Research – Giardiasis Outbreaks — United States, 2012–2017

CDC

CDC Giardia2

Summary

What is already known about this topic?

Giardiasis is a diarrheal disease caused by the parasite Giardia duodenalis, the most common cause of intestinal parasite infections in the United States.

What is added by this report?

During 2012–2017, public health officials from 26 states reported 111 giardiasis outbreaks involving 760 cases. Leading causes of outbreaks were waterborne and person-to-person exposures. Private residences and child care facilities were the most common settings of giardiasis outbreaks across all transmission modes.

What are the implications for public health practice?

To prevent and control giardiasis outbreaks, CDC recommends prompt diagnosis, maintaining good hand hygiene, cleaning and disinfecting home environments and child care facilities, and monitoring water quality in private well

Giardiasis is a diarrheal disease caused by the parasite Giardia duodenalis, the most common cause of intestinal parasite infections in the United States. Transmission occurs when Giardia cysts spread from feces to water, food, surfaces, or skin and are then ingested. Illness is characterized by gastrointestinal symptoms, including diarrhea, abdominal cramps, greasy stools, bloating or gas, nausea, vomiting, weight loss, and dehydration. Approximately 50% of infections are asymptomatic (1,2). Most symptomatic Giardia infections are self-limited in duration; however, some persons might experience a reoccurrence of symptoms or develop long-term complications (3). During 2012–2017, public health officials from 26 states reported 111 giardiasis outbreaks (760 cases) to the National Outbreak Reporting System (NORS). Three main modes of transmission for these outbreaks were identified: water exposure in 29 (26%) outbreaks, person-to-person contact in 28 (25%) outbreaks, and contaminated food in six (5%) outbreaks. A single transmission mode could not be determined in 48 (43%) of the outbreaks. Private residences and child care facilities were the most common settings of outbreaks for all the transmission modes combined. To prevent and control giardiasis outbreaks, CDC recommends prompt diagnosis, maintaining good hand hygiene, cleaning and disinfecting home environments and child care facilities, and monitoring water quality in private wells.

A giardiasis outbreak is defined as the occurrence of two or more cases of illness epidemiologically linked to a common exposure (1). Health department officials from across the United States (state, local, and District of Columbia), U.S. territories,* and freely associated states voluntarily report outbreaks to NORS. This study included giardiasis outbreak reports submitted to NORS by December 30, 2019 and data reported during 2012–2017 (the year of the earliest case illness onset date through the most recent year for which data were available). NORS data summarized in this study include primary case counts, hospitalizations, and deaths; transmission mode; exposures and settings; and earliest onset date. Negative binomial regression analysis was conducted to assess for annual trends in outbreak counts using SAS (version 9.4; SAS Institute). This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy.§

During 2012–2017, public health officials from 26 states reported 111 giardiasis outbreaks with 760 primary cases, 28 hospitalizations, 48 emergency department visits, and no deaths. Among the 703 cases with available data, 370 (53%) persons were male and 333 (47%) persons were female. Pennsylvania reported the largest number of outbreaks with 44 (40%), followed by Minnesota with 11 (10%); no other state reported >10 outbreaks (Figure 1). There was no significant trend in giardiasis outbreaks by year (χ2 = 0.67, p = 0.98) (Figure 2).

Among 29 (26%) waterborne outbreaks (370 cases), exposure sources included tap water systems (e.g., municipal systems or private wells) in nine outbreaks, outdoor freshwater consumption in seven outbreaks, treated recreational water in five outbreaks, untreated recreational water in four outbreaks, and “other” in four outbreaks (Table). Reported settings for waterborne outbreaks included 12 (41%) outdoor areas (e.g., parks and forests) five (17%) private residences, four (14%) camps or cabins, three (10%) community/municipality settings, three (10%) unknown, and two (7%) other settings. Person-to-person transmission was the primary mode identified in 28 (25%) outbreaks, resulting in 129 cases. The primary exposure settings for these outbreaks were 14 (50%) private residences and 12 (43%) child care facilities (Table). Among the 14 settings in private homes, nine (64%) were in households with children aged ≤5 years; two (14%) were in homes with only adults. Among the six (5%) foodborne outbreaks, all foods associated with the five known food exposures were eaten raw or with minimal or no processing. No outbreaks were attributed to animal contact or environmental contamination other than food and water (i.e., contact with objects or surfaces with Giardia). Among all 111 outbreaks, 48 (43%) had an indeterminate or unknown transmission mode, meaning that there was insufficient evidence to implicate one specific primary mode of transmission; 33 (69%) of these outbreaks occurred in private residences (Table).

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