Vibrio vulnificus: A Health Professional's Guide to Infection ...

Vibrio vulnificus
A Health Professional’s Guide to
Infection, Prevention & Treatment

Presenter:
Roberta M. Hammond, Ph.D.
Food and Waterborne Disease Coordinator
Bureau of Environmental Epidemiology
4052 Bald Cypress Way, Bin #A08
Tallahassee, FL 32399-1712
Phone: (850) 245-4116
Fax: (850) 922-8473
E-mail: roberta_hammond@doh.state.fl.us
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This presentation is part of a
national effort to promote
education to health care
providers, their high risk patients
and other consumers regarding
Vibrio vulnificus and ways to
prevent it.
The Department of Health and
the Department of Agriculture
and Consumer Services are
collaborative partners on this
project. Funding for this project
has been provided by the
Department of Agriculture and
Consumer Services and the
Interstate Shellfish Sanitation
Conference.
Florida Department of Agriculture and Consumer Services
CHARLES H. BRONSON, Commissioner

Vibrios
V. vulnificus
V. cholera 01
V. cholera non-01
V. parahaemolyticus
V. alginolyticus
V. fluvialis
V. hollisae
V. mimicus
V. carchariae
V. cincinnatiensis
V. damsela
V. furnissii
V. metschnikovii
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Vibrio vulnificus: : What is it
Occurs naturally in coastal
waters - especially in warm
months
Can cause illness: wound
infections, gastroenteritis,
primary septicemia
Associated foods -
primarily raw oysters, but
also clams, mussels, and
crabs
Not the result of fecal
pollution or poor product
handling
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01/23/98

Habitat
• Oysters are filter-feeders
• Vibrios attach to plankton
• Oysters filter & concentrate vibrios in oyster
tissues ~100x
• Rapid multiplication in warm conditions after
harvest
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• Low salinity
Optimal Conditions
• Warm temperatures (86 - 95º F)
• Best conditions in May-October
• Highest number of cases same period
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Illnesses Caused by
Vibrio vulnificus
Wound infections
Gastroenteritis
Primary septicemia
No outbreaks reported, only sporadic
cases
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Infective Dose
Unknown for healthy persons, but for
high-risk people, septicemia can
presumably occur with < 100 total
organisms
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Clinical Diagnosis
Culture of V. vulnificus
from
• wounds,
• diarrheic stools, or
• blood
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Diagnosis
Symptoms
• Gastrointestinal illness
• Fever
• Shock
After
• Ingestion of raw seafood (especially oysters)
• Wound infection after exposure to seawater
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How
Wound infections
• Contaminating an open wound with sea
water harboring the organism, or
• Lacerating part of the body on coral, fish,
etc. followed by contamination with the
organism.
Range from
• Mild, self-limited lesions to
• Rapidly progressive cellulitis and myositis
• Can mimic clostridial myonecrosis
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Gastroenteritis
Consumption of raw or undercooked
seafood, primarily molluscan shellfish
containing the organism can cause
gastroenteritis in otherwise healthy
individuals.
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Primary Septicemia
Microorganism enters the blood stream
Resulting in septic shock
Hypotension (death in 90% cases)
Distinctive bulbous skin lesions
Followed by death in @ 50% of cases
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Symptomology
• Early ID & treatment critical, rapid
progression into death
• Extensive necrosis & tissue destruction
around wounds and lower extremities,
requiring surgical debridement to avoid
amputation
• Fluid leakage from capillaries into tissues
causing shock
• Septicemia - bacteria in blood
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Key Characteristics
• Highly invasive through host tissues
• Resists host defenses
• Very rapid growth in tissues, especially
where iron present
• Highly destructive of tissues -
extracellular toxins & enzymes
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Examples of Vibrio vulnificus cellulitis and lesions:
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Treatment
• Wound infections & primary septicemia
require antimicrobial treatment. Most
effective:
– tetracycline,
– fluoroquinolones (e.g. ciprofloxacin);
– 3rd generation cephalosporins (e.g. ceftazidime),
– aminoglycosides (e.g. gentamicin)
• Early administration may reduce morbidity &
mortality associated with infection
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People at High Risk
Liver disease - accounts for most cases
of severe illness
Diseases of the stomach
Diabetes
AIDs or HIV positive
Impaired immune systems due to
medication or chronic illness
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Who’s s getting sick
5 states account for 79% of all cases in
last decade (178/224)
– Florida 36%
– Texas 12%
– Louisiana 11%
– California 11%
– Alabama 9%
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Restaurant or Home “Cooked”
• 70% ate shellfish in restaurants
– More frequent in Texas 91% & Florida
79%; Louisiana, Alabama, California ~50%
• 26% ate shellfish at home
– California 44%, Alabama 37%, Louisiana
29%, Florida 18%, Texas 3%
Implications for
awareness campaign
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Composite Sketch of the Victim
Male (85% of cases)
White (77%)
• Hispanic 88% in California, 21% Texas
• Asian 13% in Louisiana
40-59 years old (53 years mean &
median)
• Slightly younger in Texas & California
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Comparative Risk
Persons with liver disease at very high
risk for serious illness & death following
exposure to V. vulnificus
• RR of infection after exposure 30x higher
for person with liver disease
• RR of death 200x higher for those with
liver disease
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A Typical Case
40 - 75 year old male
Heavy drinker, cirrhosis
Unaware of or in denial
about dietary risks
# oysters consumed: 3 -
12
Septicemia
50% mortality
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Myth
Oyster Eating Myths
Fact
Hot sauce or lemon juice will kill the
bacteria
Avoid polluted water and you’ll be
fine
You can tell a good oyster from a bad
one
Alcohol (beer, wine) kills harmful
bacteria
Just a few oysters can’t hurt
Avoiding oysters in months without
“R” is safe
Among Latino populations:
consumption of raw oysters
enhances the likelihood of male
children 25
Active ingredients in hot sauce have
no more effect on bacteria than water
Vibrio vulnificus is a naturally
occurring bacterium
Vibrio vulnificus cannot be seen,
smelled or tasted
Alcohol impairs judgment, does not
kill bacteria
High risk people have died from
eating just one oyster
Higher counts of V.v. are more likely
in warmer months, but have been
reported year-round
Oyster consumption does not
influence genetics

Consumer Awareness
• 43% of all consumers are unfamiliar with any at-risk group.
• Consumer awareness that people with liver disease are at
higher risk of illness is moderate (50%).
• Consumer awareness that people with diabetes are at
higher risk of illness is minimal (19%).
• Consumers with any risk factor are significantly more
aware of who should avoid raw oysters than those with no
known risk factor.
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Source: A Baseline Survey of Raw Oyster Consumers in Four States by
Jennifer Flattery, MPH and Michelle Bashin, MHS (ISSC)

Consumer Risk Reduction Measures
• 37% at risk consumers are eating oysters less often
primarily for health reasons.
• 42% of at risk consumers are doing nothing to reduce
their risk of illness.
• Actions taken by at risk consumers to reduce their
risk of illness are usually ineffective (see myths)
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Source: A Baseline Survey of Raw Oyster Consumers in Four States by
Jennifer Flattery, MPH and Michelle Bashin, MHS (ISSC)

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Prevention
High risk groups should avoid consumption of raw
shellfish (or any raw animal protein)
Cooking shellfish to certain temperatures for specified
time periods will kill the organism (along with many
other pathogens)
Warnings regarding high risk groups and raw shellfish
consumption are required to be posted in Florida at
restaurants and retail seafood markets
Industry and regulators are considering several post
harvest treatments (PHTs) that could eliminate the
organism in oysters including:
• Irradiation
• Mild pasteurization
• Pressure treatments
• Freezing and frozen storage

2004
2003
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30
25
20
15
10
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0
Number of V. vulnificus Cases Reported in Florida, 1988-2004
Shellfish
Wound
Unknow n
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
Year
1989
1988
Number of Cases

2004
1988
30
12
10
8
6
4
2
0
Number of V. vulnificus Deaths Reported in Florida, 1988-2004
Shellfish
Wound
Unknow n
2003
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
Year
Number of Deaths

Vibrio vulnificus Cases and Deaths Associated With Oyster Consumption,
Florida, 1988-2004
Number of Cases/Deaths
18
16
14
12
10
8
6
4
2
Cases
Deaths
0
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
Year
Total Shellfish Cases, 1988-2004: 167 Total Deaths: 75 (45%)
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Vibrio vulnificus, , Florida, 2004
Exposure
Wound
Oyster
Unknown
Total
# Cases
(deaths)
12 (0 deaths)
10 (4 deaths)
15 (7 deaths)
37 (11 deaths)
2003: 28 wound (2 deaths), 14 oysters (3 deaths), 6
unknown exposure (4 deaths): Total 48 (9 deaths)
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Investigation
1. Clinical confirmation
2. Epidemiological
interviews
3. Traceback of
shellfish source
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Epidemiological Investigation
Date and time of shellfish consumption
or other exposure
Date and time of symptom onset
Symptoms and duration
Pre-existing conditions
Date of hospitalization
Date of death (where applicable)
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Traceback Investigation
NSSP Model Ordinance
for molluscan shellfish
classifies dealer types and requirements
shellfish tag information
• dealer name and address
• certification number
• date of harvest
• harvest location
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Barriers to Traceback of Shellfish
Tags not kept by
seller
Invoices not kept by
seller
Numerous
intermediate sellers
No leftover shellfish
available
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Information Coordination
Between physicians,
laboratories and health
departments
Between laboratories
and health
departments
Between state
agencies
Between state and
federal agencies

Proper Cooking Temperatures for Oysters
and Clams
• In the shell: use small pots so the shellfish in the
center are thoroughly cooked
– Boiling: after the shells open, boil another 3-5 minutes
– Steaming: in a pot that is already steaming, cook for
another 4-9 minutes
• Shucked oysters
– Boil or simmer for at least 3 minutes or until edges curl
– Fry at 375 o for at least 3 minutes
– Broil 3 inches from heat for 3 minutes
– Bake at 450 o for 10 minutes
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Recommendations
Urge at-risk patients to avoid eating raw shellfish;
to eat only shellfish that has been thoroughly
cooked.
Urge at-risk patients who are insistent on
consuming raw shellfish to only consider shellfish
that have been post-harvest treated and labeled to
kill Vibrio vulnificus bacteria
Suspect V. vulnificus infection in those at risk who
have recently eaten shellfish or been exposed to
warm sea water.

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Selected Vibrio vulnificus Education Activities
in Florida
Annual press releases and media interviews
Pamphlets, posters and displays at conferences (FEHA/FPHA
2004, FDA, FNA, etc.)
Pamphlets to liver disease support groups
This module presented to multiple professional associations
and agencies:
‣ FMA
‣ DBPR
‣ FL Dietetic Assn (FDA)
‣ FL Academy of Physician Assistants (FAPA)
‣ Local chapters of FDA and FNA
‣ 2005 – NEHA and CSTE
2004 Train-the-trainer workshop with other Gulf Coast states
Scholarly articles

Florida Vibrio vulnificus Workgroup: Florida
Vibrio vulnificus Risk Reduction Plan for Oysters
Lead agency: DOACS Molluscan Shellfish
Program
With participants from the Florida shellfish
industry (oyster dealers, harvesters, aquaculture),
academia (UF), county extension
Implements ISSC requirement for states having
more than 2 confirmed V.v. cases traced to raw
oyster consumption through.
‣ Consumer education
‣ Processing incentives
‣ Processing controls
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Source information on Vibrio vulnificus
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CDC Health Topics A-Z:
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/
vibriovulnificus_g.htm
FDA BadBug Book:
http://www.cfsan.fda.gov/~mow/chap10.html
ISSC: http://www.issc.org/ (V. vulnificus
consumer information and education
brochure order forms)

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Please contact us if you have any questions