Although most individuals with a Giardia infection are asymptomatic, this pathogen is increasingly recognized as a cause of pathologies beyond the classical manifestations.1Escobedo A.A. Almirall P. Robertson L.J. Mørch K. Franco R.M. Hanevik K. et al.Giardiasis: the ever present threat of a neglected disease.Infect Disord Drug Targets. 2010; 10: 329-348Crossref PubMed Scopus (62) Google Scholar Morbidities associated with Giardia, including extra-intestinal manifestations and long-term consequences, have been identified increasingly over the past decades.2Cantey P.T. Roy S. Lee B. Cronquist A. Smith K. Liang J. et al.Study of nonoutbreak giardiasis: novel findings and implications for research.Am J Med. 2011; 124: 1175.e1-1175.e8Abstract Full Text Full Text PDF Scopus (29) Google Scholar, 3Halliez M.C. Buret A.G. Extra-intestinal and long term consequences of Giardia duodenalis infections.World J Gastroenterol. 2013; 19: 8974-8985Crossref PubMed Scopus (248) Google Scholar, 4Almirall P. Núñez F.A. Bello J. González O.M. Fernández R. Escobedo A.A. Abdominal pain and asthenia as common clinical features in hospitalized children for giardiasis.Acta Trop. 2013; 127: 212-215Crossref PubMed Scopus (11) Google Scholar The importance of this pathogen in terms of patient well-being and its effect on quality of life, due to being a continuing cause of patient discomfort and pain, has been highlighted .5Robertson L.J. Hanevik K. Escobedo A.A. Mørch K. Langeland N. Giardiasis—why do the symptoms sometimes never stop?.Trends Parasitol. 2010; 26: 75-82Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar Unfortunately, giardiasis is not a health priority. This may be due to a lack of political will, funding, or interest from the scientific community (more focused on other scientific priorities), or to public indifference, but is most likely a combination of all of these factors. Nowadays, regardless of the stage of economic development of the affected countries, neglect of this protozoan disease is not the best option. Numerically speaking, giardiasis has never been a minor disease, even for many industrialized countries; thus, the sheer volume affected and the problems it causes warrant reflection regarding control strategies. The sequelae of Giardia infections are of considerable scientific interest as well as of public health significance. Recently a large controlled prospective study of a cohort of individuals who had confirmed Giardia infections during a waterborne outbreak in Norway was published.6Hanevik K. Wensaas K.A. Rortveit G. Eide G.E. Mørch K. Langeland N. Irritable bowel syndrome and chronic fatigue six years after Giardia infection: a controlled prospective cohort study.Clin Infect Dis. 2014; 59: 1394-1400Crossref PubMed Scopus (91) Google Scholar In that study, a significantly increased risk of both irritable bowel syndrome (IBS) and chronic fatigue (CF), even 6 years after the infection, was documented; fortunately, these decreased over time, indicating that Giardia may elicit very long-term, but slowly self-limiting complications. These data add to an all too slowly growing body of Giardia research, which, taken in aggregate, suggest that the time has come to encourage increased investigations. In this issue of the International Journal of Infectious Diseases, we present an analysis of the incidence of IBS without diarrhoea in the departments of Colombia during 2013. This was significantly associated with the incidence of giardiasis (r2 = 0.7457; p < 0.0001). Departments with higher giardiasis incidence had higher reported IBS (Figure 1), coinciding ecologically with the findings of the Norway study. Current discussion on the natural course of IBS and CF after Giardia infection has been enriched, whether manifested by classical signs and symptoms or a less straightforward clinical presentation . Important contributions have been made regarding the spectrum of illness attributable to giardiasis. It is illustrated that the potential development of sequelae may include both IBS and CF, in spite of the eradication of the organism. Additionally, this has opened new avenues of research. Further investigations on the pathogenic mechanisms behind the development of these two conditions are needed, which could lead to potential interventions to prevent them. This study also provides a clue to physicians whose patients do not respond with symptom resolution after successful therapy. They need to be aware of the potential sequelae of Giardia infection, to alert their patients of the possible importance of reporting a previous Giardia exposure when presenting for treatment if CF or IBS symptoms develop. In summary, there remains much to be known about Giardia and the spectrum of disease it causes, its epidemiology, and treatment. Collaborative studies that focus on determining precisely those who are most prone to develop CF or IBS after this infection are needed. Up to now, only old age and female sex have been identified as high risk factors for post-infectious fatigue.7Mørch K. Hanevik K. Rortveit G. Wensaas K.A. Langeland N. High rate of fatigue and abdominal symptoms 2 years after an outbreak of giardiasis.Trans R Soc Trop Med Hyg. 2009; 103: 530-532Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 8Hanevik K. Kristoffersen E.K. Sørnes S. Mørch K. Næss H. Rivenes A.C. et al.Immunophenotyping in post-giardiasis functional gastrointestinal disease and chronic fatigue syndrome.BMC Infect Dis. 2012; 12: 258Crossref PubMed Scopus (13) Google Scholar It is also important to determine whether the treatment – and the timing of initiation – might influence these outcomes. According to previous studies, the continuation of symptoms post-elimination could be more frequent in those who have experienced chronic or treatment-refractory giardiasis.9Mørch K. Hanevik K. Rortveit G. Wensaas K.A. Eide G.E. Hausken T. et al.Severity of Giardia infection associated with post-infectious fatigue and abdominal symptoms two years after.BMC Infect Dis. 2009; 9: 206Crossref PubMed Scopus (34) Google Scholar Is there any therapeutic window for possible early intervention to avoid CF and/or IBS? Stratification among patients susceptible to these complications according medical, immunological, and/or epidemiological profiles is needed to identify determinants of these clinical expressions. The Giardia isolates from patients developing long-term sequelae also deserve further study, as they may be genetically different. The study setting is also important when interpreting the results. It is also necessary to characterize the parasite genotype pattern in the region and to determine whether newly introduced genotypes could produce a synergistic interaction which could result in greater pathogenicity. Last, but not least, it is also important to evaluate the impact of Giardia infection and its post-infectious sequelae in low-income countries, where there is the greatest burden of disease and highest risk of transmission. Fortunately, research on giardiasis is growing,10Escobedo A.A. Arencibia R. Vega R.L. Almirall P. Rodríguez-Morales A.J. Alfonso M. A bibliometric study of international scientific productivity in giardiasis covering the period 1971-2010.J Infect Dev Ctries. 2015; 9: 76-86Crossref PubMed Scopus (23) Google Scholar since there is no doubt that for Giardia infection, there are still many questions to be answered. Up to now, the more you look, the more you find. However, a question arises: "How much is there?" Funding: None. Ethical approval: Not required. Conflict of interest: The authors have no conflict of interest to disclose. Estimating and mapping the incidence of giardiasis in Colombia, 2009–2013International Journal of Infectious DiseasesVol. 49PreviewInfections due to Giardia lamblia (synonymous with Giardia intestinalis and Giardia duodenalis), or giardiasis, are probably among the most common gastrointestinal conditions caused by protozoa, particularly in children, throughout the world, and especially in developing countries. This flagellated organism has been associated with acute manifestations such as diarrhoea, abdominal cramps, weight loss, nausea, and vomiting.1 In most cases, usually in healthy individuals, symptoms generally subside within <4 weeks. Full-Text PDF Open Access