National Enteric Disease Surveillance: COVIS Annual Summary, 2011
Summary of Human Vibrio Cases Reported to CDC, 2011
The Cholera and Other Vibrio Illness Surveillance (COVIS) system is a national surveillance system for human infection with pathogenic species of the family Vibrionaceae, which cause vibriosis and cholera. The Centers for Disease Control and Prevention (CDC) maintains COVIS. Information from COVIS helps track Vibrio infections and determine host, food, and environmental risk factors for these infections. CDC initiated COVIS in collaboration with the Food and Drug Administration and the Gulf Coast states (Alabama, Florida, Louisiana, Mississippi, and Texas) in 1988. Using the COVIS report form (available at http://www.cdc.gov/ nationalsurveillance/PDFs/CDC5279_COVISvibriosis.pdf ), participating health officials report cases of vibriosis and cholera. The case report includes clinical data, including information about underlying illness; detailed history of seafood consumption; detailed history of exposure to bodies of water, raw or live seafood or their drippings, or contact with marine life in the seven days before illness onset; and traceback information on implicated seafood. Before 2007, only cholera, which by definition is caused by infection with toxigenic Vibrio cholerae serogroup O1 or O139, was nationally notifiable. In January 2007, infection with other serogroups of V. cholerae and other species from the family Vibrionaceae also became nationally notifiable, as vibriosis. CDC requests that all State Health Departments send all Vibrio isolates to CDC for additional characterization. For example, CDC serotypes all V. parahaemolyticus isolates received. For V. cholerae, CDC identifies serogroups O1, O75, O139, and O141 and determines whether the isolate produces cholera toxin. Although all Vibrio infections are nationally notifiable, many cases are likely not recognized because Vibrios are not easily identified on routine enteric media. A selective medium, such as thiosulfate citrate bile salts sucrose agar (TCBS), should be used. This report summarizes human Vibrio infections occurring during 2011 reported to COVIS. Results are presented in two categories: (1) infection with pathogenic species of the family Vibrionaceae (other than toxigenic Vibrio cholerae serogroups O1 and O139), which cause vibriosis; this category includes infection with toxigenic V. cholerae of serogroups other than O1 and O139, and (2) infection with toxigenic V. cholerae serogroups O1 and O139, which cause cholera. While many Vibrio species are well-recognized human pathogens, the status of some species (including Photobacterium damselae subsp. damselae (formerly V. damsela), V. furnissii, V. metschnikovii, and V. cincinnatiensis) as human enteric or wound pathogens is less clear. Understanding the routes by which infection is transmitted is essential for control. For vibriosis, cases are summarized by place of exposure (travel-associated vs. domestically acquired). For domestically acquired vibriosis, transmission routes (e.g., foodborne, non-foodborne, and unknown, see Appendix for classification method) are determined based on reported patient exposures and specimen sites. For toxigenic V. cholerae (all serogroups), exposures are summarized by place of exposure (travelassociated vs. domestically acquired) and then, if information is available, by source (such as consumption of contaminated seafood).
This Gram-stain depicts flagellated Vibrio comma bacteria, a strain of V. cholerae.
National Center for Emerging and Zoonotic Infectious Diseases Division of Foodborne Waterborne, and Environmental Diseases
CS237579-F August 2013
I. Vibriosis
Pathogenic species of the family Vibrionaceae (excluding toxigenic V. cholerae O1 and O139)
In 2011, 853 Vibrio infections (excluding toxigenic V. cholerae O1 and O139) were reported to COVIS (Table 1). Among patients for whom information was available, 272 (34%) of 811 were hospitalized, and 48 (6%) of 785 died. The most frequently reported species was V. parahaemolyticus, which was isolated from 334 (39%) of the 853 patients. Of the patients infected with V. parahaemolyticus for whom information was available, 75 (24%) of 315 were hospitalized, and 2 (<1%) of 304 died. V. alginolyticus was isolated from 156 (18%) of the 853 patients; of the patients for whom information was available, 16 (11%) of 147 were hospitalized; no deaths were reported. V. vulnificus was isolated from 113 (13%) of the 853 patients; of the patients for whom information was available, 89 (87%) of 113 were hospitalized, and 34 (31%) of 108 died. Table 1. Vibriosis cases by species, selected demographic characteristics, and outcome, United States, 2011
Demographic Characteristics Vibrio Species Cases N V. alginolyticus V. cholerae (excluding toxigenic O1 and O139)* Photobacterium damselae subsp. damselae (formerly V. damsela) V. fluvialis Grimontia hollisae (formerly V. hollisae) V. mimicus V. parahaemolyticus V. vulnificus Species not identified Multiple species?? Total 156 86 7 37 7 15 334 113 87 11 853 % 18 10 1 4 1 2 39 13 10 1 100 Age (years) Median 33 48 55 65 50 45 45 60 44 52 47 Range 2-86 1-85 6-77 20-108 42-75 4-87 1-94 8-91 3-93 23-80 1-108 Sex Male (n/N) 118/155 59/86 4/7 18/37 7/7 11/14 225/334 87/111 51/86 7/11 587/848 % 76 69 57 49 100 79 67 78 59 64 69 Outcomes Hospitalizations n/N 16/146 28/82 3/6 18/34 4/7 6/15 75/315 89/113 19/82 4/11 272/811 % 11 34 50 53 57 47 24 87 23 36 34 Deaths n/N 0/144 3/80 0/1 0/33 0/6 0/15 7/304 34/108 4/78 0/10 48/785 % 0 4 0 0 0 0 2 31 5 0 6
*Includes 86 non-toxigenic V. cholerae (non-O1, non-O139 [68 cases], O1 [2 cases], O139 [1 case], and no serogroup specified [2 cases]) and 13 toxigenic V. cholerae (O75 [12 cases] and O141 [1 case]). ??The following combinations of Vibrio species were isolated from patients infected with multiple species: V. alginolyticus, V. parahaemolyticus (3 patients); V. cholerae O1, V. parahaemolyticus (1 patient); V. fluvialis, V. parahaemolyticus (1 patient); P. damselae subsp. damselae, Vibrio species not identified (1 patient); V. fluvialis, V. furnissii (1 patient); V. parahaemolyticus, V. vulnificus (1 patient); V. cholerae non-O1, non-O139, Vibrio species not identified (1 patient); V. alginolyticus, Vibrio species not identified (1 patient); V. alginolyticus, P. damselae subsp. damselae (1 patient). None of these are included in the rows for individual species.
August 2013
Page 2 of 10
Geographic Location
Of the 853 cases of vibriosis, 279 (33%) were reported from Gulf Coast states, 170 (20%) from Pacific Coast states, 288 (34%) from Atlantic Coast states, and 116 (14%) from non-coastal states (Figure 1). The Vibrio species reported most frequently from Gulf Coast states were V. vulnificus (26%), V. alginolyticus (22%), V. parahaemolyticus (21%), and V. cholerae (excluding toxigenic V. cholerae O1 and O139) (13%). The Vibrio species reported most frequently from non-Gulf Coast states were V. parahaemolyticus (48%), V. alginolyticus (17%), Vibrio species not identified (12%), V. vulnificus (7%) and V. cholerae (excluding toxigenic V. cholerae O1 and O139) (7%). Figure 1. Number of cases of Vibrio infections (excluding toxigenic V. cholerae O1 and O139), by state, 2011 (N=853 from 43 states).
45 2 5 2 1 6 87 24 1 16 3 2 13 73 53 10 11 8 34 8 6 10 2 2 2 30 15 9 61 4
6
MA (48) RI (2) CT (18) NJ (26) DE (6) MD (34) DC (1)
2
132
33
Region Atlantic Gulf Coast Non-Coastal Pacific
August 2013
Page 3 of 10
Transmission categories and reported exposures
Among the 853 vibriosis patients, 43 (5%) reported international travel in the seven days before illness began. Among the 810 domestically-acquired vibriosis cases, 409 (50%) were classified as confirmed or probable foodborne, 320 (40%) as confirmed or probable non-foodborne, and 81 (10%) as having an unknown transmission route (Figure 2). Illnesses peaked in the summer months for all categories, but the peak was most pronounced for foodborne infections (Figure 3). Among the 184 patients with foodborne vibriosis who reported eating a single seafood item (Table 2), 117 (63%) ate oysters (91% of whom consumed them raw), 12 (7%) ate clams (75% of whom consumed them raw), 25 (14%) ate shrimp, and 13 (7%) ate finfish. For cases with non-foodborne transmission, 243 (76%) patients reported having skin exposure to a body of water within 7 days before illness began, 28 (9%) reported handling seafood, and 40 (13%) reported contact with marine wildlife. Figure 2. Domestically acquired vibriosis cases by transmission route and species, United States, 2010 (N=871).
100 90 80 70 Percent (%) 60 50 40 30 20 10 0
0) 2) 6) ) ) 8) ) ) 2) 7) 15 =7 13 10 15 =8 =3 30 n= n= =1 n= =7 n= n= (n (n e( ae s( (n r( (n s( le sp ec ul tip ie n= (n 10 )
ler ae
la
lis
s(
s(
icu
llis
us
he
se
icu
ia
icu
V. fl
sp .d
V. m
G.
ol
V. c
ol
ul
in
m
V. v
V. a
ub
ae
ar ah
es
sn
ot Sp ec ie
lg
id
en tif M
am
ho
ho
yt
im
uv
yt
la
Confirmed Foodborne
P. d
am
Probable Foodborne
Confirmed Non-foodborne
V. p
se
ni
Probable Non-foodborne
Ot
fic
ie
d
Unknown
August 2013
Page 4 of 10
Figure 3. Domestically-acquired vibriosis cases, by month of illness onset or specimen collection (when onset date not available) and transmission route, 2011 (N=810).
120 100 80 60 40 20 0
No. of cases
Jan
Feb
Mar
Apr
Mar
Jun
Jul
Aug
Sep
Oct
Nov Unknown
Dec
Month of illness onset Total confirmed and probable foodborne Total confirmed and probable non-foodborne
Table 2. Seafood exposures among 184 patients with domestically-acquired foodborne vibriosis who reported eating a single seafood item in the week before illness onset, 2011.
Mollusks Oysters Patients who ate single seafood item n (% of 184) Patients who ate the single seafood item raw, n (% of n in row above) Clams Mussels Shrimp Crustaceans Lobster Crab Crayfish Other Other Shellfish* 1 (0.5) Finfish??
117 (64)
12 (7)
0 (0)
25 (14)
0 (0)
14 (8)
2 (1)
13 (7)
107 (91)
9 (75)
0 (0)
5 (20)
0 (0)
1 (7)
0 (0)
0 (0)
4 (31)
* Other shellfish reported: conch ?? Finfish reported: catfish, cod, haddock, halibut, salmon, unspecified sushi, tilapia, tuna.
Laboratory
In 2011, 173 isolates were confirmed at CDC as V. parahaemolyticus; 41 serotypes of V. parahaemolyticus were identified: 16% were of the pandemic clone serotype O3:K6, 10% were O4:Kuk, 10% O4:K12, 10% O1:Kuk, 10% O3:Kuk, and 21% were one of 36 other serotypes.
August 2013
Page 5 of 10
Toxigenic V. cholerae, excluding serogroups O1 and O139
Serogroup O141
In 2011, one patient with toxigenic V. cholerae serogroup O141 infection was reported. This patient reported consumption of raw oysters. The patient was not hospitalized.
Serogroup O75
In 2011, a total of 12 patients with toxigenic V. cholerae O75 infection were reported. Of note, the first reported outbreak in the United States of toxigenic V. cholerae O75 occurred in 2011. A total of 11 patients were reported as part of the outbreak; two were hospitalized and none died. All patients reported consumption of raw or lightly cooked oysters. Oyster traceback was available for 8 patients, and Apalachicola Bay harvest area 1642 was implicated as the source. The other 2011 patient with toxigenic V. cholerae O75 was lost to follow-up, so the patient’s exposures were not reported. Table 3. Cases of toxigenic V. cholerae O141 and O75 infections, 2011.
State Louisiana Florida Indiana Florida Georgia Louisiana Florida Florida Florida Florida Tennessee Alabama Louisiana Age 39 31 42 72 59 68 74 48 22 40 34 60 39 Sex F F M F M F M M M M F M F Month of Illness onset October March April April April April April April April April April May July International Travel No No No No No No No No No No No No No Exposure consumption of raw oysters consumption of raw oysters consumption of raw oysters consumption of raw oysters consumption of raw oysters consumption of raw oysters consumption of raw oysters consumption of lightly cooked oysters consumption of raw oysters consumption of raw oysters consumption of raw oysters consumption of raw oysters lost to follow-up Serogroup O141 O75 O75 O75 O75 O75 O75 O75 O75 O75 O75 O75 O75
*This patient also was infected with V. mimicus ??Illness occurred in 2009, but isolate was submitted to CDC in October 2010
August 2013
Page 6 of 10
II. Cholera
Serogroup O1 & O139
In 2011, 42 patients with toxigenic V. cholerae serogroup O1 infection were reported; 40 infections were cultureconfirmed, and two were confirmed by serologic testing. Of the 42 patients, 52% were hospitalized and none died. Thirty-nine (93%) cases were travel-associated (22 with travel to Haiti, 11 to the Dominican Republic, and 6 to other cholera-affected countries). For the other 3 cases, one patient reported consumption of imported seafood, one of ‘souvenir seafood’ from Haiti, and exposures for one were not reported. Table 4. Cases of toxigenic V. cholerae O1 infection, 2011
State Florida Florida Kansas Massachusetts Florida Massachusetts Massachusetts Massachusetts Michigan New York City New York City New York City New York City Texas Florida Florida Alaska New Mexico Guam New Jersey New York Florida Puerto Rico New York City Age 53 73 38 30 31 19 16 59 46 29 29 29 28 43 38 51 26 65 27 78 74 44 70 76 Sex M M F M F F M M F M M M M M F F M M M F M M M M Month of Illness Onset January January January January January January January Unknown February January January January January January January February March March Unknown May June June June June International Travel Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Unknown Yes Yes Yes Yes Yes Exposure Haiti Haiti Haiti Dominican Republic Consumption of ‘souvenir seafood’ (conch from Haiti) Dominican Republic Dominican Republic Dominican Republic Haiti Dominican Republic Dominican Republic Dominican Republic Dominican Republic Dominican Republic Haiti Philippines Ghana Bangladesh Unknown India Haiti Haiti Dominican Republic Haiti Serogroup O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa SEROPOSITIVE O1 ET Ogawa SEROPOSITIVE O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa
August 2013
Page 7 of 10
Table 4. Cases of toxigenic V. cholerae O1 infection, 2011
State Pennsylvania New York City Florida Kentucky Kentucky Florida Florida California New York City New York City Florida New York City Florida New York City Georgia Virginia Illiniois New York Age 56 46 34 65 35 52 42 55 51 34 50 24 62 63 52 54 41 49 Sex F F M M F F M F F F F F F M M M F F Month of Illness Onset July July July July Unknown September September September September September September October October October November December December November International Travel Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Exposure Haiti Consumption of imported shrimp Haiti Haiti Haiti Haiti Resident of Haiti Pakistan Dominican Republic Haiti Haiti Haiti Haiti Haiti Haiti Haiti Benin Haiti Serogroup O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa O1 ET Ogawa
III. Recent publications using COVIS data
Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson MA, Roy SL, et al. Foodborne illness acquired in the United States—major pathogens. Emerg Infect Dis. 2011: 17(1):7-15. Daniels NA. Vibrio vulnificus Oysters: Pearls and Perils. Clin Infect Dis. 2011: 52(6):788-792. Onifade TM, Hutchinson R, Van Zile K, Bodager D, Baker R, Blackmore C. Toxin producing Vibrio cholerae O75 outbreak, United States, March to April 2011. Euro Surveill. 2011;16(20). Newton AE, Heiman KE, Schmitz A, T??r??k T, Apostolou A, Hanson H, et al. Cholera in United States associated with epidemic in Hispaniola. Emerg Infect Dis. 2011:17:2166-2168.
August 2013
Page 8 of 10
Appendix
Method for Classification of Transmission Routes in the Cholera and Other Vibrio Illness Surveillance (COVIS) System I. Exposure categories
To classify transmission routes, the first step is to categorize patient exposures. For a given illness episode, >1 patient exposure can be reported to COVIS; each reported exposure is categorized individually. If all exposures fall into a single category, then the report is considered to have a single exposure category. If not, the report is considered to have multiple exposure categories. For a given case, if any exposure is reported, we assume that other exposures for which information was not reported were not present. Exposures are classified using three categories: 1. Seafood consumption: Ingestion of seafood. Does not include touching seafood. 2. Marine/estuarine contact: Includes direct skin contact with marine/estuarine life, bodies of water, or drippings from raw or live seafood. 3. Unknown exposure: no exposure history reported.
II. Specimen site categories
The next step in classifying transmission routes is to categorize reported specimen sites. For a given illness episode, >1 specimen site can be reported; each reported site is categorized individually. If all specimen sites fall into a single category, then the report is considered to have a single specimen site category. If not, then the report is considered to have multiple specimen site categories. Specimen sites are classified using five categories: 1. Gastrointestinal site (GI): stool, bile, appendix, rectum, gall bladder, colon 2. Blood or other normally sterile site (sterile): blood, CSF, peritoneal fluid, lumbar disc fluid, lymph node, bullae 3. Skin or soft tissue site (SST): wound, any ear (other than otitis media and middle ear, which are included in ‘other, non-sterile site’), appendage, tissue 4. Other, non-sterile site (ONS): urine, sputum, aspirate, bronchial washing, effusion, catheter, endotracheal, eye, nasal, placenta, respiratory, sinus, tonsil 5. Unknown site (unknown): no specimen site reported or no site specified for ‘other’ Note: The lists of sites for each category above are not intended to be exhaustive. Rather, they reflect the sites actually reported to COVIS and can be updated, if new sites are reported.
III. Transmission route
The final step in classifying transmission involves review of exposure and specimen site categories for each reported case. Reports are classified into one of three transmission routes, foodborne, non-foodborne, and unknown, based on criteria below: 1. Single exposure category: seafood consumption ?? Confirmed Foodborne: Vibrio isolated only from GI or sterile site OR Vibrio isolated from multiple multiple specimen site categories, including a GI site. ?? Probable Foodborne: Vibrio isolated only from SST, ONS, or unknown sites OR Vibrio isolated from multiple specimen site categories, not including GI.
August 2013
Page 9 of 10
2. Single exposure category: marine/estuarine contact ?? Confirmed Non-foodborne: Vibrio isolated only from SST or sterile site OR Vibrio isolated from multiple specimen site categories, with SST reported. ?? Probable Non-foodborne: Vibrio isolated only from GI, ONS, or unknown sites OR Vibrio isolated from multiple specimen site categories, not including SST. 3. Multiple exposure categories: both seafood consumption AND marine/estuarine contact ?? Confirmed Foodborne: Vibrio isolated only from a GI site OR Vibrio isolated from multiple specimen site categories, with GI reported and SST not reported. ?? Confirmed Non-foodborne: Vibrio isolated only from a SST site OR Vibrio isolated from multiple specimen site categories, with SST reported and GI not reported. ?? Unknown: Vibrio isolated only from a sterile, ONS, or unknown site OR Vibrio isolated from multiple specimen site categories, including either 1) both GI and SST or 2) neither GI nor SST. 4. Unknown or no reported exposure (note that categorization is the same as for multiple exposure categories) ?? Confirmed Foodborne: Vibrio isolated only from a GI site OR Vibrio isolated from multiple specimen site categories, with GI reported and SST not reported. ?? Confirmed Non-foodborne: Vibrio isolated only from a SST site OR Vibrio isolated from multiple specimen site categories, with SST reported and GI not reported. ?? Unknown: Vibrio isolated only from a sterile, ONS, or unknown site OR Vibrio isolated from multiple specimen site categories, including either 1) both GI and SST or 2) neither GI nor SST.
NCEZID Atlanta: For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 MS C-09 Telephone: 1-404-639-2206 Email: cdcinfo@cdc.gov
August 2013
Page 10 of 10