Betsy J Bricker

Animal and Plant Health Inspection Service, Buzzards Bay, Massachusetts, United States

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Publications (36)112.37 Total impact

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    ABSTRACT: The reliable differentiation of live Brucella vaccine strains from field isolates is an important element in brucellosis control programs. We describe the design, validation, and implementation of a novel single nucleotide polymorphism (SNP)-based typing platform that offers a rapid, reliable, and robust tool to achieve this with improved diagnostic accuracy compared to existing molecular tests. Furthermore, the assays described are designed such that they supplement, and can be run as an intrinsic part of, a previously described assay identifying Brucella isolates to the species level (K. K. Gopaul, C. J. Smith, M. S. Koylass, and A. M. Whatmore, BMC Microbiol. 8:86), giving a comprehensive molecular typing platform.
    Journal of clinical microbiology 02/2010; 48(4):1461-4. DOI:10.1128/JCM.02193-09 · 3.99 Impact Factor
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    ABSTRACT: Identifying the source of infectious disease outbreaks is difficult, especially for pathogens that infect multiple wildlife species. Brucella spp. are among the most problematic zoonotic agents worldwide, and they are notoriously difficult to detect and identify. We genotyped 10 variable number of tandem repeat (VNTR) DNA loci in 56 Brucella abortus isolates from bison (Bos bison), elk (Cervus elaphus), and cattle (Bos taurus) to test the wildlife species most likely to be the origin of recent outbreaks of brucellosis in cattle in the Greater Yellowstone Area. Isolates from cattle and elk were nearly identical but highly divergent from bison isolates. These data suggest elk, not bison, are the reservoir species of origin for these cattle infections. This study illustrates the potential power of VNTR genotyping to assess the origin of disease outbreaks, which are increasing worldwide following habitat fragmentation, climate change, and expansion of human and livestock populations.
    Journal of wildlife diseases 10/2009; 45(4):1174-7. DOI:10.7589/0090-3558-45.4.1174 · 1.36 Impact Factor
  • Chapter: Brucella
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    ABSTRACT: Brucellosis affects millions of animals and humans world-wide; in humans, over 500,000 new cases are reported annually. Although some vaccines are available for its prevention in animals, none exist for humans. The causative agent is the facultative intracellular bacterial pathogen belonging to the genus Brucella and is transmitted from animals to humans; infected animals experience abortion and humans undulant fever. Brucella spp. belong to the order Rhizobiales within the class alpha-Proteobacteria. This places them in a group of bacteria noted for their abilities to live in soil (e.g. Ochrobactrum) or form close associations with their host and result in either a disease (e.g. phytopathogenic Agrobacterium) or non-disease state (symbiotic Rhizobium). The scientists contributing to the chapter have a vast array of experience in studying this intracellular bacterial pathogen. The topics covered include disease history, vaccines and zoonotic implications, taxonomy, diagnostic and population dynamics, comparative and functional genomics, and host pathogen interactions related to the Brucella spp. In all, the chapter is a comprehensive look at the Brucella and the means by which we are trying to minimize the negative impacts it has on the animal kingdom.
    Genome Mapping and Genomics in Animal-Associated Microbes, 11/2008: pages 1-64;
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    ABSTRACT: We demonstrate that the "HOOF-Print" assay provides high power to discriminate among Brucella isolates collected oil a small spatial scale (within Portugal). Additionally, we illustrate how haplotype identification using non-random association among markers allows resolution of B. melitensis biovars (1 and 3). We recommend that future studies use haplotype identification when analyzing multilocus Population genetic data to help discriminate among microbial isolates such as Brucella. (c) 2008 Elsevier B.V. All rights reserved.
    Infection Genetics and Evolution 11/2008; 9(1):104-7. DOI:10.1016/j.meegid.2008.10.007 · 3.02 Impact Factor
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    Infection Genetics and Evolution 10/2008; · 3.02 Impact Factor
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    ABSTRACT: The Brucella abortus strain S19, a spontaneously attenuated strain, has been used as a vaccine strain in vaccination of cattle against brucellosis for six decades. Despite many studies, the physiological and molecular mechanisms causing the attenuation are not known. We have applied pyrosequencing technology together with conventional sequencing to rapidly and comprehensively determine the complete genome sequence of the attenuated Brucella abortus vaccine strain S19. The main goal of this study is to identify candidate virulence genes by systematic comparative analysis of the attenuated strain with the published genome sequences of two virulent and closely related strains of B. abortus, 9-941 and 2308. The two S19 chromosomes are 2,122,487 and 1,161,449 bp in length. A total of 3062 genes were identified and annotated. Pairwise and reciprocal genome comparisons resulted in a total of 263 genes that were non-identical between the S19 genome and any of the two virulent strains. Amongst these, 45 genes were consistently different between the attenuated strain and the two virulent strains but were identical amongst the virulent strains, which included only two of the 236 genes that have been implicated as virulence factors in literature. The functional analyses of the differences have revealed a total of 24 genes that may be associated with the loss of virulence in S19. Of particular relevance are four genes with more than 60 bp consistent difference in S19 compared to both the virulent strains, which, in the virulent strains, encode an outer membrane protein and three proteins involved in erythritol uptake or metabolism.
    PLoS ONE 02/2008; 3(5):e2193. DOI:10.1371/journal.pone.0002193 · 3.23 Impact Factor
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    ABSTRACT: Eighty feral swine were trapped from a herd that had been documented to be seropositive for Brucella and which had been used for Brucella abortus RB51 vaccine trials on a 7,100-hectare tract of land in South Carolina. The animals were euthanized and complete necropsies were performed. Samples were taken for histopathology, Brucella culture, and Brucella serology. Brucella was cultured from 62 (77.5%) animals. Brucella suis was isolated from 55 animals (68.8%), and all isolates were biovar 1. Brucella abortus was isolated from 28 animals (35.0%), and isolates included field strain biovar 1 (21 animals; 26.3%), vaccine strain Brucella abortus S19 (8 animals, 10.0%), and vaccine strain Brucella abortus RB51 (6 animals, 7.5%). Males were significantly more likely to be culture positive than females (92.9% vs. 60.6%). Thirty-nine animals (48.8%) were seropositive. Males also had a significantly higher seropositivity rate than females (61.9% vs. 34.2%). The relative sensitivity rates were significantly higher for the standard tube test (44.6%) and fluorescence polarization assay (42.6%) than the card agglutination test (13.1%). Lesions consistent with Brucella infection were commonly found in the animals surveyed and included inflammatory lesions of the lymph nodes, liver, kidney, and male reproductive organs, which ranged from lymphoplasmacytic to pyogranulomatous with necrosis. This is the first report of an apparent enzootic Brucella abortus infection in a feral swine herd suggesting that feral swine may serve as a reservoir of infection for Brucella abortus as well as Brucella suis for domestic livestock.
    Journal of veterinary diagnostic investigation: official publication of the American Association of Veterinary Laboratory Diagnosticians, Inc 06/2007; 19(3):227-37. DOI:10.1177/104063870701900301 · 1.35 Impact Factor
  • William C Stoffregen · Steven C Olsen · Betsy J Bricker ·
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    ABSTRACT: To determine the immunogenicity and efficacy of Brucella abortus strain RB51 (SRB51) as a vaccine in domestic pigs. Sixty-eight 6-week-old crossbred domestic pigs and twenty-four 4-month-old gilts. In experiment 1, pigs were vaccinated IM (n = 51) with 2 x 10(10) CFUs of SRB51 or sham inoculated (17). Periodic blood samples were obtained to perform blood cultures, serologic evaluations, and cell-mediated immunity assays. Necropsies were performed at selected times between weeks 1 and 23 after vaccination to determine vaccine clearance. In experiment 2, gilts were similarly vaccinated (n = 18) or sham inoculated (8) and similar samples were obtained after vaccination. Gilts were bred and challenged conjunctivally with 5.0 x 10(7) CFUs of virulent Brucella suis strain 3B. Necropsies were performed on gilts and on fetuses or neonates after abortion or parturition, respectively. Bacterial cultures and serologic evaluations were performed on samples obtained at necropsy to determine vaccine efficacy. Humoral and cell-mediated immune responses did not differ between vaccinates and controls. After vaccination, SRB51 was not isolated from blood cultures of either group and was isolated from lymphoid tissues of 3 pigs at 2 weeks (n = 2) and 4 weeks (1) after vaccination. No differences were found in isolation of B suis or in seroconversion between vaccinated and control gilts and between their neonates or aborted fetuses. Parenteral vaccination with SRB51 does not induce humoral or cell-mediated immune responses. Vaccination with SRB51 did not protect gilts or their neonates and fetuses from virulent challenge with B suis.
    American Journal of Veterinary Research 11/2006; 67(10):1802-8. DOI:10.2460/ajvr.67.10.1802 · 1.34 Impact Factor
  • Betsy J Bricker · Darla R Ewalt ·
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    ABSTRACT: A critical component of limiting bacterial disease outbreaks is the tracing of the infection to the index source, which can be facilitated by using a highly discriminating bacterial identification system that will reliably identify genetically related bacterial populations. For pathogenic bacteria with highly conserved genomes, such as the zoonotic pathogen Brucella, finding distinguishing markers or traits for strain identification is challenging. This chapter describes a relatively new procedure for identifying Brucella strains. The procedure, which is called "HOOF prints" (hypervariable octameic oligonucleotide fingerprints), is based on high levels of polymorphism observed at several genomic loci in the Brucella genomes that contain small tandemly repeated deoxyribonucleic sequences. The technique described is designed for medium- to high-throughput analyses. However, the method described can be modified to characterize fewer samples.
    Methods in Molecular Biology 02/2006; 345:141-73. DOI:10.1385/1-59745-143-6:141 · 1.29 Impact Factor
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    ABSTRACT: Brucellosis is a worldwide disease of humans and livestock that is caused by a number of very closely related classical Brucella species in the alpha-2 subdivision of the Proteobacteria. We report the complete genome sequence of Brucella abortus field isolate 9-941 and compare it to those of Brucella suis 1330 and Brucella melitensis 16 M. The genomes of these Brucella species are strikingly similar, with nearly identical genetic content and gene organization. However, a number of insertion-deletion events and several polymorphic regions encoding putative outer membrane proteins were identified among the genomes. Several fragments previously identified as unique to either B. suis or B. melitensis were present in the B. abortus genome. Even though several fragments were shared between only B. abortus and B. suis, B. abortus shared more fragments and had fewer nucleotide polymorphisms with B. melitensis than B. suis. The complete genomic sequence of B. abortus provides an important resource for further investigations into determinants of the pathogenicity and virulence phenotypes of these bacteria.
    Journal of Bacteriology 05/2005; 187(8):2715-26. DOI:10.1128/JB.187.8.2715-2726.2005 · 2.81 Impact Factor
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    Betsy J Bricker · Darla R Ewalt ·
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    ABSTRACT: A fundamental question that arises during epidemiological investigations of bacterial disease outbreaks is whether the outbreak strain is genetically related to a proposed index strain. Highly discriminating genetic markers for characterizing bacterial strains can help in clarifying the genetic relationships among strains. Under the auspices of the European Society of Clinical Microbiology and Infectious Diseases, the European Study Group for Epidemiological Markers (ESGEM) established guidelines for evaluating the performance of typing systems based of a number of criteria. Recently, HOOF-Print genotype analysis, a new method for typing Brucella abortus strains based on hypervariability at eight tandem repeat loci, was described. This paper evaluates the HOOF-Print assay by four of the criteria set out by the ESGEM: typeability, reproducibility, power of discrimination, and concordance with other typing methods. The HOOF-Print Assay was evaluated with a test population composed of 97 unrelated field isolates and 6 common laboratory strains of B. abortus. Both typeability and reproducibility of the assay were excellent. Allele diversity and frequency varied widely among the eight loci, ranging from 1 to 13 alleles. The power of discrimination, measured by the Hunter-Gaston discrimination index (HGDI), varied by locus ranging from 0 to 0.89, where a maximal value of 1.0 indicates discrimination of all strains. The HGDI values calculated for subgroups sorted by biovar were similar to the values determined for the whole population. None of the individual loci achieved the recommended HGDI threshold of 0.95, but the HGDI of the composite profiles was 0.99 (93 unique genotypes from 97 field strains evaluated), well above the recommended threshold. By comparison, the HGDI value for biovar typing was 0.61 in a test population biased with disproportionate numbers of the less common biovars. Cluster analysis based on HOOF-Print genotypes assembled the strains into hierarchical groups with no apparent association with the time or location of strain isolation. Likewise, these hierarchical groups were not homogeneous with regard to biotype. In one extreme case, two field isolates with identical fingerprints were identified as different biovars by conventional methods. The main purpose of this study was to assess the ability of HOOF-Print genotyping to discriminate unrelated field strains of B. abortus, and whether the assay met established requirements for bacterial strain typing methods. The discriminatory power of the assay was remarkable, considering the genetic homogeneity found among species within the genus. The assay met or exceeded all of the recommended levels for the performance criteria of typeability, reproducibility, and power of discrimination, however some inconsistencies with conventional biovar typing were observed. Nevertheless, the results indicate that with cautious interpretation, multilocus genotyping of polymorphic tandem repeats by HOOF-Print analysis could be a valuable complement to routine epidemiological investigations into localized B. abortus outbreaks.
    BMC Microbiology 02/2005; 5:37. DOI:10.1186/1471-2180-5-37 · 2.73 Impact Factor
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    Betsy J Bricker · Darla R Ewalt · Shirley M Halling ·
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    ABSTRACT: Currently, there are very few tools available for subtyping Brucella isolates for epidemiological trace-back. Subtyping is difficult because of the genetic homogeneity within the genus. Sequencing of the genomes from three Brucella species has facilitated the search for DNA sequence variability. Recently, hypervariability among short tandem repeat sequences has been exploited for strain-typing of several bacterial pathogens. An eight-base pair tandem repeat sequence was discovered in nine genomic loci of the B. abortus genome. Eight loci were hypervariable among the three Brucella species. A PCR-based method was developed to identify the number of repeat units (alleles) at each locus, generating strain-specific fingerprints. None of the loci exhibited species- or biovar-specific alleles. Sometimes, a species or biovar contained a specific allele at one or more loci, but the allele also occurred in other species or biovars. The technique successfully differentiated the type strains for all Brucella species and biovars, among unrelated B. abortus biovar 1 field isolates in cattle, and among B. abortus strains isolated from bison and elk. Isolates from the same herd or from short-term in vitro passage exhibited little or no variability in fingerprint pattern. Sometimes, isolates from an animal would have multiple alleles at a locus, possibly from mixed infections in enzootic areas, residual disease from incomplete depopulation of an infected herd or molecular evolution within the strain. Therefore, a mixed population or a pool of colonies from each animal and/or tissue was tested. This paper describes a new method for fingerprinting Brucella isolates based on multi-locus characterization of a variable number, eight-base pair, tandem repeat. We have named this technique "HOOF-Prints" for Hypervariable Octameric Oligonucleotide Finger-Prints. The technique is highly discriminatory among Brucella species, among previously characterized Brucella strains, and among unrelated field isolates that could not be differentiated by classical methods. The method is rapid and the results are reproducible. HOOF-Printing will be most useful as a follow-up test after identification by established methods since we did not find species-specific or biovar-specific alleles. Nonetheless, this technology provides a significant advancement in brucellosis epidemiology, and consequently, will help to eliminate this disease worldwide.
    BMC Microbiology 08/2003; 3(1):15. DOI:10.1186/1471-2180-3-15 · 2.73 Impact Factor
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    Betsy J Bricker · Darla R Ewalt · Steven C Olsen · Allen E Jensen ·
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    ABSTRACT: In a blind test, 344 samples representing 80 bacterial isolates were analyzed by the Brucella abortus species-specific polymerase chain reaction (BaSS PCR) assay for the identification and discrimination of B. abortus field strains (wild-type biovars 1, 2, and 4) from 1) B. abortus vaccine strains, 2) other Brucella species, and 3) non-Brucella bacteria. Identical samples were tested in 2 laboratories. Half the samples were fully viable, and half were bacteria that had been killed by methanol fixation. The results in 1 laboratory correctly identified 100% of the samples, resulting in a predictive value of 100% for all categories and 100% sensitivity and specificity under the prescribed conditions. The second laboratory misidentified 31 samples, resulting in a range of 66.7-100% sensitivity, 93.2-99.7% specificity, and 77.3-98.2% predictive values depending on the category. There was no significant difference in viable versus fixed bacteria for either laboratory. Subsequent review of the protocol indicated that contamination was the likely cause of 26 of the 31 erroneous identifications. The results show that the BaSS PCR assay has the potential to be a very reliable screening tool for B. abortus identification. However, the data also provide a cautionary reminder of the importance of preventing contamination in diagnostic PCR.
    Journal of veterinary diagnostic investigation: official publication of the American Association of Veterinary Laboratory Diagnosticians, Inc 08/2003; 15(4):374-8. DOI:10.1177/104063870301500413 · 1.35 Impact Factor
  • Darla R Ewalt · Betsy J Bricker ·

    Methods in Molecular Biology 02/2003; 216:97-108. · 1.29 Impact Factor
  • Betsy J Bricker ·

    Veterinary Microbiology 01/2003; 90(1-4):433-4. DOI:10.1016/S0378-1135(02)00227-4 · 2.51 Impact Factor
  • Betsy J Bricker ·
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    ABSTRACT: Numerous PCR-based assays have been developed for the identification of Brucella to improve diagnostic capabilities. Collectively, the repertoire of assays addresses several aspects of the diagnostic process. For some purposes, the simple identification of Brucella is adequate (e.g. diagnosis of human brucellosis or contamination of food products). In these cases, a genus-specific PCR assay is sufficient. Genus-specific assays tend to be simple, robust, and somewhat permissive of environmental influences. The main genetic targets utilized for these applications are the Brucella BCSP31 gene and the 16S-23S rRNA operon. Other instances require identification of the Brucella species involved. For example, most government-sponsored brucellosis eradication programs include regulations that stipulate a species-specific response. For epidemiological trace back, strain-specific identification is helpful. Typically, differential PCR-based assays tend to be more complex and consequently more difficult to perform. Several strategies have been explored to differentiate among Brucella species and strains, including locus specific multiplexing (e.g. AMOS-PCR based on IS711), PCR-RFLP (e.g. the omp2 locus), arbitrary-primed PCR, and ERIC-PCR to name a few. This paper reviews some of the major advancements in molecular diagnostics for Brucella including the development of procedures designed for the direct analysis of a variety of clinical samples. While the progress to date is impressive, there is still room for improvement.
    Veterinary Microbiology 01/2003; 90(1-4):435-46. DOI:10.1016/S0378-1135(02)00228-6 · 2.51 Impact Factor
  • R Redkar · S Rose · B Bricker · V DelVecchio ·
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    ABSTRACT: Real-time PCR-based assays specific for Brucella abortus, Brucella melitensis and Brucella suis were developed. The assays utilize an upstream primer that is derived from 3' end of the genetic element IS 711, whereas the downstream primers and probes are designed from signature sequences specific to a species or a biovar. The PCR reactions were monitored for fluorescence resonance energy transfer by including two adjacent labeled probes that hybridize to the amplicons as they are formed. The upstream probes were labeled with fluorescein at 3' end while Cy5 was attached to the 5' end of the downstream probes. An increase in the ratio of fluorescein to Cy5 fluorescence during the cycling was indicative of positive amplification event. The assays were accomplished in less than 30 min using a LightCycler in real-time mode. The assays were tested on known strains as well as field isolates and were found to be specific for all known biovars of B. abortus, B. melitensis and biovar 1 of B. suis. Therefore, specificity, sensitivity, speed and real-time detection make these assays attractive for use in epidemiological and ecological studies.
    Molecular and Cellular Probes 03/2001; 15(1):43-52. DOI:10.1006/mcpr.2000.0338 · 1.85 Impact Factor
  • Betsy J. Bricker ·
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    ABSTRACT: The three Brucella melitensis ribosomal RNA operons rrnA, rrnB, and rrnC were characterized individually. Each locus consisted of the 16S rRNA gene (rrs), followed by an intergenic spacer containing the tRNA-Ile and tRNA-Ala genes, the 23S rRNA gene (rrl), an intergenic spacer devoid of tRNA genes, the 5S rRNA gene (rrf), and an f-Met tRNA gene. The DNA sequences were identical over a 6271bp region, diverging 594bp upstream of rrs and immediately downstream of the f-Met tRNA gene. The previously uncharacterized 23S rRNA genes each contained a 178bp insertion 130bp from the 5' end. The location of the insertion matched intervening sequences (IVSs) found in other Rhizobiaceae. However, the size and sequence of the Brucella IVS differed from all previously reported IVS sequences from bacteria. The IVS region was PCR-amplified from 20 Brucella isolates representing all known Brucella species and biovars. All isolates contained only the complete IVS fragment. We compared the IVS DNA sequences of rrlC from representative strains of each of the six known Brucella species. The data revealed that the sequences were identical and differed from the B. melitensis IVS sequences by a single base pair. In other bacterial species, the IVSs are associated with post-transcriptional processing of the 23S rRNA by RNase III. We found that the Brucella 23S rRNA was slightly smaller than the 23S rRNA of Escherichia coli, known to be devoid of IVS sequences.
    Gene 10/2000; 255(1):117-26. DOI:10.1016/S0378-1119(00)00273-0 · 2.14 Impact Factor
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    Darla R. Ewalt · Betsy J. Bricker ·
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    ABSTRACT: The Brucella AMOS PCR assay was previously developed to identify and differentiate specific Brucella species. In this study, an abbreviated Brucella AMOS PCR test was evaluated to determine its accuracy in differentiating Brucella abortus into three categories: field strains, vaccine strain 19 (S19), and vaccine strain RB51/parent strain 2308 (S2308). Two hundred thirty-one isolates were identified and tested by the conventional biochemical tests and Brucella AMOS PCR. This included 120 isolates identified as B. abortus S19, 9 identified as B. abortus strain RB51, 57 identified as B. abortus biovar 1, 15 identified as B. abortus bv. 2, 1 identified as B. abortus bv. 2 (M antigen dominant), 7 identified as B. abortus bv. 4, and 22 identified as B. abortus S2308 and isolated from experimentally infected cattle. The Brucella AMOS PCR correctly identified each isolate as RB51/S2308, S19, or a field strain of Brucella.
    Journal of Clinical Microbiology 09/2000; 38(8):3085-6. · 3.99 Impact Factor
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    ABSTRACT: A multiplex amplification and detection platform for the diagnosis of Mycobacterium bovis and Brucella abortus infection simultaneously in bovine milk and nasal secretions was developed. This system (designated the bovine pathogen detection assay [BPDA]-PCR) consists of duplex amplification of species-specific targets (a region of the BCSP31K gene of B. abortus and a repeat-sequence region in the hsp65 gene of M. bovis, respectively). This is followed by a solid-phase probe capture hybridization of amplicons for detection. On the basis of spiking experiments with normal milk, the analytical sensitivity of the assay was 800 CFU equivalents/ml of milk for B. abortus and as low as 4 CFU equivalents per ml of milk for M. bovis. BPDA-PCR was validated with 45 liver samples from lemmings experimentally infected with B. abortus. The assay sensitivity, based on culture status as a "gold standard," was 93.9%. In this experiment, BPDA-PCR also identified five culture-negative liver samples as positive (41.7%). Field studies for the evaluation of BPDA-PCR were performed with samples from dairy animals from geographically distinct regions (India, Mexico, and Argentina). A high prevalence of shedding of B. abortus (samples from India) and M. bovis (samples from Mexico) was identified by BPDA-PCR. In samples from India, B. abortus shedding was identified in 86% of milk ring test-positive animals (n = 15) and 80% of milk ring test-negative cows (n = 5). In samples from Mexico, M. bovis was identified by PCR in 32.6% of pools (n = 46) of milk that each contained milk from 10 animals and in 56.2% of nasal swabs (n = 121) from cattle from tuberculin test-positive herds. In contrast, the Argentine cattle (n = 70) had a modest prevalence of M. bovis shedding in nasal swabs (2.9%) and milk (1.4%) and of B. abortus in milk (11.4%). On the basis of these analyses, we identify BPDA-PCR as an optimal tool for both screening of herds and testing of individual animals in a disease eradication program. A combination of the duplex assay, screening of milk samples in pools, and the proposed algorithm provides a highly sensitive, cost-effective, and economically viable alternative to serological testing.
    Journal of Clinical Microbiology 08/2000; 38(7):2602-10. · 3.99 Impact Factor

Publication Stats

2k Citations
112.37 Total Impact Points


  • 2007
    • Animal and Plant Health Inspection Service
      Buzzards Bay, Massachusetts, United States
  • 1993-2006
    • United States Department of Agriculture
      • Agricultural Research Service (ARS)
      Washington, D. C., DC, United States
  • 2005
    • University of Minnesota Duluth
      Duluth, Minnesota, United States
  • 1989-2003
    • Agricultural Research Service
      Kerrville, Texas, United States
  • 1988
    • Iowa State University
      Ames, Iowa, United States
    • University of Virginia
      • Department of Medicine
      Charlottesville, Virginia, United States