Preface

**Section 3 Treatment, Prevention and Public Health 131**

Chapter 8 **Pharmacological Treatment of Giardiasis 133**

Chapter 9 **Risk Assessment for Giardia in Environmental Samples 147**

Tenorio Lourdes Mariana and Leyva-Soto Luis Alonso

Ana Paola Balderrama-Carmona, Gortáres-Moroyoqui Pablo, Morán-Palacio Edgar Felipe, Ulloa-Mercado Ruth Gabriela, Díaz-

Víctor Manuel Molina Díaz

**VI** Contents

Giardiasis is still a significant infectious and parasitic disease, caused by the protozoan *Giardia intestinalis* (syn. *G. duodenalis*, *G. lamblia*). Considered among the pathogens that probably were seen by Leeuwenhoek in 1681, the first descriptions were properly attributed to Vilèm Lambl in 1859. After centuries of advance in its knowledge, today we are aware that at least 8 different genotypes exist, ranging from A to H, being of human significance those included in A and B. However, other genotypes, in addition to other species in the genus, are significantly important in multiple other animal hosts. Among genotypes A and B, there are multiple subgenotypes that are important at the same time in other animals, e.g., dogs and cats, making giardiasis also a zoonotic disease. Although its historical importance, its epidemiology is not well understood, there is still a lack of national prevalence in multiple countries (1,2) and even more of molecular epidemiology identifying such genotypes. Despite that, there are estimates of more than 200 million of cases of giardiasis occurred in the world annually. Among those cases, although in tropical countries the prevalence tends to be higher, giardiasis is globally distributed. Recently its importance in new vulnerable populations has been recognized, which is the case, for example, of pregnant women (3) which are considered increasingly more exposed when visiting giardiasis-prevalent areas (4,5). Even more, in a globalized world, multiple infectious diseases have been linked to its occurrence to climate change and variability, also including giardiasis (5). Then, the advance in research in giardiasis during the last century and particularly during the last decade includes new forms of transmission (e.g., sexual transmission), as well the need for a world congress entirely dedicated to this pathogen (together with *Cryptosporidium*) (International Giardia & Cryptosporidium Con‐ ference, held now in seven occasions) (7).

At clinical level, giardiasis can lead to acute and chronic consequences, e.g., affecting children nu‐ trition and development, as well as causing inflammatory intestinal syndrome and chronic fati‐ gue, among multiple other sequelae (8-10). All these aspects call for the need of accurate and prompt diagnosis in order to provide effective treatments that can be prescribed as monotherapy of combination therapy (11,12).

With these conceptions in mind, this book includes different topics with regard to epidemiology, biology, clinical manifestations, treatment, and prevention, of the wide spectrum of manifesta‐ tions caused by *Giardia* in humans and animals, trying to update the most significant research in many of them as well to offer a multinational perspective on different aspects. This book has been organized in three major sections: 1. "Overview, Epidemiology, and Clinical Aspects," 2. "Biologi‐ cal and Diagnostic Aspects," and 3. "Treatment, Prevention, and Public Health." Section I in‐ cludes topics related to epidemiology and clinical aspects, including particularly the malabsorption syndrome and other aspects in livestock and companion animals. Section II in‐ cludes basic aspects of *Giardia*, such as its cytoskeleton, the endomembrane system, and modern methods for its detection, such as the loop-mediate isothermal amplification. Finally, Section III discusses topics related to pharmacological management of this disease as well as the risk assess‐ ment in the environment.

Commissioning of this book by InTech editorial has been related in part to my long commitment with zoonotic parasitic and tropical diseases, being involved as the Co-Chair of the Working Group on Zoonoses of the International Society for Chemotherapy (WGZ-ISC), as well as in Co‐ lombia at the Committee on Zoonoses, Tropical Medicine and Travel Medicine of the Colombian Association of Infectious Diseases (Asociación Colombiana de Infectología, ACIN). Between 2009 and 2011, I was appointed as director of Population Studies and Epidemiology of national center for population studies in Venezuela (Fundacredesa), which performed the Second National Study of Human Growth and Development, including the survey for *Giardia* and other enteric parasites, which derived in multiple scientific analysis, products, and related publications on this and other protozoans and helminths.

After moving in 2011 to Colombia, I have been involved in research of parasitic diseases in Risaralda, where we still keep working on this important tropical disease. Part of all this is a clear reflect of the work impulse at the Research Group Infection Public Health and Infection of the Faculty of Health Sciences of the Universidad Tecnológica de Pereira, directed by Dr. Guillermo Javier Lagos-Grisales, not just a partner, a colleague, and mainly a friend but an extreme believer in our work in vectorborne and zoonotic diseases. But, I must recognize also the beginning of a significant collaboration after a meeting in Yokohama, Japan, during the International Congress of Chemotherapy, where I met Dr. Angel Arturo Escobedo, from Cuba, also part of the WGZ-ISC, who became since that year my most important collaborator on giardiasis. His work on giardiasis has kept me engaged also in this interesting parasitic disease.

Following the same philosophy as we had on my five previous books with InTech, *Current Topics in Tropical Medicine* (13), *Current Topics in Public Health* (14), *Current Topics in Echinococcosis* (15), *Current Topics in Chikungunya* (16), and *Current Topics in Malaria* (17), this book does not intend to be an exhaustive compilation, and this first edition has included not just multiple different topics but also a wide geographical participation from many countries of different regions of the world. Its on line availability through the website of InTech, as well the possibility to upload the com‐ plete book or their chapters in personal websites and institutions repositories, allows it to reach a wide audience in the globe. Continuing on the series of *Current Topics* books, we are planning to develop in the future other projects such as *Current Topics in Zika* (already in press, coming soon too), *Current Topics in Infectious Diseases*, and *Current Topics in Travel Medicine*.

I would like to give a very special thanks to InTechOpen (for the fourth time), and particularly to Maja Bozicevic and Romina Rovan (Publishing Process Managers), for the opportunity to edit this interesting and important book, as well for their constant support.

I want to take the appropriate time and space, as I used to do, to dedicate this book to my beloved family (Aurora, Alfonso José, Alejandro and Andrea, the neurologist) and particularly to my lovely wife, Diana. After 6 years together, I am so clear she is everything to me. She is the engine of my life. We have gone for difficult moments, partially related to my work, but our love has survived these challenges. And due to her support, projects like this one would be not just possible but suc‐ cessful. She is the highest blessing in my life, my soul mate and my strongest support for any jour‐ ney; she provides everything in my life, day to day. Today, despite all that we have gone together, I cannot imagine my life without her. Also to my friends and my undergraduate and postgraduate students of health sciences in Colombia, Venezuela and around Latin America. Also it is time to say thanks to my colleagues at the Working Group on Zoonoses, International Society for Chemo‐

therapy and the Committee on Zoonoses, Tropical Medicine and Travel Medicine (formerly on Zoonoses and Haemorrhagic Fevers) of the Colombian Infectious Diseases Society (ACIN). Special thanks are given to my friend and colleague Dr. Guillermo J. Lagos-Grisales, MD, MPH. Members of our research group and incubator consist of young and enthusiastic medical students and some veterinary medical students as well young medical doctors, who are pursuing significant improve‐ ments in the understanding of the epidemiology of zoonotic, vector-borne, parasitic and in general, infectious diseases, in our country with international projection. Year 2017 has been highly produc‐ tive for this recognized group, which now is classified by the national agency of science, Colcien‐ cias, in the highest rank "A1," which is positioned as a leader in infectious disease epidemiology research in the coffee-triangle region and in the country.

Finally, I hope our readers enjoy this publication as much as I did reading the chapters of *Current Topics in Giardiasis*.

#### **Prof. Alfonso J. Rodriguez-Morales**

MD, MSc, DTM&H, FRSTMH (Lon), FFTM RCPS (Glasg), FACE, PhD (c) Editor, Current Topics in Giardiasis Part-Time Faculty Instructor, Risk Factors (Epidemiology) (Coordinator) Department of Community Medicine, School of Medicine Lecturer, Frontiers Research, School of Veterinary Medicine & Zootechnics Director of Research, Faculty of Health Sciences, Universidad Tecnológica de Pereira Pereira, Risaralda, Colombia Co-Chair, Working Group on Zoonoses, International Society for Chemotherapy (ISC) Secretary, Colombian Association of Infectious Diseases (ACIN) Member of the Committee on Zoonoses, Tropical Medicine and Travel Medicine, ACIN President, ACIN Chapter Coffee Triangle Region President, Committee on Travel Medicine Pan-American Association of Infectious Diseases Senior Researcher, Colciencias (2017–2019)

#### **References**

discusses topics related to pharmacological management of this disease as well as the risk assess‐

Commissioning of this book by InTech editorial has been related in part to my long commitment with zoonotic parasitic and tropical diseases, being involved as the Co-Chair of the Working Group on Zoonoses of the International Society for Chemotherapy (WGZ-ISC), as well as in Co‐ lombia at the Committee on Zoonoses, Tropical Medicine and Travel Medicine of the Colombian Association of Infectious Diseases (Asociación Colombiana de Infectología, ACIN). Between 2009 and 2011, I was appointed as director of Population Studies and Epidemiology of national center for population studies in Venezuela (Fundacredesa), which performed the Second National Study of Human Growth and Development, including the survey for *Giardia* and other enteric parasites, which derived in multiple scientific analysis, products, and related publications on this and other

After moving in 2011 to Colombia, I have been involved in research of parasitic diseases in Risaralda, where we still keep working on this important tropical disease. Part of all this is a clear reflect of the work impulse at the Research Group Infection Public Health and Infection of the Faculty of Health Sciences of the Universidad Tecnológica de Pereira, directed by Dr. Guillermo Javier Lagos-Grisales, not just a partner, a colleague, and mainly a friend but an extreme believer in our work in vectorborne and zoonotic diseases. But, I must recognize also the beginning of a significant collaboration after a meeting in Yokohama, Japan, during the International Congress of Chemotherapy, where I met Dr. Angel Arturo Escobedo, from Cuba, also part of the WGZ-ISC, who became since that year my most important collaborator on giardiasis. His work on giardiasis has kept me engaged also in

Following the same philosophy as we had on my five previous books with InTech, *Current Topics in Tropical Medicine* (13), *Current Topics in Public Health* (14), *Current Topics in Echinococcosis* (15), *Current Topics in Chikungunya* (16), and *Current Topics in Malaria* (17), this book does not intend to be an exhaustive compilation, and this first edition has included not just multiple different topics but also a wide geographical participation from many countries of different regions of the world. Its on line availability through the website of InTech, as well the possibility to upload the com‐ plete book or their chapters in personal websites and institutions repositories, allows it to reach a wide audience in the globe. Continuing on the series of *Current Topics* books, we are planning to develop in the future other projects such as *Current Topics in Zika* (already in press, coming soon

I would like to give a very special thanks to InTechOpen (for the fourth time), and particularly to Maja Bozicevic and Romina Rovan (Publishing Process Managers), for the opportunity to edit this

I want to take the appropriate time and space, as I used to do, to dedicate this book to my beloved family (Aurora, Alfonso José, Alejandro and Andrea, the neurologist) and particularly to my lovely wife, Diana. After 6 years together, I am so clear she is everything to me. She is the engine of my life. We have gone for difficult moments, partially related to my work, but our love has survived these challenges. And due to her support, projects like this one would be not just possible but suc‐ cessful. She is the highest blessing in my life, my soul mate and my strongest support for any jour‐ ney; she provides everything in my life, day to day. Today, despite all that we have gone together, I cannot imagine my life without her. Also to my friends and my undergraduate and postgraduate students of health sciences in Colombia, Venezuela and around Latin America. Also it is time to say thanks to my colleagues at the Working Group on Zoonoses, International Society for Chemo‐

too), *Current Topics in Infectious Diseases*, and *Current Topics in Travel Medicine*.

interesting and important book, as well for their constant support.

ment in the environment.

VIII Preface

protozoans and helminths.

this interesting parasitic disease.


**Overview, Epidemiology and Clinical Aspects**

[4] Gallego V, Berberian G, Lloveras S, Verbanaz S, Chaves TS, Orduna T, Rodriguez-Mo‐ rales AJ. The 2014 FIFA World Cup: communicable disease risks and advice for visi‐ tors to Brazil--a review from the Latin American Society for Travel Medicine

[5] Almanza C, Escobedo ÁA, Rodríguez-Morales AJ. Giardia infection in foreign visitors

[6] Escobedo AA, Almirall P, Rumbaut R, Rodríguez-Morales AJ. Potential impact of mac‐ roclimatic variability on the epidemiology of giardiasis in three provinces of Cuba,

[7] Escobedo AA, Arencibia R, Vega RL, Rodríguez-Morales AJ, Almirall P, Alfonso M. A bibliometric study of international scientific productivity in giardiasis covering the pe‐

[8] Durán C, Hidalgo G, Aguilera W, Rodriguez-Morales AJ, Albano C, Cortez J, Jiménez S, Díaz M, Incani RN. Giardia lamblia infection is associated with lower body mass in‐dex

[9] Escobedo AA, Almirall P, Cimerman S, Rodríguez-Morales AJ. Sequelae of giardiasis:

[10] Rodriguez-Morales AJ, Franco-Paredes C. Giardia Infections. In: Zhang Y (Editor). En‐ cyclopedia of Global Health. ISBN 9781412941860. SAGE Publications, California, USA, 2008: Volume 2: 739. Available at: http://www.sage-ereference.com/abstract/

[11] Escobedo AA, Lalle M, Hrastnik NI, Rodríguez-Morales AJ, Castro-Sánchez E, Cimer‐ man S, Almirall P, Jones J. Combination therapy in the management of giardiasis: What laboratory and clinical studies tell us, so far. Acta Trop. 2016 Oct;162:196-205. [12] Escobedo AA, Almirall P, Rodríguez-Morales AJ, Duquesne-Rivero E, Suarez-Mella R, Ruiz-Blanco E. Could the Fight Against Treatment Failures in Giardiasis Lead to a Sec‐ ond Childhood for Quinacrine? J Infect Dis. 2017 Aug 3. doi: 10.1093/infdis/jix375. [13] Rodriguez-Morales AJ. (Editor). Current Topics in Tropical Medicine. ISBN 978-953-51-0274-8. InTech, Croatia, March 2012. Available at: http://www.intechop‐

[14] Rodriguez-Morales AJ. (Editor). Current Topics in Public Health. ISBN 978-953-51-1121-4. InTech, Croatia, May 2013. Available at: http://www.intechop‐en.com/books/current-

[15] Rodriguez-Morales AJ. (Editor). Current Topics in Echinococcosis. ISBN 978-953-51-2159-6. InTech, Croatia, September 2015. http://www.intechopen.com/books/current-topics-in-

[16] Rodriguez-Morales AJ. (Editor). Current Topics in Chikungunya. ISBN 978-953-51-2595-2. InTech, Croatia, August 2016. http://www.intechopen.com/books/current-topics-in-

[17] Rodriguez-Morales AJ. (Editor). Current Topics in Malaria. ISBN 978-953-51-2790-1. InTech, Croatia, November 2016. http://www.intechopen.com/books/current-topics-in-

an emerging public health concern. Int J Infect Dis. 2016 Aug;49:202-3.

(SLAMVI). Travel Med Infect Dis. 2014 May-Jun;12(3):208-18.

to Cuba. Travel Med Infect Dis. 2015 Nov-Dec;13(6):505-6.

2010-2012. J Infect Public Health. 2015 Jan-Feb;8(1):80-9.

riod 1971-2010. J Infect Dev Ctries. 2015 Jan 15;9(1):76-86.

values. J Infect Dev Ctries. 2010 Jun 30;4(6):417-8.

en.com/books/current-topics-in-tropical-medicine

globalhealth/n514.xml

X Preface

topics-in-public-health

echinococcosis

chikungunya

malaria

**Provisional chapter**
