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Cholera In Minnesota But
CDC Says Don't Worry, Be Happy

From Patricia Doyle

Hello Jeff - I am not a mind reader but I bet the farm that the two people contracted this at the restaurant where they ate before taking ill.

My guess is that the cook or wait staff was infected with Cholera and the staff did not wash their hands properly.

My guess is this is a case of a refugee transmitted disease.  I have predicted Cholera in the US for a time now.  Expected it.



A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases

Date: Fri 15 Sep 2017
Source: CDC. MMWR Morb Mortal Wkly Rep 2017; 66(36): 961-2 [edited]

Hall V, Medus C, Wahl G, et al. Notes from the field: _Vibrio cholerae_ serogroup O1, serotype Inaba -- Minnesota, August 2016. MMWR Morb Mortal Wkly Rep 2017; 66: 961-2
On 20 Aug 2016, the Minnesota Department of Health (MDH) was notified of a case of _Vibrio cholerae_ infection. The isolate was identified as serogroup O1, serotype Inaba at MDH. CDC determined that the isolate was non-toxigenic. The patient was a previously healthy woman, aged 43 years, with history of gastric bypass surgery. On 16 Aug [2016], she experienced profuse watery diarrhea, vomiting, abdominal cramps, and headache. On 18 Aug [2016], she sought care and submitted the stool specimen that yielded the _V. cholerae_ isolate. She reported no recent travel. However, she had consumed ceviche made with raw shrimp and raw oysters at restaurant A on 14 Aug [2016], 49 hours before illness onset. Her husband had a similar illness with a similar incubation period after eating the same foods at restaurant A.

On 22 Aug [2016], MDH sanitarians visited restaurant A and obtained tags and invoices for oyster and shrimp products; the oysters were a product of the US, and the shrimp was a product of India. Sanitarians also gathered patron contact information and credit card receipts for 12-14 Aug [2016]. 2 additional patrons reported experiencing a gastrointestinal illness that met the case definition of 3 or more episodes of watery stool in a 24-hour period within 5 days of eating at restaurant A; 1 reported eating ceviche and oysters at restaurant A. Review of complaints to the MDH foodborne illness hotline revealed a previous complaint from 2 persons who reported experiencing watery diarrhea after eating raw shrimp ceviche (but no oysters) at restaurant A on 2 Aug [2016]. These persons did not provide stool specimens, but their gastrointestinal illnesses met the case definition, resulting in a total of 6 cases, including one laboratory-confirmed case. No other _V. cholerae_ O1 Inaba cases were reported in the USA during this outbreak.

The Minnesota Department of Agriculture facilitated sampling of shrimp at the distributor from the same lots served at restaurant A on 14 Aug [2016], and most likely during 2-13 Aug [2016], and sent them to the FDA for culture. Shrimp samples yielded _V. cholerae_ non-O1, non-O139, but _V. cholerae_ O1 was not isolated. In response to the outbreak results, restaurant A placed consumer warnings on their menus about the risks of consuming raw or undercooked food items and identified raw menu items for consumers. Restaurant A also focused on other actions that might facilitate reduction of _V. cholerae_, including appropriate freezing of food items, and allowing raw food items to soak in lime juice before being served, rather than serving the items immediately after adding lime juice (1,2).

_V. cholerae_ has over 150 serogroups and has been identified in a wide range of aquatic life, including seafood (3). Whereas multiple serogroups can cause vibriosis, only serogroups O1 and O139 that also contain the cholera toxin are classified as causes of cholera (4). Previous studies have documented the presence of non-toxigenic _V. cholerae_ O1 from environmental and shrimp samples in India and Southeast Asia (5-7).

This outbreak of domestically acquired, non-toxigenic _V. cholerae_ infections, likely from shrimp consumption, included the 1st _V. cholerae_ O1 case identified in a non-traveler in Minnesota since active surveillance for _Vibrio_ began in 1996. Since 1996, MDH has detected 26 _V. cholerae_ infections, 21 (81 percent) of which were non-O1, non-O139, and 5 of which were O1. Among the 4 O1 type cases identified before the current outbreak, all patients had a recent travel history to Micronesia or India. This outbreak demonstrates the importance of investigating all seafood eaten by patients with vibriosis. In addition, investigators should include non-toxigenic _V. cholerae_ as a possible etiology of domestic foodborne outbreaks, particularly when foods eaten include those from _V. cholerae_ O1-endemic areas.

1. Nascumento DR, Vieira RH, Almeida HB, et al: Survival of _Vibrio cholerae_ O1 strains in shrimp subjected to freezing and boiling. J Food Prot 1998; 61: 1317-20;
2. Mata L, Vives M, Vicente G: Extinction of _Vibrio cholerae_ in acidic substrata: contaminated fish marinated with lime juice (ceviche). Rev Biol Trop 1994; 42: 479-85;
3. Faruque SM, Albert MJ, Mekalanos JJ: Epidemiology, genetics, and ecology of toxigenic _Vibrio cholerae_. Microbiol Mol Biol Rev 1998; 62: 1301-14;
4. Kaper JB, Morris JG Jr, Levine MMP. Cholera. Clin Microbiol Rev 1995; 8: 48-86;
5. Gopal S, Otta SK, Kumar S, et al: The occurrence of _Vibrio_ species in tropical shrimp culture environments; implications for food safety. Int J Food Microbiol 2005; 102: 151-9;
6. Dalsgaard A, Huss HH, H-Kittikun A, Larsen JL: Prevalence of _Vibrio cholerae_ and _Salmonella_ in a major shrimp production area in Thailand. Int J Food Microbiol 1995; 28: 101-13;
7. Dalsgaard A, Echeverria P, Larsen JL, et al: Application of ribotyping for differentiating _Vibrio cholerae_ non-O1 isolated from shrimp farms in Thailand. Appl Environ Microbiol 1995; 61: 245-51;

Communicated by:

[As a review, the flagellar (H) antigens of _Vibrio cholerae_ are shared with many water vibrios and, therefore, are of no use in distinguishing strains causing epidemic cholera. The O (somatic) antigens, however, do distinguish strains of _V. cholerae_ into 139 known serogroups. Almost all of these strains of _V. cholerae_ are non-virulent. Until the emergence of the Bengal (O139) strain (which is "non-O1"), a single serogroup, designated O1, has been responsible for epidemic cholera.

There are 3 distinct O1 serotypes, named Ogawa, Inaba, and Hikojima, each of which may display the "classical" or El Tor phenotype (or biotype). The biotypes are distinguished by their expression of surface antigens A, B, and C. Ogawa contains antigens A and B; Inaba antigens A and C; and Hikojima antigens A, B, and C. The latter serotype is relatively rare.

In almost all cases, non-O1, non-O139 _V. cholerae_ isolates do not possess the genes for cholera toxin as the non-toxigenic O1 in this posting. Some isolates can cause substantial diarrhea (1-4). The type III secretion system (TTSS) is a mechanism for Gram negative bacilli to introduce effector proteins into host cell cytoplasm (5). It has been reported that a functional TTSS is required for at least in some non-O1, non-O139 isolates to induce diarrhea in an animal model associated with small bowel damage and production of proinflammatory cytokines (6). In addition, TTSS contributes to virulence even in the presence of cholera toxin and TCP (6).

1. Bhattacharya MK, Dutta D, Bhattacharya SK, et al. Association of disease approximating cholera caused by _Vibrio cholerae_ of serogroups other than O1 and O139. Epidemiol Infect. 1998; 120(1): 1-5;
2. Sharma C, Thungapathra M, Ghosh A, et al. Molecular analysis of non-O1, non-O139 _Vibrio cholerae_ associated with an unusual upsurge in the incidence of cholera-like disease in Calcutta, India. J Clin Microbiol. 1998; 36: 756-63;
3. Bidinost C, Saka HA, Aliendro O, et al. Virulence factors of non-O1, non-O139 _Vibrio cholerae_ in Cordoba, Argentina. Rev Argent Microbiol. 2004; 36: 158-63;
4. Chatterjee SC, Ghosh K, Raychoudhuri A, et al. Incidence, virulence factors, and clonality among clinical strains of non-O1, non-O139 _Vibrio cholerae_ isolates from hospitalized diarrheal patients in Kolkata, India. J Clin Microbiol. 2009; 47(4): 1087-95;
5. Gatan JE, Colimer A. Type III secretion machines: bacterial devices for protein delivery into host cells. Science 1999: 284(5418): 1322-8;
6. Shin OS, Tam VC, Suzuki M, et al. Type III secretion is essential for the rapidly fatal diarrheal disease caused by non-O1, non-O139 _Vibrio cholerae_. mBio 2011; 2(3): e00106-11;
- Mod.LL

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