The true burden and risk of cholera: implications for prevention and control

Cholera in conflict: outbreak analysis and response lessons from Gadaref state, Sudan (2023-2024)

BACKGROUND

Cholera is an acute, severe, illness caused by infection with Vibrio cholerae. Cholera outbreaks are closely linked to armed conflicts and humanitarian emergencies. This study describes the cholera outbreak amidst conflict in Gadaref state, discusses the possible factors mediated its spread and proposes future improvements in preparedness and response measures.

METHODS

A retrospective analytical study was conducted using national surveillance records of cholera cases, supported by interviews with key informants involved in preparedness and response, along with a review of state reports, to identify possible factors contributing to the spread and to evaluate the response.

RESULT

The outbreak was confirmed after the isolation of Vibrio cholerae of O1 serotype, with both Inaba and Ogawa serogroups. A total of 2,047 cholera cases records reviewed. The mean age was 16.8 (SD, 15.8) with an equal gender distribution. The case fatality ratio was 2.4% and the overall attack (AR) rate was 7.38 cases per 10,000 population, with the highest in Medeinat Gadaref locality (21.07/10,000). Interviews and reports review suggest that the outbreak was likely imported to villages near Ethiopian border before spreading to other parts of Gadaref. Atbara seasonal river, was the identified source of infection at the beginning. A disrupted health system due to conflict, delays in response teams' deployment, and late implementation of control measures were identified as factors contributing to response delay and expansion of the outbreak. Oral cholera vaccine campaign was implemented in five localities, followed by an observable decline in cases.

CONCLUSION

Cholera remains a recurrent risk that has been further exacerbated by the armed conflict. The reporting of index cases from a border village highlights the need to strengthen surveillance at points of entry. Investment in case management and risk communication is necessary to improve clinical outcomes. The use of Oral Cholera Vaccine was associated with a decline in cases; however, further field studies are recommended to analyze its actual contribution in limiting the outbreak. The government's primary role in leading and financing preparedness and response interventions has been limited by the conflict, urging investment in community-led interventions, while moving to more strategic outbreak preparedness and response financing mechanisms remains a priority, with partner support being essential in conflict settings.

The Costs and Cost-Effectiveness of a Two-Dose Oral Cholera Vaccination Campaign: A Case Study in a Refugee Camp Setting in Thailand

Oral cholera vaccination (OCV) campaigns are increasingly used to prevent cholera outbreaks; however, little is known about their cost-effectiveness in refugee camps. We conducted a cost-effectiveness analysis of a pre-emptive OCV campaign in the Maela refugee camp in Thailand, where outbreaks occurred with an annual incidence rate (IR) of up to 10.7 cases per 1000. Data were collected via health sector records and interviews and household interviews. In the base-case scenario comparing the OCV campaign with no campaign, we estimated the campaign effect on the cholera IR and case fatality rate (CFR: 0.09%) from a static cohort model and calculated incremental cost-effectiveness ratios for the outcomes of death, disability-adjusted life-years (DALYs), and cases averted. In sensitivity analyses, we varied the CFR and IR. The household economic cost of illness was USD 21, and the health sector economic cost of illness was USD 51 per case. The OCV campaign economic cost was USD 289,561, 42% attributable to vaccine costs and 58% to service delivery costs. In our base case, the incremental cost was USD 1.9 million per death averted, USD 1745 per case averted, and USD 69,892 per DALY averted. Sensitivity analyses that increased the CFR to 0.35% or the IR to 10.4 cases per 1000 resulted in a cost per DALY of USD 15,666. The low multi-year average CFR and incidence of the cholera outbreaks in the Maela camp were key factors associated with the high cost per DALY averted. However, the sensitivity analyses indicated higher cost-effectiveness in a setting with a higher CFR or cholera incidence, indicating when to consider campaign use to reduce the outbreak risk.

Spatial-temporal analysis of climate and socioeconomic conditions on cholera incidence in Mozambique from 2000 to 2018: an ecological longitudinal retrospective study

OBJECTIVES

This study aims to assess both socioeconomic and climatic factors of cholera morbidity in Mozambique considering both spatial and temporal dimensions.

DESIGN

An ecological longitudinal retrospective study using monthly provincial cholera cases from Mozambican Ministry of Health between 2000 and 2018. The cholera cases were linked to socioeconomic data from Mozambique Demographic and Health Surveys conducted in the period 2000-2018 and climatic data; relative humidity (RH), mean temperature, precipitation and Normalised Difference Vegetation Index (NDVI). A negative binomial regression model in a Bayesian framework was used to model cholera incidence while adjusting for the spatiotemporal covariance, lagged effect of environmental factors and the socioeconomic indicators.

SETTING

Eleven provinces in Mozambique.

RESULTS

Over the 19-year period, a total of 153 941 cholera cases were notified to the surveillance system in Mozambique. Risk of cholera increased with higher monthly mean temperatures above 24°C in comparison to the reference mean temperature of 23°C. At mean temperature of 19°C, cholera risk was higher at a lag of 5-6 months. At a shorter lag of 1 month, precipitation of 223.3 mm resulted in an 57% increase in cholera risk (relative risk, RR 1.57 (95% CI 1.06 to 2.31)). Cholera risk was greatest at 3 lag months with monthly NDVI of 0.137 (RR 1.220 (95% CI 1.042 to 1.430)), compared with the reference value of 0.2. At an RH of 54%, cholera RR was increased by 62% (RR 1.620 (95% CI 1.124 to 2.342)) at a lag of 4 months. We found that ownership of radio RR 0.29, (95% CI 0.109 to 0.776) and mobile phones RR 0.262 (95% CI 0.097 to 0.711) were significantly associated with low cholera risk.

CONCLUSION

The derived lagged patterns can provide appropriate lead times in a climate-driven cholera early warning system that could contribute to the prevention and management of outbreaks.

Outer membrane proteins and vesicles as promising vaccine candidates against Vibrio spp. infections

Indiscriminate use of antibiotics to treat bacterial infections has brought unmanageable antibiotic-resistant strains into existence. Vibrio spp. represents one such gram-negative enteric pathogenic group with more than 100 species, infecting humans and fish. The Vibrio spp. is demarcated into two groups, one that causes cholera and the other producing non-cholera or vibriosis infections. People who encounter contaminated water are at risk, but young children and pregnant women are the most vulnerable. Though controllable, Vibrio infection still necessitates the development of preventative measures, such as vaccinations, that can lessen the severity of the infection and reduce reliance on antibiotic use. With emerging multi-drug resistant strains, efforts are needed to develop newer vaccines, such as subunit-based or outer membrane vesicle-based. Thus, this review strives to bring together available information about Vibrio spp. outer membrane proteins and vesicles, encompassing their structure, function, and immunoprotective role.

Participatory Disease Surveillance for the Early Detection of Cholera-Like Diarrheal Disease Outbreaks in Rural Villages in Malawi: Prospective Cohort Study

BACKGROUND

Cholera-like diarrheal disease (CLDD) outbreaks are complex and influenced by environmental factors, socioeconomic conditions, and population dynamics, leading to limitations in traditional surveillance methods. In Malawi, cholera is considered an endemic disease. Its epidemiological profile is characterized by seasonal patterns, often coinciding with the rainy season when contamination of water sources is more likely. However, the outbreak that began in March 2022 has extended to the dry season, with deaths reported in all 29 districts. It is considered the worst outbreak in the past 10 years.

OBJECTIVE

This study aims to evaluate the feasibility and outcomes of participatory surveillance (PS) using interactive voice response (IVR) technology for the early detection of CLDD outbreaks in Malawi.

METHODS

This longitudinal cohort study followed 740 households in rural settings in Malawi for 24 weeks. The survey tool was designed to have 10 symptom questions collected every week. The proxies' rationale was related to exanthematic, ictero-hemorragica for endemic diseases or events, diarrhea and respiratory/targeting acute diseases or events, and diarrhea and respiratory/targeting seasonal diseases or events. This work will focus only on the CLDD as a proxy for gastroenteritis and cholera. In this study, CLDD was defined as cases where reports indicated diarrhea combined with either fever or vomiting/nausea.

RESULTS

During the study period, our data comprised 16,280 observations, with an average weekly participation rate of 35%. Maganga TA had the highest average of completed calls, at 144.83 (SD 10.587), while Ndindi TA had an average of 123.66 (SD 13.176) completed calls. Our findings demonstrate that this method might be effective in identifying CLDD with a notable and consistent signal captured over time (R2=0.681404). Participation rates were slightly higher at the beginning of the study and decreased over time, thanks to the sensitization activities rolled out at the CBCCs level. In terms of the attack rates for CLDD, we observed similar rates between Maganga TA and Ndindi TA, at 16% and 15%, respectively.

CONCLUSIONS

PS has proven to be valuable for the early detection of epidemics. IVR technology is a promising approach for disease surveillance in rural villages in Africa, where access to health care and traditional disease surveillance methods may be limited. This study highlights the feasibility and potential of IVR technology for the timely and comprehensive reporting of disease incidence, symptoms, and behaviors in resource-limited settings.

Characterization of the genome and cell invasive phenotype of Vibrio diabolicus Cg5 isolated from mass mortality of Pacific oyster, Crassostrea gigas

Vibrio is an important group of aquatic animal pathogens, which has been identified as the main pathogenic factor causing mass summer mortality of Crassostrea gigas in northern China. This study aims to investigate the potential pathogenic mechanisms of Vibrio Cg5 isolate in C. gigas. We sequenced and annotated the genome of Vibrio Cg5 to analyze potential virulence factors. The gentamicin protection assays were performed with C. gigas primary cells to reveal the cell-invasive behavior of Cg5. The genome analysis showed that Cg5 was a strain of human disease-associated pathogen with multiple antibiotic resistance, and four virulence factors associated with intracellular survival were present in the genome. The gentamicin protection assays showed that Cg5 could potentially invade the cells of C. gigas, indicating that Cg5 could be a facultative intracellular pathogen of C. gigas. These results provide insights into the pathogenic mechanism of V. diabolicus, an emerging pathogenic Vibrio on aquatic animals, which would be valuable in preventing and controlling diseases in oysters.

Model-Based Estimation of Expected Time to Cholera Extinction in Lusaka, Zambia

The developing world has been facing a significant health issue due to cholera as an endemic communicable disease. Lusaka was Zambia's worst affected province, with 5414 reported cases of cholera during the outbreak from late October 2017 to May 12, 2018. To explore the epidemiological characteristics associated with the outbreak, we fitted weekly reported cholera cases with a compartmental disease model that incorporates two transmission routes, namely environment-to-human and human-to-human. Estimates of the basic reproduction number show that both transmission modes contributed almost equally during the first wave. In contrast, the environment-to-human transmission appears to be mostly dominating factor for the second wave. Our study finds that a massive abundance of environmental vibrio's with a huge reduction in water sanitation efficacy triggered the secondary wave. To estimate the expected time to extinction (ETE) of cholera, we formulate the stochastic version of our model and find that cholera can last up to 6.5-7 years in Lusaka if any further outbreak occurs at a later time. Results indicate that a considerable amount of attention is to be paid to sanitation and vaccination programs in order to reduce the severity of the disease and to eradicate cholera from the community in Lusaka.

Pharmacoinformatics and molecular dynamics simulation approach to identify anti-diarrheal potentials of Centella asiatica (L.) Urb. against Vibrio cholerae

Vibrio cholerae, the etiological agent of cholera, causes dehydration and severe diarrhea with the production of cholera toxin. Due to the acquired antibiotic resistance, V. cholerae has drawn attention to the establishment of novel medications to counteract the virulence and viability of the pathogen. Centella asiatica is a medicinal herb native to Bangladesh that has a wide range of medicinal and ethnobotanical applications including anti-bacterial properties. In the present investigation, a total of 25 bioactive phytochemicals of C. asiatica have been screened virtually through molecular docking, ADMET (Absorption, Distribution, Metabolism, Excretion, and Toxicity) analyses, and molecular dynamics simulation. Our results revealed four lead compounds as Viridiflorol (-8.7 Kcal/mol), Luteolin (-8.1 Kcal/mol), Quercetin (-8.0 Kcal/mol) and, Geranyl acetate (-7.1 Kcal/mol) against V. cholerae Toxin co-regulated pilus virulence regulatory protein (ToxT). All the lead compounds have been found to possess favorable pharmacokinetic, pharmacodynamics, and molecular dynamics properties. Toxicity analysis revealed satisfactory results with no major side effects. Molecular dynamics simulation was performed for 100 ns that revealed noteworthy conformational stability and structural compactness for all the lead compounds, especially for Quercetin. Target class prediction unveiled enzymes in most of the cases and some experimental and investigational drugs were found as structurally similar analogs of the lead compounds. These findings could aid in the development of novel therapeutics targeting Cholera disease and we strongly recommend in vitro trials of our experimental findings.Communicated by Ramaswamy H. Sarma.

Cholera outbreak in some communities in North-East Nigeria, 2019: an unmatched case-control study

BACKGROUND

Cholera, a diarrheal disease caused by the bacterium Vibrio cholerae, transmitted through fecal contamination of water or food remains an ever-present risk in many countries, especially where water supply, sanitation, food safety, and hygiene are inadequate. A cholera outbreak was reported in Bauchi State, North-eastern Nigeria. We investigated the outbreak to determine the extent and assess risk factors associated with the outbreak.

METHODS

We conducted a descriptive analysis of suspected cholera cases to determine the fatality rate (CFR), attack rate (AR), and trends/patterns of the outbreak. We also conducted a 1:2 unmatched case-control study to assess risk factors amongst 110 confirmed cases and 220 uninfected individuals (controls). We defined a suspected case as any person > 5 years with acute watery diarrhea with/without vomiting; a confirmed case as any suspected case in which there was laboratory isolation of Vibrio cholerae O1 or O139 from the stool while control was any uninfected individual with close contact (same household) with a confirmed case. Children under 5 were not included in the case definition however, samples from this age group were collected where such symptoms had occurred and line-listed separately. Data were collected with an interviewer-administered questionnaire and analyzed using Epi-info and Microsoft excel for frequencies, proportions, bivariate and multivariate analysis at a 95% confidence interval.

RESULTS

A total of 9725 cases were line-listed with a CFR of 0.3% in the state. Dass LGA had the highest CFR (14.3%) while Bauchi LGA recorded the highest AR of 1,830 cases per 100,000 persons. Factors significantly associated with cholera infection were attending social gatherings (aOR = 2.04, 95% CI = 1.16-3.59) and drinking unsafe water (aOR = 1.74, 95% CI = 1.07-2.83).

CONCLUSION

Attending social gatherings and drinking unsafe water were risk factors for cholera infection. Public health actions included chlorination of wells and distribution of water guard (1% chlorine solution) bottles to households and public education on cholera prevention. We recommend the provision of safe drinking water by the government as well as improved sanitary and hygienic conditions for citizens of the state.

What Whole Genome Sequencing Has Told Us About Pathogenic Vibrios

When the first microbial genome sequences were published just 20 years ago, our understanding regarding the microbial world changed dramatically. The genomes of the first pathogenic vibrios sequenced, including Vibrio cholerae, Vibrio parahaemolyticus, and Vibrio vulnificus revealed a functional and phylogenetic diversity previously unimagined as well as a genome structure indelibly shaped by horizontal gene transfer. The initial glimpses into these organisms also revealed a genomic plasticity that allowed these bacteria to thrive in challenging and varied aquatic and marine environments, but critically also a suite of pathogenicity attributes. In this review we outline how our understanding of vibrios has changed over the last two decades with the advent of genomics and advances in bioinformatic and data analysis techniques, it has become possible to provide a more cohesive understanding regarding these bacteria: how these pathogens have evolved and emerged from environmental sources, their evolutionary routes through time and space, how they interact with other bacteria and the human host, as well as initiate disease. We outline novel approaches to the use of whole genome sequencing for this important group of bacteria and how new sequencing technologies may be applied to study these organisms in future studies.

A fractional SVIR-B epidemic model for Cholera with imperfect vaccination and saturated treatment

Given the limited medical resources in most cholera endemic countries, in this paper, a nonlinear fractional SVIR-B (Susceptible-Vaccinated-Infected-Recovered, Bacterial) cholera epidemic model with imperfect vaccination and saturated treatment is proposed and investigated. The model performs well-posed in both epidemiologically and mathematically, especially, we demonstrate the positivity and boundedness of all solutions using the generalized mean value theorem. The control reproduction number R vt is derived using the next generation matrix method and both local and global stability analyses for the disease-free equilibrium is performed by analyzing the characteristic equation and using Lyapunov functional. Then, the existence and stability of endemic equilibria are further addressed. Sufficient conditions for the existence of backward bifurcation and Hopf bifurcation are also derived. Subsequently, an optimal control problem with vaccination, media coverage, treatment, and sanitation as control strategies is proposed and analyzed, providing a rationale for cholera control and prevention. In addition, several numerical examples are employed to illustrate our theoretical results.

The manipulation of cell signaling and host cell biology by cholera toxin

Vibrio cholerae colonizes the small intestine and releases cholera toxin into the extracellular space. The toxin binds to the apical surface of the epithelium, is internalized into the host endomembrane system, and escapes into the cytosol where it activates the stimulatory alpha subunit of the heterotrimeric G protein by ADP-ribosylation. This initiates a cAMP-dependent signaling pathway that stimulates chloride efflux into the gut, with diarrhea resulting from the accompanying osmotic movement of water into the intestinal lumen. G protein signaling is not the only host system manipulated by cholera toxin, however. Other cellular mechanisms and signaling pathways active in the intoxication process include endocytosis through lipid rafts, retrograde transport to the endoplasmic reticulum, the endoplasmic reticulum-associated degradation system for protein delivery to the cytosol, the unfolded protein response, and G protein de-activation through degradation or the function of ADP-ribosyl hydrolases. Although toxin-induced chloride efflux is thought to be an irreversible event, alterations to these processes could facilitate cellular recovery from intoxication. This review will highlight how cholera toxin exploits signaling pathways and other cell biology events to elicit a diarrheal response from the host.

Colonization with extended-spectrum beta-lactamase-producing Escherichia coli and traveler's diarrhea attack rates among travelers to India: a systematic review and meta-analysis

Background

India is an attractive destination for travelers. Unfortunately, numerous reports exist on traveler’s diarrhea (TD) and fecal colonization with extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) among international travelers visiting India. Here, we systematically reviewed studies published on the acquisition of ESBL-EC and TD attack rates among international visitors to India.

Methods

Design: Systematic review and meta-analysis.

A systematic search was performed using Google Scholar, PubMed, EMBASE, Web of Science, and gray literature from 2000 to December 2021, for studies containing data for ESBL-EC acquisition or TD experience related to a trip to India. Random effects models were used to compute the prevalence of ESBL-EC acquisition and TD attack.

Results

The literature search yielded a total of 5023 records. Of these, 31 met our inclusion criteria for systematic review and only 17 could be meta-analyzed (9 for TD, and 8 for ESBL-EC). The overall pooled attack rate of TD was 39% (95% confidence interval, CI: 25–53%). In studies where travelers' memory was used to diagnose TD, the pooled attack rate of TD was slightly higher (42%, 95% CI: 21–64%) compared to those where TD was objectively documented (33%, 95% CI: 17–49%). There were significant risks to be colonized with ESBL-EC among the travelers who experienced TD. The pooled rate of ESBL-EC colonization was 72% (CI: 67–78%). Most ESBL-EC produced CTX-M-15 enzyme. Furthermore, most of the travelers who acquired ESBL-EC were from highly industrialized countries recruited from travel clinics: Canada (n = 80), Germany (n = 69), Netherlands (n = 20), Sweden (n = 18), Japan (n = 10), Finland (n = 8), USA (n = 7), Spain (n = 5), and Denmark (n = 3).

Conclusions

TD pooled attack rate and ESBL-EC acquisition among international travelers visiting India were high in this study. However, we cannot make generalizations based upon this TD pooled attack rate for the current situation, due to a lack of current data. Our study highlights that travelers should be advised on TD to ensure that they do not disregard the risk of contracting TD and be better prepared as a result. It also illustrates the importance of international travel in acquiring antibiotic-resistant Escherichia coli.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40794-022-00179-1.

Bioengineered Probiotics: Synthetic Biology Can Provide Live Cell Therapeutics for the Treatment of Foodborne Diseases

The rising prevalence of antibiotic resistant microbial pathogens presents an ominous health and economic challenge to modern society. The discovery and large-scale development of antibiotic drugs in previous decades was transformational, providing cheap, effective treatment for what would previously have been a lethal infection. As microbial strains resistant to many or even all antibiotic drug treatments have evolved, there is an urgent need for new drugs or antimicrobial treatments to control these pathogens. The ability to sequence and mine the genomes of an increasing number of microbial strains from previously unexplored environments has the potential to identify new natural product antibiotic biosynthesis pathways. This coupled with the power of synthetic biology to generate new production chassis, biosensors and “weaponized” live cell therapeutics may provide new means to combat the rapidly evolving threat of drug resistant microbial pathogens. This review focuses on the application of synthetic biology to construct probiotic strains that have been endowed with functionalities allowing them to identify, compete with and in some cases kill microbial pathogens as well as stimulate host immunity. Weaponized probiotics may have the greatest potential for use against pathogens that infect the gastrointestinal tract: Vibrio cholerae, Staphylococcus aureus, Clostridium perfringens and Clostridioides difficile. The potential benefits of engineered probiotics are highlighted along with the challenges that must still be met before these intriguing and exciting new therapeutic tools can be widely deployed.

Screening of Potential Vibrio cholerae Bacteriophages for Cholera Therapy: A Comparative Genomic Approach

Cholera continues to be a major burden for developing nations, especially where sanitation, quality of water supply, and hospitalization have remained an issue. Recently, growing antimicrobial-resistant strains of Vibrio cholerae underscores alternative therapeutic strategies for cholera. Bacteriophage therapy is considered one of the best alternatives for antibiotic treatment. For the identification of potential therapeutic phages for cholera, we have introduced a comprehensive comparative analysis of whole-genome sequences of 86 Vibrio cholerae phages. We have witnessed extensive variation in genome size (ranging from 33 to 148 kbp), GC (G + C) content (varies from 34.5 to 50.8%), and the number of proteins (ranging from 15 to 232). We have identified nine clusters and three singletons using BLASTn, confirmed by nucleotide dot plot and sequence identity. A high degree of sequence and functional similarities in both the genomic and proteomic levels have been observed within the clusters. Evolutionary analysis confirms that phages are conserved within the clusters but diverse between the clusters. For each therapeutic phage, the top 2 closest phages have been identified using a system biology approach and proposed as potential therapeutic phages for cholera. This method can be applied for the classification of the newly isolated Vibrio cholerae phage. Furthermore, this systematic approach might be useful as a model for screening potential therapeutic phages for other bacterial diseases.

Assay for Evaluating the Abundance of Vibrio cholerae and Its O1 Serogroup Subpopulation from Water without DNA Extraction

Cholera is a severe diarrheal disease caused by Vibrio cholerae, a natural inhabitant of brackish water. Effective control of cholera outbreaks depends on prompt detection of the pathogen from clinical specimens and tracking its source in the environment. Although the epidemiology of cholera is well studied, rapid detection of V. cholerae remains a challenge, and data on its abundance in environmental sources are limited. Here, we describe a sensitive molecular quantification assay by qPCR, which can be used on-site in low-resource settings on water without the need for DNA extraction. This newly optimized method exhibited 100% specificity for total V. cholerae as well as V. cholerae O1 and allowed detection of as few as three target CFU per reaction. The limit of detection is as low as 5 × 10³ CFU/L of water after concentrating biomass from the sample. The ability to perform qPCR on water samples without DNA extraction, portable features of the equipment, stability of the reagents at 4 °C and user-friendly online software facilitate fast quantitative analysis of V. cholerae. These characteristics make this assay extremely useful for field research in resource-poor settings and could support continuous monitoring in cholera-endemic areas.

Inhibition of α-, β- and γ-carbonic anhydrases from the pathogenic bacterium Vibrio cholerae with aromatic sulphonamides and clinically licenced drugs - a joint docking/molecular dynamics study

The binding mode of aromatic sulphonamides and clinically licenced drugs to the three carbonic anhydrase (CA, EC 4.2.1.1) isoforms from the human pathogen V. cholerae was here thouroghly characterised by a joint docking and molecular dynamics in silico protocol. In fact, VchCA, VchCAβ, and VchCAγ are crucial in the pathogen life cycle and growth and represent innovative targets to fight V. cholerae proliferation overcoming the spreading chemoresistance to the available drugs. A set of 40 sulphonamides/sulfamates VchCAs inhibitors was studied using the proteins homology built 3 D models unveiling the key and stable interactions responsible for a potent CA inhibition. This study has the aim to offer insights and guidelines for the future rational design of potent and selective inhibitors targeting CA isoforms from V. cholerae or other human pathogens.

Independent Promoter Recognition by TcpP Precedes Cooperative Promoter Activation by TcpP and ToxR

Cholera is a diarrheal disease caused by the Gram-negative bacterium Vibrio cholerae. To reach the surface of intestinal epithelial cells, proliferate, and cause disease, V. cholerae tightly regulates the production of virulence factors such as cholera toxin (ctxAB) and the toxin-coregulated pilus (tcpA-F). ToxT is directly responsible for regulating these major virulence factors while TcpP and ToxR indirectly regulate virulence factor production by stimulating toxT expression. TcpP and ToxR are membrane-localized transcription activators (MLTAs) required to activate toxT expression. To gain a deeper understanding of how MLTAs identify promoter DNA while in the membrane, we tracked the dynamics of single TcpP-PAmCherry molecules in live cells using photoactivated localization microscopy and identified heterogeneous diffusion patterns. Our results provide evidence that (i) TcpP exists in three biophysical states (fast diffusion, intermediate diffusion, and slow diffusion), (ii) TcpP transitions between these different diffusion states, (iii) TcpP molecules in the slow diffusion state are interacting with the toxT promoter, and (iv) ToxR is not essential for TcpP to localize the toxT promoter. These data refine the current model of cooperativity between TcpP and ToxR in stimulating toxT expression and demonstrate that TcpP locates the toxT promoter independently of ToxR.

Climate Precursors of Satellite Water Marker Index for Spring Cholera Outbreak in Northern Bay of Bengal Coastal Regions

Cholera is a water-borne infectious disease that affects 1.3 to 4 million people, with 21,000 to 143,000 reported fatalities each year worldwide. Outbreaks are devastating to affected communities and their prospects for development. The key to support preparedness and public health response is the ability to forecast cholera outbreaks with sufficient lead time. How Vibrio cholerae survives in the environment outside a human host is an important route of disease transmission. Thus, identifying the environmental and climate drivers of these pathogens is highly desirable. Here, we elucidate for the first time a mechanistic link between climate variability and cholera (Satellite Water Marker; SWM) index in the Bengal Delta, which allows us to predict cholera outbreaks up to two seasons earlier. High values of the SWM index in fall were associated with above-normal summer monsoon rainfalls over northern India. In turn, these correlated with the La Niña climate pattern that was traced back to the summer monsoon and previous spring seasons. We present a new multi-linear regression model that can explain 50% of the SWM variability over the Bengal Delta based on the relationship with climatic indices of the El Niño Southern Oscillation, Indian Ocean Dipole, and summer monsoon rainfall during the decades 1997–2016. Interestingly, we further found that these relationships were non-stationary over the multi-decadal period 1948–2018. These results bear novel implications for developing outbreak-risk forecasts, demonstrating a crucial need to account for multi-decadal variations in climate interactions and underscoring to better understand how the south Asian summer monsoon responds to climate variability.

The impact of improved water supply on cholera and diarrhoeal diseases in Uvira, Democratic Republic of the Congo: a protocol for a pragmatic stepped-wedge cluster randomised trial and economic evaluation

INTRODUCTION

Diarrhoeal disease remains a leading cause of mortality and morbidity worldwide. Cholera alone is estimated to cause 95,000 deaths per year, most of which occur in endemic settings with inadequate water access. Whilst a global strategy to eliminate cholera by 2030 calls for investment in improved drinking water services, there is limited rigorous evidence for the impact of improved water supply on endemic cholera transmission in low-income urban settings. Our protocol is designed to deliver a pragmatic health impact evaluation of a large-scale water supply intervention in Uvira (Democratic Republic of the Congo), a cholera transmission hotspot.

METHODS/DESIGN

A stepped-wedge cluster randomised trial (SW-CRT) was designed to evaluate the impact of a large-scale drinking water supply intervention on cholera incidence among the 280,000 inhabitants of Uvira. The city was divided into 16 clusters, where new community and household taps will be installed following a randomised sequence over a transition period of up to 8 weeks in each cluster. The primary trial outcomes are the monthly incidence of "confirmed" cholera cases (patients testing positive by rapid detection kit) and of "suspected" cholera cases (patients admitted to the cholera treatment centre). Concurrent process and economic evaluations will provide further information on the context, costs, and efficiency of the intervention.

DISCUSSION

In this protocol, we describe a pragmatic approach to conducting rigorous research to assess the impacts of a complex water supply intervention on severe diarrhoeal disease and cholera in an unstable, low-resource setting representative of cholera-affected areas. In particular, we discuss a series of pre-identified risks and linked mitigation strategies as well as the value of combining different data collection methods and preparation of multiple analysis scenarios to account for possible deviations from the protocol. The study described here has the potential to provide robust evidence to support more effective cholera control in challenging, high-burden settings.

TRIAL REGISTRATION

This trial is registered on clinicaltrials.gov ( NCT02928341 , 10th October 2016) and has received ethics approval from the London School of Hygiene and Tropical Medicine (8913, 10603) and from the Ethics Committee from the School of Public Health, University of Kinshasa, Democratic Republic of the Congo (ESP/CE/088/2015).

Cholera in travellers: improving vaccination guidance in Europe

BACKGROUND

Cholera is endemic in ~50 countries worldwide and remains a disease associated with poverty, causing illness and death in the poorest and most vulnerable people. In travellers, cholera is considered a low-incidence disease, but the true impact on travellers is difficult to assess. Cholera vaccination may improve safety for certain European travellers at risk. Effective vaccines are available; however, vaccination recommendations in Europe vary considerably between countries.

METHODS

In this review, a comparison of cholera vaccination recommendations from 29 advice reference bodies across key European countries (United Kingdom, Germany, Spain, Italy, Portugal, Switzerland, Sweden, Finland, Norway, France and Denmark) is presented. The differences in perceived cholera risk are highlighted, and a comparison with the United States Centers for Disease Control and Prevention (CDC) recommendations is included.

RESULTS

In general terms, the recommendations from European organizations are ambiguous and differ widely. This contrasts with the situation in the United States, where the CDC publishes a consistent set of guidelines.

CONCLUSION

With the ease of intra-European travel, it would seem sensible to harmonize the recommendations for cholera vaccination and risk perception across Europe, providing pre-travel health advisers with a trusted source of information that allows them to provide consistent recommendations.

Cholera Risk: A Machine Learning Approach Applied to Essential Climate Variables

Oceanic and coastal ecosystems have undergone complex environmental changes in recent years, amid a context of climate change. These changes are also reflected in the dynamics of water-borne diseases as some of the causative agents of these illnesses are ubiquitous in the aquatic environment and their survival rates are impacted by changes in climatic conditions. Previous studies have established strong relationships between essential climate variables and the coastal distribution and seasonal dynamics of the bacteria Vibrio cholerae, pathogenic types of which are responsible for human cholera disease. In this study we provide a novel exploration of the potential of a machine learning approach to forecast environmental cholera risk in coastal India, home to more than 200 million inhabitants, utilising atmospheric, terrestrial and oceanic satellite-derived essential climate variables. A Random Forest classifier model is developed, trained and tested on a cholera outbreak dataset over the period 2010–2018 for districts along coastal India. The random forest classifier model has an Accuracy of 0.99, an F1 Score of 0.942 and a Sensitivity score of 0.895, meaning that 89.5% of outbreaks are correctly identified. Spatio-temporal patterns emerged in terms of the model’s performance based on seasons and coastal locations. Further analysis of the specific contribution of each Essential Climate Variable to the model outputs shows that chlorophyll-a concentration, sea surface salinity and land surface temperature are the strongest predictors of the cholera outbreaks in the dataset used. The study reveals promising potential of the use of random forest classifiers and remotely-sensed essential climate variables for the development of environmental cholera-risk applications. Further exploration of the present random forest model and associated essential climate variables is encouraged on cholera surveillance datasets in other coastal areas affected by the disease to determine the model’s transferability potential and applicative value for cholera forecasting systems.

Cholera, the Current Status of Cholera Vaccines and Recommendations for Travellers

Cholera is endemic in approximately 50 countries, primarily in Africa and South and Southeast Asia, and in these areas, it remains a disease associated with poverty. In developed nations, cholera is rare, and cases are typically imported from endemic areas by returning travellers. Cholera is readily preventable with the tools available to modern medicine. In developing nations, cholera transmission can be prevented through improved water, sanitation, and hygiene services and the use of oral cholera vaccines (OCVs). For travellers, risk can be mitigated by practicing regular hand hygiene and consuming food and water from safe sources. OCVs should be considered for high-risk travellers likely to be exposed to cholera patients or contaminated water and food. There are currently three World Health Organization pre-qualified OCVs, which are based on killed whole-cell strains of Vibrio cholerae. These established vaccines offer significant protection in adults and children for up to 2 years. A novel live attenuated vaccine that provides rapid-onset protection in adults and children is licensed in the USA and Europe only. Live attenuated OCVs may mimic the natural infection of V. cholerae more closely, generating rapid immune responses without the need for repeat dosing. These potential benefits have prompted the ongoing development of several additional live attenuated vaccines. The objective of this article is to provide a general review of the current landscape of OCVs, including a discussion of their appropriate use in international travellers.

Spatial and Temporal Patterns of Typhoid and Paratyphoid Fever Outbreaks: A Worldwide Review, 1990-2018

BACKGROUND

Analyses of the global spatial and temporal distribution of enteric fever outbreaks worldwide are important factors to consider in estimating the disease burden of enteric fever disease burden.

METHODS

We conducted a global literature review of enteric fever outbreak data by systematically using multiple databases from 1 January 1990 to 31 December 2018 and classified them by time, place, diagnostic methods, and drug susceptibility, to illustrate outbreak characteristics including spatial and temporal patterns.

RESULTS

There were 180 940 cases in 303 identified outbreaks caused by infection with Salmonella enterica serovar Typhi (S. Typhi) and Salmonella enterica serovar Paratyphi A or B (S. Paratyphi). The size of outbreak ranged from 1 to 42 564. Fifty-one percent of outbreaks occurred in Asia, 15% in Africa, 14% in Oceania, and the rest in other regions. Forty-six percent of outbreaks specified confirmation by blood culture, and 82 outbreaks reported drug susceptibility, of which 54% had multidrug-resistant pathogens. Paratyphoid outbreaks were less common compared to typhoid (22 vs 281) and more prevalent in Asia than Africa. Risk factors were multifactorial, with contaminated water being the main factor.

CONCLUSIONS

Enteric fever outbreak burden remains high in endemic low- and middle-income countries and, despite its limitations, outbreak data provide valuable contemporary evidence in prioritizing resources, public health policies, and actions. This review highlights geographical locations where urgent attention is needed for enteric fever control and calls for global action to prevent and contain outbreaks.

Mapping cholera outbreaks and antibiotic resistant Vibrio cholerae in India: An assessment of existing data and a scoping review of the literature

Although fluid and electrolyte replenishment remains the mainstay of clinical management of cholera, antibiotics are an important component of the strategy for clinical management of moderate to severe cases of cholera. The emergence of antibiotic resistance (ABR) in Vibrio cholerae has led to difficulties in case management. The past decade has also seen the development of cheap and effective oral cholera vaccines (OCVs). In addition to the two-dose strategy for widespread immunization, OCVs have also been shown to be effective in containing outbreaks using a single-dose schedule. In this scoping review we map the states and union territories (SUTs) of India which are prone to cholera outbreaks followed by a scoping review of peer-reviewed publications about ABR outbreaks of cholera employing the Arksey and O'Malley framework. Using the data reported by the Integrated Disease Surveillance Program (IDSP), we identified 559 outbreaks of cholera between 2009 and 2017, affecting 27 SUTs. We defined SUTs which had reported outbreaks in at least three out of the last five years (2012-2016) or had experienced two or more outbreaks in the same year in at least two of the last five years to be outbreak-prone. The scoping review identified 62 ABR outbreaks, with four SUTs accounting for two-thirds of them: West Bengal (14), Maharashtra (10), Odisha (10) and Delhi (7). Overall, this scoping review suggests that there is an increasing trend of ABR in Vibrio cholerae isolated from outbreaks in India. This opens up avenues for exploring the role of antibiotic stewardship in the clinical management of diarrhea, the institution of vaccination as an infection prevention intervention to reduce selection pressure, and the deployment of high quality surveillance systems which report accurate, real-time data allowing appropriate and timely public health responses. It is crucial to counter the issue of ABR in cholera before it assumes a menacing magnitude.

THE COMPUTATION OF REPRODUCTION NUMBERS FOR THE ENVIRONMENT-HOST-ENVIRONMENT CHOLERA TRANSMISSION DYNAMICS

This study presents a new model for the environment-host-environment transmission dynamics of V. cholerae in a community with an interconnected aquatic pond–river water network. For the case when the human host is the sole target of anti-cholera control and the volume of water in the pond is maximum, the disease-free equilibrium of the model is shown to be globally asymptotically stable whenever a certain epidemiological threshold, known as the basic reproduction number [Formula: see text], is less than unity. The epidemiological implication of this result is that cholera can be eliminated from the community if the control strategies implemented can bring (and maintain) [Formula: see text] to a value less than unity. Four scenarios, that represent different interpretations of the role of the V. cholerea pathogen within the environment, were studied. The corresponding basic reproduction numbers were shown to exhibit the same threshold property with respect to the value unity (i.e., if one is less (equal, greater) than unity, then the three others are also less (equal, greater) than unity. Further, it was shown that for the case where anti-cholera control is focused on the human host population, the associated type reproduction number of the model (corresponding to each of the four transmission scenarios considered) is unique. The implication of this result is that the estimate of the effort needed for disease elimination (i.e., the required herd immunity threshold) is unique, regardless of which of the four transmission scenarios is considered. However, when any of the other two bacterial population types in the aquatic environment (i.e., bacterial in the pond or river) is the focus of the control efforts, this study shows that the associated type reproduction number is not unique. Extensive numerical simulations of the model, using a realistic set of parameters from the published literature, show that the community-wide implementation of a strategy that focus on improved water quality, sanitation, and hygiene (known as WASH-only strategy), using the current estimated coverage of 50% and efficacy of 60%, is unable to lead to the elimination of the disease. Such elimination is attainable if the coverage and efficacy are increased (e.g., to 80% and 90%, respectively). Further, elimination can be achieved using a strategy that focuses on oral rehydration therapy and the use of antibiotics to treat the infected humans (i.e., treatment-only strategy) for moderate effectiveness and coverage levels. The combined hybrid WASH-treatment strategy provides far better population-level impact vis a vis disease elimination. This study ranks the three interventions in the following order of population-level effectiveness: combined WASH-treatment, followed by treatment-only and then WASH-only strategy.

Cholera in travellers: a systematic review

Exposure to cholera is a risk for individuals and groups travelling to endemic areas, and the bacteria can be imported to cholera-free countries by returning travellers. This systematic review of the literature describes the circumstances in which cholera infection can occur in travellers and considers the possible value of the cholera vaccine for prevention in travellers. PubMed and EMBASE were searched for case reports of cholera or diarrhoea among travellers, with date limits of 1 January 1990-30 April 2018. Search results were screened to exclude the following articles: diarrhoea not caused by cholera, cholera in animals, intentional cholera infection in humans, non-English articles and publications on epidemics that did not report clinical details of individual cases and publications of cases pre-dating 1990. Articles were reviewed through descriptive analytic methods and information summarized. We identified 156 cases of cholera imported as a consequence of travel, and these were reviewed for type of traveller, source country, serogroup of cholera, treatment and outcomes. The case reports retrieved in the search did not report consistent levels of detail, making it difficult to synthesize data across reports and draw firm conclusions from the data. This clinical review sheds light on the paucity of actionable published data regarding the risk of cholera in travellers and identifies a number of gaps that should drive additional effort. Further information is needed to better inform evidence-based disease prevention strategies, including vaccination for travellers visiting areas of cholera risk. Modifications to current vaccination recommendations to include or exclude current or additional traveller populations may be considered as additional risk data become available. The protocol for this systematic review is registered with PROSPERO (registration number: 122797).

Burden of typhoid fever and cholera: similarities and differences. Prevention strategies for European travelers to endemic/epidemic areas

The burden of diarrheal diseases is very high, accounting for 1.7 to 5 billion cases per year worldwide. Typhoid fever (TF) and cholera are potentially life-threatening infectious diseases, and are mainly transmitted through the consumption of food, drink or water that have been contaminated by the feces or urine of subjects excreting the pathogen. TF is mainly caused by Salmonella typhi, whereas cholera is caused by intestinal infection by the toxin-producing bacterium Vibrio cholerae. These diseases typically affect low- and middle-income countries where housing is overcrowded and water and sanitation are poor, or where conflicts or natural disasters have led to the collapse of the water, sanitation and healthcare systems. Mortality is higher in children under 5 years of age. Regarding their geographical distribution, TF has a high incidence in sub-Saharan Africa, India and south-east Asia, while cholera has a high incidence in a few African countries, particularly in the Horn of Africa and the Arabian Peninsula. In the fight against these diseases, preventive measures are fundamental. With modern air travel, transmissible diseases can spread across continents and oceans in a few days, constituting a threat to global public health. Nowadays, people travel for many reasons, such as tourism and business. Several surveys have shown that a high proportion of travelers lack adequate information on safety issues, such as timely vaccination and prophylactic medications. The main objective of this overview is to provide information to help European travelers to stay healthy while abroad, and thus also to reduce the potential importation of these diseases and their consequent implications for public health and society. The preventive measures to be implemented in the case of travel to countries where these diseases are still endemic are well known: the adoption of safe practices and vaccinations. It is important to stress that an effective preventive strategy should be based both on vaccinations and on hygiene travel guidelines. Furthermore, the emergence of multidrug-resistant strains is becoming a serious problem in the clinical treatment of these diseases. For this reason, vaccination is the main solution.

Cholera surveillance and estimation of burden of cholera

Cholera continues to be poorly controlled in multiple epidemic and endemic areas across the globe, with estimated annual incidence of 1.3-4.0 million cases, resulting in 21,000 to 143,000 deaths worldwide in 2015. The usual approach for patient diagnosis and cholera surveillance is clinical examination of cases of acute watery diarrhea (AWD), confirmed by positive culture or polymerase chain reaction tests. Rapid diagnostic tests (RDTs) are used in regions with limited laboratory capacities but have been found to demonstrate large variations in performance, ranging in sensitivity from 58% to 100% and in specificity from 60% to 100%. Most countries rely on hospital-based surveillance of diarrheal disease to compute the cholera burden. The World Health Organization (WHO) recommends that countries assess public health events involving cholera against the International Health Regulations 2005 criteria and determine need for official notification using the standard case definition. Cholera is an often under-recognized and under reported problem because of differences in case definitions, reluctance by authorities to acknowledge and report cholera, inadequacies in hospital surveillance systems, lack of effective diagnostic tests and commonalities in clinical presentation of cholera with other AWD etiologies. The resulting gap in burden data impairs economic analysis of disease impact and identification of areas for targeted control interventions. There is an urgent need to strengthen surveillance data by supplementing reported numbers with estimates from literature reviews and data from modelling studies, developing better-performing RDTs, enhancing monitoring and evaluation processes of in-country surveillance systems, and encouraging countries to report cholera cases by "rewarding" better reporting with technical support and improved access to vaccines. It is imperative that immediate steps are taken towards strengthening surveillance and reporting systems globally, especially in cholera-prone and resource-limited areas, where it will enable countries to articulate their demand for resources more accurately.

A cholera outbreak caused by drinking contaminated river water, Bulambuli District, Eastern Uganda, March 2016

BACKGROUND

A cholera outbreak started on 29 February in Bwikhonge Sub-county, Bulambuli District in Eastern Uganda. Local public health authorities implemented initial control measures. However, in late March, cases sharply increased in Bwikhonge Sub-county. We investigated the outbreak to determine its scope and mode of transmission, and to inform control measures.

METHODS

We defined a suspected case as sudden onset of watery diarrhea from 1 March 2016 onwards in a resident of Bulambuli District. A confirmed case was a suspected case with positive stool culture for V. cholerae. We conducted descriptive epidemiologic analysis of the cases to inform the hypothesis on mode of transmission. To test the hypothesis, we conducted a case-control study involving 100 suspected case-patients and 100 asymptomatic controls, individually-matched by residence village and age. We collected seven water samples for laboratory testing.

RESULTS

We identified 108 suspected cases (attack rate: 1.3%, 108/8404), including 7 confirmed cases. The case-control study revealed that 78% (78/100) of case-patients compared with 51% (51/100) of control-persons usually collected drinking water from the nearby Cheptui River (OR_MH = 7.8, 95% CI = 2.7-22); conversely, 35% (35/100) of case-patients compared with 54% (54/100) of control-persons usually collected drinking water from borehole pumps (OR_MH = 0.31, 95% CI = 0.13-0.65). The index case in Bwikhonge Sub-county had onset on 29 February but the outbreak had been on-going in the neighbouring sub-counties in the previous 3 months. V. cholera was isolated in 2 of the 7 river water samples collected from different locations.

CONCLUSIONS

We concluded that this cholera outbreak was caused by drinking contaminated water from Cheptui River. We recommended boiling and/or treating drinking water, improved sanitation, distribution of chlorine tablets to the affected villages, and as a long-term solution, construction of more borehole pumps. After implementing preventive measures, the number of cases declined and completely stopped after 6th April.

Biologic roles of the ABH and Lewis histo-blood group antigens Part I: infection and immunity

The ABH and Lewis antigens were among the first of the human red blood cell polymorphisms to be identified and, in the case of the former, play a dominant role in transfusion and transplantation. But these two therapies are largely twentieth century innovations, and the ABH and related carbohydrate antigens are not only expressed on a very wide range of human tissues, but were present in primates long before modern humans evolved. Although we have learned a great deal about the biochemistry and genetics of these structures, the biological roles that they play in human health and disease are incompletely understood. This review and its companion, to appear in a later issue of Vox Sanguinis, will focus on a few of the biologic and pathologic processes which appear to be affected by histo-blood group phenotype. The first of the two reviews will explore the interactions of two bacteria with the ABH and Lewis glycoconjugates of their human host cells, and describe the possible connections between the immune response of the human host to infection and the development of the AB-isoagglutinins. The second review will describe the relationship between ABO phenotype and thromboembolic disease, cardio-vascular disease states, and general metabolism.

Environmental and Clinical Strains of Vibrio cholerae Non-O1, Non-O139 From Germany Possess Similar Virulence Gene Profiles

Vibrio cholerae is a natural inhabitant of aquatic ecosystems globally. Strains of the serogroups O1 and O139 cause the epidemic diarrheal disease cholera. In Northern European waters, V. cholerae bacteria belonging to other serogroups (designated non-O1, non-O139) are present, of which some strains have been associated with gastrointestinal infections or extraintestinal infections, like wound infections or otitis. For this study, environmental strains from the German coastal waters of the North Sea and the Baltic Sea were selected (100 strains) and compared to clinical strains (10 isolates) that were from patients who contracted the infections in the same geographical region. The strains were characterized by MLST and examined by PCR for the presence of virulence genes encoding the cholera toxin, the toxin-coregulated pilus (TCP), and other virulence-associated accessory factors. The latter group comprised hemolysins, RTX toxins, cholix toxin, pandemic islands, and type III secretion system (TTSS). Phenotypic assays for hemolytic activity against human and sheep erythrocytes were also performed. The results of the MLST analysis revealed a considerable heterogeneity of sequence types (in total 74 STs). The presence of virulence genes was also variable and 30 profiles were obtained by PCR. One profile was found in 38 environmental strains and six clinical strains. Whole genome sequencing (WGS) was performed on 15 environmental and 7 clinical strains that were ST locus variants in one, two, or three alleles. Comparison of WGS results revealed that a set of virulence genes found in some clinical strains is also present in most environmental strains irrespective of the ST. In few strains, more virulence factors are acquired through horizontal gene transfer (i.e., TTSS, genomic islands). A distinction between clinical and environmental strains based on virulence gene profiles is not possible for our strains. Probably, many virulence traits of V. cholerae evolved in response to biotic and abiotic pressure and serve adaptation purposes in the natural aquatic environment, but provide a prerequisite for infection of susceptible human hosts. These findings indicate the need for surveillance of Vibrio spp. in Germany, as due to global warming abundance of Vibrio will rise and infections are predicted to increase.

Cholera prevention and control in Asian countries

Cholera remains a major public health problem in many countries. Poor sanitation and inappropriate clean water supply, insufficient health literacy and community mobilization, absence of national plans and cross-border collaborations are major factors impeding optimal control of cholera in endemic countries.

In March 2017, a group of experts from 10 Asian cholera-prone countries that belong to the Initiative against Diarrheal and Enteric Diseases in Africa and Asia (IDEA), together with representatives from the World Health Organization, the US National Institutes of Health, International Vaccine Institute, Agence de médecine préventive, NGOs (Save the Children) and UNICEF, met in Hanoi (Vietnam) to share progress in terms of prevention and control interventions on water, sanitation and hygiene (WASH), surveillance and oral cholera vaccine use.

This paper reports on the country situation, gaps identified in terms of cholera prevention and control and strategic interventions to bridge these gaps.

A Game-Theoretic Model of Cholera with Optimal Personal Protection Strategies

Cholera is an acute gastro-intestinal infection that affects millions of people throughout the world each year, primarily but not exclusively in developing countries. Because of its public health ramifications, considerable mathematical attention has been paid to the disease. Here we consider one neglected aspect of combating cholera: personal participation in anti-cholera interventions. We construct a game-theoretic model of cholera in which individuals choose whether to participate in either vaccination or clean water consumption programs under assumed costs. We find that relying upon individual compliance significantly lowers the incidence of the disease as long as the cost of intervention is sufficiently low, but does not eliminate it. The relative costs of the measures determined whether a population preferentially adopts a single preventative measure or employs the measure with the strongest early adoption.

Synthesis of novel benzenesulfamide derivatives with inhibitory activity against human cytosolic carbonic anhydrase I and II and Vibrio cholerae α- and β-class enzymes

The synthesis of a new series of sulfamides incorporating ortho-, meta, and para-benzenesulfamide moieties is reported, which were investigated for the inhibition of two human (h) isoforms of the zinc enzyme carbonic anhydrase (CA, EC 4.2.1.1), hCA I and II, and two Vibrio cholerae enzymes, belonging to the α- and β-CA classes (VchCAα, VchCAβ). The compounds were prepared by using the “tail approach”, aiming to overcome the scarcity of selective inhibition profiles associated to CA inhibitors belonging to the zinc binders. The built structure–activity relationship showed that the incorporation of benzhydryl piperazine tails on a phenyl sulfamide scaffold determines rather good efficacies against hCA I and VchCAα, with several compounds showing K_Is < 100 nM. The activity was lower against hCA II and VchCAβ, probably due to the fact that the incorporated tails are quite bulky. The obtained evidences allow us to continue the investigations of different tails/zinc binding groups, with the purpose to increase the effectiveness/selectivity of such inhibitors against bacterial CAs from pathogens, affording thus potential new anti-infectives.

Vibrio spp. infections

Vibrio is a genus of ubiquitous bacteria found in a wide variety of aquatic and marine habitats; of the >100 described Vibrio spp., ~12 cause infections in humans. Vibrio cholerae can cause cholera, a severe diarrhoeal disease that can be quickly fatal if untreated and is typically transmitted via contaminated water and person-to-person contact. Non-cholera Vibrio spp. (for example, Vibrio parahaemolyticus, Vibrio alginolyticus and Vibrio vulnificus) cause vibriosis - infections normally acquired through exposure to sea water or through consumption of raw or undercooked contaminated seafood. Non-cholera bacteria can lead to several clinical manifestations, most commonly mild, self-limiting gastroenteritis, with the exception of V. vulnificus, an opportunistic pathogen with a high mortality that causes wound infections that can rapidly lead to septicaemia. Treatment for Vibrio spp. infection largely depends on the causative pathogen: for example, rehydration therapy for V. cholerae infection and debridement of infected tissues for V. vulnificus-associated wound infections, with antibiotic therapy for severe cholera and systemic infections. Although cholera is preventable and effective oral cholera vaccines are available, outbreaks can be triggered by natural or man-made events that contaminate drinking water or compromise access to safe water and sanitation. The incidence of vibriosis is rising, perhaps owing in part to the spread of Vibrio spp. favoured by climate change and rising sea water temperature.

Molecular characterization of Vibrio cholerae responsible for cholera epidemics in Uganda by PCR, MLVA and WGS

Background

For almost 50 years sub-Saharan Africa, including Uganda, has experienced several outbreaks due to Vibrio cholerae. Our aim was to determine the genetic relatedness and spread of strains responsible for cholera outbreaks in Uganda.

Methodology/Principal findings

Sixty-three V. cholerae isolates collected from outbreaks in Uganda between 2014 and 2016 were tested using multiplex polymerase chain reaction (PCR), multi-locus variable number of tandem repeat analysis (MLVA) and whole genome sequencing (WGS). Three closely related MLVA clonal complexes (CC) were identified: CC1, 32% (20/63); CC2, 40% (25/63) and CC3, 28% (18/63). Each CC contained isolates from a different WGS clade. These clades were contained in the third wave of the 7^th cholera pandemic strain, two clades were contained in the transmission event (T)10 lineage and other in T13. Analysing the dates and genetic relatedness revealed that V. cholerae genetic lineages spread between districts within Uganda and across national borders.

Conclusion

The V. cholerae strains showed local and regional transmission within Uganda and the East African region. To prevent, control and eliminate cholera, these countries should implement strong cross-border collaboration and regional coordination of preventive activities.

Cholera, an acute diarrheal disease, essentially was eliminated in the western world many decades ago, but has continued to cause many deaths in sub-Saharan Africa, South America and Asia. Cholera diagnosis in most countries in sub-Saharan Africa, including Uganda, is by stool culture, serology and biochemical methods. These testing methods are unable to establish the relatedness, virulence and spread of Vibrio cholerae in region. To determine the spread, relatedness and virulence of V. cholerae responsible for the various cholera outbreaks in Uganda, we used DNA-based testing methods. We tested 63 V. cholerae isolates from samples collected in Uganda from 2014–2016. Our results showed three distinct lineages of genetically related cholera-causing bacteria. These organisms showed internal spread in Uganda and cross-border spread to neighboring countries in East Africa. These findings provide a valuable baseline and help define the context for directing control measures and technologies for cholera prevention in East Africa.

Evaluation of cholera surveillance system in Osu Klottey District, Accra, Ghana (2011-2013)

Introduction

Cholera is an acute illness characterized by profuse watery diarrhea. It is caused by vibrio cholera subgroup 01 and 0139. Rapid administration of fluid replacement therapy and supportive treatment can reduce mortality to around 1%. By the close of 2011, 10,628 cases and 100 deaths were reported in Ghana with a case fatality rate of 0.99. It is important to evaluate the cholera surveillance system in Ghana to determine if it is meeting its objective.

Methods

The study was conducted in Osu Klottey district in the Accra Metropolitan area in January 2014. We assessed the operations (attributes and performance) of the surveillance system for cholera using CDC guidelines (2001). Surveillance data records at the district level from 2011-2013 were extracted and analyzed for frequency using Microsoft excel. Stakeholders and key informants were interviewed using structured questionnaire. Records were also reviewed at some health facilities and at district levels.

Results

In 2011 and 2012, case fatality rates (1.3% and 0.65%) respectively. Males were mostly affected. The most affected age group was 20-29. In 2011, Predictive value positive was 69.2% and 50% in 2012.Cholera peaked in March 2011 and April 2012. The Government of Ghana funded the system. The system is sensitive, simple, stable, flexible, acceptable and representative. It was also useful and data quality was relatively good. Predictive Value Positive was also good.

Conclusion

The surveillance system is achieving its set out objectives. The system is sensitive, simple, stable, flexible, and acceptable. Predictive value positive was good.

Effects of a behavior change campaign on household drinking water disinfection in the Lake Chad basin using the RANAS approach

Worldwide, an estimated 700 million people rely on unimproved drinking water sources; even more consume water that is not safe to drink. Inadequate drinking water quality constitutes a major risk factor for cholera and other diarrheal diseases around the globe, especially for young children in developing countries. Household water treatment and safe storage systems represent an intermediate solution for settings that lack infrastructure supplying safe drinking water. However, the correct and consistent usage of such treatment technologies rely almost exclusively on the consumer's behavior. This study targeted at evaluating effects of a behavior change campaign promoting the uptake of household drinking water chlorination in communities along the Chari and Logone rivers in Chad. The campaign was based on formative research using health psychological theory and targeted several behavioral factors identified as relevant. A total of 220 primary caregivers were interviewed concerning their household water treatment practices and mindset related to water treatment six months after the campaign. The Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) model was used to structure the interviews as the RANAS approach had been used for designing the campaign. Results show significantly higher self-reported drinking water chlorination among participants of the intervention. Significant differences from a control group were identified regarding several behavioral factors. Mediation analysis revealed that the intervention positively affected participants' individual risk estimation for diarrheal disease, health knowledge, perceived efforts and benefits of water treatment, social support strategies, knowledge of how to perform chlorination, and perceived ability to do so. The campaign's effect on water treatment was mainly mediated through differences in health knowledge, changes in norms, and self-efficacy convictions. The findings imply that water treatment behavior can be successfully promoted using health psychological theory. However, they also indicate opportunities for improvement in the campaign design and implementation.

Spatiotemporal Variation in Environmental Vibrio cholerae in an Estuary in Southern Coastal Ecuador

Cholera emergence is strongly linked to local environmental and ecological context. The 1991-2004 pandemic emerged in Perú and spread north into Ecuador's El Oro province, making this a key site for potential re-emergence. Machala, El Oro, is a port city of 250,000 inhabitants, near the Peruvian border. Many livelihoods depend on the estuarine system, from fishing for subsistence and trade, to domestic water use. In 2014, we conducted biweekly sampling for 10 months in five estuarine locations, across a gradient of human use, and ranging from inland to ocean. We measured water-specific environmental variables implicated in cholera growth and persistence: pH, temperature, salinity, and algal concentration, and evaluated samples in five months for pathogenic and non-pathogenic Vibrio cholerae, by polymerase chain reaction (PCR). We found environmental persistence of pandemic strains O1 and O139, but no evidence for toxigenic strains. Vibrio cholerae presence was coupled to algal and salinity concentration, and sites exhibited considerable seasonal and spatial heterogeneity. This study indicates that environmental conditions in Machala are optimal for cholera re-emergence, with risk peaking during September, and higher risk near urban periphery low-income communities. This highlights a need for surveillance of this coupled cholera-estuarine system to anticipate potential future cholera outbreaks.

Natural Disasters and Cholera Outbreaks: Current Understanding and Future Outlook

PURPOSE OF REVIEW

Diarrheal diseases remain a serious global public health threat, especially for those populations lacking access to safe water and sanitation infrastructure. Although association of several diarrheal diseases, e.g., cholera, shigellosis, etc., with climatic processes has been documented, the global human population remains at heightened risk of outbreak of diseases after natural disasters, such as earthquakes, floods, or droughts. In this review, cholera was selected as a signature diarrheal disease and the role of natural disasters in triggering and transmitting cholera was analyzed.

RECENT FINDINGS

Key observations include identification of an inherent feedback loop that includes societal structure, prevailing climatic processes, and spatio-temporal seasonal variability of natural disasters. Data obtained from satellite-based remote sensing are concluded to have application, although limited, in predicting risks of a cholera outbreak(s). We argue that with the advent of new high spectral and spatial resolution data, earth observation systems should be seamlessly integrated in a decision support mechanism to be mobilize resources when a region suffers a natural disaster. A framework is proposed that can be used to assess the impact of natural disasters with response to outbreak of cholera, providing assessment of short- and long-term influence of climatic processes on disease outbreaks.

Cholera outbreak caused by drinking lake water contaminated with human faeces in Kaiso Village, Hoima District, Western Uganda, October 2015

Background

On 12 October 2015, a cholera outbreak involving 65 cases and two deaths was reported in a fishing village in Hoima District, Western Uganda. Despite initial response by the local health department, the outbreak persisted. We conducted an investigation to identify the source and mode of transmission, and recommend evidence-led interventions to control and prevent cholera outbreaks in this area.

Methods

We defined a suspected case as the onset of acute watery diarrhoea from 1 October to 2 November 2015 in a resident of Kaiso Village. A confirmed case was a suspected case who had Vibrio cholerae isolated from stool. We found cases by record review and active community case finding. We performed descriptive epidemiologic analysis for hypothesis generation. In an unmatched case-control study, we compared exposure histories of 61 cases and 126 controls randomly selected among asymptomatic village residents. We also conducted an environmental assessment and obtained meteorological data from a weather station.

Results

We identified 122 suspected cases, of which six were culture-confirmed, 47 were confirmed positive with a rapid diagnostic test and two died. The two deceased cases had onset of the disease on 2 October and 10 October, respectively. Heavy rainfall occurred on 7–11 October; a point-source outbreak occurred on 12–15 October, followed by continuous community transmission for two weeks. Village residents usually collected drinking water from three lakeshore points – A, B and C: 9.8% (6/61) of case-persons and 31% (39/126) of control-persons were found to usually use point A, 21% (13/61) of case-persons and 37% (46/126) of control-persons were found to usually use point B (OR = 1.8, 95% CI: 0.64–5.3), and 69% (42/61) of case-persons and 33% (41/126) of control-persons were found to usually use point C (OR = 6.7; 95% CI: 2.5–17) for water collection. All case-persons (61/61) and 93% (117/126) of control-persons reportedly never treated/boiled drinking water (OR = ∞, 95% CI_Fisher: 1.0 – ∞). The village’s piped water system had been vandalised and open defecation was common due to a lack of latrines. The lake water was found to be contiminated due to a gully channel that washed the faeces into the lake at point C.

Conclusions

This outbreak was likely caused by drinking lake water contaminated by faeces from a gully channel. We recommend treatment of drinking water, fixing the vandalised piped-water system and constructing latrines.

Electronic supplementary material

The online version of this article (10.1186/s40249-017-0359-2) contains supplementary material, which is available to authorized users.

Cholera toxin B subunit induces local curvature on lipid bilayers

The B subunit of the bacterial cholera toxin (CTxB) is responsible for the toxin binding to the cell membrane and its intracellular trafficking. CTxB binds to the monosialotetrahexosyl ganglioside at the plasma membrane of the target cell and mediates toxin internalization by endocytosis. CTxB induces a local membrane curvature that is essential for its clathrin-independent uptake. Using all-atom molecular dynamics, we show that CTxB induces local curvature, with the radius of curvature around 36 nm. The main feature of the CTxB molecular structure that causes membrane bending is the protruding alpha helices in the middle of the protein. Our study points to a generic protein design principle for generating local membrane curvature through specific binding to their lipid anchors.

Risk Factors for Household Transmission of Vibrio cholerae in Dhaka, Bangladesh (CHoBI7 Trial)

AbstractHousehold contacts of cholera patients are at a 100 times higher risk of a Vibrio cholerae infection than the general population. To examine risk factors for V. cholerae infections and investigate intervention strategies among this population, we followed household contacts of cholera patients for the 1-week high-risk period after the index patient obtained care. This study was nested within a randomized controlled trial of the Cholera-Hospital-Based-Intervention-for-7-days (CHoBI7), a handwashing with soap and water treatment intervention in Dhaka, Bangladesh. Rectal swab results were available from 320 household contacts of cholera patients at five time points over a 1-week period. Fecal and water samples were analyzed for V. cholerae by bacterial culture. All analyses were stratified by study arm. Within the intervention arm, stored household drinking water with a median free chlorine concentration below 0.5 mg/L was associated with a three times higher odds of a cholera infection (odds ratio [OR]: 3.0; 95% confidence interval [CI]: 1.32, 6.63). In the control arm, having V. cholerae in stored water was associated with a significantly higher odds of a symptomatic cholera infection (OR: 8.66; 95% CI: 2.11, 35.48). No association was found between observed handwashing with soap at food and stool-related events and V. cholerae infections. Stored household drinking water with detectable V. cholerae and chlorine concentrations below the World Health Organization guideline were found to be important risk factors for cholera infection among household contacts of cholera patients. These findings emphasize the need for water treatment interventions targeting this high risk population.

A cocktail of three virulent bacteriophages prevents Vibrio cholerae infection in animal models

Effective prevention strategies will be essential in reducing disease burden due to bacterial infections. Here we harness the specificity and rapid-acting properties of bacteriophages as a potential prophylaxis therapy for cholera, a severely dehydrating disease caused by Vibrio cholerae. To this end, we test a cocktail of three virulent phages in two animal models of cholera pathogenesis (infant mouse and rabbit models). Oral administration of the phages up to 24 h before V. cholerae challenge reduces colonization of the intestinal tract and prevents cholera-like diarrhea. None of the surviving V. cholerae colonies are resistant to all three phages. Genome sequencing and variant analysis of the surviving colonies indicate that resistance to the phages is largely conferred by mutations in genes required for the production of the phage receptors. For acute infections, such as cholera, phage prophylaxis could provide a strategy to limit the impact of bacterial disease on human health.

Oral Cholera Vaccination Delivery Cost in Low- and Middle-Income Countries: An Analysis Based on Systematic Review

BACKGROUND

Use of the oral cholera vaccine (OCV) is a vital short-term strategy to control cholera in endemic areas with poor water and sanitation infrastructure. Identifying, estimating, and categorizing the delivery costs of OCV campaigns are useful in analyzing cost-effectiveness, understanding vaccine affordability, and in planning and decision making by program managers and policy makers.

OBJECTIVES

To review and re-estimate oral cholera vaccination program costs and propose a new standardized categorization that can help in collation, analysis, and comparison of delivery costs across countries.

DATA SOURCES

Peer reviewed publications listed in PubMed database, Google Scholar and World Health Organization (WHO) websites and unpublished data from organizations involved in oral cholera vaccination.

STUDY ELIGIBILITY CRITERIA

The publications and reports containing oral cholera vaccination delivery costs, conducted in low- and middle-income countries based on World Bank Classification. Limits are humans and publication date before December 31st, 2014.

PARTICIPANTS

No participants are involved, only costs are collected.

INTERVENTION

Oral cholera vaccination and cost estimation.

STUDY APPRAISAL AND SYNTHESIS METHOD

A systematic review was conducted using pre-defined inclusion and exclusion criteria. Cost items were categorized into four main cost groups: vaccination program preparation, vaccine administration, adverse events following immunization and vaccine procurement; the first three groups constituting the vaccine delivery costs. The costs were re-estimated in 2014 US dollars (US$) and in international dollar (I$).

RESULTS

Ten studies were identified and included in the analysis. The vaccine delivery costs ranged from US$0.36 to US$ 6.32 (in US$2014) which was equivalent to I$ 0.99 to I$ 16.81 (in I$2014). The vaccine procurement costs ranged from US$ 0.29 to US$ 29.70 (in US$2014), which was equivalent to I$ 0.72 to I$ 78.96 (in I$2014). The delivery costs in routine immunization systems were lowest from US$ 0.36 (in US$2014) equivalent to I$ 0.99 (in I$2014).

LIMITATIONS

The reported cost categories are not standardized at collection point and may lead to misclassification. Costs for some OCV campaigns are not available and analysis does not include direct and indirect costs to vaccine recipients.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Vaccine delivery cost estimation is needed for budgeting and economic analysis of vaccination programs. The cost categorization methodology presented in this study is helpful in collecting OCV delivery costs in a standardized manner, comparing delivery costs, planning vaccination campaigns and informing decision-making.

Phenotypic and antibiogram pattern of V. cholerae isolates from a tertiary care hospital in Mumbai during 2004-2013: a retrospective cross-sectional study

OBJECTIVES

Cholera is a major gastroenteric disease with reports on fluctuation and resistance. Hence, the objective is to determine the trend in seasonality, resistance pattern, prevalent biotypes, serotypes and phage types between 2004 and 2013 among Vibrio cholerae isolates.

DESIGN

A retrospective cross-sectional study.

SETTINGS

A single-centre study was carried out at a tertiary care hospital in a metropolitan city (Mumbai) of a developing country (India).

METHODS

Records of stool specimen cultures of patients with suspected cholera from January 2004 to December 2013 were analysed. The organisms were identified as per standard protocol. Antimicrobial susceptibility testing was performed as per Clinical Laboratory Standard Institute. Biotyping, serotyping and phage typing were carried out. From the confirmed cases of cholera, demographic and laboratory details were noted. Descriptive analysis was used and the data were presented in the form of percentages.

RESULTS

Vibrio cholerae was predominant in males and was isolated from 9.41% (439/4664) of stool specimens. Variability was found in terms of the gross appearance of stool specimens, seasonal trend and antibiotic resistance pattern. The antimicrobial susceptibility showed a waxing and waning pattern for most of the antibiotics (ampicillin, cefuroxime, chloramphenicol, tetracycline) tested, while for a few others the strains were either uniformly sensitive (gentamicin, norfloxacin) or resistant (trimethoprim-sulfamethoxazole, nalidixic acid). All isolates belonged to subgroup O1 and biotype El Tor. The most common serotype was Ogawa. The predominant phage type was T2 (old scheme) and T27 (new scheme).

CONCLUSIONS

The predominant biotype, serotype and phage type were El Tor, Ogawa and T27 phage, respectively. The changing trends in antimicrobial resistance pattern over the years necessitate continued epidemiological and microbiological surveillance of the disease.

Rapid dipstick detection of Vibrio cholerae in household stored and municipal water in Dhaka, Bangladesh: CHoBI7 trial

OBJECTIVE

In urban Dhaka, Bangladesh, 30% of source water samples collected from the households of patients with cholera had detectable Vibrio cholerae. These findings indicate an urgent need for a public health intervention for this population. The Crystal VC^® dipstick test is a rapid method for detecting V. cholerae in stool and water. However, to date no study has investigated the use of the rapid dipstick test for household surveillance of stored drinking water.

METHODS

The efficacy of the Crystal VC^® dipstick test for detecting V. cholerae in the Dhaka city municipal water supply and stored household drinking water sources after enrichment for 18 h in alkaline peptone water (APW) was compared to bacterial culture as the gold standard.

RESULTS

A total of 1648 water samples (824 stored household drinking water samples and 824 municipal water supply samples) were collected from households of patients with cholera. The overall specificity and sensitivity of the dipstick test compared to bacterial culture was 99.6% (95% confidence interval (CI): 99.2%, 99.9%) and 65.6% (95% CI: 55.2%, 75%), respectively. The specificities for stored household drinking water and Dhaka city municipal supply water compared to bacterial culture were 99.8% (95% CI: 99.1%, 100%) and 99.5% (95% CI: 98.6%, 99.9%), respectively (P = 0.138), and the sensitivities were 66.7% (95% CI: 43.0%, 85.4%) and 65.3% (95% CI: 53.5%, 76.0%), respectively (P = 0.891).

CONCLUSION

The Crystal VC^® dipstick is a promising screening tool for cholera outbreak surveillance in resource-limited settings where elimination of false-positive results is critical. The lower than expected sensitivity should be further investigated in future studies.