To date, seven people, in the area affected by Hurricane Katrina, have been reported to be ill from the bacterial disease, Vibrio vulnificus. Four have died. The first cases were reported by the Mississippi Department of Health. V. vulnificus can cause an infection of the skin when open wounds are exposed to warm seawater. People at greatest risk for illness from V. vulnificus are those with weakened immune systems and the elderly. Because V. vulnificus is a bacterium in the same family as the bacteria that causes cholera, some media reports have confused the two pathogens.

As part of the current investigation, CDC and other response agencies are working with health departments in affected states to help identify persons who might be at increased risk for V. vulnificus and recommend appropriate treatment for them.

What is Vibrio vulnificus?
Vibrio vulnificus is a bacterium that is a rare cause of illness in the United States.  The illness is very different from cholera, which is caused by different bacteria, called Vibrio cholerae.  V. vulnificus infections do not spread directly from one person to another, and are a serious health threat predominantly to persons with underlying illness, such as liver disease or a compromised immune system.  The organism is a natural inhabitant of warm coastal waters. Infection can occur after a wound is exposed to warm coastal waters where the V. vulnificus organism is growing.  Infection may also be acquired by eating raw or undercooked seafood from those waters.

CDC receives reports of over 400 Vibrio illnesses each year.  Of those, about 90 per year are due to V. vulnificus.  Most Vibrio vulnificus illness occurs during warm weather months.

Symptoms of infection with V. vulnificus
·       Acute illness, with a rapid decline in health following exposure
·       If exposed by contamination of an open wound, increasing swelling, redness, and pain at the site of the wound
·       Illness typically begins within 1-3 days of exposure, but begins as late as 7 days after exposure for a small percentage of cases

·       Fever
·       Swelling and redness of skin on arms or legs, with blood-tinged blisters
·       Low blood pressure and shock

By contrast, the symptoms of cholera are profuse watery diarrhea, vomiting. cramps, and low-grade fever.

Illness caused by V. vulnificus
Wound infections may start as redness and swelling at the site of the wound that then can progress to affect the whole body. V. vulnificus typically cause a severe and life-threatening illness characterized by fever and chills, decreased blood pressure (septic shock), and blood-tinged blistering skin lesions (hemorrhagic bullae). Overall, V. vulnificus infections are fatal about 40% of the time.  Wound infections with V. vulnificus are fatal about 20% of the time, and aggressive surgical treatment can prevent death.

How people become infected
V. vulnificus is found in oysters and other shellfish in warm coastal waters during the summer months. Since it is naturally found in warm marine waters, people with open wounds can be exposed to V. vulnificus through direct contact with seawater, shellfish, and marine wildlife. There is no evidence for person-to-person transmission of V. vulnificus.

Persons who have immunocompromising conditions, and, especially those with chronic liver disease, are particularly at risk for V. vulnificus infection when they eat raw or undercooked seafood, particularly shellfish harvested from the Gulf of Mexico, or if they bathe a cut or scrape in marine waters. About three-quarters of patients with Vibrio vulnificus infections have known underlying hepatic disease or other immunocompromising illness.  Otherwise healthy persons are at much lower risk of Vibrio vulnificus infection. 

Concerns in hurricane-affected areas
Persons with immunocompromising conditions and especially those with chronic liver disease should avoid exposure of open wounds or broken skin to warm salt or brackish water, and avoid consuming undercooked shellfish harvested from such waters.  More information on caring for wounds may be found in the CDC document Emergency Wound Management for Hurricane Professionals.

After a coastal flood disaster, large numbers of persons with illnesses that affect their resistance to infection may be exposed to seawater.  Injury prevention is especially important in high risk persons.  Wounds exposed to seawater should be washed with soap and water as soon as possible, infected wounds should be evaluated by a doctor, and clinicians should aggressively monitor these wounds. 

Diagnosis
V. vulnificus infection is diagnosed by microbiologic culture of the wound, by blood cultures, or by stool culture in the case of patients who consumed raw or undercooked seafood.

Treatment
V. vulnificus infection is treated with antibiotics. When this infection is suspected, treatment with a combination of a third-generation cephalosporin (e.g., ceftazidime) and doxycycline is recommended.  V. vulnificus wound infections should be treated with aggressive attention to the wound site; amputation of the affected limb is sometimes necessary.

Recovery
V. vulnificus infection is an acute illness, and those who recover should not expect long-term consequences.

Information about Vibrio surveillance may be found at http://www.cdc.gov/foodborneoutbreaks/vibrio_sum.htm

September 5, 2005,

Guidelines for the Management of Acute Diarrhea

This is an official CDC Health Advisory

these situations.

CHILDREN

∙ Young age (e.g., aged <6 months or weight <18 lbs.)

∙ Premature birth, history of chronic medical conditions or concurrent illness

∙ Visible blood in stool

∙ High output diarrhea, including frequent and substantial volumes of stool

∙ Persistent vomiting

∙ Change in mental status (e.g., irritability, apathy, or lethargy)

∙ For breastfed infants, nursing should be continued

∙ No unnecessary laboratory tests or medications should be administered

o Fever

o Bloody or mucoid stool

o Suspicion of sepsis

OLDER CHILDREN AND ADULTS

∙ Elderly age

∙ History of chronic medical conditions or concurrent illness

∙ Fever ≥39 °C (102.2 °F)

∙ Visible blood in stool

∙ High output of diarrhea, including frequent and substantial volumes of stool

∙ Persistent vomiting

∙ Change in mental status (e.g., irritability, apathy, or lethargy)

Principles of appropriate treatment for ADULTS with diarrhea and dehydration

∙ No unnecessary laboratory tests or medications should be administered

o Fever

o Bloody or mucoid stool

o Suspicion of sepsis

This document is also available online with a table describing the degrees of dehydration at

http://www.bt.cdc.gov/disasters/hurricanes/dguidelines.asp

The purpose of these recommendations is two-fold:

• Immunization records are unlikely to be available for a large number of displaced children and adults. 
  
• It is important that immunizations are kept current if possible.

• Although the possibility of an outbreak is low in a vaccinated U.S. population, it is possible that outbreaks of varicella, rubella, mumps, or measles could occur.  
  
• Although measles and rubella are no longer endemic to the United States, introductions do occur, and crowded conditions would facilitate their spread.
• Hepatitis A incidence is low in the affected areas, but post-exposure prophylaxis in these settings would be logistically difficult and so vaccination is recommended. 

under crowded conditions.

I.Recommended immunizations

• Childhood and Adolescent Immunization Schedule:

• •Adult Immunization Schedule:
  

If immunization records are not available:

This includes the following vaccines:

• Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) 
  
• Inactivated Poliovirus vaccine (IPV) 
  
• Haemophilus influenzae type b vaccine (Hib) 
  
• Hepatitis B vaccine (HepB) 
  
• Pneumococcal conjugate vaccine (PCV) 
  
• Measles-mumps-rubella vaccine (MMR) 
  
• Varicella vaccine if no history of chickenpox 
  
• Influenza vaccine if in Tier 1.

www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a4.htm

Children and adolescents (aged 11-18 years) should receive the following

recommended immunizations:

• Adult formulation tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) 
  
• Meningococcal conjugate vaccine (MCV (ages 11-12 and 15 years only) 
  
• Influenza vaccine if in Tier 1* (MMWR 2005;54:749-750)

www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a4.htm

Adults (aged >18 years) should receive the following recommended

immunizations:

• Adult formulation tetanus and diphtheria toxoids (Td) if >10 years since receipt of any tetanus toxoid-containing vaccine 
  
• Pneumococcal polysaccharide vaccine (PPV) for adults ≥65 years or with a high risk condition (MMWR 1997;46(No. RR-8):12-13) 
  
• Influenza vaccine if in Tier 1*(MMWR 2005;54:749-750).

www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a4.htm

II.Crowded Group Settings

Influenza

Everyone ≥6 months of age should receive influenza vaccine.

Children 8 years old or younger should receive 2 doses, at least one month apart.

Varicella

MMR

Hepatitis A

Screening should be performed by self-report.

Documentation

Diarrheal diseases

Vaccination against typhoid and cholera are not recommended.

*Influenza Tier 1 (MMWR 2005;54:749-750).

www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a4.htm

Tier 1 recommendations include the following priority groups:

•Persons ages >65 years with comorbid conditions

•Residents of long-term care facilities

•Persons >65 years without comorbid conditions

•Healthcare personnel who provide direct patient care

•Household contacts and out-of-home caregivers of children aged <6 months.

This document is also available online at

http://www.bt.cdc.gov/disasters/hurricanes/katrina/vaccrecdisplaced.asp

1. Tetanus and diphtheria toxoid (receipt of primary series, and Td booster within 10 years)
   
   
2. Hepatitis B vaccine series for persons who will be performing direct patient care or otherwise expected to have contact with bodily fluids

• hepatitis A vaccine (low probability of exposure, even under these conditions, in U.S. ) No transmission from contaminated water has been identified in the U.S. since the 1980's. Hepatitis A outbreaks have not occurred following other hurricanes or floods in other parts of the country, including the devastating hurricanes in Florida last year, and the Midwestern floods of the late 1990's. The Gulf Region has had few hepatitis A cases in recent years, with less than 10 in the past 3 months reported from the New Orleans area. Thus, even though the water and sewage systems are damaged or out of operation in many areas along the Gulf Coast , the risk of a hepatitis A epidemic is extremely low. Vaccine will take at least one to two weeks to provide substantial immunity.
  
  
• typhoid vaccine (low probability of exposure, even under these conditions, in U.S. ).
  
• cholera vaccine (low probability of exposure, even under these conditions, in U.S. , plus no licensed cholera vaccine available in the U.S. ).
  
• meningococcal vaccine (no expectation of increased risk of meningococcal disease among emergency responders).
  
• rabies vaccine series (the full series is required for protection). Persons who are exposed to potentially rabid animals should be evaluated and receive standard post-exposure prophylaxis, as clinically appropriate.