Louisiana Morbidity Report Louisiana Office of Public Health - Infectious Disease Epidemiology Section P.O. Box 60630, New Orleans, LA 70160 (504) 568-5005 www.oph.dhh.state.la.us/infectiousdisease/index.html M. J. “Mike” Foster, Jr. David W. Hood GOVERNOR SECRETARY November-December 2003 Volume 14 Number 6 species, V. vulnificus, V. parahaemolyticus and V. cholerae non-01 Vibrio In Louisiana, 1993-2002 account for 73% of the cases (Figure 2). Summary Figure 2: Vibrio serotypes, Louisiana 1993-2002 Susan Wilson, RN MSN CIC Total Number From 1993 to 2002, a total of 429 cases of vibrio illness were 160 reported to the Office of Public Health, Infectious Disease Epidemi- 140 ology Section. The number of cases per year ranged from 30 to 61 120 cases with an average incidence rate of 1.0 case per 100,000 (Figure 100 1). 80 60 Figure 1: Vibrio cases* by year, Louisiana 1993-2002 Total Number Total 40 70 20 0 60 U n Alg Cho Dams Fluv Holl Mimi Mult N Para Vul k on / i l n N - o - 01 t 50 01 t yp ed 40 Serotype 30 Among patients for whom information was available, the me- 20 dian age of vibrio cases was 48 years (range 1 to 95 years). Age- Number ofNumber Cases specific case rates were higher in age groups 45 years and older than 10 among all other age groups (Figure 3). 0 1993 1994 1995 19 19 1998 19 2000 2001 20 96 97 99 02 Figure 3: Vibrio Case Rate by Age Groups, Louisiana, 1993-2002 Year N = 429; * includes Cholerae-01 40 35 These infections were associated with nine different vibrio or- 30 ganisms (V. alginolyticus, V. cholerae-01, V. cholerae non-01, V. 25 23.7 damsela, V. fluvialis, V. hollisae, V. mimicus, V. parahaemolyticus ! 20 18.8 17.9 and V. vulnificus, as well as cases involving multiple vibrios). Three ! 16.7 ! ! 15 10 8.05 7.4 !"#$%#$ 6.5 ! Case Rate per 100,000 ! ! 5 2.6 1.2 1.6 ! ! 0 ! 0 5 10 20 25 35 45 55 65 75 Vibrio in Louisiana, 1993-2002 Summary ....................................................1 -0 -09 - - - - - - - + 4 19 24 34 44 54 64 74 Vibrio in Louisiana - January-October, 2003 ................................................3 Age Group Alligators and West Nile Virus ....................................................................4 This age distribution shows an increase in vibrio cases among Conjunctivitis Outbreak ...............................................................................5 advancing age groups, an expectant finding for vibrio disease among older adults who may also comprise a high risk population group. OPH Training Offering ...............................................................................5 Male cases outnumbered female cases by more than 2:1 (291 versus Scene from the Alexandria Antibiotic Resistance Kickoff .............................5 135 cases). Race and ethnicity was known in 97% of the total cases; of these, a significantly higher proportion was reported Region 1 Norovirus Outbreak .......................................................................6 among Whites (76%) versus African-Americans (18%). Announcement of Publication......................................................................6 (Continued on next page) Louisiana Morbidity Report November-December 2003 Vibrios in Louisiana, Ten Year Summary (Cont.) The month of onset for vibrio illnesses reportedly occurred Figure 6: Reported Vibrio Cases by Parish Louisiana, 1993-2002 from April through September with peaks observed in the summer months which correlate with the warm environmental conditions 1 4 2 that foster vibrio growth (Figure 4). 1 Figure 4: Vibrio cases by month of onset, Louisiana, 1993-2002 90 2 80 1 2 1 2 70 6 3 2 15 5 25 60 4 8 17 5 1 3 3 3 68 50 2 3 10 3 6 90 24 2 40 42 23 9 Number ofNumber Cases 30 20 10 The role of vibrio species as causative agents of gastroenteri- 0 tis, wound infection and primary septicemia has been well-estab- Jan Feb Mar A May Ju Ju Aug Sep Oct Nov Dec pr n l lished and known to cause diverse clinical presentations. Of the Month of Illness Onset three major categorical syndromes reported, the largest proportion N = 429 of case-patients presented with gastroenteritis (48%) followed by Contact with Gulf waters with high salinities and temperatures wound infections (34%) and primary septicemia (13%). as well as the sustenance of vibrio pathogens for long periods, have the potential to cause infections for at-risk individuals either from Gastroenteritis shellfish harvested for consumption or by contact exposure to wa- Along with other Gulf Coastal states, vibrio surveillance con- ter during occupational and/or recreational activities. No large out- ducted in Louisiana over this ten-year period showed that gastro- breaks of vibrio infections were identified in Louisiana during this enteritis was the most commonly reported syndrome of vbrio infec- ten-year surveillance period. Vibrio infections had generally occurred tions. Among 202 case-patients diagnosed as gastroenteritis, the as sporadic cases which have been consistent with prior experience most frequently reported symptoms were diarrhea (82%), nausea in the United States. (68%), vomiting (54%) and fever (51%). Overall, 151 (77%) cases Of the case-patients who reported any underlying illnesses, reported eating seafood within seven days before illness. The mean the most frequently reported conditions are represented, (Figure 5). time between seafood consumption and onset of illness was 2.2 days. The median duration of illness was 6.5 days. Forty-three Figure 5: Vibrio cases with underlying conditions, Louisiana, 1993-2002 percent of the reported cases required hospitalization with a median hospital stay of three days. The vibrio species most frequently iden- Heart disease Yes Liver disease Yes tified among gastroenteritis case-patients were V. cholera non-01, 33% 27% V. mimicus, V. fluvialis and V. parahaemolyticus. Wound Infections Unk Unk 2% 2% Wound and soft tissue infections are the second most serious extra-intestinal infections caused by exposure to seawater or raw No No 71% 65% Louisiana Morbidity Report Diabetes Alcoholism Volume 14 Number 6 November-December 2003 Yes 24% Yes 20% The Louisiana Morbidity Report is published bimonthly by the Infectious Disease Epidemiology Section of the Louisiana Office of Public Health to inform physicians, nurses, and public health Unk Unk professionals about disease trends and patterns in Louisiana. 1% 3% Address correspondence to Louisiana Morbidity Report, Infectious No Disease Epidemiology Section, Louisiana Department of Health No 77% and Hospitals, P.O. Box 60630, New Orleans, LA 70160. 75% Assistant Secretary, OPH Sharon Howard, MSW State Epidemiologist Raoult Ratard, MD MPH MS The geographic distribution of case-patients by parish of resi- dence was known in 98% of the reported cases. At least 64% of the Editors Susan Wilson, MSN cases were reported from the six southeastern parishes of the state: Rosemarie Robertson, BS MT(C) CNMT Jefferson, Terrebonne, Orleans, St. Tammany, St. Bernard and Layout & Design Ethel Davis, CST Lafourche (Figure 6). 2 Louisiana Morbidity Report November-December 2003 seafood drippings with vibrio organisms. Clinical presentations death from V. vulnificus infection for patients with liver disease who range from mild erythema to severe cellulitis with fasciitis and myo- eat raw oysters. V. vulnificus naturally occurs in the marine environ- sitis. A total of 144 case-patients developed wound infections asso- ment and is considered to be an opportunistic pathogen in individu- ciated with vibrio pathogens. Of these, 128 case-patients were ex- als having compromised immune systems or medical disorders. posed as a result of various activities such as accidents incurred Physicians should recognize the importance of obtaining a thor- while boating, handling raw seafood and seafood drippings as well ough patient history in relation to the endemicity of vibrio infec- as lacerations sustained during a fishing/shrimping event. The age tions in Louisiana. There is an emphasis for clinicians to provide range of wound associated case patients was from 11 to 83 years of the community with health risk information to those identified as age with a mean of 51 years. Cellulitis (77%) was the most fre- most likely to develop infections and severe complications. Pa- quently reported symptom followed by fever (67%), muscle aches tients with liver or immune dysfunctions should be warned to avoid (35%) and bullae (28%). One hundred eighteen (83%) case-patients raw molluscan seafoods, such as oysters. Early detection and ini- required hospitalization with a mean duration of illness of thirteen tiation of antimicrobial therapy for invasive V. vulnificus infections days. Ten (8%) deaths were reported among wound patients. Eighty- remain as an aggressive approach due to the rapid progression from seven of the 144 cases had a history of underlying conditions at the clinical illness to death. time of vibrio exposure. These included heart disease (41%), diabe- The seawater exposure data in this report associated with vibrio tes (30%), alcoholism (28%) and liver disease (27%). V. vulnificus wound infections suggests that it is also necessary to inform such and V. parahaemolyticus accounted for 83% of the vibrio species high risk patients to avoid seawater or brackish water exposure and identified among wound patients with the majority attributed to V. discourage such contact for “therapeutic” purposes. Persons-at- vulnificus. risk of acquiring vibrio wound infections through percutaneous exposures via occupational or recreational contact should