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Cases reported by territories were excluded from the analysis, because detailed demographic census data are not available to calculate rates by age and sex. Rates were not calculated for race, ethnicity, or month of onset due to large proportion of missing data for these variables (i.e., 26.1%, 39.6%, and 40.1% respectively). Average annual giardiasis rates were calculated by demographic variables (e.g., age and sex) and jurisdiction. To examine reporting over time, giardiasis rates were calculated by year (2010 to 2019) and case status (confirmed or nonconfirmed). To account for differences in the seasonal use of recreational water, the West region was further subdivided into Northwest and Southwest. In addition to analyzing data nationally and by reporting jurisdiction, data were analyzed by region (Northeast, Midwest, South, and West regions), as defined by the U.S. Region and total population estimates included only jurisdictions that reported (Supplemental Table 1). Census Bureau data were obtained using their Application Programming Interface and the R censusapi package ( 7 вЂ“ 8). Rates were calculated by dividing the number of giardiasis cases by each yearвЂ™s mid-year census estimates ( 6) and multiplying by 100,000. Numbers, percentages, and incidence (cases per 100,000 population) of giardiasis were calculated in aggregate for the United States and separately for each reporting jurisdiction.

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Data cleaning processes included case deduplication and the verification of case status (e.g., confirmed, nonconfirmed). National giardiasis surveillance data for 2019 were analyzed using R version 4.0.3. Cases not classified as confirmed, probable, or suspect are classified as unknown. A national case definition for suspected cases of giardiasis does not exist the definition varies by state. A probable case of giardiasis meets the clinical description and is epidemiologically linked to a confirmed case. Nonconfirmed cases of giardiasis include probable, suspected, and unknown cases. Laboratory-confirmed giardiasis is defined as the detection of Giardia organisms, antigen, or DNA in stool, intestinal fluid, tissue samples, biopsy specimens, or other biological samples ( 5). The current (2011) case definition differs from the 1997 definition in clarifying that clinical symptoms are necessary for categorizing giardiasis cases as confirmed.ДЄ confirmed case of giardiasis is defined as a case that meets the clinical description and the criteria for laboratory confirmation. The definition of a confirmed case of giardiasis has changed over time the first national case definition was published in 1997 ( 4), and a revised case definition was published in 2011 ( 5). NORS data are not presented here however, summaries of data on waterborne disease outbreaks are published elsewhere. State, DC, US territory, and freely associated state public health agencies voluntarily notify CDC of giardiasis outbreaks via the National Outbreak Reporting System (NORS). The number of health departments submitting can vary from year to year depending on which states have designated giardiasis as reportable in their jurisdictions. State and territorial health departments, the District of Columbia (DC), and the New York City health departments, in turn, voluntarily notify CDC of cases via the National Notifiable Disease Surveillance System (NNDSS). Healthcare providers and laboratories that diagnose confirmed giardiasis cases report to the local or state health departments. National data are collected through passive surveillance.

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Giardiasis is a nationally notifiable disease the first full year of reporting was 1993. Each year in the United States, it is estimated that Giardia causes more than 1.1 million illnesses ( 3). intestinalis), which causes gastrointestinal symptoms such as diarrhea, abdominal cramps, bloating, weight loss, or malabsorption ( 1, 2).

Giardiasis is an illness caused by the protozoan parasite Giardia duodenalis (formerly called G.

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