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Egypt J. Aquat. Biol. & Fish., Vol. 15, No.

3: 93-98 (2011) ISSN 1110 - 6131

Analysis of potential microbiological risks in Ichthyotherapy using

Kangal fish (Garra rufa)

Karin Heistingerl; H. Heistingerl; H. Lussy2 and N. Nowotny2

1-Veterinary Clinic Lilienfeld, Babenbergerstrasse 22, A-3180Lilienfeld, Austria;
2- Zoonoses and Emerging Infections Group, Clinical Virology, Department of
Pathobiology, University of Veterinary Medicine, Vienna, Veterinaerplatz 1, A-
1210Vienna, Austria.

Atopic dermatitis (neurodermitis), psoriasis vulgaris and acne are more and more treated
with the alternative way of KANGAL FISH (Garra rufa or reddish suction-barbel)
THERAPY. Therefore the human patient takes curebaths with about 150 Kangalfish. The
therapeutic effect achieves through nibbling the infected epidermis and secretion of an
enzyme (dithranol) containing isolate during the nibble activity.
Although this therapy has been described as very successful, the potential risk of
transmitting pathogens has never been examined yet. This work gives first results of the
immune interaction of reddish suction-barbel with an unspecific agens (human pathogen
virus). Also the immune response in the fish to bacterial pathogens, that could be harmful for
the patients (Aeromonas, Pseudomonas, Mycobacteria etc.) are described in this work.
Mammalian DNA virus does not survive on fish tissue.
Mammalian RNA virus does survive on fish tissue for at least 5 minutes but does not interact
with fish immune system. Aeromonas sp. and Pseudomonas sp. propagate on fish mucous
membrane, even if they are not of a specific species (Aeromonas cavae). Staphylococcus sp.
and Streptococcus sp. propagate on fish mucous membrane if the tissue was pre-injured.
Enterobacteriaceae do not propagate on fish mucous membrane but do propagate in the
water. Mycobacterium marinum propagates on various fish tissues. Mycobacterium marinum
and piscium also propagate on the patient if the fish were stocked pre-infected. This paper
can be used for the monitoring of hygiene in kangal fish therapy (ichthyotherapy).

Keywords: Ichthyotherapy, Garra rufa, atopic dermatitis, neurodermitis, psoriasis vulgaris,

acne, zoonis, Aeromonacea, Pseudomonacea, Enterobacteriacea, Mycobacteriacea,
human pathogen virus

Ichthyotherapy or kangal fish therapy was first mentioned in the medical journal "The
Lancet" (Warwick, 1989). The kangal fish (Garra rufa) can measure up to 14 cm in length.
These fish belong to the big log sucker family and were first mentioned by the biologist
Jakob Heckel in 1843. Furthermore, they are members of the carp family (Cyprinidae) and
can usually be found in the Jordan River, in the Orontes River, in the Euphrat-Tigris river

The 15th Conf. of the Egypt. Soc. of Fisheries Development in cooperation with
The 4th Global Fisheries & Aquaculture Research Conf.
94 Karin Heistinger et al.

systems and in the rivers near the coast of northern Syria and the Turkish region of Kangal,
which the fish is named after. The fish lives there in warm water with a temperature of 37C.
However, in the hot pools of Kangal, where plankton and blue-green algae are scarce, these
fish feed on the skin scales of bathers. Since 1960, this randomly discovered fact has been
used to help people with psoriasis (Ozcelik, 2000). Physicians in Germany and Austria have
also recently started using ichthyotherapy to help patients suffering from psoriasis, atopic
dermatitis and acne. In the meantime, the medical effectiveness of ichthyotherapy has been

scientifically proven (Grassberger, 2006), although no healing can be achieved with this
therapy, only an abatement of the symptoms. Despite the good results of the therapy, people
are still concerned about the risk of infections. Psoriasis patients have small bleeding lesions
from time to time, which poses the risk of a potential transfer of viruses between patients via
the nibbling fish. This leads to the question of whether the kangal fish can transfer human
immunodeficiency viruses or hepatitis viruses between people (Heistinger, 2004). On the
other hand, a further question arises concerning the fish and the therapy tub water, where
zoonose viruses can affect patients.
During ichthyotherapy, 150-200 fish are kept in 300-800 1 treatment tubs, and the
patient bathes at least one hour per day in these tubs for three weeks. There are two different
types of bathtubs for the treatment. Type 1 is a circulatory tub that is constantly supplied
with fresh water which is purified, sterilized, temperated and aerated. In this system, the
water is exchanged two to three times in 24 hours. Throughout the duration of the treatment,
the patient is provided with his/her own treatment tub and fish. After the end of the
treatment, the fish are kept in a resting tub (quarantine) for a few weeks before treatment
with another patient begins.
Type 2 is also a circulatory tub, which sterilizes the water five times in one hour using
a UV-C sterilization system. This kind of tub is occupied with up to four people per day.
After each treatment, the bath water is emptied to a third of its volume and the sides of the
tub are cleaned with an 02 separating disinfectant.
Chemical disinfectants cannot be used because the fish would not survive that kind of
treatment. The fish stay in the tubs approximately three weeks before they spend a few
weeks in the resting tub. The keeping of the fish in the resting tub is very cost-intensive;
therefore, it would be better to use less fish and have shorter periods of quarantine in the
resting tubs and still be able to prevent the exposure of patients to any risks of infection.
To minimize the risk of infection, each patient is asked to show his/her health
certificate, which must demonstrate the absence of human immunodeficiency viruses or
hepatitis viruses in his/her body, before he/she starts ichthyotherapy.
The following questions arose during the existing ichthyotherapy and were analyzed
scientifically in this dissertation: Which health risks resulting from infections can arise for
the patients during ichthyotherapy?
Is it possible that the fish can act as a vector e.g. for human immunodeficiency viruses
or hepatitis viruses and how long can these viruses be verified in the fish?
Is it possible to define a certain quarantine period for the fish after ichthyotherapy and to rule
out any risks of infection after this period? Is it possible to keep fish without any bacteria
like zoonose viruses?
The aim of this examination is to eliminate a potential transfer risk of viruses as well
as to draw up an action plan for hygiene to make the medically effective treatment of
ichthyotherapy safer.
Analysis of potential microbiological risks in Ichthyotherapy using Kangal fish 95


Principles of the transmission testing
A certain number of Gana rufa (N=100, specific pathogen free animals) are held
under spa circumstances (therapy bathtub). The fish (n=50, 2 trials) are infected with the test
pathogen via prepared food (immersion: 100 TCID50).
Every minute, a fish is caught, narcotized and tissue samples are taken of the mouth
and tongue mucous membrane. The samples are transmitted on cell culture (virus check) and
culture plates (bacterial check). Re-isolation of germs is attempted.
Frequency of the testing: The virus transmission was tested twice, the bacterial
transmission was tested every 14 days over a period of 6 months.
The transfer risk of human pathogenic viruses
50 fish were fed with fish food laced with EFIV 1 (an enveloped DNA virus) and an
additional 50 fish were fed with fish food laced with Equine Rhinoviruses (a non-enveloped
RNA virus). After that, swab samples of the fish's mouths were taken every minute. Then
the fish's mouth swab samples were put into an insulating medium and the cell culture was
used to look for proof of viruses.
The fish food that was used is a common ornamental fish food in aquaculture, which
is enriched with gelatin and glutamate dissolved in water. This fish food is also used as a
basis for oral vaccinations of fish stocks.
Feeding attempt without any additions of viruses
30 ml (3 g) flakes food (Tetramin sole food for ornamental fish) are mixed with 10 ml
stabilizer solution (0.5 g gelatin/2 g glutamate)
Checking the water values: temperature, pH value, 02 saturation Sorting the fish
Feeding attempt with EHV1
30 ml (3 g) flakes food (Tetramin sole food for ornamental fish) are mixed with 9 ml
stabilizer solution (0.5g gelatin/2 g glutamate) as well as with 1 ml virus suspension.
Swab samples of the fish's mouths were taken every minute after the feeding and the
examiner also started to check the water values and the behavior of the fish.
Feeding attempt with Equine Rhinovirus
30 ml (3 g) flakes food (Tetramin sole food for ornamental fish) are mixed with 9 ml
stabilizer solution (0.5 g gelatin/2 g glutamate) as well as with 1 ml virus suspension.
Swab samples of the fish's mouths were taken every minute after the feeding and the
examiner also started to check the water values and the behavior of the fish.
The transfer risk of bacteria that are harmful for patients
For examining the transfer risk of bacteria in ichthyotherapy, a spectrum of bacteria
had been chosen which is usually known as potential zoonose germs in pools and spas such
as in fish fanning (aquaculture and ornamental fish farming)
Gram-negative bacteria
Aeromonas sp. and Pseudomonas sp. are known as ubiquitous, widespread water
germs, and Aeromonas hydrophila in particular is noted for being an opportunistic infectious
agent of general infections or local gangrene.
Enterobacteriaceae such as E.coli, Salmonella spp. or Klebsiella pneumoniae are
documented as diarrhea and/or septicemia viruses.
The existence of Edwardsiella - especially Edwardsiella tarda - is known in the
keeping of hot water fish tanks and this can lead to gastroenteritis and to meningitis as well
as encephalitis via bacterial dissemination.
Gram-positive bacteria
96 Karin Heistinger et al.

Staphylococcus sp. and Streptococcus sp. Isolated from fish glue and fish tank water.
Mycobacterium marinum, fortuitum and cheloniae on the fish glue.
As a result of the above mentioned spectrum of germs, the following action plan was
developed for the fish used in ichthyotherapy:
The tub water was examined on the basis of benchmarks and limits for the microbiological
check of pool areas and tub water defined by the EU regulation 2006/7/EG of 15. 02. 2006,
published as L64/37-5/2006 and Austrian national regulations for the hygiene of baths
Austrian national regulations such as the Baderhygienegesetz BGB1. 254/1996 and 658/1996,
the Baderhygieneverordnung BgB1. 420/1998, and ()NORM M6230-1 as well as ()NORM
Schema of the microbiological check:
Aeromonas sp. In skin smears of five fish every 14 days In 100 tub water *
Pseudomonas sp. In skin smears of five fish every 14 days In 100 tub water *
Enterobacteria ceae In skin smears of five fish every 14 days In 100 tub water *
*Every 14 days; if the limits are not exceeded after a period of 6 months, the frequency of
the check can be reduced to once a month.
Edwardsiella sp. In skin smears of five fish every 14 days
Staphylococcus sp. and Streptococcus sp. In skin smears of five fish every 14 days
Mycobacteria (Mycobacterium marinum, fortuitum, cheloniae)
At the beginning of every new used fish charge as well as every new input of Garra rufa.

Behavior of the fish during and after the feeding attempt
All fish showed a psychological reaction after the feeding. Reflexes, which are used
to check behavior (shortening reaction, eye turning reflex), were quick and completely
discernible. The typical nibbling of the fish was observable during and also after the
examination period. None of the fish used for the examination showed clinical signs of any
fish disease after the end of the examination.
The following water values were measured:
Temp: 30C pH: 7.1 02 saturation: 112%
The transfer risk of human pathogenic viruses
Results of the feed uptake: prompt and complete each time
Swab samples of the fish's mouth 1-5 (swab samples from the 1st to 5th minute) for the fish
fed with the Equine Rhinovirus-laced fish food were cpe positive, whereas samples 6-50
were cpe negative.
Swab samples of the fish fed with the EHV 1-laced fish food were completely cpe negative.
The transfer risk of zoonose bacteria
The bacteriological control schema stood the test of time during the examination
period of 6 months and proved itself as a necessary tool to guarantee the essential quality
assurance in ichthyotherapy. According to the regulations for the operation of pool areas and
the convenience of implementation (taking of samples from the fish and tub water by
professionals, analysis of the results by accredited specialists, preparation of fish health
certificates by specialist veterinary surgeons), it is possible to use the same kangal fish
several times if the microbiological monitoring is performed on a regular basis. The transfer
of human pathogenic viruses from fish to patients can be completely eliminated.
Analysis of potential microbiological risks in Ichthyotherapy using Kangal fish 97

Psoriasis is a very difficult disease to deal with and therefore demands a constant
search for new possibilities to treat it. Ichthyotherapy has already been well known in Turkey
for quite a long time, but this kind of treatment is also being used more and more in Austria.
In the meantime, the medical effectiveness of ichthyotherapy has been scientifically proven
by a pilot study.
There is an ongoing discussion regarding the potential risks of infection for the
patients, but no one has started an investigation to verify these assumptions. It is
scientifically proven that viruses with endothermic external hosts usually cannot survive in
cold-blooded animals. On the other hand, examinations regarding the surviving time of those
viruses in fish had not yet been conducted. In many countries where ichthyotherapy is
offered, the patients are asked to show a virological certificate with information on human
immunodeficiency viruses as well as hepatitis viruses.
However, these testimonials do not provide any security because the patient can get
infected by those viruses during the ichthyotherapy, which lasts 3-7 weeks, and because it is
possible that no positive evidence for human immunodeficiency viruses or hepatitis viruses
was present at the time when the testimonial was taken (diagnostic window). In our opinion,
a scientifically verified period in which 100% of the human pathogenic viruses have died off
in the fish confirms the statement that absolutely no transfer risk occurs in ichthyotherapy.
For this examination, EHV 1 and Equine Rhinoviruses were taken as model viruses because
they have nearly the same characteristics as the human herpes viruses and human
immunodeficiency viruses. On the basis of these assumptions, the experimental set-up can be
limited to the scientific question and no special safety requirements are needed to protect the
people conducting the examination. The food laced with viruses was spread equally among
all fish in the examination group due to the feeding. This made it possible to assume that all
fish had the same amounts of viruses in their mouth's mucosa.
Over a period of one hour, one mouth swab sample was taken from each fish every
minute in order to determine the exact time at which the viruses died off in the fish's body.
Both of the selected virus types were totally gone after one hour and it is therefore possible
to postulate that 1. No quarantine period of three weeks is necessary before the fish are given
to a new patient. 2. Furthermore, a one-hour break between the treatment of two different
patients in one tub should be sufficient to eliminate the transfer risks of viruses. Hence, the
use of one tub with the same Garra rufa for several patients is possible.
A bacterial hygienic risk of kangal fish therapy is proven in any case. Therefore, it is
necessary to examine the presence or absence of any bacteria to make ichthyotherapy safer
for patients. This bacteriological examination, which was undertaken for 6 months, showed
that repeated use of the same fish for different patients is possible if the bacterial flora of the
fish and therapy bathtub is checked regularly and positive fish are removed.
The highest risk is posed by fish-zoonose Tubercolosis.
Therefore, the therapy fish that are used must be free of the germs Mycobacterium
marinum and piscium.
Kangal fish therapy (ichthyotherapy) is a very special medical treatment for different
kinds of human dermatitis, particulary atopic dermatitis and psoriasis vulgaris.
A transmission of human pathogenic virus by the vector Garra rufa can be ruled out
if the break between two applications lasts more than 15 minutes (Therefore, 60 minutes are
98 Karin Heistinger et al.

A bacterial hygienic risk of kangal fish therapy is proven in any case. The highest
hygienic risk is posed by fish-zoonose Mycobacteriosis. Therefore, the density of human
pathogenenic bacteria that was found in the fish and also in the tub water needs to be
checked on a regular basis. This work can be used for the monitoring of hygiene in kangal
fish therapy (ichthyotherapy).

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