Molecular characterization of Cryptosporidium isolates obtained from human immunodeficiency virus-infected individuals living in Switzerland, Kenya, and the United States

A meta-analysis of Cryptosporidium species in humans from southern Africa (2000-2020)

Abstract

The epidemiology of cryptosporidiosis in southern Africa is largely unknown. The disease is associated with diarrhea and nutritional deficiencies, leading to severe morbidity and mortality among immune-compromised patients. This study aimed to assess the pooled prevalence of Cryptosporidium spp. infection among immune-compromised humans in southern Africa over the past 20 years. Reports of Cryptosporidium spp. infection in humans published between 2000 and 2020 using Google Scholar, PubMed, Ovid Medline, African Journal Online (AJOL), and Web of Science literature databases were obtained. Inclusion criteria of sorted articles for Cryptosporidium spp. infection were standardized using preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist. A total of 22 eligible studies were sorted for meta-analysis. Overall prevalence of Cryptosporidium spp. infection in southern African countries with reports was 16.8% (95% CI 9.7-25.3). Sub-group analysis showed a pooled prevalence of 25.2, 20.5, and 17.9% among HIV/AIDS patients, children, and diarrhoeic individuals, respectively. Pooled prevalence was highest in South Africa and lowest in Zimbabwe across examined individuals. The pooled prevalence of Cryptosporidium spp. infections in diarrhoeic patients was highest in individuals from Botswana (17.6%) which is significantly different (Χ ² = 9.337; P = 0.002) from South Africans (12.7%). South African individuals with HIV/AIDS showed the highest pooled prevalence of Cryptosporidium infections than other countries. The high prevalence of Cryptosporidium spp. infections among immune-compromised patients in southern Africa showed that the pathogen is of significant importance in this region. Continuous studies on the genetic characterization of Cryptosporidium spp. isolates and associated risk factors are needed across southern Africa to identify the predominant subtypes in humans.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s12639-021-01436-4.

Cryptosporidiosis and Giardiasis in Buffaloes (Bubalus bubalis)

Cryptosporidium spp. and Giardia duodenalis infect the gastrointestinal tracts of animals and humans. Both parasite groups are distributed worldwide and cause significant economic losses in animal productivity. Infected hosts presenting with and without clinical manifestations can eliminate infective forms of these protozoa, which are particularly important to One Health. Compared to the published research on cattle, relatively few studies have examined the epidemiology of cryptosporidiosis and giardiasis in buffaloes. This short review describes the global occurrence of Cryptosporidium spp. and G. duodenalis in buffaloes, including the molecular techniques employed for the identification of species/assemblages and genotypes of these protozoa. Genetic analyses of isolates of G. duodenalis and Cryptosporidium spp. from various sources (environmental, animal, and human) have been performed to investigate their epidemiology. In buffaloes, the species Cryptosporidium parvum, Cryptosporidium ryanae, Cryptosporidium bovis, and Cryptosporidium suis-like have been characterized, as well as assemblages A and E of G. duodenalis. We demonstrate that buffaloes can be infected by species of Cryptosporidium spp. and G. duodenalis assemblages with zoonotic potential. Epidemiological studies that utilize molecular biology techniques represent an important resource for efforts to control and prevent the spread of these protozoans.

Cryptosporidium Infections in Africa-How Important Is Zoonotic Transmission? A Review of the Evidence

Cryptosporidium, a protozoan parasite in the phylum Apicomplexa, is the etiological agent of cryptosporidiosis, an intestinal infection characterized by profuse watery diarrhea. Over 30 species of Cryptosporidium are recognized, some host specific whereas others infect a broader host range. Cryptosporidium hominis and Cryptosporidium parvum are the species most commonly associated with human infection; C. hominis is largely associated only with human infections, but C. parvum is also associated with infection in animals, especially young ruminants. In some regions, cryptosporidiosis is a serious veterinary problem, particularly for calves, and lambs. Many outbreaks of human cryptosporidiosis have been associated with zoonotic transmission following contact with infected animals. In Africa, where cryptosporidiosis is a major contributor to pediatric morbidity and mortality, evidence suggests transmission is principally anthroponotic. Given the frequent close contact between humans and animals in Africa, the apparent predominance of human-to-human transmission is both interesting and puzzling. In this article, after a brief "text book" introduction to the parasite, we consider in separate sections the different aspects of relevance to Cryptosporidium transmission in African countries, describing different aspects of the various species and subtypes in human and animal infections, considering livestock management practices in different African countries, and looking for any characteristic "hot spots" where zoonotic transmission has apparently occurred. Studies where transmission networks have been investigated are particularly relevant. Finally, in a separate section, we try to gather these different strands of evidence together in order to assess the reasons behind the apparent predominance of anthroponotic transmission in Africa. Reviewing the available evidence provides an opportunity to re-think transmission pathways, not only in Africa but also elsewhere, and also to pose questions. Does the predominance of human-to-human transmission in Africa reflect a relative absence of zoonotic C. parvum in African livestock? Are Africans less susceptible to zoonotic Cryptosporidium infection, perhaps resulting from early immunostimulation by C. hominis or due to inherent genetic traits? Is the African environment-in all its variety-simply more detrimental to oocyst survival? Will the so-called hypertransmissible subtypes, currently relatively rare in Africa, be introduced from Europe or elsewhere, and, if so, will they fade out or establish and spread? Our intention with this manuscript is not only to summarize and consolidate diverse data, thereby providing an overview of data gaps, but also to provide food for thought regarding transmission of a parasite that continues to have a considerable impact on both human and animal health.

Prevalence of Giardia and Cryptosporidium in young livestock and dogs in Magude District of Maputo Province, Mozambique

BACKGROUND

Giardia and Cryptosporidium species are significant zoonotic parasites of humans and domesticated animals.

OBJECTIVES

The study aimed to determine the prevalence of Giardia and Cryptosporidium in livestock and dogs of the Magude District.

METHOD

The flotation technique (Willis), modified Ziehl-Neelsen (mZN) and direct and indirect immunofluorescence (DIF and IIF) techniques were applied to determine the prevalence of Giardia and Cryptosporidium species in faecal samples of dog pups (156), goat kids (60) and calves (480) from the Magude District of Mozambique from February to September 2015.

RESULTS

Using Willis, IIF and DIF, the prevalence of Giardia in calves was 0%, 8.1%, and 6.0%; in dogs 0.6%, 8.3% and 5.7% and for goats 0% and 13.3% (IIF was not performed), respectively. The prevalence of Cryptosporidium in calves using Willis, mZN, IIF and DIF was 0%, 3.8%, 4.7% and 0.4% and in dogs 0%, 0.6%, 6.4% and 0.6%, respectively. The parasite was not detected in goats.

CONCLUSION

Results from the present study showed that IIF performed better diagnosis of Giardia and Cryptosporidium, and that the mZN can be used as an alternative for Cryptosporidium because of the high cost of IIF. There is a need for identification of genotypes or subtypes of these parasites through application of molecular techniques in order to determine their zoonotic potential, and we advocate a 'one health' approach in the control and prevention of these parasites.

Molecular investigation of Cryptosporidium in farmed chickens in Hubei Province, China, identifies 'zoonotic' subtypes of C. meleagridis

BACKGROUND

Cryptosporidium is a key genus of parasitic protists that infect humans and other vertebrates (mammals and birds). Birds are typically infected with C. avium, C. baileyi, C. galli and/or C. meleagridis, the latter of which is recognised as being zoonotic. Stimulated by the previous finding of C. meleagridis subtypes IIIbA21G1R1, IIIbA22G1R1 and IIIbA26G1R1 in diarrhoeic children in Wuhan city and environs in Hubei Province, China, we performed a molecular epidemiological survey to explore whether these or similar subtypes might occur in farmed chickens in this province.

METHODS

PCR-coupled sequencing analyses of regions in the small subunit (SSU) of the nuclear ribosomal RNA and 60 kDa glycoprotein (gp60) genes were utilised to characterise Cryptosporidium in faecal samples from chickens (n = 471) from 14 farms from six distinct regions in Hubei Province.

RESULTS

Cryptosporidium baileyi (33/471; 7.0%) and C. meleagridis (15/471; 3.2%) were identified in chickens on eight farms in five of the six distinct geographical regions. No significant age-associated difference in the prevalence of C. baileyi was evident, whereas the prevalence of C. meleagridis was significantly higher in younger (≤ 4 months) than in older chickens (> 4 months). For C. meleagridis, two subtype families, IIIb and IIIe, were defined; some of the subtypes (i.e. IIIbA26G1R1b and IIIbA22G1R1c) characterised here matched those identified previously in diarrhoeic children in Wuhan.

CONCLUSIONS

This is the first molecular study reporting the genetic identity and prevalence of C. baileyi and C. meleagridis in chickens in Hubei. The findings suggest that C. meleagridis subtypes IIIbA26G1R1b and IIIbA22G1R1c are cross-transmissible between chickens and humans, raising awareness about the significance of birds as potential reservoirs of zoonotic variants of Cryptosporidium. Future studies might focus on investigating the prevalence of 'zoonotic' subtypes of Cryptosporidium meleagridis in various species of wild and domesticated birds, and on comparing them with those found in humans in China and other countries.

Practical Guidance for Clinical Microbiology Laboratories: Laboratory Diagnosis of Parasites from the Gastrointestinal Tract

This Practical Guidance for Clinical Microbiology document on the laboratory diagnosis of parasites from the gastrointestinal tract provides practical information for the recovery and identification of relevant human parasites. The document is based on a comprehensive literature review and expert consensus on relevant diagnostic methods. However, it does not include didactic information on human parasite life cycles, organism morphology, clinical disease, pathogenesis, treatment, or epidemiology and prevention. As greater emphasis is placed on neglected tropical diseases, it becomes highly probable that patients with gastrointestinal parasitic infections will become more widely recognized in areas where parasites are endemic and not endemic. Generally, these methods are nonautomated and require extensive bench experience for accurate performance and interpretation.

Prevalence of Cryptosporidium species isolated from HIV/AIDS patients in southwest of Iran

This study aimed to determine the prevalence and species of Cryptosporidium among HIV/AIDS patients in southwest of Iran. Two hundred fifty faecal samples from HIV patients were examined for the presence of Cryptosporidium oocysts using a conventional coproscopic approach. Such oocysts were detected in 18 (7.2%) out of 250 faecal samples. Genomic DNAs from 250 samples were then subjected to a nested-PCR-RFLP technique targeting different loci of 18S rRNA gene for species identification. Out of 250 samples, 27 (10.8%) were positive for different Cryptosporidium spp; Restriction patterns resulting from the digestion of the nested amplicon with restriction endonucleases VspI and SspI showed that C. parvum (70.38%) was the most prevalent species, followed by C. hominis (25.92%) and C. meleagridis (3.7%), respectively. The mean CD4+ T-cell count was 215 cells/μL. There was a strong association between cryptosporidiosis and CD4+ T-cell count (P = 0.000) with the highest prevalence recorded among patients with CD4+ T-cell count < 200 cells/μL. This confirms that there is a low opportunity for this parasite to get established as the patients CD4+ T-cell count increases. Also HIV infection increased the risk of having Cryptosporidium. Our epidemiological findings are useful for any preventive intervention to control disease diffusion.

Prevalence, transmission, and host specificity of Cryptosporidium spp. in various animal groups from two French zoos

Cryptosporidium represents a major cause of gastrointestinal illness in humans and animals including domestic, wild, and in captivity animals, and more than 30 validated species of Cryptosporidium are recognized as infectious to different hosts such as mammals, birds, reptiles, amphibians, and fish. Therefore, numerous investigations have been conducted worldwide in order to shed light on the epidemiology of this parasite and to explore its potential reservoirs. Few surveys, targeting humans and animals have been carried out regarding the epidemiology of Cryptosporidium spp. in France and no data are available about the circulation of this parasite in French zoological gardens. Herein, we determined the prevalence of Cryptosporidium in animals housed in two French zoos. A total of 307 fecal samples belonging to 161 species were screened by nested PCR. Overall, Cryptosporidium DNA was detected in 1.9% of the 161 species and 1% of the total number of fecal samples tested. Additionally, three Cryptosporidium species were identified: C. galli, C. andersoni, and C. tyzzeri. To our knowledge, this is the first molecular study focused on Cryptosporidium infection in captivity animals in France. This study is of interest considering the exposure of a large number of humans and animals to this waterborne protozoan, found ubiquitously in the environment.

Cryptosporidium and Giardia in Africa: current and future challenges

Cryptosporidium and Giardia are important causes of diarrhoeal illness. Adequate knowledge of the molecular diversity and geographical distribution of these parasites and the environmental and climatic variables that influence their prevalence is important for effective control of infection in at-risk populations, yet relatively little is known about the epidemiology of these parasites in Africa. Cryptosporidium is associated with moderate to severe diarrhoea and increased mortality in African countries and both parasites negatively affect child growth and development. Malnutrition and HIV status are also important contributors to the prevalence of Cryptosporidium and Giardia in African countries. Molecular typing of both parasites in humans, domestic animals and wildlife to date indicates a complex picture of both anthroponotic, zoonotic and spill-back transmission cycles that requires further investigation. For Cryptosporidium, the only available drug (nitazoxanide) is ineffective in HIV and malnourished individuals and therefore more effective drugs are a high priority. Several classes of drugs with good efficacy exist for Giardia, but dosing regimens are suboptimal and emerging resistance threatens clinical utility. Climate change and population growth are also predicted to increase both malnutrition and the prevalence of these parasites in water sources. Dedicated and co-ordinated commitments from African governments involving "One Health" initiatives with multidisciplinary teams of veterinarians, medical workers, relevant government authorities, and public health specialists working together are essential to control and prevent the burden of disease caused by these parasites.

Cryptosporidium and cryptosporidiosis: the African perspective

The present overview discusses the findings of cryptosporidiosis research conducted in Africa and highlights the currently available information on Cryptosporidium epidemiology, genetic diversity, and distribution on the African continent, particularly among vulnerable populations, including children. It also emphasizes the burden of cryptosporidiosis, which is underestimated due to the presence of many silent asymptomatic carriers.Cryptosporidiosis is recognized as one of the leading causes of childhood diarrhea in African countries. It has dramatic adverse effects on child growth and development and causes increased mortality on a continent where HIV, poverty, and lack of sanitation and infrastructure increase the risk of cryptosporidial waterborne infection.

Molecular characterization of human Cryptosporidium spp. isolates after an unusual increase in late summer 2012

Background

During the late summer 2012, a number of medical microbiological laboratories (MMLs) reported an unusual increase in cases of cryptosporidiosis, a gastrointestinal infection caused by the protozoan parasites Cryptosporidium spp. Prompted by this signal, the National Institute of Public Health and the Environment (RIVM) started an epidemiological investigation into possible causes. Simultaneously, samples diagnosed at MMLs were sent to RIVM for genotyping, aiming to further identify the possible source of the increase.

Methods

Genotyping was performed by sequencing a fragment of the GP60 gene. Additional genotyping was performed on a subset of samples using six microsatellite markers. Population genetic analysis was performed using BEAST.

Results

The majority of the samples were typed as C. hominis, and a single GP60 genotype (IbA10G2) largely predominated. Genotyping microsatellite markers further supported the circulation of a single genetic type. Population genetic analysis with genotypes found in previous years is inconsistent with a decrease in effective population size.

Conclusions

The conclusion of this finding is that the rise reflects more an overall increase and not a common source outbreak.

Molecular characterization and first report of Cryptosporidium genotypes in human population in the Slovak Republic

In our study, we examined 91 fecal samples from five different groups of people containing HIV patients, hemodialysis patients, kidney transplant recipients, immunocompetent humans without clinical signs, and humans with suspected cryptosporidiosis. The purpose of our study was to determine species and genotype composition of representatives of Cryptosporidium spp. using PCR analysis of small subunit ribosomal RNA gene and 60-kDa glycoprotein gene and examine their phylogenetic relationship. In HIV-positive/AIDS-infected group of patients and in hemodialysis patients, no presence of Cryptosporidium species was detected. In two kidney transplant recipients, we detected species/genotypes Cryptosporidium parvum IIaA13G1T1R1 (KT355488) and Cryptosporidium hominis IaA11G2R8 (KT355489) and in two immunocompetent patients with clinical symptoms, we identified Cryptosporidium muris and C. hominis IbA10G2T1 (KT355490). In the group of healthy immunocompetent individuals without clinical signs, we identified species/genotype C. hominis IbA11G2 (KT355491) in one sample.

A perspective on Cryptosporidium and Giardia, with an emphasis on bovines and recent epidemiological findings

Cryptosporidium and Giardia are two common aetiological agents of infectious enteritis in humans and animals worldwide. These parasitic protists are usually transmitted by the faecal-oral route, following the ingestion of infective stages (oocysts or cysts). An essential component of the control of these parasitic infections, from a public health perspective, is an understanding of the sources and routes of transmission in different geographical regions. Bovines are considered potential sources of infection for humans, because species and genotypes of Cryptosporidium and Giardia infecting humans have also been isolated from cattle in molecular parasitological studies. However, species and genotypes of Cryptosporidium and Giardia of bovids, and the extent of zoonotic transmission in different geographical regions in the world, are still relatively poorly understood. The purpose of this article is to (1) provide a brief background on Cryptosporidium and Giardia, (2) review some key aspects of the molecular epidemiology of cryptosporidiosis and giardiasis in animals, with an emphasis on bovines, (3) summarize research of Cryptosporidium and Giardia from cattle and water buffaloes in parts of Australasia and Sri Lanka, considering public health aspects and (4) provide a perspective on future avenues of study. Recent studies reinforce that bovines harbour Cryptosporidium and Giardia that likely pose a human health risk and highlight the need for future investigations of the biology, population genetics and transmission dynamics of Cryptosporidium and Giardia in cattle, water buffaloes and other ruminants in different geographical regions, the fate and transport of infective stages following their release into the environment, as well as for improved strategies for the control and prevention of cryptosporidiosis and giardiasis, guided by molecular epidemiological studies.

Molecular characterisation of Cryptosporidium (Apicomplexa) in children and cattle in Romania

To investigate the transmission of species of Cryptosporidium Tyzzer, 1907 in Timis County, Romania, 48 isolates of Cryptosporidium coccidia from 11 children, 29 calves and eight pigs were characterised by molecular analysis of two loci (SSU rRNA and 60-kDa glycoprotein gene). Overall, 22 isolates were amplified and sequence analyses revealed that all isolates were Cryptosporidium parvum Tyzzer, 1912. Two subtype families were identified, IIa and IId. Subtype IIdA22G1 (n = 4) was the single C. parvum subtype found in children. Subtypes found in calves included IIdA27G1 (n = 8), a novel subtype, IIdA25G1 (n = 5), IIdA22G1 (n = 2), IIdA21G1a (n = 1), and IIaA16G1R1 (n = 1). Subtype IIdA26G1 was found in a pig. These results were significantly different from previous Romanian reports, as the five subtypes of family IId identified in this study were never identified previously in this country. Thus, cattle may be a source of Cryptosporidium infections for humans and the transmission dynamics of C. parvum in Romania is more complex than previously believed.

Prevalence and molecular epidemiology of Cryptosporidium parvum in dairy calves in Punjab (India)

Cryptosporidium parvum is an important zoonotic protozoan parasite that infects the gastrointestinal tract of vertebrate animals and man. The current study was contemplated for molecular detection of Cryptosporidium species prevalent in dairy calves in Punjab, India. A total of 302 faecal samples were screened by modified Ziehl-Neelsen staining technique for the detection of Cryptosporidium oocysts. Molecular characterisation was done using PCR followed by sequence analysis of the representative isolates. An overall prevalence of 26.15 % was obtained with the highest prevalence obtained in 0-30 day old calves in both diarrhoeic and non-diarrhoeic animals. PCR analysis revealed the expected bands at 1,325 and 835 bp from all the isolates for primary and secondary/nested PCR respectively. Ten representative samples were sequenced in both directions. Phylogenetic analysis revealed the presence of C. parvum in all the samples. The high rate of calves infected with C. parvum can act as a great source of zoonotic cryptosporidiosis which indicates a potential risk of zoonotic transmission from animal to human beings in Punjab (India).

Molecular and parasitological study of cryptosporidium isolates from cattle in ilam, west of iran

BACKGROUND

Cryptosporidiosis is one of the most important parasitic infections in human and animals. This study was designed for survey on the prevalence of Cryptosporidium infection in farms of Ilam, west of Iran, using parasitology method and genotyping by Nested PCR-RFLP.

METHODS

Fecal samples of 217 cattle were collected fresh and directly from the rectum of cattle. All of the samples were examined by microscopic observation after staining with modified Ziehl-Neelsen (MZN). Genomic DNA extracted by using EURx DNA kit. A Nested PCR-RFLP protocol amplifying 825 bp fragment of 18s rRNA gene conducted to differentiate species and genotyping of the isolates using SspI and VspI as restriction enzymes.

RESULTS

The prevalence of Cryptosporidium infection in cattle using both methods is 3.68%. Most of the positive cattle were calves under six months. Species diagnosis carried out by digesting the secondary PCR product with SspI that C. parvum generated 3 visible bands of 448, 247 and 106 bp and digested by VspI restriction enzyme generated 2 visible bands of 628 and 104bp. In this investigation all of the positive samples were Cryptosporidium parvum.

CONCLUSION

C. parvum (bovine genotype) detected in all positive cattle samples in Ilam, west of Iran. The results of the present study can help for public health care systems to prevention and management of cryptosporidiosis in cattle and the assessment of cattle cryptosporidiosis as a reservoir for the human infection.

Cryptosporidiosis in HIV/AIDS patients in Kenya: clinical features, epidemiology, molecular characterization and antibody responses

We investigated the epidemiological and clinical features of cryptosporidiosis, the molecular characteristics of infecting species and serum antibody responses to three Cryptosporidium-specific antigens in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) patients in Kenya. Cryptosporidium was the most prevalent enteric pathogen and was identified in 56 of 164 (34%) of HIV/AIDS patients, including 25 of 70 (36%) with diarrhea and 31 of 94 (33%) without diarrhea. Diarrhea in patients exclusively infected with Cryptosporidium was significantly associated with the number of children per household, contact with animals, and water treatment. Cryptosporidium hominis was the most prevalent species and the most prevalent subtype family was Ib. Patients without diarrhea had significantly higher serum IgG levels to Chgp15, Chgp40 and Cp23, and higher fecal IgA levels to Chgp15 and Chgp40 than those with diarrhea suggesting that antibody responses to these antigens may be associated with protection from diarrhea and supporting further investigation of these antigens as vaccine candidates.

High applicability of a novel method for gp60-based subtyping of Cryptosporidium meleagridis

Cryptosporidium meleagridis is a common cause of cryptosporidiosis in avian hosts and the third most common species involved in human cryptosporidiosis. Sequencing of the highly polymorphic 60-kDa glycoprotein (gp60) gene is a frequently used tool for investigation of the genetic diversity and transmission dynamics of Cryptosporidium. However, few studies have included gp60 sequencing of C. meleagridis. One explanation may be that the gp60 primers currently in use are based on Cryptosporidium hominis and Cryptosporidium parvum sequence data, potentially limiting successful amplification of the C. meleagridis gp60 gene. We therefore aimed to design primers for better gp60 subtyping of C. meleagridis. Initially, ∼1,440 bp of the gp60 locus of seven C. meleagridis isolates were amplified using primers flanking the open reading frame. The obtained sequence data (∼1,250 bp) were used to design primers for a nested PCR targeting C. meleagridis. Twenty isolates (16 from human and 4 from poultry) previously identified as C. meleagridis by analysis of small subunit (SSU) rRNA genes were investigated. Amplicons of the expected size (∼900 bp) were obtained from all 20 isolates. The subsequent sequence analysis identified 3 subtype families and 10 different subtypes. The most common subtype family, IIIb, was identified in 12 isolates, represented by 6 subtypes, 4 new and 2 previously reported. Subtype family IIIe was found in 3 isolates represented by 3 novel, distinct subtypes. Finally, IIIgA31G3R1 was found in 1 human isolate and 4 poultry isolates, all originating from a previously reported C. meleagridis outbreak at a Swedish organic farm.

Cryptosporidium pathogenicity and virulence

Cryptosporidium is a protozoan parasite of medical and veterinary importance that causes gastroenteritis in a variety of vertebrate hosts. Several studies have reported different degrees of pathogenicity and virulence among Cryptosporidium species and isolates of the same species as well as evidence of variation in host susceptibility to infection. The identification and validation of Cryptosporidium virulence factors have been hindered by the renowned difficulties pertaining to the in vitro culture and genetic manipulation of this parasite. Nevertheless, substantial progress has been made in identifying putative virulence factors for Cryptosporidium. This progress has been accelerated since the publication of the Cryptosporidium parvum and C. hominis genomes, with the characterization of over 25 putative virulence factors identified by using a variety of immunological and molecular techniques and which are proposed to be involved in aspects of host-pathogen interactions from adhesion and locomotion to invasion and proliferation. Progress has also been made in the contribution of host factors that are associated with variations in both the severity and risk of infection. Here we provide a review comprised of the current state of knowledge on Cryptosporidium infectivity, pathogenesis, and transmissibility in light of our contemporary understanding of microbial virulence.

Immunity and the emergence of virulent pathogens

The emergence/re-emergence of infectious diseases has been one of the major concerns for human and wildlife health. In spite of the medical and veterinary progresses as to prevent and cure infectious diseases, during the last decades we have witnessed the emergence/re-emergence of virulent pathogens that pose a threat to humans and wildlife. Many factors that might drive the emergence of these novel pathogens have been identified and several reviews have been published on this topic in the last years. Among the most cited and recognized drivers of pathogen emergence are climate change, habitat destruction, increased contact with reservoirs, etc. These factors mostly refer to environmental determinants of emergence. However, the immune system of the host is probably the most important environmental trait parasites have to cope with. Here, we wish to discuss how immune-mediated selection might affect the emergence/re-emergence of infectious diseases and drive the evolution of disease severity. Vaccination, natural (age-associated) and acquired immunodeficiencies, organ transplantation, environmental contamination with chemicals that disrupt immune functions form populations of hosts that might exert specific immune-mediated selection on a range of pathogens, shaping their virulence and evolution, and favoring their spread to other populations of hosts.

Prevalence of cryptosporidiosis in dairy cattle, cattle-keeping families, their non-cattle-keeping neighbours and HIV-positive individuals in Dagoretti Division, Nairobi, Kenya

This paper reports a study estimating the prevalence of cryptosporidiosis, an emerging zoonosis, in people and cattle in Dagoretti, Nairobi. A repeated cross-sectional survey was carried out among randomly selected cattle keepers in Dagoretti, their dairy cattle and their non-cattle-keeping neighbours in the dry and wet seasons of 2006. A survey was also carried out among a group of people living with human immunodeficiency virus (HIV). Faecal samples were examined for Cryptosporidium oocysts using the modified Ziehl-Neelsen method; 16 % of the samples were also examined using immunofluorescence antibody (IFA) technique. Quality control consisted of blind reviews of slides, examining split samples and confirming slide results with IFA. We found that members of dairy households had a dry season cryptosporidiosis prevalence of 4 % and wet season prevalence of 0.3 %, and non-dairy households, a prevalence of 5 and 0 %, respectively. The cattle dry season prevalence was 15 %, and the wet season prevalence, 11 %. The prevalence in people living with HIV was 5 %. The laboratory quality control system showed some inconsistency within and between different tests, indicating challenges in obtaining consistent results under difficult field and working conditions. In conclusion, this is the first reported study to simultaneously survey livestock, livestock keepers and their neighbours for cryptosporidiosis. We failed to find evidence that zoonotic cryptosporidiosis is important overall in this community. This study also draws attention to the importance of quality control and its reporting in surveys in developing countries.

Molecular analysis of 18S rRNA gene of Cryptosporidium parasites from patients living in Iran, Malawi, Nigeria and Vietnam

Cryptosporidium species are one of the most common causes of gastrointestinal infection in humans around the world. This study has aimed to investigate the hyper variable region of the 18S rRNA gene in Cryptosporidium for exact parasite identification. DNA was extracted from 26 fecal samples from which initially Cryptosporidium oocysts were identified by Ziehl-Neelsen acid-fast , Auramine phenol and ELISA techniques. Nested PCR, targeting the most polymorphic region of the 18S rRNA gene and genotyping was performed by restriction endonuclease digestion of the PCR product followed by nucleotide sequencing and phylogenic analysis. Among 26 isolates analyzed, three species of Cryptosporidium were identified; 38.5% of the isolates were C. hominis while 53.8% of the isolates were C. parvum and 7.7% of the isolates were C. meleagridis, which the last two species have the potentially zoonotic transmission. The only 11T subtype of C. hominis was demonstrated. These strains clustered distinctly into either human or animal origin regardless of the geographical origin, age, or immunity status of the patients. In summary, this work is the first report of C. meleagridis infecting human in Iran. Moreover, it suggested that multi-locus study of Cryptosporidium species in developing countries would be necessary to determine the extent of transmission of cryptosporidiosis in the populations.

Cryptosporidium meleagridis: infectivity in healthy adult volunteers

Most Cryptosporidium infections in humans are caused by C. parvum or C. hominis. However, genotyping techniques have identified infections caused by unusual Cryptosporidium species. Cryptosporidium meleagridis has been identified in ≤ 1% of persons with diarrhea, although prevalence is higher in developing nations. We examined the infectivity of C. meleagridis in healthy adults. Five volunteers were challenged with 10(5) C. meleagridis oocysts and monitored six weeks for fecal oocysts and clinical manifestations. Four volunteers had diarrhea; three had detectable fecal oocysts; and one infected volunteer remained asymptomatic. Fecal DNA from two volunteers was amplified by using a polymerase chain reaction specific for the Cryptosporidium small subunit ribosomal RNA gene. Nucleotide sequence of these amplicons was diagnostic for C. meleagridis. All infections were self-limited; oocysts were cleared within ≤ 12 days of challenge. These studies establish that healthy adults can be infected and become ill from ingestion of C. meleagridis oocysts.

Evolution of Cryptosporidium in vitro culture

This overview discusses findings from culturing Cryptosporidium spp. in cell and axenic cultures as well as factors limiting the development of this parasite in cultivation systems during recent years. A systematic review is undertaken of findings regarding the life cycle of the parasite, taking into account physiological, biochemical and genetic aspects, in the hope that this attempt will facilitate future approaches to research and developments in the understanding of Cryptosporidium biology.

First genetic classification of Cryptosporidium and Giardia from HIV/AIDS patients in Malaysia

Given the HIV epidemic in Malaysia, genetic information on opportunistic pathogens, such as Cryptosporidium and Giardia, in HIV/AIDS patients is pivotal to enhance our understanding of epidemiology, patient care, management and disease surveillance. In the present study, 122 faecal samples from HIV/AIDS patients were examined for the presence of Cryptosporidium oocysts and Giardia cysts using a conventional coproscopic approach. Such oocysts and cysts were detected in 22.1% and 5.7% of the 122 faecal samples, respectively. Genomic DNAs from selected samples were tested in a nested-PCR, targeting regions of the small subunit (SSU) of nuclear ribosomal RNA and the 60kDa glycoprotein (gp60) genes (for Cryptosporidium), and the triose-phosphate isomerase (tpi) gene (for Giardia), followed by direct sequencing. The sequencing of amplicons derived from SSU revealed that Cryptosporidium parvum was the most frequently detected species (64% of 25 samples tested), followed by C. hominis (24%), C. meleagridis (8%) and C. felis (4%). Sequencing of a region of gp60 identified C. parvum subgenotype IIdA15G2R1 and C. hominis subgenotypes IaA14R1, IbA10G2R2, IdA15R2, IeA11G2T3R1 and IfA11G1R2. Sequencing of amplicons derived from tpi revealed G. duodenalis assemblage A, which is of zoonotic importance. This is the first report of C. hominis, C. meleagridis and C. felis from Malaysian HIV/AIDS patients. Future work should focus on an extensive analysis of Cryptosporidium and Giardia in such patients as well as in domestic and wild animals, in order to improve the understanding of transmission patterns and dynamics in Malaysia. It would also be particularly interesting to establish the relationship among clinical manifestation, CD4 cell counts and genotypes/subgenotypes of Cryptosporidium and Giardia in HIV/AIDS patients. Such insights would assist in a better management of clinical disease in immuno-deficient patients as well as improved preventive and control strategies.

Genotyping of Cryptosporidium spp. in clinical samples: PCR-RFLP analysis of the TRAP-C2 gene

AIM

The aim of the present study was to determine the species and genotypes of Cryptosporidium spp. among children with diarrhea by PCR-RFLP using the TRAP-C2 gene.

BACKGROUND

Cryptosporidium is a globally distributed protozoan parasite and one of the most common causes of infection and diarrhea in humans.

PATIENTS AND METHODS

Four hundred and sixty nine stool samples were collected from children less than 12 years with diarrhea who had been referred to Pediatrics Medical Centers in Gazvin provinces. The presence of Cryptosporidium oocysts was determined by Ziehl-Neelsen acid fast staining, then, genomic DNA was extracted from positive samples and nested PCR-RFLP was performed to amplify the TRAP-C2 gene.

RESULTS

The overall prevalence of Cryptosporidium infection in children was 2.5 %. Results of nested PCR amplification showed that of 12 positive children samples, 10 (83.3%) were belonged to C. parvum, followed by C. hominis in 1 (8.3%) and mixed infection in 1 isolate (8.3%).

CONCLUSION

This study showed that Cryptosporidium parvum (the zoonotic genotypes) is more prevalent than other Cryptosporidium species in children from this area. This suggests that zoonotic transmission is the main mode of transmission of Cryptosporidium infection in Iran.

Evaluation of multiplex tandem real-time PCR for detection of Cryptosporidium spp., Dientamoeba fragilis, Entamoeba histolytica, and Giardia intestinalis in clinical stool samples

The aim of this study was to describe the first development and evaluation of a multiplex tandem PCR (MT-PCR) assay for the detection and identification of 4 common pathogenic protozoan parasites, Cryptosporidium spp., Dientamoeba fragilis, Entamoeba histolytica, and Giardia intestinalis, from human clinical samples. A total of 472 fecal samples submitted to the Department of Microbiology at St. Vincent's Hospital were included in the study. The MT-PCR assay was compared to four real-time PCR (RT-PCR) assays and microscopy by a traditional modified iron hematoxylin stain. The MT-PCR detected 28 G. intestinalis, 26 D. fragilis, 11 E. histolytica, and 9 Cryptosporidium sp. isolates. Detection and identification of the fecal protozoa by MT-PCR demonstrated 100% correlation with the RT-PCR results, and compared to RT-PCR, MT-PCR exhibited 100% sensitivity and specificity, while traditional microscopy of stained fixed fecal smears exhibited sensitivities and specificities of 56% and 100% for Cryptosporidium spp., 38% and 99% for D. fragilis, 47% and 97% for E. histolytica, and 50% and 100% for G. intestinalis. No cross-reactivity was detected in 100 stool samples containing various other bacterial, viral, and protozoan species. The MT-PCR assay was able to provide rapid, sensitive, and specific simultaneous detection and identification of the four most important diarrhea-causing protozoan parasites that infect humans. This study also highlights the lack of sensitivity demonstrated by microscopy, and thus, molecular methods such as MT-PCR must be considered the diagnostic methods of choice for enteric protozoan parasites.

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.

Silent information regulator 2 proteins encoded by Cryptosporidium parasites

Screening in a database has revealed that Cryptosporidium hominis encodes a silent information regulator 2 (Sir2), a nicotinamide adenine dinucleotide (NAD)-dependent protein deacetylase. Cellular localization of the protein, ChSir2, was analyzed by the use of the social amoeba Dictyostelium discoideum as a model system. Fluorescent microscopic analysis showed that ChSir2 fused with green fluorescent protein was localized in the D. discoideum nucleus. D. discoideum expressing ChSir2 grew faster and reached higher cell density than did D. discoideum harboring a control vector. These results suggest that ChSir2 is a nucleus-localizing protein that plays an important role in the growth of C. hominis. We cloned and sequenced the genes for Sir2 orthologs encoded by three isolates of C. hominis, two isolates of Cryptosporidium parvum and one isolate of Cryptosporidium meleagridis. The orthologs conserve critical catalytic or NAD-binding residues but do not have similarity with human Sir2 proteins (SIRTs). Cryptosporidium Sir2 orthologs would therefore be attractive therapeutic targets. The Cryptosporidium orthologs were classified into four variants based on their nucleotide sequences. Each of the four variants produces its own unique restriction fragment length polymorphism pattern by digestion with TfiI.

Identification of a high diversity of Cryptosporidium species genotypes and subtypes in a pediatric population in Nigeria

A longitudinal study was conducted to determine the epidemiology of Cryptosporidium in 1,636 children in Nigeria. Oocyst prevalence ranged from 15.6% to 19.6% over one year. Cryptosporidium hominis (34), C. parvum (25), C. parvum/C. hominis (4), C. meleagridis (5), Cryptosporidium rabbit genotype (5), Cryptosporidium cervine genotype (3), and C. canis (1) were identified by polymerase chain reaction-restriction fragment length polymorphism analysis. Glycoprotein 60 subgenotyping showed that 28 amplifiable C. hominis isolates consisted of 12 subtypes that belonged to 5 subtype families (Ia, Ib, Id, Ie, and 1 novel subtype family, Ih) and 23 amplifiable C. parvum isolates consisted of 6 subtypes that belonged to 4 subtype families (IIa, IIc, Iii, and IIm). Three C. meleagridis isolates sub-genotyped by sequence analysis of the small subunit ribosomal RNA gene fragment were type 1. This study is the first one to genetically characterize Cryptosporidium species and subtypes in Nigeria and highlights the presence of a high Cryptosporidium diversity in this pediatric population.

Longitudinal multi-locus molecular characterisation of sporadic Australian human clinical cases of cryptosporidiosis from 2005 to 2008

Cryptosporidium is a gastrointestinal parasite that is recognised as a significant cause of non-viral diarrhea in both developing and industrialised countries. In the present study, a longitudinal analysis of 248 faecal specimens from Australian humans with gastrointestinal symptoms from 2005 to 2008 was conducted. Sequence analysis of the 18S rRNA gene locus and the 60kDa glycoprotein (gp60) gene locus revealed that 195 (78.6%) of the cases were due to infection with Cryptosporidium hominis, 49 (19.8%) with Cryptosporidium parvum and four (1.6%) with Cryptosporidium meleagridis. A total of eight gp60 subtype families were identified; five C. hominis subtype families (Ib, Id, Ie, If and Ig), and two C. parvum subtype families (IIa and IId). The Id subtype family was the most common C. hominis subtype family identified in 45.7% of isolates, followed by the Ig subtype family (30.3%) and the Ib subtype family (20%). The most common C. parvum subtype was IIaA18G3R1, identified in 65.3% of isolates. The more rare zoonotic IId A15G1 subtype was identified in one isolate. Statistical analysis showed that the Id subtype was associated with abdominal pain (p<0.05) and that in sporadic cryptosporidiosis, children aged 5 and below were 1.91 times and 1.88 times more likely to be infected with subtype Id (RR 1.91; 95% CI, 1.7-2.89; p<0.05) and Ig (RR 1.88; 95% CI, 1.10-3.24; p<0.05) compared to children aged 5 and above. A subset of isolates were also analysed at the variable CP47 and MSC6-7 gene loci. Findings from this study suggest that anthroponotic transmission of Cryptosporidium plays a major role in the epidemiology of cryptosporidiosis in Western Australian humans.

Clinical significance of enteric protozoa in the immunosuppressed human population

Globally, the number of immunosuppressed people increases each year, with the human immunodeficiency virus (HIV) pandemic continuing to spread unabated in many parts of the world. Immunosuppression may also occur in malnourished persons, patients undergoing chemotherapy for malignancy, and those receiving immunosuppressive therapy. Components of the immune system can be functionally or genetically abnormal as a result of acquired (e.g., caused by HIV infection, lymphoma, or high-dose steroids or other immunosuppressive medications) or congenital illnesses, with more than 120 congenital immunodeficiencies described to date that either affect humoral immunity or compromise T-cell function. All individuals affected by immunosuppression are at risk of infection by opportunistic parasites (such as the microsporidia) as well as those more commonly associated with gastrointestinal disease (such as Giardia). The outcome of infection by enteric protozoan parasites is dependent on absolute CD4(+) cell counts, with lower counts being associated with more severe disease, more atypical disease, and a greater risk of disseminated disease. This review summarizes our current state of knowledge on the significance of enteric parasitic protozoa as a cause of disease in immunosuppressed persons and also provides guidance on recent advances in diagnosis and therapy for the control of these important parasites.

Etiological agents of diarrhea in patients infected by the human immunodeficiency virus-1: a review

Despite the importance of understanding the epidemiology of agents responsible for infectious diarrhea in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) population, the number of articles about this subject is relatively few. The current article summarizes published data on bacterial, fungal, viral and parasitic enteropathogens in the HIV/AIDS seropositive subjects in different countries, regions and localities. In general, there is a great difference in the frequencies of etiological agents due to factors which include immune status, geographical location, climate and socioeconomic conditions. It is important to stress that a great prevalence of infection by emergent agents has been reported in the more advanced stages of AIDS. Therefore, to establish specific treatment depends directly on knowledge of these agents and risk factors associated to their distribution. Moreover, the colonization by potential pathogenic agents verified in these individuals is high thus implicating that they act as carriers. Finally, public health measures of control and prevention must take into consideration the regional previously identified enteropathogens, especially in areas where HIV prevalence is high.

Detection and differentiation of Cryptosporidium hominis and Cryptosporidium parvum by dual TaqMan assays

Rapid identification of the two major species of Cryptosporidium associated with human infections, Cryptosporidium hominis and Cryptosporidium parvum, is important for investigating outbreaks of cryptosporidiosis. This study reports the development and validation of a real-time PCR TaqMan procedure for detection of Cryptosporidium species and identification of C. hominis and C. parvum in stool specimens. This procedure comprised a generic TaqMan assay targeting the 18S rRNA for sensitive detection of Cryptosporidium species, as well as two other TaqMan assays for identification of C. hominis and C. parvum. The generic Cryptosporidium species assay can be duplexed with the C. parvum-specific assay. The generic Cryptosporidium species assay was able to detect ten Cryptosporidium species and did not cross-react with a panel of ten other protozoan parasites. The generic Cryptosporidium species assay could detect 1-10 oocysts in a 300 microl stool specimen, whilst each of the species-specific TaqMan assays had detection sensitivities that were approximately tenfold higher. The 18S rRNA assay was found to detect Cryptosporidium species in 49/55 DNA extracts from stool specimens containing either C. hominis or C. parvum. The C. hominis TaqMan assay correctly identified C. hominis in 24/31 validation panel specimens containing this species. The C. parvum-specific assay correctly identified C. parvum in 21/24 validation panel specimens containing this species. This real-time PCR procedure was used to detect and identify C. hominis and C. parvum in stool specimens from outbreak investigations in the USA and Botswana, resulting in identification of C. hominis and/or C. parvum in 66/67 stool specimens shown to be positive for these species using other techniques. From the outbreak specimens tested, the TaqMan procedure was found to have a specificity of 94%. This TaqMan PCR procedure should be a valuable tool for the laboratory diagnosis of cryptosporidiosis caused by C. hominis and C. parvum during outbreak investigations.

Genetic classification of Cryptosporidium isolates from humans and calves in Slovenia

To assess the importance of cattle as a source of human cryptosporidial infections in Slovenia, Cryptosporidium isolates from calves and humans with cryptosporidiosis were characterized genetically by direct DNA sequencing, targeting a variable region of the 60 subtypes', were identified, of which 7 were novel. In humans, C. hominis Ia (subtype IaA17R3) and Ib (IbA10G2) and Cryptosporidium parvum IIa (IIaA9G1R1, IIaA11G2R1, IIaA13R1, IIaA14G1R1, IIaA15G1R1, IIaA15G2R1, IIaA16G1R1, IIaA17G1R1 and IIaA19G1R1), IIc (IIcA5G3), and IIl (IIlA16R2) were recorded; this is the first record of the latter subtype in humans. In cattle, C. parvum IIa (IIaA13R1, IIaA15G2R1, IIaA16R1 and IIaA16G1R1) and IIl (IIlA16R2 and IIlA18R2) were recorded. Of the 15 subtypes identified, subtypes of C. parvum IIa were the most frequently encountered (>90%) in both humans and calves. The present findings suggest that zoonotic transmission plays an important role in sporadic human cryptosporidiosis in Slovenia.