Blooms of cyanobacteria have been documented throughout history, all over the world. Mass populations of these organisms typically present hazards to human health and are known for the production of a wide range of highly toxic metabolites-cyanotoxins, of which among the most common and most investigated are the microcystins. The toxicity of the family of microcystin congeners to animal and cell models has received much attention; however, less is known about their negative effects on human health, whether via acute or chronic exposure. Useful information may be acquired through epidemiological studies since they can contribute to knowledge of the relationships between cyanotoxins and human health in environmental settings. The aim of this review is to compile and evaluate the available published reports and epidemiological investigations of human health incidents associated with exposure to mass populations of cyanobacteria from throughout the world and to identify the occurrence and likely role of microcystins in these events. After an initial screening of 134 publications, 42 publications (25 on the chronic and 17 on the acute effects of cyanotoxins) describing 33 cases of poisonings by cyanobacterial toxins in 11 countries were reviewed. The countries were Australia, China, Sri Lanka, Namibia, Serbia, Sweden, UK, Portugal, Brazil, USA, and Canada. At least 36 publications link cyanobacteria/cyanotoxins including microcystins to adverse human health effects. The studies were published between 1960 and 2016. Although the scattered epidemiological evidence does not provide a definitive conclusion, it can serve as additional information for the medical assessment of the role of microcystins in cancer development and other human health problems. This paper discusses the major cases of cyanotoxin poisonings as well as the strengths, weaknesses, and importance of the performed epidemiological research. This study also proposes some recommendations for future epidemiological work.

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Cyanotoxins are secondary metabolites produced by cyanobacteria. They pose a threat to human health and the environment. This review summarises the existing data on human exposure to cyanotoxins through drinking water, recreational activities (e.g., swimming, canoeing or bathing), the aquatic food web, terrestrial plants, food supplements, and haemodialysis. Furthermore, it discusses the tolerable daily intake and guideline values for cyanotoxins (especially microcystins) as well as the need to implement risk management measures via national and international legislation.

This review aims to summarise the outcomes of some recent European research concerning toxic cyanobacteria and cyanotoxins, with an emphasis on developments within the framework of the CYANOCOST Action: COST Action ES1105, Cyanobacterial Blooms and Toxins in Water Resources: Occurrence, Impacts and Management. Highlights of the Action include phycological and ecological studies, development of advanced techniques for cyanotoxin analysis, elucidation of cyanotoxin modes of action, management techniques to reduce cyanobacterial mass development, and research on methods and practices for cyanotoxin removal during drinking water treatment. The authors have identified a number of gaps in knowledge. Proposed directions for future research on toxic cyanobacteria and cyanotoxins are also discussed.

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Cyanobacteria produce toxic metabolites known as cyanotoxins. These bioactive compounds can cause acute poisoning, and some of them may promote cancer through chronic exposure. Direct ingestion of and contact with contaminated water is one of the many exposure routes to cyanotoxins. The aim of this article was to review the incidence of 13 cancers during a 10-year period in Serbia and to assess whether there is a correlation between the cancer incidences and cyanobacterial bloom occurrence in reservoirs for drinking water supply. The types of cancers were chosen and subjected to epidemiological analyses utilizing previously published data. Based on the epidemiological and statistical analysis, the group of districts in which the incidences of cancers are significant, and may be considered as critical, include Nišavski, Toplički, and Šumadijski district. A significantly higher incidence of ten cancers was observed in the three critical districts as compared to the remaining 14 districts in Central Serbia. These elevated incidences of cancer include: brain cancer, heart, mediastinum and pleura cancer, ovary cancer, testicular cancer, gastric cancer, colorectal cancer, retroperitoneum and peritoneum cancer, leukemia, malignant melanoma of skin, and primary liver cancer. In addition, the mean incidence of five chosen cancers was the highest in the three critical regions, then in the rest of Central Serbia, while the lowest values were recorded in Vojvodina. Persistent and recurrent cyanobacterial blooms occur during summer months in reservoirs supplying water to waterworks in the three critical districts. People in Central Serbia mainly use surface water as water supply (but not all the water bodies are blooming) while in Vojvodina region (control region in this study) only groundwater is used. Among the 14 "noncritical" districts, reservoirs used for drinking water supply have been affected by recurrent cyanobacterial blooms in two districts (Rasinski and Zaječarski), but the waterworks in these districts have been performing ozonation for more than 30 years. We propose that the established statistical differences of cancer incidences in Serbia could be related to drinking water quality, which is affected by cyanobacterial blooms in drinking water reservoirs in certain districts. However, more detailed research is needed regarding cyanobacterial secondary metabolites as risk factors in tumor promotion and cancerogenesis in general.

Today, the occurrence of harmful cyanobacterial blooms is a common phenomenon and a potential global health problem. Cyanobacteria can produce metabolites highly toxic to humans. More than 80% of reservoirs used for water supply in Central Serbia have bloomed over the past 80 years. A 10-year epidemiological study showed a significant increase in the incidence of primary liver cancer (PLC) in the regions where water from the blooming reservoirs was used for human consumption. At the same time, no correlation was found between the incidence of PLC and other risk factors, such as cirrhosis and hepatitis viruses. Given the strong association with PLC induction and various known possible mechanisms of carcinogenic action, it is highly possible that, cyanotoxins--acting as initiator and promoter--may be the major risk factor that acts synergistically with other risk factors to cause increased incidence of PLC. However, at present, it is still not certain whether cyanotoxins alone were sufficient to induce PLC. Therefore, additional assessment of the health risks that may arise from human exposure to cyanotoxins is advisable.

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