Sources of Infection & Risk Factors

Naegleria fowleri is a free-living ameba that causes primary amebic meningoencephalitis (PAM), a disease of the central nervous system.^{1, 2} PAM is a rare disease* that is almost always fatal. In the United States,** there have been 157 PAM infections from 1962 through 2022 with only four survivors. These infections have primarily occurred in southern-tier states, with almost half of all infections occurring in Texas and Florida. PAM also disproportionately affects males and children. The reason for this distribution pattern is unclear but may reflect the types of water activities (such as diving or watersports) that might be more common among young boys.³

For figures and tables representing information on cases of PAM that occurred from 1962 through 2022, visit Publications, Data, & Statistics.

Naegleria fowleri is a heat-loving (thermophilic) ameba found around the world ^1, ². Naegleria fowleri grows best at higher temperatures up to 115°F (46°C) and can survive for short periods at higher temperatures ^3, ⁴. Naegleria fowleri is naturally found in warm freshwater environments such as lakes and rivers ^5-9, naturally hot (geothermal) water such as hot springs ¹⁰, warm water discharge from industrial or power plants ^{11, 12}, geothermal well water ^{13, 14}, poorly maintained or minimally chlorinated swimming pools ¹⁵, water heaters ¹⁶, and soil ⁵, where it lives by feeding on bacteria and other microbes in the environment. Sampling of lakes in the southern tier of the United States indicates that Naegleria fowleri is commonly present in many southern tier lakes in the United States during the summer ^5-9 but infections have also recently occurred in northern states ¹⁷. Naegleria is not found in salt water, like the ocean.

References

Marciano-Cabral F, Cabral G. The immune response to Naegleria fowleri amebae and pathogenesis of infection. FEMS Immunol Med Microbiol.2007;51:243-59.
Visvesvara GS. Free-living amebae as opportunistic agents of human disease. J Neuroparasitol. 2010;1.
Griffin JL. Temperature tolerance of pathogenic and nonpathogenic free-living amoebas. Science. 1972;178(4063):869-70.
Chang SL. Resistance of pathogenic Naegleria to some common physical and chemical agents. [PDF – 8 pages] Appl Environ Microbiol. 1978;35:368-75.
Maclean RC, Richardson DJ, LePardo R, Marciano-Cabral F. The identification of Naegleria fowleri from water and soil samples by nested PCR. Parasitol Res. 2004;93(3):211–17.
Wellings FM, Amuso PT, Chang SL, Lewis AL. Isolation and identification of pathogenic Naegleria from Florida lakes. Appl Environ Microbiol. 1977;34:661–7.
John DT, Howard MJ. Seasonal distribution of pathogenic free-living amebae in Oklahoma waters. Parasitol Res. 1995;81(3):193–201.
Duma RJ. Study of pathogenic free-living amebas in fresh-water lakes in Virginia. EPA Publication. 1980;EPA-PB-126369, Summary, 1981 is EPA-600/S1-80-037.
Ettinger MR, Webb SR, Harris SA, McIninch SP, C Garman G, Brown BL. Distribution of free-living amoebae in James River, Virginia, USA. Parasitol Res. 2003;89(1):6-15.
Sheehan KB, Fagg JA, Ferris MJ, Henson JM. PCR detection and analysis of the free-living amoeba Naegleria in hot springs in Yellowstone and Grand Teton National Parks. Appl Environ Microbiol. 2003;69:5914-8.
Sykora JK, Keleti G, Martinez AJ. Occurrence and pathogenicity of Naegleria fowleri in artificially heated waters. Appl Envion Microbiol. 1983;45(3):974-9.
Stevens AR, Tyndall RL, Coutant CC, Willaert E. Isolation of the etiological agent of primary amoebic meningoencephalitis from artificially heated waters. Appl Environ Microbiol. 1977;34(6):701-5.
Marciano-Cabral F, MacLean R, Mensah A, LaPat-Polasko L. Identification of Naegleria fowleri in domestic water sources by nested PCR. Appl Environ Microbiol. 2003;69(10):5864-9.
Blair B, Sarkar P, Bright KR, Marciano-Cabral F, Gerba CP. Naegleria fowleri in well water. Emerg Infect Dis. 2008;14(9):1499-501.
Yoder JS, Eddy BA, Visvesvara GS, Capewell L, Beach MJ. The epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008. Epidemiol Infect. 2010;138(7):968-75.
Yoder JS, Straif-Bourgeois S, Roy SL, Moore TA, Visvesvara GS, Ratard RC, Hill V, Wilson JD, Linscott AJ, Crager R, Kozak NA, Sriram R, Narayanan J, Mull B, Kahler AM, Schneeberger C, da Silva AJ, Beach MJ. Deaths from Naegleria fowleri associated with sinus irrigation with tap water: a review of the changing epidemiology of primary amebic meningoencephalitis. Clin Infect Dis. 2012;1-7.
Kemble SK, Lynfield R, DeVries AS, Drehner DM, Pomputius WF 3rd, Beach MJ, Visvesvara GS, da Silva AJ, Hill VR, Yoder JS, Xiao L, Smith KE, Danila R. Fatal Naegleria fowleri infection acquired in Minnesota: possible expanded range of a deadly thermophilic organism. Clin Infect Dis. 2012;54:805-9.

N=157
State of exposure unknown for 4 cases.
Map does not picture 1 case from the U.S. Virgin Islands.

PAM infections have been reported from around the world ¹^,². Infections have primarily occurred in southern-tier states in the United States ³, but infections were documented in Minnesota in 2010 and 2012 ⁴ and other northern states since that time. Almost half of all reported infections have occurred in Florida and Texas. In the United States and the rest of the world, PAM is primarily spread by swimming in warm freshwater lakes and rivers (about 70% of U.S. infections from 1962 through 2022) ³. Other recreational water types like hot springs and canals have also been linked to PAM infections ³.

Seven infections in the United States have been associated with water from drinking water systems. In these cases, people got infected from swimming, using a slip-n-slide, putting their head underwater in a bathtub, using a neti pot for nasal irrigation, or performing ritual nasal rinsing or ablution. PAM infections also occurred in the 1970s and 1980s in Australia ⁹^,¹⁰ that were linked to showering, swimming, or having other nasal exposure to contaminated drinking water. The infections were linked to piping drinking water overland, sometimes for hundreds of kilometers, which raised water temperatures, lowered disinfectant levels, and allowed Naegleria fowleri to grow and thrive. Several water systems in the states of Western Australia and South Australia continue to monitor regularly for Naegleria fowleri colonization in drinking water distribution systems ¹¹. Infections from contaminated water used for religious practices ^{8, 12} have also been reported.

References

Marciano-Cabral F, Cabral G. The immune response to Naegleria fowleri amebae and pathogenesis of infection. FEMS Immunol Med Microbiol. 2007;51:243-59.
Visvesvara GS. Free-living amebae as opportunistic agents of human disease. J Neuroparasitol. 2010;1.
Yoder JS, Eddy BA, Visvesvara GS, Capewell L, Beach MJ. The epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008. Epidemiol Infect. 2010;138(7):968-75.
Kemble SK, Lynfield R, DeVries AS, Drehner DM, Pomputius WF 3rd, Beach MJ, Visvesvara GS, da Silva AJ, Hill VR, Yoder JS, Xiao L, Smith KE, Danila R. Fatal Naegleria fowleri infection acquired in Minnesota: possible expanded range of a deadly thermophilic organism. Clin Infect Dis. 2012;54:805-9.
Marciano-Cabral F, MacLean R, Mensah A, LaPat-Polasko L. Identification of Naegleria fowleri in domestic water sources by nested PCR. Appl Environ Microbiol. 2003;69(10):5864-9.
Cope JR, Ratard RC, Hill VR, Sokol T, Causey JJ, Yoder JS, Mirani G, Mull B, Mukerjee KA, Narayanan J, Doucet M, Qvarstrom Y, Poole CN, Akingbola OA, Ritter JM, Xiong Z, da Silva A, Roellig D, Van Dyke R, Stern H, Xiao L, Beach MJ. The first association of a primary amebic meningoencephalitis death with culturable Naegleria fowleri in tap water from a U.S. treated public drinking water system. Clin Infect Dis. 2015;doi:10.1093/cid/civ017.
Yoder JS, Straif-Bourgeois S, Roy SL, Moore TA, Visvesvara GS, Ratard RC, Hill V, Wilson JD, Linscott AJ, Crager R, Kozak NA, Sriram R, Narayanan J, Mull B, Kahler AM, Schneeberger C, da Silva AJ, Beach MJ. Deaths from Naegleria fowleri associated with sinus irrigation with tap water: a review of the changing epidemiology of primary amebic meningoencephalitis. Clin Infect Dis. 2012;1-7.
CDC. Primary amebic meningoencephalitis associated with ritual nasal rinsing — St. Thomas, U.S. Virgin Islands, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(45):903.
Anderson K, Jamieson A. Primary amoebic meningoencephalitis. Lancet. 1972;1:902–3.
Dorsch MM, Cameron AS, Robinson BS. The epidemiology and control of primary amoebic meningoencephalitis with particular reference to South Australia. Trans R Soc Trop Med Hyg. 1983;77:372-7.
Puzon GJ, Lancaster JA, Wylie JT, Plumb IJ. Rapid detection of Naegleria fowleri in water distribution pipeline biofilms and drinking water samples.Environ Sci Technol. 2009;43(17):6691-6.
Shakoor S, Beg MA, Mahmood SF, Bandea R, Sriram R, Noman F, Ali F, Visvesvara GS, Zafar A. Primary amebic meningoencephalitis caused by Naegleria fowleri, Karachi, Pakistan. [PDF - 4 pages] Emerg Infect Dis. 2011:17;258-61.

PAM is a rare* disease. From 1962 through 2022, 157 infections in the United States have been reported to CDC. Other infections have been diagnosed in stored autopsy samples dating back to 1937 ¹. The annual number of U.S. infections ranges from 0 to 8, with higher numbers appearing to occur in heat wave years when air and water temperatures are higher. It does not appear that the number of infections has increased since CDC established its Free-living Ameba (FLA) Laboratory and PAM registry in 1978.

References

SN Gustavo. Fatal primary amebic meningoencephalitis. A retrospective study in Richmond, Virginia. Am J Clin Pathol. 1970;54:737-42.

You cannot get infected from drinking water contaminated with Naegleria. You can only be infected when contaminated water goes up into your nose.

People become infected when water containing Naegleria fowleri enters the nose, usually while swimming. People do not get infected by drinking contaminated water. The ameba migrates to the brain along the olfactory nerve, through a bony plate in the skull called the cribriform plate, where it reaches the brain and begins to destroy the brain tissue ^1,2. There is no evidence that Naegleria fowleri spreads via water vapor or aerosol droplets (such as shower mist or vapor generated from a humidifier). There is also no evidence that the ameba spreads from one person to another.

Organ transplants from donors infected by Naegleria fowleri have been recorded, but none of the organ recipients became infected ^3-5. However, the occurrence of Naegleria fowleri outside the brain has been observed; Naegleria fowleri has been documented in tissue sections of lung, kidney, heart, spleen, and thyroid from two deceased PAM cases ⁶. Therefore, transmission of Naegleria fowleri by donor organs is likely possible, though the risk is still unknown. The risks of transplanting an organ possibly harboring Naegleria fowleri should be carefully weighed for each individual organ recipient against the potentially greater risk of delaying the transplant while waiting for another suitable organ. This warrants continued study of the benefits and risks of transplanting organs or tissues from people infected by Naegleria fowleri.

References

Marciano-Cabral F, Cabral G. The immune response to Naegleria fowleri amebae and pathogenesis of infection. FEMS Immunol Med Microbiol. 2007;51:243-59.
Visvesvara GS. Free-living amebae as opportunistic agents of human disease. J Neuroparasitol. 2010;1.
Kramer MH, Lerner CJ, Visvesvara GS. Kidney and liver transplants from a donor infected with Naegleria fowleri. J Clin Microbiol. 1997;35:1032-3.
Bennett WM, Nespral JF, Rosson MW, McEvoy KM. Use of organs for transplantation from a donor with primary meningoencephalitis due to Naegleria fowleri. Am J Transplant. 2008;8:1334-5.
Tuppeny M. Primary amoebic meningoencephalitis with subsequent organ procurement: a case study. J Neurosci Nurs. 2011;43(5):274-9.
Roy SL, Metzger R, Chen JG, Laham FR, Martin M, Kipper SW, Smith LE, Lyon GM 3rd, Haffner J, Ross JE, Rye AK, Johnson W, Bodager D, Friedman M, Walsh DJ, Collins C, Inman B, Davis BJ, Robinson T, Paddock C, Zaki SR, Kuehnert M, DaSilva A, Qvarnstrom Y, Sriram R, Visvesvara GS. Risk for transmission of Naegleria fowleri from solid organ transplantation. Am J Transplant. 2014;14(1):163-71.

PAM infections have been reported from around the world ^1, ². From 1962 through 2022, 157 infections have been documented in the United States with a median age of 11 years and range of 8 months to 66 years. Infections have occurred in all age groups, but 123 cases (79%) have occurred in children and adolescents younger than age 18. Over three-quarters (>75%) of infections have been in males. Infected people were often reported to have participated in water-related activities such as swimming underwater, diving, and head dunking that could have caused water to go up the nose ³.

Naegleria fowleri has also been documented to infect animals such as cattle ⁴ and a South American tapir ⁵. Experimental infection can be induced in other species including mice, which are used as the model system for studying Naegleria fowleri infections resulting from swimming ⁶.

References

Marciano-Cabral F, Cabral G. The immune response to Naegleria fowleri amebae and pathogenesis of infection. FEMS Immunol Med Microbiol. 2007;51:243-59.
Visvesvara GS. Free-living amebae as opportunistic agents of human disease. J Neuroparasitol. 2010;1.
Yoder JS, Eddy BA, Visvesvara GS, Capewell L, Beach MJ. The epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008. Epidemiol Infect. 2010;138(7):968-75.
Visvesvara GS, De Jonckheere JF, Sriram R, Daft B. Isolation and molecular typing of Naegleria fowleri from the brain of a cow that died of primary amebic meningoencephalitis. J Clin Microbiol. 2005;43(8):4203-4.
Lozano-Alarcón F, Bradley GA, Houser BS, Visvesvara GS. Primary amebic meningoencephalitis due to Naegleria fowleri in a South American tapir. Vet Pathol. 1997;34:239-43.
John DT, Nussbaum SL. Naegleria fowleri infection acquired by mice through swimming in amebae-contaminated water. J Parasitol. 1983;69:871-4.

Infections linked to freshwater swimming mostly occur during the heat of summer in July and August in the northern hemisphere when water temperatures peak and water levels are low ¹. Infections can increase during heat wave years as water temperatures increase.

References

Yoder JS, Eddy BA, Visvesvara GS, Capewell L, Beach MJ. The epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008. Epidemiol Infect. 2010;138(7):968-75.

No data exist to accurately estimate the true risk of PAM. Hundreds of millions of visits to swimming venues occur each year in the United States¹ that result in 0-8 infections per year. The extremely low occurrence of PAM makes epidemiologic study difficult. It is unknown why certain persons become infected with the amebae while millions of others exposed to warm recreational fresh waters, including those who were swimming with people who became infected, do not. Attempts have been made to determine what concentration of Naegleria fowleri in the environment poses an unacceptable risk ². However, no method currently exists that accurately and reproducibly measures the numbers of amebae in the water. This makes it unclear how a standard might be set to protect human health and how public health officials would measure and enforce such a standard.

References

US Census Bureau. Statistical Abstract of the United States: 2012. Arts, Recreation, and Travel: Participation in Selected Sports Activities 2009. [XLS – 1 MB] 2012.
Cabanes PA, Wallet F, Pringuez E, Pernin P. Assessing the risk of primary amoebic meningoencephalitis from swimming in the presence of environmental Naegleria fowleri. Appl Environ Microbiol. 2001;67(7):2927-31.

References

Marciano-Cabral F, Cabral G. The immune response to Naegleria fowleri amebae and pathogenesis of infection. FEMS Immunol Med Microbiol.2007;51:243-59.
Visvesvara GS. Free-living amebae as opportunistic agents of human disease. J Neuroparasitol. 2010;1.
Yoder JS, Eddy BA, Visvesvara GS, Capewell L, Beach MJ. The epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008. Epidemiol Infect. 2010;138:968-75.

*Rare Disease
There is no universal definition of a “rare disease” but the U.S. Rare Disease Act of 2002 defined a rare disease as affecting less than 200,000 people in the U.S. and this definition has been adopted by the National Institutes of Health, Genetic and Rare Diseases Information Centers.

**Including U.S. states, territories, and commonwealths.