Vibrio parahaemolyticus Foodborne

Illness Associated with Oysters,

Australia, 2021–2022
Emily Fearnley, Lex E.X. Leong, Alessia Centofanti, Paul Dowsett, Barry G. Combs,
Anthony D.K. Draper, Helen Hocking, Ben Howden, Kristy Horan, Mathilda Wilmot,
Avram Levy, Louise A. Cooley, Karina J. Kennedy, Qinning Wang, Alicia Arnott,
Rikki M.A. Graham, Vitali Sinchenko, Amy V. Jennison, Stacey Kane, Rose Wright

The bacterium Vibrio parahaemolyticus is ubiquitous in whom reported consuming Australia-grown oysters. Cases
tropical and temperate waters throughout the world and were reported from all states and territories of Australia. The
causes infections in humans resulting from water exposure outbreak comprised 2 distinct strains of V. parahaemolyti-
and from ingestion of contaminated raw or undercooked cus, sequence types 417 and 50. We traced oysters with
seafood, such as oysters. We describe a nationwide out- V. parahaemolyticus proliferation back to a common grow-
break of enteric infections caused by Vibrio parahaemolyti- ing region within the state of South Australia. The outbreak
cus in Australia during September 2021–January 2022. A prompted a national recall of oysters and subsequent im-
total of 268 persons were linked with the outbreak, 97% of provements in postharvest processing of the shellfish.

V ibrio parahaemolyticus is a marine and estuarine bac-

terium that is ubiquitous in tropical and temperate
waters worldwide (1). Infections, including wound in-
America, Europe, and New Zealand, predominantly
associated with consumption of filter-feeding bivalve
shellfish, such as oysters and mussels (6–12). V. para-
fections, can occur in humans through exposure to wa- haemolyticus infections show seasonal patterns, with
ter, and enteric infections are attributed most commonly increases in warmer months, because V. parahaemolyti-
to ingestion of raw or undercooked seafood. Invasive cus will grow in seawater at temperatures >14°C–19°C
bloodstream infections and death rarely occur (2,3). Hu- (6). Climate change can increase the distribution and
man infection is not associated with person-to-person incidence of V. parahaemolyticus (6,13), and a rise in wa-
spread or transmission through the fecal–oral route, ter temperature is the main environmental factor as-
and environmental presence of V. parahaemolyticus has sociated with growth of V. parahaemolyticus in oysters.
not been linked to fecal contamination (4). The virulence Postharvest risk reduction strategies focus on rapid
of V. parahaemolyticus is associated with the presence of cooling and maintaining cold refrigeration of oys-
a thermostable direct hemolysin (coded by tdh gene) or ters throughout the supply chain to prevent bacterial
thermostable related hemolysin (trh gene) (5). growth, which occurs at air temperatures >10°C (14).
Foodborne V. parahaemolyticus outbreaks have Until recently, foodborne outbreaks of V. para-
been reported across Asia, the United States, South haemolyticus were rare in Australia. Only 4 outbreaks

Author affiliations: South Australian Department for Health and Tasmania, Australia (L.A. Cooley); Canberra Hospital and
Wellbeing, Adelaide, South Australia, Australia (E. Fearnley, Health Services, Canberra, Australian Capital Territory, Australia
A. Centofanti); University of South Australia, Adelaide (L.E.X. Leong); (K.J. Kennedy); Westmead Hospital, Westmead, New South Wales,
SA Pathology, Adelaide (L.E.X. Leong, H. Hocking); Department of Australia (Q. Wang); The University of Sydney, Sydney, New
Primary Industries and Regions, Adelaide (P. Dowsett); Department South Wales, Australia (A. Arnott, V. Sintchenko); Queensland
of Health Western Australia, Perth, Western Australia, Australia Health Forensic and Scientific Services, Coopers Plains,
(B.G. Combs); Northern Territory Centre for Disease Control, Queensland, Australia (R.M.A. Graham, A.V. Jennison); Australian
Darwin, Northern Territory, Australia (A.D.K. Draper); The Peter Government Department of Health and Aged Care, Canberra
Doherty Institute for Infection and Immunity, Melbourne, Victoria, (S. Kane, R. Wright)
Australia (B. Howden, K. Horan, M. Wilmont); PathWest Laboratory
Medicine, Perth, (A. Levy); Royal Hobart Hospital, Hobart, DOI: http://doi.org/10.3201/eid3011.240172

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 30, No. 11, November 2024 2271
SYNOPSIS

were reported during 2002–2019, affecting a total of analysis was performed on sequence type (ST) 417 or
24 persons (15). Two previously reported outbreaks ST50 V. parahaemolyticus isolates on AusTrakka (a na-
were linked to consumption of oysters; 1 from oysters tional genomic surveillance platform) and determined
produced in Tasmania and 1 from oysters grown in to be highly related within each ST. We considered
South Australia. Only 29 locally acquired, sporadic outbreak cases as probable if they were typed as ST417
foodborne cases of V. parahaemolyticus were reported or ST50 without further phylogenetic analysis on
in Australia in 2016–2020; 22 of the infected persons AusTrakka and as possible if isolates were unable to
reporting oyster consumption (76%) (15). V. parahae- be further typed (no ST). Cases were excluded if case-
molyticus infections might be underreported in Aus- patients had traveled overseas in the 7 days before on-
tralia because pathology laboratories rarely include it set, if another ST was identified, or if the sequences did
in routine fecal testing procedures and the infection not cluster by phylogenetic analysis on AusTrakka. We
is a notifiable condition in only 4 of the 8 states and used a broad case definition to include both STs in the
territories of Australia. outbreak investigation to describe the overall increase
In September 2021, at the end of the winter season in locally acquired V. parahaemolyticus cases.
in the Southern Hemisphere, health officials identi- We entered case data into REDCap v10.3.4
fied an increase in locally acquired V. parahaemolyticus (Vanderbilt University, https://projectredcap.org).
cases in South Australia, and a similar trend was later We calculated proportions, medians, and ranges by
noted in other jurisdictions of Australia. In Novem- using Stata BE v17 (Stata, https://www.stata.com).
ber 2021, through the OzFoodNet network, a multi- Where data were missing, we calculated a proportion
jurisdictional outbreak investigation commenced to with known responses only.
coordinate the public health response. OzFoodNet is
a network of epidemiologists across Australia who Environmental Investigations
are responsible for undertaking surveillance and Jurisdictional food regulatory authorities conducted
outbreak investigations of foodborne disease (16). In- traceback investigations for oyster exposures. Trace-
vestigators worked closely with jurisdictional public back activity revealed harvest area and dates, and
health laboratories and with the Australia food regu- investigators then sought information relative to tem-
latory authorities who implement control measures. perature control. Food regulatory personnel collected
oyster samples from case households and retail prem-
Methods ises. The South Australian Shellfish Quality Assurance
V. parahaemolyticus infection is a notifiable disease Program collected oyster samples direct from growers.
under legislation in the Australia jurisdictions of the Technicians processed and tested oyster samples in ap-
Northern Territory, South Australia, Tasmania, and proved laboratories across jurisdictions to determine
Western Australia, where laboratories are required to the presence of V. parahaemolyticus according to the
report cases to their respective health departments. Australian standards for food microbiology examina-
Public health authorities contacted diagnostic labo- tion for specific organisms. Methods involved grind-
ratories in the remaining Australia jurisdictions to ing 25 g of oysters with alkaline peptone water before
request reported detections of V. parahaemolyticus in overnight incubation at 36°C ± 2°C. Laboratory tech-
fecal specimens (under the auspices of an OzFoodNet nicians isolated V. parahaemolyticus from the ground
multijurisdictional outbreak investigation). samples on thiosulfate–citrate–bile salts–sucrose agar
at 36°C ± 2°C. They collected positive green-colonies
Epidemiologic Investigation and sent the samples to public health laboratories for
We defined an outbreak case as illness in any person whole-genome sequencing (WGS).
with a fecal specimen testing positive for V. para-
haemolyticus during September 7, 2021–February 18, Genomic Sequencing and Analysis of
2022. We conducted a descriptive case series investi- V. parahaemolyticus
gation, which entailed telephone interviews of case- Public health laboratories in each jurisdiction se-
patient using a standardized questionnaire to obtain quenced V. parahaemolyticus isolates from cases and
demographic information (age, sex, jurisdiction of food samples for species confirmation and ST de-
residence), onset of illness, symptoms, medications, termination through multilocus sequence typing
risk factors, and consumption of seafood during the (https://github.com/tseemann/mlst) (17). Techni-
exposure period (defined as 7 days before onset). cians performed WGS by using Illumina platforms
We classified cases as confirmed outbreak cases (MiSeq and NextSeq 500/550; Illumina, https://
if single-nucleotide polymorphism (SNP) cluster illumina.com) with paired-end reads. Public health

2272 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 30, No. 11, November 2024
 V. parahaemolyticus Associated with Oysters

laboratories shared the raw sequencing reads of most not notifiable, Victoria (26%, n = 69) and Queensland
isolates to AusTrakka (18). The national analysis team (22%, n = 59) (Table 1). Some case-patients reported
performed quality filtering, virulence gene detection, spending their entire incubation period in other ju-
and phylogenetic analyses by using Snippy version risdictions, including a Tasmania resident exposed
4.6.0 (https://github.com/tseemann/snippy) for in South Australia and a South Australia resident ex-
cluster identification. Laboratory researchers deter- posed in Western Australia. More case-patients were
mined genomic clusters for respective STs by using male (57%) than female (43%). All jurisdictions with
single-linkage clustering based on the SNP distance >5 outbreak cases included cases of both ST50 and
threshold of 5 SNPs, 10 SNPs, and 20 SNPs. The labo- ST417. The median age of case-patients was 52 years
ratories also performed pangenome analysis by us- (range 1–90 years) (Table 2).
ing Roary version 3.13.0 (https://sanger-pathogens. Of those with available information, 25% of case
github.io/Roary) (19) to include other publicly avail- patients (51/206) sought treatment at hospital emer-
able V. parahaemolyticus genomes from PubMLST gency departments and 13% (27/209) of case-patients
(https://pubmlst.org) and visualized a phyloge- were hospitalized; emergency department informa-
netic tree by using ggtree (https://guangchuangyu. tion was not reported for 3 case-patients. Of 24 cases
github.io/software/ggtree). Genome sequences were with length of hospitalization recorded, the median
uploaded to the National Center for Biotechnology stay was 2.5 days (range 1–7 days). There were no
Information’s Sequence Read Archive under the Bio- deaths. Of those who responded to symptom-specific
Project Accession nos. PRJNA1129299, PRJNA783474, questions, all 195 case-patients interviewed reported
PRJNA856407, and PRJNA1131944. diarrhea, and 85% (165) reported abdominal pain.
One case-patient had V. parahaemolyticus isolated
Results from both a fecal specimen and blood culture. The
median duration of illness for 131 cases with data
Epidemiologic Investigation available was 7 days (range 1–17 days); however, 40
We investigated a total of 268 outbreak cases from all cases were still unwell at the time of interview and
Australia jurisdictions:184 confirmed cases, 29 prob- were therefore not included in this calculation.
able cases, and 55 possible cases (Figure 1). The out- Of 206 case-patients interviewed, 199 (97%) report-
break occurred over a 5-month period, and the peak ed consuming oysters, 189 (92%) reported consuming
of cases occurred in mid-November 2021. Infections at least some of the oysters raw, and 25 (12%) reported
of ST50 were reported initially, followed by predomi- consuming oysters for >1 meal in the week before on-
nant reports of ST417 infections; subsequent reports set. For case-patients who consumed oysters on only a
then revealed a period of high overlap of the 2 STs. single occasion (n = 131), the median incubation period
We noted the highest percentage of reported cases was 1 day (range 4 hours to 7 days). The median num-
from residents of South Australia (28%, n = 76), fol- ber of oysters eaten per case-patient was 6 (range 1–31
lowed by 2 jurisdictions where V. parahaemolyticus is oysters). Case-patients purchased oysters at a range of
Figure 1. Epidemic curve of
Vibrio parahaemolyticus outbreak
cases by specimen collection
date, outbreak case classification,
and sequence typing, Australia,
September 7, 2021–February 18,
2022. ST, sequence type.

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 30, No. 11, November 2024 2273
SYNOPSIS

Table 1. Vibrio parahaemolyticus outbreak cases (by jurisdiction of residence and ST, Australia, September 7,2021–February 18,
2022*
Jurisdiction of residence ST50 ST417 No ST available Total no. (%) cases
South Australia 31 44 1 76 (28)
Victoria 23 46 0 69 (26)
Queensland 4 11 44 59 (22)
Western Australia 7 23 3 33 (12)
New South Wales 5 15 6 26 (10)
Australian Capital Territory 0 3 0 3 (1)
Tasmania 0 1 0 1 (0.4)
Northern Territory 0 0 1 1 (0.4)
Total 70 143 55 268
*ST, sequence type.

venues, including restaurants (n = 71), supermarkets brokers, wholesalers, retailers, and food services.
or seafood stores (n = 23), farms (n = 17), oyster tours Brokers and processors could receive stock from mul-
(n = 9), and takeaway venues (n = 8). Exposure to other tiple growers on the same day and often from differ-
seafood was common, including 41% (n = 84) who re- ent growing regions. Processors could manage mul-
ported consuming fish (varied types) and 37% (n = 76) tiple suppliers on the same day, and opportunities
who consumed prawns in the 7 days before onset. For for traceability were sometimes lost because records
those who consumed fish or prawns, most reported lacked details of where batches had been distribut-
food to have been cooked. Less than 20% of case pa- ed. Sometimes, processors recorded shuck dates but
tients reported consuming seafood other than oysters, not harvest dates on packaging. There was no single
fish, or prawns (Table 3). From 166 case interviews, method of easily identifying unlabeled oysters once
25% (42) of case-patients reported they had taken med- original traceability was misplaced by the processor.
ication that reduced stomach acid (e.g., reflux or ulcer Traceback indicated oysters had been sourced from
medications) in the month before onset. different growing regions in South Australia, includ-
ing Smoky Bay, Streaky Bay, and Coffin Bay, with the
Environmental Investigation largest proportion traced back to Coffin Bay. Within
Traceback of oysters was complex because the supply Coffin Bay, there were 32 accredited growers, and it
chain could include farmers, processors (harvesters), was impossible to definitively link oysters to any sin-
gle grower. In total, 173 oyster exposures were able to
Table 2. Vibrio parahaemolyticus outbreak cases by be traced back to Coffin Bay.
demographic and clinical characteristics, Australia, September 7, Of 117 oyster samples tested for V. parahaemolyti-
2021–February 18, 2022
Characteristic No. (%) cases, n = 268
cus, 14 tested positive (7 from South Australia, 3 from
Sex Queensland, 3 from Victoria, 1 from Western Austra-
M 152 (57) lia). All positive oysters were ST417. Those V. para-
F 115 (43) haemolyticus–positive oyster samples were from vari-
Not stated 1 (0.4)
Age group, y ous sources, including case-patient households, retail
0–9 1 (0.4) vendors, distributors, and direct-purchase farms. We
10–19 3 (1) traced the original source of all 14 positive oyster
20–29 12 (5)
30–39 38 (14)
samples to Coffin Bay.
40–49 64 (24) The Department of Primary Industries and Re-
50–59 58 (22) gions of South Australia (PIRSA) closed the Coffin
60–69 59 (22) Bay growing area on November 16, 2021, for harvest
70–79 23 (9)
>80 10 (4) of oysters. A national recall of Coffin Bay raw pacific
Symptoms* oysters occurred on November 19, 2021, conducted
Diarrhea 206/206 (100) via Emergency Orders under the South Australian
Watery diarrhea 159/161 (99)
Abdominal pain 165/195 (85) Food Act 2001. PIRSA also served compliance orders
Lethargy 153/191 (80) on accredited growers in Coffin Bay on November 18,
Nausea 138/200 (69) 2021, specifying legislative requirements for grow-
Fever 98/203 (48)
Headache 96/198 (48)
ers to resume harvesting. Growers were required to
Vomiting 71/204 (35) implement a Vibrio control program and provide evi-
Bloody diarrhea 8/181 (4) dence that they had infrastructure available to main-
*Values indicate number of case-patients who reported the symptom of
those who answered the symptom question. Not all case-patients were
tain cold chain, could address food safety require-
asked about all symptoms. ments, could verify monitoring and traceability, and

2274 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 30, No. 11, November 2024
 V. parahaemolyticus Associated with Oysters

could validate refrigeration capabilities. The Vibrio Table 3. Vibrio parahaemolyticus outbreak case-patients
control program required growers to place oysters reporting exposure to seafood in the 7 days before onset of
illness, Australia, September 7, 2021–February 18, 2022
under active refrigeration within 7 hours of harvest,
Seafood No. (%) cases exposed
ensure oysters were at ≤10°C within 24 hours of har- Oysters 199 (97)
vest, ensure oysters were dispatched and transported Oysters eaten raw 189 (95)
at ≤10°C, and ensure enhanced traceability by includ- Fish* 84 (41)
Fish eaten raw 14 (17)
ing the harvest date, area, and aquaculture license Prawns 76 (37)
number on invoices. Vibrio control programs were Prawns eaten raw 4 (11)
implemented in all oyster-growing areas across South Squid 37 (18)
Australia during this outbreak investigation. PIRSA Scallops 29 (14)
Mussels 19 (9)
also conducted microbiological sampling of oysters to Lobster/crayfish 17 (8)
clear growing zones in Coffin Bay before emergency Crab 13 (6)
orders were able to be lifted. Octopus 11 (5)
Clams/cockles 5 (2)
Roe 5 (2)
Genomic Epidemiology and Pathogenicity Abalone 3 (2)
Most outbreak cases (79%) could be classified as con- *Fish includes multiple types of fresh fish and canned fish and different
species of fish, including salmon, tuna, barramundi, kingfish, swordfish,
firmed or probable cases, including 143 cases typed whiting, snapper, and flathead.
as ST417 and 70 cases typed as ST50. Cases of both
STs occurred throughout the duration of the outbreak mostly on point source events, such as outbreaks on
(Figure 1). All isolates from the 14 positive oyster cruise ships (8,20,21). The communitywide outbreak
samples were ST417 V. parahaemolyticus. in this report highlights the potential risks associated
Phylogeny confirmed that ST417 and ST50 V. with consumption of raw oysters in Australia. Raw
parahaemolyticus were not closely related (Figure 2, shellfish, particularly oysters, are known to be a com-
http://wwwnc.cdc.gov/EID/article/30/11/24- mon source of Vibrio foodborne illness, but recent
0172-F2.htm). Because of the distinct nature of those trends observe increasing numbers of sporadic and
strains of V. parahaemolyticus, we performed phy- outbreak cases, across an internationally wider span,
logenetic SNP clustering analyses on each ST indi- somewhere cases had not been previously reported
vidually. We grouped all clinical cases of ST417 and (8,11,22). V. parahaemolyticus has been isolated from
oyster samples from Australia submitted for national other shellfish, including mussels, prawns, clams,
analysis in AusTrakka (n = 135) into a single cluster and scallops during food surveillance studies, and
at a 5-SNP threshold. Clustering analysis of V. para- has been identified as the cause of outbreaks in coun-
haemolyticus ST50 grouped 65 clinical cases at the tries other than Australia (3,23–25).
10-SNP threshold. Further analysis at the narrower The identification of 2 unrelated STs, ST417 and
5-SNP threshold revealed 2 distinct but related clus- ST50, within this outbreak indicated the cause to be
ters (n = 35 and n = 28; 2 were unclustered at 5 SNPs). more relative to environmental factors influencing
We excluded 4 cases from the outbreak based on ge- favorable growth conditions for V. parahaemolyticus
nomic analysis: 1 ST50 case unclustered at the 10-SNP across the oyster-growing region than to a single tem-
threshold on phylogenetic analysis in AusTrakka and perature-abuse error or single point source event. The
3 cases that were different STs (2 ST1140 and 1 ST36). appearance of those 2 strains could also be indicative
Both STs of V. parahaemolyticus isolated from of >1 outbreak occurring at the same time, with com-
cases in this outbreak investigation harbored viru- mon contributing factors. However, multiple strains
lence genes required for pathogenicity. Specifically, or types of a pathogen can cause discrete outbreaks
all V. parahaemolyticus ST417 isolates harbored the and require a common public health investigation
virulence gene trh, and all ST50 harbored 2 virulence and response (26,27). The epidemiologic evidence
genes, tdh and trh. in this investigation indicated raw oysters grown in
South Australia as the cause of both ST417 and ST50
Discussion V. parahaemolyticus infections across Australia. Pre-
This V. parahaemolyticus outbreak was caused by 2 vious V. parahaemolyticus outbreaks have reported
STs and had a considerable effect on the population single-strain infections, predominantly by using tra-
of Australia because of the nationwide distribution ditional O and K serotyping methods (8,25). Longitu-
of oysters across mainland jurisdictions and cases oc- dinal studies in Asia have identified a range of strains
curring over a 5-month period. Recent investigations within a region (28), and other reports have high-
of other V. parahaemolyticus outbreaks have focused lighted highly virulent pandemic strains (e.g., ST36)

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 30, No. 11, November 2024 2275
SYNOPSIS

detected across a widening international geographic children compared with adults (35). The outbreak we
range (1,13). Although minimal data are available in studied showed higher severity of illness than some
Australia regarding V. parahaemolyticus strains linked previous outbreaks; for example, we noted 13% of
to locally acquired cases, recent increased use of ge- case patients hospitalized and a single case with sep-
nomic methods and practices will likely change that. ticemia, compared with a study that investigated an
The emergence of WGS characterization in Austra- outbreak associated with Alaska oysters, where there
lia will also contribute to global knowledge regard- were no hospitalizations (8). Conversely, we noted
ing emerging and pathogenic strains. The presence a lower hospitalization rate for case-patients (13%)
of the trh virulence gene in both strains within this compared with a longer-term study that reported a
outbreak—and the additional tdh gene in the ST50 hospitalization rate of 44% (9). Individual factors and
case isolates—correlates with prior literature noting the pathogenicity of different strains could affect dis-
that the presence of those virulence genes contributes ease severity in outbreaks.
to clinical symptoms but that both genes are not re- The first limitation of our investigation is that cul-
quired to cause illness (29). ture for V. parahaemolyticus is not always attempted on
International risk assessments have been con- diarrheal samples in diagnostic laboratories in Aus-
ducted for V. parahaemolyticus in seafood, noting tralia, and V. parahaemolyticus targets are often omit-
the pathogenicity of the organism, the growth of V. ted in routine fecal multiplex PCR kits employed for
parahaemolyticus increasing with increased water tem- direct detection of enteropathogens. Also, there was
peratures, and the need for strict postharvest con- likely underreporting of cases because V. parahaemo-
trols to reduce the risk for foodborne disease (6,12). lyticus is not a notifiable condition in all jurisdictions
Outbreaks have occurred more frequently during in Australia. However, public health laboratories
warmer months (3) and at times when seawater tem- were contacted by their respective health depart-
peratures have increased (8,20) or other environmen- ments and asked to provide information on enteric
tal factors have had an influence (e.g., El Niño events V. parahaemolyticus cases. Further typing of strains by
or decreases in salinity) (10,30). In response to the WGS is also not consistently conducted across Aus-
outbreak we have described, oyster growers imple- tralia and sometimes must be specifically requested
mented postharvest controls through a Vibrio control if an outbreak is suspected. During this outbreak,
program, where oysters were placed under active some requests for further typing were made several
refrigeration. General trends of increased sea surface weeks after the initial isolation, at which point no
temperatures in Australia (31) and the seasonal oc- specimens were available for shipment to the public
currence of the Leeuwin current, which brings warm health laboratories. Because of incomplete typing of
tropical waters to Western and South Australia (31), all case isolates in this outbreak, some cases might
potentially created favorable conditions for growth of have been of a different ST and might not have been
V. parahaemolyticus in South Australia oyster-growing specifically linked to the current outbreak. In addi-
bays. We believe that further research would improve tion, V. parahaemolyticus outbreak cases we studied
understanding of risk factors for V. parahaemolyticus coincided with a national surge in SARS-CoV-2 in-
outbreaks in Australia’s prone regions, including on- fections in Australia, putting strain on public health
going environmental surveillance at harvest sites to resources. Therefore, not all case-patients were able
monitor seawater temperatures, salinity, and harvest to be interviewed, and not all isolates were able to be
conditions, as well as at points along the storage and further typed.
transport chain to consumers. There were also limitations in the traceback of
We noted that many outbreak case-patients in oysters within a complex supply chain, including dis-
this study consumed medication that reduces stom- tributors and retailers receiving stock from multiple
ach acid, a finding noted in previous studies that in- growers and different growing regions, leading to
vestigated risk for V. parahaemolyticus and other bac- potential mixing of stock, some incomplete records
terial gastroenteric infections (32,33). Gastric acidity and invoicing, and case-patients having multiple
also decreases with age (34); therefore, infection sus- exposures to oysters within their incubation period.
ceptibility could increase with age, which is consis- Mixing of oyster stock could also have contributed to
tent with our observed median case patient age of 52 the identification of multiple strains of V. parahaemo-
years. The fact that a large portion of our case-patients lyticus in cases included in this outbreak. Although
were older adults might also be related to food con- traceback was unable to be completed for all cases,
sumption patterns in the general population of Aus- oysters consumed by most casepatients were traced
tralia, where mollusks are less commonly eaten by to at least the harvest area.

2276 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 30, No. 11, November 2024
 V. parahaemolyticus Associated with Oysters

In conclusion, evidence for the source of this out- References

break was strong, considering the oyster consump- 1. Baker-Austin C, Oliver JD, Alam M, Ali A, Waldor MK,
Qadri F, et al. Vibrio spp. infections. Nat Rev Dis Primers.
tion among case-patients, traceback of the source of 2018;4:1. https://doi.org/10.1038/s41572-018-0005-8
oysters consumed by case-patients, and identification 2. Heymann DL. Control of communicable diseases manual,
of the same strain of V. parahaemolyticus in both oys- 20th edition. Washington: American Public Health
ters and case patients. The reduction in cases of V. Association; 2015.
3. Daniels NA, MacKinnon L, Bishop R, Altekruse S, Ray B,
parahaemolyticus after the recall of oysters and wide Hammond RM, et al. Vibrio parahaemolyticus infections in
implementation of Vibrio control programs supports the United States, 1973–1998. J Infect Dis. 2000;181:1661–6.
this evidence. This outbreak of V. parahaemolyticus as- https://doi.org/10.1086/315459
sociated with consumption of Australia-grown oys- 4. Mannas H, Mimouni R, Chaouqy N, Hamadi F,
Martinez-Urtaza J. Occurrence of Vibrio and Salmonella
ters, largely consumed raw, has led to improvements species in mussels (Mytilus galloprovincialis) collected along
in postproduction control and traceability in the oys- the Moroccan Atlantic coast. Springerplus. 2014;3:265.
ter industry in South Australia. The outbreak also https://doi.org/10.1186/2193-1801-3-265
spotlighted the virulent potential of V. parahaemolyti- 5. Lopez-Joven C, de Blas I, Furones MD, Roque A.
Prevalences of pathogenic and non-pathogenic Vibrio
cus and the value in distinguishing it as a nationally parahaemolyticus in mollusks from the Spanish Mediterranean
notifiable disease in Australia. Improved surveillance Coast. Front Microbiol. 2015;6:736. https://doi.org/10.3389/
data, including strain identification from a wider fmicb.2015.00736
range of regions, and a clearer understanding of un- 6. Wang D, Flint SH, Palmer JS, Gagic D, Fletcher GC,
On SLW. Global expansion of Vibrio parahaemolyticus
derreporting have been highlighted by the World threatens the seafood industry: perspective on controlling its
Health Organization as priorities for improving risk biofilm formation. Lebensm Wiss Technol. 2022;158:113182.
assessment processes for V. parahaemolyticus (22). In- https://doi.org/10.1016/j.lwt.2022.113182
creased surveillance across all jurisdictions in Austra- 7. González-Escalona N, Cachicas V, Acevedo C, Rioseco ML,
Vergara JA, Cabello F, et al. Vibrio parahaemolyticus diar-
lia would improve outbreak detection and ensure a rhea, Chile, 1998 and 2004. Emerg Infect Dis. 2005;11:129–31.
prompt and coordinated public health response. https://doi.org/10.3201/eid1101.040762
8. McLaughlin JB, DePaola A, Bopp CA, Martinek KA,
Acknowledgments Napolilli NP, Allison CG, et al. Outbreak of Vibrio
parahaemolyticus gastroenteritis associated with Alaskan
The authors thank the extended outbreak investigation oysters. N Engl J Med. 2005;353:1463–70. https://doi.org/
team for contributions to this investigation, including the 10.1056/NEJMoa051594
public health officers, food regulators, primary industry 9. Wu Y, Wen J, Ma Y, Ma X, Chen Y. Epidemiology of
regulators, diagnostic laboratories, and public health foodborne disease outbreaks caused by Vibrio
parahaemolyticus, China, 2003–2008. Food Control.
laboratories in all jurisdictions. We thank specifically SA 2014;46:197–202. https://doi.org/10.1016/j.foodcont.
Pathology, PathWest Laboratory Medicine WA, Institute 2014.05.023
of Clinical Pathology and Medical Research-NSW Health 10. Daniels NA, Ray B, Easton A, Marano N, Kahn E,
Pathology, and Public Health Microbiology Forensic and McShan AL II, et al. Emergence of a new Vibrio
parahaemolyticus serotype in raw oysters: a prevention
Scientific Services (Queensland), Microbiological quandary. JAMA. 2000;284:1541–5. https://doi.org/10.1001/
Diagnostic Unit. We also thank the AusTrakka National jama.284.12.1541
Analysis team as well as the OzFoodNet Network, which 11. Newton A, Kendall M, Vugia DJ, Henao OL, Mahon BE.
is funded by the Australian Government Department of Increasing rates of vibriosis in the United States,
1996–2010: review of surveillance data from 2 systems.
Health and Aged Care. We extend thanks also to Food Clin Infect Dis. 2012;54(Suppl 5):S391–5. https://doi.org/
Standards Australia and New Zealand and the 10.1093/cid/cis243
Department of Agriculture, Fisheries, and Forestry. 12. Food and Agriculture Organization of the United Nations/
World Health Organization. Risk assessment of Vibrio
Ethics approval was not required for this study because parahaemolyticus in seafood: Interpretative summary and
the outbreak investigation was conducted under the technical report.. Microbiological Risk Assessment Series
No. 16. Rome: The Organizations; 2011 [cited 2022 Jul 28].
relevant state, territory, and national public health
https://www.who.int/publications/i/item/9789241548175
legislation for investigation and response to acute public 13. Martinez-Urtaza J, van Aerle R, Abanto M, Haendiges J,
health events. Myers RA, Trinanes J, et al. Genomic variation and evolution
of Vibrio parahaemolyticus ST36 over the course of a
transcontinental epidemic expansion. MBio. 2017;8:e01425–
About the Author 17. https://doi.org/10.1128/mBio.01425-17
Dr Fearnley is an infectious disease epidemiologist, 14. Food and Drug Administration. U.S. Department of Health
and Human Services, 2005. Quantitative risk assessment
working in the OzFoodNet network of epidemiologists in
on the public health impact of pathogenic Vibrio
Australia. Her research interests include foodborne and parahaemolyticus in raw oysters. [cited 2022 Jun 7].
zoonotic diseases and enteric disease modeling. https://www.fda.gov/food/cfsan-risk-safety-assessments/

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 30, No. 11, November 2024 2277
SYNOPSIS

quantitative-risk-assessment-public-health-impact-pathogenic- Outbreak Working Group. Hepatitis E outbreak in the

vibrio-parahaemolyticus-raw-oysters central part of Italy sustained by multiple HEV genotype 3
15. Harlock M, Quinn S, Turnbull AR. Emergence of strains, June–December 2019. Viruses. 2021;13:1159.
non-choleragenic Vibrio infections in Australia. Commun https://doi.org/10.3390/v13061159
Dis Intell. 2022;46. https://doi.org/10.33321/cdi.2022.46.8 27. European Centre for Disease Prevention and Control.
16. Australian Government Department of Health and Aged Multi-country outbreak of multiple Salmonella enterica
Care. 2023. OzFoodNet network. [cited 2023 Oct 6]. serotypes linked to imported sesame-based products—14
https://www.health.gov.au/our-work/ozfoodnet-network October 2021. European Food Safety Authority, 2021
17. Jolley KA, Maiden MCJ. BIGSdb: Scalable analysis of [cited 2024 June 19] https://www.ecdc.europa.eu/sites/
bacterial genome variation at the population level. BMC default/files/documents/ROA_S%20Mbandaka_
Bioinformatics. 2010;11:595. https://doi.org/10.1186/ S%20Havana_UI-716_14-October-2021.pdf
1471-2105-11-595 28. Li Y, Xie X, Shi X, Lin Y, Qiu Y, Mou J, et al. Vibrio
18. Hoang T, da Silva AG, Jennison AV, Williamson DA, parahaemolyticus, southern coastal region of China, 2007–2012.
Howden BP, Seemann T. AusTrakka: Fast-tracking Emerg Infect Dis. 2014;20:685–8. https://doi.org/10.3201/
nationalized genomics surveillance in response to the eid2004.130744
COVID-19 pandemic. Nat Commun. 2022;13:865. 29. Ragunath P. Roles of thermostable direct hemolysin (TDH)
https://doi.org/10.1038/s41467-022-28529-9 and TDH-related hemolysin (TRH) in Vibrio parahaemolyticus.
19. Page AJ, Cummins CA, Hunt M, Wong VK, Reuter S, Frontiers Microbiol. 2015;5:805.
Holden MTG, et al. Roary: rapid large-scale prokaryote 30. Gonzalez-Escalona N, Gavilan RG, Toro M, Zamudio ML,
pan genome analysis. Bioinformatics. 2015;31:3691–3. Martinez-Urtaza J. Outbreak of Vibrio parahaemolyticus
https://doi.org/10.1093/bioinformatics/btv421 sequence type 120, Peru, 2009. Emerg Infect Dis.
20. Taylor M, Cheng J, Sharma D, Bitzikos O, Gustafson R, 2016;22:1235–7. https://doi.org/10.3201/eid2207.151896
Fyfe M, et al. Outbreak of Vibrio parahaemolyticus associated 31. Bureau of Meteorology. State of the climate report, 2022
with consumption of raw oysters in Canada, 2015. [cited 2022 Jun 7] http://www.bom.gov.au/state-of-the-
Foodborne Pathog Dis. 2018;15:554–9. https://doi.org/ climate/oceans.shtml
10.1089/fpd.2017.2415 32. Hassing RJ, Verbon A, de Visser H, Hofman A, Stricker BH.
21. Martinez-Urtaza J, Powell A, Jansa J, Rey JLC, Montero OP, Proton pump inhibitors and gastroenteritis. Eur J
Campello MG, et al. Epidemiological investigation of a Epidemiol. 2016;31:1057–63. https://doi.org/10.1007/
foodborne outbreak in Spain associated with U.S. West Coast s10654-016-0136-8
genotypes of Vibrio parahaemolyticus. Springerplus. 2016;5:87. 33. Cribb DM, Varrone L, Wallace RL, McLure AT, Smith JJ,
https://doi.org/10.1186/s40064-016-1728-1 Stafford RJ, et al. Risk factors for campylobacteriosis in
22. Food and Agriculture Organization of the United Nations/ Australia: outcomes of a 2018–2019 case-control study.
World Health Organization. Advances in science and risk BMC Infect Dis. 2022;22:586. https://doi.org/10.1186/
assessment tools for Vibrio parahaemolyticus and V. vulnificus s12879-022-07553-6
associated with seafood. Meeting report. Microbiological 34. Koo J, Marshall DL, DePaola A. Antacid increases survival
Risk Assessment Series No. 35. Rome: The Organizations; of Vibrio vulnificus and Vibrio vulnificus phage in a
2021 [cited 2022 Jun 7] https://doi.org/10.4060/cb5834en gastrointestinal model. Appl Environ Microbiol.
23. Lopatek M, Wieczorek K, Osek J. Prevalence and 2001;67:2895–902. https://doi.org/10.1128/
antimicrobial resistance of Vibrio parahaemolyticus isolated AEM.67.7.2895-2902.2001
from raw shellfish in Poland. J Food Prot. 2015;78:1029–33. 35. Australian Bureau of Statistics. Australian Health Survey:
https://doi.org/10.4315/0362-028X.JFP-14-437 Nutrition First results—foods and nutrients, 2011–2012
24. Cruz CD, Hedderley D, Fletcher GC. Long-term study of [cited 2024 Jan 18]. https://www.abs.gov.au/statistics/
Vibrio parahaemolyticus prevalence and distribution in New health/health-conditions-and-risks/australian-health-
Zealand shellfish. Appl Environ Microbiol. 2015;81:2320–7. survey-nutrition-first-results-foods-and-nutrients/
https://doi.org/10.1128/AEM.04020-14 latest-release#data-downloads
25. Centers for Disease Control and Prevention. Vibrio
parahaemolyticus infections associated with consumption of Address for correspondence: Emily Fearnley, SA Health,
raw shellfish—three states, 2006. MMWR. 2006;55:854–6.
SA Pathology, PO Box 14 Rundle Mall, Adelaide, South Australia
26. Garbuglia AR, Bruni R, Villano U, Vairo F, Lapa D,
Madonna E, et al.; The Other Members Of The Hev 5000, Australia; email:[email protected]

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