Risk factors for sporadic cryptosporidiosis among immunocompetent persons in the United States from 1999 to 2001

Estimates of enteric illness attributable to contact with animals and their environments in the United States

BACKGROUND

Contact with animals and their environment is an important, and often preventable, route of transmission for enteric pathogens. This study estimated the annual burden of illness attributable to animal contact for 7 groups of pathogens: Campylobacter species, Cryptosporidium species, Shiga toxin-producing Escherichia coli (STEC) O157, STEC non-O157, Listeria monocytogenes, nontyphoidal Salmonella species, and Yersinia enterocolitica.

METHODS

By using data from the US Foodborne Diseases Active Surveillance Network and other sources, we estimated the proportion of illnesses attributable to animal contact for each pathogen and applied those proportions to the estimated annual number of illnesses, hospitalizations, and deaths among US residents. We established credible intervals (CrIs) for each estimate.

RESULTS

We estimated that 14% of all illnesses caused by these 7 groups of pathogens were attributable to animal contact. This estimate translates to 445 213 (90% CrI, 234 197-774 839) illnesses annually for the 7 groups combined. Campylobacter species caused an estimated 187 481 illnesses annually (90% CrI, 66 259-372 359), followed by nontyphoidal Salmonella species (127 155; 90% CrI, 66 502-219 886) and Cryptosporidium species (113 344; 90% CrI, 22 570-299 243). Of an estimated 4933 hospitalizations (90% CrI, 2704-7914), the majority were attributable to nontyphoidal Salmonella (48%), Campylobacter (38%), and Cryptosporidium (8%) species. Nontyphoidal Salmonella (62%), Campylobacter (22%), and Cryptosporidium (9%) were also responsible for the majority of the estimated 76 deaths (90% CrI, 5-211).

CONCLUSIONS

Animal contact is an important transmission route for multiple major enteric pathogens. Continued efforts are needed to prevent pathogen transmission from animals to humans, including increasing awareness and encouraging hand hygiene.

Enteric pathogens in stool samples of Chicago-area water recreators with new-onset gastrointestinal symptoms

BACKGROUND

Characterizing pathogens responsible for recreational waterborne gastrointestinal illness is important in estimating risk and developing management strategies to prevent infection. Although water recreation is associated with sporadic cases of gastrointestinal illness, pathogens responsible for such illness are not well characterized.

METHODS

A prospective cohort study was conducted enrolling non-water recreators (such as cyclists and joggers) and two groups of limited-contact waters recreators (such as boaters and kayakers): those on an effluent-dominated urban waterway and those on general use waters. Stool samples were collected from participants who developed gastrointestinal symptoms during a three-week follow-up period. Samples were analyzed for bacterial, viral, and protozoan pathogens. Logistic regression models were used to identify associations between water recreation and the presence of pathogens in stool samples.

RESULTS

Among 10,998 participants without gastrointestinal symptoms at baseline, 2,429 (22.1%) developed at least one symptom during 21 days of follow-up. Of those, 740 (30.5%) provided at least one stool sample, of which 76 (10.3%) were positive for a pathogen. Rotavirus, found primarily among adults, accounted for 53 of the 76 (70%) infections. Among participants with symptoms, pathogen presence was not associated with water recreation or the extent of water exposure. The range of pathogens that could be identified and sample size limitations may have contributed to this lack of association.

CONCLUSIONS

We did not find specific pathogens or groups of pathogens associated with recreational waterborne gastrointestinal illness. Although pathogens responsible for outbreaks of waterborne gastrointestinal illness have been described, microbes that cause sporadic cases remain poorly defined.

Cryptosporidium species in Australian wildlife and domestic animals

Cryptosporidium is an important enteric parasite that is transmitted via the fecal-oral route, water and food. Humans, wildlife and domestic livestock all potentially contribute Cryptosporidium to surface waters. Most species of Cryptosporidium are morphologically indistinguishable and can only be identified using molecular tools. Over 24 species have been identified and of these, 7 Cryptosporidium species/genotypes are responsible for most human cryptosporidiosis cases. In Australia, relatively few genotyping studies have been conducted. Six Cryptosporidium species (C. hominis, C. parvum, C. meleagridis, C. fayeri, C. andersoni and C. bovis) have been identified in humans in Australia. However, little is known about the contribution of animal hosts to human pathogenic strains of Cryptosporidium in drinking water catchments. In this review, we focus on the available genotyping data for native, feral and domestic animals inhabiting drinking water catchments in Australia to provide an improved understanding of the public health implications and to identify key research gaps.

Enteric protozoa in the developed world: a public health perspective

Several enteric protozoa cause severe morbidity and mortality in both humans and animals worldwide. In developed settings, enteric protozoa are often ignored as a cause of diarrheal illness due to better hygiene conditions, and as such, very little effort is used toward laboratory diagnosis. Although these protozoa contribute to the high burden of infectious diseases, estimates of their true prevalence are sometimes affected by the lack of sensitive diagnostic techniques to detect them in clinical and environmental specimens. Despite recent advances in the epidemiology, molecular biology, and treatment of protozoan illnesses, gaps in knowledge still exist, requiring further research. There is evidence that climate-related changes will contribute to their burden due to displacement of ecosystems and human and animal populations, increases in atmospheric temperature, flooding and other environmental conditions suitable for transmission, and the need for the reuse of alternative water sources to meet growing population needs. This review discusses the common enteric protozoa from a public health perspective, highlighting their epidemiology, modes of transmission, prevention, and control. It also discusses the potential impact of climate changes on their epidemiology and the issues surrounding waterborne transmission and suggests a multidisciplinary approach to their prevention and control.

Evidence of Cryptosporidium transmission between cattle and humans in northern New South Wales

Cryptosporidium is an enteric parasite of public health significance that causes diarrhoeal illness through faecal oral contamination and via water. Zoonotic transmission is difficult to determine as most species of Cryptosporidium are morphologically identical and can only be differentiated by molecular means. Transmission dynamics of Cryptosporidium in rural populations were investigated through the collection of 196 faecal samples from diarrheic (scouring) calves on 20 farms and 63 faecal samples from humans on 14 of these farms. The overall prevalence of Cryptosporidium in cattle and humans by PCR and sequence analysis of the 18S rRNA was 73.5% (144/196) and 23.8% (15/63), respectively. Three species were identified in cattle; Cryptosporidium parvum, Cryptosporidium bovis and Cryptosporidium ryanae, and from humans, C. parvum and C. bovis. This is only the second report of C. bovis in humans. Subtype analysis at the gp60 locus identified C. parvum subtype IIaA18G3R1 as the most common subtype in calves. Of the seven human C. parvum isolates successfully subtyped, five were IIaA18G3R1, one was IIdA18G2 and one isolate had a mix of IIaA18G3R1 and IIdA19G2. These findings suggest that zoonotic transmission may have occurred but more studies involving extensive sampling of both calves and farm workers are needed for a better understanding of the sources of Cryptosporidium infections in humans from rural areas of Australia.

Direct healthcare costs of selected diseases primarily or partially transmitted by water

Despite US sanitation advancements, millions of waterborne disease cases occur annually, although the precise burden of disease is not well quantified. Estimating the direct healthcare cost of specific infections would be useful in prioritizing waterborne disease prevention activities. Hospitalization and outpatient visit costs per case and total US hospitalization costs for ten waterborne diseases were calculated using large healthcare claims and hospital discharge databases. The five primarily waterborne diseases in this analysis (giardiasis, cryptosporidiosis, Legionnaires' disease, otitis externa, and non-tuberculous mycobacterial infection) were responsible for over 40 000 hospitalizations at a cost of $970 million per year, including at least $430 million in hospitalization costs for Medicaid and Medicare patients. An additional 50 000 hospitalizations for campylobacteriosis, salmonellosis, shigellosis, haemolytic uraemic syndrome, and toxoplasmosis cost $860 million annually ($390 million in payments for Medicaid and Medicare patients), a portion of which can be assumed to be due to waterborne transmission.

A statewide outbreak of Cryptosporidium and its association with the distribution of public swimming pools

In order to characterize the association between county-level risk factors and the incidence of Cryptosporidium in the 2007 Iowa outbreak, we used generalized linear mixed models with the number of Cryptosporidium cases per county as the dependent variable. We employed a spatial power covariance structure, which assumed that the correlation between the numbers of cases in any two counties decreases as the distance between them increases. County population size was included in the model to adjust for population differences. Independent variables included the number of pools in specific pool categories (large, small, spa, wading, waterslide) and pool-owner classes (apartment, camp, country club or health club, hotel, municipal, school, other) as well as the proportion of residents aged <5 years. We found that increases in the number of bigger pools, pools with more heterogeneous mixing (municipal pools vs. country club or apartment pools), and pools catering to young children (wading pools) are associated with more cases at the county level.

Video observation of hand hygiene practices at a petting zoo and the impact of hand hygiene interventions

Petting zoos are popular attractions, but can also be associated with zoonotic disease outbreaks. Hand hygiene is critical to reducing disease risks; however, compliance can be poor. Video observation of petting zoo visitors was used to assess animal and environmental contact and hand hygiene compliance. Compliance was also compared over five hand hygiene intervention periods. Descriptive statistics and multivariable logistic regression were used for analysis. Overall hand hygiene compliance was 58% (340/583). Two interventions had a significant positive association with hand hygiene compliance [improved signage with offering hand sanitizer, odds ratio (OR) 3·38, P<0·001; verbal hand hygiene reminders, OR 1·73, P=0·037]. There is clearly a need to improve hand hygiene compliance at this and other animal exhibits. This preliminary study was the first to demonstrate a positive impact of a hand hygiene intervention at a petting zoo. The findings suggest that active, rather than passive, interventions are more effective for increasing compliance.

Water and sewage systems, socio-demographics, and duration of residence associated with endemic intestinal infectious diseases: a cohort study

BACKGROUND

Studies of water-related gastrointestinal infections are usually directed at outbreaks. Few have examined endemic illness or compared rates across different water supply and sewage disposal systems. We conducted a cohort study of physician visits and hospitalizations for endemic intestinal infectious diseases in a mixed rural and urban community near Vancouver, Canada, with varied and well-characterized water and sewage systems.

METHODS

Cohort members and their disease events were defined via universal health insurance data from 1995 through 2003. Environmental data were derived from municipal, provincial, and federal government sources. Logistic regression was used to examine associations between disease events and water and sewage systems, socio-demographic characteristics, and temporal factors.

RESULTS

The cohort included 126,499 individuals and approximately 190,000,000 person-days. Crude incidence rates were 1,353 physician visits and 33.8 hospitalizations for intestinal infectious diseases per 100,000 person-years. Water supply chlorination was associated with reduced physician visit incidence (OR: 0.92, 95% CI 0.85-1.0). Two water systems with the highest proportions of surface water had increased incidence (ORs: 1.57, 95% CI 1.39-1.78; and 1.45, 95% CI 1.28-1.64). Private well water and well depth were not associated with increased risk, likely because of residents' awareness of and attention to water quality. There was increased crude incidence with increasing precipitation in the population served by surface water supplies, but this trend did not remain with adjustment for other variables. Municipal sewer systems were associated with increased risk (OR: 1.26, 95% CI 1.14-1.38). Most socio-demographic variables had predicted associations with risk: higher rates in females, in the very young and the elderly, and in residents of low income areas. Increased duration of area residence was associated with reduced risk (OR, duration ≥ 6 years: 0.69, 95% CI 0.60-0.80 vs. < 1 year: 1.16, 95% CI 1.03-1.30).

CONCLUSIONS

This large cohort study, with objective data on exposures and outcomes, demonstrated associations between endemic infectious intestinal diseases and factors related to water supply, sewage disposal, socio-demographics, and duration of residency. The results did not always follow prior expectations based on studies examining outbreaks and single systems, and underscore the importance of studying factors associated with endemic disease across water and sewage system types.

Infectious agents of food- and water-borne illnesses

Food- and water-borne infections have afflicted mankind since the earliest days of human development and preceded the emergence of civilization. Despite current knowledge of microbial pathogenicity, modern methods of food production and rigorous industrial hygiene, these infections are still commonplace and exact significant health and economic tolls on human populations in all parts of the globe. This review uses data derived from new surveillance networks to survey the current epidemiology of bacterial, protozoan and viral pathogens transmitted by food and water. In addition, we will discuss clinical features of human disease caused by pathogens of current and emerging relevance.

Infection Rate of Cryptosporidium parvum among Diarrheic Children in Isfahan

OBJECTIVE

Cryptosporidiosis is an important enteric parasitic infection among infants and children in developing countries with significant morbidity and mortality especially among immuno-suppressed individuals. The aim of the present study was to estimate the prevalence of enteric cryptosporidiosis in children presenting with diarrhea in Isfahan.

METHODS

This cross-sectional study was conducted from August 2007 to June 2008 in three university hospitals in Isfahan. Children aged 1 month to 10 years presenting with acute or persistent diarrhea were selected consecutively. The oocyst of C. parvum was investigated in stool specimens using a modified acid-fast staining method.

FINDINGS

During the study period, 606 children (mean age 42.4±30.0 months, 58.1% female) were recruited. Acute and persistent diarrhea was present in 422 (69.6%) and 184 (30.4%) of the children, respectively. Twenty eight (4.6%) specimens were oocyst positive. The prevalence of Cryptosporidium infection was significantly higher in children with persistent diarrhea compared to children with acute diarrhea (12.5% vs 1.2%; P<0.001). Most of the infected children were under 5 years of age (89.2%), however, the age difference between infected and non-infected children was not statistically significant. Also, there was no significant difference between infected and non-infected children in gender.

CONCLUSION

The prevalence of Cryptosporidiosis in children presenting with persistent diarrhea is considerable and we suggest routine stool examination for Cryptosporidium in this group of children.

Global distribution, public health and clinical impact of the protozoan pathogen cryptosporidium

Cryptosporidium spp. are coccidians, oocysts-forming apicomplexan protozoa, which complete their life cycle both in humans and animals, through zoonotic and anthroponotic transmission, causing cryptosporidiosis. The global burden of this disease is still underascertained, due to a conundrum transmission modality, only partially unveiled, and on a plethora of detection systems still inadequate or only partially applied for worldwide surveillance. In children, cryptosporidiosis encumber is even less recorded and often misidentified due to physiological reasons such as early-age unpaired immunological response. Furthermore, malnutrition in underdeveloped countries or clinical underestimation of protozoan etiology in developed countries contribute to the underestimation of the worldwide burden. Principal key indicators of the parasite distribution were associated to environmental (e.g., geographic and temporal clusters, etc.) and host determinants of the infection (e.g., age, immunological status, travels, community behaviours). The distribution was geographically mapped to provide an updated picture of the global parasite ecosystems. The present paper aims to provide, by a critical analysis of existing literature, a link between observational epidemiological records and new insights on public health, and diagnostic and clinical impact of cryptosporidiosis.

Genetic richness and diversity in Cryptosporidium hominis and C. parvum reveals major knowledge gaps and a need for the application of "next generation" technologies--research review

Cryptosporidium species (apicomplexan protists) are a major cause of diarrhoeal disease (= cryptosporidiosis) in humans worldwide. The impact of cryptosporidiosis is also compounded by the spread of HIV/AIDS and a lack of cost-effective anti-cryptosporidial chemotherapeutics or vaccines. Mitigation of the impact of cryptosporidiosis in humans needs to focus on prevention and control strategies, built on a sound understanding of the epidemiology of Cryptosporidium species. Refined epidemiological studies rely on the use of molecular tools employing informative genetic markers. Currently, the 60-kDa glycoprotein gene (gp60) is the most suitable and widely used genetic marker for Cryptosporidium species infecting humans. Here, we undertake an analysis of all publicly-available gp60 sequence data and associated literature for C. hominis and C. parvum, and yield useful insights into the richness, diversity and distribution of genetic variants, and link these variants to human cryptosporidiosis. This global analysis reveals that, despite high genetic richness in Cryptosporidium isolates from humans, there is a surprisingly low diversity. It also highlights limited knowledge about the genetics of cryptosporidiosis in developing nations and in many animals that might act as infection sources. Clearly, there is a major need for more comprehensive studies of Cryptosporidium infecting humans and other animals in Africa and Asia. As molecular technologies improve and become affordable, future studies should utilize "next generation" sequencing and bioinformatic platforms to conduct comparative 'genome sequence surveys' to test the validity of current genetic classifications based on gp60 data. Complemented by in vitro and in vivo investigations, these biotechnological advances will also assist significantly in the search for new intervention strategies against human cryptosporidiosis.

Cryptosporidium surveillance and risk factors in the United States

Surveillance for Cryptosporidium in the United States indicates that the reported incidence of infection has increased dramatically since 2004. The reasons for this increase are unclear but might be caused by an actual increase in incidence, improved surveillance, improved awareness about cryptosporidiosis, and/or increases in testing practices resulting from the licensing of the first-ever treatment for cryptosporidiosis. While regional differences remain, the incidence of cryptosporidiosis appears to be increasing across the United States. Onset of illness is most common during the summer, particularly among younger children. Cryptosporidiosis case reporting also influences outbreak detection and reporting; the recent rise in cases coincides with an increase in the number of reported cryptosporidiosis outbreaks, particularly in treated recreational water venues. Risk factors include ingesting contaminated recreational or drinking water, exposure to infected animals, having close contacts with cryptosporidiosis, travel to disease-endemic areas, and ingestion of contaminated food. Advances in molecular characterization of clinical specimens have improved our understanding of the changing epidemiology and risk factors. Prevention and control of cryptosporidiosis requires continued efforts to interrupt the transmission of Cryptosporidium through water, food, and contact with infected persons or animals. Of particular importance is continued improvement and monitoring of drinking water treatment and advances in the design, operation, and management of recreational water venues coupled with behavioral changes among the swimming public.

Simultaneous detection of serum immunoglobulin G antibodies to Cryptosporidium parvum by multiplex microbead immunoassay using 3 recognized specific recombinant C. parvum antigens

Cryptosporidiosis is a significant diarrheal disease in both humans and other mammals worldwide. In the present study, we established and validated a multiplex microbead immunoassay (MIA) for surveillance of Cryptosporidium parvum infections. In the multiplex MIA, 3 specific recombinant proteins, CP23, SA35, and SA40, were used as the capture antigens simultaneously. The antibody directed against CP23 is an index of historic infection, and those against SA35 and SA40 are indices of recent infection. The multiplex MIA yielded essentially identical results with that of monoplex MIA using these 3 recombinant proteins, and the reproducibility of the multiplex MIA results was high when standardized with a calibration curve. With multiplex MIA, we detected that the pediatric population showed a higher percentage of recent infections (seropositive rates of antibodies directed against CP23, SA35, and SA40 were 6.28%, 23.19%, and 22.71%, respectively, n = 207), whereas the adult population showed a higher percentage of historic infections (seropositive rates of antibodies directed against CP23, SA35, and SA40 were 24.40%, 11.48%, and 16.75%, respectively, n = 209).

Sporadic Salmonella enterica serotype Javiana infections in Georgia and Tennessee: a hypothesis-generating study

From 1996 to 2004, the incidence of Salmonella Javiana infections increased in FoodNet, the U.S. national active foodborne disease surveillance programme. Contact with amphibians and consumption of tomatoes have been associated with outbreaks of S. Javiana infection. To generate and test hypotheses about risk factors associated with sporadic S. Javiana infections, we interviewed patients with laboratory-confirmed S. Javiana infection identified in Georgia and Tennessee during August-October 2004. We collected data on food and water consumption, animal contact, and environmental exposure from cases. Responses were compared with population-based survey exposure data. Seventy-two of 117 identified S. Javiana case-patients were interviewed. Consumption of well water [adjusted odds ratio (aOR) 4.3, 95% confidence interval (CI) 1.6-11.2] and reptile or amphibian contact (aOR 2.6, 95% CI 0.9-7.1) were associated with infection. Consumption of tomatoes (aOR 0.5, 95% CI 0.3-0.9) and poultry (aOR 0.5, 95% CI 0.2-1.0) were protective. Our study suggests that environmental factors are associated with S. Javiana infections in Georgia and Tennessee.

Cryptosporidium and cryptosporidiosis

Cryptosporidium is one of the most common enteric protozoan parasites of vertebrates with a wide host range that includes humans and domestic animals. It is a significant cause of diarrhoeal disease and an ubiquitous contaminant of water which serves as an excellent vehicle for transmission. A better understanding of the development and life cycle of Cryptosporidium, and new insights into its phylogenetic relationships, have illustrated the need to re-evaluate many aspects of the biology of Cryptosporidium. This has been reinforced by information obtained from the recent successful Cryptosporidium genome sequencing project, which has emphasised the uniqueness of this organism in terms of its parasite life style and evolutionary biology. This chapter provides an up to date review of the biology, biochemistry and host parasite relationships of Cryptosporidium.

A modified case-control study of cryptosporidiosis (using non-Cryptosporidium-infected enteric cases as controls) in a community setting

Data from the first sentinel site (Waterloo Region, Ontario) of the Canadian Integrated Enteric Disease Surveillance System (C-EnterNet) were used in a secondary-based case-control study of laboratory-confirmed Cryptosporidium infections to study the role of various exposure factors. The incidence of cryptosporidiosis in Waterloo Region was almost double both the provincial and national rates. Persons ill with one of nine other enteric infections (amoebiasis, campylobacteriosis, cyclosporiasis, giardiasis, listeriosis, salmonellosis, shigellosis, verotoxigenic E. coli infections, yersiniosis) captured by the surveillance system were used as the control group. Of 1204 cases of enteric illness in the sentinel area between April 2005 and December 2007, 36 cases and 803 controls were selected after excluding outbreak and international travel-related cases. Univariable analyses (Pearson chi2 and Fisher's exact tests) and multivariable logistic regression were performed. Results of the multivariable analysis found that cryptosporidiosis was associated with swimming in a lake or river (OR 2.9, 95% CI 1.2-7.4), drinking municipal water (a potential surrogate for urban respondents vs. rural) (OR 2.4, 95% CI 1.04-5.7), and having a family member with a diarrhoeal illness (OR 2.9, 95% CI 1.3-6.4).

Multiple risk factors associated with a large statewide increase in cryptosporidiosis

Cryptosporidiumspecies have emerged as a major cause of outbreaks of diarrhoea and have been associated with consumption of contaminated recreational and drinking water and food as well as contact with infected attendees of child-care programmes. In August 2007, the Colorado Department of Public Health and Environment detected an increase in cryptosporidiosis cases over baseline values. We conducted a case-control study to assess risk factors for infection and collected stool specimens from ill persons for microscopy and molecular analysis. Laboratory-confirmed cases (n=47) were more likely to have swallowed untreated water from a lake, river, or stream [adjusted matched odds ratio (aOR) 8·0, 95% confidence interval (CI) 1·3–48·1], have had exposure to recreational water (aOR 4·6, 95% CI 1·4–14·6), or have had contact with a child in a child-care programme or in diapers (aOR 3·8, 95% CI 1·5–9·6). Although exposure to recreational water is commonly implicated in summertime cryptosporidiosis outbreaks, this study demonstrates that investigations of increased incidence of cases in summer should also examine other potential risk factors. This study emphasizes the need for public health education efforts that address the multiple transmission routes forCryptosporidiumand appropriate prevention measures to avoid future transmission.

Risks of recreational exposure to waterborne pathogens among persons with HIV/AIDS in Baltimore, Maryland

OBJECTIVES

We assessed the prevalence of recreational activities in the waterways of Baltimore, MD, and the risk of exposure to Cryptosporidium among persons with HIV/AIDS.

METHODS

We studied patients at the Johns Hopkins Moore Outpatient AIDS Clinic. We conducted oral interviews with a convenience sample of 157 HIV/AIDS patients to ascertain the sites used for recreational water contact within Baltimore waters and assess risk behaviors.

RESULTS

Approximately 48% of respondents reported participating in recreational water activities (fishing, crabbing, boating, and swimming). Men and women were almost equally likely to engage in recreational water activities (53.3% versus 51.3%). Approximately 67% (105 of 157) ate their own catch or that of friends or family members, and a majority (61%, or 46 of 75) of respondents who reported recreational water contact reported consumption of their own catch.

CONCLUSIONS

Baltimoreans with HIV/AIDS are engaging in recreational water activities in urban waters that may expose them to waterborne pathogens and recreational water illnesses. Susceptible persons, such as patients with HIV/AIDS, should be cautioned regarding potential microbial risks from recreational water contact with surface waters.

High resolution melting-curve (HRM) analysis for the diagnosis of cryptosporidiosis in humans

Cryptosporidiosis of humans is an intestinal disease caused predominantly by infection with Cryptosporidium hominis or C. parvum. This disease is transmitted mainly via the faecal-oral route (water or food) and has major socioeconomic impact globally. The diagnosis and genetic characterization of the main species and population variants (also called "genotypes" and "subgenotypes") of Cryptosporidium infecting humans is central to the prevention, surveillance and control of cryptosporidiosis, particularly as there is presently no cost effective anti-cryptosporidial chemotherapeutic regimen or vaccine available. In the present study, we established a polymerase chain reaction (PCR)-coupled high resolution melting-curve (HRM) analysis method, utilizing the second internal transcribed spacer (ITS-2) of nuclear ribosomal DNA as the genetic marker, for the diagnosis of Cryptosporidium hominis, C. parvum or C. meleagridis infection. An evaluation of the method revealed intra- and inter-assay variabilities of <1.5 and 3.5%, respectively. Cryptosporidium hominis, C. parvum and C. meleagridis were detected in 97, 44 and 2, respectively, of the 143 Cryptosporidium oocyst DNA samples originating from Australians with clinical cryptosporidiosis. The melting profiles characterized by peaks of 72.47+/-0.33 degrees C and 74.19+/-0.45 degrees C (profile 1), 72.17+/-0.32 degrees C (profile 2) and 73.33+/-0.03 degrees C (profile 3) genetically identified as C. hominis, C. parvum and C. meleagridis, respectively. In conclusion, PCR-coupled melting analysis of ITS-2 achieved the diagnosis of Cryptosporidium hominis, C. parvum or C. meleagridis infection. This approach is well suited for the rapid screening of large numbers of Cryptosporidium oocyst DNA samples and, although qualitative, is significantly less time-consuming to carry out than electrophoretic analysis and has the added advantage of data storage and analysis capabilities in silico. This method provides a useful tool for investigating the epidemiology and outbreaks of cryptosporidiosis, and could be applicable to species of Cryptosporidium other than those investigated herein.

Cryptosporidium--biotechnological advances in the detection, diagnosis and analysis of genetic variation

Cryptosporidiosis is predominantly a gastrointestinal disease of humans and other animals, caused by various species of protozoan parasites representing the genus Cryptosporidium. This disease, transmitted mainly via the faecal-oral route (in water or food), is of major socioeconomic importance worldwide. The diagnosis and genetic characterization of the different species and population variants (usually recognised as "genotypes" or "subgenotypes") of Cryptosporidium is central to the prevention, surveillance and control of cryptosporidiosis, particularly given that there is presently no broadly applicable treatment regimen for this disease. Although traditional phenotypic techniques have had major limitations in the specific diagnosis of cryptosporidiosis, there have been major advances in the development of molecular analytical and diagnostic tools. This article provides a concise account of Cryptosporidium and cryptosporidiosis, and focuses mainly on recent advances in nucleic acid-based approaches for the diagnosis of cryptosporidiosis and analysis of genetic variation within and among species of Cryptosporidium. These advances represent a significant step toward an improved understanding of the epidemiology as well as the prevention and control of cryptosporidiosis.

Implications of biofilm-associated waterborne Cryptosporidium oocysts for the water industry

Waterborne Cryptosporidium has been responsible for drinking water-associated disease outbreaks in a number of developed countries. As a result of the resistance of Cryptosporidium to chlorine, which is typically applied as a final barrier to protect the quality of distributed drinking water, current management practices are focused on source-water management and water treatment as ways of preventing Cryptosporidium from entering drinking-water supplies. In the event that treatment barriers fail, surprisingly little is known of the fate of oocysts once they enter a distribution system. To assess properly the risks of waterborne Cryptosporidium, a more thorough understanding of the fate of oocysts in water distribution systems, with emphasis on Cryptosporidium-biofilm interactions, is required.

FoodNet: overview of a decade of achievement

The Foodborne Diseases Active Surveillance Network (FoodNet) performs active, population-based laboratory surveillance for nine common foodborne pathogens and one syndrome in a catchment area of 44.5 million persons. FoodNet surveillance data are an important resource for examining trends in specific diseases over time. Population surveys and laboratory surveys have been used to estimate the burden of disease, for example that there are 38.6 cases of Salmonella infection for each reported case. FoodNet case-control studies have identified new risk factors for E. coli O157, Campylobacter, and several Salmonella serotypes. FoodNet sites have demonstrated the value of delivered stool kits for improving the rate of confirming an etiology in foodborne disease outbreaks. FoodNet helps build capacity for foodborne disease surveillance in participating sites and through close collaborations with PulseNet, EHS-Net, Global SalmSurv, and other partners.

Serological responses to Cryptosporidium-specific antigens in Czech populations with different water sources

Serological responses to Cryptosporidium-specific antigens (15/17 and 27 kDa) were compared among populations in four areas of the Czech Republic that use drinking water from clearly defined sources: (1) wells in a fractured sandstone aquifer, (2) riverbank infiltration, or (3) two different filtered and chlorinated surface waters. Among persons surveyed in the area with riverbank-infiltration water, 33% had a strong serological response to the 15/17-kDa antigen group whereas, in the other three areas, over 72% of persons had a strong response. These response differences suggest that Cryptosporidium exposures and infection were lower in the area with bank infiltration. The large percentage of the study population with a strong serological response to both antigens suggests high levels of previous infections that may have resulted in protective immunity for cryptosporidiosis. This may be one reason why no waterborne cryptosporidiosis outbreaks and few cases of cryptosporidiosis have been reported in the Czech Republic.

Activities, achievements, and lessons learned during the first 10 years of the Foodborne Diseases Active Surveillance Network: 1996-2005

Since the establishment of the Foodborne Diseases Active Surveillance Network (FoodNet) in 1996, it has been an essential resource for the surveillance and investigation of foodborne disease in the United States. FoodNet has had a major impact on food safety because it conducts population-based, active surveillance for laboratory-confirmed infections from 9 pathogens commonly transmitted through food. Each year, FoodNet publishes the National Report Card on Food Safety, which is used by regulatory agencies, industry and consumer groups, and public health personnel to prioritize and evaluate food safety interventions and monitor progress toward national health objectives. FoodNet also determines the human-health impact of foodborne illness by conducting related epidemiological studies that contribute to the estimates of the overall burden of foodborne illness, attribute the burden of foodborne illness to specific foods and settings, and address important foodborne disease-related issues, such as antimicrobial resistance and sequelae from foodborne infections. This article summarizes the activities, achievements, and lessons learned during the first 10 years of FoodNet.

Parasites of the small intestine

This paper discusses the most important parasites that inhabit the human small intestine. Beginning with the protozoa and proceeding through the various species of cestodes, nematodes, and trematodes that inhabit the human small bowel, the most important organisms are presented. Possible future developments are discussed along with pathophysiology and treatment in this phylogenic approach. Zoonotic illnesses, those diseases that by their rarity are of little import, and diseases without significant clinical or social implications are beyond the scope of this article and are not discussed.

Risk factors for sporadic Shiga toxin-producing Escherichia coli O157 infections in FoodNet sites, 1999-2000

To monitor risk factors for illness, we conducted a case-control study of sporadic Shiga toxin-producing Escherichia coli O157 (STEC O157) infections in 1999-2000. Laboratory-confirmed cases of STEC O157 infection were identified through active laboratory surveillance in all or part of seven states. Patients and age-matched controls were interviewed by telephone using a standard questionnaire. Information was collected on demographics, clinical illness, and exposures to food, water, and animals in the 7 days before the patient's illness onset. During the 12-month study, 283 patients and 534 controls were enrolled. STEC O157 infection was associated with eating pink hamburgers, drinking untreated surface water, and contact with cattle. Eating produce was inversely associated with infection. Direct or indirect contact with cattle waste continues to be a leading identified source of sporadic STEC O157 infections.

Evidence supporting zoonotic transmission of Cryptosporidium spp. in Wisconsin

Cryptosporidium hominis and Cryptosporidium parvum are the primary species of Cryptosporidium that infect humans. C. hominis has an anthroponotic transmission cycle, while C. parvum is zoonotic, infecting cattle and other ruminants, in addition to humans. Most cryptosporidiosis outbreaks in the United States have been caused by C. hominis, and this species is often reported as the primary cause of cryptosporidiosis in this country. However, outbreaks account for only 10% of the overall cryptosporidiosis cases, and there are few data on the species that cause sporadic cases. The present study identified the species/genotypes and subgenotypes of Cryptosporidium in 49 cases of sporadic cryptosporidiosis in Wisconsin during the period from 2003 to 2005. The species/genotype of isolates was determined by PCR restriction fragment length polymorphism analysis of the 18S rRNA and Cryptosporidium oocyst wall protein genes. The C. parvum and C. hominis isolates were subgenotyped by sequence analysis of the GP60 gene. Forty-four of 49 isolates were identified as C. parvum, and 1 was identified as C. hominis. Of the remaining isolates, one was identified as being of the cervine genotype, one was identified as being a cervine genotype variant, and two were identified as being of a novel human genotype, previously reported as W17. Nine different subgenotypes were identified within the C. parvum species, and two of these were responsible for 60% of the cases. In this study we found that most sporadic cases of cryptosporidiosis in Wisconsin are caused by zoonotic Cryptosporidium species, indicating that zoonotic transmission could be more frequently associated with sporadic cases in the United States.

Wide geographic distribution of Cryptosporidium bovis and the deer-like genotype in bovines

Recent studies in the United States reported that approximately 85% of pre-weaned dairy calves were infected with zoonotic Cryptosporidium parvum, whereas only 1-2% of post-weaned calves and 1-2-year-old heifers were infected with this species. Cryptosporidium bovis and Cryptosporidium deer-like genotype were much more prevalent in the post-weaned animals. It is not clear whether the same infection pattern also occurs in other geographic areas. In this study, to determine whether the same Cryptosporidium infection pattern was present in other geographic areas, we genotyped Cryptosporidium specimens collected from two farms in China and India, using specimens from farms in Georgia, USA for comparison. C. bovis was the most common species found in pre- and post-weaned calves in all three areas. In Georgia, the deer-like genotype was found frequently in pre- and post-weaned calves and Cryptosporidium andersoni was found in one post-weaned calf. Both C. bovis and the deer-like genotype were found in the few milking cows examined in Georgia. There were no differences in the small subunit rRNA gene sequences obtained from C. bovis or deer-like genotype among the three areas. One adult yak in China, however, was infected with a species similar to C. bovis, with only three nucleotide mutations in the target gene. All four common bovine Cryptosporidium spp. were differentiated from each other by restriction fragment length polymorphism analysis of PCR products with enzymes SspI and MboII. Thus, both C. bovis and the deer-like genotype are found in all age groups of cattle in diverse geographic areas and host adaptation of C. bovis might have occurred in yaks.

Epidemiological and clinical features of travel-associated cryptosporidiosis

Data concerning the clinical and epidemiological features of travel-associated cryptosporidiosis are lacking. In order to investigate the impact of this disease on travellers' health, a retrospective study was conducted at the Institute of Tropical Medicine, Berlin. In total, 57 cryptosporidial infections were identified between 2000 and 2004, resulting in a prevalence of 2.9% in patients with travel-associated diarrhoea. Travel to south-central Asia, especially India, was associated with a higher prevalence of infection than was travel to other destinations. Clinically, the disease resembled giardiasis, but fever and arthralgias seemed to occur more frequently.

Detection of Cryptosporidium, Giardia and Enterocytozoon bieneusi in surface water, including recreational areas: a one-year prospective study

Accidental ingestion of natural waters while bathing carries a risk of infection by waterborne protozoa such as Cryptosporidium, Giardia and, possibly, microsporidia. In order to evaluate this risk, we conducted a one-year prospective study of two recreational lakes and three river sites located near Paris, where bathing and boating are frequent. Twenty-litre water samples were collected monthly from each site. Concentrated samples were submitted to immunomagnetic separation followed by immunofluorescence (IMS-IF) for Cryptosporidium and Giardia detection. PCR and PCR restriction fragment length polymorphism (PCR-RFLP) were used for the genetic characterization of Cryptosporidium species on IMS-IF-positive samples. PCR were systematically performed to detect Enterocytozoon bieneusi. Bacteria counts were also determined. IMS-IF revealed low counts of Giardia cysts and Cryptosporidium oocysts in the recreational lakes, with occasional peaks (max. 165 cysts/10 L and 9 oocysts/10 L). By contrast, the river sites were consistently and sometimes heavily contaminated throughout the year. Enterocytozoon bieneusi was found in only two river samples. PCR-RFLP genotyping showed the presence of C. hominis and C. parvum. No correlation was found between the presence or counts of parasites and bacteria, except between the presence of Giardia and high counts of Escherichia coli and enterococci. Based on a previously developed model for quantitative risk assessment of waterborne parasitic infections, we estimated that the mean risk of infection by Cryptosporidium and Giardia associated with swimming was <10(-4) in the recreational lakes, and frequently higher at the river sites.

Parasites of the small intestine

This paper discusses the most important parasites that inhabit the human small intestine. Beginning with the protozoa and proceeding through the various species of cestodes, nematodes, and trematodes that inhabit the human small bowel, the most important organisms are presented. Possible future developments are discussed along with pathophysiology and treatment in this phylogenic approach. Zoonotic illnesses, those diseases that by their rarity are of little import, and diseases without significant clinical or social implications are beyond the scope of this article and are not discussed.

Recurrent outbreaks of cryptosporidiosis associated with calves among students at an educational farm programme, Minnesota, 2003

Enteric illness outbreaks among middle-/high-school students in consecutive semesters of an educational farm programme were investigated with retrospective cohort studies. During the first outbreak, 31/92 (34%) interviewed students were ill. Risk factors included participating in animal science class (RR 8.1, 95% CI 1.2-55.2) and contact with calves (RR 4.2, 95% CI 1.1-16.2). Stool samples from seven students and two calves yielded Cryptosporidium parvum. Students cared for animals in street clothes and practised poor hand washing. During the second outbreak, 37/81 (46%) interviewed animal science students were ill. Risk factors included having visible manure on hands, and wearing coveralls and boots. Stool samples from seven students and eight calves yielded C. parvum. Student hand washing was still inadequate. Coveralls/boots were cleaned infrequently and removed after hand washing. These outbreaks of cryptosporidiosis resulted from calf contact and inadequate hygiene practices. The failure to adequately implement recommended interventions contributed to the second outbreak.

Advances in the epidemiology, diagnosis and treatment of cryptosporidiosis

Cryptosporidiosis, the disease caused by protozoa of the genus Cryptosporidium, represents a major public health problem in both developing and developed countries. The infection can be severe and life threatening among immunocompromised individuals, particularly in AIDS patients and in those with primary immunodeficiency diseases. This review examines the essential aspects of the epidemiology of the infection, highlighting the role of animals, water and food. A critical evaluation of the diagnostic tools used in clinical settings is also provided. Lastly, the review examines the chemotherapeutic options available to treat the infection, and underlines the need to design and test new drugs. The review concludes with a five-year outlook on some aspects of interest for future research on this pathogen.

The zoonotic transmission of Giardia and Cryptosporidium

The molecular characterisation of Giardia and Cryptosporidium has given rise to a more epidemiological meaningful and robust taxonomy. Importantly, molecular tools are now available for 'typing' isolates of the parasites directly from clinical and environmental samples. As a consequence, information on zoonotic potential has been obtained although the frequency of zoonotic transmission is still poorly understood. Analysis of outbreaks and case-control studies, especially when coupled with genotyping data, is slowly providing information on the public health significance of zoonotic transmission. Such studies support the hypothesis that Cryptosporidium hominis is spread only between humans but that the major reservoir for Cryptosporidium parvum is domestic livestock, predominantly cattle, and that direct contact with infected cattle is a major transmission pathway along with indirect transmission through drinking water. The situation is less clearcut for Giardia duodenalis but the evidence does not, in general, support zoonotic transmission as a major risk for human infections. However, for both parasites there is a need for molecular epidemiological studies to be undertaken in well-defined foci of transmission in order to fully determine the frequency and importance of zoonotic transmission.

Detection of Cryptosporidium sp. in non diarrheal faeces from children, in a day care center in the city of São Paulo, Brazil

The protozoan Cryptosporidium sp. has been frequently detected in faeces from children with persistent diarrhoea. This work achieved to investigate an outbreak of cryptosporidiosis, in a day care center, attending children of high socio-economic level, between 0 and six years old. The outbreak was detected through the network of public health, when stool samples, not diarrhoeic, were examined at the Parasitology Service of the Adolfo Lutz Institute. Among the 64 examined children, 13 (20.3%) showed oocysts of Cryptosporidium sp. in the faeces examined by Kinyoun technique: seven children one year old, three, two years old and three, three years old. Among the 23 examined adults, only a 22 years old woman, possibly having an immunocomprometiment, was positive. Clinical and epidemiological aspects were investigated by questionnaires, highlighting the occurrence of the outbreak in a very dry period.

An outbreak of Cryptosporidium hominis infection at an Illinois recreational waterpark

Cryptosporidium has become increasingly recognized as a pathogen responsible for outbreaks of diarrhoeal illness in both immunocompetent and immunocompromised persons. In August 2001, an Illinois hospital reported a cryptosporidiosis cluster potentially linked to a local waterpark. There were 358 case-patients identified. We conducted community-based and waterpark-based case-control studies to examine potential sources of the outbreak. We collected stool specimens from ill persons and pool water samples for microscopy and molecular analysis. Laboratory-confirmed case-patients (n=77) were more likely to have attended the waterpark [odds ratio (OR) 16.0, 95% confidence interval (CI) 3.8-66.8], had pool water in the mouth (OR 6.0, 95% CI 1.3-26.8), and swallowed pool water (OR 4.5, 95% CI 1.5-13.3) than age-matched controls. Cryptosporidium was found in stool specimens and pool water samples. The chlorine resistance of oocysts, frequent swimming exposures, high bather densities, heavy usage by diaper-aged children, and increased recognition and reporting of outbreaks are likely to have contributed to the increasing trend in number of swimming pool-associated outbreaks of cryptosporidiosis. Recommendations for disease prevention include alteration of pool design to separate toddler pool filtration systems from other pools. Implementation of education programmes could reduce the risk of faecal contamination and disease transmission.

Unravelling Cryptosporidium and Giardia epidemiology

Molecular biology has provided insights into the taxonomy and epidemiology of Cryptosporidium and Giardia, which are major causes of protozoal diarrhoea in humans worldwide. For both genera, previously unrecognized differences in disease, symptomatology, zoonotic potential, risk factors and environmental contamination have been identified using molecular tools that are appropriate for species, genotype and subtype analysis. In this article, to improve understanding of the epidemiology of cryptosporidiosis and giardiasis, we consider specific requirements for the development of more-effective molecular identification and genotyping systems that should be applicable to both clinical and environmental samples.

Foodborne protozoan parasites

This report addresses Cryptosporidium, Giardia, Cyclospora, and more briefly, Toxoplasma as the main parasitic protozoa of concern to food production worldwide. Other parasitic protozoa may be spread in food or water but are not considered as great a risk to food manufacture. The protozoan parasites Cryptosporidium, Giardia, and Cyclospora have proven potential to cause waterborne and foodborne disease. Toxoplasma gondii has been considered a risk in specific cases, but humans are not its primary host. Cryptosporidium and Giardia are widespread in the environment, particularly the aquatic environment, and major outbreaks of cryptosporidiosis and giardiasis have occurred as a result of contaminated drinking water. Large outbreaks of waterborne cyclosporiasis have not been identified. Cryptosporidium, Giardia, and Cyclospora have potential significance in the preparation and consumption of fresh produce and in catering practice, in which ready-to-eat foods may be served that have not received heat treatment. None of the three organisms Cryptosporidium, Giardia, and Cyclospora has been shown to be a problem for heat processed food or tap water that has undergone appropriate treatment at a water treatment works. All three are sensitive to standard pasteurisation techniques. Although humans are not a primary host for T. gondii, the potential exists for both waterborne and foodborne toxoplasmosis. Parasitic protozoa do not multiply in foods, but they may survive in or on moist foods for months in cool, damp environments. Their ecology makes control of these parasites difficult. For general control of parasitic protozoa in the food chain, the following steps are necessary: - Follow good hygienic practice in food service and catering industries.- Minimise dissemination of cysts and oocysts in the farming environment and via human waste management.- Include these microorganisms in Hazard Analysis Critical Control Point (HACCP) plans of water suppliers, industries or sectors that use fresh produce, and operations in which contaminated process or ingredient water could end up in the product (e.g., where water supplies may become contaminated).

Population-based laboratory surveillance for Giardia sp. and Cryptosporidium sp. infections in a large Canadian health region

BACKGROUND

Giardia lamblia (intestinalis) and Cryptosporidium parvum are the two most important intestinal parasites infecting North Americans but there is a paucity of active population-based surveillance data from Canada. This study determined the incidence of and demographic risk factors for developing Giardia sp. and Cryptosporidium sp. infections in a general Canadian population.

METHODS

Population-based laboratory surveillance was conducted among all residents of the Calgary Health Region (CHR; population approximately = 1 million) during May 1, 1999 and April 30, 2002.

RESULTS

Giardia sp. infection occurred at a rate of 19.6 per 100,000 populations per year. Although the yearly incidence was stable, a significant seasonal variation was observed with a peak in late summer to early fall. Males were at higher risk for development of this infection as compared to females (21.2 vs. 17.9 per 100,000/yr; relative risk (RR) 1.19; 95% confidence interval (CI), 1.00-1.40, p = 0.047), and there was a significant decrease in risk associated with an increasing age. Cryptosporidium sp. infection occurred at an overall rate of 6.0 per 100,000 populations per year although a large outbreak of Cryptosporidium sp. infections occurred in the second half of the summer of 2001. During August and September of 2001, the incidence of cryptosporidiosis was 55.1 per 100,000 per year as compared to 3.1 per 100,000 per year for the remainder of the surveillance period (p < 0.0001). Cryptosporidiosis was largely a disease of children with an incidence of 17.8 per 100,000 per year occurring among those aged < 20 years of age compared to 1.25 per 100,000 per year for adults > or = 20 years of age (RR 14.19; 95% CI, 9.77-21.11; p < 0.0001).

CONCLUSION

This study provides important information on the occurrence and demographic risk groups for acquisition of giardiasis and cryptosporidiosis in a non-selected Canadian population.

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