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Cryptosporidium accounted for 77.4% (322) of outbreaks, while Giardia was identified as the etiological agent in 17.1% (71). Toxoplasma gondii and Naegleria fowleri were the primary causes in 1.4% (6) and 1% (4) of outbreaks, respectively. Blastocystis hominis, Cyclospora cayetanensis, and Dientamoeba fragilis were independently identified in 0.72% (3) of outbreaks. Moreover, Acanthamoeba spp., Entamoeba histolytica, Vittaforma corneae, and Enterocytozoon bieneusi were independently the causal agents in 0.24% (1) of the total outbreaks. The majority of the outbreaks (195, 47%) were reported in North America. The suspected sources for 313 (75.2%) waterborne parasitic outbreaks were recreational water and\/or swimming pools, accounting for 92% of the total Cryptosporidium outbreaks. Furthermore, 25.3% of the outbreaks caused by Giardia were associated with recreational water and\/or swimming pools. Developing countries are most likely to be impacted by such outbreaks due to the lack of reliable monitoring strategies and water treatment processes. There is still a need for international surveillance and reporting systems concerning both waterborne diseases and water contamination with parasitic protozoa.<\/jats:p>","DOI":"10.2166\/wh.2023.094","type":"journal-article","created":{"date-parts":[[2023,9,4]],"date-time":"2023-09-04T16:17:25Z","timestamp":1693844245000},"page":"1421-1447","update-policy":"https:\/\/doi.org\/10.2166\/iwapcrossmarkpolicypage","source":"Crossref","is-referenced-by-count":114,"title":["Waterborne transmission of protozoan parasites: a review of worldwide outbreaks \u2013 an update 2017\u20132022"],"prefix":"10.2166","volume":"21","author":[{"given":"Pavlina","family":"Bourli","sequence":"first","affiliation":[{"name":"a School of the Environment, Department of Marine Sciences, University of the Aegean, University Hill, Mytilene, Lesvos 81100, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aida Vafae","family":"Eslahi","sequence":"additional","affiliation":[{"name":"b Medical Microbiology Research Center, Qazvin University of Medical Sciences, Qazvin, Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ourania","family":"Tzoraki","sequence":"additional","affiliation":[{"name":"a School of the Environment, Department of Marine Sciences, University of the Aegean, University Hill, Mytilene, Lesvos 81100, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0733-0470","authenticated-orcid":false,"given":"Panagiotis","family":"Karanis","sequence":"additional","affiliation":[{"name":"c Medical Faculty and University Hospital, University of Cologne, Cologne, Germany"},{"name":"d Medical School, Department of Basic and Clinical Sciences, Anatomy Centre, University of Nicosia, Nicosia, Cyprus"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"945","published-online":{"date-parts":[[2023,9,4]]},"reference":[{"key":"key-10.2166\/wh.2023.094-1","doi-asserted-by":"publisher","DOI":"10.1016\/j.fawpar.2021.e00142"},{"key":"key-10.2166\/wh.2023.094-2","doi-asserted-by":"publisher","DOI":"10.1016\/j.rvsc.2020.10.019"},{"key":"key-10.2166\/wh.2023.094-3","doi-asserted-by":"publisher","DOI":"10.3390\/microorganisms7090317"},{"key":"key-10.2166\/wh.2023.094-4","doi-asserted-by":"publisher","DOI":"10.1016\/B978-0-12-409548-9.10899-1"},{"key":"key-10.2166\/wh.2023.094-5","doi-asserted-by":"publisher","DOI":"10.1016\/j.saa.2021.120475"},{"key":"key-10.2166\/wh.2023.094-6","doi-asserted-by":"publisher","DOI":"10.1016\/j.watres.2011.10.013"},{"key":"key-10.2166\/wh.2023.094-7","doi-asserted-by":"publisher","DOI":"10.1186\/s13071-015-1026-8"},{"key":"key-10.2166\/wh.2023.094-8","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.mm6644a3"},{"key":"key-10.2166\/wh.2023.094-9","doi-asserted-by":"publisher","DOI":"10.3389\/fcimb.2020.00401"},{"key":"key-10.2166\/wh.2023.094-10","first-page":"441","article-title":"Recreational water risk: pathogens and fecal indicators","volume-title":"Environmental Toxicology: Selected Entries from the Encyclopedia of Sustainability Science and Technology","author":"Boehm","year":"2012"},{"key":"key-10.2166\/wh.2023.094-11","doi-asserted-by":"publisher","DOI":"10.1016\/j.meegid.2021.104859"},{"key":"key-10.2166\/wh.2023.094-12","doi-asserted-by":"publisher","DOI":"10.3201\/eid2612.200227"},{"key":"key-10.2166\/wh.2023.094-13","unstructured":"Centers for Disease Control and Prevention (CDC). 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