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Research Paper

Why are so many enteric pathogen infections asymptomatic? Pathogen and gut microbiome characteristics associated with diarrhea symptoms and carriage of diarrheagenic E. coli in northern Ecuador

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Article: 2281010 | Received 31 May 2023, Accepted 05 Nov 2023, Published online: 22 Nov 2023

References

  • Mokomane M, Kasvosve I, de Melo E, Pernica JM, Goldfarb DM. The global problem of childhood diarrhoeal diseases: emerging strategies in prevention and management. Ther Adv Infect Dis. 2018;5(1):29–23. doi:10.1177/2049936117744429.
  • Troeger C, Blacker BF, Khalil IA, Rao PC, Cao S, Zimsen SR, Albertson SB, Stanaway JD, Deshpande A, Abebe Z, et al. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the global burden of disease study 2016. Lancet Infect Dis. 2018;18(11):1211–1228. doi:10.1016/S1473-3099(18)30362-1.
  • Farthing M, Salam MA, Lindberg G, Dite P, Khalif I, Salazar-Lindo E, Ramakrishna BS, Goh K-L, Thomson A, Khan AG, et al. Acute Diarrhea in Adults and Children: A Global Perspective. J Clin Gastroenterol. 2013;47(1):12–20. doi:10.1097/MCG.0b013e31826df662.
  • Sultana R, Luby SP, Gurley ES, Rimi NA, Swarna ST, Khan JAM, Nahar N, Ghosh PK, Howlader SR, Kabir H, et al. Cost of illness for severe and non-severe diarrhea borne by households in a low-income urban community of Bangladesh: a cross-sectional study. PLoS Negl Trop Dis. 2021;15(6):e0009439. doi:10.1371/journal.pntd.0009439.
  • Barr W, Smith A. Acute Diarrhea in Adults. Am Fam Physician. 2014;89:180–189.
  • Levine MM, Robins-Browne RM. Factors that explain excretion of enteric pathogens by persons without diarrhea. Clin Infect Dis. 2012;55(suppl_4):S303–11. doi:10.1093/cid/cis789.
  • Jesser KJ, Levy K. Updates on defining and detecting diarrheagenic Escherichia coli pathotypes. Curr Opin Infect Dis. 2020;33(5):372–380. doi:10.1097/QCO.0000000000000665.
  • Dobrindt U. (Patho-)genomics of Escherichia coli. Int J Med Microbiol. 2005;295(6–7):357–371. doi:10.1016/j.ijmm.2005.07.009.
  • Pawlowski SW, Warren CA, Guerrant R. Diagnosis and treatment of acute or persistent diarrhea. Gastroenterology. 2009;136(6):1874–1886. doi:10.1053/j.gastro.2009.02.072.
  • Servin AL. Pathogenesis of human diffusely adhering Escherichia coli expressing afa/Dr adhesins (afa/Dr DAEC): current insights and future challenges. Clin Microbiol Rev. 2014;27(4):823–869. doi:10.1128/CMR.00036-14.
  • Nataro JP, Yikang D, Cookson S, Cravioto A, Savarino SJ, Guers LD, Levine MM, Tacket CO. Heterogeneity of enteroaggregative Escherichia coli virulence demonstrated. J Infect Dis. 1995;171(2):465–468. doi:10.1093/infdis/171.2.465.
  • Qadri F, Saha A, Ahmed T, Al Tarique A, Begum YA, Svennerholm AM. Disease burden due to enterotoxigenic Escherichia coli in the first 2 years of life in an urban community in Bangladesh. Infect Immun. 2007;75(8):3961–3968. doi:10.1128/IAI.00459-07.
  • Stephan R, Schumacher S. Resistance patterns of non-O157 shiga toxin-producing Escherichia coli (STEC) strains isolated from animals, food and asymptomatic human carriers in Switzerland. Lett Appl Microbiol. 2001;32(2):114–117. doi:10.1046/j.1472-765x.2001.00867.x.
  • Baker JM, Hasso-Agopsowicz M, Pitzer VE, Platts-Mills JA, Peralta-Santos A, Troja C, Archer H, Guo B, Sheahan W, Lingappa J, et al. Association of enteropathogen detection with diarrhoea by age and high versus low child mortality settings: a systematic review and meta-analysis. Lancet Glob Health. 2021;9(10):e1402–10. doi:10.1016/S2214-109X(21)00316-8.
  • Kotloff KL, Nataro JP, Blackwelder WC, Nasrin D, Farag TH, Panchalingam S, Wu Y, Sow SO, Sur D, Breiman RF, et al. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the global enteric multicenter study, GEMS): a prospective, case-control study. Lancet. 2013;382(9888):209–222. doi:10.1016/S0140-6736(13)60844-2.
  • Platts-Mills JA, Babji S, Bodhidatta L, Gratz J, Haque R, Havt A, McCormick BJJ, McGrath M, Olortegui MP, Samie A, et al. Pathogen-specific burdens of community diarrhoea in developing countries: a multisite birth cohort study (MAL-ED). Lancet Glob Health. 2015;3(9):e564–75. doi:10.1016/S2214-109X(15)00151-5.
  • Denamur E, Clermont O, Bonacorsi S, Gordon D. The population genetics of pathogenic Escherichia coli. Nat Rev Microbiol. 2020;19(1):37–54. doi:10.1038/s41579-020-0416-x.
  • Boisen N, Scheutz F, Rasko DA, Redman JC, Persson S, Simon J, Kotloff KL, Levine MM, Sow S, Tamboura B, et al. Genomic characterization of enteroaggregative Escherichia coli from children in Mali. J Infect Dis. 2012;205(3):431–444. doi:10.1093/infdis/jir757.
  • Pena-Gonzalez A, Soto-Giro MJ, Smith S, Sistrunk J, Montero L, Pa M, acute a, Ortega E, JK H, Cevallos W, Trueba G, Levy K. Metagenomic signatures of gut infections caused by different Escherichia coli pathotypes. Appl Environ Microbiol. 2019;85(24).10.1128/AEM.01820-19
  • Liu J, Platts-Mills JA, Juma J, Kabir F, Nkeze J, Okoi C, Operario DJ, Uddin J, Ahmed S, Alonso PL, et al. Use of quantitative molecular diagnostic methods to identify causes of diarrhoea in children: a reanalysis of the GEMS case-control study. Lancet. 2016;388(10051):1291–1301. doi:10.1016/S0140-6736(16)31529-X.
  • Platts-Mills JA, Operario DJ, Houpt ER. Molecular Diagnosis of Diarrhea: Current Status and Future Potential. Curr Infect Dis Rep. 2012;14(1):41–46. doi:10.1007/s11908-011-0223-7.
  • Barletta F, Ochoa TJ, Mercado E, Ruiz J, Ecker L, Lopez G, Mispireta M, Gil AI, Lanata CF, Cleary TG. Quantitative real-time polymerase chain reaction for enteropathogenic escherichia coli: a tool for investigation of asymptomatic versus symptomatic infections. Clin Infect Dis. 2011;53(12):1223–1229. doi:10.1093/cid/cir730.
  • Smith SM, Montero L, Paez M, Ortega E, Hall E, Bohnert K, Sanchez X, Puebla E, Endara P, Cevallos W, et al. Locals get travellers’ diarrhoea too: risk factors for diarrhoeal illness and pathogenic Escherichia coli infection across an urban-rural gradient in Ecuador. Trop Med Int Health. 2019;24(2):205–219. doi:10.1111/tmi.13183.
  • Rothstein AP, Jesser KJ, Feistel DJ, Konstantinidis KT, Trueba G, Levy K. Population genomics of diarrheagenic Escherichia coli uncovers high connectivity between urban and rural communities in Ecuador. Infect Genet Evol. 2023;113:105476. doi:10.1016/j.meegid.2023.105476.
  • Montero L, Smith SM, Jesser KJ, Paez M, Ortega E, Peña-Gonzalez A, Soto-Girón MJ, Hatt JK, Sánchez X, Puebla E, et al. Distribution of Escherichia coli pathotypes along an urban–rural gradient in Ecuador. Am J Trop Med Hyg. 2023;109(3):559–567. doi:10.4269/ajtmh.23-0167.
  • Rodriguez-R LM, Gunturu S, Harvey WT, Rosselló-Mora R, Tiedje JM, Cole JR, Konstantinidis KT. The microbial genomes atlas (MiGA) webserver: taxonomic and gene diversity analysis of archaea and bacteria at the whole genome level. Nucleic Acids Res. 2018;46(W1):W282–8. doi:10.1093/nar/gky467.
  • Cox MP, Peterson DA, Biggs PJ. SolexaQA: At-a-glance quality assessment of Illumina second-generation sequencing data. BMC Bioinform. 2010;11(1):485. doi:10.1186/1471-2105-11-485.
  • Peng Y, Leung HCM, Yiu SM, Chin FYL. IDBA-UD: a de novo assembler for single-cell and metagenomic sequencing data with highly uneven depth. Bioinformatics. 2012;28(11):1420–1428. doi:10.1093/bioinformatics/bts174.
  • Luo C, Rodriguez RL, Konstantinidis KT. MyTaxa: an advanced taxonomic classifier for genomic and metagenomic sequences. Nucleic Acids Res. 2014;42(8):e73. doi:10.1093/nar/gku169.
  • Callahan BJ, McMurdie PJ, Rosen MJ, Han AW, Johnson AJA, Holmes SP. DADA2: High-resolution sample inference from Illumina amplicon data. Nat Methods. 2016;13(7):581–583. doi:10.1038/nmeth.3869.
  • Bokulich NA, Kaehler BD, Rideout JR, Dillon M, Bolyen E, Knight R, Huttley GA, Gregory Caporaso J. Optimizing taxonomic classification of marker-gene amplicon sequences with QIIME 2’s q2-feature-classifier plugin. Microbiome. 2018;6:90. doi:10.1186/s40168-018-0470-z.
  • McDonald D, Price MN, Goodrich J, Nawrocki EP, DeSantis TZ, Probst A, Andersen GL, Knight R, Hugenholtz P. An improved greengenes taxonomy with explicit ranks for ecological and evolutionary analyses of bacteria and archaea. ISME J. 2012;6(3):610–618. doi:10.1038/ismej.2011.139.
  • McMurdie PJ, Holmes S, Watson M. Phyloseq: an R package for reproducible interactive analysis and graphics of microbiome census data. PloS One. 2013;8(4):e61217. doi:10.1371/journal.pone.0061217.
  • Rotmistrovsky K, Agarwala R. BMTagger: Best Match Tagger for removing human reads from metagenomics datasets. 2011. https://www.hmpdacc.org/doc/HumanSequenceRemoval_SOP.pdf
  • Wood DE, Lu J, Langmead B. Improved metagenomic analysis with Kraken 2. Genome Biol. 2019;20(1):257. doi:10.1186/s13059-019-1891-0.
  • Lu J, Breitwieser FP, Thielen P, Salzberg SL. Bracken: estimating species abundance in metagenomics data. PeerJ Computer Science. 2017;3:e104. doi:10.7717/peerj-cs.104.
  • Rodriguez-R LM, Konstantinidis KT. The enveomics collection: a toolbox for specialized analyses of microbial genomes and metagenomes. PeerJ Preprints. 2016;e1900v1. https://peerj.com/preprints/1900/
  • Nayfach S, Pollard KS. Average genome size estimation improves comparative metagenomics and sheds light on the functional ecology of the human microbiome. Genome Biol. 2015;16(1):51. doi:10.1186/s13059-015-0611-7.
  • R Core Team. R: a language and environment for statistical computing [Internet]. 2017; Available from: https://www.R-project.org
  • Altschul SF, Gish W, Miller W, Myers EW, Lipman DJ. Basic local alignment search tool. J Mol Biol. 1990;215(3):403–410. doi:10.1016/S0022-2836(05)80360-2.
  • Gu Z, Eils R, Schlesner M. Complex heatmaps reveal patterns and correlations in multidimensional genomic data. Bioinformatics. 2016;32(18):2847–2849. doi:10.1093/bioinformatics/btw313.
  • Hsieh TC, Ma KH, Chao A, McInerny G. iNEXT: an R package for rarefaction and extrapolation of species diversity (H ill numbers). Methods Ecol Evol. 2016;7(12):1451–1456. doi:10.1111/2041-210X.12613.
  • Rodriguez-R LM, Konstantinidis KT. Nonpareil: a redundancy-based approach to assess the level of coverage in metagenomic datasets. Bioinformatics. 2014;30(5):629–635. doi:10.1093/bioinformatics/btt584.
  • Ondov BD, Treangen TJ, Melsted P, Mallonee AB, Bergman NH, Koren S, Phillippy AM. Mash: fast genome and metagenome distance estimation using MinHash. Genome Biol. 2016;17(1):132. doi:10.1186/s13059-016-0997-x.
  • Weiss S, Xu ZZ, Peddada S, Amir A, Bittinger K, Gonzalez A, Lozupone C, Zaneveld JR, Vázquez-Baeza Y, Birmingham A, et al. Normalization and microbial differential abundance strategies depend upon data characteristics. Microbiome. 2017;5(1):27. doi:10.1186/s40168-017-0237-y.
  • Dixon P. VEGAN, a package of R functions for community ecology. J Vegetation Sci. 2003;14(6):927–930. doi:10.1111/j.1654-1103.2003.tb02228.x.
  • Martin BD, Witten D, Willis AD. Modeling microbial abundances and dysbiosis with beta-binomial regression. Ann Appl Stat. 2020;14(1):94–115. doi:10.1214/19-AOAS1283.
  • Segata N, Izard J, Waldron L, Gevers D, Miropolsky L, Garrett WS, Huttenhower C. Metagenomic biomarker discovery and explanation. Genome Biol. 2011;12(6):R60. doi:10.1186/gb-2011-12-6-r60.
  • Cao Y, Dong Q, Wang D, Zhang P, Liu Y, Niu C, Marschall T. microbiomeMarker: an R/Bioconductor package for microbiome marker identification and visualization. Bioinformatics. 2022;38(16):4027–4029. doi:10.1093/bioinformatics/btac438.
  • Hyatt D, Chen G-L, LoCascio PF, Land ML, Larimer FW, Hauser LJ. Prodigal: prokaryotic gene recognition and translation initiation site identification. BMC Bioinform. 2010;11(1):119. doi:10.1186/1471-2105-11-119.
  • Steinegger M, Söding J. Clustering huge protein sequence sets in linear time. Nat Commun. 2018;9(1):2542. doi:10.1038/s41467-018-04964-5.
  • Ruiz-Perez CA, Conrad RE, Konstantinidis KT. MicrobeAnnotator: a user-friendly, comprehensive functional annotation pipeline for microbial genomes. BMC Bioinform. 2021;22(1):11. doi:10.1186/s12859-020-03940-5.
  • Chen L, Yang J, Yu J, Yao Z, Sun L, Shen Y, Jin Q. VFDB: a reference database for bacterial virulence factors. Nucleic Acids Res. 2005;33(Database issue):D325–8. doi:10.1093/nar/gki008.
  • Seemann T. Prokka: rapid prokaryotic genome annotation. Bioinformatics. 2014;30(14):2068–2069. doi:10.1093/bioinformatics/btu153.
  • Page AJ, Cummins CA, Hunt M, Wong VK, Reuter S, Holden MTG, Fookes M, Falush D, Keane JA, Parkhill J. Roary: rapid large-scale prokaryote pan genome analysis. Bioinformatics. 2015;31(22):3691–3693. doi:10.1093/bioinformatics/btv421.
  • Price MN, Dehal PS, Arkin AP, Poon AFY. FastTree 2–approximately maximum-likelihood trees for large alignments. PloS One. 2010;5(3):e9490. doi:10.1371/journal.pone.0009490.
  • Xu S, Li L, Luo X, Chen M, Tang W, Zhan L, Dai Z, Lam TT, Guan Y, Yu G. Ggtree: a serialized data object for visualization of a phylogenetic tree and annotation data. iMeta. 2022;1(4):e56. doi:10.1002/imt2.56.
  • Borges R, Machado JP, Gomes C, Rocha AP, Antunes A, Hancock J. Measuring phylogenetic signal between categorical traits and phylogenies. Bioinformatics. 2019;35(11):1862–1869. doi:10.1093/bioinformatics/bty800.
  • Brynildsrud O, Bohlin J, Scheffer L, Eldholm V. Rapid scoring of genes in microbial pan-genome-wide association studies with Scoary. Genome Biol. 2016;17(1):238. doi:10.1186/s13059-016-1108-8.
  • Martin RM, Bachman MA. Colonization, infection, and the accessory genome of Klebsiella pneumoniae. Front Cell Infect Microbiol. 2018 [cited 2023 Oct 12];8. Available from. 10.3389/fcimb.2018.00004
  • Riveros M, García W, García C, Durand D, Mercado E, Ruiz J, Ochoa TJ. Molecular and phenotypic characterization of diarrheagenic Escherichia coli strains isolated from Bacteremic children. Am J Trop Med Hyg. 2017;97(5):1329–1336. doi:10.4269/ajtmh.17-0066.
  • Hejnova J, Dobrindt U, Nemcova R, Rusniok C, Bomba A, Frangeul L, Hacker J, Glaser P, Sebo P, Buchrieser C. Characterization of the flexible genome complement of the commensal Escherichia coli strain A0 34/86 (O83: K24: H31). Microbiology. 2005;151(2):385–398. doi:10.1099/mic.0.27469-0.
  • Dong N, Zhang R, Liu L, Li R, Lin D, Chan E-C, Chen S. Genome analysis of clinical multilocus sequence type 11 Klebsiella pneumoniae from China. Microb Genom. 2018;4(2):e000149. doi:10.1099/mgen.0.000149.
  • Hashemizadeh Z, Kalantar-Neyestanaki D, Mansouri S. Association between virulence profile, biofilm formation and phylogenetic groups of Escherichia coli causing urinary tract infection and the commensal gut microbiota: a comparative analysis. Microb Pathog. 2017;110:540–545. doi:10.1016/j.micpath.2017.07.046.
  • Sousa Gerós A, Simmons A, Drakesmith H, Aulicino A, Frost JN. The battle for iron in enteric infections. Immunology. 2020;161(3):186–199. doi:10.1111/imm.13236.
  • Westermann C, Gleinser M, Corr SC, Riedel CU. A critical evaluation of bifidobacterial adhesion to the host tissue. Front Microbiol. 2016;7:1220. doi:10.3389/fmicb.2016.01220.
  • Kamada N, Chen GY, Inohara N, Núñez G. Control of pathogens and pathobionts by the gut microbiota. Nat Immunol. 2013;14(7):685–690. doi:10.1038/ni.2608.
  • Chung the H, Le S-N. Dynamic of the human gut microbiome under infectious diarrhea. Curr Opin Microbiol. 2022;66:79–85. doi:10.1016/j.mib.2022.01.006.
  • Pickard JM, Zeng MY, Caruso R, Núñez G. Gut microbiota: Role in pathogen colonization, immune responses, and inflammatory disease. Immunol Rev. 2017;279(1):70–89. doi:10.1111/imr.12567.
  • Baldelli V, Scaldaferri F, Putignani L, Del Chierico F. The role of Enterobacteriaceae in gut microbiota dysbiosis in inflammatory bowel diseases. Microorganisms. 2021;9(4):697. doi:10.3390/microorganisms9040697.
  • Stevens EJ, Bates KA, King KC, Bliska JB. Host microbiota can facilitate pathogen infection. PLoS Pathog. 2021;17(5):e1009514. doi:10.1371/journal.ppat.1009514.
  • Mirsepasi-Lauridsen HC, Vallance BA, Krogfelt KA, Petersen AM. Escherichia coli pathobionts associated with inflammatory bowel disease. Clin Microbiol Rev. 2019;32(2):10.1128/cmr.00060–18. doi:10.1128/CMR.00060-18.
  • De R, Mukhopadhyay AK, Dutta S. Metagenomic analysis of gut microbiome and resistome of diarrheal fecal samples from Kolkata, India, reveals the core and variable microbiota including signatures of microbial dark matter. Gut Pathog. 2020;12(1):32. doi:10.1186/s13099-020-00371-8.
  • Winter SE, Winter MG, Xavier MN, Thiennimitr P, Poon V, Keestra AM, Laughlin RC, Gomez G, Wu J, Lawhon SD, et al. Host-derived nitrate boosts growth of E. coli in the inflamed gut. Sci. 2013;339(6120):708–711. doi:10.1126/science.1232467.
  • Carvalho FA, Koren O, Goodrich JK, Johansson MEV, Nalbantoglu I, Aitken JD, Su Y, Chassaing B, Walters WA, González A, et al. Transient inability to manage proteobacteria promotes chronic gut inflammation in TLR5-deficient mice. Cell Host & Microbe. 2012;12(2):139–152. doi:10.1016/j.chom.2012.07.004.
  • Stecher B, Denzler R, Maier L, Bernet F, Sanders MJ, Pickard DJ, Barthel M, Westendorf AM, Krogfelt KA, Walker AW, et al. Gut inflammation can boost horizontal gene transfer between pathogenic and commensal Enterobacteriaceae. Proc Natl Acad Sci USA. 2012;109(4):1269–1274. doi:10.1073/pnas.1113246109.
  • Rivera-Chávez F, Lopez CA, Bäumler AJ. Oxygen as a driver of gut dysbiosis. Free Radic Biol Med. 2017;105:93–101. doi:10.1016/j.freeradbiomed.2016.09.022.
  • Zafar H, Saier MH. Gut bacteroides species in health and disease. Gut Microbes. 2021;13(1):1848158. doi:10.1080/19490976.2020.1848158.
  • Vacca M, Celano G, Calabrese FM, Portincasa P, Gobbetti M, De Angelis M. The controversial role of human gut Lachnospiraceae. Microorganisms. 2020;8(4):573. doi:10.3390/microorganisms8040573.
  • Singh P, Teal TK, Marsh TL, Tiedje JM, Mosci R, Jernigan K, Zell A, Newton DW, Salimnia H, Lephart P, et al. Intestinal microbial communities associated with acute enteric infections and disease recovery. Microbiome. 2015;3(1):45. doi:10.1186/s40168-015-0109-2.
  • Patin NV, Peña-Gonzalez A, Hatt JK, Moe C, Kirby A, Konstantinidis KT, Manning SD, Cooper VS. The role of the gut microbiome in resisting norovirus infection as revealed by a human challenge study. mBio. 2020;11(6):e02634–20. doi:10.1128/mBio.02634-20.
  • Pop M, Walker AW, Paulson J, Lindsay B, Antonio M, Hossain MA, Oundo J, Tamboura B, Mai V, Astrovskaya I, et al. Diarrhea in young children from low-income countries leads to large-scale alterations in wintestinal microbiota composition. Genome Biol. 2014;15(6):R76. doi:10.1186/gb-2014-15-6-r76.
  • De Filippo C, Cavalieri D, Di Paola M, Ramazzotti M, Poullet JB, Massart S, Collini S, Pieraccini G, Lionetti P. Impact of diet in shaping gut microbiota revealed by a comparative study in children from Europe and rural Africa. Proc Natl Acad Sci U S A. 2010;107(33):14691–14696. doi:10.1073/pnas.1005963107.
  • Lee SC, Tang MS, Lim YAL, Choy SH, Kurtz ZD, Cox LM, Gundra UM, Cho I, Bonneau R, Blaser MJ, et al. Helminth colonization is associated with increased diversity of the gut microbiota. PLoS Negl Trop Dis. 2014;8(5):e2880. doi:10.1371/journal.pntd.0002880.
  • Patra AK, Yu Z, Jensen PA. Genomic insights into the distribution of Peptidases and proteolytic capacity among Prevotella and paraprevotella species. Microbiol Spectr. 2022;10(2):e02185–21. doi:10.1128/spectrum.02185-21.
  • Thomson P, Medina DA, Garrido D. Human milk oligosaccharides and infant gut bifidobacteria: Molecular strategies for their utilization. Food Microbiol. 2018;75:37–46. doi:10.1016/j.fm.2017.09.001.
  • Servin AL. Antagonistic activities of lactobacilli and bifidobacteria against microbial pathogens. FEMS Microbiol Rev. 2004;28(4):405–440. doi:10.1016/j.femsre.2004.01.003.
  • Levine MM, Caplan ES, Waterman D, Cash RA, Hornick RB, Snyder MJ. Diarrhea caused by Escherichia coli that produce only heat stable enterotoxin. Infect Immun. 1977;17(1):78–82. doi:10.1128/iai.17.1.78-82.1977.
  • Levine MM, Bergquist EJ, Nalin DR, Waterman DH, Hornick RB, Young CR, Sotman S, Rowe B. Escherichia coli strains that cause diarrhoea but do not produce heat-labile or heat-stable enterotoxins and are non-invasive. Lancet. 1978;1(8074):1119–1122. doi:10.1016/S0140-6736(78)90299-4.
  • Soto-Giron M, Peña Gonzalez A, Hatt J, Montero L, Páez M, Ortega E, Smith S, Cevallos W, Trueba G, Konstantinidis K, et al. Gut microbiome response to acute diarrheal disease across a rural-to-urban gradient in northern Ecuador. Am J Trop Med Hyg. 2021;104(6):2275.