Barra (northern coast of Rio de Janeiro state) the coastal erosion has dramatically impacted the region [37]. The landward advance of the sea has already caused several consequences for local residents, including habitation loss, economical impacts, and historic and touristic impairments. In places where before there were houses and streets, and an established local commerce, is now part of coastal water or shows a scenario of destruction: about 400 houses in 16 blocks away have been demolished by the power of the waves (Figure 2). Atafona is located at the south side of the Paraíba do Sul River, the main river of the Rio the Janeiro state. The environmental variables and anthropogenic influences are thought to trigger the disasters that have been observed since 1950 [37]. The reduction of the fluvial discharge, as result of the human activities along Paraíba does Sul River, has contributed to the degradation of the coastal zone in Atafona. The sea level rise triggered by the climate change probably may influence increasing the impact in the coastal.
Images showing the coastal erosion caused by the sea energy in Atafona, São João da Barra, northern Rio de Janeiro state, Brazil. Downloaded from: http://viafanzine.jor.br/site_vf/pag/1/na_terra_fotos.htm
The toxins produced by toxic algal blooms (HAB - Harmful Algal Bloom) have the ability to bioconcentrate through the food chain. Therefore, humans, like many other animals that occupy the highest scales of this chain are vulnerable to the adverse effects of these toxins [3, 38]. The greatest risk of poisoning and gastrointestinal infections are linked to sea food consumption, especially of bivalve mollusks (mussels and oysters), because they are filter feeders, which makes these organisms accumulate large amounts of HABs. Bathers are also exposed to the effects of blooms of toxic algae by ingestion and inhalation of "spray" produced by the action of breaking waves containing HABs [39].
Worldwide, sea weed toxins have been associated with cases of human poisoning and animals fatalities [38, 40]. Moreover, massive blooms of toxic and nontoxic algae can cause sharp decrease of oxygen (hypoxia) in place of occurrence, resulting in massive death of marine life and affecting recreation, fish commerce, tourism and public health [38]. From 5000 species of phytoplankton, about 300 occur in massive blooms and slightly more than 80 are known to be toxic [3, 41]. The HAB species are classified as toxin producers (can contaminate sea food or kill fish) and as high biomass producers (can cause hypoxia or anoxia and die off of marine life, when reach high concentrations) [42]. The “toxic producers” HAB species can cause shellfish poisonings and potential impacts on public health, and the “high biomass produces” are thought to promote massive mortalities of fish and reductions in yields in deteriorated environments.
Some blooms of toxic algae can persist in the environment due to the inhibiting power of the toxins on the growth of other phytoplankton species, or reduce the predation of zooplankton. The human poisonings caused by exposure to HABs cause serious problems to human health, which can lead to death or produce sequels. However, it is not uncommon physicians in coastal regions, where most cases occur, erroneously diagnose the symptoms of poisoning, or attributed other factors to them [43]. In addition, there is evidence that colorectal cancer is strongly associated with the ingestion of biotoxins produced by marine microalgae through the consumption of bivalve mollusks [44]. There are five recognized types of poisoning caused by ingestion of HAB: paralytic shellfish poisoning (PSP), neurotoxic shellfish poisoning (NSP), diarrheic shellfish poisoning (DSP), amnesic shellfish poisoning (ASP) and ciguatera poisoning (CFP) [1, 3, 4, 6, 38, 39]. Different from the other four types of HAB poisoning the CFP is caused by the ingestion of reef fishes contaminated by toxins produced by dinoflagellates. Therefore the toxin can enter in the food chain and impact top predators, such as humans [42].
Although there is record of HABs before the transformation of coastal ecosystems by anthropogenic activities, in recent decades has increased dramatically the number of problems associated with HABs around the globe. However, part of this growth is associated with the growth of environmental monitoring. A potential route of spread of these organisms lies in the transport of ballast water in ships. In addition, bivalve mollusks commercially introduced for aquaculture in the countries can also carry the organism in various ways [45]. Global environmental changes such as the destruction of reefs, nutrient enrichment of coastal waters by nitrogen and phosphorus, as well as global climate change, may serve to explain the increase of red tides reported worldwide, as well as the growth of human diseases related with exposure to marine toxins or associated with the events. Also, cholera outbreaks have been associated with HABs from the knowledge that marine copepods are capable of carrying the bacteria Vibrio cholerae, feed of algal blooms. Therefore, these blooms can lead to spread of cholera and outbreaks associated with the frequency of flooding and extreme events [46]. Shuval [40] estimated that marine biotoxins associated mainly with blooms of toxic algae cause an estimated 100,000 to 200,000 cases of severe poisoning annually worldwide and approximately 10,000 to 20,000 deaths and a similar number of very severe cases with neurological sequel, such as paralysis. Furthermore, HABs events can produce mass deaths of marine organisms and cause heavy economic losses, mainly in the extractive fishing, aquaculture and tourism [1, 4, 43].
In Brazilian coastal water, toxic algae bloom has caused impacts on biodiversity and resulting economic impairment, principally on aquaculture and fishery activities. In Baía de Todos os Santos, Bahia state (Brazilian coast), a massive mortality of fishes and shellfishes was registered in 2007. About 50 tons of fishes and shellfishes were killed, which resulted in negative consequences for fisheries and aquaculture, due to the prohibition to commercialize organisms for consumption from this contaminated area. Similarly, in Florianópolis, Santa Catarina state, southern Brazil, an harmful algal bloom of pseudo-nitzschia were identified, resulting in a preventing official measure to protect the population against the effect caused by the event. Despite the identification of harmful algal blooms in coastal regions of Brazil and their association with impacts on biodiversity, few studies have focused to understand the impacts on human health. However, cases of human death have been registered associated with consumption of water from reservoirs with bloom of cyanobacteria potentially hazardous.
A drastic epidemic gastroenteritis outbreak was registered in Itaparica, region of Bahia State associated with the flooding of a Dam reservoir in 1988. From about 2,000 gastroenteritis cases identified, 88 resulted in death along a period of 42 days. Bacterial, toxicological and virological analises were conducted in fecal and blood samples from the patients, and drinking water was examined for microorganisms and metals. Clinical results were also reviewed to understand and identify the etiologic agent. The laboratory analyses indicated that the source of the epidemiology was water from the Dam, which revealed the presence of high concentrations of toxin produced by cyanobacteria (genus Anabaena and Microcystis). The cases of infectious disease were restricted to the areas supplied by drinking water from the dam. Also in 1996, 54 fatalities were recorded in Caruaru (Pernambuco state, northeastern Brazil) in hospitalized patients with chronic renal failure. During hemodialysis sessions, the patients received untreated water contaminated with cyanobacteria.
The microbiological activities are of great importance for many ecological processes in the marine ecosystem. Their functions are essential for the maintenance of biogeochemical cycles required for the maintenance of life [48]. Marine ecosystem provides a natural habitat for a range of microbial pathogens such as bacteria, viruses and parasites. Some pathogens inhabit the water, while other can live attached to particles or inside of marine organisms.
High concentrations of these microbes within coastal waters should indicate that the water or even seafood may be contaminated by human waste [1, 49]. However, the use of indicator microbes to test the quality coast waters for recreation and sea food consumption has been questioned, particularly in the subtropical and tropical marine environments, mainly in areas with no point source of contamination identified [1, 50]. An example is bacteria species from the families Aeromonadaceae and Vibrionaceae that are naturally inhabitants of the marine environments. Many species of this family are not related with fecal contamination of coastal waters; therefore, the use of enteric bacteria as indicators of microbiological water quality is strongly limited [1, 50]. Vibrio species, especially V. cholerae, V. parahaemolyticus, and V. vulnificus, are frequently associated with infectious diseases through the ingestion of shellfish or even fish [42, 50, 51]. Vibrio and Aeromonas species are clinically important for humans and biodiversity health, causing gastroenteritis of infections through the open wounds resulting in septicemia. A large number of people worldwide have been impacted by the infections of pathogenic microbes in coastal waters. More than 170 million cases of respiratory and enteric impairments associated with recreation and seafood consumption coastal waters contaminated with infectious microbes have been reported [52]. In the United States (USA) 33% of shellfish harvesting waters are impacted by micropathogens. Currently, 62% of the coastal beaches of the Rio de Janeiro state (Brazil) are classified as inappropriate for recreation, principally due to contamination with fecal bacteria. In addition, 20,300 recreational beach warnings were reported in USA in 2008 due to the fecal microbe presence in coastal waters [53].
In Table 1 we present some results of bacteriological surveys (Aeromonadaceae and Vibrionacea species) that have been carried out with many specimens of marine mammals, seabirds and sea turtles from Brazilian coast. The microbiological samples were collected during a long term beach monitoring program for research and conservation of marine mammals, seabirds and sea turtles. This monitoring program has been conducted since 1999 by the GEMM-Lagos from the National School of Public Health (ENSP/FIOCRUZ). The bacteriological analyses were conducted in the National Reference Laboratory for Bacterial Enteroinfections (LRNEB) from the Oswaldo Cruz Institute (IOC/FIOCRUZ).The samples were collected through the sterilized swabs introduced carefully in the mouth, eyes, nostrils, genital slit, anus and open wounds of sick or recently dead animals. Twenty species of bacteria were detected in the animals sampled, five and 15 belonging to the family Aeromonadaceae and Vibrionaceae respectively. The most prevalent microbial species at the marine animals sampled were Vibrio alginolyticus and Aeromonascaviae, both representing 69% of detection. Green sea turtle (Chelonia mydas), Guiana dolphins (Sotalia guianensis) and Kelp gull (Larus dominicanus) presented 65, 45 and 35% of the 20 species of bacteria found in the analyses, respectively.
Interestingly, the three more affected species share the same habitat preferences. Both marine species are commonly observed in coastal waters of Rio de Janeiro state and prey on coastal marine food. Kelp gull are commonly found in high density consuming rest of human food at the beach, and coastal dead fishes. It is important to highlight that humans are exposed to the feces of this bird during recreation on the beach. All green sea turtles sampled were juveniles and use coastal waters mainly to eat sea algae. Many specimens have been found sick and associated with the ingestion of marine debris [54, 55]. Guiana dolphins use coastal estuarine waters where they prey on fishes, squids and shrimps. The most important conservation problems of the species is the accidental mortality in fishing nets, but persistent pollutants seems to be also a problem for the conservation of this species [10, 56, 57]. Simultaneous occurrence of different species isolated were observed in the species sampled what could revels the possibility of synergic actions. Considering that these bacteria are recognized as emergent pathogens, and the relevance of the findings for public health in light of the growing area of “ocean and human health” we would like to emphasize the importance of this investigation, which indicates the aquatic environment as a possible route of transmission among marine biota, which includes humans. Aquatic animals are prone to bacterial infections in the same way as land animals, especially when they are under stress condition. Disease may occur systemically or be confined to external surfaces such as the skin or gills specially by pathogenic bacteria which are ubiquitous in the environment, or may form part of the normal internal bacterial flora of an aquatic animal [51].
In the marine ecosystem, the distribution of a viral or bacterial pathogen is directly determined by its virulence, as well as the number of susceptible hosts available. This balance between pathogen and host generates and maintains the variety of both groups. In some occasions, this delicate and normal relationship breaks, mainly due to the forces of aggression on the environment or environmental imbalances, resulting in the abundance of pathogens and increased vulnerability on marine biodiversity and public health [48]. Physical, chemical and biological marine environment may influence the number and diversity of marine microbes. However, Wang et al. [58] observed that high levels of organochlorine pollutants have been found in the tissues of Hong Kong’s cetaceans, this class of chemical can cause immunosuppression, with an increased vulnerability to bacterial infections. Aquatic mammals are animals sensitive to changes in their habitat and for that reason considered excellent health indicators in environmental monitoring programs.
Ingestion of inadequately cooked seafood exposes people to parasitic infections, particularly with anisakids and cestodes, which reports increase of parasitic contamination in shellfish from polluted waters [1, 59]. In addition, many studies have shown human pathogens emerging in the marine environment and associated with infectious diseases in marine mammals exposed to polluted waters including: giardiasis, papillomavirus, brucellosis, lobomycosis, toxoplasmosis, etc.[60, 61].
Shuval [40] estimated that each year about 2.5 million clinical cases of hepatitis infections occur globally, with about 25,000 deaths and 25,000 cases of liver deficiencies associated with consumption of contaminated seafood, especially mussels. Moreover, this author estimated an overall economic impact of 7.2 billion per year associated with these conditions. Iwamoto et al. [62] showed the report to CDC during 1973 to 2006, 188 outbreaks of seafood-associated infections, causing 4,020 illnesses, 161 hospitalizations, and 11 deaths, were reported to the Food-Borne Disease Outbreak Surveillance System. Most of these seafood-associated outbreaks (n=43; 76.1%) were due to a bacterial agent; 40 (21.3%) outbreaks had a viral etiology, and 5 (2.6%) had a parasitic cause.Therefore it is necessary to adress appropriate studies to characterize the impact over the ocean\'s capacity to maintain environmental quality important to the health of marine population and the microbiological hazards present in marine ecosystems to prevent outbreaks by seafood consumption and recreational use of these waters.
BACTERIA FAMILY (BELOW) | BACTERIA SPECIES(BELOW) | WHALES | DOLPHINS | SEABIRDS | SEA TURTLES | |||||||||
Megaptera novaeangliae | Eubalaena australis | Balaenoptera acutorostrata | Stenella frontalis | Sotalia guianensis | Pontoporia blainvillei | Delphinus sp. | Sula Leucogaster | Larus dominicanus | Spheniscus magellanicus | Chelonia mydas | Lepidochelys olivacea | Caretta caretta | ||
AEROMONADACEA | A. veronii | |||||||||||||
A. caviae | ||||||||||||||
A. hydrophila | ||||||||||||||
A. media | ||||||||||||||
A. trota | ||||||||||||||
VIBRIONACEAE | V. alginolyticus | |||||||||||||
V. vulnificus | ||||||||||||||
V. parahaemolyticus | ||||||||||||||
V. cincinnatiensis | ||||||||||||||
V. fluvialis | ||||||||||||||
V. furnisii | ||||||||||||||
V. mimicus | ||||||||||||||
V. harveyi | ||||||||||||||
V. mediterranei | ||||||||||||||
V. aestuarinus | ||||||||||||||
V. pelagius | ||||||||||||||
V. campbelii | ||||||||||||||
V. hepatarius | ||||||||||||||
V. coralliitycus | ||||||||||||||
V. fischeri |
Vibrio and Aeromonas species isolated form marine mammals, seabirds found sic on the beaches alond the coast of Rio de Janeiro state, southeastern Brazil.
The bioinvasion, refers to some exotic species introduced into a new environment, and which for the absence of natural controls such as parasites and diseases, become extremely harmful to local biodiversity, especially in disturbed habitats [11, 63]. When a species introduced into a new environment has success in establishing itself and its population increases, it tends to compete and eliminate native species, or cause damage to local ecology and affect socio-economic pattern and public health [45]. The bioinvasion is considered one of the most important threats to biodiversity and integrity of marine ecosystems, especially in coastal regions. However, this question had deserved attention only after the signing of the Convention on Biological Diversity in June 1992. Bioinvasions have occurred in all regions of the world, and the largest carrier of exotic species to new areas is navigation, where the ballast water of ships acting as a “vector” for introduction of species [63].
Climate change, nitrogen deposition and contaminants in the marine environment appear to help the successful accommodation of invasive species in a new habitat, especially microorganisms [11, 64]. Several marine species have caused heavy economic and ecologic impacts in a habitat invaded. Once established, the elimination of exotic species in the new habitat is very costly or even impossible, therefore, the policies related to bioinvasion have been linked to measures to prevent introduction of exotic species [65]. The exchange of ballast water of ships in coastal areas of a new marine ecosystem is considered the main introduction factor for alien species [11, 63]. One of the main problems of bioinvasion related to public health is the introduction of toxic algae that cause poisoning and other pathogens such as Vibrio cholerae, which causes of infection [13, 63, 64].
In 1991, cholera appeared in Latin America, and until recently caused more than 1.2 million of infections and 12,000 deaths. It is believed that Peru served as an entry in the South American continent [63]. However, Brazil has achieved the highest number of cases across the continent in 1993 and 1994, most recently in 1999 on the coast of Paraná, with 467confirmed cases [13]. There is scientific evidence showing that the first cases of cholera occurred in the coastal ports, which suggests that outbreaks or epidemics could have been caused by the ballast water of ships arriving from endemic areas [63]. In a study conducted by the National Health Surveillance Agency (ANVISA) in 2002 detected the presence of Vibrio cholerae and Escherichia coli in high proportions in samples collected from ballast water of ships in various ports of Brazil, supporting the hypothesis of ships as carriers of the pathogen [13].
Chemical contamination is one of the main challenges for the conservation status of the marine environment. Environmental contaminants have compromised the quality of water and air, affecting biodiversity in ecosystems, contaminating food and endangering human health. The vast majority of waste produced by anthropogenic activities inevitably reaches the oceans and is widely dispersed and may even reach free regions of the release of pollutants, such as the Antarctic region [3, 5, 12, 66, 67].
Approximately 80% of the contamination that reaches the oceans has their emission sources on the continents, via air routes, direct discharges into the oceans by effluents, industrial, agricultural and other sources [68]. The ocean contamination in associated with the concentration of people living in coastal regions around the world [18]. The contaminants of highest concern are those that have environmental persistence, are capable of long-range transport, can biomagnify in food chain and bioaccumulate in humans and animal tissues and have potentially significant impacts on humans and environmental health [66, 69-71]. The sources and amount of emissions are also extremely important. Persistent organic pollutants (POPs), polycyclic aromatic hydrocarbons (PAHs) and some metals present the chemical characteristics mentioned above.
The human activities have considerably altered the geochemical and biogeochemical cycles of the metals in nature, especially during the last and current century. Once the environment, the metallic elements can occur in various chemical forms and thus may increase or decrease its toxic properties [1, 72]. Mercury, which has been associated with various human health problems, is used in wide range of industrial processes. When released into the environment, bacteria can quickly transform its inorganic form in inorganic mercury (methyl-mercury). Methyl-mercury can concentrate in the marine food chain, and may cause cytotoxic effects, kidney and brain of those exposed [10, 57, 72]. Concentrations 1-2 mg / kg brain tissue may cause neurological damage. Furthermore, due to its ability to cross the placental barrier, methyl-mercury becomes extremely harmful to fetuses exposed [1]. Due to the extensive contamination with mercury, individuals consuming fish (principally predator species) frequently exhibit the highest levels of methyl-mercury in their tissues. Top predator species such as marine mammals, sharks and seabirds present extremely high concentrations or mercury in their tissues, and people that consume meat of organisms from these groups generally are exposed to high concentrations.
The human vulnerability for persistent contaminants in the ocean is strongly linked to the origin and trophic position of the marine food consumed. An example of this is people in Iraq and Japan, which may have higher levels of 50-100 ppm of methyl-mercury in hair samples, when the average concentration of this compound in humans is less than 1 ppm [73]. Cadmium also has the ability to bioaccumulate in the marine environment and is often found in biological samples taken from this environment. Cadmium is recognized as a human carcinogen; however, the increased risk is related to human exposure to this element can lead to proteinuria and renal failure.
Arsenic and lead are also potentially harmful to human and environmental health. These are usually found in living organisms and marine sediments, industrial discharges being a major source of environmental emissions. Several related contaminants have been found in tissues of marine organisms, and in some cases these have been associated with adverse effects on the exposed organisms [3]. One of the variables which can cause confusion and lack of causal association studies is the presence of mixtures of a considerable range of these specific contaminants present in the oceans. This mixture could cause adverse effects acting in concert, and perhaps at low levels, which could obscure associations in studies using only specific contaminants.
Persistent organic pollutants (POPs) pose potential risks to human health and the environment. Exposure to POPs can cause serious human and environmental health impacts including certain cancers, birth defects, dysfunctional immune and reproductive systems and greater susceptibility to disease [1, 70].
The main human exposure to POPs in the oceans is through fish consumption [74]. One of the most relevant POPs even today is the pesticide DDT, which despite its commercialization and application banned in most countries, is still used in some tropical and subtropical nations for vector control, such as malaria [69, 75, 76]. According to the International Agency for Research on Cancer (IARC), DDT is possibly carcinogenic and sub-acute exposures may cause problems in the central nervous system and also impair the immunological integrity. Similarly, PCBs (polychlorinated biphenyls) have caused severe impacts on the exposed organisms and public health, mainly through fish consumption [74].
PAHs are pollutants of great environmental persistence, and together with its derivatives have important carcinogenic, mutagenic and genotoxic [71]. PAHs are formed by thermal transformation of fossil fuels. Thus, forest fires, industrial processes and petrochemical activities are major contributors to environmental contamination by PAHs [1, 71]. These can also be formed naturally, but anthropogenic is that is causing concern. PAHs are highly soluble and rapidly absorbed through the lungs, the intestines and the skin of experimental animals, regardless of route of administration. The carcinogenic effects of some PAHs Of crucial importance to environmental and public health, fish consumption is the main source of human exposure relating to ocean pollution.
The oceans have a valuable relationship with human wellbeing through ecosystem services, the source of discoveries for pharmacology and biomedicine, cultural values, and simply the satisfaction of people, which stems from the harmony of healthy oceans and their stable biodiversity. The marine ecosystem services include the stabilization of the coast, the regulation of nutrients and climate, and the management of pollutants, energy resources, and natural products of values for biomedicine, tourism and recreation. Therefore, besides the importance of the quality of the oceans to maintain the integrity of biodiversity residing in this biome, oceans also produce beneficial effects and essential for the maintenance and stability of terrestrial ecosystems to the welfare and human health [2, 3, 42].
The coastal regions provide an important natural place for human leisure, which contribute for both physical and psychological benefits. There is medical evidence showing that the access to natural environments improves health and wellbeing, prevents disease and helps the development of recover from illness. Coastal environments stimulate fitness and leisure activities (e.g. swimming, surfing and coastal walking, beach sports) [42]. These physical and mental exercises can prevent cardiovascular diseases and help to reduce obesity and cancer [42]. In addition, the leisure activities may help to prevent or improve many mental health issues, such as reduction of stress.
Great efforts have been made to evaluate the complex economic values of environmental services and natural resources. Generally, the conservation of the ecosystem is considered more economically profitable than the economic values arising from the acquisition and use of its resources, which often leave severe environmental liabilities [30, 77]. Constanza et al. [77] showed that while the coastal areas cover only 8% of global land surface, the services and benefits from this area are responsible for approximately 43% of the total value of global ecosystem services valued at 12.6 trillion dollars.
In the last six decades there has been a growing interest in bioactive substances with properties derived from marine organisms [1, 4, 16, 78]. Already in the 1950s Bergman and Feeney [79] discovered two drugs of importance to medicine (ARA-C and ARA-A), based on nucleoside present in marine sponges (Tectitethya crypta and Streptomyces antibiotics). Formulated synthetically from the discovery of these researchers, the Ara-C is indicated for the treatment of non-lymphocytic leukemia, the leukemia meninges and chronic myelocytic leukemia, whereas the Ara-A is indicated for the treatment of viral infections caused by Herpes simplex and Herpes zoster[4, 43, 80]. Another valuable contribution of importance to medicine was the discovery of azidothymidine, AZT. This synthetic derivative, originating from marine sponges, is currently still one of the most effective drugs in the treatment of acquired immunodeficiency syndrome (AIDS) [43, 80]. From the work of these researchers, scientists began to explore marine biodiversity and its potential for the discovery of new bioactive compounds, aimed at advancement of pharmacology and biomedicine in the treatment of diseases known to cause severe damage on the population. The success of the discovery of new bioactive compounds and their pharmacological effects, extracted from marine organisms has been demonstrated from formulations of new anticancer treatments, and infectious diseases and inflammation [81]. However, much emphasis has been attributed to the discovery of anti-cancer compounds derived from marine organisms due in large part to the availability of funds for supporting studies aiming to find new compounds. The oceans are rich source of chemical and biological diversity, with hundreds of thousands, maybe even millions of new species are still unknown, especially micro-organisms that represent a great opportunity for the discovery of new species and new chemicals. Another approach of extreme importance is the study of marine organisms as a basis for discovery in biomedicine. Research on the natural history, taxonomy, physiology and biochemistry of marine organisms has served as a model for biomedical research to elucidate issues relevant to the physiology, biochemistry and human disease.
The pressure of human activities on marine environment generates ecosystem modifications that affect the people depending on the vulnerability of the population exposed. The past and current human development needs great modification to ensure the stabilization and homeostasis of the ocean. In addition, it is important to better understand the dynamic of the marine processes which can contribute to prevent the risks associated with human exposure. It includes the development of a system capable to generate information of a wide range of complex environment processes that should be used to prevent human and biodiversity impacts. Climate change and other anthropogenic pressures have the ability to influence many environmental factors, important for human health, such as fisheries, HABs, pathogens and contaminants. Environmental model are required to better understand the ocean and ecosystem dynamics their role on climate change, as well as to prevent impacts resulting from the modifying ecosystems. The development of indicators is needed to establish measures to study and prevent the impacts of the oceans changes on human health. The conservation of the marine environments, principally those with no apparent alterations, are greatly encouraged to avoid human and biodiversity.
We thank the laboratory team from the National Reference Laboratory for Bacterial Enteroinfections (LRNEB) from the Oswaldo Cruz Institute (IOC/FIOCRUZ). We would like to thank the PhDs Rosalina Koifman, Sérgio Koifman and Aldo Pacheco Ferreira from the National School of Public Health (ENSP/FIOCRUZ) for the encouragement to prepare this work. The first author J. F. Moura is funded by the Fiocruz Foundation (FIOCRUZ). In addition, we thank the invite of the In Tech to publish this book chapter.
Recurrent pneumothorax which is associated with menstruation is named as “catamenial pneumothorax” (CPX). It was first reported by Maurer et al. [1] and was presented to be a form of ectopic endometriosis and the term CPX was stated by Lillington et al. [2].
“Catamenial” is a name from Greek meaning “monthly.” CPX is most commonly associated with endometriosis, but other etiological mechanisms of this disease exist [3, 4, 5, 6].
In the literature, CPX is defined to be a recurrent pneumothorax occurring up to 24 h before or within 72 h after the onset of menstruation [4, 6], and on the other hand, not necessarily appearing every month [7]. Symptoms and signs of CPX are mostly unspecific so much clinical suspicion has to be maintained [8]. CPX is a rare entity; however, regarding literature, about one-third of all surgically treated cases of pneumothorax in women are diagnosed to be CPX [9, 10, 11, 12].
Therefore, thoracic endometriosis should always be suspected in reproductive-age woman who suffer chest pain from spontaneous pneumothorax.
Thoracic endometriosis syndrome may be associated with other causes than pelvic endometriosis. In the first 24–48 h of menstruation, symptoms begin to appear and are usually seen on the right side of the chest. In 90% of the patients, chest pain is the most common symptom, and in one-third of the patients, shortness of breath is rarely seen, but hemoptysis is also added to the clinical picture [13]. In the light of these findings, the diagnosis of the disease is made clinically.
From 3 to 6% of spontaneous pneumothorax cases are catamenial pneumothorax, about one-third of all surgically treated cases of pneumothorax in affected women.
The mean age of onset is reported to be 32–35 years [3, 4, 12, 14, 15, 16, 17]. CPX may also develop as late as at 39 years of age [18, 19]. CPX occurs most often (85–95%) unilaterally, usually occurring on the right side of the chest, but there are cases on which pneumothorax also occurs on the left side or bilaterally [11, 15, 16, 17, 18, 19, 20, 21].
CPX is generally considered to be a rare entity, and there is an incidence less than 3–6% among women who suffer from spontaneous pneumothorax. Such a low incidence rate may be a result of decreased disease awareness and underdiagnosis [4, 8, 9, 10, 19, 22, 23, 24, 25, 26, 27, 28, 29].
Yet, the incidence of catamenial pneumothorax was much higher among women at reproductive age who were referred for surgical treatment because of recurrent spontaneous pneumothorax, ranging between 18 and 33% [9, 10, 11, 12, 22].
In a recent study [24, 29, 30], 156 premenopausal women who underwent surgery for spontaneous pneumothorax were reviewed retrospectively, and 31.4% (49/156) of the patients were classified as CPX.
In a retrospective study, Alifano et al. reported thoracic endometriosis in 13 out of 35 (37%) patients who underwent reoperation for recurrent spontaneous pneumothorax [29]. Catamenial pneumothorax was the initial diagnosis in eight cases and idiopathic pneumothorax in four cases [29]. Under/misdiagnosis of thoracic endometriosis can be referred to several causes, including decreased disease awareness, incomplete scanning for the lesions, variations in the size, appearance, and number of the lesions [24, 30].
The etiopathology of catamenial pneumothorax remains unclear, but there are some theories explaining the etiopathogenesis of catamenial pneumothorax. These theories include physiological, migrational, microembolic-metastatic, and the diaphragmatic theory of air passage [17] (Table 1).
Physiological hypothesis | High levels of circulating prostaglandin F2 during menstrual cycle cause vasoconstriction, and this induces alveolar rupture and pneumothorax. |
Metastatic or lymphovascular microembolization hypothesis | Endometrial tissue spreads through the venous and/or the lymphatic system to the lungs, and subsequent catamenial necrosis of endometrial parenchymal site adjacent to visceral pleura causes pneumothorax |
Transgenital-transdiaphragmatic passage of air hypothesis | Absence of cervical mucus during menstruation provides air passage from the vagina to the uterus, through the cervix. Then air enters the peritoneal cavity straight through the fallopian tubes and reaches to the pleural space by diaphragmatic defects. |
Migration hypothesis | Following catamenial necrosis of this diaphragmatic endometrial implants results in diaphragmatic perforations. Endometrial tissue then passes through this diaphragmatic perforation and spreads into the thoracic cavity. Ectopic endometrial tissue implants to the visceral pleura and following catamenial necrosis of this tissue causes rupture of the underlying alveoli, and pneumothorax occurs. |
The etiopathology of catamenial pneumothorax remains unclear, but there are some theories explaining the etiopathogenesis of catamenial pneumothorax.
These theories include physiological, migrational, microembolic-metastatic, and the diaphragmatic theory of air passage.
According to the physiologic hypothesis, high levels of circulating prostaglandin F2 during menstrual cycle cause vasoconstriction and this induces alveolar rupture and pneumothorax. Pulmonary bullae blebs may be more sensitive to ruptures during hormonal changes. There are no pathognomonic lesions in such cases and this issue supports the physiologic theory [4, 7, 8, 24, 31].
In metastatic or lymphovascular microembolization theory, endometrial tissue spread through the venous and/or the lymphatic system to the lungs, and subsequent catamenial necrosis of endometrial parenchymal site adjacent to visceral pleura causes pneumothorax. If parenchymal endometrial focus is located centrally, hemoptysis may be present as a symptom [3, 4, 7, 8, 22, 24, 30, 31, 32]. Endometrial tissue can be detected in the lung parenchyma, at knee, in the brain, and in the eye. This supports the metastatic theory [12].
According to the transgenital-transdiaphragmatic passage of air theory, absence of cervical mucus during menstruation provides air passage from the vagina to the uterus, through the cervix. Then, air enters the peritoneal cavity straight through the fallopian tubes and reaches to the pleural space by diaphragmatic defects [4, 7, 8, 22, 24, 31]. This passage is facilitated by the difference in atmospheric pressures between pleural space and peritoneal space since the atmospheric pressure in the pleural cavity is less than the pressure in the peritoneal cavity.
There are few reports in the literature regarding transgenital-transdiaphragmatic passage of air theory. There are rare cases reporting simultaneous [33, 34] or undulating episodes CPX and pneumoperitoneum [35], and also case reports defining radiologic findings of small diaphragmatic defects associated with ipsilateral CPX [21]. But repeated episodes of pneumothorax after hysterectomy, fallopian tube ligation, and diaphragmatic resection provide evidence that all the CPX cases can be explained by this theory [7, 24, 29, 36].
Migration theory is based on retrograde menstruation which causes in pelvic seeding of endometrial tissue and migration of this tissue to the subdiaphragmatic sites through the peritoneal fluid flow. Endometrial tissue is mostly implanted to the right hemidiaphragm because peritoneal circulation prefers a clockwise flow through the right paracolic gutter to right hemidiaphragm and the liver facilitates flow with its piston-like activity. Catamenial necrosis of this diaphragmatic endometrial implants results in diaphragmatic perforations. Endometrial tissue then passes through this diaphragmatic perforation and spreads into the thoracic cavity. Ectopic endometrial tissue implants to the visceral pleura and following catamenial necrosis of this tissue cause rupture of the underlying alveoli, and pneumothorax occurs [3, 4, 7, 8, 22, 24, 30, 31]. Endometrial diaphragmatic implants exist along with diaphragmatic perforations [37], and endometrial tissue can be seen at the edges of the diaphragmatic perforations in many cases of CPX [22]; these findings may support the migration theory in the etiopathology of catamenial pneumothorax.
The typical clinical manifestations of CPX include spontaneous pneumothorax with or before menses presented with pain, dyspnea, and cough. Scapular and thoracic pain may also be present before or during menstruation. There may also be a history of previous episodes of spontaneous pneumothorax, history of previous uterine surgery, primary or secondary infertility or uterine scratching, pelvic endometriosis diagnosis, and history of catamenial hemoptysis or catamenial hemothorax [30].
Medical history and occurrence of typical symptoms are crucial for the diagnosis of catamenial pneumothorax, and these findings should be systematically investigated [11]. Although existence of these findings creates high suspicion on catamenial pneumothorax, their absence does not exclude a diagnosis of catamenial pneumothorax [24, 30].
Intermittent presentations out of menstrual bleeding time should not exclude the diagnosis of noncatamenial endometriosis-associated pneumothorax even in the absence of symptoms and pelvic endometriosis [9, 24, 38].
The clinical course of CPX is usually mild or moderate, but sometimes be life-threatening. Widespread thoracic endometriosis after previous operations is reported in the literature as case reports [39]. A young woman who experienced an episode of life-threatening hemopneumothorax who has been treated by urgent tube thoracostomy and thoracotomy was reported by Morcos et al. [39]. Lung wedge resection, parietal pleurectomy, and partial diaphragmatic excision have also been performed in this case.
Patients with CPX are reported to have a mean age of 35 (range 15–54) years at presentation [40].
Catamenial pneumothorax can also have very rare presentations in the literature. Simultaneous occurrence of pneumoperitoneum and catamenial pneumothorax [33, 34], catamenial pneumoperitoneum mimicking acute abdomen in a woman with multiple episodes of pneumothorax [35], pneumothorax, and pneumoperitoneum in a patient with spontaneous diaphragmatic rupture has been reported in the literature [41].
Medical history is the main pathway on the way to the diagnosis of CPX. Synchronicity of the clinical course with menses is the main character of the disease, but on the other hand intraoperative visual inspection and appropriate histological examination of the pathognomonic lesions are crucial for the diagnosis of endometriosis-related pneumothorax. The surgeon needs to be vigilant because it can easily be missed if not cautious [7, 24, 29, 42].
Chest radiogram, computed tomography, and magnetic resonance imaging are the imaging modalities that can be used for the diagnosis of catamenial pneumothorax. Although there are no disease-specific diagnostic criteria, pneumothorax is usually right sided. On the other hand, left-sided or bilateral cases are present. Air-fluid leveling may also occur at chest radiogram, in some cases. Hemopneumothorax may also be a part of clinical course [24, 30]. Loculated fluids can be seen in cases with the history of previous surgery [39].
Only in a few number of cases, small diaphragmatic defects can be detected with careful examination of chest radiogram, which refers to diaphragmatic perforations. Also when a right-sided pneumothorax with a round opacity on the right hemidiaphragm occurs, liver protrusion into a large diaphragm defect is suspected [21, 43]. This type of partial intrathoracic liver herniation at the right hemidiaphragm on chest radiogram and CT [24, 44] has been reported in the literature. There are also reports in the literature regarding diaphragmatic masses on CT [23] and pleural masses on MRI that refers to endometrial implants [45].
CT findings of hemoptysis are nonspecific; they may differ from a focal ground-glass opacity to consolidation because of alveolar filling, similarly in hemoptysis caused by other disease [46]. Especially in nondependent lung parenchyma, these findings facilitate the location of the site of bleeding. In the early period of the disease, endobronchial clots may be present, which cause atelectasis in some cases. There are also reports revealing band-like opacities referring to linear fibrosis sites, which result from chronic hemorrhage [46].
MRI is another imaging modality that can be used for confirming thoracic endometriosis in some cases. CT has some disadvantages especially in spatial resolution, but MRI has high-contrast resolution and can better characterize hemorrhagic lesions. Representation of diaphragmatic or pleural implants with MRI can help to clarify the diagnosis and management of the patient with catamenial pneumothorax [46].
MRI may also be useful for patients with catamenial hydropneumothorax; small pleural endometriomas characterized by the presence of small cystic hyperintense lesions can be revealed by MRI images of visceral or parietal pleura [46].
Coexisting pneumothorax and pneumoperitoneum are other findings that can be seen on radiography and computed tomography [33, 34].
Increased levels of cancer antigen 125 have been associated with endometriosis. It is not considered a specific marker, but it can play a role in early diagnosis of endometriosis-related pneumothorax [47, 48].
Characteristic lesions of the catamenial pneumothorax include single or multiple diaphragmatic spots, perforations, nodules, and visceral or parietal pleural spots and nodules. Pericardial nodules have also been reported in some cases.
These lesions have not been found in all patients with catamenial pneumothorax, but they have been revealed in some cases with noncatamenial pneumothorax. Detection of endometrial tissue is not mandatory in these lesions. On the other hand, endometrial tissue has usually been found in diaphragmatic and pleural nodules, but it is rarely detected at the edges of the diaphragmatic perforations [30].
Visceral and parietal pleural lesions are less frequently detected than diaphragmatic defects, spots, and nodules.
The diaphragmatic lesions usually located at the centrum tendineum and can be single or multiple. They usually settle adjacent to nodules. They can be outlined as perforations, fenestrations, holes, stomata, and pores [24, 30, 49] (Figure 1a and b).
(a) and (b) Thoracoscopic view of diaphragmatic endometriosis. Fenestrations can be seen on the surface of the diaphragm (arrows). (c) The liver is visible after surgical resection. (d) Sutured diaphragm after endometriosis resection. Images are used with the permission of Demetrio Larrain [49].
They can be tiny holes measuring 1–3 millimeters in diameter [7, 50], or larger defects measuring up to 10 mm [4, 18] or more than 10 mm [8] or represent as undetected holes proven only by diagnostic pneumoperitoneum [42].
Diaphragmatic defects are usually found close to coexisting nodules or spots, and endometrial tissue is sporadically found at the edges of the defects [4, 9, 11, 22]. This situation supports the theory claiming that the diaphragmatic defects represent the breakdown of endometrial implants during menstrual cycle [22, 24].
There are also case reports of larger lacerations that accompany with intrathoracic liver protrusion, but these presentations are very rare.
A patient with catamenial pneumothorax on the right hemithorax was reported by Pryshchepau et al. Liver of the patient was protruded through a large diaphragmatic defect [44].
Visouli et al. also reported five cases of catamenial pneumothorax [24], which contains a case very similar regarding liver protrusion, and they have recommended that these findings should be included in the characteristic findings of catamenial and thoracic endometriosis-related pneumothorax, although this presentation is very rare [24].
Catamenial pneumothorax with a huge diaphragmatic laceration and partial intrathoracic liver herniation was reported by Bobbio et al. [43], and Makhija et al. [51] reported a patient with multiple diaphragmatic fenestrations. The largest lesion was reported to have a diameter of 10 cm.
Spontaneous rupture of the right hemidiaphragm and intrathoracic liver herniation was also reported in the literature [41]. Pneumothorax and pneumoperitoneum was detected in a patient with a history of premenstrual periscapular pain. At the edge of the diaphragmatic defect, a nodule looking like an endometrial implant was found in that patient. Histological examination of the nodule revealed endometriosis with hemosiderin-loaded macrophages. This case is considered as endometriosis-related, but the histological criteria set by the authors was not appropriate [9, 11]. Additionally, previously mentioned cases of large diaphragmatic defects were considered to be limited diaphragmatic ruptures and stated that endometriosis was responsible for these ruptures [43, 44].
Endometrial tissue is usually detected on histopathological examination of the spots or nodules accompanying catamenial pneumothorax so these lesions are considered to be endometrial implants. Diaphragm, visceral, and parietal pleura are the common sites for location. Pericardial implants were also reported by Fonseca et al. [52]. The lesions may be single or multiple and may have varying size. They may have different presentations in color as brown, purple, red, violet, blueberry, black, white, grayish, and grayish-purple [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 51].
Diaphragmatic and thoracic lesions may be present in all cases, but on the other hand, only one or more of them can be seen either [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 39, 53, 54].
In some cases of catamenial pneumothorax, characteristic findings may be absent and blebs and bullae may be the only pathological findings. In some cases, no characteristic thoracic findings may be detected [7, 12, 20, 22, 23, 24].
Detection of characteristic lesions during thoracotomy or thoracoscopy depends on thorough and deliberate examination of the thorax, including the diaphragm. This also depends on the stage of the disease and catamenial behavior of the disease and longer-term variation [22, 24, 30, 42].
Surgical treatment is the gold standard in treatment of catamenial pneumothorax, not only for its better results but less recurrences after treatment as well. Surgery has better results compared with medical treatment [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20].
Korom et al. [7] reviewed 195 cases of CPX among 229 cases and reported that 154 cases (78%) were treated surgically. Among surgically treated patients, diaphragmatic repair (38%), pleurodesis (81%), and lung wedge resection (20%) were performed.
There is common consensus in the literature that the appropriate approach to CPX has to be minimally invasive so video-assisted thoracoscopic surgery (VATS) is the choice of treatment. VATS not only provides magnification but complete visualization of diaphragm as well [23].
Video-assisted thoracoscopic surgery (VATS) has been mainly in use since 2000 in the treatment of thoracic diseases with several advantages over conventional thoracotomy. Incision may be extended when extensive diaphragmatic repair is required, and also a muscle-sparing thoracotomy may offer better access in such cases. Thoracotomy may be an option especially in recurrent interventions or in reoperations [4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30].
The lung examination for bullae, bleb, and air leakage is very important, but the diaphragm should also be carefully examined for fenestrations and spots or nodules. In addition, it is critical to examine the parietal pleura, lung, and pericardium in terms of spots and nodules.
Bagan et al. recommended the use of surgical treatment during menstruation. Thus, they stated that endometriotic lesions may be better visualized during menstrual period [22]. Slasky et al. used the pneumoperitoneum method to reveal unseen diaphragmatic fenestrations [42]. Identification of the lesions within the thorax is made easier by the magnification provided by VATS [4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30]. The tissue samples from these lesions make it easy to diagnose thoracic endometriosis [10].
Resection of all visible lesions such as bullae or bleb and also resection of endometriosis-induced thoracic lesions have been recommended by Alifano et al. Limited wedge resection of the diseased lung tissue, limited parietal pleurectomy, and partial diaphragmatic resection were suggested surgical techniques for the elimination of intrathoracic lesions [4].
Excision and wedge resection of bullae and blebs [7, 12, 23, 30], along with pleurodesis or pleurectomy, has been mainly performed in the literature [7, 8, 12, 23, 30, 47]. Pleurodesis was found to be the most common intervention [29]. The majority of pleurodesis performed was mechanical pleurodesis (abrasion or pleurectomy), which has been found to be more successful in comparison to chemical pleurodesis [6].
Addressing the diaphragmatic pathology is of paramount importance. Diaphragmatic plication and/or resection of the diseased area have been reported [7, 12, 23, 24, 30, 49] (Figure 1c and d).
Recurrence is the most common complication of CPX, and there are reported recurrence rates of 20–40% [4, 7, 41, 51]. Alifano et al. suggested that diaphragmatic resection with removal of endometrial implants is the preferred method compared to single diaphragmatic plication because plication has an disadvantage of leaving endometrial implants untreated [29, 38]. Still, recurrences may develop even after diaphragmatic resection [29].
Fewer recurrences after diaphragmatic coverage with a polyglactin mesh were reported by Bagan et al. To prevent recurrences, they suggested a systematic diaphragmatic covering, including the normal appearance of diaphragms, treating ocular defects, strengthening the diaphragm, and inducing adhesions to the lung [7].
There are also reports on diaphragmatic coverage with a polyglactin or polypropylene mesh [8], a polytetrafluoroethylene (PTFE) mesh [15], or a bovine pericardial patch [24], which has been reported with good mid-term results.
Hormonal treatment has a supplementary role in the treatment of catamenial pneumothorax. With the administration of hormonal therapy, it is possible to prevent recurrences of catamenial pneumothorax.
A multidisciplinary approach is mandatory for the management of the disease and administration of gonadotrophin-releasing hormone (GnRH) analogue, which results in the lack of menses, and is suggested for all patients with proven catamenial pneumothorax in the early postoperative period for 6–12 months [4, 7, 8, 22, 24, 30, 48]. Patients without documented catamenial character or histologically proven thoracic endometriosis may also benefit from hormonal treatment even in the presence of characteristic lesions [24, 30].
Woman’s plans concerning pregnancy are very crucial, when deciding whether to start hormonal therapy or not. In such therapies, oral contraceptive pills (estrogen-progestogen) are usually used which induce menses every 28 days or they are used continuously without inducing menses. These pills also include progestogens, and they may be administered orally, intramuscularly, or in intrauterine way. There are also several medications, which are currently in use. Medical treatment is recommended in patients when catamenial pneumothorax is associated with endometriosis [17].
The aim of early GnRH analogue delivery is to prevent cyclic hormonal changes and to suppress the activity of the ectopic endometrium until effective pleurodesis occurs, because time is needed for the formation of effective pleural adhesions [38].
Hormonal treatment is advised for longer periods especially after reoperations for catamenial pneumothorax.
Proven ineffectiveness of the therapy or significant side effects of the drugs are the contraindications of hormonal therapy [29].
There is an accepted surgical algorithm and treatment in catamenial pneumothorax [55], which is described in Figure 2 in detail.
Accepted surgical algorithm and treatment in catamenial pneumothorax.
Practically, surgery for catamenial pneumothorax has very low mortality and morbidity. Recurrence is the most common complication of CPX, and there are reported recurrence rates of 20–40% [4, 7, 41, 53].
High recurrence rates are much higher than surgically treated idiopathic pneumothorax [8, 9, 10, 22, 23, 24, 29].
A low recurrence rate (8.3%), at a mean follow-up of 45.8 months, was reported by Attaran et al., by video thoracoscopic abrasion and pleurectomy, diaphragmatic repair and PTFE mesh coverage for the repair of diaphragmatic defects, and a routine postoperative hormonal treatment [55].
Also Alifano et al. reported that the highest postoperative recurrence rate in 114 women who were operated due to recurrent spontaneous pneumothorax was in the catamenial pneumothorax group (32%), and this was followed by a noncatamenial endometriosis-associated pneumothorax group (27%). They also reported a recurrence rate of 5.3%, at a mean of 32.7 months of follow-up, in patients with noncatamenial nonendometriosis-associated pneumothorax [32].
Incomplete surgical treatment of lesions and lack of additional hormonal treatment in the early postoperative period [23, 24, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54] may increase the risk of recurrence [24, 30, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56].
Young women with pneumothorax, especially in the perimenstrual period, should be suspected of catamenial pneumothorax. Failure occurs most frequently when recurrent catamenial pneumothorax occurs.
The lesions of the parietal and visceral pleura should be carefully examined and removed during surgery. Diaphragm reconstruction is required every time when fenestrations are detected in diaphragm.
Hormonal therapy is also recommended because it facilitates the effectiveness of the surgical results.
Multidisciplinary approach with early postoperative hormonal treatment, which deals with all thoracic pathologies including disease awareness, early diagnosis, diaphragmatic repair, and surgical management of the main chronic systemic disease, may eventually lead to a reduction in the rate of recurrence of catamenial pneumothorax [3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 23, 24, 30, 32].
Treatment of women of childbearing age is different from men of the same age group. CPX should be excluded in the cohort of women, especially when the pneumothorax is repeated. Full examination of the diaphragm should be part of the operation. Surgeons who perform VATS should be experienced to resect and repair diaphragms with fenestrations and endometrial deposits, including keyhole laying down of synthetic mesh.
There is no conflict of interest.
We would like to thank Dr. Demetrio Larraín who kindly gave us permission to use his images in our chapter.
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