Genotypic assays confirmed all V. cholerae isolates by the presence of ompW. These isolates could be more virulent upon acquisition of cholera toxin in the future, which compares with findings by Eibach et al. The DNA was then stored at -20C for further analysis. All visitors or residents in areas where cholera is occurring or has occurred should follow recommendations to prevent getting sick: To receive email updates about this topic, enter your email address: We take your privacy seriously. Cholera is an acute diarrheal illness caused by certain strains of the bacterium Vibrio cholerae. A directory of local health departments is located at, Visit the Centers for Disease Control and Prevention website at. Bookshelf Use only bottled beverages or water that has been boiled or treated with chlorine for drinking, brushing teeth, or cleaning food preparation surfaces. Of the 10 virulent factors characterized, 6 (O1-rfb+ctxB+toxR+hlyA+rtxA+rtxC) were common among all the 5 clones. (EPEC) (40.8%) and rotavirus A (27.5%). Available at:https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON391. These cookies may also be used for advertising purposes by these third parties. Antibiotic susceptibility profile of Vibrio cholerae isolates across three outbreak years. Adv Exp Med Biol. Development of customized standard operation procedures for disease transmitted by the fecal-oral route and distribution to health care facilities to improve cholera case management. V. cholerae O1 and O139 serogroup organisms are the causes of epidemic cholera. eCollection 2022. Uninfected dead bodies have never been reported as the source of epidemics. At least four cases from clone A (3 cases) and clone B (1 case) were from the Central region. Although production of CT, encoded by the ctxAB genes, is directly responsible for the manifestation of diarrhoea [43], cholera pathogenesis relies on the synergistic action of additional genes. Trolle H, Forsberg B, King C, Akande O, Ayres S, Alfvn T, Elimian K. BMC Public Health. Interestingly, none of the remaining 14 (8.3%) non-O1/O139 V. cholerae isolates which were also negative for the ctxB gene were part of the large clones. Cholera Surveillance in the United States - Annual COVIS Summaries of Vibrio Illnesses WHO. Sunlight-induced propagation of the lysogenic phage encoding cholera toxin. The requirements for preventing outbreaks include improvement in sanitation, provision of safe drinking water, and safe food and water practices as well as hand washing. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Cholera is a highly virulent, lethal diarrhoeal disease caused by ingestion of water or food contaminated with the bacterium, Vibrio cholerae (V. cholerae). You will be subject to the destination website's privacy policy when you follow the link. We recognize this as a limitation of the study. Antibiotics are also sometimes used. WHO does not recommend any travel or trade restrictions on Pakistan based on the currently available information. Virulence. CDC twenty four seven. Since the first reported outbreak in 1970, Ghana has experienced many epidemics [2, 3]. Surveillance for early case detection, confirmation and response in other provinces and regions of Pakistan should be reinforced. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. National Library of Medicine Although approximately 200 recognized O serogroups have been. From the antibiotic susceptibility screening, we observed increasing antibiotic resistance among the V. cholerae isolates from 2012, 2014 and 2015 cholera outbreak seasons (Fig 2). Vibrios can survive for a long time in coastal waters contaminated by human faeces. Spatial analysis was performed using both the MLVA and epidemiological (residential address) data. Severe cases also require intravenous fluid replacement. WHO has provided support to health authorities in Pakistan through: The risk of potential international spread from Sindh province exists given that the most affected districts are located in Karachi city which is an industrial center as well as transport hub with airport and seaport; it is also the largest city in Pakistan and capital of Sindh province. Similar patterns have been reported from studies in Mozambique and Ghana [3336], but are in contrast to reports from India and South Mozambique [37, 38]. This implies that the inter serotype polymorphism in virulence markers may affect the efficacy of vaccines with limited strain composition in specific geographical areas. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Centers for Disease Control and Prevention. Their inability to be part of large clones may be due to the absence of the ctxB gene which makes them less virulent. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Vibrio cholerae remains a major public health threat worldwide, causing millions of cholera cases each year. It is caused by a gram-negative, toxigenic organism, Vibrio cholerae, which is found in aquatic environments. Copyright: 2020 Danso et al. MLVA differentiated the isolates into 2 large unique clones A and B, with each predominating in a particular year. PLOS ONE promises fair, rigorous peer review, Choleragenic V. cholera O1 and O139 are the only causative agents of the disease. Cookies used to make website functionality more relevant to you. [34] and Abana et al. doi: 10.1093/infdis/jit195. Cholera caused by Vibrio cholerae O139 was first reported in Bangladesh and India in 1992. 2023 Jan 3;23(1):527. doi: 10.3390/s23010527. Wkly Epidemiol Rec. Vibrio cholerae is the aetiological agent of cholera, an epidemic disease of significant public health importance owing to its rapid spread in areas with poor sanitation and hygiene, and its severe consequences when access to health care is limited. We conducted a molecular epidemiological study to detect virulence markers and antimicrobial resistance patterns of V. cholerae isolates obtained from the 20122015 cholera outbreaks in Ghana. The .gov means its official. The pathogenesis of cholera is complex involving several factors that aid V. cholerae bacteria to colonize and release enterotoxin (CT) that disrupts ion transport by intestinal epithelial cells. Advocacy and coordination through multiple high-level meetings. Oral cholera vaccines should be used in conjunction with improvements in WASH activities to control cholera outbreaks and for prevention in areas known to be at high risk for cholera. National Public Health and Reference Laboratory, Accra, Ghana, Affiliations: David Opare, O1 polyvalent anti-sera and monovalent anti-sera were used to define isolates as Ogawa, Inaba or Hikojima serotype. Isaac Darko Otchere, We are grateful to the staff of National Public Health and Reference Laboratory who collected the isolates. V. cholerae cell lysate was used as DNA template as previously described by Nandi et al. doi:10.1371/journal.pone.0236016, Editor: Iddya Karunasagar, Nitte University, INDIA, Received: December 23, 2019; Accepted: June 27, 2020; Published: July 10, 2020. 1998 Dec;66(12):5819-25. doi: 10.1128/IAI.66.12.5819-5825.1998. Should I be worried about getting cholera from others? 5 more], 2023;1404:213-232. doi: 10.1007/978-3-031-22997-8_11. Descriptions of clinical illness consistent with cholera date back to antiquity [1], [2]. Currently, there is no evidence of cross-border spread of the disease. A high rate of V. cholerae resistant to first- and second-line antibiotics occurs. In view of lysogenic conversion by CTXPhi as a possible mechanism of origination of new toxigenic clones of V. cholerae, it appears that the continual emergence of new toxigenic strains and their selective enrichment during cholera outbreaks constitute an essential component of the natural ecosystem for the evolution of epidemic V. cholerae strains and genetic elements that mediate the transfer of virulence genes. Cholera Dynamics and the Emergence of Pandemic Vibrio cholerae. Clinicians provisional diagnosis indicated cholera 139 (88.5%), gastroenteritis 6 (3.8%), gastroenteritis/malaria 3 (1.9%), diarrhoea 8 (5.2%) and retroviral infection 1 (0.6%). fluids might be necessary. Of 277 isolates analysed, 168 (60.6%) were confirmed to be V. cholerae and 109 (39.4%) isolates constituted other bacteria (Escherichia coli, Aeromonas sobria, Pseudomonas aeruginosa, Enterobacter cloacae and Enterococci faecalis). This solution is used throughout the world to treat diarrhea. Cholera in Times of Chaos. estimated 1.3 to 4 million people around the world get cholera each year and 21,000 to 143,000 people, Ending Cholera a Global Roadmap to 2030, Centers for Disease Control and Prevention (CDC), Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Foodborne, Waterborne, and Environmental Diseases (DFWED), Infection Control for Cholera in Health Care Settings, CDC Works With Global Partners to End Cholera, Clinical Presentation & Management in Haiti, CDC Responds to Cholera Outbreak in Haiti, Global Water, Sanitation, & Hygiene (WASH), Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Department of Health & Human Services. Improving access to safe drinking water and sanitation infrastructure, as well as improving IPC measures in healthcare facilities, with hygiene practices and food safety in affected communities are the most effective means of controlling cholera. While bacteria of cluster A were mostly responsible for the cholera outbreak in 2015, those of cluster B were responsible for 2014 outbreak cases which suggests an active transmission of V. cholerae instead of independent cases. Find answers to frequently asked questions about Cholera. These cookies may also be used for advertising purposes by these third parties. Laboratory support to civil hospitals to conduct water and environmental sampling. Prince Asare, Most people infected with V. cholerae do not develop any symptoms, although the bacteria are present in their faeces for 1-10 days after infection and are shed back into the environment, potentially infecting other people. It is very important that special replacement fluids containing the right balance of electrolytes (sodium, chloride, and potassium), sugar and water are used to replace the lost fluids. To determine the genomic epidemiology and origins of O139 in China, we sequenced 104 O139 isolates collected from Zhejiang Province, China, during 1994-2018 and compared them with 57 O139 genomes from other countries in Asia. All the 14 non-O1/non-O139 V. cholerae isolates were negative for the ctxB gene. During the 19th and 20th centuries, the disease spread globally beyond Asia seven times, referred to as cholera pandemics. In the United States, cholera occurs in persons who travel to foreign countries where outbreaks of cholera are occurring and who drink contaminated water and food there, or those who eat raw or undercooked seafood, including seafood from the Gulf of Mexico. Dispose of feces in a sanitary manner to prevent contamination of water and food sources. Careers. Prospective travelers to areas where cholera is common should carefully follow recommendations for obtaining safe food and water at their destination, and seek medical attention promptly if they develop symptoms of cholera. Ablekuma is densely populated and a low socio-economic sub-urban area which may have accounted for the outbreak [52]. The disease is not likely to spread directly from one person to another. Sensors (Basel). The frequency and diversity of other pathogens associated with diarrhoea in Ghana, concurs with similar reports from Nigeria, Bangladesh, Tanzania and Sierra Leone [2831]. Technical support for surveillance, case management including infection, prevention and control (IPC), data management and social mobilization. Unauthorized use of these marks is strictly prohibited. This includes advocating and guiding appropriate authorities on the response to the cholera outbreak and providing support to the provincial cholera control cell. When autocomplete results are available use up and down arrows to review and enter to select. Each reaction volume in a total of 25l comprised of 13.5l of nuclease free water, 2.5l (10pmol/l) of forward primer, 2.5l (10pmol/l) of reverse primer, 0.7l (2.5mM) of dNTPs, 0.3l (5U/ul) of hot start taq plus polymerase, 2.5l of 10X PCR coral load buffer (Qiagene) and 3l of template. In severe cases, when treatment is unavailable or delayed, death can occur within a few hours due to loss of large amounts of fluid. Community engagement and health education messages have been developed and disseminated in high-risk communities. The bacteria naturally live in brackish or saltwater where they attach themselves easily to the chitin-containing shells of crabs, shrimps, and other shellfish.Some strains of V. cholerae are pathogenic to humans and cause a deadly disease called cholera, which can be derived from the consumption of . MLVA Clustering analysis based on copy-numbers of the 5 VNTRs used for the study identified two major clusters (clusters A and B) of V. cholerae. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. 2023;1404:65-75. doi: 10.1007/978-3-031-22997-8_4. 2023;1404:127-147. doi: 10.1007/978-3-031-22997-8_7. The isolates were concurrently sub-cultured on thiosulphate-citrate-bile salt-sucrose (TCBS) agar, blood agar and in alkaline peptone water and all three media were aerobically incubated overnight at 37 C. Colonies were subjected to Analytical profile index (API 20E) standard biochemical tests. The 2012 V. cholerae isolates showed high resistance patterns to sulfamethoxazole-trimethoprim (3/4, 75%) and nalidixic acid (1/4, 25%) but were susceptible to over 70% of the antibiotics (S1 Table). Without treatment, death can occur within hours. Accessibility Front Genet. eCollection 2019. At least four cases from clone A (3 cases) and clone B (1 case) were from the Central region. For full functionality of this site, please enable JavaScript. Infect Immun. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. Phylogenetic tree of multi-locus variable number of tandem-repeat (VNTR) analysis (MLVA) for, PLOS is a nonprofit 501(c)(3) corporation, #C2354500, based in San Francisco, California, US. All information these cookies collect is aggregated and therefore anonymous. Overcrowding, poverty, insufficient water and sanitation facilities incre Alternatively, the Inaba serotype could have been imported. Although the mechanism by which CT causes diarrhea is known, it is not clear why V. cholerae should infect and elaborate the lethal toxin in the host. Cholera patients should be evaluated and treated quickly. eCollection 2022. Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium, Vibrio cholera. The ecosystem comprising V. cholerae, CTXPhi, the aquatic environment, and the mammalian host offers an understanding of the complex relationship between pathogenesis and the natural selection of a pathogen. Please enable it to take advantage of the complete set of features! Cholera affects both children and adults and can kill within hours if untreated. Whereas cluster A was dominated by isolates from the year 2015 except for 5 isolates in 2014 and 1 in 2012, cluster B was dominated by isolates from 2014 with the exception of 6 isolated in 2015. This site needs JavaScript to work properly. Front Genet. Keywords: They help us to know which pages are the most and least popular and see how visitors move around the site. Broad Street pump with handle removed. Francine Ntoumi, PMC The infection is not likely to spread directly from one person to another; therefore, casual contact with an infected person is not a risk factor for becoming ill. Cholera infection is often mild or without symptoms, but can be severe. All isolates from 2014 and 2015 were multidrug resistant against the selected antibiotics. The World Health Organization (WHO) estimates that in 2018, there were 1.3 to 4.0 million cases and 21,000 to 143,000 deaths due to cholera globally [1]. Out of the 15 districts within Greater Accra and Central Region (Fig 5), the strains were mostly clustered in the Accra Metropolis mainly within the Ablekuma sub-district. Shellfish eaten raw have been a source of infection. Vibrio cholerae is a species of Gram-negative, facultative anaerobe and comma-shaped bacteria. Faruque SM, Asadulghani, Saha MN, Alim AR, Albert MJ, Islam KM, Mekalanos JJ. What should I do if I or someone I know gets sick? Do not eat raw or undercooked meats and seafood, or raw or undercooked fruits and vegetables unless they are peeled. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. Institute for Environment and Sanitation Studies, University of Ghana, Legon, Accra, Ghana, Affiliation: The two most distinguishing epidemiologic features of the disease are its tendency to appea Cholera epidemiology in Nigeria: an overview Molecular epidemiological surveillance has revealed clonal diversity among toxigenic V. cholerae strains and a continual emergence of new epidemic clones. The identification of several virulence genes among the two different genotypes of V. cholerae isolates calls for scaleup of preventive strategies to reduce transmission and strengthening of public health laboratories for rapid antimicrobial susceptibility testing to guide accurate treatment. Our findings suggest that 91.7% of the cases were caused by toxigenic V. cholerae capable of causing highly dehydrating diarrhoea. West African Centre for Cell Biology of Infectious Pathogens, University of Ghana Legon, Legon, Accra, Ghana, In severe illness, intravenous (I.V.) Unable to load your collection due to an error, Unable to load your delegates due to an error. WHO recommends strengthening of the disease surveillance system. Call your local health department. Unable to load your collection due to an error, Unable to load your delegates due to an error, Genetic organization of the TCP pathogenicity island of, Model for the ToxR/ToxT regulatory cascade of, Proposed model for the emergence of new strains of toxigenic. This underscores the need to scale up laboratory-based surveillance of diarrhoeal diseases so that accurate identification of the specific aetiology of diarrhoeal diseases can be made using the Integrated Disease Surveillance and Response (IDSR) approach to effectively identify causative agent to enhance appropriate therapy. The MLVA was achieved using five previously described loci by Danin Poleg et al. Copyright 2019 The Authors. These clusters were independent of age, sex or geographical location meaning the only factor that was significantly associated with the clustering was the year of isolation (2014 and 2015). CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Of the 277 bacteria revived, 168 (61%) were both phenotypically and genotypically characterised as V. cholerae and the remaining 109 (39%) isolates were identified as: Aeromonas sobria: 14 (12.8%), Vibrio parahaemolyticus: 2 (1.8%), Pseudomonas aeruginosa: 7 (6.4%), Enterobacter cloacae: 16 (14.8%), Enterococci faecalis: 31 (28.4%), Escherichia coli: 26 (23.9%), Klebsiella pneumonia: 6 (5.5%) and Proteus mirabilis: 7 (6.4%). ST75 isolates were found across large spatial and temporal distances, suggesting local ST75 spread. ABSTRACT. The ctxAB gene plays a critical role towards the dehydration caused by toxigenic V. cholerae and is responsible for the pathogenesis. Cholera infection is often mild or without symptoms, but can sometimes be severe and life-threatening. Nevertheless, there were few 2014 outbreak genotypes that persisted in 2015 signifying the inefficiency of the control measures put in place or existence of an unknown environmental reservoir. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Adwoa Asante-Poku, government site. [35]. Cholera is most likely to occur and spread in places with inadequate water treatment, poor sanitation, and inadequate hygiene. To address this knowledge gap, we aimed to assess the prevalence of enteric pathogens, identify risk factors and seasonal variations, and describe associations between pathogens among diarrheic patients in the Lebanese community. Further spread to other provinces would worsen the situation given the frequent population movement. Hasan MM, Islam MU, Sadeq MJ, Fung WK, Uddin J. Most people can be treated successfully through prompt administration of oral rehydration solution (ORS). Seven cholera pandemics have been experienced globally and it continues to cause outbreaks locally and regionally across the African continent [1, 2]. 2001 Nov;39(11):4086-92. doi: 10.1128/JCM.39.11.4086-4092.2001. Thus, this calls for more stringent public health control measures to prevent spread of these virulent strains. Escherichia coli ATCC 25922 and Klebsiella pneumonia ATCC 700603 were used as negative and positive controls respectively. Approximately 1 in 10 people who get sick with cholera will develop severe symptoms such as watery diarrhea, vomiting, and leg cramps. Of the 168: 151 (89.8%), 3 (1.8%) and 14 (8.3%) were of the Ogawa, Inaba and non-O1/non-O139 serotypes respectively. https://www.miru-vntrplus.org/MIRU/index.faces, http://www.who.int/news-room/fact-sheets/detail/cholera, http://www.ghanahealthservice.org/downloads/Weekly_Epid_Bulletin_Week_1_2015.pdf, http://www.ghanahealthservice.org/ghs-category.php?cid=5, http://www.moh-ghana.org/UploadFiles/Publications/ghana_national_drug_policy_2nd_edition140204043036.pd, Corrections, Expressions of Concern, and Retractions. and transmitted securely. Among these, results are available for 71 samples, of which 70% have shown presence of Vibrio cholerae while Escherichia Coli and coliform was detected in 55% and 90% of samples, respectively. 2004 Jul 30;79(31):281-8. The aim of this study was to evaluate the spread of potentially pathogenic Vibrio spp. Antibiotics are commonly used in animal husbandry as growth supplements to prevent infection and to increase yield. In 2022, Sindh province is facing a significant increase in cholera cases with 234 laboratory confirmed cases reported between 15 January to 27 May. We detected several virulence genes among the V. cholerae isolates. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. Identification of several virulence genes among the two different genotypes of V. cholerae isolates and resistance to first- and second-line antibiotics, calls for scaleup of preventive strategies to reduce transmission, and strengthening of public health laboratories for rapid antimicrobial susceptibility testing to guide accurate treatment. Is a vaccine available to prevent cholera? 2022 Aug 15;42:279. doi: 10.11604/pamj.2022.42.279.36368. Dorothy Yeboah-Manu Within the global phylogeny, all isolates from Pakistan formed 2 new . Abstract Enterotoxigenic strains of Vibrio cholerae O-1, biotype El Tor, isolated from a case of cholera in Texas in 1973, an outbreak of cholera in Louisiana in 1978, and Louisiana sewage samples in 1980 and 1981 were analyzed for their genetic similarities. With proper treatment, even severely ill patients can be saved. 2012 Nov 15;3(7):556-65. doi: 10.4161/viru.22351. 2023 Jan 4;13:1010870. doi: 10.3389/fgene.2022.1010870. broad scope, and wide readership a perfect fit for your research every time. Before V. cholerae is a noninvasive intestinal pathogen. Only 61% of the isolates from the presumed cholera cases were confirmed to be caused by V. cholerae O1 and pathogens other than vibrios were detected. Balasubramanian D, Lpez-Prez M, Almagro-Moreno S. Adv Exp Med Biol. Non-O1 and non-O139 V. cholerae can cause isolated cases of usually mild gastroenteritis. Bookshelf Without treatment, death can occur within hours. In Punjab, although response activities are taking place, the province is still recording an increased number of suspected cholera cases, including in Lahore, the provincial capital and large international commercial hub. A cholera-endemic area is an area where confirmed cholera cases were detected during the last three years with evidence of local transmission (cases are not imported from elsewhere). Cholera remains a major global public health threat and continuous emergence of new Vibrio cholerae strains is of major concern. Moreover, utilization of discriminating tools such as multi-locus variable number of tandem repeats analysis (MLVA) will aid in tracking disease spread, which is crucial for disease control. Microbiology and Epidemiology Vibrio cholerae is a curved motile gram-negative bacillus. All information these cookies collect is aggregated and therefore anonymous. They help us to know which pages are the most and least popular and see how visitors move around the site. When traveling in countries where cholera is present, eat only thoroughly cooked hot foods or fruits/vegetables that you peel just before eating (e.g., bananas). Drink only bottled, boiled, or chemically treated water and bottled or canned beverages. Conducting field visits to various hospitals to support surveillance, laboratory testing for cholera confirmation, water quality monitoring, improving IPC measures and case management. The O1 serogroup isolates (154/168, 91.7%) carried the cholera toxin ctxB gene as detected by PCR. Competing interests: The authors have declared that no competing interests exist. Sir A. Zumla is in receipt of a UK National Institutes of Health Research (NIHR) Senior Investigator award. In response to the outbreak, the provincial health authorities of Sindh, Balochistan and Punjab have issued high alert notifications to concerned District Health Offices. West African Centre for Cell Biology of Infectious Pathogens, University of Ghana Legon, Legon, Accra, Ghana, FOIA Cholera bacteria can also live in the environment in brackish rivers and coastal waters. Phenotypic drug susceptibility testing by Kirby-Bauer disc diffusion method was performed using Muller-Hinton Agar in accordance with the Clinical and Laboratory Standards Institute (CLSI) guidelines [10]. In August 2010, Pakistan experienced major floods and a subsequent cholera epidemic. Saving Lives, Protecting People. People with cholera shed the bacteria in their feces (stool). Rebaudet S, Sudre B, Faucher B, Piarroux R. J Infect Dis. We describe the molecular epidemiology of cholera in South Africa during 2018-2020. Some travelers have brought contaminated seafood home from abroad, resulting in cholera. Revisiting the Global Epidemiology of Cholera in Conjuction With the Genomics of Vibrio cholerae Front Public Health. Pan Afr Med J. In addition to Sindh province, three districts in Balochistan have reported 31 confirmed cases and nine deaths while two districts in Punjab have reported 25 confirmed cases. Samuel Duodu, Would you like email updates of new search results? Disease Outbreak News; Cholera in Pakistan. Persons living in places with unsafe drinking water, poor sanitation, and inadequate hygiene are at the highest risk for cholera. Community engagement including support for social mobilizers in highly affected districts and health awareness sessions that are being conducted on a daily basis. In the latter case, molecular analysis of clinical strains both confirmed the importation of cholera from Nepal in 2010 14 , 30 and demonstrated the subsequent clonal . How long after infection do the symptoms appear? We detected the tcpA gene which is a colonization factor in 59% of the isolates suggesting that about 40% of the isolates though may express the cholera toxin might be impaired with their ability to colonize the host. To understand the transmission dynamics of V. cholerae and strategize for subsequent spread of the disease in the sub-region, the National Public Health and Reference Laboratory (NPHRL) of the Ghana Health Service, requested the Noguchi Memorial Institute for Medical Research to undertake this study.
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