title: Risk of giardiasis from consumption of wilderness water in North America: a systematic review of epidemiologic data.
abstract: OBJECTIVE
  A meta-analytic study was conducted to test the hypothesis that consumption of water from North American backcountry sources poses a statistically significant risk for acquisition of giardiasis.
  
  
  METHODS
  The biomedical literature was surveyed by accessing Medline, and identified studies were supplemented with references in current reviews, published dissertations, and prior communications with state health departments. Studies were classified by methodologic design and subjected to predetermined inclusion criteria. Odds ratios with 95% confidence intervals, chi-squares, and P-values for epidemiologic surveys were either computed from raw data or abstracted directly from the included studies.
  
  
  RESULTS
  Of 104 articles identified in the initial screening, nine met the inclusion criteria. Neither of two case reports met the criteria of the Centers for Disease Control and Prevention (CDC) for waterborne disease outbreak. Two prospective studies were identified, but neither showed a significant association. Of four case-control studies providing data, three reported an odds ratio of greater than one.
  
  
  CONCLUSIONS
  Published reports of confirmed giardiasis among outdoor recreationalists clearly demonstrate a high incidence among this population. However, the evidence for an association between drinking backcountry water and acquiring giardiasis is minimal. Education efforts aimed at outdoor recreationalists should place more emphasis on handwashing than on water purification. Further studies should attempt to separate the specific risk factor of drinking water from backcountry sources from other behaviors among this group that may contribute to the risk.
authors.affiliation: Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112, USA. twelch2@mailhost.tcs.tulane.edu
authors.forename: T P
authors.initials: TP
authors.lastname: Welch
mesh_terms: D000818:Animals; D016022:Case-Control Studies; D004326:Drinking; D005618:Fresh Water / Q000469:parasitology*; D016829:Giardia lamblia / Q000254:growth & development / Q000302:isolation & purification; D005873:Giardiasis / Q000453:epidemiology* / Q000469:parasitology / Q000635:transmission*; D006801:Humans; D016239:MEDLINE; D015201:Meta-Analysis as Topic; D009656:North America / Q000453:epidemiology; D011446:Prospective Studies; D011998:Recreation; D012189:Retrospective Studies; D012307:Risk Factors