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	author = {Scott, G and Williams, J C and Stephenson, E H}
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	author = {Sabin, A B}
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	year = {2001},
	pages = {933-944},
	author = {Jernigan, J. A. and Stephens, D. S. and Ashford, D. A. and Omenaca, C. and Topiel, M. S> and Galbraith, M. and Tapper, M. and Zaki, S. and Popovic, T. and Meyer, R. F. and Quinn, C. P. and Harper, S. A. and Fridkin, S. K. and Sejvar, J. J. and Shepard, C. W. and McConnell, M. and Guarner, J. and Sheith, W-j. and Malecki, J. M. and Gerberding, J. L. and Hughes, J. M. and Perkins, B. A.}
}
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	year = {2001},
	pages = {933},
	publisher = {Centers for Disease Control and Prevention},
	author = {Jernigan, John A and Stephens, David S and Ashford, David A and Omenaca, Carlos and Topiel, Martin S and Galbraith, Mark and Tapper, Michael and Fisk, Tamara L and Zaki, Sherif and Popovic, Tanja}
}
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	author = {Vogt, RL and Sours, HE and Barrett, T and Feldman, RA and Dickinson, RJ and Witherell, L}
}
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@article {tribble2009campylobacter,
	title = {Campylobacter jejuni strain CG8421: a refined model for the study of Campylobacteriosis and evaluation of Campylobacter vaccines in human subjects},
	journal = {Clinical infectious diseases},
	volume = {49},
	number = {10},
	year = {2009},
	pages = {1512{\textendash}1519},
	publisher = {The University of Chicago Press},
	author = {Tribble, David R and Baqar, Shahida and Carmolli, Marya P and Porter, Chad and Pierce, Kristen K and Sadigh, Katrin and Guerry, Patricia and Larsson, Catherine J and Rockabrand, David and Ventone, Cassandra H and others}
}
@article {tbcppsglrv,
	title = {Campylobacter jejuni strain CG8421: a refined model for the study of Campylobacteriosis and evaluation of Campylobacter vaccines in human subjects},
	journal = {Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America},
	volume = {49},
	number = {10},
	year = {2009},
	pages = {1512-1519},
	url = {http://cat.inist.fr/?aModele=afficheN\&cpsidt=22121873},
	author = {Tribble, D. R. and Baqar, S. and Carmolli, M. P. and Porter, C. and Pierce, K. K. and Sadigh, K. and Guerry, P. and Larsson, C. J. and Rockabrand, D. and Ventone, C. H. and others}
}
@article {tbcppsglrvpldfgdjrhdk09,
	title = {Campylobacter jejuni Strain CG8421: A Refined Model for the Study of Campylobacteriosis and Evaluation of Campylobacter Vaccines in Human Subjects},
	journal = {Clinical Infectious Diseases},
	volume = {49},
	year = {2009},
	pages = {10},
	author = {Tribble, D R and Baqar, S and Carmolli, M P and Porter, C and Pierce, K K and Sadigh, K and Guerry, P and Larsson, C J and Rockabrand, D and Ventone, C H and Poly, F and Lyon, C E and Dakdouk, S and Fingar, A and Gilliland, T and Daunais, P and Jones, E and Rymarchyk, S and Huston, C and Darsley, M and Kirkpatrick, B D}
}
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	title = {Cell-Mediated Protection against Pulmonary Yersinia pestis Infection},
	journal = {Infection and Immunity},
	volume = {73},
	year = {2005},
	pages = {11},
	doi = {10.1128/IAI.73.11.7304-7310.2005},
	url = {https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1273885/},
	author = {Parent, M A and Berggren, K N and Kummer, L W and Wilhelm, L B and Szaba, F M and Mullarky, I K and Smiley, S T}
}
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	volume = {147},
	year = {1983},
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	doi = {https://doi.org/10.1093/infdis/147.2.302},
	url = {https://academic.oup.com/jid/article-abstract/147/2/302/967140?redirectedFrom=fulltext\&login=false },
	author = {Muller, D and Edwards, M L and Smith, D W}
}
@article {mes83,
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	journal = {Journal of Infectious Diseases},
	volume = {147},
	year = {1983},
	pages = {302-307},
	url = {http://www.jstor.org/stable/30115078},
	author = {Muller, D. and M. L. Edwards and D. W. Smith}
}
@article {muller1983changes,
	title = {Changes in iron and transferrin levels and body temperature in experimental airborne legionellosis},
	journal = {Journal of Infectious Diseases},
	volume = {147},
	number = {2},
	year = {1983},
	pages = {302{\textendash}307},
	publisher = {The University of Chicago Press},
	author = {Muller, Daniel and Edwards, Mark L and Smith, Donald W}
}
@article {1228,
	title = {Cholera surveillance during the Haiti epidemic{\textemdash}the first 2 years},
	journal = {New England Journal of Medicine},
	volume = {368},
	year = {2013},
	pages = {599{\textendash}609},
	doi = {10.1056/NEJMoa1204927},
	author = {Barzilay, EJ and Schaad, Nicolas and Magloire, Roc and Mung, KS and Boncy, Jacques and Dahourou, GA and Mintz, ED and Steenland, MW and Vertefeuille, JF and Tappero, JW}
}
@article {1229,
	title = {Cholera surveillance during the Haiti epidemic{\textemdash}the first 2 years},
	journal = {New England Journal of Medicine},
	volume = {368},
	year = {2013},
	pages = {599{\textendash}609},
	author = {Barzilay, Ezra J and Schaad, Nicolas and Magloire, Roc and Mung, Kam S and Boncy, Jacques and Dahourou, Georges A and Mintz, Eric D and Steenland, Maria W and Vertefeuille, John F and Tappero, Jordan W}
}
@article {rzms06,
	title = {Clinical and Pathologic Changes in a Guinea Pig Aerosol Challenge Model of Acute Q Fever},
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	volume = {74},
	year = {2006},
	pages = {11},
	author = {Russell-Lodrigue, K. E. and Zhang, G. Q. and McMurray, D. N. and Samuel, J. E.}
}
@article {hunter2001community,
	title = {Community surveys of self-reported diarrhoea can dramatically overestimate the size of outbreaks of waterborne cryptosporidiosis},
	journal = {Water Science and Technology},
	volume = {43},
	number = {12},
	year = {2001},
	pages = {27{\textendash}30},
	publisher = {IWA Publishing},
	author = {Hunter, PR and Syed, Q}
}
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	author = {Labatiuk, C. W. and Schaefer, F. W. and Finch, G. R. and Belosevic, M.}
}
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	volume = {29},
	year = {1999},
	pages = {2},
	doi = {10.1086/520219},
	url = {http://cid.oxfordjournals.org.proxy1.cl.msu.edu/content/29/2/381.full.pdf+html},
	author = {Simpson, A. J. H. and Suputtamongkol, Y. and Smith, M. D. and Angus, B. J. and Rajanuwong, A. and Wuthiekanun, V. and Howe, P. A. and others}
}
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	pages = {374{\textendash}376},
	publisher = {Springer},
	author = {Martinelli, Fabrizia and Caruso, Arnaldo and Moschini, Lina and Turano, Adolfo and Scarcella, Carmelo and Speziani, Fabrizio}
}
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	url = {https://pubmed.ncbi.nlm.nih.gov/10902259/ },
	author = {Willocks, LJ and Sufi, F and Wall, R and Seng, C and Swan, AV}
}
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	url = {https://www.eurosurveillance.org/content/10.2807/ese.14.12.19156-en },
	author = {Karagiannis, I and Schimmer, B and de Roda Husman, AM}
}
@article {esjssjb88,
	title = {Cross-species transmission of Giardia spp.: inoculation of beavers and muskrats with cysts of human, beaver, mouse, and muskrat origin},
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}
@article {cdsg88,
	title = {Cryptosporidial diarrhoea in AIDS and its treatment},
	year = {1988},
	note = {593-597},
	author = {Connolly, G. M. and Dryden, M. S. and Shanson, D. C. and Gazzard, B. G.}
}
@article {hwmsdb,
	title = {De la Macorra F and Corozza FA (1966) Study of induced typhoid fever in man. I. Evaluation of vaccine effectiveness},
	journal = {Transactions of the Association of American Physicians},
	volume = {79},
	year = {Submitted},
	pages = {361},
	author = {Hornick, R B and Woodward, T E and McCrumb, F R and Snyder, M J and Dawkins, A T and Bulkeley, J T}
}
@book {hhmxkt06,
	title = {Deaths: Final Data for National Vital Statistics Reports.},
	year = {2006},
	publisher = {National Center for Health Statistics},
	organization = {National Center for Health Statistics},
	url = {http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf},
	author = {Heron, M. and Hoyert, D. and Murphy, S. L. and Xu, J. and Kochanek, K. D. and Tejada-Vera, B.},
	editor = {Division of Vital Statistics}
}
@article {1856,
	title = {Defective Phagocytosis and Clearance of <i>Pseudomonas aeruginosa</i> in the Lung Following Bone Marrow Transplantation},
	journal = {The Journal of Immunology},
	volume = {171},
	year = {2003},
	month = {2003/10/15/},
	pages = {4416 - 4424},
	abstract = {<p>Abstract Bone marrow transplantation (BMT) is an important therapeutic option for a variety of malignant and nonmalignant disorders. Unfortunately, BMT recipients are at increased risk of infection, and in particular, pulmonary complications occur frequently. Although the risk of infection is greatest during the neutropenic period immediately following transplant, patients are still vulnerable to pulmonary infections even after neutrophil engraftment. We evaluated the risk of infection in this postengraftment period by using a well-established mouse BMT model. Seven days after syngeneic BMT, B6D2F1 mice are no longer neutropenic, and by 3 wk, they demonstrate complete reconstitution of the peripheral blood. However, these mice remain more susceptible throughout 8 wk to infection after intratracheal administration of Pseudomonas aeruginosa; increased mortality in the P. aeruginosa-infected BMT mice correlates with increased bacterial burden in the lungs as well as increased systemic dissemination. This heightened susceptibility to infection was not secondary to a defect in inflammatory cell recruitment to the lung. The inability to clear P. aeruginosa in the lung correlated with reduced phagocytosis of the bacteria by alveolar macrophages (AMs), but not neutrophils, decreased production of TNF-α by AMs, and decreased levels of TNF-α and IFN-γ in the bronchoalveolar lavage fluid following infection. Expression of the β2 integrins CD11a and CD11c was reduced on AMs from BMT mice compared with wild-type mice. Thus, despite restoration of peripheral blood count, phagocytic defects in the AMs of BMT mice persist and may contribute to the increased risk of infection seen in the postengraftment period.</p>
},
	isbn = {0022-1767, 1550-6606},
	url = {https://journals.aai.org/jimmunol/article/171/8/4416/35775/Defective-Phagocytosis-and-Clearance-of},
	author = {Ojielo, Charles I. and Cooke, Kenneth and Mancuso, Pete and Standiford, Theodore J. and Olkiewicz, Krystyna M. and Clouthier, Shawn and Corrion, Leigh and Ballinger, Megan N. and Toews, Galen B. and Paine, Robert and Moore, Bethany B.}
}
@article {1917,
	title = {Defective phagocytosis and clearance of Pseudomonas aeruginosa in the lung following bone marrow transplantation},
	journal = {The Journal of Immunology},
	volume = {171},
	year = {2003},
	pages = {4416{\textendash}4424},
	author = {Ojielo, Charles I and Cooke, Kenneth and Mancuso, Pete and Standiford, Theodore J and Olkiewicz, Krystyna M and Clouthier, Shawn and Corrion, Leigh and Ballinger, Megan N and Toews, Galen B and Paine, Robert and others}
}
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	title = {Diarrhea caused by Escherichia coli that produce only heat-stable enterotoxin},
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	author = {Levine, M M and Caplan, E S and Waterman, D and Cash, R A and Hornick, R B and Snyder, M J}
}
@article {collier2012direct,
	title = {Direct healthcare costs of selected diseases primarily or partially transmitted by water},
	journal = {Epidemiology \& Infection},
	volume = {140},
	number = {11},
	year = {2012},
	pages = {2003{\textendash}2013},
	publisher = {Cambridge University Press},
	author = {Collier, SA and Stockman, LJ and Hicks, LA and Garrison, LE and Zhou, FJ and Beach, MJ}
}
@article {powell_dose-response_nodate,
	title = {Dose-{Response} {Envelope} for {Escherichia} coli},
	year = {Submitted},
	pages = {24},
	abstract = {Escherichia coli O157:H7 is an emerging food and waterborne pathogen in the U.S. and internationally. The objective of this work was to develop a dose-response model for illness by this organism that bounds the uncertainty in the dose-response relationship. No human clinical trial data are available for E. coli O157:H7, but such data are available for two surrogate pathogens: enteropathogenic E. coli (EPEC) and Shigella dysenteriae. E. coli O157:H7 outbreak data provide an initial estimate of the most likely value of the dose-response relationship within the bounds of an envelope de{\textregistered}ned by beta-Poisson dose-response models {\textregistered}t to the EPEC and S. dysenteriae data. The most likely value of the median effective dose for E. coli O157:H7 is estimated to be approximately 190 000 colony forming units (cfu). At a dose level of 100 cfu, the median response predicted by the model is six percent.},
	author = {Powell, Mark R and Ebel, Eric and Schlosser, Wayne and Walderhaug, Mark and Kause, Janell}
}
@article {tts04,
	title = {Dose response for infection by Escherichia coli O157:H7 from outbreak data},
	journal = {Risk Analysis: An Official Publication of the Society for Risk Analysis},
	volume = {24},
	number = {2},
	year = {2004},
	pages = {401-407},
	url = {http://onlinelibrary.wiley.com/doi/10.1111/j.0272-4332.2004.00441.x/pdf},
	author = {Teunis, P. and Takumi, K. and Shinagawa, K.}
}
@article {s05,
	title = {Dose response modelling of Escherichia coli O157 incorporating data from foodborne and environmental outbreaks},
	journal = {International Journal of Food Microbiology},
	volume = {103},
	number = {1},
	year = {2005},
	pages = {35-47},
	author = {Strachan, N. J. C. al.}
}
@article {mcmsobdrdm84,
	title = {Dose Response of Cold-Adapted, Reassortant Influenza A/California/10/78 Virus (H1N1) in Adult Volunteers},
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	year = {1984},
	pages = {5},
	url = {https://www.ncbi.nlm.nih.gov/pubmed/6726007},
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}
@article {mctbsc85,
	title = {Dose Response of Influenza A/Washington/897/80 (H3N2) Avian-Human Reassortant Virus in Adult Volunteers},
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	year = {1985},
	pages = {1},
	url = {http://www.jstor.org/stable/30104663?seq=1$\#$page_scan_tab_contents},
	author = {Murphy, B R and Clements, M L and Tierney, E L and Black, R E and Stienberg, J and Chanock, R M}
}
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	title = {Dose-response envelope for Escherichia coli O157:H7},
	journal = {Quantitative Microbiology},
	volume = {2},
	year = {2000},
	pages = {141-163},
	url = {http://www.springerlink.com/content/k3t3768n75w16246/fulltext.pdf},
	author = {Powell, M R and Eric Ebel and Wayne Schlosser and Mark Walderhaug and Janell Kause}
}
@article {stawmrmd08,
	title = {Dose-Response Model for Listeria monocytogenes-Induced Stillbirths in Nonhuman Primates},
	journal = {Infection and Immunity},
	volume = {76},
	year = {2008},
	pages = {2},
	author = {Smith, M A and Takeuchi, K and Anderson, G and Ware, G O and McClure, H M and Raybourne, R B and Mytle, N and Doyle, M P}
}
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	title = {Drinking water quality in household supply infrastructure{\textemdash}A survey of the current situation in Germany},
	journal = {International journal of hygiene and environmental health},
	volume = {213},
	number = {3},
	year = {2010},
	pages = {204{\textendash}209},
	publisher = {Elsevier},
	author = {V{\"o}lker, Sebastian and Schreiber, Christiane and Kistemann, Thomas}
}
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	url = {https://onlinelibrary.wiley.com/doi/abs/10.1002/jmv.1890140402},
	author = {Stephenson, E H and Larson, E W and Dominik, J W}
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	volume = {125},
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	pages = {1},
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}
@article {dupont_immunity_1972,
	title = {Immunity in {Shigellosis}. {I}. {Response} of {Man} to {Attenuated} {Strains} of {Shigella}},
	journal = {The Journal of Infectious Diseases},
	volume = {125},
	number = {1},
	year = {1972},
	pages = {5{\textendash}11},
	abstract = {Four attenuated strains of Shigella flexneri 2a have been tested for stability and safety as vaccines in man. One strain, a Shigella-Escherichia coli hybrid, was virulent for man in doses of 108 cells, while a mutant strain reverted to virulence when 1010 cells were administered orally. Two vaccine strains, a Shigella mutant E. coli hybrid and a streptomycin-dependent mutant, were safely given to adult males in doses of 5{\textendash}10 {\texttimes} 1010 cells. Pretreatment with sodium bicarbonate was essential for the assurance of intestinal transit of viable vaccine organisms, and less than one-third of those vaccinated developed rises in humoral antibody. Streptomycin-independent revertants could be recovered only rarely in vivo when the streptomicin-dependent mutant was used, and one revertant found was avirulent. These studies have outlined the important biologic requirements of potential live oral shigella vaccines. Strains must not penetrate the intestinal mucosa and must be stable without reverting to virulence at levels of dosage used.},
	issn = {0022-1899},
	doi = {10.1093/infdis/125.1.5},
	url = {https://doi.org/10.1093/infdis/125.1.5},
	author = {DuPont, Herbert L. and Hornick, Richard B. and Snyder, Merrill J. and Libonati, Joseph P. and Formal, Samuel B. and Gangarosa, Eugene J.}
}
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}
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	author = {Schoen, Mary E and Ashbolt, Nicholas J}
}
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	number = {5},
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	author = {Zhang, Zhe and McCann, Carole and Hanrahan, Jennifer and Jencson, Annette and Joyce, Daniel and Fyffe, Steven and Piesczynski, Steve and Hawks, Robert and Stout, Janet E and Victor, L Yu and others}
}
@article {schwake2016legionella,
	title = {Legionella DNA markers in tap water coincident with a Spike in Legionnaires{\textquoteright} disease in Flint, MI},
	journal = {Environmental Science \& Technology Letters},
	volume = {3},
	number = {9},
	year = {2016},
	pages = {311{\textendash}315},
	publisher = {ACS Publications},
	author = {Schwake, David Otto and Garner, Emily and Strom, Owen R and Pruden, Amy and Edwards, Marc A}
}
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	volume = {46},
	number = {5},
	year = {2004},
	pages = {52},
	publisher = {American Society of Heating, Refrigeration and Air Conditioning Engineers, Inc.},
	author = {Stout, Janet E and Muder, Robert R}
}
@article {borella2004legionella,
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	number = {3},
	year = {2004},
	pages = {457},
	publisher = {Centers for Disease Control and Prevention},
	author = {Borella, Paola and Montagna, M Teresa and Romano-Spica, Vincenzo and Stampi, Serena and Stancanelli, Giovanna and Triassi, Maria and Neglia, Rachele and Marchesi, Isabella and Fantuzzi, Guglielmina and Tat{\`o}, Daniela and others}
}
@article {yang2012legionella,
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	author = {Yang, Genyan and Benson, Robert F and Ratcliff, Rodney M and Brown, Ellen W and Steigerwalt, Arnold G and Thacker, W Lanier and Daneshvar, Maryam I and Morey, Roger E and Saito, Atsushi and Fields, Barry S}
}
@article {stout1992legionella,
	title = {Legionella pneumophila in residential water supplies: environmental surveillance with clinical assessment for Legionnaires{\textquoteright} disease.},
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	publisher = {Elsevier},
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}
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	year = {1999},
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	number = {2},
	year = {2009},
	pages = {99},
	publisher = {National Institute of Public Health},
	author = {Bonadonna, Lucia and Briancesco, RosseIla and Della Libera, Simonetta and Lacchetti, Ines and Paradiso, Rosa and Semproni, Maurizio}
}
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}
@article {kotloff_modified_1995,
	title = {A modified {Shigella} volunteer challenge model in which the inoculum is administered with bicarbonate buffer: clinical experience and implications for {Shigella} infectivity},
	journal = {Vaccine},
	volume = {13},
	number = {16},
	year = {1995},
	month = {jan},
	pages = {1488{\textendash}1494},
	abstract = {{In the absence of a definitive immunologic correlate of protection against shigellosis, promising Shigella vaccine candidates have been selected based on their ability to confer resistance against experimental challenge with wild-type Shigella in healthy adult volunteers. A limitation of this model has been the low and often variable attack rate of illness among controls, necessitating repeated inpatient studies to demonstrate statistically significant results. In this study, the Shigella challenge model was modified by using bicarbonate buffer instead of skimmed milk as the delivery vehicle to enhance survival of the ingested challenge inoculum. To determine the ability of the modified model to detect protective efficacy, 11 veteran volunteers (previously challenged with S. flexneri 2a in bicarbonate buffer) and 12 immunologically naive control subjects were challenged with 1.4 {\texttimes} 103 c.f.u. S. flexneri 2a. Shigellosis occurred in 3 veterans and 11 control subjects (27 vs 92\%},
	keywords = {bacillary dysentery, infectivity, vaccines, volunteers},
	issn = {0264-410X},
	doi = {10.1016/0264-410X(95)00102-7},
	url = {https://www.sciencedirect.com/science/article/pii/0264410X95001027},
	author = {Kotloff, Karen L. and Nataro, James P. and Losonsky, Genevieve A. and Wasserman, Steven S. and Hale, Thomas L. and Taylor, David N. and Sadoff, Jerald C. and Levine, Myron M.}
}
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}
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	title = {Occurrence of Legionella in hot water systems of single-family residences in suburbs of two German cities with special reference to solar and district heating},
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	number = {1},
	year = {2008},
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	publisher = {Elsevier},
	author = {Mathys, Werner and Stanke, Juliane and Harmuth, Margarita and Junge-Mathys, Elisabeth}
}
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	year = {1998},
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	url = {https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809481/ },
	author = {Furtado, C and Adak, GK and Stuart, JM and Wall, PG and Evans, HS and Casemore, DP}
}
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	title = {Pathogenesis of Escherichia coli diarrhea},
	journal = {The New England journal of medicine},
	volume = {285},
	year = {1971},
	pages = {1},
	author = {DuPont, H L and Formal, S B and Hornick, R B and Snyder, M J and Libonati, J P and Sheahan, D G and LaBrec, E H and Kalas, J P}
}
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	title = {Pathogenesis of {Escherichia} coli {Diarrhea}},
	journal = {New England Journal of Medicine},
	volume = {285},
	number = {1},
	year = {1971},
	note = {Publisher: Massachusetts Medical Society},
	pages = {1{\textendash}9},
	issn = {0028-4793},
	doi = {10.1056/NEJM197107012850101},
	url = {https://www.nejm.org/doi/10.1056/NEJM197107012850101},
	author = {DuPont, Herbert L. and Formal, Samuel B. and Hornick, Richard B. and Snyder, Merrill J. and Libonati, Joseph P. and Sheahan, Daniel G. and LaBrec, Eugene H. and Kalas, John P.}
}
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	title = {Pathogenesis of experimental Coxsackie virus infection},
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	year = {1963},
	pages = {61-66},
	author = {Suptel, E A}
}
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	title = {Pathogenesis of Lassa virus infection in guinea pigs},
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	year = {1982},
	pages = {2},
	url = {http://iai.asm.org/content/37/2/771.abstract},
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}
@article {ldfhtgsl73,
	title = {Pathogenesis of Shigella dysenteriae 1 (Shiga) Dysentery},
	journal = {Journal of Infectious Diseases},
	volume = {127},
	year = {1973},
	pages = {3},
	author = {Levine, M M and DuPont, H L and Formal, S B and Hornick, R B and Takeuchi, A and Gangarosa, E J and Snyder, M J and Libonati, J P}
}
@article {levine_pathogenesis_1973,
	title = {Pathogenesis of {Shigella} dysenteriae 1 ({Shiga}) {Dysentery}},
	journal = {The Journal of Infectious Diseases},
	volume = {127},
	number = {3},
	year = {1973},
	pages = {261{\textendash}270},
	abstract = {The Shiga bacillus is exceptional among enteric pathogens in possessing two potential pathogenetic modes of action, invasiveness and enterotoxin. The role of each was investigated. ,Two fully virulent (invasive toxigenic) and two modified (noninvasive toxigenic and invasive nontoxigenic) Shiga strains were defined in animal and in-vitro models. The virulent strains produced disease in volunteers in doses as low as 101 organisms. Illness was characterized by fever, short-lived diarrhea, and passage of scanty stools of blood and mucus. During illness, the pathogen was isolated from one of 16 samples of small-intestinal contents, and free toxin could not be demonstrated. Concomitantly, large numbers of Shiga organisms were excreted in stool. The major lesions were in the large bowel where clinical colitis was confirmed by proctoscopy and biopsy. Large numbers of a noninvasive toxigenic strain (106-1011 organisms) were well tolerated by 85 of 86 men. One volunteer had dysentery after the organism had reverted to an invasive form. In contrast, an invasive nontoxigenic strain caused shigellosis in monkeys and volunteers. Epithelial penetration is the cardinal virulence property of Shigella dysenteriae 1. The role of Shiga toxin in human disease remains to be defined.},
	issn = {0022-1899},
	doi = {10.1093/infdis/127.3.261},
	url = {https://doi.org/10.1093/infdis/127.3.261},
	author = {Levine, Myron M. and DuPont, Herbert L. and Formal, Samuel B. and Hornick, Richard B. and Takeuchi, Akio and Gangarosa, Eugene J. and Snyder, Merrill J. and Libonati, Joseph P.}
}
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	abstract = {{\textless}h3{\textgreater}Background{\textless}/h3{\textgreater}{\textless}p{\textgreater}Acute renal failure has long been associated with severe Rocky Mountain spotted fever (RMSF). Despite many descriptions of the protean manifestations of this disease, relatively little is known concerning the risk factors for acute renal failure. Only a few studies have examined the outcome of patients infected with \textit{Rickettsia rickettsii} who develop renal insufficiency, and these studies had methodological problems.{\textless}/p{\textgreater}{\textless}h3{\textgreater}Objective{\textless}/h3{\textgreater}{\textless}p{\textgreater}To study the incidence, risk factors, and outcomes of acute renal failure in a large group of hospitalized patients with definite or probable RMSF.{\textless}/p{\textgreater}{\textless}h3{\textgreater}Methods{\textless}/h3{\textgreater}{\textless}p{\textgreater}The clinical records of 114 patients with definite or probable RMSF were retrospectively reviewed to identify clinical and biochemical abnormalities at the time of admission that were associated with the development of acute renal failure and subsequent mortality. Renal failure was defined as a serum creatinine (Cr) above 2 mg/dL. Logistic regression was used to study the association between these variables and the outcomes during hospitalization: death and the development of acute renal failure.{\textless}/p{\textgreater}{\textless}h3{\textgreater}Results{\textless}/h3{\textgreater}{\textless}p{\textgreater}The mortality rate in this series was 14\%; 19\% of the patients developed acute renal failure. The development of acute renal failure increased the odds ratio (OR) of dying by a factor of 17 (\textit{P} = 0.001). Factors at the time of hospitalization that were associated at a univariate level with subsequent mortality included elevated serum Cr, increased age, increased level of AST, increased level of bilirubin, decreased serum sodium and platelet count, the presence of neurological involvement, and being male. Both the presence of neurological involvement and an elevated serum Cr at presentation were independently associated with increased mortality by multivariate analysis. Three patients developed acute renal failure that required hemodialysis, and only 1 of these 3 patients survived; he was ultimately discharged with a normal serum Cr. Factors at presentation that were associated with the development of acute renal failure included increased bilirubin, increasing age, thrombocytopenia, and the presence of neurological involvement. Both age and decreased platelet count at presentation were independently associated with the development of acute renal failure by multivariate analysis.{\textless}/p{\textgreater}{\textless}h3{\textgreater}Conclusion{\textless}/h3{\textgreater}{\textless}p{\textgreater}Acute renal failure was a frequent complication of RMSF in this series of patients from a tertiary referral medical center. The presence of acute renal failure was strongly associated with death. Clinical and biochemical variables are useful in predicting which patients will develop acute renal failure.{\textless}/p{\textgreater}},
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