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Cholera Associated with Food Transported from El Salvador -- Indiana, 1994

Since the onset of the cholera epidemic in Latin America in 1991, most cases of cholera in the United States have occurred among persons traveling to the United States from cholera-affected areas or who have eaten contaminated food brought or imported from these areas. In December 1994, a cluster of cholera cases occurred among persons in Indiana who had shared a meal of contaminated food brought from El Salvador. This report summarizes the investigation of the cases conducted by the Indiana State Department of Health (ISDH) in collaboration with the local health departments in Jasper and Newton counties (Indiana), the Illinois Department of Public Health, and the DeWitt-Piatt (Illinois) Bi-County Health Department.

On December 30, 1994, a 56-year-old male resident of Illinois who was visiting relatives in Indiana had onset of severe watery diarrhea, nausea, and vomiting. On December 31, he was evaluated at a local hospital and admitted because of dehydration and hypothermia. Culture of a stool sample obtained from the patient on admission yielded toxigenic Vibrio cholerae O1, serotype Ogawa, biotype El Tor. The culture was confirmed by ISDH, the Kentucky Department for Health Services, and CDC. He was treated with intravenous rehydration and antibiotics and was discharged on January 7, 1995. The patient's 51-year-old wife also had onset of watery diarrhea on December 30. She was evaluated at the same hospital on December 31 and again on January 2, 1995. Stool cultures obtained on both occasions were negative for bacterial pathogens but were not cultured specifically for V. cholerae on thiosulfate-citrate-bile salts-sucrose (TCBS) agar.

During the month preceding onset of their illnesses, these persons had neither traveled outside the United States nor eaten raw shellfish. On December 29, while visiting their 26-year-old daughter in Indiana, they shared a meal with her and their 18-year-old son. The meal comprised palm fruit, bread, and white cheese, all of which had been brought from El Salvador to Indiana 2 days earlier by a relative. Neither their daughter nor son reported diarrhea.

To determine the number of persons infected with V. cholerae O1, serum was obtained from the four persons who shared the meal and from the 28-year-old son-in-law who did not eat any of the food items from El Salvador. Vibriocidal antibody titers greater than or equal to 640, indicating recent infection with V. cholerae O1, were detected in the four persons who had shared the meal but not in the son-in-law. Although the relative who brought the food had returned to El Salvador before he could be interviewed, family members reported that he had had no diarrheal illness while in the United States. The methods of preparation of the foods in El Salvador could not be determined; however, the palm fruit was reportedly home-canned in a salt and vinegar solution. No food items were available for testing. Reported by: N Bailey, M Louck, MD, Jasper County Health Dept, Rensselaer; D Hopkins, J Parker, MD, Newton County Health Dept, Morocco; A Oglesby, D Ewert, MPH, B Barrett, K Laurie, E Muniz, MD, State Epidemiologist, Indiana State Dept of Health. N Wade, DeWitt-Piatt Bi-County Health Dept, Clinton; P Piercy, MSPH, BJ Francis, MD, State Epidemiologist, Illinois Dept of Public Health. T Maxson, DrPH, M Russell, R Finger, MD, State Epidemiologist, Dept for Health Svcs, Kentucky Cabinet for Human Resources. Foodborne and Diarrheal Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Although most recent cases of cholera in the United States have been associated with international travel (1,2), three U.S. outbreaks have been linked to consumption of food transported from other countries: two associated with crab meat transported in suitcases from Ecuador (3,4) and one associated with commercial frozen coconut milk imported from Thailand (5). The investigation of the cases in Indiana did not implicate a specific contaminated food item; however, of the three food items transported from El Salvador, canned palm fruit is more likely to support the growth of V. cholerae than dry foods, such as bread or cheese.

Since the introduction of cholera into Latin America in 1991, approximately 1 million cases and 9000 associated deaths have been reported to the Pan American Health Organization (PAHO) (2). In 1994, El Salvador and 12 other countries in Latin America reported cholera cases to PAHO (2). Travelers to Latin America and cholera-affected areas in Asia and Africa should eat only foods that have been cooked and are still hot and should drink only beverages that are carbonated or made from boiled or chlorinated water. Travelers also should be advised not to transport food from cholera-affected areas.

The health-care providers who evaluated and treated the patients in this report initially did not suspect cholera because the patients had had no history of recent travel. Patients with severe diarrhea or suspected cholera should be asked about histories of recent travel and consumption of foods transported from another country. Stool samples obtained from persons with suspected cholera should be cultured on TCBS agar because other media routinely used for stool cultures may not support the growth of V. cholerae. Isolates of V. cholerae should be sent to a state public health laboratory for serogrouping; isolates that are serogroup O1 or O139 should subsequently be referred to CDC for toxin testing.

References

  1. CDC. Cholera associated with international travel, 1992. MMWR 1992;41:664-7.

  2. CDC. Update: Vibrio cholerae O1 -- western hemisphere, 1991-1994, and V. cholerae O139 -- Asia, 1994. MMWR 1995;44:215-9.

  3. CDC. Cholera -- New York, 1991. MMWR 1991;40:516-8.

  4. Finelli L, Swerdlow D, Mertz K, Ragazzoni H, Spitalny K. Outbreak of cholera associated with crab brought from an area with epidemic disease. J Infect Dis 1992;166:1433-5.

  5. Taylor JL, Tuttle J, Pramukul T, et al. An outbreak of cholera in Maryland associated with imported commercial frozen fresh coconut milk. J Infect Dis 1993;167:1330-5.


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