Cyclospora outbreak associated with chlorinated drinking water

Surrogates of foodborne and waterborne protozoan parasites: A review

The protozoan parasites Cryptosporidium parvum, Cyclospora cayetanensis, and Toxoplasma gondii are major causes of waterborne and foodborne diseases worldwide. The assessment of their removal or inactivation during water treatment and food processing remains challenging, partly because research on these parasites is hindered by various economical, ethical, methodological, and biological constraints. To address public health concerns and gain new knowledge, researchers are increasingly seeking alternatives to the use of such pathogenic parasites. Over the past few decades, several non-pathogenic microorganisms and manufactured microparticles have been evaluated as potential surrogates of waterborne and foodborne protozoan parasites. Here, we review the surrogates that have been reported for C. parvum, C. cayetanensis, and T. gondii oocysts, and discuss their use and relevance to assess the transport, removal, and inactivation of these parasites in food and water matrices. Biological surrogates including non-human pathogenic Eimeria parasites, microorganisms found in water sources (anaerobic and aerobic spore-forming bacteria, algae), and non-biological surrogates (i.e. manufactured microparticles) have been identified. We emphasize that such surrogates have to be carefully selected and implemented depending on the parasite and the targeted application. Eimeria oocysts appear as promising surrogates to investigate in the future the pathogenic coccidian parasites C. cayetanensis and T. gondii that are the most challenging to work with.

Review on Cyclosporiasis Outbreaks and Potential Molecular Markers for Tracing Back Investigations

Cyclosporiasis is an emerging disease caused by Cyclospora cayetanensis, which induces protracting and relapsing gastroenteritis and has been linked to huge and complicated travel- and food-related outbreaks worldwide. Cyclosporiasis has become more common in both developing and developed countries as a result of increased global travel and the globalization of the human food supply. It is not just a burden on individual human health but also a worldwide public health problem. As a pathogen of interest, the molecular biological characteristics of C. cayetanensis have advanced significantly over the last few decades. However, only one FDA-approved molecular platform has been commercially used in the investigation of cyclosporiasis outbreaks. More potential molecular markers and genotyping of C. cayetanensis in samples based on the polymorphic region of the whole genomes might differentiate between separate case clusters and would be useful in tracing back investigations, especially during cyclosporiasis outbreak investigations. Considering that there is no effective vaccine for cyclosporosis, epidemiological investigation using effective tools is crucial for controlling cyclosporiasis by source tracking. Therefore, more and more epidemiological investigative studies for human cyclosporiasis should be promoted around the world to get a deeper understanding of its characteristics as well as management. This review focuses on major cyclosporiasis outbreaks and potential molecular markers for tracing back investigations into cyclosporiasis outbreaks.

Detection of Cyclospora cayetanensis in produce irrigation and wash water using large-volume sampling techniques

The recent increase of reported cyclosporiasis outbreaks associated with fresh produce has highlighted the need for understanding environmental transmission of Cyclospora cayetanensis in agricultural settings and facilities. Conducting such environmental investigations necessitates robust sample collection and analytical methods to detect C. cayetanensis in water samples. This study evaluated three sample collection methods for recovery of C. cayetanensis oocysts from water samples during seeded recovery experiments. Two filtration-based methods, dead-end ultrafiltration (DEUF) and USEPA Method 1623.1, were evaluated for oocyst recovery from irrigation water. A non-filter-based method, continuous flow centrifugation (CFC), was evaluated separately for recovery from creek water and spent produce wash water. Median C. cayetanensis recovery efficiencies were 17% for DEUF and 16-22% for Method 1623.1. The DEUF method proved to be more robust than Method 1623.1, as the recovery efficiencies were less variable and the DEUF ultrafilters were capable of filtering larger volumes of high-turbidity water without clogging. Median C. cayetanensis recovery efficiencies for CFC were 28% for wash water and 63% for creek water, making it a viable option for processing water with high turbidity or organic matter. The data from this study demonstrate the capability of DEUF and CFC as filter-based and non-filter-based options, respectively, for the recovery of C. cayetanensis oocysts from environmental and agricultural waters.

Cyclospora cayetanensis and Cyclosporiasis: An Update

Cyclospora cayetanensis is a coccidian parasite of humans, with a direct fecal-oral transmission cycle. It is globally distributed and an important cause of foodborne outbreaks of enteric disease in many developed countries, mostly associated with the consumption of contaminated fresh produce. Because oocysts are excreted unsporulated and need to sporulate in the environment, direct person-to-person transmission is unlikely. Infection by C. cayetanensis is remarkably seasonal worldwide, although it varies by geographical regions. Most susceptible populations are children, foreigners, and immunocompromised patients in endemic countries, while in industrialized countries, C. cayetanensis affects people of any age. The risk of infection in developed countries is associated with travel to endemic areas and the domestic consumption of contaminated food, mainly fresh produce imported from endemic regions. Water and soil contaminated with fecal matter may act as a vehicle of transmission for C. cayetanensis infection. The disease is self-limiting in most immunocompetent patients, but it may present as a severe, protracted or chronic diarrhea in some cases, and may colonize extra-intestinal organs in immunocompromised patients. Trimetoprim-sulfamethoxazole is the antibiotic of choice for the treatment of cyclosporiasis, but relapses may occur. Further research is needed to understand many unknown epidemiological aspects of this parasitic disease. Here, we summarize the biology, epidemiology, outbreaks, clinical symptoms, diagnosis, treatment, control and prevention of C. cayetanensis; additionally, we outline future research needs for this parasite.

Detection of Cryptosporidium parvum and Cyclospora cayetanensis infections among people living in a slum area in Kathmandu valley, Nepal

Objective

The aim of this study is to determine the prevalence of Cyclospora cayetanensis and Cryptosporidium parvum infections among people living a slum in Kathmandu valley, Nepal.

Results

Ten different parasites were detected in the stool samples; the prevalence of any parasite was in 27.1% (71/262). The prevalence of C. cayetanensis and C. parvum were 14.1% (10/71) and 5.6% (4/71), respectively. This study showed high prevalence of intestinal parasitic infections along with the coccidian parasites in the slum area of Kathmandu Valley.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2779-2) contains supplementary material, which is available to authorized users.

Neglected waterborne parasitic protozoa and their detection in water

Outbreak incidents raise the question of whether the less frequent aetiological agents of outbreaks are really less frequent in water. Alternatively, waterborne transmission could be relevant, but the lack of attention and rapid, sensitive methods to recover and detect the exogenous stages in water may keep them under-recognized. High quality information on the prevalence and detection of less frequent waterborne protozoa, such as Cyclospora cayetanensis, Toxoplasma gondii, Isospora belli, Balantidium coli, Blastocystis hominis, Entamoeba histolytica and other free-living amoebae (FLA), are not available. This present paper discusses the detection tools applied for the water surveillance of the neglected waterborne protozoa mentioned above and provides future perspectives.

Cyclospora Infection among School Children in Kathmandu, Nepal: Prevalence and Associated Risk Factors

Background: The intestinal coccidian protozoa Cyclospora cayetanensis has emerged as an important cause of parasitic diarrhea among children living in developing countries. This study aimed to determine the prevalence of Cyclospora among the school children of Kathmandu with reference to various associated risk factors.

Methodology: A total of five hundred and seven stool samples from students between the age of 3–14 years, studying in 13 different schools in Kathmandu were collected during the study period (May–November, 2014) and processed at the Public Health Research Laboratory, Institute of Medicine, Kathmandu, Nepal. A modified acid fast staining technique (Kinyoun’s method) was used to detect oocyst of Cyclospora from the formal-ether concentrated stool samples.

Results: Cyclospora was detected in 3.94% (20/507) of the stool samples examined. The prevalence was found to be highest among the students in the 3–5 year age group i.e. 10.15% (13/128), peaking during the rainy season (June–August). The detection rate was found to be significantly higher (p < 0.05) among children presenting with diarrheal symptoms, household keeping livestock and consumers of raw vegetables/fruits, showing a prevalence of 10.57% (11/104), 10.11% (9/89) and 7.25% (14/193) respectively.

Conclusion: Consumption of untreated drinking water, fresh produce (raw fruits/vegetables) without proper washing and the presence of livestock at home were found to be predisposing factors for higher susceptibility of infection due to Cyclospora. This finding confirms the existence of a public-health issue with potentially serious consequences whereby children can be infected through exposure to oocysts in contaminated food and water and get ill as a result.

Environmentally Transmitted Pathogens

This chapter describes a variety of pathogens found in the environment that are capable of infecting humans and causing disease. Different classes of pathogens are discussed including bacteria, parasites and viruses. For each pathogen, data are provided on the incidence of the organism in a particular environmental matrix such as water, food or municipal waste. In addition, we discuss: the disease caused by the particular microbe; the mode of transmission; the incubation time needed within the host prior to the onset of disease; and the duration of illness. Fate and transport of pathogens in the environment are also described. A variety of bacterial pathogens are discussed including waterborne and waterbased bacteria. Parasites discussed include protozoa, nematodes, cestodes and trematodes. For viruses, both enteric and respiratory viruses are included.

Efficacy of wash solutions in recovering Cyclospora cayetanensis, Cryptosporidium parvum, and Toxoplasma gondii from basil

Parasitic diseases can be acquired by ingestion of contaminated raw or minimally processed fresh produce (herbs and fruits). The sensitivity of methods used to detect parasites on fresh produce depends in part on the efficacy of wash solutions in removing them from suspect samples. In this study, six wash solutions (sterile E-Pure water, 3% levulinic acid-3% sodium dodecyl sulfate, 1 M glycine, 0.1 M phosphate-buffered saline, 0.1% Alconox, and 1% HCl-pepsin) were evaluated for their effectiveness in removing Cyclospora cayetanensis, Cryptosporidium parvum, and Toxoplasma gondii from basil. One hundred or 1,000 oocysts of these parasites were inoculated onto the adaxial surfaces of 25 g of basil leaves, placed in stomacher bags, and stored for 1 h at 21°C or 24 h at 4°C. Leaves were hand washed in each wash solution for 1 min. DNA was extracted from the wash solutions and amplified using PCR for the detection of all parasites. Oocysts inoculated at a concentration of 1,000 oocysts per 25 g of basil were detected in all wash solutions. At an inoculum concentration of 100 oocysts per 25 g, oocysts were detected in 18.5 to 92.6% of the wash solutions. The lowest variability in recovering oocysts from basil inoculated with 100 oocysts was observed in 1% HCl-pepsin wash solution. Oocyst recovery rates were higher at 1 h than at 24 h postinoculation. Unlike most bacteria, parasites cannot be enriched; therefore, an optimal recovery process for oocysts from suspected foods is critical. The observations in this study provide guidance concerning the selection of wash solutions giving the highest retrieval of parasite oocysts.

Cyclospora cayetanensis in a pediatric hospital in Morelia, México

Cyclospora cayetanensis, a coccidian parasite, can cause gastrointestinal illness in humans and is characterized by watery and persistent diarrhea and abdominal pain. Cyclosporiasis has been associated with traveler's diarrhea. The infection is acquired through food and waterborne transmission, particularly by consumption of contaminated fresh fruits and vegetables. In the present study, stool samples from 8,877 children were examined for ova and parasites at the Pediatric Hospital of Morelia in Michoacán, Mexico, during 2000-2009. Sixty children (0.67%) had Cyclospora in their stools. Diarrhea (45.8%), abdominal pain (39.6%), and vomiting (18.8%) were the most frequent symptoms of cases with cyclosporiasis. Most of the cases (93.3%) were observed during June-August, the rainy season. In 45 children, Cyclospora was the only parasitic pathogen detected (75%); 15 children were co-infected with commensal, pathogenic, or both groups of parasites. Our findings suggest that C. cayetanensis is endemic to Michoacán and shows characteristically temporal patterns.

Occurrence of Cryptosporidium, Giardia, and Cyclospora in influent and effluent water at wastewater treatment plants in Arizona

We investigated the occurrence of Cryptosporidium, Giardia, and Cyclospora at two wastewater treatment plants (WWTPs) in Arizona over a 12-month period, from August 2011 to July 2012. Influent and effluent wastewater samples were collected monthly, and protozoan (oo)cysts were concentrated using an electronegative filter, followed by the detection of protozoa using fluorescent microscopy (Cryptosporidium oocysts and Giardia cysts) and PCR-based methods (Cryptosporidium spp., Giardia intestinalis, and Cyclospora cayetanensis). The concentration of Giardia cysts in the influent was always higher than that of Cryptosporidium oocysts (mean concentration of 4.8-6.4×10(3) versus 7.4×10(1)-1.0×10(2)(oo)cysts/l) with no clear seasonality, and log10 reduction of Giardia cysts was significantly higher than that of Cryptosporidium oocysts for both WWTPs (P<0.05). Log10 reduction of Giardia cysts at the WWTP utilizing activated sludge was significantly higher than the other WWTP using trickling filter (P=0.014), while no statistically significant difference between the two WWTPs was observed for the log10 reduction of Cryptosporidium oocysts (P=0.207). Phylogenetic analysis revealed that G. intestinalis strains identified in wastewater belonged to two assemblages, AII and B, which are potentially infectious to humans. C. cayetanensis was also detected from both influent and effluent using a newly developed quantitative PCR, with the highest influent concentration of 1.2×10(4)copies/l. Our results demonstrated that these protozoan pathogens are prevalent in the study area and that efficacy of the conventional wastewater treatment processes at physically removing (oo)cysts is limited.

Molecular characterization of human-pathogenic microsporidia and Cyclospora cayetanensis isolated from various water sources in Spain: a year-long longitudinal study

Recent studies suggest the involvement of water in the epidemiology of Cyclospora cayetanensis and some microsporidia. A total of 223 samples from four drinking water treatment plants (DWTPs), seven wastewater treatment plants (WWTPs), and six locations of influence (LI) on four river basins from Madrid, Spain, were analyzed from spring 2008 to winter 2009. Microsporidia were detected in 49% of samples (109/223), Cyclospora spp. were detected in 9% (20/223), and both parasites were found in 5.4% (12/223) of samples. Human-pathogenic microsporidia were detected, including Enterocytozoon bieneusi (C, D, and D-like genotypes), Encephalitozoon intestinalis, Encephalitozoon cuniculi (genotypes I and III), and Anncaliia algerae. C. cayetanensis was identified in 17 of 20 samples. To our knowledge, this is the first study that shows a year-long longitudinal study of C. cayetanensis in drinking water treatment plants. Additionally, data about the presence and molecular characterization of the human-pathogenic microsporidia in drinking water, wastewater, and locations of influence during 1 year in Spain are shown. It is noteworthy that although the DWTPs and WWTPs studied meet European and national regulations on water sanitary quality, both parasites were found in water samples from these plants, supporting the idea that new and appropriate controls and regulations for drinking water, wastewater, and recreational waters should be proposed to avoid health risks from these pathogens.

Enteric protozoa in the developed world: a public health perspective

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

Pathogens for travelers' diarrhea in Nepal and resistance patterns

At the top of the world, Nepal leads the world in travelers' diarrhea. A review of the rates, pathogens and resistance patterns over 3 decades reveals a persistent problem of increasing alarm. A look at root causes provides insight into this oppressive, inconvenient offense to travelers to an otherwise mystical Himalayan paradise.

Epidemiology of Cyclospora cayetanensis: A review focusing in endemic areas

Cyclospora cayetanensis is an intestinal coccidian protozoon that has emerged as an important cause of endemic or epidemic diarrhoeal illness in children and adults worldwide. Humans appear to be the only natural hosts. However, the role of animals as natural reservoirs is uncertain but of increasing concern. Human-to-human spread of the parasite occurs indirectly via the environment through oocysts in contaminated water, food or soil. In endemic areas, risk factors associated with the infection include contaminated water or food, contact with soil or animals, type of sanitation and low socioeconomic status. Infections linked to soil contact provide reasons to believe that this route of spread may be more common than realised in disadvantaged community settings. C. cayetanensis is an important cause of traveller's diarrhoea and numerous large foodborne outbreaks associated with the globalisation of the food supply and importation of fruits and vegetables from developing countries have occurred. Waterborne outbreaks have also been reported. Implementation of measures to prevent or control the spread of Cyclospora oocysts in the environment is critical. In endemic areas, the most important steps to prevent infection are improving environmental sanitation and health education. Significant gaps remain in our understanding of the epidemiology of human cyclosporiasis that highlight the need for continued research in several aspects of C. cayetanensis.

An outbreak of cyclosporiasis in 1996 associated with consumption of fresh berries- Ontario

BACKGROUND

A large foodborne outbreak of cyclosporiasis occurred in North America in 1996. An index cluster of cases associated with a catered event on May 11, 1996, in Ontario sparked the recognition of this outbreak in Canada.

OBJECTIVES

To describe the Ontario experience with the North American outbreak of cyclosporiasis in 1996.

PATIENTS AND METHODS

Public health units investigated the index and subsequent event-associated clusters. Investigations included retrospective cohort studies of clusters, traceback of suspect foods and a case-control study of sporadic cases. These activities, coordinated with those in the United States, were part of an international investigation.

RESULTS

In Ontario, 232 cases of cyclosporiasis (20 laboratory-confirmed and 72 clinically defined cases associated with seven events plus 140 additional laboratory-confirmed sporadic cases) were identified between May 1 and July 30, 1996. For the index cluster, a strawberry flan with raspberries and blueberries was the only significant exposure (relative risk 2.16, P=0.02). Fresh berries were served at all seven events associated with clusters of cases. Raspberries were definitely served at three events, possibly served at three events, and not served at one event. Only imported berries were available in Ontario in May 1996, when initial clusters and sporadic cases were identified. The raspberries served at the two events with well documented traceback data came from Guatemala. Univariate analyses of the matched case-control study demonstrated that illness was associated with consumption of raspberries (matched odds ratio 21.0, 95% CI 3.48 to 448) and strawberries (matched odds ratio 28.5, 95% CI 4.02 to 478). Further evidence amassed by the international investigation compellingly implicated Guatemalan raspberries as the vehicle of the outbreak.

CONCLUSION

Cyclosporiasis may be acquired domestically from the consumption of contaminated produce. The scope and vehicle of this international foodborne outbreak were recognized through a coordinated public health response.

Update on Cyclospora cayetanensis, a food-borne and waterborne parasite

The coccidian parasite Cyclospora cayetanensis is recognized as an emerging pathogen that causes protracted diarrhea in humans. The first cases of Cyclospora infection were reported in the late 1970s and were observed among expatriates and travelers in regions where infections are endemic. Since then, Cyclospora has been considered a cause of traveler's diarrhea. Epidemiological investigations were reported and examined in areas of endemicity even before the true identity of Cyclospora was elucidated. Cyclospora was fully characterized in the early 1990s, but it was not until the 1995 Cyclospora outbreak in the United States and Canada that it caught the attention of the public and physicians. The biology, clinical presentation, epidemiology, diagnosis, treatment, and control of cyclosporiasis are reviewed, with a focus on diagnostic assays currently being used for clinical and environmental samples. Challenges and limitations in working with Cyclospora are also discussed.

Environmentally Transmitted Pathogens

Pathogenic microorganisms usually originate from an infected host or directly from the environment; however, only a small proportion of these microbes cause infection. This chapter discusses the pathogens that are transmitted through the environment such as bacteria, viruses, and protozoa. Many human pathogens can be transmitted only by direct or close contact with an infected person or animal such as herpesvirus. Virus transmission by the airborne route may be both direct and indirect inhalation of infectious droplets or through contact with contaminated fomites. Water-borne diseases—such as yellow fever, dengue, filariasis, malaria, onchocerciasis, and sleeping sicknessare transmitted by insects that breed in water or live near water. The common bacterial pathogens transmitted through water include Salmonella, Escherichia coli, Shigella, Campylobacter, Yersinia, Vibrio, Helicobacter, and Legionella. Opportunistic pathogens are also numerous in the environment, and the most important opportunistic pathogen is Pseudomonas aeruginosa. Viruses are a leading cause of gastroenteritis and water-borne outbreaks may be caused by norovirus, hepatitis A virus, Coxsackie virus, echovirus, and adenoviruses. Respiratory diseases are also associated with a large number of viruses such as rhinoviruses, coronaviruses, parainfluenza viruses, respiratory syncytial virus (RSV), influenza virus, and adenovirus. Generally, viral and protozoan pathogens survive longer in the environment than enteric bacterial pathogens.

Cyclosporiasis: a point source outbreak acquired in Guatemala

BACKGROUND

Cyclosporiasis is a disease due to Cyclospora cayetanensis, an emerging coccidian parasite first described in 1979. It is an orally transmitted disease that is more frequent in tropical and subtropical areas. Cyclospora cayetanensis has been mainly described as a cause of travelers' diarrhea. This pathogen has given rise to a number of epidemic outbreaks attributable to ingestion of imported foods, particularly from tropical areas.

METHODS

Descriptive study of clinical and epidemiological data of a small epidemic outbreak of C cayetanensis-induced gastroenteritis.

RESULTS

Seven confirmed cases of C cayetanensis among Spanish nationals who had traveled to Antigua Guatemala are described. The incubation period was 6 days. Diarrhea, asthenia, anorexia, borborygmi, flatulence, and abdominal distension were present in all cases. Fever and heart burn in 85.7%. Weight loss in 71.4%. Abdominal pain, rectal tenesmus, and nausea in 42.8%. Vomiting and eructation in 14.2%. Heart burn was a frequent symptom, a finding not often previously described. The infection was probably acquired from raspberry juice. All cases improved with trimethoprim/sulphametoxazol.

CONCLUSIONS

Cyclosporiasis is a cause of travelers' diarrhea. Parasitology laboratories must be advised of clinical suspicion of cyclosporiasis so that they can conduct a suitable targeted study; otherwise, false negative results may arise.

Foodborne protozoan parasites

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

Human cyclosporiosis in Turkey

Six patients infected with Cyclospora cayetanensis who sought medical care at three different hospitals in Turkey are herein presented. Four patients were male and the others were female and their ages ranged from 7 to 62 years. The first patient was HIV-positive and presented with watery diarrhea with a frequency of up to 18 times a day for more than ten months and diagnosed as cyclosporiosis in Kayseri, 1996. The second patient was also HIV positive and diagnosed as cyclosporiosis in Kayseri, 2000. The third patient was an acute myeloblastic leukemia (AML) patient and diagnosed in Istanbul, 2000. The fourth patient was idiopathic hepatic cirrhosis complaining of diarrhea and weakness and diagnosed in Kayseri, 2001. The fifth and sixth patients were immunocompetent patients complaining of diarrhea and diagnosed in Izmir and Kayseri, 2002. Diarrhea occurring from one to ten times a day continued for 7 to 70 d in the last 5 patients. Treatment with a trimethoprim/sulfamethoxazole compound was done for all patients. Both symptomatic and parasitologic improvements were quickly observed. In summary, C. cayetanensis infection is rare in Turkey and most patients infected with this pathogen tend to be immunosuppressive individuals at present.

Cyclospora cayetanensis in a patient with travelers' diarrhea: case report and review

In recent years, several studies have shown that Cyclospora cayetanensis is a worldwide intestinal pathogen, and it has been implicated in a number of sporadic cases and epidemic outbreaks of diarrheal illness in several endemic areas. The parasite is associated with prolonged and relapsing watery diarrhea in immunocompetent persons, as well as in AIDS patients. Most reports of Cyclospora infection concern travelers visiting endemic countries. In European countries, a few cases of Cyclospora cayetanensis infection have been reported, and almost all of them were observed in persons after foreign travel.

Cyclospora cayetanensis: a review of an emerging parasitic coccidian

Cyclospora cayetanensis is a sporulating parasitic protozoan that infects the upper small intestinal tract. It has been identified as both a food and waterborne pathogen endemic in many developing countries. It is an important agent of Traveller's Diarrohea in developed countries and was responsible for numerous foodborne outbreaks in the United States and Canada in the late 1990s. Like Cryptosporidium, infection has been associated with a variety of sequelae such as Guillain-Barré syndrome, reactive arthritis syndrome (formally Reiter syndrome) and acalculous cholecystitis. There has been much debate as to where to place C. cayetanensis taxonomically due to its homology with Eimeria species. To date, the only genomic DNA sequences available are the ribosomal DNA of C. cayetanensis and three other species; within these a high degree of homology has been observed. This homology and the lack of sequence data from other Cyclospora species have hindered identification methods.

Emerging Causes of Traveler's Diarrhea: Cryptosporidium, Cyclospora, Isospora, and Microsporidia

Travel is a risk factor for acquiring infection with a spore-forming protozoa: Cryptosopridium, Cyclospora, Microsporidia, and Isospora. Certain travel destinations have a high disease burden and intense exposure. Patients present with persistent diarrhea and a history of recent travel to a developing country in the tropics. Very mild infections may be underdiagnosed and may cause typical traveler's diarrhea. In a patient with a history of travel and persistent diarrhea unresponsive to the usual antibiotic and antidiarrhea treatment, stool studies for all four of these protozoa infections should be performed. If immune status is normal and the disease is mild, symptomatic therapy may suffice. Effective treatment is available for Cyclospora, Microsporidia, and Isospora.

Emerging waterborne infections: contributing factors, agents, and detection tools

Because microorganisms are easily dispersed, display physiological diversity, and tolerate extreme conditions, they are ubiquitous and may contaminate and grow in water. The presence of waterborne enteric pathogens (bacteria, viruses, and protozoa) in domestic water supplies represents a potentially significant human health risk. Even though major outbreaks of waterborne disease are comparatively rare, there is substantial evidence that human enteric pathogens that are frequently present in domestic water supplies are responsible for low-level incidence of waterborne microbial disease. Although these diseases are rarely debilitating to healthy adults for more than a few hours to a few days, enteric pathogens can cause severe illness, even death, for young children, the elderly, or those with compromised immune systems. As the epidemiology of waterborne diseases is changing, there is a growing global public health concern about new and reemerging infectious diseases that are occurring through a complex interaction of social, economic, evolutionary, and ecological factors. New microbial pathogens have emerged, and some have spread worldwide. Alternative testing strategies for waterborne diseases should significantly improve the ability to detect and control the causative pathogenic agents. In this article, we provide an overview of the current state of knowledge of waterborne microbial pathogens, their detection, and the future of new methods in controlling these infectious agents.

Concentration of Cryptosporidium, microsporidia and other water-borne pathogens by continuous separation channel centrifugation

AIMS

The aim of this study was to determine the effectiveness of continuous separation channel centrifugation for concentrating water-borne pathogens of various taxa and sizes.

METHODS AND RESULTS

Cryptosporidium parvum oocysts, Giardia lamblia cysts, Encephalitozoon intestinalis spores and Escherichia coli were seeded into different water matrices at densities ranging from 5 to 10 000 organisms l(-1) and recovered using continuous separation channel centrifugation. All pathogens were enumerated on membrane filters using microscopy. Recovery efficiencies were usually > 90%. Oocyst recovery did not vary with source water turbidity or with centrifuge flow rate up to 250 ml min(-1). Based on excystation, this concentration method did not alter oocyst viability.

CONCLUSIONS

Continuous separation channel centrifugation is an effective means of concentrating water-borne pathogens.

SIGNIFICANCE AND IMPACT OF THE STUDY

Methods are needed for detecting pathogens in drinking water to ensure public health. The first step for any pathogen detection procedure is concentration. However, this step has been problematic because recovery efficiencies of conventional methods, like filtration, are often low and variable, which may lead to false negatives. Continuous separation channel centrifugation can simultaneously concentrate multiple pathogens as small as 1 microm with high and reproducible efficiency in a variety of water matrices.

Cryptosporidium parvum and Cyclospora cayetanensis: a review of laboratory methods for detection of these waterborne parasites

Cryptosporidium and Cyclospora are obligate, intracellular, coccidian protozoan parasites that infest the gastrointestinal tract of humans and animals causing severe diarrhea illness. In this paper, we present an overview of the conventional and more novel techniques that are currently available to detect Cryptosporidium and Cyclospora in water. Conventional techniques and new immunological and genetic/molecular methods make it possible to assess the occurrence, prevalence, virulence (to a lesser extent), viability, levels, and sources of waterborne protozoa. Concentration, purification, and detection are the three key steps in all methods that have been approved for routine monitoring of waterborne oocysts. These steps have been optimized to such an extent that low levels of naturally occurring Cryptosporidium oocysts can be efficiently recovered from water. The filtration systems developed in the US and Europe trap oocysts more effectively and are part of the standard methodologies for environmental monitoring of Cryptosporidium oocysts in source and treated water. Purification techniques such as immunomagnetic separation and flow cytometry with fluorescent activated cell sorting impart high capture efficiency and selective separation of oocysts from sample debris. Monoclonal antibodies with higher avidity and specificity to oocysts in water concentrates have significantly improved the detection and enumeration steps. To date, PCR-based detection methods allow us to differentiate the human pathogenic Cryptosporidium parasites from those that do not infect humans, and to track the source of oocyst contamination in the environment. Cell culture techniques are now used to examine oocyst viability. While fewer studies have focused on Cyclospora cayetanensis, the parasite has been successfully detected in drinking water and wastewater using current methods to recover Cryptosporidium oocysts. More research is needed for monitoring of Cyclospora in the environment. Meanwhile, molecular methods (e.g. molecular markers such as intervening transcribed spacer regions), which can identify different genotypes of C. cayetanensis, show good promise for detection of this emerging coccidian parasite in water.

Outbreak of cyclosporiasis associated with basil in Missouri in 1999

During the summer of 1999, an outbreak of cyclosporiasis occurred among attendees of 2 events held on 24 July in different counties in Missouri. We conducted retrospective cohort studies of the 2 clusters of cases, which comprised 62 case patients. The chicken pasta salad served at one event (relative risk [RR], 4.25; 95% confidence interval [CI], 1.80-10.01) and the tomato basil salad served at the other event (RR, 2.95; 95% CI, 1.72-5.07) were most strongly associated with illness. The most likely vehicle of infection was fresh basil, which was included in both salads and could have been grown either in Mexico or the United States. Leftover chicken pasta salad was found to be positive for Cyclospora DNA by means of polymerase chain reaction analysis, and 1 sporulated Cyclospora oocyst was found by use of microscopy. This is the second documented outbreak of cyclosporiasis in the United States linked to fresh basil and the first US outbreak for which Cyclospora has been detected in an epidemiologically implicated food item.

Viability of Giardia intestinalis cysts and viability and sporulation state of Cyclospora cayetanensis oocysts determined by electrorotation

Electrorotation is a noninvasive technique that is capable of detecting changes in the morphology and physicochemical properties of microorganisms. Electrorotation studies are reported for two intestinal parasites, Giardia intestinalis and Cyclospora cayetanensis. It is concluded that viable and nonviable G. intestinalis cysts can be differentiated by this technique, and support for this conclusion was obtained using a fluorogenic vital dye assay and morphological indicators. The viability of C. cayetanensis oocysts (for which no vital dye assay is currently available) can also be determined by electrorotation, as can their sporulation state. Modeling of the electrorotational response of these organisms was used to determine their dielectric properties and to gain an insight into the changes occurring within them. Electrorotation offers a new, simple, and rapid method for determining the viability of parasites in potable water and food products and as such has important healthcare implications.

Cyclospora cayetanensis: a review, focusing on the outbreaks of cyclosporiasis in the 1990s

Cyclospora cayetanensis, a coccidian parasite that causes protracted, relapsing gastroenteritis, has a short recorded history. In retrospect, the first 3 documented human cases of Cyclospora infection were diagnosed in 1977 and 1978. However, not much was published about the organism until the 1990s. One of the surprises has been the fact that a parasite that likely requires days to weeks outside the host to become infectious has repeatedly caused foodborne outbreaks, including large multistate outbreaks in the United States and Canada. In this review, I discuss what has been learned about this enigmatic parasite since its discovery and what some of the remaining questions are. My focus is the foodborne and waterborne outbreaks of cyclosporiasis that were documented from 1990 through 1999. The occurrence of the outbreaks highlights the need for health care personnel to consider that seemingly isolated cases of infection could be part of widespread outbreaks and should be reported to public health officials. Health care personnel should also be aware that stool specimens examined for ova and parasites usually are not examined for Cyclospora unless such testing is specifically requested and that Cyclospora infection is treatable with trimethoprim-sulfamethoxazole.

Extraction-free, filter-based template preparation for rapid and sensitive PCR detection of pathogenic parasitic protozoa

Within the last several years, the protozoan parasites Cyclospora cayetanensis, Cryptosporidium parvum, and microsporidia have become recognized as important, rapidly emerging human pathogens in immunocompromised and immunocompetent individuals. Since the early 1990s, many of the reported outbreaks of enteric illness caused by these microorganisms have been attributed to food- and water-borne contamination. Many inherent obstacles affect the success of current surveillance and detection methods used to monitor and control levels of contamination by these pathogens. Unlike methods that incorporate preenrichment for easier and unambiguous identification of bacterial pathogens, similar methods for the detection of parasitic protozoa either are not currently available or cannot be performed in a timely manner. We have developed an extraction-free, filter-based protocol to prepare DNA templates for use in PCR to identify C. cayetanensis and C. parvum oocysts and microsporidia spores. This method requires only minimal preparation to partially purify and concentrate isolates prior to filter application. DNA template preparation is rapid, efficient, and reproducible. As few as 3 to 10 parasites could be detected by PCR from direct application to the filters. In studies, as few 10 to 50 Encephalitozoon intestinalis spores could be detected when seeded in a 100-microliter stool sample and 10 to 30 C. cayetanensis oocysts could be detected per 100 g of fresh raspberries. This protocol can easily be adapted to detect parasites from a wide variety of food, clinical, and environmental samples and can be used in multiplex PCR applications.

Cyclosporiasis associated with imported raspberries, Florida, 1996

OBJECTIVES

Until 1995, infection with Cyclospora cayetanenis, a parasite that causes gastroenteritis, was diagnosed in the US primarily in overseas travelers; its modes of transmission were largely unknown. In 1995, 45 cases of cyclosporiasis were diagnosed in Florida residents who had no history of recent foreign travel, but an investigation could not pinpoint a source for the parasite. In 1996, a North American outbreak of cyclosporiasis resulted in more than 1400 cases, 180 of them in Florida. The authors investigated the 1996 Florida outbreak to identify the vehicle of transmission.

METHODS

The authors conducted a matched case-control study in which each of 86 laboratory-confirmed sporadic cases was matched with up to four controls. They also investigated nine clusters of cases associated with common meals and attempted to trace implicated foods to their countries of origin.

RESULTS

In the case control study, eating raspberries was strongly associated with cyclosporiasis (matched odds ratio = 31.9; 95% confidence interval [CI] 7.4, 138.2). In the cluster investigation, raspberries were the only food common to all nine clusters of cases; a summary analysis showed a strong association between consumption of raspberries and confirmed or probable cyclosporiasis (risk ratio = 17.6; 95% CI 1.9, 188.8). Guatemala was the sole country of origin for raspberries served at six of nine events.

CONCLUSIONS

Guatemalan raspberries were the vehicle for the 1996 Florida cyclosporiasis outbreak. Cyclospora is a foodborne pathogen that may play a growing role in the etiology of enteric disease in this country as food markets become increasingly international.

Cyclospora: an enigma worth unraveling

In part, Cyclospora cayetanensis owes its recognition as an emerging pathogen to the increased use of staining methods for detecting enteric parasites such as Cryptosporidium. First reported in patients in New Guinea in 1977 but thought to be a coccidian parasite of the genus Isospora, C. cayetanensis received little attention until it was again described in 1985 in New York and Peru. In the early 1990s, human infection associated with waterborne transmission of C. cayetanensis was suspected; foodborne transmission was likewise suggested in early studies. The parasite was associated with several disease outbreaks in the United States during 1996 and 1997. This article reviews current knowledge about C. cayetanensis (including its association with waterborne and foodborne transmission), unresolved issues, and research needs.

Cyclospora: review of an emerging parasite

Cyclospora is a parasite traditionally associated with diarrhea in travelers to endemic countries. Recently, several cases of cyclosporiasis were reported in nontravelers in the United States and Canada, implicating various fruits and vegetables as vehicles of infection. The life cycle of cyclospora is not fully known, but is believed to involve both asexual and sexual stages of proliferation. Food- and water-borne transmission of infection have been implicated. Patients infected with Cyclospora cayetanensis have protracted watery diarrhea. Various generalized symptoms are also present, making cyclosporiasis indistinguishable from infectious diarrhea caused by other microorganisms. Diagnosis depends on identifying the organism by microbiologic examination of stool samples. Treatment consists of supportive care, maintenance of fluid and electrolyte status, symptomatic relief, and antibiotic therapy. Trimethoprim-sulfamethoxazole is the only antibiotic available that is effective in eradicating the organism.

Epidemiologic studies of Cyclospora cayetanensis in Guatemala

In 1996 and 1997, cyclosporiasis outbreaks in North America were linked to eating Guatemalan raspberries. We conducted a study in health-care facilities and among raspberry farm workers, as well as a case-control study, to assess risk factors for the disease in Guatemala. From April 6, 1997, to March 19, 1998, 126 (2.3%) of 5, 552 surveillance specimens tested positive for Cyclospora; prevalence peaked in June (6.7%). Infection was most common among children 1.5 to 9 years old and among persons with gastroenteritis. Among 182 raspberry farm workers and family members monitored from April 6 to May 29, six had Cyclospora infection. In the case-control analysis, 62 (91%) of 68 persons with Cyclospora infection reported drinking untreated water in the 2 weeks before illness, compared with 88 (73%) of 120 controls (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.4, 10.8 by univariate analysis). Other risk factors included water source, type of sewage drainage, ownership of chickens or other fowl, and contact with soil (among children younger than 2 years).

Cyclosporiasis in a traveler returning from South America

Cyclospora is a coccidian, previously referred to as a cyanobacterium-like body, with an epidemiology similar to that of Cryptosporidium parvum. In recent years, several studies have shown that Cyclospora is not a rare opportunistic pathogen but rather is the cause of common, worldwide intestinal infections in healthy adults and children. Previous reports of diarrhea resulting from Cyclospora sp. have been linked to travelers and immunocompromised patients. The species has a worldwide distribution. Although Cyclospora infection has been reported from Southeast Asia, Papua New Guinea, Indonesia, India, Pakistan, Nepal, the Middle East, North Africa, the United Kingdom, the Caribbean, the United States, Central America, and South America, the true prevalence of this parasite in any population is unknown. The parasite is associated with prolonged self-limiting and relapsing watery diarrhea, anorexia, fatigue, and sometimes myalgia. Fever is infrequent.

Persistent diarrhea in the returned traveler

In conclusion, the causes of chronic diarrhea in the returned traveler are protean. Careful evaluation requires an understanding of where the traveler has been, when they were there, the type of diarrheal illness, medications taken, and knowledge of the patients' other medical problems. Protozoa, particularly G. lamblia, C. parvum, and C. cayatenensis, are among the more commonly identified agents. If the patient is immunocompromised, microsporidia and Isospora become more likely, and a prior history of antimicrobial use raises the possibility of C. difficile colitis. Occasionally helminths, which establish intimate contact with the intestinal mucosa, may also cause prolonged diarrhea. If these and other gastrointestinal insults, such as tropical sprue, small bowel overgrowth, lactose intolerance, and processes unrelated to travel are excluded by more invasive studies or clinical history, the patient can be reassured that idiopathic chronic diarrhea is usually self-limited.

Cyclospora

Although Cyclospora infection has been documented in humans worldwide since at least 1977, it is only in the past 2 years that this organism has come into prominence as a result of major foodborne outbreaks in the United States and Canada. Cyclospora causes significant gastrointestinal disease in immunocompetent and immunocompromised hosts and can be successfully treated with trimethoprim-sulfamethoxazole. The infection is under-recognized because our methods for diagnosis are rudimentary and insensitive. The mechanisms by which the parasite causes disease, the range of animal hosts, and the natural reservoir are unknown. Cyclospora is a unique coccidian parasite that has just begun to emerge; as yet, we have no clue as to where it comes from or where it hides.

An outbreak in 1996 of cyclosporiasis associated with imported raspberries. The Cyclospora Working Group

BACKGROUND

Cyclospora cayetanensis is a parasite that causes gastroenteritis. Until last year most of the documented cases of cyclosporiasis in North America were in overseas travelers. In 1996, a large outbreak of cyclosporiasis occurred in North America. We investigated this outbreak.

METHODS

Health departments solicited information from clinicians and laboratories on cases of cyclosporiasis, which were then reported to the Centers for Disease Control and Prevention and to Health Canada. We conducted retrospective cohort studies for the cases associated with events (e.g., luncheons) and attempted to identify the sources of the implicated food.

RESULTS

A total of 1465 cases of cyclosporiasis were reported by 20 states, the District of Columbia, and 2 provinces. Of these cases, 978 (66.8 percent) were laboratory confirmed and 725 (49.5 percent) were associated with 55 events that were held from May 3 through June 14. Raspberries were definitely served at 50 events and may have been served at 4 events. For 27 of the 41 events for which adequate data were available (65.8 percent), the associations between the consumption of berries (raspberries with or without other berries) and cyclosporiasis were statistically significant (P<0.05). For all 29 events for which there were good data, the raspberries definitely came from Guatemala (21 events, 72.4 percent) or may have come from Guatemala (8 events, 27.6 percent). As few as five Guatemalan farms could have accounted for the 25 events for which the raspberries could be traced to a single exporter per event. The mode of contamination of the raspberries remains unclear.

CONCLUSIONS

This large outbreak of cyclosporiasis in North America in 1996 was associated with the consumption of Guatemalan raspberries. The outbreak illustrates the need to consider that a local cluster of foodborne illness may be part of a widespread outbreak and to pursue investigations to the source of the implicated vehicle.

Agents of diarrhea

Diarrhea is a common problem for AIDS patients, and is chronic and debilitating. A thorough evaluation will reveal a pathogen in the majority of patients, and the organisms most frequently identified in AIDS patients with chronic diarrhea are Cryptosporidium, microsporidia, and Mycobacterium avium complex. Bacterial pathogens are more common in AIDS patients than in the general population and may present in different ways from infections in immunocompetent hosts. Other pathogens, including Cryptosporidium and microsporidia, are difficult to diagnose and have no effective therapy. Moreover, enteric viruses and HIV itself may contribute to the diarrhea. In addition to microbes, other factors such as medication, immune dysregulation, automatic dysfunction, and nutritional supplementation play a substantial role in diarrhea of AIDS patients.

Waterborne protozoan pathogens

Protozoan parasites were the most frequently identified etiologic agents in waterborne disease outbreak from 1991 to 1994. The waterborne parasites Giardia lamblia, Naegleria fowleri, Acanthamoeba spp., Entamoeba histolytica, Cryptosporidium parvum, Cyclospora cayetanesis, Isospora belli, and the microsporidia are reviewed. For each parasite, the review includes history, life cycle, incidence, symptoms, and therapy. Clinical detection methods are compared, and emerging technologies are discussed. Information on the association of these parasites with waterborne outbreaks is reviewed. Current information on protozoan parasites identified as etiological agents in waterborne outbreaks is discussed. Water industry issues related to recent disease outbreaks are examined in the context of water quality testing regulations for G. lamblia and those proposed for C. parvum. The review identifies the limitations of the American Society of Testing and Materials water-testing method for these parasites. An overview of federal regulations affecting the water industry and laboratories that test for water quality is also provided. The article highlights the importance of the clinical laboratory as a frontline defense for the detection of infectious organisms. The review points to the need for clinical laboratories, physicians, and public health personnel to cooperatively plan and assess the challenge of meeting this potential public health threat.

Protozoal agents: what are the dangers for the public water supply?

Safe and efficient treatment of drinking water has been one of the major public health advances of the twentieth century. People in developed countries generally take for granted that their water is safe to drink, a luxury the majority of the world's population does not have. The leading cause of infant mortality in the developing world is infectious diarrhea, and the prevalence of diarrheal pathogens is largely influenced by the quality and quantity of clean water available for drinking and washing. Until recently, modern water treatment had all but eliminated these concerns in developed nations. Over the past two decades, however, the safety of our water supply has been threatened by the emergence of Cryptosporidium parvum, a protozoal pathogen. The hearty oocysts of this organism survive chlorination and filtration to cause a diarrheal illness that, while unpleasant enough in healthy people, is devastating in immunocompromised individuals. The 1993 Milwaukee outbreak, in which 403,000 people developed diarrhea from drinking water that met all the updated federal safety standards, demonstrated the tremendous public health importance of this organism. While earlier attention had focused on Giardia and amebic infections, the other "emerging" protozoan besides Cryptosporidium is Cyclospora. This review discusses the protozoal pathogens, including Cryptosporidium parvum, Giardia lamblia, Entamoeba histolytica, and Cyclospora cayetanensis, that cause waterborne diarrheal outbreaks and the threats they pose to the public.