Reduction of cholera in Bangladeshi villages by simple filtration

Mechanisms of cholera transmission via environment in India and Bangladesh: state of the science review

OBJECTIVES

Cholera has a long history in India and Bangladesh, the region where six out of the past seven global pandemics have been seeded. The changing climate and growing population have led to global cholera cases remaining high despite a consistent improvement in the access to clean water and sanitation. We aim to provide a holistic overview of variables influencing environmental cholera transmission within the context of India and Bangladesh, with a focus on the mechanisms by which they act.

CONTENT

We identified 56 relevant texts (Bangladesh n = 40, India n = 7, Other n = 5). The results of the review found that cholera transmission is associated with several socio-economic and environmental factors, each associated variable is suggested to have at least one mediating mechanism. Increases in ambient temperature and coastal sea surface temperature support cholera transmission via increases in plankton and a preference of Vibrio cholerae for warmer waters. Increased rainfall can potentially support or reduce transmission via several mechanisms.

SUMMARY AND OUTLOOK

Common issues in the literature are co-variance of seasonal factors, limited access to high quality cholera data, high research bias towards research in Dhaka and Matlab (Bangladesh). A specific and detailed understanding of the relationship between SST and cholera incidence remains unclear.

Effect of a Water, Sanitation, and Hygiene Program on Handwashing with a Cleansing Agent among Diarrhea Patients and Attendants in Healthcare Facilities in the Democratic Republic of the Congo: A Randomized Pilot of the PICHA7 Program

Healthcare-acquired infections are a major problem in healthcare facility settings around the world. The Democratic Republic of the Congo (DRC) has over 2 million diarrhea patients hospitalized each year. These healthcare settings become high-risk environments for spreading diarrheal illnesses such as cholera. The objective of the Preventative Intervention for Cholera for 7 Days (PICHA7) program is to develop evidence-based water, sanitation, and hygiene (WASH) interventions to reduce cholera and other severe diarrheal diseases in the DRC. The study objective was to evaluate the effectiveness of PICHA7 program delivery in increasing handwashing with a cleansing agent at stool/vomit- and food-related events in a healthcare facility setting among diarrhea patients and patient attendants. A pilot of the PICHA7 program was conducted among 284 participants in 27 healthcare facilities from March 2020 to November 2021 in urban Bukavu in the South Kivu Province of the DRC. The standard arm received the standard message provided in the DRC to diarrhea patients on the use of oral rehydration solution and a basic WASH message at healthcare facility discharge. The PICHA7 arm received the PICHA7 WASH pictorial module delivered by a health promoter focused on handwashing with a cleansing agent at the bedside of the diarrhea patient in the healthcare facility and provision of a soapy water bottle (water and detergent powder). Within 24 h of intervention delivery, a three-hour structured observation of handwashing practices at stool/vomit- and food-related events (key events) was conducted in healthcare facilities of diarrhea patients and their attendants. Compared to the standard arm, there was significantly more handwashing with a cleansing agent at key events in the PICHA7 arm (40% vs. 15%) (odds ratio: 5.04; (95% confidence interval (CI): 2.01, 12.7)). These findings demonstrate that delivery of the PICHA7 WASH pictorial module and provision of a soapy water bottle to diarrhea patients and their attendants presents a promising approach to increase handwashing with a cleansing agent among this high-risk population in healthcare facilities in the eastern DRC.

Outer membrane vesicles and the outer membrane protein OmpU govern Vibrio cholerae biofilm matrix assembly

Biofilms are matrix-encased microbial communities that increase the environmental fitness and infectivity of many human pathogens including Vibrio cholerae. Biofilm matrix assembly is essential for biofilm formation and function. Known components of the V. cholerae biofilm matrix are the polysaccharide Vibrio polysaccharide (VPS), matrix proteins RbmA, RbmC, Bap1, and extracellular DNA, but the majority of the protein composition is uncharacterized. This study comprehensively analyzed the biofilm matrix proteome and revealed the presence of outer membrane proteins (OMPs). Outer membrane vesicles (OMVs) were also present in the V. cholerae biofilm matrix and were associated with OMPs and many biofilm matrix proteins suggesting that they participate in biofilm matrix assembly. Consistent with this, OMVs had the capability to alter biofilm structural properties depending on their composition. OmpU was the most prevalent OMP in the matrix, and its absence altered biofilm architecture by increasing VPS production. Single-cell force spectroscopy revealed that proteins critical for biofilm formation, OmpU, the matrix proteins RbmA, RbmC, Bap1, and VPS contribute to cell-surface adhesion forces at differing efficiency, with VPS showing the highest efficiency whereas Bap1 showing the lowest efficiency. Our findings provide new insights into the molecular mechanisms underlying biofilm matrix assembly in V. cholerae, which may provide new opportunities to develop inhibitors that specifically alter biofilm matrix properties and, thus, affect either the environmental survival or pathogenesis of V. cholerae.IMPORTANCECholera remains a major public health concern. Vibrio cholerae, the causative agent of cholera, forms biofilms, which are critical for its transmission, infectivity, and environmental persistence. While we know that the V. cholerae biofilm matrix contains exopolysaccharide, matrix proteins, and extracellular DNA, we do not have a comprehensive understanding of the majority of biofilm matrix components. Here, we discover outer membrane vesicles (OMVs) within the biofilm matrix of V. cholerae. Proteomic analysis of the matrix and matrix-associated OMVs showed that OMVs carry key matrix proteins and Vibrio polysaccharide (VPS) to help build biofilms. We also characterize the role of the highly abundant outer membrane protein OmpU in biofilm formation and show that it impacts biofilm architecture in a VPS-dependent manner. Understanding V. cholerae biofilm formation is important for developing a better prevention and treatment strategy framework.

Anticipatory decision-making for cholera in Malawi

Climate change raises an old disease to a new level of public health threat. The causative agent, Vibrio cholerae, native to aquatic ecosystems, is influenced by climate and weather processes. The risk of cholera is elevated in vulnerable populations lacking access to safe water and sanitation infrastructure. Predictive intelligence, employing mathematical algorithms that integrate earth observations and heuristics derived from microbiological, sociological, and weather data, can provide anticipatory decision-making capabilities to reduce the burden of cholera and save human lives. An example offered here is the recent outbreak of cholera in Malawi, predicted in advance by such algorithms.

VP3 Phage Combined with High Salt Promotes the Lysis of Biofilm-Associated Vibrio cholerae

Cholera, caused by pathogenic Vibrio cholerae, poses a significant public health risk through water and food transmission. Biofilm-associated V. cholerae plays a crucial role in seasonal cholera outbreaks as both a reservoir in aquatic environments and a direct source of human infection. Although VP3, a lytic phage, shows promise in eliminating planktonic V. cholerae from the aquatic environment, its effectiveness against biofilm-associated V. cholerae is limited. To address this limitation, our proposed approach aims to enhance the efficacy of VP3 in eliminating biofilm-associated V. cholerae by augmenting the availability of phage receptors on the surface of Vibrio cholerae. TolC is a receptor of VP3 and a salt efflux pump present in many bacteria. In this study, we employed NaCl as an enhancer to stimulate TolC expression and observed a significant enhancement of TolC expression in both planktonic and biofilm cells of V. cholerae. This enhancement led to improved adsorption of VP3. Importantly, our findings provide strong evidence that high salt concentrations combined with VP3 significantly improve the elimination of biofilm-associated V. cholerae. This approach offers a potential strategy to eliminate biofilm-formation bacteria by enhancing phage-host interaction.

Coral Disease and Ingestion: Investigating the Role of Heterotrophy in the Transmission of Pathogenic Vibrio spp. using a Sea Anemone (Exaiptasia pallida) Model System

Understanding disease transmission in corals can be complicated given the intricacy of the holobiont and difficulties associated with ex situ coral cultivation. As a result, most of the established transmission pathways for coral disease are associated with perturbance (i.e., damage) rather than evasion of immune defenses. Here, we investigate ingestion as a potential pathway for the transmission of coral pathogens that evades the mucus membrane. Using sea anemones (Exaiptasia pallida) and brine shrimp (Artemia sp.) to model coral feeding, we tracked the acquisition of the putative pathogens, Vibrio alginolyticus, V. harveyi, and V. mediterranei using GFP-tagged strains. Vibrio sp. were provided to anemones using 3 experimental exposures (i) direct water exposure alone, (ii) water exposure in the presence of a food source (non-spiked Artemia), and (iii) through a "spiked" food source (Vibrio-colonized Artemia) created by exposing Artemia cultures to GFP-Vibrio via the ambient water overnight. Following a 3 h feeding/exposure duration, the level of acquired GFP-Vibrio was quantified from anemone tissue homogenate. Ingestion of spiked Artemia resulted in a significantly greater burden of GFP-Vibrio equating to an 830-fold, 3,108-fold, and 435-fold increase in CFU mL^-1 when compared to water exposed trials and a 207-fold, 62-fold, and 27-fold increase in CFU mL^-1 compared to water exposed with food trials for V. alginolyticus, V. harveyi, and V. mediterranei, respectively. These data suggest that ingestion can facilitate delivery of an elevated dose of pathogenic bacteria in cnidarians and may describe an important portal of entry for pathogens in the absence of perturbing conditions. IMPORTANCE The front line of pathogen defense in corals is the mucus membrane. This membrane coats the surface body wall creating a semi-impermeable layer that inhibits pathogen entry from the ambient water both physically and biologically through mutualistic antagonism from resident mucus microbes. To date, much of the coral disease transmission research has been focused on mechanisms associated with perturbance of this membrane such as direct contact, vector lesions (predation/biting), and waterborne exposure through preexisting lesions. The present research describes a potential transmission pathway that evades the defenses provided by this membrane allowing unencumbered entry of bacteria as in association with food. This pathway may explain an important portal of entry for emergence of idiopathic infections in otherwise healthy corals and can be used to improve management practices for coral conservation.

Environmental Reservoirs of Pathogenic Vibrio spp. and Their Role in Disease: The List Keeps Expanding

Vibrio species are natural inhabitants of aquatic environments and have complex interactions with the environment that drive the evolution of traits contributing to their survival. These traits may also contribute to their ability to invade or colonize animal and human hosts. In this review, we attempt to summarize the relationships of Vibrio spp. with other organisms in the aquatic environment and discuss how these interactions could potentially impact colonization of animal and human hosts.

Combating cholera by building predictive capabilities for pathogenic Vibrio cholerae in Yemen

Cholera remains a global public health threat in regions where social vulnerabilities intersect with climate and weather processes that impact infectious Vibrio cholerae. While access to safe drinking water and sanitation facilities limit cholera outbreaks, sheer cost of building such infrastructure limits the ability to safeguard the population. Here, using Yemen as an example where cholera outbreak was reported in 2016, we show how predictive abilities for forecasting risk, employing sociodemographical, microbiological, and climate information of cholera, can aid in combating disease outbreak. An epidemiological analysis using Bradford Hill Criteria was employed in near-real-time to understand a predictive model's outputs and cholera cases in Yemen. We note that the model predicted cholera risk at least four weeks in advance for all governorates of Yemen with overall 72% accuracy (varies with the year). We argue the development of anticipatory decision-making frameworks for climate modulated diseases to design intervention activities and limit exposure of pathogens preemptively.

Outbreak of diarrheal diseases causes mortality in different geographical locations of Bangladesh during the 2021 COVID-19 era

Objectives

Diarrhea is a major public health problem in low- and middle-income countries, including Bangladesh. Of the different spectrums of diarrheal diseases, cholera occurs every year, causing outbreaks and epidemics following a biannual seasonal pattern. Due to the COVID-19 pandemic, hospitalization for diarrheal diseases decreased in 2020 compared to the previous years. However, in 2021, massive outbreaks occurred in different geographical locations of the country. We described that an outbreak of diarrheal diseases causes mortality in different geographical locations in Bangladesh.

Method

In this study, we present a report of diarrhea outbreaks that were reported in 2018-2021 in different parts of Bangladesh, and data have been captured from different sources such as print and electronic media as well as from a nationwide surveillance system.

Results

Among these locations, districts of Barisal Division, Kishorganj, Noakhali, Gopalganj, Bandarban, and Chattogram were the major hotspots of the outbreaks where high morbidity due to acute watery diarrhea and even mortality, which is usually low in Bangladesh, were recorded.

Conclusion

Early detection and prevention and strengthening of the surveillance system are needed to combat the diarrheal upsurge, take immediate control, and adopt preventive strategies.

New Insights into Vibrio cholerae Biofilms from Molecular Biophysics to Microbial Ecology

With the discovery that 48% of cholera infections in rural Bangladesh villages could be prevented by simple filtration of unpurified waters and the detection of Vibrio cholerae aggregates in stools from cholera patients it was realized V. cholerae biofilms had a central function in cholera pathogenesis. We are currently in the seventh cholera pandemic, caused by O1 serotypes of the El Tor biotypes strains, which initiated in 1961. It is estimated that V. cholerae annually causes millions of infections and over 100,000 deaths. Given the continued emergence of cholera in areas that lack access to clean water, such as Haiti after the 2010 earthquake or the ongoing Yemen civil war, increasing our understanding of cholera disease remains a worldwide public health priority. The surveillance and treatment of cholera is also affected as the world is impacted by the COVID-19 pandemic, raising significant concerns in Africa. In addition to the importance of biofilm formation in its life cycle, V. cholerae has become a key model system for understanding bacterial signal transduction networks that regulate biofilm formation and discovering fundamental principles about bacterial surface attachment and biofilm maturation. This chapter will highlight recent insights into V. cholerae biofilms including their structure, ecological role in environmental survival and infection, regulatory systems that control them, and biomechanical insights into the nature of V. cholerae biofilms.

PAS Domain-Containing Chemoreceptors Influence the Signal Sensing and Intestinal Colonization of Vibrio cholerae

Bacterial chemotaxis is the phenomenon in which bacteria migrate toward a more favorable niche in response to chemical cues in the environment. The methyl-accepting chemotaxis proteins (MCPs) are the principal sensory receptors of the bacterial chemotaxis system. Aerotaxis is a special form of chemotaxis in which oxygen serves as the signaling molecule; the process is dependent on the aerotaxis receptors (Aer) containing the Per-Arnt-Sim (PAS) domain. Over 40 MCPs are annotated on the genome of Vibrio cholerae; however, little is known about their functions. We investigated six MCPs containing the PAS domain in V. cholerae El Tor C6706, namely aer2, aer3, aer4, aer5, aer6, and aer7. Deletion analyses of each aer homolog gene indicated that these Aer receptors are involved in aerotaxis, chemotaxis, biofilm formation, and intestinal colonization. Swarming motility assay indicated that the aer2 gene was responsible for sensing the oxygen gradient independent of the other five homologs. When bile salts and mucin were used as chemoattractants, each Aer receptor influenced the chemotaxis differently. Biofilm formation was enhanced by overexpression of the aer6 and aer7 genes. Moreover, deletion of the aer2 gene resulted in better bacterial colonization of the mutant in adult mice; however, virulence gene expression was unaffected. These data suggest distinct roles for different Aer homologs in V. cholerae physiology.

Impact of Gene Repression on Biofilm Formation of Vibrio cholerae

Vibrio cholerae, the etiological agent of cholera, is a facultative intestinal pathogen which can also survive in aquatic ecosystems in the form of biofilms, surface-associated microbial aggregates embedded in an extracellular matrix, which protects them from predators and hostile environmental factors. Biofilm-derived bacteria and biofilm aggregates are considered a likely source for cholera infections, underscoring the importance of V. cholerae biofilm research not just to better understand bacterial ecology, but also cholera pathogenesis in the human host. While several studies focused on factors induced during biofilm formation, genes repressed during this persistence stage have been fairly neglected. In order to complement these previous studies, we used a single cell-based transcriptional reporter system named TetR-controlled recombination-based in-biofilm expression technology (TRIBET) and identified 192 genes to be specifically repressed by V. cholerae during biofilm formation. Predicted functions of in-biofilm repressed (ibr) genes range from metabolism, regulation, surface association, transmembrane transport as well as motility and chemotaxis. Constitutive (over)-expression of these genes affected static and dynamic biofilm formation of V. cholerae at different stages. Notably, timed expression of one candidate in mature biofilms induced their rapid dispersal. Thus, genes repressed during biofilm formation are not only dispensable for this persistence stage, but their presence can interfere with ordered biofilm development. This work thus contributes new insights into gene silencing during biofilm formation of V. cholerae.

From rivers to marine environments: A constantly evolving microbial community within the plastisphere

Plastics accumulate in the environment and the Mediterranean Sea is one of the most polluted sea in the world. The plastic surface is rapidly colonized by microorganisms, forming the plastisphere. Our unique sampling supplied 107 plastic pieces from 22 geographical sites from four aquatic ecosystems (river, estuary, harbor and inshore) in the south of France in order to better understand the parameters which influence biofilm composition. In parallel, 48 enrichment cultures were performed to investigate the presence of plastic degrading-bacteria in the plastisphere. In this context, we showed that the most important drivers of microbial community structure were the sampling site followed by the polymer chemical composition. The study of pathogenic genus distribution highlighted that only 11% of our plastic samples contained higher proportions of Vibrio compared to the natural environment. Finally, results of the enrichment cultures showed a selection of hydrocarbon-degrading microorganisms suggesting their potential role in the plastic degradation.

Sustainable groundwater treatment technologies for underserved rural communities in emerging economies

Worldwide, about one out of two people depend on groundwater resources to satisfy their drinking water needs. While groundwater typically is of higher quality than surface water, pollution and geologic conditions may require treating groundwater to meet safe water quality criteria. Herein, a critical overview is presented of water treatment technologies for rural and underserved communities in emerging economies that depend on groundwater. Given that small to medium sized rural communities in emerging economies often lack the financial resources to support technologically complex and expensive centralized public water treatment systems, the focus is on proven technologies that are sustainable and acceptable by the rural population. After an overview of the underlying treatment mechanisms and the principal groundwater contaminants targeted by the traditional, advanced, and experimental water treatment technologies, we identify the groundwater quality parameters that may impact or interfere with the technology performance. We also introduce enabling environmental factors that might govern the implementation of water treatment technologies in the target communities and a brief discussion of safe storage of water after treatment to underline the importance of protecting the water from re-contamination. Our overview is further supported by tabulated summaries of the principal (dis)advantages of each technology covered herein, including cost considerations and social acceptance. Overall, our review suggests that underserved rural communities have sustainable and affordable options for cases where the quality of local groundwater resources requires treatment.

Contrasting Epidemiology of Cholera in Bangladesh and Africa

In Bangladesh and West Bengal cholera is seasonal, transmission occurs consistently annually. By contrast, in most African countries, cholera has inconsistent seasonal patterns and long periods without obvious transmission. Transmission patterns in Africa occur during intermittent outbreaks followed by elimination of that genetic lineage. Later another outbreak may occur because of reintroduction of new or evolved lineages from adjacent areas, often by human travelers. These then subsequently undergo subsequent elimination. The frequent elimination and reintroduction has several implications when planning for cholera's elimination including: a) reconsidering concepts of definition of elimination, b) stress on rapid detection and response to outbreaks, c) more effective use of oral cholera vaccine and WASH, d) need to readjust estimates of disease burden for Africa, e) re-examination of water as a reservoir for maintaining endemicity in Africa. This paper reviews major features of cholera's epidemiology in African countries which appear different from the Ganges Delta.

Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies

Background

Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged.

Objectives

Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews.

Methods

This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis.

Results

There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation.

Conclusion

Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.

Knowledge on and preventive practices of cholera in Al-Mahweet - Yemen, 2018: a cross-sectional study

Yemen has experienced one of the world's worst cholera outbreaks in the recent history of cholera records. This study aims to identify knowledge and practices among people of Al-Mahweet governorate toward cholera infection, which can play a critical role in reducing cholera morbidity and shaping the public health response. A cross-sectional study was conducted in an area of high cholera prevalence in 2018 using structured questionnaires. Most community respondents were able to correctly identify the symptoms and risk factors of cholera. While 65% of the respondents in this study knew that proper disposal of human waste is an essential measure of cholera prevention, only 11% of the respondents knew that proper washing of fruits and vegetables lowers the risk of cholera infection. About 62.5% of households did not treat water for safe drinking. Water was scarce in about 30% of households and near-home defecation was observed in about 23%. In conclusion, this study reveals several gaps in different aspects of hygienic and preventive practices including water treatment, waste disposal, and defecation practices. Cholera response should contain comprehensive health promotion interventions to improve the public's knowledge and enhance healthy practices. Stakeholders should support communities with sustainable water and sanitation systems.

Crystal Structure of VpsR Revealed Novel Dimeric Architecture and c-di-GMP Binding Site: Mechanistic Implications in Oligomerization, ATPase Activity and DNA Binding

VpsR, the master regulator of biofilm formation in Vibrio cholerae, is an atypical NtrC1 type bEBP lacking residues essential for σ⁵⁴-RNAP binding and REC domain phosphorylation. Moreover, transcription from P_vpsL, a promoter of biofilm biosynthesis, has been documented in presence of σ⁷⁰-RNAP/VpsR/c-di-GMP complex. It was proposed that c-di-GMP and VpsR together form an active transcription complex with σ⁷⁰-RNAP. However, the impact of c-di-GMP imparted on VpsR that leads to transcription activation with σ⁷⁰-RNAP remained elusive, largely due to the lack of the structure of VpsR and knowledge about c-di-GMP:VpsR interactions. In this direction we have solved the crystal structure of VpsR^RA, containing REC and AAA⁺ domains, in apo, AMPPNP/GMPPNP and c-di-GMP bound states. Structures of VpsR^RA unveiled distinctive REC domain orientation that leads to a novel dimeric association and noncanonical ATP/GTP binding. Moreover, we have demonstrated that at physiological pH VpsR remains as monomer having no ATPase activity but c-di-GMP imparted cooperativity to convert it to dimer with potent activity. Crystal structure of c-di-GMP:VpsR^RA complex reveals that c-di-GMP binds near the C-terminal end of AAA⁺ domain. Trp quenching studies on VpsR^R, VpsR^A, VpsR^RA, VpsR^AD with c-di-GMP additionally demonstrated that c-di-GMP could potentially bind VpsR^D. We propose that c-di-GMP mediated tethering of VpsR^D with VpsR^A could likely favor generating the specific protein-DNA architecture for transcription activation.

Effectiveness of hygiene kit distribution to reduce cholera transmission in Kasaï-Oriental, Democratic Republic of Congo, 2018: a prospective cohort study

INTRODUCTION

Household contacts of cholera cases are at a greater risk of Vibrio cholerae infection than the general population. There is currently no agreed standard of care for household contacts, despite their high risk of infection, in cholera response strategies. In 2018, hygiene kit distribution and health promotion was recommended by Médecins Sans Frontières for admitted patients and accompanying household members on admission to a cholera treatment unit in the Democratic Republic of Congo.

METHODS

To investigate the effectiveness of the intervention and risk factors for cholera infection, we conducted a prospective cohort study and followed household contacts for 7 days after patient admission. Clinical surveillance among household contacts was based on self-reported symptoms of cholera and diarrhoea, and environmental surveillance through the collection and analysis of food and water samples.

RESULTS

From 94 eligible households, 469 household contacts were enrolled and 444 completed follow-up. Multivariate analysis suggested evidence of a dose-response relationship with increased kit use associated with decreased relative risk of suspected cholera: household contacts in the high kit-use group had a 66% lower incidence of suspected cholera (adjusted risk ratio (aRR) 0.34, 95% CI 0.11 to 1.03, p=0.055), the mid-use group had a 53% lower incidence (aRR 0.47, 95% CI 0.17 to 1.29, p=1.44) and low-use group had 22% lower incidence (aRR 0.78, 95% CI 0.24 to 2.53, p=0.684), compared with household contacts without a kit. Drinking water contamination was significantly reduced among households in receipt of a kit. There was no significant effect on self-reported diarrhoea or food contamination.

CONCLUSION

The integration of a hygiene kit intervention to case-households may be effective in reducing cholera transmission among household contacts and environmental contamination within the household. Further work is required to evaluate whether other proactive localised distribution among patients and case-households or to households surrounding cholera cases can be used in future cholera response programmes in emergency contexts.

Environmental parameters associated with incidence and transmission of pathogenic Vibrio spp

Vibrio spp. thrive in warm water and moderate salinity, and they are associated with aquatic invertebrates, notably crustaceans and zooplankton. At least 12 Vibrio spp. are known to cause infection in humans, and Vibrio cholerae is well documented as the etiological agent of pandemic cholera. Pathogenic non-cholera Vibrio spp., e.g., Vibrio parahaemolyticus and Vibrio vulnificus, cause gastroenteritis, septicemia, and other extra-intestinal infections. Incidence of vibriosis is rising globally, with evidence that anthropogenic factors, primarily emissions of carbon dioxide associated with atmospheric warming and more frequent and intense heatwaves, significantly influence environmental parameters, e.g., temperature, salinity, and nutrients, all of which can enhance growth of Vibrio spp. in aquatic ecosystems. It is not possible to eliminate Vibrio spp., as they are autochthonous to the aquatic environment and many play a critical role in carbon and nitrogen cycling. Risk prediction models provide an early warning that is essential for safeguarding public health. This is especially important for regions of the world vulnerable to infrastructure instability, including lack of 'water, sanitation, and hygiene' (WASH), and a less resilient infrastructure that is vulnerable to natural calamity, e.g., hurricanes, floods, and earthquakes, and/or social disruption and civil unrest, arising from war, coups, political crisis, and economic recession. Incorporating environmental, social, and behavioural parameters into such models allows improved prediction, particularly of cholera epidemics. We have reported that damage to WASH infrastructure, coupled with elevated air temperatures and followed by above average rainfall, promotes exposure of a population to contaminated water and increases the risk of an outbreak of cholera. Interestingly, global predictive risk models successful for cholera have the potential, with modification, to predict diseases caused by other clinically relevant Vibrio spp. In the research reported here, the focus was on environmental parameters associated with incidence and distribution of clinically relevant Vibrio spp. and their role in disease transmission. In addition, molecular methods designed for detection and enumeration proved useful for predictive modelling and are described, namely in the context of prediction of environmental conditions favourable to Vibrio spp., hence human health risk.

A Review of the Environmental Trigger and Transmission Components for Prediction of Cholera

Climate variables influence the occurrence, growth, and distribution of Vibrio cholerae in the aquatic environment. Together with socio-economic factors, these variables affect the incidence and intensity of cholera outbreaks. The current pandemic of cholera began in the 1960s, and millions of cholera cases are reported each year globally. Hence, cholera remains a significant health challenge, notably where human vulnerability intersects with changes in hydrological and environmental processes. Cholera outbreaks may be epidemic or endemic, the mode of which is governed by trigger and transmission components that control the outbreak and spread of the disease, respectively. Traditional cholera risk assessment models, namely compartmental susceptible-exposed-infected-recovered (SEIR) type models, have been used to determine the predictive spread of cholera through the fecal–oral route in human populations. However, these models often fail to capture modes of infection via indirect routes, such as pathogen movement in the environment and heterogeneities relevant to disease transmission. Conversely, other models that rely solely on variability of selected environmental factors (i.e., examine only triggers) have accomplished real-time outbreak prediction but fail to capture the transmission of cholera within impacted populations. Since the mode of cholera outbreaks can transition from epidemic to endemic, a comprehensive transmission model is needed to achieve timely and reliable prediction with respect to quantitative environmental risk. Here, we discuss progression of the trigger module associated with both epidemic and endemic cholera, in the context of the autochthonous aquatic nature of the causative agent of cholera, V. cholerae, as well as disease prediction.

Searching for the Secret of Stickiness: How Biofilms Adhere to Surfaces

Bacterial biofilms are communities of cells enclosed in an extracellular polymeric matrix in which cells adhere to each other and to foreign surfaces. The development of a biofilm is a dynamic process that involves multiple steps, including cell-surface attachment, matrix production, and population expansion. Increasing evidence indicates that biofilm adhesion is one of the main factors contributing to biofilm-associated infections in clinics and biofouling in industrial settings. This review focuses on describing biofilm adhesion strategies among different bacteria, including Vibrio cholerae, Pseudomonas aeruginosa, and Staphylococcus aureus. Techniques used to characterize biofilm adhesion are also reviewed. An understanding of biofilm adhesion strategies can guide the development of novel approaches to inhibit or manipulate biofilm adhesion and growth.

Historical and contemporary views on cholera transmission: are we repeating past discussions? Can lessons learned from cholera be applied to COVID-19?

Cholera, a devastating diarrheal disease that caused several global pandemics in the last centuries, may share some similarities with the new COVID‐19. Cholera has affected many populations in history and still remains a significant burden in developing countries. The main transmission route was thought to be predominantly through contaminated drinking water. However, revisiting the historical data collected during the Copenhagen 1853 cholera outbreak allowed us to re‐evaluate the role of drinking‐water transmission in a city‐wide outbreak and reconsider some critical transmission routes, which have been neglected since the time of John Snow. Recent empirical and cohort data from Bangladesh also strengthened the dynamic potentiality of other transmission routes (food, fomite, fish, flies) for transmitting cholera. Analyzing this particular nature of the cholera disease transmission, this paper will describe how the pattern of transmission routes are similar to COVID‐19 and how the method of revisiting old data can be used for further exploration of new and known diseases.

Biofilms by bacterial human pathogens: Clinical relevance - development, composition and regulation - therapeutical strategies

Notably, bacterial biofilm formation is increasingly recognized as a passive virulence factor facilitating many infectious disease processes. In this review we will focus on bacterial biofilms formed by human pathogens and highlight their relevance for diverse diseases. Along biofilm composition and regulation emphasis is laid on the intensively studied biofilms of Vibrio cholerae, Pseudomonas aeruginosa and Staphylococcus spp., which are commonly used as biofilm model organisms and therefore contribute to our general understanding of bacterial biofilm (patho-)physiology. Finally, therapeutical intervention strategies targeting biofilms will be discussed.

Does improved risk information increase the value of cholera prevention? An analysis of stated vaccine demand in slum areas of urban Bangladesh

As the world's longest running pandemic, cholera poses a substantial public health burden in Bangladesh, where human vulnerability intersects with climatic variability. Barriers to safe water and sanitation place the health of millions of Bangladeshis in jeopardy - especially those who have highly constrained choices in preventing and responding to cholera. In this paper we investigate demand for cholera prevention among residents in the Mirpur and Karail slum areas of urban Dhaka. Using survey data from 2023 households in two slum areas, we analyze responses from a contingent valuation questionnaire that elicited willingness to pay (WTP) for cholera vaccines across household members and under varying disease risk scenarios, finding higher valuation for cholera prevention for children and under scenarios of greater epidemic risk. We estimate the average WTP for a cholera vaccine for a child ranges from TK 134-167 (US$ 1.58-1.96). Consistently, respondents with prior knowledge of the cholera vaccine reported lower WTP valuations, providing suggestive evidence of concerns about vaccine effectiveness and preferences for cholera treatment over prevention. We supplement the contingent valuation analysis with cost of illness estimates from both our household sample as well as from administrative hospital records of over 34,000 cholera patients. We estimate that a household incurs costs of TK 801-922 (US$ 9.43-10.50) per episode of cholera that requires medical treatment. Taken together, these findings indicate higher WTP for cholera treatment compared to prevention, but increased interest in prevention under early warning system scenarios of high disease risk.

Pathogenicity and virulence regulation of Vibrio cholerae at the interface of host-gut microbiome interactions

The Gram-negative bacterium Vibrio cholerae is responsible for the severe diarrheal pandemic disease cholera, representing a major global public health concern. This pathogen transitions from aquatic reservoirs into epidemics in human populations, and has evolved numerous mechanisms to sense this transition in order to appropriately regulate its gene expression for infection. At the intersection of pathogen and host in the gastrointestinal tract lies the community of native gut microbes, the gut microbiome. It is increasingly clear that the diversity of species and biochemical activities within the gut microbiome represents a driver of infection outcome, through their ability to manipulate the signals used by V. cholerae to regulate virulence and fitness in vivo. A better mechanistic understanding of how commensal microbial action interacts with V. cholerae pathogenesis may lead to novel prophylactic and therapeutic interventions for cholera. Here, we review a subset of this burgeoning field of research.

Impact of Low-Cost Point-of-Use Water Treatment Technologies on Enteric Infections and Growth among Children in Limpopo, South Africa

Enteric infections early in life have been associated with poor linear growth among children in low-resource settings. Point-of-use water treatment technologies provide effective and low-cost solutions to reduce exposure to enteropathogens from drinking water, but it is unknown whether the use of these technologies translates to improvements in child growth. We conducted a community-based randomized controlled trial of two water treatment technologies to estimate their effects on child growth in Limpopo, South Africa. We randomized 404 households with a child younger than 3 years to receive a silver-impregnated ceramic water filter, a silver-impregnated ceramic tablet, a safe-storage water container alone, or no intervention, and these households were followed up quarterly for 2 years. We estimated the effects of the interventions on linear and ponderal growth, enteric infections assessed by quantitative molecular diagnostics, and diarrhea prevalence. The silver-impregnated ceramic water filters and tablets consistently achieved approximately 1.2 and 3 log reductions, respectively, in total coliform bacteria in drinking water samples. However, the filters and tablets were not associated with differences in height (height-for-age z-score differences compared with no intervention: 0.06, 95% CI: −0.29, 0.40, and 0.00, 95% CI: −0.35, 0.35, respectively). There were also no effects of the interventions on weight, diarrhea prevalence, or enteric infections. Despite their effectiveness in treating drinking water, the use of the silver-impregnated ceramic water filters and tablets did not reduce enteric infections or improve child growth. More transformative water, sanitation, and hygiene interventions that better prevent enteric infections are likely needed to improve long-term child growth outcomes.

Species-Specific Quorum Sensing Represses the Chitobiose Utilization Locus in Vibrio cholerae

The marine facultative pathogen Vibrio cholerae forms complex multicellular communities on the chitinous shells of crustacean zooplankton in its aquatic reservoir. V. cholerae-chitin interactions are critical for the growth, evolution, and waterborne transmission of cholera. This is due, in part, to chitin-induced changes in gene expression in this pathogen. Here, we sought to identify factors that influence chitin-induced expression of one locus, the chitobiose utilization operon (chb), which is required for the uptake and catabolism of the chitin disaccharide. Through a series of genetic screens, we identified that the master regulator of quorum sensing, HapR, is a direct repressor of the chb operon. We also found that the levels of HapR in V. cholerae are regulated by the ClpAP protease. Furthermore, we show that the canonical quorum sensing cascade in V. cholerae regulates chb expression in an HapR-dependent manner. Through this analysis, we found that signaling via the species-specific autoinducer CAI-1, but not the interspecies autoinducer AI-2, influences chb expression. This phenomenon of species-specific regulation may enhance the fitness of this pathogen in its environmental niche.IMPORTANCE In nature, bacteria live in multicellular and multispecies communities. Microbial species can sense the density and composition of their community through chemical cues using a process called quorum sensing (QS). The marine pathogen Vibrio cholerae is found in communities on the chitinous shells of crustaceans in its aquatic reservoir. V. cholerae interactions with chitin are critical for the survival, evolution, and waterborne transmission of this pathogen. Here, we show that V. cholerae uses QS to regulate the expression of one locus required for V. cholerae-chitin interactions.

VpsR Directly Activates Transcription of Multiple Biofilm Genes in Vibrio cholerae

Vibrio cholerae biofilm biogenesis, which is important for survival, dissemination, and persistence, requires multiple genes in the Vibrio polysaccharides (vps) operons I and II as well as the cluster of ribomatrix (rbm) genes. Transcriptional control of these genes is a complex process that requires several activators/repressors and the ubiquitous signaling molecule, cyclic di-GMP (c-di-GMP). Previously, we demonstrated that VpsR directly activates RNA polymerase containing σ⁷⁰ (σ⁷⁰-RNAP) at the vpsL promoter (P _vpsL ), which precedes the vps-II operon, in a c-di-GMP-dependent manner by stimulating formation of the transcriptionally active, open complex. Using in vitro transcription, electrophoretic mobility shift assays, and DNase I footprinting, we show here that VpsR also directly activates σ⁷⁰-RNAP transcription from other promoters within the biofilm formation cluster, including P _vpsU , at the beginning of the vps-I operon, P _rbmA , at the start of the rbm cluster, and P _rbmF , which lies upstream of the divergent rbmF and rbmE genes. In this capacity, we find that VpsR is able to behave both as a class II activator, which functions immediately adjacent/overlapping the core promoter sequence (P _vpsL and P _vpsU ), and as a class I activator, which functions farther upstream (P _rbmA and P _rbmF ). Because these promoters vary in VpsR-DNA binding affinity in the absence and presence of c-di-GMP, we speculate that VpsR's mechanism of activation is dependent on both the concentration of VpsR and the level of c-di-GMP to increase transcription, resulting in finely tuned regulation.IMPORTANCE Vibrio cholerae, the bacterial pathogen that is responsible for the disease cholera, uses biofilms to aid in survival, dissemination, and persistence. VpsR, which directly senses the second messenger c-di-GMP, is a major regulator of this process. Together with c-di-GMP, VpsR directly activates transcription by RNA polymerase containing σ⁷⁰ from the vpsL biofilm biogenesis promoter. Using biochemical methods, we demonstrate for the first time that VpsR/c-di-GMP directly activates σ⁷⁰-RNA polymerase at the first genes of the vps and ribomatrix operons. In this regard, it functions as either a class I or class II activator. Our results broaden the mechanism of c-di-GMP-dependent transcription activation and the specific role of VpsR in biofilm formation.

Scnn1b-Transgenic BALB/c Mice as a Model of Pseudomonas aeruginosa Infections of the Cystic Fibrosis Lung

The opportunistic pathogen Pseudomonas aeruginosa is responsible for much of the morbidity and mortality associated with cystic fibrosis (CF), a condition that predisposes patients to chronic lung infections. P. aeruginosa lung infections are difficult to treat because P. aeruginosa adapts to the CF lung, can develop multidrug resistance, and can form biofilms. Despite the clinical significance of P. aeruginosa, modeling P. aeruginosa infections in CF has been challenging. Here, we characterize Scnn1b-transgenic (Tg) BALB/c mice as P. aeruginosa lung infection models. Scnn1b-Tg mice overexpress the epithelial Na+ channel (ENaC) in their lungs, driving increased sodium absorption that causes lung pathology similar to CF. We intranasally infected Scnn1b-Tg mice and wild-type littermates with the laboratory P. aeruginosa strain PAO1 and CF clinical isolates and then assessed differences in bacterial clearance, cytokine responses, and histological features up to 12 days postinfection. Scnn1b-Tg mice carried higher bacterial burdens when infected with biofilm-grown rather than planktonic PAO1; Scnn1b-Tg mice also cleared infections more slowly than their wild-type littermates. Infection with PAO1 elicited significant increases in proinflammatory and Th17-linked cytokines on day 3. Scnn1b-Tg mice infected with nonmucoid early CF isolates maintained bacterial burdens and mounted immune responses similar to those of PAO1-infected Scnn1b-Tg mice. In contrast, Scnn1b-Tg mice infected with a mucoid CF isolate carried high bacterial burdens, produced significantly more interleukin 1β (IL-1β), IL-13, IL-17, IL-22, and KC, and showed severe immune cell infiltration into the bronchioles. Taken together, these results show the promise of Scnn1b-Tg mice as models of early P. aeruginosa colonization in the CF lung.

ChiS is a noncanonical DNA-binding hybrid sensor kinase that directly regulates the chitin utilization program in Vibrio cholerae

Two-component signal transduction systems (TCSs) represent a major mechanism that bacteria use to sense and respond to their environment. Prototypical TCSs are composed of a membrane-embedded histidine kinase, which senses an environmental stimulus and subsequently phosphorylates a cognate partner protein called a response regulator that regulates gene expression in a phosphorylation-dependent manner. Vibrio cholerae uses the hybrid histidine kinase ChiS to activate the expression of the chitin utilization program, which is critical for the survival of this facultative pathogen in its aquatic reservoir. A cognate response regulator for ChiS has not been identified and the mechanism of ChiS-dependent signal transduction remains unclear. Here, we show that ChiS is a noncanonical membrane-embedded one-component system that can both sense chitin and directly regulate gene expression via a cryptic DNA binding domain. Unlike prototypical TCSs, we find that ChiS DNA binding is diminished, rather than stimulated, by phosphorylation. Finally, we provide evidence that ChiS likely activates gene expression by directly recruiting RNA polymerase. This work addresses the mechanism of action for a major transcription factor in V. cholerae and highlights the versatility of signal transduction systems in bacterial species.

Changes in the Microbiome of Mariculture Feed Organisms after Treatment with a Potentially Probiotic Strain of Phaeobacter inhibens

The Phaeobacter genus has been explored as probiotics in mariculture as a sustainable strategy for the prevention of bacterial infections. Its antagonistic effect against common fish pathogens is predominantly due to the production of the antibacterial compound tropodithietic acid (TDA), and TDA-producing strains have repeatedly been isolated from mariculture environments. Despite many in vitro trials targeting pathogens, little is known about its impact on host-associated microbiomes in mariculture. Hence, the purpose of this study was to investigate how the addition of a TDA-producing Phaeobacter inhibens strain affects the microbiomes of live feed organisms and fish larvae. We used 16S rRNA gene sequencing to characterize the bacterial diversity associated with live feed microalgae (Tetraselmis suecica), live feed copepod nauplii (Acartia tonsa), and turbot (Scophthalmus maximus) eggs/larvae. The microbial communities were unique to the three organisms investigated, and the addition of the probiotic bacterium had various effects on the diversity and richness of the microbiomes. The structure of the live feed microbiomes was significantly changed, while no effect was seen on the community structure associated with turbot larvae. The changes were seen primarily in particular taxa. The Rhodobacterales order was indigenous to all three microbiomes and decreased in relative abundance when P. inhibens was introduced in the copepod and turbot microbiomes, while it was unaffected in the microalgal microbiome. Altogether, the study demonstrates that the addition of P. inhibens in higher concentrations, as part of a probiotic regime, does not appear to cause major imbalances in the microbiome, but the effects were specific to closely related taxa.IMPORTANCE This work is an essential part of the risk assessment of the application of roseobacters as probiotics in mariculture. It provides insights into the impact of TDA-producing Phaeobacter inhibens on the commensal bacteria related to mariculture live feed and fish larvae. Also, the study provides a sequencing-based characterization of the microbiomes related to mariculture-relevant microalga, copepods, and turbot larvae.

Upregulation of virulence genes promotes Vibrio cholerae biofilm hyperinfectivity

Vibrio cholerae remains a major global health threat, disproportionately impacting parts of the world without adequate infrastructure and sanitation resources. In aquatic environments, V. cholerae exists both as planktonic cells and as biofilms, which are held together by an extracellular matrix. V. cholerae biofilms have been shown to be hyperinfective, but the mechanism of hyperinfectivity is unclear. Here we show that biofilm-grown cells, irrespective of the surfaces on which they are formed, are able to markedly outcompete planktonic-grown cells in the infant mouse. Using an imaging technique designed to render intestinal tissue optically transparent and preserve the spatial integrity of infected intestines, we reveal and compare three-dimensional V. cholerae colonization patterns of planktonic-grown and biofilm-grown cells. Quantitative image analyses show that V. cholerae colonizes mainly the medial portion of the small intestine and that both the abundance and localization patterns of biofilm-grown cells differ from that of planktonic-grown cells. In vitro biofilm-grown cells activate expression of the virulence cascade, including the toxin coregulated pilus (TCP), and are able to acquire the cholera toxin-carrying CTXФ phage. Overall, virulence factor gene expression is also higher in vivo when infected with biofilm-grown cells, and modulation of their regulation is sufficient to cause the biofilm hyperinfectivity phenotype. Together, these results indicate that the altered biogeography of biofilm-grown cells and their enhanced production of virulence factors in the intestine underpin the biofilm hyperinfectivity phenotype.

c-di-GMP modulates type IV MSHA pilus retraction and surface attachment in Vibrio cholerae

Biofilm formation by Vibrio cholerae facilitates environmental persistence, and hyperinfectivity within the host. Biofilm formation is regulated by 3',5'-cyclic diguanylate (c-di-GMP) and requires production of the type IV mannose-sensitive hemagglutinin (MSHA) pilus. Here, we show that the MSHA pilus is a dynamic extendable and retractable system, and its activity is directly controlled by c-di-GMP. The interaction between c-di-GMP and the ATPase MshE promotes pilus extension, whereas low levels of c-di-GMP correlate with enhanced retraction. Loss of retraction facilitated by the ATPase PilT increases near-surface roaming motility, and impairs initial surface attachment. However, prolonged retraction upon surface attachment results in reduced MSHA-mediated surface anchoring and increased levels of detachment. Our results indicate that c-di-GMP directly controls MshE activity, thus regulating MSHA pilus extension and retraction dynamics, and modulating V. cholerae surface attachment and colonization.

Environmental reservoir dynamics predict global infection patterns and population impacts for the fungal disease white-nose syndrome

Infectious diseases can have devastating effects on populations, and the ability of a pathogen to persist in the environment can amplify these impacts. Understanding how environmental pathogen reservoirs influence the number of individuals that become infected and suffer mortality is essential for disease control and prevention. We integrated disease data with population surveys to examine the influence of the environmental reservoir on disease impacts for a devastating fungal disease of bats, white-nose syndrome. We find that the extent of pathogen present in the environment predicts how many hosts become infected and suffer mortality during disease outbreaks. These results provide a target for managing contamination levels in the environment to reduce population impacts.

Disease outbreaks and pathogen introductions can have significant effects on host populations, and the ability of pathogens to persist in the environment can exacerbate disease impacts by fueling sustained transmission, seasonal epidemics, and repeated spillover events. While theory suggests that the presence of an environmental reservoir increases the risk of host declines and threat of extinction, the influence of reservoir dynamics on transmission and population impacts remains poorly described. Here we show that the extent of the environmental reservoir explains broad patterns of host infection and the severity of disease impacts of a virulent pathogen. We examined reservoir and host infection dynamics and the resulting impacts of Pseudogymnoascus destructans, the fungal pathogen that causes white-nose syndrome, in 39 species of bats at 101 sites across the globe. Lower levels of pathogen in the environment consistently corresponded to delayed infection of hosts, fewer and less severe infections, and reduced population impacts. In contrast, an extensive and persistent environmental reservoir led to early and widespread infections and severe population declines. These results suggest that continental differences in the persistence or decay of P. destructans in the environment altered infection patterns in bats and influenced whether host populations were stable or experienced severe declines from this disease. Quantifying the impact of the environmental reservoir on disease dynamics can provide specific targets for reducing pathogen levels in the environment to prevent or control future epidemics.

The Critical Role of Compliance in Delivering Health Gains from Environmental Health Interventions

Gains in reducing childhood disease burden rely heavily on effective means of preventing environmental exposures. For many environmental health interventions, such as point-of-use water treatment, sanitation, or cookstoves, exposures are strongly influenced by user behaviors and the degree to which participants adhere to the prescribed preventive measures. In this commentary, we articulate the need for increased attention on user behaviors-critically, the careful measurement and inclusion of compliance-to strengthen exposure assessment and health impact trials in environmental health intervention research. We focus here on water, sanitation, and hygiene interventions to illustrate the problem with the understanding that this issue extends to other environmental health interventions.

Prevention and control of cholera with household and community water, sanitation and hygiene (WASH) interventions: A scoping review of current international guidelines

Introduction

Cholera remains a frequent cause of outbreaks globally, particularly in areas with inadequate water, sanitation and hygiene (WASH) services. Cholera is spread through faecal-oral routes, and studies demonstrate that ingestion of Vibrio cholerae occurs from consuming contaminated food and water, contact with cholera cases and transmission from contaminated environmental point sources. WASH guidelines recommending interventions for the prevention and control of cholera are numerous and vary considerably in their recommendations. To date, there has been no review of practice guidelines used in cholera prevention and control programmes.

Methods

We systematically searched international agency websites to identify WASH intervention guidelines used in cholera programmes in endemic and epidemic settings. Recommendations listed in the guidelines were extracted, categorised and analysed. Analysis was based on consistency, concordance and recommendations were classified on the basis of whether the interventions targeted within-household or community-level transmission.

Results

Eight international guidelines were included in this review: three by non-governmental organisations (NGOs), one from a non-profit organisation (NPO), three from multilateral organisations and one from a research institution. There were 95 distinct recommendations identified, and concordance among guidelines was poor to fair. All categories of WASH interventions were featured in the guidelines. The majority of recommendations targeted community-level transmission (45%), 35% targeted within-household transmission and 20% both.

Conclusions

Recent evidence suggests that interventions for effective cholera control and response to epidemics should focus on case-centred approaches and within-household transmission. Guidelines did consistently propose interventions targeting transmission within households. However, the majority of recommendations listed in guidelines targeted community-level transmission and tended to be more focused on preventing contamination of the environment by cases or recurrent outbreaks, and the level of service required to interrupt community-level transmission was often not specified. The guidelines in current use were varied and interpretation may be difficult when conflicting recommendations are provided. Future editions of guidelines should reflect on the inclusion of evidence-based approaches, cholera transmission models and resource-efficient strategies.

Linking Decision Theory and Quantitative Microbial Risk Assessment: Tradeoffs Between Compliance and Efficacy for Waterborne Disease Interventions

Achieving health gains from the U.N. Sustainable Development Goals of universal coverage for water and sanitation will require interventions that can be widely adopted and maintained. Effectiveness-how an intervention performs based on actual use-as opposed to efficacy will therefore be central to evaluations of new and existing interventions. Incomplete compliance-when people do not always use the intervention and are therefore exposed to contamination-is thought to be responsible for the lower-than-expected risk reductions observed from water, sanitation, and hygiene interventions based on their efficacy at removing pathogens. We explicitly incorporated decision theory into a quantitative microbial risk assessment model. Specifically, we assume that the usability of household water treatment (HWT) devices (filters and chlorine) decreases as they become more efficacious due to issues such as taste or flow rates. Simulations were run to examine the tradeoff between device efficacy and usability. For most situations, HWT interventions that trade lower efficacy (i.e., remove less pathogens) for higher compliance (i.e., better usability) contribute substantial reductions in diarrheal disease risk compared to devices meeting current World Health Organization efficacy guidelines. Recommendations that take into account both the behavioral and microbiological properties of treatment devices are likely to be more effective at reducing the burden of diarrheal disease than current standards that only consider efficacy.

Vibrio cholerae residing in food vacuoles expelled by protozoa are more infectious in vivo

Vibrio cholerae interacts with many organisms in the environment, including heterotrophic protists (protozoa). Several species of protozoa have been reported to release undigested bacteria in expelled food vacuoles (EFVs) when feeding on some pathogens. While the production of EFVs has been reported, their biological role as a vector for the transmission of pathogens remains unknown. Here we report that ciliated protozoa release EFVs containing V. cholerae. The EFVs are stable, the cells inside them are protected from multiple stresses, and large numbers of cells escape when incubated at 37 °C or in the presence of nutrients. We show that OmpU, a major outer membrane protein positively regulated by ToxR, has a role in the production of EFVs. Notably, cells released from EFVs have growth and colonization advantages over planktonic cells both in vitro and in vivo. Our results suggest that EFVs facilitate V. cholerae survival in the environment, enhancing their infectious potential and may contribute to the dissemination of epidemic V. cholerae strains. These results improve our understanding of the mechanisms of persistence and the modes of transmission of V. cholerae and may further apply to other opportunistic pathogens that have been shown to be released by protists in EFVs.

Broad approaches to cholera control in Asia: Water, sanitation and handwashing

Cholera has been eliminated as a public health problem in high-income countries that have implemented sanitation system separating the community's fecal waste from their drinking water and food supply. These expensive, highly-engineered systems, first developed in London over 150 years ago, have not reached low-income high-risk communities across Asia. Barriers to their implementation in communities at highest risk for cholera include the high capital and operating costs for this technological approach, limited capacity and perverse incentives of local governments, and a decreasing availability of water. Interim solutions including household level water treatment, constructing latrines and handwashing promotion have only marginally reduced the risk of cholera and other fecally transmitted diseases. Increased research to develop and policy flexibility to implement a new generation of solutions that are designed specifically to address the physical, financial and political constraints of low-income communities offers the best prospect for reducing the burden of cholera across Asia.

VpsR and cyclic di-GMP together drive transcription initiation to activate biofilm formation in Vibrio cholerae

The small molecule cyclic di-GMP (c-di-GMP) is known to affect bacterial gene expression in myriad ways. In Vibrio cholerae in vivo, the presence of c-di-GMP together with the response regulator VpsR results in transcription from P_vpsL, a promoter of biofilm biosynthesis genes. VpsR shares homology with enhancer binding proteins that activate σ54-RNA polymerase (RNAP), but it lacks conserved residues needed to bind to σ54-RNAP and to hydrolyze adenosine triphosphate, and P_vpsL transcription does not require σ54 in vivo. Consequently, the mechanism of this activation has not been clear. Using an in vitro transcription system, we demonstrate activation of P_vspL in the presence of VpsR, c-di-GMP and σ70-RNAP. c-di-GMP does not significantly change the affinity of VpsR for P_vpsL DNA or the DNase I footprint of VpsR on the DNA, and it is not required for VpsR to dimerize. However, DNase I and KMnO₄ footprints reveal that the σ70-RNAP/VpsR/c-di-GMP complex on P_vpsL adopts a different conformation from that formed by σ70-RNAP alone, with c-di-GMP or with VpsR. Our results suggest that c-di-GMP is required for VpsR to generate the specific protein–DNA architecture needed for activated transcription, a previously unrecognized role for c-di-GMP in gene expression.

Regulated Proteolysis in Vibrio cholerae Allowing Rapid Adaptation to Stress Conditions

The lifecycle of the causative agent of the severe secretory diarrheal disease cholera, Vibrio cholerae, is characterized by the transition between two dissimilar habitats, i.e., as a natural inhabitant of aquatic ecosystems and as a pathogen in the human gastrointestinal tract. Vibrio cholerae faces diverse stressors along its lifecycle, which require effective adaptation mechanisms to facilitate the survival fitness. Not surprisingly, the pathogen's transcriptome undergoes global changes during the different stages of the lifecycle. Moreover, recent evidence indicates that several of the transcription factors (i.e., ToxR, TcpP, and ToxT) and alternative sigma factors (i.e., FliA, RpoS, and RpoE) involved in transcriptional regulations along the lifecycle are controlled by regulated proteolysis. This post-translational control ensures a fast strategy by the pathogen to control cellular checkpoints and thereby rapidly respond to changing conditions. In this review, we discuss selected targets for regulated proteolysis activated by various stressors, which represent a key feature for fast adaptation of V. cholerae.

DNA-uptake pili of Vibrio cholerae are required for chitin colonization and capable of kin recognition via sequence-specific self-interaction

How bacteria colonise surfaces and how they distinguish the individuals around them are fundamental biological questions. Type IV pili are a widespread and multi-purpose class of cell surface polymers. Here we directly visualise the DNA-uptake pilus of Vibrio cholerae, which is produced specifically during growth upon its natural habitat - chitinous surfaces. As predicted, these pili are highly dynamic and retract prior to DNA-uptake during competence for natural transformation. Interestingly, DNA-uptake pili can also self-interact to mediate auto-aggregation. This capability is conserved in disease-causing pandemic strains, which typically encode the same major pilin subunit, PilA. Unexpectedly, however, we discovered that extensive strain-to-strain variability in PilA, present in environmental isolates, creates a set of highly specific interactions, enabling cells producing pili composed of different PilA subunits to distinguish between one another. We go on to show that DNA-uptake pili bind to chitinous surfaces, are required for chitin colonisation under flow, and that pili capable of self-interaction connect cells on chitin within dense pili networks. Our results suggest a model whereby DNA-uptake pili function to promote inter-bacterial interactions during surface colonisation. Moreover, they provide evidence that type IV pili could offer a simple and potentially widespread mechanism for bacterial kin recognition.

Composite Membranes Derived from Cellulose and Lignin Sulfonate for Selective Separations and Antifouling Aspects

Cellulose-based membrane materials allow for separations in both aqueous solutions and organic solvents. The addition of nanocomposites into cellulose structure is facilitated through steric interaction and strong hydrogen bonding with the hydroxy groups present within cellulose. An ionic liquid, 1-ethyl-3-methylimidazolium acetate, was used as a solvent for microcrystalline cellulose to incorporate graphene oxide quantum dots into cellulose membranes. In this work, other composite materials such as, iron oxide nanoparticles, polyacrylic acid, and lignin sulfonate have all been uniformly incorporated into cellulose membranes utilizing ionic liquid cosolvents. Integration of iron into cellulose membranes resulted in high selectivity (>99%) of neutral red and methylene blue model dyes separation over salts with a high permeability of 17 LMH/bar. With non-aqueous (alcohol) solvent, iron-cellulose composite membranes become less selective and more permeable, suggesting the interaction of iron ions cellulose OH groups plays a major role in pore structure. Polyacrylic acid was integrated into cellulose membranes to add pH responsive behavior and capacity for metal ion capture. Calcium capture of 55 mg Ca2+/g membrane was observed for PAA-cellulose membranes. Lignin sulfonate was also incorporated into cellulose membranes to add strong negative charge and a steric barrier to enhance antifouling behavior. Lignin sulfonate was also functionalized on the commercial DOW NF270 nanofiltration membranes via esterification of hydroxy groups with carboxyl group present on the membrane surface. Antifouling behavior was observed for both lignin-cellulose composite and commercial membranes functionalized with lignin. Up to 90% recovery of water flux after repeated cycles of fouling was observed for both types of lignin functionalized membranes while flux recovery of up to 60% was observed for unmodified membranes.

Tilapia (Oreochromis niloticus) as a Putative Reservoir Host for Survival and Transmission of Vibrio cholerae O1 Biotype El Tor in the Aquatic Environment

Studies have reported the occurrence of Vibrio cholerae in fish but little is known about the interaction between fish and toxigenic V. cholerae as opposed to phytoplankton, which are well-established aquatic reservoirs for V. cholerae. The present study determined the role of tilapia (Oreochromis niloticus) as a reservoir host for survival and transmission of V. cholerae in aquatic environments. Three experiments were performed with one repetition each, where O. niloticus (∼2 g) kept in beakers were inoculated with four V. cholerae strains (5 × 10⁷ cfu/mL). Firstly, infected tilapia were kept in stagnant water and fed live brine shrimp (Artemia salina) larvae daily. Secondly, infected tilapia were kept without feeding and water was changed every 24 h. Thirdly, infected tilapia were fed and water was renewed daily. Infected tilapia and non-infected controls were sacrificed on days 1, 2, 3, 7, and 14 post-inoculation and V. cholerae were enumerated in intestinal content and water. Another experiment assessed the transmission of V. cholerae from infected to non-infected tilapia. The study revealed that El Tor biotype V. cholerae O1 and V. cholerae non-O1 colonized tilapia intestines and persisted at stable concentrations during the second week of the experiment whereas the Classical biotype was undetectable after 1 week. In stagnant water with feeding, V. cholerae counts dropped to 10⁵ cfu/ml in water and from 10⁷ to 10⁴ cfu/intestine in fish after 14 days. When water was renewed, counts in water decreased from 10⁷ to 10³ cfu/ml and intestinal counts went from 10⁶ to 10² cfu/intestine regardless of feeding. All strains were transmitted from infected to naïve fish after 24 h of cohabitation. Tilapia like other fish may play an essential role in the survival and dissemination of V. cholerae O1 in aquatic environments, e.g., the seventh pandemic strains mostly. In this study, tilapia were exposed to high concentrations of V. cholerae to ensure initial uptake and follow-up studies with lower doses resembling natural concentrations of V. cholerae in the aquatic environment are needed to confirm our findings.

Evaluation of adaptive low cost solar water pasteurization device for providing safe potable water in rural households

This study was conducted to evaluate the effectiveness of a simplified, low cost, pasteurization device in inactivating the diarrheal pathogens present in pond/lake/river water in order to provide safe potable water to people living in the rural areas of low resource countries. In this process, water in polyethylene bags was exposed to sunshine, where UV radiation emissions and heat absorption from the sunshine occurs simultaneously, and maintaining the heating at <60 °C, and minimum UV radiation emissions of 996.2 W/m² for approximately 30 minutes was found enough to inactivate diarrheal pathogens in water. The synergistic effect of heat, UV radiation emission and holding time causes the destruction of diarrheal pathogens. However, the performance of the device depends on the thickness of the insulation and the air gap between polyethylene bags. Regardless of sample sources, the highest population reduction of Escherichia coli observed in the bacterial challenge study was 6.8 ± 0.4 log CFU/ml. The physicochemical properties were found acceptable compared with USEPA potable water quality except turbidity, which is acceptable according to the BDS standard, and the shelf-life study results demonstrated that 6 months' storage of pasteurization device-treated water at room temperature is possible without compromising water quality. Therefore, this simplified pasteurization device could be useful in potable water-scarce areas of the world.