# Food and Drinking Water as Sources of Pathogenic Protozoans: An Update
## 4 _Cryptosporidium_ spp.
### Cryptosporidium _spp. in Food_  
Until 2020, more than 40 foodborne cryptosporidiosis outbreaks were documented worldwide. Unpasteurized milk, unpasteurized apple cider, and salads were among the foods most commonly implicated [113; 127]. Until 2000, most foodborne outbreaks of cryptosporidiosis were reported in the USA and UK, while later, most cryptosporidiosis outbreaks were related to fresh produce and were reported in Sweden, Denmark, and Norway [127]. A systematic review and a meta-analysis revealed significant associations of cryptosporidiosis with meat and dairy foods for the mixed population and with composite foods for children. The association of cryptosporidiosis with raw milk was significant for both the mixed population and children. Moreover, associations with cryptosporidiosis were observed for barbecued foods, meat of non-specified origin, except beef, and dishes prepared outside the home. The association with dishes prepared outside the home and barbecued foods could be linked to contamination by an infected handler. The association with meat could reflect fecal contamination of carcasses during the slaughter process though _Cryptosporidium_ spp. was isolated from animal feces but not from carcasses [128]. In a retrospective study carried out in China, eating raw foods was found to increase the prevalence of cryptosporidiosis, despite the absence of reports of foods contaminated with _Cryptosporidium_ oocytes in the country [124]. A 3-year case-control study involving 17 regional laboratories in the Netherlands led to the identification of hundreds of cases each year with a predominance of _C. parvum_ infections. In the first and third years, foodborne transmission cases were more likely to have had a picnic or barbeque. In the second year, no association with dietary routes was found, while in the third year, cases were associated with drinking water sources other than tap water [121]. In Quebec, from 2016 to 2017, confirmed cases of cryptosporidiosis were linked to raw vegetables (nine cases), raw fruits (eight cases), unpasteurized drinks (six cases), raw herbs (one case), and raw shellfish (one case), with the majority of cases attributed to _C. parvum_ subtypes IIaA15G2R1, IIaA16G3R1, and IIaA16G2R1 [89]. In France from 2017 until 2019, 36 cases were caused by shellfish and 6 by farm cider [90]. Outbreaks of cryptosporidiosis from unpasteurized milk occurred in the USA, Australia, and the UK before 2020 [90; 113], and _C. parvum_ was listed among the microbiological hazards potentially transmissible through milk in the EU [129; 130]. In France, 180 cases were attributed to unpasteurized milk in 2017-2019 [90]. In the same country, _C. parvum_ IIaA15G2R1 caused an outbreak linked to unpasteurized curd cheese and an outbreak from contaminated milk. The contaminated dairy foods could not be analyzed, but _C. parvum_ subtype IIaA15G2R1 was isolated from calves in the dairy farms of origin [9]. Pasteurized milk caused an outbreak involving _C. parvum_ subtype IIaA19G1R1 in England because of post-pasteurization contamination of the vending machine placed in the producing farm. Multiple locus variable number of tandem repeats (MLVA) profiling showed that isolates from two patients and one calf in the farm were identical. Indeed, _C. parvum_ is a common cause of enteritis in calves and its oocysts can persist in the farm environment even after cleaning and disinfection. Since bacteriological indicators of post-pasteurization contamination were not eliminated by sanitization of the vending machine, the authors warned that vending machines on-farm represent a public health concern [131]. Apple juice was the cause of cryptosporidiosis outbreaks in the USA, France, and Norway [90; 132]. In the latter country, _C. parvum_ subtype IIaA14G1R1 caused illnesses among employees who consumed unpasteurized apple juice from the same container. After inspecting the producing farm, it was inferred that contamination came from a few apples accidentally dropped during collection.