Epidemiology of giardiasis in Tasmania: a potential risk to residents and visitors

Enterocytozoon bieneusi of animals-With an 'Australian twist'

Enterocytozoon bieneusi is a microsporidian microorganism that causes intestinal disease in animals including humans. E. bieneusi is an obligate intracellular pathogen, typically causing severe or chronic diarrhoea, malabsorption and/or wasting. Currently, E. bieneusi is recognised as a fungus, although its exact classification remains contentious. The transmission of E. bieneusi can occur from person to person and/or animals to people. Transmission is usually via the faecal-oral route through E. bieneusi spore-contaminated water, environment or food, or direct contact with infected individuals. Enterocytozoon bieneusi genotypes are usually identified and classified by PCR-based sequencing of the internal transcribed spacer region (ITS) of nuclear ribosomal DNA. To date, ~600 distinct genotypes of E. bieneusi have been recorded in ~170 species of animals, including various orders of mammals and reptiles as well as insects in >40 countries. Moreover, E. bieneusi has also been found in recreational water, irrigation water, and treated raw- and waste-waters. Although many studies have been conducted on the epidemiology of E. bieneusi, prevalence surveys of animals and humans are scant in some countries, such as Australia, and transmission routes of individual genotypes and related risk factors are poorly understood. This article/chapter reviews aspects of the taxonomy, biology and epidemiology of E. bieneusi; the diagnosis, treatment and prevention of microsporidiosis; critically appraises the naming system for E. bieneusi genotypes as well as the phylogenetic relationships of these genotypes; provides new insights into the prevalence and genetic composition of E. bieneusi populations in animals in parts of Australia using molecular epidemiological tools; and proposes some areas for future research in the E. bieneusi/microsporidiosis field.

Global Medicine, Parasites, and Tasmania

Until the 1970s, infectious disease training in most medical schools was limited to those diseases common in the area of instruction. Those wishing to explore a more globalised curriculum were encouraged to undertake specialist postgraduate training at schools or institutes of tropical medicine. However, the increase in global trade and travel from the 1970s onward led to dramatic changes in the likelihood of returning travellers and new immigrants presenting with tropical infections in temperate regions. Furthermore, population growth and the changing relationships between animals, the environment, and man in agriculture accentuated the importance of a wider understanding of emerging infectious diseases, zoonotic diseases and parasitic infections. These epidemiological facts were not adequately reflected in the medical literature or medical curriculum at the time. The orientation on tropical infections needed specialised attention, including instruction on diagnosis and treatment of such infections. We describe key global health events and how the changing field of global medicine, from the 1970s to early 2000, impacted on medical education and research. We describe the impact of global health changes in the Tasmanian context, a temperate island state of Australia. We retrospectively analysed data of patients diagnosed with parasites and present a list of endemic and non-endemic parasites reported during this period. Finally, we reflect on the new approaches to the changing needs of global health and challenges that medical programmes, learners and educators face today.

Is open defaecation in outdoor recreation and camping areas a public health issue in Australia? A literature review

Issue addressed

In Australia, natural areas used for outdoor recreation activities or camping often have limited or no sanitation infrastructure. Recreationist and campers may use open defaecation practices where toilets are not provided. Contaminated soils and watercourses are associated with gastrointestinal illnesses. This review aims to determine if open defaecation is a public health issue in outdoor recreation and camping areas in Australia.

Method

A literature review was conducted using the following search engines: CINAHL, Informit Database, Scopus, ProQuest Science & Technology, Medline (Ovid) and EBSCOhost. Inclusion criteria for this review were both experimental and observational research designs for studies describing the public health issues associated with open defaecation practice.

Results

Out of 12 147 papers identified, only three studies met the inclusion criteria, showing a lack of research into this area. Included were two studies that addressed human waste management practices in outdoor environments and the breakdown of human waste in alpine regions of Tasmania. The third study measured water contamination at a freshwater beach on K'gari‐Fraser Island, Queensland. Visitors to natural areas are potentially at high risk of illness due to exposure to faecal contamination from other visitors using unsafe open defaecation practices in high‐use camping areas.

Conclusion

The limited number of studies addressing open defaecation in the outdoor recreation and camp areas in Australia indicates this review is a starting point to identify critical areas that may be of concern when managing visitors in an outdoor recreation setting. This review recommends investigating barriers and enablers motivating human disposal waste in these settings to help formulate health promotion content; environmental management policies related to sanitation and hygiene should be also underpinned by public health policy; and providing appropriate sanitation options depending on the ecological and visitor numbers to natural areas.

So what‐relevance of findings

Outdoor recreation activities offer physical and mental health benefits for communities. The popularity of outdoor recreation activities is on the increase in Australia. With the rise in visitation to natural areas, management of human waste needs to be addressed to reduce the public health risk of illness.

Wildlife parasitology in Australia: past, present and future

Wildlife parasitology is a highly diverse area of research encompassing many fields including taxonomy, ecology, pathology and epidemiology, and with participants from extremely disparate scientific fields. In addition, the organisms studied are highly dissimilar, ranging from platyhelminths, nematodes and acanthocephalans to insects, arachnids, crustaceans and protists. This review of the parasites of wildlife in Australia highlights the advances made to date, focussing on the work, interests and major findings of researchers over the years and identifies current significant gaps that exist in our understanding. The review is divided into three sections covering protist, helminth and arthropod parasites. The challenge to document the diversity of parasites in Australia continues at a traditional level but the advent of molecular methods has heightened the significance of this issue. Modern methods are providing an avenue for major advances in documenting and restructuring the phylogeny of protistan parasites in particular, while facilitating the recognition of species complexes in helminth taxa previously defined by traditional morphological methods. The life cycles, ecology and general biology of most parasites of wildlife in Australia are extremely poorly understood. While the phylogenetic origins of the Australian vertebrate fauna are complex, so too are the likely origins of their parasites, which do not necessarily mirror those of their hosts. This aspect of parasite evolution is a continuing area for research in the case of helminths, but remains to be addressed for many other parasitic groups.

Molecular characterization of Cryptosporidium and Giardia from the Tasmanian devil (Sarcophilus harrisii)

The Tasmanian devil (Sarcophilus harrisii) is a carnivorous marsupial found only in the wild in Tasmania, Australia. Tasmanian devils are classified as endangered and are currently threatened by devil facial tumour disease, a lethal transmissible cancer that has decimated the wild population in Tasmania. To prevent extinction of Tasmanian devils, conservation management was implemented in 2003 under the Save the Tasmanian Devil Program. This study aimed to assess if conservation management was altering the interactions between Tasmanian devils and their parasites. Molecular tools were used to investigate the prevalence and diversity of two protozoan parasites, Cryptosporidium and Giardia, in Tasmanian devils. A comparison of parasite prevalence between wild and captive Tasmanian devils showed that both Cryptosporidium and Giardia were significantly more prevalent in wild devils (p < 0.05); Cryptosporidium was identified in 37.9% of wild devils but only 10.7% of captive devils, while Giardia was identified in 24.1% of wild devils but only 0.82% of captive devils. Molecular analysis identified the presence of novel genotypes of both Cryptosporidium and Giardia. The novel Cryptosporidium genotype was 98.1% similar at the 18S rDNA to Cryptosporidium varanii (syn. C. saurophilum) with additional samples identified as C. fayeri, C. muris, and C. galli. Two novel Giardia genotypes, TD genotype 1 and TD genotype 2, were similar to G. duodenalis from dogs (94.4%) and a Giardia assemblage A isolate from humans (86.9%). Giardia duodenalis BIV, a zoonotic genotype of Giardia, was also identified in a single captive Tasmanian devil. These findings suggest that conservation management may be altering host-parasite interactions in the Tasmanian devil, and the presence of G. duodenalis BIV in a captive devil points to possible human-devil parasite transmission.

Giardia--from genome to proteome

In this review, the current status of genomic and proteomic research on Giardia is examined in terms of evolutionary biology, phylogenetic relationships and taxonomy. The review also describes how characterising genetic variation in Giardia from numerous hosts and endemic areas has provided a better understanding of life cycle patterns, transmission and the epidemiology of Giardia infections in humans, domestic animals and wildlife. Some progress has been made in relating genomic information to the phenotype of Giardia, and as a consequence, new information has been obtained on aspects of developmental biology and the host-parasite relationship. However, deficiencies remain in our understanding of pathogenesis and host specificity, highlighting the limitations of currently available genomic datasets.

Seasonality in human zoonotic enteric diseases: a systematic review

Background

Although seasonality is a defining characteristic of many infectious diseases, few studies have described and compared seasonal patterns across diseases globally, impeding our understanding of putative mechanisms. Here, we review seasonal patterns across five enteric zoonotic diseases: campylobacteriosis, salmonellosis, vero-cytotoxigenic Escherichia coli (VTEC), cryptosporidiosis and giardiasis in the context of two primary drivers of seasonality: (i) environmental effects on pathogen occurrence and pathogen-host associations and (ii) population characteristics/behaviour.

Methodology/Principal Findings

We systematically reviewed published literature from 1960–2010, resulting in the review of 86 studies across the five diseases. The Gini coefficient compared temporal variations in incidence across diseases and the monthly seasonality index characterised timing of seasonal peaks. Consistent seasonal patterns across transnational boundaries, albeit with regional variations was observed. The bacterial diseases all had a distinct summer peak, with identical Gini values for campylobacteriosis and salmonellosis (0.22) and a higher index for VTEC (Gini = 0.36). Cryptosporidiosis displayed a bi-modal peak with spring and summer highs and the most marked temporal variation (Gini = 0.39). Giardiasis showed a relatively small summer increase and was the least variable (Gini = 0.18).

Conclusions/Significance

Seasonal variation in enteric zoonotic diseases is ubiquitous, with regional variations highlighting complex environment-pathogen-host interactions. Results suggest that proximal environmental influences and host population dynamics, together with distal, longer-term climatic variability could have important direct and indirect consequences for future enteric disease risk. Additional understanding of the concerted influence of these factors on disease patterns may improve assessment and prediction of enteric disease burden in temperate, developed countries.

Parasite zoonoses and wildlife: emerging issues

The role of wildlife as important sources, reservoirs and amplifiers of emerging human and domestic livestock pathogens, in addition to well recognized zoonoses of public health significance, has gained considerable attention in recent years. However, there has been little attention given to the transmission and impacts of pathogens of human origin, particularly protozoan, helminth and arthropod parasites, on wildlife. Substantial advances in molecular technologies are greatly improving our ability to follow parasite flow among host species and populations and revealing valuable insights about the interactions between cycles of transmission. Here we present several case studies of parasite emergence, or risk of emergence, in wildlife, as a result of contact with humans or anthropogenic activities. For some of these parasites, there is growing evidence of the serious consequences of infection on wildlife survival, whereas for others, there is a paucity of information about their impact.

Variation in Giardia: implications for taxonomy and epidemiology

The taxonomy, life cycle patterns and zoonotic potential of Giardia infecting mammals and birds have been poorly understood and controversial for many years. The development of molecular tools for characterising isolates of Giardia directly from faeces or environmental samples has made an enormous contribution to resolving these issues. It is now clear that the G. duodenalis morphological group is a species complex comprising a series of what appear to be largely host-adapted species, and at least two zoonotic species for which humans are the major host, but which are also capable of infecting other mammals. It is proposed that this new information be reflected in the redesignation of several species of Giardia described previously. The molecular epidemiological tools that are now available need to be applied in different endemic foci of Giardia transmission, as well as in outbreak situations, in order to understand better the frequency of zoonotic transmission as well as to develop more effective approaches to controlling giardiasis.

The zoonotic significance and molecular epidemiology of Giardia and giardiasis

The taxonomy and molecular epidemiology of Giardia and Giardia infections are reviewed in the context of zoonotic and waterborne transmission. Evidence to support the zoonotic transmission of Giardia is very strong, but how frequent such transmission occurs and under what circumstances, have yet to be determined. Zoonotic origin for waterborne outbreaks of Giardia infection appears to be uncommon. Similarly, livestock are unlikely to be an important source of infection in humans. The greatest risk of zoonotic transmission appears to be from companion animals such as dogs and cats, although further studies are required in different endemic foci in order to determine the frequency of such transmission.

Cyst morphology and sequence analysis of the small subunit rDNA and ef1 alpha identifies a novel Giardia genotype in a quenda (Isoodon obesulus) from Western Australia

Sequence analysis of the small subunit ribosomal DNA (SSU-rDNA) and elongation factor 1 alpha (ef1 alpha) was performed on Giardia cysts isolated from faeces collected from a quenda (Isoodon obesulus) in the southwest of Western Australia. The SSU-rDNA and ef1 alpha were sequenced in their entirety and correspondingly aligned with the published sequence information of other known species and genotypes of Giardia. Phylogenetic analysis of the SSU-rDNA and ef1 alpha sequences identified the quenda isolate as a novel genotype of Giardia not previously reported. We believe that this quenda Giardia isolate constitutes a distinct species, which may be endemic within the Australian native fauna.

Prevalence of Giardiasis due to wastewater reuse for agriculture in the suburbs of Asmara City, Eritrea

A study was undertaken to assess the health impact of utilization of the raw domestic sewage for vegetable cultivation in the suburbs of the capital city of Asmara, Eritrea. Standard techniques were adopted for the analysis of the samples. Results showed heavy contamination of vegetables by faecal coliforms as well as with Giardia cysts. Stool samples of 75 farmers who were occupationally exposed revealed that 45% of them were harbouring giardia cysts. The dietary intake of raw salads (lettuce, cabbage) grown on the raw sewage appear to be a causative factor of Giardiasis in the farming community as well as in the town of Tsadachristian located on the suburbs of the capital city of Asmara. The hospital data of the affected town is compared with other towns of Eritrea. The result indicates agriculture reuse of untreated wastewater is a major cause for the increase in Giardasis.

Bacterial removal from inexpensive portable water treatment systems for travelers

BACKGROUND

There are many personal portable water treatment systems for travelers on the market, including chemical agents, iodine resin purifiers and filters. However, information on the real efficacy of these systems in the field is often lacking. We have therefore estimated the capabilities of several inexpensive personal portable water treatment systems for travelers to remove bacteria in various situations of water quality, using stressed indigenous strains of bacteria.

METHODS

Four chemical agents (Drinkwell chlorine, Hydroclonazone, Aquatabs, 2% iodine in ethanol), two iodine resin purifiers (the straw PentaPure Outdoor M1-E, the PentaPure Traveler purifying and filtration system) and four filters (the flexible bottle Pres2Pure, the hand-pump filters Mini Ceramic, First Need Deluxe and WalkAbout) were evaluated in triplicate using both turbid and clear water at 25 degrees C. Bacteria were counted by conventional culturing techniques, colorimetric and fluorescent assays of coliforms and Escherichia coli enzyme activities (Colilert)/Quantitray method), and viable but not culturable bacteria were assessed quantitatively by 5-cyano-2,3-dilotyl-tetrazolium staining.

RESULTS

The best systems were the three hand-pump filters, Mini Ceramic, First Need Deluxe, and WalkAbout. All had a submicron filtration element that completely removed 3 log (99.9%) or more of viable bacteria, and no coliforms or E. coli were detected in the effluent. The PentaPure Traveler removed more than 99.3% of the viable bacteria. The only chemical agents that gave a bacterial inactivation of over 2 log in clear water were the Drinkwell chlorine, the Aquatabs, and the 2% iodine in ethanol. The three other devices, Hydroclonazone, Outdoor M1-E, and Pres2Pure, performed poorly, as coliforms and E. coli were detected in the treated water by the Colilert method. The chemical agents and the iodine resin straw performed poorly on raw river water; coliforms and E. coli were detected in the treated water.

CONCLUSIONS

These data demonstrate the differences between the systems tested. The effectiveness of other devices on the market should also be tested, so as to help travelers and hikers select the most appropriate portable water treatment system.