Genetic Diversity of Cryptosporidium in Children in an Urban Informal Settlement of Nairobi, Kenya

Prevalence and Molecular Characterization of Cryptosporidium Species in Diarrheic Children in Cameroon

Cryptosporidiosis remains a major cause of diarrhea-related childhood death, particularly in developing countries. Although effective anti-retroviral therapy has significantly reduced the cryptosporidiosis burden in western nations, the situation in developing countries remains alarming due to limited therapeutic options and a lack of preventive measures. To better control disease transmission and develop effective prevention strategies, a thorough understanding of the genetic diversity of circulating species is crucial. While cryptosporidiosis has previously been reported in Cameroon, information on the genetic diversity of parasite strains is lacking. In a large cross-sectional study conducted between March 2020 and March 2021 in four regions of Cameroon, Southwest, Littoral, Center and West, a total of 1119 fecal samples of children (n = 1119) were collected and genetically analyzed. This study aimed to assess the genetic diversity of Cryptosporidium strains circulating in this patient cohort in Cameroon. Using modified Ziehl-Neelsen fecal smear staining, an overall prevalence of 8.5% (96/1119) was recorded. PCR analysis revealed a prevalence of 15.4% in the Center, 7.2% in the Littoral, 10.5% in the West, and 13.1% in the Southwest regions. Molecular analysis identified Cryptosporidium. hominis and Cryptosporidium parvum as circulating species, with all subtype families suggesting anthroponotic transmission. No zoonotic subtypes of C. parvum were detected. These findings confirm that cryptosporidiosis transmission in Cameroon is primarily anthroponotic. Nonetheless, much larger epidemiological surveys, including other patient cohorts, are necessary for final confirmation of this statement.

Risk Factors and Circulating Subtypes of Cryptosporidium spp. and Giardia duodenalis in Hospitalized Children in Mozambique

Cryptosporidium spp. and Giardia duodenalis are important diarrheal agents in children in developing countries. Little is known about their molecular epidemiology; as such, the objective of this study was to determine the risk factors and genetic diversity of both parasites in diarrheal samples in Mozambique. In this study, two nested PCRs targeting ssurRNA and gp60 genes were used for genetic diversity of Cryptosporidium spp. and b-giardin for G. duodenalis. Sociodemographic and clinical characteristics were obtained through questionnaires. The location (odds ratio [OR] 3.499), mother's education level (OR 2.150) and age were significant factors for acquiring infection by Cryptosporidium spp. (p < 0.05). Cryptosporidium hominis was the predominant (77.8%) species. Four families (three C. hominis and one C. parvum) were identified, with the highest for Ib (73.9%), followed by Id (13%), Ia (8.7%) and IIc (4.3%). The location (p-value < 0.001), drinking untreated water (p-value = 0.04) and living in masonry houses (p-value = 0.002) were identified as risks associated with G. duodenalis infection. Assemblage A was the dominant type (65.2%). Among the subassemblages of assemblage A, AII was the most frequent (86.6%), followed by AIII (6.6%). For assemblage B, subassemblages BIII (87.5%) and BIV (12.5%) were identified. The dominance of the subtype IbA9G3 of C. hominis, as well as the AII subassemblage of G. duodenalis, seems to indicate that the transmission of both protozoa occurs mainly through the anthroponotic route.

Prevalence and Risk Factors of Waterborne and Foodborne Protozoan Pathogens in Kenya: A One Health Perspective

Intestinal infections affect approximately 450 million people globally, predominantly impacting children and immunocompromised individuals in low- and middle-income countries (LMICs) due to inadequate water, sanitation, and hygiene (WASH) conditions, poverty, malnutrition, and low literacy. In Kenya, the prevalence of intestinal infections is elevated by warm tropical climates and socioeconomic factors. This scoping review evaluates the national prevalence, risk factors, and contamination sources of intestinal protozoa in Kenya, using a One Health approach to synthesize existing data from various human, animal, and environmental studies. A comprehensive literature search identified 292 studies, of which 67 met the inclusion criteria, covering the period from 1966 to 2024. The review found that most studies utilized stool microscopy, a method with limited sensitivity, and largely focused on vulnerable human populations, with minimal investigation into environmental reservoirs. Key protozoa identified included Entamoeba histolytica, Cryptosporidium, and Giardia, with transmission driven by poor WASH conditions, environmental factors, and close human-animal interactions. The findings highlight significant gaps in environmental surveillance and suggest the need for a robust, integrated One Health approach to better understand and control protozoan infections in Kenya.

Molecular characterization of Cryptosporidium spp. in symptomatic children from Cape Verde

Cryptosporidiosis has been identified as one of the leading causes of diarrhea and diarrhea-associated deaths in young children in sub-Saharan Africa. In Cape Verde, available data on human infections caused by Cryptosporidium spp. are limited. The aim of the present study was to analyze the molecular epidemiology of Cryptosporidium spp. in Cape Verde. Stool samples were obtained from patients on the Santiago and Sal islands (Cape Verde); 10/105 (9.5 % CI: 4.7; 16.8) from the Santiago Island and 4/85 (4.7 % CI: 1.3; 11.6) from the Sal Island presented Cryptosporidium sp., and were analyzed by nested-PCR of the SSU rRNA gene and nested-PCR of the 60 kDa glycoprotein gene for subtyping. Two species, Cryptosporidium hominis and Cryptosporidium felis, were identified. In Santiago Island, only C. hominis was detected, while both species were found in Sal Island. Cryptosporidium hominis IfA 14G1R5 subtype was identified in children from Santiago and Sal. Although the consumption of non-bottled water is a risk factor for infection by Cryptosporidium spp. on Santiago Island, none of the factors analysed (age, gender, clinical symptoms, source of drinking water, presence of animals at home, attending kindergarten or school, and having a bathroom at home) were significantly related to the presence of Cryptosporidium spp. in Sal Island. Cryptosporidium hominis is the most commonly identified species associated with cryptosporidiosis in the studied population, indicating a predominance of anthroponotic transmission. This study provides the first data on C. hominis subtyping in Cape Verde and the first report of C. felis in humans from this region, demonstrating the possibility of zoonotic transmission. The obtained results highlight the need for further molecular and epidemiological studies of Cryptosporidium spp. infections in human and animals from Cape Verde, in order to investigate the transmission dynamics of cryptosporidiosis and develop effective control strategies to prevent the spread of the disease.

Molecular characterization and zoonotic risk assessment of Cryptosporidium spp. in children and calves in Bangladesh

Cryptosporidium is a gastro-intestinal protozoan parasite that has been found to infect both humans and livestock. This study investigated the parasite in 998 fecal samples from Bangladeshi children (n = 299) and calves (n = 699) to determine its prevalence, genetic variation, and zoonotic importance. The nested PCR and sequencing of the SSU rRNA gene in the samples showed a Cryptosporidium infection rate of 2.3% (7/299) in children and 15.7% (110/699) in calves. Statistical analysis revealed insignificant variations in Cryptosporidium infections among children across age, gender, and study area, while in calves, the infection rate significantly differed based on location and breed. Genotyping of seven human isolates of Cryptosporidium confirmed C. hominis (n = 5) and C. parvum (n = 2). After characterizing 110 Cryptosporidium isolates from calves, C. andersoni (n = 55), C. ryanae (n = 29), C. bovis (n = 14), C. parvum (n = 10), C. ubiquitum (n = 1), and C. occultus (n = 1) were identified. Cryptosporidium hominis and C. parvum-positive samples were further subjected to nested PCR and sequencing of the glycoprotein 60 (gp60) gene for subtyping. Four C. hominis subtypes (IaA19R3, IaA23R3, IbA9G3, and IdA15G1) and one C. parvum subtype (IIdA15G1) were observed. In conclusion, Cryptosporidium was prevalent in calves but less common in children in the study locations, and the presence of zoonotic Cryptosporidium species and subtypes in calves raises concerns regarding zoonotic transmission to humans.

Genetic diversity of Cryptosporidium species in Njoro Sub County, Nakuru, Kenya

Cryptosporidium spp. cause cryptosporidiosis in humans through zoonotic and anthroponotic transmission. Previous studies illustrated the significance of domestic animals as reservoirs of this parasite. Cryptosporidium occurs in Njoro River; a main source of water to humans and animals. However, there is no information on the Cryptosporidium spp. and genotypes circulating in Njoro Sub County. A total of 2174 samples from humans, cattle, chickens, sheep and goats were assessed for the presence of Cryptosporidium spp. Thirty-three positive samples were subsequently successfully sequenced and compared to Cryptosporidium sequences in the GenBank repository using NCBI's (National Center for Biotechnology Information) online BLAST (Basic Local Alignment Search Tool) algorithmic program. Sequence alignment was done using the Clustal W program and phylogenetic analysis was executed in MEGA X (Molecular Evolutionary Genetics Analysis version X). The prevalence of cryptosporidiosis in Njoro Sub County is 6.99%. Cryptosporidium spp. present in the watershed showed great genetic diversity and nine Cryptosporidium species were recorded: Cryptosporidium parvum, Cryptosporidium hominis, Cryptosporidium ubiquitum, Cryptosporidium meleagridis, Cryptosporidium andersoni, Cryptosporidium baileyi, Cryptosporidium muris, Cryptosporidium xiaoi and Cryptosporidium viatorum. This is the first study to report the presence of C. viatorum in Kenya. Cattle is the major reservoir of zoonotic Cryptosporidium spp. while goats harbored the lowest number of species. Humans and domestic animals drink the contaminated water from Njoro River, humans are therefore, exposed to a high cryptosporidiosis risk.

A review of the diversity of Cryptosporidium in Rattus norvegicus, R. rattus and Mus musculus: What we know and challenges for the future

The aim of this paper is to review the diversity of Cryptosporidium species and genotypes infecting synantropic rodents. A total of 27 papers published between 1990 and 2020 assed the presence of Cryptosporidium in these rodents worldwide and described 17 different species and genotypes of Cryptosporidium. A great variation in the prevalence values were observed (0-63%). The most frequent species/genotypes were Rat genotype I and IV for R. norvegicus and Rat genotype II and III R. rattus, while C. tyzzeri was for M. musculus. Cryptosporidium parvum, the second most common species after C. hominis involved in human cryptosporidiosis cases, was the third most detected Cryptosporidium species in R, norvergicus (9.4% of the positive samples) and the 3 rodent species are common host for C. muris, also recognized as zoonotic. Besides, these synanthopic rodents can harbor Cryptosporidium species whose natural hosts are cattle, bovids, pigs, other rodent species, birds and a broad range of mammals. Considering the diversity described so far, it would have a great epidemiological impact to know how the variation of Cryptosporidium species composition along urban-rural gradients is like, including synanthropic rodents, wild and domestic animals and environmental samples, and to analyze the causal factors of such variation.

Transmission of Cryptosporidium Species Among Human and Animal Local Contact Networks in Sub-Saharan Africa: A Multicountry Study

BACKGROUND

Cryptosporidiosis has been identified as one of the major causes of diarrhea and diarrhea-associated deaths in young children in sub-Saharan Africa. This study traces back Cryptosporidium-positive children to their human and animal contacts to identify transmission networks.

METHODS

Stool samples were collected from children < 5 years of age with diarrhea in Gabon, Ghana, Madagascar, and Tanzania. Cryptosporidium-positive and -negative initial cases (ICs) were followed to the community, where stool samples from households, neighbors, and animal contacts were obtained. Samples were screened for Cryptosporidium species by immunochromatographic tests and by sequencing the 18S ribosomal RNA gene and further subtyped at the 60 kDa glycoprotein gene (gp60). Transmission clusters were identified and risk ratios (RRs) calculated.

RESULTS

Among 1363 pediatric ICs, 184 (13%) were diagnosed with Cryptosporidium species. One hundred eight contact networks were sampled from Cryptosporidium-positive and 68 from negative ICs. Identical gp60 subtypes were detected among 2 or more contacts in 39 (36%) of the networks from positive ICs and in 1 contact (1%) from negative ICs. In comparison to Cryptosporidium-negative ICs, positive ICs had an increased risk of having Cryptosporidium-positive household members (RR, 3.6 [95% confidence interval {CI}, 1.7-7.5]) or positive neighboring children (RR, 2.9 [95% CI, 1.6-5.1]), but no increased risk of having positive animals (RR, 1.2 [95% CI, .8-1.9]) in their contact network.

CONCLUSIONS

Cryptosporidiosis in rural sub-Saharan Africa is characterized by infection clusters among human contacts, to which zoonotic transmission appears to contribute only marginally.

A novel genotyping method for Cryptosporidium hominis

Cryptosporidiosis remains the leading protozoan induced cause of diarrhoea-associated mortality worldwide. Cryptosporidium hominis, the anthroponotically transmitted species within the Cryptosporidium genus, contributes significantly to the global burden of infection, accounting for the majority of clinical cases in many countries. This study applied high resolution melting analysis, a post-real-time PCR application, to the differentiation of six globally prevalent C. hominisgp60-subtypes. This novel method targeted three microsatellite, tandem repeat containing genetic markers, gp60, the genetic marker upon which current Cryptosporidium subtype nomenclature is based, MSB, and MSE, by which to differentiate between C. hominis isolates. This multi-locus approach successfully differentiated between all six C. hominisgp60-subtypes studied, some of which, such as IbA10G2, are known to exhibit global ubiquity. Thus, this method has the potential to be universally employed as a sensitive, cost effective and highly reproducible means to rapidly differentiate between C. hominisgp60-subtypes. Such a method would be of particular utility in epidemiological studies and outbreak scenarios, providing cost effective, clinically accessible alternative to DNA sequencing. The success of this preliminary study also supports further analysis of an expanded C. hominisgp60-subtype range and the potential expansion of the multi-locus panel in order to improve the discriminatory power of this approach.

Molecular Characterisation of Cryptosporidium spp. in Mozambican Children Younger than 5 Years Enrolled in a Matched Case-Control Study on the Aetiology of Diarrhoeal Disease

Cryptosporidium is a leading cause of childhood diarrhoea and associated physical and cognitive impairment in low-resource settings. Cryptosporidium-positive faecal samples (n = 190) from children aged ≤ 5 years enrolled in the Global Enteric Multicenter Study (GEMS) in Mozambique detected by ELISA (11.5%, 430/3754) were successfully PCR-amplified and sequenced at the gp60 or ssu rRNA loci for species determination and genotyping. Three Cryptosporidium species including C. hominis (72.6%, 138/190), C. parvum (22.6%, 43/190), and C. meleagridis (4.2%, 8/190) were detected. Children ≤ 23 months were more exposed to Cryptosporidium spp. infections than older children. Both C. hominis and C. parvum were more prevalent among children with diarrhoeal disease compared to those children without it (47.6% vs. 33.3%, p = 0.007 and 23.7% vs. 11.8%, p = 0.014, respectively). A high intra-species genetic variability was observed within C. hominis (subtype families Ia, Ib, Id, Ie, and If) and C. parvum (subtype families IIb, IIc, IIe, and IIi) but not within C. meleagridis (subtype family IIIb). No association between Cryptosporidium species/genotypes and child's age was demonstrated. The predominance of C. hominis and C. parvum IIc suggests that most of the Cryptosporidium infections were anthroponotically transmitted, although zoonotic transmission events also occurred at an unknown rate. The role of livestock, poultry, and other domestic animal species as sources of environmental contamination and human cryptosporidiosis should be investigated in further molecular epidemiological studies in Mozambique.

Molecular Epidemiology of Human Cryptosporidiosis in Low- and Middle-Income Countries

Cryptosporidiosis is one of the most important causes of moderate to severe diarrhea and diarrhea-related mortality in children under 2 years of age in low- and middle-income countries. In recent decades, genotyping and subtyping tools have been used in epidemiological studies of human cryptosporidiosis. Results of these studies suggest that higher genetic diversity of Cryptosporidium spp. is present in humans in these countries at both species and subtype levels and that anthroponotic transmission plays a major role in human cryptosporidiosis. Cryptosporidium hominis is the most common Cryptosporidium species in humans in almost all the low- and middle-income countries examined, with five subtype families (namely, Ia, Ib, Id, Ie, and If) being commonly found in most regions. In addition, most Cryptosporidium parvum infections in these areas are caused by the anthroponotic IIc subtype family rather than the zoonotic IIa subtype family. There is geographic segregation in Cryptosporidium hominis subtypes, as revealed by multilocus subtyping. Concurrent and sequential infections with different Cryptosporidium species and subtypes are common, as immunity against reinfection and cross protection against different Cryptosporidium species are partial. Differences in clinical presentations have been observed among Cryptosporidium species and C. hominis subtypes. These observations suggest that WASH (water, sanitation, and hygiene)-based interventions should be implemented to prevent and control human cryptosporidiosis in low- and middle-income countries.

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

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

Increased diversity and novel subtypes among clinical Cryptosporidium parvum and Cryptosporidium hominis isolates in Southern Ireland

Reported incidence rates of cryptosporidiosis in Ireland are consistently among the highest in Europe. Despite the national prevalence of this enteric parasite and the compulsory nature of incidence surveillance and reporting, in-depth analyses seeking to genotype clinical isolates of Cryptosporidium on an intra-species level are rarely undertaken in Ireland. This molecular epidemiology study of 163 clinical Cryptosporidium isolates was conducted in Southern Ireland, from 2015 to 2018, in order to ascertain population subtype heterogeneity. Analysis was conducted via real-time PCR amplification and gp60 gene sequencing, which successfully determined the subtype designation of 149 of the 163 (91.4%) tested isolates. Overall, 12 C. parvum and five C. hominis subtypes were identified, with the incidence of the regionally predominant C. parvum species found to primarily occur during springtime months, while C. hominis incidence was largely confined to late summer and autumnal months. Additionally, one C. parvum and four C. hominis subtypes were newly reported by this study, having not been previously identified in clinical or livestock infection in Ireland. Overall, these data give insight into the diversification of the Cryptosporidium population and emergent subtypes, while also allowing comparisons to be made with clinical epidemiological profiles reported previously in Ireland and elsewhere.

First study of Cryptosporidium spp. occurrence in eared doves (Zenaida auriculata)

Cryptosporidium is a protozoan parasite with a wide range of hosts, including humans. However, only a few Cryptosporidium species have been described in birds (C. meleagridis, C. baileyi, C. galli and C. avium). The aim of this study was to investigate the occurrence of Cryptosporidium spp. in feces of eared doves (Zenaida auriculata), followed by molecular characterization of the parasite. A total of 196 animals of both sexes were trap-captured; the animals were culled and the intestinal contents were collected for DNA extraction. After extraction, a nested-PCR (nPCR), which amplifies a fragment of the 18S rRNA gene of Cryptosporidium spp., was performed. The amplicons obtained were purified and sequenced. PCR analysis revealed that 30 animals (15.3%) were positive for Cryptosporidium spp. There was no significant sex-dependent enrichment of Cryptosporidium occurrence (p > 0.05). Only 15 out of the 30 positive samples were successfully sequenced and their species determined, of which, 13 (86.7%) and 2 (13.3%) were C. meleagridis and C. galli, respectively. Herein, we present for the first time a molecular characterization of Cryptosporidium from feces of eared doves (Z. auriculata) and propose that these birds are a potential source of C. meleagridis infection in humans.

Retrospective analysis of Cryptosporidium species in Western Australian human populations (2015-2018), and emergence of the C. hominis IfA12G1R5 subtype

Cryptosporidium species are a major cause of diarrhoea worldwide. In the present study, a retrospective analysis of 109 microscopically Cryptosporidium-positive faecal specimens from Western Australian patients, collected between 2015 and 2018 was conducted. Sequence analysis of the 18S rRNA and the 60 kDa glycoprotein (gp60) gene loci identified four Cryptosporidium species: C. hominis (86.2%, 94/109), C. parvum (11.0%, 12/109), C. meleagridis (1.8%, 2/109) and C. viatorum (0.9%, 1/109). Subtyping at the gp60 locus identified a total of 11 subtypes including the emergence of the previously rare C. hominis IfA12G1R5 subtype in 2017 as the dominant subtype (46.7%, 21/45). This subtype has also recently emerged as the dominant subtype in the United States but the reasons for its emergence are unknown. This is also the first report of C. viatorum in humans in Australia and a novel subtype (XVaA3g) was identified in the one positive patient.

Anthroponotic transmission of Cryptosporidium parvum predominates in countries with poorer sanitation: a systematic review and meta-analysis

Background

Globally cryptosporidiosis is one of the commonest causes of mortality in children under 24 months old and may be associated with important longterm health effects. Whilst most strains of Cryptosporidium parvum are zoonotic, C. parvum IIc is almost certainly anthroponotic. The global distribution of this potentially important emerging infection is not clear.

Methods

We conducted a systematic review of papers identifying the subtype distribution of C. parvum infections globally. We searched PubMed and Scopus using the following key terms Cryptospor* AND parvum AND (genotyp* OR subtyp* OR gp60). Studies were eligible for inclusion if they had found C. parvum within their human study population and had subtyped some or all of these samples using standard gp60 subtyping. Pooled analyses of the proportion of strains being of the IIc subtype were determined using StatsDirect. Meta-regression analyses were run to determine any association between the relative prevalence of IIc and Gross Domestic Product, proportion of the population with access to improved drinking water and improved sanitation.

Results

From an initial 843 studies, 85 were included in further analysis. Cryptosporidium parvum IIc was found in 43 of these 85 studies. Across all studies the pooled estimate of relative prevalence of IIc was 19.0% (95% CI: 12.9–25.9%), but there was substantial heterogeneity. In a meta-regression analysis, the relative proportion of all C. parvum infections being IIc decreased as the percentage of the population with access to improved sanitation increased and was some 3.4 times higher in those studies focussing on HIV-positive indivduals.

Conclusions

The anthroponotic C. parvum IIc predominates primarily in lower-income countries with poor sanitation and in HIV-positive individuals. Given the apparent enhanced post-infectious virulence of the other main anthroponotic species of Cryptosporidium (C. hominis), it is important to learn about the impact of this subtype on human health.

Electronic supplementary material

The online version of this article (10.1186/s13071-018-3263-0) contains supplementary material, which is available to authorized users.

Genotypic Characterization of Cryptosporidium Species in Humans and Peri-Domestic Animals in Ekiti and Oyo States, Nigeria

Cryptosporidiosis is one of the leading causes of diarrhea in humans and several other vertebrate species. Because surveys of Cryptosporidium genotypes from animals and humans living in the same region are rare, our understanding of the importance of zoonotic transmission in the epidemiology of cryptosporidiosis remains superficial. PCR was used to amplify a portion of the Cryptosporidium 18S small subunit ribosomal RNA gene from fecal DNA from humans and livestock living in Ekiti and Oyo states, Nigeria. PCR-positive samples were further analyzed using PCR targeting the heat-shock protein HSP-70, the actin, and the sporozoite glycoprotein gene gp60. A questionnaire was used to collect demographic information. Sixteen of 187 samples collected were Cryptosporidium 18S PCR positive. Of these, 5 samples originating from HIV-positive patients, 5 from otherwise healthy children, 2 from chickens, 3 from goats, and 1 from a dog were positive for at least 1 marker. Sequencing of the 18S rRNA amplicons revealed the presence of Cryptosporidium parvum in 2 HIV positive patients and in a child; the actin sequence confirmed the presence of this species. Two samples of HIV-positive patients amplified Cryptosporidium hominis 18S rRNA, one of them confirmed by the HSP-70, actin, and gp60 sequences. Cryptosporidium meleagridis was found in another HIV patient, while C. hominis was detected in 3 children (of which 2 were confirmed by gp60). Cryptosporidium muris was found in 1 child. In birds, we found C. meleagridis and, significantly, C. parvum, whereas we detected C. parvum and C. muris in 1 goat each. The only dog sampled was positive for Cryptosporidium canis. We conclude that, in the environment we surveyed, humans and animals are a potential part of the same transmission cycle. Measures to prevent zoonotic transmission should therefore be considered to reduce the prevalence of cryptosporidiosis.

Molecular detection of Cryptosporidium species in street-sampled dog faeces in Ibadan, Nigeria

Cryptosporidium, an intestinal protozoan parasite that infects a wide range of animals, is shed to the environment through the faeces of infected hosts that include humans and companion animals. Environmental contamination with infective oocysts increases the risk of transmission of this zoonotic pathogen to other susceptible host. In this study, Cryptosporidium was detected by polymerase chain reaction amplification of the 18S rRNA gene in 2.5% (5/203) of dog faecal samples randomly collected from 23 streets of Ibadan, southwestern Nigeria. Nucleotide sequencing of the 18S rRNA gene yielded two genotypes, C. parvum and C. muris in three and two samples, respectively. Further amplification of the gp60 gene-coding 60-kDa glycoprotein for subtype determination detected two isolates as C. parvum subtype IIc family. C. parvum subtype IIc is a human-derived pathogen while C. muris has been reported to infect rodents and even humans. The findings of this study suggest that free-ranging urban dogs could act as reservoirs and potential sources of environmental contamination with Cryptosporidium species of public health importance.

Clinical, environmental, and behavioral characteristics associated with Cryptosporidium infection among children with moderate-to-severe diarrhea in rural western Kenya, 2008-2012: The Global Enteric Multicenter Study (GEMS)

Background

Cryptosporidium is a leading cause of moderate-to-severe diarrhea (MSD) in young children in Africa. We examined factors associated with Cryptosporidium infection in MSD cases enrolled at the rural western Kenya Global Enteric Multicenter Study (GEMS) site from 2008-2012.

Methodology/Principal findings

At health facility enrollment, stool samples were tested for enteric pathogens and data on clinical, environmental, and behavioral characteristics collected. Each child’s health status was recorded at 60-day follow-up. Data were analyzed using logistic regression. Of the 1,778 children with MSD enrolled as cases in the GEMS-Kenya case-control study, 11% had Cryptosporidium detected in stool by enzyme immunoassay; in a genotyped subset, 81% were C. hominis. Among MSD cases, being an infant, having mucus in stool, and having prolonged/persistent duration diarrhea were associated with being Cryptosporidium-positive. Both boiling drinking water and using rainwater as the main drinking water source were protective factors for being Cryptosporidium-positive. At follow-up, Cryptosporidium-positive cases had increased odds of being stunted (adjusted odds ratio [aOR] = 1.65, 95% CI: 1.06–2.57), underweight (aOR = 2.08, 95% CI: 1.34–3.22), or wasted (aOR = 2.04, 95% CI: 1.21–3.43), and had significantly larger negative changes in height- and weight-for-age z-scores from enrollment.

Conclusions/Significance

Cryptosporidium contributes significantly to diarrheal illness in young children in western Kenya. Advances in point of care detection, prevention/control approaches, effective water treatment technologies, and clinical management options for children with cryptosporidiosis are needed.

Cryptosporidium is an important cause of childhood diarrhea. Research on cryptosporidiosis in countries where it is endemic remains limited; few studies have comprehensively examined risk factors for children in Kenya and similar settings. We examined characteristics associated with Cryptosporidium in children with moderate-to-severe diarrhea in rural western Kenya. We found there is little to clinically distinguish cryptosporidiosis from other childhood diarrhea in the absence of point of care diagnostics. Infants had the highest odds of Cryptosporidium infection; it has been previously established that Cryptosporidium infections in infancy can have severe consequences. Prolonged/persistent duration diarrhea and growth shortfalls were significantly more pronounced among cases with Cryptosporidium. Undernutrition and stunting in children in low- and middle-income countries have predicted decreased cognitive and school performance, thus long-term consequences could be appreciable. Using rainwater as the primary drinking water source and boiling drinking water were protective against Cryptosporidium infection, thus certain water sources may contribute to transmission. Like other studies in Kenya, we predominantly identified Cryptosporidium hominis, an anthropogenic species. Advances in point of care detection, prevention and control approaches, effective water treatment technologies, and clinical management options are needed to mitigate the potentially severe and long-term consequences of Cryptosporidium infection in children.

Pathogens transmitted in animal feces in low- and middle-income countries

Animals found in close proximity to humans in low-and middle-income countries (LMICs) harbor many pathogens capable of infecting humans, transmissible via their feces. Contact with animal feces poses a currently unquantified-though likely substantial-risk to human health. In LMIC settings, human exposure to animal feces may explain some of the limited success of recent water, sanitation, and hygiene interventions that have focused on limiting exposure to human excreta, with less attention to containing animal feces. We conducted a review to identify pathogens that may substantially contribute to the global burden of disease in humans through their spread in animal feces in the domestic environment in LMICs. Of the 65 potentially pathogenic organisms considered, 15 were deemed relevant, based on burden of disease and potential for zoonotic transmission. Of these, five were considered of highest concern based on a substantial burden of disease for which transmission in animal feces is potentially important: Campylobacter, non-typhoidal Salmonella (NTS), Lassa virus, Cryptosporidium, and Toxoplasma gondii. Most of these have a wide range of animal hosts, except Lassa virus, which is spread through the feces of rats indigenous to sub-Saharan Africa. Combined, these five pathogens cause close to one million deaths annually. More than half of these deaths are attributed to invasive NTS. We do not estimate an overall burden of disease from improperly managed animal feces in LMICs, because it is unknown what proportion of illnesses caused by these pathogens can be attributed to contact with animal feces. Typical water quantity, water quality, and handwashing interventions promoted in public health and development address transmission routes for both human and animal feces; however, sanitation interventions typically focus on containing human waste, often neglecting the residual burden of disease from pathogens transmitted via animal feces. This review compiles evidence on which pathogens may contribute to the burden of disease through transmission in animal feces; these data will help prioritize intervention types and regions that could most benefit from interventions aimed at reducing human contact with animal feces.

Lateral Flow Loop-Mediated Isothermal Amplification Test with Stem Primers: Detection of Cryptosporidium Species in Kenyan Children Presenting with Diarrhea

Background. Cryptosporidium is a protozoan parasite and a major cause of diarrhea in children and immunocompromised patients. Current diagnostic methods for cryptosporidiosis such as microscopy have low sensitivity while techniques such as PCR indicate higher sensitivity levels but are seldom used in developing countries due to their associated cost. A loop-mediated isothermal amplification (LAMP) technique, a method with shorter time to result and with equal or higher sensitivity compared to PCR, has been developed and applied in the detection of Cryptosporidium species. The test has a detection limit of 10 pg/µl (~100 oocysts/ml) indicating a need for more sensitive diagnostic tools. This study developed a more sensitive lateral flow dipstick (LFD) LAMP test based on SAM-1 gene and with the addition of a second set of reaction accelerating primers (stem primers). Results. The stem LFD LAMP test showed analytical sensitivity of 10 oocysts/ml compared to 100 oocysts/ml (10 pg/ul) for each of the SAM-1 LAMP test and nested PCR. The stem LFD LAMP and nested PCR detected 29/39 and 25/39 positive samples of previously identified C. parvum and C. hominis DNA, respectively. The SAM-1 LAMP detected 27/39. On detection of Cryptosporidium DNA in 67 clinical samples, the stem LFD LAMP detected 16 samples and SAM-2 LAMP 14 and nested PCR identified 11. Preheating the templates increased detection by stem LFD LAMP to 19 samples. Time to results from master mix preparation step took ~80 minutes. The test was specific, and no cross-amplification was recorded with nontarget DNA. Conclusion. The developed stem LFD LAMP test is an appropriate method for the detection of C. hominis, C. parvum, and C. meleagridis DNA in human stool samples. It can be used in algorithm with other diagnostic tests and may offer promise as an effective diagnostic tool in the control of cryptosporidiosis.

First detection of Cryptosporidium DNA in blood and cerebrospinal fluid of HIV-infected patients

Human cryptosporidiosis is an intestinal infection caused by different species belonging to the genus Cryptosporidium in both immunocompetent and immunocompromised individuals. The life cycle of Cryptosporidium sp. when affecting the digestive system is well known but the infection of other organs is less studied. Molecular methods are necessary for species and subtypes identification. The goal of this work is to propose a new approach that contributes to the diagnosis of the extra-intestinal dissemination process of Cryptosporidium infection. Cryptosporidium sp. was detected in stool and biopsy samples of two HIV-infected patients. DNA was extracted from feces, biopsy specimens, blood, and cerebrospinal fluid (CSF). All samples were analyzed by nested PCR-RFLP of the 18S rDNA, real-time PCR, and gp60 subtyping. Cryptosporidium DNA was detected in stool and tissue samples and it was also present in blood and CSF samples. Both cases were characterized as Cryptosporidium hominis subtype IeA11G3T3. This is the first report that demonstrates the presence of Cryptosporidium DNA in blood and CSF of HIV-infected patients.

Prevalence of Cryptosporidium, microsporidia and Isospora infection in HIV-infected people: a global systematic review and meta-analysis

BACKGROUND

Diarrhea caused by opportunistic intestinal protozoa is a common problem in HIV infection. We aimed to establish the prevalence of Cryptosporidium, misrosporidia, and Isospora in HIV-infected people using a systematic review and meta-analysis, which is central to developing public policy and clinical services.

METHODS

We searched PubMed, ScienceDirect, Google Scholar, Embase, Chinese Web of Knowledge, Wanfang, and Chongqing VIP databases for studies reporting Cryptosporidium, microsporidia, or Isospora infection in HIV-infected people. We extracted the numbers of people with HIV and protozoa infection, and estimated the pooled prevalence of parasite infection by a random effects model.

RESULTS

Our research identified 131 studies that reported Cryptosporidium, microsporidia, and Isospora infection in HIV-infected people. We estimated the pooled prevalence to be 14.0% (3283/43,218; 95% CI: 13.0-15.0%) for Cryptosporidium, 11.8% (1090/18,006; 95% CI: 10.1-13.4%) for microsporidia, and 2.5% (788/105,922; 95% CI: 2.1-2.9%) for Isospora. A low prevalence of microsporidia and Isospora infection was found in high-income countries, and a high prevalence of Cryptosporidium and Isospora infection was found in sub-Saharan Africa. We also detected a high prevalence of Cryptosporidium, microsporidia, and Isospora infection in patients with diarrhea. Sensitivity analysis showed that three studies significantly affect the prevalence of Isospora, which was adjusted to 5.0% (469/8570; 95% CI: 4.1-5.9%) by excluding these studies.

CONCLUSIONS

Our findings suggest that HIV-infected people have a high prevalence of Cryptosporidium, microsporidia, and Isospora infection in low-income countries and patients with diarrhea, especially in sub-Saharan Africa, reinforcing the importance of routine surveillance for opportunistic intestinal protozoa in HIV-infected people.

HIV and diarrhoea: what is new?

PURPOSE OF REVIEW

The review examines the changing causes and the investigation of infectious and noninfectious diarrhoea in individuals with HIV.

RECENT FINDINGS

Despite the excellent prognosis conferred by combination antiretroviral therapy, diarrhoea is still common in HIV-positive individuals and is associated with reduced quality of life and survival. There is increasing interest in the importance of Th17 and Th22 T cells in the maintenance of mucosal immunity within the gut, and in the role of the gut microbiome in gut homeostasis. Bacterial causes of HIV-associated diarrhoea continue to be important in resource-poor settings. In other settings, sexually transmitted enteric infections such as lymphogranuloma venereum and shigellosis are increasingly reported in men who have sex with men. HIV increases the risk of such infections and the presence of antimicrobial resistance. Parasitic causes of diarrhoea are more common in individuals with uncontrolled HIV and low CD4 counts. Noninfectious causes of diarrhoea include all classes of antiretroviral therapy, which is under-recognised as a cause of poor treatment adherence. Pancreatic dysfunction is remediable and the diagnostic workup of HIV-related diarrhoea should include faecal elastase measurements. New antimotility agents such as crofelemer may be useful in managing secretory diarrhoea symptoms.

SUMMARY

Clinicians looking after patients with HIV should ask about diarrhoeal symptoms, which are under-reported and may have a remediable infectious or noninfectious cause.

Pediatric cryptosporidiosis: An evaluation of health care and societal costs in Peru, Bangladesh and Kenya

Cryptosporidium is a leading cause of pediatric diarrhea in resource-limited settings; yet, few studies report the health care costs or societal impacts of this protozoan parasite. Our study examined direct and indirect costs associated with symptomatic cryptosporidiosis in infants younger than 12 months in Kenya, Peru and Bangladesh. Inputs to the economic burden model, such as disease incidence, population size, health care seeking behaviour, hospital costs, travel costs, were extracted from peer-reviewed literature, government documents, and internationally validated statistical tools for each country. Indirect losses (i.e. caregiver income loss, mortality, and growth faltering) were also estimated. Our findings suggest that direct treatment costs per symptomatic cryptosporidiosis episode were highest in Kenya ($59.01), followed by Peru ($23.32), and Bangladesh ($7.62). The total annual economic impacts for the 0-11 month cohorts were highest in Peru ($41.5M; range $0.88-$599.3M), followed by Kenya ($37.4M; range $1.6-$804.5M) and Bangladesh ($9.6M, range $0.28-$91.5M). For all scenarios, indirect societal costs far outweighed direct treatment costs. These results highlight the critical need for innovative improvements to current prevention, diagnostic and treatment strategies available in resource poor settings, as well as the need for solutions that span multiple disciplines including food and water safety, sanitation and livestock production.

Prevalence of Toxoplasma gondii and Other Gastrointestinal Parasites in Domestic Cats from Households in Thika Region, Kenya

Gastrointestinal (GIT) parasites of domestic cats (Felis catus) not only cause morbidity but are also potential zoonotic agents. The current study aimed at establishing the prevalence of GIT parasites in cats kept by households in Thika region, Kenya. Fecal samples were collected randomly from 103 cats and analyzed for presence of parasites using standard parasitological methods. In descending order, the prevalence of the detected protozoa parasites was Isospora spp. 43.7% (95% CI: 40.4–47%), Cryptosporidium spp. 40.8% (95% CI: 37.5–44.1%), Toxoplasma gondii 7.8% (95% CI: 4.5–11.1%), and Entamoeba spp. 2.9% (95% CI: 1.6–6.2%). The prevalence of the observed helminths was Strongyloides stercoralis 43.7% (95% CI: 40.4–47%), Toxocara cati 23.3% (95% CI: 20–26.6%), Ancylostoma spp. 9.7% (95% CI: 6.4–13%), Dipylidium caninum 8.7% (95% CI: 5.4–12.0%), and Acanthocephala spp. 1.9% (95% CI: 1–4.2%). The percentage of cats excreting at least one species of parasite was 73.2% (95% CI = 69.9–76.5%). The study shows that the cats have high spectrum (9) of parasites which are known to affect the cat's health and some are of zoonotic significance.

Multiplex PCR detection of Cryptosporidium sp, Giardia lamblia and Entamoeba histolytica directly from dried stool samples from Guinea-Bissauan children with diarrhoea

BACKGROUND

In developing countries, diarrhoea is the most common cause of death for children under five years of age, with Giardia lamblia, Cryptosporidium and Entamoeba histolytica as the most frequent pathogenic parasites. Traditional microscopy for stool parasites has poor sensitivity and specificity, while new molecular methods may provide more accurate diagnostics. In poor regions with sample storage hampered by uncertain electricity supply, research would benefit from a method capable of analysing dried stools.

METHODS

A real-time multiplex PCR method with internal inhibition control was developed for detecting Giardia lamblia, Cryptosporidium hominis/parvum and Entamoeba histolytica directly from stool specimens. Applicability to dried samples was checked by comparing with fresh ones in a small test material. Finally, the assay was applied to dried specimens collected from Guinea-Bissauan children with diarrhoea.

RESULTS

The PCR's analytical sensitivity limit was 0.1 ng/ml for G. lamblia DNA, 0.01 ng/ml for E. histolytica DNA and 0.1 ng/ml for Cryptosporidium sp. In the test material, the assay performed similarly with fresh and dried stools. Of the 52 Guinea-Bissauan samples, local microscopy revealed a parasite in 15%, while PCR detected 62% positive for at least one parasite: 44% of the dried samples had Giardia, 23% Cryptosporidium and 0% E. histolytica.

CONCLUSIONS

Our new multiplex real-time PCR for protozoa presents a sensitive method applicable to dried samples. As proof of concept, it worked well on stools collected from Guinea-Bissauan children with diarrhoea. It provides an epidemiological tool for analysing dried specimens from regions poor in resources.

Cryptosporidium and Giardia in Africa: current and future challenges

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