United States
            Environmental Protection
            Agency
                Office of Science and Technology
                Off ice of Water
                Washington, DC 20460
EPA-822-R-01-009
March 2001
www.epa.gov
&EPA
 Cryptosporidium: Drinking
Water Health Advisory








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I.            Introduction

Purpose

             The Health Advisory Program, sponsored by the Office of Water (OW), provides information on
the health effects, analytical methodology, and treatment technology that would be useful in dealing with the
contamination of drinking water.  Most of the Health Advisories prepared by OW are for chemical substances.
This Health Advisory is different in that it addresses contamination of drinking water by a microbial pathogen,
including the issues of infective dose (i.e., the number of particles of a pathogen necessary to cause an infection
in a host) and pathogen control. Therefore, the format and contents of this Health Advisory necessarily vary
somewhat from the standard Health Advisory document.

             Health Advisories serve as informal technical guidance to assist federal, state, and local officials
responsible for protecting public health when emergency spills or contamination situations occur.  They are not
to be construed as legally enforceable federal standards. The Health Advisories are subject to change as new
information becomes available.

             This Health Advisory summarizes the information presented in the Office of Water's Criteria
Document for Cryptosporidium (USEPA, 1994) and its addendum (USEPA, 200Ib). Individuals desiring
further detail should consult these documents, which are available from the U.S. Environmental Protection
Agency, OW Resource Center, Room M6099; Mail Code: PC-4100, 401 M Street, S.W., Washington, D.C.
20460; the telephone number is (202) 260-7786.  The documents also can be obtained by calling the Safe
Drinking Water Hotline at 1-800-426-4791.

Summary

             Cryptosporidium oocysts are common and widespread in ambient water and can persist for
months in this environment.  The dose that can infect humans is low, and a number of waterborne disease
outbreaks caused by this protozoan have occurred in the United States, most notably in Milwaukee, Wisconsin,
where an estimated 400,000 people became ill in 1993.  Otherwise healthy people recover within several weeks
after becoming ill, but illness may persist and contribute to death in those whose immune systems have been
seriously weakened (e.g., AIDS patients). Drugs effective in preventing or controlling this disease are not yet
available. The public health concern is worsened by the resistance of Cryptosporidium to commonly used water
disinfection practices such as chlorination. However, a well-operated water filtration system is capable of
removing at least 99 of 100  Cryptosporidium oocysts in the water. Monitoring for this organism in water is
currently difficult and expensive.  EPA believes  that there is sufficient information to conclude that
Cryptosporidium may cause a health problem and occurs in public water supplies at levels that may pose a risk
to human health.

II.          General Information

History

            Cryptosporidium was described by Tyzzer in 1907 but remained medically unimportant to
             humans until the first cases of cryptosporidiosis in humans were reported  in 1976 by Nime et al.
             and Miesel et al. (Payer et a/., 1997a).  Cryptosporidium was first recognized as a waterborne
             pathogen during an outbreak in Braun Station, Texas (1984), in which more than 2,000
             individuals were afflicted with cryptosporidiosis (D'Antonio et al., 1985; Graczyk et al., 1998a).
             Since that time, outbreaks affecting more than one million individuals have been documented

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       Cryptosporidium: Drinking Water Health Advisory
March 2001
             throughout North America and Europe, with the single largest epidemic occurring in Milwaukee,
             Wisconsin, in 1993 (Mackenzie etal.,  1994).
Organism Description

Taxonomy
             Cryptosporidium is one of several protozoan genera in the phylum Apicomplexa, which develop
             within the gastrointestinal tract of vertebrates throughout their entire life cycles (Payer etal.,
             2000). Apicomplexans are obligate intracellular parasites. They are characterized by the presence
             of special organelles located at the tips (apexes) of cells that contain materials used to penetrate
             the host cells and establish successful infections. Examples of Apicomplexa other than
             Cryptosporidium include Plasmodium (the causative agent of malaria) (Tortora et al., 1994).

             The taxonomy of the genus Cryptosporidium is uncertain and changing. The current
             classification scheme entails ten species of Cryptosporidium (Payer et al., 2000). Table 1 lists
             these ten Cryptosporidium species and the host organism(s) in which each parasite was originally
             found; some of these species have since been shown to occur in additional hosts (Payer etal.,
             2000; Payer et al.,  1997a).  Cryptosporidium has been observed in over 150 mammalian species
             (Payer et al., 2000); however, illness in humans is confined primarily to infections associated
             with C. parvum (O'Donoghue, 1995).

                                Table 1. Valid Cryptosporidium Species
Cryptosporidium Species
C. andersoni
C. baileyi
C.felis
C. meleagridis
C. muris
C. nasorum
C. parvum
C. saurophilum
C. serpentis
C. wrairi
Initially Described Host Species
Bos taurus (cattle)
Gallus gallus (domestic chicken)
Felis catis (domestic cat)
Meleagris gallopavo (turkey)
Mus musculus (house mouse)
Naso liter atus (fish)
Mus musculus (house mouse)
Eumeces schneideri (skink)
Elaphe guttata (corn snake)
E. subocularis (rat snake)
Sanzinia madagasarensus (Madagascar boa)
Cavia porcellus (guinea pig)
              Source:  Adapted from Payer et al. (2000) and Payer et al. (1997a)
              The taxonomy of Cryptosporidium is in the forefront of current research on the parasite, and
              changes may be forthcoming. Molecular studies have found considerable evidence of genetic

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       Cryptosporidium: Drinking Water Health Advisory	March 2001

              heterogeneity among isolates of C. parvum from different vertebrate species, and findings from
              these studies indicate that a series of host-adapted genotypes or strains of the parasite exist
              (Awad-El-Kariemera/.,  1998; Payer etal., 2000; Morganetal., 1999a: Morgan^ a/.,  1999b;
              Morgan etal., 1999c; Morgan^al., 1999d; Morgan^al., 1998; Spanoetal., 1998a; Spanoet
              al., 1998b; Sulaimane^a/., 1998; Xiao etal., 1999a; Xiao etal., 1999b).

             Separate subpopulations within the C. parvum strain exist, one that infects primarily humans and
              one that infects primarily animals (Carraway et al.,  1994; Awad-El-Kariem, 1996; Awad-El-
              Kariem et al., 1998). Two genotypes with genetic differences among adhesion proteins have
              been found; the H (human) genotype was found exclusively in human isolates and the C (cattle)
              genotype was found in both calf isolates and in isolates from human patients reporting exposure
              to infected cattle (Peng etal., 1997).

             In addition to the human  and cattle genotypes, characterizations of C. parvum isolates from other
              vertebrate species have revealed host-specific genotypes in mice, pigs, marsupials, and dogs
              (Payer etal, 2000;  Morgan et al, 2000; Morgan et al, 1999a; Morgan et al, 1999b; Morgan et
              al, 1999c; Morgan etal, 1999e; Morgan et al, 1998; Pereira etal, 1998; Xiao et al, 1999b).

Life Cycle/Morphological Features

             Cryptosporidium has a complex life cycle, which is completed in one to eight days and takes
              place within the body of the host (either humans or any of a wide variety of animal species).
              Cryptosporidium is excreted in the feces of an infected host in the form of an oocyst. The oocyst
              represents the only  stage  of the life cycle that exists outside the  host and consists of four
              sporozoites housed within a sturdy, multi-layered wall.  Oocysts of C. parvum are small,
              generally measuring four to six micrometers in diameter and are spherical-to-ovoid in shape
              (Payer andUngar, 1986).  The life cycle is repeated when sporulated oocysts excreted by an
              infected host are ingested by a new host and the sporozoites excyst within the small intestine.  A
              complete description of the life cycle of Cryptosporidium is provided in the 1994USEPA
              Cryptosporidium Criteria Document (see Figure II-1, p. II-5).

             Robertson et al.  (1993, 1994) provided evidence that the suture spanning part of the
              circumference of the oocyst inner wall described in ultrastructural studies is not the same
              structure  as the apparent "fold" in the oocyst wall seen using fluorescence microscopy. Their
              ability to reversibly induce the folds suggests that this structure is probably artifactual.  As a
              result, the researchers recommend that the apparent fold no longer be considered a diagnostic
              feature of Cryptosporidium parvum.

Environmental Fate

             The thick-walled oocyst is appreciably resistant to natural decay in the environment as well as to
              most disinfection processes. Walker et al. (1998) reviewed laboratory and field studies on the
              survival and transport of  C. parvum oocysts. Oocysts can survive for months in soil under cool,
              dark conditions and for up to one year in low-turbidity water.  Infectivity appears to be lost when
              oocysts are frozen, freeze-dried, boiled, or heated at or above 60C for 5 to 10 minutes
              (Badenochetal., 1990).

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       Cryptosporidium: Drinking Water Health Advisory	March 2001

            In general, shorter freezing times are required to neutralize infectivity when lower freezing
             temperatures are used (e.g., 1 hour at -70C vs.  168 hours at -15C to completely neutralize
             infectivity) (Payer and Nerad, 1996). Robertson et al. (1992) demonstrated that oocysts were
             inactivated after incubation at -22C for 18 days.

            Water temperature can affect oocyst infectivity; Payer et al. (1998) demonstrated that oocysts
             retained their infectivity for 1 week in -10C water but remained infectious for up to 24 weeks in
             20C water.  Warming oocysts to 45C for 5 to 20 minutes was effective in completely
             neutralizing their infectivity (Anderson, 1985).  Under conditions of high water temperatures,
             Payer (1994) indicated that all evidence of C. parvum infectivity was lost within 60 seconds
             when temperatures exceeded 72C or when temperatures of at least 64C were maintained for 2
             minutes. Harp et al.  (1996) demonstrated that oocysts suspended in water or milk lost infectivity
             after heating to 71.7C for 5 to 15 seconds in a lab oratory-scale pasteurizer.

            The infectivity of oocysts from calf fecal samples which had been subjected to drying in either
             the summer (i.e.,  18C to 29C, 60% humidity) or winter (i.e., -1C to 10C, 60% humidity) was
             completely lost within 1 to 4 days (Anderson, 1986).

            C. parvum oocysts are more resistant to chemical agents than the majority of protozoa  A
             complete description of the morphological features of each life cycle stage of Cryptosporidium
             (oocyst, sporozoite, trophozoite, merozoite, microgametocyte, macrogametocyte) is provided in
             the 1994 Cryptosporidium Criteria Document (see pp. II-7 - II-9 of the 1994 document).

Species Transmission

            Cryptosporidium can be transmitted from person to person, or from farm livestock (e.g., cattle,
             sheep, or pigs) to humans, through the fecal-oral route (Casernore, 1990).  Ingestion of drinking
             water contaminated with oocysts is the major mode of transmission.  Other routes of
             transmission include fecal contamination of fomites(i.e., inanimate objects such as clothes, pens,
             doorknobs)  and contamination of recreational waters (e.g., swimming pools).

Direct Transmission Between Humans

            A number of studies have shown that person-to-person transmission of cryptosporidiosis
             infection may occur within family homes, day-care centers, hospitals, and in urban environments
             where population densities are high (USEPA, 1994).  The route of infection is either direct,
             through fecal-oral contact, or indirect, through fomites.  The rate of transmission between
             immunocompromised individuals is higher than between immunocompetent individuals (Heald
             and Bartlett, 1994).  Secondary transmission of cryptosporidiosis has also been observed among
             humans whose occupation places them near primary cases within a confined space. For example,
             an outbreak occurred among crew members on a U.S. Coast Guard cutter that had obtained water
             from the city of Milwaukee during the 1993 epidemic (Moss et al., 1994). It was suggested that
             the disease was transmitted from person to person. It  is difficult, however, to distinguish between
             primary infections (i.e., those due to ingestion of contaminated water) and secondary infections
             (i.e., those due to contact with fecal contaminated fomites, food, or other infected individuals).
             In some instances it may not be possible to determine whether transmission between humans is

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       Cryptosporidium: Drinking Water Health Advisory	March 2001

             the primary cause of cryptosporidiosis, especially in situations when humans have also come into
             contact with animals through occupational or recreational activities (Adam et a/., 1994).

            Infected individuals will shed oocysts in their feces and can be expected to transmit the infection
             to other family or community members. In addition, day-care centers are a potential source for
             secondary spread of cryptosporidiosis because of their high density of a susceptible population
             and the inadequate personal hygiene habits of the children.

Transmission from Animals to Humans

            The 1994 USEPA Cryptosporidium Criteria Document cites adequate evidence for the
             transmission of Cryptosporidium from animals, particularly livestock, to humans.  Often
             Cryptosporidium species infecting vertebrates, only one, C. parvum, represents a global public
             health problem due to its zoonotic potential (Graczyk et a/., 1998a).

            Transport of oocysts through migratory waterfowl may have epidemiological implications, as the
             birds  can consume and transport C. parvum even though they are not susceptible to infection.  In
             experimental studies, C. parvum oocysts retained their infectivity after being excreted in the
             feces  of ducks and/or geese dosed orally (Payer et a/., 1997b) or by intubation  (Graczyk et a/.,
             1996; Graczyk et a/., 1997).  In another study,  C. parvum oocysts that were recovered from
             goose fecal samples collected in the Chesapeake Bay successfully infected laboratory mice
             (Graczyk et a/., 1998b). Viable Cryptosporidium oocysts have been found in fecal samples and
             cloacal lavages of gulls which fed sewage or other refuse (Smithed a/., 1993).  Transmission
             from  waterfowl is most likely to occur around reservoirs or in waters where shellfish are
             harvested for human consumption.

            Insects have also been shown to carry C. parvum oocysts on their outer surfaces as well as in
             their  intestinal tracts. House flies (Musca domestica) exposed to bovine feces containing C.
             parvum oocysts transported oocysts to other surfaces via fecal deposition (Graczyk et a/.,  1999).
             This study also demonstrated that oocysts were found on the exoskeletons and in the intestinal
             tracts of the exposed flies. In a study by Malhison and Ditrich (1999), oocysts were collected on
             the external surfaces and in the intestinal tracts of dung beetles exposed to C. parvum oocyst-
             supplemented dung. Zerpaand Huicho (1994) reported a case of cryptosporidial diarrhea in a
             20-month-old male child in which Cryptosporidium oocysts were detected in the digestive tract
             of cockroaches (Periplaneta americand) found in the garden of the child's home. No other
             potential sources of infection were identified.

III.          Occurrence

Worldwide Distribution

            Cryptosporidium occur in numerous mammalian, avian, reptilian, piscine, and  amphibian hosts
             worldwide (Payer,  1997; Payer et al, 2000; Hoover ef or/., 1981; O'Donoghue, 1995).

            Since 1982, human cryptosporidiosis has been documented in 95 countries on every continent
             except Antarctica (Payer, 1997).  Human cryptosporidiosis occurs in developed and developing

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       Cryptosporidium: Drinking Water Health Advisory	March 2001

             countries, urban and rural areas, and in temperate as well as tropical climates (Payer, 1997;
             O'Donoghue, 1995).
Surface Waters
             Cryptosporidium may be more common in surface water than ground water because surface
             waters are more vulnerable to direct contamination from sewage discharges and runoff. Lisle
             and Rose (1995) reported that between 5.6% and 87.1% of source waters (i.e., surface, spring,
             and groundwater samples not impacted by domestic and/or agricultural waste) tested contained
             0.003 to 4.74 Cryptosporidium oocysts/L. In another major study, LeChevallier and Norton
             (1995) reported finding oocysts in 60.2% of surface waters tested in the U.S. and Canada.
             However, all surface waters are subject to a complex set of watershed processes and
             characteristics that may lead to the presence of Cryptosporidium oocysts  (Crockett and Haas,
             1997; States etal., 1997; LeChevallier et al., 1997).

             Cryptosporidium oocysts have also been found in more than 50% of raw  sewage samples
             (Bukhari et al., 1997; Zuckerman et al., 1997), 4.5% of raw water samples, and 3.5% of treated
             water samples (Wallis et al., 1996).  Ong et al. (1996a, 1996b) found that water from rivers
             flowing through cattle pastures in British  Columbia exhibited higher Cryptosporidium counts
             than did water in a protected watershed.
Ground Water
Soil
             Cryptosporidium oocysts are found less frequently in ground water than in surface water,
             although new data contradict previous assumptions that ground water is inherently free of
             parasites such as Cryptosporidium. For example, Hancock et al. (1998) recently reported a study
             of 199 ground water samples tested for Cryptosporidium.  They found that 5% of vertical wells,
             20% of springs, 50% of infiltration galleries, and 45% of horizontal wells tested contained
             Cryptosporidium oocysts.
             Limited studies have been performed to ascertain the presence or viability of Cryptosporidium in
             soil in several documented outbreaks.  However, transport of Cryptosporidium oocysts to water
             from feces-contaminated soil during weather events has been suggested as the most probable
             mechanism of source water contamination (Kramer et al.,  1996). Vertical movement of oocysts
             can occur through the soil, as demonstrated in 30-cm soil cores (Mawdsley et al., 1996a).
             Twenty-one days after inoculation, the majority of oocysts still in the soil remained in the top
             two  cm of the soil cores, but some were found as deep as 30 cm. The number of oocysts
             recovered decreased with increasing soil depth. Another study by Mawdsley et al.  (1996b)
             confirmed these results but also suggested that a large proportion of oocysts are retained in the
             runoff rather than being adsorbed onto the soil surface.
Foods and Beverages
              Several foodborne outbreaks in recent years have highlighted the role of Cryptosporidium as a
              foodborne pathogen. The presence of Cryptosporidium has been documented in raw milk

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       Cryptosporidium: Drinking Water Health Advisory	March 2001

             (Badenoche^a/., 1990), unpasteurized apple cider (Millarde^a/., 1994), uncooked meat
             products (Casemore et a/., 1997), uncooked (and possibly unwashed) green onions (Quinn et a/.,
             1998), and fresh produce (Monge and Chinchilla, 1995). Refrigeration does not affect oocyst
             viability (Friedman et al., 1997).

Environmental Factors Affecting Cryptosporidium Survival

            In the absence of freezing conditions, colder water temperatures tend to promote the survival of
             most microorganisms.  For example, C. parvum oocysts may survive outside of mammalian
             hosts for several months or more depending upon water temperature (Straub et al., 1994). In
             freezing conditions, C. parvum oocysts are not necessarily rendered noninfectious (Payer et al.,
             1991; Payer, 1997). Oocyst stability under freezing conditions is at least partially dependent
             upon the surrounding matrix.  For example, fecal material can confer a cryopreservative effect
             (Satterefor/., 1999).

            Under conditions of high water temperatures, Payer (1994) indicated that all evidence of C.
             parvum infectivity was lost within 60 seconds when temperatures exceeded 72C or when
             temperatures of at least 64C were maintained for 2 minutes. It is important to note, however,
             that such water temperatures are not typical environmental conditions.

            Physical shear forces may also affect oocyst viability.  Such shear forces could result from the
             potentially abrasive effects of sand and gravel particles or fast-flowing waters.  In addition,
             oocysts could be subject to such shear forces in rapid sand filters. Parker and Smith (1993)
             demonstrated rapid inactivation  of oocysts in  a mixed sand reactor.

            Microbial predation may be an important influence on oocyst survival in natural waters. For
             example, Sattar et al. (1999) observed that oocysts incubated in dialysis cassettes suspended in
             natural waters exhibited significantly longer survival times when bacterial populations were
             excluded from the suspension water.

Specific Disease Outbreaks

Outbreaks Associated with Drinking Water

            A number of cryptosporidiosis outbreaks have been associated with drinking water (Rose et al.,
             1997; Solo-Gabriele and Meumeister, 1996).  Deficiencies in water treatment systems are often
             cited as a major reason for outbreaks, and even the best of systems can be overwhelmed by a
             high density of oocysts entering the source waters over a short period of time.  For example, a
             national survey over a 2-year test period (1993 and 1994) identified 5 outbreaks; these 5
             outbreaks resulted in 403,271 cases (Kramer et al., 1996). Of this total, 403,000 were from the
             outbreak in Milwaukee, Wisconsin, 103 were from Las Vegas, Nevada, and 27 were from an
             outbreak at a resort in Minnesota.  Some notable outbreaks in the United States associated with
             drinking water are summarized in Table 2 below.

          Table 2. Notable Outbreaks of Cryptosporidiosis Associated with Drinking Water in the U.S.

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       Cryptosporidium: Drinking Water Health Advisory
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Year
1984
1986
1987
1991
1992
1993
1993
1993
1993
1994
1995
State
Texas
New Mexico
Georgia
Pennsylvania
Oregon
Wisconsin
Washington
Minnesota
Nevada
Washington
Florida
Number of
Cases
2006
78
12,960
551
15,000
403,000
7
27
103
104
72
Source
Ground water
Surface water
River
Ground water
Spring/river
Lake
Private Well
Lake
Lake
Community Well
Not applicable
Deficiency
Sewage contamination
Untreated
Treatment deficiency
Treatment deficiency
Treatment deficiency
Treatment deficiency
Surface contamination
Unknown
Inadequate filtration
Sewage contamination
Cross connection
       Source:  USEPA (200 Ib)

Outbreaks Associated with Recreational Waters

      Fourteen outbreaks of gastroenteritis related to recreational waters were reported by nine states during
       1993 and 1994 (Kramer et al, 1996).  Ten of these outbreaks were caused by Cryptosporidium or
       Giardia, with five outbreaks specifically linked to Cryptosporidium. Three of the Cryptosporidium
       outbreaks were associated with motel swimming pools, and two were associated with community
       swimming pools.  All five pools were filtered or chlorinated.  One had a malfunctioning filter, but none
       of the other pools had identifiable treatment deficiencies.  The inability of chlorine at levels normally
       used in swimming pools to kill Cryptosporidium, coupled with inadequate maintenance of pool filtration
       equipment, has been suggested as the primary cause of swimming pool related cryptosporidiosis.
       Kramer et al. (1998) reported on an outbreak involving 38 individuals who contracted cryptosporidiosis
       while swimming in a recreational lake.  The authors speculated that contamination of the lake came from
       either infected swimmers or contaminated run-off

Foodborne Outbreaks
       Foodborne outbreaks of cryptosporidiosis have only rarely been reported Harp et al. (1996) reported
       that standard commercial pasteurization techniques kill 100% of C. parvum oocysts. In October 1993, an
       outbreak of cryptosporidiosis occurred among students and staff who consumed contaminated apple
       cider while attending an agricultural fair in central Maine. This incident was the first large outbreak in
       which foodborne Cryptosporidium could be identified and documented as the causative agent (Millard et
       al.,  1994). Cryptosporidium oocysts were detected in the stools of 50 (89%) of the primary and
       secondary case subjects tested. Oocysts were detected in the apple cider, on the cider press, and in the
       stool specimen of a calf on the farm of the supplier of the apples used to make the cider. This outbreak
       underscores the need for precautions by agricultural producers to avoid contamination of foodstuffs by
       infectious agents commonly present in the farm environment.

       Two more foodborne outbreaks, one involving apple cider and another associated with green onions,
       were reported in a review by Rose and Slifko (1999).  A community outbreak in New York was
       associated with a cider mill using apples picked from an orchard located near livestock. Another
       outbreak was traced back to a dinner banquet in Washington in which unwashed green onions were the
       suspected cause (Quinnetal.., 1998;  Rose and Slifko, 1999).

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       Cryptosporidium: Drinking Water Health Advisory	March 2001


      The Minnesota Department of Health reported on cryptosporidiosis in 50 attendees of a social gathering
       who ate a salad contaminated during preparation by a day-care worker (CDC, 1996b).

Outbreaks Among Travelers

      Cryptosporidiosis has emerged as an important cause of traveler's diarrhea, particularly among people
       visiting developing countries. Travelers to developed countries such as the U.S. have also acquired
       Cryptosporidium infections. For example, MacKenzie et al. (1995) reported that visitors to Milwaukee
       during the 1993 outbreak transmitted the parasite to members of their households upon returning home.

Outbreaks at Day-care Centers

      Several outbreaks of cryptosporidiosis have occurred in day-care centers in the United States; these
       outbreaks are summarized in "Cryptosporidium: Risk for Infants and Children" (USEPA, 200la).

IV.    Health Effects

Animals

Symptoms

      Most cases of cryptosporidiosis in mammals involve infections by C. parvum (Payer, 1997;
       O'Donoghue, 1995). The most common features of cryptosporidiosis in mammals are profuse diarrhea,
       dehydration, fever, anorexia, and weight loss.

      In general, the severity of the infection depends on the species, age, and immune status of the host
       (Payer, 1997).  Infections are primarily seen in younger animals and animals with compromised immune
       systems, while  infected healthy adult animals may be asymptomatic or develop only mild clinical signs
       (Payer, 1997; O'Donoghue,  1995).

      Adult animals often appear asymptomatic while shedding small numbers of oocysts (Casemore et al,
       1997; Payer, 1997; O'Donoghue, 1995).

Therapy and Prevention

      Management of cryptosporidiosis in all animals involves a combination of antidiarrheal drugs and
       anticryptosporidial drugs, along with other preventive measures (e.g., rehydration with fluids and
       electrolytes) (Blagbum and Soave,  1997).

      Prevention of cryptosporidiosis in domestic animals is best achieved by eliminating contact with viable
       oocysts as much as possible.  This involves isolation of infected animals and disinfection of all articles
       that come into contact with the infected animals. This is particularly difficult in settings with large
       numbers of animals such as farms or zoos (Blagburn and Soave, 1997).

      Sources of infection in animals include: other infected animals of the same or different species (e.g., it is
       believed that rodents can infect calves or cattle with C. parvum); mechanical carriers such as insects,

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       Cryptosporidium: Drinking Water Health Advisory	March 2001

       birds and humans; contaminated feed and water; and other contaminated fomites such as bedding,
       brushes, shovels, and feed utensils (Payer,  1997).

Humans

Symptoms and Clinical Features

      The clinical manifestations of cryptosporidiosis in humans are directly related to the immunocompetence
       of the host, and may include profuse, non-bloody, watery diarrhea that usually resolves spontaneously
       within approximately 48 hours. Variability in clinical symptoms is appreciable and may include renal
       failure and liver disease (Griffiths, 1998).  Other symptoms reported by individuals afflicted with
       cryptosporidiosis include abdominal cramps, vomiting, lethargy and general malaise.

      The incubation period in humans is estimated to vary between two to ten days (Arrowood, 1997), with a
       mean  incubation of approximately seven to nine days (Juranek and MacKenzie, 1998).

Epidemiological Data

      Because C. parvum is ubiquitous, infects most mammals, and is highly infectious, all human populations
       are at  risk of infection to some degree (Griffiths, 1998).  Since 1982,  human cryptosporidiosis has been
       reported in almost 100 countries (Ungar, 1990); the impact is greatest in developing countries.

      Cryptosporidium is the third or fourth most commonly identified pathogen in the world, and the reported
       infection rates are higher in developing countries,  especially in children. Seasonal and temporal trends
       vary from country to country and occurrence may  indirectly reflect rainfall and farming events such as
       lambing (Casernore, 1990).

      The occurrence of Cryptosporidium infection in Gambian children has seasonal peaks associated with
       rain and high relative humidity (Adegbola et al, 1994).  Factors accounting for the seasonal distribution
       of Cryptosporidium, particularly in developing countries, may include increased survival of oocysts in a
       high relative humidity environment and an increased possibility of dissemination of oocysts to children
       as a result of decreased domestic and environmental hygiene in the rainy season.

      Domestic animals such as calves and lambs are common zoonotic reservoirs implicated in occupational
       exposure, indirect zoonotic transmission, and contamination of food (e.g., sausages, offal, and raw milk).
       Animals also contribute to environmental contamination in sources such as watersheds, food crops, and
       recreational waters.

      Cryptosporidiosis may also be associated with nosocomial (hospital-acquired) infections, sexual
       transmission, or traveler's diarrhea (Casemore, 1990). Cryptosporidium is a primary cause of traveler's
       diarrhea, typically being transmitted through contaminated food or water.  Casemore (1990) observed
       that the severity of disease from  infection is greatest among children less than five years of age and
       among immunocompromised patients.

      Epidemiological  data indicates that immunocompromised populations are at high risk of infection with
       Cryptosporidium oocysts. This increased risk has been  demonstrated in patients undergoing
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       Cryptosporidium: Drinking Water Health Advisory	March 2001

       chemotherapy for cancer (Tanyuksel et al., 1995), patients with AIDS (Clayton et al, 1994), infants and
       children (USEPA, 200la), and the elderly (Logar et al, 1996).

      Cryptosporidiosis is recognized as a significant disease in child care settings (Cordell and Addiss, 1994).
       The 1994 Cryptosporidium Criteria Document discussed the high prevalence of Cryptosporidiosis in
       children and noted that the evidence comes primarily from reports of diarrhea in day-care centers.
       Furthermore, there have been several reports documenting high prevalences of Cryptosporidium in day-
       care settings (Addiss et al., 1991). Additionally, an outbreak was reported in a day camp where 74% of
       the 104 persons attending the camp,  including 72 of the 98 children and 5 of the 6 counselors, showed
       symptoms of Cryptosporidium infection (CDC, 1996a). Additional information regarding
       Cryptosporidiosis in children is provided in "Cryptosporidium: Risk for Infants and Children" (USEPA,
       200 la).

Therapeutic Management

      Cryptosporidiosis is self-limiting in most patients (Griffiths, 1998).  The recommended management of
       Cryptosporidium-infected immunocompromised patients includes careful monitoring of hydration and
       electrolyte balance, with oral  or intravenous hydration and supplemental nutrition as necessary.
       Antimotility agents (e.g., opiates or somatostatin and its analogues) may also be helpful in preventing
       dehydration. Patients co-infected with HIV should continue or begin antiretroviral therapy to suppress
       viral replication and boost CD4+ cell counts.  Patients currently undergoing chemotherapy or
       immunosuppressive therapy should be removed from treatment.

      The most promising development in the treatment of Cryptosporidiosis is associated with the
       introduction in 1996 of protease inhibitors for the treatment of HIV infection.  A decrease in the
       prevalence of intestinal Cryptosporidiosis coindded with the widespread use of protease inhibitors in
       HIV-infected patients (Le Moing et al., 1998).

      The results of other studies suggest that combination antiretroviral therapy that incorporates a protease
       inhibitor provides HIV-infected patients the best chance for changing the course of Cryptosporidiosis
       (Maggi et al, 2000; Miao et al, 1999).

      To date, no chemotherapeutic agents have been consistently effective in the management of
       cryptosporidial infections (Blagburn and Soave, 1997;  O'Donoghue, 1995). Although anecdotal success
       has been reported following treatment with some compounds, most have proven ineffective in controlled
       studies. As many as 100 compounds have been shown to be ineffective for the treatment of
       Cryptosporidiosis; some of the many compounds that have been investigated including spiramycin,
       azithromycin, clarithromycin, roxithromycin, diclazuril, letrazuril, paromomycin, nitazoxanide,
       difluoromethylornithine, and  atovaquone (Blagburn and Soave, 1997).
Immunity
       The importance of cellular immunity in resolving Cryptosporidium infection is highlighted by the
       contrasting ability of immunocompetent and immunocompromised individuals to resolve infections
       (Griffiths, 1998).
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       Cryptosporidium: Drinking Water Health Advisory	March 2001

      Specific IgG, IgM, IgA, and IgE antibodies have been detected in patients with confirmed
       Cryptosporidium infection (Ungar et al., 1986; Casemore, 1987; Laxer etal., 1990; Kassaetal., 1991);
       however, the role of these antibodies in combating infection remains unclear (O'Donoghue, 1995).

      There is also evidence in humans for protective immunity to cryptosporidial infection (Reese et al.,
       1982; Current, 1994;  Okhuysen et al,  1998).  For example, repeat infections in dairy cattle workers
       occur but are generally much milder than the first infection (Reese et al., 1982).  Furthermore,
       permanent residents in areas where cryptosporidiosis is common often acquire mild or asymptomatic
       infections while visitors may become very ill  (Current, 1994).  Okhuysen et al. (1998) reported on the
       rechallenge of human volunteers previously infected with Cryptosporidium. Nineteen healthy,
       immunocompetent adults were challenged with 500 oocysts one year after a primary infection.  Fewer
       study subjects shed oocysts after the second exposure, compared to their first exposure (16% vs. 63%).
       Although the percentage of subjects with diarrhea was similar, the clinical severity, as determined by the
       number of unformed  stools passed, was less following rechallenge compared to the primary challenge
       response. Antibody responses (IgG and IgA) did not correlate to the presence or absence of infection.

Chronic Conditions

      Chronic illness resulting from cryptosporidial infection may manifest itself as a series of intermittent
       episodes or may be persistent. Duration of illness in cryptosporidiosis is influenced primarily by the
       immune status of the  individual, with most immunocompetent individuals overcoming the acute enteritis
       stage within two weeks. Chronic enteritis in immunocompromised individuals may last as  long as the
       immune impairment.

      Immunocompromised populations include AIDS patients, patients undergoing chemotherapy for
       treatment of neoplasms, persons undergoing immune suppression treatment to prevent rejection of skin
       or organ transplants, malnourished individuals, patients with concurrent infectious diseases such as
       measles, the elderly.  A functional threshold has been  established using the number of CD4+
       lymphocytes (a specific type of immune cell) to define the probability that infection will resolve;
       patients with CD4+ counts below 200 cells/ L are most likely to suffer chronic infection (Payer et al.,
       1997 a).

Mechanisms ofPathogenesis

      Only recently have alternative mechanisms of Cryptosporidium pathogenesis been proposed.
       Cryptosporidium sporozoites and merozoites invade the absorptive cells covering the small intestinal
       villi, damaging and eventually killing the enterocytes.  When killed enterocytes are extruded from the
       intestinal epithelium,  crypt cells are signaled to repair the damage.  Additionally, there is infiltration of
       prostaglandin (PGE)  secreting inflammatory cells.  Both crypt cells and PGE are known  to stimulate
       chloride ion secretion; in addition, PGE inhibits sodium chloride absorption (Clark and Sears, 1996).
       This disruption in the absorption/secretion balance can lead to diarrhea (Argenzio et al.,  1993).
       Alternatively, it has been suggested that the diarrhea may be caused by a toxin (Guarino  et al.,  1994;
       GuannoetaL, 1995).
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       Cryptosporidium: Drinking Water Health Advisory	March 2001

V.     Risk Assessment

      Environmental risk assessments based upon exposure to chemical pollutants have historically relied
       upon a conceptual framework generally considered inadequate formicrobial pathogen risk assessment.
       Although most human populations are assumed to be at risk for cryptosporidiosis to at least some
       degree, it has been difficult to collect accurate figures describing the prevalence of infection in humans.
       This is due to limitations in public health reporting systems and to incomplete characterization of oocyst
       speciation and survival under various environmental conditions. Dose-response data obtained from
       human volunteer challenge studies contribute to the ability to quantify the risks associated with
       Cryptosporidium exposure.

      The framework for assessing chemical exposures  does not account for a number of microbial
       considerations including: pathogen-host interactions, secondary spread of microorganisms, short- and
       long-term immunity, the carrier state, host animal reservoirs, animal-to-human transmission, human-to-
       human transmission, and environmental and physiological conditions that encourage propagation of
       microorganisms. Although significant data gaps exist in the complete characterization of the
       pathogenesis of Cryptosporidium, risk assessment approaches will enable health officials to
       communicate with water utilities, interpret water quality surveys, and define the adequacy of treatment
       in terms of acceptable public health risks (Rose et a/., 1997).

Dose-Response Studies

      In an experiment reported by DuPont et al. (1995), among 29 human subjects who were provided 30 or
       more oocysts, 62 % became infected. Acute illness lasted approximately 2.5 to 3.5  days with 4 to 11
       loose stools produced per day.  These findings suggest that human-to-human transmi ssion of C. parvum
       is more likely to occur 2.5 to 3.5 days following infection in the primary case. Linear regression of the
       dose-response data indicated a human ID50 (the infectious dose causing disease in 50% of the
       population) of 132 oocysts.  The authors concluded that a 'low' dose of C. parvum oocysts was
       sufficient to cause infection in healthy adults with no serologic evidence of past infection by this parasite
       (DuPont etal, 1995).

      A number of dose-response studies using monkeys, gnotobiotic lambs and several strains of mice are
       presented  in the 1994 Cryptosporidium Criteria Document.  Casemore (1990) reported a 2- to 5-day
       incubation period for C. parvum and an excretion period of about 8 to 14 days in animals (species not
       identified). DuPont et al.  (1995) reported that the ID50 for the Iowa strain of C. parvum oocysts
       necessary  to infect neonatal mice was 60, or approximately half of the ID50 required to produce infection
       in humans (132 oocysts).  The test strain of C. parvum  in this case, however, was adapted to a mouse
       model prior to challenge studies, and this may account  for the disparity in ID50 values. The relative
       similarity  among infectious doses in mice and humans suggests that such mouse models are potentially
       useful in estimating certain human risks associated with cryptosporidiosis.

      Okhuysen et al. (1999) investigated the infectivily of three geographically diverse isolates (IOWA, UCP,
       and TAMU) of C.  parvum genotype C in healthy  adult volunteers.  The TAMU isolate had significantly
       higher virulence, based on ID50 (9, 87, and 1042 oocysts for the TAMU, IOWA, and UCP isolates,
       respectively) and attack rate (86, 59, and 52% for TAMU, UCP, and IOWA, respectively). In addition,
       the mean time to onset of illness was shorter for the TAMU isolate (5 days vs. 9 to 11  days with the
       other two  isolates), and a trend toward longer duration  of diarrhea was observed in subjects infected with


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       Cryptosporidium: Drinking Water Health Advisory	March 2001

       the TAMU isolate (94.5 hours, compared to 81.6 and 64.2 hours for the UCP and IOWA isolates,
       respectively).

Environmental Factors

      As noted previously, Cryptosporidium oocysts are prevalent in surface waters and are less prevalent in
       ground waters. They are also found more often in waters in areas where animals such as cows are found,
       or where sewage runoff from urban areas occurs.

      Oocysts are resistant to a wide variety of environmental factors (e.g., temperature and chemical
       oxidation). As discussed previously in this report, this resistance, or hardiness, enables oocysts to
       survive outside the host for extended periods of time, thus increasing the chances for the organisms to
       encounter  new hosts.

      The primary route of human infection by C. parvum involves ingestion of contaminated drinking water
       (Casemore, 1990).  One of the primary difficulties in conducting risk assessments for Cryptosporidium
       arises from uncertainties associated with estimated levels of infectious oocysts in drinking water
       supplies.  In addition, most detection methods for Cryptosporidium do not distinguish between viable
       and nonviable oocysts.

      Nahrstedt  and Gimbel (1996) examined the influence of various factors contributing to the uncertainty in
       the determination of Cryptosporidium and Giardia concentrations in water samples.  These factors were
       built into a statistical model, which was designed using experimental data, to provide more accurate
       estimates of oocyst/cyst concentration in a given water body once a sample from that body has been
       analyzed.

Epidemiologic Considerations

      The USEPA estimated in 1993 that approximately 155 million people may be exposed to
       Cryptosporidium in contaminated water every year. It is difficult to accurately estimate valid figures to
       describe the risk  of acquiring cryptosporidiosis, for reasons such as the large number of unreported
       cases, the possibility of asymptomatic infections, and underestimated environmental levels (USEPA,
       1994).  Therefore, there is a disparity between the environmental occurrence data and the clinical data,
       as many unreported cases or asymptomatic cases go unnoticed.

      In the United States, the incidence of cryptosporidiosis often is estimated on the basis of surveill ance
       data and reports of outbreaks that appear in the published literature.  The CDC currently maintains an
       active surveillance system for cryptosporidiosis aimed at collecting information on both outbreaks and
       sporadic cases. While cryptosporidiosis is not a reportable disease in all states (CDC, 1994), it has been
       designated as notifiable at the national level since 1995 (CDC, 1998). It is important to note, however,
       that the CDC's surveillance of cryptosporidiosis is passive, in that the system is dependent upon a
       physician ordering a diagnostic test for Cryptosporidium.  Most of this testing is done on adults who
       have AIDS and, as such, these surveillance data are not an adequate basis for estimating the true
       incidence  of cryptosporidiosis in the United States.

      Groups at  higher risk of exposure and infection to Cryptosporidium include secondary contacts of
       infected individuals, farm workers (Lengerich et a/., 1993), immunocompromised or immune-


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       Cryptosporidium: Drinking Water Health Advisory	March 2001

       suppressed individuals (Heald and Bartlett, 1994), and international travelers to regions where
       cryptosporidiosis is endemic.

      Groups that may experience more severe symptoms if infected with Cryptosporidium include children
       and immunocompromised or immune-suppressed individuals (Molbak et al., 1994; Atherton et al.,
       1995).

Risk Assessment Models

      Several risk models have been developed that assess the probability of cryptosporidiosis infection.
       These models are based upon assumptions concerning the levels of infectious oocysts in drinking water
       and upon the data generated from volunteer challenge studies. The estimated annual risk of waterborne
       cryptosporidiosis based upon these models ranges from 1 in 1,000 to 1 in 100,000 (Haas, 1994; Perz et
       al,  1998).

      An exponential dose-response model developed by Haas (1994) was derived from studies in human
       volunteers conducted by DuPont et al. (1995) and Chappell et al. (1996), and also the Milwaukee
       cryptosporidiosis epidemic (Haas, 1994).  This model describes the probability of infection (P:) given
       exposure: P:=l-e~rN, where r represents the fraction of ingested oocysts that must survive to establish an
       infection and N is the daily exposure to oocysts (i.e., the concentration of oocysts in drinking water
       multiplied by the number of liters of water consumed in a day).  According to the exponential model,
       Cryptosporidium exposure during the Milwaukee epidemic ranged from 0.6 to 1.3 oocysts per liter.
       Haas also applied the risk assessment model to consider data from previous water monitoring studies,
       and reported that the annual risk of contracting cryptosporidiosis in the United States may range  from 4
       in 1,000 to 1 in 100,000.

      Perz et al. (1998) applied a risk assessment approach to examine the role of tap water in waterborne
       cryptosporidiosis.  The model was based upon the assumption that clinical infection results from
       exposure to a single oocyst.  A theoretical C. parvum density in drinking water of 1 oocyst per 1,000
       liters was used.  The number of annual Cryptosporidium infections (Ij) was estimated as: ^ = C  POPj
       Qj   T-, where C is the concentration of C. parvum (oocysts/1 of water), POPj is the number of persons in
       the exposed subgroup, Qj is the  annual water intake in liters per year, j is the population subgroup
       (categorized by age and AIDS status), and rj is single organism infectivity (infection/organism/person).
       The model was applied to derive the median annual risk of infection among immunocompetent
       individuals (1 in 1,000 probability using the assumed exposure level of 1 oocyst per 1,000  liters). The
       dominant parameter contributing to uncertainties in this risk assessment was oocyst concentration (e.g., a
       10-liter sample volume for monitoring is too small to detect concentrations of 1 oocyst per 1,000 liters),
       suggesting that improvements in Cryptosporidium monitoring techniques will  facilitate future risk
       assessment efforts.

      The usefulness of the ILSI Framework for microbial risk assessment was tested by Teunis and Havelaar
       (1999).  They used the Framework to determine the human health risk of C. parvum in an urban
       population obtaining drinking water from a river. In the model, agricultural run-off and a sewage plant
       were contaminating sources and the water was treated conventionally (i.e., coagulation/flotation, and
       filtration and ozonation). Based on the model assumptions and data used, the median yearly individual
       risk of infection resulting from a well performing water treatment process was  calculated as
       approximately 10"6. The authors concluded that the ILSI Framework was a useful tool for defining


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       Cryptosporidium: Drinking Water Health Advisory	March 2001

       information needs and organizing available information in a consistent manner.  Future research needs
       and suggestions for improving the framework were also discussed.

      Haas et al. (1996) used dose-response data on Cryptosporidium to establish waterborne concentrations
       of pathogen that led to various levels of risk.  The concentration of oocysts in finished water for daily
       risks identical to a 1 in 10,000 annual risk of infection is 0.003/1OOL (95% confidence interval 0.0018 -
       0.0064/100L).

Federal Regulations

      Cryptosporidium is regulated by the federal government as a primary drinking water contaminant.  The
       federal regulatory activity associated with Cryptosporidium in drinking water was prompted by the 1996
       Amendments to the Safe Drinking Water Act.  The most significant promulgated and proposed rules are
       the Information Collection Rule (promulgated in 1996) (USEPA, 1996), the Interim Enhanced  Surface
       Water Treatment Rule, and the Long Term I Enhanced Surface Water Treatment and Filter Backwash
       Rule.

      The Information Collection Rule required water utilities serving more than 10,000 people to test source
       water and finished water over an 18-month period (July 1997 to December 1998) (USEPA, 1996). The
       monthly testing included a variety of analytes including coliforms, turbidity, and Cryptosporidium. The
       rule was primarily a research effort and the USEPA is using the information for the development of
       future rules.  The data generated from the Information Collection Rule is now available through
       Envirofacts (http://www.epa.gOv/enviro/html/icr/icr_query.html).

      The Interim Enhanced Surface Water Treatment Rule, promulgated on December 16, 1998 (USEPA,
       1998), applies to water utilities using surface water, or groundwater under the direct influence of surface
       water, and serving more than 10,000 people and was designed to establish physical removal efficiencies
       and to minimize Cryptosporidium levels in finished water. It set a maximum contaminant level goal
       (MCLG) of zero for Cryptosporidium. For systems that filter water during the treatment process, the
       rule requires a minimum 2-log Cryptosporidium removal efficiency. This rule includes
       Cryptosporidium in the watershed control requirement for unfiltered public water systems. The  Agency
       estimates that as a result of the implementation of this rule, the likelihood of endemic illness from
       Cryptosporidium will decrease by 110,000 to 463,000 cases annually. The Agency believes that the rule
       also will reduce the likelihood of the occurrence of outbreaks of cryptosporidiosis by providing  a larger
       margin of safety against such outbreaks for some systems.

      The Long Term I Enhanced Surface Water Treatment and Filter Backwash Rule was proposed April 10,
       2000 (USEPA, 2000) and  should be finalized by late Spring 2001. These provisions apply to smaller
       water systems (i.e., those serving less than 10,000 people) using surface water or groundwater under the
       direct influence of surface water systems. The requirements for the control of Cryptosporidium  are
       similar to those of the Interim Enhances  Surface Water Treatment Rule. The Long Term I Enhanced
       Surface Water Treatment provisions make Cryptosporidium a pathogen of concern for unfiltered
       systems, and such systems must comply  with updated watershed control requirements. The Filter
       Backwash provisions will reduce the potential risks associated with recycling of contaminants removed
       during the filtration process.  These provisions apply to all water systems that recycle water, regardless
       of population served.  Physical removal is critical to the control of Cryptosporidium because it is highly
       resistant to standard disinfection practices.


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       Cryptosporidium: Drinking Water Health Advisory	March 2001


VI.    Analysis and Treatment

Analysis of Water Samples

Collection

      The current standard method for monitoring Cryptosporidium in water is EPA's Method 1622 (USEPA,
       1999).  This sample collection method relies on filtration using a capsule filter followed by
       immunomagnetic separation of the oocysts from the material captured. Before implementation of
       Method 1622, wound yarn filters were the most common filtration system in use; however, the use of
       capsule filters resulted in improved retention of oocysts. Calcium carbonate flocculation methods,
       which can concentrate up to 10 liters of water, have also been shown superior to wound yam filters but
       may interfere with viability determinations.  Centrifugation-based concentration technologies such as
       vortex flow filtration, cross flow filtration, and continuous centrifugation could potentially recover
       greater numbers of oocysts than the currently used methods; however, they require interlaboratory
       validation.  Flow cytometry also shows considerable recovery increases using either seeded or
       environmental samples. However, performance is influenced by water turbidity and composition.

Detection

      To determine oocyst concentrations, Method 1622 requires well slide staining using fluorescently
       labeled monoclonal antibodies and 4',6-diamidino-2-phenylindole (DAPI), and the cells are visualized
       by fluorescence and differential interference contrast (DIG) microscopy (USEPA, 1999). Several
       applications of polymerase chain reaction (PCR) technology have been described for the detection of
       Cryptosporidium., some of which may be able to distinguish viable from nonviable oocysts; however,
       enzymatic inhibition remains problematic.  Laser scanning devices have also performed well in early
       studies. More research is required on this technology.

      Since the determination of Cryptosporidium viability is critical in assessing the public health threat of
       cryptosporidiosis, a number of viability assays have been described and compared to animal infectivity
       models. Some viability assays (e.g., in vitro excystation and vital dye staining) have produced
       conservative estimates of oocyst viability when compared to animal modeling data. Limitations in
       viability assays have precluded their routine use in environmental samples (Black et a/., 1996; Belosevic
       etal, 1997; Jenkins ef a/., 1997).

Analysis of Biological Samples

      The 1994 Cryptosporidium Criteria Document described the increased sensitivity of immunofluorescent
       antibody-based (IF A) procedures, although traditional staining methods such as the Ziehl-Neelsen stain
       are still widely used.  Enzyme immunoassay (EIA) methods are fast, inexpensive, easily performed, and
       show sensitivity approaching that of immunofluorescence methods. However, a lack of confirmatory
       analyses may preclude their routine use. Several molecular techniques including PCR based methods
       have also been developed but are not yet widely used (Filkorn et a/., 1994; Johnson et a/., 1995).
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       Cryptosporidium: Drinking Water Health Advisory
March 2001
Drinking Water

Removal of Cryptosporidium

      Of the technologies available to the drinking water industry, membrane processes (forms of micro- and
       ultra-filtration) appear to provide the most significant levels of Cryptosporidium removal.  Conventional
       treatment practices appear capable of meeting 2-log removals in most of the cases studied to date.
       Although direct filtration and in-line filtration may be expected to be less effective than conventional
       treatment, this has not yet been demonstrated in a conclusive manner. Alternative technologies such as
       diatomaceous earth filtration and slow sand filtration appear capable of achieving comparable, if not
       better, levels of Cryptosporidium removal than conventional treatment.  A comparison of removal
       efficiencies of some bench-, pilot-, and full-scale water treatment processes is presented in Table 3
       below.

        Table 3. Cryptosporidium Removal Efficiencies for Selected Physical and Chemical Processes
Treatment Process Description
Coagulation + Gravity Settling
Coagulation + Filtration
Coagulation + Gravity Settling +
Filtration
Coagulation + Dissolved Air
Flotation
Slow Sand Filtration
Diatomaceous Earth Filtration
Coagulation + Microfiltration
Ultrafiltration
Removal Achieved (log)
Bench Scale
< 1.0a






2.0-2.63




Pilot Scale
1.4- 1.8b
2.7 - 5.9b
2.5- 3. 8h
2.7-2.91*
4.2- 5. 2b
>5.3f
2.1 -2.81*

>3.7C
>4.0C
>6.0d
>6.0d
Full Scale
0.4- 1.7s
1.6-4.06


1.6-4.06
<0.5-3.0f
1.0-2.5





  * Range of average removal efficiencies based on reservoir and river water sources.
  Source: Adapted from Frey et al. (1998)
  References cited by Frey et al. (1998):a Plummer et al, 1995;b Patania et al., 1995;c Schuler et al, 1988;d
  Jacangelo et al, 1995;e Nieminski and Ongerth, 1995;f LeChavallier et al, 1991;8 Kelley et al, 1994;
  h Anderson etal., 1996; and'Nieminski,  1995.

Inactivation of Cryptosporidium
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       Cryptosporidium: Drinking Water Health Advisory	March 2001

      Ozone appears to be the best chemical disinfectant for Cryptosporidium inactivation (Korich, et al.,
       1990; Finch et al., 1997), and chlorine dioxide is the second most effective disinfectant (Peeters, et al.,
       1989; Korich, et al., 1990; Finch et al., 1997, Liyanage, et al., 1997a).  Mixed oxidant and ultraviolet
       light systems appear to be promising, but have only been tested in minimal fashion when compared with
       ozone (Venczel, et al., 1997; Campbell, et al., 1995; Arrowood, et al., 1996).  Also holding some
       promise are the sequential disinfection  systems of ozone followed by chlorine and ozone followed by
       monochloramine (Liyanage et al., 1997b, Finch etal., 1997).

VII.   Research Requirements

      Frey et al. (1998) evaluated the current state of Cryptosporidium research, determined the gaps in the
       data, and assessed future research needs.  This section presents some of the existing needs for research.

Source Water Occurrence

      The source  and occurrence of Cryptosporidium in watersheds has b een characterized, although
       continued improvements in  monitoring methods and analytical techniques would increase our
       understanding  of these issues.  Research to discover specific contamination sources also would
       contribute to public health protection.

Health Effects

      Continued research in drug therapy is important in optimal treatment of Cryptosporidium. There has
       been very little progress in elucidating the pathogenic mechanisms involved in cryptosporidiosis,
       although the EPA-sponsored human infectivity studies should provide useful information.

Risk Assessment

      More information is needed  to better identify and characterize outbreaks, to assess the risks to
       susceptible  populations, and to identify the infectious dose and virulence of Cryptosporidium across
       different populations. In addition, better diagnostic serological methods need to be developed, validated,
       and more serology-based epidemiology studies need to be completed. Risk assessment also would be
       improved by calibration of risk assessment models to make them more precise.

Analysis

      Detection methods continue to be quite variable and the need still exists for a standard method that is
       accurate, precise, quick and  affordable. Many of the newer technologies have not been sufficiently
       validated outside the laboratory. The analysis of large sample volumes still presents a challenge for
       detection. In addition, not enough is known about the basic cell biology of Cryptosporidium. Greater
       knowledge  in this area will not only help in the development of an accurate detection method, but it will
       also advance the improvement of viability, infectivity, and speciation assays for environmental
       Cryptosporidium. Finally researchers are still faced with the challenge of overcoming interferences
       posed by environmental samples for molecular-based techniques.

Drinking Water Treatment
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       Cryptosporidium: Drinking Water Health Advisory	March 2001

      There is a great need for development and evaluation of possible/optimal methods for disinfection and
       removal of Cryptosporidium (e.g., ozonation, UV, improved filtration). In addition, due to concerns
       associated with chlorination byproducts, compounds other than chlorine should be sought as residual
       disinfectants in finished drinking water supplies. Complete evaluation of treatment for oocyst removal is
       dependent on better detection methods and more rigorous enumeration practices. Other gaps in the data
       regarding treatment of drinking water include the usefulness and efficacy of surrogates to determine
       success of treatment, the impact of the treatment process on oocyst viability and survival at the
       molecular level, and guidelines or a decision matrix to assist in treatment selection.

VIII.  References

Adam, A.A., Hassan, H.S., Shears, P., and Elshibly, E. 1994. Cryptosporidium in Khartoum, Sudan. J. E.
African Med., 71:11:745-746.

Adiss, D.G., Stewart, J.M., Finton, R.J., Wahlquist, S.P., Williams, R.M.,Dickerson, J.W., Harrison, S.C., and
Juranek, D.D. 1991. Giardia lamblia and Cryptosporidium infections in child day-care centers in Fulton County
Georgia. Fed. Infect. Dis. I,  10:907-911.

Adegbola, R., Demba, E, De Verr, G., andTodd, J. 1994. Cryptosporidium infection in Gambian children less
than 5 years of age. J. Trop. Med. Hyg., 97:103-107.

Anderson, B.C. 1985. Moist heat inactivation of Cryptosporidium sp. Am. J. Public Health, 75:12:1433-1434.

Anderson, B.C. 1986. Effect  of drying on the infectivity of cryptosporidia-laden calf feces for 3- to 7-day-old
mice. Am. J. Vet. Res., 47:10:2272-2273.

Anderson, W.L., Champlin, T.L., Clunie, W.F.,Hendricks, D.W., Klein, DA., Kregrensin, P., and Sturbaum, G.
1996. Biological particle surrogates for filtration performance evaluation. Proc. AWWA ACE, Toronto,
Ontario, [as cited in Frey et al. (1998)]

Argenzio, R.A., Leece J., and Powell D.W. 1993. Prostanoids inhibit intestinal NaCl absorption in experimental
porcine cryptosporidiosis. Gastroenterol., 104:440-447.

Arrowood, MJ.  1997. Diagnosis. In: Cryptosporidium and Cryptosporidiosis, Payer R (ed), CRC Press, New
York.

Arrowood, M.J., Xie, L.T., Rieger, K., and Dunn, J. 1996. Disinfection of Cryptosporidium parvum oocysts by
pulsed light treatment evaluated in an in vitro cultivation model. J. Eukaryot. Microbiol., 43:5:888.

Atherton, F., Newman, C.,  and Casemore, D.P. 1995. An outbreak of water-borne cryptosporidiosis associated
with a public water supply  in the UK. Epidemiol. Infect., 115:123-131.

Awad-El-Kariem, F.M. 1996. Significant parity of different phenotypic and genotypic markers between human
and animal strains of Cryptosporidium parvum. J. Eukaryot. Microbiol., 43:5:708.
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       Cryptosporidium: Drinking Water Health Advisory	March 2001

Awad-El-Kariem, P.M., Robinson, H.A., Petry, F., McDonald, V., Evans, D., and Casemore, D. 1998.
Differentiation between human and animal isolates of Cryptosporidium parvum using molecular and biological
markers. Parasitol. Res., 84:4:297-301.

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       Cryptosporidium: Drinking Water Health Advisory	March 2001

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