Saturday, September 08, 2012

Backpacker Giardia: Debunking a Skeptical Paper

Water on the Desert Trail: Mexico to Canada
The paper Giardiasis as a threat to backpackers in the United States: a survey of state health departments (Welch TR, Welch TP) contains this statement: Thus, neither health department surveillance nor the medical literature support the widely held perception that giardiasis is a significant risk to backpackers in the United States. In some respects, this situation resembles that recently described by Campbell and Smith in reference to shark attacks [18]: an extraordinarily rare event to which the public and the press have seemingly devoted inappropriate attention.

That conclusion is convincing, misleading, and untrue. In Risk of Giardiasis from Consumption of Wilderness Water in North America: A Systematic Review of Epidemiologic Data, Welch, TP himself says: Published reports of confirmed giardiasis among outdoor recreationists clearly demonstrate a high incidence among this population.

A good example of the laughable research in this paper is this sentence: Giardiasis and similar enteric illnesses in developed nations are overwhelmingly spread by direct fecal-oral or food-borne transmission, not by contaminated drinking water. Verifiable facts from unbiased sources say just the opposite. Giardiasis outbreaks in the United States, 1971–2011 found 98% of individual cases were waterborne, and 2.1% were foodborne or person-to-person.

These are just some of the studies refute the authors' claim that medical literature does not support the perception (waterborne) transmission of giardia for backcountry travelers is a significant risk:

Giardiasis in Colorado: an epidemiologic study
"drinking untreated mountain water is an important cause of endemic infection"

An outbreak of giardiasis in a group of campers
"These surveys show that campers exposed to mountain stream water are at risk of acquiring giardiasis."

Factors associated with acquiring giardiasis in British Columbia residents "the authors concluded that consumption of local water while participating in outdoor activities, such as camping, was associated with a higher risk of giardiasis than in controls who participated in such activities but did not ingest local waters."

Acute Giardiasis: An Improved Clinical Case Definition for Epidemiologic Studies
"an outbreak of waterborne giardiasis occurred in a group of 93 university students and faculty participating in a geology field course in Colorado. All cases occurred in one subgroup of persons who were heavily exposed to untreated stream water on a field trip, and the risk of illness was strongly related to the amount of untreated stream water consumed."

Giardia Prevalence among 1-to-3-Year-Old Children in Two Washington State Counties
 "Significant increases in [giardiasis] prevalence were observed, however, if the child had a history of drinking untreated surface water (from streams or lakes during recreational activities)"
While the EPA, FDA, CDC and the Mayo Clinic say that waterborne giardiasis for backpackers is a concern, this paper claims hygiene is the primary culprit for giardiasis in backpackers while implying there is little if any risk from waterborne transmission. If Drs. Welch or anyone else knows of studies that support that claim, similar to the above, I hope someone will point me to them and I will include a link. I have already debunked the well known Rockwell paper, and part of the paper being discussed now, here.

This paper says: Nineteen of these outbreaks were attributed to consumption of contaminated drinking water; only two outbreaks were reported among individuals identified as campers or backpackers From that it would be easy to conclude that giardia must not be very dangerous to backpackers. However, an outbreak is "the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season." Backpackers are commonly treated for giardiasis, so it rarely gets reported as an outbreak. Why ask a question in a survey which will guarantee misleading results?

"Several backpackers appear weekly at Centinela Mammoth Hospital in Mammoth Lakes sick enough with giardiasis to need urgent care," said Dr. Jack Bertman, an emergency physician, who noted, "We publicize it a great deal more in Mammoth." As rare as shark attack Dr. Welch? How many cases of Giardiasis were reported in that county (Modoc) in 2008-2010? Zero. Including my case. In that single county backpacker giardiasis was, technically, infinitely under-reported.

Actually, approximately 99% of giardiasis cases go unreported (based on official reported figures vs estimated infection rates) By extrapolating reported rates of cases vs unreported, and camper/backpacker outbreaks vs other outbreaks, I come up with a number of 62,000 giardiasis cases a year for waterborne transmission in the backcountry. Fuzzy numbers? Absolutely, but much more reflective of reality that the “2 outbreaks a year” reported in this paper.

This paper says It appears to be common wisdom among outdoor recreationists in the United States that there is widespread fecal contamination of wilderness waters. That common wisdom is proven: (Giardia) Cysts have been found all months of the year in surface waters from the Arctic to the tropics in even the most pristine of surface waters.

Attempting to refute An outbreak of giardiasis in a group of campers the paper says No cysts were identified in suspect water, Well, the water testing filter didn’t work.  Doesn't that seem relevant to mention in a scientific paper?

The paper goes on to say. there was no association between water consumption rates and the likelihood of disease. The authors discounted food or fecal-oral spread, commenting that the former had never been reported. To quote from that paper's abstract: The temporal distribution of cases and the absence of clustering among food preparation subgroups suggested a common source exposure. They discounted food preparation for good reason, because it didn’t correlate to food sharing groups! It DID correlate to one common source, the drinking water. And water consumption rates?? Was there a correlation between food consumption rates and infection? Apparently not. The conclusion of water-borne giardiasis made sense then, and it makes sense now.

There is an even more egregious "mistake" in Giardiasis from Wilderness Water. Citing Giardiasis in Colorado: an epidemiologic study it says Responses indicated that 38% of cases vs 18% of controls had camped overnight in backcountry areas. He ignores the very next line in the abstract to that paper which says and drank untreated mountain water (50% vs. 17%.) There it is, in black and white. The infection rate was TRIPLE for drinking untreated mountain water in this large group. I think it's a great example of confirmation bias and is bad science, at best.

The paper goes on to say: An excellent effort at such a study, however, was recently reported by ZelI and Sorenson [17]. Although 16% of a cohort they studied developed transient gastrointestinal illness following a visit to an area of high use, none developed symptomatic giardiasis. I agree  that it is one of the very best studies of it’s kind. However, what the authors don't say is that one person was empirically diagnosed with giardiasis, was treated, and quickly recovered. Historically, giardiasis was often not detected with a single test. Two more people tested positive for giardia but were asymptomatic at the time of the last test. Many giardiasis cases are asymptomatic. So it is certain at least 5.7% got Giardia, and it seems more than likely that 3 of 35 got giardia, for a total of 8 1/2%. On a SINGLE TRIP. To me, the authors went far beyond a little spin in trying to make a point.

The CDC SPECIFICALLY cited a TR Welch paper and said Although the advice to universally filter and disinfect backcountry drinking water to prevent disease has been debated (62), the health consequences of ignoring that standard water treatment advice have been documented in WBDOSS [Waterborne Disease and Outbreaks Associated with Drinking Water and Water]  In other words, there is documentation, with data, by the Centers for Disease Control and Prevention, that Dr. Welch is wrong.

My conclusion: Giardiasis as a threat to backpackers in the United States: a survey of state health departments is deeply flawed and misleading for the reasons outlined. For backpackers, there is more scientific evidence to support the spread of Giardiasis through water than there is through hygiene. That said, there is good scientific evidence that hygiene plays a significant role in gastrointestinal health for outdoors people. Logic tells me there are some cases of giardiasis in the backpacker community as the result of poor hygiene despite lack of studies to properly support that claim. Having been diagnosed with giardiasis three times, I am treating my water and washing my hands. Others are welcome to make their own risk assessment.
[Note, there are two authors named Dr. Welch who have written on giardiasis. Welch, TR, and Welch, TP. I've attempted to keep them straight in this blog post.]

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