SALMONELLA
                              
One of the coliform group                         Salmonella articles
Also see Salmonella dublin  
and
Arizona

In a Droffner and Brinton study (1995), "It was observed that Salmonella and E. coli survived for 59 days at
about 60  degrees C in an industrial compost." However, they reported, "The bacteria became undetectable
after the  temperature decreased from 62 degrees C to about 40 degrees C in the compost curing."
http://www.ncbi.nlm.nih.gov/pubmed/8672222

EPA claims Salmonella is a Primary Pathogen in Sludge Biosolids that only causes Gastroenteritis, enteric fever

Salmonella typhimurium and almost all other serotypes of Salmonella which cause human gastroenteritis
produce hydrogen sulfide from both thiosulfate and sulfite (2).
http://jb.asm.org/cgi/reprint/179/21/6736.pdf

EPA's contention is that Salmonella only cause:

3.     Salmonella sp ------------------------------------ Gastroenteritis and enteric fever.

Salmonella - all species and all serotypes

Salmonella (a coliform & sometimes fecal coliform) is one of the Enterobacteriaceae family. Infections
include, aneurysms, arterial infections or endocarditis, pneumonia or empyema, urinary tract infections,
meningitis, septic arthritis and osteomyelitis, Enteric fever, rose spots) on the chest and abdomen,-
intracranial, bone and joint, soft tissue, arterial, pancreatic, gallbladder and liver, kidneys
(glomerulitis), the genitourinary tract infections, Necrotizing fasciitis "flesh eating" infections,
Typhoid (enteric fever), bacteremia, Pneumonia, heart valves (endocarditis), pericarditis, peritonitis,
otitis media, cholecystitis, endophthalmitis, cutaneous abscesses, and infected cephalhematoma, It is
antibiotic resistant and now produces poisonous Hydrogen Sulfide (H2S) gas.

In the 1975 study, “
[Epidemiology of salmonellae and fertilizing of grassland with sewage sludge
(author's transl)]
,” E. Hess and C. Breer, reported, “Our investigations prove that sludge contains
Salmonellae in more than 90% of samples. The maximum number of organisms reached 10(7) per liter.
One of our most important findings was the fact that neither aerobic stabilization nor anaerobic
digestion significantly reduces the contamination with Salmonellae. Moreover we found that
Salmonellae in sewage sludge spread on grass may survive up to 72 weeks. Fertilizing with unsanitized
sludge may therefore lead to transmission from plant to animal. The increasing number of Salmonella
carriers among our herds of cattle and their striking accumulation during the grazing period
demonstrate that such transmission represents a growing danger. Sanitizing of sludge to be used as
fertilizer is therefore urgent. We have investigated the sanitary effect of pasteurisation and of gamma
irradiation on sewage sludge. After a proper pasteurisation in 5 plants (70 degrees C for 30 minutes)
98-100% of tested sludge samples contained less than 10 Enterobacteriaceae per gramm. The
application of 300 krad resulted in a percentage of 97.2% of samples with less than 10
Enterobacteriaceae per gramm.”
http://www.ncbi.nlm.nih.gov/pubmed/1189797

In the 1989 proposed Part 503 sewage sludge regulation, EPA acknowledged Salmonella to be a
Primary pathogen in sludge and claimed that it only caused Gastroenteritis and enteric fever.
However, Salmonella Typhi causes typhoid as does the different clones referred to as Salmonella
paratyphi, while Salmonella Typhimurium causes a typhoid like disease in mice. Although Salmonella
Typhi is host specific to humans, it and the other 2,500+ Salmonella Enteritidis clones that affect
humans and animals may be spread through sewage products, food and water.

According to The Department of Biology at San Diego State University:
    “The three main serovars of Salmonella enterica are Typhimurium, Enteritidis, and
    Typhi [clones]. –
    Salmonella enterica serovar Typhimurium (Also called Salmonella Typhimurium or
    abbreviated to S. Typhimurium) Until recently the most common cause of food
    poisoning by Salmonella species was due to S. Typhimurium. As its name suggests, it
    causes a typhoid-like disease in mice. In humans S. Typhimurium does not cause as
    severe disease as S. Typhi, and is not normally fatal. The disease is characterized by
    diarrhea, abdominal cramps, vomiting and nausea, and generally lasts up to 7 days.
    Unfortunately, in immunocompromized people, that is the elderly, young, or people with
    depressed immune systems, Salmonella infections are often fatal if they are not treated
    with antibiotics. –
    Salmonella enterica serovar Enteritidis (Also called Salmonella Enteritidis or
    abbreviated to S. Enteritidis). In the last 20 years or so, S. Enteritidis has become the
    single most common cause of food poisoning in the United States. S. Enteritidis causes a
    disease almost identical to the very closely related S. Typhimurium. S. Enteritidis is
    particularly adept at infecting chicken flocks without causing visible disease, and
    spreading from hen to hen rapidly. Many people have blamed the recent increase in the
    rise of S. Enteritidis infections on the use of mass production chicken farms. When tens
    or hundreds of thousands of chickens live together, die together, and are processed
    together a Salmonella infection can rapidly spread throughout the whole food chain. A
    compounding factor is that chickens from a single farm may be distributed over many
    cities, and even states, and hence Salmonella infections can be rapidly dispersed through
    millions of people. –
    Salmonella enterica serovar Typhi. (Also called Salmonella Typhi or abbreviated to S.
    Typhi) This bacterium is the causative agent of typhoid fever. Although typhoid fever is
    not widespread in the United States, it is very common in under-developed countries,
    and causes a serious, often fatal disease. The symptoms of typhoid fever include nausea,
    vomiting, fever and death. Unlike the other Salmonella discussed below, S. Typhi can
    only infect humans, and no other host has been identified. The main source of S. Typhi
    infection is from swallowing infected water. Food may also be contaminated with S.
    Typhi, if it is washed or irrigated with contaminated water.”
    http://www.salmonella.org/info.html

In a 2001 study, “
Soft Tissue and Cartilage Infection by Salmonella oranienburg in a Healthy Girl,”
Ariel R. PorcallA, MD, et al., National Institutes of Health, reported, “Compared with Salmonella typhi
and S. paratyphi, whose transmission is solely person-to-person, nontyphoid salmonellal infections are
acquired through contact with a number of sources such as poultry, livestock, pets, and animal
products. Because of an increasing number of possible sources, the incidence of nontyphoid
salmonellosis has increased dramatically since the early 1980s.[2] Children younger than 5 years of
age, especially those younger than 1 year of age, appear to have the highest incidence of salmonellosis.
– In the general population, focal suppurative extraintestinal complications have been recognized in 7%
to 10% of cases of salmonellosis. These infections may occur almost anywhere in the body, but the
most common sites are the bones and the meninges. Typically, salmonellal osteomyelitis and meningitis
follow enteric fever or bacteremia. In infants, complications of salmonellosis include pneumonia,
osteomyelitis, septic arthritis, pericarditis, peritonitis, otitis media, cholecystitis, endophthalmitis,
cutaneous abscesses, and infected cephalhematoma.”
http://www.medscape.com/viewarticle/410765

According to The European Bioinformatics Institute (EBI) “
Salmonella enterica serovars often have a
broad host range and some cause both gastrointestinal and systemic disease
. The serovar Paratyphi A is
restricted to humans and causes only systemic disease. The sequence and microarray analysis of the
Paratyphi A genome indicates that it is similar to the Typhi genome but suggests that it has a more
recent evolutionary origin. – Salmonella paratyphi is part of the Enterobacteriaceae family; it is a
Gram-negative motile, aerobic rod which is facultatively anaerobic and there is serological
identification of somatic and flagellar antigens. – Salmonella paratyphi causes bacterial enteric fever
which is characterised by an abrupt onset, continued fever, malaise, headache, anorexia, enlargement of
spleen, bradycardia, rose spots on trunk occur on approximately 25% of Caucasians, constipation is
more common than diarrhea in adults; complications include perforation/hemorrhage/ulceration of the
intestines, less frequently psychosis, hepatitis, cholecystitis, pneumonitis, and pericarditis. It is
clinically similar to typhoid fever but milder with lower fatality rate. Common enterocolitis may result
without enteric fever this is characterised by headache, abdominal pain, nausea, vomiting, diarrhea and
dehydration. After entering the small intestine wall, the Salmonella invades through the lymphatic
system to the lymph nodes and after a period of multiplication invades the blood stream. From there the
bacteria invades the liver, gall bladder, spleen, kidney and bone marrow where it multiplies and causes
infection of these organs. From here they again invade the blood stream causing secondary bacteremia.
The secondary bacteremia is responsible for causing fever and clinical illness. – It is transmitted by
direct or indirect contact with faeces or rarely the urine of a patient or carrier, contaminated food,
especially milk, milk products and shellfish, it may be contaminated by the hands of a carrier or flies
may be a possible vector. A few outbreaks related to water supplies have been documented. The
incubation period is 1 to 3 weeks.”
http://www.ebi.ac.uk/2can/genomes/bacteria/Salmonella_paratyphi.html

In the 1990 study, “
Evolutionary genetic relationships of clones of Salmonella serovars that cause
human typhoid and other enteric fevers
,” R.K. Selander, et al., Institute of Molecular Evolutionary
Genetics, Mueller Laboratory, Pennsylvania State University at University Park, stated, “Multilocus
enzyme electrophoresis was employed to measure chromosomal genotypic diversity and evolutionary
relationships among 761 isolates of the serovars Salmonella typhi, S. paratyphi A, S. paratyphi B, S.
paratyphi C, and S. sendai, which are human-adapted agents of enteric fever, and S. miami and S. java,
which are serotypically similar to S. sendai and S. paratyphi B, respectively, but cause gastroenteritis in
both humans and animals. To determine the phylogenetic positions of the clones of these forms within
the context of the salmonellae of subspecies I, comparative data for 22 other common serovars were
utilized. Except for S. paratyphi A and S. sendai, the analysis revealed no close phylogenetic
relationships among clones of different human-adapted serovars, which implies convergence in host
adaptation and virulence factors. Clones of S. miami are not allied with those of S. sendai or S.
paratyphi A, being, instead, closely related to strains of S. panama. Clones of S. paratyphi B and S. java
belong to a large phylogenetic complex that includes clones of S. typhimurium, S. heidelberg, S.
saintpaul, and S. muenchen. Most strains of S. paratyphi B belong to a globally distributed clone that is
highly polymorphic in biotype, bacteriophage type, and several other characters, whereas strains of S.
java represent seven diverse lineages. The flagellar monophasic forms of S. java are genotypically
more similar to clones of S. typhimurium than to other clones of S. java or S. paratyphi B. Clones of S.
paratyphi C are related to those of S. choleraesuis. DNA probing with a segment of the viaB region
specific for the Vi capsular antigen genes indicated that the frequent failure of isolates of S. paratyphi C
to express Vi antigen is almost entirely attributable to regulatory processes rather than to an absence of
the structural determinant genes themselves. Two clones of S. typhisuis are related to those of S.
choleraesuis and S. paratyphi C, but a third clone is not. Although the clones of S. decatur and S.
choleraesuis are serologically and biochemically similar, they are genotypically very distinct. Two
clones of S. typhi were distinguished, one globally distributed and another apparently confined to
Africa; both clones are distantly related to those of all other serovars studied.”
http://www.ncbi.nlm.nih.gov/pubmed/1973153

In the 1994 study,
“Unusual manifestations of salmonellosis—a surgical problem,” M.K. LALITHA
and R. JOHN, reported, “From January 1981 to December 1992, of 6250 cases of salmonellosis treated
at the Christian Medical college and Hospital, Vellore, India, 100 patients with focal pyogtenic
infection caused by salmonellae required surgical intervention in addition to medical therapy. Thirtyone
had involvement of the hepatobiliary system, and 10 more had other intra-abdominal infections.
Involvement of bone and joint as well as soft tissue constituted 15% each. The site of infection in
patients with soft tissue abscesses included skin (7), Parotid (2), thyroid (3), Breast (1), inguinal node
(1), Branchial sinus (1), and injection site (1). Three patients had arterial infections. Noteworthy among
the cases of genital infections was one case of salmonella infection in a pre-exiting hydrocele, and one
case of epididymo-orchitis with a loculated salmonella infection. Salmonella infection in a pre-existing
ovarian cyst was seen in a patient with endometriosis. The salmonella serotypes most frequently
encountered were S. typhi (36) and S. typhimurium(36) and S. paratyphi A (15). The importance of
recognition of these protean manifestations of salmonellosis in an endemic setting is discussed. The
microbilogical evaluation of properly obtained specimens is mandatory in such unusual Pyogenic
infections.” http://qjmed.oxfordjournals.org/content/87/5/301.abstract

According to the 2005 World Health Organization Fact Sheet, Fact sheet 9N°139,
“Drug-resistant
Salmonella
), Salmonellosis, is one of the most common and widely distributed foodborne diseases. It
constitutes a major public health burden and represents a significant cost in many countries. Millions of
human cases are reported worldwide every year and the disease results in thousands of deaths.
Salmonellosis is caused by the bacteria Salmonella. Today, there are over 2500 known types, or
serotypes, of Salmonella. In recent years problems related to Salmonella have increased significantly,
both in terms of incidence and severity of cases of human salmonellosis. – In the United States of
America, an estimated 1.4 million non-typhoidal Salmonella infections, resulting in 168,000 visits to
physicians, 15 000 hospitalizations and 580 deaths annually. Cost estimates per case of human
salmonellosis range from approximately US$ 40 to US$ 4.6 million respectively for uncomplicated
cases to cases ending with hospitalization and death. The total cost associated with Salmonella is
estimated at US$ 3 billion annually in the United States. – S. Enteritidis caused the most recent
epidemic, which peaked in humans in 1992 in many European countries. Its current slight decline sets
the scene for re-emergence of S. Typhimurium as the most important serotype in human salmonellosis.”
http://www.who.int/mediacentre/factsheets/fs139/en/index.html

Salmonella in Animals

In the Virginia Cooperative Extension, Virginia Tech, and Virginia State University fact sheet 400-460
Zoonotic Diseases of Cattle,” Kevin D. Pelzer, Associate Professor, Large Animal Clinical Sciences,
Virginia Tech; and Nancy Currin, D.V.M., Veterinary Extension Publication Specialist, Virginia Tech,
report, “Salmonella are bacteria that are shed in the feces of infected animals. Many animals are
susceptible to Salmonella, including cattle. Infection occurs as a result of the ingestion of contaminated
feed, water, or grass. The bacterium can live for months to years in the environment, especially in wet
and warm conditions. Young, stressed or pregnant animals are the most susceptible to Salmonella
infection. Infection may result in fever, foul smelling diarrhea, and severe dehydration. People acquire
Salmonella from undercooked contaminated meat, infected eggs, or unpasteurized milk products. If
hands are not washed after direct contact with infected feces, then accidental ingestion of bacteria can
occur. Humans may develop diarrhea, abdominal cramping, and fever, which can be very severe.
Animals with diarrhea should be isolated and the area disinfected. Meat and eggs should be adequately
cooked and proper food handling hygiene should be used. Always wash hands after touching or
working with animals.” http://pubs.ext.vt.edu/400/400-460/400-460.html
In the 2008 study, “Outbreak of Salmonella typhimurium in cats and humans associated with infection
in wild birds,” M. A. Tauni1and A. öSterlund, said, “An outbreak of Salmonella typhimurium infection
in cats and humans in Sweden in 1999, associated with wild birds, is described. In the county of
Värmland, 62 sick cats were examined. All were anorectic and lethargic, 57 per cent had vomiting and
31 per cent had diarrhoea. It was considered likely that salmonellosis was transmitted from cats to
humans, but there were only a few such cases.”
http://onlinelibrary.wiley.com/doi/10.1111/j.1748-5827.2000.tb03214.x/abstract

Salmonella in Plants

In 2011, Amanda J. Deering, et al., Purdue University at West Lafayette, reported on the “Examination
of the Internalization of Salmonella serovar Typhimurium in Peanuts, Arachis hypogaea, Using
Immunocytochemical Techniques
.” They said, “A variety of products of plant origin, such as tomatoes,
melons, peppers and peanuts, have been implicated in Salmonella spp. associated outbreaks in recent
years. Although these bacteria have been found to internalize within some plants associated with
foodborne-related outbreaks, the internalization in peanut plants has not been examined to date. To
investigate internalization and where the bacteria localize within the plant, intact peanut seeds were
contaminated with Salmonella serovar Typhimurium expressing green fluorescent protein (GFP) for 30
min. and immunocytochemical techniques were used to localize the bacterium within the stem tissue of
16-day-old peanut plants. An average of 13.6 bacteria/mm3 were localized within the sampled tissue.
The bacteria were found to be associated with every major tissue (cortical, vascular, epidermal and
pith) and corresponding cell type. The cortical cells located to the outside of the vascular bundles
contained the majority of the Salmonella cells (72.4%). Additional growth experiments demonstrated
peanut seedlings could support the reproduction of Salmonella to high levels (109 CFU/plant) after 2
days following seed contamination. Together, these results show that Salmonella Typhimurium can
internalize within many different plant tissue types after a brief seed contamination event and that the
bacteria are able to grow and persist within the plant.”
http://www.purdue.edu/newsroom/research/2011/story-print-deploy-layout_1_14364_14364.html

Agencies, studies and facts don't always give an accurate picture of health hazards.

Salmonellosis is one of the most common and widely distributed foodborne diseases. It constitutes a major public
health burden and represents a significant cost in many countries. Millions of human cases are reported worldwide
every year and the disease results in thousands of deaths. Salmonellosis is caused by the bacteria Salmonella. Today,
there are over 2500 known types, or serotypes, of Salmonella.

In recent years problems related to Salmonella have increased significantly, both in terms of incidence and severity of
cases of human salmonellosis. While some countries have managed to reverse the increasing incidence of human
salmonellosis, new concerns have been identified. Since the beginning of the 1990s, strains of Salmonella which are
resistant to a range of antimicrobials1, including first-choice agents for the treatment of humans, have emerged and are
threatening to become a serious public health problem. This resistance results from the use of antimicrobials both in
humans and animal husbandry. Multi-drug resistance to "critically important antimicrobials"2 are compounding the
problems.


Cardiovascular: Salmonella infections (commonly S typhimurium or S choleraesuis) may produce arterial infections or
endocarditis.

Pulmonary: Salmonella pneumonia or empyema is rare in the absence of comorbid illnesses such as underlying lung
disease, malignancy, diabetes, sickle cell anemia, or alcohol abuse.

Genitourinary: Individuals with urolithiasis or structural abnormalities or individuals who are undergoing
immunosuppressive therapy are predisposed to Salmonella urinary tract infections.

Neurologic: Salmonella meningitis may rarely occur, typically in infants and young children.

Skeletal: Infection with salmonellae may cause septic arthritis and osteomyelitis. The latter affects the long bones and
typically occurs in patients with sickle cell disease.

Integument: Enteric fever may be associated with pink, blanchable, slightly raised macules (rose spots) on the chest and
abdomen

From January 1981 to December 1992, of 6250 cases of salmonellosis treated at the Christian Medeical college and
Hospital, Vellore, India, 100 patients with focal pyogtenic infection caused by salmonellae required surgical intervention
in addition to medical therappy. Thirty-one had involvement of the hepatobiliary system, and 10 more had other intra-
abdominal infections. Involvement of bone and joint as well as soft tissue constituted 15% each. The site of infection in
patients with soft tissue abscesses incleded skin (7)Parotid ,(2)thyroid, (3)Breast (1)inguinal node (1), Branchial sinus
(1) and injectiion site (1). Three patients had arterial infections. Noteworthy among the cases of genital infections was
one case of salmonella infection in a pre-exiting hydrocele, and one case of epididymo-orchitis with a loculated
salmonella infection. Salmonella infection in a pre-existing ovarian cyst was seen in a patient with endometriosis. The
salmonella serotypes most frequently encountered were S. typhi(36) and S.typhimurium(36) andS. paratyphi A (15). The
importance of recongnition of these protean manifestations of salmonellosis in an endemic setting is discussed. The
microbilogical evaluation of properly obtained specimens is mandatory in such unusual Pyogenic infections.

A case of rarely encountered
Salmonella typhi osteomyelitis of left occipital bone leading to extradural abscess, is
reported. The causative organism was not suspected until the culture report was obtained. The patient responded
promptly to surgical drainage and antibiotic therapy.

Necrotizing fasciitis is an uncommon manifestation of Salmonella infection. We report a case of Salmonella group D
septic arthritis complicated with necrotizing fasciitis in a 51-year-old man who had noninsulin dependent diabetes
mellitus and rheumatoid arthritis. He presented with fever and severe right hip pain complicated with septic shock and
disseminated intravascular coagulation. Crepitation was noticed upon physical examination, and plain films showed
numerous air bubbles in the soft tissue around the hip joint. Prompt antibiotic therapy and surgical management were
performed with a successful response. The causative organism was Salmonella group D. Antibiotic was given in the total
course of 3 months, and there was
no relapse of salmonellosis after 2 years follow up.

Localized salmonella soft tissue infections have been rarely described in humans. We report a case of necrotizing
fasciitis caused by Salmonella serogroup C in a patient with systemic lupus erythematosus who was successfully treated
with surgical debridement and cefoperazone-sulbactam. In addition, we provide a literature review on risk factors and
treatment of this uncommon disease sequelae.

Pathogenic species include S. arizo´nae (salmonellosis), S. choleraesuis (a strain pathogenic for pigs that may infect
humans), S. enteritidis (gastroenteritis), S. enteritidis serotype paraty´phi A (paratyphoid fever), S. typhi (typhoid fever),
and S. enteritidis serotype typhimu´rium (food poisoning and paratyphoid fever).
http://medical-dictionary.thefreedictionary.com/Salmonella

2,200 strains, Each type can produce gastrointestinal upset, enteric fever, and specific localized infections, nausea and
cramping abdominal pain, watery diarrhea, fever, vomiting, spread through bloodstream to infect other sites, such as the
bones (particularly in people with sickle cell disease), joints, or heart valves (Merck)

Salmonella: S. typhimurium and S. enteritidis are the two leading causes of salmonellosis (inflammation of the
intestine caused by Salmonella).  S. typhi is unique because it is only carried by humans. This intracellular parasite can
cause typhoid fever (enteric fever) which is characterized by fever, diarrhea, and inflammation of the infected organs.

Typhoid fever (enteric fever) is caused by Salmonella typhi . Typhoid bacteria enter the digestive tract and gain access
to the bloodstream. Inflammation of the small and large intestine follows. In severe infections, which can be life
threatening, sores may develop in the small intestine. These sores bleed and sometimes perforate the intestinal wall.
loss of appetite, fever, headache, joint pain, sore throat, constipation (or, less commonly, diarrhea), and abdominal pain
and tenderness. A brassy, nonproductive cough is common. Nosebleed may occur. fever remains high, and the person
may become delirious, slow heartbeat and extreme exhaustion, intestinal bleeding or perforation occurs,  Pneumonia
may develop, Infection of the gallbladder and liver also may occur. A blood infection (bacteremia) occasionally leads to
infection of bones (osteomyelitis), heart valves (endocarditis), kidneys (glomerulitis), the genitourinary tract, or the
tissues covering the brain and spinal cord (meningitis). Infection of muscles may lead to abscesses (collections of pus).
(Merck)

Because of an increasing number of possible sources, the incidence of nontyphoid salmonellosis has increased
dramatically since the early 1980s.[2] Children younger than 5 years of age, especially those younger than 1 year of
age, appear to have the highest incidence of salmonellosis.[3]

In the general population, focal suppurative extraintestinal complications have been recognized in 7% to 10% of cases
of salmonellosis. These infections may occur almost anywhere in the body, but the most common sites are the bones
and the meninges. Typically, salmonellal osteomyelitis and meningitis follow enteric fever or bacteremia. In infants,
complications of salmonellosis include pneumonia, osteomyelitis, septic arthritis, pericarditis, peritonitis, otitis media,
cholecystitis, endophthalmitis, cutaneous abscesses, and infected cephalhematoma.[3]

Isolated
soft tissue infections due to Salmonella sp, however, are rare and occur mostly in adults. In one series of
primarily adult patients with nontyphoid salmonellosis diagnosed in a hospital over a 5-year period, focal soft tissue
infections comprised only about 1.5% of the study population, with two of the eight patients having had a previous
episode of salmonellal gastroenteritis. The infections were manifested as plantar, abdominal wall, and perianal
abscesses, empyema, and pericarditis.[4] A review of the literature described only 30 cases of salmonellal pyomyositis
during the past four decades, with bacteremia present in two thirds of these patients.[5]

Baby Calf Health: Common Diarrheal Diseases
Salmonellosis - Salmonellosis usually affects calves between 10 days and 3 months of age. The most common sero-
types are Salmonella typhimurium and S. dublin. Disease severity will be determined by the virulence of the sero-type(s)
involved, the concentration of Salmonella in environment and the immune status of the calves. Salmonella can be
transmitted by fecal-oral contamination or aerosolized.