Neglected infections of poverty among the indigenous peoples of the arctic

Environmental stressors and zoonoses in the Arctic: Learning from the past to prepare for the future

The risk of zoonotic disease transmission from animals to humans is elevated for people in close contact with domestic and wild animals. About three-quarters of all known human infectious diseases are zoonotic, and potential health impacts of these diseases are higher where infectious disease surveillance and access to health care and public health services are limited. This is especially the case for remote circumarctic regions, where drivers for endemic, emerging, and re-emerging zoonotic diseases include anthropogenic influences, such as pollution by long-range transport of industrial chemicals, climate change, loss of biodiversity and ecosystem alterations. In addition to these, indirect effects including natural changes in food web dynamics, appearance of invasive species and thawing permafrost also affect the risk of zoonotic disease spill-over. In other words, the Arctic represents a changing world where pollution, loss of biodiversity and habitat, and maritime activity are likely driving forward occurrence of infectious diseases. As a broad international consortium with a wide range of expertise, we here describe a selection of case studies highlighting the importance of a One Health approach to zoonoses in the circumarctic, encompassing human health, animal health, and environmental health aspects. The cases highlight critical gaps in monitoring and current knowledge, focusing on environmental stressors and lifestyle factors, and they are examples of current occurrences in the Arctic that inform on critically needed actions to prepare us for the future. Through these presentations, we recommend measures to enhance awareness and management of existing and emerging zoonoses with epidemic and pandemic potential while also focusing on the impacts of various environmental stressors and lifestyle factors on zoonoses in the Arctic.

Comparative review of One Health and Indigenous approaches to wildlife research in Inuit Nunangat

There is increasing interest in One Health and Indigenous methodologies and approaches in wildlife research, but they are not widely used research applications in the Arctic. Both approaches are wide in scope and originate from different knowledge systems but are often compared synonymously. We review the literature of overlap between the term One Health and Inuit Qaujimajatuqangit (Inuit Indigenous Knowledge) throughout Inuit Nunaat on wildlife research. Three databases (SCOPUS, Web of Science, and BIOSIS) were used to find English language articles and books within the bounds of Inuit Nunaat. While One Health and Inuit Qaujimajatuqangit research approaches share synergies, they are fundamentally disparate owing to their differences in epistemology, including views on the natural environment and wildlife management. We describe current examples of One Health being operationalized in Inuit Nunaat and identify potential to address larger and more complex questions about wildlife health, with examples from terrestrial and marine Arctic wildlife. Both Indigenous methodologies and One Health naturally have a human component at their core, which seamlessly lends itself to discussions on wildlife management, as human actions and regulations directly impact environment and wildlife health.

Human echinococcosis incidence in Canada: A retrospective descriptive study using administrative hospital and ambulatory visit data, 2000-2020

Background

Echinococcosis is a zoonotic disease caused by the ingestion of tapeworm eggs shed by canids. The potential recent establishment of a more virulent European-type strain may be impacting human echinococcosis in Canada, yet information is limited.

Objective

Administrative hospital and ambulatory visit data were used to provide a baseline of human echinococcosis cases in Canada between 2000-2020.

Methods

Canadian Institute of Health Information's Discharge Abstract Database, Hospital Morbidity Database and National Ambulatory Care Reporting System were combined to identify cases. Risk ratios (RR) by demographic factors and cumulative incidences (CIN) over place and time were calculated.

Results

A total of 806 echinococcosis cases were identified in Canada between 2000-2020, for a mean annual CIN of 1.3 cases per million population. Over the two decades, the mean annual CIN of cases increased nationally (1.3-1.4 cases per million), in the Northwest Territories (6.3-9.1 cases per million), in Alberta (1.5-2.4 cases per million) and in the Atlantic provinces (0.2-0.6 cases per million). Those from the Territories had the highest risk of echinococcosis (RR 17.1; 95% confidence interval: 8.7-33.7).

Conclusion

Though explanations are multifactorial, the new European-type strain may have a role in the small absolute increase in echinococcosis CIN in Canada observed over the study period. The CIN is likely underestimated and the validity of administrative data for analyzing zoonoses warrants investigation. Though this study contributes important awareness and a baseline, improved data are needed to clarify the effects of the new strain and inform public health response.

Clinical Implications for the Comprehensive Interpretation of Radiologic and Immunodiagnostic Tests in Patients Suspected of Parasitic Hepatic Cyst, a Rare Case in Korea

Cystic echinococcosis (CE) is a representative neglected tropical disease (NTD) with increased morbidity and mortality but is ignored and overlooked in developed countries. Serological and radiographic findings are helpful in distinguishing these parasites; however, conflicting results of these can make it difficult to diagnose if medical knowledge of hepatic parasitic disease, including the etiology, features of imaging, and immunodiagnostic test, is not acquired. We report the case of a male patient with dyspepsia and right epigastric pain who had positive results for cysticercosis antibodies on immunodiagnostic examination. Abdominal ultrasonography revealed two huge communicating cystic lesions measuring 8–11 cm. Further evaluations for cysticercosis of the brain (neurocysticercosis) and eyes (intraocular cysticercosis) were unremarkable throughout the brain imaging test and fundus examination. A laparoscopic right hemi-hepatectomy was performed for diagnosis and treatment. On histopathological examination, diverse stages of Echinococcus granulosus were identified. Albendazole was administered postoperatively, and the patient was also followed up. We should be aware of the etiologies that have been prevalent in parasite infection thought to be the cause of hepatic cysts. Moreover, we make an effort to ascertain the patient’s nationality, past travel experiences, and immediate environment, including any animals and pets. We present the case of a patient who was worried about the possibility of liver invasion of cysticercus due to the positivity of the cysticercosis antibody and was ultimately diagnosed with CE.

Domestic water security in the Arctic: A scoping review

INTRODUCTION

More than 50 million people living in the Arctic nations remain without access to safely managed drinking water services. Remote northern communities, where large numbers of Indigenous peoples live, are disproportionally affected. Recent research has documented water and health-related problems among Indigenous communities, including poor water quality and insufficient quantities of water.

OBJECTIVE

The objective of this scoping review is to examine the extent of available water security evidence as well as identify research gaps and intervention priorities to improve access to domestic water in the Arctic and Subarctic regions of the eight Arctic nations (Canada, the Kingdom of Denmark (Greenland), Finland, Iceland, Norway, Sweden, Russia, and the United States (Alaska)).

METHODS

An extensive literature review was conducted to retrieve relevant documentation. Arctic & Antarctic Regions, Compendex, Geobase, Georef, MEDLINE and Web of Science databases were searched to identify records for inclusion. The initial searches yielded a total of 1356 records. Two independent reviewers systematically screened identified records using selection criteria. Descriptive analyses were used to summarize evidence of included studies.

RESULTS

A total of 55 studies, mostly conducted in Canada and the United States, were included and classified by four predetermined major dimensions: 1) Water accessibility and availability; 2) Water quality assessment; 3) Water supply and health; 4) Preferences and risk perceptions.

CONCLUSIONS

This scoping review used a global approach to provide researchers and stakeholders with a summary of the evidence available regarding water security and domestic access in the Arctic. Culturally appropriate health-based interventions are necessary to ensure inclusive water services and achieve the Sustainable Development Goals (SDG) targets for universal access to water.

Synthesizing the connections between environmental disturbances and zoonotic spillover

Zoonotic spillover is a phenomenon characterized by the transfer of pathogens between different animal species. Most human emerging infectious diseases originate from non-human animals, and human-related environmental disturbances are the driving forces of the emergence of new human pathogens. Synthesizing the sequence of basic events involved in the emergence of new human pathogens is important for guiding the understanding, identification, and description of key aspects of human activities that can be changed to prevent new outbreaks, epidemics, and pandemics. This review synthesizes the connections between environmental disturbances and increased risk of spillover events based on the One Health perspective. Anthropogenic disturbances in the environment (e.g., deforestation, habitat fragmentation, biodiversity loss, wildlife exploitation) lead to changes in ecological niches, reduction of the dilution effect, increased contact between humans and other animals, changes in the incidence and load of pathogens in animal populations, and alterations in the abiotic factors of landscapes. These phenomena can increase the risk of spillover events and, potentially, facilitate new infectious disease outbreaks. Using Brazil as a study model, this review brings a discussion concerning anthropogenic activities in the Amazon region and their potential impacts on spillover risk and spread of emerging diseases in this region.

Socio-economic and environmental factors affecting breastfeeding and complementary feeding practices among Batwa and Bakiga communities in south-western Uganda

Improving breastfeeding and complementary feeding practices is needed to support good health, enhance child growth, and reduce child mortality. Limited evidence is available on child feeding among Indigenous communities and in the context of environmental changes. We investigate past and present breastfeeding and complementary feeding practices within Indigenous Batwa and neighbouring Bakiga populations in south-western Uganda. Specifically, we describe the demographic and socio-economic characteristics of breastfeeding mothers and their children, and individual experiences of breastfeeding and complementary feeding practices. We investigate the factors that have an impact on breastfeeding and complementary feeding at community and societal levels, and we analysed how environments, including weather variability, affect breastfeeding and complementary feeding practices. We applied a mixed-method design to the study, and we used a community-based research approach. We conducted 94 individual interviews (n = 47 Batwa mothers/caregivers & n = 47 Bakiga mothers/caregivers) and 12 focus group discussions (n = 6 among Batwa & n = 6 among Bakiga communities) from July to October 2019. Ninety-nine per cent of mothers reported that their youngest child was currently breastfed. All mothers noted that the child experienced at least one episode of illness that had an impact on breastfeeding. From the focus groups, we identified four key factors affecting breastfeeding and nutrition practices: marginalisation and poverty; environmental change; lack of information; and poor support. Our findings contribute to the field of global public health and nutrition among Indigenous communities, with a focus on women and children. We present recommendations to improve child feeding practices among the Batwa and Bakiga in south-western Uganda. Specifically, we highlight the need to engage with local and national authorities to improve breastfeeding and complementary feeding practices, and work on food security, distribution of lands, and the food environment. Also, we recommend addressing the drivers and consequences of alcoholism, and strengthening family planning programs.

Outbreak of Amazonian Toxoplasmosis: A One Health Investigation in a Remote Amerindian Community

Background:Toxoplasma gondii is a parasite of worldwide importance but its burden in indigenous communities remains unclear. In French Guiana, atypical strains of T. gondii originating from a complex rainforest cycle involving wild felids have been linked to severe infections in humans. These cases of Amazonian toxoplasmosis are sporadic and outbreaks are rarely described. We report on the investigation of an outbreak of acute toxoplasmosis in a remote Amerindian village. We discuss the causes and consequences of this emergence.

Methods: In May 2017, during the rainy season and following an episode of flooding, four simultaneous cases of acute toxoplasmosis were serologically confirmed in two families living the village. Other non-diagnosed cases were then actively screened by a medical team along with epidemiological investigations. Inhabitants from nine households were tested for T. gondii antibodies and parasite DNA by PCR when appropriate. Samples of water, cat feces and cat rectal swabs, soil, and meat were tested for T. gondii DNA by PCR. Positive PCR samples with sufficient DNA amounts were genotyped using 15 microsatellite markers.

Results: Between early May and early July 2017, out of 54 tested inhabitants, 20 cases were serologically confirmed. A fetus infected at gestational week 10 died but other cases were mild. Four patients tested positive for parasite DNA and two identical strains belonging to an atypical genotype could be isolated from unrelated patients. While domestic cats had recently appeared in the vicinity, most families drank water from unsafe sources. Parasite DNA was recovered from one water sample and nine soil samples. Three meat samples tested positive, including wild and industrial meat.

Conclusions: The emergence of toxoplasmosis in such a community living in close contact with the Amazon rainforest is probably multifactorial. Sedentary settlements have been built in the last few decades without providing safe water sources, increasing the risk of parasite circulation in cases of dangerous new habits such as cat domestication. Public health actions should be implemented in these communities such as safe water supply, health recommendations, and epidemiological surveillance of acute toxoplasmosis. A “One Health” strategy of research involving medical anthropology, veterinary medicine, and public health needs to be pursued for a better understanding of the transmission routes and the emergence of this zoonosis.

Parasites and Metals in Walleye (Sander vitreus) and Northern Pike (Esox lucius) from Boreal Montreal Lake (Saskatchewan, Canada): Assessment of Human Health Risks

Industrial activities conducted in Northern Canada have raised concerns among Indigenous communities regarding wildlife contamination and potential consequences for human health. Therefore, an investigation on the chemical (metals/metalloids) and biological (parasite) burden of adult walleye (Sandervitreus) and northern pike (Esoxlucius) from Montreal Lake, Saskatchewan, was conducted to assess health risks related to fish consumption. Dissection revealed that both fishes displayed typical parasite communities, with Eubothrium sp. (Cestoda) and Raphidascarisacus (Nematoda) occurring the most frequently. None of the identified parasite species were infectious to humans. Concentrations of most inorganic contaminants in fish muscle were low and both walleye and pike can be considered healthy components of a balanced diet. However, due to slightly elevated mercury concentrations, excessive daily consumption of these fishes is not recommended, as mercury exposure over time may lead to adverse health effects.

Human Seroprevalence to 11 Zoonotic Pathogens in the U.S. Arctic, Alaska

Background: Due to their close relationship with the environment, Alaskans are at risk for zoonotic pathogen infection. One way to assess a population's disease burden is to determine the seroprevalence of pathogens of interest. The objective of this study was to determine the seroprevalence of 11 zoonotic pathogens in people living in Alaska. Methods: In a 2007 avian influenza exposure study, we recruited persons with varying wild bird exposures. Using sera from this study, we tested for antibodies to Cryptosporidium spp., Echinococcus spp., Giardia intestinalis, Toxoplasma gondii, Trichinella spp., Brucella spp., Coxiella burnetii, Francisella tularensis, California serogroup bunyaviruses, and hepatitis E virus (HEV). Results: Eight hundred eighty-seven persons had sera tested, including 454 subsistence bird hunters and family members, 160 sport bird hunters, 77 avian wildlife biologists, and 196 persons with no wild bird exposure. A subset (n = 481) of sera was tested for California serogroup bunyaviruses. We detected antibodies to 10/11 pathogens. Seropositivity to Cryptosporidium spp. (29%), California serotype bunyaviruses (27%), and G. intestinalis (19%) was the most common; 63% (301/481) of sera had antibodies to at least one pathogen. Using a multivariable logistic regression model, Cryptosporidium spp. seropositivity was higher in females (35.7% vs. 25.0%; p = 0.01) and G. intestinalis seropositivity was higher in males (21.8% vs. 15.5%; p = 0.02). Alaska Native persons were more likely than non-Native persons to be seropositive to C. burnetii (11.7% vs. 3.8%; p = 0.005) and less likely to be seropositive to HEV (0.4% vs. 4.1%; p = 0.01). Seropositivity to Cryptosporidium spp., C. burnetii, HEV, and Echinococcus granulosus was associated with increasing age (p ≤ 0.01 for all) as was seropositivity to ≥1 pathogen (p < 0.0001). Conclusion: Seropositivity to zoonotic pathogens is common among Alaskans with the highest to Cryptosporidium spp., California serogroup bunyaviruses, and G. intestinalis. This study provides a baseline for use in assessing seroprevalence changes over time.

Prevalence and genetic characterization of Giardia spp. and Cryptosporidium spp. in dogs in Iqaluit, Nunavut, Canada

There are few epidemiologic studies on the role of dogs in zoonotic parasitic transmission in the Circumpolar North. The objectives of this study were to: (a) estimate the faecal prevalence of Giardia spp. and Cryptosporidium spp. in dogs; (b) investigate potential associations between the type of dog population and the faecal presence of Giardia spp. and Cryptosporidium spp.; and (c) describe the molecular characteristics of Giardia spp. and Cryptosporidium spp. in dogs in Iqaluit, Nunavut. We conducted two cross-sectional studies in July and September 2016. In July, the team collected daily faecal samples for 3 days from each of 20 sled dogs. In September, the team collected three faecal samples from each of 59 sled dogs, 111 samples from shelter dogs and 104 from community dogs. We analysed faecal samples for the presence of Giardia spp. and Cryptosporidium spp. using rapid immunoassay and flotation techniques. Polymerase chain reaction (PCR) and sequencing of target genes were performed on positive faecal samples. Overall, the faecal prevalence of at least one of the target parasites, when one faecal sample was chosen at random for all dogs, was 8.16% (CI: 5.52-11.92), and for Giardia spp. and Cryptosporidium spp., prevalence was 4.42% (CI: 2.58-7.49) and 6.12% (CI: 3.88-9.53), respectively. The odds of faecal Giardia spp. in sled dogs were significantly higher than those in shelter and community dogs (OR 10.19 [CI: 1.16-89.35]). Sequence analysis revealed that 6 faecal samples were Giardia intestinalis, zoonotic assemblage B (n = 2) and species-specific assemblages D (n = 3) and E (n = 1), and five faecal samples were Cryptosporidium canis. Giardia intestinalis is zoonotic; however, Cryptosporidium canis is rare in humans and, when present, usually occurs in immunosuppressed individuals. Dogs may be a potential source of zoonotic Giardia intestinalis assemblage B infections in residents in Iqaluit, Nunavut, Canada; however, the direction of transmission is unclear.

A Comparative Study on the Faecal Bacterial Community and Potential Zoonotic Bacteria of Muskoxen (Ovibos moschatus) in Northeast Greenland, Northwest Greenland and Norway

Muskoxen (Ovibos moschatus) are ruminants adapted to a high-fibre diet. There is increasing interest in the role that gut microbes play in the digestion and utilization of these specialized diets but only limited data available on the gut microbiome of high-Arctic animals. In this study, we metabarcoded the 16S rRNA region of faecal samples from muskoxen of Northeast Greenland, Northwest Greenland and Norway, and quantified the effects of physiological and temporal factors on bacterial composition. We found significant effects of body mass, year of sampling and location on the gut bacterial communities of North East Greenland muskoxen. These effects were however dwarfed by the effects of location, emphasizing the importance of the local ecology on the gut bacterial community. Habitat alterations and rising temperatures may therefore have a considerable impact on muskoxen health and reproductive success. Moreover, muskoxen are hunted and consumed in Greenland, Canada and Alaska; therefore, this study also screened for potential zoonoses of food safety interest. A total of 13 potentially zoonotic genera were identified, including the genera Erysipelothrix and Yersinia implicated in recent mass die-offs of the muskoxen themselves.

Climate Change and the Neglected Tropical Diseases

Climate change is expected to impact across every domain of society, including health. The majority of the world's population is susceptible to pathological, infectious disease whose life cycles are sensitive to environmental factors across different physical phases including air, water and soil. Nearly all so-called neglected tropical diseases (NTDs) fall into this category, meaning that future geographic patterns of transmission of dozens of infections are likely to be affected by climate change over the short (seasonal), medium (annual) and long (decadal) term. This review offers an introduction into the terms and processes deployed in modelling climate change and reviews the state of the art in terms of research into how climate change may affect future transmission of NTDs. The 34 infections included in this chapter are drawn from the WHO NTD list and the WHO blueprint list of priority diseases. For the majority of infections, some evidence is available of which environmental factors contribute to the population biology of parasites, vectors and zoonotic hosts. There is a general paucity of published research on the potential effects of decadal climate change, with some exceptions, mainly in vector-borne diseases.

Trichinella Nativa Outbreak With Rare Thrombotic Complications Associated With Meat From a Black Bear Hunted in Northern Ontario

Background

Although trichinellosis is known to cause thrombotic disease, serious thrombotic events are rare and have not been previously associated with Trichinella nativa infection.

Methods

Patient interviews and medical chart reviews were conducted on 10 men who became ill following consumption of a common source of black bear meat. Trichinella serology on patient sera as well as polymerase chain reaction (PCR) and larval identification of the meat samples was conducted.

Results

All 10 exposed individuals developed an acute illness clinically compatible with trichinellosis, characterized by fever, abdominal pain, and diarrhea, along with eosinophilia ranging from 0.9 × 109/L to 6.1 × 109/L. Within 2 weeks of the diarrheal illness, systemic symptoms developed in all exposed individuals characterized by fever, myalgia, periorbital edema, and fatigue. ST-elevation myocardial infarction and sinus venous tract thrombosis occurred as a complication of trichinellosis in 2 patients. Acute serology was nonreactive in all patients, though convalescent serology was reactive in 6 of 8 (75%) patients for whom sera was available. Multiplex PCR identified T. nativa from the bear meat, and was corroborated by microscopic larval identification.

Conclusions

We report a 100% attack rate of T. nativa from bear meat among those who were exposed, and demonstrate that this species can cause serious thrombotic complications of trichinellosis in humans. Education of hunters and the public regarding the importance of proper preparation of wild game prior to ingestion is warranted.

Enteric Parasites in Arctic Communities: Tip of the Iceberg?

Human enteric parasitoses, particularly from Cryptosporidium, were recently recognized as being highly prevalent in parts of the Arctic. This is important because cryptosporidiosis has been repeatedly associated with impaired growth and development and may synergize with other challenges faced by children in remote Arctic communities, such as overcrowding and food insecurity.

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study

BACKGROUND

International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.

METHODS

Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.

FINDINGS

Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

INTERPRETATION

We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.

FUNDING

The Lowitja Institute.

Cryptosporidium hominis Is a Newly Recognized Pathogen in the Arctic Region of Nunavik, Canada: Molecular Characterization of an Outbreak

Background

Cryptosporidium is a leading cause of childhood diarrhea in low-resource settings, and has been repeatedly associated with impaired physical and cognitive development. In May 2013, an outbreak of diarrhea caused by Cryptosporidium hominis was identified in the Arctic region of Nunavik, Quebec. Human cryptosporidiosis transmission was previously unknown in this region, and very few previous studies have reported it elsewhere in the Arctic. We report clinical, molecular, and epidemiologic details of a multi-village Cryptosporidium outbreak in the Canadian Arctic.

Methodology/Principal Findings

We investigated the occurrence of cryptosporidiosis using a descriptive study of cases with onset between April 2013 and April 2014. Cases were defined as Nunavik inhabitants of any age presenting with diarrhea of any duration, in whom Cryptosporidium oocysts were detected by stool microscopy in a specialised reference laboratory. Cryptosporidium was identified in stool from 51 of 283 individuals. The overall annual incidence rate (IR) was 420 / 100,000 inhabitants. The IR was highest among children aged less than 5 years (1290 /100,000 persons). Genetic subtyping for stool specimens from 14/51 cases was determined by DNA sequence analysis of the 60 kDa glycoprotein (gp60) gene. Sequences aligned with C. hominis subtype Id in all cases. No common food or water source of infection was identified.

Conclusions/Significance

In this first observed outbreak of human cryptosporidiosis in this Arctic region, the high IR seen is cause for concern about the possible long-term effects on growth and development of children in Inuit communities, who face myriad other challenges such as overcrowding and food-insecurity. The temporal and geographic distribution of cases, as well as the identification of C. hominis subtype Id, suggest anthroponotic rather than zoonotic transmission. Barriers to timely diagnosis delayed the recognition of human cryptosporidiosis in this remote setting.

In mid-2013, an outbreak of moderate-to-severe diarrhea caused by Cryptosporidium was identified in the Arctic region of Nunavik, Quebec, and it predominantly affected young children. Cryptosporidium is a leading cause of childhood diarrhea in low-resource settings, but was previously unknown in this region. This is important because cryptosporidiosis has been repeatedly associated with impaired growth and development, and may interact with other challenges currently faced by children in remote Arctic communities, such as overcrowding and food-insecurity. Although animals in the Arctic have previously been found to harbour Cryptosporidium parvum, which can infect both animals and humans, we found that the Cryptosporidium identified in the stool of affected people all belonged to the species C. hominis, which is only known to infect humans. Together with the temporal and geographic distribution of cases, this suggests that cryptosporidiosis in this outbreak was transmitted person-to-person, rather than acquired from contact with animals. The emergence of Cryptosporidium infections in Arctic communities may have public health impacts beyond the occurrence of diarrhea.

Bibliometric analysis of medicine-related publications on poverty (2005-2015)

BACKGROUND

Poverty is a global problem. The war against poverty requires not only financial support, but also poverty-related research to pinpoint areas of high need of intervention. In line with international efforts to fight poverty and negative consequences, we carried out this study to give a bibliometric overview of medicine-related literature on poverty. Such a s study is an indicator of the extent of interaction of various international key players on the war against poverty-related health problems.

METHODS

Scopus was used to achieve the objective of this study. The time span set for this study was 2005-2015. Poverty-related articles under the subject area "Medicine" were used to give bibliometric indicators such as annual growth of publications, international collaboration, highly cited articles, active countries, institutions, journals, and authors.

RESULTS

The total number of retrieved articles was 1583. The Hirsh-index of retrieved articles was 56. A modest and fluctuating increase was seen over the study period. Visualization map of retrieved articles showed that "HIV", infectious diseases, mental health, India, and Africa were most commonly encountered terms. No significant dominance of any particular author or journal was observed in retrieved articles. The United States of America had the largest share in the number of published articles. The World Health Organization and Centers for Disease Prevention and Control were among top active institutions/organizations. International collaboration was observed in less than one third of publications. Top cited articles focused on three poverty-related health issues, mainly, infectious diseases, malnutrition, and child development/psychology. Most of top articles were published in high impact journals.

CONCLUSIONS

Data indicated that articles on poverty were published in high influential medical journals indicative of the importance of poverty as a global health problem. However, the number publications and the extent of international collaborations was lower than expected given the huge burden of poverty-related health problems.

Wildlife parasites in a One Health world

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One Health emphasizes the interdependence of human, animal, and environmental health.

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Wildlife parasites are ubiquitous; how do we decide which are One Health issues?

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We propose questions to help to prioritize wildlife parasites in a One Health context.

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We suggest principles for taking action on wildlife parasites with One Health significance.

One Health has gained a remarkable profile in the animal and public health communities, in part owing to the pressing issues of emerging infectious diseases of wildlife origin. Wildlife parasitology can offer insights into One Health, and likewise One Health can provide justification to study and act on wildlife parasites. But how do we decide which wildlife parasites are One Health issues? We explore toxoplasmosis in wildlife in the Canadian Arctic as an example of a parasite that poses a risk to human health, and that also has potential to adversely affect wildlife populations of conservation concern and importance for food security and cultural well-being. This One Health framework can help communities, researchers, and policymakers prioritize issues for action in a resource-limited world.

A review of invasive Haemophilus influenzae disease in the Indigenous populations of North America

Historically, the highest incidence rates of invasive Haemophilus influenzae disease in the world were found in North American and Australian Indigenous children. Although immunization against H. influenzae type b (Hib) led to a marked decrease in invasive Hib disease in countries where it was implemented, this disease has not been eliminated and its rates in Indigenous communities remain higher than in the general North American population. In this literature review, we examined the epidemiology of invasive H. influenzae disease in the pre-Hib vaccine era, effect of carriage on disease epidemiology, immune response to H. influenzae infection and Hib vaccination in Indigenous and Caucasian children, and the changing epidemiology after Hib conjugate vaccine has been in use for more than two decades in North America. We also explored reasons behind the continued high rates of invasive H. influenzae disease in Indigenous populations in North America. H. influenzae type a (Hia) has emerged as a significant cause of severe disease in North American Indigenous communities. More research is needed to define the genotypic diversity of Hia and the disease burden that it causes in order to determine if a Hia vaccine is required to protect the vulnerable populations.

People, pets, and parasites: one health surveillance in southeastern Saskatchewan

Residents of remote and Indigenous communities might experience higher exposure to some zoonotic parasites than the general North American population. Human sero-surveillance conducted in two Saulteaux communities found 113 volunteers exposed as follows: Trichinella (2.7%), Toxocara canis (4.4%), Echinococcus (4.4%), and Toxoplasma gondii (1.8%). In dogs, 41% of 51 fecal samples were positive for at least one intestinal parasite, 3% of 77 were sero-positive for Borrelia burgdorferi, and 21% of 78 for T. gondii. Echinococcus exposure was more likely to occur in non-dog owners (odds ratio [OR]: 11.4, 95% confidence interval [CI]: 1.2-107, P = 0.03); while T. canis was more likely to occur in children (ages 4-17) (OR: 49, 95% CI: 3.9-624; P = 0.003), and those with a history of dog bites (OR: 13.5, 95% CI: 1.02-179; P = 0.048). Our results emphasize the use of dogs as sentinels for emerging pathogens such as Lyme disease, and the need for targeted surveillance and intervention programs tailored for parasite species, cultural groups, and communities.

The use of the United States FDA programs as a strategy to advance the development of drug products for neglected tropical diseases

Neglected tropical diseases (NTDs) are infections which are endemic in poor populations in lower- and middle-income countries (LMIC). Approximately one billion people have now or are at risk of getting an NTD and yet less than 5% of research dollars are focused on providing treatments and prevention of these highly debilitating and deadly conditions. The United States Food and Drug Administration (FDA) Orphan Drug Designation program (ODDP) provides orphan status to drugs and biologics, defined as those intended for the safe and effective treatment, diagnosis or prevention of rare diseases and/or disorders that affect fewer than 200 000 people in the United States, or that affect more than 200 000 persons but are not expected to recover the costs of developing and marketing a treatment drug. These regulations have led to the translation of rare disease knowledge into innovative rare disease therapies. The FDA Guidance for Industry on developing drugs for the treatment and prevention of NTDs describes the following regulatory strategies: Orphan Product Designation, Fast Track Designation, Priority Review Designation, Accelerated Approval and Tropical Disease Priority Review Voucher. This paper will discuss how these regulations and especially the ODDP can improve the clinical development and accessibility of drug products for NTDs.

Combating infectious diseases of poverty: a year on

The Infectious Diseases of Poverty journal, launched a year ago, is a platform to engage outside the traditional disciplinary boundaries, and disseminate high quality science towards the improvement of health. This paper reviews the milestone achievements during its first year of operation. The journal has filled an important niche, addressing some of the main priorities in the Global Report for Research on Infectious Diseases of Poverty. Highlights include the publication of three thematic issues on health systems, surveillance and response systems, as well as co-infection and syndemics. The thematic issues have foregrounded the importance and innovation that can be achieved through transdisciplinary research. The journal has been indexed by PubMed since April 2013, with the publication of a total of 38 articles. Finally, the journal is delivering to wider range readers both in developing and developed countries with sustained efforts with a focus on relevant and strategic information towards elimination of infectious diseases of poverty.

Parasite zoonoses and wildlife: One Health, spillover and human activity

This review examines parasite zoonoses and wildlife in the context of the One Health triad that encompasses humans, domestic animals, wildlife and the changing ecosystems in which they live. Human (anthropogenic) activities influence the flow of all parasite infections within the One Health triad and the nature and impact of resulting spillover events are examined. Examples of spillover from wildlife to humans and/or domestic animals, and vice versa, are discussed, as well as emerging issues, particularly the need for parasite surveillance of wildlife populations. Emphasis is given to Trypanosoma cruzi and related species in Australian wildlife, Trichinella, Echinococcus, Giardia, Baylisascaris, Toxoplasma and Leishmania.

The polar bear in the room: diseases of poverty in the Arctic

In the face of global warming, budgetary austerity and impoverished Arctic residents, the nations of the circumpolar region are presented with a number of difficult choices regarding the provision of health care to the far-flung and isolated regions of their northernmost provinces. Complicating that picture is the reality of neglected tropical diseases in areas far from their perceived normal equatorial range as well as endemic food-borne diseases, including protozoan and helminth parasites, respiratory and gastrointestinal diseases and vaccine-preventable illnesses.

This paper discusses the problems of caring for the health and well-being of indigenous populations suffering from extreme poverty, isolation and discrimination in the circumpolar region. After presenting difficulties as supported by the extant literature, the paper continues by suggesting solutions that include novel telenursing applications, targeted distance-educational programs and local community-based health care assistant (HCA) vocational training. These programs will provide cost-effective care that increases life-spans, improves quality of life and provides opportunities to distressed populations in isolated rural communities of the Far North.

The toolkit presented in the paper is intended to spur discussion on community health programs that could be adopted to provide proper and humane care for marginalized Arctic populations in an extreme and rapidly changing environment.

Nutritional status of indigenous children: findings from the First National Survey of Indigenous People's Health and Nutrition in Brazil

INTRODUCTION

The prevalence of undernutrition, which is closely associated with socioeconomic and sanitation conditions, is often higher among indigenous than non-indigenous children in many countries. In Brazil, in spite of overall reductions in the prevalence of undernutrition in recent decades, the nutritional situation of indigenous children remains worrying. The First National Survey of Indigenous People's Health and Nutrition in Brazil, conducted in 2008-2009, was the first study to evaluate a nationwide representative sample of indigenous peoples. This paper presents findings from this study on the nutritional status of indigenous children < 5 years of age in Brazil.

METHODS

A multi-stage sampling was employed to obtain a representative sample of the indigenous population residing in villages in four Brazilian regions (North, Northeast, Central-West, and Southeast/South). Initially, a stratified probabilistic sampling was carried out for indigenous villages located in these regions. Households in sampled villages were selected by census or systematic sampling depending on the village population. The survey evaluated the health and nutritional status of children < 5 years, in addition to interviewing mothers or caretakers.

RESULTS

Height and weight measurements were taken of 6,050 and 6,075 children, respectively. Prevalence rates of stunting, underweight, and wasting were 25.7%, 5.9%, and 1.3%, respectively. Even after controlling for confounding, the prevalence rates of underweight and stunting were higher among children in the North region, in low socioeconomic status households, in households with poorer sanitary conditions, with anemic mothers, with low birthweight, and who were hospitalized during the prior 6 months. A protective effect of breastfeeding for underweight was observed for children under 12 months.

CONCLUSIONS

The elevated rate of stunting observed in indigenous children approximates that of non-indigenous Brazilians four decades ago, before major health reforms greatly reduced its occurrence nationwide. Prevalence rates of undernutrition were associated with socioeconomic variables including income, household goods, schooling, and access to sanitation services, among other variables. Providing important baseline data for future comparison, these findings further suggest the relevance of social, economic, and environmental factors at different scales (local, regional, and national) for the nutritional status of indigenous peoples.

Parasitic zoonoses: one health surveillance in northern Saskatchewan

We report the results of a joint human-animal health investigation in a Dene community in northern Saskatchewan, where residents harvest wildlife (including moose, bear, elk, and fish), live in close contact with free roaming dogs, and lack access to permanent veterinary services. Fecal analysis of owned and free-roaming dogs over two consecutive years (N = 92, 103) identified several parasites of public health concern, including Toxocara canis, Diphyllobothrium spp., Echinococcus/Taenia, Cryptosporidium spp. and Giardia spp. Administration of pyrantel pamoate to a subset of dogs (N = 122) in the community in the first year was followed by reduced shedding of T. canis and other roundworms in the second year, demonstrating the potential utility of canine de-worming as a public health intervention. Using direct agglutination tests with confirmatory indirect fluorescent antibody test, 21% of 47 dogs were sero-positive for exposure to Toxoplasma gondii. Using enzyme-linked immunosorbent assay (ELISA) sero-prevalence rates in 201 human volunteers were as follows: Toxoplasma gondii (14%), Echinococcus granulosus (48%), Toxocara canis (13%) and Trichinella spp. (16%). Overall 65% of participants were sero-positive for at least one parasite. A survey administered to volunteers indicated few associations between widely accepted risk factors for parasite exposure and serological status, emphasizing the importance of environmental transmission of these parasites through soil, food, and waterborne routes.

Parasites are ubiquitous, and while some parasitize only one host, others are capable of crossing species barriers. Zoonotic parasites move between animals and people, and in some cases cause significant veterinary, medical and/or public health problems. Such parasites may be more prevalent in areas where veterinary and medical services are scarce, and especially if sanitation infrastructure is suboptimal. Additional risk factors include reliance on country foods, proximity to pets that come in contact with wildlife, and eating undercooked or raw fish and game. We visited one northern Indigenous community over two consecutive years to determine the prevalence of internal parasites in dogs, as well as to demonstrate the effect of selective deworming on reducing environmental contamination by zoonotic parasites. In addition, we collected blood samples and administered surveys to human volunteers in order to explore the relationship between exposure to four zoonotic parasites and several widely accepted risk factors for exposure (e.g. pet ownership). Our findings indicate that levels of parasite exposure in this community were higher than similar studies conducted in other Canadian Indigenous communities. Public health interventions that utilize a one health strategy by integrating medical, veterinary and environmental expertise may be the most effective approach in reducing human and animal exposure to parasites in this community.

Neglected tropical diseases of Oceania: review of their prevalence, distribution, and opportunities for control

Among Oceania's population of 35 million people, the greatest number living in poverty currently live in Papua New Guinea (PNG), Fiji, Vanuatu, and the Solomon Islands. These impoverished populations are at high risk for selected NTDs, including Necator americanus hookworm infection, strongyloidiasis, lymphatic filariasis (LF), balantidiasis, yaws, trachoma, leprosy, and scabies, in addition to outbreaks of dengue and other arboviral infections including Japanese encephalitis virus infection. PNG stands out for having the largest number of cases and highest prevalence for most of these NTDs. However, Australia's Aboriginal population also suffers from a range of significant NTDs. Through the Pacific Programme to Eliminate Lymphatic Filariasis, enormous strides have been made in eliminating LF in Oceania through programs of mass drug administration (MDA), although LF remains widespread in PNG. There are opportunities to scale up MDA for PNG's major NTDs, which could be accomplished through an integrated package that combines albendazole, ivermectin, diethylcarbamazine, and azithromycin, in a program of national control. Australia's Aboriginal population may benefit from appropriately integrated MDA into primary health care systems. Several emerging viral NTDs remain important threats to the region.

Tradition and transition: parasitic zoonoses of people and animals in Alaska, northern Canada, and Greenland

Zoonotic parasites are important causes of endemic and emerging human disease in northern North America and Greenland (the North), where prevalence of some parasites is higher than in the general North American population. The North today is in transition, facing increased resource extraction, globalisation of trade and travel, and rapid and accelerating environmental change. This comprehensive review addresses the diversity, distribution, ecology, epidemiology, and significance of nine zoonotic parasites in animal and human populations in the North. Based on a qualitative risk assessment with criteria heavily weighted for human health, these zoonotic parasites are ranked, in the order of decreasing importance, as follows: Echinococcus multilocularis, Toxoplasma gondii, Trichinella and Giardia, Echinococcus granulosus/canadensis and Cryptosporidium, Toxocara, anisakid nematodes, and diphyllobothriid cestodes. Recent and future trends in the importance of these parasites for human health in the North are explored. For example, the incidence of human exposure to endemic helminth zoonoses (e.g. Diphyllobothrium, Trichinella, and Echinococcus) appears to be declining, while water-borne protozoans such as Giardia, Cryptosporidium, and Toxoplasma may be emerging causes of human disease in a warming North. Parasites that undergo temperature-dependent development in the environment (such as Toxoplasma, ascarid and anisakid nematodes, and diphyllobothriid cestodes) will likely undergo accelerated development in endemic areas and temperate-adapted strains/species will move north, resulting in faunal shifts. Food-borne pathogens (e.g. Trichinella, Toxoplasma, anisakid nematodes, and diphyllobothriid cestodes) may be increasingly important as animal products are exported from the North and tourists, workers, and domestic animals enter the North. Finally, key needs are identified to better assess and mitigate risks associated with zoonotic parasites, including enhanced surveillance in animals and people, detection methods, and delivery and evaluation of veterinary and public health services.

Innovation for the 'bottom 100 million': eliminating neglected tropical diseases in the Americas

An estimated 100 million people in the Latin American and Caribbean (LAC) region live on less than US$2 per day, while another 46 million people in the US live below that nation's poverty line. Almost all of the 'bottom 100 million' people suffer from at least one neglected tropical disease (NTD), including one-half of the poorest people in the region infected with hookworms, 10% with Chagas disease, and up to 1-2% with dengue, schistosomiasis, and/or leishmaniasis. In the US, NTDs such as Chagas disease, cysticercosis, toxocariasis, and trichomoniasis are also common among poor populations. These NTDs trap the poorest people in the region in poverty, because of their impact on maternal and child health, and occupational productivity. Through mass drug administration (MDA), several NTDs are on the verge of elimination in the Americas, including lymphatic filariasis, onchocerciasis, trachoma, and possibly leprosy. In addition, schistosomiasis may soon be eliminated in the Caribbean. However, for other NTDs including hookworm infection, Chagas disease, dengue, schistosomiasis, and leishmaniasis, a new generation of 'anti-poverty vaccines' will be required. Several vaccines for dengue are under development by multinational pharmaceutical companies, whereas others are being pursued through non-profit product development partnerships (PDPs), in collaboration with developing country manufacturers in Brazil and Mexico. The Sabin Vaccine Institute PDP is developing a primarily preventive bivalent recombinant human hookworm vaccine, which is about to enter phase 1 clinical testing in Brazil, as well as a new therapeutic Chagas disease vaccine in collaboration with several Mexican institutions. The Chagas disease vaccine would be administered to seropositive patients to delay or prevent the onset of Chagasic cardiomyopathy (secondary prevention). Together, MDA and the development of new anti-poverty vaccines afford an opportunity to implement effective control and elimination strategies for the major NTDs in the Americas.

A review on diagnostic and preventive aspects of cystic echinococcosis and human cysticercosis

Cystic echinococcosis and human cysticercosis have recently been included in the list of "neglected tropical diseases" by the World Health Organization (WHO). Both are zoonoses which are prevalent throughout the world and lead to considerable mortality, morbidity, and economic losses as well. This review deals with the disease burden of these two neglected cestode infections. Diagnostic modalities with their specific advantages and disadvantages have also been discussed. Recent developments in immunodiagnostic assays for the two diseases have been dealt with. Various control strategies including the use of veterinary vaccines have been highlighted.

Helicobacter pylori in First Nations and recent immigrant populations in Canada

The diminishing prevalence of Helicobacter pylori infection among most segments of the Canadian population has led to changes in the etiologies and patterns of associated upper gastrointestinal diseases, including fewer peptic ulcers and their complications. Canadian Aboriginals and recent immigrants are among populations in which the prevalence of H pylori infection remains high and, therefore, the health risks imposed by H pylori remain a significant concern. Population-based strategies for H pylori eradication in groups with a low prevalence of infection are unlikely to be cost effective, but such measures are attractive in groups in which the prevalence rates of infection remain substantial. In addition to a lower prevalence of peptic ulcers and dyspepsia, the public health value of eradication may be particularly important if this leads to a reduction in the prevalence of gastric cancer in high prevalence groups. Therefore The Canadian Helicobacter Study Group held a conference that brought together experts in the field to address these issues, the results of which are reviewed in the present article. Canadians with the highest prevalence of H pylori infection are an appropriate focus for considering the health advantages of eradicating persistent infection. In Canadian communities with a high prevalence of both H pylori and gastric cancer, there remains an opportunity to test the hypothesis that H pylori infection is a treatable risk factor for malignancy.

Neglected tropical diseases of the Middle East and North Africa: review of their prevalence, distribution, and opportunities for control

The neglected tropical diseases (NTDs) are highly endemic but patchily distributed among the 20 countries and almost 400 million people of the Middle East and North Africa (MENA) region, and disproportionately affect an estimated 65 million people living on less than US$2 per day. Egypt has the largest number of people living in poverty of any MENA nation, while Yemen has the highest prevalence of people living in poverty. These two nations stand out for having suffered the highest rates of many NTDs, including the soil-transmitted nematode infections, filarial infections, schistosomiasis, fascioliasis, leprosy, and trachoma, although they should be recognized for recent measures aimed at NTD control. Leishmaniasis, especially cutaneous leishmaniasis, is endemic in Syria, Iran, Iraq, Libya, Morocco, and elsewhere in the region. Both zoonotic (Leishmania major) and anthroponotic (Leishmania tropica) forms are endemic in MENA in rural arid regions and urban regions, respectively. Other endemic zoonotic NTDs include cystic echinococcosis, fascioliasis, and brucellosis. Dengue is endemic in Saudi Arabia, where Rift Valley fever and Alkhurma hemorrhagic fever have also emerged. Great strides have been made towards elimination of several endemic NTDs, including lymphatic filariasis in Egypt and Yemen; schistosomiasis in Iran, Morocco, and Oman; and trachoma in Morocco, Algeria, Iran, Libya, Oman, Saudi Arabia, Tunisia, and the United Arab Emirates. A particularly noteworthy achievement is the long battle waged against schistosomiasis in Egypt, where prevalence has been brought down by regular praziquantel treatment. Conflict and human and animal migrations are key social determinants in preventing the control or elimination of NTDs in the MENA, while local political will, strengthened international and intersectoral cooperative efforts for surveillance, mass drug administration, and vaccination are essential for elimination.

Polyparasitism is associated with increased disease severity in Toxoplasma gondii-infected marine sentinel species

In 1995, one of the largest outbreaks of human toxoplasmosis occurred in the Pacific Northwest region of North America. Genetic typing identified a novel Toxoplasma gondii strain linked to the outbreak, in which a wide spectrum of human disease was observed. For this globally-distributed, water-borne zoonosis, strain type is one variable influencing disease, but the inability of strain type to consistently explain variations in disease severity suggests that parasite genotype alone does not determine the outcome of infection. We investigated polyparasitism (infection with multiple parasite species) as a modulator of disease severity by examining the association of concomitant infection of T. gondii and the related parasite Sarcocystis neurona with protozoal disease in wild marine mammals from the Pacific Northwest. These hosts ostensibly serve as sentinels for the detection of terrestrial parasites implicated in water-borne epidemics of humans and wildlife in this endemic region. Marine mammals (151 stranded and 10 healthy individuals) sampled over 6 years were assessed for protozoal infection using multi-locus PCR-DNA sequencing directly from host tissues. Genetic analyses uncovered a high prevalence and diversity of protozoa, with 147/161 (91%) of our sampled population infected. From 2004 to 2009, the relative frequency of S. neurona infections increased dramatically, surpassing that of T. gondii. The majority of T. gondii infections were by genotypes bearing Type I lineage alleles, though strain genotype was not associated with disease severity. Significantly, polyparasitism with S. neurona and T. gondii was common (42%) and was associated with higher mortality and more severe protozoal encephalitis. Our finding of widespread polyparasitism among marine mammals indicates pervasive contamination of waterways by zoonotic agents. Furthermore, the significant association of concomitant infection with mortality and protozoal encephalitis identifies polyparasitism as an important factor contributing to disease severity in marine mammals.

Severity of toxoplasmosis, a water-borne zoonosis, varies widely from chronic and benign to acutely fatal. Here, we investigate polyparasitism (infection with multiple parasite species) as one factor governing the spectrum of disease in Toxoplasma gondii infections. This study utilized wild marine mammals as sentinels to detect contamination of waterways by T. gondii and a similar protozoan, Sarcocystis neurona, which have been linked to water-borne outbreaks in humans and wildlife along North America's Pacific Coast. Using genetic tools, we found high rates of protozoal infection, predominantly concomitant infections, in animals inhabiting major waterways of the Pacific Northwest. These dual infections of T. gondii and S. neurona were more frequently associated with mortality and protozoal encephalitis than single infections, indicating a role for polyparasitism in disease severity. Finally, rare T. gondii genotypes linked to a major human outbreak in the Pacific Northwest were abundant in marine mammals of the region, emphasizing wildlife as relevant sentinels for evaluation of human health risks. Our data implicate polyparasitism as a critical factor associated with the severity of protozoal disease. We also identify the need for vigilant surveillance of public waterways to prevent fecal contamination recurrently threatening human and wildlife health along the Pacific coast.

Multiple zoonotic pathogens identified in canine feces collected from a remote Canadian indigenous community

Five genera of potentially zoonotic bacteria and parasites were detected in environmentally collected fecal samples from a remote indigenous community in Northern Saskatchewan, Canada. Organisms identified include Toxocara canis, Echniococcus granulosus, Giardia duodenalis, Cryptosporidium spp., and Campylobacter spp. The prevalence and intensity of Giardia spp. and Campylobacter spp. in fecal samples was particularly remarkable. Three-quarters of samples tested contained at least one zoonotic species of Campylobacter, and C. jejuni-containing feces had an average of 2.9 x 10(5) organisms/g. Over one-half of samples tested contained Giardia spp. with an average of 9,266 cysts/g. Zoonotic G. duodenalis Assemblage A was the only Giardia spp. genotype identified. These data suggest that canine feces have the potential to pose a significant health risk to Canadians in rural and remote indigenous communities.