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Greminger S, Strahm C, Notter J, Martens B, Helfenstein S, Den Hollander J, Frischknecht M. Vertebral osteomyelitis with Campylobacter jejuni - a case report and review of the literature of a very rare disease. J Bone Jt Infect 2024; 9:59-65. [PMID: 38601004 PMCID: PMC11002916 DOI: 10.5194/jbji-9-59-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/02/2024] [Indexed: 04/12/2024] Open
Abstract
Infections with Campylobacter species mainly cause gastrointestinal disease and are usually self-limiting. Systemic complications such as bacteremia and osteoarticular infections are rare. Here we report a very rare case of a vertebral osteomyelitis due to C. jejuni, and we reviewed the literature for similar cases, identifying six other cases. Therapy should be guided on resistance testing if available due to emerging resistance rates, especially to fluoroquinolones. Azithromycin may be a treatment option for C. jejuni spondylodiscitis.
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Affiliation(s)
- Simone Greminger
- Medical Center Pflanzberg, Poststrasse 20, 8274 Tägerwilen, Switzerland
| | - Carol Strahm
- Division of Infectious Diseases, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
| | - Julia Notter
- Division of Infectious Diseases, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
| | - Benjamin Martens
- Center for Spine Surgery Eastern Switzerland, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
| | - Seth Florian Helfenstein
- Division of General Internal Medicine, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
| | - Jürgen Den Hollander
- Cantonal network of Radiology and Nuclear Medicine, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
| | - Manuel Frischknecht
- Division of Infectious Diseases, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
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2
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Pölzler T, Stüger HP, Lassnig H. Prevalence of most common human pathogenic Campylobacter spp. in dogs and cats in Styria, Austria. Vet Med Sci 2018; 4:115-125. [PMID: 29851311 PMCID: PMC5980169 DOI: 10.1002/vms3.93] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The aim of this study was to determine the frequency of occurrence of most common human pathogenic Campylobacter species, Campylobacter jejuni (C. jejuni) and Campylobacter coli (C. coli), in dogs and cats in Styria, Austria. In the period from April 2010 to April 2012, 842 faecal samples from dogs and cats from Styria, Austria were examined for Campylobacter (C.) species (spp.). All samples were subjected to qualitative microbiological culture testing, and additionally, some of them have been studied using qualitative real‐time PCR. In microbiological culture, 5.9% of all samples investigated were C. spp. positive. With 3.1% out of positive samples, C. jejuni was the most common type. Campylobacter upsaliensis (C. upsaliensis) was detected only in 0.5% of the samples. The remaining positive samples (2.4%) were classified as C. species (sp.). C. coli could not be found in any of the samples. A higher prevalence of C. jejuni was found in kittens with 14.3% and in diarrhoeic dogs (7.4%) and cats (23.8%). The real‐time PCR revealed for dogs and cats together, 27% of C. jejuni‐positive faecal and 8% positive faecal swap samples. The obtained C. jejuni strains underwent antibiotic resistance testing using three different tests (agar diffusion, MIC testing and E‐test) with different numbers of antibiotics. From the antibiotics used in this study, several showed high test‐dependent resistance rates (cephalexin, cefovecin, kanamycin, sulfamethoxazole/trimethoprim, penicillin G, ciprofloxacin, enrofloxacin, marbofloxacin, nalidixic acid). Overall, the prevalence of C. spp. in this study was very low compared to others, with the exception of C. jejuni in kittens and diarrhoeic animals. The results of the real‐time PCR suggest that the rate of colonization of C. jejuni was actually higher than the results of the culture showed. As the resistance rates of C. jejuni isolates partly were very high, possible transmission of (multi‐) resistant C. jejuni strains to humans especially from kittens and diarrhoeic animals must be expected.
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Affiliation(s)
- Thomas Pölzler
- Centre for Foodborne Infectious Diseases in Graz, Department of Veterinary Microbiology (VEMI), Institute for Medical Microbiology and Hygiene, Graz (IMED Graz), Austrian Agency for Health and Food Safety (AGES), Graz, Austria
| | - Hans-Peter Stüger
- Division for Data, Statistics and Risk Assessment (DSR), Austrian Agency for Health and Food Safety, Graz, Austria
| | - Heimo Lassnig
- Centre for Foodborne Infectious Diseases in Graz, Department of Veterinary Microbiology (VEMI), Institute for Medical Microbiology and Hygiene, Graz (IMED Graz), Austrian Agency for Health and Food Safety (AGES), Graz, Austria
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3
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Genetic diversity and antimicrobial resistance profiles of Campylobacter coli
and Campylobacter jejuni
isolated from broiler chicken in farms and at time of slaughter in central Italy. J Appl Microbiol 2017; 122:1348-1356. [DOI: 10.1111/jam.13419] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 02/04/2017] [Accepted: 02/08/2017] [Indexed: 12/12/2022]
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4
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Genotypes and antibiotic resistance of bovine Campylobacter and their contribution to human campylobacteriosis. Epidemiol Infect 2014; 143:2373-80. [PMID: 25511436 DOI: 10.1017/s0950268814003410] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Campylobacter jejuni and Campylobacter coli are the most important bacterial causes of human gastroenteritis. Chicken has been recognized as a major source for human infection, whereas cattle might also contribute to a lesser extent. However, there is a paucity of information available regarding Campylobacter in Swiss cattle and their role for human campylobacteriosis. To gain more information on genotypes and antibiotic resistance of bovine C. jejuni and C. coli and on their contribution to human disease, 97 cattle isolates were analysed. Multilocus sequence typing (MLST) and flaB typing were applied and the gyrA and 23S rRNA genes were screened for point mutations responsible for quinolone and macrolide resistance, respectively. A total of 37 sequence types (STs) and 44 flaB types were identified, including two sequence types and five flaB types not previously described. Most common sequence types were ST21 (21%), ST61 (12%) and ST48 (11%). Only one isolate was macrolide resistant while 31% (n = 30) were quinolone resistant. Source attribution indicated chicken as the main source of human infection with cattle being second. In conclusion, cattle should not be underestimated as a potential source of human campylobacteriosis.
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5
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Torralbo A, Borge C, Allepuz A, García-Bocanegra I, Sheppard SK, Perea A, Carbonero A. Prevalence and risk factors of Campylobacter infection in broiler flocks from southern Spain. Prev Vet Med 2014; 114:106-13. [DOI: 10.1016/j.prevetmed.2014.01.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 01/07/2014] [Accepted: 01/19/2014] [Indexed: 02/03/2023]
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Risk factors for campylobacteriosis in two washington state counties with high numbers of dairy farms. J Clin Microbiol 2013; 51:3921-7. [PMID: 24025908 DOI: 10.1128/jcm.01433-13] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Campylobacteriosis is a frequently reported, food-borne, human bacterial disease that can be associated with ruminant reservoirs, although public health messages primarily focus on poultry. In Washington State, the two counties with the highest concentrations of dairy cattle also report the highest incidences of campylobacteriosis. Conditional logistic regression analysis of case-control data from both counties found living or working on a dairy farm (odds ratio [OR], 6.7 [95% confidence interval [CI], 1.7 to 26.4]) and Hispanic ethnicity (OR, 6.4 [95% CI, 3.1 to 13.1]) to have the strongest significant positive associations with campylobacteriosis. When the analysis was restricted to residents of one county, Hispanic ethnicity (OR, 9.3 [95% CI, 3.9 to 22.2]), contact with cattle (OR, 5.0 [95% CI, 1.3 to 19.5]), and pet ownership (OR, 2.6 [95% CI, 1.1 to 6.3]) were found to be independent risk factors for disease. Campylobacter jejuni isolates from human (n = 65), bovine (n = 28), and retail poultry (n = 27) sources from the same counties were compared using multilocus sequence typing. These results indicated that sequence types commonly found in human isolates were also commonly found in bovine isolates. These findings suggest that, in areas with high concentrations of dairy cattle, exposure to dairy cattle may be more important than food-borne exposure to poultry products as a risk for campylobacteriosis.
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7
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Bratz K, Bücker R, Gölz G, Zakrzewski SS, Janczyk P, Nöckler K, Alter T. Experimental infection of weaned piglets with Campylobacter coli--excretion and translocation in a pig colonisation trial. Vet Microbiol 2012; 162:136-43. [PMID: 22986057 DOI: 10.1016/j.vetmic.2012.08.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 08/21/2012] [Accepted: 08/22/2012] [Indexed: 10/27/2022]
Abstract
Campylobacter (C.) is one of the most common food-borne pathogen causing bacterial enteric infections in humans. Consumption of meat and meat products that have been contaminated with Campylobacter are the major source of infection. Pigs are a natural reservoir of Campylobacter spp. with C. coli as the dominant species. Even though some studies focussed on transmission of C. coli in pig herds and the excretion in faeces, little is known about the colonisation and excretion dynamics of C. coli in a complex gut microbiota present in weaned piglets and the translocation to different tissues. Therefore, an experimental trial was conducted to evaluate the colonisation and translocation ability of the porcine strain C. coli 5981 in weaned pigs. Thus, ten 35 days old piglets were intragastrically inoculated with strain C. coli 5981 (7 × 10(7)CFU/animal) encoding resistances against erythromycin and neomycin. Faecal samples were taken and C. coli levels were enumerated over 28 days. All piglets were naturally colonised with C. coli before experimental inoculation, and excretion levels ranged from 10(4) to 10(7)CFU/g faeces. However, no strain showed resistances against the additional antimicrobials used. Excretion of C. coli 5981 was seen for all piglets seven days after inoculation and highest counts were detectable ten days after inoculation with 10(6)CFU/g faeces. Post-mortem, translocation and subsequent invasion of luminal C. coli was observed for gut tissues of the small intestine and for the gut associated lymphatic tissues, such as jejunal mesenteric lymph nodes and tonsils as well as for spleen and gall bladder. In conclusion, this pig colonisation trial offers the opportunity to study C. coli colonisation in weaned piglets using the porcine strain C. coli 5981 without the need for gnotobiotic or specific pathogen-free animals.
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Affiliation(s)
- Katharina Bratz
- Institute of Food Hygiene, Freie Universität Berlin, Germany.
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8
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Development and validation of a comparative genomic fingerprinting method for high-resolution genotyping of Campylobacter jejuni. J Clin Microbiol 2011; 50:788-97. [PMID: 22170908 DOI: 10.1128/jcm.00669-11] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Campylobacter spp. are a leading cause of bacterial gastroenteritis worldwide. The need for molecular subtyping methods with enhanced discrimination in the context of surveillance- and outbreak-based epidemiologic investigations of Campylobacter spp. is critical to our understanding of sources and routes of transmission and the development of mitigation strategies to reduce the incidence of campylobacteriosis. We describe the development and validation of a rapid and high-resolution comparative genomic fingerprinting (CGF) method for C. jejuni. A total of 412 isolates from agricultural, environmental, retail, and human clinical sources obtained from the Canadian national integrated enteric pathogen surveillance program (C-EnterNet) were analyzed using a 40-gene assay (CGF40) and multilocus sequence typing (MLST). The significantly higher Simpson's index of diversity (ID) obtained with CGF40 (ID = 0.994) suggests that it has a higher discriminatory power than MLST at both the level of clonal complex (ID = 0.873) and sequence type (ID = 0.935). High Wallace coefficients obtained when CGF40 was used as the primary typing method suggest that CGF and MLST are highly concordant, and we show that isolates with identical MLST profiles are comprised of isolates with distinct but highly similar CGF profiles. The high concordance with MLST coupled with the ability to discriminate between closely related isolates suggests that CFG40 is useful in differentiating highly prevalent sequence types, such as ST21 and ST45. CGF40 is a high-resolution comparative genomics-based method for C. jejuni subtyping with high discriminatory power that is also rapid, low cost, and easily deployable for routine epidemiologic surveillance and outbreak investigations.
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Kudirkienė E, Malakauskas M, Malakauskas A, Bojesen A, Olsen J. Demonstration of persistent strains of
Campylobacter jejuni
within broiler farms over a 1‐year period in Lithuania. J Appl Microbiol 2010; 108:868-877. [DOI: 10.1111/j.1365-2672.2009.04490.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- E. Kudirkienė
- Department of Food Safety and Animal Hygiene, Faculty of Veterinary Medicine, Lithuanian Veterinary Academy, Kaunas, Lithuania
| | - M. Malakauskas
- Department of Food Safety and Animal Hygiene, Faculty of Veterinary Medicine, Lithuanian Veterinary Academy, Kaunas, Lithuania
| | - A. Malakauskas
- Department of Infectious Diseases, Faculty of Veterinary Medicine, Lithuanian Veterinary Academy, Kaunas, Lithuania
| | - A.M. Bojesen
- Department of Veterinary Disease Biology, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark
| | - J.E. Olsen
- Department of Veterinary Disease Biology, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark
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10
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Scientific Opinion on Quantification of the risk posed by broiler meat to human campylobacteriosis in the EU. EFSA J 2010. [DOI: 10.2903/j.efsa.2010.1437] [Citation(s) in RCA: 158] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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11
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Acke E, McGill K, Lawlor A, Jones BR, Fanning S, Whyte P. Genetic diversity among Campylobacter jejuni
isolates from pets in Ireland. Vet Rec 2010; 166:102-6. [DOI: 10.1136/vr.c357] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- E. Acke
- School of Agriculture, Food Science and Veterinary Medicine; University College Dublin, Belfield; Dublin 4 Ireland
- Veterinary Teaching Hospital; Institute of Veterinary, Animal and Biomedical Sciences; Massey University; Private Bag 11222 Palmerston North 4442 New Zealand
| | - K. McGill
- School of Agriculture, Food Science and Veterinary Medicine; University College Dublin, Belfield; Dublin 4 Ireland
| | - A. Lawlor
- School of Agriculture, Food Science and Veterinary Medicine; University College Dublin, Belfield; Dublin 4 Ireland
| | - B. R. Jones
- School of Agriculture, Food Science and Veterinary Medicine; University College Dublin, Belfield; Dublin 4 Ireland
| | - S. Fanning
- School of Agriculture, Food Science and Veterinary Medicine; University College Dublin, Belfield; Dublin 4 Ireland
| | - P. Whyte
- School of Agriculture, Food Science and Veterinary Medicine; University College Dublin, Belfield; Dublin 4 Ireland
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12
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Wassenaar T, Fernández-Astorga A, Alonso R, Marteinsson V, Magnússon S, Kristoffersen A, Hofshagen M. Comparison ofCampylobacter fla-SVR genotypes isolated from humans and poultry in three European regions. Lett Appl Microbiol 2009; 49:388-95. [DOI: 10.1111/j.1472-765x.2009.02678.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Havelaar AH, van Pelt W, Ang CW, Wagenaar JA, van Putten JPM, Gross U, Newell DG. Immunity to Campylobacter: its role in risk assessment and epidemiology. Crit Rev Microbiol 2009; 35:1-22. [PMID: 19514906 DOI: 10.1080/10408410802636017] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Acquired immunity is an important factor in the epidemiology of campylobacteriosis in the developing world, apparently limiting symptomatic infection to children of less than two years. However, also in developed countries the highest incidence is observed in children under five years and the majority of Campylobacter infections are asymptomatic, which may be related to the effects of immunity and/or the ingested doses. Not accounting for immunity in epidemiological studies may lead to biased results due to the misclassification of Campylobacter-exposed but apparently healthy persons as unexposed. In risk assessment studies, health risks may be overestimated when immunity is neglected.
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Affiliation(s)
- Arie H Havelaar
- Centre for Infectious Diseases Control Netherlands, National Institute for Public Health and the Environment, PO Box 1, 3720 BA Bilthoven, The Netherlands
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14
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Development of cpn60-based real-time quantitative PCR assays for the detection of 14 Campylobacter species and application to screening of canine fecal samples. Appl Environ Microbiol 2009; 75:3055-61. [PMID: 19304828 DOI: 10.1128/aem.00101-09] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Campylobacter species are important organisms in both human and animal health. The identification of Campylobacter currently requires the growth of organisms from complex samples and biochemical identification. In many cases, the condition of the sample being tested and/or the fastidious nature of many Campylobacter species has limited the detection of campylobacters in a laboratory setting. To address this, we have designed a set of real-time quantitative PCR (qPCR) assays to detect and quantify 14 Campylobacter species, C. coli, C. concisus, C. curvus, C. fetus, C. gracilis, C. helveticus, C. hyointestinalis, C. jejuni, C. lari, C. mucosalis, C. rectus, C. showae, C. sputorum, and C. upsaliensis, directly from DNA extracted from feces. By use of a region of the cpn60 (also known as hsp60 or groEL) gene, which encodes the universally conserved 60-kDa chaperonin, species-specific assays were designed and validated. These assays were then employed to determine the prevalence of Campylobacter species in fecal samples from dogs. Fecal samples were found to contain detectable and quantifiable levels of C. fetus, C. gracilis, C. helveticus, C. jejuni, C. showae, and C. upsaliensis, with the majority of samples containing multiple Campylobacter species. This study represents the first report of C. fetus, C. gracilis, C. mucosalis, and C. showae detection in dogs and implicates dogs as a reservoir for these species. The qPCR assays described offer investigators a new tool to study many Campylobacter species in a culture-independent manner.
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15
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Leblanc Maridor M, Denis M, Lalande F, Beaurepaire B, Cariolet R, Fravalo P, Federighi M, Seegers H, Belloc C. Experimental infection of specific pathogen-free pigs with Campylobacter: excretion in faeces and transmission to non-inoculated pigs. Vet Microbiol 2008; 131:309-17. [PMID: 18539408 DOI: 10.1016/j.vetmic.2008.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2008] [Revised: 04/04/2008] [Accepted: 04/10/2008] [Indexed: 11/28/2022]
Abstract
Campylobacter species are leading agents of human bacterial gastroenteritis and consumption of food of animal origin is a major source of infection. Although pigs are known to frequently exhibit high counts of Campylobacter in their faeces, more information is needed about the dynamics of this excretion. An experimental trial was conducted to evaluate the faecal excretion of Campylobacter by 7-week-old specific pathogen-free piglets inoculated per os with three Campylobacter strains (one C. coli isolated from a pig, one C. coli and one C. jejuni from chickens) alone or simultaneously (5x10(7)CFU/strain). Non-inoculated pigs were housed in adjacent pens. Pigs were monitored for 80 days for clinical signs and by bacteriological analysis of faeces. Pigs inoculated with porcine C. coli or with a mix of the three strains excreted from 10(3) to 10(6)CFU/g of faeces with a slight decrease at the end of the trial. Animals inoculated with poultry C. coli or C. jejuni strain excreted a lower quantity and some of them stopped excreting. At the end of the trial, only C. coli was detected in the faeces of pigs inoculated simultaneously with the three bacteria. Moreover, the transmission of Campylobacter was noticed between pens for the two C. coli strains and all the neighbouring animals became shedders with a level of excretion similar to the inoculated pigs. Intermittence in the Campylobacter excretion was also observed. Finally, our study highlighted a host preference of Campylobacter, namely C. coli seems to have a higher colonization potential for pigs than C. jejuni.
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Affiliation(s)
- Mily Leblanc Maridor
- INRA, Veterinary School, Unit of Bio-aggression, Epidemiology and Risk Analysis in Animal Health, UMR 1300, BP 40706, 44307 Nantes Cedex 03, France.
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16
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Denno DM, Klein EJ, Young VB, Fox JG, Wang D, Tarr PI. Explaining unexplained diarrhea and associating risks and infections. Anim Health Res Rev 2007; 8:69-80. [PMID: 17692144 DOI: 10.1017/s1466252307001302] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Gastrointestinal illnesses are common afflictions. However, knowledge of their etiology is often lacking. Moreover, most cases of infections with reportable enteric pathogens (Campylobacter jejuni, Escherichia coli O157:H7, Salmonella, Shigella, Yersinia, Cryptosporidia and Giardia) have sporadic modes of acquisition, yet control measures are often biased towards mitigation of risks discerned by outbreak analysis. To determine the etiology of unexplained diarrhea it is important to study populations that can be matched to appropriate controls and to couple thorough classic microbiologic evaluation on receipt of specimens with archiving and outgrowth capabilities. Research evaluations should address the potential roles of a broad panel of candidate bacterial pathogens including diarrheagenic E. coli, Listeria monocytogenes, Helicobacters and jejuni Campylobacters, and also apply novel massively parallel sequencing and nucleic acid detection technologies that allow the detection of viral pathogens. To fill voids in our knowledge regarding sources of known enteric pathogens it will be critical to extend case-control studies to assess risk factors and exposures to patients with non-epidemic illnesses and to appropriate controls. By filling these gaps in our knowledge it should be possible to formulate rational prevention mechanisms for human gastrointestinal illnesses.
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Affiliation(s)
- Donna M Denno
- Department of Health Services, University of Washington School of Medicine, Seattle, WA, USA
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