Vibrio Parahaemolyticus An overview for public health staff Katherine Denter, MPH student Walden University PUBH 6165-4 Instructor: Dr. Robert Marino Fall Term, 2010 November 5, 2010

Vibrio Parahaemolyticus An overview for public health staff Welcome, and thank you for coming today. My name is Katherine Denter and I am a health educator here at the health department. The presentation for today has been created for communicable disease staff who may be asked to provide information to the public or to commercial shellfish farms on vibrio parahaemolyticus, or conduct investigations into outbreaks.

Learning Outcomes By the end of this course you should be able to: Describe where Vibrio Parahaemolyticus is found List 2 items food items that can harbor Vibrio Parahaemolyticus List 2 adverse effects on humans Explain 2 prevention strategies By the end of this presentation you should be able to describe what vibrio parahaemolyticus is, list the effects on humans, and list prevention strategies. This presentation will also provide you with some of the current research that has been done regarding vibrio parahaemolyticus. November 5, 2010

Vibrio There are 8 species of Vibrio V. alginolyticus V. cholerae V. fluvialis V. hollisae V. metschnikovii V. mimcus V. parahaemolyticus V. vulnificus There are 8 different species of vibrio. They are vibrio alginolyticus, cholerae, fluvialis, hollisae, metschnikovii, mimcus, parahaemolyticus, and vulnificus. Centers for Disease Control and Prevention, (2008). Summary of human vibrio cases reported to CDC, 2008. Retrieved from: www.cdc.gov/nationalsurveillance/PDFs/Jackson_vibrio_CSTE2008_FINAL.PDF November 5, 2010

Vibrio in Washington In the state of Washington V. parahaemolyticus is the most common species This presentation will focus only on this species of vibrio Washington State Department of Health, (2010). Vibriosis in Shellfish. Retrieved from www.doh.wa.gov/ehp/sf/Pubs/vibrio-fs.htm While there are 8 different species of vibrio, only one is typically found in the state of Washington, which is v. parahaemolyticus. The rest of this presentation will focus only on this species. November 5, 2010

V. Parahaemolyticus V. parahaemolyticus is a bacteria that is found in brackish saltwater. In the same family as the bacteria that causes cholera. It is halophilic – which means it is an organism that requires salt. Centers for Disease Control and Prevention, (2009). Vibrio parahaemolyticus general information. Retrieved from http://www.cdc.gov/nczved/divisions/dfbmd/diseases/vibriop/ Washington State Department of Health, (2010). Vibriosis in Shellfish. Retrieved from www.doh.wa.gov/ehp/sf/Pubs/vibrio-fs.htm V. Parahaemolyticus is a bacteria that is found in brackish saltwater. It is in the same family as the bacteria that causes cholera, and it is a halophilic organism, which means it requires salt. November 5, 2010

This is V. parahaemolyticus under magnification. The CDC has provided a magnified view of v. parahaemolyticus. Other species like V. vulnificus have a little tail on them. Photo provided by the CDC as public domain and free of copyright restrictions. Centers for Disease Control and Prevention, (2005). Vibrio parahaemolyticus. Public Health Image Library. Retrieved from http://phil.cdc.gov/phil/details.asp November 5, 2010

V. Parahaemolyticus “V. parahaemolyticus is the leading cause of seafood-associated gastroenteritis in the United States, typically associated with the consumption of raw oysters gathered from warm-water estuaries” (McLaughlin et al, 2005, p. 1463) McLaughlin et al, (2005). Outbreak of Vibrio parahaemolyticus gastroenteritis associated with Alaskan oysters. New England Journal of Medicine, 353(14), 1463 – 1470. Retrieved from www.nejm.org Researches McLaughlin et al state that V. Parahaemolyticus is the leading cause of seafood-associated gastroenteritis in the US and it is typically associated with eating raw oysters. When you are talking to someone you suspect of having vibrio asking about consumption of raw shellfish would be a good place to start, making note to ask specifically about raw oysters. November 5, 2010

Environment V. parahaemolyticus is found naturally in coastal waters It is typically found in high concentrations in warmer months The peak month for vibrio is July. Centers for Disease Control and Prevention, (2008). Summary of human vibrio cases reported to CDC, 2008. Retrieved from: www.cdc.gov/nationalsurveillance/PDFs/Jackson_Vibrio_CSTE2008_FINAL.PDF Washington State Department of Health, (2010). Vibriosis in Shellfish. Retrieved from www.doh.wa.gov/ehp/sf/Pubs/vibrio-fs.htm V. Parahaemolyticus is found naturally in coastal waters. Higher concentrations are found during the warmer months, especially July. November 5, 2010

Who is at Risk Anyone who eats raw or undercooked shellfish could be at risk. Persons who use antacids could be at an increased risk. It is thought reduced stomach acid allows the bacteria to easily pass into the intestinal system. Washington State Department of Health, (2010). Vibriosis in Shellfish. Retrieved from www.doh.wa.gov/ehp/sf/Pubs/vibrio-fs.htm Anyone who eats raw shellfish could become infected with the V. parahaemolyticus bacteria. Persons who take antacids could be at an increased risk for infection. It is thought that the reduced stomach acids allow the bacteria to more easily pass through the stomach and into the small intestine. A case investigation should include questions regarding antacid use. November 5, 2010

How it’s Spread V. parahaemolyticus can be spread to humans through the consumption of raw or undercooked shellfish. It can also cause an infection if a person has an open wound and they are exposed to warm seawater that has the V. parahaemolyticus bacteria in it. Centers for Disease Control and Prevention, (2009). Vibrio parahaemolyticus general information. Retrieved from www.cdc.gov/nczved/divisions/dfbmd/diseases/vibriop/ The most common way for someone to become ill from V. parahaemolyticus is to eat raw or undercooked shellfish. And as I mentioned previously, mostly through eating raw oysters. Occasionally people can also become infected with V. parahaemolyticus if they have an open wound and that is exposed to contaminated seawater. November 5, 2010

Spread, continued Once ingested V. parahaemolyticus moves through the digestive system into the small intestines where the bacteria excretes a toxin which causes gastrointestinal illness. U.S. Food and Drug Administration, ( ). Bad Bug Book, vibrio parahaemolyticus. Retrieved from: www.fda.gov/Food/FoodSafety/FooborneIllness/ Once someone eats contaminated shellfish the V. parahaemolyticus bacteria goes through the stomach and into the small intestines. Once there the bacteria excretes a toxin that causes gastrointestinal illness. November 5, 2010

Incubation Typical incubation period is 4 – 96 hours after ingestion. The FDA reports a mean of 15 hours. Illness usually lasts for 3 days. The FDA reports a mean of 2.5 days U.S. Food and Drug Administration, (2 ). Bad Bug Book – vibrio parahaemolyticus. Retrieved from Once the contaminated shellfish has been ingested it can take anywhere from 4 to 96 hours for the illness to manifest. The FDA has reported that the average is 15 hours from ingestion to illness. However, as I mentioned earlier antacid use could make the incubation period closer to the 4 hour mark. An individual will usually be ill for about 3 days. However, if a person is immunocompromised the illness could last longer. November 5, 2010

Human Effects When contaminated shellfish are ingested V. parahaemolyticus can cause: Watery diarrhea Abdominal cramping Nausea, vomiting Fever or chills Centers for Disease Control and Prevention, (2009). Vibrio parahaemolyticus general information. Retrieved from www.cdc.gov/nczved/divisions/dfbmd/diseases/vibriop/ After the incubation period an individual could experience watery diarrhea, abdominal cramping, nausea, vomiting, fever or chills. These symptoms are characteristic of other types of illness so it is important when you are talking to patients/clients that you find out what they have eaten in the past 3 days to determine if V. parahaemolyticus could be the cause. November 5, 2010

Diagnosis Individuals who may have vibrio infections need to provide a stool, blood, or wound sample for lab confirmation. Centers for Disease Control and Prevention, (2009). Vibrio parahaemolyticus, general information. Retrieved from U.S. Food and Drug Administration, (2 ). Bad Bug Book – vibrio parahaemolyticus. Retrieved from If you suspect an individual has been exposed to V. parahaemolyticus a medical professional will need to collect either a stool sample, a blood sample, or a wound sample, depending on the circumstances. These need to be collected according to lab specifications. The CDC has reported that labs often times do not use the correct medium for this test, so it is important that lab staff are alerted to use the correct medium. Keeping in contact with your lab regarding what type of test you need for the individual can help reduce the chance that V. parahaemolyticus is not pick up due to incorrect testing methods. November 5, 2010

Case Investigation If V. parahaemolyticus is suspected the following information should be collected: Consumer food history Shellfish handling practices by consumer Whether the symptoms and incubation period of the illnesses are consistent with suspected etiologic agent. U.S. Food and Drug Administration, (2007). Chapter II risk assessment and risk management. National Shellfish Sanitation Program Guide for the Control of Molluscan Shellfish. Retrieved from http://www.fda.gov/Food/FoodSafety/Product-SpecificInformation/Seafood/FederalStatePrograms/NationalShellfishSanitationProgram/UCM046413 In the event you suspect a patient/client of having an gastroenteritis due to vibrio the US Food and Drug Administration recommends you collect the following data from the individual. One, a food history usually going back two days prior to onset of symptoms. Second, if the individual ate shellfish, ask them how they were handled. Were they kept cold, did they eat them raw, how were they cooked. Lastly you will need to determine if the information provided to you by the individual fits with the symptoms of V. parahaemolyticus and if the incubation period is correct. November 5, 2010

Treatment In most cases, no treatment is necessary If a person has a weakened immune system, severe disease may occur. In those circumstances hospitalization may be needed along with antibiotics. Washington State Department of Health, (2010). Vibriosis in Shellfish. Retrieved from www.doh.wa.gov/ehp/sf/Pubs/vibrio-fs.htm Most individuals will not need any type of treatment other than to consume extra fluids. Try to discourage the use of anti-diarrheal medications as their use can increase the length of time the bacteria is in the body. If someone is immunocompromised severe illness may occur. In these cases hospitalization may be required, and antibiotics should be prescribed. Follow up with the individuals primary care physician may be necessary. November 5, 2010

Burden of Disease The next few slides will provide data on the number of V. parahaemolyticus cases in the U.S. and Washington State. This data can be used by your public health agency to create targeted education to at-risk populations. Now that you know a little about what V. parahaemolyticus is I would like to provide you with some data about infection rates in the US and specifically here in Washington State. This data can help you determine who your at-risk population are for targeted health information. November 5, 2010

Public Health Reporting As of 2007, all cases of V. parahaemolyticus are required to be reported to local health departments, and to the CDC. Small outbreaks can lead to the closure of beaches and commercial farms to harvesting. Centers for Disease Control and Prevention, (2008). Summary of human vibrio cases reported to CDC, 2008. Retrieved from: www.cdc.gov/nationalsurveillance/PDFs/Jackson_vibrio_CSTE2008_FINAL.PDF Washington State Department of Health, (2010). Vibriosis in Shellfish. Retrieved from www.doh.wa.gov/ehp/sf/Pubs/vibrio-fs.htm The data that I will be presenting today is from 2008, prior to 2007 cases of V. parahaemolyticus were not a notifiable condition. The collection of data can be useful when you are considering closing a commercial farm or public beach to shellfish harvesting. In most cases large outbreaks are not needed to close beaches or farms to harvesting. 2 or 3 people becoming ill due to V. parahaemolyticus may cause harvest to be stopped. This is why it is so important to stress to physicians that reporting possible cases is extremely important and could prevent large scale outbreaks. November 5, 2010

V. Parahaemolyticus Infections According to the Centers for Disease Control there are an estimated 4,500 cases of V. parahaemolyticus each year in the U.S.. Not every case gets reported to the CDC or to local public health. This may be due to minor illness. Centers for Disease Control and Prevention, (2009). Vibrio parahaemolyticus general information. Retrieved from http://www.cdc.gov/nczved/divisions/dfbmd/diseases/vibriop/ The Centers for Disease Control and Prevention estimate that there are 4,500 cases of V. parahaemolyticus each year. The total number of reported cases is much lower, this is due to lack of reporting by individuals to local health departments. By providing education to individuals, clinics, and physician offices about the need to report these cases, data collection could be improved. November 5, 2010

2008 Data For calendar year 2008 the CDC reported: A total of 588 confirmed vibrio cases in the U.S. Of those, 30 came from Washington State 270 (24%) of those cases were V. parahaemolyticus 67 needed to be hospitalized 4 died Centers for Disease Control and Prevention, (2008). Summary of human vibrio cases reported to CDC, 2008. Retrieved from: www.cdc.gov/nationalsurveillance/PDFs/Jackson_Vibrio_CSTE2008_FINAL.PDF During 2008, 588 confirmed cases of vibrio were reported to the CDC. Of those cases 30 came from Washington State. Breaking those cases out by specie, 270 of the 588 cases were due to V. parahaemolyticus. 67 of those cases needed to be hospitalized and 4 died. November 5, 2010

Vibrio Case Report by Age >1 yr 2 cases 1- 4 yrs 11 cases 5 -14 yrs 39 cases 15 – 24 yrs 44 cases 25 – 39 yrs 103 cases 40 - 64 yrs 263 cases >65 yrs 121 cases We can break the data out a little more and look at vibrio cases by age. Now these cases are for all species of vibrio. As you can see persons age 40 – 64 years of age had the most reported cases. The cases in children under 1 year of age may be due more from putting their finger in their mouth which have either touched a raw shellfish or contaminated water. I can’t really see a 10 month old slurping down an oyster. Centers for Disease Control and Prevention, (2010). Summary of notifiable disease – United States, 2008. Morbidity and Mortality Weekly Report, 57(54), retreive3d from www.cdc.gov/mmwr November 5, 2010

Vibrio Cases by Gender Males 348 cases Females 138 cases Gender not reported 102 cases As you can see from this slide more males than females report vibrio infections. This could be a good place for targeted educational materials. Centers for Disease Control and Prevention, (2010). Summary of notifiable disease – United States, 2008. Morbidity and Mortality Weekly Report, 57(54), retreive3d from www.cdc.gov/mmwr November 5, 2010

Vibrio Cases by Race American Indian / Alaska Native Asian or Pacific Islander 29 cases Black 35 cases White 278 cases This slide give a breakdown of vibrio cases by race, however as you can see race is not always reported with the case information so this only gives a little information on the cases. Centers for Disease Control and Prevention, (2010). Summary of notifiable disease – United States, 2008. Morbidity and Mortality Weekly Report, 57(54), retreive3d from www.cdc.gov/mmwr November 5, 2010

Prevention The next slide covers prevention methods to reduce V. parahaemolyticus infections in your community. I’m now going to move into some vibrio prevention methods. These prevention methods could be shared with the general public or with commercial farms. November 5, 2010

Common Prevention Harvest shellfish as soon as possible with the receding tide. Do not harvest shellfish that have been exposed to sun for more than 1 hour Keep shellfish cold after harvesting Washington State Department of Health, (2010). Vibriosis in Shellfish. Retrieved from www.doh.wa.gov/ehp/sf/Pubs/vibrio-fs.htm The state of Washington does allow harvesting of shellfish during certain times of the year. By providing these easy vibrio prevention tips to the public you could reduce vibrio infections. First let people know that shellfish should be harvested as soon as possible with the receding tide. Posting tidal information could be a great way to ensure this happens. Second, let people know that shellfish should not be harvested if they have been exposed to the sun for longer than an hour. Lastly, informing people that they will need to keep their shellfish cold once they have been harvested, and up until the time they are either cooked or eaten. November 5, 2010

Water Temperature Research conducted on Alaskan oysters in 2004 found that water temperature above 15° C at the time of harvest provides an increased risk of V. parahaemolyticus infection. This lead to cruise ship passengers becoming ill after eating raw oysters that had been collected in the warmer water. McLaughlin et al, (2005). Outbreak of Vibrio parahaemolyticus gastroenteritis associated with Alaskan oysters. New England Journal of Medicine, 353(14), 1463 – 1470. Retrieved from www.nejm.org Prevention can also occur at the environmental level. Research done by McLaughlin et al in 2005 found that Alaskan oysters exposed to water above 15 degrees Celsius are more likely to have vibrio bacteria. Their research was based around a vibrio outbreak on a cruise ship in 2004. Cruise passengers had eaten oyster that were collected that day and brought over to the ship, which lead to 17 percent of the passengers becoming ill. A prevention method could involve providing monitoring equipment or education to commercial farmers that they should not collect shellfish if the water temperature is optimal for vibrio. Public areas could be monitored by environmental health staff and closed to harvesting during these periods. November 5, 2010

Cleaning Shellfish Chae, Cheney, & Su conducted research in 2009 where they found that oyster cleaned in seawater below 15° C lead to a reduction in the amount of V. parahaemolyticus in the oysters. Chae, M.J., Cheney, D., & Su, Y.-C., (2009). Temperature effects on the depuration of vibrio parahaemolyticus and vibrio vulnificus from the American oyster (Crassostrea virginica). Journal of food Science, 74(2), M62 – M66. DOI: 10.1111/j.1750-3841.2008.01031.x Prevention methods can also be taken after the shellfish has been collected and they are being cleaned. This prevention method would most likely be taken by commercial farmers. Once a shellfish is harvested, depuration often times is done to remove sand and other objects from the shellfish. This involves soaking the shellfish in clean water so that the shellfish can naturally filter out the sand and contaminates as the clean water is taken in. However, if water contaminated with vibrio is used then the shellfish will intake the bacteria and you are only removing sand. Chae, Cheney, & Su conducted research in 2009 where they tested depuration in different water temperatures and they found that if water below 15 degrees Celsius is used, vibrio bacteria is reduced. This information could be used by commercial farmers who use this method before transport of the shellfish. November 5, 2010

Storage and Transport The National Shellfish Sanitation Program has set guidelines for the storage and transportation of shellfish: Shellfish are cooled to an internal temp of 10° Celsius Shucked or processed shellfish cooled to a temp of 7.2° Celsius Transported on ice or in refrigerated trucks US Food and Drug Administration, (2007). Chapter IX transportation. National Shellfish Sanitation Program Guide for the Control of Molluscan Shellfish. Retrieved from http://www.fda.gov/Food/FoodSafety/Product-SpecificInformation/Seafood/FederalStatePrograms/NationalShellfishSanitationProgram/UCM047135 The US Food and Drug Administration has created a set of guidelines regarding the sale, transportation, farming, and harvesting of shellfish. In those guidelines the following stipulations are set when shellfish are being transported: One, shellfish must be cooled to an internal temperature of 10 degrees Celsius Two, if the shellfish have been shucked (removed from their shell) or processed in any other way they need to be cooled to a temperature of 7.2 degrees Celsius Three, shellfish must be transported either on ice, or in refrigerated trucks. While these stipulations are mostly for commercial farmers, the general public should also be made aware that if they harvest shellfish from a public beach, they need to transport the shellfish on ice to prevent bacteria growth. November 5, 2010

Storage Research Burnham, Janes, Jakus, Supan, DePaola & Bell conducted cold storage research in 2009 and they report that: At 5° Celsius V. parahaemolyticus bacteria can survive but it cannot grow. At 8° Celsius V. parahaemolyticus bacteria counts increased over initial baseline. At 10° Celsius V. parahaemolyticus bacteria counts increased substantially. Burnham, V.E., Janes, M.E., Jakus, L.A., Supan, J., DePaola, A., & Bell, J., (2009). Growth and survival of vibrio vulnificus and vibrio parahaemolyticus strains during cold storage. Journal of Food Science, 74(6), M314 – MM318. DOI: 10.1111/j.1750-3841.2009.01227.x While we are talking about cold storage, I have some interesting research to show you. In 2009 researchers Burnham, Janes, Jakus, Supan and Bell took V. parahaemolyticus bacteria in saltwater and exposed it to varying degrees of cold. At both 10 degrees and 8 degrees Celsius V. parahaemolyticus bacteria were able to continue growing, however once the temperature was dropped down to 5 degrees Celsius the bacteria were no longer able to grow. This shows that while the US Food and Drug Administration requires shellfish to be kept at 10 degrees Celsius during transport that does not guarantee that any V. parahaemolyticus bacteria already in the shellfish won’t continue to grow. Keeping up on the latest research around this subject will be important as you may be able to alter your own educational materials and recommendations based on new findings. November 5, 2010

Learning Outcomes Review Describe where Vibrio Parahaemolyticus is found List 2 items food items that can harbor Vibrio Parahaemolyticus List 2 adverse effects on humans Explain 2 prevention strategies At the beginning of this presentation I listed 4 learning outcomes. At this time I would like to assess how I did on achieving these outcomes. Can anyone describe to me where Vibrio Parahaemolyticus is found? (answer – naturally occurring in ocean waters and in shellfish) Can anyone list two food items that people could eat that could possibly be contaminated with Vibrio Parahaemolyticus? (answer - oysters, mollusks, etc…) Can anyone list 2 adverse effects on human who consume shellfish contaminated with Vibrio Parahaemolyticus? (answers - nausea, vomiting, diarrhea, etc…) Can anyone explain 2 prevention techniques that could be used by shellfish farmers or by the general public to prevent Vibrio Parahaemolyticus infections? (answer – correct cleaning, cooking, etc..) November 5, 2010

Questions I want to thank you all for your attention today. I covered quite a bit of material and I was wondering if anyone had any further questions? It is my hope that the information I provided you with today can be used to help you provide educational materials to both the public and to any commercial farms that you may work with. For those of you who may want a little more information on the next slide I have some additional sources you may want to consult. Thank you again for letting me come and present to you today. November 5, 2010

Additional Reading Guide for the Control of Molluscan Shellfish 2007 http://www.fda.gov/Food/FoodSafety/Product-SpecificInformation/Seafood/FederalStatePrograms/NationalShellfishSanitationProgram/ucm046353.htm Procedures to Investigate Food Borne Illness http://www.foodprotection.org/publications/other-publications/ Environmental Health – Chapter 7 Drinking Water Moeller, D.W., (2005). Environmental heath. Cambridge, MA: Harvard University Press November 5, 2010

References Burnham, V.E., Janes, M.E., Jakus, L.A., Supan, J., DePaola, A., & Bell, J., (2009). Growth and survival of vibrio vulnificus and vibrio parahaemolyticus strains during cold storage. Journal of Food Science, 74(6), M314 – MM318. DOI: 10.1111/j.1750-3841.2009.01227.x Centers for Disease Control and Prevention, (2010). Summary of notifiable disease – United States, 2008. Morbidity and Mortality Weekly Report, 57(54), retreive3d from www.cdc.gov/mmwr Centers for Disease Control and Prevention, (2009). Vibrio parahaemolyticus general information. Retrieved from http://www.cdc.gov/nczved/divisions/dfbmd/diseases/vibriop Centers for Disease Control and Prevention, (2008). Summary of human vibrio cases reported to CDC, 2008. Retrieved from: www.cdc.gov/nationalsurveillance/PDFs/Jackson_vibrio_CSTE2008_FINAL.PDF Centers for Disease Control and Prevention, (2005). Vibrio parahaemolyticus. Public Health Image Library. Retrieved from http://phil.cdc.gov/phil/details.asp November 5, 2010

References, continued Chae, M.J., Cheney, D., & Su, Y.-C., (2009). Temperature effects on the depuration of vibrio parahaemolyticus and vibrio vulnificus from the American oyster (Crassostrea virginica). Journal of food Science, 74(2), M62 – M66. DOI: 10.1111/j.1750-3841.2008.01031.x McLaughlin, J.B., DePaola, A., Bopp, C.A., Martinek, K.A., Napolilli, N.P., Allison, C.G., Murray, S.L., Thompson, E.C., Bird, M.E., & Middaugh, J.P., (2005). Outbreak of vibrio parahaemolyticus gastroenteritis associated with Alaskan oysters. New England Journal of Medicine, 353(14), 1463 – 1470. Retrieved from www.nejm.org U.S. Food and Drug Administration, ( ). Bad Bug Book, vibrio parahaemolyticus. Retrieved from: www.fda.gov/Food/FoodSafety/FooborneIllness U.S. Food and Drug Administration, (2007). Section II Model Ordinance. National Shellfish Sanitation Program Guide for the Control of Molluscan Shellfish. Retrieved from http://www.fda.gov/Food/FoodSafety/Product-SpecificInformation/Seafood/FederalStatePrograms/NationalShellfishSanitationProgram/UCM046413 November 5, 2010

References, continued US Food and Drug Administration, (2007). Chapter IX transportation. National shellfish sanitation program guide for the control of molluscan shellfish 2007. Retrieved from http://www.fda.gov/Food/FoodSafety/Product-SpecificInformation/Seafood/FederalStatePrograms/NationalShellfishSanitationProgram/UCM047135 Washington State Department of Health, (2010). Vibriosis in Shellfish. Retrieved from www.doh.wa.gov/ehp/sf/Pubs/vibrio-fs.htm November 5, 2010