Giardiasis: a review on assemblage distribution and epidemiology in India

Potential activity of Ferula macrecolea essential oil for treating Giardia lamblia infection through modulating electrolytes and suppressing NF-κB p65 pathway

Background

The pharmacological treatment of Giardia lamblia infection involves the use of chemical agents, such as metronidazole (MNZ). However, these medications are associated with a range of adverse effects, and their effectiveness is not definitively established. In light of the previously discussed information and the recognized antimicrobial properties of Ferula macrecolea, this study aims to investigate both the in vitro and in vivo anti-giardial effects of F. macrecolea essential oil (FME) on G. lamblia infection.

Methods

Gas chromatography-mass spectrometry (GC-MS) was utilized to analyze the chemical composition of the prepared FME. The MTT colorimetric assay was employed to assess FME's in vitro anti-giardial and cytotoxic activities. FME's in vivo effects were evaluated compared to MNZ in mice infected with G. lamblia. Additionally, the effects of FME therapy on serum electrolyte levels and the expression levels of inflammatory cytokines were assessed.

Results

The primary components of FME were identified as terpinolene (78.72%), n-nonanal (4.47%), and linalool (4.35%). FME significantly reduced the viability and growth rate of G. lamblia trophozoites (IC50 = 21.6 μg/mL) and cysts (IC50 = 27.6 μg/mL) in a dose-dependent manner compared to the control group (p < 0.001). The CC50 value for FME against normal intestinal cells was determined to be 207.4 μg/mL. In vivo, assays demonstrated that the administration of various doses of FME, particularly in combination with MNZ over 7 days, resulted in a statistically significant reduction in the mean number and viability of Giardia cysts, serum level electrolytes (sodium and potassium), and the expression levels of interleukin-1 (IL-1), tumor necrosis factor-alpha (TNF-α), nuclear factor κB p65 (NF-κB p65), and Toll-like receptor 4 (TLR-4) in mice with giardiasis (p < 0.001).

Conclusion

This study's results demonstrate the extract's efficacy in vitro against G. lamblia, exhibiting minimal cytotoxicity towards normal cells. Furthermore, the extract was shown to manage giardiasis in murine models by modulating electrolyte levels and inflammatory responses via suppressing the NF-κB p65/TLR pathways. However, further research is necessary to clarify the specific efficacy and mechanisms of action of the extract in combating G. lamblia infection.

Prevalence and Risk Factors of Giardia intestinalis Infestation and Assemblage of Isolates Among Monastery Primary School Children in Yangon, Myanmar

Giardiasis is one of the major causes of diarrhea among children. To determine the prevalence, risk factors, and genotype of Giardia intestinalis, a cross-sectional descriptive study was done on stool samples of 462 children attending three monastery primary schools from North Okkalapa Township in Yangon, Myanmar from January 2016 to February 2019. Socioeconomic data were collected using a pre-tested questionnaire after obtaining informed consent. Direct wet mount, formalin-ether sedimentation, and trichrome staining techniques were used for the primary identification and then molecular identification was carried out by conventional polymerase chain reaction (PCR)-sequencing assay. G. intestinalis was identified in 11.7% (54/462) of students. There was no significant association with water source (p=0.948) and drinking untreated water (p=0.595). The infection was more common in children with low-educated parents, unsanitary garbage disposal practices, and no restrooms. All isolates were G. intestinalis assemblage B. This is the first study characterizing human isolates in a lower region of Myanmar, at the molecular level [MOU1]. These findings pointed out the high prevalence of G. intestinalis among primary school children from densely populated and low-resource settings.

Molecular appraisal of Giardia intestinalis from Western India: A prospective observational study

Background

Giardia intestinalis is an intestinal protozoan which commonly causes parasitic gastroenteritis globally. It is a species complex consisting of at least eight assemblages (genotypes). In India, Giardia is mostly underreported and missed in asymptomatic cases.

Aim

The aim of this study was to genotype the G. intestinalis isolates from stool samples of patients at a tertiary care center in Rajasthan, India, and to clinically correlate it.

Methods

This prospective pilot cross-sectional study was conducted from 2019 to 2021 in a tertiary care center in western India. Patients who were microscopically positive for giardiasis were enrolled. DNA was extracted from their stool samples and amplified by polymerase chain reaction (PCR) using 4E1-HP as the target sequence. Anthropometric measurements and analysis were done for children by using Anthrocal application.

Results

A total of 50 patients were enrolled. Diarrhea was present in 18 patients (36%). Among these, 6 were immunocompromised and had different comorbidities. Among the children <12 years of age, 55.17% (n = 16/29) were stunted (<-2 S.D.), and among <5 years, 44.4% (n = 4/9) showed wasting (<-2 S.D.). A PCR product corresponding to assemblage B of G. intestinalis was amplified in 47 stool specimens. Only three stool samples were negative for both assemblages A and B and posed an interesting enigma.

Conclusion

In this study, a predominance of assemblage B of G. intestinalis was detected in 94% of the isolates. Furthermore, the possibility of zoonotic transmission could not be ruled out.

Real-time loop-mediated isothermal amplification for the detection of Giardia duodenalis in fecal specimens

INTRODUCTION

Giardiasis is a leading cause of subacute or chronic diarrhoea and is frequently associated with impaired physical, cognitive and psychosocial development, especially in children. The diagnosis relies mainly on the microscopic evaluation of stool specimens that have a low sensitivity. In contrast, molecular advancements like the polymerase chain reaction and Real-time loop-mediated isothermal amplification (Real-time LAMP) are promising techniques and reportedly have better diagnostic characteristics.

METHODS

We have evaluated the performance of Real-time LAMP for detecting Giardia in ninety stool specimens compared to microscopy and nested PCR.

RESULTS

A total of 35 fecal samples were detected positive by microscopy, 41 by nested PCR and 43 by real-time LAMP. Microscopy and nested PCR detected 33, microscopy and real-time LAMP detected 35, and nested PCR and real-time LAMP detected 41 positive samples.

CONCLUSION

The real-time LAMP assay was found suitable for the rapid and accurate detection of G. duodenalis with a better sensitivity in comparison to nested PCR and microscopy. Furthermore, besides being sensitive and rapid, LAMP had the advantage of an adequate rapid turn-around time of eleven to 15 ​min as compared to 5 ​h of nested PCR.

[Feline and canine giardiosis: An Update]

Giardia duodenalis is a facultative pathogenic intestinal parasite. Giardiosis in dogs and cats may appear with or without clinical signs. Typical signs include diarrhea with or without vomiting. The prevalence in young animals is high and may amount to up to 50%. There are 8 different genotypes (A - H), which are called assemblages. Assemblages C and D are most common in dogs and assemblage F most frequent in cats. However, animals may also be infected with the zoonotically effective assemblages A and B or exhibit mixed infections. The immunofluorescence test (IFA), the enzyme-linked immunosorbent assay (ELISA) and fecal centrifugation using zinc sulphate solution are currently recommended as diagnostic methods. Polymerase chain reaction (PCR) may be used to determine the corresponding assemblage. Approved treatments for giardiosis include fenbendazole and metronidazole. In addition, undertaking specific hygiene measures is warranted. Only animals showing clinical signs or those living in the same household with high-risk patients (e. g. immunosuppressed humans) are recommended to receive medication. The aim of treatment is clinical improvement of the diseased dogs and cats. Frequently, complete elimination of Giardia is not attained.

The ever -present need for biopsy to diagnose coeliac disease safely

Coeliac disease (CD) is an autoimmune enteropathy which occurs in genetically predisposed individuals on exposure to gluten. The recommended diagnostic approach includes serological screening by Anti-tissue Transglutaminase antibody (anti-tTG) followed by a small intestinal biopsy. As high anti-tTG antibody is expected to be significantly associated with MARSH III histopathological changes in the small intestine, it has now become the basis for a biopsy-free approach to diagnose CD. However, we report cases of giardiasis mimicking CD both clinically and serologically; differentiation demands small intestinal biopsy.

Prevalence of Intestinal Parasites and Associated Factors Among Psychiatric Patients Attending Felege Hiwot Comprehensive Specialized Referral Hospital, Northwest Ethiopia

Background

Intestinal parasitic infections are among the major public health problems in resource-poor countries such as Ethiopia. Certain segments of the population such as psychiatric patients are believed to be at higher risk of infection because of their poor hygiene practices. However, information on the prevalence and contributing factors among psychiatric patients is limited in Ethiopia.

Methods

A facility-based cross-sectional study was conducted among 432 psychiatric patients attending Felege Hiwot Comprehensive Specialized Referral Hospital, Northwest Ethiopia from May to July 2020. Participants were selected using a systematic random sampling technique. Data on socio-demography and associated factors were collected using a pre-tested structured questionnaire. Stool sample was collected and processed for parasitological examination using direct wet mount, modified Richie’s concentration, Kato-Katz and modified Ziehl-Neelsen staining techniques following standard protocols. Data were entered and analyzed using Statistical Package for the Social Sciences software version 20. The prevalence of intestinal parasitosis and associated factors were computed by descriptive statistics and binary logistic regression at 95% confidence interval (CI), respectively. Association between variables was considered statistically significant only if P-value <0.05 at 95% confidence level.

Results

A total of 168 (38.9%) participants were positive for at least a single species of intestinal parasite. Hookworm, Entamoeba histolytica/Entamoeba dispar and Ascaris lumbricoides were the most frequent parasites, detected in 74 (17.1%), 47 (10.9%) and 37 (8.6%) participants, respectively. Double infection was detected in 16 (9.5%) participants where 8 (4.8%) had hookworm and Ascaris lumbricoides co-infections. Not washing raw fruits and vegetables before eating (adjusted odds ratio = 8.402; 95% CI: 3.055–23.109; P <0.001) and having a psychiatric diagnosis other than bipolar disorder (adjusted odds ratio = 3.104; 95% CI: 1.334–7.222; P = 0.009) were significantly associated with intestinal parasitic infections.

Conclusion

The prevalence of intestinal parasites among psychiatric patients was significant. Therefore, improving hygiene practice and implementing regular screening for intestinal parasitic infection among psychiatric patients are recommended so as to control parasite transmission and improve the health of psychiatric patients.

A study on intestinal parasitic infections among school children in Karaikal

Introduction

Intestinal parasitic infections (IPIs) play a major role in global disease burden with significant morbidity. The most vulnerable age group was school going children and is transmitted through soil. About 90% of infected individuals remain asymptomatic. The present study was designed to screen for IPI among school children in Karaikal, to identify the asymptomatic infections and to assess the type and occurrence of IPIs.

Methodology

A cross-sectional study was carried out from July to September 2018 among school children in the age group of 6-14 years after getting ethical clearance. A total of 335 single stool samples were collected. The samples were subjected to macroscopic examination, microscopic examination and subjected to concentration techniques such as salt floatation and formal ether sedimentation technique. Two separate fresh stool smears were made on the microscopic slides for trichrome and modified acid-fast staining. The results were calculated as percentage, frequency/proportion, and Chi-square test using IBM SPSS software version 19.

Results

Only 90 (28%) out of 324 stool samples were positive for the presence of intestinal parasites. The sensitivity of formal ether sedimentation technique (58%) was higher than other techniques. None of the ova of helminths detected. Modified acid-fast staining was negative for coccidian parasites.

Conclusions

The low prevalence of protozoan parasites and total absence of helminths in the study revealed the effective role of nationwide deworming program and Swachh Bharat Abhiyan program. However, anthelminthic does not cover the protozoan parasites and it exists among asymptomatic healthy population.

Etiological Spectrum of Infective Diarrhea in Renal Transplant Patient by Stool PCR: An Indian Perspective

Introduction:

Diarrhea is a common cause of morbidity and mortality among renal transplant patients. The etiological spectrum of pathogens varies with regional diversity, socioeconomic conditions, sanitation, and eating habits. We aimed to delineate the etiological profile of gastrointestinal pathogens in renal transplant patients using the stool Polymerase chain reaction.

Methods:

In this single-center, retrospective analysis of patients from January 2016 to January 2018, all renal transplant patients who were admitted with severe diarrhea and underwent the stool Polymerase chain reaction (PCR) were included. In the control group, we included patients from the general population who were admitted with similar complaints in the general medicine ward and underwent stool PCR over the same duration.

Results:

One hundred ten admissions occurred over 2 years in the transplant group. 86% of samples were positive for infection. More than one organism was seen in 68% of the patient. Norovirus was the most common organism isolated. Giardia lamblia with Norovirus was the most common coinfection among the transplant population. In the control group, 87% of samples tested positive, with 53% of patients having more than one organism. Enteroaggregative E. coli was the common organism, Enteroaggregative E. coli with Enteropathogenic E. coli and Enterotoxigenic E. coli were the most common organism in combination. Both the groups had similar incidence of infection with multiple organisms.

Conclusion:

The etiological profile of gastrointestinal pathogens differs significantly between the transplant and general population. Coinfections are common in both populations. Norovirus is the most common pathogen in the transplant population, presenting as isolated as well as in coinfections.

Prevalence and Associated Risk Factors of Human Intestinal Protozoan Parasitic Infections in Ethiopia: A Systematic Review and Meta-Analysis

Background

Human intestinal protozoan parasitic infections (HIPPIs) are a series of public health problems in developing countries like Ethiopia. The overall prevalence of HIPPIs in Ethiopia is not known. Therefore, this systematic review and meta-analysis study is aimed at determining the overall prevalence of HIPPIs in Ethiopia.

Methods

Articles written in English were searched from online public databases. Searching terms used were "prevalence," "intestinal protozoan parasite," "associated factors," and "Ethiopia." We used Stata version 14 for meta-analysis and Cochran's Q test statistics and the I ² test for heterogeneity.

Result

A total of 286 articles were reviewed, but only 45 of them fulfilled the inclusion criteria. The pooled prevalence of HIPPIs in Ethiopia was 25.01% (95% CI: 20.08%-29.95%) where Entamoeba histolytica/dispar is the most prevalent (14.09%, 95% CI: 11.03%-17.14%) followed by Giardia lamblia (10.03%, 95% CI: 7.69%-12.38%) and Cryptosporidium spp. (5.93%, 95% CI: 2.95%-8.91%). This meta-analysis showed that family size (OR: 3.7, 95% CI: 1.45-5.85), source of drinking water (OR: 3.33, 95% CI: 1.30-5.36), open field defecation (OR: 2.91, 95% CI: 1.60-4.21), handwashing habit (OR: 2.82, 95% CI: 2.01-3.63), playing with soil (OR: 2.15, 95% CI: 1.01-3.29), the habit of eating raw vegetables (OR: 1.77, 95% CI: 1.03-2.51), and fingernail trimming (OR: 1.70, 95% CI: 0.89-2.25) were strongly associated with the HIPPIs in Ethiopia. High heterogeneity on the prevalence of HIPPIs was observed among studies within and among regions (I ² > 99% and P ≤ 0.01).

Conclusion

The prevalence of HIPPIs was significantly high among the Ethiopian population. Family size, source of drinking water, open field defecation, handwashing habit, the habit of eating raw vegetables, and fingernail trimming habits were significantly associated with HIPPIs.

Role of Polymerase Chain Reaction in Stool and Duodenal Biopsy for Diagnosis of Giardiasis in Patients with Persistent/Chronic Diarrhea

BACKGROUND

Giardia duodenalis is a common cause of chronic diarrhea especially in tropical countries. Diagnosis is based on microscopy (three stool samples) for trophozoites/cysts. Role of stool or duodenal biopsy PCR as a diagnostic method needs to be defined. We conducted a prospective study to determine the diagnostic characteristics of G. duodenalis stool and duodenal biopsy PCR in comparison to stool microscopy (reference standard). Later, we compared other techniques with stool PCR, considering it as new reference standard and characterized the type of Giardia assemblage.

METHODS

G. duodenalis stool nested PCR was first evaluated using 40 positive controls and 50 negative controls considering stool microscopy as reference standard. Patients with chronic diarrhea (n = 100) were evaluated by stool microscopy and nested PCR. In 30 patients in whom upper gastrointestinal endoscopy was performed, duodenal biopsy samples were obtained and evaluated by histopathology, imprint cytology, and nested PCR. The type of Giardia assemblage was detected by assemblage-specific PCR.

RESULTS

Stool nested PCR was found to have sensitivity and specificity of 100% and 94%, respectively, compared to stool microscopy. In patients with chronic diarrhea, 48% had evidence of Giardia infection. Stool microscopy detected 65%, stool PCR detected an additional 27%, and duodenal biopsy PCR detected an additional 8% of cases. The commonest assemblage found was assemblage B. Clinical and demographic characteristics were similar in patients harboring either assemblage A or B.

CONCLUSION

Stool PCR is more sensitive than stool microscopy. By utilizing stool microscopy, stool nested PCR, and duodenal biopsy PCR in sequential manner, diagnostic yield can be increased.

Molecular and epidemiological characterization of Giardia Intestinalis assemblages detected in Djelfa, Algeria

Giardia intestinalis is a flagellated protozoan that lives and proliferates in the small intestine of the host causing giardiasis. The route of transmission is the fecal-oral route, either directly or indirectly. Limited genetic information on G. intestinalis is known in Algeria. This study aimed to estimate the prevalence of G. intestinalis assemblages in the city of Djelfa. A total of 355 fecal samples were collected from symptomatic and asymptomatic school children aged ranged between 6 and 11 years old. Genotyping was done to the Giardia positive samples (n = 30) targeting the beta-giardin gene by applying PCR/RFLP assay. Our data showed that most of the cases were asymptomatic (56.7%). Co-infection with other intestinal parasites was found in 16.6% of cases. We obtained 28/30 positive PCR products while two samples only showed false-negative results, and only 20 samples have shown strong PCR products suitable for RFLP analysis. Assemblage A (70%) was more prevalent than assemblage B (30%) and was more expressed by signs than assemblage B. Moreover, only assemblage A was associated with close contacts with domestic animals and birds. In conclusion, this study gave the first molecular data on G. intestinalis isolates in the city of Djelfa. Further expanded studies using more genes and covering other cities in Algeria are mostly needed.

Cytopreparation of duodenal biopsy fixative improves detection rate of giardia in clinically suspected cases

INTRODUCTION

Giardia intestinalis is a flagellated protozoan, frequently documented as an agent for enteric illness worldwide. Laboratory procedures for diagnosis include stool examination, antigenic detection assays and, at times, mucosal biopsy. We hypothesised that the formalin fixative used as a preservative for mucosal biopsy can be a good diagnostic sample for detecting surface mucosal and luminal infective agents such as giardia. The aim of the study was to find out the utility of processing the remaining formalin fixative as a complementary diagnostic method for detecting giardia.

METHODS

This study included 200 cases of duodenal biopsies sampled over 6 months. The biopsies were picked up using clean forceps and the remaining fixative was processed using standard cytospin protocol. The cytospin preparation and formalin-fixed paraffin-embedded tissue sections were examined by two pathologists independently blinded to each others findings.

RESULTS

On cytology, trophozoites of giardia were detected in 23 out of 200 cases (11.50%). The cytomorphology of pear-shaped organism with paired flagella and nuclei is very diagnostic. One case also showed presence of cryptosporidium spores. No other intestinal parasite was seen. Out of the 23 positive cytology samples, only 12 (6%) corresponding formalin-fixed paraffin-embedded tissue sections showed presence of giardia.

CONCLUSION

Concurrent examination of duodenal biopsy and the formalin fixative cytopreparation in cases with high index of clinical suspicion of giardiasis proved to be a useful adjunct to biopsy diagnosis of giardiasis, which was statistically significant (P < .0001). This approach adds negligible cost and effort but with good diagnostic yield. We recommend that the formalin cytopreparation be used as a complementary technique to biopsy for cases suspected of intestinal parasitic infection.

Molecular characterization of Giardia lamblia in children less than 5 years of age with diarrhoea attending the Bengo General Hospital, Angola

Background

Giardia lamblia is a pathogenic intestinal protozoan with high prevalence in developing countries, especially among children. Molecular characterization has revealed the existence of eight assemblages, with A and B being more commonly described in human infections. Despite its importance, to our knowledge this is the first published molecular analysis of G. lamblia assemblages in Angola.

Methods

The present study aimed to identify the assemblages of G. lamblia in children with acute diarrhoea presenting at the Bengo General Hospital, Angola. A stool sample was collected and microscopy and immunochromatographic tests were used. DNA was extracted and assemblage determination was performed through amplification of the gene fragment ssu-rRNA (175 bp) and β-giardin (511 bp) through polymerase chain reaction and DNA sequencing.

Results

Of the 16 stool samples screened, 12 were successfully sequenced. Eleven isolates were assigned to assemblage B and one to assemblage A. Subassemblage determination was not possible for assemblage B, while the single isolate assigned to assemblage A was identified as belonging to subassemblage A3.

Conclusion

This study provides information about G. lamblia assemblages in Bengo Province, Angola and may contribute as a first step in understanding the molecular epidemiology of this protozoan in the country.

GenBank accession numbers for the ssur-RNA gene: MF479750, MF479751, MF479752, MF479753, MF479754, MF479755, MF479756, MF479757, MF479758, MF479759, MF479760, MF479761.

GenBank accession numbers for the β-giardin gene: MF565378, MF565379, MF565380, MF565381.

Molecular characterisation and taxon assemblage typing of giardiasis in primary school children living close to the shoreline of Lake Albert, Uganda

As part of an epidemiological survey for gastrointestinal parasites in school children across five primary schools on the shoreline of Lake Albert, the prevalence of giardiasis was 87.0% (n = 254) as determined by real-time PCR analysis of faecal samples with a genus-specific Giardia 18S rDNA probe. Faecal samples were further characterised with taxon assemblage-specific triose phosphate isomerase (TPI) Taqman® probes and by sequence characterisation of the β-giardin gene. While less sensitive than the 18S rDNA assay, general prevalence by TPI probes was 52.4%, with prevalence by taxon assemblage of 8.3% (assemblage A), 35.8% (assemblage B) and 8.3% co-infection (A & B assemblages). While assemblage B was dominant across the sample, proportions of assemblages A and B, and co-infections thereof, varied by school and by age of child; mixed infections were particularly common at Runga school (OR = 6.9 [95% CI; 2.5, 19.3]) and in children aged 6 and under (OR = 2.7 [95% CI; 1.0, 7.3]). Infection with assemblage B was associated with underweight children (OR = 2.0 [95% CI; 1.0, 3.9]). The presence of each assemblage was also confirmed by sequence analysis of the β-giardin gene finding sub-assemblage AII and further genetic diversity within assemblage B. To better explore the local epidemiology of giardiasis and its impact on child health, additional sampling of school children with assemblage typing would be worthwhile.

Occurrence, genotyping, and health risk of Cryptosporidium and Giardia in recreational lakes in Tianjin, China

Cryptosporidium and Giardia are critical parasites in the etiology of diarrhea worldwide, and often cause waterborne outbreaks. The presence of Cryptosporidium and Giardia in recreational lakes was investigated with molecular characterization, and a comprehensive quantitative microbial risk assessment (QMRA) of protozoan infections was performed, considering multiple exposure pathways, differences in age, sex, and disease severity, and the genotypes of the protozoa. Forty-three (82.7%) and 51 (98.1%) water samples were positive for Cryptosporidium oocysts and Giardia cysts, respectively, with average counts of 3.65 oocysts/10 L and 12.58 cysts/10 L, respectively. Six Cryptosporidium species and three Giardia lamblia assemblages were confirmed with molecular analyses. The protozoan concentration was significantly associated with water turbidity, but not with the total coliform numbers. Swimming in the lakes entailed the highest incidence risk of 5.72 × 10^-4 per person per year (pppy) (95% confidence interval (CI): 0.03-43.33 × 10^-4) for Cryptosporidium and 4.04 × 10^-4 pppy (95% CI: 0.01-32.66 × 10^-4) for Giardia, whereas wading entailed the lowest risk (2.20 × 10^-4 and 1.70 × 10^-4 pppy, respectively). The annual burdens attributable to recreational-water-associated cryptosporidiosis and giardiasis were 3.44 (95% CI: 0.04-23.51) and 1.81 (95% CI: 0.01-12.96) disability-adjusted life years per 1,000,000 individuals per year, respectively. Children were more likely to have an individual disease burden than adults, and males were more likely than females. Sensitivity analysis highlighted the great importance of controlling the proportion of exposed individuals and reducing the frequency of exposure. The methodology and results of this study will allow us to better evaluate and reduce the burden of Cryptosporidium and/or Giardia infections associated with recreational water use in China and other countries.

Presence and molecular characterization of Cryptosporidium and Giardia in recreational lake water in Tianjin, China: a preliminary study

Little is known about the occurrence of Cryptosporidium and Giardia in recreational water in China. A total of 52 samples were collected from recreational lakes in Tianjin during a high-occurrence season (June-October) for the waterborne cryptosporidiosis and giardiasis, and the occurrence and genotypes of Cryptosporidium and Giardia were investigated. The results showed that 82.7% (43) and 98.1% (51) of samples were positive for Cryptosporidium oocyst and Giardia cysts, respectively. The mean concentration of parasites was 3.65 oocysts/10 L and 12.58 cysts/10 L, respectively. Molecular characterization revealed that the presence of Cryptosporidium parvum, C. andersoni, C. hominis, C. meleagridis, C. fragile, C. ubiquitum, and Giardia lamblia assemblage A, B and D. The protozoan contamination in the studied lakes may originate from animal feces on ground, which was washed into the lake by stormwater runoff. Nevertheless, there is a potential risk of infection during recreational activities in the lake because the dominant detected protozoan genotypes are common human pathogens. Moreover, microbial indicators analysis does not adequately indicate the protozoan contamination in recreational water. The information from this study will be valuable for future protozoan source tracking, and any further control interventions against Cryptosporidium and/or Giardia infection associated with recreational water.

Goats in the city: prevalence of Giardia duodenalis and Cryptosporidium spp. in extensively reared goats in northern India

BACKGROUND

Various characteristics of goats mean they are highly suitable livestock for backyard rearing by people with limited resources. They are a popular livestock choice in India, where they are often kept to supplement an already scarce income. In these settings, hygiene and sanitation standards tend to be low, and weakens the interface between humans and animals, thus reducing the barrier between them and thereby increasing the likelihood that zoonotic and anthroponotic infections will occur.

RESULTS

This study reports an investigation of the occurrence of Cryptosporidium spp. and Giardia duodenalis in goats being reared in different settings in urban and peri-urban areas in northern India, and addressed the zoonotic potential of these important protozoan parasites shed from goats living close to humans. The overall prevalence of G. duodenalis was 33.8 and 0.5% for Cryptosporidium spp.; the relatively low prevalence of cryptosporidiosis may reflect that most samples were derived from adult animals. The prevalence of G. duodenalis excretion was found to be similar to that reported in other studies. However, although other studies have reported a predominance of non-zoonotic Assemblage E in goats, in this study potentially zoonotic Assemblages predominated [Assemblage A (36%) and Assemblage B (32%)].

CONCLUSIONS

The results of this study indicate that in this area where goats and humans are living in close proximity, there may be sharing of intestinal parasites, which can be detrimental for both host species.

The single cyclic nucleotide-specific phosphodiesterase of the intestinal parasite Giardia lamblia represents a potential drug target

Background

Giardiasis is an intestinal infection correlated with poverty and poor drinking water quality, and treatment options are limited. According to the Center for Disease Control and Prevention, Giardia infections afflict nearly 33% of people in developing countries, and 2% of the adult population in the developed world. This study describes the single cyclic nucleotide-specific phosphodiesterase (PDE) of G. lamblia and assesses PDE inhibitors as a new generation of anti-giardial drugs.

Methods

An extensive search of the Giardia genome database identified a single gene coding for a class I PDE, GlPDE. The predicted protein sequence was analyzed in-silico to characterize its domain structure and catalytic domain. Enzymatic activity of GlPDE was established by complementation of a PDE-deficient Saccharomyces cerevisiae strain, and enzyme kinetics were characterized in soluble yeast lysates. The potency of known PDE inhibitors was tested against the activity of recombinant GlPDE expressed in yeast and against proliferating Giardia trophozoites. Finally, the localization of epitope-tagged and ectopically expressed GlPDE in Giardia cells was investigated.

Results

Giardia encodes a class I PDE. Catalytically important residues are fully conserved between GlPDE and human PDEs, but sequence differences between their catalytic domains suggest that designing Giardia-specific inhibitors is feasible. Recombinant GlPDE hydrolyzes cAMP with a K_m of 408 μM, and cGMP is not accepted as a substrate. A number of drugs exhibit a high degree of correlation between their potency against the recombinant enzyme and their inhibition of trophozoite proliferation in culture. Epitope-tagged GlPDE localizes as dots in a pattern reminiscent of mitosomes and to the perinuclear region in Giardia.

Conclusions

Our data strongly suggest that inhibition of G. lamblia PDE activity leads to a profound inhibition of parasite proliferation and that GlPDE is a promising target for developing novel anti-giardial drugs.

Cellular signaling by the cyclic nucleotides cAMP and cGMP is ubiquitously found in organisms from human to unicellular parasites. Cyclic nucleotide-specific phosphodiesterases (PDEs) are pivotal regulators of these signaling processes and these enzymes represent important drug targets for a variety of diseases. Eleven PDE families are distinguished in humans and selective inhibition of a single human PDE family without targeting others is feasible. In parasites, interference in the signaling mechanism by PDE inhibition may be fatal. The diarrhea-causing parasite Giardia lamblia contains only one single PDE, named GlPDE. GlPDE activity is highly impaired by a range of PDE inhibitors, which also suppress parasite proliferation in vitro. Thus, there is a good agreement between PDE inhibition and parasite drug susceptibility. We demonstrate molecular differences between human PDEs and GlPDE that can be exploited for the development of GlPDE-selective inhibitors. Finally, our data may suggest localization of GlPDE to mitosome organelles, which are absent in human cells and thus are in the focus as possible targets for the treatment of giardiasis. This may add to the notion that GlPDE represents a potential target for the development of novel anti-giardial drugs.

Determinants and Impact of Giardia Infection in the First 2 Years of Life in the MAL-ED Birth Cohort

BACKGROUND.

Giardia are among the most common enteropathogens detected in children in low-resource settings. We describe here the epidemiology of infection with Giardia in the first 2 years of life in the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project (MAL-ED), a multisite birth-cohort study.

METHODS.

From 2089 children, 34916 stool samples collected during monthly surveillance and episodes of diarrhea were tested for Giardia using an enzyme immunoassay. We quantified the risk of Giardia detection, identified risk factors, and assessed the associations with micronutrients, markers of gut inflammation and permeability, diarrhea, and growth using multivariable linear regression.

RESULTS.

The incidence of at least 1 Giardia detection varied according to site (range, 37.7%-96.4%) and was higher in the second year of life. Exclusive breastfeeding (HR for first Giardia detection in a monthly surveillance stool sample, 0.46 [95% confidence interval (CI), 0.28-0.75]), higher socioeconomic status (HR, 0.74 [95% CI, 0.56-0.97]), and recent metronidazole treatment (risk ratio for any surveillance stool detection, 0.69 [95% CI, 0.56-0.84]) were protective. Persistence of Giardia (consecutive detections) in the first 6 months of life was associated with reduced subsequent diarrheal rates in Naushahro Feroze, Pakistan but not at any other site. Giardia detection was also associated with an increased lactulose/mannitol ratio. Persistence of Giardia before 6 months of age was associated with a -0.29 (95% CI, -0.53 to -0.05) deficit in weight-for-age z score and -0.29 (95% CI, -0.64 to 0.07) deficit in length-for-age z score at 2 years.

CONCLUSIONS.

Infection with Giardia occurred across epidemiological contexts, and repeated detections in 40% of the children suggest that persistent infections were common. Early persistent infection with Giardia, independent of diarrhea, might contribute to intestinal permeability and stunted growth.

Occurrence of Giardia, Cryptosporidium, and Entamoeba in wild rhesus macaques (Macaca mulatta) living in urban and semi-rural North-West India

Giardia duodenalis, Cryptosporidium spp., and Entamoeba spp. are intestinal protozoa capable of infecting a range of host species, and are important causes of human morbidity and mortality. Understanding their epidemiology is important, both for public health and for the health of the animals they infect. This study investigated the occurrence of these protozoans in rhesus macaques (Macaca mulatta) in India, with the aim of providing preliminary information on the potential for transmission of these pathogens between macaques and humans. Faecal samples (n = 170) were collected from rhesus macaques from four districts of North-West India. Samples were analysed for Giardia/Cryptosporidium using a commercially available direct immunofluorescent antibody test after purification via immunomagnetic separation. Positive samples were characterised by sequencing of PCR products. Occurrence of Entamoeba was investigated first by using a genus-specific PCR, and positive samples further investigated via species-specific PCRs for Entamoeba coli, Entamoeba histolytica, Entamoeba dispar and Entamoeba moshkovskii. Giardia cysts were found in 31% of macaque samples, with all isolates belonging to Assemblage B. Cryptosporidium oocysts were found in 1 sample, however this sample did not result in amplification by PCR. Entamoeba spp. were found in 79% of samples, 49% of which were positive for E. coli. Multiplex PCR for E. histolytica, E. dispar and E. moshkovskii, did not result in amplification in any of the samples. Thus in 51% of the samples positive at the genus specific PCR, the Entamoeba species was not identified. This study provides baseline information on the potential for transmission of these zoonotic parasites at the wildlife-human interface.

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Intestinal protozoa in wild rhesus macaques (n = 170) in India investigated.

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Cryptosporidium oocysts identified in only one sample.

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No zoonotic Entamoeba detected, but Entamoeba coli and unknown Entamoeba spp.

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Giardia duodenalis cysts detected in approximately 30% samples.

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Only Assemblage B Giardia, even when exposure to Assemblages A and E in calves.

Nested PCR targeting intergenic spacer (IGS) in genotyping of Giardia duodenalis isolated from symptomatic and asymptomatic infected Egyptian school children

Distinct sequences of Giardia duodenalis assemblages raised the hypothesis that certain assemblages may contribute to its clinical outcome. However, sequences analysis is time consuming, expensive, and needs many manual operations. Nested PCR targeting intergenic spacer (IGS) region was applied successfully to genotype G. duodenalis. This study aimed to identify the prevalence of G. duodenalis assemblages among giardiasis school children and its relation to the presence of symptoms using nested IGS/PCR. Of 65 microscopically confirmed Giardia-positive samples, 65 samples were genotyped proving high sensitivity (92.3%) of IGS/PCR. Negative IGS/PCR samples were also negative for β-giardin gene. Subassemblage AI was the commonest with 66.6% (20/30) among asymptomatic children compared to 53.3% (16/30) of symptomatic, while assemblage B was found in 40% (12/30) of symptomatic compared to 20% (6/30) of asymptomatic. The difference was significant. AII was only found in asymptomatic with 13.4% (4/30), while mixed infections (AI&B) were recorded only in 6.6% (2/30) of symptomatic group. A significant relation was found between younger children susceptibility for AI and B infections as presented in 77.7 (12/16) and 83.3% (10/12) of symptomatic, respectively, and 80 (16/80) and 33.4% (2/4) of asymptomatic, respectively. Significant relations were found between AI with intermittent diarrhea and B with chronic. A significant relation was found between assemblage distributions and heavy infection intensity. In conclusion, higher incidence of assemblage B among symptomatic children compared to asymptomatic could denote its possible pathogenic potential.

Frequency, diagnostic performance of coproantigen detection and genotyping of the Giardia among patients referred to a multi-level teaching hospital in northern India

Giardiasis, a common gastrointestinal parasitic infection in tropics, is diagnosed on stool microscopy (gold standard); however, its sensitivity is low due to intermittent fecal shedding. Coproantigen detection (ELISA) is useful but requires further evaluation. We aimed to study: (a) detection of Giardia by stool microscopy and/or coproantigen, (b) diagnostic performance of fecal antigen detection and microscopy, and c) genotypic characterization of G. lamblia using PCR specific for triose phosphate isomerase (tpi) gene. Stool samples from 2992 patients were examined by microscopy from March 2013 to March 2015 in a multi level teaching hospital in northern India. Giardia coproantigen detection was performed by ELISA in a subset of patients. Genetic characterization of G. lamblia was performed by PCR targeting tpi gene in a subset of microscopy positive stool samples. Of 2992 patients, 132 (4.4%) had Giardia by microscopy (cyst/trophozoite) and/or ELISA. ELISA was performed in 264 patients; of them, 127 were positive by microscopy. Sensitivity, specificity, positive and negative predictive values of ELISA were 91, 91, 94, and 91%, respectively, using microscopy as a gold standard. PCR was performed in 116 randomly selected samples having Giardia using tpi gene. Assemblages A and B were found among 44 (38%) and 72 (62%) patients, respectively. Assemblage B was more often associated with malnutrition and loss of appetite than A (48/72 [67%] vs. 21/44 [48%], P = 0.044 and 17/72 [24%] vs. 14/44 [32%], P = 0.019). We conclude that 4.4% of studied population had giardiasis. Fecal antigen is a useful method for diagnosis and assemblage B is the most common genotype.

Molecular Characterization of Cryptosporidium Species and Giardia duodenalis from Symptomatic Cambodian Children

Background

In a prospective study, 498 single faecal samples from children aged under 16 years attending an outpatient clinic in the Angkor Hospital for Children, northwest Cambodia, were examined for Cryptosporidium oocysts and Giardia cysts using microscopy and molecular assays.

Methodology/Principal Findings

Cryptosporidium oocysts were detected in 2.2% (11/498) of samples using microscopy and in 7.7% (38/498) with molecular tests. Giardia duodenalis cysts were detected in 18.9% (94/498) by microscopy and 27.7% (138/498) by molecular tests; 82% of the positive samples (by either method) were from children aged 1–10 years. Cryptosporidium hominis was the most common species of Cryptosporidium, detected in 13 (34.2%) samples, followed by Cryptosporidium meleagridis in 9 (23.7%), Cryptosporidium parvum in 8 (21.1%), Cryptosporidium canis in 5 (13.2%), and Cryptosporidium suis and Cryptosporidium ubiquitum in one sample each. Cryptosporidium hominis and C. parvum positive samples were subtyped by sequencing the GP60 gene: C. hominis IaA16R6 and C. parvum IIeA7G1 were the most abundant subtypes. Giardia duodenalis was typed using a multiplex real-time PCR targeting assemblages A and B. Assemblage B (106; 76.8% of all Giardia positive samples) was most common followed by A (12.3%) and mixed infections (5.1%). Risk factors associated with Cryptosporidium were malnutrition (AOR 9.63, 95% CI 1.67–55.46), chronic medical diagnoses (AOR 4.51, 95% CI 1.79–11.34) and the presence of birds in the household (AOR 2.99, 95% CI 1.16–7.73); specifically C. hominis (p = 0.03) and C. meleagridis (p<0.001) were associated with the presence of birds. The use of soap was protective against Giardia infection (OR 0.74, 95% CI 0.58–0.95).

Conclusions/Significance

This is the first report to describe the different Cryptosporidium species and subtypes and Giardia duodenalis assemblages in Cambodian children. The variety of Cryptosporidium species detected indicates both anthroponotic and zoonotic transmission in this population. Interventions to improve sanitation, increase hand washing after defecation and before preparing food and promote drinking boiled water may reduce the burden of these two parasites.

The parasites Cryptosporidium and Giardia frequently cause diarrhea in children worldwide. They can be transmitted from animals to humans and between humans, either through direct contact, from sewage, or by contamination of food and water. The importance of these infections in Cambodian children is unknown. Animals are an essential part of life in Southeast Asia with livestock as well as domestic animals living in close proximity to humans. We previously conducted a prospective study to determine the intestinal parasites causing disease in symptomatic children attending hospital in Siem Reap, Northwestern Cambodia. This study examines these two parasites in more detail using molecular methods which provide better detection and are more discriminating. We were able to determine the different”strains” of Cryptosporidium and Giardia and, along with risk factor data, concluded that most of the infections were spread between people or within households suggesting that public health programmes should concentrate on improved sanitation, community handwashing initiatives and better food and water hygiene practices.

Cyclic AMP Regulates Social Behavior in African Trypanosomes

The protozoan parasite Trypanosoma brucei engages in surface-induced social behavior, termed social motility, characterized by single cells assembling into multicellular groups that coordinate their movements in response to extracellular signals. Social motility requires sensing and responding to extracellular signals, but the underlying mechanisms are unknown. Here we report that T. brucei social motility depends on cyclic AMP (cAMP) signaling systems in the parasite's flagellum (synonymous with cilium). Pharmacological inhibition of cAMP-specific phosphodiesterase (PDE) completely blocks social motility without impacting the viability or motility of individual cells. Using a fluorescence resonance energy transfer (FRET)-based sensor to monitor cAMP dynamics in live cells, we demonstrate that this block in social motility correlates with an increase in intracellular cAMP levels. RNA interference (RNAi) knockdown of the flagellar PDEB1 phenocopies pharmacological PDE inhibition, demonstrating that PDEB1 is required for social motility. Using parasites expressing distinct fluorescent proteins to monitor individuals in a genetically heterogeneous community, we found that the social motility defect of PDEB1 knockdowns is complemented by wild-type parasites in trans. Therefore, PDEB1 knockdown cells are competent for social motility but appear to lack a necessary factor that can be provided by wild-type cells. The combined data demonstrate that the role of cyclic nucleotides in regulating microbial social behavior extends to African trypanosomes and provide an example of transcomplementation in parasitic protozoa.

IMPORTANCE

In bacteria, studies of cell-cell communication and social behavior have profoundly influenced our understanding of microbial physiology, signaling, and pathogenesis. In contrast, mechanisms underlying social behavior in protozoan parasites are mostly unknown. Here we show that social behavior in the protozoan parasite Trypanosoma brucei is governed by cyclic-AMP signaling systems in the flagellum, with intriguing parallels to signaling systems that control bacterial social behavior. We also generated a T. brucei social behavior mutant and found that the mutant phenotype is complemented by wild-type cells grown in the same culture. Our findings open new avenues for dissecting social behavior and signaling in protozoan parasites and illustrate the capacity of these organisms to influence each other's behavior in mixed communities.

Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

Up-to-date evidence on levels and trends for age-sex-specific all-cause and cause-specific mortality is essential for the formation of global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013) we estimated yearly deaths for 188 countries between 1990, and 2013. We used the results to assess whether there is epidemiological convergence across countries.

METHODS

We estimated age-sex-specific all-cause mortality using the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data. We generally estimated cause of death as in the GBD 2010. Key improvements included the addition of more recent vital registration data for 72 countries, an updated verbal autopsy literature review, two new and detailed data systems for China, and more detail for Mexico, UK, Turkey, and Russia. We improved statistical models for garbage code redistribution. We used six different modelling strategies across the 240 causes; cause of death ensemble modelling (CODEm) was the dominant strategy for causes with sufficient information. Trends for Alzheimer's disease and other dementias were informed by meta-regression of prevalence studies. For pathogen-specific causes of diarrhoea and lower respiratory infections we used a counterfactual approach. We computed two measures of convergence (inequality) across countries: the average relative difference across all pairs of countries (Gini coefficient) and the average absolute difference across countries. To summarise broad findings, we used multiple decrement life-tables to decompose probabilities of death from birth to exact age 15 years, from exact age 15 years to exact age 50 years, and from exact age 50 years to exact age 75 years, and life expectancy at birth into major causes. For all quantities reported, we computed 95% uncertainty intervals (UIs). We constrained cause-specific fractions within each age-sex-country-year group to sum to all-cause mortality based on draws from the uncertainty distributions.

FINDINGS

Global life expectancy for both sexes increased from 65.3 years (UI 65.0-65.6) in 1990, to 71.5 years (UI 71.0-71.9) in 2013, while the number of deaths increased from 47.5 million (UI 46.8-48.2) to 54.9 million (UI 53.6-56.3) over the same interval. Global progress masked variation by age and sex: for children, average absolute differences between countries decreased but relative differences increased. For women aged 25-39 years and older than 75 years and for men aged 20-49 years and 65 years and older, both absolute and relative differences increased. Decomposition of global and regional life expectancy showed the prominent role of reductions in age-standardised death rates for cardiovascular diseases and cancers in high-income regions, and reductions in child deaths from diarrhoea, lower respiratory infections, and neonatal causes in low-income regions. HIV/AIDS reduced life expectancy in southern sub-Saharan Africa. For most communicable causes of death both numbers of deaths and age-standardised death rates fell whereas for most non-communicable causes, demographic shifts have increased numbers of deaths but decreased age-standardised death rates. Global deaths from injury increased by 10.7%, from 4.3 million deaths in 1990 to 4.8 million in 2013; but age-standardised rates declined over the same period by 21%. For some causes of more than 100,000 deaths per year in 2013, age-standardised death rates increased between 1990 and 2013, including HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anaemias. Diarrhoeal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than 5 years. The most important pathogens are rotavirus for diarrhoea and pneumococcus for lower respiratory infections. Country-specific probabilities of death over three phases of life were substantially varied between and within regions.

INTERPRETATION

For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries. Important gaps exist in the empirical data for cause of death estimates for some countries; for example, no national data for India are available for the past decade.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

Up-to-date evidence on levels and trends for age-sex-specific all-cause and cause-specific mortality is essential for the formation of global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013) we estimated yearly deaths for 188 countries between 1990, and 2013. We used the results to assess whether there is epidemiological convergence across countries.

METHODS

We estimated age-sex-specific all-cause mortality using the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data. We generally estimated cause of death as in the GBD 2010. Key improvements included the addition of more recent vital registration data for 72 countries, an updated verbal autopsy literature review, two new and detailed data systems for China, and more detail for Mexico, UK, Turkey, and Russia. We improved statistical models for garbage code redistribution. We used six different modelling strategies across the 240 causes; cause of death ensemble modelling (CODEm) was the dominant strategy for causes with sufficient information. Trends for Alzheimer's disease and other dementias were informed by meta-regression of prevalence studies. For pathogen-specific causes of diarrhoea and lower respiratory infections we used a counterfactual approach. We computed two measures of convergence (inequality) across countries: the average relative difference across all pairs of countries (Gini coefficient) and the average absolute difference across countries. To summarise broad findings, we used multiple decrement life-tables to decompose probabilities of death from birth to exact age 15 years, from exact age 15 years to exact age 50 years, and from exact age 50 years to exact age 75 years, and life expectancy at birth into major causes. For all quantities reported, we computed 95% uncertainty intervals (UIs). We constrained cause-specific fractions within each age-sex-country-year group to sum to all-cause mortality based on draws from the uncertainty distributions.

FINDINGS

Global life expectancy for both sexes increased from 65.3 years (UI 65.0-65.6) in 1990, to 71.5 years (UI 71.0-71.9) in 2013, while the number of deaths increased from 47.5 million (UI 46.8-48.2) to 54.9 million (UI 53.6-56.3) over the same interval. Global progress masked variation by age and sex: for children, average absolute differences between countries decreased but relative differences increased. For women aged 25-39 years and older than 75 years and for men aged 20-49 years and 65 years and older, both absolute and relative differences increased. Decomposition of global and regional life expectancy showed the prominent role of reductions in age-standardised death rates for cardiovascular diseases and cancers in high-income regions, and reductions in child deaths from diarrhoea, lower respiratory infections, and neonatal causes in low-income regions. HIV/AIDS reduced life expectancy in southern sub-Saharan Africa. For most communicable causes of death both numbers of deaths and age-standardised death rates fell whereas for most non-communicable causes, demographic shifts have increased numbers of deaths but decreased age-standardised death rates. Global deaths from injury increased by 10.7%, from 4.3 million deaths in 1990 to 4.8 million in 2013; but age-standardised rates declined over the same period by 21%. For some causes of more than 100,000 deaths per year in 2013, age-standardised death rates increased between 1990 and 2013, including HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anaemias. Diarrhoeal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than 5 years. The most important pathogens are rotavirus for diarrhoea and pneumococcus for lower respiratory infections. Country-specific probabilities of death over three phases of life were substantially varied between and within regions.

INTERPRETATION

For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries. Important gaps exist in the empirical data for cause of death estimates for some countries; for example, no national data for India are available for the past decade.

FUNDING

Bill & Melinda Gates Foundation.

"Freezing" parasites in pre-Himalayan region, Himachal Pradesh: Experience with mini-FLOTAC

BACKGROUND

Helminths and protozoa infections pose a great burden especially in developing, countries, due to morbidity caused both by acute and chronic infections. Data on distribution of intestinal parasitic infections among the native and expatriates populations in Himachal Pradesh are scarce. The aim of our survey was to analyze the intestinal parasitic burden in communities from Dharamsala, Kangra district, in clinical and public health settings. We also field-tested the mini- FLOTAC, an innovative diagnostic device.

METHODS

Subjects referring to the Tibetan Delek Hospital for abdominal discomfort and all children of the Tibetan Primary School in Dharamsala were screened for intestinal parasitic infections with direct smear, formol-ether concentration (FEC) method and mini-FLOTAC, their clinical history was recorded, and correlations between clinical symptoms and infections analyzed.

RESULTS

152 subjects were screened for intestinal parasites, of which 72 subjects in the outpatients department (OPD) (36 expatriates and 36 natives) and 80 in the school. 60% of schoolchildren and 57% of OPD patients were found positive for any infection, the most represented were protozoa infections (50%), whereas helminthic infections accounted only for 13% and 20% in OPD patients and schoolchildren, respectively. The most prevalent among helminths was Ascaris lumbricoides (11%). Giardia intestinalis was more present among schoolchildren than the OPD patients (20% vs 6%) and E. histolytica/dispar was more prevalent among the OPD patients (42%) than the school children (23%). Correlations were found between nausea and loose or watery stools and parasitic infections, particularly in expatriates, whereas schoolchildren, despite being as infected as adults, were completely asymptomatic. Mini-FLOTAC detected higher number of helminth infections whereas FEC method was more accurate for the diagnosis of protozoa.

CONCLUSIONS

This study presents an accurate snapshot of intestinal parasitic infections in Dharamsala, and their high prevalence calls for more awareness and control measures. Mini-FLOTAC is a promising and simple technique for the diagnosis of helminth infections.

High prevalence of Strongyloides stercoralis infection among the elderly in Brazil

Little is known about the frequency of intestinal parasites in the elderly due to a lack of attention given to the occurrence of these infections among older adults. This study compares the frequency of Strongyloides stercoralis and other enteroparasites between elderly living in nursing homes (n = 100) and those noninstitutionalized (n = 100) from Uberlândia, state of Minas Gerais, southeastern Brazil, associated with data of epidemiological and socio-demographic conditions. Through coproparasitological examination of both groups, enteroparasites were detected in 15 of 200 individuals examined (7.5%; CI: 5.1- 9.9). S. stercoralis was the most frequent parasite 10/200 (5%; CI: 4.2-5.8), being significantly higher in males and in individuals with autonomy for daily living activities. There were no statistical differences in the prevalence of parasites between the two groups compared. In conclusion, S. stercoralis infection was highly prevalent in elderly patients and it does not depend on whether the individual was institutionalized or not.

Transmission and epidemiology of zoonotic protozoal diseases of companion animals

Over 77 million dogs and 93 million cats share our households in the United States. Multiple studies have demonstrated the importance of pets in their owners' physical and mental health. Given the large number of companion animals in the United States and the proximity and bond of these animals with their owners, understanding and preventing the diseases that these companions bring with them are of paramount importance. Zoonotic protozoal parasites, including toxoplasmosis, Chagas' disease, babesiosis, giardiasis, and leishmaniasis, can cause insidious infections, with asymptomatic animals being capable of transmitting disease. Giardia and Toxoplasma gondii, endemic to the United States, have high prevalences in companion animals. Leishmania and Trypanosoma cruzi are found regionally within the United States. These diseases have lower prevalences but are significant sources of human disease globally and are expanding their companion animal distribution. Thankfully, healthy individuals in the United States are protected by intact immune systems and bolstered by good nutrition, sanitation, and hygiene. Immunocompromised individuals, including the growing number of obese and/or diabetic people, are at a much higher risk of developing zoonoses. Awareness of these often neglected diseases in all health communities is important for protecting pets and owners. To provide this awareness, this review is focused on zoonotic protozoal mechanisms of virulence, epidemiology, and the transmission of pathogens of consequence to pet owners in the United States.