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NAEGLERIA FOWLERI

PATHOGEN SAFETY DATA SHEET - INFECTIOUS SUBSTANCES

SECTION I - INFECTIOUS AGENT

NAME: Naegleria fowleri

SYNONYM OR CROSS REFERENCE: Primary amoebic meningoencephilitis (PAM) Footnote 1, Footnote 2, brain eating amoeba Footnote 3, naegleriasis Footnote 4.

CHARACTERISTICS: The ameboid form of Naegleria fowler is elongated, 15-30 μm, and feeds on Gram-negative bacteria Footnote 4, Footnote 5. The cytoplasm is granular, has a single nucleus with a prominent and contains vacuoles Footnote 6. Blunt lobular pseudopodia are formed at the widest point. The flagellated form is smaller, with a pear shape and two flagellae at the broad end. N. fowleri cysts are round, 7-15 μm in diameter and have a thick smooth double wall Footnote 4, Footnote 5. N. fowleri is thermophilic, preferring water temperatures between 35 and 46ºC Footnote 7.

SECTION II - HAZARD IDENTIFICATION

PATHOGENICITY/TOXICITY: N. fowleri is the causative agent of primary amoebic meningoencephilitis (PAM) Footnote 4, Footnote 5, Footnote 8-Footnote 10. PAM is an acute, fulminating, rapidly fatal disease that is often observed after exposure to fresh water, with symptoms such as sore throat, blocked nasal passages, fever, vomiting, stiff neck, confusion, and abnormal behaviour Footnote 4-Footnote 6, Footnote 11, Footnote 12. Three to four days after the onset of the initial symptoms, mental confusion and coma occur. Death usually occurs 3-4 days after coma. Time from infection to death is 7-10 days Footnote 9. Mortality rate is estimated at greater than 95% Footnote 7.

EPIDEMIOLOGY: Worldwide Footnote 4. The most commonly infected are children, young adult and immunocompetent patients. Between 1996 and 2003 there were 179 cases reported in humans.

HOST RANGE: Humans and animals, including cattle and South American tapir Footnote 11. Experimentally induced infections have been observed in sheep, mice, rabbits, monkeys and guinea pigs Footnote 4, Footnote 12.

INFECTIOUS DOSE: Unknown.

MODE OF TRANSMISSION: N. fowleri enters the nasal passage, carried in contaminated water, while the individual is swimming or diving in freshwater, then penetrates through the mucosal layer and travels along the olfactory nerve to the brain Footnote 5. Once it has reached the brain, N. fowleri will consume erythrocytes and nerve cells, causing damages and inflammation Footnote 9. Ingestion of contaminated water does not lead to PAM Footnote 5.

INCUBATION PERIOD: The first symptoms appear 1-7 days after infection Footnote 4, Footnote 12, and death by PAM may occur 7-10 days after infection Footnote 12.

COMMUNICABILITY: Not transmitted from person-to-person Footnote 4, Footnote 5.

SECTION III - DISSEMINATION

RESERVOIR: N. fowleri has been isolated from fresh water, soil, sewage, sludge, dust Footnote 2, and nasal passages and throats of healthy humans Footnote 6.

ZOONOSIS: None.

VECTORS: None.

SECTION IV – STABILITY AND VIABILITY

DRUG SUSCEPTIBILITY: N. fowleri is susceptible to amphotericin B, which is often used in combination with rifampin, orindazol, miconazol, sulisoxazole, or chloramphenicol Footnote 13. Miltefosine and voriconazole has also been found to be effective against infection Footnote 6.

DRUG RESISTANCE: Resistance of Naegleria spp. has been shown against fluconazole and itraconazole Footnote 14. This area remains a growing concern when repeated doses are administered, especially in endemic regions.

SUSCEPTIBILITY TO DISINFECTANTS: N. fowleri is susceptible to NaCl at concentrations greater then 1%, w/v Footnote 15. N. fowleri is susceptible to chlorine at concentrations of 0.5 and 1.0 mg/L, ozone, and Deciquam 222 Footnote 16.

PHYSICAL INACTIVATION: Heating water to 50ºC for 5 minutes will kill all forms of the amoebae Footnote 17. Both amoeba and cysts can tolerate temperature of 65ºC for 1-3 minutes and temperatures below 20ºC inhibit reproduction Footnote 15. Degradation occurs when temperatures reach below 10ºC. Dehydration is lethal to N. fowleri.

SURVIVAL OUTSIDE HOST: N. fowleri can survive in water at temperature up to 45ºC and at pH 4.6 - 9.5Footnote 5.

SECTION V - FIRST AID / MEDICAL

SURVEILLANCE: Monitor for symptoms. Identification is done by microscopic examination of CSF for presence of amoebic organism Footnote 2, Footnote 4, Footnote 8. Molecular biology techniques such as PCR and real-time PCR have been recently developed for detecting N. fowleri Footnote 18.

Note: All diagnostic methods are not necessarily available in all countries.

FIRST AID/TREATMENT: Treatment of PAM is rarely successful and depends on prompt diagnosis and administration of medication Footnote 9. The usual course of treatment involves amphotericin B administered in combination with rifampin and other antifungals Footnote 13.

IMMUNIZATION: None.

PROPHYLAXIS: None. Recreational waters should maintain effective levels of chlorine to protect against harbouring N. fowleri amoebas Footnote 12.

SECTION VI - LABORATORY HAZARD

LABORATORY-ACQUIRED INFECTIONS: None reported Footnote 10.

SOURCES/SPECIMENS: Water, soil Footnote 11, cerebral spinal fluid, brain and lung tissue, skin, and corneal biopsy material Footnote 2.

PRIMARY HAZARDS: Inhalation of aerosols during manipulation of infectious samples or cultures is the primary hazard associated with N. fowleri Footnote 19.

SPECIAL HAZARDS: None.

SECTION VII - EXPOSURE CONTROLS / PERSONAL PROTECTION

RISK GROUP CLASSIFICATION: Risk group 3.

CONTAINMENT REQUIREMENTS: Containment Level 3 facilities, equipment, and operational practices for work involving infectious or potentially infectious materials, animals, or cultures.

PROTECTIVE CLOTHING: Personnel entering the laboratory should remove street clothing and jewellery, and change into dedicated laboratory clothing and shoes, or don full coverage protective clothing (i.e., completely covering all street clothing). Additional protection may be worn over laboratory clothing when infectious materials are directly handled, such as solid-front gowns with tight fitting wrists, gloves, and respiratory protection. Eye protection must be used where there is a known or potential risk of exposure to splashes Footnote 21.

OTHER PRECAUTIONS: All activities with infectious material should be conducted in a biological safety cabinet (BSC) or other appropriate primary containment device in combination with personal protective equipment. Centrifugation of infected materials must be carried out in closed containers placed in sealed safety cups, or in rotors that are loaded or unloaded in a biological safety cabinet. The use of needles, syringes, and other sharp objects should be strictly limited. Open wounds, cuts, scratches, and grazes should be covered with waterproof dressings. Additional precautions should be considered with work involving animals or large scale activities Footnote 21.

SECTION VIII - HANDLING AND STORAGE

SPILLS: Allow aerosols to settle and, wearing protective clothing, gently cover spill with paper towels and apply an appropriate disinfectant, starting at the perimeter and working towards the centre. Allow sufficient contact time before clean up Footnote 21.

DISPOSAL: Decontaminate all wastes that contain or have come in contact with the infectious organism before disposing by autoclave, chemical disinfection, gamma irradiation, or incineration Footnote 21.

STORAGE: The infectious agent should be stored in leak-proof containers that are appropriately labelled Footnote 21.

SECTION IX - REGULATORY AND OTHER INFORMATION

REGULATORY INFORMATION: The import, transport, and use of pathogens in Canada is regulated under many regulatory bodies, including the Public Health Agency of Canada, Health Canada, Canadian Food Inspection Agency, Environment Canada, and Transport Canada. Users are responsible for ensuring they are compliant with all relevant acts, regulations, guidelines, and standards.

UPDATED: September 2011

PREPARED BY: Pathogen Regulation Directorate, Public Health Agency of Canada.

Although the information, opinions and recommendations contained in this Pathogen Safety Data Sheet are compiled from sources believed to be reliable, we accept no responsibility for the accuracy, sufficiency, or reliability or for any loss or injury resulting from the use of the information. Newly discovered hazards are frequent and this information may not be completely up to date.

Copyright ©

Public Health Agency of Canada, 2011

Canada

REFERENCES:

Footnote 1
Schuster, F. L. (2002). Cultivation of pathogenic and opportunistic free-living amebas. Clinical Microbiology Reviews, 15(3), 342-354.

Footnote 2
Visvesvara, G. S. (2007). Pathogenic and Opportunistic Free-Living Amebae. In P. R. Murray (Ed.), Manual of Clinical Microbiology (pp. 2082). Washington, D.C.: ASM Press.

Footnote 3
Mowbrey, K., & Dacks, J. B. (2009). Evolution and diversity of the Golgi body. FEBS Letters, 583(23), 3738-3745. doi:DOI: 10.1016/j.febslet.2009.10.025

Footnote 4
Acha, N., & Szyfres, B. (2003). Zoonoses. Parasitoses. Protozooses listed I to V (Infections Caused by Free-Living Amabae; Malaria in Nonhuman Primates' Microsporidiosis; Sarcocystosis; Toxoplasmosis; Visceral Leishmanianis). Zoonoses and Communicable Diseases Common to Man and Animals (Third ed., pp. 58-95) Pan American Health Organization.

Footnote 5
Schuster, F. L., & Visvesvara, G. S. (2004). Free-living amoebae as opportunistic and non-opportunistic pathogens of humans and animals. International Journal for Parasitology, 34(9), 1001-1027. doi:10.1016/j.ijpara.2004.06.004

Footnote 6
Visvesvara, G. S. (2010). Amebic meningoencephalitides and keratitis: challenges in diagnosis and treatment. Current Opinion in Infectious Diseases, 23(6), 590-594. doi:10.1097/QCO.0b013e32833ed78b

Footnote 7
Barnett, N. D., Kaplan, A. M., Hopkin, R. J., Saubolle, M. A., & Rudinsky, M. F. (1996). Primary amoebic meningoencephalitis with Naegleria fowleri: clinical review. Pediatric Neurology, 15(3), 230-234.

Footnote 8
Rai, R., Singh, D. K., Srivastava, A. K., & Bhargava, A. (2008). Primary amebic meningoencephalitis. Indian Pediatrics, 45(12), 1004-1005.

Footnote 9
Marciano-Cabral, F., & Cabral, G. A. (2007). The immune response to Naegleria fowleri amebae and pathogenesis of infection. FEMS Immunology and Medical Microbiology, 51(2), 243-259. doi:10.1111/j.1574-695X.2007.00332.x

Footnote 10
Collins, C. H., & Kennedy, D. A. (1999). Endoparasites. Laboratory-acquired Infections: History, incidence, causes, and prevention (4th ed., pp. 253-255). Oxford: Butterworth Heimann.

Footnote 11
Lozano-Alarcon, F., Bradley, G. A., Houser, B. S., & Visvesvara, G. S. (1997). Primary amebic meningoencephalitis due to Naegleria fowleri in a South American tapir. Veterinary Pathology, 34(3), 239-243.

Footnote 12
Schuster, F. L., & Visvesvara, G. S. (2004). Amebae and ciliated protozoa as causal agents of waterborne zoonotic disease. Veterinary Parasitology, 126(1-2), 91-120. doi:10.1016/j.vetpar.2004.09.019

Footnote 13
Schuster, F. L., & Visvesvara, G. S. (2004). Opportunistic amoebae: challenges in prophylaxis and treatment. Drug Resistance Updates: Reviews and Commentaries in Antimicrobial and Anticancer Chemotherapy, 7(1), 41-51. doi:10.1016/j.drup.2004.01.002

Footnote 14
Tiewcharoen, S., Junnu, V., & Chinabut, P. (2002). In vitro effect of antifungal drugs on pathogenic Naegleria spp. The Southeast Asian Journal of Tropical Medicine and Public Health, 33(1), 38-41.

Footnote 15
Marciano-Cabral, F. (1988). Biology of Naegleria spp. Microbiological Reviews, 52(1), 114-133.

Footnote 16
Cursons, R. T., Brown, T. J., & Keys, E. A. (1980). Effect of disinfectants on pathogenic free-living amoebae: in axenic conditions. Applied and Environmental Microbiology, 40(1), 62-66.

Footnote 17
Krauss, H., Weber, A., Appel, M., Enders, B., Isenberg, H. D., Schiefer, H. G., Slenczka, W., von Graevenitz, A., & Zahner, H. (2003). Parasitic Zoonoses. Zoonoses: Infectious Diseases Transmissible from Animals to Humans. (3rd ed., pp. 261-403). Washington, DC.: ASM press.

Footnote 18
Marciano-Cabral, F., & Cabral, G. A. (2007). The immune response to Naegleria fowleri amebae and pathogenesis of infection. FEMS Immunology and Medical Microbiology, 51(2), 243-259. doi:10.1111/j.1574-695X.2007.00332.x

Footnote 19
Chosewood, L. C., & Decaudin, A. (Eds.). (2007). Biosafety in Microbiological and Biomedical Laboratories (5th ed.). Washington: US Government Printing Office.

Footnote 20
Human Pathogens and Toxins Act. S.C. 2009, c. 24. Government of Canada, Second Session, Fortieth Parliament, 57-58 Elizabeth II, 2009, (2009).

Footnote 21
Public Health Agency of Canada. (2004). In Best M., Graham M. L., Leitner R., Ouellette M. and Ugwu K. (Eds.), Laboratory Biosafety Guidelines (3rd ed.). Canada: Public Health Agency of Canada.