Clinical and environmental wastewater-based bacteriophage surveillance for high-impact diarrheal diseases, including cholera, in Bangladesh
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Bacteriophages (phages) likely play a critical role in modulating transmission dynamics of diarrheal pathogens. This study investigated the role of phages in modulating the prevalence and seasonal patterns of major diarrheal pathogens, Vibrio cholerae O1 (VCO1), enterotoxigenic Escherichia coli (ETEC), Shigella spp., and Salmonella spp. in diarrheal patients and environmental wastewater specimens collected from six different sites in Dhaka, Bangladesh, in 2024. VCO1, ETEC, Shigella , and Salmonella were detected in 10.1%, 7.8%, 1.7%, and 2.4% of diarrheal specimens, respectively. In contrast, phages targeting these pathogens were more frequently isolated, with detection rates of 20% for VCO1, 30% for ETEC, 57% for Shigella , and 9.2% for Salmonella -specific phages. Adults showed a significantly higher burden of VCO1 and corresponding phages compared to children <5 years ( P <0.001). Seasonal analysis revealed significant correlations between VCO1 (37.3%) and corresponding phages (57.6%) peaking in late September in both clinical (R = 0.53, P < 0.0001) and environmental wastewater specimens (R = 0.65, P <0.001). The highest correlation (R=0.68) was found between the increased rate of wastewater phages in the preceding week and a rise in cholera cases in the following week. ETEC and ETEC phages isolated from wastewater also showed strong correlations (R = 0.65, P <0.001). Cross-specificity analysis demonstrated that VCO1 phages were highly specific to their targets, whereas ETEC and Shigella phages exhibited broader host ranges, with some Shigella phages capable of infecting ETEC and Salmonella spp. Overall, these findings underscore the potential of bacteriophages as an alternate or adjunctive tool for cholera surveillance.
Importance
Understanding the dynamics between phages and their bacterial hosts is critical for elucidating disease burden, yet their potential for surveillance remains underexplored. To our knowledge, this is the first study that longitudinally investigated major diarrheal pathogens and their phages in both clinical and environmental sources to assess the potential of bacteriophages as a tool to improve diarrheal surveillance. The high frequency of phages compared to the host bacterial counterparts suggests a valuable, yet underutilized, role for phages in surveillance systems. Strong seasonal alignment between V. cholerae O1 and its phages, both peaking in late September, suggesting phage dynamics may reflect pathogen transmission. Our findings suggest that wastewater-derived vibrio phages may serve as an early indicator for predicting cholera burden. These results highlight our limited understanding of the complex interplay between phages and their bacterial hosts, particularly in shaping pathogen populations in endemic settings.
