Transmission also occurs sexually by oral-anal contact.
Infection is common in areas with poor sanitation, in mental institutions and in homosexual males.
Infection rates are highest in areas where sanitation is poor. Cases are most common in tropical areas and in institutions where it is difficult to maintain high standards of hygiene. Homosexual males are also at high risk. Most infections do not result in any symptoms. Clinical disease can range in severity from mild stomach discomfort with alternating bouts of diarrhea and constipation to severe diarrhea.