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
CDC. Cholera associated with international travel, 1992. MMWR
1992;41:664-7.
CDC. Update: Vibrio cholerae O1 -- western hemisphere,
1991-1994,
and V. cholerae O139 -- Asia, 1994. MMWR 1995;44:215-9.
CDC. Cholera -- New York, 1991. MMWR 1991;40:516-8.
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.
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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