Abstract
Giardiasis is the intestinal infection caused by Giardia lamblia, in which pathogenicity was cast doubted for decades but now is recognized as one of the most common causes of diarrheal disease worldwide. Originally described as waterborne transmitted, it has been broad described as of fecal-oral, person-to-person contact, and sexual transmission also. Although it is recognized as endemic throughout the world, most cases are reported from tropical countries with regular outbreaks commonly reported from developed countries. In humans, giardiasis normally produces a self-limited infection without symptoms, but some patients may present intestinal symptoms such as diarrhea and abdominal pain, and few show symptoms long after parasites clear up. Upon diagnosis, we may choose among several effective treatment alternatives, but not every patient responds to such therapies. Hence, having specific knowledge about the epidemiology of Giardia, it is critical for its prevention, which is the best strategy to protect us against such important disease.
Keywords
- giardiasis
- Giardia
- Giardia lamblia
- epidemiology
- life cycle stages
1. Introduction
Giardiasis is the intestinal infection caused by
The epidemiology of giardiasis still is a matter of great discussion. From the original debates around its pathogenicity to the later ones about its speciation and biology,
Commonly, giardiasis prevalence among poor populations is reported as very high, and when the infection became chronic, it has been associated also with malnutrition and cognitive deficits [5]. In developed countries, giardiasis represents the leading cause of traveler’s diarrhea and is frequently reported among citizens that traveled to developing countries and expose themselves to untreated water from lakes, streams, and swimming pools [6–8]. These and other epidemiologic characteristics of giardiasis will be discussed in detail in this chapter based on the classical and latest literature.
2. Etiologic agent
Microscopically,
Species | Hosts | Morphology |
---|---|---|
|
Amphibians | Longer and slender than |
|
Herons and other birds | Similar to |
|
Mammals including humans, dogs, and some wild species | Teardrop shaped with claw-shaped median bodies |
|
Rodents, voles, and muskrats | Similar to |
|
Rodents | Shorter and rounder than |
|
Psittacine birds | Similar to |
3. Life cycle
Life cycle begins with the infection by the ingestion of the cyst. Then the excystation continues, which starts at the stomach triggered by the exposure of the cyst to the gastric acid, the presence of bile and trypsin in the duodenum and/or the alkaline, protease-rich milieu, duodenum [2]. Excystation ends at the proximal small intestine where the emerging parasites (excyzoites) quickly transform into trophozoites that attach to the intestinal epithelial cells using the adhesive disc. The adhesive disc is essential for attachment and appears to play a major role in the virulence of
Reservoir hosts include humans, as well as a variety of animals, including cats, dogs, dairy cattle, beavers, and other farm, wild, and domesticated animals such as horses, pigs, cows, chinchillas, alpacas, lemurs, sheep, guinea pigs, monkeys, goats, and rats [20]. However, among all these animal hosts, only beavers, dogs, and humans have been implicated as a source of infection in different waterborne epidemics and outbreaks of giardiasis in humans. Additionally, it is important to highlight the key role of “reverse zoonotic transmission” (zooanthroponotic) in the epidemiology of
Even in developed countries such as the United States, it is common to isolate
4. Incidence and burden of disease
Worldwide, the incidence of Giardiasis has been estimated in 2.8 × 108 cases per year [31]. However, several epidemiological studies have reported that such rates could be significantly underestimated, with giardiasis prevalence rates ranging from 10 to 20% of the general population [32], from 10 to 50% in developing countries [33, 34], and from 2 to 5% in developed countries [35, 36]. This could be explained by the large fraction of asymptomatic carriers, which regardless of the absence of symptoms also contribute to the transmission of the diseases.
Giardiasis is a ubiquitous disease so it occurred across broad epidemiological contexts and with a broad range of distributions. On one side, in most developed countries such as the United Kingdom [37] and Germany [8],
The high prevalence of
5. Giardiasis epidemiology
The
Surveillance data cases have shown that giardiasis infects populations with a bimodal age distribution, peaking at ages 0–9 years and 45–49 years, without gender preferences [35], and within areas that are endemic, giardiasis commonly shows a seasonal pattern, with most cases occurring in the summer months due to a recent history of drinking untreated surface water and a history of swimming in a lake or pond or swimming in any natural body of fresh water [47]. Other risk factors that have been reported as associated to giardiasis in endemic areas include living in areas that use at-risk tap water (i.e., filtered or unfiltered surface water [48, 49] or unfiltered shallow well water [48]) or in rural areas [49].
One of the most common mechanisms of transmission of
adults that work in child-care organizations or day-care centers [52];
institutionalized individuals [53];
men who have sex with men [54];
immunocompromised individuals (chronic variable immunodeficiency, hypogammaglobulinemia, HIV, immunosuppressed individuals, cystic fibrosis, and others) [55, 56]; and
international travelers or any subject (hikers, campers, sportsman’s adventures, and others) exposed to drinking untreated water from lakes, streams, and swimming pools [57].
Waterborne transmission is recognized as the most common transmission, with numerously documented outbreaks throughout the world [46, 58]. This includes the consumption of contaminated water from pools, rivers, or lakes, as well as from contaminated drinking water, either unpurified or inadequately purified. There have been multiple documented cases of cysts in the municipal water supply here in the United States, although such scenarios do not account for the vast majority of infections [35].
Foodborne transmission of
Fecal-oral transmission is also a significant mechanism of transmission and is the one responsible for the outbreaks in day-cares and nurseries. These outbreaks reflect the close contact between young children, who are significantly more likely to pass the parasite fecal-orally at day-cares than at home. For example, in the Netherlands, where around half of preschool children are cared for in day-care centers, a mean of 2.5 days a week, children at day-care centers are twice as likely to test positive to
Sexual transmission of
To sum up, it is really important that healthcare providers consider
References
- 1.
Ford BJ. The discovery of giardia. Microscope. 2005; 53 :147-153 - 2.
Adam RD. Biology of Giardia lamblia . Clinical Microbiology Review. 2001;14 :447-475 - 3.
Kotloff KL, Nataro JP, Blackwelder WC, Nasrin D, Farag TH, Panchalingam S, Wu Y, Sow SO, Sur D, Breiman RF, Faruque AS, Zaidi AK, Saha D, Alonso PL, Tamboura B, Sanogo D, Onwuchekwa U, Manna B, Ramamurthy T, Kanungo S, Ochieng JB, Omore R, Oundo JO, Hossain A, Das SK, Ahmed S, Qureshi S, Quadri F, Adegbola RA, Antonio M, Hossain MJ, Akinsola A, Mandomando I, Nhampossa T, Acacio S, Biswas K, O'Reilly CE, Mintz ED, Berkeley LY, Muhsen K, Sommerfelt H, Robins-Browne RM, Levine MM. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): A prospective, case-control study. Lancet. 2013; 382 :209-222 - 4.
Bartelt LA, Platts-Mills JA. Giardia: A pathogen or commensal for children in high-prevalence settings? Current Opinion in Infectious Disease. 2016; 29 :502-507 - 5.
Fraser D, Bilenko N, Deckelbaum RJ, Dagan R, El-On J, Naggan L. Giardia lamblia carriage in Israeli Bedouin infants: Risk factors and consequences. Clinical Infectious Disease. 2000;30 :419-424 - 6.
Brodsky RE, Spencer HC Jr., Schultz MG. Giardiasis in American travelers to the Soviet Union. Journal of Infectious Disease. 1974; 130 :319-323 - 7.
Lopez CE, Juranek DD, Sinclair SP, Schultz MG. Giardiasis in American travelers to Madeira Island, Portugal. American Journal of Tropical Medicine and Hygiene. 1978; 27 :1128-1132 - 8.
Jelinek T, Loscher T. Epidemiology of giardiasis in German travelers. Journal of Travel Medicine. 2000; 7 :70-73 - 9.
Wolfe MS. Giardiasis. Clinical Microbiology Review. 1992; 5 :93-100 - 10.
Monis PT, Caccio SM, Thompson RC. Variation in giardia: Towards a taxonomic revision of the genus. Trends in Parasitology. 2009; 25 :93-100 - 11.
Caccio SM, Thompson RC, McLauchlin J, Smith HV. Unravelling Cryptosporidium and giardia epidemiology. Trends in Parasitology. 2005;21 :430-437 - 12.
Feng Y, Xiao L. Zoonotic potential and molecular epidemiology of Giardia species and giardiasis. Clinical Microbiology Review. 2011;24 :110-140 - 13.
Lasek-Nesselquist E, Welch DM, Sogin ML. The identification of a new Giardia duodenalis assemblage in marine vertebrates and a preliminary analysis ofG. duodenalis population biology in marine systems. Int Journal of Parasitology. 2010;40 :1063-1074 - 14.
Caccio SM, Ryan U. Molecular epidemiology of giardiasis. Molecular and Biochemical Parasitology. 2008; 160 :75-80 - 15.
Dawson SC. An insider's guide to the microtubule cytoskeleton of giardia. Cellular Microbiology. 2010; 12 :588-598 - 16.
Hagen KD, Hirakawa MP, House SA, Schwartz CL, Pham JK, Cipriano MJ, De La Torre MJ, Sek AC, Du G, Forsythe BM, Dawson SC. Novel structural components of the ventral disc and lateral crest in Giardia intestinalis . PLoS Neglected Tropical Disease. 2011;5 :e1442 - 17.
Brown JR, Schwartz CL, Heumann JM, Dawson SC, Hoenger A. A detailed look at the cytoskeletal architecture of the Giardia lamblia ventral disc. Journal of Structural Biology. 2016;194 :38-48 - 18.
Lujan HD, Mowatt MR, Byrd LG, Nash TE. Cholesterol starvation induces differentiation of the intestinal parasite Giardia lamblia . Proceedings of National Academy Science United States of America. 1996;93 :7628-7633 - 19.
Einarsson E, Troell K, Hoeppner MP, Grabherr M, Ribacke U, Svard SG. Coordinated changes in gene expression throughout encystation of Giardia intestinalis . PLoS Neglected Tropical Disease. 2016;10 :e0004571 - 20.
Gilman RH, Brown KH, Visvesvara GS, Mondal G, Greenberg B, Sack RB, Brandt F, Khan MU. Epidemiology and serology of Giardia lamblia in a developing country: Bangladesh. Transactions of the Royal Society of Tropical Medicine and Hygiene. 1985;79 :469-473 - 21.
Trout JM, Santin M, Fayer R. Giardia and Cryptosporidium species and genotypes in coyotes ( Canis latrans ). Journal of Zoo and Wildlife Medicine. 2006;37 :141-144 - 22.
Thompson RC, Colwell DD, Shury T, Appelbee AJ, Read C, Njiru Z, Olson ME. The molecular epidemiology of Cryptosporidium and Giardia infections in coyotes from Alberta, Canada, and observations on some cohabiting parasites. Veterinary Parasitology. 2009; 159 :167-170 - 23.
Fayer R, Santin M, Trout JM, DeStefano S, Koenen K, Kaur T. Prevalence of Microsporidia, Cryptosporidium spp., and Giardia spp. in beavers ( Castor canadensis ) in Massachusetts. Journal of Zoo and Wildlife Medicine. 2006;37 :492-497 - 24.
Kutz SJ, Thompson RA, Polley L, Kandola K, Nagy J, Wielinga CM, Elkin BT. Giardia assemblage A: Human genotype in muskoxen in the Canadian Arctic. Parasit Vectors. 2008; 1 :32 - 25.
Graczyk TK, Bosco-Nizeyi J, Ssebide B, Thompson RC, Read C, Cranfield MR. Anthropozoonotic Giardia duodenalis genotype (assemblage) a infections in habitats of free-ranging human-habituated gorillas, Uganda. Journal of Parasitology. 2002;88 :905-909 - 26.
Moro D, Lawson MA, Hobbs RP, Thompson RC. Pathogens of house mice on arid Boullanger Island and subantarctic Macquarie Island, Australia. Journal of Wildlife Disease. 2003; 39 :762-771 - 27.
Appelbee AJ, Thompson RC, Olson ME. Giardia and Cryptosporidium in mammalian wildlife—current status and future needs. Trends in Parasitology. 2005; 21 :370-376 - 28.
Beer KD, Gargano JW, Roberts VA, Hill VR, Garrison LE, Kutty PK, Hilborn ED, Wade TJ, Fullerton KE, Yoder JS. Surveillance for waterborne disease outbreaks associated with drinking water—United States, 2011-2012. MMWR Morbidity and Mortality Weekly Report. 2015; 64 :842-848 - 29.
Pires SM, Fischer-Walker CL, Lanata CF, Devleesschauwer B, Hall AJ, Kirk MD, Duarte AS, Black RE, Angulo FJ. Aetiology-specific estimates of the global and regional incidence and mortality of diarrhoeal diseases commonly transmitted through food. PLoS One. 2015; 10 :e0142927 - 30.
Torgerson PR, Devleesschauwer B, Praet N, Speybroeck N, Willingham AL, Kasuga F, Rokni MB, Zhou XN, Fevre EM, Sripa B, Gargouri N, Furst T, Budke CM, Carabin H, Kirk MD, Angulo FJ, Havelaar A, de Silva N. World Health Organization estimates of the global and regional disease burden of 11 foodborne parasitic diseases, 2010: A data synthesis. PLoS Medicine. 2015; 12 :e1001920 - 31.
Lane S, Lloyd D. Current trends in research into the waterborne parasite Giardia. Critical Reviews in Microbiology. 2002; 28 :123-147 - 32.
Gbakima AA. Intestinal parasitic infections and swamp development in Sierra Leone. African Journal of Health Sciences. 1994; 1 :175-178 - 33.
Savioli L, Smith H, Thompson A. Giardia and Cryptosporidium join the 'neglected diseases initiative'. Trends in Parasitology. 2006; 22 :203-208 - 34.
Daly ER, Roy SJ, Blaney DD, Manning JS, Hill VR, Xiao L, Stull JW. Outbreak of giardiasis associated with a community drinking-water source. Epidemiology and Infection. 2010; 138 :491-500 - 35.
Painter JE, Gargano JW, Collier SA, Yoder JS. Centers for Disease C, Prevention. Giardiasis surveillance—United States, 2011-2012. MMWR. 2015;64(3):15-25 - 36.
Yoder JS, Gargano JW, Wallace RM, Beach MJ, Centers for Disease C, Prevention. Giardiasis surveillance--United States, 2009-2010. MMWR Surveillance Summary. 2012; 61 :13-23 - 37.
Takaoka K, Gourtsoyannis Y, Hart JD, Armstrong M, Daniel A, Mewse E, Phillips D, Bailey RL. Incidence rate and risk factors for giardiasis and strongyloidiasis in returning UK travellers. Journal of Travel Medicine. 2016;23(5):1-6 - 38.
Schnell K, Collier S, Derado G, Yoder J, Gargano JW. Giardiasis in the United States—an epidemiologic and geospatial analysis of county-level drinking water and sanitation data, 1993-2010. Journal of Water and Health. 2016; 14 :267-279 - 39.
Rodriguez-Morales AJ, Granados-Alvarez S, Escudero-Quintero H, Vera-Polania F, Mondragon-Cardona A, Diaz-Quijano FA, Sosa-Valencia L, Lozada-Riascos CO, Escobedo AA, Liseth O, Haque U. Estimating and mapping the incidence of giardiasis in Colombia, 2009-2013. International Journal of Infectious Disease. 2016; 49 :204-209 - 40.
Garcia-Cervantes PC, Baez-Flores ME, Delgado-Vargas F, Ponce-Macotela M, Nawa Y, De-la-Cruz-Otero MD, Martinez-Gordillo MN, Diaz-Camacho SP. Giardia duodenalis genotypes among schoolchildren and their families and pets in urban and rural areas of Sinaloa, Mexico. Journal of Infection in Developing Countries. 2017;11 :180-187 - 41.
Lee MF, Cadogan P, Eytle S, Copeland S, Walochnik J, Lindo JF. Molecular epidemiology and multilocus sequence analysis of potentially zoonotic Giardia spp. from humans and dogs in Jamaica. Parasitology Research. 2017; 116 :409-414 - 42.
Moore CE, Elwin K, Phot N, Seng C, Mao S, Suy K, Kumar V, Nader J, Bousfield R, Perera S, Bailey JW, Beeching NJ, Day NP, Parry CM, Chalmers RM. Molecular characterization of Cryptosporidium Species and Giardia duodenalis from symptomatic Cambodian children. PLoS Neglected Tropical Diseases. 2016;10 :e0004822 - 43.
Kosek MN, Investigators M-EN. Causal pathways from enteropathogens to environmental enteropathy: Findings from the MAL-ED birth cohort study. EBioMedicine. 2017; 18 :109-117 - 44.
Rogawski ET, Bartelt LA, Platts-Mills JA, Seidman JC, Samie A, Havt A, Babji S, Trigoso DR, Qureshi S, Shakoor S, Haque R, Mduma E, Bajracharya S, Gaffar SMA, Lima AAM, Kang G, Kosek MN, Ahmed T, Svensen E, Mason C, Bhutta ZA, Lang DR, Gottlieb M, Guerrant RL, Houpt ER, Bessong PO. Determinants and impact of Giardia infection in the first 2 years of life in the MAL-ED birth cohort. Journal of the Pediatric Infectious Diseases Society. 2017; 6 :153-160 - 45.
Pijnacker R, Mughini-Gras L, Heusinkveld M, Roelfsema J, van Pelt W, Kortbeek T. Different risk factors for infection with Giardia lamblia assemblages A and B in children attending day-care centres. European Journal of Clinical Microbiology and Infectious Disease. 2016;35 :2005-2013 - 46.
Adam EA, Yoder JS, Gould LH, Hlavsa MC, Gargano JW. Giardiasis outbreaks in the United States, 1971-2011. Epidemiology and Infection. 2016; 144 :2790-2801 - 47.
Dennis DT, Smith RP, Welch JJ, Chute CG, Anderson B, Herndon JL, von Reyn CF. Endemic giardiasis in New Hampshire: A case-control study of environmental risks. Journal of Infectious Disease. 1993; 167 :1391-1395 - 48.
Gagnon F, Duchesne JF, Levesque B, Gingras S, Chartrand J. Risk of giardiasis associated with water supply in an endemic context. International Journal of Environmental Health Research. 2006; 16 :349-359 - 49.
Odoi A, Martin SW, Michel P, Holt J, Middleton D, Wilson J. Determinants of the geographical distribution of endemic giardiasis in Ontario, Canada: A spatial modelling approach. Epidemiology and Infection. 2004; 132 :967-976 - 50.
Duffy TL, Montenegro-Bethancourt G, Solomons NW, Belosevic M, Clandinin MT. Prevalence of giardiasis in children attending semi-urban daycare centres in Guatemala and comparison of 3 giardia detection tests. Journal of Health, Population and Nutrition. 2013; 31 :290-293 - 51.
Nunez FA, Hernandez M, Finlay CM. Longitudinal study of giardiasis in three day care centres of Havana City. Acta Tropica. 1999; 73 :237-242 - 52.
Boreham PF, Shepherd RW. Giardiasis in child-care centres. Medical Journal of Australia. 1984; 141 :263 - 53.
Mascarini LM, Donalisio MR. Giardiasis and cryptosporidiosis in children institutionalized at daycare centers in the state of Sao Paulo. Revista da Sociedade Brasileira de Medicina Tropical. 2006; 39 :577-579 - 54.
Beltrami JF, Shouse RL, Blake PA. Trends in infectious diseases and the male to female ratio: Possible clues to changes in behavior among men who have sex with men. AIDS Education and Prevention. 2005; 17 :49-59 - 55.
Abaza SM, Makhlouf LM, el-Shewy KA, el-Moamly AA. Intestinal opportunistic parasites among different groups of immunocompromised hosts. Journal of the Egyptian Society of Parasitology. 1995; 25 :713-727 - 56.
Cruz I, Ricardo JL, Nunes JF, Serras AC, Porto MT, Lopes JM, Veloso FT, Freitas J. Giardia and immune deficiency. American Journal of Gastroenterology. 1991; 86 :1554-1555 - 57.
Holtan NR. Giardiasis. A crimp in the life-style of campers, travelers, and others. Postgraduate Medicine Journal. 1988; 83 :54-6, 59-61 - 58.
Guzman-Herrador B, Carlander A, Ethelberg S, Freiesleben de Blasio B, Kuusi M, Lund V, Lofdahl M, MacDonald E, Nichols G, Schonning C, Sudre B, Tronnberg L, Vold L, Semenza JC, Nygard K. Waterborne outbreaks in the Nordic countries, 1998 to 2012. EuroSurveillance. 2015; 20 - 59.
Rendtorff RC, Holt CJ. The experimental transmission of human intestinal protozoan parasites. IV. Attempts to transmit Entamoeba coli and Giardia lamblia cysts by water. American Journal of Hygiene. 1954;60(3):327-338 - 60.
Enserink R, Scholts R, Bruijning-Verhagen P, Duizer E, Vennema H, de Boer R, Kortbeek T, Roelfsema J, Smit H, Kooistra-Smid M, van Pelt W. High detection rates of enteropathogens in asymptomatic children attending day care. PLoS One. 2014; 9 :e89496 - 61.
Escobedo AA, Almirall P, Alfonso M, Cimerman S, Chacin-Bonilla L. Sexual transmission of giardiasis: A neglected route of spread? Acta Tropica. 2014; 132 :106-111 - 62.
Manatsathit S, Tansupasawasdikul S, Wanachiwanawin D, Setawarin S, Suwanagool P, Prakasvejakit S, Leelakusolwong S, Eampokalap B, Kachintorn U. Causes of chronic diarrhea in patients with AIDS in Thailand: A prospective clinical and microbiological study. Journal of Gastroenterology. 1996; 31 :533-537 - 63.
Espelage W, an der Heiden M, Stark K, Alpers K. Characteristics and risk factors for symptomatic Giardia lamblia infections in Germany. BMC Public Health. 2010;10 :41