Logo of jcmPermissionsJournals.ASM.orgJournalJCM ArticleJournal InfoAuthorsReviewers
J Clin Microbiol. 2009 May; 47(5): 1568–1571.
Published online 2009 Mar 18. doi:  10.1128/JCM.02040-08
PMCID: PMC2681878

Cholera Outbreaks Caused by an Altered Vibrio cholerae O1 El Tor Biotype Strain Producing Classical Cholera Toxin B in Vietnam in 2007 to 2008 [down-pointing small open triangle]


Vibrio cholerae O1 isolates collected during cholera outbreaks occurring from late 2007 to early 2008 in northern Vietnam were revealed to represent an altered strain containing the RS1 element followed by a CTX prophage harboring El Tor type rstR and classical ctxB on the large chromosome.

Cholera continues to impose a major toll of both epidemic and endemic proportions worldwide, accounting for an estimated 120,000 deaths annually in spite of the advances in rehydration therapy and disease management (12). Cholera is caused by the gram-negative toxigenic bacterium Vibrio cholerae. More than 200 serogroups of V. cholerae are known, but only serogroups O1 and O139 cause epidemic and pandemic cholera (12). The O1 serogroup of V. cholerae is categorized into one of two biotypes, classical and El Tor, based on the results of assays such as agglutination of chicken red blood cells, Voges-Proskauer reaction, and polymyxin B resistance tests (7). Cholera toxin (CT) is encoded by the ctxAB gene, which is located on the CTX prophage integrated on the V. cholerae chromosome (7). The classical toxin (epitype CT1) is produced by classical biotype strains and U.S. Gulf Coast strains, while the El Tor type toxin (CT2) is generated by El Tor biotype strains and O139 strains (10). These two toxins differ in the CT B subunit by 2 out of 124 amino acids, and a PCR-based method to discriminate the classical type ctxB and El Tor type ctxB was recently described elsewhere (9).

Beginning in the late 1990s, El Tor biotype strains with the classical biotype traits (hybrid strains or Matlab variants) and El Tor strains producing classical toxin (altered strains) have been described previously (10, 13). Among the altered strains, two types of CTX prophages containing classical ctxB have been reported. One is the CTX prophage harboring classical rstR and classical ctxB genes, as seen in the V. cholerae isolates collected in Mozambique (4, 8), and the other is the CTX prophage containing El Tor rstR and classical ctxB. The Mozambican strain contains a tandem repeat of the classical CTX prophage on the small chromosome. In contrast, the altered strains vary by their CTX prophage type and presence of the RS1 element, and the exact array of the CTX prophage and the RS1 element on the genome of these strains has yet to be clarified (13).

Before 2005, only a few cases of cholera were reported in the northern part of Vietnam. However, by the end of 2007, major outbreaks of cholera were occurring in this region (14). The first case of cholera was reported on 23 October 2007 in Hanoi, Vietnam, and up until 11 April 2008, a cumulative total number of 3,271 cases were reported from 18 northern provinces in Vietnam.

In this study, we analyzed 70 V. cholerae isolates which were collected from patients and the physical environment in northern Vietnam during three cholera outbreaks between November 2007 and February 2008. Of the 70 isolates, 38 were collected in 2007 and 32 were collected in 2008. Isolates were collected as follows: 50 from patients, 10 from people who were in contact with patients, 5 from water samples, 3 from food, and 2 from vegetables. For comparison, 12 isolates collected from the same area of Vietnam between 1995 and 2004 were also analyzed (one collected in 1995, two collected in 2002, three collected in 2003, and six collected in 2004). All of the 70 isolates were identified as being of the V. cholerae O1 Ogawa serotype. By use of the polymyxin B sensitivity and Voges-Proskauer tests, all of the isolates were classified as being of the El Tor biotype (Table (Table11).

Biotype characterization of V. cholerae O1 isolates from Vietnam

The genetic structures of the CTX prophage and RS1 element on the genome of Vietnamese isolates were determined by a number of PCR and sequencing. Primers used in this study and their sequences are listed in Table Table2,2, and their locations are shown in Fig. Fig.11.

FIG. 1.
Genetic map of the CTX prophage and RS1 element in V. cholerae O1 strains. For comparison, the CTX prophage and the RS1 element on each chromosome of the El Tor reference strain N16961 (6), the classical biotype reference strain O395 (3), the Mozambican ...
Primer sequences used in this studya

rstR type.

Only the El Tor type-specific primer set (rstRETF/rstAR) amplified a DNA fragment from the Vietnamese isolates. The DNA sequences of the amplified fragments from the Vietnamese isolates and from the El Tor biotype reference strain N16961 were found to be identical. No DNA fragment was amplified from the Vietnamese isolates with the classical rstR-specific primer set (rstRclaF/rstAR). For additional confirmation of the absence of other types of rstR, namely, rstRCal (O139 type) and rstRenv (environmental type), we used PCR primers rstRCalF/rstRCalR and rstREnvF/rstREnvR, and no PCR product was identified from the Vietnamese isolates (11).

Presence and the location of rstC (RS1).

A DNA fragment was amplified from the Vietnamese isolates with the rstC-specific primer set rstCF/rstCR, which implies that there is a rstC gene(s) in the genome. With the primer pair ctxBF/rstCR, a CTX prophage-RS1 array can be determined and, similarly, an RS1-CTX prophage array can be identified with the rstCF/cepR primer set. A DNA fragment was amplified from the Vietnamese isolates only by the rstCF/cepR primer pair, which suggests that the RS1-CTX prophage array exists on the genome of the Vietnamese isolates. The same primer pair, rstCF/cepR, produced identical DNA fragments from all of the 70 Vietnamese isolates, which indicates that all of the isolates contain the same RS1-CTX prophage array on the genome.

Absence of the tandem repeat of CTX prophage and RS1.

The presence or absence of a tandem repeat of CTX prophage can be determined by using the primer pair ctxBF/cepR. No DNA fragment was amplified from the Vietnamese isolates, indicating that a tandem repeat of the CTX prophage does not exist on the genome. A tandem repeat of RS1 element can be verified by the PCR primer set rstCF4/rstCR4; however, no DNA fragment was amplified from the Vietnamese isolates, implying that they do not have a tandem repeat of RS1 on their genome.

Location of RS1-CTX prophage array.

Two primer pairs, Ch1F/rstAR and ctxBF/Ch1R, produced corresponding DNA fragments from the Vietnamese isolates, indicating that the RS1-CTX prophage array is located on the large chromosome. The sequences of the DNA fragment encompassing the RS1 element and the DNA fragment encompassing the ctxB and downstream integration site were deposited in GenBank (Fig. (Fig.1).1). The absence of CTX prophage or RS1 on the small chromosome was confirmed by the PCR product of primer pair Ch2F/Ch2R, and the DNA sequence of this fragment was deposited in GenBank.

Toxin type determination.

From the DNA sequence of the ctxB fragment amplified with primer set ctxBF/Ch1R, we identified His and Thr at the 39th and 68th amino acid positions, which shows that this ctxB gene is of the classical type (10).

Multilocus sequence typing (MLST) analysis.

The allele profile for the nine loci (dnaE, lap, rstA, gmd, recA, pgm, gyrB, cat, and chi) of the Vietnamese isolates was found to be the same as that for the seventh pandemic cholera strain, N16961, and for the Mozambican strain (Table (Table1)1) (5, 8).

We also analyzed V. cholerae O1 strains from countries neighboring Vietnam, namely, four clinical isolates collected from the cholera patients during a recent outbreak in the Lao People's Democratic Republic (February 2008) and two altered strains from Bangladesh, AR-32732 and MQ-1194, isolated in 1999 and 2001, respectively (1). They were found to contain the same RS1-CTX prophage array (El Tor rstR and classical ctxB) as seen in the isolates from the Vietnamese outbreaks in 2007 and 2008. We also collected and analyzed 400 V. cholerae isolates from Kolkata, India, between 2003 and 2007 and observed that these Indian isolates also contain the same RS1-CTX prophage array (data not shown). An analysis of their genetic relatedness is currently being conducted.

Interestingly, 12 isolates that were collected between 1995 and 2004 in northern Vietnam were identified being of as serotype O1 Inaba and biotype El Tor, and they contained a tandem repeat of the classical CTX prophage on the small chromosome, similar to the Mozambican isolates (8). A few of the isolates have an additional classical CTX prophage on the large chromosome (data not shown). This suggests that the isolates responsible for the 2007 and 2008 epidemics in Vietnam were recently introduced into the area. The isolates collected between 1995 and 2004 in Vietnam were not responsible for any major cholera outbreak in recent decades, while the similar V. cholerae strains were isolated during a series of outbreaks in Mozambique in 2003. The differences among the altered strains with respect to their ability to cause epidemics, as well as their genetic backgrounds, should be further elucidated.

Our findings indicate that the altered strains are prevalent in south and southeast Asia, and they may be gradually spreading globally. More information about strains from other continents should be investigated in order to monitor the global distribution of the hybrid and altered strains.

Nucleotide sequence accession numbers.

The DNA sequences for the fragment encompassing the RS1 element and the fragment encompassing ctxB and the downstream integration site were deposited in GenBank under accession numbers EU837140 and EU837141, respectively. The DNA sequence of the Ch2F/Ch2R primer pair PCR product was deposited in GenBank under accession number EU837142.


This work was supported by the Cholera Vaccine Initiative, funded by the Bill and Melinda Gates Foundation. The International Vaccine Institute is supported by the governments of Korea, Sweden, and Kuwait. J.H.L., S.Y.C., and D.W.K. were supported by grant number RTI05-01-01 from the Regional Technology Innovation Program of the Ministry of Knowledge and Economy and grant R01-2006-000-10255-0 from the Basic Research Program of the Korea Science and Engineering Foundation.


[down-pointing small open triangle]Published ahead of print on 18 March 2009.


1. Abd, H., A. Saeed, A. Weintraub, G. B. Nair, and G. Sandstrom. 2007. Vibrio cholerae O1 strains are facultative intracellular bacteria, able to survive and multiply symbiotically inside the aquatic free-living amoeba Acanthamoeba castellanii. FEMS Microbiol. Ecol. 6033-39. [PubMed]
2. Davis, B. M., H. H. Kimsey, W. Chang, and M. K. Waldor. 1999. The Vibrio cholerae O139 Calcutta bacteriophage CTXΦ is infectious and encodes a novel repressor. J. Bacteriol. 1816779-6787. [PMC free article] [PubMed]
3. Davis, B. M., K. E. Moyer, E. F. Boyd, and M. K. Waldor. 2000. CTX prophages in classical biotype Vibrio cholerae: functional phage genes but dysfunctional phage genomes. J. Bacteriol. 1826992-6998. [PMC free article] [PubMed]
4. Faruque, S. M., V. C. Tam, N. Chowdhury, P. Diraphat, M. Dziejman, J. F. Heidelberg, J. D. Clemens, J. J. Mekalanos, and G. B. Nair. 2007. Genomic analysis of the Mozambique strain of Vibrio cholerae O1 reveals the origin of El Tor strains carrying classical CTX prophage. Proc. Natl. Acad. Sci. USA 1045151-5156. [PMC free article] [PubMed]
5. Garg, P., A. Aydanian, D. Smith, J. G. Morris, Jr., G. B. Nair, and O. C. Stine. 2003. Molecular epidemiology of O139 Vibrio cholerae: mutation, lateral gene transfer, and founder flush. Emerg. Infect. Dis. 9810-814. [PMC free article] [PubMed]
6. Heidelberg, J. F., J. A. Eisen, W. C. Nelson, R. A. Clayton, M. L. Gwinn, R. J. Dodson, D. H. Haft, E. K. Hickey, J. D. Peterson, L. Umayam, S. R. Gill, K. E. Nelson, T. D. Read, H. Tettelin, D. Richardson, M. D. Ermolaeva, J. Vamathevan, S. Bass, H. Qin, I. Dragoi, P. Sellers, L. McDonald, T. Utterback, R. D. Fleishmann, W. C. Nierman, O. White, S. L. Salzberg, H. O. Smith, R. R. Colwell, J. J. Mekalanos, J. C. Venter, and C. M. Fraser. 2000. DNA sequence of both chromosomes of the cholera pathogen Vibrio cholerae. Nature 406477-483. [PubMed]
7. Kaper, J. B., J. G. Morris, Jr., and M. M. Levine. 1995. Cholera. Clin. Microbiol. Rev. 848-86. [PMC free article] [PubMed]
8. Lee, J. H., K. H. Han, S. Y. Choi, M. E. Lucas, C. Mondlane, M. Ansaruzzaman, G. B. Nair, D. A. Sack, L. von Seidlein, J. D. Clemens, M. Song, J. Chun, and D. W. Kim. 2006. Multilocus sequence typing (MLST) analysis of Vibrio cholerae O1 El Tor isolates from Mozambique that harbour the classical CTX prophage. J. Med. Microbiol. 55165-170. [PubMed]
9. Morita, M., M. Ohnishi, E. Arakawa, N. A. Bhuiyan, S. Nusrin, M. Alam, A. K. Siddique, F. Qadri, H. Izumiya, G. B. Nair, and H. Watanabe. 2008. Development and validation of a mismatch amplification mutation PCR assay to monitor the dissemination of an emerging variant of Vibrio cholerae O1 biotype El Tor. Microbiol. Immunol. 52314-317. [PubMed]
10. Nair, G. B., F. Qadri, J. Holmgren, A. M. Svennerholm, A. Safa, N. A. Bhuiyan, Q. S. Ahmad, S. M. Faruque, A. S. Faruque, Y. Takeda, and D. A. Sack. 2006. Cholera due to altered El Tor strains of Vibrio cholerae O1 in Bangladesh. J. Clin. Microbiol. 444211-4213. [PMC free article] [PubMed]
11. Nusrin, S., G. Y. Khan, N. A. Bhuiyan, M. Ansaruzzaman, M. A. Hossain, A. Safa, R. Khan, S. M. Faruque, D. A. Sack, T. Hamabata, Y. Takeda, and G. B. Nair. 2004. Diverse CTX phages among toxigenic Vibrio cholerae O1 and O139 strains isolated between 1994 and 2002 in an area where cholera is endemic in Bangladesh. J. Clin. Microbiol. 425854-5856. [PMC free article] [PubMed]
12. Sack, D. A., R. B. Sack, G. B. Nair, and A. K. Siddique. 2004. Cholera. Lancet 363223-233. [PubMed]
13. Safa, A., N. A. Bhuyian, S. Nusrin, M. Ansaruzzaman, M. Alam, T. Hamabata, Y. Takeda, D. A. Sack, and G. B. Nair. 2006. Genetic characteristics of Matlab variants of Vibrio cholerae O1 that are hybrids between classical and El Tor biotypes. J. Med. Microbiol. 551563-1569. [PubMed]
14. World Health Organization. 2008. Outbreak news. Severe acute watery diarrhoea with cases positive for Vibrio cholerae, Viet Nam. Wkly. Epidemiol. Rec. 83157-158. [PubMed]

Articles from Journal of Clinical Microbiology are provided here courtesy of American Society for Microbiology (ASM)
PubReader format: click here to try


Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...


  • Cited in Books
    Cited in Books
    PubMed Central articles cited in books
  • MedGen
    Related information in MedGen
  • Nucleotide
    Published Nucleotide sequences
  • Protein
    Published protein sequences
  • PubMed
    PubMed citations for these articles
  • Substance
    PubChem Substance links

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...