Global Distribution, Public Health and Clinical Impact of the Protozoan Pathogen Cryptosporidium
Identifieur interne : 000393 ( Pmc/Checkpoint ); précédent : 000392; suivant : 000394Global Distribution, Public Health and Clinical Impact of the Protozoan Pathogen Cryptosporidium
Auteurs : Lorenza Putignani [Italie] ; Donato Menichella [Italie]Source :
- Interdisciplinary Perspectives on Infectious Diseases [ 1687-708X ] ; 2010.
Abstract
Url:
DOI: 10.1155/2010/753512
PubMed: 20706669
PubMed Central: 2913630
Affiliations:
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Global Distribution, Public Health and Clinical Impact of the Protozoan Pathogen <italic>Cryptosporidium</italic></title><author><name sortKey="Putignani, Lorenza" sort="Putignani, Lorenza" uniqKey="Putignani L" first="Lorenza" last="Putignani">Lorenza Putignani</name><affiliation wicri:level="1"><nlm:aff id="I1">Microbiology Unit, Bambino Gesù Pediatric Hospital, Scientific Institute, Piazza Sant'Onofrio 4, 00165 Rome, Italy</nlm:aff><country xml:lang="fr">Italie</country><wicri:regionArea>Microbiology Unit, Bambino Gesù Pediatric Hospital, Scientific Institute, Piazza Sant'Onofrio 4, 00165 Rome</wicri:regionArea><placeName><settlement type="city">Rome</settlement><region nuts="2">Latium</region></placeName></affiliation></author><author><name sortKey="Menichella, Donato" sort="Menichella, Donato" uniqKey="Menichella D" first="Donato" last="Menichella">Donato Menichella</name><affiliation wicri:level="1"><nlm:aff id="I1">Microbiology Unit, Bambino Gesù Pediatric Hospital, Scientific Institute, Piazza Sant'Onofrio 4, 00165 Rome, Italy</nlm:aff><country xml:lang="fr">Italie</country><wicri:regionArea>Microbiology Unit, Bambino Gesù Pediatric Hospital, Scientific Institute, Piazza Sant'Onofrio 4, 00165 Rome</wicri:regionArea><placeName><settlement type="city">Rome</settlement><region nuts="2">Latium</region></placeName></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">20706669</idno><idno type="pmc">2913630</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2913630</idno><idno type="RBID">PMC:2913630</idno><idno type="doi">10.1155/2010/753512</idno><date when="2010">2010</date><idno type="wicri:Area/Pmc/Corpus">000468</idno><idno type="wicri:Area/Pmc/Curation">000468</idno><idno type="wicri:Area/Pmc/Checkpoint">000393</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Global Distribution, Public Health and Clinical Impact of the Protozoan Pathogen <italic>Cryptosporidium</italic></title><author><name sortKey="Putignani, Lorenza" sort="Putignani, Lorenza" uniqKey="Putignani L" first="Lorenza" last="Putignani">Lorenza Putignani</name><affiliation wicri:level="1"><nlm:aff id="I1">Microbiology Unit, Bambino Gesù Pediatric Hospital, Scientific Institute, Piazza Sant'Onofrio 4, 00165 Rome, Italy</nlm:aff><country xml:lang="fr">Italie</country><wicri:regionArea>Microbiology Unit, Bambino Gesù Pediatric Hospital, Scientific Institute, Piazza Sant'Onofrio 4, 00165 Rome</wicri:regionArea><placeName><settlement type="city">Rome</settlement><region nuts="2">Latium</region></placeName></affiliation></author><author><name sortKey="Menichella, Donato" sort="Menichella, Donato" uniqKey="Menichella D" first="Donato" last="Menichella">Donato Menichella</name><affiliation wicri:level="1"><nlm:aff id="I1">Microbiology Unit, Bambino Gesù Pediatric Hospital, Scientific Institute, Piazza Sant'Onofrio 4, 00165 Rome, Italy</nlm:aff><country xml:lang="fr">Italie</country><wicri:regionArea>Microbiology Unit, Bambino Gesù Pediatric Hospital, Scientific Institute, Piazza Sant'Onofrio 4, 00165 Rome</wicri:regionArea><placeName><settlement type="city">Rome</settlement><region nuts="2">Latium</region></placeName></affiliation></author></analytic><series><title level="j">Interdisciplinary Perspectives on Infectious Diseases</title><idno type="ISSN">1687-708X</idno><idno type="eISSN">1687-7098</idno><imprint><date when="2010">2010</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p><italic>Cryptosporidium</italic> spp. are coccidians, oocysts-forming apicomplexan protozoa, which complete their life cycle both in humans and animals, through zoonotic and anthroponotic transmission, causing cryptosporidiosis. The global burden of this disease is still underascertained, due to a conundrum transmission modality, only partially unveiled, and on a plethora of detection systems still inadequate or only partially applied for worldwide surveillance. In children, cryptosporidiosis encumber is even less recorded and often misidentified due to physiological reasons such as early-age unpaired immunological response. Furthermore, malnutrition in underdeveloped countries or clinical underestimation of protozoan etiology in developed countries contribute to the underestimation of the worldwide burden. Principal key indicators of the parasite distribution were associated to environmental (e.g., geographic and temporal clusters, etc.) and host determinants of the infection (e.g., age, immunological status, travels, community behaviours). The distribution was geographically mapped to provide an updated picture of the global parasite ecosystems. The present paper aims to provide, by a critical analysis of existing literature, a link between observational epidemiological records and new insights on public health, and diagnostic and clinical impact of cryptosporidiosis.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Goodgame, Rw" uniqKey="Goodgame R">RW Goodgame</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Eckmann, L" uniqKey="Eckmann L">L Eckmann</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pierce, Kk" uniqKey="Pierce K">KK Pierce</name></author><author><name sortKey="Kirkpatrick, Bd" uniqKey="Kirkpatrick B">BD Kirkpatrick</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Chen, X M" uniqKey="Chen X">X-M Chen</name></author><author><name sortKey="Keithly, Js" uniqKey="Keithly J">JS Keithly</name></author><author><name sortKey="Paya, Cv" 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Interdiscip Perspect Infect Dis</journal-id><journal-id journal-id-type="publisher-id">IPID</journal-id><journal-title-group><journal-title>Interdisciplinary Perspectives on Infectious Diseases</journal-title></journal-title-group><issn pub-type="ppub">1687-708X</issn><issn pub-type="epub">1687-7098</issn><publisher><publisher-name>Hindawi Publishing Corporation</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">20706669</article-id><article-id pub-id-type="pmc">2913630</article-id><article-id pub-id-type="doi">10.1155/2010/753512</article-id><article-categories><subj-group subj-group-type="heading"><subject>Review Article</subject></subj-group></article-categories><title-group><article-title>Global Distribution, Public Health and Clinical Impact of the Protozoan Pathogen <italic>Cryptosporidium</italic></article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Putignani</surname><given-names>Lorenza</given-names></name><xref ref-type="aff" rid="I1"></xref><xref ref-type="corresp" rid="cor1">*</xref></contrib><contrib contrib-type="author"><name><surname>Menichella</surname><given-names>Donato</given-names></name><xref ref-type="aff" rid="I1"></xref></contrib></contrib-group><aff id="I1">Microbiology Unit, Bambino Gesù Pediatric Hospital, Scientific Institute, Piazza Sant'Onofrio 4, 00165 Rome, Italy</aff><author-notes><corresp id="cor1">*Lorenza Putignani: <email>l_putignani@yahoo.com</email></corresp><fn fn-type="other"><p>Academic Editor: Bettina Fries</p></fn></author-notes><pub-date pub-type="ppub"><year>2010</year></pub-date><pub-date pub-type="epub"><day>14</day><month>7</month><year>2010</year></pub-date><volume>2010</volume><elocation-id>753512</elocation-id><history><date date-type="received"><day>4</day><month>9</month><year>2009</year></date><date date-type="rev-recd"><day>7</day><month>1</month><year>2010</year></date><date date-type="accepted"><day>11</day><month>5</month><year>2010</year></date></history><permissions><copyright-statement>Copyright © 2010 L. Putignani and D. Menichella.</copyright-statement><copyright-year>2010</copyright-year><copyright-holder>Copyright © 2010 Lorenza Putignani and Donato Menichella.</copyright-holder><license license-type="open-access"><license-p>This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p><italic>Cryptosporidium</italic> spp. are coccidians, oocysts-forming apicomplexan protozoa, which complete their life cycle both in humans and animals, through zoonotic and anthroponotic transmission, causing cryptosporidiosis. The global burden of this disease is still underascertained, due to a conundrum transmission modality, only partially unveiled, and on a plethora of detection systems still inadequate or only partially applied for worldwide surveillance. In children, cryptosporidiosis encumber is even less recorded and often misidentified due to physiological reasons such as early-age unpaired immunological response. Furthermore, malnutrition in underdeveloped countries or clinical underestimation of protozoan etiology in developed countries contribute to the underestimation of the worldwide burden. Principal key indicators of the parasite distribution were associated to environmental (e.g., geographic and temporal clusters, etc.) and host determinants of the infection (e.g., age, immunological status, travels, community behaviours). The distribution was geographically mapped to provide an updated picture of the global parasite ecosystems. The present paper aims to provide, by a critical analysis of existing literature, a link between observational epidemiological records and new insights on public health, and diagnostic and clinical impact of cryptosporidiosis.</p></abstract></article-meta></front><floats-group><fig id="fig1" position="float"><label>Figure 1</label><caption><p><italic>Life cycle of Cryptosporidium in the enterocyte.</italic> Following oocyst ingestion by a host, and excystation, the sporozoites are released and parasitize epithelial cells of the gastrointestinal tract. In these cells, the parasites undergo asexual multiplication (<italic>schizogony </italic>or<italic> merogony</italic>) and then sexual multiplication (<italic>gametogony</italic>), producing microgamonts and macrogamonts. Upon fertilization of the macrogamonts by the microgametes, oocysts develop and sporulate in the infected host. Two different types of oocysts are produced: the <italic>thick-walled</italic>, which is commonly excreted by the host, after <italic>sporogony</italic>, and the <italic>thin-walled</italic> oocyst, which is primarily involved in autoinfection. Putignani and Menchella, 2010.</p></caption><graphic xlink:href="IPID2010-753512.001"></graphic></fig><fig id="fig2" position="float"><label>Figure 2</label><caption><p><italic>Description of transmission modes of Cryptosporidium.</italic> Following ingestion (and possibly inhalation) by a suitable host (e.g., human host), excystation occurs (<italic>infective stage</italic>, (1)). The released sporozoites invade epithelial cells of the gastrointestinal tract or other tissues, complete their cycle producing oocysts which exit host (<italic>diagnostic stage</italic>, (2)) and are released in the environment (3). Transmission of <italic>Cryptosporidium</italic> mainly occurs by ingestion of contaminated water (e.g., surface, drinking or recreational water), food sources (e.g., chicken salad, fruits, vegetables) or by person-to-person contact (community and hospital infections) (4). Zoonotic transmission of <italic>C. parvum</italic> occurs through exposure to infected animals (person-to-animal contact) or exposure to water (<italic>reservoir</italic>) contaminated by feces of infected animals (4). Putignani and Menchella, 2010.</p></caption><graphic xlink:href="IPID2010-753512.002"></graphic></fig><fig id="fig3" position="float"><label>Figure 3</label><caption><p><italic>Venn Diagram of factors leading to Cryptosporidium infection.</italic> Parasite, host and environmental indexes acting as key factors for the global burden of cryptosporidiosis. For details see <xref ref-type="table" rid="tab1">Table 1</xref>. Putignani and Menchella, 2010.</p></caption><graphic xlink:href="IPID2010-753512.003"></graphic></fig><fig id="fig4" position="float"><label>Figure 4</label><caption><p><italic>Geography of worldwide occurrence of human cryptosporidiosis outbreaks and sporadic cases.</italic> A color-coded distribution of the main cases of cryptosporidosis reported in the literature during the last decade (1998–2008) for the entire population (adults and children) is here represented. Waterborne and foodborne diseases are represented by red and grey color, respectively. Spreading of the infection due to HIV immunological impairment is represented by green and travel-related disease by pink color. When not applicable the definition of waterborne and foodborne disease, the term community disease has been applied to person-to-person contacts and represented by a pale blue color. For countries characterised by two or three coexisting transmission modes, a double color-filling effect plus thick border lines have been used, consistently with the above reported code. Putignani and Menchella, 2010.</p></caption><graphic xlink:href="IPID2010-753512.004"></graphic></fig><fig id="fig5" position="float"><label>Figure 5</label><caption><p><italic>Geographical distribution of Italian studies on Cryptosporidium surveillance.</italic> A map of the principal surveillance studies performed on environmental and human samples is here reported by using the following color codes: red for environmental samples (water, animal); green for human samples associated to HIV in adults; pink for children samples. Symbols refer to different Italian regions: Ab, Abruzzo; Ap, Apulia; Ca, Campania; ER, Emilia Romagna; FVG, Friuli Venezia Giulia; La, Latium; Lo, Lombardia; Ma, Marche; Pi, Piedmont; Sa, Sardinia; Si, Sicily; Tu, Tuscany; Ve, Veneto. Putignani and Menchella, 2010.</p></caption><graphic xlink:href="IPID2010-753512.005"></graphic></fig><fig id="fig6" position="float"><label>Figure 6</label><caption><p><italic>Schematic life cycle of the most recurrent Cryptosporidium coinfective and coemerging parasitic agents. Panel (a). Giardia intestinalis</italic> (also called <italic>Giardia lamblia </italic>or <italic>Giardia duodenalis</italic>) is a flagellate parasite (Diplomonadida). Both cysts and trophozoites can be found in nondiarrheal feces (<italic>diagnostic and infective stages</italic>, (1)). Cysts are resistant forms and are responsible for transmission of giardiasis (<italic>infective stage</italic>, (2)). Infection occurs by the ingestion of water or food contaminated by cysts, or by the fecal-oral route (hands or fomites). In the small intestine, excystation releases trophozoites which multiply by longitudinal binary fission, remaining in the lumen of the proximal small bowel where they can be free or attached to the mucosa. Encystation occurs as the parasites transit toward the colon. <italic>Panel (b)</italic>. <italic>Cyclospora cayetanensis </italic>is a coccidian parasite (Apicomplexa). When passed in stools, the oocyst is not infective (on the contrary of <italic>Cryptosporidium</italic>, thus direct fecal-oral transmission cannot occur). In the environment, sporulation occurs after days or weeks, resulting in division of the sporont into two sporocysts, each containing two sporozoites (<italic>diagnostic and infective stages</italic>, (1)). Fresh food and water can serve as vehicles for transmission and the sporulated oocysts are ingested (<italic>infective stage</italic>, (2)). The oocysts excyst in the gastrointestinal tract, freeing the sporozoites which invade the epithelial cells of the small intestine. Inside the cells they undergo asexual multiplication and sexual development to mature into oocysts, which will be shed in stools. <italic>Panel (c)</italic>. <italic>Blastocystis hominis</italic> is a Heterokontid Chromista (Stramenopiles). The thick-walled cyst present in the stools (<italic>diagnostic stage</italic>, (1)), which varies tremendously in size from 6 to 40 <italic>μ</italic>m, is believed to be responsible for external transmission, possibly by the fecal-oral route through ingestion of contaminated water or food (<italic>infective stage</italic>, (2)). The cysts infect epithelial cells of the digestive tract and multiply asexually. Vacuolar forms of the parasite give origin to multi vacuolar and ameboid forms. The multivacuolar form develops into a precyst that gives origin to a thin-walled cyst, thought to be responsible for autoinfection. The ameboid form gives origin to a precyst, which develops into thick-walled cyst by schizogony. The thick-walled cyst is excreted in feces. <italic>Panel (d)</italic>. <italic>Entamoeba histolytica/dispar</italic> is an Amoebozoa parasite. Cysts and trophozoites are passed in feces (<italic>diagnostic and infective stages</italic>, (1)), the first found in formed, whereas the latest in diarrheal stool. Infection by <italic>E. histolytica</italic> occurs by ingestion of mature cysts in fecally contaminated food, water, or hands. Excystation occurs in the small intestine and trophozoites are released, which migrate to the large intestine and multiply by binary fission to produce cysts, where both stages are passed in the feces. Cysts can survive days to weeks in the external environment and are responsible for transmission (<italic>diagnostic and infective stages</italic>, (2)). Trophozoites passed in the stool are rapidly destroyed once outside the body, and if ingested would not survive exposure to the gastric environment. In many cases, the trophozoites remain confined to the intestinal lumen (<italic>noninvasive infection</italic>) of individuals who are asymptomatic carriers, passing cysts in their stool. In some patients the trophozoites invade the intestinal mucosa (<italic>intestinal disease</italic>), or, through the bloodstream, extraintestinal sites such as the liver, brain, and lungs (<italic>extraintestinal disease</italic>), with resultant pathologic manifestations. It has been established that the invasive and noninvasive forms represent two separate species, respectively, <italic>E. histolytica</italic> and <italic>E. dispar</italic>. These two species are morphologically indistinguishable unless <italic>E. histolytica</italic> is observed with ingested red blood cells (erythrophagocytosis). Infective and diagnostic stages, as well as body organs, are graphically reported, when surely assessed in the life cycle of the parasites. Modified from pictures available at the CDC site for parasite identification and diagnosis (<ext-link ext-link-type="uri" xlink:href="http://www.dpd.cdc.gov/dpdx/HTML/Para_Health.htm">http://www.dpd.cdc.gov/dpdx/HTML/Para_Health.htm</ext-link>). Putignani and Menchella, 2010.</p></caption><graphic xlink:href="IPID2010-753512.006a"></graphic><graphic xlink:href="IPID2010-753512.006b"></graphic></fig><table-wrap id="tab1" position="float"><label>Table 1</label><caption><p>Factors that affect prevalence and adequate surveillance of cryptosporidiosis.</p></caption><table frame="hsides" rules="groups"><tbody><tr><td align="left" rowspan="1" colspan="1"><italic>Epidemiological indexes</italic></td></tr><tr><td align="left" rowspan="1" colspan="1">Population age</td></tr><tr><td align="left" rowspan="1" colspan="1">Gender</td></tr><tr><td align="left" rowspan="1" colspan="1">Individual immunological status</td></tr><tr><td align="left" rowspan="1" colspan="1">Geographical distribution and ethnic group</td></tr><tr><td align="center" colspan="1" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Human activities</italic></td></tr><tr><td align="left" rowspan="1" colspan="1">Hygienic and diet practices</td></tr><tr><td align="left" rowspan="1" colspan="1">Rural and urban settings</td></tr><tr><td align="left" rowspan="1" colspan="1">Human waste contamination</td></tr><tr><td align="left" rowspan="1" colspan="1">Livestock pollution</td></tr><tr><td align="left" rowspan="1" colspan="1">Water treatment systems; food preparation styles and procedures</td></tr><tr><td align="left" rowspan="1" colspan="1">Travels, immigration</td></tr><tr><td align="center" colspan="1" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Environmental and social affecting factors</italic></td></tr><tr><td align="left" rowspan="1" colspan="1">Animal pollution</td></tr><tr><td align="left" rowspan="1" colspan="1">Famine, malnutrition, dehydration</td></tr><tr><td align="left" rowspan="1" colspan="1">Geography, international adoptions</td></tr><tr><td align="left" rowspan="1" colspan="1">Calamities (typhoons, local wars, floods, etc)</td></tr><tr><td align="left" rowspan="1" colspan="1">Climate variation, pollution, deforestation and seasonal rains</td></tr><tr><td align="center" colspan="1" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Under-ascertainment factors in surveillance</italic></td></tr><tr><td align="left" rowspan="1" colspan="1">Improper sampling of contaminated water systems and food</td></tr><tr><td align="left" rowspan="1" colspan="1">Difficulty to identify the likely source of infection</td></tr><tr><td align="left" rowspan="1" colspan="1">Misidentification of outbreak sources</td></tr><tr><td align="left" rowspan="1" colspan="1">Multiple protozoan coinfections</td></tr><tr><td align="center" colspan="1" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Under-ascertainment factors in clinics and diagnosis</italic></td></tr><tr><td align="left" rowspan="1" colspan="1">Poor or diversified symptom presentations and low clinician's sensitivity to consider protozoa as agents of gastrointestinal infections</td></tr><tr><td align="left" rowspan="1" colspan="1">Limited inclusion of protozoan searching in operational diagnostic workflows</td></tr><tr><td align="left" rowspan="1" colspan="1">Self-limiting infection course in immunocompetent adults and children</td></tr><tr><td align="left" rowspan="1" colspan="1">Low inclusion of advanced molecular tools for routine diagnosis</td></tr></tbody></table></table-wrap><table-wrap id="tab2" position="float"><label>Table 2</label><caption><p>Worldwide distribution of principal sporadic cases and surveillance data reported in the last decade (1998–2008): case characteristics.</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Samples (surveillance study or sporadic cases)</th><th align="left" rowspan="1" colspan="1">Country</th><th align="left" rowspan="1" colspan="1">Age<break></break> (human cases)</th><th align="left" rowspan="1" colspan="1">Technique/genotyping tool</th><th align="left" rowspan="1" colspan="1">Species/genotypes/subgenotypes<sup>1</sup></th><th align="center" rowspan="1" colspan="1">Reference</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">India</td><td align="left" rowspan="1" colspan="1">Children</td><td align="left" rowspan="1" colspan="1">18S rRNA, SSU, COWP, Cpgp40/15, TRAP-C1-based PCR</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis </italic>(Ia, Id, Ie, Ib),<italic> C. parvum </italic>(Ic), <italic>C. felis </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B36">36</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Environmental (water)</td><td align="left" rowspan="1" colspan="1">China</td><td align="left" rowspan="1" colspan="1">—</td><td align="left" rowspan="1" colspan="1">18S rRNA PCR-RFLP and sequence analyses; GP60</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis </italic>(IbA19G2, IbA20G2, and IbA21G2), Ia, Id, Ie (IeA12G3T3), If (IfA22G1) <italic>C. meleagridis</italic>, <italic>C. baileyi</italic>, <italic>C. parvum</italic>, <italic>C. suis</italic>, <italic>C. muris</italic>, rat genotype, avian genotype 3</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B41">41</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Perù</td><td align="left" rowspan="1" colspan="1">Children</td><td align="left" rowspan="1" colspan="1">GP60</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis </italic>(Ia, Ib, Id, Ie, Id),<italic> C. parvum </italic>(IIc), <italic>C. meleagridis</italic>, <italic>C. canis</italic>, <italic>C. felis </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B50">50</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Ireland</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">18S rRNA and COWP PCR-RFLP; GP60</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis </italic>(IbA10G2), <italic>C. parvum </italic>(IIaA18G3R1)</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B51">51</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Belgium</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">70-kDa heat shock protein, 60-kDa glycoprotein (GP60)</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis</italic> (IbA10G2, IbA9G3) <italic>C. parvum</italic> (IIaA15G2R1, IIcA5G3a, IIdA16G1 IIaA15G2R1)</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B62">62</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">UK</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">COWPand small sub-unit (SSU) rRNAgene PCR-RFLP</td><td align="left" rowspan="1" colspan="1"><italic>C. parvum, C. hominis</italic>, <italic>C. meleagridis</italic>, <italic>C. felis</italic>, <italic>C. canis</italic>, <italic>Cryptosporidium</italic> cervine, horse, skunk genotypes</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B63">63</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Haiti</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">18S rRNAPCR-RFLP</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis</italic>, <italic>C. parvum, C. felis </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B69">69</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Perù</td><td align="left" rowspan="1" colspan="1">Adults</td><td align="left" rowspan="1" colspan="1"> GP60</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis</italic> (Ia, Ib, Id, Ie) <italic>C. canis</italic>, <italic>C. felis</italic>, <italic>C. parvum</italic>, <italic>C. meleagridis </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B74">74</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human and animal stools</td><td align="left" rowspan="1" colspan="1">Portugal</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">GP60</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis</italic> (Ib, If), <italic>C. parvum</italic> (IIa, IIb, IIc and IId)</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B83">78</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Environmental (water)</td><td align="left" rowspan="1" colspan="1">France</td><td align="left" rowspan="1" colspan="1">—</td><td align="left" rowspan="1" colspan="1">IMS-IFA<sup>2</sup>, 18S rRNA PCR-RFLP</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis</italic>, <italic>C. parvum </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B141">96</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Animal stools</td><td align="left" rowspan="1" colspan="1">Ireland</td><td align="left" rowspan="1" colspan="1">Neonatal calves</td><td align="left" rowspan="1" colspan="1">GP60</td><td align="left" rowspan="1" colspan="1"><italic>C. parvum </italic>(IIaA18G3R1), <italic>C. bovis</italic>,<italic> Cryptosporidium </italic>deer-like genotype</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B144">101</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Environmental (water)</td><td align="left" rowspan="1" colspan="1">Portugal</td><td align="left" rowspan="1" colspan="1">—</td><td align="left" rowspan="1" colspan="1">IMS-IFA<sup>1</sup>, PCR</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis</italic> (IdA15) <italic>C. parvum</italic> (IIaA15G2R1, IIaA16G2R1, IIdA17G1)</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B146">103</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Animal and human stools</td><td align="left" rowspan="1" colspan="1">Portugal</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">GP60</td><td align="left" rowspan="1" colspan="1"><italic> C. hominis</italic>, <italic>C. parvum</italic>, <italic>C. felis</italic>, <italic>C. meleagridis </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B147">104</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">MI (USA)</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">18S rRNA and COWPPCR-RFLP; GP60</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis</italic>, <italic>C. parvum</italic> (cervine genotype, cervine genotype variant, human genotype W17)</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B190">148</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Animal and human stools</td><td align="left" rowspan="1" colspan="1">Iran</td><td align="left" rowspan="1" colspan="1">Children and one adult</td><td align="left" rowspan="1" colspan="1">18S rRNA PCR-RFLP</td><td align="left" rowspan="1" colspan="1"><italic>C. parvum</italic>, <italic>C. hominis</italic> (anthroponotic and zoonotic genotype)</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B206">164</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Animal stools</td><td align="left" rowspan="1" colspan="1">China</td><td align="left" rowspan="1" colspan="1">Neonatal calves</td><td align="left" rowspan="1" colspan="1">70-kDa heat shock protein; 18S rRNA, actin-based PCR</td><td align="left" rowspan="1" colspan="1"><italic>C. andersoni</italic>, <italic>C. ryanae </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B207">165</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Animal stools</td><td align="left" rowspan="1" colspan="1">India</td><td align="left" rowspan="1" colspan="1">Neonatal calves</td><td align="left" rowspan="1" colspan="1">18S rRNA PCR-RFLP</td><td align="left" rowspan="1" colspan="1"><italic>C. parvum</italic>, <italic>C. hominis </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B244">206</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">UK</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">SSCP-based analysis of the 18S rRNA SSU and ITS-2 spacer</td><td align="left" rowspan="1" colspan="1"><italic>C. parvum </italic>(types 1 and 2)</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B245">208</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">UK</td><td align="left" rowspan="1" colspan="1">Adults</td><td align="left" rowspan="1" colspan="1">GP60</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis</italic> (IbA10G2)</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B246">209</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Kenya, Malawi, Brazil, Vietnam, UK</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">18S rRNA PCR-RFLP</td><td align="left" rowspan="1" colspan="1"><italic>C. parvum</italic> (human genotype), <italic>C. parvum</italic> (bovine genotype), <italic>C. meleagridis</italic>, <italic>C. muris </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B259">222</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Switzerland, Kenya, USA</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">18S rRNA; HSP-70; acetyl coenzyme A synthetase</td><td align="left" rowspan="1" colspan="1"><italic>C. parvum </italic>(“human” genotype, “cattle” genotype), <italic>C. felis, C. meleagridis </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B260">223</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Spain</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">18S rRNA-, COWP-based PCR-RFLP</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis</italic>, C<italic>. parvum</italic>, <italic>C. meleagridis</italic>, <italic>C. felis </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B261">224</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Equatorial Guinea</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">COWP-based PCR-RFLP</td><td align="left" rowspan="1" colspan="1"><italic>C. parvum</italic>, <italic>C. hominis</italic>,<italic> C. meleagridis </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B269">232</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human and animal stools</td><td align="left" rowspan="1" colspan="1">Thailand</td><td align="left" rowspan="1" colspan="1">Adults</td><td align="left" rowspan="1" colspan="1">18S rRNA PCR</td><td align="left" rowspan="1" colspan="1"><italic>C. parvum </italic></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B276">239</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Perù</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">18S rRNA-based PCR-RFLP</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis</italic>, <italic>C. meleagridis</italic>, <italic>C. parvum</italic>, <italic>C. canis</italic>, <italic>C. felis, Cryptosporidium </italic>(pig genotype)</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B277">240</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Poland</td><td align="left" rowspan="1" colspan="1">Adults and children</td><td align="left" rowspan="1" colspan="1">COWP and <italic>β</italic>-tubulin-based PCR</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis</italic>,<italic> C. parvum</italic>, <italic>C. meleagridis</italic>,</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B283">254</xref>] </td></tr><tr><td align="center" colspan="6" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Human stools</td><td align="left" rowspan="1" colspan="1">Madagascar</td><td align="left" rowspan="1" colspan="1">Children</td><td align="left" rowspan="1" colspan="1">GP60</td><td align="left" rowspan="1" colspan="1"><italic>C. hominis </italic>(Ia, Id, Ie), <italic>C. parvum</italic> (IIc)</td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B298">275</xref>]</td></tr></tbody></table><table-wrap-foot><fn><p><sup>1</sup>When available, reported subgenotypes are the most common detected.</p></fn><fn><p><sup>2</sup>IMS-IFA, immunomagnetic separation followed by immunofluorescence assay: Method 1623 of the <italic>USA Environmental Protection Agency</italic> (USEPA).</p></fn></table-wrap-foot></table-wrap><table-wrap id="tab3" position="float"><label>Table 3</label><caption><p>Public data sources exploited in the current study.</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Site name</th><th align="center" rowspan="1" colspan="1">Link</th><th align="center" rowspan="1" colspan="1">Reference</th></tr></thead><tbody><tr><td align="center" colspan="3" rowspan="1"><italic>International surveillance networks</italic></td></tr><tr><td align="center" colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Neglected Diseases Initiative of the World Health Organization</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.who.int/neglected_diseases/en/">http://www.who.int/neglected_diseases/en/</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B59">59</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Center for Disease Control and Prevention</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://emergency.cdc.gov/agent/agentlist-category.asp">http://emergency.cdc.gov/agent/agentlist-category.asp</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B138">93</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">San Francisco Bay Area Cryptosporidiosis Surveillance Project</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.sfphes.org/water/index_crypto.htm">http://www.sfphes.org/water/index_crypto.htm</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B178">136</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">C-EnterNet (Canadian Integrated Enteric Disease Surveillance System)</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.phac-aspc.gc.ca/c-enternet/index-eng.php">http://www.phac-aspc.gc.ca/c-enternet/index-eng.php</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B195">153</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Public Health Agency of Canada</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.phac-aspc.gc.ca/index-eng.php">http://www.phac-aspc.gc.ca/index-eng.php</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B196">154</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">FoodNet</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.cdc.gov/FoodNet/">http://www.cdc.gov/FoodNet/</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B221">183</xref>] </td></tr><tr><td align="center" colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="3" rowspan="1"><italic>Suites of free and open-epidemiology data source</italic></td></tr><tr><td align="center" colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Tri-County Health Department</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.tchd.org/">http://www.tchd.org/</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B192">150</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">AIDS site</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://data.unaids.org/en/default/asp">http://data.unaids.org/en/default/asp</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B203">161</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Communicable Diseases Branch</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.health.qld.gov.au/ph/cdb/default.asp">http://www.health.qld.gov.au/ph/cdb/default.asp</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B282">245</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">NetEpi</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://code.google.com/p/netepi">http://code.google.com/p/netepi</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B296">273</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Epi Info</italic> software</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.who.int/chp/steps/resources/EpiInfo/en/index.html">http://www.who.int/chp/steps/resources/EpiInfo/en/index.html</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B297">274</xref>] </td></tr><tr><td align="center" colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="3" rowspan="1"><italic>Open-access peer-reviewed journals</italic></td></tr><tr><td align="center" colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Euroserveillance Europe's Journal on infectious diasese epidemiology, prevention and control</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.eurosurveillance.org/">http://www.eurosurveillance.org/</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B63">63</xref>, <xref ref-type="bibr" rid="B80">81</xref>, <xref ref-type="bibr" rid="B98">98</xref>, <xref ref-type="bibr" rid="B120">99</xref>, <xref ref-type="bibr" rid="B92">178</xref>, <xref ref-type="bibr" rid="B96">246</xref>–<xref ref-type="bibr" rid="B115">248</xref>, <xref ref-type="bibr" rid="B108">276</xref>, <xref ref-type="bibr" rid="B107">291</xref>, <xref ref-type="bibr" rid="B116">292</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Center for Disease Control and Prevention: Morbidity and Mortality Weekly Report (MMWR)</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.cdc.gov/mmwr/">http://www.cdc.gov/mmwr/</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B137">92</xref>, <xref ref-type="bibr" rid="B173">131</xref>, <xref ref-type="bibr" rid="B174">132</xref>, <xref ref-type="bibr" rid="B188">146</xref>, <xref ref-type="bibr" rid="B198">156</xref>, <xref ref-type="bibr" rid="B223">185</xref>–<xref ref-type="bibr" rid="B229">191</xref>, <xref ref-type="bibr" rid="B114">249</xref>, <xref ref-type="bibr" rid="B100">258</xref>, <xref ref-type="bibr" rid="B134">260</xref>, <xref ref-type="bibr" rid="B306">285</xref>, <xref ref-type="bibr" rid="B113">293</xref>–<xref ref-type="bibr" rid="B123">295</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Public Health Agency of Canada</td><td align="center" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.phac-aspc.gc.ca/surveillance-eng.php">http://www.phac-aspc.gc.ca/surveillance-eng.php</ext-link></td><td align="center" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B86">86</xref>, <xref ref-type="bibr" rid="B124">296</xref>, <xref ref-type="bibr" rid="B125">297</xref>]</td></tr></tbody></table></table-wrap><table-wrap id="tab4" position="float"><label>Table 4</label><caption><p>Worldwide distribution of principal <italic>waterborne</italic>, <bold>foodborne</bold>, <bold><italic>travel-related, </italic></bold> and community outbreaks reported in the last decade (1998–2008): case characteristics.</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Outbreak<sup>1</sup> type</th><th align="center" rowspan="1" colspan="1">Country</th><th align="center" rowspan="1" colspan="1">Ill<sup>2</sup></th><th align="center" rowspan="1" colspan="1">Age</th><th align="center" rowspan="1" colspan="1">Likely causes for outbreak occurring</th><th align="center" rowspan="1" colspan="1">Species /genotype</th><th align="left" rowspan="1" colspan="1">Reference</th></tr></thead><tbody><tr><td align="center" colspan="7" rowspan="1">2008</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">Finland</td><td align="center" rowspan="1" colspan="1">72 personnel of the Public Works Department in Helsinki</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Salad mixture suspected</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B92">178</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">Sweden</td><td align="center" rowspan="1" colspan="1">21 guests and staff at a wedding reception</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Sauce containing chopped fresh parsley</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B93">179</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">2007</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Norway</td><td align="center" rowspan="1" colspan="1">89 hotel guests</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">In-house water contamination</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B94">298</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">Scotland (UK)</td><td align="center" rowspan="1" colspan="1">6 veterinary students</td><td align="center" rowspan="1" colspan="1">Young adults</td><td align="center" rowspan="1" colspan="1">Lapse in hygiene, especially handwashing</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> (subgenotype IIaA19G2R1)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B95">299</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">England (UK)</td><td align="center" rowspan="1" colspan="1">57 swimming pool visitors</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Swimming pool contamination</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum </italic><italic>C. hominis</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B96">246</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic>/ <bold>foodborne</bold></td><td align="center" rowspan="1" colspan="1">Germany</td><td align="center" rowspan="1" colspan="1">201 soldiers</td><td align="center" rowspan="1" colspan="1">Young adults</td><td align="center" rowspan="1" colspan="1">Tap water/food contamination in a military field exercise</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> (genotype 2)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B97">300</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Ireland (UK)</td><td align="center" rowspan="1" colspan="1">182</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Contamination of treated water</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis </italic><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B98">98</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Sweden</td><td align="center" rowspan="1" colspan="1">800–1000</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Contamination of an outdoor swimming-pool</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B99">250</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">ID (USA)</td><td align="center" rowspan="1" colspan="1">50 park visitors</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Exposure to water from a splash feature</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis </italic>(subgenotype IaA28R4)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B100">258</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">2006</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">England (UK)</td><td align="center" rowspan="1" colspan="1">35 school people</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Surface water contamination during a farm visit</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B101">251</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne </italic></td><td align="center" rowspan="1" colspan="1">CO (USA)</td><td align="center" rowspan="1" colspan="1">21 attendes to a pool party</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Swimming, pool contamination</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis</italic> (subgenotype IbA10G2)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B85">85</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold><italic>Travelers' infection</italic></bold></td><td align="center" rowspan="1" colspan="1">FL (USA)</td><td align="center" rowspan="1" colspan="1">29 retired people</td><td align="center" rowspan="1" colspan="1">Elderly</td><td align="center" rowspan="1" colspan="1">Environmental contamination with animal feces</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> (subgenotype IIaA16G1R1b)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B102">207</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">ME (USA)</td><td align="center" rowspan="1" colspan="1">14 people</td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Unknown</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="2" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm">http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm</ext-link></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">PA (USA)</td><td align="center" rowspan="1" colspan="1">2 people</td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Unknown</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">FL (USA)</td><td align="center" rowspan="1" colspan="1">9 children<sup>3</sup></td><td align="center" rowspan="1" colspan="1">4 years<sup>4</sup></td><td align="center" rowspan="1" colspan="1">Water fountain contamination</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B103">261</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">Japan</td><td align="center" rowspan="1" colspan="1">4 company members</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Contamination of raw meat dish</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> (genotype IIa)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B104">301</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">2005</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">Denmark</td><td align="center" rowspan="1" colspan="1">99 company employees</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Buffet salad eating</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B105">180</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">Scotland (UK)</td><td align="center" rowspan="1" colspan="1">62 people</td><td align="center" rowspan="1" colspan="1">Adults and children</td><td align="center" rowspan="1" colspan="1">Outbreak linked to a wildlife centre visit</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B106">247</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Wales (UK)</td><td align="center" rowspan="1" colspan="1">100</td><td align="center" rowspan="1" colspan="1">Mostly young adults</td><td align="center" rowspan="1" colspan="1">Contamination of raw and treated water</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B107">291</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Turkey</td><td align="center" rowspan="1" colspan="1">191 inhabitants<sup>5</sup></td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Contamination of water tank</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B108">276</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">2005–2004</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">Spain</td><td align="center" rowspan="1" colspan="1">24 day-care children</td><td align="center" rowspan="1" colspan="1">Children</td><td align="center" rowspan="1" colspan="1">Children diaper use</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B109">252</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">2004</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Norway</td><td align="center" rowspan="1" colspan="1">115<sup>6</sup></td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Water supply contamination</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum </italic>(bovin genotype, genotype 2, cervine genotype)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B110">277</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">Croatia</td><td align="center" rowspan="1" colspan="1">One family members</td><td align="center" rowspan="1" colspan="1">Elderly and adults</td><td align="center" rowspan="1" colspan="1">Nosocomial and person-to-person contamination</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B111">302</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">CA (USA)</td><td align="center" rowspan="1" colspan="1">273 park attendants</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Contamination of a water park</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> (genotype IIc)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B112">127</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">NY (USA)</td><td align="center" rowspan="1" colspan="1">212 people<sup>7</sup></td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Contamination of unpasteurized apple cider</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm">http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm</ext-link></td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">2003</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Yorkshire and The Humber (UK)</td><td align="center" rowspan="1" colspan="1">66 people attending at the pool</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Contamination of water at a public pool</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B113">293</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">South West (UK)</td><td align="center" rowspan="1" colspan="1">21 children attending at the water park</td><td align="center" rowspan="1" colspan="1">Children</td><td align="center" rowspan="1" colspan="1">Leisure facility of a 'water splash zone</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B114">249</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">South East of England (UK)</td><td align="center" rowspan="1" colspan="1">17 people attending at the pool</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Contamination of water at a public pool</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B114">249</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Midlands (UK)</td><td align="center" rowspan="1" colspan="1">122 people attending at the park</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Contamination of a fountain water in a public park</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B114">249</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">South West of England (UK)</td><td align="center" rowspan="1" colspan="1">63 people attending at the animal centre</td><td align="center" rowspan="1" colspan="1">Children</td><td align="center" rowspan="1" colspan="1">Interactive water feature at an animal attraction centre</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> (genotype 2)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B115">248</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">Wales (UK)</td><td align="center" rowspan="1" colspan="1">17 people attending at the school visit</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Open farm, school visit</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> (subgenotype IIaA15G2R1)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B78">79</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">Wales (UK)</td><td align="center" rowspan="1" colspan="1">36 people attending at the visit</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Residential farmcentre, school visit</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum C. hominisC. meleagridis</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B63">63</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Majorca (Spain)</td><td align="center" rowspan="1" colspan="1">179 travellers</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Hotel pool water contamination</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B116">292</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">OH (USA)</td><td align="center" rowspan="1" colspan="1">144 inhabitants</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Contamination of unpasteurized apple cider</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> subgenotype IIaA15G2R1, IIaA17G2R1</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B117">182</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">MN (USA)</td><td align="center" rowspan="1" colspan="1">31 middle-/high-school students</td><td align="center" rowspan="1" colspan="1">Young people</td><td align="center" rowspan="1" colspan="1">Contact with calves</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B118">303</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">MN (USA)</td><td align="center" rowspan="1" colspan="1">37 middle-/high-school students</td><td align="center" rowspan="1" colspan="1">Young people</td><td align="center" rowspan="1" colspan="1">Manure on hands</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B118">303</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">MN (USA)</td><td align="center" rowspan="1" colspan="1">9 people</td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Contamination of food in a hotel banquet room</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm">http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm</ext-link></td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">2002</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">Yorkshire and The Humber (UK)</td><td align="center" rowspan="1" colspan="1">47 people attending at the nursery</td><td align="center" rowspan="1" colspan="1">Children and adults</td><td align="center" rowspan="1" colspan="1">Contamination at a day care nursery</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum C. hominis C. meleagridis</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B63">63</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Multiple exposure:<italic> Waterborne </italic>and Community</td><td align="center" rowspan="1" colspan="1">Wales (UK)</td><td align="center" rowspan="1" colspan="1">4 people</td><td align="center" rowspan="1" colspan="1">3 children and 1 adult</td><td align="center" rowspan="1" colspan="1">Contamination of a private drinking water supply private water supply, farm visits and personal contact</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> (subgenotype IIaA17G1R1)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B78">79</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">South East of England (UK)</td><td align="center" rowspan="1" colspan="1">21 people</td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Contamination of a public drinking water supply</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B113">293</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">South East of England (UK)</td><td align="center" rowspan="1" colspan="1">31 people</td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Contamination of a public drinking water supply</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B113">293</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">North West of England (UK)</td><td align="center" rowspan="1" colspan="1">50 school people<sup>8</sup></td><td align="center" rowspan="1" colspan="1">Adults and children</td><td align="center" rowspan="1" colspan="1">Contamination of a private drinking water supply at a college</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B113">293</xref>, <xref ref-type="bibr" rid="B119">294</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Northern Ireland (UK)</td><td align="center" rowspan="1" colspan="1">29 people</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Contamination of raw and treated water, and land surrounding the lake watershed</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B120">99</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">Netherlands</td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Children</td><td align="center" rowspan="1" colspan="1">Not reported, during a pet farm visit</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> (genotype C1)</td><td align="left" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.cryptosporidium.it/">http://www.cryptosporidium.it/</ext-link></td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">NY (USA)</td><td align="center" rowspan="1" colspan="1">13 veterinary students</td><td align="center" rowspan="1" colspan="1">Young people</td><td align="center" rowspan="1" colspan="1">Hands contamination by calves contacts</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B121">304</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">FL (USA)</td><td align="center" rowspan="1" colspan="1">37 people</td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Contamination of food in a hotel banquet room</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="2" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm">http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm</ext-link></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">GA (USA)</td><td align="center" rowspan="1" colspan="1">6 people</td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Contamination of food in a private home</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp. </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">2001</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">France</td><td align="center" rowspan="1" colspan="1">291 county inhabitants</td><td align="center" rowspan="1" colspan="1">Adults and children</td><td align="center" rowspan="1" colspan="1">Public water supply contamination</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis</italic> (genotype Ib,Id) <italic>C. parvum</italic> (genotype IIa)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B84">84</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">France</td><td align="center" rowspan="1" colspan="1">573</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Contamination of tap water</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> (genotype 1)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B122">305</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">South West of England (UK)</td><td align="center" rowspan="1" colspan="1">14</td><td align="center" rowspan="1" colspan="1">Adults and children</td><td align="center" rowspan="1" colspan="1">Contact with astream at a beach</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B119">294</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">South East of England (UK)</td><td align="center" rowspan="1" colspan="1">30</td><td align="center" rowspan="1" colspan="1">Adults and children</td><td align="center" rowspan="1" colspan="1">Contamination at a day care nursery</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">Unpublished data</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">South East of England (UK)</td><td align="center" rowspan="1" colspan="1">152 people attending at a school<sup>8</sup></td><td align="center" rowspan="1" colspan="1">Adults and children</td><td align="center" rowspan="1" colspan="1">Contamination of outdoor school pool water</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B119">294</xref>, <xref ref-type="bibr" rid="B123">295</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Canada (USA)</td><td align="center" rowspan="1" colspan="1">1039 people</td><td align="center" rowspan="1" colspan="1">Young adults</td><td align="center" rowspan="1" colspan="1">Contamination of drinking water</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B124">296</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Canada (USA)</td><td align="center" rowspan="1" colspan="1">59 people attending an Ukrainian dance festival</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Contamination of a swimming pool in a hotel</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B125">297</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">(IL) USA</td><td align="center" rowspan="1" colspan="1">358 waterpark attendants</td><td align="center" rowspan="1" colspan="1">Adults and children</td><td align="center" rowspan="1" colspan="1">Contamination of waterpark and person-to-person contact</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis</italic> (genotype Ia)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B126">259</xref>] </td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">Queensland (Australia)</td><td align="center" rowspan="1" colspan="1">8 inhabitants</td><td align="center" rowspan="1" colspan="1">Children</td><td align="center" rowspan="1" colspan="1">Contamination of drinking unpasteurised milk</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B127">262</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">New Zealand</td><td align="center" rowspan="1" colspan="1">20 farm inhabitants</td><td align="center" rowspan="1" colspan="1">Children</td><td align="center" rowspan="1" colspan="1">Hand contamination by calve contact</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B128">264</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">Tasmania (Australia)</td><td align="center" rowspan="1" colspan="1">36 participants at the agricultural show</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Contamination associated with an animal nursery</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B129">306</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">Brazil</td><td align="center" rowspan="1" colspan="1">224 day care attendants</td><td align="center" rowspan="1" colspan="1">Children</td><td align="center" rowspan="1" colspan="1">Person-to-person contact</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis</italic> (genotype 1)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B130">307</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">2001–2000</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Northern Ireland (UK)</td><td align="center" rowspan="1" colspan="1">347</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Contamination of drinking water</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum </italic>(bovine genotype; human genotype)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B79">80</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Haiti</td><td align="center" rowspan="1" colspan="1">93 patients</td><td align="center" rowspan="1" colspan="1">Adults and children</td><td align="center" rowspan="1" colspan="1">Contaminated water and overcrowded conditions of urban slums</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis</italic>,<italic> C. parvum, C. felis </italic></td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B69">69</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">2000</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">England and Wales (UK)</td><td align="center" rowspan="1" colspan="1">58</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Contamination of drinking water</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum </italic>(genotype 2)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B131">308</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">England and Wales (UK)</td><td align="center" rowspan="1" colspan="1">207</td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Contamination of drinking water</td><td align="center" rowspan="1" colspan="1"><italic>C. hominis</italic> and<italic> C. parvum </italic>alleles</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B132">309</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Yorkshire and The Humber (UK)</td><td align="center" rowspan="1" colspan="1">41 people attending a public pool</td><td align="center" rowspan="1" colspan="1">Adults and children</td><td align="center" rowspan="1" colspan="1">Contamination of pool water</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic> (subgenotype IIaA17G1R1)</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B78">79</xref>, <xref ref-type="bibr" rid="B123">295</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Majorca (Spain)</td><td align="center" rowspan="1" colspan="1">>250</td><td align="center" rowspan="1" colspan="1">Adults and children</td><td align="center" rowspan="1" colspan="1">Contamination of a hotel pool water</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B80">81</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Community</td><td align="center" rowspan="1" colspan="1">Netherlands</td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Children</td><td align="center" rowspan="1" colspan="1">School children visiting a pet farm</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.cryptosporidium.it/">http://www.cryptosporidium.it/</ext-link></td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">IL (USA)</td><td align="center" rowspan="1" colspan="1">8</td><td align="center" rowspan="1" colspan="1">Not reported</td><td align="center" rowspan="1" colspan="1">Contamination of coleslaw in a private home</td><td align="center" rowspan="1" colspan="1"><italic>C. parvum</italic></td><td align="left" rowspan="1" colspan="1"><ext-link ext-link-type="uri" xlink:href="http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm">http://www.cdc.gov/foodborneoutbreaks/outbreak_data.htm</ext-link></td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">1999</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Russia</td><td align="center" rowspan="1" colspan="1">50</td><td align="center" rowspan="1" colspan="1">Adults</td><td align="center" rowspan="1" colspan="1">Contamination of drinking water</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B133">310</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">FL (USA)</td><td align="center" rowspan="1" colspan="1">38 park visitors</td><td align="center" rowspan="1" colspan="1">Adults and children</td><td align="center" rowspan="1" colspan="1">Contamination of a water fountain</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B134">260</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="center" colspan="7" rowspan="1">1998</td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Waterborne</italic></td><td align="center" rowspan="1" colspan="1">Spain</td><td align="center" rowspan="1" colspan="1">21</td><td align="center" rowspan="1" colspan="1">Children</td><td align="center" rowspan="1" colspan="1">Contamination of tap water</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B135">253</xref>] </td></tr><tr><td align="center" colspan="7" rowspan="1"><hr></hr></td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>Foodborne</bold></td><td align="center" rowspan="1" colspan="1">DC (USA)</td><td align="center" rowspan="1" colspan="1">88 students and employees</td><td align="center" rowspan="1" colspan="1">Young adults and adults</td><td align="center" rowspan="1" colspan="1">Contamination of food by a food handler in a cafeteria</td><td align="center" rowspan="1" colspan="1"><italic>Cryptosporidium </italic>spp.</td><td align="left" rowspan="1" colspan="1">[<xref ref-type="bibr" rid="B136">311</xref>]</td></tr></tbody></table><table-wrap-foot><fn><p><sup>1</sup>In presence of two or more cases of similar infection, with a common exposure in the community not related to waterborne or foodborne diasese, the term of community disease was used. </p></fn><fn><p><sup>2</sup>Number and category of people with symptom referable to cryptosporidiosis. </p></fn><fn><p><sup>3</sup>This outbreak was characterised by a <italic>Cryptosporidium</italic> infection in 9 of the 11 children, a coinfection of <italic>Giardia</italic> and <italic>Cryptosporidium</italic> in 2 of the 11 children and a concomitant infection of other 38 additional children by only <italic>Giardia </italic>oocysts triggered by the same likely source. </p></fn><fn><p><sup>4</sup>Median age. </p></fn><fn><p><sup> 5</sup>Outbreak characterised by a concomitant waterborne <italic>Cyclospora </italic>outbreak. </p></fn><fn><p><sup>6</sup>Outbreak characterised by a concomitant waterborne <italic>Giardia </italic>outbreak. </p></fn><fn><p><sup>7</sup>Outbreak characterised by a concomitant foodborne <italic>E. coli</italic> O111 outbreak. </p></fn><fn><p><sup>8</sup>Outbreak characterised by a concomitant waterborne Norovirus outbreak.</p></fn></table-wrap-foot></table-wrap></floats-group></pmc><affiliations><list><country><li>Italie</li></country><region><li>Latium</li></region><settlement><li>Rome</li></settlement></list><tree><country name="Italie"><region name="Latium"><name sortKey="Putignani, Lorenza" sort="Putignani, Lorenza" uniqKey="Putignani L" first="Lorenza" last="Putignani">Lorenza Putignani</name></region><name sortKey="Menichella, Donato" sort="Menichella, Donato" uniqKey="Menichella D" first="Donato" last="Menichella">Donato Menichella</name></country></tree></affiliations></record>Pour manipuler 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