If there's one paper that really
made my eye balls pop over the past 30 days, it's the paper appearing a couple of days ago in BMC Infectious
Diseases by Safadi et al. on
Blastocystis in a cohort of
Senegalese children. The paper is open access
and can be downloaded
here. But I'll be jumping right at it:
A 100%
prevalence of Blastocystis in a cohort of 93 Senegalese children!
The children represented a mixed group of children with and without symptoms. And yes, they were all colonised!
|
Are Senegalese children obligate carriers of Blastocystis? Image courtesy of whl.travel. |
I
will not at all try and discuss the potential clinical implications of this. I
don't think we currently have the appropriate tools to ascertain to which
extent a 100% Blastocystis prevalence is a public health problem.
However, technically and scientifically, I'm extremely pleased to see a study like this
one. My group and some of my colleagues have somewhat similar data in the
pipeline, and it's great to see this next generation of survey data emerging
from different regions of the world, based on the use of highly sensitive molecular tools to
screen for Blastocystis. I cannot emphasise the importance of this too much.
The
authors hoovered faecal samples from the children for Blastocystis-specific
DNA using both PCR + sequencing (barcode region) and real-time PCR.
Importantly, quite a few samples negative by barcoding were positive by
real-time PCR, and so if the authors had included only PCR + sequencing,
the prevalence would have been only 75% or so. It may be not very surprising
that barcoding PCR did not pick up all cases of Blastocystis, but then
again, it has always been known that the barcoding PCR is not diagnostic - one
of the primers, RD5, is a general eukaryotic primer, while the other one, BhRDr
is Blastocystis-specific. Also, the PCR product is about 600 bp; diagnostic
PCRs should preferably be designed to produced much smaller amplicons (100 bp or
so) for a variety of reasons.
The
research team subtyped all samples, and found ST3 to be the most prevalent
subtype - colonising about 50% of the children. ST1 and ST2 were also common,
while ST4 was found in only 2 children and only in mixed infections. Mixed subtype infections was seen in 8
cases. Note the small fraction of ST4. This subtype is very common in Europe but
seems to be rare in most other regions.
There
is no doubt that we with molecular tools are now starting to obtain data that
represent a more precise snapshot of reality than before when tools of low
sensitivity and unable to give strain information were used. And while qPCR can
take us a long way in terms of precisely distinguishing positive from negative
samples, we still have an amplification step that may interfere with the DNA
information that we obtain. The French group involved in this study has over
multiple studies done an admirable job in terms of pursuing the extent of
mixed subtype infections. Whether the data are based on sequencing of PCR
products amplified by genus-specific primers, or whether real-time PCR
using genus-specific primers is used, it can still be argued that these
methods have limitations due to application of genus-specific primers in both
cases. It is going to be interesting to compare the evidence that we have
collected from subtyping over the past few years with analysis of metagenomics
data, which are independent of PCR amplification, and thus not subject to
potential bias.
A
100% prevalence means that transmission pressure is massive. Three subtypes are
common. Still, mixed infections are present in less than 10%. If this is indeed
a realistic picture, this may imply that once established, a Blastocystis
strain is capable of keeping other strains at bay? In keeping with waht I said above, it is also possible that the
extent of mixed infections is higher, and that the PCR methods only detect the
more predominant strain, making the prevalence of mixed ST infection seem low.
It's tempting to believe that such a high prevalence of
Blastocystis compared to Europe is due to exposure to contaminated water, but how does this explain a whopping 30%
Blastocystis prevalence
in the background population in Denmark, a country characterised by
supreme hygienic standards and 'perfect plumbing' with all potable water
being pumped up from the ground (ie. hardly no surface water)? Have all
individuals positive for
Blastocystis in Denmark been out traveling to more exotic countries with less well controlled water infrastructures? Or is
Blastocystis just
highly transmissible through e.g. direct contact? And will all who are
exposed develop colonisation? What are the determinants?
It's probably not fair to dismiss the idea of
Blastocystis being waterborne (as one of the modes of transmission) due to the
fact that Blastocystis has not been cause of waterborne outbreaks. If
Blastocystis is non-pathogenic, it can easily be transmitted by water. In fact,
if Blastocystis is waterborne and never gives rise to outbreaks, what does this tell
us about it's pathogenic potential? Well, acute disease such as that seen for some bacteria, viruses, and Cryptosporidium, Giardia and microsporidia is probably not something that is
associated with the organism.
I
could have wished for allele analysis of the subtypes detected. It should be
possible in all cases where barcode sequences were available, - simply and easy
using this online tool. But the data is available in GenBank so everyone
interested can have a look.
There
is plenty of interesting things to address, but for now I'll leave it here, and
on behalf of all of us interested in Blastocystis research just thank the people behind the paper for publishing this important study!
And nope, this is no April Fool!
Literature:
El
Safadi D, Gaayeb L, Meloni D, Cian A, Poirier P, Wawrzyniak I, Delbac
F, Dabboussi F, Delhaes L, Seck M, Hamze M, Riveau G, & Viscogliosi E
(2014). Children of Senegal River Basin show the highest prevalence of
Blastocystis sp. ever observed worldwide. BMC Infectious Diseases, 14 (1) PMID: 24666632