Characteristics of a sharp decrease in Vibrio parahaemolyticus infections and seafood contamination in Japan

Antimicrobial resistance and genomic analysis of Vibrio parahaemolyticus isolates from foodborne outbreaks, Huzhou, China, 2019-2023

Objective

The purpose of this study was to investigate the epidemiological and genomic characteristics of Vibrio parahaemolyticus (V. parahaemolyticus) isolates from outbreaks in Huzhou, China.

Methods

This study aims to analyze the epidemiological data on V. parahaemolyticus outbreaks reported in Huzhou from 2019 to 2023. A total of 70 V. parahaemolyticus outbreak isolates were collected. The antibiotic resistance, serotypes, molecular typing, and genomic characteristics of these isolates were analyzed.

Results

Most outbreaks of V. parahaemolyticus infection occurred in the summer, and the majority of outbreaks occurred in restaurants and rural banquets. High resistance rates were observed for ampicillin (AMP, 24.29%), followed by tetracycline (TET, 15.71%) and trimethoprim-sulfamethoxazole (SXT, 15.71%). The newly emerged serotype O10:K4 became dominant from 2021 to 2023, with most isolates belonging to ST3. The resistance gene blaCARB was frequently detected among these isolates. The pulsed-field gel electrophoresis (PFGE) and whole-genome single-nucleotide polymorphisms (wgSNPs) effectively differentiated the nine outbreaks.

Conclusion

The newly emerged serotype O10:K4 became dominant from 2021 to 2023, with most isolates being ST3. PFGE and WGS technologies provided reliable methods for typing and identifying V. parahaemolyticus for outbreaks.

Vibriosis in South Asia: A systematic review and meta-analysis

OBJECTIVES

South Asia remains home to foodborne diseases caused by the Vibrio species. We aimed to compile and update information on the epidemiology of vibriosis in South Asia.

METHODS

For this systematic review and meta-analysis, we searched PubMed, Web of Science, EMBASE, and Google Scholar for studies related to vibriosis in South Asia published up to May 2023. A random-effects meta-analysis was used to estimate the pooled isolation rate of non-cholera-causing Vibrio species.

RESULTS

In total, 38 studies were included. Seven of these were case reports and 22 were included in the meta-analysis. The reported vibriosis cases were caused by non-O1/non-O139 V. cholerae, V. parahaemolyticus, V. fluvialis, and V. vulnificus. The overall pooled isolation rate was 4.0% (95% confidence interval [CI] 3.0-5.0%) in patients with diarrhea. Heterogeneity was high (I2 = 98.0%). The isolation rate of non-O1/non-O139 V. cholerae, V. parahaemolyticus, and V. fluvialis were 9.0 (95% CI 7.0-10.0%), 1.0 (95% CI 1.0-2.0%), and 2.0 (95% CI: 1.0-3.0%), respectively. Regarding V. parahaemolyticus, O3:K6 was the most frequently isolated serotype. Cases peaked during summer. Several studies reported antibiotic-resistant strains and those harboring extended-spectrum beta-lactamases genes.

CONCLUSIONS

This study demonstrates a high burden of infections caused by non-cholera-causing Vibrio species in South Asia.

Prevalence, virulence characteristics, and antimicrobial resistance of Vibrio parahaemolyticus isolates from raw seafood in a province in Northern Thailand

Vibrio parahaemolyticus (V. parahaemolyticus) is commonly found in seawater and seafood products, but evidence is limited of its presence in seafood marketed in locations very distant from coastal sources. This study determined the prevalence and characterization of V. parahaemolyticus in seafood from markets in landlocked Phayao province, Northern Thailand. Among 120 samples, 26 (21.7%) were positive for V. parahaemolyticus, being highest in shrimp (43.3%), followed by shellfish (36.7%), and squid (6.7%), but was not found in fish. V. parahaemolyticus comprised 33 isolates that were non-pathogenic and non-pandemic. Almost all isolates from shrimp and shellfish samples were positive for T3SS1. Only five isolates (15.2%) showed two antimicrobial resistance patterns, namely, kanamycin-streptomycin (1) carrying sul2 and ampicillin-kanamycin-streptomycin (4) that carried tetA (2), tetA-sul2 (1), as well as one negative. Antimicrobial susceptible V. parahaemolyticus isolates possessing tetA (67.9%) and sul2 (3.5%) were also found. Six isolates positive for integron class 1 and/or class 2 were detected in 4 antimicrobial susceptible and 2 resistant isolates. While pathogenic V. parahaemolyticus was not detected, contamination of antimicrobial resistance V. parahaemolyticus in seafood in locations distant from coastal areas requires ongoing monitoring to improve food safety in the seafood supply chain.

A systematic review, meta-analysis and meta-regression of the global prevalence of foodborne Vibrio spp. infection in fishes: A persistent public health concern

Human vibriosis, caused by pathogenic Vibrio spp., such as Vibrio parahaemolyticus, Vibrio cholerae and Vibrio vulnificus, has been increasing worldwide, mediated by increasing consumption of seafood. The present study was conducted to examine the global prevalence of V. vulnificus, V. parahaemolyticus and V. cholerae in fishes. We searched PubMed, Web of Science, Scopus, and CNKI for peer-reviewed articles and dissertations prior to December 31, 2021. A total of 24,831 articles were retrieved, and 82 articles contained 61 fish families were included. The global pooled prevalence of V. cholerae, V. parahaemolyticus and V. vulnificus in fishes was 9.56 % (95 % CI: 2.12-20.92), 24.77 % (95 % CI: 17.40-32.93) and 5.29 % (95 % CI: 0.38-13.61), respectively. Subgroup and meta-regression analyses showed that study-level covariates, including temperature, country, continent, origin and detection methods partly explained the between-study heterogeneity. These heterogeneities were underpinned by differences of the three Vibrio spp. in fishes at geographical and climatic scales. These results reveal a high global prevalence of pathogenic Vibrio spp. in fishes and highlight the need for implementation of more effective prevention and control measures to reduce food-borne infection in humans.

Prevalence, Genomic Characterization, and Risk Assessment of Human Pathogenic Vibrio Species in Seafood

ABSTRACT

Pathogenic Vibrio species are largely responsible for human diseases associated with consumption of contaminated seafood. The aim of this study was to determine the prevalence, population densities, species diversity, and molecular characteristics of pathogenic Vibrio in various seafood commodities and the health risks associated with consumption of these contaminated commodities. Samples of finfish and shellfish (oysters and sea urchins) were collected from various regions and analyzed for Vibrio with the most-probable-number (MPN) technique. Genomic DNA of putative Vibrio isolates was analyzed by whole genome sequencing for taxonomic identification and identification of virulence and antimicrobial resistance genes. The risk of Vibrio-related illnesses due to the consumption of contaminated seafood was assessed with Risk Ranger. Populations of presumptive Vibrio were 2.6 to 4.4 log MPN/g and correlated with season; Vibrio levels were significantly higher (P < 0.05) in the summer. Fifteen Vibrio isolates were identified as Vibrio alginolyticus (five isolates), Vibrio parahaemolyticus (six isolates), Vibrio harveyi (two isolates), and Vibrio diabolicus (two isolates). Two of the six V. parahaemolyticus isolates (ST 2504 and ST 2505) from oysters harbored either the tdh gene for thermostable direct hemolysin or the trh gene for thermostable direct hemolysin-related hemolysin. In addition to virulence genes, the shellfish isolates also harbored genes encoding resistance to multiple antibiotics, including tetracycline, penicillin, quinolone, and β-lactams, thus arousing concern. The risk assessment predicted that an estimated 21 cases of V. parahaemolyticus-associated gastroenteritis could occur in the general population annually due to consumption of contaminated oysters. This study highlights both the wide prevalence and diversity of Vibrio in seafood and the potential for certain strains to threaten public health.

HIGHLIGHTS

Quantitative Risk Assessment of Vibrio parahaemolyticus Toxi Infection Associated with the Consumption of Roasted Shrimp (Penaeus monodon)

In this study, a risk assessment on Vibrio parahaemolyticus infections was carried out in order to estimate the likelihood of gastroenteritis for Cameroonians after consumption of roasted shrimp (Penaeus monodon). The Codex Alimentarius Commission framework was used in this study. Based on the distribution of total V. parahaemolyticus in shrimp and literature information indicating that nonhaemolysing carrier strains could be pathogenic to humans, the cooking, and consumption patterns, the daily exposure level generated in this study, and the dose-response model from other studies, the infectious risk was evaluated and quantified by the Monte Carlo simulation. This simulation was realized based on 10,000 iterations using the Model Risk software, version 4.0, in combination with Microsoft Excel. To better quantify the exposure of consumers and the resulting risk of infection, several scenarios reflecting the minimal, average, and maximal exposures were undertaken. According to the results, the 90% confidence intervals for minimum and maximum exposures ranged from 15 to 24 colony-forming units per day (cells/day) and from 160 to 228 cells/day, respectively. Based on the modal scenario, 90% of the population consuming this shrimp is exposed to V. parahaemolyticus loads ranging from 74 to 110 cells/day, indicating a risk of infection ranging from 1.2 to 1.8 cases per million of consumption. The estimated number of annual disease cases based on annual production is between 1 and 10 cases. This reflects a relatively low risk of infection for roasted shrimp. Good hygiene practices during handling, cooking, and storage may help reduce the actual risk.

Isolation and Characterization of a Lytic Vibrio parahaemolyticus Phage vB_VpaP_GHSM17 from Sewage Samples

Vibrio parahaemolyticus is a major foodborne pathogen and the main cause of diarrheal diseases transmitted by seafood such as fish, shrimp, and shellfish. In the current study, a novel lytic phage infecting V. parahaemolyticus, vB_VpaP_GHSM17, was isolated from the sewage of a seafood market, Huangsha, Guangzhou, and its morphology, biochemistry, and taxonomy features were identified. Morphological observation revealed that GHSM17 had an icosahedral head with a short, non-contractile tail. The double-stranded DNA genome of GHSM17 consisted of 43,228 bp with a GC content of 49.42%. In total, 45 putative ORFs were identified in the GHSM17 genome. Taxonomic analysis indicated GHSM17 belonging to genus Maculvirus, family Autographiviridae. In addition, GHSM17 was stable over a wide range of temperatures (20-60 °C) and pH (5-11) and was completely inactivated after 70 min of ultraviolet irradiation. The bacterial inhibition assay revealed that GHSM17 could inhibit the growth of V. parahaemolyticus within 8 h. The results support that phage GHSM17 may be a potential candidate in the biological control of V. parahaemolyticus contamination in aquaculture.

Synergistic effects of endolysin Lysqdvp001 and ε-poly-lysine in controlling Vibrio parahaemolyticus and its biofilms

The synergistic antibacterial effects between endolysin Lysqdvp001 and ε-poly-lysine (ε-PL) against Vibrio parahaemolyticus (V. parahaemolyticus) were investigated in this study. Lysqdvp001 combined with ε-PL exhibited a strong antibacterial synergism against V. parahaemolyticus. The combinations of Lysqdvp001 (≥60 U/mL) and ε-PL (≥0.2 mg/mL) dramatically decreased cell density of the bacterial suspensions at both 25 °C and 37 °C. Surface zeta potential increment and membrane hyperpolarization of V. parahaemolyticus were observed after treatment by ε-PL and its combination with Lysqdvp001. More β-lactamase and β-galactosidase were leaked from V. parahaemolyticus with combined treatment of Lysqdvp001 and ε-PL than from the bacteria treated with single Lysqdvp001 or ε-PL. Fluorescence and transmission electron microscope revealed that Lysqdvp001 and ε-PL synergistically induced the damage and morphological destruction of V. parahaemolyticus cells. When applying in Gadus macrocephalus, Penaeus orientalis and oyster, the two antimicrobials' cocktail allowed for 3.75, 4.16 and 2.50 log₁₀CFU/g reductions of V. parahaemolyticus, respectively. Besides, Lysqdvp001 in combination with ε-PL removed approximately 44%-68% of V. parahaemolyticus biofilms on polystyrene, glass and stainless steel surfaces. These results demonstrated that Lysqdvp001 and ε-PL might be used together for controlling V. parahaemolyticus and the bacterial biofilms in food industry.

Managing the risk of Vibrio parahaemolyticus infections associated with oyster consumption: A review

Vibrio parahaemolyticus is a Gram-negative bacterium that is naturally present in the marine environment. Oysters, which are water filter feeders, may accumulate this pathogen in their soft tissues, thus increasing the risk of V. parahaemolyticus infection among people who consume oysters. In this review, factors affecting V. parahaemolyticus accumulation in oysters, the route of the pathogen from primary production to consumption, and the potential effects of climate change were discussed. In addition, intervention strategies for reducing accumulation of V. parahaemolyticus in oysters were presented. A literature review revealed the following information relevant to the present study: (a) managing the safety of oysters (for human consumption) from primary production to consumption remains a challenge, (b) there are multiple factors that influence the concentration of V. parahaemolyticus in oysters from primary production to consumption, (c) climate change could possibly affect the safety of oysters, both directly and indirectly, placing public health at risk, (d) many intervention strategies have been developed to control and/or reduce the concentration of V. parahaemolyticus in oysters to acceptable levels, but most of them are mainly focused on the downstream steps of the oyster supply chain, and (c) although available regulation and/or guidelines governing the safety of oyster consumption are mostly available in developed countries, limited food safety information is available in developing countries. The information provided in this review may serve as an early warning for managing the future effects of climate change on the safety of oyster consumption.

Development of a monoclonal antibody for specific detection of Vibrio parahaemolyticus and analysis of its antigen

Vibrio parahaemolyticus is a major foodborne pathogen worldwide. Contamination of V. parahaemolyticus in foods must be detected as quickly as possible because raw seafood, a major source of V. parahaemolyticus infection, is shipped immediately after production due to its short expiration date. In this study, we generated monoclonal antibodies (mAbs) against V. parahaemolyticus to develop a rapid and specific detection assay. Obtained mAbs were categorized into four groups according to their specificity. Of the groups, Group 1 (mAb VP7, VP11, and VP24) reacted to O1-O12 of V. parahaemolyticus without cross-reaction with human pathogenic Vibrio spp. (V. alginolyticus, V. cholerae, V. fluvialis, V. furnissii, V. mimicus, and V. vulnificus). We developed an immunochromatographic (IC) strip for the rapid detection of V. parahaemolyticus in the field using VP7 as a membrane-immobilized antibody and VP24 as a colloidal gold-conjugated antibody. The IC strip detected any and all serogroups (O1 to O12) or isolates (clinical, food, and environmental strains) of V. parahaemolyticus, regardless of the presence of virulence factors thermostable direct hemolysin (TDH) or TDH-related hemolysin (TRH). It did not cross-react with any other non-V. parahaemolyticus strains tested. To elucidate the target of the IC strip, we analyzed the antigen recognized by these mAbs. Group 1 mAbs showed two specific bands at molecular masses of approximately 11 and 16 kDa by western blotting analysis. Nano liquid chromatography mass spectrometry (LC-MS)/MS analysis revealed that the candidate antigen recognized by these mAbs was outer membrane (OM) lipoprotein Q87G48. We verified that mAb VP7 detected His-tagged OM lipoprotein synthesized by reconstituted cell-free protein synthesis reagent. Reactivity to an N-terminus deletion form and protease digestion form of the OM lipoprotein showed that the extent of epitope recognized by VP mAbs was 22nd-41st amino acids (AAs) from N-terminus of the OM lipoprotein, with the sequence "²²SDDAATANAAKLDEL³⁶." This region was also confirmed to be a V. parahaemolyticus-specific sequence by comparing putative orthologs of OM lipoprotein among Vibrio spp. The C-terminus deletion form (1st-39th AAs) including the sequence primarily recognized by VP mAbs (22nd-36th AAs) showed poor reactivity, indicating that the sequence after 40 residues of OM lipoprotein is also important for recognition by VP mAbs and VP mAbs recognize a conformational epitope. Bioinformatics research demonstrated that the OM lipoprotein is an ortholog of the lpp protein conserved throughout many bacteria. Lpp is an abundant and constitutively expressed protein and exists on the bacterial surface, suggesting it may be a good target for detection of V. parahaemolyticus.

Genome sequence analysis of Vibrio parahaemolyticus lytic phage Vp_R1 with a C3 morphotype

Phage Vp_R1 belongs to the family Podoviridae and has a C3 morphotype, with an elongated head with a diameter of 190 ± 1.1 nm and an ultrashort tail with a length of 9 ± 1.2 nm. The double-stranded DNA genome is 112.1 kb long, has a mol% G + C content of 40.3, contains 129 ORFs, and encodes four tRNAs. Phylogenetic analysis suggests that phage Vp_R1 is a novel member of the genus Kuravirus.

Application of molecular tools to elucidate the microbiota of seafood

The aim of this review is to present the methodologies currently applied to identify microbiota and pathogens transmitted to humans through seafood consumption, focusing on molecular techniques and pointing out their importance, advantages, disadvantages and applicability. Knowledge of available techniques allows researchers to identify which technique best fits their expectations. With such discernment, it will be possible to infer which disadvantages will be present and, therefore, not interfering with the final result. Two methodologies can be employed for this purpose, dependent and independent cultures. However, the dependent culture has certain limitations that can be solved through the independent cultivation techniques, such as PCR, PFGE and NGS, especially through the sequencing of the 16S rRNA region, providing a complete view of microbial diversity. These have revolutionized microbiological knowledge, mainly because they allow for the identification of uncultivable micro-organisms, which represent a substantial portion of total micro-organisms, making it possible to elucidate not yet described taxa which may display pathogenic potential, besides quantifying microbial communities, microbiota genetics, translated proteins and produced metabolites. In addition, transcriptomic and metabolomic techniques also allow for the evaluation of possible impacts that microbial communities may create in their environment, as well as the determination of potential pathogenicity to humans.

Microbiological Quality of Seafood Marketed in Taiwan

Seafood is often associated with foodborne illnesses, and Vibrio parahaemolyticus is the most common pathogen implicated in outbreaks in Taiwan. In this study, the microbiological quality of 300 raw or mixed ready-to-eat (RTE) and other cooking-needed seafood samples was examined. The total aerobic and coliform counts of the RTE samples were significantly higher than those of other cooking-needed samples. On average, 55.8 and 29.7% of the RTE samples failed to meet the local microbiological standards for total aerobic (5 log CFU/g) and coliform (3 log most probable number [MPN] per g), counts respectively; the corresponding percentages for the RTE samples from Taipei City were 9.1 and 18.2%, respectively. The total aerobic and coliform counts in the RTE samples from supermarkets and chain restaurants were significantly lower than those from traditional restaurants. The Vibrio species were more frequently identified in the cooking-needed samples than in RTE samples. Low incidences of V. parahaemolyticus (1.4%), V. vulnificus (1.9%), and V. cholerae (0%) were detected in most RTE samples. High densities of V. parahaemolyticus and V. vulnificus (1,200 MPN/g) were detected in a few RTE samples, only one of which contained toxigenic (tdh(+)) V. parahaemolyticus. The results of this investigation reveal that better hygiene of seafood providers such as chain restaurants, supermarkets, and traditional restaurants in Taipei City would effectively improve the microbiological quality of the seafood. The results will facilitate the establishment of measures for controlling the risks associated with seafood in Taiwan.

Practical Guidance for Clinical Microbiology Laboratories: Diagnosis of Bacterial Gastroenteritis

Bacterial gastroenteritis is a disease that is pervasive in both the developing and developed worlds. While for the most part bacterial gastroenteritis is self-limiting, identification of an etiological agent by bacterial stool culture is required for the management of patients with severe or prolonged diarrhea, symptoms consistent with invasive disease, or a history that may predict a complicated course of disease. Importantly, characterization of bacterial enteropathogens from stool cultures in clinical laboratories is one of the primary means by which public health officials identify and track outbreaks of bacterial gastroenteritis. This article provides guidance for clinical microbiology laboratories that perform stool cultures. The general characteristics, epidemiology, and clinical manifestations of key bacterial enteropathogens are summarized. Information regarding optimal specimen collection, transport, and processing and current diagnostic tests and testing algorithms is provided. This article is an update of Cumitech 12A (P. H. Gilligan, J. M. Janda, M. A. Karmali, and J. M. Miller, Cumitech 12A, Laboratory diagnosis of bacterial diarrhea, 1992).

Roles of thermostable direct hemolysin (TDH) and TDH-related hemolysin (TRH) in Vibrio parahaemolyticus

Vibrio parahaemolyticus is the leading cause of seafood borne bacterial gastroenteritis in the world, often associated with the consumption of raw or undercooked seafood. However, not all strains of V. parahaemolyticus are pathogenic. The thermostable direct hemolysin (TDH) or TDH-related hemolysin (TRH) encoded by tdh and trh genes, respectively, are considered major virulence factors in V. parahaemolyticus. However, about 10% of clinical strains do not contain tdh and/or trh. Environmental isolates of V. parahaemolyticus lacking tdh and/or trh are also highly cytotoxic to human gastrointestinal cells. Even in the absence of these hemolysins, V. parahaemolyticus remains pathogenic indicating other virulence factors exist. This mini review aims at discussing the possible roles of tdh and trh genes in clinical and environmental isolates of V. parahaemolyticus.

Vibrio parahaemolyticus, Southern Coastal Region of China, 2007-2012

We analyzed the prevalence and characteristics of Vibrio parahaemolyticus among patients with acute infectious diarrhea in the southern coastal region of China. V. parahaemolyticus was the leading cause of bacterial infectious diarrhea in this region during 2007–2012. Serotype O3:K6 strains were most common, followed by serotypes O4:K8 and O3:K29.

Vibrio parahaemolyticus: a review on the pathogenesis, prevalence, and advance molecular identification techniques

Vibrio parahaemolyticus is a Gram-negative halophilic bacterium that is found in estuarine, marine and coastal environments. V. parahaemolyticus is the leading causal agent of human acute gastroenteritis following the consumption of raw, undercooked, or mishandled marine products. In rare cases, V. parahaemolyticus causes wound infection, ear infection or septicaemia in individuals with pre-existing medical conditions. V. parahaemolyticus has two hemolysins virulence factors that are thermostable direct hemolysin (tdh)-a pore-forming protein that contributes to the invasiveness of the bacterium in humans, and TDH-related hemolysin (trh), which plays a similar role as tdh in the disease pathogenesis. In addition, the bacterium is also encodes for adhesions and type III secretion systems (T3SS1 and T3SS2) to ensure its survival in the environment. This review aims at discussing the V. parahaemolyticus growth and characteristics, pathogenesis, prevalence and advances in molecular identification techniques.

Impact of seafood regulations for Vibrio parahaemolyticus infection and verification by analyses of seafood contamination and infection

Consumption of seafood contaminated with Vibrio parahaemolyticus causes foodborne infections, which are on the rise owing to increased consumption of raw seafood in Asia, Europe, North America, and other regions. V. parahaemolyticus infections have been common in Japan since the 1960s. Following an epidemic in 1997, the Japanese Ministry of Health, Labour, and Welfare instituted regulations for seafood in 1999, which appear to be reducing V. parahaemolyticus infections. In this review, we describe the scientific findings for these regulations. Analyses of the V. parahaemolyticus serotypes and isolate characteristics in samples from infected patients and contaminated seafood are discussed. In addition, based on the results of a survey, we show that new food safety regulations have led to improvements in food hygiene at many seafood retail shops, food service facilities, and restaurants. This example from Japan could be of immense help to control foodborne infections in other countries.

Trends in the epidemiology of pandemic and non-pandemic strains of Vibrio parahaemolyticus isolated from diarrheal patients in Kolkata, India

A total of 178 strains of V. parahaemolyticus isolated from 13,607 acute diarrheal patients admitted in the Infectious Diseases Hospital, Kolkata has been examined for serovar prevalence, antimicrobial susceptibility and genetic traits with reference to virulence, and clonal lineages. Clinical symptoms and stool characteristics of V. parahaemolyticus infected patients were analyzed for their specific traits. The frequency of pandemic strains was 68%, as confirmed by group-specific PCR (GS-PCR). However, the prevalence of non-pandemic strains was comparatively low (32%). Serovars O3:K6 (19.7%), O1:K25 (18.5%), O1:KUT (11.2%) were more commonly found and other serovars such as O3:KUT (6.7%), O4:K8 (6.7%), and O2:K3 (4.5%) were newly detected in this region. The virulence gene tdh was most frequently detected in GS-PCR positive strains. There was no association between strain features and stool characteristics or clinical outcomes with reference to serovar, pandemic/non-pandemic or virulence profiles. Ampicillin and streptomycin resistance was constant throughout the study period and the MIC of ampicillin among selected strains ranged from 24 to >256 µg/ml. Susceptibility of these strains to ampicillin increased several fold in the presence of carbonyl cyanide-m-chlorophenyldrazone. The newly reported ESBL encoding gene from VPA0477 was found in all the strains, including the susceptible ones for ampicillin. However, none of the strains exhibited the β-lactamase as a phenotypic marker. In the analysis of pulsed-field gel electrophoresis (PFGE), the pandemic strains formed two different clades, with one containing the newly emerged pandemic strains in this region.