# Food and Drinking Water as Sources of Pathogenic Protozoans: An Update
## 4 _Cryptosporidium_ spp.
### Epidemiology of Cryptosporidiosis  
According to the GEMS, _Cryptosporidium_ spp. was among the enteric pathogens associated with an increased risk of death in children aged 12-23 months with moderate to severe diarrhea (MSD) and was among the four major pathogens associated with MSD and faltering growth in developing countries. Most cases of cryptosporidosis occurred before the age of two in low-income regions such as rural Western Gambia, Kenya, Mali, and Mozambique [116,117] confirming the results of a multisite birth cohort community-based study the MAL-ED (Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project, [[https://www.fic.nih.gov/About/Staff/Pages/mal-ed.aspx#:-text=Etiology](https://www.fic.nih.gov/About/Staff/Pages/mal-ed.aspx#:-text=Etiology)]([https://www.fic.nih.gov/About/Staff/Pages/mal-ed.aspx#:-text=Etiology](https://www.fic.nih.gov/About/Staff/Pages/mal-ed.aspx#:-text=Etiology)), %20 Risk%20 Factors%20 and%20 Interactions,infections%20 and%20 their%20 effects%20, accessed on 4 April 2024) for eight countries of Africa, Asia, and South America [114]. The Global Burden of Disease Study (GBD) in 2016 listed _Cryptosporidium_ as the fifth leading cause of diarrhea in children younger than five years, accounting for more than 57,000 deaths and more than 12.9 million disability-adjusted life years (DALYs) considering growth impairment and increased risk of subsequent infectious diseases [113]. In southwest Ethiopia, diarrhea caused by _Cryptosporidium_ in children younger than two years was strongly associated with malnutrition [118]. In studies carried out in Cameroon [101], Egypt, and Iraq [119], it was found that breastfeeding was protective against _Cryptosporidium_ infection in children within six months, and for a cryptosporidiosis outbreak in Botswana, hospitalization and mortality in children were associated primarily with non-breakfeeding. However, breastfeeding for more than two years was found to be a risk factor for pediatric cryptosporidiosis in Malaysia [101]. Cryptosporidiosis was more frequent over the age of two in industrialized nations, probably because exposure occurs later as a consequence of better hygienic conditions [28]. In many of these countries, _Cryptosporidium_ was recognized as a relevant human pathogen with consequent improvement in surveillance. In 2016, _Cryptosporidium_ spp. were ranked as the foodborne parasite of second-highest priority in northern and western Europe and the eighth-highest-priority foodborne parasite in eastern and southwestern Europe by the European Network for Foodborne Parasites (Euro-FBP) [120]. Cryptosporidiosis became a notifiable disease in the year 2000 in Canada [89], in Ireland and Sweden in 2004, and in the UK in 2010 [90,100]. Foodborne _Cryptosporidium_ infections are mandatorily notifiable in the UK [90]. In Sweden, the incidence of human cryptosporidiosis increased from 0.8 cases/100,000 inhabitants in 2005 to 6.8 cases/100,000 inhabitants in 2022, possibly as a consequence of using molecular diagnostic tools and increased awareness after two large waterborne outbreaks that occurred in 2010 and 2011 [100]. In France, reporting is not mandatory, but the National Reference Center-Expert Laboratory (CNR-LE) monitored the national epidemiology of cryptosporidiosis since 2017 on the basis of private laboratory reporting from the entire French territory [90]. Proactive monitoring led to an increase in outbreak reports, with 11 outbreaks caused by drinking water and food identified in France and French Guiana from 2017 to 2020 [9]. In the Netherlands, cryptosporidiosis is not a notifiable disease and no surveillance program exists, but after a large increase in cryptosporidiosis cases in 2012, _Cryptosporidium_ infections were better monitored in the country with the participation of private laboratories [121].