Research – An outbreak of cryptosporidiosis associated with drinking water in north-eastern Italy, August 2019: microbiological and environmental investigations



The enteric parasite , along with norovirus,  and rotavirus, is among the most frequent causes of waterborne disease [1,2]. In humans, transmission of  occurs via the faecal-oral route, either through direct exposure to infected people (person-to-person infection) or animals (animal-to-person infection), or through ingestion of water (drinking water, recreational water such as swimming pools, water parks, lakes, rivers) or consumption of raw or undercooked food contaminated with infectious oocysts [3]. Infection may remain asymptomatic or manifest as acute gastroenteritis (> 80% of infected individuals). Symptoms occur 1 to 12 days (mean: 7 days) after exposure and usually last 6 to 9 days. The severity and duration of symptoms are linked to the immune status of the host, and cryptosporidiosis can be life threatening in immunosuppressed individuals [4].

There are many  species that can infect humans, but the vast majority of cases are due to , a zoonotic species that also infects young ruminants, and , which is essentially only a human pathogen [5]. The environmental route of transmission is of high relevance for  [6]. This is due to several factors including: (i) the high survival rate of oocysts in water (more than 24 months at 20°C), (ii) high resistance to disinfection (30 mg/L of free chlorine are needed to achieve 99% inactivation at pH 7, with a recommended value of 0.2 mg/L for drinking water) [6], (iii) low infectious dose (10–132 oocysts in healthy adults [7]) and (iv) low host specificity [5]. Oocysts lose their infectivity when frozen, boiled or heated over 60°C [6].

The ability of  to survive at high chlorine concentrations [8] and, consequently, at the disinfectant concentrations commonly used in water treatment, has always been a challenge for water treatment plant operators. However, other disinfectants, such as chlorine dioxide, ozone, UV rays and filtration have proved to be rather effective in removing . Water safety mainly depends on the combination of different treatment stages, and a multi-barrier approach is a key paradigm for ensuring safe drinking water [6]. Nonetheless, in small water supplies managed by local communities that serve only few thousand people, multi-barrier treatment systems are usually not implemented. Thus, in order to ensure the safety of drinking water, more traditional treatments, e.g. disinfection, are used and water quality is checked against certain regulatory parameters.

During 2017–20, 60 waterborne outbreaks of cryptosporidiosis have been detected in Europe, the majority of which involving treated recreational water (swimming pools) as the vehicle of infection [9]. The number of outbreaks linked to contaminated drinking water has shown a notable decrease in the past decades, although, when occurring, large numbers of individuals may be involved, as exemplified by the outbreaks reported in 2010–11 in Sweden [10,11].

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