Antibiotic resistant Escherichia coli and Salmonella in Russian rooks (Corvus frugilegus) wintering in the Czech Republic

AIMS: To characterize antibiotic resistant Escherichia coli and Salmonella isolates in rooks wintering in the Czech Republic. METHODS AND RESULTS: Three hundred and sixty-three faeces samples from rooks were examined for antibiotic resistant Escherichia coli and Salmonella. Altogether 13.7%E. coli isolates were resistant to antimicrobial agents tested. The dominant type of resistance was to tetracycline. Resistant E. coli isolates were examined for antibiotic resistance genes and class 1 integrons. Five of 29 antibiotic resistant isolates possessed the int1 gene. Nine Salmonella isolates (2.5%) were found in rook faeces. All the isolates belonged to serotype Salmonella enterica serovar Enteritidis phage type PT8 and PT23. CONCLUSIONS: The study suggests that rooks can be infected by antibiotic resistant E. coli and Salmonella isolates, probably reflecting the presence of such isolates in their sources of food and/or water in the environment. SIGNIFICANCE AND IMPACT OF THE STUDY: Rooks can serve as reservoirs and vectors of antibiotic resistant E. coli and Salmonella isolates and potentially transmit these isolates over long distances.     

Antibiotic resistance of gram-negative enteric bacteria from pigs in three herds with different histories of antibiotic exposure

The antibiotic resistance patterns of gram-negative fecal bacteria from pigs in three herds with different histories of antibiotic exposure were examined. In general, smaller proportions of antibiotic-resistant or multiply resistant fecal isolates (P less than 0.05) were obtained from pigs in a herd not exposed to antimicrobial agents for 154 months than from pigs in a herd continuously exposed to antimicrobial agents at subtherapeutic doses or from pigs in a herd exposed only to therapeutic doses of antimicrobial agents. The proportions of antibiotic-resistant and multiply resistant strains were greater among isolates from pigs in the therapeutic herd than in the non-antibiotic-exposed herd (P less than 0.05). The proportion of antibiotic-resistant isolates in the non-lactose-fermenting population was greater than that in the lactose-fermenting population, regardless of herd. The results suggest that any form of antimicrobial exposure will increase the prevalence of antimicrobial resistance and multiple resistance of fecal bacteria.     

Antibiotic resistance of gram-negative enteric bacteria from pigs in three herds with different histories of antibiotic exposure.

The antibiotic resistance patterns of gram-negative fecal bacteria from pigs in three herds with different histories of antibiotic exposure were examined. In general, smaller proportions of antibiotic-resistant or multiply resistant fecal isolates (P less than 0.05) were obtained from pigs in a herd not exposed to antimicrobial agents for 154 months than from pigs in a herd continuously exposed to antimicrobial agents at subtherapeutic doses or from pigs in a herd exposed only to therapeutic doses of antimicrobial agents. The proportions of antibiotic-resistant and multiply resistant strains were greater among isolates from pigs in the therapeutic herd than in the non-antibiotic-exposed herd (P less than 0.05). The proportion of antibiotic-resistant isolates in the non-lactose-fermenting population was greater than that in the lactose-fermenting population, regardless of herd. The results suggest that any form of antimicrobial exposure will increase the prevalence of antimicrobial resistance and multiple resistance of fecal bacteria.     

Survey of Shiga toxigenic Escherichia coli O157 and drug-resistant coliform bacteria from in-line milk filters on dairy farms in the Czech Republic

Aims: To determine the occurrence of Shiga toxin‐producing Escherichia coli (STEC) O157 and coliform bacteria isolates resistant to antimicrobial agents in dairy herds by examining milk filters and to analyse the influence of management factors and antibiotic use on antimicrobial resistance. Methods and Results: A total of 192 in‐line milk filters were sampled on 192 dairy farms in the Czech Republic. Information on feeding, husbandry, production, and antibiotic therapy were obtained by questionnaire. The milk filters were cultured for STEC O157 and coliform bacteria. All recovered isolates were examined for antimicrobial susceptibility and presence of antimicrobial‐resistance genes. STEC O157 was detected in four (2%) of the filters. Resistant nonpathogenic E. coli and coliform bacteria isolates with specific genes were detected in 44 (23%) of the filters. Conclusions: The study demonstrated a high prevalence of resistant coliform bacteria in milk filters obtained on Czech dairy farms. Significance and Impact of the Study: The occurrence of resistant coliform bacteria in milk filters was significantly higher among isolates from farms where antibiotic therapy against mastitis was employed during the dry period (P < 0·05).     

Variations in antibiotic resistance profile in Enterobacteriaceae isolated from wild Australian mammals

We carried out a retrospective analysis of 946 strains of Enterobacteriaceae isolated from wild Australian mammals between 1993 and 1997. The prevalence of resistance to fixed concentrations of 32 antimicrobial agents was determined, and the respective roles that taxonomic family of the host, state of origin and bacterial species play in defining prevalence and range of resistance were investigated. Our results demonstrated a low but widespread prevalence of antimicrobial resistance in wild isolates. Only amikacin, ciprofloxacin, meropenem and gentamicin inhibited growth in all 946 samples. There was extensive variation in the combination of antibiotics to which isolates were resistant, and multiple antibiotic resistance was common. Geographical location and host group significantly influenced the antibiotic resistance profile of an isolate, whereas bacterial species influenced both the resistance profile of an isolate and the number of antibiotics it was resistant to. The role of these factors in determining observed antibiotic resistance profiles suggests that any study measuring resistance in wild isolates should include the broadest possible range of bacterial species, host species and sampling locations. As such, this study provides an important new baseline for future measurements of antibiotic resistance in the Australian environment.     

Effect of age and housing location on antibiotic resistance of fecal coliforms from pigs in a non-antibiotic-exposed herd.

The relationship of age and housing location to single antibiotic resistance, multiple antibiotic resistance, and resistance patterns of fecal coliforms obtained during a 20-month period from pigs in a herd that was not exposed to antibiotics for 126 months was determined. Bacteria resistant to single and multiple antibiotics were isolated more frequently (P less than 0.01) from pigs under 7 months of age. A greater proportion of isolates from pigs over 6 months of age was sensitive to the 13 antimicrobial agents tested (P less than 0.01), while a smaller proportion showed resistance to single (P less than 0.05) and multiple (P less than 0.01) antibiotics. More than 80% of the resistant isolates were resistant to tetracycline, streptomycin, or sulfisoxazole. Resistance was greater (P less than 0.01) for pigs in the finishing unit than for those on pasture. Resistance to ampicillin, carbenicillin, and tetracycline was greater (P less than 0.05) for pigs in the finishing unit than for those in the farrowing house. More isolates from pigs on pasture were sensitive to all antimicrobial agents tested (P less than 0.01). A greater proportion of isolates from pigs in the finishing unit showed resistance to a single antibiotic (P less than 0.01). The data from this study suggest that exposure to antibiotics is not the only factor that influences the prevalence of bacteria that are resistant to single and multiple antibiotics in the feces of domestic animals and that considerable research is needed to define the factors influencing antibiotic resistance in fecal bacteria.     

Effect of age and housing location on antibiotic resistance of fecal coliforms from pigs in a non-antibiotic-exposed herd

The relationship of age and housing location to single antibiotic resistance, multiple antibiotic resistance, and resistance patterns of fecal coliforms obtained during a 20-month period from pigs in a herd that was not exposed to antibiotics for 126 months was determined. Bacteria resistant to single and multiple antibiotics were isolated more frequently (P less than 0.01) from pigs under 7 months of age. A greater proportion of isolates from pigs over 6 months of age was sensitive to the 13 antimicrobial agents tested (P less than 0.01), while a smaller proportion showed resistance to single (P less than 0.05) and multiple (P less than 0.01) antibiotics. More than 80% of the resistant isolates were resistant to tetracycline, streptomycin, or sulfisoxazole. Resistance was greater (P less than 0.01) for pigs in the finishing unit than for those on pasture. Resistance to ampicillin, carbenicillin, and tetracycline was greater (P less than 0.05) for pigs in the finishing unit than for those in the farrowing house. More isolates from pigs on pasture were sensitive to all antimicrobial agents tested (P less than 0.01). A greater proportion of isolates from pigs in the finishing unit showed resistance to a single antibiotic (P less than 0.01). The data from this study suggest that exposure to antibiotics is not the only factor that influences the prevalence of bacteria that are resistant to single and multiple antibiotics in the feces of domestic animals and that considerable research is needed to define the factors influencing antibiotic resistance in fecal bacteria.     

Detection of Salmonella spp. in retail raw food samples from Vietnam and characterization of their antibiotic resistance

A study was conducted to examine the levels of Salmonella spp. contamination in raw food samples, including chicken, beef, pork, and shellfish, from Vietnam and to determine their antibiotic resistance characteristics. A total of 180 samples were collected and examined for the presence of Salmonella spp., yielding 91 Salmonella isolates. Sixty-one percent of meat and 18% of shellfish samples were contaminated with Salmonella spp. Susceptibility of all isolates to a variety of antimicrobial agents was tested, and resistance to tetracycline, ampicillin/amoxicillin, nalidixic acid, sulfafurazole, and streptomycin was found in 40.7%, 22.0%, 18.7%, 16.5%, and 14.3% of the isolates, respectively. Resistance to enrofloxacin, trimethoprim, chloramphenicol, kanamycin, and gentamicin was also detected (8.8 to 2.2%). About half (50.5%) of the isolates were resistant to at least one antibiotic, and multiresistant Salmonella isolates, resistant to at least three different classes of antibiotics, were isolated from all food types. One isolate from chicken (serovar Albany) contained a variant of the Salmonella genomic island 1 antibiotic resistance gene cluster. The results show that antibiotic resistance in Salmonella spp. in raw food samples from Vietnam is significant.     

A heterodimer comprised of two bovine lactoferrin antimicrobial peptides exhibits powerful bactericidal activity against Burkholderia pseudomallei

Melioidosis is a severe infectious disease that is endemic in Southeast Asia and Northern Australia. Burkholderia pseudomallei, the causative agent of this disease, has developed resistance to an increasing list of antibiotics, demanding a search for novel agents. Lactoferricin and lactoferrampin are two antimicrobial domains of lactoferrin with a broad spectrum of antimicrobial activity. A hybrid peptide (LFchimera) containing lactoferrampin (LFampin265–284) and a part of lactoferricin (LFcin17–30) has strikingly higher antimicrobial activities compared to the individual peptides. In this study, the antimicrobial activities of this chimeric construct (LFchimera1), as well as of another one containing LFcin17–30 and LFampin268–284, a shorter fragment of LFampin265–284 (LFchimera2), and the constituent peptides were tested against 7 isolates of B. pseudomallei and compared to the preferential antibiotic ceftazidime (CAZ). All isolates including B. pseudomallei 979b shown to be resistant to CAZ, at a density of 10⁵ CFU/ml, could be killed by 5–10 μM of LFchimera1 within 2 h, while the other peptides as well as the antibiotic CAZ only inhibited the B. pseudomallei strains resulting in an overgrowth in 24 h. These data indicate that LFchimera1 could be considered for development of therapeutic agents against B. pseudomallei.     

乳铁蛋白的多功能生物活性与临床进展

目前,为应对抗生素耐药性问题,需要探索更多的抗生素替代物用于对抗微生物的感染。乳铁蛋白是一类源自哺乳动物乳汁或其他粘膜分泌的一种糖基化蛋白,具有广谱抗微生物活性、免疫调节以及抗癌作用。乳铁蛋白对于易受感染的早产儿也有很好的耐受作用,基本无不良反应,具有良好的开发前景。本文主要概述乳铁蛋白的基本性质、多功能的生物学活性和作用机制,并探讨牛乳铁蛋白与talactoferrin的临床研究情况。     

Antibiotic resistance in strains of Listeria spp. from meat products

The susceptibility or resistance to 26 antimicrobial agents was determined for 64 strains of Listeria monocytogenes and 102 strains of L. innocua isolated from Italian meat products. Some strains of L. monocytogenes were found to be resistant to tetracycline, erythromycin, co-trimoxazole and clindamycin. No plasmids were found in any L. monocytogenes strain. Five strains of L. innocua contained a 7.9 kbp plasmid, but these isolates were not resistant to any antibiotic in common and treatment with curing agents could not eliminate resistance to antibiotics. These results suggest that antibiotic resistance was not likely to be plasmid mediated in our strains.     

Antibiotic resistance and plasmid profile of Aeromonas hydrophila isolates from cultured fish, Telapia (Telapia mossambica)

Strains of Aeromonas hydrophila isolates from skin lesions of the common freshwater fish, Telapia mossambica , were screened for the presence of plasmid DNA by agarose gel electrophoresis and tested for susceptibility to 10 antimicrobial agents. Of the 21 fish isolates examined, all were resistant to ampicillin and sensitive to gentamycin. Most isolates were resistant to streptomycin (57%), tetracycline (48%) and erythromycin (43%). While seven of 21 isolates harboured plasmids, with sizes ranging from 3 to 63·4 kilobase pair (kb), it was only possible to associate the presence of a plasmid with antibiotic resistance (ampicillin and tetracycline) in strain AH11. Both the plasmid and the associated antimicrobial resistance could be transferred to an Escherichia coli recipient by single-step conjugation at a frequency of 4·3×10⁻³ transconjugants per donor cell.     

Comparison of disc diffusion and epsilometer (E-test) testing techniques to determine antimicrobial susceptibiliy of Campylobacter isolates of food and human clinical origin

The antibiotic resistance profiles of 75 Campylobacter isolates of food and human clinical origin was determined by two agar diffusion susceptibility methods; disc diffusion and epsilometer-test (E-test). The most common therapeutic antimicrobials, erythromycin, ciprofloxacin and tetracycline were studied, along with chloramphenicol, ampicillin and naladixic acid. The resistance observed for each antimicrobial, as determined by both of methods, were statistically compared using Fisher two-tailed analysis.Of the six antimicrobials studied only two were shown to have statistically different patterns when resistance was compared by disc diffusion and E-test. The percentage of isolates resistant to clinically relevant antimicrobials using both techniques ranged from 6.6 to 21.3% for erythromycin, 25.3–26.6% for tetracycline and 33.3–36.0% for ciprofloxacin. The prevalence of multi-drug resistant (MDR) campylobacters (isolates resistant to 2 or more antimicrobials) for both disc diffusion and E-test was 44%. It can be concluded that, for four of the six antimicrobials assessed, antimicrobial resistance prevalences could be equally determined by either of the methods studied.     

Resistance of urinary tract infection pathogens and choice of antibacterial therapy in pediatric urologic practice]

The data on antibiotic resistance of the main uropathogens isolated from patients with urinary tract infection in an urologic department (319 isolates) and outpatient and diagnostic units (360 isolates) are presented. It was shown that by the antibiotic resistance the Escherichia coli isolates from the urologic department patients and outpatients did not practically differ: 44.1 and 47.8% of the isolates were resistant to ampicillin, 26.7 and 23.4% were resistant to amoxycillin/clavulanate, 28.9 and 24.9% were resistant to co-trimoxazole and 26.5% was resistance to cefuroxime (outpatients). The basic differences referred to Pseudomonas aeruginosa: resistance to ceftazidime in 38.5% of the isolates and resistance to gentamicin in 36.2% of the isolates. The activity against P. aeruginosa could be arranged as follows in the decreasing order: amikacin = meropenem > imipenem > cefepime = cefoperazone/sulbactam > gentamicin = ceftazidime. Resistance of P. aeruginosa to fluoroquinolones (ciprofloxacin and levofloxacin) remained low (7.4 and 8.0% respectively). No ampicillin resistance was revealed in the isolates of Enterococcus faecalis.     

A set of novel multiplex Taqman real-time PCRs for the detection of diarrhoeagenic Escherichia coli and its use in determining the prevalence of EPEC and EAEC in a university hospital

Background

Escherichia coli isolates of equine faecal origin were investigated for antibiotic resistance, resistance genes and their ability to perform horizontal transfer.

Methods

In total, 264 faecal samples were collected from 138 horses in hospital and community livery premises in northwest England, yielding 296 resistant E. coli isolates. Isolates were tested for susceptibility to antimicrobial drugs by disc diffusion and agar dilution methods in order to determine minimum inhibitory concentrations (MIC). PCR amplification was used to detect genes conferring resistance to: ampicillin (TEM and SHV beta-lactamase), chloramphenicol (catI, catII, catIII and cml), tetracycline (tetA, tetB, tetC, tetD, tet E and tetG), and trimethoprim (dfrA1, dfrA9, dfrA12, dfrA13, dfr7, and dfr17).

Results

The proportion of antibiotic resistant isolates, and multidrug resistant isolates (MDR) was significantly higher in hospital samples compared to livery samples (MDR: 48% of hospital isolates; 12% of livery isolates, p < 0.001). Resistance to ciprofloxacin and florfenicol were identified mostly within the MDR phenotypes. Resistance genes included dfr, TEM beta-lactamase, tet and cat, conferring resistance to trimethoprim, ampicillin, tetracycline and chloramphenicol, respectively. Within each antimicrobial resistance group, these genes occurred at frequencies of 93% (260/279), 91%, 86.8% and 73.5%, respectively; with 115/296 (38.8%) found to be MDR isolates. Conjugation experiments were performed on selected isolates and MDR phenotypes were readily transferred.

Conclusions

Our findings demonstrate that E. coli of equine faecal origin are commonly resistant to antibiotics used in human and veterinary medicine. Furthermore, our results suggest that most antibiotic resistance observed in equine E. coli is encoded by well-known and well-characterized resistant genes common to E. coli from man and domestic animals. These data support the ongoing concern about antimicrobial resistance, MDR, antimicrobial use in veterinary medicine and the zoonotic risk that horses could potentially pose to public health.     

A Locked Nucleic Acid (LNA)-Based Real-Time PCR Assay for the Rapid Detection of Multiple Bacterial Antibiotic Resistance Genes Directly from Positive Blood Culture

Bacterial strains resistant to various antibiotic drugs are frequently encountered in clinical infections, and the rapid identification of drug-resistant strains is highly essential for clinical treatment. We developed a locked nucleic acid (LNA)-based quantitative real-time PCR (LNA-qPCR) method for the rapid detection of 13 antibiotic resistance genes and successfully used it to distinguish drug-resistant bacterial strains from positive blood culture samples. A sequence-specific primer-probe set was designed, and the specificity of the assays was assessed using 27 ATCC bacterial strains and 77 negative blood culture samples. No cross-reaction was identified among bacterial strains and in negative samples, indicating 100% specificity. The sensitivity of the assays was determined by spiking each bacterial strain into negative blood samples, and the detection limit was 1–10 colony forming units (CFU) per reaction. The LNA-qPCR assays were first applied to 72 clinical bacterial isolates for the identification of known drug resistance genes, and the results were verified by the direct sequencing of PCR products. Finally, the LNA-qPCR assays were used for the detection in 47 positive blood culture samples, 19 of which (40.4%) were positive for antibiotic resistance genes, showing 91.5% consistency with phenotypic susceptibility results. In conclusion, LNA-qPCR is a reliable method for the rapid detection of bacterial antibiotic resistance genes and can be used as a supplement to phenotypic susceptibility testing for the early detection of antimicrobial resistance to allow the selection of appropriate antimicrobial treatment and to prevent the spread of resistant isolates.     

Infections with Van B phenotype Enterococcus faecium and E. faecalis in patients with immune deficiency during the course of hematologic neoplasms

In this work, we have analyzed the second outbreak of VRE with the VanB phenotype to be identified in the country. The aim of this study was to characteristics of the types of resistance to glycopeptide antibiotic and to check the resistance patterns of these pathogens. A trial of monitoring the risk factors for colonization or infection with VRE as well as epidemiological investigation were undertaken. Genus identification of the isolates was performed according to the method of Facklam and Collins, and species were identified using the API 20 Strep test. MICs of different antimicrobial agents were determined by the E-test method. The isolates collected during the investigation demonstrated resistance to multiple antimicrobials, which is a common characteristic of VRE. Isolates were found to be uniformly resistant to penicillin, fluoroquinolones, tetracycline and to high concentrations of aminoglycosides. The only drugs with in vitro activity against the isolates were ampicillin (VRES), linezolid (VRES, VREM) and quinupristin-dalfopristin (VREM). Except for a single VREM isolate, they all revealed the typical VanB phenotype with resistance to vancomycin and susceptibility to teicoplanin. One of the VREM isolates turned out to be resistant to teicoplanin, which coincided with the use of this antibiotic in the patient's therapy. Its vanB gene variant differed by a single mutation from that found in other isolates; however, it also lacked a large part of the vanB gene claster, including the regulatory genes vanRB and -SB, and the vancomycin--inducible promoter PYB. Our studies have found an association between colonization or infection with VRE and the mean duration of hospital stay, previously administration of glycopeptide, cephalosporins and imipenem. These organisms were a common cause of monoethiological bloodstream infections.     

Susceptibility of Arcobacter butzleri isolates to 23 antimicrobial agents

AIMS: The objective of this study was to determine the susceptibility of Arcobacter butzleri isolates to various antimicrobial agents used in the treatment of infectious diseases in humans and animals. METHODS AND RESULTS: Thirty-nine A. butzleri strains isolated from broiler chickens were tested for their susceptibility to 23 antimicrobial agents using a disc diffusion method. All isolates were resistant to aztreonam, cefuroxime sodium, cephalothin, orbenin, oxacillin, penicillin G and trimethoprim/sulphamethoxazol. Of the 39 isolates tested, 26 were also found resistant to amoxycillin, amoxycillin/clavulanic acid and ampicillin. One isolate was resistant to, and four showed intermediate level of resistance to, erythromycin. All isolates were susceptible to amikacin, chloramphenicol, danofloxacin, enrofloxacin, nitrofurantoin, nalidixic acid, tetracyclines and tobramycin. CONCLUSIONS: The majority of the isolates were found resistant to antibiotics commonly used for the treatment of infectious bacterial diseases in humans and animals. SIGNIFICANCE AND IMPACT OF THE STUDY: This study shows that A. butzleri strains vary in their resistance to certain kinds of antibiotics and caution should be taken when choosing a suitable antibiotic for the treatment of disease(s) caused by this organism.     

Activity of the Antimicrobial Peptide and Thanatin Analog S-thanatin on Clinical Isolates of <Emphasis Type="Italic">Klebsiella pneumoniae</Emphasis> Resistant to Conventional Antibiotics with Different Structures

The treatment of infections caused by bacteria resistant to the vast majority of antibiotics is a challenge worldwide. To evaluate the effect of S-thanatin (an analog of thanatin, a cationic antimicrobial peptide isolated from the hemipteran insect Podisus maculiventris) against microbial resistant to antibiotics, we studied its bactericidal kinetics, synergistic effect, resistance, and activity on clinical isolates of Klebsiella pneumoniae resistant to conventional antibiotics with different structures. The bactericidal rate of S-thanatin was more than 99% against K. pneumoniae ATCC 700603 when bacterial cultures were monitored for 60 min. The peptide was synergistic with β-lactam cefepime in most of the clinical MDR isolates tested (7/8). An average value of FIC was 0.3708. No synergy was found between the peptide and amoxicillin, gentamycin, tetracycline, or ciprofloxacin in all bacteria tested. A total of 48 isolates of K. pneumoniae with different resistance spectrum tested was susceptible to S-thanatin. The MICs were 6.25–25 μg/ml. No significant difference in the MICs of S-thanatin between the sensitive isolates and the resistant isolates to single antibiotic was observed (P > 0.05). The resistance of K. pneumoniae ATCC 700603 to S-thanatin was slightly higher, when cultured at sub-inhibitory concentration for 5 days. S-thanatin may be an attractive candidate for developing into an antimicrobial agent.     

Phenotypic and genetic analysis of Enterobacter spp. from a Brazilian oligotrophic freshwater lake

We characterized a population of Enterobacter spp. of the Enterobacter cloacae complex isolated from an oligotrophic lake; most isolates were identified as E. cloacae. Fingerprinting polymerase chain reaction (PCR), along with morphological, biochemical, physiological, and plasmid profiles analyses, including antimicrobial susceptibility testing, were performed on 22 environmental isolates. Misidentification occurred when using the API 20E identification system. Analysis of 16S rDNA sequences confirmed the close relatedness between species of the E. cloacae complex. The tDNA PCR allowed the differentiation and identification of the E. cloacae isolates. Evaluation of genetic diversity by 16S rDNA sequence, tDNA, internal transcribed spacers, and enterobacterial repetitive intergenic concensus profiles revealed nearly identical isolates, although they exhibited different physiological and antimicrobial resistance profiles. Among the Enterobacter isolates, 96% were resistant to at least one antimicrobial; multiple resistance was also found at a high frequency (86%). The antimicrobials against which resistance was found most frequently were beta-lactams, chloramphenicol, and streptomycin. Plasmids were found in 21 of the 22 Enterobacter isolates. This confirms the conception that antibiotic resistance can occur in oligotrophic freshwater lake bacteria, which has important implications for public health.