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Al-Adham ISI, Jaber N, Ali Agha ASA, Al-Remawi M, Al-Akayleh F, Al-Muhtaseb N, Collier PJ. Sporadic regional re-emergent cholera: a 19th century problem in the 21st century. J Appl Microbiol 2024; 135:lxae055. [PMID: 38449342 DOI: 10.1093/jambio/lxae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/24/2024] [Accepted: 03/04/2024] [Indexed: 03/08/2024]
Abstract
Cholera, caused by Vibrio cholerae, is a severe diarrheal disease that necessitates prompt diagnosis and effective treatment. This review comprehensively examines various diagnostic methods, from traditional microscopy and culture to advanced nucleic acid testing like polymerase spiral reaction and rapid diagnostic tests, highlighting their advantages and limitations. Additionally, we explore evolving treatment strategies, with a focus on the challenges posed by antibiotic resistance due to the activation of the SOS response pathway in V. cholerae. We discuss promising alternative treatments, including low-pressure plasma sterilization, bacteriophages, and selenium nanoparticles. The paper emphasizes the importance of multidisciplinary approaches combining novel diagnostics and treatments in managing and preventing cholera, a persistent global health challenge. The current re-emergent 7th pandemic of cholera commenced in 1961 and shows no signs of abeyance. This is probably due to the changing genetic profile of V. cholerae concerning bacterial pathogenic toxins. Given this factor, we argue that the disease is effectively re-emergent, particularly in Eastern Mediterranean countries such as Lebanon, Syria, etc. This review considers the history of the current pandemic, the genetics of the causal agent, and current treatment regimes. In conclusion, cholera remains a significant global health challenge that requires prompt diagnosis and effective treatment. Understanding the history, genetics, and current treatments is crucial in effectively addressing this persistent and re-emergent disease.
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Affiliation(s)
- Ibrahim S I Al-Adham
- Faculty of Pharmacy and Medical Sciences, University of Petra, Amman 961343, Jordan
| | - Nisrein Jaber
- Faculty of Pharmacy, Al Zaytoonah University of Jordan, Amman 11733, Jordan
| | - Ahmed S A Ali Agha
- Faculty of Pharmacy and Medical Sciences, University of Petra, Amman 961343, Jordan
| | - Mayyas Al-Remawi
- Faculty of Pharmacy and Medical Sciences, University of Petra, Amman 961343, Jordan
| | - Faisal Al-Akayleh
- Faculty of Pharmacy and Medical Sciences, University of Petra, Amman 961343, Jordan
| | - Najah Al-Muhtaseb
- Faculty of Pharmacy and Medical Sciences, University of Petra, Amman 961343, Jordan
| | - Phillip J Collier
- Faculty of Pharmacy and Medical Sciences, University of Petra, Amman 961343, Jordan
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Monira S, Barman I, Jubyda FT, Ali SI, Islam A, Rahman KMZ, Rashid MU, Johura FT, Sultana M, Zohura F, Bhuyian SI, Parvin T, Sack D, Ahmed T, Saif-Ur-Rahman KM, Hossain M, Watanabe H, George CM, Alam M. Gut microbiota shifts favorably with delivery of handwashing with soap and water treatment intervention in a prospective cohort (CHoBI7 trial). JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2023; 42:146. [PMID: 38129922 PMCID: PMC10740293 DOI: 10.1186/s41043-023-00477-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Cholera can result in the expulsion of important microbiota from the gut and result in death if left untreated. The disease transmits mainly via drinking water carrying Vibrio cholerae; and household contacts (HHC) of cholera patients are at elevated risk during the first week of infection. The gut microbiota profiles of HHC-children of cholera patients at Dhaka city slums were investigated before (day 0) and after (day 8) delivery of chlorinated water as part of the major study 'CHoBI7 trial (cholera-hospital-based intervention for 7 days)'. RESULT Results of sequencing and analysis of bacterial community DNA revealed the predominance of two bacterial phyla: Bacteroidetes and Firmicutes at day 0 with a relative abundance of 62 ± 6 (mean ± SEM%) and 32 ± 7, respectively. The pattern reversed at day 8 with a decreased relative abundance of Bacteroidetes (39 ± 12; p = 0.034) and an increased abundance of Firmicutes (49 ± 12; p = 0.057). Of 65 bacterial families confirmed at day 0, six belonging to Proteobacteria including Vibrionaceae disappeared at day 8. Interestingly, the relative abundance of four Firmicutes families-Lachnospiraceae, Bifidobacteriaceae, Clostridiaceae, and Ruminococcaceae was increased in all five study children at day 8. CONCLUSION The observed exclusion of pathogenic Proteobacteria and enhancement of beneficial Firmicutes in the gut of children delivered with chlorinated water as part of WASH intervention reflect a great promise of the CHoBI7 program in preventing cholera and improving child health.
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Affiliation(s)
- Shirajum Monira
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Indrajeet Barman
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Fatema Tuz Jubyda
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Sk Imran Ali
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Aminul Islam
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Kazi Mohammad Zillur Rahman
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Mahamud-Ur Rashid
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Fatema-Tuz Johura
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Marzia Sultana
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Fatema Zohura
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Sazzadul Islam Bhuyian
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - Tahmina Parvin
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - David Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tahmeed Ahmed
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
| | - K M Saif-Ur-Rahman
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh
- Evidence Synthesis Ireland and Cochrane Ireland, College of Medicine, Nursing, and Health Sciences, University of Galway, Galway, Ireland
| | - Maqsud Hossain
- NSU Genome Research Institute, North South University, Dhaka, Bangladesh
| | - Haruo Watanabe
- National Institutes of Infectious Diseases (NIID), Tokyo, Japan
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Munirul Alam
- Molecular Ecology and Metagenomics Laboratory, Infectious Diseases Division, icddr,b, (International Centre for Diarrhoeal Diseases Research Bangladesh), Dhaka, Bangladesh.
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Islam MT, Hegde ST, Khan AI, Bhuiyan MTR, Khan ZH, Ahmmed F, Begum YA, Afrad MH, Amin MA, Tanvir NA, Khan II, Habib ZH, Alam AN, McMillan NA, Shirin T, Azman AS, Qadri F. National Hospital-Based Sentinel Surveillance for Cholera in Bangladesh: Epidemiological Results from 2014 to 2021. Am J Trop Med Hyg 2023; 109:575-583. [PMID: 37580033 PMCID: PMC10484282 DOI: 10.4269/ajtmh.23-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/06/2023] [Indexed: 08/16/2023] Open
Abstract
Despite focusing on cholera burden, epidemiologic studies in Bangladesh tend to be limited in geographic scope. National-level cholera surveillance data can help inform cholera control strategies and assess the effectiveness of preventive measures. Hospital-based sentinel surveillance among patients with suspected diarrhea in different sites across Bangladesh has been conducted since 2014. We selected an age-stratified sample of 20 suspected cholera cases each week from each sentinel site, tested stool for the presence of Vibrio cholerae O1/O139 by culture, and characterized antibiotic susceptibility in a subset of culture-positive isolates. We estimated the odds of being culture positive among suspected cholera cases according to different potential risk factors. From May 4, 2014 through November 30, 2021, we enrolled 51,414 suspected cases from our sentinel surveillance sites. We confirmed V. cholerae O1 in 5.2% of suspected cases through microbiological culture. The highest proportion of confirmed cholera cases was from Chittagong (9.7%) and the lowest was from Rangpur Division (0.9%). Age, number of purges, duration of diarrhea, occupation, and season were the most relevant factors in distinguishing cholera-positive suspected cases from cholera-negative suspected cases. Nationwide surveillance data show that cholera is circulating in Bangladesh and the southern region is more affected than the northern region. Antimicrobial resistance patterns indicate that multidrug resistance (resistance to three or more classes of antibiotics) of V. cholerae O1 could be a major threat in the future. Alignment of these results with Bangladesh's cholera-control program will be the foundation for future research into the efficacy of cholera-control initiatives.
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Affiliation(s)
- Md Taufiqul Islam
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- School of Medical Science, Griffith University, Gold Coast, Australia
| | - Sonia Tara Hegde
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ashraful Islam Khan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Taufiqur Rahman Bhuiyan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Zahid Hasan Khan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Faisal Ahmmed
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Yasmina Ara Begum
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mokibul Hassan Afrad
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Ashraful Amin
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nabid Anjum Tanvir
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ishtiakul Islam Khan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Zakir Hossain Habib
- Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka, Bangladesh
| | - Ahmed Nawsher Alam
- Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka, Bangladesh
| | - Nigel A. McMillan
- School of Medical Science, Griffith University, Gold Coast, Australia
| | - Tahmina Shirin
- Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka, Bangladesh
| | - Andrew S. Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Firdausi Qadri
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Jubyda FT, Nahar KS, Barman I, Johura FT, Islam MT, Sultana M, Ullah W, Tasnim J, Biswas SR, Monir MM, George CM, Camilli A, Ahmed N, Ross AG, Clemens JD, Alam M. Vibrio cholerae O1 associated with recent endemic cholera shows temporal changes in serotype, genotype, and drug-resistance patterns in Bangladesh. Gut Pathog 2023; 15:17. [PMID: 37046358 PMCID: PMC10090749 DOI: 10.1186/s13099-023-00537-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/23/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Despite the advancement in our understanding of cholera and its etiological agent, Vibrio cholerae, the prevention and treatment of the disease are often hindered due to rapid changes in drug response pattern, serotype, and the major genomic islands namely, the CTX-prophage, and related genetic characteristics. In the present study, V. cholerae (n = 172) associated with endemic cholera in Dhaka during the years 2015-2021 were analyzed for major phenotypic and genetic characteristics, including drug resistance patterns. RESULTS Results revealed that the V. cholerae strains belonged to serogroup O1 biotype El Tor carrying El Tor -specific genes rtxC, tcpA El Tor, and hlyA El Tor, but possessed classical-biotype cholera toxin. Serotypes of V. cholerae strains differed temporally in predominance with Inaba during 2015-2017, and again in 2020-2021, while Ogawa was the predominant serotype in 2018-2019. Also, ctxB1 was predominant in V. cholerae associated with cholera during 2015-2017, while ctxB7 was predominant in 2018, and in the subsequent years, as observed until 2021. V. cholerae strains differed in their antibiotic resistance pattern with a majority (97%) being multi-drug resistant (MDR) and belonging to six sub-groups. Notably, one of these MDR strains was resistant to eleven of the eighteen antibiotics tested, with resistance to fourth-generation cephalosporin (cefepime), and aztreonam. This extreme drug resistant (XDR) strain carried resistance-related genes namely, extended-spectrum β-lactamases (ESBL), blaOXA-1 and blaPER-3. CONCLUSION The observed temporal switching of serotypes, as well as the ctxB genotype, and the emergence of MDR/XDR V. cholerae and their association with endemic cholera in Dhaka underscore the need for routine monitoring of the pathogen for proper patient management.
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Affiliation(s)
- Fatema Tuz Jubyda
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
- Department of Microbiology, Jahangirnagar University, Dhaka, Bangladesh
| | - Kazi Sumaita Nahar
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Indrajeet Barman
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Fatema-Tuz Johura
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Mohammad Tarequl Islam
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Marzia Sultana
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Wali Ullah
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Jarin Tasnim
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Sahitya Ranjan Biswas
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Md Mamun Monir
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | | | | | - Niyaz Ahmed
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
- Pathogen Biology Laboratory, Department of Biotechnology and Bioinformatics, University of Hyderabad, Hyderabad, Telangana State, India
| | - Allen G Ross
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
- Charles Sturt University, Orange, NSW, Australia
| | - John D Clemens
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Munirul Alam
- icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh.
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Monir MM, Islam MT, Mazumder R, Mondal D, Nahar KS, Sultana M, Morita M, Ohnishi M, Huq A, Watanabe H, Qadri F, Rahman M, Thomson N, Seed K, Colwell RR, Ahmed T, Alam M. Genomic attributes of Vibrio cholerae O1 responsible for 2022 massive cholera outbreak in Bangladesh. Nat Commun 2023; 14:1154. [PMID: 36859426 PMCID: PMC9977884 DOI: 10.1038/s41467-023-36687-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 02/09/2023] [Indexed: 03/03/2023] Open
Abstract
In 2022, one of its worst cholera outbreaks began in Bangladesh and the icddr,b Dhaka hospital treated more than 1300 patients and ca. 42,000 diarrheal cases from March-1 to April-10, 20221. Here, we present genomic attributes of V. cholerae O1 responsible for the 2022 Dhaka outbreak and 960 7th pandemic El Tor (7PET) strains from 88 countries. Results show strains isolated during the Dhaka outbreak cluster with 7PET wave-3 global clade strains, but comprise subclade BD-1.2, for which the most recent common ancestor appears to be that responsible for recent endemic cholera in India. BD-1.2 strains are present in Bangladesh since 2016, but not establishing dominance over BD-2 lineage strains2 until 2018 and predominantly associated with endemic cholera. In conclusion, the recent shift in lineage and genetic attributes, including serotype switching of BD-1.2 from Ogawa to Inaba, may explain the increasing number of cholera cases in Bangladesh.
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Affiliation(s)
- Md Mamun Monir
- Infectious diseases division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Mohammad Tarequl Islam
- Infectious diseases division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Razib Mazumder
- Laboratory Sciences and Services Division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Dinesh Mondal
- Laboratory Sciences and Services Division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Kazi Sumaita Nahar
- Infectious diseases division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Marzia Sultana
- Infectious diseases division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Masatomo Morita
- Department of Bacteriology, National Institute of Infectious Diseases (NIID), Tokyo, Japan
| | - Makoto Ohnishi
- Department of Bacteriology, National Institute of Infectious Diseases (NIID), Tokyo, Japan
| | - Anwar Huq
- Maryland Pathogen Research Institute, University of Maryland, College Park, MD, USA
| | - Haruo Watanabe
- Department of Bacteriology, National Institute of Infectious Diseases (NIID), Tokyo, Japan
| | - Firdausi Qadri
- Infectious diseases division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Mustafizur Rahman
- Infectious diseases division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Nicholas Thomson
- Parasites and Microbes Programme, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom
| | - Kimberley Seed
- Department of Plant and Microbial Biology, University of California, Berkeley, CA, USA
| | - Rita R Colwell
- Maryland Pathogen Research Institute, University of Maryland, College Park, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Munirul Alam
- Infectious diseases division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh.
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