Molecular epidemiologic tools for waterborne pathogens Cryptosporidium spp. and Giardia duodenalis

1Protozoan parasites are important causes of diarrhea and other enteric diseases in humans. They include mostly Cryptosporidium spp., Giardia duodenalis, Cyclospora cayetanensis, Cystoisospora belli, Entamoeba histolytica, and Toxoplasma gondii, although human infections with the latter are usually associated with non-gastrointestinal symptoms. Other protozoa in humans are not considered major pathogens, such as other Entamoeba spp., Blastocystis hominis, and Balantidium coli. As these pathogens use the fecal-oral route to maintain the lifecycle, foodborne and waterborne transmission are important in disease epidemiology. Among them, Cryptosporidium spp. and G. duodenalis are best known for their potential to cause large waterborne outbreaks of illness, thus are major targets in recent research on waterborne protozoan pathogens in humans. Earlier waterborne outbreaks of diseases by these pathogens were mostly associated with drinking water, but more recently, recreational water-associated outbreaks of cryptosporidiosis and giardiasis are increasingly reported, and for cryptosporidiosis, they are now responsible for most waterborne outbreaks in the United States.

2Molecular diagnostic tools have long been used in studies of the transmission of Cryptosporidium spp. and G. duodenalis. This is largely due to the existence of a large number of morphologically identical species or genotypes within both group of protozoa, which require the use of molecular diagnostic tools for differentiation. Thus far, over 30 Cryptosporidium species and many genotypes of unknown species status have been described. Similarly, there are at least eight genotypes (assemblages) of G. duodenalis that are likely cryptic species. Because of the existence of host specificity among Cryptosporidium species and G. duodenalis genotypes, characterizations of pathogens at the species or genotype level are helpful to the assessment of infection sources in humans and public health potential of parasites in animals and the environment. Advanced characterization of human-pathogenic species or genotypes can be used in case linkage, tracking of virulent subtypes, and assessment of disease burdens attributable to different transmission routes. This can be achieved through conventional subtyping based on sequence analysis of individual polymorphic genes, multilocus typing, and comparative genomic analysis. In this report, we will review various molecular diagnostic tools used in the characterization of human-pathogenic Cryptosporidium spp. and G. duodenalis.

3Accurate identification of Cryptosporidium species requires the use of genotyping tools. Currently, most Cryptosporidium genotyping tools use PCR targeting the small subunit (SSU) rRNA gene, largely because of the existence of conserved Cryptosporidium-specific sequence for designing primers that allow broad specific detection of all Cryptosporidium spp. and semi-conserved and hypervariable regions that can be used for the differentiation of various species and genotypes by restriction fragment length polymorphism (RFLP), melting curve, or DNA sequence analyses. PCR tools targeting other genes were used in early Cryptosporidium research, but they are now infrequently used in Cryptosporidium genotyping because of their narrow detection range; they can only be used for genotyping Cryptosporidium species that are closely related to C. parvum or C. hominis because of the nature of sequences used in primer design.

4Among the SSU rRNA-based Cryptosporidium genotyping tools, the PCR-RFLP tool using nested PCR amplification of a ~ 830-bp fragment and restriction analysis of the secondary PCR products using enzymes SspI and VspI is the most commonly used one. It can be used in genotyping Cryptosporidium spp. from both humans and animals. More recently, the use of VspI has been replaced with MboII in RFLP analysis of PCR products from Cryptosporidium spp. in ruminants. The technique requires stringent PCR conditions, but when optimized, can be used effectively in detecting single oocysts in water samples. Alternatively, a PCR assay that targeting a smaller fragment of the SSU rRNA gene can be used. The technique is more adaptable to other PCR buffers, although is slightly less specific for Cryptosporidium (mostly presenting a minor problem to the analysis of water samples) and requires DNA sequence analysis in Cryptosporidium genotype determination.

5In recent years, qPCR assays are increasingly used in genotyping human-pathogenic Cryptosporidium spp. Several species-specific genotyping tools based on the SSU rRNA and other genes have been developed for C. hominis, C. parvum, and C. cuniculus. One major issue is the broad range of Cryptosporidium species that can occur in humans, which has limited the wide use of these species-specific qPCR assays. However, some of these tools also include a SSU rRNA-based generic qPCR assay for the detection of all Cryptosporidium species, which can be used in conjunction with C. parvum and C. hominis-specific assays for rapid differentiation of the two dominant Cryptosporidium species in human specimens. Recently, using fluorescence resonance energy transfer probes and melt curve analysis, one SSU rRNA-based PCR assays has been developed for rapid genotyping to five common Cryptosporidium species in human specimens. In addition to the potential of streamlining the detection and identification of Cryptosporidium spp. in human clinical specimens, qPCR-based genotyping assays have been used in quantifying Cryptosporidium oocysts in these specimens, although low levels of oocysts that are typically found in drinking water samples cannot be accurately quantified.

6Next generation sequencing techniques are now increasingly used in Cryptosporidium genotyping, especially accurate identifications of mixed Cryptosporidium genotypes. Their usage in sequencing SSU rRNA and actin PCR products from several Cryptosporidium species of humans and animals was effectively demonstrated. Although they are more expensive than traditional Sanger sequencing when analyzing small numbers of specimens, with the use of product indexing, the costs are comparable when specimens are processed in batches. With standardization, these techniques are likely to be used in routine Cryptosporidium genotyping in future.

7The use of genotyping tools in the analysis of clinical specimens has led to the identification of over 20 Cryptosporidium species and genotypes in humans (Table 1). With the exception of C. meleagridis, which infects both birds and mammals, all other human-pathogenic Cryptosporidium species and genotypes are pathogens of mammals. It is likely that some other mammalian Cryptosporidium species and genotypes will be found in humans in future. Clearly, these species and genotypes differ significantly in human infectivity, reflected by the differences in their frequency in both sporadic human cases and outbreaks. Molecular epidemiologic studies have also identified differences in the distribution of Cryptosporidium species and genotypes in humans between developing countries and industrialized nations. Thus, C. hominis is the dominant species in humans in developing countries, whereas both C. hominis and C. parvum are common in humans in most industrialized nations. Other species, such as C. meleagridis, C. felis, C. canis, C. ubiquitum, C. cuniculus, C. muris and chipmunk genotype I are mainly animal pathogens, with the exception of C. viatorum, which appears to be exclusively a human pathogen. These species are responsible for variable numbers of human infections depending on socioeconomic development and intensity of agriculture. Among them, C. meleagridis, C. canis, C. viatorum and C. muris are mostly found in children and HIV + persons in developing countries, whereas C. ubiquitum, C. cuniculus, and chipmunk genotype I are mainly found in immunocompetent and immunocompromised persons in industrialized nations. As these Cryptosporidium species and genotypes have different host ranges, the difference in Cryptosporidium species distribution could be a reflection of differences in the importance of various transmission routes in cryptosporidiosis epidemiology. The remaining Cryptosporidium species or genotypes have been reported in only a few patients (Table 1). In addition to differences in human infectivity, Cryptosporidium species differ from each other in virulence, with C. hominis more virulent and causing more clinical presentations in most studies. In a few studies, however, patients infected C. parvum had longer duration of diarrhea or higher occurrence of vomiting than those with C. hominis,.

8Genotyping tools have been widely used in studies of the transmission of G. duodenalis in humans and animals. This has led to the identification of eight genotypes or assemblages of G. duodenalis that differ from each other in host range. Among them, assemblages A and B are major human-pathogens, but are also found in various mammals. In contrast, assemblages C to H are host-adapted G. duodenalis genotypes, being found in specific groups of animals (Table 2). Therefore, assemblages C and D are mostly found in canine animals, assemblage E in hoofed livestock and wildlife, assemblage F in cats, assemblage G in rodents, and assemblage H in seals and other marine mammals.

9Early genotyping of G. duodenalis had used mostly PCR-sequence analysis of the SSU rRNA gene. Because of the low sequence polymorphism at this genetic locus, the use of these tools have led to the erroneous detections of G. duodenalis assemblages C, D, E and F in a small number of human specimens. More recent genotyping assays employ PCR targeting the more polymorphic β-giardin (bg), glutamate dehydrogenase (gdh), and triosephosphate isomerase (tpi) genes. Because differences in the sensitivity of the PCR assays and occasional discrepant genotyping results among genetic loci, it is recommended that G. duodenalis genotypes be determined by multilocus analysis, although human specimens genotyped at the three markers occasionally cannot be assigned unequivocally to either assemblage A or B.

10DNA sequence analysis of PCR products are generally used in determination of G. duodenalis genotypes. However, RFLP analysis of PCR products is still used in resource-limited countries. This approach needs validation, as intragenotypic nucleotide variations in these polymorphic genes are common and are generally dispersed across the entire genes, leading to possible variations in RFLP patterns within some G. duodenalis assemblages such as assemblage B. In recent years, assemblage-specific PCR and qPCR assays have been developed for the detection of G. duodenalis assemblages A, B and E in clinical specimens. These assays are valuable in the detection of concurrent infections with mixed G. duodenalis genotypes.

11The use of genotyping tools have identified mostly the presence of G. duodenalis assemblages A and B in humans. Globally, more humans are infected with assemblage B than assemblage A. This is especially the case for Asian, Oceanian, European, and African countries. Both genotypes appear to be equally distributed in the Americas and human infections in Mexico are largely caused by assemblage A.

12Other G. duodenalis genotypes have been only occasionally detected in humans, with the possible exception of assemblage E, which has recently been detected in substantial numbers of human cases in rural areas of Egypt, Rio de Janeiro, Brazil, and Queensland, Australia. In contrast, animals are mostly infected with host-adapted G. duodenalis assemblages (C and D in canine animals, E in hoofed livestock, F in cats, and G in rodents) and assemblage A, with noticeable exception of nonhuman primates, beavers and a few other animals, which are commonly infected with assemblage B. The different distribution of G. duodenalis assemblages between humans and animals indicated that unlike in cryptosporidiosis, zoonotic transmission might not be important in giardiasis epidemiology.

13Epidemiological studies of giardiasis in humans using genotyping tools have also revealed possible virulence differences between G. duodenalis assemblages A and B in humans. Some reports suggest that assemblage A is more virulent than assemblage B, while others, especially several recent ones, have indicated the opposite. One factor not considered was the intra-assemblage variation, which could possibly account for some differences between the studies. Data on genotype distribution of G. duodenalis in outbreaks of human giardiasis are helpful in delineating differences in virulence between assemblages A and B in humans, but only a dozen of outbreaks have been investigated thus far using genotyping tools. Most earlier reported giardiasis outbreaks were caused by assemblage B, with the exception of one waterborne outbreak in Canada and one hospital-associated outbreak in China, which were caused by assemblage A, indicating that assemblage B could be more virulent than assemblage A. A recent report, however, has shown that all four drinking water-associated outbreaks of giardiasis in small towns, British Columbia investigated were caused by mixed assemblages A and B, with B dominating. Despite the higher proportion of human infections due to assemblage B, assemblage A, especially the anthroponotic sub-assemblage AII, appears to be the dominant G. duodenalis in urban wastewater. Thus, in addition to possible differences in virulence, there could be other biological differences between the two major human-pathogenic G. duodenalis assemblages.

14Subtyping tools have been used extensively in assessing intra-species diversity of C. parvum, C. hominis and other human-pathogenic Cryptosporidium spp. in endemic areas, role of zoonotic infections in cryptosporidiosis epidemiology, and contamination or infection sources during cryptosporidiosis outbreaks. Most subtyping tools are based on sequence analysis of the gene encoding the 60 kDa glycoprotein (gp60), which is known to be involved in invasion by Cryptosporidium spp.. The gp60 gene is highly polymorphic, categorizing C. parvum and C. hominis each into multiple subtype families by nucleotide sequence differences. Within each subtype family, subtypes differ from each other mostly in the number of tri-nucleotide repeats (TCA, TCG or TCT) region downstream of the signal peptide sequence of the gene.

15A nomenclature system has been established for naming Cryptosporidium subtypes. The name of Cryptosporidium subtypes starts with the subtype family designation (Ia, Ib, Id, Ie, If, etc. for C. hominis; IIa, IIb, IIc, IId, etc. for C. parvum; IIIa, IIIb, IIIc, IIId, etc. for C. meleagridis). This is followed by the number of TCA (represented by the letter A), TCG (represented by the letter G), or TCT (represented by the letter T) repeats. For example, the subtype name IeA11G3T3 indicates that isolate belongs to the C. hominis subtype family Ie and has 11 copies of the TCA repeat, 3 copies of the TCG repeat, and 3 copies of the TCT repeat in the trinucleotide repeat region of the gene. In some subtype families, isolates may have identical number of the trinucleotide repeats, but differ from each other in the copy number of other repetitive sequences (designed as R at the end of the subtype name). For example, in the C. parvum IIa subtype family, subtypes have 1–3 copies of the ACATCA sequence immediately downstream from the trinucleotide repeats, which are represented by R1, R2 and R3. Similarly, subtypes within the C. hominis subtype families Ia and If frequently have different copies of a 15-bp repetitive sequence (AAGACGGTGGTAAGG or its variations in the Ia subtype family and AAGAAGGCAAAGAAG or its variations in the If subtype family). In addition, subtypes in the C. parvum subtype family IIc all have five copies of TCA and three copies of TCG repeats (IIcA5G3), but differ from each other in sequences of the 3′ region of the gene. These subtypes are differentiated from each by alphabetical extensions, such as IIcA5G3a and IIcA5G3b. The GenBank accession numbers of known Cryptosporidium subtype families are shown in Table 3.

16Subtyping tools targeting the gp60 gene has been developed recently for several other human-pathogenic Cryptosporidium species such as C. meleagridis, C. ubiquitum, C. viatorum, and Cryptosporidium skunk genotype and chipmunk genotype I. These new subtyping tools are needed as PCR primers based on C. parvum and C. hominis sequences cannot amplify efficiently the gp60 gene of these divergent Cryptosporidium spp. Recent whole genome sequencing has greatly facilitated the design of PCR primers for them. Subtyping tools for other important zoonotic Cryptosporidium species such as C. felis and C. canis are not yet available due to the lack of whole genome sequence data.

17There are significant phenotypic differences among subtype families of Cryptosporidium spp. Among the three most common C. parvum subtype families, IIa is mostly found in cattle, IId is mostly found in sheep and goats, whereas IIc is mostly found in humans, with the former two responsible for zoonotic cryptosporidiosis. However, in areas with extensive transmission of C. parvum in cattle, such as European countries, IIa subtypes can be found in lambs and goat kids, while in China, where IIa subtypes are largely absent in the country, dairy calves are mostly infected with IId subtypes. Host adaptation has also been identified in C. ubiquitum and C. tyzzeri based on sequence analysis of the gp60 gene. In humans, differences in clinical presentations and virulence have been observed among some C. hominis or C. parvum subtype families. At the subtype level, gp60 subtypes IbA10G2 of C. hominis and IIaA15G2R1 of C. parvum are widely distributed and responsible for numerous outbreaks of human cryptosporidiosis, probably due to their biological fitness and high virulence. In Peru, this subtype is associated with more clinical symptoms in infected children than other C. hominis subtypes.

18Subtyping of G. duodenalis is currently done by sequence analysis of the PCR products of tpi, gdh, and bg genes, which leads to the identification of subtypes in addition to assemblages, based on the presence of SNPs within each assemblage. Within assemblage A, there are several subtypes at each of the genetic loci, frequently named as A1–A6. At the gdh locus, A1 and A5 subtypes have similar sequences, forming a subgroup that is divergent from the second subgroup formed by A2-A4. In contrast, the A6 subtype has very divergent sequence from other subtypes. The separation of the former two subgroups is not as evident at the tpi and bg loci, although the A6 subtype has very divergent sequences at both loci. There is apparent host adaption at the subtype level for the three common assemblage A subtypes at each genetic locus, with A1 subtype mostly found in animals, A2 mostly in humans, and A6 almost exclusively in wild ruminants.

19Extensive genetic heterogeneity also occurs in assemblage B and other G. duodenalis genotypes. There are many more subtypes of assemblage B at these three genetic loci than assemblage A subtypes, but there are no robust formations of subgroups of assemblage B subtypes in phylogenetic analysis of tpi, gdh, and bg sequences. Indeed because of the presence of allelic sequence heterozygosity in assemblage B at these genotyping and subtyping loci, it may be difficult to subtype assemblage B specimens based on sequence analysis of PCR products from these loci. Many subtypes are also seen in assemblage E, with no formation of host-specific subgroups in nucleotide sequences from the three genetic loci. Subtyping of assemblage E specimens has been used extensively in recent studies of G. duodenalis transmission in ruminants in China.

20Because of the likely occurrence of genetic recombination among isolates, results of gp60-based subtyping alone are unlikely to reflect intra-species diversity of Cryptosporidium spp. in disease endemic areas. To increase the resolution of gp60-based subtyping and facilitate population genetic studies, multilocus fragment (MLFT) or sequence (MLST) typing tools have been developed for C. parvum and C. hominis. These tools largely target sequences with microsatellite and minisatellite repeats, which are also known as variable-number tandem-repeats.

21Results of isolate characterizations using MLFT tools have confirmed the existence of host-segregated C. parvum populations and identified differences in population genetic structure between C. parvum and C. hominis. In addition, significant geographic segregation of C. parvum populations has been identified among European countries, with population isolation by physical distance. However, because of a predominantly panmictic population structure, there has been no apparent geographic sub-structuring in C. parvum within Scotland and the Upper Midwest United States. As a result, distinct C. parvum MLFT types are frequently confined to individual farms. In Spain, C. parvum in cattle has a panmictic structure while C. parvum in sheep has a clonal structure, probably a reflection of differences in population genetic structure between gp60 IIa and IId subtype families. Recently, efforts have been made to evaluate existing MLFT markers and identify additional markers for robust MLFT analysis of C. parvum specimens.

22MLST tools are increasingly used in genetic characterizations of C. parvum and C. hominis specimens from humans and animals. Compared with MLFT, MLST tools have the advantage of unambiguous comparability of nucleotide sequence data among distant laboratories and possible interpretation of MLST data in the context of whole genome sequence data (for example, it is possible to infer MLST types based on whole genome sequences for comparative analysis of existing data). The use of these tools in the characterizations of specimens from endemic areas has identified mostly a clonal population structure for C. hominis and the existence of geographically segregated C. hominis subpopulations among developing countries, with populations in Jamaica and Peru significantly different from those in India and Kenya. It has further supported the clonal nature of C. parvum IId subtypes from diverse areas. A systematic MLST analysis of 32 polymorphic markers in chromosome 6 had shown a high genetic heterogeneity within C. hominis IbA10G2 specimens from children living in a small community in Lima, Peru. Despite the overall clonal population structure of C. hominis subtypes in the community, genetic recombination was detected in the virulent IbA10G2 subtype. Genetic recombination was also shown to be a driving force for the emergence of the major C. hominis outbreak subtype IaA28R4 and C. parvum outbreak subtype IIaA15G2R1 in the United States.

23One of the MLST tools has been used effectively in the identification of a clonal population structure of C. meleagridis and the likely occurrence of cross-species transmission of infections between birds and human in Lima, Peru. Based on some of the same targets and additional ones from comparative genomic analysis, a MLST tool has been developed for C. ubiquitum, which has confirmed the existence of host-adapted C. ubiquitum populations and likely occurrence of genetic recombination among rodent-adapted gp60 subtype families. An MLST tool has also been developed for the gastric species C. andersoni and C. muris. It has been used effectively in population genetic characterizations of bovine C. andersoni in China, with the identification of mostly an epidemic population structure.

24There are currently no high-resolution MLST tools for G. duodenalis. The multilocus genotyping tool based on sequence analysis of the gdh, bg, and tpi loci has been used as a MLST tool in subtyping assemblages A, B and E as discussed above. Data from these loci have even been used in population genetic characterizations of the pathogen in humans and animals. An MLST subtype nomenclature system has been developed for assemblage A based on sequence analysis of the bg, gdh, and tpi genes. This has allowed the identification of three sub-assemblages within assemblage A: AI, AII, and AIII (Table 4). Similar to the existence of host-adaptation at the subtype level, there are differences in the distribution of these sub-assemblages among hosts, with AI dominating in animals, AII dominating in humans, and AIII mostly in wild ruminants, although the former two are both human pathogens.

25In contrast, sequence analysis of assemblage B specimens at the three genetic loci has identified numerous subtypes, which are inconsistently segregated among loci. Thus, the BIII and BIV sub-assemblages originally identified by allozyme analysis are not supported by MLST analysis. MLST analysis of assemblage B specimens is further complicated by allelic sequence heterozygosity at some of the genetic loci. This also occurs in assemblages C, D and E, but not assemblage A at these genotyping loci. Nevertheless, geographic segregation and host-adaptation have been identified in assemblage B in captive nonhuman primates in China using the current MLST tool; isolates from China were significantly different from those from Italy and Sweden, and isolates from ring-tailed lemurs and squirrel monkeys were genetically different from those from other nonhuman primates. Clearly, better MLST tools targeting genetic loci with homogenous sequences are needed for high-resolution typing and population genetic characterizations of G. duodenalis. This becomes feasible with the recent identification of numerous highly polymorphic genes within assemblage A or B through comparative genomics.

26Comparative genomics is increasingly used in the characterization of human pathogenic Cryptosporidium spp. For a considerable period, whole genome sequence (WGS) data are available from only four laboratory-propagated Cryptosporidium isolates. With the recent development of next generation sequencing techniques and procedures for isolation and enrichment of pure Cryptosporidium DNA, many Cryptosporidium isolates have been sequenced and data of them are available in public databases such as NCBI and CryptoDB. As expected, most of the isolates sequenced are from C. parvum and C. hominis, but several other Cryptosporidium species have also been sequenced, including C. meleagridis, C. ubiquitum, C. baileyi, and C. andersoni.

27Despite the high sequence similarity (~ 97%) between C. parvum and C. hominis genomes, comparative analyses of the WGS data have identified some differences in gene content between the two major human-pathogenic Cryptosporidium species. The gene gains and losses mainly occur in the subtelomeric regions of several chromosomes, and involve mostly two Cryptosporidium-specific secretory protein families: MEDLE proteins and insulinase-like proteases. These differences have also been observed between them and C. ubiquitum, and between C. parvum gp60 subtype families IIa and IId. In addition to these gene gains and losses, these Cryptosporidium species and C. parvum have highly divergent sequences in genes encoding invasion-associated and immunodominant mucin proteins and other families of secretory proteins. These genetic differences could be responsible for some of the phenotypic differences among closely related Cryptosporidium species and host-adapted C. parvum subtype families. This has been recently supported by a preliminary study of MEDLE-2, which was shown to be involved in the invasion of host cells.

28Comparative genomic analysis of C. hominis isolates from the United States has confirmed the occurrence of genetic recombination in virulent outbreak subtypes IbA10G2 and IaA28R4. Genomes of the two subtypes are highly similar, with major sequence differences occurring at the 5′ (around cgd6_60) and 3′ (around cgd6_5270) subtelomeric regions and around gp60 (cgd6_1080), all within chromosome 6. In these areas, the genomes have shown some hallmarks of genetic recombination, with bi-allelic sequences in these areas and a mosaic pattern in sequence types across the chromosome. As the sequence differences involve a secretory protease (cgd6_60) and an invasion-related mucin protein (gp60), both of which are among the most polymorphic genes in Cryptosporidium spp., genetic recombination could play a potential role in the emergence of hyper-transmissible C. hominis subtypes, as previously indicated by MLST characterizations of IbA10G2 in Peru and IaA28R4 in the United States.

29The genomes of C. hominis IbA10G2 in European countries appear to be highly conserved. A comparative genomic analysis of WGS data from several IbA10G2 isolates has identified fewer than 50 SNPs among most isolates from Europe, with the exception of one isolate (SWEH9) from Spain. In contrast, the genome of IbA10G2 isolates from Guatemala is divergent from genomes of European isolates. This is in contrast with IbA10G2 in the United States, where two types of genomes are present among the few isolates sequenced, one of which is similar to the one in European countries. Several SNP features unique to the C. hominis IbA10G2 subtype have been identified in a recent comparative genomic analysis, including the restoration of a loss-of-function mutation seen in other C. hominis subtypes from developing countries. The high genome sequence conservation in IbA10G2 presents a significant challenge in epidemiologic tracking of this subtype, which is a major outbreak subtype in European countries and responsible for almost all autochthonous C. hominis infections there. Recently, based on WGS data from 17 isolates, a panels of nine loci with 10 SNVs were selected for the development of a PCR-next generation sequencing technique, which had identified 10 sequence types among 44 clinical isolates in Sweden.

30WGS data are available from several laboratory isolates of assemblages A, B and E. Results of comparative analysis have shown significant differences among the three genotypes in genome size, gene content, gene arrangement, nucleotide sequences, and surface molecule repertoires. For example, the genomes of AI and B have only about 70% nucleotide sequence identity across the syntenic regions. The divergence between sub-assemblages AI and AII is approximately 1% in sequences, with differences mainly localized to the variable regions of the genomes. There are approximately 35 AII-specific genes but only two AI-specific genes.

31An approach has been developed recently for whole genome sequencing of G. duodenalis in clinical specimens. It uses a procedure similar to the one developed for Cryptosporidium spp. for isolating G. duodenalis cysts in clinical specimens. This could facilitate WGS-based characterization of G. duodenalis specimens and increase the use of comparative genomics in the identification of contamination source during giardiasis outbreaks, as indicated by the retrospective investigation of a drinking water-associated outbreak in Creston, British Columbia, Canada.

32The use of molecular diagnostic tools in epidemiologic studies has significantly improved our understanding of the transmission of waterborne protozoan parasites in the United States, especially Cryptosporidium spp. Compared with other industrialized nations, the United States has a high diversity of Cryptosporidium spp. in humans at both species and subtype levels. In addition to C. hominis and C. parvum, several emerging Cryptosporidium species or genotypes, such as C. ubiquitum and chipmunk genotype I, are responsible for substantial numbers of cryptosporidiosis cases, especially in rural states. For C. ubiquitum, humans in the United States are infected with rodent-adapted subtype families XIIb–XIId, whereas those in the United Kingdom are mainly with ruminant-adapted subtype family XIIa. As C. ubiquitum is one of the most common Cryptosporidium species in drinking source water in the United States and rodent-adapted subtype families are also the dominant C. ubiquitum subtypes in drinking source water, consumption of drinking water contaminated by infected wildlife could be the source of human infections. The genetic similarity in Cryptosporidium chipmunk genotype I among isolates from humans, wild mammals, and drinking source water supports the potential role of wildlife and drinking source water in the transmission of emerging Cryptosporidium spp. in rural United States.

33Genotyping and subtyping data on C. parvum occurrence in sporadic cases of cryptosporidiosis indicate that farm animals, especially pre-weaned calves, are important in cryptosporidiosis epidemiology in rural United States. Like in the United Kingdom, there are apparent differences in the distribution of C. hominis and C. parvum between rural states and other states, with C. parvum as the dominant species in sporadic cases in Minnesota and Wisconsin and C. hominis as the dominant species in southern states. A high C. parvum subtype diversity was identified in humans in Minnesota and Wisconsin. As the dominant subtypes are also common ones in pre-weaned calves in the United States, these animals are potential sources of zoonotic infections in humans. This is also supported by the numerous reports of calf-contact associated outbreaks of human cryptosporidiosis in the United States and results of case-control studies, and by results of MLFT analysis of C. parvum isolates from humans and cattle in Upper Midwest states. The recent identification of cryptosporidiosis occurrence in Nebraska due to occupational animal exposure, especially to cattle, reinforces the importance of zoonotic infection in cryptosporidiosis epidemiology in rural U.S. states.

34Among the > 20 C. parvum subtypes found in humans in the United States, IIaA15G2R1, is the dominant C. parvum subtype, responsible for numerous outbreaks of cryptosporidiosis (Table 5). Data from a recent MLST study have shown extensive heterogeneity within IIaA15G2R1. Because of the widespread occurrence of genetic recombination within the subtype, there is frequent discordance in subtyping results between gp60 and other genetic markers. As a result, there is no clear population diversion between IIaA15G2R and non-IIaA15G2R subtypes. Other population differentiation exists within C. parvum, evident by the presence of one subpopulation with an epidemic population structure and wide geographic distribution and another subpopulation with a clonal population structure and geographic segregation. Genetic recombination between the epidemic and geographically segregated C. parvum populations appears to be associated with the emergence of the hyper-transmissible IIaA15G2R1 subtype, which is also the dominant C. parvum subtype in humans in other industrialized nations. Thus, the IIaA15G2R1 subtype at the gp60 locus is probably a fitness marker for C. parvum and the wide spread of IIaA15G2R1 subtype around the world appears independent of sequence characteristics at other genetic loci. This needs confirmations from comparative genomic analysis of WGS data generated in recent years.

35A high genetic heterogeneity is also present in C. hominis in the United States. In addition to the virulent IbA10G2 subtype, which is the dominant C. hominis subtype in European countries and Australia, several other C. hominis subtypes are common in sporadic and outbreaks cases in the United States, such as IaA28R4 and IfA12G1R5 (Table 5). In early years, IbA10G2 was the dominant C. hominis subtype in the United States. A new subtype, IaA28R4, however, appeared in the United States in 2005 and by 2007 it had become the dominant C. hominis subtype for sporadic cases and outbreaks in the United States (Table 5). Accompanied with the occurrence of the new subtype was a near three-fold increase in the incidence of cryptosporidiosis in the United States during 2004 to 2008. In recent years, subtype IaA28R4 has been replaced by IfA12G1R5, which was first seen in AIDS patients and was responsible for a 2009 cryptosporidiosis outbreak associated with the care of an AIDS patient in Oregon. Since 2013, it has emerged as the dominant C. hominis subtype in sporadic and outbreak-associated cases. During this period, the incidence of cryptosporidiosis in the United States has remained at a high level.

36Recent MLST and comparative genomic analysis indicate that genetic recombination has played a major role in the emergence of hyper-transmissible C. hominis subtypes in the United States. Results of the MLST analysis indicate that there were at least two origins of IaA28R4 within the United States. Like IIaA15G2R1 within the United States, discordant subtyping results of IaA28R4 isolates were observed between gp60 and other genetic markers, indicating that the emergence of these IaA28R4 variants was largely due to genetic recombination. Although IaA28R4 was first identified in a cryptosporidiosis outbreak in Ohio in 2005 and was the cause of another outbreak in the same area in 2008, IaA28R4 circulating in Ohio was genetically different from IaA28R4 in southwestern states. Results of comparative genomic analysis indicate that the genomes of two IaA28R4 isolates were very similar to those of IbA10G2, indicating that IaA28R4 could be the progeny of genetic recombination of IbA10G2 and another C. hominis subtype of the Ia subtype family. The genetic recombination was most obvious in the subtelomeric and gp60 regions of chromosome 6. Thus, genetic recombination might lead to the emergence of hyper-transmissible gp60 subtypes of both C. parvum and C. hominis.

37Molecular characterizations of animal and human isolates have also played a role in clarifications of the potential role of beavers in the transmission of G. duodenalis in the United States. Giardiasis has been popularly known as beaver fever in North America, probably because some hikers and campers became ill from drinking stream water presumably contaminated with Giardia cysts from beavers. This was supported by results of investigations of several waterborne outbreaks of giardiasis in late 1970s and early 1980s, in which beavers in drinking source watershed were found to be shedding G. duodenalis cysts. Results of molecular characterizations have shown that beavers are frequently infected with G. duodenalis assemblage B, which is the major cause of giardiasis outbreaks in the United States. In studies conducted in Maryland and Massachusetts, 11 beavers were identified having assemblage B. In one drinking water-associated outbreak of giardiasis in New Hampshire, the assemblage B subtype found in human cases was different from known subtypes in humans, but identical to the one previously found in beavers in Massachusetts. Although these reports did not provide any concrete evidence of the initial contamination source, they suggest that beavers could be environmental reservoirs for sustaining the contamination of drinking source water by G. duodenalis assemblage B. This has been supported by the investigation of one waterborne giardiasis outbreak in Creston, British Columbia, in which one beaver was identified by epidemiologic investigations as the likely cause of source water contamination. WGS analysis of one beaver isolate and one human isolate from the outbreak generated very similar genomes of sub-assemblage AI.

38The use of molecular diagnostic tools has significantly improved our understanding of cryptosporidiosis epidemiology. It has led to the identification of major differences in infection sources of Cryptosporidium spp. in humans between developing countries and industrialized nations, differences in clinical presentations and virulence among Cryptosporidium species and C. hominis subtypes, and roles of genetic recombination in the emergence of virulent and hyper-transmissible C. hominis and C. parvum subtypes. These tools are now widely used in outbreak investigations and surveillance of cryptosporidiosis in industrialized nations. With the introduction of whole genome sequencing and comparative genomics in Cryptosporidium characterization, it is expected that molecular epidemiology of cryptosporidiosis would remain a highly active research area.

39Despite these major achievements, many challenges remain. After over 20 years of major investments in drinking water treatment as a response to the massive 1993 Milwaukee outbreak, cryptosporidiosis remains the most important waterborne disease in industrialized nations, incidence of cryptosporidiosis in the United States has increased nearly threefold since 2005, and drinking water-associated outbreaks of cryptosporidiosis still present a significant public health and economic problem in European countries. The identification of environmental and epidemiological factors involved requires systematic molecular characterizations of Cryptosporidium specimens submitted to national cryptosporidiosis surveillance systems. The latter has been in place for some time in the United Kingdom but is in the early stage of implementation in the United States as part of the CryptoNet program. While genotype and subtype data are useful in the identification and investigation of zoonotic outbreaks due to unusual C. parvum subtypes and differentiation of autochthonous and travel-associated C. hominis infections in European countries, their utilities are limited in molecular surveillance of the dominant C. hominis subtypes in Europe (IbA10G2) and the United States (currently IfA12G1R5). This was demonstrated in the investigation of an increased transmission of IbA10G2 in multiple European countries in late summer, 2012, in which molecular characterizations did not identify an endemic source. In fact, advanced molecular analysis beyond gp60 sequence analysis would not increase significantly the discrimination of these hyper-transmissible C. hominis subtypes, including comparative genomic analysis. Supplemental epidemiological data are helpful in the investigation of such outbreaks.

40Molecular analysis probably can exert its biggest impact on improving knowledge of cryptosporidiosis epidemiology in developing countries, where cryptosporidiosis has been identified as the second most cause of modest to severe diarrhea and diarrhea-associated mortality in young children, and diverse C. hominis subtypes are circulating in endemic areas. While data from genotyping and subtyping studies of clinical specimens have suggested that anthroponotic infection is important in cryptosporidiosis epidemiology in these areas, the role of various transmission routes is not very clear for the formulation of evidence-based intervention strategies. This would require the integrated use of molecular diagnostic tools in well-designed epidemiological studies, which usually involve the use of longitudinal cohort or case-control design, or regression and multivariate analyses of risk factors. Thus far, such studies are few in numbers, and WGS and comparative genomic analyses have not been used in characterizations of Cryptosporidium spp. in developing countries. The population genetics of C. hominis in developing countries is probably complicated; genetic recombination among diverse subtypes could occur more frequently as a result of high cryptosporidiosis endemicity. Advanced molecular characterizations of specimens from well-designed epidemiologic investigations will likely lead to better understanding of the spread of virulent C. hominis subtypes in under-developed communities, as demonstrated in a MLST characterization of C. hominis from a longitudinal cohort study of cryptosporidiosis conducted in a shantytown in Lima, Peru.

41In contrast, molecular analysis of G. duodenalis has thus far mostly generated data useful in understanding of zoonotic potential of isolates in various animals. Because of host-adaptation at both genotype and subtype levels, zoonotic transmission of G. duodenalis is likely to be less important in giardiasis epidemiology compared with cryptosporidiosis. Much of the current attentions on zoonotic transmission of G. duodenalis have focused on assemblage A because of its wide occurrence in animals compared with assemblage B. As humans are more commonly infected with assemblage B and there is a difference in the distribution of assemblage A subtypes between humans and animals, more attention should be directed to zoonotic transmission of assemblage B, which appears to be to the dominant G. duodenalis genotype in a few groups of animals, such as beavers, muskrats, chinchillas, rabbits, horses, and nonhuman primates. Some of the animals are aquatic or their fecal materials can be easily transported to water, thus could contribute to source water contamination with G. duodenalis assemblage B. The identification of assemblage E humans in several recent studies indicates that it could be an emerging human pathogenic G. duodenalis genotype, even in urban areas. Additional molecular epidemiological investigations should be conducted to identify its source and transmission routes.

42The use of molecular diagnostic tools has unfortunately not improved significantly our knowledge of endemic and epidemic giardiasis in humans. This is due to both technical difficulties and neglect. Thus far, most molecular epidemiological studies of giardiasis in humans are conducted with clinical specimens from outpatients. The long duration of cyst shedding after the initial infection, presence of allelic sequence heterozygosity in some genotyping and subtyping markers, high occurrence of concurrent infections with mixed genotypes, and multiple episodes of infections in early childhood have made it challenging to delineate the transmission mechanism and virulence of G. duodenalis in humans. With recent developments in whole genome sequencing and comparative genomic analysis of G. duodenalis, new genotyping and subtyping markers can be identified for the development of next generation molecular tools. As assemblages A and B evolve very differently and have divergent genomes, it may be useful to develop assemblage-specific subtyping tools. The use of these advanced molecular diagnostic tools in epidemiological investigations of endemic giardiasis in developing countries and in surveillance and outbreak investigations of epidemic giardiasis in industrialized nations, as performed in several recent studies, may lead to improved understanding of molecular epidemiology of giardiasis.