The most frequent pathogens associated with parasite-induced diarrhea in the US are Giardia and Cryptosporidium [1-3]. Giardia is the leading cause of human intestinal parasitic infection [4] and has been associated with an estimated 1.2 million cases of foodborne illness [5]. Cryptosporidium is also a major cause of parasite-induced diarrhea [2,3] and has been associated with an estimated ~0.75 million cases of foodborne illness [5]. Cryptosporidium, furthermore, is the leading cause of waterborne outbreaks of parasite-induced diarrhea [6]. Pediatric Giardia and Cryptosporidium infections appear more frequent than commonly perceived in the US and may have therefore been understudied/underreported in the past [7]. Caregivers of children with these parasitic infections may have a low general awareness of the management and treatment of the condition. We have been unable to identify any survey results in the literature that assess the general awareness of Giardia and/or Cryptosporidium among caregivers of pediatric patients. We therefore conducted a survey of caregivers of children ages 1-12 years concerning their perceptions, attitudes, and management with respect to parasitic diarrhea in order to identify potential gaps in their knowledge that might be improved.

Study design

The study was sponsored by Lupin Pharmaceuticals Inc. (Baltimore, MD). Harris Poll Co. (New York, NY) was responsible for the conduct and completion of the online survey, its submission to potential participants, data collection, result tabulation, statistical analysis, and final reporting to the sponsor. The survey was designed by Atom Strategic Consulting, LLC (Randolph, NJ) in collaboration with academic physicians from pediatric infectious disease, pediatric gastroenterology, and epidemiology specialties (The Persistent Diarrhea Working Group) and staff from the Centers of Disease Control and Prevention (CDC) [see Acknowledgments] also provided addition input into the survey’s creation. The survey was conducted by Harris Poll on behalf of Atom Strategic Consulting LLC.

Caregiver survey

The survey was conducted during July 1-14, 2014. Potential survey participants were identified from Harris Poll’s general population database, and were invited to take part via direct e-mail to complete a target quota of 1000 respondents. A total of 141,300 contacts were made to achieve the survey target. Participants were randomly identified sequentially by their response to initial screening questions: they had to be US residents, have ≥ 1 child ages 1-12 years who were living at home, and be the primary caregiver who was also responsible for taking the child/children to the doctor and making medical decisions. Furthermore, children under the care of the caregiver must have had ≥ 1 episode of diarrhea. Those who completed the survey were offered a modest fee for their time.

After the screening questions, survey questions were organized in the following order: general questions about diarrhea experience, treatment approach, persistent diarrhea care, and persistent diarrhea prevention. This was followed specific questions concerning general parasite knowledge, caregiver approach to diarrhea management, and receptivity to treatment. There were a maximum of 42 survey questions that included eight screening questions, five demographic questions, five calibration questions, and 24 questions concerning pediatric diarrhea (causes, definition, treatment, and parasite awareness).

Data analysis

Data were described descriptively as n (%) or mean ± SD for the total respondent cohort and for pre-selected respondent subgroups. These subgroups were defined by response to survey questions: number of children in home (1/ ≥ 2); relationship to child (mother/father/other); heard of Giardia (yes/no); heard of Cryptosporidium (yes/no); children with diarrhea should be allowed to swim, attend school, etc. (yes/no); number of times children had diarrhea ≥ 3 days (0/1/ ≥ 2); receptivity to a 3-day course of treatment (very or somewhat unreceptive/neither receptive nor unreceptive/somewhat or very receptive); and education level (high school or less/college or associate’s degree/college graduate/ postgraduate). Statistical testing (IBM SPSS software) across subgroups was performed using the t-test with P < .05 considered as statistically significant.

Respondent demographics

A total of 1048 caregiver respondents completed the survey. Their demographics are summarized in Table 1. Caregivers were more frequently female (59%) and the mother (55%). Race/ethnicity was White (65%), Hispanic (15%), African American (13%), or other (7%). The number of children in their household was 1 (52%), 2 (34%), or ≥ 3 (15%). Mean caregiver age was 38.4 ± 9.18 years.

Table 1: Caregiver Demographics (N = 1048).

Survey analysis

Results for selected primary survey questions are summarized in Tables 2-4. The denominator for percent calculations is for the total respondents (N = 1048) unless specified otherwise (data missing or subgroup analysis). Multiple choice responses were permissible for some survey questions so the total number of answers exceeded the number of respondents.

Table 2: Definition/burden of pediatric diarrhea.

Table 3: Awareness/management pediatric parasite-induced diarrhea.

Table 4: Treatment of pediatric diarrhea.

Responses with respect to caregiver opinion on the definition and burden of pediatric diarrhea are summarized in Table 2. Approximately two-thirds (64%) of caregivers stated that their children had ever suffered from diarrhea that had lasted > 3 days. Forty-one percent of caregivers responded that their child had experienced repeated problems with diarrhea that is difficult to treat or that lasts for several days. Approximately three-quarters (76%) of caregivers would typically seek medical care from a physician for their child experiencing diarrhea within 1-3 days of onset, infrequently right away (11%) or never (9%), and rarely > 3 days after onset (4%). Approximately threequarters (78%) of caregivers considered that their day-to-day life was somewhat to extremely disrupted when their child had diarrhea. Fiftynine percent considered their child was fairly to extremely distressed when they experienced persistent diarrhea and, of these, 28% were considered very/extremely distressed. With respect to care for a child with persistent diarrhea, almost two-thirds of caregivers (65%) stated they would have to stay at home with their child until they were able to return to normal activity.

Responses with respect to caregiver awareness/management of pediatric diarrhea are summarized in Table 3. The major sources or resources used by caregivers to learn about best care for children with diarrhea were the internet (69%) followed by asking a relative (54%): relatively few caregivers specified their child’s physician (6%) or nurse (4%) when asked to specify any other sources or resources to learn best care. About two-thirds of respondents specified washing their own (75%) or child’s (72%) hands prior to or after risk activities (e.g. food handling, diaper changing, toilet use) with respect to preventative advice or techniques when a child has persistent diarrhea; just over onehalf kept their child away from child-care settings (57%) or did not let their child swim or attend a water park (55%). Most caregivers (42%) did not know whether their pediatrician tested a stool sample if their child had diarrhea, 30% said they did, and 28% said they did not.

Just over one-half of caregivers had not heard of the parasites, Giardia (54%) or Cryptosporidium (60%). Among caregivers who had heard of Giardia and/or Cryptosporidium (n = 430), approximately one-quarter were aware that alcohol-based hand gels and sanitizers did not inactivate Giardia or Cryptosporidium (24%) and that the CDC/ American Academy of Pediatrics (AAP) recommend that children diagnosed with cryptosporidiosis should not swim until 2 weeks after their diarrhea had completely resolved (27%): about one-third of caregivers did not know the answer to either question.

About one-third (37%) of caregivers knew all the five main routes of transmission which were specified in the survey that can lead to Giardia and Cryptosporidium infection and a similar proportion (35%) did not know any of these, with small proportions knowing some of the individual routes of transmission. Subgroup analysis showed that caregivers with some college education or less were significantly (P < .05) more likely than those with a college degree or postgraduate education to not know which activities lead to infection, and those who had heard of Giardia or Cryptosporidium were significantly (P < .05) more likely than those who have not to agree that all five activities can lead to infection. A high proportion of caregivers (85%) did not believe that children with diarrhea should be allowed to swim, go to a water park, or attend school. Among caregivers who had pets in their home (n = 730), 28% were concerned about the possibility of crossinfection between pets and children (or vice versa) during episodes of diarrhea in either children or pets and a similar proportion (27%) were not concerned, with most (45%) not knowing. Subgroup analysis showed that caregivers who had heard of Cryptosporidium or Giardia were significantly (P < 0.05) more likely than those who had not to be concerned about cross-infection between pets and children (or vice versa).

Responses to questions pertaining to treatment of pediatric diarrhea are summarized in Table 4. When asked how they would seek treatment for a child with persistent diarrhea, about one-half (49%) of caregivers would seek medical care from their physician or the doctor’s office and about one-third (32%) would treat using over the counter medications. Typically, they would seek treatment from a doctor or pharmacist on the fourth or fifth day after their child had persistent diarrhea for ≥ 3 days. Most caregivers (83%) had never asked for specific medications to treat their child’s diarrhea. When asked how receptive they would be to have their physician prescribe a 3-day course of medicine to treat their child’s diarrhea even without knowing the diagnosis, just under onehalf of caregivers (43%) would be somewhat or very receptive and onequarter (25%) would be neither receptive nor unreceptive. A higher percentage (58%) of caregivers would be somewhat or very receptive to have their physician prescribe a 3-day course of a liquid medication to treat their child’s diarrhea, 30% would be neither receptive nor unreceptive, and 12% were somewhat or very unreceptive. If there was a medication for treating persistent diarrhea available from their physician, approximately one-half (48%) of caregivers would get this medication to treat their child as soon as possible after the diarrhea starts and about one-quarter (27%) would request more information. Those requesting more information most commonly wanted to know about side effects/risks and when to start/need the medication.

Until the present survey, there would appear to be no published information in the literature concerning awareness of giardiasis and cryptosporidiosis among caregivers of children. Admittedly, the assessment of general awareness about causes of diarrhea in general in children among caregivers of those same children is not well studied. A study published in 2002 assessed parental knowledge of the causes and signs of diarrhea and dehydration [8]. The study also examines parental-care practices during an episode of diarrhea. A wide variation in the level of awareness of signs, causes, and treatment of diarrhea was detected. General knowledge of diarrhea was related positively to accessibility of health information, level of education, ethnicity, and experience with dehydration. The authors concluded that in children, dehydration from diarrhea may be prevented by increasing parents’/ caregivers’ general knowledge of diarrhea and dehydration and the appropriate usage of oral rehydration solutions. Two older studies also assessed parenteral awareness and practices in acute diarrhea but again without focus on parasite induced diarrhea [9,10]. The results of these studies revealed general poor awareness of symptoms or “danger signs” of diarrhea regardless of background and incomplete awareness of solutions available to address diarrhea.

The authors conclude that more aggressive education should be undertaken via emerging mass media and other agencies on recognition and treatment of diarrhea in infants [9].

The current survey results reflect responses from caregivers based in the United States. The consistent finding across all studies, regardless of the decade in which they were conducted, was that awareness of causes, route of transmission, and treatment options of diarrhea were generally not well known by caregivers or parents.

Of particular interest to us was the burden of care to the caregiver who was responsible for the child. The majority of caregivers found their child’s diarrhea to be at least somewhat disruptive (78%). More than half (59%) think the condition is at least fairly distressing for their child. This was markedly different from similar data derived from pediatricians who did not recognize the distress to the child or the burden of care to the caregiver at nearly the same rate as the caregiver noted.

It was encouraging that a larger than anticipated percent of caregivers recognized the need to isolate their affected child from other to prevent the potential for spread. Most caregivers reported that they kept their child at home until the diarrhea resolved either under supervision of the caregiver (65%) or a sitter/other person (17%).

Of concern was the caregiver’s knowledge about transmission prevention. With respect to preventative measures when their child had persistent diarrhea, about three-quarters of caregivers had performed hand washing with soap and water when performing risk activities such as food handing (75%) or toileting (72%). Rigorous hand washing with soap and hot water is a pivotal measure in the control of infectious diarrhea, specifically with respect to parasitic infections such as Giardia and Cryptosporidium among contacts of children with diarrhea [11,12], and this message should receive further emphasis among caregivers. Further with respect to preventative measures, just over half of the caregivers would keep their child away from child-care settings (57%) or stop allowing them to swim or attend a water park (55%) while they still had diarrhea. However, when asked directly whether children with diarrhea should be allowed to swim, go to a water park, or attend school, 85% of caregivers said no. There would therefore appear to be a gap between caregiver knowledge with respect to what they should do and their actual practice.

With respect to questions specifically applying to Giardia and Cryptosporidium, relatively low proportions of caregivers had heard of Giardia (36%) and, less so, Cryptosporidium (28%). Among caregivers who had heard of Giardia and/or Cryptosporidium, there was appeared to be a significant gap in their knowledge concerning awareness that alcohol-based hand gels and sanitizers do not effectively inactivate both Cryptosporidium and possibly Giardia [13]: 41% were unaware of the ineffectiveness of alcohol-based hand gels and sanitizers and 35% did not know whether this infectious disease control method was ineffective towards these parasites.

Giardia infection results from ingestion of fecally contaminated food or water or contact with infected persons or less so with infected animals [14]. Fecal-oral transmission can occur in child-care centers and within households [14]. Child-care center outbreaks have been associated with toddler wading pools where diapered children share the same water. Similar transmission can potentially occur at any water park where contact with contaminated water occurs [15]. Like other enteric infections, rates of giardiasis increase during warmer months [7], likely because of more frequent exposure to contaminated water through swimming or camping. Similarly, Cryptosporidium infection also results following ingestion of fecally contaminated food or water or contact with infected persons or animals [16]. Cryptosporidium is extremely chlorine tolerant and so can survive in a properly chlorinated pool or other treated recreational water venues for more than 10 days [17-19]. This creates a special challenge for outbreaks linked to recreational water such as swimming pools. Like Giardia, Cryptosporidium transmission can also occur at any water park where contact with contaminated water occurs [15,20]. The CDC/AAP recommendation that patients with cryptosporidiosis should abstain from swimming until 2 weeks after their diarrhea had completely resolved [15,21]. The 2-week restriction on swimming also applies to children who have been treated with a 3-day course of nitazoxanide for diarrhea induced by either Giardia or Cryptosporidium [22]. In our survey, even among caregivers who had heard of Giardia and Cryptosporidium, only 25% correctly identified that children with cryptosporidiosis should not swim until 2 weeks after their diarrhea has completely resolved. A more detailed discussion on transmission of Giardia and Cryptosporidium and recommendations on prevention and control of these parasitic infections was recently provided by Painter et al. [14,23].

In conclusion, awareness by caregivers of pediatric diarrhea, and more specifically persistent diarrhea induced by Giardia and Cryptosporidium, appears low, particularly with respect to some important considerations such as ineffectiveness of alcohol-based hand gels and sanitizers, modes of transmission, and restrictions on swimming. A key to minimizing the burden and impact of parasitic infection in the community may lie in the improvement of awareness among caregivers. In particular, education should be directed at appropriate management and treatment of giardiasis and cryptosporidiosis in children with persistent diarrhea. Improved caregiver education with respect to the management and treatment of diarrhea induced by either Giardia or Cryptosporidium in children should be made available using various and appropriate media, particularly via the internet, with reinforcement by all healthcare professionals with whom they come in contact.

We would like to thank Jonathan S. Yoder, MSW, MPH, and Michele Hlavsa, RN, MPH, (Centers for Disease Control and Prevention, Atlanta, GA) for their input into survey creation and Peter Todd, PhD, of Tajut Ltd. (Kaiapoi, New Zealand) for writing assistance.

Funding: Medical writing assistance provided by Peter Todd, PhD, was supported financially by Lupin Pharmaceuticals, Inc. during the preparation of this manuscript. Survey conductance by Harris Poll was supported financially by Lupin Pharmaceuticals, Inc.