Research in Veterinary Science xxx (xxxx) xxx–xxx

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Research in Veterinary Science

journal homepage: www.elsevier.com/locate/rvsc

Giardia duodenalis in humans and animals – Transmission and disease

Brent R. Dixon
⁎

Bureau of Microbial Hazards, Food Directorate, Health Canada, 251 Sir Frederick Banting Driveway, Ottawa, Ontario K1A 0K9, Canada

ARTICLE INFO ABSTRACT

Keywords: Giardia duodenalis is a protozoan parasite infecting the upper intestinal tract of humans, as well as domestic and
Giardia wild animals worldwide. Transmission of giardiasis occurs through the faecal-oral route, and may be either
Transmission direct (i.e., person-to-person, animal-to-animal or zoonotic) or indirect (i.e., waterborne or foodborne). While
Symptoms asymptomatic infections are common in both humans and animals, a wide range of enteric symptoms have been
Diagnosis
reported, along with extra-intestinal and post-infectious complications. A definitive diagnosis of giardiasis is
Treatment
Control
generally made by detection of cysts in stool specimens through microscopical examination of wet mounts, or
through the use of permanent or fluorescent antibody stains. More recently, molecular methods have become
popular for diagnosis and for testing environmental samples. Symptomatic giardiasis is often treated to reduce
the duration of symptoms, to prevent complications, and to minimize transmission of the parasite to other hosts.
Direct faecal-oral transmission of giardiasis can be largely controlled thorough improved hygiene and sanitation.
In the case of waterborne transmission, a multiple barrier approach, including limiting access of people and
animals to watersheds and reservoirs, and treatment using flocculation, filtration and disinfection, is necessary
to minimize the risk. Since foodborne transmission is often associated with the consumption of fresh produce, a
number of control measures can be taken during pre- and post-harvest, as well as at the food handler/consumer
level to minimize the risk of contamination, or for removing or inactivating parasites. Good husbandry and farm
management practices are important in controlling the spread of giardiasis in livestock and companion animals.

1. Introduction
Giardia duodenalis (syn. G. lamblia, G. intestinalis) is a flagellate
protozoan parasite infecting the upper intestinal tract of humans and a
wide range of other mammals worldwide. It has a direct life cycle
consisting of an environmentally resistant transmission stage known as
a cyst, which is oval in shape, 8–12 μm in length, and contains four
nuclei. Cysts are shed in large numbers with the faeces of the host, and
may remain infectious for months in water or in cool, damp areas (Feng
and Xiao, 2011). The infective dose is thought to be as low as 10 cysts
(Rendtorff, 1954), facilitating transmission from host-to-host. Giardia
duodenalis is transmitted to new hosts through the faecal-oral route,
including direct contact with human or animal faeces containing cysts,
or consumption of cyst-contaminated food or water. After ingestion,
cysts excyst in the small intestine, releasing two motile, binucleated
trophozoites, each with four pairs of flagellae and an adhesive disc for
attachment to intestinal epithelial cells. Trophozoites reproduce
asexually by longitudinal binary fission before encysting in response to
the presence of bile salts and slightly alkaline pH (Ankarklev et al.,
2010; Feng and Xiao, 2011; Leung et al., 2019; Ryan and Cacciò, 2013).
Giardia duodenalis is one of the most common intestinal parasites in
humans throughout the world, with an estimated 200 million people
infected (Certad et al., 2017). Prevalence rates for giardiasis generally
range from 2 to 7% in developed countries, and from 20 to 30% in most
studies done in developing countries (Dixon et al., 2011). Along with
Cryptosporidium, Giardia was included in the WHO Neglected Diseases
Initiative in 2004 (Savioli et al., 2006). High risk groups include infants
and young children, the elderly, institutionalized individuals, travelers,
and immunocompromised individuals (Cacciò et al., 2018; Leung et al.,
2019).
Giardia duodenalis is also very commonly reported in domestic an-
imals and wildlife, and numerous prevalence studies have been re-
ported worldwide, particularly on livestock (Feng and Xiao, 2011).
There are marked variations in reported infection rates in cattle, pigs,
sheep and goats, likely due to the age of the animals, their management
practices, and the detection methods used (Feng and Xiao, 2011; Santin,
2020). In most such studies, young animals demonstrate higher pre-
valence rates than adults (Santin, 2020). The infection rate is also high
and variable in companion animals, especially dogs and cats (Ballweber
et al., 2010; Bouzid et al., 2015). In addition, numerous reports have
documented the presence of G. duodenalis in captive and wild animals,
including beavers, ungulates, canids, felids, non-human primates,

⁎
Corresponding author.
E-mail address: brent.dixon@canada.ca.

https://doi.org/10.1016/j.rvsc.2020.09.034
Received 26 June 2020; Received in revised form 25 September 2020; Accepted 29 September 2020
0034-5288/ Crown Copyright © 2020 Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Brent R. Dixon, Research in Veterinary Science, https://doi.org/10.1016/j.rvsc.2020.09.034
B.R. Dixon
marsupials, marine mammals, and even fish (Feng and Xiao, 2011;
Ryan and Cacciò, 2013). In addition to G. duodenalis, seven other spe-
cies of Giardia are currently accepted as valid (Ryan and Zahedi, 2019),
but are not thought to be infectious to humans. These include: G. agilis
in amphibians, G. ardeae and G. psittaci in birds, G. muris and G. microti
in rodents, G. peramelis in bandicoots, and G. cricetidarum in hamsters.
Despite their morphological similarity, isolates of G. duodenalis
show considerable genetic heterogeneity. There are currently eight re-
cognized genotypes within the G. duodenalis species complex, known as
Assemblages A to H. While Assemblages A and B have been reported in
humans and a wide range of other mammalian hosts, other G. duode-
nalis assemblages are host-adapted, with Assemblages C and D being
found mainly in canines, Assemblage E in hoofed livestock and wildlife,
Assemblage F in cats, Assemblage G in rodents, and Assemblage H in
seals (Cacciò et al., 2018; Heyworth, 2016; Ryan and Zahedi, 2019;
Xiao and Feng, 2017).
Humans are, almost exclusively, infected with G. duodenalis
Assemblages A and B, with the latter predominating worldwide (Xiao
and Feng, 2017). However, mixed infections of Assemblages A and B
are also commonly reported, especially in developing countries (Ryan
and Cacciò, 2013). Assemblages C, D, E and F have only rarely been
identified in humans (Cacciò et al., 2018; Ryan et al., 2019). Some
authors have proposed that Assemblages A and B represent separate
species, and have referred to them as G. duodenalis and G. enterica,
respectively (Thompson and Ash, 2019). In addition to humans, these
two assemblages are also infective to many domestic and wild animals,
and are considered to be potentially zoonotic (Feng and Xiao, 2011).
While Assemblage E predominates in cattle, sheep and pigs,
Assemblage A is also frequently reported, and is likely more widespread
in cattle than previously thought (Feng and Xiao, 2011; Ryan and
Cacciò, 2013; Ryan and Zahedi, 2019; Santin, 2020). Assemblage B is
less commonly reported in farm animals. While the distribution of
Giardia assemblages in cattle has been reported to be age-specific, with
Assemblage A predominating in pre-weaned calves and Assemblage E in
older animals (see Ryan and Cacciò, 2013), this was not supported by
another study reporting Assemblage A only in post-weaned calves and
heifers (Santín et al., 2009). Most studies doing molecular character-
ization of Giardia isolates from dogs and cats have reported the pre-
sence of Assemblages C and D, although Assemblage A and, to a lesser
extent, Assemblage B have also been reported in dogs (Feng and Xiao,
2011; Ryan and Cacciò, 2013). In cats, Giardia Assemblage F pre-
dominates, but Assemblage A has also been reported worldwide
(Ramírez-Ocampo et al., 2017; Ryan and Cacciò, 2013). Interestingly,
most other assemblages have also been reported in cats (Feng and Xiao,
2011; Ramírez-Ocampo et al., 2017). Along with some host-adapted
assemblages, the Assemblages A and B are commonly reported in cap-
tive and wild animals, including ruminants, rodents, marsupials and
primates (Feng and Xiao, 2011; Ryan and Cacciò, 2013). Assemblages A
and B have also been reported in wild canids, along with Assemblages C
and D (Feng and Xiao, 2011).
There are three recognized sub-assemblages within Assemblage A
(AI, AII, AIII), and there appears to be some host-adaptation at this level
as well. For example, sub-assemblage AI has been most commonly
found in animals (e.g., cattle, water buffalo, cats, pigs, sheep), although
it has also been reported in humans. Sub-assemblage AII has been re-
ported mainly in humans, and AIII mainly in wild ruminants (Feng and
Xiao, 2011; Ryan and Cacciò, 2013; Xiao and Feng, 2017). While these
findings suggest there is a potential for zoonotic and zooanthroponotic
transmission of sub-assemblages AI and AII respectively, further mole-
cular epidemiological studies will be necessary to clarify this. The sub-
assemblages BIII and BIV, originally identified by allozyme electro-
phoretic studies, have not been supported by more recent DNA se-
quence analyses, although numerous Assemblage B subtypes have been
identified (Feng and Xiao, 2011; Xiao and Feng, 2017).
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Research in Veterinary Science xxx (xxxx) xxx–xxx
2. Transmission and epidemiology
Transmission of giardiasis occurs through the faecal-oral route, and
may be either direct (i.e., person-to-person, animal-to-animal or zoo-
notic) or indirect (i.e., waterborne or foodborne). Person-to-person
transmission is a major source of infection and has been widely docu-
mented, particularly in day care centers, nursing homes, and other in-
stitutional settings, where personal hygiene may be poor (Adam et al.,
2016). Sexual transmission of giardiasis has also been documented
(Escobedo et al., 2014).
Since a large number of different mammals also serve as hosts for G.
duodenalis, often including Assemblages A and B, there has been con-
siderable attention paid to the possibility of zoonotic transmission,
particularly from cattle, as well as dogs and cats (Ballweber et al., 2010;
Ryan and Cacciò, 2013; Thompson and Ash, 2016). However, there
remains relatively little direct evidence in support of zoonotic trans-
mission of G. duodenalis, and its significance in human infections is not
as clear as it is with Cryptosporidium (Heyworth, 2016; Ryan and
Zahedi, 2019; Thompson and Ash, 2016; Xiao and Feng, 2017). It is also
important to note that the presence of common genotypes in humans
and companion animals does not conclusively support zoonotic trans-
mission (Feng and Xiao, 2011). Despite the lack of direct evidence, the
high prevalence of G. duodenalis infections in livestock, and the pre-
sence of zoonotic assemblages, is a concern in terms of possible trans-
mission to humans, either through direct contact (e.g., farmers, veter-
inarians and animal handlers) or indirectly through the contamination
of food and water (Budu-Amoako et al., 2011; Santin, 2020). Reverse
zoonotic transmission (zooanthroponosis) has also been proposed,
especially between humans and wildlife, or companion animals
(Heyworth, 2016; Ryan and Cacciò, 2013; Thompson and Ash, 2016).
The waterborne route is probably the most widely recognized means
of transmission of giardiasis, with numerous outbreaks being associated
with cyst-contaminated drinking water (Ryan et al., 2019). Illness
outbreaks associated with recreational water have also been increas-
ingly reported (Adam et al., 2016; Xiao and Feng, 2017). In a review of
worldwide waterborne protozoan parasitic illness outbreaks from 2011
to 2016, Efstratiou et al. (2017a) determined that, of the 381 outbreaks
documented, Giardia spp. was the cause of 37% (142) of them, with the
majority (63%, 239) being associated with Cryptosporidium spp. These
142 waterborne outbreaks amounted to a total of 1110 cases of giar-
diasis, and occurred almost exclusively in the U.S. and New Zealand,
with only one each being reported from the Republic of Korea and
Belgium. Untreated water, contaminated drinking water and recrea-
tional water were all implicated in these outbreaks. The 381 water-
borne outbreaks reported from 2011 to 2016 represented a large in-
crease from the 199 outbreaks reported previously for a similar period
of time (2004 to 2010) (Baldursson and Karanis, 2011), which is likely
attributable to the significant advances in data reporting and surveil-
lance systems (Efstratiou et al., 2017a). It is important to note that the
reporting and documentation of waterborne infections and outbreaks is
very limited in developing countries where the risk is highest, so the
true burden of illness is largely unknown (Efstratiou et al., 2017a).
Waterborne parasitic infections are also under-diagnosed and under-
reported in many developed countries. Surface water may become
contaminated with Giardia cysts through a number of means, including
agricultural run-off, sewage discharge, storm water discharge, and di-
rect access to water sources by domestic and wild animals.
While considerably less common than other routes, foodborne
transmission of giardiasis has become more widely recognized in recent
years. Giardia duodenalis was 11th overall in a global ranking of food-
borne parasites by importance (FAO/WHO, 2014). The foodborne route
has been associated with increasing globalization of the food trade,
international travel, and changes in consumer habits (Dixon, 2016). An
estimated 7–15% of domestically acquired cases of giardiasis in the U.S.
are foodborne (Scallan et al., 2011; Torgerson et al., 2015). Giardia
cysts have been detected on a variety of foods, including fresh produce,
B.R. Dixon
dairy products, meat, shellfish and processed foods (Ryan et al., 2019).
In particular, numerous surveillance studies worldwide have reported
the presence of Giardia on fresh produce, including leafy greens, herbs,
berries, green onions, carrots, tomatoes, etc. (Dixon, 2016; Dixon, 2015;
Ryan et al., 2019).
Relatively few foodborne outbreaks of giardiasis have been reported
worldwide, almost all in the U.S., where a total of 38 outbreaks were
reported from 1971 to 2011 (Adam et al., 2016). It is likely that the
number of foodborne outbreaks of giardiasis is greatly underestimated
due to inadequate surveillance and reporting in many countries (Ryan
et al., 2019). While the type of food involved in these outbreaks is often
not determined, a variety of foods have, nevertheless, been linked.
Fresh produce has been most commonly implicated, including salads,
raw vegetables and fresh fruit. Other foods implicated include canned
salmon, raw oysters, ice, and various processed foods (e.g., noodle
salad, chicken salad, dairy products, sandwiches and tripe soup) (Adam
et al., 2016; Dixon, 2015; Dixon et al., 2011; Ryan et al., 2019).
Fresh produce may become contaminated with the infectious stages
of parasites at any number of points from farm level to the food
handler/consumer level (Dixon, 2016). At the farm level, contamina-
tion of fresh produce may occur during production, harvesting,
packaging, or transport. Contamination with Giardia cysts is associated
with poor personal hygiene, and may occur directly from the hands of
infected farm workers (or their equipment), or those who are in close
contact with infected individuals. Direct contamination of fresh pro-
duce may also occur through the application of animal faeces or human
faeces (‘night soil’) as fertilizer to crop lands. Finally, direct access to
crops by livestock and other animals represents another potential
source of contamination. Indirect contamination of produce at the farm
level may occur through the use of faecally-contaminated water in ir-
rigation, mixing of pesticides, or washing of produce, hands or equip-
ment (Dixon, 2015). The direct contamination of fresh produce by food
handlers who are themselves infected, or who have been in close con-
tact with infected individuals, is likely a major contributor, and has
been identified as the direct cause of a number of illness outbreaks
(Adam et al., 2016; Dixon, 2016; Dixon et al., 2011; Ryan et al., 2019).
3. Clinical signs and pathogenesis
Giardia is a non-invasive parasite which infects the small intestine
and colonizes the lumen and epithelial surface (Certad et al., 2017). The
attachment of trophozoites to the epithelial cells lining the small in-
testine results in shortening of microvilli, and targets specific signalling
networks that can activate apoptosis, leading to the loss of intercellular
junctions, cytoskeletal rearrangement, and barrier dysfunction, which
contribute to diarrhea (Allain and Buret, 2020; Certad et al., 2017;
Einarsson et al., 2016). While G. duodenalis trophozoites are generally
localized in the proximal small intestine, they have also been identified
in the stomach, distal small intestine, caecum, and pancreas (Halliez
and Buret, 2013).
While asymptomatic infections are common, a wide range of
symptoms, including diarrhea, bloating, epigastric pain, nausea and
vomiting have been reported following a 1–2 week incubation period
(Allain and Buret, 2020; Certad et al., 2017). Young children are most
susceptible to symptoms (Thompson and Ash, 2016). Although Giardia
is generally considered an important cause of diarrhea, the significance
of diarrhea in giardiasis has been controversial due to the high fre-
quency of asymptomatic infections (Leung et al., 2019; Ryan et al.,
2019). There is, in fact, some evidence suggesting that Giardia protects
against diarrhea caused by concurrent infections with other enteric
pathogens (Allain and Buret, 2020).
An acute phase of giardiasis generally lasts for 1–3 weeks, although
symptoms may last for months. Most infections are self-limiting, but
recurrence is common. Chronic infections result in malnutrition, mi-
cronutrient deficiencies, malabsorption and weight loss, and are asso-
ciated with impaired growth and cognitive development in young
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Research in Veterinary Science xxx (xxxx) xxx–xxx
children (Allain and Buret, 2020; Certad et al., 2017). Post-infectious
complications include irritable bowel syndrome, functional dyspepsia,
and chronic fatigue syndrome, while extra-intestinal complications can
include lower cognitive function, ocular pathologies, arthritis, allergies,
hypokalaemic myopathy, cancer, and others (Allain and Buret, 2020;
Leung et al., 2019). The mechanisms linking these extra-intestinal
complications with giardiasis have yet to be established, but they are
not associated with the direct invasion by the parasite (Halliez and
Buret, 2013).
While animals are often asymptomatic, a variety of symptoms have
been reported in domestic animals (Thompson and Ash, 2016). In li-
vestock, giardiasis can cause diarrhea, poor growth, weight loss, re-
duced productivity and even death, resulting in significant economic
losses (Cacciò et al., 2018; Santin, 2020). Even subclinical infections
can reduce growth and productivity in these animals (Santin, 2020).
While infected dogs and cats are often asymptomatic, diarrhea is fre-
quently reported in infected puppies and kittens (Siwila, 2017).
The fact that Giardia infections cause symptoms in some hosts, but
not in others, may be related to variability in virulence among strains,
the nutritional status of the host, the gut microbiota, coinfections with
other enteric pathogens, and host immune responses (Allain and Buret,
2020; Certad et al., 2017; Feng and Xiao, 2011; Thompson and Ash,
2019). There is no clear correlation, however, between the Giardia as-
semblage causing an infection and the clinical manifestations. Studies
done in Spain, UK, Turkey, Egypt, Bangladesh, Australia and Peru de-
monstrated that the majority of symptomatic cases were associated
with G. duodenalis Assemblage A (especially AII), whereas other studies
done in the Netherlands, UK, Spain, Saudi Arabia, Egypt, Ethiopia,
Malaysia and Cuba demonstrated that most symptomatic infections
were associated with Assemblage B (Cacciò et al., 2018; Feng and Xiao,
2011; Xiao and Feng, 2017). Intra-assemblage variation is thought to
account for some of the differences in these results (Feng and Xiao,
2011; Xiao and Feng, 2017).
4. Diagnosis
A definitive diagnosis of giardiasis is made by detection of cysts or
trophozoites in stool specimens through microscopical examination of
wet mounts or concentrated samples (e.g., zinc sulfate flotation or
formalin-ethyl acetate sedimentation), or through permanent staining
with trichrome or iron hematoxylin stains following stool preservation
in polyvinyl alcohol (PVA), 10% formalin, sodium acetate-acetic acid-
formalin (SAF) and/or merthiolate‑iodine-formalin (MIF) (Hooshyar
et al., 2019; Leung et al., 2019). Since cysts are shed sporadically, the
examination of multiple stool specimens over time is recommended
(e.g., three serial specimens collected every 2–3 days) (Hooshyar et al.,
2019; Leung et al., 2019). While microscopy does not necessarily re-
quire expensive equipment or reagents and is, therefore, more acces-
sible, it is labour intensive, subjective, and requires significant ex-
pertise. The use of fluorescent antibody staining (or
immunofluorescence assay, IFA) has increased the sensitivity and spe-
cificity of microscopy but is still time-consuming and requires a skilled
microscopist (Ryan et al., 2017). Furthermore, microscopical methods
do not allow for the differentiation of species and assemblages that
molecular methods can afford.
To overcome some of the limitations associated with microscopy,
rapid faecal antigen detection tests, including immunochromatographic
and enzyme-linked immunosorbent assay (ELISA), have been developed
and are widely used (Hooshyar et al., 2019; Soares and Tasca, 2016).
These tests are, however, prone to false-positive and false-negative re-
sults (Ryan et al., 2017).
Molecular methods are now very commonly used in developed
countries for the detection of Giardia in humans and animals, and have
contributed greatly to the understanding of transmission patterns
(Thompson and Ash, 2016). PCR-based methods, in particular, are
rapid and objective compared to microscopy, and allow for the
B.R. Dixon
determination of species and assemblages through DNA sequencing,
detection of multiple targets by multiplexing, and quantitation of re-
sults (Ryan et al., 2017; Xiao and Feng, 2017). As a result, the use of
molecular approaches in testing for Giardia can provide a better un-
derstanding of the transmission patterns and zoonotic potential of iso-
lates.
When PCR is used for diagnosis and/or characterization of Giardia,
stool specimens should either be left unpreserved, and stored in a re-
frigerator or freezer, or they should be collected and stored in a pre-
servative that is compatible with molecular methods, and stored at
room temperature. A number of fixatives and preservatives are com-
mercially available for this purpose. Alternatively, stools can be mixed
in 2.5% potassium dichromate and stored for up to one month prior to
PCR testing (Kuk et al., 2012).
Commonly targeted genes for the identification and molecular
characterization of Giardia include the small subunit ribosomal DNA
(SSU-rDNA), the internal transcribed spacers (ITS1 and ITS2), the ß-
giardin, the triosephosphate isomerase (TPI), and the glutamate dehy-
drogenase (GDH) genes (Ryan and Cacciò, 2013; Thompson and Ash,
2016; Xiao and Feng, 2017). The SSU-rDNA gene is a highly conserved
multi-copy gene and generally provides greater amplification success,
but does not offer the resolution of other single-copy genes needed for
subtyping (Thompson and Ash, 2016). However, discordant results in
assemblage identification may be obtained using different target genes
(Ryan and Cacciò, 2013), and more refined tools are needed.
Ryan et al. (2017) highlighted a number of recent and emerging
technologies for the detection of enteric parasites that address short-
comings in some of the existing diagnostic tests. For example, a number
of commercial multiplex PCR panels are now available for the si-
multaneous detection of common enteric protozoan parasites, including
Giardia (Ryan et al., 2017). Many of these assays are based on real-time
PCR, and have become popular in testing for the presence of protozoan
parasites, such as Giardia, in clinical and environmental samples as they
provide fast and high-throughput detection, and allow for the quanti-
tation of target DNA sequences (Ryan et al., 2017). Next generation
sequencing (NGS) is a rapid and high-throughput technology that can
be used to sequence entire genomes, or specific areas of the genome.
NGS allows for the identification of novel genotypes and mixed infec-
tions, and is becoming widely used, not only in diagnosis, but also in
epidemiology and outbreak investigations (Ryan et al., 2017, 2019;
Thompson and Ash, 2019). Draft genome sequencing data is currently
available for numerous G. duodenalis isolates, including those from
Assemblages A, B and E (Cacciò et al., 2018; Ortega-Pierres et al., 2018;
Tsui et al., 2018; Xiao and Feng, 2017). Recently, reference quality
genomes of three Giardia isolates were assembled using a hybrid ap-
proach involving a combination of both NGS and third-generation
(long-read) sequencing (Pollo et al., 2020).
For testing foods, water and other environmental samples for the
presence of G. duodenalis, many of the same methods used in diagnosis
are employed. For example, water samples are routinely tested using a
standardized method, USEPA Method 1623 (USEPA, 2005), which in-
volves filtration of large volumes of water (minimum 10 L), con-
centration of Giardia cysts and Cryptosporidium oocysts using im-
munomagnetic separation (IMS), and staining with fluorescently
labeled monoclonal antibodies, as well as 4′,6-diamidino-2-pheny-
lindole (DAPI), followed by fluorescence microscopy. Differential in-
terference contrast (DIC) microscopy is also used in the method to
confirm the identification of cysts and oocysts based on their mor-
phology. The added value of the nuclear stain, DAPI, is that it allows for
morphological confirmation, as well as viability determination, of any
cysts and oocysts observed. While the standardized Method 1623 is the
most widely used, the three main steps in analysing water samples for
Giardia and Cryptosporidium, i.e., particle concentration, selective con-
centration (separation) of target organisms, and detection, identifica-
tion and enumeration, can be also be accomplished using a variety of
alternative methods and technologies (Efstratiou et al., 2017b). For
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Research in Veterinary Science xxx (xxxx) xxx–xxx
example, flotation can be used instead of the costly IMS concentration
of cysts and oocysts, and PCR-based methods can be used for detection,
allowing for the differentiation of parasite species and assemblages/
genotypes, which is not possible using microscopy (Efstratiou et al.,
2017b).
Testing foods for the presence of Giardia cysts is particularly pro-
blematic for a number of reasons, including the identification and
collection of implicated foods, the small numbers of cysts likely to be
present on foods, the difficulties in eluting cysts from foods, the lack of
enrichment steps, and the inefficiencies in the detection methods
available. While microscopy is commonly used in food surveillance
studies, particularly in developing countries, PCR is increasingly being
used for this purpose. An important consideration in PCR testing is that
only Giardia DNA is detected, and does not necessarily indicate the
presence of intact cysts. Detection of Giardia in foods using either mi-
croscopical or molecular methods, can be improved through the use of
IMS to isolate cysts (Ryan et al., 2019). This improvement has been
incorporated into a standardized ISO method for the detection and
enumeration of Cryptosporidium and Giardia in fresh leafy green vege-
tables and berry fruits (ISO, 2016).
The viability or infectivity of Giardia cysts contaminating foods or
water samples is only very rarely addressed due to a lack of effective
and reliable methods (Ryan et al., 2019). A number of in vitro and in
vivo methods have been used to estimate viability, including mRNA-
real-time PCR assays, fluorescence in situ hybridization (FISH), vital
dyes, excystation assays, and animal infection studies, but these are
often limited in their usefulness by the assay time, the cost and, in the
case of vital dyes, the inherent bias (Rousseau et al., 2018; Ryan et al.,
2019).
5. Treatment
Management of giardiasis involves maintaining optimal hydration
and electrolyte balance, and minimizing the severity and duration of
diarrhea (Leung et al., 2019). Symptomatic giardiasis should be treated
to reduce the duration of symptoms, to prevent complications, and to
minimize transmission of the parasite to other hosts (Leung et al.,
2019). The most commonly used drugs, the nitroimidazoles (e.g., me-
tronidazole and tinidazole), have well established efficacy in the
treatment of giardiasis (Argüello-García et al., 2020). They are, how-
ever, often associated with adverse effects and require multiple doses,
leading to poor patient compliance (Argüello-García et al., 2020; Leung
et al., 2019; Ortega-Pierres et al., 2018; Thompson and Ash, 2016).
Several other drugs, including albendazole, paromomycin and nita-
zoxanide have also been successfully used in treating giardiasis
(Argüello-García et al., 2020). However, treatment failures are com-
monly reported with most of these drugs, as is drug resistance
(Argüello-García et al., 2020; Carter et al., 2018; Lalle and Hanevik,
2018; Ortega-Pierres et al., 2018; Ryan et al., 2019). In this case, the
use of alternative or novel drugs, or combinations of drugs, have been
effective (Argüello-García et al., 2020; Carter et al., 2018; Lalle and
Hanevik, 2018). Recently, probiotics have been shown to kill tropho-
zoites, and to reduce parasite burden, cyst shedding and duration of
infection (Allain and Buret, 2020; Argüello-García et al., 2020).
While there are currently no drugs licenced for Giardia in ruminants,
anthelmintic drugs, such as albendazole and fenbendazole, have been
used successfully (Santin, 2020; Siwila, 2017). Treatment of livestock is
controversial, however, as the high prevalence of infection in these
animals, and the large numbers of cysts in the environment, makes it
likely that reinfection will occur (Santin, 2020).
While giardiasis is often mild in dogs and cats, treatment is re-
commended to minimize the risk of transmission to other animals or to
humans. Fenbendazole is commonly used in treating both dogs and cats
(Siwila, 2017). Metronidazole is also effective but safety concerns limit
its use. Other drugs used to treat giardiasis in humans have also been
shown to be efficacious in dogs, including nitazoxanide (Moron-Soto
B.R. Dixon
et al., 2017).
Giardia possesses a mechanism for antigenic variation which allows
trophozoites to evade the host's immune response, but creates chal-
lenges for the development of effective vaccines. While a vaccine for
human giardiasis is not commercially available, vaccines have been
developed for dogs and cats (Serradell et al., 2016).
6. Control measures
Thorough hand washing is essential in reducing the likelihood of
becoming infected with Giardia, or of spreading the infection, especially
in the cases of person-to-person, zoonotic and foodborne transmission.
The people at greatest risk of infection, and of transmitting giardiasis
through these routes, would include, among many others, children and
staff in day cares, travelers, animal handlers, veterinarians, petting zoo
visitors, and food handlers. It is important that symptomatic in-
dividuals, and recently recovered individuals, be excluded, wherever
possible, from activities such as day cares, swimming, handling and
preparing food, etc., as they would pose a risk of transmission to others.
Public health information and training/educational programs regarding
personal and food hygiene are important in increasing awareness and
minimizing the risk of transmission of giardiasis as well as other enteric
pathogens.
Minimizing transmission among animals is probably more challen-
ging. In the case of ruminants, where 100% cumulative prevalence is
frequently reported in longitudinal studies (Santin, 2020), improved
husbandry and good management practices are important in decreasing
the numbers of cysts in the farm environment and reducing the spread
of infection. Regular cleaning and disinfection, prompt removal of
faeces from animal housing, use of single-cow calving areas, and access
to colostrum by neonates are all important practices in this regard
(Santin, 2020). In dogs and cats, preventative measures include bathing
the animals, cleaning and disinfecting their environment and limiting
their access to untreated water and faecally-contaminated areas. Par-
ticular attention should be paid to kennel or shelter environments
where infections are more common, and the risk of animal-to-animal
transmission is greater (Ballweber et al., 2010).
In the case of waterborne transmission, a multiple barrier approach,
including limiting access of people and animals to watersheds and re-
servoirs, and treatment using flocculation, filtration and disinfection, is
necessary to minimize the risk (Efstratiou et al., 2017b). Water treated
with chlorine still poses a risk as the infectious stages of many parasites,
including Giardia, are much more resistant to chlorine than are bac-
terial pathogens. However, many filtration methods routinely used in
water treatment are effective in removing Giardia cysts. While other
technologies used in the water industry, such as ultraviolet light, ozone,
and irradiation, can also be effective in inactivating parasites, these
technologies are expensive and are not generally available in many
smaller communities or in developing regions. If drinking water is
suspected of being contaminated with Giardia cysts, bottled water can
be an option, and boiling tap water for at least one minute can be used
as an emergency measure.
Since fresh produce is very often consumed raw, without any further
processing, the development and implementation of effective control
measures for minimizing the risk of contamination, or for removing or
inactivating parasites, is crucial in reducing the risk of illness in con-
sumers. At the pre-harvest stage, these controls include the use of
properly treated water, monitoring the health and hygiene of farm
workers, improved on-farm sanitation, and restricting access of live-
stock and other animals to crops and to surface waters (Dixon, 2016;
FAO/WHO, 2014). While composted animal and human faeces are
widely used as fertilizers, the effectiveness of composting in in-
activating parasites is not entirely clear (Van Herk et al., 2004). Post-
harvest control measures include primarily the use of treated water for
washing and processing produce, and for cleaning hands and equip-
ment, as well as the monitoring and enforcement of good personal
5
Research in Veterinary Science xxx (xxxx) xxx–xxx
hygiene in food handlers. The use of chemical and physical disin-
fectants directly on foods, or on working surfaces and equipment,
should also be considered as potential barriers to foodborne transmis-
sion of protozoan parasites (Dixon, 2016). While most protozoan
parasites are thought to be very resistant to the chemical disinfectants
commonly used in the food industry (Dixon et al., 2011; Ortega and
Sanchez, 2010), some disinfectant gases have been shown to be quite
effective (Ortega et al., 2008). In terms of physical disinfection, a
variety of technologies have been shown to be effective against para-
sites on fresh produce or in juices, including pasteurization (Deng and
Cliver, 2001), irradiation (Dubey et al., 1998), and high pressure pro-
cessing (Kniel et al., 2007; Lindsay et al., 2008; Slifko et al., 2000). Most
of these studies were done on Cryptosporidium and Toxoplasma, how-
ever, and relatively little is known regarding the effectiveness of phy-
sical disinfection against Giardia. Commercial freezing appears to be
effective in destroying the infectious stages of protozoan parasites on
berries and other produce items as no illness outbreaks have been as-
sociated with frozen products (Dixon, 2015).
At the food handler/consumer level, good personal hygiene, parti-
cularly frequent hand washing, is of considerable importance in redu-
cing the risk of contaminating foods with protozoan parasites. While
there is relatively little experimental data available with regard to
Giardia, treatments such as cooking and freezing may be used as final
barriers against foodborne transmission. However, as most fruits, and
many vegetables, are consumed raw, these inactivation steps will not
always be applicable. Finally, travelers to developing countries, with
higher prevalences of giardiasis, should be instructed, through travel
clinics and public health messaging, to be cautious in their selection of
foods and beverages, and to be mindful of good personal hygiene
(Leung et al., 2019).
7. Future studies and research needed
While both waterborne and person-to-person transmission of giar-
diasis are well recognized, the true burden of illness resulting from
these routes, particularly in developing countries, is unclear due to
inadequate testing. In addition, there is currently little direct evidence
in support of zoonotic transmission, despite the very high prevalence of
infection in livestock and companion animals, and the common as-
semblages reported between humans and animals. Similarly, the food-
borne route of infection is not well recognized, with relatively few
foodborne outbreaks having been documented, and a paucity of food
surveillance studies from developed countries. Standardized methods
allowing for rapid, sensitive, and low-cost diagnoses, as well as for
surveillance testing of food and water samples, will be needed to ad-
dress some of these important knowledge gaps. Furthermore, the con-
tinued development and application of tools for genotyping Giardia
isolates, characterizing novel genotypes, and identifying mixed infec-
tions, will be necessary to clarify the transmission patterns and host
specificity of this parasite, and will be invaluable in surveillance studies
and outbreak investigations. Whole genome sequencing will likely be
very useful in identifying additional variable loci, to be used alone or in
multi-locus sequence typing. However, this work will first require the
generation of reference quality genomes for isolates from all Giardia
assemblages, as well as the improvement and streamlining of bioin-
formatics pipelines.
While Giardia cysts are known to be robust and resistant to en-
vironmental extremes, our knowledge of the actual viability of Giardia
cysts contaminating foods or water samples is limited. Viability and/or
infectivity are of considerable importance in terms of estimating risk to
consumers, but are only very rarely addressed in surveillance studies
and outbreak investigations, mainly due to a lack of practical methods.
The development and application of more rapid, cost-effective, and
accurate methods for determining viability would be invaluable in
surveillance studies and outbreak investigations, as well as for evalu-
ating the effectiveness of chemical disinfectants and physical
B.R. Dixon
inactivation technologies against Giardia cysts, for use in both the food
and water industries.
Our understanding of the pathogenesis and symptomatology of
giardiasis has improved greatly in recent years, but there remain many
unanswered questions, including why Giardia infections cause symp-
toms in some hosts, but not in others, and how does an infection result
in post-infectious and extra-intestinal complications? These questions
will need to be answered in order to accurately estimate risk, and to
effectively treat and control giardiasis in both humans and animals.
Like many other diseases, the drug treatment of giardiasis is hampered
by treatment failures, adverse effects, and drug resistance. The con-
tinued development and evaluation of novel drugs will, therefore, be
important in effectively treating infections in the future.
Finally, recognizing that Giardia is a common infection in humans
and many animals, and is often transmitted through food and water, a
collaborative and multidisciplinary One-Health approach involving
public health officials, epidemiologists, veterinarians, farmers, en-
vironmental scientists, food safety experts and many others, will be
important in effectively controlling the spread of giardiasis.
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