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Assoc. Prof. Dr. Yvonne Lim Ai Lian Department of Parasitology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Water Safety Conference.

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Presentation on theme: "Assoc. Prof. Dr. Yvonne Lim Ai Lian Department of Parasitology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Water Safety Conference."— Presentation transcript:

1 Assoc. Prof. Dr. Yvonne Lim Ai Lian Department of Parasitology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Water Safety Conference 2010

2 2 In

3  Aim - Halving by 2015 the proportion of people without sustainable access to safe drinking water and proper sanitation. 3 7 Declared as the International Decade for Action – Water for Life Declared as the International Decade for Action – Water for Life

4  Every year, unsafe water, coupled with a lack of basic sanitation, kills at least 1.6 million children under the age of five years especially from diarrheal diseases. (Source: WHO and UNICEF 2006) 4 Water Safety Conference November , Kuching, Malaysia

5 5 Water Safety Conference November , Kuching, Malaysia

6 Cryptosporidium GiardiaEntamoeba Blastocystis Cyclospora ToxoplasmaIsospora Acanthamoeba Parasites that can cause diarrheal diseases

7 7 ParasiteNumber of outbreak(s) Crytosporidium165 Giardia132 Entamoeba9 Cyclospora6 Toxoplasma3 Isospora3 Blastocystis2 Balantidium1 Microsporidium1 Acanthamoeba1 Naegleria1 Source: Karanis et al., Waterborne transmission of protozoan parasites: a worldwide review of outbreaks and lessons learnt. Journal of Water and Health 5: Water Safety Conference November , Kuching, Malaysia

8 In 2005 – WHO included both Giardia and Cryptosporidium in the ‘Neglected Diseases Initiative’ (Savioli et al., 2006). In WHO has recognised Cryptosporidium as a ‘reference’ for water quality (Medema et al., 2006). 8 World Health Organization Global recognition Water Safety Conference November , Kuching, Malaysia

9  Discovered by Antonie Van Leeuwenhoek in 1681  Common intestinal parasite (especially in children) 9

10 10 How does Giardia get into human body?

11  In healthy people (immunocompetent) - self-limiting  Main symptom – diarrhoea (initially frequent and watery but later becomes bulky, sometimes frothy, greasy and offensive)  In acute cases - flatulence, sulphurous belching, abdominal distension with cramps  In chronic cases - malaise, weight loss & vitamins A, B12 malabsorption, disaccharidase (lactase) deficiencies  Young children “failure to thrive”  In healthy people (immunocompetent) - self-limiting  Main symptom – diarrhoea (initially frequent and watery but later becomes bulky, sometimes frothy, greasy and offensive)  In acute cases - flatulence, sulphurous belching, abdominal distension with cramps  In chronic cases - malaise, weight loss & vitamins A, B12 malabsorption, disaccharidase (lactase) deficiencies  Young children “failure to thrive” 11 Gas or flatulence Water Safety Conference November , Kuching, Malaysia

12  Nitroimidazole drugs (i.e. metronidazole, tinidazole and ornidazole) - highly effective  Quinacrine - excellent efficacy but poorly tolerated in children  Furazolidone - effective alternative but must be administered four times a day for 7 to 10 days  Paromomycin - used during early pregnancy, because it is not systematically absorbed, but it is not always effective 12 Water Safety Conference November , Kuching, Malaysia

13  Important pathogen in immunocompromised people (e.g., HIV/AIDS) – opportunistic parasite  May cause an acute gastrointestinal disease that can lead to death in these individuals  Oocysts (infective stage) ◦ extremely hardy to environmental pressures ◦ easily spread via water ◦ difficult to inactivate (by chlorination) or to remove from water intended for consumption without the use of filtration 13 Cryptosporidium Water Safety Conference November , Kuching, Malaysia

14 14 How does Cryptosporidium get into human body?

15 In immunocompetent people - self-limiting Main symptom – non-bloody watery diarrhea without fever Other symptoms – low grade fever, nausea & vomiting, abdominal pain In immunocompetent people - self-limiting Main symptom – non-bloody watery diarrhea without fever Other symptoms – low grade fever, nausea & vomiting, abdominal pain 15 What are the symptoms of Cryptosporidium infections? Water Safety Conference November , Kuching, Malaysia

16 In immunocompromised patients (e.g., HIV/AIDS)  Diarrhea – up to 17 litres a day  Bowel-movement frequency – 6-25 per day  Fluid losses of 3-6 litres per day is common  Abdominal cramping and pain  Low grade fever  Nausea  Vomiting  Tiredness  Profound weight loss – especially in chronic cases In immunocompromised patients (e.g., HIV/AIDS)  Diarrhea – up to 17 litres a day  Bowel-movement frequency – 6-25 per day  Fluid losses of 3-6 litres per day is common  Abdominal cramping and pain  Low grade fever  Nausea  Vomiting  Tiredness  Profound weight loss – especially in chronic cases 16 What are the symptoms of Cryptosporidium infections in HIV/AIDS patients? Water Safety Conference November , Kuching, Malaysia

17  Currently, there is no drug of choice.  Symptomatic treatment.  In HIV patients, cryptosporidiosis treatment of choice is immune reconstitution using HAART.  This acts prophylacticly. 17 Water Safety Conference November , Kuching, Malaysia

18 HUMAN ElderlyChildren Immuno- compromised WATER Oceans StreamsRivers ANIMAL Cattle Dogs Chicken Goat Cats Sewage Drinking Water Web of interactions between human, animal and the environment Water Safety Conference November , Kuching, Malaysia

19  High excretion rate for prolonged period by infected hosts ◦ Infected calf - up to 10 5 cysts g -1 faeces ◦ Infected human - up to 10 6 cysts g -1 faeces ◦ For several days and weeks  Low infectious dose ◦ eg (oo)cysts  Robustness of the transmission stages (i.e., cysts and oocysts) ◦ enables them to survive some water treatment processes  Wide host range - humans and animals ◦ increases the potential for environmental spread and contamination  Small size –4-10  m ◦ aid their penetration through sand filters 19 Why are Cryptosporidium and Giardia easily transmitted via water? Water Safety Conference November , Kuching, Malaysia

20 In Malaysia Petronas Twin Towers

21 Journal of Water and Health, 2008

22 22 Key: Human population Animal population Water samples

23  Prevalence of Giardia – 2.6 – 25% ◦ Out of every 100 people, at least 3-25 have Giardia infection.  Prevalence of Cryptosporidium – 0.9 – 23%  Out of every 100 people, at least 1-23 have Cryptosporidium infection. 23 Water Safety Conference November , Kuching, Malaysia

24 Occurrence of Giardia and Cryptosporidium in domestic and wild animals in Malaysia (4.1-36%) 24

25 25

26 Water typeNumbers examined GiardiaCryptosporidium % positiveRange of cysts/L % positiveRange of oocysts/L Environmental water Rivers %0.1 – 12, % Well2817.9% % Drinking water treatment plants Dam Raw9248% %0.05 – 3.0 Treated Backwash water2100% % Household water Kitchen tap Household storage containers 20100%0.4 – Sewage water treatment plants Influent30100% %1-80 Effluent3083.3% %20-80 Occurrence of Giardia and Cryptosporidium (oo)cysts in Malaysian water 26

27 Human populations Giardia duodenalis assemblage A Giardia duodenalis assemblage B Cryptosporidium hominis IaA14R1, IbA10G2R2, IdA15R2, IeA11G2T3R1, IfA11G1R2 Cryptosporidium parvum IIdA15G2R1 Cryptosporidium meleagridis Cryptosporidium felis Bird and cattle Cryptosporidium parvum Goat Giardia duodenalis assemblage A and E Zoological watershed Giardia duodenalis assemblage A and B Recreational water Giardia duodenalis assemblage A 27

28 Monis et al Giardia sp.GenotypeMajor host G. duodenalisAssemblage AHumans and other primates, dogs, cats, livestock, rodents and other wild mammals Assemblage BHumans and other primates, dogs, some species of wild mammals Assemblage C, DDogs Assemblage ECattle, other hoofed livestock Assemblage FCats Assemblage GRats G. agilisAmphibians G. murisRodents G. microtiMuskrats, voles G. psittaciBirds G. ardeaeBirds Which species of Giardia is dangerous to humans?

29 29 Which species of Cryptosporidium are dangerous to humans? SpeciesMajor Hosts Cryptosporidium parvum*Human, mouse, cattle, pig, sheep, horse, goat Cryptosporidium hominis*Human Cryptosporidium meleagridis*Human, turkey Cryptosporidium felis*Human, cat Cryptosporidium canis*Human, dog Cryptosporidium muris*Human, mouse Cryptosporidium suis*Human, pig Cryptosporidium andersoniCattle Cryptosporidium baileyiChicken Cryptosporidium bovisCattle Cryptosporidium fayeriKangaroo Cryptosporidium fragileBlack-spined toad Cryptosporidium galliChicken Cryptosporidium macropodumKangaroo Cryptosporidium molnariFish Cryptosporidium ryanaeCattle Cryptosporidium saurophilumLizard Cryptosporidium scopthalmiFish Cryptosporidium serpentisSnake, lizards Cryptosporidium varaniiLizard Cryptosporidium wairiPig

30 30

31  Detection of these organisms have been sporadic, uncoordinated and not systematic.  Making these data less useful for effective and accurate interpretation. 31

32  The need for regulatory procedures in Malaysia.  Putting in place mechanisms of monitoring and surveillance.  Event-driven monitoring of source water for Cryptosporidium and Giardia contamination  Site-specific risk assessment  Site-specific monitoring programme 32

33 33

34 34 Development of a risk assessment model for Cryptosporidium and Giardia in Malaysia Extensive application of the risk assessment in all catchment areas in Malaysia Utilisation of predictive model such as Geographical Information System (GIS) to map out the areas with various risk levels Comprehensive determination of occurrence, density, viability and molecular characterisation of Cryptosporidium and Giardia isolated from samples of high risk areas REGULATED MONITORING AND SURVEILLANCE SYSTEM

35  The late Prof. Rohani Ahmad (National University of Malaysia, UKM)  The late Prof. Huw Smith (Director, Scottish Parasite Diagnostic Laboratory, Glasgow) 35

36  Division of Engineering Services, Ministry of Health Malaysia  National University of Malaysia (UKM)  Universiti Putra Malayasia (UPM)  Universiti Malaysia Terengganu  Scottish Parasite Diagnostic Laboratory  Drinking Water and Wastewater Treatment Plant Operators in various parts of Malaysia 36

37 37 Thank you Promoting clean and safe water supply Yvonne Lim Ai Lian Water Safety Conference November , Kuching, Malaysia


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