Zoonotic Risk of Cryptosporidium spp. Prevention with One Health Approach in Indonesia

Abstract

An important part of the One Health approach to preventing Cryptosporidium spp. infection is to better understand the environmental, epidemiologic, and aetiologic factors associated with Cryptosporidium infection to formulate better risk management. The future One Health strategy aims to integrate multidisciplinary knowledge and coordinate actions to create global synergies that benefit all aspects of human, animal, and environmental health (the One Health Triad). This multidisciplinary approach recognizes the complexity of the ecosystems in which humans and animals coexist. To prevent disease transmission to humans, it is necessary to control and eliminate disease in animals. This is not only to protect human health but also to protect animal health and welfare, maintain food security, and reduce poverty.

1. Introduction

Cryptosporidiosis is an infection of the small intestine caused by intracellular unicellular organisms, Cryptosporidium spp., infecting microvillous epithelial cells in the gastrointestinal and respiratory tract of vertebrate animals [1]. Cryptosporidiosis, one of the neglected zoonotic diseases, is a disease whose transmission depends on interactions between humans and domestic animals or surrounding wildlife reservoirs [2]. Oocysts, the infective stage of Cryptosporidium, are environmentally resistant, especially Cryptosporidium parvum, which is widely distributed and can be transmitted to humans through direct contact with animals via oocyst contamination of water and food. Transmission between animals and humans does not occur to the same extent either in the wild or in some more favorable environments, such as intensive and confined animal farms, where animals are more isolated from humans or have been conditioned [3]. Although they do not spread rapidly at a global scale and are limited by ecological boundaries, the disease can be fatal if not treated early or properly. These diseases tend to be missed by doctors and other health-care providers and are not regularly screened, resulting in underdiagnosis and underreporting [4]. The underreporting makes it difficult to estimate the true burden of the disease, so published studies tend to be conservative or cited broadly [5]. Consequently, there is a lack of accountability for these zoonotic diseases at provincial, national, and even regional levels and a lack of priority for control in human and animal health [6]. Eventually, these diseases may impact animal health and productivity and may cause animal deaths. Thus, there are double burdens on human and animal health in dealing with these issues [7].

An important part of the One Health concept for the prevention of Cryptosporidium infection is a better understanding of the environmental, epidemiological, and etiological factors associated with Cryptosporidium infection to formulate better risk management [8]. The future One Health strategy aims to integrate multidisciplinary knowledge, and coordinate interventions, to create global synergies that serve all aspects of health care for humans, animals, and the environment (One Health Triad) [9]. This multidisciplinary approach takes into account the complexity of ecosystems where humans and animals coexist. To prevent disease transmission in humans, it is necessary to control and eliminate disease in animals. This is not only to protect public health but also to protect the health and improve animal welfare, maintain food security, and reduce poverty.

2. Cryptosporidium spp.

Cryptosporidiosis is a small intestinal infection caused by intracellular protozoa, Cryptosporidium spp., which infect microvillous epithelial cells of vertebrate gastrointestinal and respiratory tracts. It causes chronic diarrhea in children, adults, AIDS patients, and other immunocompromised individuals. The oocysts, the infective stage of Cryptosporidium, are known to be environmentally resistant and widely distributed. They can be transmitted to humans through direct contact with animals by contamination of water and food with oocysts and can cause outbreaks in various locations [10]. Common symptoms of cryptosporidiosis are sometimes underdiagnosed, leading to suboptimal treatment and prevention efforts [11]. Cryptosporidiosis is self-limiting, localized to the intestinal tract, and relatively resistant to reinfection in immunocompetent individuals. In patients with impaired cellular immune response (e.g., AIDS, malnourishment, and CD40-CD154 system deficiency), Cryptosporidium spp. often leads to persistent or chronic diarrhea, and it is not uncommon for the infection to reach the bile ducts, which is potentially life-threatening and is known to contribute to poorly absorbed antivirals and treatment failure in HIV [12].

Understanding the epidemiology of human and environmental cryptosporidiosis is critical to preventing and controlling the disease. There are also several factors that promote the transmission of Cryptosporidium infections, such as rapid modernization, exponential population growth, increased population movement, and higher rates of HIV/AIDS [13]. Cryptosporidiosis epidemics are linked to lack of clean water, poor sanitation, overcrowded housing, many animals in the environment at risk of water contaminated by infected human or animal fecal matter, proximity to rivers or farms, flooded housing, season, nutrition, drinking water from lakes or swimming pools, poor diapering, unsanitary practices in nurseries, exposure to sick people in hospitals, and exposure to infected animals in zoos, farms, or veterinary hospitals. The increase in the means of transportation, both within and between countries, and the development of tourism in developing countries have also increased the potential for the spread of several infectious diseases, including cryptosporidiosis [10].

In recent years, more research has focused on the high prevalence of Cryptosporidium infections in farms and the role of these animals in the risk of zoonotic transmission of the parasite either directly or indirectly through water or food, such as contaminated vegetables and fruits through aboveground fertilization or irrigation with contaminated water [14]. Cryptosporidium oocysts in livestock products such as milk, eggs, and meat have also been found in several cases. Livestock appears to be a source of transmission in outbreaks occurring in several countries. On the other hand, livestock living close to rivers may also be a potential source of transmission to the surrounding water. Animals suspected of harboring these pathogens are sometimes asymptomatic, even appearing healthy, without signs of illness or other symptoms indicating the presence of the pathogen. Transmission occurs through people touching, handling, feeding, or being around these animals or through contact with animals during birthing and cage cleaning or through contamination of clothing, shoes, cage floors, or other hygienic items [15].

The current methods of examination for the detection of these parasites in feces are still based on light microscopy or immunoassays, which have a low level of sensitivity and specificity. Molecular techniques, especially PCR-based genotyping techniques, aim to determine the coding genes and gene structure of Cryptosporidium isolates [16]. Molecular characterization provides useful information not only in the differentiation of genotypes/subgenotypes between isolates of different species strains but also in the knowledge of the coevolution and adaptation mechanisms of the host-parasite and the spread of the infection in the host population [17]. Similar to human and veterinary samples, water and environmental samples should also be tested for oocyst contamination using molecular techniques [18].

3. Zoonotic transmission of Cryptosporidium spp.

There have been many reports of outbreaks or cases of cryptosporidiosis in various countries. Children with a history of contact with cattle or goats are particularly susceptible. Recent genotyping studies have showed that only C. parvum is capable of zoonotic transmission but was found in several host species (humans, cattle, pigs, and goats) [19]. The high incidence of C. parvum in cattle and goats and the presence of large numbers of oocysts, especially in young animals, make these species very important sources of infection for environmental contamination with Cryptosporidium oocysts, which can spread to humans [20].

The genotyping and subtyping of parasites can be an effective added value for the surveillance and epidemiology of infectious diseases. Using the 18S rRNA gene is widely recommended as a target for screening Cryptosporidium from fecal and environmental samples due to the high copy number of sequences in the genome, thus increasing detection sensitivity [21]. Therefore, more comprehensive molecular epidemiological studies of genetic diversity, mode of transmission, and zoonotic potential should be performed in different host types (human, animal, and environment) [22]. Molecular screening techniques, such as polymerase chain reaction (PCR), are an important part of the One Health approach as they can facilitate the understanding of zoonotic transmission routes by identifying parasite species with a much higher degree of specificity than traditional microscopy [23]. Proper management of sources of infection, including animals, their housing, water sources, and the surrounding environment, can reduce the risk of zoonotic transmission [8].

The World Health Organization (WHO) states that except for emerging zoonoses such as SARS ,HPAI, and H5N1, most other zoonoses are not prioritized by national and international health systems. They are therefore referred to as Neglected Zoonotic Diseases (NZD) [24]. The morbidity and mortality associated with these neglected zoonotic diseases are difficult to assess in their entirety. Many of the neglected zoonoses are difficult to diagnose [25]. They are found in poor communities where surveillance and medical or veterinary care are inadequate. This leads to underreporting of the true prevalence of disease and does not receive the attention it deserves.

Research conducted in a community of cattle farmers in Sleman Regency Yogyakarta, Indonesia, demonstrated the transmission of Cryptosporidium spp. from animals to their owners through phylogenetic examination [26]. Cryptosporidium species were identified through PCR examination using specific primers, namely, Cr18S-S1: 5′TAAACGGTAGGGTATTGGCCT-3′ (forward) and Cry18S-AS1 3′-CAGAC TTGCCCTCCAATTGATA-5′ (reverse) with a target of 240 bp [27]. The results of the DNA electrophoresis were then sequenced according to the Sanger method. A phylogenetic analysis of Cryptosporidium in the 18S small subunit (SSU) rRNA gene was carried out to determine the genetic diversity and relationship between the human samples and several animal samples with other isolates from the gene banks as shown in Figure 1.

Figure 1.

Phylogenetic tree Cryptosporidium spp. from human and livestock isolates using the neighbor-joining method in the Mega X application, based on the 18S rRNA gene. Bootstrap analysis was performed with 1000 replications to assess the reliability of this phylogenetic tree.

Phylogenetic analysis of human isolates revealed 21 human, six bovine, and seven goat isolates clustered with Cryptosporidium parvum and Cryptosporidium hominis. In another branch, there were five human isolates and two bovine isolates that clustered with Cryptosporidium meleagridis but were still in the same clade as Cryptosporidium parvum. There were nine human isolates clustering with Cryptosporidium hominis, six bovine isolates clustering with Cryptosporidium bovis. On the other branch, two bovine and one human isolates clustered with Cryptosporidium andersoni. In this phylogenetic tree, species clustered very strongly, with high bootstrap values (99%).

Cluster groupings between human and animal species are shown in the phylogenetic tree above. This indicates that there is a relationship, or close relationship, between Cryptosporidium species in animals and that in humans. The relation may be due to ownership of the animals or due to environmental sources, such as cages owned by other people or water sources contaminated with feces from other infected animals. The transmission of infection from one animal to another is facilitated by the placement of cages in proximity in a group of animals. The results of this molecular analysis revealed zoonotic Cryptosporidium clusters of Cryptosporidium parvum, Cryptosporidium hominis, Cryptosporidium andersoni, Cryptosporidium bovis, and Cryptosporidium meleagridis species in the farming community in Mulati Sleman Regency, Yogyakarta. The clusters detected were from both animal and human samples, indicating close contact between animals and humans within the farm community. Thus, the presence of or some contact with animals (livestock) is essential for zoonotic disease transmission. Initiatives to control animal-associated zoonotic diseases are usually already in place at each farm site. However, a better understanding of the contact patterns of microorganism transmission from animals to humans is necessary for prevention and therefore deserves more attention.

In general, the results of this study indicate the possibility of transmission of Cryptosporidium infection from animals to humans (zoonosis) and/or from humans to humans (anthroponosis). Statistical analysis results indicate that livestock ownership plays a significant role in Cryptosporidium infection, especially when there is a history of diarrhea. Cryptosporidium parvum, Cryptosporidium hominis, Cryptosporidium andersoni, Cryptosporidium bovis, and Cryptosporidium meleagridis have been identified as zoonotic organisms in humans and animals. All cases of Cryptosporidium infection found in this study were asymptomatic in humans as they occurred in immunocompetent individuals; these results should raise our awareness of similar infections in immunocompromised individuals. It has the potential to cause an outbreak that threatens public health if not handled and managed appropriately. The lack of routine screening for Cryptosporidium at the first level of health care and the lack of specific and sensitive diagnostic tools to detect this oocyst parasite mean that cases of Cryptosporidium infection are still rarely found in Indonesia [28].

Bases encoding the 18S rRNA gene can be used to construct phylogenetic trees showing an organism’s ancestry and relatedness [29]. In most genomes, multiple copies of the 18S rRNA bases are arranged in tandem on a single chromosome, and many of these occur many times due to frequent gene conversions. Sequence homogeneity among these simultaneously produced 18S rRNA copies is required for accurate inference of phylogenetic relationships. Some genomes have divergent copies of 18S rRNA distributed along the chromosome. As previously described, the diversity of Cryptosporidium species is also distinguished based on 18S rRNA gene phylogenetics [30]. Rooney explained that genetic variation in this 18S rDNA gene results from the evolutionary process of birth and death, where new genes arise through duplication and self-evolution and acquire new functions, become nonfunctional, or are deleted [31]. Due to the high number of copy sequences in the genome of the 18S rRNA gene, more than one species can be found in an individual, so it can be referred to as a mixed infection. Similarly, Kurniawan et al. [32] found single (C. hominis, C. felis, and C. meleagridis), double (C. hominis and C. meleagridis), and triple (C. hominis, C. meleagridis, and C. parvum) infections [32]. However, this mixed infection may result from failure to concentrate the fecal sample prior to DNA extraction. Morphological differentiation is still difficult, and species differences in this host can be determined only by PCR and sequencing. In general, the information provided by the identification of genotypes and subgenotypes of Cryptosporidium species in humans and animals in different geographical areas is useful for understanding the transmission patterns of the parasite and the zoonotic potential of animals in the population. Further comprehensive epidemiologic studies are needed to determine whether zoonotic transmission is closely linked to this immunocompromised population, given the significant prevalence of potentially zoonotic C. parvum. This is in line with the study by Iqbal et al. [33], where a more in-depth analysis of the level of genetic diversity of Cryptosporidium is required to determine a more comprehensive molecular epidemiology in Malaysia [33].

Detection of zoonotic genotypes of Cryptosporidium spp. allows the prevention of potential risks and consequences of zoonoses in immunocompetent human populations. Therefore, further investigations are needed, considering different spatiotemporal factors, using molecular diagnostic tools, and simultaneously assessing Cryptosporidium spp. genotypes in other domestic animals, water sources, and environments such as soil contaminated with animal or human waste. There is an urgent need for better diagnostic tools to identify Cryptosporidium infections [34]. Several studies point to the importance of health-care workers in rural areas or in close contact with at-risk animals being trained to recognize zoonotic diseases they encounter as well. Many studies have shown that misdiagnosis of Cryptosporidium infection results from misinterpreting microscopic findings. These errors lead to a differential diagnosis beyond the actual infection and may eventually lead to failed disease control efforts [35].

In terms of exposure to infected animals, farm workers are at increased risk of infection because they are the first to be exposed to infected animals and are therefore at higher risk of acquiring several zoonotic infections. Farm workers are exposed to these microorganisms daily in every aspect of their work. Direct contact with animals and animal butchering have been identified as the highest risk factors for Cryptosporidium infection [36]. For people who have occupational contact with livestock, the risk of becoming infected with Cryptosporidium oocysts can occur in any activity related to livestock, from handling, bathing, feeding, cleaning manure, and providing water to slaughterhouses. For farm family members who do not have contact with livestock, infection can be acquired through contact at home. Nonanimal workers are much less exposed to zoonotic agents than animal workers [11]. However, in developing countries, where people are exposed to animal infections either at work or at home, it is often impossible to distinguish the route of microbial transmission.

From an environmental perspective, optimizing the management of water sources, reclaimed water, and water for tourism must also be considered in efforts to prevent waterborne Cryptosporidiosis. The protection of water sources and swimming pools is an important element of cryptosporidiosis control, as contamination of drinking water and swimming pools is the primary mode of infection [37]. Primary prevention in the management of infections can be achieved only through a good understanding of transmission routes, sources of contamination (human and animal), disease prevalence in a population, and host risk factors. Although most of the sources of Cryptosporidium infection in this study population were due to contact with livestock because of living in farm communities, there is still a need for efforts in public health education and intervention. Health-care providers and the public need to be aware of the multiple modes of transmission of Cryptosporidium to prevent sporadic Cryptosporidium infections in asymptomatic individuals [38]. The fact that zoonotic properties of Cryptosporidium have been detected in both human and animal samples suggests that zoonotic transmission may be an important piece of information at this study site. Considering the risk factors that influence the transmission of Cryptosporidiosis in the livestock population, it seems that the zoonotic potential of this parasite needs to be further studied in other communities to formulate better strategies for the prevention of this infectious disease.

In addition, there remains a need to improve the compatibility of reporting systems for neglected diseases in humans and livestock to understand the burden of disease in an area. The results of this research need to be disseminated to the livestock population, as well as knowledge on how to avoid the spread of Cryptosporidium infection to other livestock or the surrounding population.

4. One Health approach

One Health is an approach, not a new discipline, highlighted as “the collaborative efforts of multiple disciplines - working at local, national and global levels - to achieve optimal health for humans, animals and the environment” [39]. Another definition of One Health is the effective application of interdisciplinary expertise to improve human, animal, and environmental health in the management of zoonoses and zoonotic emergencies that are complex and include prevention, surveillance, and response to zoonoses [40]. The One Health Initiative was launched in November 2009 by the One Health Commission, a national nonprofit partnership of the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), Department of Agriculture (USDA), and other global health agencies, and the Institute for Laboratory Animal Research, to identify the linkages between human, animal, and ecosystem health and to quantify the potential value of a One Health approach at the national and global levels [41].

One Health Concept (one health, one medical science, and one world) has the goal of reducing the risk of high-impact diseases in the animal-human ecosystem [42]. It is an approach to addressing complex challenges at the interface of animal, human, and environmental health, such as emergency pandemic diseases, the global food crisis, and climate change, through integrated and expanded multi-sectoral and multi-professional collaboration to improve long-term health and well-being [43].

Hippocrates, a Greek physicist, said that air, water, and place play an important role in public health, illustrating that environmental factors can affect human health and leading him to write: “The concept of public health is highly dependent on environmental health” [44]. This concept emphasizes that human health, animal health, and environmental health are interconnected. This suggests a coordinated, collaborative, transdisciplinary, and cross-sectoral approach to address potential and existing risks from the interface between animals, humans, and ecosystems [45].

Although this is not a new concept, the approach is increasingly being used to address health issues such as infectious diseases in developing countries, food and environmental safety, and chronic diseases [46]. One Health requires systems thinking, the ability to build successful multidisciplinary teams, and the leadership skills to coordinate effectively with stakeholders from a range of disciplines and sectors [47].

We know that there are many threats to our health status, both globally and locally. Cryptosporidiosis is currently very widespread globally, with high prevalence in several countries [48]. The disease could pose serious problems for Indonesia as well if it cannot effectively address the threat. Cryptosporidium is highly contagious, and only a few oocysts are needed to transmit the disease to a healthy person. Another factor that contributes to the transmission and spread of Cryptosporidium is the limited number of treatments available. The only drug approved by the US Food and Drug Administration (FDA) is nitazoxanide. However, nitazoxanide is moderately effective only in malnourished children and immunocompetent people and fails to treat immunocompromised people such as those living with HIV.

One Health, as defined by Schwabe [43], is a global strategy to improve health and well-being by reducing and preventing disease risks arising from interactions between people, animals, and their environment. An essential part of the One Health approach to preventing Cryptosporidium infection is to understand the environmental, epidemiological, and human factors associated with Cryptosporidium infection to formulate better risk management. The objectives of the approach focus on the prevention of cryptosporidiosis, including improved detection, diagnosis, and treatment; the importance of understanding zoonotic transmission; risk management; and better environmental stewardship. Global livestock trade, climate change, pathogen ecology, and bioterrorism are all interlinked threats that need to be addressed professionally using a One Health (OH) approach, where multidisciplinary teams work across disciplines and sectors to respond [49]. This requires engaging people who share the vision of improving health in Indonesia.

One Health is the unity of multiple practices working together locally, nationally, and globally to achieve optimal human, animal, and environmental health. Humans, animals, and the environment combine to form the One Health Triad as seen at Figure 2 [50]. The One Health strategy aims to integrate multidisciplinary knowledge and coordinate actions to create global synergies that benefit all aspects of human, animal, and environmental health. This multidisciplinary approach recognizes the complexity of the ecosystem in which humans and animals coexist. Efforts to control disease in animals will be easy in humans. The goal is not only to protect human health but also to protect animal health and welfare, maintain food security, and reduce poverty [51].

Figure 2.

The One Health Triad shows the interplay of health issues between wildlife, domestic animals, the environment, and human health that are interconnected [50].

5. One Health implementation in Indonesia

The interaction between livestock and humans is increasing due to the increase of basic human needs. In developing countries such as Indonesia, livestock play an important role in household welfare. Under certain conditions, livestock can serve to alleviate poverty [40]. Furthermore, interacting with animals also provides many benefits for children and adults, including reducing anxiety and lowering blood pressure [52]. Environmental degradation caused by land conversion, waste (domestic and industrial), and natural disasters are factors that increase vulnerability to disease. The world is facing an increasing threat of new infectious diseases, known as emerging infectious diseases (EIDs), 70% of which are zoonotic or transmitted from animals to humans and include bacteria, viruses, fungi, protozoa, and parasites [42]. In Southeast Asia, social and cultural practices combined with weak health infrastructure facilitate zoonoses to occur and spread. Southeast Asia has become a hotspot for the emergence of new infectious diseases (EIDs) due to significant changes in population growth and corresponding climatic conditions and abundant wildlife [53]. Due to the unpreparedness of the system to work synergistically, the outbreak of EIDs has caused multiple impacts and many casualties. World experts recommend One Health as a concept for addressing zoonotic threats [54].

One Health is a global strategy to expand interdisciplinary collaboration and communication in all aspects of health care for people, animals, and the environment. These strategies will advance 21st century health care by accelerating biomedical research discoveries, improving public health outcomes, rapidly expanding scientific knowledge, and improving medical education and clinical care. If properly implemented, this concept will help protect and save millions of lives in our present and future generations [55].

One Health has been implemented and applied in Indonesia. The implementation at the level of education in universities has been carried out in the form of training activities, workshops, seminars, and forms of cooperation that have been developed by several agencies from different sectors. There remains a need to improve and expand the understanding of the main concepts of One Health, the health pursued in the approach, and the actions broken down into several forms of intersectoral cooperation that can be applied, solved, and sustained for the welfare of human lives in relation to the national social governance system [40]. In Indonesia’s One Health system, cross-sectoral roles still focus on health (physicians, veterinarians, public health, dentists, etc.). In the field, cross-sectoral roles should not stop at the concept, but should have directly implemented activities in a sustainable and integrated manner that are actively reported and published. In Cryptosporidium infection transmission, pathogenic Cryptosporidium oocysts affect animals and humans, where the parasite shares the same ecosystem for living and circulating. The efforts of one sector alone will not be enough to prevent or reduce the spread of Cryptosporidium infection. The concept of One Health or multi-sectoral approach in the management of Cryptosporidium infection, including the laboratory network, is expected to prevent or overcome the spread of Cryptosporidium infection [56].

The One Health approach in Indonesia has been advanced and is in the process of being prepared for the next stage of development. Seminars, trainings, and workshops in collaboration with health sectors, as well as incorporating One Health approach into health courses at each university, have been gradually implemented. There is a need to increase the understanding of One Health concept, starting from individual health, which focuses on health management in health sector, to One Health concept, which focuses on more complex individual health [57].

In order to develop an effective and integrated zoonosis prevention and control plan, the first step is the identification of potential zoonotic problems and knowledge gaps in specific areas and mapping of zoonotic diseases in Indonesia. For a more global understanding of knowledge gaps and research needs in zoonosis prevention and control, an expansion of surveillance methods is needed in Indonesia as part of an interdisciplinary and multi-sectoral strategic network on zoonoses [58].

Neglected zoonotic diseases (NZDs) are diseases that are a major cause of animal and human illness and death, especially among poor people living near animals, often in unsanitary conditions and with inadequate health services. The best way to combat these diseases is to manage the livestock reservoir because it is the most cost-effective. However, control and elimination of these diseases requires human intervention, increased public awareness to reduce human–animal contact, and/or modification of the environment to control the rate of spread of infection. To date, cryptosporidiosis has not been included in the 2019 WHO-OIE list of neglected zoonotic diseases, following anthrax, bovine tuberculosis (Mycobacterium tuberculosis complex), brucellosis, rabies, cysticercosis/taeniasis, echinococcosis, and trypanosomosis [24]. Similarly, in the list of strategic diseases in Indonesia, cryptosporidiosis is still not included as one of the potential epidemic diseases or strategic infectious animal diseases. So far, there have been many studies on cryptosporidiosis worldwide but not many in Indonesia [59]. It is time that more attention is paid to this disease in Indonesia, as it has a major impact when it breaks out.

Cryptosporidiosis, as one of the neglected zoonotic diseases, is a disease whose transmission is dependent on the interaction between humans and domestic animals or the wildlife reservoirs that surround them. Whether in the wild or in some more favorable environments, such as intensive and controlled animal production, where animals are more isolated from humans or are conditioned, transmission between animals and humans does not occur to the same degree. Although the disease does not spread rapidly on a global scale and is limited by ecological boundaries, it can be fatal without early or appropriate treatment. Neglected zoonotic diseases (NZDs) not only represent a significant burden to human health on a global scale but also place a significant financial burden on their owners in terms of livestock production. The One Health approach aims to reduce the economic losses caused by human-animal NZDs, in addition to controlling diseases caused by the interaction between people, animals, and their environment. There is a strong link between human health, livestock health, and household economic well-being in livestock-dependent communities. It is estimated that nearly a billion people depend on livestock for their livelihoods and nutrition [51]. However, the relationships between animal health and productivity and human health and well-being are complex, and a quantitative understanding of these relationships is important for poverty reduction and public health interventions through improved human and animal health.

Early warning systems for livestock diseases and prediction of their occurrence and spread to new areas are important requirements for the control of zoonoses, including cryptosporidiosis. This system is easier and more economical than dealing with the disease after it has spread. The prevention and control of zoonotic diseases is dependent on the early detection of the disease agents. The early detection of such agents plays an important role in the formulation of disease control policies, for prevention and mitigation. One of the pillars for early and rapid detection of these diseases is targeted surveillance of the environment and livestock at high risk of zoonotic infection. The presence of a well-equipped laboratory with qualified staff and the ability to detect zoonoses is very important in support of early disease detection. Good communication with all stakeholders is essential to identify the needs for disease surveillance, epidemiology, and capacity building of the laboratory [60]. Detection and mapping of the distribution of the parasite can be accelerated by molecular characterization and visualization of different Cryptosporidium genotypes from all regions of Indonesia. Screening techniques can be developed by collaborating with several universities and the private sector in Indonesia. The strength of Indonesian laboratories in disease control and prevention will be demonstrated through bioinformatics reporting of Cryptosporidium infections.

In line with the One Health approach, synchronized surveillance with laboratory capacity building for detection and prevention of zoonoses will be implemented. This will include surveillance at the animal-human interface for early detection of Cryptosporidium infection. We can learn how zoonotic agents emerge and spread through the livestock-human interface by testing samples from infected livestock and comparing the results with similar surveillance of human and other livestock samples. This surveillance requires good community cooperation, especially farmer/livestock groups as main community, village or hamlet officials, local government, district or provincial health, and livestock services in coordination with the General Livestock and Health Agencies. The report will be used to prevent and control zoonotic cryptosporidiosis at national, provincial, and district/city levels.

6. Conclusions

A better understanding of the environmental, epidemiological, and etiological factors associated with Cryptosporidium infections is a future One Health strategy aimed at improving health outcomes for humans, animals, and the environment. This multidisciplinary approach considers the complexity of ecosystems where humans and animals live together to prevent and control disease transmission to humans. This is not only to protect human health but also to protect animal health and welfare, maintain food security, and reduce poverty.

Acknowledgments

The author is grateful to the supervisors and professors who have provided guidance in the completion of this doctoral study.

Conflict of interest

The authors declare no conflict of interest.