As Delaware coastal waters warm, risk of deadly bacteria rises

Editor's note: This story was originally published in 2018.

Michael Funk survived the Vietnam War and overcame his battle with throat cancer, but it only took a few days for microscopic bacteria from Assawoman Bay to claim his life.

Funk had pulled his crab pots and boat out of the water in Ocean City, Maryland, in mid-September 2016, as he had done hundreds of times before. But this time the Vibrio vulnificus bacteria flourishing in the warm water got into a cut on his leg.

Often inaccurately called “flesh-eating bacteria,” Vibrio vulnificus is always present in salty water along the coast, but the number of cases rise with the warm weather of June through October. That paints a target on the backs of summer crabbers, fishermen and people just wading into bays that feel more like bathtubs.

Vibrio bacteria are like the sharks of the aquatic microbial world: They are always there, but people tend to forget they exist until someone loses a limb. Or worse.

And as global warming raises worldwide temperatures, the rate of infections could rise, researchers say.

It already may be on the rise in Delaware. The Centers for Disease Control and Prevention began tracking Vibrio-related illnesses and deaths in the Gulf Coast states in 1989, but it took other coastal states like Delaware another decade or longer to join them.

According to the CDC, Delaware had no reported cases until 2003, when it had one illness. In 2017, a dozen people became ill with Vibrio-related infections, state data show.

“It tends to be much more abundant at the end of the summer, when it’s warm and people are swimming and exposed to salt water and fresh water,” said Dr. Rita Colwell, a Vibrio expert from John Hopkins University. “You can’t eradicate it.”

Already this year, a crabber in New Jersey was told he might lose all his limbs, but now faces the likely loss of some toes and fingers. A fisherman in Texas waded in the water there before dying from the infection. One person died in Florida and another in Virginia after slurping down raw oysters infected with the bacteria.

"Vibrio disease really has meaning for the Eastern Shore and for Maryland and Delaware because Vibrio vulnificus is present in the (Chesapeake) Bay and it causes one to two deaths, not every year, but sufficiently frequently," said Colwell, who is a distinguished professor at the University of Maryland College Park and Johns Hopkins.

The organism can cause an infection that poisons blood, collapses internal organs, eats away flesh and flatlines patients in hours or days, said Colwell.

“It can really do a job on your muscle tissue,” she said. “When it gets systemic it can attack your internal organs. But it doesn’t strike everybody.”

While she and other public health experts worry about the bacteria, there’s no real warning system in Delaware to alert swimmers, fishers and crabbers when the risk is high. There’s also no system tracking and disseminating information about the bacteria, which exists all the time, but multiplies faster in warm water.

As dire as that sounds, fatal Vibrio infections are still considered rare by the Centers for Disease Control because fewer than 200,000 people are infected each year. On average, about 27 people around the country die each year.

However, the CDC estimates that number may be closer to 100 deaths each year, with upwards of 80,000 infections.

It is unclear how many cases may be misdiagnosed or underreported, not only on Delmarva, but in every coastal state that sees Vibrio-related deaths and illnesses each year. In the recent case of the crabber in New Jersey, he was misdiagnosed twice before doctors realized that it was Vibrio vulnificus, not cellulitis, attacking his system.

"If it enters a wound or cut or abrasion and isn’t treated right away with antibiotic, it can prove fatal within 24 to 48 hours," Colwell said. “If you’re swimming in the bay and get an infected wound, get thee to the doctor.”

What is Vibrio?

In the days and weeks following the death of her husband of 46 years, Marcia Funk repeatedly asked the same questions: What is Vibrio, why had she never heard of it before and where were the warnings?

“There was no warning at the boat ramp or nothing,” she said. “Now I see all these kids out here on jet skis and paddleboards and it makes me a huge wreck. I don’t look at the water in the same way.”

On Delmarva, there are two Vibrio species of concern: The potentially deadly Vibrio vulnificus, which claimed Funk’s life, and Vibrio parahaemolyticus.

Both can cause stomach cramps, nausea, watery diarrhea, vomiting and fever after ingesting shellfish contaminated by the bacteria, but Vibrio vulnificus also is capable of wreaking havoc on open wounds while Vibrio parahaemolyticus causes food poisoning. They are the two species most common in Delmarva, but another dozen species cause illnesses in the United States.

Vibrio vulnificus prefers warm, brackish water, where fresh water meets salt water. The bacteria prefer water that is at least 64 degrees with a salinity between 15 to 25 parts per thousand. Ocean water averages about 35 parts per thousand. The bacteria can live in crystal clear water or mud, meaning they survive with or without dissolved oxygen in the water.

That is how it can flourish in the environment of a body once it finds its way into a cut.

Vibrio parahaemolyticus prefers a more salty situation. That is the main reason that Delaware, Maryland and other states prohibit commercial oyster harvesting in the summer and early fall — when the water is warm enough for the bacteria to multiply and pose a threat.

In colder conditions, the bacteria go dormant and pose little threat, Colwell said.

People who suffer liver problems, immune system deficiencies, diabetes or have high amounts of iron in their blood are particularly susceptible to fatal infections, especially from Vibrio vulnificus. But anyone who ingests contaminated, raw seafood or exposes an open wound to salt water could face life-threatening consequences.

When air temperatures hit 90 degrees, some Vibrio species, like Vibrio parahaemolyticus, can double their numbers within an hour. NOAA’s National Centers for Coastal Ocean Science says Vibrio parahaemolyticus “has one of the fastest growth rates of all estuarine bacteria.”

Just like mosquitoes, they are a constant part of the environment and will always be a drawback to warm summer days and nights spent on the water.

"They're part of a natural, healthy ecosystem,” said Michael Bott, an environmental scientist with the Delaware Division of Watershed Stewardship. “The state can't remove Vibrios."

Even so, there is no monitoring system for Vibrio bacteria in Delaware’s waterways, he said.

There are, however, prediction models from NOAA, designed primarily for watermen, that calculate temperature and salinity to show when and where Vibrios are plentiful, and how quickly they can multiply in those conditions. But unless a person happened to stumble on that online database, they might not know the potential dangers lurking in their next oyster or plunge in the bay.

Watermen know the risks and take care to harvest from cooler waters and keep their shellfish chilled. If a raw oyster or clam is not kept chilled from the water to boat to market to dinner plate, that is when Vibrio have a chance to multiply and pose a threat to whoever slurps them down.

The deadliest risk is with Vibrio vulnificus wound infections. For the sensitive risk groups mentioned earlier, this type of infection can come with about a 50-percent survival rate and turn deadly in a matter of hours.

“It migrates away,” Colwell said. “It gets very ugly. You can have a fever and chills. It has to be treated properly and quickly. If it goes systemic, it can be lethal.”

Marcia Funk, who has owned the Ocean City condo for nearly four decades, said her husband had no underlying health conditions that she knew of, other than his earlier battle with throat cancer, a bad knee and a case of cellulitis earlier that year.

But he did have open wounds and irritated skin on his legs when he was cleaning his crab pots and waded in the bay in fall 2016, she said.

Kent Island, Maryland, resident Tim Sutch, said he also had no underlying health conditions during his encounter with the bacteria last summer nearly intact.

He said he had heard of Vibrio before, but never thought it could happen to him because it’s rare.

Sutch counts himself among the lucky ones after losing only half of his middle finger last year after he pricked it on a fish bone in a tributary of the Chesapeake Bay.

“I was in the hospital for six days and I consider myself one of the luckiest people alive,” the 56-year-old fisherman said. “If it does make it to your bloodstream, you can kiss yourself goodbye.”

What Vibrio can do

Before Sutch had his finger partially amputated last fall, it looked like there was "a dried up grape" stuck to the end of his finger.

"And talk about a horrible odor," he said. Other than the extreme pain in his finger, which eventually turned purple, black and blue, he could not recall any other unique symptoms.

Marcia Funk said her husband's infection began with vomiting.

"He had thrown up in the street," she said. "He never ate any dinner. He stayed in bed."

They called the paramedics twice that night. The first time, he thought he skipped a pain pill and that was why he was sick. The second time he called, they took him to the hospital.

He spent one night at Atlantic General Hospital in Berlin, Maryland, where doctors removed the flesh from his knee to his ankle before he was flown to the University of Maryland’s Shock Trauma Center in Baltimore to have his leg amputated. But the amputation came too late. The bacterial infection had reached his bloodstream and organs, his wife said.

He died on Sept. 15, 2016, about 36 hours after symptoms first appeared.

“It’s really scary,” Funk’s widow said. “I thought he just had a cut on his leg and got some sort of infection.”

It wasn’t until a nurse asked her husband to stop sitting up to grab his leg at the first hospital that Marcia realized how serious the infection was.

“One of the nurses said in a harsh voice, ‘Mr. Funk, please, you are a dying man and we’re doing everything in our power to save your life. Please lay down.’

"And he was. He didn’t know it. I didn’t know it at the time,” she said. “It’s unbelievable, but it’s out there.”

Dr. Marci Drees, an infection prevention officer and hospital epidemiologist with the Christiana Care Health System, said extreme cases of Vibrio infections are very uncommon. In the last five years, she said she has only seen two cases of Vibrio infections at Christiana.

"It's an uncommon disease, but more common this time of year," she said.

Still, those Vibrio vulnificus infections are severe enough that the infectious disease board exams always have one question about them, she said.

If misdiagnosed, as The Washington Post reported in the case of a New Jersey crabber who risked losing his limbs after an infection, the consequences can be devastating.

"Sometimes it may get missed because the patient doesn't look that sick," Drees said.

Some scientists have found that Vibrio bacteria also have developed resistance to antibiotics, which can make treatment for people in the risk group even more difficult.

The highest documented death toll from Vibrio vulnificus recorded by the CDC was in 2010, when 36 people died. That year, there were 927 reported Vibrio-related infections, and a total of 45 Vibrio-related deaths.

To put that into perspective, cases of hypothermia in the United States proved far more deadly that year as cold killed more than 1,500 people. On average, cold claims more than 600 lives annually, far more than the average 27 lives lost to Vibrio each year.

Delaware health officials said an initial review found no recorded Vibrio vulnificus infections in the First State. They also said there are no documented deaths related to Vibrio since the state started tracking cases in 2005, but could not confirm that information without first reviewing each individual case. Officials also said they are unsure — and have not investigated why — Vibrio illnesses have doubled in Delaware in recent years.

Necrotizing fasciitis, which is the “flesh-eating” symptom of a Vibrio infection, also is considered rare, with 700 to 1,200 cases reported every year. The CDC estimates cases of necrotizing fasciitis of all kinds are underreported.

“The sky is not falling,” Colwell said. “But Vibrio vulnificus is the one people need to understand.”

Scientists: We have some bad news

Colwell was one of several authors on a study that looked at how the rise in water temperatures over the last 54 years in the North Atlantic affected Vibrios. They studied nine areas from Nova Scotia to the coast of Iceland to the Iberian Coast of Spain, andfound a link between an increase in bacteria and an increase in water temperature in eight of those study areas.

They use that data to suggest that Vibrio infections could pose a greater risk to public health as waters warm due to climate change.

“The evidence is strong that ongoing climate change is influencing outbreaks of Vibrio infections on a worldwide scale,” the paper published in 2016 reads.

Colwell said this may be the first scientifically supported demonstration of an increase in human illness that could be directly linked to climate change.

Federal data show an increase in recent years of illnesses caused by Vibrio species.

From 1997 to 2014, 466 people died from Vibrio-related infections, CDC data show. That number could be far higher if the CDC's estimate of 100 deaths each year is accurate.

Vibrio vulnificus was the cause of nearly 75 percent of reported deaths, while Vibrio parahaemolyticus accounted for 35 fatalities, according to CDC data.

Cholera, which is caused by a different species of Vibrio, Vibrio cholerae, proves deadly in many other parts of the world, although there are cases in the United States as well. Delaware had one reported case in 2013, state officials said.

Vibrio cases nationally have more than tripled to 1,252 in 2014, the last year for which data were available, since the U.S. started tracking cases in 1997, when there were 386.

Several scientific papers suggest better tracking and better education for the public is needed.

“There’s no warning, there’s no nothing,” said Marcia Funk. She worries that other people could encounter the bacteria at the same place and never know.

“I want people to know. Ocean City might not want to scare off tourists, but people need to be more aware.”

HOW TO AVOID INFECTION

There are two simple, surefire ways to avoid Vibrio infections: Don’t eat raw shellfish or seafood and never go into the water with an open wound.

But for those who live along the coast, here are a few other tips:

• Make sure raw shellfish is properly cooled at all times
• Do not go into brackish water (where the water is a mix of fresh and saltwater) with an open wound
• If you go into any water with an open wound, make sure it is adequately covered and protected
• If you get a wound while in the water, immediately and thoroughly clean it
• If a wound appears infected after being in the water (brackish or saltwater, especially), seek medical attention immediately
• Consult your doctor about the risks of Vibrio if you have any underlying medical conditions, such as liver problems, immune system disorders, diabetes, or high iron in the blood (hemochromatosis)
• Consult the National Oceanic and Atmopsheric Administration’s Vibrio prediction models at https://products.coastalscience.noaa.gov/vibrioforecast/
• Learn more about Vibrio at www.cdc.gov/vibrio

Contact reporter Maddy Lauria at (302) 345-0608, mlauria@delawareonline.com or on Twitter @MaddyinMilford.