Epidemiologic study of Vibrio vulnificus infections by using variable number tandem repeats

Virulent properties and genomic diversity of Vibrio vulnificus isolated from environment, human, diseased fish

The incidence of Vibrio vulnificus infections, with high mortality rates in humans and aquatic animals, has escalated, highlighting a significant public health challenge. Currently, reliable markers to identify strains with high virulence potential are lacking, and the understanding of evolutionary drivers behind the emergence of pathogenic strains is limited. In this study, we analyzed the distribution of virulent genotypes and phenotypes to discern the infectious potential of V. vulnificus strains isolated from three distinct sources. Most isolates, traditionally classified as biotype 1, possessed the virulence-correlated gene-C type. Environmental isolates predominantly exhibited YJ-like alleles, while clinical and diseased fish isolates were significantly associated with the nanA gene and pathogenicity region XII. Hemolytic activity was primarily observed in the culture supernatants of clinical and diseased fish isolates. Genetic relationships, as determined by multiple-locus variable-number tandem repeat analysis, suggested that strains originating from the same source tended to cluster together. However, multilocus sequence typing revealed considerable genetic diversity across clusters and sources. A phylogenetic analysis using single nucleotide polymorphisms of diseased fish strains alongside publicly available genomes demonstrated a high degree of evolutionary relatedness within and across different isolation sources. Notably, our findings reveal no direct correlation between phylogenetic patterns, isolation sources, and virulence capabilities. This underscores the necessity for proactive risk management strategies to address pathogenic V. vulnificus strains emerging from environmental reservoirs.IMPORTANCEAs the global incidence of Vibrio vulnificus infections rises, impacting human health and marine aquacultures, understanding the pathogenicity of environmental strains remains critical yet underexplored. This study addresses this gap by evaluating the virulence potential and genetic relatedness of V. vulnificus strains, focusing on environmental origins. We conduct an extensive genotypic analysis and phenotypic assessment, including virulence testing in a wax moth model. Our findings aim to uncover genetic and evolutionary factors that drive pathogenic strain emergence in the environment. This research advances our ability to identify reliable virulence markers and understand the distribution of pathogenic strains, offering significant insights for public health and environmental risk management.

A case report of Vibrio vulnificus sepsis in a diabetic patient

Vibrio vulnificus is a facultative anaerobic, alkalophilic, halophilic, mesophilic, Gram-negative bacterium that can cause severe wound infection, sepsis and diarrhea. This paper reported a case of 85-year-old male patient infected with Vibrio vulnificus due to being stabbed by a sea shrimp. This patient also had diabetes with a long history of alcoholism. Due to bacterial pathogenicity and the patient's underlying diseases, his condition deteriorated rapidly. Based on the rapid diagnosis of Vibrio vulnificus using the next-generation sequencing（NGS）technology and blood culture method, as well as the selection of the most effective antibiotics via drug sensitivity test, this patient underwent precise antimicrobial treatment, thorough debridement and drainage within the shortest possible time, and thus the prognosis of this patient was greatly improved. In this paper, we have systematically explored the epidemiology, clinical features, diagnosis and treatment of Vibrio vulnificus infection, thus providing a practical reference for the clinicians to quickly identify and treat possible Vibrio vulnificus infection in diabetic patients after contacting with sea water or seafood.

Prognostic Factors of Mortality in Vibrio vulnificus Sepsis and Soft Tissue Infections: Meta-Analysis

Background: Vibrio vulnificus is a rare but life-threatening infection that effects the population near warm coastal areas. This infection could be fulminant and rapidly progress to severe sepsis and necrotizing soft tissue infection. Early diagnosis and treatment are critical to saving patients' lives. With multiple studies reporting discrepancies in prognostic factors and different treatment protocols, we aimed through this meta-analysis to assess these factors and protocols and the impact on the outcome of the infection. Materials and Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of PubMed, Embase, and Cochrane Library databases by two independent reviewers was reported. Studies evaluating prognostic factors and treatment outcomes of Vibrio vulnificus infections were included. Comprehensive Meta-Analysis, version 3.0 was used. Results: Two hundred eleven studies were identified. Of those, eight studies met our inclusion criteria. The following factors on presentation were associated with higher mortality rates; concomitant liver disease (odds ratio [OR], 4.38; 95% confidence interval [CI], 2.43-7.87; p < 0.001), renal disease (OR, 3.90; 95% CI, 1.37-11.12; p = 0.011), septic shock (OR, 2.82; 95% CI, 1.84-4.31; p < 0.001), higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 3.40; 95% CI, 2.26-5.12; p < 0.001), elevated band cells count (OR, 2.61; 95% CI, 1.13-6.0; p = 0.024), hypoalbuminemia (OR, 3.41; 95% CI, 1.58-7.35; p = 0.002), and infection involving multiple limbs (OR, 4.36; 95% CI, 1.72-11.07; p = 0.002). Interestingly, different antibiotic regimens did not have any impact on outcomes, however, delayed surgical intervention after the first 12 or 24 hours was associated with higher mortality rates (OR, 2.64; 95% CI, 1.39-5.0; p = 0.003 and OR, 2.99; 95% CI, 1.54-5.78; p = 0.001, respectively). Conclusion: The presence of liver or renal disease, higher APACHE II scores, septic shock, hypoalbuminemia, or elevated band cell on presentation should alert the physician to the higher risk of mortality. Different antibiotic regimens did not impact the outcomes in these patients and delayed surgical intervention is associated with worsening of mortality.

Phylogeny and life cycle of the zoonotic pathogen Vibrio vulnificus

Vibrio vulnificus is a zoonotic pathogen able to cause diseases in humans and fish that occasionally result in sepsis and death. Most reviews about this pathogen (including those related to its ecology) are clearly biased towards its role as a human pathogen, emphasizing its relationship with oysters as its main reservoir, the role of the known virulence factors as well as the clinic and the epidemiology of the human disease. This review tries to give to the reader a wider vision of the biology of this pathogen covering aspects related to its phylogeny and evolution and filling the gaps in our understanding of the general strategies that V. vulnificus uses to survive outside and inside its two main hosts, the human and the eel, and how its response to specific environmental parameters determines its survival, its death, or the triggering of an infectious process.

Draft Genome Sequence of Environmental Bacterium Vibrio vulnificus CladeA-yb158

We report the genome sequence of the environmental Vibrio vulnificus biotype 1_cladeA. This draft genome of the CladeA-yb158 strain, isolated in Israel, represents this newly emerged clonal group that contains both clinical and environmental strains.

Variable Number of Tandem Repeats (VNTR) analysis of Flavobacterium psychrophilum from salmonids in Chile and Norway

Background

Flavobacterium psychrophilum causes serious fish diseases such RTFS and BCWD, affecting the aquaculture industry worldwide. Commercial vaccines are not available and control of the disease depends on the use of antibiotics. Reliable methods for detection and identification of different isolates of this bacterium could play an important role in the development of good management strategies. The aim of this study was to identify genetic markers for discrimination between isolates. A selection of eight VNTRs from 53 F. psychrophilum isolates from Norway, Chile, Denmark and Scotland were analyzed. The results were compared with previous work on the same pathogen using MLST for genetic differentiation.

Results

The VNTR analysis gave a separation between the F. psychrophilum isolates supporting the results of previous MLST work. A higher diversity was found among the Chilean isolates compared to those from Norway, which suggests a more homogenous reservoir in Norway. Transgenerational transmission of F. psychrophilum from other countries, exporting salmon embryos to Chile, may explain the differences in diversity. The same transmission mechanisms could also explain the wide geographical distribution of identical isolates in Norway. But, this could also be a result of movement of smolts and embryos. The selected VNTRs are stable genetic markers and no variation was observed after several passages on agar plates at different temperatures.

Conclusions

These VNTRs are important additions for genotyping of F. psychrophilum isolates. Future studies on VNTRs of F. psychrophilum should include isolates from more host species from a wider geographical area. To get a more robust genotyping the VNTRs should be used in concert with MLST. Future studies of isolates with high and low virulence should focus on identifying virulence markers using VTNRs and MLST.

Electronic supplementary material

The online version of this article (doi:10.1186/s12917-015-0469-7) contains supplementary material, which is available to authorized users.

Occurrence of Vibrio parahaemolyticus, Vibrio cholerae, and Vibrio vulnificus in the Aquacultural Environments of Taiwan

The occurrence of Vibrio parahaemolyticus, Vibrio vulnificus, and Vibrio cholerae in a total of 72 samples from six aquaculture ponds for groupers, milk fish, and tilapia in southern Taiwan was examined by the membrane filtration and colony hybridization method. The halophilic V. parahaemolyticus was only recovered in seawater ponds, with a high isolation frequency of 86.1% and a mean density of 2.6 log CFU/g. V. cholerae was found in both the seawater and freshwater ponds but preferentially in freshwater ponds, with a frequency of 72.2% and a mean density of 1.65 log CFU/g. V. vulnificus was identified mainly in seawater ponds, with an isolation frequency of 27.8%. The density of V. parahaemolyticus in seawater ponds was positively related to water temperature (Pearson correlation coefficient, r = 0.555) and negatively related to salinity (r = 2 0.333). The density of V. cholerae in all six ponds was positively related to water temperature (r = 0.342) and negatively related to salinity (r = 2 0.432). Two putatively pathogenic tdh(+) V. parahaemolyticus isolates (1.4% of the samples) and no ctx(+) V. cholerae isolates were identified. The experimental results may facilitate assessments of the risk posed by these pathogenic Vibrio species in Taiwan, where aquaculture provides a large part of the seafood supply.

Comparative genomic analysis of clinical and environmental Vibrio vulnificus isolates revealed biotype 3 evolutionary relationships

In 1996 a common-source outbreak of severe soft tissue and bloodstream infections erupted among Israeli fish farmers and fish consumers due to changes in fish marketing policies. The causative pathogen was a new strain of Vibrio vulnificus, named biotype 3, which displayed a unique biochemical and genotypic profile. Initial observations suggested that the pathogen erupted as a result of genetic recombination between two distinct populations. We applied a whole genome shotgun sequencing approach using several V. vulnificus strains from Israel in order to study the pan genome of V. vulnificus and determine the phylogenetic relationship of biotype 3 with existing populations. The core genome of V. vulnificus based on 16 draft and complete genomes consisted of 3068 genes, representing between 59 and 78% of the whole genome of 16 strains. The accessory genome varied in size from 781 to 2044 kbp. Phylogenetic analysis based on whole, core, and accessory genomes displayed similar clustering patterns with two main clusters, clinical (C) and environmental (E), all biotype 3 strains formed a distinct group within the E cluster. Annotation of accessory genomic regions found in biotype 3 strains and absent from the core genome yielded 1732 genes, of which the vast majority encoded hypothetical proteins, phage-related proteins, and mobile element proteins. A total of 1916 proteins (including 713 hypothetical proteins) were present in all human pathogenic strains (both biotype 3 and non-biotype 3) and absent from the environmental strains. Clustering analysis of the non-hypothetical proteins revealed 148 protein clusters shared by all human pathogenic strains; these included transcriptional regulators, arylsulfatases, methyl-accepting chemotaxis proteins, acetyltransferases, GGDEF family proteins, transposases, type IV secretory system (T4SS) proteins, and integrases. Our study showed that V. vulnificus biotype 3 evolved from environmental populations and formed a genetically distinct group within the E-cluster. The unique epidemiological circumstances facilitated disease outbreak and brought this genotype to the attention of the scientific community.

Genome-wide SNP-genotyping array to study the evolution of the human pathogen Vibrio vulnificus biotype 3

Vibrio vulnificus is an aquatic bacterium and an important human pathogen. Strains of V. vulnificus are classified into three different biotypes. The newly emerged biotype 3 has been found to be clonal and restricted to Israel. In the family Vibrionaceae, horizontal gene transfer is the main mechanism responsible for the emergence of new pathogen groups. To better understand the evolution of the bacterium, and in particular to trace the evolution of biotype 3, we performed genome-wide SNP genotyping of 254 clinical and environmental V. vulnificus isolates with worldwide distribution recovered over a 30-year period, representing all phylogeny groups. A custom single-nucleotide polymorphism (SNP) array implemented on the Illumina GoldenGate platform was developed based on 570 SNPs randomly distributed throughout the genome. In general, the genotyping results divided the V. vulnificus species into three main phylogenetic lineages and an additional subgroup, clade B, consisting of environmental and clinical isolates from Israel. Data analysis suggested that 69% of biotype 3 SNPs are similar to SNPs from clade B, indicating that biotype 3 and clade B have a common ancestor. The rest of the biotype 3 SNPs were scattered along the biotype 3 genome, probably representing multiple chromosomal segments that may have been horizontally inserted into the clade B recipient core genome from other phylogroups or bacterial species sharing the same ecological niche. Results emphasize the continuous evolution of V. vulnificus and support the emergence of new pathogenic groups within this species as a recurrent phenomenon. Our findings contribute to a broader understanding of the evolution of this human pathogen.

Bacterial zoonoses of fishes: a review and appraisal of evidence for linkages between fish and human infections

Human contact with and consumption of fishes presents hazards from a range of bacterial zoonotic infections. Whereas many bacterial pathogens have been presented as fish-borne zoonoses on the basis of epidemiological and phenotypic evidence, genetic identity between fish and human isolates is not frequently examined or does not provide support for transmission between these hosts. In order to accurately assess the zoonotic risk from exposure to fishes in the context of aquaculture, wild fisheries and ornamental aquaria, it is important to critically examine evidence of linkages between bacteria infecting fishes and humans. This article reviews bacteria typically presented as fish-borne zoonoses, and examines the current strength of evidence for this classification. Of bacteria generally described as fish-borne zoonoses, only Mycobacterium spp., Streptococcus iniae, Clostridium botulinum, and Vibrio vulnificus appear to be well-supported as zoonoses in the strict sense. Erysipelothrix rhusiopathiae, while transmissible from fishes to humans, does not cause disease in fishes and is therefore excluded from the list. Some epidemiological and/or molecular linkages have been made between other bacteria infecting both fishes and humans, but more work is needed to elucidate routes of transmission and the identity of these pathogens in their respective hosts at the genomic level.

Insight into the evolution of Vibrio vulnificus biotype 3's genome

Vibrio vulnificus is an aquatic bacterium and an important human pathogen. Strains of V. vulnificus are biochemically classified into three biotypes. The newly emerged biotype 3 appears to be rather clonal and geographically restricted to Israel, where it caused an outbreak of wound infections and bacteremia. To understand the evolution of the bacterium's genome, we sequenced and analyzed the genome of biotype 3 strain VVyb1(BT3), and then conducted a microbial environmental survey of the hypothesized niche from which it probably evolved. The genome of this environmental isolate revealed higher similarity to the published biotype 1 genomes of clinical strains (90%) than to the environmental strains (87%), supporting the virulence of the biotype 3 group. Moreover, 214 of the total 5361 genes were found to be unique to strain VVyb1(BT3), having no sequence similarity to any of the known genomes of V. vulnificus; 35 of them function in DNA mobility and rearrangement, supporting the role of horizontal gene transfer in genome evolution. Interestingly, 29 of the “unique” genes had homologies among Shewanella species. In a survey conducted in aquaculture ponds in Israel, we successfully co-isolated Shewanella and V. vulnificus from the same niche, further supporting the probable contribution of Shewanella to the genome evolution of biotype 3. Indeed, one gene was found in a S. algae isolate. Surprisingly, molecular analysis revealed that some of the considered unique genes are harbored by non-sequenced biotype 1 strains isolated from the same environment. Finally, analyses of the biotype 3 genome together with the environmental survey suggested that its genome originated from a biotype 1 Israeli strain that acquired a rather small number of genes from other bacterial species in the niche, such as Shewanella. Therefore, aquaculture is likely to play a major role as a man-made ecological niche in bacterial evolution, leading the emergence of new pathogenic groups in V. vulnificus.

Molecular characterization and antibiotic susceptibility of Vibrio vulnificus in retail shrimps in Hangzhou, People's Republic of China

Vibrio vulnificus is a gram-negative bacterium that occurs naturally in estuarine and marine water and is associated with wound infections or septicemia related to the consumption of raw shellfish in humans. The molecular characteristics and antibiotic susceptibilities of V. vulnificus strains in shrimps from retail markets in Hangzhou, People's Republic of China, were investigated in this study. Thirty-three samples were positive for V. vulnificus in 78 shrimp samples which were collected from 15 retail markets between July and August 2012; the most-probable-number values ranged from 3 to 1,600 g(-1) in these positive samples, with a median most-probable-number value of 72 g(-1). Twenty-five biotype 1 strains and eight biotype 2 strains were identified by biochemical tests, and all strains could be definitively genotyped. By 16S rRNA genotyping, 21.2% (7 of 33) were classified as genotype A, 63.6% (21 of 33) as genotype B, and 15.2% (5 of 33) as genotype AB, while by virulence-correlated gene (vcg) typing, 21.2% (7 of 33) were characterized as genotype E and 78.8% (26 of 33) were genotype C. More than 50% of those isolates were identified as the potentially virulent type vcg type C-16S rRNA B (CB). The antibiotic susceptibilities of the V. vulnificus strains to 21 antimicrobial agents were tested as well. Some strains showed resistance or intermediate resistance to cefepime (3.03%), tetracycline (6.06%), aztreonam (24.24%), streptomycin (45.45%), gentamicin (93.94%), tobramycin (100%), and cefazolin (100%). Multiple-locus variable-number tandem repeat-based fingerprinting analysis (MLVA) was successfully applied to these 33 isolates and yielded 30 patterns that clustered into two MLVA groups; with a calculated Simpson's index of diversity of 0.994, this revealed that MLVA had great discriminating power for V. vulnificus. To minimize the potential risk of V. vulnificus infections due to the consumption of raw shrimp, it is necessary to monitor the hygiene status of seafood.

Transcriptome profiling analysis of Vibrio vulnificus during human infection

Vibrio vulnificus is a waterborne pathogen that was responsible for an outbreak of severe soft-tissue infections among fish farmers and fish consumers in Israel. Several factors have been shown to be associated with virulence. However, the transcriptome profile of the pathogen during human infection has not been determined yet. We compared the transcriptome profile, using RNA sequencing, of a human-pathogenic strain harvested directly from tissue of a patient suffering from severe soft-tissue infection with necrotizing fasciitis, with the same strain and three other environmental strains grown in vitro. The five sequenced libraries were aligned to the reference genomes of V. vulnificus strains CMCP6 and YJ016. Approximately 47.8 to 62.3 million paired-end raw reads were generated from the five runs. Nearly 84 % of the genome was covered by reads from at least one of the five runs, suggesting that nearly 16 % of the genome is not transcribed or is transcribed at low levels. We identified 123 genes that were differentially expressed during the acute phase of infection. Sixty-three genes were mapped to the large chromosome, 47 genes mapped to the small chromosome and 13 genes mapped to the YJ016 plasmid. The 123 genes fell into a variety of functional categories including transcription, signal transduction, cell motility, carbohydrate metabolism, intracellular trafficking and cell envelope biogenesis. Among the genes differentially expressed during human infection we identified genes encoding bacterial toxin (RtxA1) and genes involved in flagellar components, Flp-coding region, GGDEF family protein, iron acquisition system and sialic acid metabolism.

Genome Sequence of the Pathogenic Bacterium Vibrio vulnificus Biotype 3

We report the first genome sequence of the pathogenic Vibrio vulnificus biotype 3. This draft genome sequence of the environmental strain VVyb1(BT3), isolated in Israel, provides a representation of this newly emerged clonal group, which reveals higher similarity to the clinical strains of biotype 1 than to the environmental ones.

Genetic diversity of the human pathogen Vibrio vulnificus: a new phylogroup

The biotype 3 group of the human pathogen Vibrio vulnificus emerged in Israel probably as a result of genome hybridization of two bacterial populations. We performed a genomic and phylogenetic study of V. vulnificus strains isolated from the environmental niche from which this group emerged - fish aquaculture in Israel. The genetic relationships and evolutionary aspects of 188 environmental and clinical isolates of the bacterium were studied by genomic typing. Genetic relations were determined based on variation at 12 variable number tandem repeat (VNTR, also termed SSR) loci. Analysis revealed a new cluster, in addition to the main groups of biotype 1& 2 and biotype 3. Similar grouping results were obtained with three different statistical approaches. Isolates forming this new cluster presented unclear biochemical profile nevertheless were not identified as biotype 1 or biotype 3. Further examination of representative strains by multilocus sequence typing (MLST) of 10 housekeeping genes and 5 conserved hypothetical genes supported the identification of this as yet undiscovered phylogroup (phenotypically diverse), termed clade A herein. This new clonal subgroup includes environmental as well as clinical isolates. The results highlight the fish aquaculture environment, and possibly man-made ecological niches as a whole, as a source for the emergence of new pathogenic strains.

Predominant effect of host genetics on levels of Lactobacillus johnsonii bacteria in the mouse gut

The gut microbiota is strongly associated with the well-being of the host. Its composition is affected by environmental factors, such as food and maternal inoculation, while the relative impact of the host's genetics have been recently uncovered. Here, we studied the effect of the host genetic background on the composition of intestinal bacteria in a murine model, focusing on lactic acid bacteria (LAB) as an important group that includes many probiotic strains. Based on 16S rRNA gene genotyping, variation was observed in fecal LAB populations of BALB/c and C57BL/6J mouse lines. Lactobacillus johnsonii, a potentially probiotic bacterium, appeared at significantly higher levels in C57BL/6J versus BALB/c mouse feces. In the BALB/c gut, the L. johnsonii level decreased rapidly after oral administration, suggesting that some selective force does not allow its persistence at higher levels. The genetic inheritance of L. johnsonii levels was further tested in reciprocal crosses between the two mouse lines. The resultant F1 offspring presented similar L. johnsonii levels, confirming that mouse genetics plays a major role in determining these levels compared to the smaller maternal effect. Our findings suggest that mouse genetics has a major effect on the composition of the LAB population in general and on the persistence of L. johnsonii in the gut in particular. Concentrating on a narrow spectrum of culturable LAB enables the isolation and characterization of such potentially probiotic bacterial strains, which might be specifically oriented to the genetic background of the host as part of a personalized-medicine approach.

Genetic characterization of Vibrio vulnificus strains from tilapia aquaculture in Bangladesh

Outbreaks of Vibrio vulnificus wound infections in Israel were previously attributed to tilapia aquaculture. In this study, V. vulnificus was frequently isolated from coastal but not freshwater aquaculture in Bangladesh. Phylogenetic analyses showed that strains from Bangladesh differed remarkably from isolates commonly recovered elsewhere from fish or oysters and were more closely related to strains of clinical origin.

Environmental monitoring of Vibrio cholerae using chironomids in India

Environmental Vibrio cholerae strains belonging to the non-O1/non-O139 serogroups are natural inhabitants of freshwater including estuarine environments. Recent findings indicated that chironomids (Diptera: Chironomidae), the most widely distributed insects in freshwater, serve as a natural reservoir of these bacteria. Here we study the role of chironomids, particularly exuviae as carriers and as a monitoring tool for the distribution of V. cholerae in the environment. During a survey conducted in India (June 2006), 326 V. cholerae non-O1/non-O139 isolates were isolated from chironomid egg masses, larvae and exuviae. In addition, a heat-stable enterotoxin (nag-st) positive strain was isolated from exuviae during the local cholera outbreak. We identified 62 different strains in a subset of 102 isolates by analysis of variable number of tandem repeats (VNTR), demonstrating a high variation of V. cholerae on hosting chironomids. Our results show that chironomids can both maintain and distribute this overwhelming diversity of environmental V. cholerae strains, including toxigenic ones. Exuviae proved to be an efficient tool for the monitoring of environmental V. cholerae, offering simple, direct and practical access for on-shore collection. Finally, finding toxigenic V. cholerae on chironomids in endemic areas, together with molecular typing, may potentially improve monitoring of cholera in the future.

Global Warming and Trans-Boundary Movement of Waterborne Microbial Pathogens

Potential ramifications of climate change, as they relate to waterborne pathogens (primarily viruses, bacterial and parasitic protozoa), are the focus of this chapter. It seems clear that climate change will impact on waterborne pathogens in various ways (Rose et al. 2001), pertinent to transboundary issues are: (1) increases in intense storm events (increasing sewage/animal waste flows into waterways/aquifers) (Charron et al. 2004; Schijven and de Roda Husman 2005; Yang and Goodrich 2009; De Toffol et al. 2009; Richardson et al. 2009); (2) warmer surface water temperatures or salinity changes (for increased autochthonous pathogen growth) (Niemi et al. 2004; Koelle et al. 2005; Lebarbenchon et al. 2008); and (3) changes in food production, as most obvious in animal diseases (Lightner et al. 1997; Rapoport and Shimshony 1997), but also of concern with zoonoses and from changes in social behavior (Schwab et al. 1998; Nancarrow et al. 2008; CDC 2009a). When considering trans-boundary effects on waterborne pathogens, it is therefore the flow of pathogens in surface water (fresh and marine) and in groundwater, as well as in the varying ways water is used/reused in association with human activities (e.g., food production) that are the trans-boundary issues discussed in this chapter (examples in Table 5.1). Changes in infectious and vector-borne diseases associated with rising sea levels, losses of habitat, international travel etc. are not addressed in this chapter.