Vibrioses(Not Cholera)

 

Literature Recommendations

Exclusion-Case in SOS*
(Symptomatic)

Yes [2, 3a, 4a, 5]
Grade III-A

Exclusion-Case in SOS*
(Asymptomatic or previously symptomatic but now recovered)

No [3a, 4a]
Grade III-C

Clearance-Case in SOS*

Not required [3, 4]
Grade III-C

Exclusion of Contact
(Symptomatic)

Yes [2, 3a, 4a, 5]
Grade III-A

Exclusion of Contact
(Asymptomatic)

Specific recommendation excluding asymptomatic contacts unavailable in literature reviewed.

Exclusion-Case in Children
(Group setting with children ≤ 5 years of age)
(Symptomatic)

Yes [2, 8]
Grade III-A

Exclusion-Case in Children
(Group setting with children ≤ 5 years of age)
(Asymptomatic or previously symptomatic but now recovered)

No [2, 8]
Grade III-A

◊ Applicable Code

None
* SOS (Sensitive Occupations or Situations) is not defined precisely in either the Code of Regulations or Health & Safety Code. See Attachment 2 for the definition of food workers.
◊ See California Code of Regulations, Attachment 1, for details.
+ Local health departments may elect to follow more restrictive exclusion and clearance criteria

a exclude until 48hrs after 1st normal stool. Clinical surveillance of cases

Disease Trends in the U.S.:

The literature is replete with information on outbreaks in the United States due to V. parahaemolyticus and V. vulnificus, and there is relatively little specific information on outbreaks caused by the other Vibrioses (not V. Cholerae O1 or O139).

In 2006, three separate states reported a total of 177cases of V. parahaemolyticus and 122 cases were associated with 17 clusters (defined as two or more ailing persons linked to the same shellfish source) (20). Seventy-two cases were confirmed and one hundred five probable. The identified source was contaminated shellfish from Washington and British Columbia sold to various restaurants (20).

In 2005, following hurricane Katrina 22 new cases of Vibrio infection were identified. The organisms responsible were “V. parahaemolyticus, V. vulnificus, and nontoxogenic V. cholerae, all which are most commonly acquired from the environment and are not likely to cause outbreaks from person to person spread (19).” Seventeen cases were wound infections, and a result of wading through floodwaters and four were gastrointestinal illness (19).

In Florida from 1982-1993 there were over 650 Vibrio infections reported (690 infections in 675 people), some persons were infected with more than one Vibrio species. The annual incidence of Vibrio infection was 5.1/100,000 persons older than seventeen (17). The majority of gastroenteritis cases were a result of eating seafood.

Since the middle of the 1990’s there has been a dramatic upsurge in incidence of V. parahaemolyticus in the United States which is likely linked to the emergence a new clonal group that could potentially cause pandemics and contains isolates in serotype O3:K6, O4:K68, and O1:K nontypeable along with elevating water temperatures in areas where (9, 16). From 1973-1998 40 outbreaks with over 1000 resulting cases of V. parahaemolyticus were reported to the Center for Disease Control and Prevention (CDC). The majority of these were linked to the ingestion of seafood, predominantly shellfish (16).

From 1988-1996 there were 422 cases reported of V. vulnificus 204 were a result of eating seafood, and only 23% of these cases presented with gastrointestinal illnesses (14). One hundred eighty-nine infections were a result of wound exposure to seawater or to drippings from seafood (14)

In California from 1983-1993 the Department of Health Services received reports on 24 V vulnificus cases, 18 of which were fatal primarily resulting from sepsis. The majority of these patients had eaten oysters (18). From May 1993-October 1995, in Los Angeles County, raw oyster consumption caused 10 cases of V. vulnificus bacteremia leading to the death of seven individuals. Furthermore in that same region in 1996, five additional cases occurred four of which ended in death (18).

Vibrioses (Not Cholera)
The most important noncholera Vibrio species associated with diarrhea are V. parahaemolyticus, V. cholerae non-O1, V. mimicus, V. hollisae, V. fluvialis, and V. furnissii. V. vulnificus causes primary septicemia and severe wound infections, especially in people with immunodeficiency or liver disease. V. parahaemolyticus, V. damsela, and V. alginolyticus also are associated with wound infections (10).
Organism: Vibrio species are gram-negative, facultative anaerobes that can carry out fermentative and respiratory metabolism. They use their single polar flagellum for motility (6). V. parahaemolyticus is a common cause of gastroenteritis, and is the leading cause of food borne illness in Japan. V. vulnificus is a highly invasive and rapidly fatal pathogen (fatality range from 20-30%) (6). In the U.S. it is the principal cause of death associated with eating seafood. This is a direct result of its ability to produce serious wound infections and sepsis in patients with pre-existing liver disease and those who are immunocompromised (9).  In such patients V. vulnificus can promptly pass through the gut mucosa inducing sepsis and skin lesions within one and one half days after symptoms of infection start (18).

Reservoir of infection: Present in aquatic environments around the world (mainly in brackish waters) and tend to prefer salty environments. Their numbers reach their nadir in warmer seasons (1, 9). They can cling to zooplankton and shellfish and are present in various tissues of shellfish such as clams, oysters and mussels. These shellfish can accumulate bacteria within themselves as they filter-feed and concentrate the bacteria to levels 100 times that of the water that surrounds them (6, 9). Vibrio isolates can also live and propagate in a variety of foods items (1). In the warmer summer months, potentially 100% of oysters will carry V. vulnificus and/or V. parahaemolyticus (9)

Modes of transmission: Primarily from the consumption of raw or undercooked seafood, especially shellfish and from ingestion of surface water (1). Gastroenteritis usually follows ingestion of uncooked or undercooked seafood, especially oysters, crabs, and shrimp. Wound infections commonly result from exposure of abrasions to contaminated seawater or from punctures resulting from handling of contaminated shellfish. Exposure to contaminated water during natural disasters such as hurricanes has resulted in wound infections attributable to V. vulnificus. Enteritis is generally not communicable person to person (10).

Attack rates: are varied by species:
V. parahaemolyticus during the 1973-1998 periods it was 56% for persons consuming the suspected seafood (16).
           
Infectious dose:  V. parahaemolyticus 100000 to 10000000 organisms (16).

Incubation Period: is 12-72 hours (19). According to Red Book®, “the median incubation period of enteritis is 23 hours (range = 5 to 92 hours) (10).”
V. parahaemolyticus mean incubation period is 15-17 hours (range: 4-96 hours) (12, 9).
V. vulnificus Incubation period is one to seven days (15)

Infectious Period: not known in nature whether these infections can be transmitted from person to person. A period of communicability would only last as long as Vibrios are excreted (several days) (1, 3)

Asymptomatic carrier state: Has been documented to occur in V. cholerae non-O1 (14).

Diagnosis: is by the isolation of Vibrio organisms from stool or vomitus of individuals with gastroenteritis, along with blood samples and exudates of lesion. When isolating the organism from stool, utilize a selective medium that has thiosulfate citrate bile salts sucrose (TCBS agar) (1, 6, 16)

Preventive Measures
Exclusions:

  1. Persons with active diarrhea should be excluded from work until 48 hours after 1st normal stool (3, 4- Guidelines and Consensus documents) {Grade III-A}
  2. According to a joint collaborative project of The American Academy of Pediatrics, American Public Health Association & National Resource Center for Health and Safety (2002), in a child care setting, caregivers with “diarrhea (defined as 3 or more stools in 24 hr or blood in stool) shall be excluded from childcare. Exclusion for acute diarrhea shall continue until diarrhea stops or stools are deemed non-infectious by licensed health care professional. Children who develop diarrhea should be isolated from other children pending arrival of parent who should remove them from the facility. Children and caregivers who excrete intestinal pathogens but no longer have diarrhea generally may be allowed to return once diarrhea stops, except in those with Shigella, E. Coli O157:H7 or Salmonella Typhi (2- Guidelines and Consensus documents).” {Grade III-A}
  3. According to the Public Health Laboratory Service (2004), “person-to-person transmission hasn’t been demonstrated and secondary spread is rare even where sanitation is suboptimal suggesting infectious dose is high in healthy individuals (3 Guidelines and Consensus documents).” {Grade III-A}
  4. According to the American Academy of Pediatrics (2005), “Temporary exclusion is recommended when a child has diarrhea: defined as more watery stools, decreased form of stool that is not associated with dietary changes and increased frequency of passing stool that is not contained by the child’s ability to use the toilet. Exclusion until diarrhea resolves(8- Guidelines and Consensus documents).” {Grade III-A}
  5. According to Cruickshank (1990), “a food handler who is symptomatically ill with a gastrointestinal illness presents a real hazard and should be excluded from work (22).” Evidence Based Literature. {Grade III-A}
  6. According to Bolyard et al. (1998), “Restriction from patient care and the patient’s environment, or food handling is indicated for personnel with diarrhea or acute gastrointestinal symptoms, regardless of the causative agent (21 pg. 308). Evidence based reviews with guidelines formed out of reviewed literary sources. {Grade III-A}

References:

    1. Heymann, D.L. ed. Control of Communicable Disease Manual, 18th edition.2004. American Public Health Association, Washington, DC. Pgs 103-114. Guidelines and Consensus document
    2. APHA, AAP, & NRCHS. Exclusion and Inclusion of Ill Children in Child Care Facilities and Care of Ill Children in Child Care. National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care. Second Edition. 2002. A Joint Collaborative Project of The American Academy of Pediatrics Elk Grove Village, IL., The American Public Health Association Washington, D.C. & The National Resource Center for Health and Safety in Child Care, University of Colorado Health Sciences Center at Fitzsimons Campus Aurora, CO. Guidelines and Consensus document
    3. Public Health Laboratory Service, Advisory Committee on Gastrointestinal infections. Preventing Person to Person Spread Following Gastrointestinal Infections: Guidelines for Public Health Physicians and Environmental Health officers. Communicable Disease and Public Health 2004; 7(4):362-384. Guidelines and Consensus document
    4. Communicable Disease Report Review. The Prevention of Human Transmission of Gastrointestinal infection, infestations, and bacterial infestations. A Guide for Public Health Physicians and Environmental Health officers in England and Wales 1995; Volume 5 Number 11: R158-172 Guidelines and Consensus document
    5. Guerrant RL, Van Gilder T, Steiner TS, et al. Practice Guidelines for the Management of Infectious diarrhea. Clinical Infectious Disease February 2001:32:331-350. Evidence based reviews with guidelines formed out of reviewed literary sources
    6. Tantillo GM, Fontanarosa M, Di Pinto A & Musti M.  A REVIEW: Updated perspectives on emerging vibrios associated with human infections. Letters in Applied Microbiology 2004, 39, 117–126. Evidence Based Literature
    7. Daniels NA and Shafaie A. A Review of Pathogenic Vibrio Infections for Clinicians. Infections in Medicine 2000; 17:665–685. Evidence Based Literature
    8. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide 2005 Aronson SS and Shope TR eds. Chapter 5. Accessed on 7/30/07 at www.aap.org. Guideline and Consensus document
    9. Morris JG. Cholera and Other Types of Vibriosis: A Story of Human Pandemics and Oysters on the Half Shell. Clinical Infectious Diseases 2003; 37:272–280. Evidence Based Literature.
    10. American Academy of Pediatrics. Section 3 Summaries of Infectious Diseases Vibrio Infections In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006: 728-729. Guideline and Consensus documents
    11. CDC. MMWR. Vibrio parahaemolyticus Infections Associated with Consumption of Raw Shellfish --- Three States, 2006; 55(31):854-856. Review of Outbreaks and Epidemiology
    12. CDC. MMWR. Outbreak of Vibrio parahaemolyticus Infections Associated with Eating Raw Oysters -- Pacific Northwest, 1997. 1998; 47(22):457-462. Review of Outbreaks and Epidemiology.
    13. Morris JG Jr. Non-O group 1 Vibrio Cholerae: A look at the Epidemiology of an Occasional Pathogen. Epidemiology Review 1990; 12:179-191. Review of Outbreaks and Epidemiology.
    14. Shapiro RL, Altekruse S, Hutwanger L et al. The Role of Gulf Coast Oysters Harvested in Warmer Months in Vibrio vulnificus Infections in the United States 1988-1996. Journal of Infectious Disease 1998; 178:752-759. Review of Outbreaks and Epidemiology.
    15. CDC. Diagnosis and Management of Foodborne Illnesses. A Primer for Physicians and Other Health Care Professionals. MMWR 2004; 53(RR-4):1-29. Evidence based reveiw
    16. Daniels NA, MacKinnon L, Bishop R, et al. Vibrio parahaemolyticus Infections in the United States, 1973-1998 Journal of Infectious Disease 2000; 181:1661-1666. Review of Outbreaks and Epidemiology.
    17. Hladyy WG & Konltz KC. The Epidemiology of Vibrio Infections in Florida, 1981-1993. Journal of Infectious Diseases 1996; 173:1176-1183. Review of Outbreaks and Epidemiology.
    18. Mouzin E, Mascola L, Tormey MP, & Dassey DE. Prevention of Vibrio vulnificus Infections Assessment of Regulatory Educational Strategies. JAMA 1997; 278(7):576-578. Review of Outbreaks and Epidemiology.
    19. CDC. Vibrio Illnesses after Hurricane Katrina-Multiple States August-September 2005. MMWR 2005; 54(37):928-931. Review of Outbreaks and Epidemiology.
    20. CDC. Vibrio parahaemolyticus Infections Associated with Consumption of Raw Shellfish-Three States-2006. MMWR 2006; 55(31): 854-856. Review of Outbreaks and Epidemiology.
    21. Bolyard EA, Tablan OC, Williams WW, et al. Guideline for infection control in health care personnel, 1998. American Journal of Infection Control 1998; 26(3):289-354. Evidence based reviews with guidelines formed out of reviewed literary sources.
    22. Cruickshank JG. Food Handlers and Food Poisoning. BMJ 1990; 300(6917):207-208. Evidence Based Literature.