Epidemiology And Trends For Vibriosis In Connecticut,

Transcription

1 Yale Uiversity EliScholar A Digital Platform for Scholarly Publishig at Yale Public Health Theses School of Public Health Jauary 2012 Epidemiology Ad Treds For Vibriosis I Coecticut, Olivia Ellis Yale Uiversity, microlabrat@aol.com Follow this ad additioal works at: Recommeded Citatio Ellis, Olivia, "Epidemiology Ad Treds For Vibriosis I Coecticut, " (2012). Public Health Theses This Ope Access Thesis is brought to you for free ad ope access by the School of Public Health at EliScholar A Digital Platform for Scholarly Publishig at Yale. It has bee accepted for iclusio i Public Health Theses by a authorized admiistrator of EliScholar A Digital Platform for Scholarly Publishig at Yale. For more iformatio, please cotact elischolar@yale.edu.

2 EPIDEMIOLOGY AND TRENDS FOR VIBRIOSIS IN CONNECTICUT, BY Olivia L. Ellis Thesis for submissio to the Yale School of Public Health for the requiremet of the Degree of Master of Public Health Divisio of Epidemiology of Microbial Disease 2012 [1]

3 ACKNOWLEDGEMENTS I would like to exted my utmost thaks ad gratitude to Dr. James Hadler for his limitless patiece ad costructive guidace throughout the course of this work. I would also like to thak Dr. Maria Diuk-Wasser for her commets ad advice regardig this study. I am idebted to my colleagues Sharo Hurd, Paula Clogher, Dayel Olso, Jim Meek ad the rest of the Yale Emergig Ifectios Program staff for their help, support, ecouragemet, ad istructio o this project ad several others, icludig the iitiatio of the CT FoodCORE team. I would like to ackowledge the local ad state health departmets of Coecticut for their efforts i collectig this data as well as Aa Newto ad Cheryl Bopp at the Ceters for Disease Cotrol ad Prevetio for providig data for aalysis. I would also like to thak all of my family ad frieds for all of their love ad support durig the writig of this thesis ad throughout my course of study at Yale. [2]

4 ABSTRACT Backgroud: Behavior ad eviromet play a sigificat role i the acquisitio of vibriosis. Vibrio data collected over the past twelve years suggests that icidece of vibriosis has icreased i Coecticut. Vibriosis is a physicia ad laboratory reportable illess i Coecticut. Surveillace data was collected by Coecticut FoodNet ad Coecticut Departmet of Public Health staff. These data were aalyzed to evaluate the epidemiology ad treds i icidece over time. Methods: Icidece rates were stratified by demographic, geographic, bacteriologic ad cliical groups ad treds i the icidece ad percetage of cases i these groups were aalyzed over time. Because risk factors for developig vibriosis could be depedet o specific behaviors, treds i the percetage of cases with selected exposures were also aalyzed over the twelve year time period. Results: The icidece of vibriosis icreased over the past twelve years i Coecticut, from a icidece of 1.83 per millio populatio i 1999 to 8.95 i Icidece rates were highest amog me, durig the summer ad fall moths, i those over the age of 50 years, ad i people who reside i coastal couties. While icreases i icidece rate/umber of cases were see for most demographic, geographic, bacteriologic, ad cliical ad exposure groups, oly the percetages of all case-patiets who had woud ifectios ad had direct ski ad woud exposure to water icreased over time. Coclusios: Possible explaatios for the overall icrease iclude: warmer water temperatures with higher Vibrio levels ad/or more people spedig more time i cotact with potetially cotamiated water, especially the elderly. The faster relative icrease i woud ifectios ad relative icrease exposures ivolvig ski, merit particular study to determie factors for their faster icrease ad moitorig to see if they cotiue to cause a icreasig proportio of all cases. [3]

5 TABLE OF CONTENTS Abstract....3 Itroductio..5 Methods...8 Results 11 Discussio..15 Coclusios 21 Recommedatios..22 Refereces.. 24 Tables ad Figures...25 [4]

6 INTRODUCTION Vibrio is a geus of comma shaped, Gram egative, oxidase positive bacteria i the family Vibrioaceae. This bacterial geus is commoly foud i warm, brackish water of marie estuaries. Vibrio species are oe of 31 major kow foodbore pathoges i the Uited States [1]. Huma vibriosis is caused by ifectio with ay of at least 12 species i the geus Vibrio [2]. Vibriosis is associated with three major sydromes that cause illess i humas icludig: gastroeteritis, woud ifectios, ad septicemia. It was just five years ago, i 2007, that huma vibriosis (o-cholera Vibrio species) became a atioally otifiable disease i the Uited States [3]. Cosumptio of raw or cotamiated shellfish has bee idetified as a major source of these ifectios [4]. Vibrio parahaemolyticus is the leadig cause of food poisoig caused by cosumptio of cotamiated seafood, especially raw oysters, worldwide [5]. Additioally, V. parahaemolyticus is the most commo cause of seafood-associated gastroeteritis i the Uited States [4]. Other risk factors for acquirig vibriosis, besides shellfish cosumptio are wadig or swimmig i brackish water, woud exposure i water or uitetioal igestio of cotamiated water i marie eviromets. I additio to these behavioral risk factors, certai uderlyig coditios such as old age, liver disease, ad diabetes ca predispose idividuals to illess caused by Vibrio [6]. The true burde of most vibriosis ifectio is difficult to estimate due to the fact that most ifectios require laboratory cofirmatio, ad may of those affected may ot seek medical treatmet for their ailmets. However, laboratory-cofirmed cases do represet a portio of ifectios withi a commuity; ad for this reaso, stable surveillace systems offer a estimate of the curret treds i of Vibrio ifectio withi the populatio. [5]

7 Vibrio species cause a estimated 8,000 ifectios per year i the Uited States [7]. There were a total of 160 case-patiets with Vibrio spp. (aual icidece 0.35 per 100,000 or 3.5 per millio populatio) reported at the te atioal FoodNet sites i 2009 [8]. Species iformatio was available for 154 Vibrio spp. ifectios ad the most commoly reported species were V. parahaemolyticus (52%, 80/154) ad (14%, 22/154) were V. vulificus or V. algiolyticus. The estimated icidece icreased (85%, 95% CI=36%-150%) for vibriosis i 2009 whe compared to data from [8]. This icreasig tred has cotiued sice 2002 [8]. I 2010, the te atioal FoodNet sites reported 193 case-patiets with Vibrio ifectios (aual icidece 0.4 per 100,000 or 4.0 per millio populatio) [9]. Amog the 186 Vibrio atioally reported specimes with species iformatio i 2010, the most commo were V. parahaemolyticus (57%) ad V. vulificus (13%) [9]. Betwee the years , the rate of atioally laboratory-cofirmed vibriosis cases icreased [9]. Additioally, overall atioal icidece of vibriosis i 2010 icreased whe compared agaist rates from years ad the years [9]. Compared to data from , the estimated icidece for 2010 icreased (115%, 95% CI=60%-187%) [9]. I 2011, Scalla, et. al. estimated atioal rates of hospitalizatio for toxigeic V. cholerae, V. vulificus, V. parahaemolyticus, ad other Vibrio spp. [1]. Additioally, death rates were estimated for toxigeic V. cholerae, V. vulificus, V. parahaemolyticus, ad other Vibrio spp. [1]. While these mortality rates are useful for uderstadig Vibrio-specific disease severity, the reported FoodNet icidece rates are oly idirectly derived estimates of the true burde of vibriosis ad do ot shed light o treds i Coecticut. Over the past twelve years, there has bee a progressive icrease i the umber of icidet Vibrio cases i Coecticut. Although Vibrio ifectios may be less commo tha other [6]

8 foodbore illesses uder atioal surveillace, Vibrio ifectios are icreasig [9] ad vibriosis icidece i the Uited States remais higher tha the Healthy People Food Safety Goal of 0.2 cases per 100,000 (or 2 cases per millio populatio) that is set for 2020 [9]. The most successful public health itervetios are depedet upo complete assessmet ad accurate kowledge of the risk factors that are associated with a particular illess. Therefore, uderstadig the epidemiology of Vibrio ifectios will assist public health professioals at targetig prevetio ad itervetio efforts to reduce Vibrio icidece i Coecticut ad across the Uited States. Vibriosis is a importat atioal public health problem because these ifectios have the potetial to be associated with severe morbidity ad mortality. Furthermore, these ifectios are importat because chages i their icidece could hypothetically result from the impacts of climate chage icludig warmig seawater. Previous studies have established a associatio betwee warmer water temperatures ad the presece of Vibrio [4]. Thus, sea surface temperatures may be a importat determiat of risk associated with acquirig vibriosis. This thesis presets a aalysis of the epidemiology ad treds i vibriosis i Coecticut over twelve years ad a comparative observatioal tred aalysis of cliical data collected through routie surveillace efforts. The objective herei is to describe the frequecy of Vibrio ifectios i Coecticut, describe the treds i icidece of Vibrio over the past twelve years of active surveillace i Coecticut, to describe the cliical ad epidemiological attributes of Vibrio ifectio, ad to make recommedatios based o these fidigs. [7]

9 METHODS Study Desig I Coecticut, vibriosis has bee both a physicia ad laboratory reportable ifectious disease sice I additio to these reportig requiremets, Coecticut participates i the Emergig Ifectios Program s FoodNet project (FN-CT), which coducts statewide laboratorybased active surveillace for vibriosis i cooperatio with the Coecticut Departmet of Public Health (DPH), the Ceters for Disease Cotrol ad Prevetio (CDC), ad the Yale School of Public Health. The FN-CT site was oe of the first i the Uited States, iitiated i 1996, ad demographic iformatio was collected from case report forms for all culture-cofirmed Vibrio ifectios betwee the years 1996 ad However, vibriosis data was iitially collected oly i two couties (New Have ad Hartford), util 1999, whe all Vibrio isolates (statewide) were required to be submitted to the state public health laboratory for cofirmatory testig. Therefore, this study utilizes FN-CT surveillace data betwee the years Oly icidet cases reported betwee 1999 ad 2010 were icluded i this aalysis i order to determie treds associated with icidece over time. To verify completeess of reportig, all i-state hospital ad referece laboratories were routiely audited as part of FN-CT surveillace. Every attempt was made by local health or DPH staff to iterview all culture-cofirmed cases via telephoe i order to complete the CDC s, Cholera ad Other Vibrio Illess Surveillace Report (COVIS) form. The data collected o this report icludes cliical data, iformatio about uderlyig illesses, history of seafood cosumptio, ad potetial exposures durig the seve days prior to illess oset. Upo completio, COVIS reports are set to the CDC ad etered ito a atioal database. [8]

10 Laboratory Methods Vibrios are ot easily idetified o routie eteric media because Vibrio species emulate ormal eteric flora ad appear as lactose fermetig coloies o MacCokey agar. Therefore, laboratory-cofirmed ad suspected cases of Vibrio must be submitted to the DPH Laboratory for cofirmatory testig ad species idetificatio o the selective media thiosulfate citrate bile salts sucrose (TCBS), sulfide idole motility (SIM), lysie iro agar slat (LIA), motility idole orithie (MIO), ad triple sugar iro agar (TSI), 0%, 1%, 3%, 6%, ad 8% salts. If the orgaism is oxidase positive from a blood agar plate the it is subcultured to a API strip for species idetificatio. Statistical Methods Yearly icidece rates were calculated usig the 2000 Uited States Cesus Bureau populatio estimates or mid-year populatio estimates from DPH [9]. Yearly icidece rates were tested for tred ad data were compared by strata defied by age, sex, race, source, couty, percetage of people with a give sydrome (gastroitestial, woud, septicemia), risk factors, ad seaso usig the chi-square test. Aalyses were performed usig SAS versio 9.2 (SAS Istitute), EpiIfo versio 6.0 (CDC), ad Microsoft Excel. A umber of variables were aalyzed for treds over the twelveyear period via the chi-square test for tred usig mid-year populatio estimates ad the Uited States Cesus populatio iformatio for the idividual years 2000 ad Data were examied for sigificace i tred by chi-square over four three-year itervals ( , , , ).The mid-year populatio estimates were used for treds aalyzed over these time itervals, except i the case of , which had a mid-year [9]

11 populatio durig a atioal cesus year. Excel was used to assess the associatio betwee icidece rates ad time i years for each idividual year. [10]

12 RESULTS From Jauary 1, 1999 through December 31, 2010, 174 icidet cases of vibriosis were reported to DPH. The icidece for vibriosis over the twelve-year period uder aalysis was 4.26 per millio perso-years. Table 1 shows the distributio of the dataset by age, sex, race, ethicity, source, hospitalizatio, couty, seaso, ad year. The most distict fidig was a progressive icrease i icidece by year, with icidece climbig from 1.83 per millio populatio i 1999 to 8.95 per millio populatio i The icidece of Vibrio also varied sigificatly by age ad was most commo i idividuals over 50 years of age (8.03 per millio perso-years). I additio to this fidig, adults i the year age group ad the 50 ad older age group were respectively 2.46 ad 5.63 times more likely to be ifected with Vibrio tha their youger referet couterparts, aged Vibrio i Coecticut had a sigificatly higher icidece i me (5.81 per millio perso years) tha i wome (2.80 per millio perso years) (p ), with male cases accoutig for 66% of all Vibrio ifectios whereas wome oly accouted for 34%. Icidece rates by race/ethicity were ot calculated due to a large proportio of missig data (24%). Whites accouted for 71% (124/174) of the total cases reported. Of the cases with a kow ethicity, 90% (103/115) were o-hispaic. Overall, 52% of the cases were diagosed based o stool isolates ad about 29% were diagosed based o isolates from wouds. Relatively few cases (9%, =15) were diagosed based o positive blood cultures. Most, 79%, idividuals received care i a outpatiet settig while 21% were hospitalized for their illess. The survival outcome for 5 patiets was ukow or lost-to-follow-up ad 2 patiets died. The icidece of vibriosis was highest i the coastal couties of Middlesex (6.99 per millio perso-years) ad Fairfield (5.95 per millio perso-years) ad lowest i the ilad, o-coastal couties of [11]

13 Widham (3.06 per millio perso-years) ad Hartford (2.33 per millio perso-years) for the twelve years uder study. The majority of all cases occurred i the moths of July-September (72%). Overall, 86% of vibriosis occurred durig summer ad fall (warm water seaso) as opposed to witer ad sprig (14%, cold water seaso). Because Vibrio icidece icreased over time, we examied a umber of variables to see if treds icreased for all demographic, geographic ad diagosis site subgroups. I geeral, vibriosis icreased for all groups, but more sigificatly for some (ages 0-19 ad > 50 years, coastal residece, ad woud source of ifectio) (Table 2). Vibrio cases i childre 0-19 years had a 8-fold icrease, people age 50 ad over had a 4.4-fold icrease i cases, vibriosis cases i coastal residets accouted for a 4.36-fold icrease, ad wouds accouted for a 5.42-fold icrease i Vibrio cases compared to a overall 3.37-fold icrease i Vibrio whe comparig icidece from to icidece i Cliical ad risk factor iformatio was available for 166 patiets who were iterviewed with a COVIS report form. The most commo exposures amogst those with vibriosis icluded cosumptio of ay seafood (57%), cosumptio of raw seafood (34%), swimmig (26%), ad walkig i water (17%), ad woud exposures i water (14%). We examied whether ifectio site ad ay of the exposures became more commo over time (Table 3). Although a umber of exposures appeared to icrease over time, oly the percet woud ifectios ad percet of people with woud exposure i water icreased at statistically sigificat levels (p=0.02 ad p=0.007, respectively). The majority (81%, 46/57) of persos with raw seafood exposures were diagosed based o stool culture. The remaiig persos with raw seafood exposures were diagosed based o [12]

14 isolates that were from wouds (7%), blood (11%), ad from aother source (1%). The majority of persos with exposure of a woud to water (86%, 19/23) had their diagosis cofirmed based o woud culture; 9% were based o blood culture ad 5% were based o isolates from stool or other specimes. Wouds were also the most commo diagostic sites of persos with swimmig exposures (49%, 21/43), who walked i water (54%, 15/28), ad who hadled or cleaed seafood (47%, 8/17). I Coecticut, 59% of the Vibrio isolates collected betwee 1999 ad 2010 were V. parahaemolyticus. The secod most commo species isolated was V. algiolyticus (16%) followed by V. fluvialis (8%) (Table 4). Differet species accouted for larger percetages of specimes from certai sites. V. parahaemolyticus accouted for the largest percetage of isolates from stool (76%, 68/90) ad wouds (54%, 27/50), ad there were o V. algiolyticus or V.vulificus isolates made from a stool source. V. vulificus was resposible for causig 33% (5/15) of the blood ifectios. Additioally, positive blood ad woud specimes were more commoly acquired from those > 50 years old (93%, 14/15 ad 54%, 27/50, respectively). While there were o positive specimes collected from a woud source durig the cold water moths, 100% (50/50) of the woud ifectios occurred durig the warm water moths. There was o sigificat differece betwee specime source types collected i coastal couties versus ocoastal couties. While the total umber of Vibrio species icreased i icidece sigificatly over time, the most proouced icrease occurred i the sigle species, V. parahaemolyticus (Table 5). Symptoms experieced by patiets whose Vibrio was isolated from stool icluded predomiatly cramps (92%, 56/61), diarrhea (87%, 79/91), ad ausea (81%, 42/52) (Table 6). For those whose Vibrio was isolated from a woud, muscle pai (31%, 9/29), ad fever (19%, [13]

15 7/36) were the most commoly reported symptoms. Patiets with blood ifectios most commoly reported symptoms of fever (67%, 10/15), diarrhea (40%, 6/15), ad ausea (20%, 3/15). A total of 18% (31/166) of patiets were reported to have developed cellulitis. Of the 166 patiets, 39% had at least oe pre-existig coditio; heart disease was the most frequetly reported 13%, followed by diabetes 8%, ad maligacy 7% (Table 7). A few of the reported cases 6% had previous gastric surgery ad 5% reported a history of alcoholism. Overall, 66% (110/166) of Coecticut patiets reported beig treated with atibiotics for their Vibrio ifectios. [14]

16 DISCUSSION I this study, Vibrio isolates from the state of Coecticut were examied for features of epidemiological relevace ad treds i icidece from Although there was a decrease i the umber of reported Vibrio cases i 2007, whe Vibrio became a atioally otifiable disease, atioally reported cases of Vibrio ifectio have geerally bee icreasig at FoodNet sites sice 2000 [9]. However, i the state of Coecticut, Vibrio icidece has exhibited a icreasig tred above that of what is observed atioally. Icidece icreased approximately 5-fold over the 12 years, ad the umber of cases icreased i all demographic, geographic, bacteriologic ad exposure groups examied. The groups that icreased the most, as measured by treds i their proportio of all cases were those with woud ifectios, who had woud exposure to water or who walked i potetially cotamiated water ad who did so durig the summer ad fall warm water moths. I Coecticut, vibriosis was most ofte associated with gastroitestial ifectio caused by V. parahaemolyticus. However, the percetage of woud ifectios has icreased sigificatly over time, icreasig at a higher rate tha other ifectio sites, most otably-gastroitestial ifectio sites. Vibriosis was foud to be more commo i me, i those over the age of 50 years, i residets of coastal couties, ad durig summer ad fall moths. These data support the theory that vibriosis may be icreasig i Coecticut as a result of climate chages or chages i behavior amog susceptible idividuals, icludig icreasig rates of water exposure. I Coecticut, rates have icreased early 5-fold while at all FoodNet sites combied icidece rates have oly icreased 2-fold over the same time period [9, 11]. Vibriosis rates i Coecticut for 2010 were close to 9 per millio populatio whereas the atioal icidece rate reported for all FoodNet sites was reported to be 4 per millio populatio [9]. I 2010 Florida [15]

17 reported vibriosis rates higher tha the atioal average at 7 per millio populatio with most cases also occurrig i warm water seasos, i coastal couties ad amog those 65 ad older [12]. Although the umber of cases i Florida was cosiderably higher, at 130, the populatiobased icidece rate was still lower tha that of Coecticut [12]. Additioally, vibriosis rates i Florida appear to have bee icreasig sice 2008, ad they were o a steady declie for the sixyear period of [12]. Sice it is difficult to compare data amog differet sites due to various surveillace system methodologies, the higher relative icidece may be a artifact of a more sesitive laboratory-based surveillace system i Coecticut (ad Florida sice 2008) [12]. However, the icreasig icidece withi Coecticut raises the issue of whether laboratory testig methods might have chaged over time, a possibility that was beyod the scope of this paper to explore. O the other had, Vibrio are more commo i warmer waters (temperatures > 17 C-20 C) [13]. Therefore, this remarkable icrease i icidece may be due to icreasig sea surface temperatures ad higher cocetratios of Vibrio i the water. The 2008 Soud Report from the Log Islad Soud Study does state that seasoal temperatures measured at the Millstoe Power Statio i New Lodo, CT have icreased over the past 30 years [14]. The 2010 Soud Report states that the temperature has icreased 1 C (1.8 F) sice 1976 accordig to data collected at the Millstoe statio [15]. The 2010 Soud Report also metios a overall icrease i the umber of warm water species withi the soud over the last two decades [14, 15]. Additioally, icreasig levels of huma activity i potetially cotamiated water sources could be cotributig to the icreasig icidece, especially i cases where woud ifectio occurs. Perhaps this icrease i Vibrio icidece is the result of a combiatio of all of these factors. The State of the Gulf of Maie Report ad other studies o climate suggest that climate chage may [16]

18 cause chages i the structure of the microbial commuity, especially due to chages i water temperature ad saliity caused by a icreasig frequecy of extreme weather evets [16]. The State of Maie Report also suggests that huma populatio ad coastal developmet may be cotributig to higher levels of effluet ad urba ruoff, subsequetly leadig to the icreasig icidece of vibriosis [16]. Nutriet levels idirectly affect Vibrio cocetratios via stimulatio of phytoplakto growth ad death, which produces a eergy source for Vibrio growth [16]. I Coecticut, me have a higher level of risk for developig vibriosis tha wome. These fidigs are similar to previous reports of o-cholera vibriosis cases i Califoria from [17]. There are a few importat reasos why me may be at a higher risk of developig vibriosis tha wome. Me may have a higher icidece of vibriosis because me may participate i recreatioal water activities ad eat raw or udercooked seafood more frequetly tha wome [18]. Wome also have a greater awareess of food safety risk ad better food safety practices, which may decrease their risk of developig foodbore ifectios [19]. Iterestigly, the female hormoe estroge has bee foud to cotribute to this geder specificity, which i some maer provides protectio agaist the lethal V. vulificus edotoxi [20]. People over the age of 50 had the highest risk for developig vibriosis compared to all other age groups i Coecticut throughout the study period. Foodbore illess amog the elderly is becomig a icreasigly importat cocer as the umber of adults that are sixty-five ad older is expected to reach 55 millio by the year 2020 i the Uited States [18]. Thus, the populatio is agig ad as the elderly populatio icreases it is likely that we ca expect to see a cotiued rise i the umber of vibriosis cases withi this populatio. Although this age group has a greater awareess of food safety risk ad better food safety practices, this age group is [17]

19 more vulerable to foodbore illess due to decreased immue fuctio [21]. Older adults may also be more proe to have pre-existig or uderlyig health coditios that put them at a higher risk for developig ifectio i geeral (diabetes, maligacies, heart disease, liver disease, loss of stomach acidity, major surgeries, malutritio, ad dimiished physiological capacity, etc.) [22]. I additio to this, these idividuals may have more leisure time to sped participatig i activities (e.g., fishig) that ivolve cotact with potetially cotamiated water sources like the Log Islad Soud. Icidece of vibriosis was higher i coastal couties ad icreased sigificatly more tha i o-coastal couties over the twelve-year study period. This is ot a surprisig fidig as most cases of vibriosis are reported i coastal states [12, 23]. Additioally, this supports the hypothesis that people who live i closer proximity to the Log Islad Soud may visit the water more frequetly tha those who live farther away from the shore. I additio to this tred, almost all cases of vibriosis occurred i the warm water moths durig the summer ad fall (July- November) supportig the hypothesis that warmer water surface temperatures may be i part to blame for the hike i icidece over the years as warmer water temperatures promote Vibrio growth as is see i V. cholerae ad may attract more people for recreatioal purposes [24]. There is a kow associatio betwee vibriosis ad cosumptio of raw or udercooked seafood. A large umber of cases who reported cosumig raw seafood had their positive specimes collected from stool, suggestig that raw seafood was the source of their ifectio. It is ukow whether there is a icreased risk of vibriosis because more people are eatig raw seafood or if the level of risk associated with this behavior has icreased. However, it is of iterest that the percetage of all cases with raw seafood exposure ad with gastroitestial ifectio did ot icrease while the percetage with woud ifectios ad woud exposure to [18]

20 water did. It is coceivable that awareess of the risk of gettig vibriosis from raw/udercooked seafood is higher tha awareess of the risk of gettig severe woud ifectios from water exposures ad that the former level of awareess is modulatig exposures more tha the latter is over time. More evirometal moitorig ad behavioral studies are eeded to ivestigate this issue further. Differet species appear to be causig a differet spectrum of ifectios (e.g., V. parahaemolyticus seems to cause all types of ifectios, V. vulificus seems to cause oly severe bloodstream ifectios, V. algiolyticus causes maily woud (ski) ifectios while V. fluvialis causes maily gastroitestial ifectios), yet all species are icreasig more or less equally i CT. The global icrease across species i CT is cosistet with the mai hypotheses for the overall icrease: warmer water meas a more hospitable eviromet for vibrio i geeral. Thus each perso exposed is more likely to ecouter Vibrio, Also cosistet with this hypothesis, there is a higher risk of developig symptomatic ifectio i warmer weather especially whe wouds are exposed to water, ad loger seasos mea that more people get exposed. [19]

21 Limitatios This study was limited by several importat factors. First, it is ot kow if cliical laboratory or provider efforts to detect Vibrio have icreased over time. If better detectio methods have replaced those used i the past, this may have biased the results of the study toward fidig more of a icrease i vibriosis tha there really was. We did ot have good iformatio about site of ifectio, so the site from where the diagostic isolate (source) was obtaied was used as a proxy for the site of ifectio that was experieced by the patiet (assumig woud isolates mea ski ifectio, stool isolates mea ifectio of the gastroitestial tract ad blood isolates mea more severe ifectio from either a gastroitestial or ski source). If the specime source icorrectly represeted the site of ifectio, the our results would ot represet the true distributio of ifectio sites. I additio, a umber of specimes came from other sources ad did ot cotribute to the statistics o site of ifectio. If these had bee able to be classified as ski or gastroitestial sites, our data might be somewhat differet. Aother limitatio was that we had o deomiator data for how may people had each exposure. Therefore, we could ot calculate risk from each exposure. Additioally, there is o data o the treds associated with the exposures of iterest to kow if they are chagig over time. Fially, there is o microbiological data o Vibrio couts i the Log Islad Soud to kow if there have bee chages over time. [20]

22 CONCLUSIONS Vibrio icidece has icreased i Coecticut. Vibriosis is more commo i older age groups, i males, i residets of coastal couties ad durig warm weather seasos. This is most likely due to the higher levels of exposure to potetially cotamiated water or food amog those most at risk. Additioally, a icreasig frequecy of warmer days durig the warm water moths may be predisposig people to havig more frequet ad/or loger exposures to potetially cotamiated water. The icrease i cases has bee most rapid amog persos livig i coastal areas, i those with woud ifectios, durig warm water seasos, ad i those who walk i potetially cotamiated water, especially those with wouds. Agai, possible explaatios for the relatively faster rate of icrease i woud ifectios iclude: warmer water temperatures with higher Vibrio levels ad/or more people spedig more time i cotact with potetially cotamiated water. Additioal moitorig ad study are eeded if we are to succictly correlate Vibrio cases with evirometal ad exposure data. [21]

23 RECOMMENDATIONS The data preseted herei reflects the eed for cotiued surveillace i order to uderstad the icrease i icidece of vibriosis i Coecticut. I order to determie if Vibrio exposures are icreasig as a result of higher bacterial load i the Log Islad Soud, more evirometal moitorig must take place i order to determie if there is a potetial coectio betwee huma health ad the eviromet. Further studies are eeded i order to determie the frequecy of exposures of cocer i order to produce risk calculatios ad to see if risk with ay specific type of exposure is chagig over time. Prevetio-related recommedatios iclude public educatio efforts that target the populatios at highest risk for developig vibriosis (older adults, particularly those with uderlyig medical coditios, me, those livig i coastal couties). Because vibriosis i CT is most ofte associated with gastroitestial ifectio ad caused by V. parahaemolyticus, postig warig sigs about the risks associated with cosumptio of raw or udercooked shellfish at restaurats ad shellfish beds may be useful for educatig ad advisig the public about risk ivolved with these practices at these locatios. Additioally, postig advisories (or havig pamphlets) cautioig persos with ope wouds to avoid cotact with the water because of the risk of developig serious Vibrio ifectio - ad those who get cuts i their feet or ski while at the Log Islad Soud seashore or while i the Log Islad Soud should promptly wash ad clea them with soap ad water ad seek medical attetio promptly if they develop sigs of ifectio. However, it has bee suggested that these warigs do ot reach vulerable populatios [25] ad that procedures such as cold/heat shock or irradiatio may be more a effective meas for reducig pathoge couts i raw shellfish products [26]. [22]

24 There is o idicator for these aturally occurrig pathoges ad detectio of Vibrio spp. i the eviromet has bee difficult [27]. Because Vibrio growth is stimulated by the availability of utriets i the water, pollutio cotrol ad evirometal maagemet are importat compoets of ifectious disease prevetio. There is a great eed for iterdiscipliary iteractio amogst the various health ad evirometal agecies withi the state ad across the atio. These collaboratios are imperative to the missio of the Oe Health Iitiative ad the Healthy People Food Safety Goals for [23]

25 REFERENCES 1. Scalla, Elaie., et al. Foodbore Illess Acquired i the Uited States Major Pathoges. Emergig Ifectious Diseases. Vol. 17, No. 1, Jauary Daiels, NA, Shafaie, A. A Review of Pathogeic Vibrio Ifectios for Cliicias. Ifect Med 17(10): , Simms, Jeifer N., et al. Eviro Health Isights. 2011;5: Epub 2011 Nov McLaughli, Joseph B. et al. Outbreak of Vibrio parahaemolyticus Associated with Alaska Oysters. N Egl J Med.: October 6, 2005; 353: Ha, Haihog. et al. Geome plasticity of Vibrio parahaemolyticus: Microevolutio of the Pademic Group. BioMed Cetral Geomics: November ; 9: Dechet, Amy M., et al. Nofoodbore Vibrio Ifectios: A Importat Cause of Morbidity ad Mortality i the Uited States, Cliical Ifectious Diseases. 2008; 46: Mead, PS, Slutsker L, Dietz V, et al. Food-related illess ad Death i the Uited States. Emergig Ifectious Disease 1999;5: Matyas, B. et al. MMWR. Prelimiary FoodNet Data o the Icidece of Ifectio with Pathoges Trasmitted Commoly Through Food---10 States, April 16, (14); Gilliss, D., et al. MMWR. Vital Sigs: Icidece ad Treds of Ifectio with Pathoges Trasmitted Commoly Through Food Foodbore Diseases Active Surveillace Network, 10 U.S. Sites, Jue 10, (22); [24]

26 10. CT DPH. Aual Tow ad Couty Populatio for Coecticut. Accessed o Jauary 28, Shallow S., et al., MMWR. Prelimiary FoodNet Data o the Icidece of Foodbore Illesses Selected Sites, Uited States, April 06, (13); Departmet of Health, Florida, 2010 Florida Morbidity Statistics Report. Accessed April 20, Morris, GJ. Cholera ad Other Types of Vibriosis: A Story of Huma Pademics ad Oysters o the Half Shell. Cliical Ifectious Diseases, 2003;37: The Log Islad Soud Study. Soud Health 2008 Report. At Accessed o April 30, The Log Islad Soud Study. Soud Health At Accessed April 30, The Gulf of Maie Coucil o the Marie Eviromet. State of the Gulf of Maie Report: Microbial Pathoges ad Biotoxis, September Accessed April 20, Cummigs, Kate et al. CDPH. Epidemiologic Summary of No-Cholera Vibriosis i Califoria, Accessed April 18, [25]

27 18. Altekruse SF, Yag S, Timbo BB, Agulo FJ. A multi-state survey of cosumer foodhadlig ad food-cosumptio practices. Am J Prev Med. 1999;16(3): Aderso, Amy., et al. Food Safety Perceptios ad Practices of Older Adults. Public Health Rep Mar-Apr; 126(2): Oliver. JD. Woud ifectios caused by Vibrio vulificus ad other marie bacteria. Epidemiol Ifect Ju;133(3): Roy K, Haddix AC, Ikeda RM, Curry CW, Truma I, Thacker SB. Moitorig progress toward CDC s health protectio goals: health outcome measures by life stage. Public Health Reports 2009; 124: Smith, JL. Foodbore Illess i the Elderly. Joural of Food Protectio, 1998; 61; CSTE. Accessed April 19, Huq, et al. Ifluece of water temperature, saliity, ad ph o survival ad growth of toxigeic Vibrio cholerae serovar 01 associated with live copepods i laboratory microcosms. Applied ad Evirometal Microbiology (1984). Volume: 48, Issue: 2, Pages: Mouzi E, Mascola L, Tormey MP, Dassey DE. Prevetio of Vibrio vulificus ifectios: assessmet of regulatory educatioal strategies. JAMA 1997; 278: [26]

28 26. Oliver JD, Kaper JB. Vibrio species. I: Food Microbiology: fudametals ad frotiers. Doyle MP, Beuchat LR, Motville TJ, eds. Washigto, DC: America Society for Microbiology, 1997: Jada, MJ, et al., Curret Perspectives o the Epidemiology ad Pathogeesis of Cliically Sigificat Vibrio spp. Cliical Microbiology Reviews, July 1988; [27]

29 Table 1. Epidemiological ad Geographic Features of Vibriosis i CT, (N=174) Variable Frequecy (N) Percet Icidece per millio perso-years Relative Risk *p-value Age (years) Referet p Sex Female Referet p Male Race Asia Black Ukow White Ethicity Hispaic No-Hispaic Ukow Race/Ethicity Asia/NoHispaic Black/No-Hispaic Ukow/Hispaic Ukow/NoHispaic Ukow/Ukow White/Hispaic White/NoHispaic White/Ukow Source Stool Referet - Woud Blood Other Hospitalizatio Yes No Couty -Coastal Middlesex Fairfield New Lodo New Have Couty-NoCoastal Referet - Tollad Litchfield Widham Hartford Seaso Witer Referet - Sprig Summer Fall Cold Water Referet p Warm Water Species parahaemolyticus algiolyticu fluvialis vulificus cholerae other Year Referet p Cumulative *p-value for tred i proportios, species missig for oe observatio [28]

30 Figure 1.Vibriosis Icidece by Year Usig 2000 Cesus ad CT Mid-year Populatio Estimates [29]

31 Table 2. Epidemiological, Demographic ad Geographic Treds of Vibriosis i CT by Time Period, (N-174) Variable Frequecy (N) Percet Icidece per millio perso-years Relative Risk *p-value Grouped Years Referet p Age Referet Age Referet Age Referet p Male Referet Female Referet Couty-Coastal Referet p Couty-NoCoastal Referet Cold Water Referet Warm Water Referet p Stool Referet Woud Referet p Blood Referet Other Referet *p-value for time tred [30]

32 Table 3. Percetage of Iterviewed Vibriosis Cases with Selected Possible Exposures to Vibrio spp. by Time Period CT, (COVIS reports, N=166) Variable Frequecy (N) Percet Relative Risk *p-value Exposures Swimmig Referet Walkig i water Referet Woud Exposure i water Referet Seafood Drippigs (raw or live) Referet Hadlig/Cleaig Seafood Referet Boatig Referet Cosumig Ay Seafood Referet Cosumig Ay Raw Seafood Referet Comorbidities Ay Precoditio Referet *p-value for time tred [31]

33 Table 4. Vibriosis Species, Age Group, Seaso ad Couty by Source of Ifectio (N=174)* Species parahaemolyticus algiolyticus fluvialis cholerae, o-o1, oo139 vulificus Other/Ukow Vibrio spp. Total N Age Group Stool 68 (76%) 0 (0%) 11 (12%) 4 (4%) 0 (0%) 7 (8%) 90 (52%) Stool (0%) (29%) (68%) (47%) Total 90 (52%) Seaso Stool Cold Water 18 (75%) Warm Water 72 (48%) Total 90 N (52%) Couty Stool Coastal 65 (40%) Woud 27 (54%) 18 (36%) 0 (0%) 1 (2%) 3 (6%) 1 (2%) 50 (29%) Woud 6 (75%) 2 (29%) 15 (24%) 27 (28%) 50 (29%) Woud 0 (0%) 50 (33%) 50 (29%) Wouds 39 (30%) Blood 4 (27%) 1 (7%) 2 (13%) 2 (13%) 5 (33%) 1 (7%) 15 (9%) Blood 0 (0%) 0 (0%) 1 (2%) 14 (14%) 15 (9%) Blood 2 (8%) 13 (9%) 15 (9%) Blood 11 (8%) Other 4 (22%) 8 (44%) 1 (6%) 1 (6%) 0 (0%) 4 (22%) Total 103 (59%) 27 (15%) 14 (8%) 8 (5%) 8 (5%) 13 (7%) 18 (10%) 173* (100%) Other Total 2 8 (25%) 3 7 (43%) 4 (6%) 10 (10%) 19 (10%) Other 4 (17%) 15 (10%) 19 (11%) Other 17 (12%) (100%) Total (100%) Total 132 p-value No-Coastal 25 (59%) Total 90 (51%) 11 (26%) 50 (29%) 4 (10%) 15 (9%) 2 (5%) 19 (11%) (100%) *Total does ot add to 174 due to missig data [32]

34 Table 5. Reported Vibriosis Cases by Species, Age, Grouped Years by Time Period, CT, (N=174)* Species parahaemolyticus algiolyticus fluvialis cholerae, o-o1, oo139 vulificus Other/Ukow Vibrio spp. Total (62%) 3 (0%) 0 (0%) 1 (5%) 2 (10%) 2 (8%) 21 (12%) (47%) 5 (36%) 6 (19%) 4 (13%) 0 (0%) 2 (2%) 32 (19%) (73%) 5 (7%) 1 (2%) 1 (2%) 2 (4%) 4 (7%) 48 (28%) (56%) 14 (44%) 7 (10%) 2 (3%) 4 (6%) 5 (22%) 72 (42%) Total 103 (59%) 27 (15%) 14 (8%) 8 (5%) 8 (5%) 13 (7%) 173* (100%) p-value Age Group (4%) 3 (9%) 3 (6%) 8 (11%) 15 (9%) (48%) 14 (44%) 16 (33%) 22 (30%) 62 (36%) (48%) 15 (47%) 29 (61%) 43 (59%) 97 (56%) Total 21 (12%) 32 (18%) 48 (28%) 73 (42%) 174 (100%) * Total does ot add to 174 due to missig data [33]

35 Table 6. Percet Vibriosis cases by Symptoms ad Source, COVIS reports, CT, (=166) Symptoms Stool Woud Blood Diarrhea 87% 5% 7% Cramps 92% 2% 3% Nausea 81% 6% 9% Fever 50% 19% 28% Muscle Pai 55% 31% 14% Headache 78% 9% 3% Vomitig 82% 6% 12% Cellulitis 3% 83% 13% Table 7. Percet Vibriosis cases with Pre-existig Coditios, COVIS Reports CT, (=166) Pre-existig Coditios Percetage Heart Disease 13% Diabetes 8% Gastric Surgery 6% Maligacy 7% Real Disease 3% Liver Disease 4% Alcoholism 5% Hematologic Disease 3% Ay Pre-existig Coditio 39% [34]