Bacillary dysentery from World War 1 and NCTC1, the first bacterial isolate in the National Collection.

In early 1915, a 28-year-old man arrived at No 14 Stationary Hospital in Wimereux, France. Although no clinical records remain, we believe he would have presented with bloody diarrhoea and severe abdominal cramping, and he was diagnosed with dysentery. On March 13, 1915, the patient, who we believe was Private Ernest Cable of the 2nd Battalion of the East Surrey Regiment (appendix), died. Lieutenant William Broughton-Alcock, whose military records identify him as a bacteriologist for No 14 Stationary Hospital, collected this isolate—later identifi ed as a Shigella fl exneri serotype 2a bacterium—which was the fi rst bacterial isolate deposited in the UK National Collection of Type Cultures (NCTC) using the original isolate name Cable. Although World War 1 was the fi rst confl ict in which more military deaths were attributable to hostile action than disease, millions of soldiers were aff ected by infectious agents, and many lives were lost as a result. The poor sanitary conditions of trench warfare meant infectious diseases such as dysentery were prevalent. This diarrhoeal disease is typically transmitted via the faecal–oral route or through contaminated food or water. The same day that Lieutenant Broughton-Alcock arrived for duty, No 14 was designated entirely as an Infectious Hospital. The war diary of the Matron-in-Chief of the British Expeditionary Force, E Maud McCarthy, provides insight into the management of infectious disease, such as the use of overalls in the wards by nursing staff and the need for a separate kitchen, a disinfector for clothing, and an incinerator for urine and faeces. We sequenced the revived isolate of S fl exneri isolated in World War 1 (now called NCTC1), as described by Baker and colleagues in The Lancet. The genome of NCTC1 provides insight into the evolution of bacillary dysentery during the 100 years since World War 1. Despite its isolation before the discovery and widespread use of antibiotics, NCTC1 was resistant to both penicillin and erythromycin, consistent with the ancient origins of antimicrobial resistance genes. Although the genome of NCTC1 was largely conserved over time—98% of the genes in NCTC1 were found in isolate 2002017, isolated in China in 2002—changes in the genome over time were associated with the acquisition of virulence factors, immune evasion, and resistance to more antimicrobials. Results of our genome studies suggest that S fl exneri was already a well adapted pathogen and that it continues to respond to selection pressures. Bacillary dysentery surpassed typhoid and cholera as the main diarrhoeal disease in military populations during World War 1, and today hundreds of thousands of deaths are attributed to this pathogen. Risk factors for dysentery epidemics during World War 1 are strikingly similar to those today: hygiene breakdown, predisposition because of malnutrition, shortage of specifi c therapies, and problems with bacteriological diagnosis. The fi rst two risk factors explain the current epidemiological distribution of bacillary dysentery as mainly a disease of developing nations. The third factor remains a challenge, with no licensed vaccine available and contemporary shigella isolates that are multidrug resistant. However, bacteriological diagnosis is much improved and in the 100 years since the start of World War 1 advances in molecular diagnostic approaches, such as whole genome sequencing, have aff orded unprecedented insights into the spread and evolution of bacteria such as shigella.