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Background Global estimates for cholera annually approximate 4 million cases worldwide with 95,000 deaths. Recent outbreaks, including Haiti and Yemen, are reminders that cholera is still a global health concern. Cholera outbreaks can rapidly induce high death tolls by overwhelming the capacity of health facilities, especially in remote areas or areas of civil unrest. Recent studies demonstrated that stool specimens preserved on filter paper facilitate molecular analysis of Vibrio cholerae in resource limited settings. Specimens preserved in a rapid, low-cost, safe and sustainable manner for sequencing provides previously unavailable data about circulating cholera strains. This may ultimately contribute new information to shape public policy response on cholera control and elimination. Methodology/Principal findings Whole genome sequencing (WGS) recovered close to a complete sequence of the V. cholerae O1 genome with satisfactory genome coverage from stool specimens enriched in alkaline peptone water (APW) and V. cholerae culture isolates, both spotted on filter paper. The minimum concentration of V. cholerae DNA sufficient to produce quality genomic information was 0.02 ng/μL. The genomic data confirmed the presence or absence of genes of epidemiological interest, including cholera toxin and pilus loci. WGS identified a variety of diarrheal pathogens from APW-enriched specimen spotted filter paper, highlighting the potential for this technique to explore the gut microbiome, potentially identifying co-infections, which may impact the severity of disease. WGS demonstrated that these specimens fit within the current global cholera phylogenetic tree, identifying the strains as the 7th pandemic El Tor. Conclusions WGS results allowed for mapping of short reads from APW-enriched specimen and culture isolate spotted filter papers. This provided valuable molecular epidemiological sequence information on V. cholerae strains from remote, low-resource settings. These results identified the presence of co-infecting pathogens while providing rare insight into the specific V. cholerae strains causing outbreaks in cholera-endemic areas., Author summary Cholera affects more than 4 million people globally every year; people predominantly living in poverty or in resource-constrained conditions including political crises or natural disasters. Cholera’s typical presentation is characterized by rapid onset of acute watery diarrhea and vomiting which can progress from watery stool to shock in as little as four hours. Laboratory conditions needed for culture confirmation and strain preservation are rarely to never present in these affected areas. In fact, many cholera endemic areas in Sub-Saharan African are so remote that even treatment response alone is often challenging. Here we present the genomic analysis of DNA extracted from dried filter paper, which is a low-cost, low-tech and sustainable method. Previously this method has facilitated cholera confirmation by PCR, but we demonstrate that this method is also suitable for whole genome sequencing and subsequent strain characterization by presenting the analysis of samples from an outbreak in a remote area of Cameroon. This method will facilitate the understanding of the molecular epidemiology in cholera-prone areas, which were previously too challenging to attempt. It also introduces a method that can be used on a broader scale for diarrheal disease surveillance, including providing a window into co-infection and microbiome analyses.

Confirmation of a cholera epidemic is based on bacteriological identification of the agent and requires the sending of samples to a culture laboratory, often in countries with limited resources. Comparison of the use of filter paper with the use of Cary-Blair reference medium for stool transport showed that this simple transport medium is appropriate for the recovery of Vibrio cholerae .

Dear Sir: We read with great interest the recent article by Debes and others1 concerning simplified cholera surveillance methods performed in the Far North Region of Cameroon in 2013–2014. The authors described the novel use of filter paper to preserve DNA specimens for polymerase chain reaction (PCR) confirmation of cholera. In another recent article,2 they used the same sampling method to genotype Vibrio cholerae using multiple loci variable number tandem repeat (VNTR) analysis (MLVA), in the same resource-constrained area. In both studies, stool specimens were initially enriched for 6–8 hours in alkaline peptone water (APW). One to two drops of the enrichment were subsequently aliquoted onto Whatman 903 Protein Saver Cards (GE Healthcare Limited, Chalfont St.Giles, UK) and allowed to air-dry. While investigating the origin of a cholera epidemic in the Republic of Guinea3 in September 2012, we experimented direct dried stool sampling on filter paper in the neighboring Sierra Leone, without prior enrichment in APW. Indeed, analysis of surveillance data and field investigations suggested a recent importation of cholera from Sierra Leone. However, lacking laboratory capacities in this country impaired the inclusion of samples for genetic comparison with Guinean culture isolates.4 Dried blood or saliva specimens on filter paper are relatively easy to collect, store, and transport, as they are not subject to United Nations biosafety regulations for transport of category B infectious substances.5 Moreover, direct PCR detection of V. cholerae on stool samples has been shown to represent a successful diagnosis method for cholera.6 With official authorization of Sierra Leonean health authorities, 17 suspected cholera patients were thus anonymously sampled in cholera treatment units in several coastal districts (Supplemental Figure 1). One or two drops of their watery diarrhea were directly collected from nonchlorinated buckets below cholera cots and then deposited onto each sample area of Whatman FTA Elute Micro Cards (GE Healthcare Limited, Chalfont St. Giles, UK). Each sample was air-dried for approximately 5 minutes in a shaded area, sealed with a Desiccant Packet (GE Healthcare Limited, Chalfont St. Giles, UK) into individual Multi-Barrier Pouches (GE Healthcare Limited, Chalfont St. Giles, UK), transported to Marseille, France, and stored at ambient temperature. For technical reasons, DNA extraction was performed only in June 2015. Using a scalpel, a 1-cm2 area of the filter paper was removed and suspended in 500 μL NucliSENS® easyMAG® lysis buffer (bioMerieux, Marcy l'Etoile, France) overnight at 4°C. The DNA was then extracted using a NucliSENS® easyMAG® platform (bioMerieux, Marcy l'Etoile, France) as previously described,7 and the supernatants were stored at −20°C for downstream PCR assays. To check for conserved DNA, a 16S ribosomal DNA PCR was performed as previously described.8 Six previously described VNTRs7 were independently genotyped for each sample. All primer pairs were verified to be specific for V. cholerae using National Center for Biotechnology Information (NCBI) Basic Local Alignment Search Tool (BLAST), and one primer set was located within the cholera toxin A subunit promoter region. MLVA results of the Sierra Leonean samples were included within the genotype panel of 35 Guinean isolates isolated via conventional culture in February–September 2012 (Supplemental Figure 1) and genotyped using the same method.7 The presence of amplifiable bacterial DNA was confirmed by 16S PCR in all 17 filter paper samples (Supplemental Table 1). Toxigenic V. cholerae was confirmed and MLVA genotyping was completed for nine of them. All VNTR-specific PCRs were negative for the eight remaining samples, which suggest that the corresponding patients may have been affected by noncholera acute watery diarrhea. The panel of nine genotyped samples from Sierra Leone displayed four distinct MLVA types (1, 5, 6, and 7). Together with the samples from Guinea, these MLVA types formed a single clonal complex of 13 closely related MLVA types (Supplemental Figure 1). Two MLVA types (5 and 6) were common to both Sierra Leonean and Guinean samples (Supplemental Figure 1). We thus confirm that filter paper is a very convenient, inexpensive, and efficient tool to sample suspected cholera cases for delayed molecular studies, including V. cholerae MLVA genotyping, even after several years of storage at room temperature. Moreover, we demonstrate that prior stool enrichment in APW is not necessary to perform specific V. cholerae PCRs, which renders sampling even easier. Further experiments are required to determine whether this method of DNA collection and conservation is sufficient for V. cholerae whole-genome single nucleotide polymorphism–based phylogenetics. In addition, MLVA genotyping of these cholera filter paper samples further bolsters the initial conclusion that Sierra Leone and the Republic of Guinea were affected in 2012 by the same transborder cholera epidemic,3 which was genetically related to outbreaks in Togo between 2010 and 2012.7 Such genotyping results can provide valuable insight to optimize control and prevention strategies. Direct stool sampling on filter papers should therefore be included in the rapid response package to investigate cholera epidemics, especially when V. cholerae culture and strain storage facilities are not available or biosafety shipping to specialized genotyping laboratories is too complicated.

The "View now" link directs to the finding aid only. Please email wvrhcref@mail.wvu.edu or call 304-293-3536 for more information about accessing collection A&M 1563 Alfred Beckley (1802-1888) Papers, 1832-1856. Correspondence of General Alfred Beckley and his wife Emily Craig. Several of the letters are by Beckley's mother from Lexington, Kentucky and comment on the Presidential election of 1832 in that state, the reception of President Jackson's in Lexington, 1832 the Cholera scourge, and local social affairs. The rest of the letters are concerned with family matters.

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Cholera is both an endemic and epidemic disease in many low and middle-income countries (LMICs). Strategies for cholera control include improving water, sanitation, and hygiene; providing early and effective treatment; and deploying oral cholera vaccine (OCV). This last strategy is relatively new, and countries considering its introduction are interested in knowing the potential cost not only of the vaccine, but also the cost of introduction. This paper describes the costing of OCV introduction in LMICs using a publicly available Excel-based tool known as the CholTool. It includes estimates of delivery cost categories which cover not only the service delivery costs (e.g. vaccine procurement, handling, storage, and transport; vaccination administration, monitoring supervision, and field support), but also the programmatic costs associated with introducing a new vaccine (i.e. microplanning, communication and training materials development, sensitization/social mobilization, and personnel training) to ensure that a comprehensive estimate is provided with health payer perspective. CholTool takes the user through a structured sequence of interlinked modules containing input parameter cells (assumptions), decision cells (variable selections), and formulas (calculations) to produce customized cost estimates based on standardized methods. The tool provides both financial and economic cost estimates, to ensure that both costs are available for consideration. Four examples of applications of CholTool are presented in three countries- one in Ethiopia, two in Malawi and one in Nepal. The estimates of economic delivery cost per dose (including service delivery and programmatic costs) were (in USD 2016): $2.89 in Ethiopia, $3.04 in Malawi1, $3.35 in Malawi2 and $3.06 in Nepal. A cost projection conducted before the campaign using the tool and a retrospective costing using the tool in Nepal resulted in no significant difference between economic delivery costs per dose.

Cholera is one of the major public health problems in the state of Odisha, India since centuries. The current paper is a comprehensive report on epidemiology of cholera in Odisha, which was documented from 1993. PubMed and Web of Knowledge were searched for publications reporting cholera in Odisha during the period 1993–2015. The search was performed using the keywords ‘Odisha’ and/or ‘Orissa’ and ‘Cholera’. In addition, manual search was undertaken to find out relevant papers. During the study period, a total of 37 cholera outbreaks were reported with an average of >1.5 cholera outbreaks per year and case fatality ratio was 0.3%. Vibrio cholerae O1 Ogawa serotype was the major causative agent in most of the cholera cases. The recent studies demonstrated the prevalence of V. cholerae O1, El Tor variants carrying ctxB1, ctxB7 and Haitian variant tcpA allele associated with polymyxin B sensitivity and these variants are replacing the proto type El Tor. The first report of variant ctxB7 in Odisha during super-cyclone 1999 predicted its emergence and subsequent spread causing cholera outbreaks. The prevalence of multidrug-resistant V. cholerae at different time periods created alarming situation. The efficacy trial of oral cholera vaccine (OCV, Shanchol) in a public health set-up in Odisha has shown encouraging results which should be deployed for community level vaccination among the vulnerable population. This paper has taken an effort to disseminate the valuable information of epidemiology of cholera that will influence the policy-makers and epidemiologists for constant surveillance in other parts of Odisha, India and around the globe.

The cholera vaccine can protect patients with inflammatory bowel disease (IBD) against both cholera and travelers’ diarrhea. However, both immunosuppressive treatment and IBD can affect its vaccine immunogenicity. The aim of this study was to assess the immunogenicity and safety of the cholera vaccine in children with IBD. Children older than 6 years with diagnosed IBD were enrolled in this multicenter study. All patients were administered two doses of the oral cholera vaccine (Dukoral®). Anti-cholera toxin B subunit IgA and IgG seroconversion rates were evaluated in a group with immunosuppressive (IS) treatment and a group without IS treatment (NIS). Immunogenicity was assessed in 70 children, 79% of whom received IS treatment. Post-vaccination seroconversion was displayed by 33% of children, for IgA, and 70% of children, for IgG. No statistically significant differences were found in the immune responses between the IS and NIS groups: 35% vs. 27% (p = .90), for IgA, and 68% vs. 80.0% (p = .16), for IgG, respectively. One case of IBD exacerbation after vaccination was reported. The oral cholera vaccine is safe. The immunogenicity of the oral cholera vaccine in children with IBD was lower than previously observed in healthy ones. The treatment type does not seem to affect the vaccine immunogenicity.

Background: The new influx of Forcibly Displaced Myanmar Nationals (FDMNs) into Bangladesh started in August 2017 through different entry points of Bangladesh. Considering the imminent threat of infectious diseases outbreaks, the Government of Bangladesh (GoB) decided to vaccinate children against three deadly diseases (measles, rubella and poliomyelitis) and oral cholera vaccine (OCV) for all except

Background Yemen has recently faced the largest cholera outbreak in the world, which started at the end of 2016. By the end of 2017, the cumulative reported cases from all governorates reached 777,229 with 2134 deaths. Al Hudaydah was one of the most strongly affected areas, with 88,741 (18%) cases and 244 (12%) deaths reported. Objective The aim of this study was to determine the risk factors associated with cholera transmission in Al Hudaydah city, Yemen. Methods From December 1, 2017 to January 10, 2018, a total of 104 patients with cholera (57 women and 47 men) who presented at cholera treatment centers in Al Hudaydah city with three or more watery stools in a 24-hour period and with moderate or severe dehydration were identified for inclusion in this study. Each case was matched by age and gender with two controls who were living in the neighboring house. A semistructured questionnaire was used to collect data on behavioral and environmental risk factors such as drinking water from public wells, storing water in containers, consumption of unwashed vegetables or fruits, and sharing a toilet. Results The median age of the cases and controls was 20 years (range 5-80) and 23 years (range 5-85), respectively. Only 6% of cases and 4% of controls were employed. Multivariate analysis showed that eating unwashed vegetables or fruits (odds ratio [OR] 7.0, 95% CI 1.6-30.6, P=.01), storing water in containers (OR 3.0, 95% CI 1.3-7.3, P=.01), drinking water from a public well (OR 2.5, 95% CI 1.1-5.7, P=.02), and using a public toilet (OR 5.2, 95% CI 1.1-24.4, P=.04) were significantly associated with cholera infection risk. Conclusions The cholera transmission risk factors in Al Hudaydah city were related to water and sanitation hygiene. Therefore, increasing awareness of the population on the importance of water chlorination, and washing fruits and vegetables through a health education campaign is strongly recommended.

Background Cholera poses a significant global health burden. In Bangladesh, cholera is endemic and causes more than 100,000 cases each year. Established environmental reservoirs leave millions at risk of infection through the consumption of contaminated water. The Global Task Force for Cholera Control has called for increased environmental surveillance to detect contaminated water sources prior to human infection in an effort to reduce cases and deaths. The OmniVis rapid cholera detection device uses loop-mediated isothermal amplification and particle diffusometry detection methods integrated into a handheld hardware device that attaches to an iPhone 6 to identify and map contaminated water sources. Objective The aim of this study was to evaluate the usability of the OmniVis device with targeted end users to advance the iterative prototyping process and ultimately design a device that easily integrates into users’ workflow. Methods Water quality workers were trained to use the device and subsequently completed an independent device trial and usability questionnaire. Pretraining and posttraining knowledge assessments were administered to ensure training quality did not confound trial and questionnaire Results Device trials identified common user errors and device malfunctions including incorrect test kit insertion and device powering issues. We did not observe meaningful differences in user errors or device malfunctions accumulated per participant across demographic groups. Over 25 trials, the mean time to complete a test was 47 minutes, a significant reduction compared with laboratory protocols, which take approximately 3 days. Overall, participants found the device easy to use and expressed confidence and comfort in using the device independently. Conclusions These results are used to advance the iterative prototyping process of the OmniVis rapid cholera detection device so it can achieve user uptake, workflow integration, and scale to ultimately impact cholera control and elimination strategies. We hope this methodology will promote robust usability evaluations of rapid pathogen detection technologies in device development.