Subtyping Cryptosporidium spp. in Supporting Investigations of Waterborne and Foodborne Outbreaks of Cryptosporidiosis

Transcription

1 Subtyping Cryptosporidium spp. in Supporting Investigations of Waterborne and Foodborne Outbreaks of Cryptosporidiosis Lihua Xiao Molecular Epidemiology Laboratory & CryptoNet Division of Parasitic Diseases Centers for Disease Control and Prevention The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention

2 Cryptosporidiosis Non-Outbreak Case Reports and Outbreak Reports Associated with Recreational Water Use: United States, * Numb ber of Case Repo orts Sporadic Cases 143% increase since 2004 Est. 750,000 cases/year Report Year Numb ber of Outbrea aks Outbreaks Year *Case Reports: Yoder JS, Beach MJ. MMWR (2007) 57(SS-7):1-10; Outbreak reports: N=132, p, ( ) ( ) ; p, Yoder JS et al MMWR 57(SS-9): data preliminarily based on CDC Logs, not verified by states

3 Cryptosporidiosis Incidence: United States, Incidence/100, < >3.6

4 Cryptosporidiosis Incidence: United States, Incidence/100, < >3.6

5 Cryptosporidiosis Incidence: United States, Incidence/100, < >3.6

6 Cryptosporidiosis Incidence: United States, Incidence/100, < >3.6

7 Transmission of Cryptosporidiosis Anthroponotic Zoonotic Dire ect Cont tact Foodborne Waterborne

8 Roles of Molecular Epidemiologic Tools in Investigations i of fcryptosporidiosis i i Outbreaks Identification i of outbreaks Differentiation of sporadic and cluster cases Differentiation of outbreaks Concurrent outbreaks in neighboring areas Secondary spread of outbreak strains Tracking of infection and contamination sources Anthroponotic versus zoonotic Linkage between cases and water/food/animal/food handler Tracking gof temporal and geographic g spread of pathogen

9 Species and Subtypes of Cryptosporidium in Outbreaks Outbreak Year Route No. of patient Species hominis /parvum Subtype Milwaukee, WI 1993 Waterborne 5 5/0 IbA10G2 (4/4) Maine 1993 Foodborne 1 0/1 Las Vegas, Nev Waterborne 4 3/1 IbA10G2 (3/3) Gainesville, FL 1995 Waterborne 6 6/0 IbA9G3 (4/4) Cobb Co., GA 1995 Waterborne 3 3/0 Ib A10G2 (3/3) Minnesota 1997 Waterborne 5 0/5 IIaA15G2R1 (4/4) Spokane, WA 1997 Foodborne 7 7/0 IdA18 (7/7) Austin, Texas 1998 Waterborne 5 4/1 Washington, DC 1998 Foodborne /0 IbA10G2 (15/15) Charleston, SC 2000 Waterborne 6 6/0 IaA24R4 (6/6) Canon, CO 2000 Waterborne 3 0/3 IcA5G3 (3/3) Omaha, NE 2000 Waterborne /0 IaA24R4 (12/12) Powell, OH 2000 Waterborne 31 mix infections IdA17G1 (28/28) N. Ireland 2000 Waterborne 33 0/33 IIa A18G3R1(30/30) N. Ireland 2000 Waterborne /0 IbA10G2 (31/31) N. Ireland 2001 Waterborne /8 IbA10G2 (36/36) E. Peoria, IL 2001 Waterborne /0 IaA14R3 (11/11) N. Battleford, Saskatchewan 2001 Waterborne /0 IdA19 (5/7), IbA10G2 (2/7) San Antonio, TX 2002 Waterborne 1 1/0 IbA10G2 (1/1) Douglas Co., KS 2003 Waterborne /0 IdA17 (48/48) Stark Co., OH 2003 Foodborne 8 0/8 IIaA15G2R1 (4/8), IIaA17G2R1 (4/8)

10 Species and Subtypes of Cryptosporidium in Outbreaks, continued Outbreak Year Route No. of patient Species hominis/ parvum Subtype Ireland 2003 Waterborne 9 0/9 IIcA5G3h (9/9) San Luis Obispo Co., CA 2004 Waterborne 6 0/6 IIcA5G3 (6/6) Colorado 2004 Waterborne 1 1/0 Negative Auglaize Co, OH 2004 Waterborne 17 17/0 IdA15G1 (17/17) Hamilton County, OH 2005 Waterborne 7 7/0 IaA28R4 (6/7), IdA15G2 (1/7) Seneca Lake, NY 2005 Waterborne /1 IbA10G2 (129), IeA11G3T3 (4), IIaA15G2R1 (1) Oregon 2005 Waterborne 4 0/4 Nassau, FL 2006 Unknown 5 0/5 IIaA16G1R1b (5/5) Anderson, SC 2006 Waterborne 4 4/0 IaA28R4 (4/4) Tazewell Co, IL 2006 Waterborne 4 4/0 IbA10G2 (4/4) Lone Tree, CO 2006 Waterborne 5 5/0 IbA10G2 (5/5) Ashtabula Co., OH 2006 Foodborne 2 2/0 IdA14 (2/2) Chester Co, PA 2007 Waterborne 6 6/0 IaA28R4 (6/6) Okmulgee, OK 2007 Waterborne 12 11/1 IdA15G1 (11/12), IIaA17G2R2 (1/12) Muskogee, OK 2007 Waterborne 2 0/2 IIaA17G2R2 (2/2) Rankin Co, MS 2007 Waterborne 4 0/4 IIaA20G2R1 (4/4) Puerto Rico 2007 Waterborne 6 6/0 IdA16 (5/6), IaA25R3 (1/6) Kansas 2007 Waterborne 2 2/0 IdA15G1 (2/2) Ada Co, Idaho 2007 Waterborne 2 2/0 IaA28R4 (2/2) Maricopa Co, AZ 2008 Waterborne 6 6/0 IaA28R4 (6/6) NM 2008 Waterborne 5 4/1 IaA20R3 (4/4) NM 2008 Daycare 8 8/0 IaA20R3 (5/8), IaA15R3 (2/8), IaA28R4 (1/8) Franklin Co, OH 2008 Waterborne 27 27/0 IaA28R4 (19/20), IaA29R4 (1/20) Tarrant & Dallas Co, TX 2008 Waterborne /2 IaA28R4 (144/230), IaA15R3 (35/230), IdA15G1 (20/230), IgA27 (15/230), IaA20R3 (4/230) Saline Co, KS 2008 Waterborne 1 1/0 IaA20R3 (1/1)

11 Major Subtypes in Outbreaks of Cryptosporidiosis Subtype Families Subtypes Outbreaks C. hominis Ib Ia IbA10G2 Milwaukee, WI (1993); Las Vegas NV (1994); Cobb, GA (1995); Washington, DC (2000); N. Ireland (2000); N. Ireland (2001); Saskatchewan (2001); San Antonio, TX (2002); Seneca Lake, NY (2005); Tazewell, IL (2006); Lone Tree, CO (2006) IbA3G3 Gainsville, FL (1995) IaA14R3 E. Peoria, IL (2001) IaA15R3 NM daycare (2008), Dallas, TX 92008) IaA20R3 NM daycare (2008), NM water (2008), Dallas (2008) IaA24R4 Charleston, SC (2000); Omaha, NE (2000) Hamilton, OH (2005); Anderson, SC (2006), Chester, PA (2007), Ada, ID (2007), Maricopa, AZ (2008), NM Daycare (2008), Frankin, OH (2008), Dallas, TX (2008) IaA28R4 IdA14 Ashtabula, OH (2006) IdA15G1 Auglaize, OH (2004), Okmulgee, OK (2007), KS (2007), Dallas, TX (2008) IdA16 Puerto Rico (2007) Id IdA17 Douglas, KS (2003) IdA17G1 Powell, OH (2000) IdA18 Spokane, WA (1997) IdA19 Saskatchewan (2001) Ig IgA27 Dallas, TX (2008) C. parvum IIa IIaA15G2R1 Maine (1993); Minnesoda (1997); Stark, OH (2003) IIaA16G1R1b Nassau, FL (2006) IIaA17G2R1 Stark, OH (2003) IIaA17G2R2 Muskogee, OK (2007) IIaA18G3R1 N. Ireland (2000) IIaA20G2R1 Rankin, MS (2007) IIc IIcA5G3 Canon, CO (2003); N. Ireland (2003); San Luis Obispo, CA (2004); Botswana (2006)

12 Molecular Surveillance of Cryptosporidiosis: Dominance of Ch C. hominis ii Subtype IaA28R4 in Sporadic Cases in Fall IaA28R4 27 Idaho 2 IaA28R4 8 Colorado 6 IaA28R4 Iowa New Mexico

13 Molecular Surveillance of Cryptosporidiosis: Dominance of C. hominis Subtype IaA28R4 in Sporadic Cases in Fall 2008 IIaA17G2R1, 1 Texas New Mexico IgA27, 1 IdA15G1, 6 IaA15R3, 6 IIaA15G2R1, 1 IIaA17G2R1, 6 IaA15R3, 3 C IaA28R4, 4 IaA28R4, 28 IaA20R3, 5 IdA15G1, 5

14 Tracking Contamination Source in Recreational Outbreaks of fcryptosporidiosis i i in 2007 No. of C. hominis/c. Location patient t parvum Subtype in patient t Subtype in water Chester Co, PA 6 6/0 IaA28R4 (6/6) Negative Okmulgee, OK* 12 11/1 IdA15G1 (11/12) IIaA17G2R2 (1/12) IdA15G1 in pool backwash Muskogee, OK* 2 0/2 IIaA17G2R2 (2/2) IIaA17G2R2 in pool backwash Rankin Co, MS 4 0/4 IIaA20G2R1 Negative Puerto Rico 6 6/0 IdA16 (5/6) Not tested IaA25R3 (1/6) Kansas 2 2/0 IdA15G1 (2/2) Not tested Ada Co, Idaho 2 2/0 IaA28R4 (2/2) IaA28R4 in interactive splash park water, filter backwash, and drinking fountain *Swimming pool-associated outbreaks in two neighboring counties at the same time

15 Laboratory-Confirmed Cases of Cryptosporidiosis - Ohio Apple Cider Outbreak 2003, N=26 Number of Cases Epi Curve of Apple Cider-associated 5 Prim ary Case 4 Secondary Case /1/03 9/16/03 10/1/03 10/16/03 10/31/03 11/15/03 Date of Onset Foodborne Outbreak of Probable Cases of Cryptosporidiosis Ohio Apple Cider Cryptosporidiosis in Ohio, 2003 ses Number of Ca Probable Cases of Cryptosporidiosis - Ohio Apple Cider Outbreak 2003, N=119 (2 have unknown onset dates) Primary Case Secondary Case 9/1/03 9/16/03 10/1/03 10/16/03 10/31/03 11/15/03 Date of Onset

16 Genotyping and Subtyping Results of Specimens Associated with the Ohio Cider-associated ed Outbreak of Cryptosporidiosis, 2003 Lab No. Patient ID Genotype Subtype C. parvum IIaA17G2R C. parvum IIaA17G2R1&IIaA15G2R C. parvum IIaA17G2R C. parvum IIaA15G2R C. parvum IIaA15G2R C. parvum IIaA15G2R C. parvum IIaA17G2R C. parvum IIaA17G2R Apple Cider (OC1) C. parvum IIaA17G2R1&IIaA15G2R * C. hominis IbA9G * C. hominis IbA9G * C. hominis IbA9G * C. hominis IbA9G * C. hominis IbA9G * C. parvum&c. hominisiba9g3, IIaA17G2R1, IIaA15G * cervine genotype N/D *From children attending a daycare during the apple cider outbreak

17 The Distribution of the Two Apple Cider Outbreak-Associated Cryptosporidium parvum Subtypes (IIaA15G2R1 and IIaA17G2R1) in Cattle in Eastern United States IIaA11G2R1 IIaA15G2R2 IIaA15G2R2 IIaA11G2R1 IIaA17G2R1 IIaA15G2R1 IIaA15G2R1 IIaA15G2R2 IIaA15G2R1 IIaA15G2R1 IIaA16G1R1 IIaA16G2R1 IIaA16G3R2 IIaA16G3R1 IIa17G2R1 IIaA15G2R1 IIa15G2R1 IIaA15G2R1 IIaA11G2R1 IIaA18G2R1 IIaA15G2R2 IIaA19G2R1 IIaA15G2R1

18 Epi Curve of Cryptosporidiosis Outbreak at a Summer Camp, North Carolina All Cases Session B campers Arrive + Swim Test State Notified CDC Notified, Pool and dl Lake Closed 8 Cases 6 Session B Campers Depart /21/2009 6/22/2009 6/23/2009 6/24/2009 6/25/2009 6/26/2009 6/27/2009 6/28/2009 6/29/2009 6/30/2009 7/1/2009 7/2/2009 7/3/2009 7/4/2009 7/5/2009 7/6/2009 Dt Dates Camper vs staff Cases /23/2009 6/24/2009 6/25/2009 6/26/2009 6/27/2009 6/28/2009 6/29/2009 6/30/2009 7/1/2009 7/2/2009 7/3/2009 7/4/2009 7/5/2009 7/6/2009 Dates Preliminary data by L. Chang et al. Staff Camper

19 Case Density by Cabin (Labeled) 7 cases 4 cases 3 cases 2 cases 1 cases 0 cases HILLSIDE RIVERSIDE W V U T S R Z Y D1 E1 C1 TAJAR Lake UPPER DWELLING MOUNTAIN SIDE G N H M I L ROBIN S NEST J K RIDDLE S HOUSE BROOKSIDE Preliminary data by L. Chang et al.

20 Significant Risk Factors in Occurrence of Cryptosporidiosis: NC Camp Outbreak, 2009 Food exposure e Exposure Ill (%) Non-Ill (%) P-Value New camper lunch on 6/ Dinner Salad on 6/ Recreational water exposure G.V. Pool Lake Lure Animal exposure Calves Cows Washed hands after contact with waste Preliminary data by L. Chang et al.

21 Results of Water Testing NC Camp Outbreak, 2009 Crypto Source Fecal coliforms (cfu/100 ml) Positive? Drinking Water Wells None No Kitchen Sink None No Swimming Pool NA/ Not tested No Lake-Swimming Area NA/ Not tested No Other Lake Samples Meets water quality criteria No (6-18) Forget Me Not Stream Meets water quality criteria (63) French Broad River NA/ Not tested No Carson Creek & Hillside NA/ Not tested No Creek No Preliminary data by L. Chang et al.

22 Results of Cryptosporidium Subtyping of Specimens from Humans and Animals: Identification of Pet Farm Animals as Possible Pathogen Source in NC Camp Outbreak, 2009 Cryptosporidium parvum # Sbt Subtype Human 8 IIaA17G2R1 (8) Calf 3 IIaA17G2R1(2), IIaA15G2R1 (1) Goat kid 1 IIaA17G2R1 (1) Piglet 1 IIaA17G2R1 (1)

23 The Need for a Cryptosporidium Molecular Surveillance Partnership Integrate data access with NORS, EHS-Net systems Clinical Samples Sporadic vs. outbreak, risk factor, and clinical & geographic differences Animal and human isolate tracking & surveillance Animal Samples Environmental Samples Water and food source tracking & surveillance

24 CryptoNet: A National Sequence-based Molecular Surveillance System Create a national data platform for rapidly collecting Cryptosporidium isolates for typing/subtyping analysis: Stools standard typing methods sequences into national database rapid analysis & comparison analysis results back to states/partners

25 CryptoNet Structure Data Management and QA/QC Data integrity SOP development Lab certification Proficiency testing CryptoNet Database Server (BioNumerics) Data Analyses Species/subtyping Sequence matching Geographic spread Clinical i l comparison Epi comparison CDC side Data uploading Analysis downloads Client Side State HD s/international Clients/ Others (Sequence, Epi, Outbreak, Animal, Environmental data)

26 FY2009: CryptoNet: Planned Activities Entry of sequence, clinical, epidemiologic data Standardize Cryptosporidium subtyping tools FY2010: Develop CryptoNet/BioNumerics interface scripts Beta-test/revise sequence DB and CryptoNet Develop elop standard operating procedures res (SOPs) Test CryptoNet in surveillance and outbreaks FY2011: Train state/local labs on subtyping/cryptonet use Release of CryptoNet Beyond: Establish stool collection network, sentinel sites?

27 CryptoNet: Challenges Lack of a national specimen collection system and reference lab Support from state DOH Participation in the development and testing of CryptoNet Wide practice of Cryptosporidium genotyping and subtyping Provision of suitable specimens from sporadic cases and outbreaks Few specimens from sporadic cases are available for typing Many available specimens are preserved in formalin and LV- PVA fixatives

28 Acknowledgments Molecular l Epidemiology i Water epi team, DPD/CDC Laboratory, DPD/CDC Michele Hlavsa Jonathan Yoder Michael Beach EIS Officers (L. Chang, P. Cantey, B. Blackburn, etc.) State and local health departments CryptoNet, DPD/CDC Satomi ikato Patricia Wilkins Michael Beach Chris Braden Lihua Xiao TX, OH, NC, SC, IL, NM, ID, IA, OK, NY, CO, KS, MS, PA, WA, MN, WI, GA, NV, FL, AZ, PR, etc. CaliciNet Duping Zheng Jan Vinjie PulseNet Brenda Brown Peter Gerner-Smidt