Cryptosporidium in water and food

Transcription

1 6 th International Conference on Sustainable Solid Waste Management June 2018 Cryptosporidium in water and food Prof. Panagiotis Karanis Medical School, University of Cologne, Germany November 2017, Sousse, Tunisia

2 Contents of this presentation 1 Short self introduction Cryptosporidium What are the facts: Importance of Crypto Prevalence & outbreaks What is Cryptosporidium? Transmission & life cycle Crypto in food Diagnosis Treatment & prevention Water treatment & pathogen removal What are the problems? Inter alia tourism in danger What are the solutions? Take home message

3 PANAGIOTIS KARANIS Professor & Director of The Centre of Biomedicine and Infectious Diseases, Qinghai University in Xining, China PANAGIOTIS KARANIS Professor at The Medical School, University of Cologne, Germany

4 CHINA Qinghai Province XINING

5 1000 Talent Plan of the Chinese Government

6 Upgraded to Key State Laboratory for Plateau Ecology and Agriculture 1000 TP of the Chinese Government

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8 7 Prof. Dr. Panagiotis Karanis Short CV 1959: Born in Chrysso / Evritania / Greece 1979: Germany / Studies of Biology & Medicine 1992: PhD in Parasitology / Bonn University / Germany 1999: Habilitation (Venia legendi) in Parasitology, Medical School / Bonn University / Germany 2000 today: Professor at Cologne Medical School / Germany 1999, 2003, 2004: Visiting Professor at the National Research Center for Protozoan Diseases (NRCPD) / Japan : Professor, NRCPD / Japan : Professor, Center for Biomedicine and Infectious Diseases, Qinghai University / China

9 Dormant / transmissive stage: Oocyst Oocysts with infectious sporozoites: Size: 5 μm 2 y survival in the environment by 4 C What is Cryptosporidium? Parasite (Protozoon), cause disease called Cryptosporidiosis in humans Most common species Cryptosporidium hominis & C. parvum, other species There are 34 different Cryptosporidium species and 62 genotypes

10 THE IMPORTANCE OF CRYPTOSPORIDIUM

11 Clinical importance of Cryptosporidium Food- and waterborne gastroenteritis Cryptosporidium is responsible for: 1 Mio children s deaths / year Human colon cancer Transplant rejection

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13 Occurrence & worldwide outbreaks of Cryptosporidium WORLDWIDE & UBIQUITOUS

14 Cryptosporidium Prevalence Immunosuppressed, HIV-infected and organ transplants. Children, in particular 0-2; 2-4 years. In industrialized countries: Crypto. - detection in 2-4% patients with diarrhea. Crypto.- detection by 1-4% healthy, asymptomatic humans. In developing countries the prevalence is higher compared to industrialized countries. In Germany: since 2001 registered by RKI: cases with increasing number from July to the end of November.

15 Global burden of food-borne / water-borne (diarrheal) diseases currently unknown 1.8 million people died from diarrheal diseases (WHO 2005) due to contaminated food and drinking water. This is not just a problem of the underdeveloped world. About 76 million cases of food-borne diseases, resulting in hospitalizations and deaths, are estimated to occur each year only in the U.S.A. (Mead et al., 1999). Over 200 known microbial, chemical or physical agents can cause illness when ingested. Over the last 20 years, at least in the industrialized world, water- and food-borne diseases caused by bacteria, parasites, viruses and prions have significantly moved up the political agenda and generated substantial media attention.

16 Cryptosporidium: diarrhea 15 Cryptosporidium is the number 2 cause (after Rota virus) of diarrhea associated mortality in children under 5 years of age, worldwide Kotlof et al. (2013)

17 Cryptosporidium: waterborne 16 transmission and worldwide outbreaks From the begin of the last century until 2016, Cryptosporidium was responsible for 60% (524/913) of all reported waterborne outbreaks caused by protozoan parasites Karanis et al (2007); Baldursson & Karanis (2011); Efstratiou et al (2017)

18 Cryptosporidium: outbreaks 17 Largest waterborne Cryptosporidium outbreak: Milwaukee, USA in 1993 (1) 403,000 individuals with cryptosporidiosis via contaminated drinking water illness associated cost of US $96.2 million 100 deaths (2) Second largest waterborne outbreak occurred in: Östersund, Sweden in ,000 individuals infected (3) Another waterborne outbreak: Skellefteå, Sweden in ,500 individuals (4) (1) MacKenzie et al (1995); (2) Corso et al (2003); (3) Widerström et al (2014); (4) Bjelkmar et al (2017)

19 INCREASE OF: Waterborne diseases Foodborne diseases Vectorborne diseases

20 Unlimited Mobility

21 MIGRANTS & REFUGEES

22 Transmission of Cryptosporidium Human - to - Human Animal - Human - Animal Water Food Air

23 Cryptosporidium Life Cycle 22 Gastroenteritis Food

24 Identify the contamination sources!

25 CRYPTOSPORIDIUM IN WATER & FOOD

26 Cryptosporidium: foodborne transmission 25 Main causes of foodborne Cryptosporidium outbreaks usually associated with food service and catering industries: Cold pressed non alcoholic apple cider Ozonated apple cider Milk Béarnaise sauce Raw meat, raw liver Chicken salad Pre cut mixed salad leaves (bagged salad) Frisée salad Fruit juice Molluscs Sprouted seeds Highly expected of being vehicles for transmission of Cryptosporidium: freshly produced, and when consumed with minimal preparation. Ahmed & Karanis (2017). An overview of methods / techniques for the detection of Cryptosporidium in food samples. Parasitol Res 117,

27 26 33 years review (Ahmed & Karanis, 2017, in press): Cryptosporidium detection in food material

28 Cryptosporidium: foodborne 27 transmission and worldwide outbreaks Cryptosporidium was ranked 5th out of 24 potentially foodborne parasites in terms of importance as a foodborne pathogen FAO/WHO 2014

29 Cryptosporidium: foodborne transmission 28 Cryptosporidium is among the 10 foodborne pathogens monitored by the FoodNet surveillance system in the United States Crim et al. (2014)

30 Cryptosporidium: foodborne 29 transmission and worldwide outbreaks Cryptosporidium is particularly suited to foodborne transmission and is responsible for > 8 million cases of foodborne illness annually

31 30 33 years review (Ahmed & Karanis, 2017): Documented outbreaks of cryptosporidiosis associated with different food materials Infected food Causative species Location of No. of people Year of outbreak Reference/s material /subtype of outbreak affected occurrence Cryptosporidium * Sausage NP UK (North Wales) Casemore et al., 1986 Milk NP Mexico Elsser et al., 1986 Kefir prepared in the nursery milk kitchen Fresh pressed apple cidar NP Russia Romanova et al., 1992 C. parvum France (central Millard et al., Maine) 1994 Chicken salad C. parvum US (Minnesota) CDC, 1996 Unpasteurized NP Connecticut and CDC, 1997 apple cidar New York School Milk (cow NP UK Gelletlie et al., milk) 1997 Uncooked green C. parvum US (Spokane) CDC, 1998 onions (suspected) Fruit/vegetables C. parvum US (Washington) Quiroz et al., 2000 related to food handler Unpasteurized milk Ozonated apple cider Unpasteurized apple cidar Unpasteurized apple cidar Salad (peeled carrots, grated carrots, red pepper) Milk and diary products Raw meat and raw liver (Yukke) Béarnaise sauce containing chopped fresh parsley Arugula salad C. parvum / 4 subtypes (IIaA16G1R1, IIaA15G2R1, IIdA22G1, IId19G1) NM (C. parvum suspected) Australia (Queensland) Harper et al., 2002 C. parvum/ US (Ohio) Blackburn et al., IIaA17G2R C. parvum USA Danyluk et al., 2012; Vojdaniet al., 2008 C. parvum USA Danyluk et al., 2012; Vojdani et al C. hominis Denmark Ethelberg et al., 2009 NP Germany NP 2006 EFSA, 2007 C. parvum / IIa Japan Yoshida et al., 2007 C. parvum Sweden Insulander et al., 2008 Sweden (Stockholm) Insulander et al., 2013 Salad mixture was C. parvum Finland Pönka et al., 2009 suspected from same canteen Ham from a C. parvum / USA (North CDC, 2011 sandwich bar IIaA17G2R1 Carolina) No identified food C. parvum Norway Rimseliene et al., item. suspected 2011 (Peeled carrots left in water) Pre-cut mixed C. parvum / England and Over McKerr et al., salad leaves IIaA15G2R1 Scotland 2015 Frisée salad C. parvum / Finland Over Åberg et al., 2015

32 Cryptosporidium: foodborne 31 transmission and worldwide outbreaks Foodborne outbreaks of cryptosporidiosis have been increasingly reported, however most foodborne outbreaks are never recognized, and those that are recognized, frequently are poorly investigated if at all, and often go unreported Robertson (2014)

33 Investigation DIAGNOSIS Recognition

34 33 40 years Overview (Efstratiou, Ongerth, Karanis 2017): Detection methods for Crypto & Giardia monitoring

35 Detection of Cryptosporidium oocysts by staining e.g. Giemsa Eosine modified Ziehl-Neelsen-Staining = mzns in stool smears Immunfluorescence = IFT Copro-Antigen-detection (ELISA) Molecular detection (PCR)

36 35 40 years review (Ahmed & Karanis, 2017, in press): Cryptosporidium detection in stool material

37 36 Cryptosporidium in stool (Light microscope)

38 Cryptosporidium in stool (Light microscope, IFT) 37

39 38 Cryptosporidium in stool (Light microscope, IFT) Cryptosporidium Giardia

40 Cryptosporidiosis endoscopy 39 Exogen toxic duodenitis with severe erythema. Cryptosporidium infection leads to malabsorption syndrome and diarrhea Pott (1998). Gastroskopie Atlas. Schattauer Verlag

41 TREATMENT / THERAPY

42 Cryptosporidium: No drugs 41 There is no effective treatment for cryptosporidiosis in all populations and no vaccine is available Only symptomatic therapy!

43 PREVENTION Wash hands, clean toilets Boil water Food (particular vegetables) good washing + boiling Know and prevent the potential infection sources + transmission routes Note: Carriers of Cryptosporidium oocysts are sources for fecal-oral transmission

44 WATER TREATMENT & PATHOGEN REMOVAL

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46 Water treatment 1. Backwash water (very dirty) 2. First filtrate (low turbidity - drinking water quality) Note: No disinfection!

47 Unexpected events: dangerous for drinking water preparation Thessaloniki, Greece, May 2018

48 47 Unexpected events: dangerous for drinking water preparation

49 48 Cryptosporidium: What are the Problems? Outbreaks Waterborne Foodborne Children, elderlies, immunosuppressed at risk No disinfection No therapy Swimming pools Tourism industries / Hotel business in danger

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60 Suggestions and Conclusions Multi barrier system for water treatment 2. Simplify detection and diagnosis procedures 3. Standardized Surveillance System in all countries + international networking 4. Revision of guidelines/recommendations for swimming pool users + prevention of transmission of infectious diseases 4. Education / skills 5. Develop culture system in vitro 6. Drug + therapy development 7. Cooperate with the experts

61 TAKE HOME MESSAGE Cryptosporidium is one of the most important pathogen causing diarrhea + diarrhea related death Underreported / Underdiagnosed No therapy yet / No vaccine Transmission by water + food Swimming pools: Tourism / hotel business in danger Fecal oral route of transmission Cooperate with the experts!

62 Thank you for your attention! Prof. Dr. Panagiotis Karanis contact: November 2017, Sousse, Tunisia

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65 Giardia & Cryptosporidium proof in 6 water treatment plants in Germany ( ) Karanis et al., 1998: Distribution and removal of Giardia and Cryptosporidium in water supplies in Germany