Warnings lag in Mid-Atlantic as deadly marine bacteria increases threat in summer

As a Maryland man was losing his battle against deadly bacteria in fall 2016, a Dover man was fighting the same microscopic organism in the same Delmarva hospital.

Delaware's Robert Dunn, like Michael Funk, was at war with a Vibrio vulnificus wound infection which Dunn contracted while catching crabs. Naturally occurring bacteria found in the brackish coastal waters of Delaware and elsewhere, Vibrio vulnificus is often inaccurately called “flesh-eating bacteria” for its ability to release enzymes that can rot flesh and shut down internal organs.

Always there, Vibrio multiplies dangerously in warm water and can become deadly.

Yet, even though doctors, scientists, fishermen, state regulators and the National Oceanic and Atmospheric Administration know it exists and can pose a serious health threat, especially in summer, there's little notice or warning to the public when it does.

AN INTRO TO VIBRIO:As Delaware coastal waters warm, risk of deadly bacteria rises

Dunn figures that may be because it would hurt tourism, but experts say it's because the bacteria is always there and there's nothing they can do to kill it or even accurately warn people exactly where it is a threat.

“It’s not that the state is not monitoring,” said Michael Bott, an environmental scientist at the Delaware Department of Natural Resources and Environmental Control. “It’s that we know those risk levels are associated with temperatures and salinities. The risk is always going to be there during the warmer months.”

Testing every nook of the Delaware Bay and Sussex County’s Inland Bays would be nearly impossible. And if one water sample revealed low levels of Vibrio, that could mislead the public into thinking the waterway — which could have wildly different results between one end and the other — is Vibrio-free, Bott said.

In addition, testing for total Vibrios is not necessarily an accurate illustration of the true threat to public health. Within a sample, there could be cells of Vibrios, like vulnificus, that are highly infectious and others that are not. Plus, no one knows exactly how much of the bacteria it takes to make someone deathly ill.

The infections also are considered rare and particularly lethal to people who have underlying health conditions, meaning governments may not want to put their dollars into tracking, testing and warning for something that doesn't affect many.

But Dunn and others wonder.

“When you’re looking at a [multi-billion dollar] tourism industry between Lewes and Chincoteague," Dunn said, "they’re not going to tell some guy who is paying $1,800 for a two-bedroom condo in Ocean City or Fenwick Island that he can’t go near the water.

“I believe that.”

As global warming continues to raise worldwide temperatures, some experts fear the rate of infections, which peak from June through October, could rise even more, researchers say.

Vibrio infections can be caused by eating raw oysters contaminated by the bacteria or when the bacteria finds its way into a cut or wound on the skin. For some, that can mean an extremely irritated cut or stomach. For others with underlying health conditions, the most serious form of the infection can quickly lead to amputations and death.

It is unclear exactly how many people are infected by Vibrio each year. Many experts say infections are likely underreported or misdiagnosed.

In Delaware, cases have reached an all-time peak in recent years, with 12 infections reported in 2016 and 2017. Nationally, cases also have been on the rise, with more than 1,200 infections and 34 deaths reported in 2014. But those officially reported numbers stand against the U.S. Centers for Disease and Control’s estimate that 80,000 illnesses and 100 deaths occur each year.

And it's hard to tell where Vibrio strikes.

The U.S. Centers for Disease tracks cases by the residence of the victim. If, for example, someone who lives in Maryland gets a Vibrio infection in Delaware, that case is counted as a Maryland case.

The only way to know where each case began is to individually inspect each report, meaning it's highly impractical to find out how many Vibrio infections begin in Delaware waters.

Bott can say for sure that there's never been a Vibrio vulnificus or Vibrio parahaemolyticus infection from eating shellfish harvested in Delaware waters.

Still, in Delaware, the only public health warnings shared by the state this year went directly to hospitals. Healthcare providers are urged to be on high alert for the bug in the peak risk months of the summer and early fall, officials said.

“We often have to prioritize,” said Delaware Public Health spokeswoman Jennifer Brestel. “I’m not saying Vibrio … are less important. The information is there, it just may not be popped out at the front and center.”

Even if a workable warning system could be put into action, it would have to include personal responsibility, experts say.

Right now, crabbers and seafood lovers largely have to track water conditions themselves and know where their food comes from, allowing them to decide whether that cocktail-laden half-shell is really worth it.

“Life is not a no-risk activity,” Bott said. “This has always been around. This has always been a risk.”

The science isn’t there yet

One Saturday in late August 2016, the morning after the Dunns had enjoyed a dinner of crabs Robert caught near the Delaware Bay's Woodland Beach, the Dover couple realized something was terribly wrong.

Two hours after their early morning breakfast, Robert began vomiting and shaking uncontrollably. When his wife, Kathleen, finally convinced him to go to a walk-in clinic, he could not get out of his chair.

That’s when they called 911, and Dunn’s fight for survival began.

“I’m lucky to be alive,” Robert said. “I’m a success story in the fact that I’m still here.”

It would take multiple surgeries, medications and months in hospitals and rehabilitation centers in Delaware and Maryland before Dunn could return home to Velcro shoes, walking sticks and a life of pain. He the Vibrio and septic shock, a condition in which the body starts shutting down functions to survive after an infection gets into the blood.

Vibrio had found its way into a cut on his hand that he didn’t even know he had and overnight caused a nasty infection near the wound that entered his bloodstream.

Dunn said he had never heard of Vibrio before his near-death encounter. But he did know after working for a Delaware clam company that shellfish are bottom feeders exposed to all the good and bad of the bays.

Professionals who work on the water and face the greatest risk of exposure to Vibrio are generally aware of the dangers to themselves and their customers, industry experts say. State and local regulatory agencies, as well as national trade organizations, offer Vibrio educational outreach and trainings in an industry that once thrived in the First State.

When it comes to oysters, Vibrio parahaemolyticus causes more problems, but Vibrio vulnificus claims more lives when it gets into a wound or oysters. 

Vibrio parahaemolyticus generally only causes symptoms of food poisoning that are overcome by otherwise healthy people. About a dozen other Vibrio species also can make people sick.

“I don’t want to say it’s much ado about nothing because there are fatalities involved, but for Vibrio vulnificus, we’re talking 60 to 80 illnesses a year nationwide,” said “Vibrio evangelist” Robert Rheault. He is the executive director of the East Coast Shellfish Growers Association.

“More than half of those are wound infections, and most of them are in the Gulf," he said. "One of the reasons people don’t know much about it is because most doctors will never see a case in their entire career.”

For Bott, who oversees the guidelines for Delaware’s commercial oyster harvesters, observable data is key to local decision-making.

“We don’t hypothesize when managing a resource like that,” he said. “You base it off actual data.”

State and federal regulations protect the public by requiring shellfish be kept on ice or chilled within hours after harvest and enforcing an industry-driven prohibition on collecting oysters from the Delaware Bay in the riskier months. 

But an uninformed user could negate all of that hard work by leaving a bag of oysters unchilled for too long on a summer day.

It is also easy for someone with liver problems, immune systems disorders, diabetes or high iron in their blood — the main underlying health problems that can turn an infection into a lengthy hospital stay or worse — to ignore the U.S. Food & Drug Administration-backed advisories on menus that warn vaguely of the risks of eating raw or undercooked food.

“At some point, we have to take some responsibility for our actions,” Rheault said.

When people get sick from Vibrio vulnificus or Vibrio parahaemolyticus after eating raw oysters, reports rarely specify whether the consumer was properly handling the shellfish, he said. And nearly all victims have some type of underlying health condition, he said.

“There was a guy in Maryland who I suggest ... committed suicide by oyster,” Rheault said. That man had recently had a transplant and was still on medication when he ate bacteria-laden shellfish and later died. In another case, Rheault said, a man had five underlying, pre-existing conditions “that should have precluded him from eating any raw oysters.”

“If you’re not a healthy person, don’t eat raw eggs or undercooked seafood,” Rheault said. “Once you pull the oyster out of the water and he’s not pumping, the bacteria inside of him will start dividing and that’s totally determined by the temperature.”

Vibrio parahaemolyticus, among the leading cause of foodborne illnesses nationwide, can double its population within an hour if the temperature is about 90 degrees. The more bacteria in an oyster, the greater risk that even an otherwise healthy person might spend some unwanted time in the bathroom or in a hospital.

Vibrio vulnificus wound infections in those with compromised health can lead to amputations or death within 48 hours or less.

Rheault said the “science is not there yet” to predict when and where the bacteria could pose a serious threat. To begin, samples would require costly DNA analysis to determine if the Vibrio in them is capable of making someone sick.

Scientists thought they had isolated a gene that would tell them whether or not a Vibrio sample was infectious. Then several recent cases of Vibrios were tested and did not show that gene, he said.

“There are hundreds of strains of Vibrio parahaemolyticus," Rheault said. "And the thing about bacteria is they are genetic sluts. They swap genes like crazy.”

While experts have a good idea of how many Vibrio parahaemolyticus cells are needed to make someone sick, that threshold is unknown for the more deadly Vibrio vulnificus.

“Nobody is going to sign up for that study,” Rheault said.

Funding for scientific studies is limited, he said. He's struggled for two decades to get the funding and resources needed to develop a simple test that could be used out on a boat while oysters are gathered.

“It’s literally the proverbial needle in the haystack," Rheault said. "You’re looking for a very specific gene in a field of absolutely benign Vibrios.”

Changes on the horizon?

At the University of Maryland College Park, scientists who have been studying Vibrio for decades have made headway on one species: Vibrio cholerae.

They have developed a model to predict outbreaks of Cholera, an acute, diarrheal illness that kills many around the world. This year, the model worked.

“We were able to predict the outbreak in Saudi Arabia,” said Dr. Rita Colwell, a distinguished professor at the University of Maryland and Johns Hopkins University. “If you know there’s going to be an outbreak … you can get vaccines shipped in quickly and be prepared when the first victims appear and avoid an epidemic.”

Colwell said she and her colleagues have also developed a model to predict when Vibrio vulnificus could cause problems in the Chesapeake Bay by using satellite data and environmental indicators such as water temperature and salinity.

"I think the biggest problem is that it's not recognized as a threat [because] it doesn't occur in large numbers," Colwell said. "Something that the state health department might consider [is] having Vibrio alerts like you have asthma alerts."

NOAA has predictive models for Vibrio parahaemolyticus, which were validated with actual samples taken from places like the Delaware Bay, said Bott.

It's a good tool that people at higher risk of infection can use to track the possible presence of Vibrios, Bott said.

“At the end of the day, this comes down to taking your health in your own hands,” he said. "Knowing your risk factor is very important."

There is a smattering of official warnings about the bacteria.

The state offers information online and in pamphlets handed out at beach area events such as the University of Delaware’s Coast Day. Informational signs on some state-owned lands along the Delaware Inland Bays generally warn about unspecified naturally occurring bacteria. In Maryland, fishing licenses also come with warnings about bacteria.

“For Delaware, we try to post them in the public access areas,” Bott said. “You do the best you can and try to post those signs to reach the greatest amount of people.”

The lack of signs may reflect a lack of federal regulatory mechanism for testing recreational waters for Vibrio, like it does for other bacteria such as enterococcus and E. coli.

Placing signs at private docks comes with its own obstacles, and it's probably unnecessary to post warnings on ocean-side beaches where the water is often too salty or too cool to foster dangerous levels of Vibrio, officials say.

“We live in a resort area and they don’t necessarily always want to have this information out there,” said Kathy Phillips, executive director of the Assateague Coastal Trust in Berlin, Maryland. “And I don’t think that’s right.”

Phillips works with a team that helps Maryland test the water of popular places along the back bays of Ocean City, Maryland, for enterococcus, an indicator that other harmful bacteria may be lurking beneath the surface.

“The public should be better notified, and people should be more engaged in understanding what’s in the water where they swim,” she said. Her organization has created a user-friendly application to track bacteria counts called Swim Guide. Delaware does the same through a partnership with the University of Delaware’s Citizen Monitoring Program.

“The scary thing about Vibrio is we know it grows here in our coastal bays,” Phillips said. “Lots of times the water looks beautiful and it’s all sparkly, but it’s a good idea to know what’s there in the water.”

While Vibrio can prove deadly – it claims about 27 lives across the country every year – it still is considered a rare disease.

University of Delaware professor, researcher and oyster aquaculture expert John Ewart has cut himself in and near the water countless times and has all the scars to prove it. Just retired, he has spent most of his career on the water, working on lobster boats and growing oysters in a small shack near the university’s campus in Lewes. 

But he has never had a Vibrio infection.

“Why is it that people aren’t being notified?" he asks. "Well, it hasn’t really represented itself as a broader danger. It’s not on an epidemic scale.”

Ewart remembers when Vibrio infections were largely limited to the Gulf Coast. But as water temperatures have warmed, some fish are heading into deeper waters or swimming farther north than ever before and some Vibrios are becoming more active where they once did not thrive, he said.

“Probably in 10 years, or down the road with more incidents occurring, it could build to a public warning status," Ewart said. "Right now it’s kind of a random hit-or-miss.”

Greater risk, greater outreach?

As more retirees – who are more likely to have underlying health conditions such as diabetes than the general public – flock to Delmarva, getting the word out about Vibrio risks may be all the more important.

If the documented rise in worldwide water temperatures continues, bath-like bays may bubble with bacteria more often.

“As health departments, we always try to do a more effective job of reaching people on a whole range of things that can affect their health,” said Dr. Cliff Mitchell, director of Maryland Public Health’s environmental health bureau. 

Even if scientists found an efficient, affordable way to track exactly when and where Vibrio could pose a threat, the only thing officials can do is warn people to stay away, Mitchell said.

“You can’t spray for Vibrio,” he said. “You can’t change the salinity of the bay. Nature can do that, but we can’t.”

Any warnings would be only recommendations that people can choose to ignore, just as the warnings that those with health conditions should not eat raw shellfish.

“Generally speaking, we post advisories when situations occur that are unusual, when there is an increase in risk such that we feel the public ought to expect things are not normal and therefore they should change their behavior,” Mitchell said.

Governments and others know Vibrio infections can be severe and even fatal.

"We take that very seriously in the advice we give to people. But we also want people to put that risk into perspective and context," he said. "That’s a good conversation for people to have with their primary care provider.”

Sumitha Nagarajan, Delaware’s state epidemiologist, said Delaware has a "very good" surveillance system. She said she would have to dig through case reports to know which species caused illnesses or why Delawareans have reported more illnesses recently.

“The CDC is really who we look to as guidance for surveillance and tracking the data,” Nagarajan said. “Our protocol for how we are tracking the data and following it are in line for the CDC.”

She said Vibrio parahaemolyticus, which usually causes symptoms akin to food poisoning, is the larger Vibrio threat in Delaware. She said she knew of no reported cases from Vibrio vulnificus. Public health officials have been unable to provide a breakdown by Vibrio species, but said the bacteria has never claimed the life of a Delawarean since record-keeping began.

“Because our case numbers have been low in the past, it is not something you would see a lot of messaging on,” said Brestel, public health’s spokeswoman. “You want people to pay attention when there’s an absolute risk, but also not completely frighten them. That’s the balance that we weigh. We base it off of risk.”

While Mid-Atlantic states do not often put out public notices about the risk of Vibrio because the chances of infection are so low, Gulf Coast states that see more illnesses and deaths will sometimes warn the public when things get bad.

So far this summer in Florida, 21 people have gotten sick and three have died. That promoted health officials to reach out to local media to spread the word on the annual Vibrio threat.

The same goes for Texas, where about 90 people are infected every year. Officials recently released a general warning about the bacteria.

While it is clear that individuals need to educate themselves on risks they face when consuming raw food or getting into wild waterways, it is also clear that hospitals need to be able to quickly diagnose Vibrio infections.

If doctors at Bayhealth Kent General Hospital in Dover had not immediately and accurately diagnosed Dunn’s infection, the outcome could have been much different.

“I want people to realize how perilous your existence can be,” Kathleen said. “Your whole life can change in seconds. Not only your life, but the lives of those around you.”

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

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