Document Type : Original Article

Authors

1 Ph.D. Candidate in Epidemiology, Department of Epidemiology and Biostatistics, School of Health, Tehran University of Medical Sciences, Tehran, Iran/Research Center of Psychiatry and Behavioral Sciences, Tabriz University of Medical Sciences, Tabriz, Iran

2 Research Center of Psychiatry and Behavioral Sciences, Tabriz University of Medical Sciences, Tabriz, Iran

3 MD, Research Center of Psychiatry and Behavioral Sciences, Tabriz University of Medical Sciences, Tabriz, Iran

4 Department of Disease Control and Prevention, Tabriz University of Medical Sciences, Malekan, Iran

5 Department of Communicable Disease, Tabriz University of Medical Sciences, Tabriz, Iran

Abstract

Background and aims: Experience transfer and the knowledge utilization of rapid and timely outbreak
control can be the key path-finding to health systems (HSs). The aim of this study was to investigate an
Entamoeba histolytica diarrhea outbreak through timely control.
Methods: A case-control study and an environmental survey were conducted to identify the source
of infection and the outbreak etiological agent. Sixty-two confirmed cases in Idahluye Bozorg village,
Iran, and 62 group-matched controls (in terms of age and sex) were selected from the healthy neighbors
of the same village during the same period. Then, multiple logistic regression was applied to calculate
the adjusted odds ratio for diarrhea risk.
Results: Totally, 250 cases were identified by a continuous common source epidemic from January
19th to 31st, 2018. Out of the total 36 stool samples, E. histolytica was detected as the common
organism. In addition, the final analysis indicated that network drinking water (NDW) increased the
odds of diarrhea (16.56, 95% CI = 4.14-64.87), whereas well water and boiling water had protective
effects and decreased the odds of diarrhea by 81% and 66%, respectively.
Conclusion: Overall, the source of infection was detected due to the contamination of underground
NDW by pipe sewage erosion. Therefore, additional monitoring of water systems is necessary,
especially during the summer and regarding full readiness for outbreak control.

Keywords

1. DuPont HL. Acute infectious diarrhea in immunocompetent adults. N Engl J Med. 2014;370(16):1532-40. doi: 10.1056/ NEJMra1301069. 2. Doyle J, Abdelmalak B. Anesthesia for otolaryngologic surgery. Cambridge: Cambridge University Press; 2013. p. 282-7. 
3. Masoumi-Asl H, Kolifarhood G, Gouya MM. The epidemiology of cholera in the Islamic Republic of Iran, 1965-2014. East Mediterr Health J. 2019. doi: 10.26719/emhj.19.051. 
4. Walker CLF, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013;381(9875):1405-16. doi: 10.1016/s0140- 6736(13)60222-6. 
5. Shirley DT, Farr L, Watanabe K, Moonah S. A review of the global burden, new diagnostics, and current therapeutics for amebiasis. Open Forum Infect Dis. 2018;5(7):ofy161. doi: 10.1093/ofid/ofy161. 
6. Ryan KJ, Ray CG. Sherris medical microbiology. 4th ed. McGraw Hill; 2004. p. 733-8. 
7. Haghighi A, Riahi SM, Taghipour A, Spotin A, Javanian M, Mohammadi M, et al. Amoebiasis in Iran: a systematic review and meta-analysis. Epidemiol Infect. 2018;146(15):1880-90. doi: 10.1017/s0950268818001863.
8. World Health Organization (WHO). Guidelines for the collection of clinical specimens during field investigation of outbreaks. Geneva: WHO; 2000. 
9. Delpisheh A, Azizi H, Dantalab Esmaeili E, Haghiri L, Karimi G, Abbasi F. The quality of care and blood sugar control in type ?? Diabetic patients of rural areas under the care by family physicians. Iranian Journal of Diabetes and Metabolism. 2016;14(3):189-98. [Persian]. 
10. Rai KR, Mukhiya RK, Thapa S, Rai G, Kc S, Thapa PM, et al. Diarrheal disease outbreak in Gaidatar village of Rautahat District, Nepal. BMC Res Notes. 2019;12(1):124. doi: 10.1186/s13104-019-4156-9. 
11. Esterhameyan M, Masumi-Asl H, Farsar AR, Shafeie T, Etemad K, Khorrami Z. Diarrhea Outbreak Associated with Drinking Water in Pardis city, Tehran 2014. Community Health. 2018;5(2):113-21. doi: 10.22037/ch.v5i2.17879. 
12. Barati H, Golmohmmadi A, Momeni I, Mpradi G. A cholera outbreak investigation in Karaj district in 2008. Iranian Journal of Epidemiology. 2010;6(3):28-34. [Persian]. 
13. Ranjbar R, Rahbar M, Naghoni A, Farshad S, Davari A, Shahcheraghi F. A cholera outbreak associated with drinking contaminated well water. Arch Iran Med. 2011;14(5):339-40. 
14. Masumi-Asl M, Eshrati B, Hosseini-Asl M, et al. A diarrhea outbreak investigation in Dah Cheshmeh village, Farsancounty, 2014. Iranian Journal of Infectious Diseases and Tropical Medicine. 2005;10(28):11-4. [Persian]. 
15. Chen KT, Chen CJ, Chiu JP. A school waterborne outbreak involving both Shigella sonnei and Entamoeba histolytica. J Environ Health. 2001;64(4):9-13, 26.
16. Barwick RS, Uzicanin A, Lareau S, Malakmadze N, Imnadze P, Iosava M, et al. Outbreak of amebiasis in Tbilisi, Republic of Georgia, 1998. Am J Trop Med Hyg. 2002;67(6):623-31. doi: 10.4269/ajtmh.2002.67.623. 
17. Escolà-Vergé L, Arando M, Vall M, Rovira R, Espasa M, Sulleiro E, et al. Outbreak of intestinal amoebiasis among men who have sex with men, Barcelona (Spain), October 2016 and January 2017. Euro Surveill. 2017;22(30). doi: 10.2807/1560- 7917.es.2017.22.30.30581.
18. Nishise S, Fujishima T, Kobayashi S, Otani K, Nishise Y, Takeda H, et al. Mass infection with Entamoeba histolytica in a Japanese institution for individuals with mental retardation: epidemiology and control measures. Ann Trop Med Parasitol. 2010;104(5):383-90. doi: 10.1179/136485910x1274355476 0388. 
19. Balarak D, Joghatayi A, Jafari Modrek M, Ansari H. The Study of Consumed Vegetables Parasitic Infections in Qom City in 2014: A Short Report. Journal of Rafsanjan University of Medical Sciences. 2016;14(10):895-902. [Persian]. 
20. Zamini G, Hamidi P, Khadem Erfan MB, Faridi A, Ghahramani E, Babaei E. Prevalence of Parasitic Contamination of Raw Vegetables in Sanandaj, Iran, in 2013. Journal of Health Research in Community. 2017;2(4):54-8. [Persian]. 
21. Malaki M, Shoaran M, Bagheri SH, Moazeni S. A 9 year old girl with acute renal failure following entamoeba histolytica infection: a case report (case report). Medical Journal of Tabriz University of Medical Sciences. 2010;32(3):81-3. [Persian]. 
22. Shimokawa C, Kabir M, Taniuchi M, Mondal D, Kobayashi S, Ali IK, et al. Entamoeba moshkovskii is associated with diarrhea in infants and causes diarrhea and colitis in mice. J Infect Dis. 2012;206(5):744-51. doi: 10.1093/infdis/jis414. 
23. Fotedar R, Stark D, Marriott D, Ellis J, Harkness J. Entamoeba moshkovskii infections in Sydney, Australia. Eur J Clin Microbiol Infect Dis. 2008;27(2):133-7. doi: 10.1007/s10096- 007-0399-9. 
24. Ximénez C, Morán P, Rojas L, Valadez A, Gómez A. Reassessment of the epidemiology of amebiasis: state of the art. Infect Genet Evol. 2009;9(6):1023-32. doi: 10.1016/j. meegid.2009.06.008. 
25. Ali IK, Hossain MB, Roy S, Ayeh-Kumi PF, Petri WA Jr, Haque R, et al. Entamoeba moshkovskii infections in children, Bangladesh. Emerg Infect Dis. 2003;9(5):580-4. doi: 10.3201/ eid0905.020548. 26. Leung PO, Chen KH, Chen KL, Tsai YT, Liu SY, Chen KT. Epidemiological features of intestinal infection with Entamoeba histolytica in Taiwan, 2002-2010. Travel Med Infect Dis. 2014;12(6 Pt A):673-9. doi: 10.1016/j.tmaid.2014.04.010. 
27. Pons W, Young I, Truong J, Jones-Bitton A, McEwen S, Pintar K, et al. A systematic review of waterborne disease outbreaks associated with small non-community drinking water systems in Canada and the United States. PLoS One. 2015;10(10):e0141646. doi: 10.1371/journal.pone.0141646. 
28. Petri WA, Haque R Jr. Entamoeba species, including amebiasis. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases. 7th ed. Philadelphia, PA, USA: Churchill Livingstone; 2010. p. 3411e25. 
29. Robilotti E, Powell E, Usiak S, Taur Y, Babady NE, Kamboj M. The Perils of Multiplex Gastrointestinal Pathogen Panels: Pseudo-outbreaks of Salmonellae and Entamoeba histolytica in Immunocompromised Hosts. Infect Control Hosp Epidemiol. 2018;39(7):867-70. doi: 10.1017/ice.2018.95. 
30. Efstratiou A, Ongerth JE, Karanis P. Waterborne transmission of protozoan parasites: Review of worldwide outbreaks - An update 2011-2016. Water Res. 2017;114:14-22. doi: 10.1016/j.watres.2017.01.036.
31. Oyugi EO, Boru W, Obonyo M, Githuku J, Onyango D, Wandeba A, et al. An outbreak of cholera in western Kenya, 2015: a case control study. Pan Afr Med J. 2017;28(Suppl 1):12. doi: 10.11604/pamj.supp.2017.28.1.9477. 
32. Gilchrist CA, Petri SE, Schneider BN, Reichman DJ, Jiang N, Begum S, et al. Role of the Gut Microbiota of Children in Diarrhea Due to the Protozoan Parasite Entamoeba histolytica. J Infect Dis. 2016;213(10):1579-85. doi: 10.1093/infdis/ jiv772. 
33. Ngobeni R, Samie A, Moonah S, Watanabe K, Petri WA Jr, Gilchrist C. Entamoeba Species in South Africa: Correlations With the Host Microbiome, Parasite Burdens, and First Description of Entamoeba bangladeshi Outside of Asia. J Infect Dis. 2017;216(12):1592-600. doi: 10.1093/infdis/jix535.