Diarrheal Outbreaks Research Articles

Effectiveness of emergency water treatment practices in refugee camps in South Sudan.

ObjectiveTo investigate the concentration of residual chlorine in drinking water supplies in refugee camps, South Sudan, March–April 2013.MethodsFor each of three refugee camps, we measured physical and chemical characteristics of water supplies at four points after distribution: (i) directly from tapstands; (ii) after collection; (iii) after transport to households; and (iv) after several hours of household storage. The following parameters were measured: free and total residual chlorine, temperature, turbidity, pH, electrical conductivity and oxidation reduction potential. We documented water handling practices with spot checks and respondent self-reports. We analysed factors affecting residual chlorine concentrations using mathematical and linear regression models.FindingsFor initial free residual chlorine concentrations in the 0.5–1.5 mg/L range, a decay rate of ~5x10-3 L/mg/min was found across all camps. Regression models showed that the decay of residual chlorine was related to initial chlorine levels, electrical conductivity and air temperature. Covering water storage containers, but not other water handling practices, improved the residual chlorine levels.ConclusionThe concentrations of residual chlorine that we measured in water supplies in refugee camps in South Sudan were too low. We tentatively recommend that the free residual chlorine guideline be increased to 1.0 mg/L in all situations, irrespective of diarrhoeal disease outbreaks and the pH or turbidity of water supplies. According to our findings, this would ensure a free residual chlorine level of 0.2 mg/L for at least 10 hours after distribution. However, it is unknown whether our findings are generalizable to other camps and further studies are therefore required.

Water, Sanitation, and Hygiene at the World's Largest Mass Gathering.

The 2013 Kumbh Mela, a Hindu religious festival and the largest human gathering on earth, drew an estimated 120 million pilgrims to bathe at the holy confluence of the Ganga (Ganges) and Yamuna rivers. To accommodate the massive numbers, the Indian government constructed a temporary city on the flood plains of the two rivers and provided it with roads, electricity, water and sanitation facilities, police stations, and a tiered healthcare system. This phenomenal operation and its impacts have gone largely undocumented. To address this gap, the authors undertook an evaluation and systematic monitoring initiative to study preparedness and response to public health emergencies at the event. This paper describes the water, sanitation, and hygiene components, with particular emphasis on preventive and mitigation strategies; the capacity for surveillance and response to diarrheal disease outbreaks; and the implications of lessons learned for other mass gatherings.

Epidemiological and antibiotic susceptibility profiles of infectious bacterial diarrhoea in Juba, South Sudan.

Background: Diarrhoeal diseases have remained a major health problem in South Sudan where they accounted 45% prevalence in under five-year olds. Between 2006 and 2007, the country reported a morbidity of 8,337 cases and 176 deaths due to diarrhoeal outbreaks. Methodology: We investigated causative agents of diarrhoeal diseases and their antibiogram in persons presenting with diarrhoea to selected health facilities in Juba. Results: Bacterial agents were prevalent in 20 (6.9%) of the 286 patients with 5.7% (4/70) in under five-year olds alone. S. dysenteriae 50% (10/20) accounted for the majority of the identified pathogens followed S. flexneri 25% (5/20) and S. typh 25% (5/20). Antibiotic testing showed that S. flexneri (5/5) and S. typhi (5/5) were all 100% sensitive to ceftriaxone, and gentamicin while S. dysenteriae had varying sensitivity to ciprofloxacin (70%), nalidixic acid (90%), and ceftriaxone(100%). These pathogens had 100% resistance to amoxicillin, ampicillin, tetracycline and cotrimoxazole. No difference existed in isolation rates among different age groups, educational status, gender, water drank, use of chlorine, toilet use, exposure at home to diarrhoea patient, hand washing with soap and location of residence. However, diarrhoeagenic bacteria isolation was higher for participants with no source of income (OR=6.08, p<0.05). Conclusion: With emerging menace of resistance to commonly used antibiotics in South Sudan we recommend antibiotic resistance monitoring and regulation of antibiotic use.

An Outbreak of Foodborne Illness Caused by Enteroaggregative Escherichia coli in a High School in South Korea.

In June 2013, a diarrheal outbreak occurred among high school students in Incheon, South Korea. We investigated the outbreak to identify the pathogen and mode of transmission. A case-control study using a self-administered questionnaire was conducted by local authorities and the Korean Centers for Disease Control and Prevention. Bacterial cultures of stool samples, environmental samples, and samples of preserved food items were prepared. PCR, serotyping, and pulsed-field gel electrophoresis (PFGE) were used to identify and characterize the outbreak-related pathogen. We identified 54 cases of gastroenteritis, with symptoms including diarrhea, abdominal pain, and nausea. None of the food items served in the high school cafeteria were significantly associated with illness, although the odds ratio for kippered trotters mixed with vegetables was relatively high (odds ratio: 2.92, 95% confidence interval: 0.62-13.69). Enteroaggregative Escherichia coli (EAEC) was isolated from this item and the stool samples from 22 symptomatic students and 4 asymptomatic food handlers. The PFGE patterns of EAEC isolated from these sources were indistinguishable. This outbreak was caused by EAEC, and kippered trotters mixed with vegetables, perhaps contaminated by asymptomatic food handlers, were linked to the outbreak. This case-control study highlights the importance of safe food preparation.

Giardia lamblia binding immunoglobulin protein triggers maturation of dendritic cells via activation of TLR4‐MyD88‐p38 and ERK1/2 MAPKs

SummaryMuch remains unknown about the mammalian immune response to Giardia lamblia, a protozoan pathogen that causes diarrhoeal outbreaks. We fractionated protein extracts of G. lamblia trophozoites by Viva‐spin centrifugation, DEAE ion exchange and gel filtration chromatography. Resultant fractions were screened for antigenic molecules by western blots analysis using anti‐G. lamblia antibodies (Abs), resulting in identification of G. lamblia binding immunoglobulin protein (GlBiP). Maturation of mouse dendritic cells (DCs) in response to recombinant GlBiP (rGlBiP) was detected by increased expression of surface molecules such as CD80, CD86 and MHC class II; these mature DCs, produced pro‐inflammatory cytokines (TNF‐α, IL‐12 and IL‐6). Especially, the truncated rGlBiP containing the heat‐shock protein 70 domain‐induced cytokine production from mouse DCs. rGlBiP‐induced DC activation was initiated by TLR4 in a MyD88‐dependent way and occurred through activation of p38 and ERK1/2 MAPKs as well as increased activity of NF‐κB and AP‐1. Moreover, CD4+ T cells stimulated with rGlBiP‐treated DCs produced high levels of IL‐2 and IFN‐γ. Together, our results suggest that GlBiP contributes to maturation of DCs via activation of TLR4‐MyD88‐p38, ERK1/2 MAPK, NF‐κB and AP‐1.

Genome Sequences of 228 Shiga Toxin-Producing Escherichia coli Isolates and 12 Isolates Representing Other Diarrheagenic E.coli Pathotypes.

Shiga toxin-producing Escherichia coli (STEC) are a common cause for food-borne diarrheal illness outbreaks and sporadic cases. Here, we report the availability of the draft genome sequences of 228 STEC strains representing 32 serotypes with known pulsed-field gel electrophoresis (PFGE) types and epidemiological relationships, as well as 12 strains representing other diarrheagenic E. coli pathotypes.

Diarrheal Outbreak Caused by Atypical EnteropathogenicEscherichia coliO157:H45 in South Korea

Background: In May 2013, an outbreak of gastroenteritis occurred in a high school in Incheon, South Korea. We investigated the outbreak in order to identify the pathogen and mode of transmission. A case-control study was performed using standardized questionnaires with a case definition of illness with diarrhea. Stool samples, environmental samples, and samples from preserved food items were collected to test pathogens. Pulsed-field gel electrophoresis (PFGE) was performed on the outbreak-related Escherichia coli strains. Thirty-three people (attack rate: 2.5%) met the case definition, and the pattern of the epidemic curve suggested a point-source outbreak. The common symptoms of cases were diarrhea (100.0%), abdominal pain (75.8%), chills (45.5%), and nausea (39.4%). Cases were found to be 8.26 times more likely to have eaten spicy fish soup with cod (95% confidence interval: 1.05-65.01). Consumption of egg soup with spring onions or braised eggs with razor clam flesh was significantly associated with illness. Atypical enteropathogenic E. coli O157:H45 was isolated from samples of 9 cases (27.3%) and tuna bibimbap. PFGE patterns of all tested isolates of O157 serotype were indistinguishable. This outbreak was caused by atypical enteropathogenic E. coli O157:H45 and the food vehicle was suspected to be tuna bibimbap. The statistical analysis was not in concordance with the microbiologic tests, probably owing to low pathogenicity of atypical enteropathogenic E. coli O157. This is the first report of an outbreak caused by atypical enteropathogenic E. coli O157.

Cholera outbreaks (2012) in three districts of Nepal reveal clonal transmission of multi-drug resistant Vibrio cholerae O1.

BackgroundAlthough endemic cholera causes significant morbidity and mortality each year in Nepal, lack of information about the causal bacterium often hinders cholera intervention and prevention. In 2012, diarrheal outbreaks affected three districts of Nepal with confirmed cases of mortality. This study was designed to understand the drug response patterns, source, and transmission of Vibrio cholerae associated with 2012 cholera outbreaks in Nepal.MethodsV. cholerae (n = 28) isolated from 2012 diarrhea outbreaks {n = 22; Kathmandu (n = 12), Doti (n = 9), Bajhang (n = 1)}, and surface water (n = 6; Kathmandu) were tested for antimicrobial response. Virulence properties and DNA fingerprinting of the strains were determined by multi-locus genetic screening employing polymerase chain reaction, DNA sequencing, and pulsed-field gel electrophoresis (PFGE).ResultsAll V. cholerae strains isolated from patients and surface water were confirmed to be toxigenic, belonging to serogroup O1, Ogawa serotype, biotype El Tor, and possessed classical biotype cholera toxin (CTX). Double-mismatch amplification mutation assay (DMAMA)-PCR revealed the V. cholerae strains to possess the B-7 allele of ctx subunit B. DNA sequencing of tcpA revealed a point mutation at amino acid position 64 (N → S) while the ctxAB promoter revealed four copies of the tandem heptamer repeat sequence 5'-TTTTGAT-3'. V. cholerae possessed all the ORFs of the Vibrio seventh pandemic island (VSP)-I but lacked the ORFs 498–511 of VSP-II. All strains were multidrug resistant with resistance to trimethoprim-sulfamethoxazole (SXT), nalidixic acid (NA), and streptomycin (S); all carried the SXT genetic element. DNA sequencing and deduced amino acid sequence of gyrA and parC of the NAR strains (n = 4) revealed point mutations at amino acid positions 83 (S → I), and 85 (S → L), respectively. Similar PFGE (NotI) pattern revealed the Nepalese V. cholerae to be clonal, and related closely with V. cholerae associated with cholera in Bangladesh and Haiti.ConclusionsIn 2012, diarrhea outbreaks in three districts of Nepal were due to transmission of multidrug resistant V. cholerae El Tor possessing cholera toxin (ctx) B-7 allele, which is clonal and related closely with V. cholerae associated with cholera in Bangladesh and Haiti.

Infectious diseases in early education and child care programs.

1. Timothy R. Shope, MD, MPH* 1. *Department of Pediatrics, Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA. * Abbreviations: AAP: : American Academy of Pediatrics CFOC3: : Caring for Our Children , 3rd ed ECE: : early care and education RSV: : respiratory syncytial virus Out-of-home care and education are the norms for most young children and lead to increased exposure to infectious diseases. Pediatricians need to be aware of strategies to reduce the risk of infection and guidelines for determining exclusion and return to care for mildly ill children who participate in group care arrangements. After completing this article, readers should be able to: 1. Recognize the risks of infectious diseases in children who participate in early care and education programs. 2. Understand methods for reducing infectious diseases in early care and education settings. 3. Identify which infectious diseases require exclusion from early care and education programs. Two-thirds of children younger than 6 years participate in nonparental out-of-home early education and child care. Demographic trends during the past several decades reflect an increased desire and need to work for men and women who are parents. During the first 2 years of participation, children enrolled in early care and education (ECE) programs experience a higher incidence of respiratory and diarrheal infections, otitis media, and antibiotic-resistant bacteria compared with their peers primarily cared for at home. The types of infection generally reflect common respiratory and gastrointestinal viruses in circulation in the community. However, there are some infectious diseases that can cause outbreaks or clusters of infections in ECE settings. When ill children are excluded from an ECE facility, parents may miss work, lose income, and seek health care services in an effort to return their children to child care. Pediatricians need to be aware of the infectious disease risks of child care attendance and various strategies for reducing them. In addition, pediatricians need to be knowledgeable about rational exclusion and return …

Vibrio fluvialis: an emerging human pathogen

Vibrio fluvialis is a pathogen commonly found in coastal environs. Considering recent increase in numbers of diarrheal outbreaks and sporadic extraintestinal cases, V. fluvialis has been considered as an emerging pathogen. Though this pathogen can be easily isolated by existing culture methods, its identification is still a challenging problem due to close phenotypic resemblance either with Vibrio cholerae or Aeromonas spp. However, using molecular tools, it is easy to identify V. fluvialis from clinical and different environmental samples. Many putative virulence factors have been reported, but its mechanisms of pathogenesis and survival fitness in the environment are yet to be explored. This chapter covers some of the major discoveries that have been made to understand the importance of V. fluvialis.

On the fiftieth anniversary Postinfectious irritable bowel syndrome: mechanisms related to pathogens

Gastrointestinal (GI) infections resulting from bacterial, viral, and parasitic pathogens predispose to postinfectious irritable bowel syndrome (PI-IBS) and other functional GI disorders. Existing literature supports the role of enterochromaffin cell hyperplasia, serotonin synthesis and reuptake, impaired barrier function, altered immune activation, and potentially mast cell activation in the pathophysiology of PI-IBS. The objective of this review was to summarize from the literature the characteristics of the pathogens commonly implicated in PI-IBS, their acute enteritis phases, and the changes seen in the postinfectious phase that may contribute toward development of IBS. A limitation of our current understanding is that the postinfectious GI sequelae reported in prior studies followed epidemic diarrheal outbreaks often involving more than one pathogen, or the studies focused on highly selected, tertiary referral patients. Understanding the mechanisms, natural history, and optimized management of individuals suffering PI-IBS following the more typical sporadic infection requires larger studies of PI-IBS following GI infections encountered in community settings. These studies should include genetic, physiological, and molecular studies to provide more generalizable information that can ultimately be used to diagnose, manage, and potentially prevent the development of PI-IBS.

A study of waterborne diseases during flooding using Radarsat-2 imagery and a back propagation neural network algorithm

Flood disasters are closely associated with an increased risk of infection, particularly from waterborne diseases. Most studies of waterborne diseases have relied on the direct determination of pathogens in contaminated water to assess disease risk. In contrast, this study aims to use an indirect assessment that employs a back propagation neural network (BPNN) for modelling diarrheal outbreaks using data from remote sensing and dissolved-oxygen (DO) measurements to reduce cost and time. Our study area is in Ayutthaya province, which was very severely affected by the catastrophic 2011 Thailand flood. BPNN was used to model the relationships among the parameters of the flood and the water quality and the risk of people becoming infected. Radarsat-2 scenes were utilized to estimate flood area and duration, while the flood water quality was derived from the interpolation of DO samples. The risk-ratio function was applied to the diarrheal morbidity to define the level of outbreak detection and the outbreak periods. Tests of the BPNN prediction model produced high prediction accuracy of diarrheal-outbreak risk with low prediction error and a high degree of correlation. With the promising accuracy of our approach, decision-makers can plan rapid and comprehensively preventive measures and countermeasures in advance.

Porcine Epidemic Diarrhea Virus Variants with High Pathogenicity, China

Porcine Epidemic Diarrhea Virus Variants with High Pathogenicity, China

Epidemiological and genetic analysis of human group C rotaviruses isolated from outbreaks of acute gastroenteritis in Yokohama, Japan, between 2006 and 2012

Group C rotavirus (GCRV) infection has been described in several parts of the world, predominantly as sporadic cases of acute gastroenteritis. Little is known about the yearly changes in the GCRV strains from diarrheal outbreaks. Stool samples collected from outbreaks of acute gastroenteritis in Yokohama, Japan, between 2006 and 2012 that were negative for norovirus, sapovirus, and group A rotavirus, were screened for GCRV using a reverse passive hemagglutination method. The GCRV strains were characterized by nucleotide sequence and phylogenetic analysis of their VP6, VP7, VP4, and NSP4 genes. Samples from nine of 735 outbreaks in Yokohama (1%) contained GCRV, and eight of these outbreaks occurred in primary schools. The nucleotide sequences of the strains detected in this study were more closely related to Asian strains than to those from other regions of the world. The nucleotide sequences of the VP7 gene in these nine strains differed, and yearly changes were observed in the amino acid sequences of the VP4 genes. Phylogenetic trees constructed using the nucleotide sequences of the VP6, VP7, VP4, and NSP4 genes showed that sublineage S1 has divided into S1-1 and S1-2 in the VP4 gene only. Our results confirm that the prevalent strains of GCRV change yearly in Yokohama. This is the first study to demonstrate GCRV-associated gastroenteritis outbreaks in Yokohama, Japan.

Control of bacterial virulence by the RalR regulator of the rabbit-specific enteropathogenic Escherichia coli strain E22.

Atypical enteropathogenic Escherichia coli (aEPEC) causes endemic diarrhea, diarrheal outbreaks, and persistent diarrhea in humans, but the mechanism by which aEPEC causes disease is incompletely understood. Virulence regulators and their associated regulons, which often include adhesins, play key roles in the expression of virulence factors in enteric pathogenic bacteria. In this study we identified a transcriptional regulator, RalR, in the rabbit-specific aEPEC strain, E22 (O103:H2) and examined its involvement in the regulation of virulence. Microarray analysis and quantitative real-time reverse transcription-PCR demonstrated that RalR enhances the expression of a number of genes encoding virulence-associated factors, including the Ral fimbria, the Aap dispersin, and its associated transport system, and downregulates several housekeeping genes, including fliC. These observations were confirmed by proteomic analysis of secreted and heat-extracted surface-associated proteins and by adherence and motility assays. To investigate the mechanism of RalR-mediated activation, we focused on its most highly upregulated target operons, ralCDEFGHI and aap. By using primer extension, electrophoretic mobility shift assay, and mutational analysis, we identified the promoter and operator sequences for these two operons. By employing promoter-lacZ reporter systems, we demonstrated that RalR activates the expression of its target genes by binding to one or more 8-bp palindromic sequences (with the consensus of TGTGCACA) located immediately upstream of the promoter core regions. Importantly, we also demonstrated that RalR is essential for virulence since infection of rabbits with E22 carrying a knockout mutation in the ralR gene completely abolished its ability to cause disease.

Overcoming barriers in evaluating outbreaks of diarrheal disease in resource poor settings: assessment of recurrent outbreaks in Chobe District, Botswana.

BackgroundDiarrheal illness remains a leading cause of global morbidity and mortality, with the majority of deaths occurring in children <5 years of age. Lack of resources often prohibits the evaluation of outbreak characteristics and limits progress in managing this important disease syndrome, particularly in Africa. Relying only on existing medical staff and hospital resources, we assess the use of a questionnaire survey tool to identify baseline outbreak characteristics during recurrent diarrheal outbreaks in Chobe, Botswana.MethodsUsing historical surveillance data (2006–2009), the temporal pattern of recurrent diarrheal outbreaks was evaluated among patients <5 years of age presenting to health facilities in Chobe District. Using a questionnaire survey tool, medical staff from selected health facilities assessed patients (all ages) presenting with diarrheal disease during two diarrheal outbreaks (2011–2012). Cluster analysis and classification and regression trees (CART) were used to evaluate patient attributes by outbreak.ResultsWe identified a bimodal, annual pattern of acute diarrhea in children <5 years of age across years (Wilcox test, W = 456.5, p = 0.052). Historical outbreak periods appeared to coincide with major hydrological phenomena (rainfall/flood recession). Across health facilities, a significant percent of patients in the prospective study were in the ≥5 age class (44%, n = 515 and 35%, n = 333 in the dry and wet season outbreaks, respectively). Cluster analysis of questionnaire data identified two main branches associated with patient age (<5 and ≥5 years of age). Patients did not cluster by outbreak or village. CART examination identified sex and hospitalization as being most predictive of patients <5 years and household diarrhea in patients ≥5 years. Water shortages and water quality deficiencies were identified in both outbreaks.ConclusionsDiarrhea is a persistent, seasonally occurring disease in Chobe District, Botswana. Lack of variation in outbreak variables suggests the possibility of environmental drivers influencing outbreak dynamics and the potential importance of human-environmental linkages in this region. Public health strategy should be directed at securing improved water service and correcting water quality deficiencies. Public health education should include increased emphasis on sanitation practices when providing care to household members with diarrhea. While global diarrheal disease surveillance is directed at the under-5 age group, this may not be appropriate in areas of high HIV prevalence such as that found in our study area where a large immune-compromised population may warrant increased surveillance across age groups. The approach used in this study provided the first detailed characterization of diarrheal disease outbreaks in the area, an important starting point for immediate intervention and development of working hypotheses for future disease investigations. While data derived from this approach are necessarily limited, they identify critical information on outbreak characteristics in resource poor settings where data gaps continue and disease incidence is high.

A multiplex RT-PCR assay for rapid and differential diagnosis of four porcine diarrhea associated viruses in field samples from pig farms in East China from 2010 to 2012

Since October 2010, clinical outbreaks of diarrhea in suckling piglets have reemerged in pig-producing areas of China, causing an acute increase in the morbidity and mortality in young piglets. Four viruses, porcine epidemic diarrhea virus (PEDV), transmissible gastroenteritis virus (TGEV), porcine group A rotaviruses (GAR), and porcine circovirus 2 (PCV2), are the major causative agents of enteric disease in piglets. A novel multiplex reverse transcription-polymerase chain reaction (mRT-PCR) was developed for simultaneous detection of the four viruses in field samples from piglets. A mixture of four previously published pairs of primers were used for amplification of viral gene, yielding four different amplicons with sizes of 481bp for PCV2, 651bp for PEDV, 859bp for TGEV, and 309bp for GAR, respectively. The sensitivity of the mRT-PCR using plasmids containing the specific viral target fragments was 2.17×103, 2.1×103, 1.74×104 and 1.26×104copies for the four viruses, respectively. A total of 378 field samples were collected from suckling piglets with diarrhea in East China from October 2010 to December 2012, and detected by mRT-PCR. The PEDV-positive rates of the three years were 69.2%, 62.8% and 54.9%, respectively, suggesting that PEDV was a major pathogen in these diarrheal outbreaks. Taken together, all data indicated that this mRT-PCR assay was a simple, rapid, sensitive, and cost-effective detection method for clinical diagnosis of mixed infections of porcine diarrhea associated viruses.

Analysis of Vibrio cholerae Genome Sequences Reveals Unique rtxA Variants in Environmental Strains and an rtxA -Null Mutation in Recent Altered El Tor Isolates

ABSTRACTVibrio cholerae genome sequences were analyzed for variation in the rtxA gene that encodes the multifunctional autoprocessing RTX (MARTX) toxin. To accommodate genomic analysis, a discrepancy in the annotated rtxA start site was resolved experimentally. The correct start site is an ATG downstream from rtxC resulting in a gene of 13,638 bp and deduced protein of 4,545 amino acids. Among the El Tor O1 and closely related O139 and O37 genomes, rtxA was highly conserved, with nine alleles differing by only 1 to 6 nucleotides in 100 years. In contrast, 12 alleles from environment-associated isolates are highly variable, at 1 to 3% by nucleotide and 3 to 7% by amino acid. The difference in variation rates did not represent a bias for conservation of the El Tor rtxA compared to that of other strains but rather reflected the lack of gene variation in overall genomes. Three alleles were identified that would affect the function of the MARTX toxin. Two environmental isolates carry novel arrangements of effector domains. These include a variant from RC385 that would suggest an adenylate cyclase toxin and from HE-09 that may have actin ADP-ribosylating activity. Within the recently emerged altered El Tor strains that have a classical ctxB gene, a mutation arose in rtxA that introduces a premature stop codon that disabled toxin function. This null mutant is the genetic background for subsequent emergence of the ctxB7 allele resulting in the strain that spread into Haiti in 2010. Thus, similar to classical strains, the altered El Tor pandemic strains eliminated rtxA after acquiring a classical ctxB.

Large outbreak of cholera caused by El Tor variant Vibrio cholerae O1 in the eastern coast of Odisha, India during 2009.

A large outbreak of cholera reported during April-July 2009 in the Kendrapada district of Odisha, India was investigated. Forty-one rectal swabs and 41 water samples, collected from diarrhoeal patients and from different villages were bacteriologically analysed for the isolation of bacterial enteriopathogens, antibiogram profile and detection of various toxic genes. The bacteriological analysis of rectal swabs and environmental water samples revealed the presence of V. cholerae O1 Ogawa biotype El Tor. The V. cholerae strains were resistant to ciprofloxacin, co-trimoxazole, chloramphenicol, streptomycin, ampicillin, furazolidone and nalidixic acid. The multiplex polymerase chain reaction (PCR) assay on V. cholerae strains revealed the presence of ctxA and tcpA genes. The mismatch amplification of mutation assay (MAMA) PCR on clinical and environmental isolates of V. cholerae revealed that the strains were El Tor biotype, which harboured the ctxB gene of the classical strain. The random amplified polymorphic DNA PCR analysis and pulsed-field gel electrophoresis results indicated that the V. cholerae isolates belonged to the same clone. This investigation gives a warning that the El Tor variant of V. cholerae has spread to the coastal district causing a large outbreak that requires close monitoring and surveillance on diarrhoeal outbreaks in Odisha.

A Foodborne Outbreak of Gastrointestinal Illness Caused by Enterotoxigenic &lt;i&gt;Escherichia coli&lt;/i&gt; Serotype O169:H41 in Osaka, Japan

We describe our laboratory investigation of a massive foodborne outbreak of gastrointestinal illness caused by enterotoxigenic Escherichia coli (ETEC) serotype O169:H41 that occurred during a 2-day traditional festival held in September 2012 in Osaka Prefecture, Japan. Of 126 customers who patronized a particular Japanese restaurant during the event, 102 developed symptoms of gastrointestinal disease. We isolated strains of ETEC serotype O169:H41 from 1 food sample and from fecal samples collected from 19 of 34 patients and 2 of 4 food handlers. Pulsed-field gel electrophoresis analysis of these isolates suggested that the foodborne pathogen that caused the diarrheal outbreak was a specific clone of ETEC serotype O169:H41. Based on these findings and our interviews with the restaurant owner and employees, we concluded that a likely cause of the outbreak was an overwhelmed capacity of the restaurant kitchen in terms of preservation of sanitary procedures during the festival and the inability of the restaurant staff to handle the relatively large quantity of food to ensure a lack of contamination with ETEC. Thus, we reconfirm that ETEC strains of serotype O169:H41 remain important causes of domestic foodborne outbreaks in developed countries, including Japan.