Cyclosporiasis – France ex Mexico

This case of cyclospora may have no relation to the Canadian outbreak; or may.

A 64-year-old French [female] with type 2 diabetes mellitus was referred to our department on [Mon 3 Jul 2017] because she was suffering from protracted diarrhea.

Symptoms began on [Sat 10 Jun 2017] as she was just returning from a touristic trip in Cancun (Quintana Roo State, Mexico) where she stayed from [Mon 29 May to Fri 9 Jun 2017] with her husband.

She acknowledged having moderate watery diarrhea with abdominal discomfort, bloating, transient vomiting, 5 kg weight [approx. 11.02 pounds] loss and fatigue. Empiric therapy with oral Metronidazole 500 mg 3 times a day for 7 days she received previously failed to improve her symptoms. Of note, a 1st microscopic stool examination failed to identify parasites and no enteropathogenic bacteria was found by culture on selective media.

Up to 3 extra stool specimens where sent to the laboratory of clinical parasitology in our hospital.

Oocysts of Cyclospora cayetanensis where evidenced by autofluorescence after Bailenger concentration technique.

At least 20 sick with Cyclospora in Canada

Health-types in Canada are investigating locally acquired Cyclospora infections in two provinces. The source of the outbreak has not been identified. Previous outbreaks in Canada and the United States (US) have been linked to imported fresh produce. The investigation is ongoing.

In Canada, a total of 20 cases have been reported in two provinces: British Columbia (5) and Ontario (15). Individuals became sick between May and early June of this year. The majority of cases (60%) are male, with an average age of 53 years. The investigation into the source of the outbreak is ongoing. To date, no multi-jurisdictional outbreaks of Cyclospora have been linked to produce grown in Canada.

The outbreak investigation is active and the public health notice will be updated on a regular basis as the investigation evolves.

People living or travelling in tropical or subtropical regions of the world who eat fresh produce or drink untreated water may be at increased risk for infection because the parasite is found in some of these regions.

Washing is never enough but are they linked? Summer means Cyclospora in Canada, Mexico and Texas

Finally, some decent risk-based advice from a government agency.

Washing will not remove Cyclospora from fresh produce.

pesto.basil_.cyclosporaWashing removes very little of anything from fresh produce.

Canada’s Public Health Agency is investigating 51 cases of people infected with the single-celled parasite Cyclospora cayetanensis between mid-May and late-July. Forty-four of the 51 cases reported so far have been in Ontario.

The infection can cause watery diarrhea, fatigue, stomach pain

Though uncommon in food and drinking water in Canada and the U.S., the parasite often persists on fruit and vegetables even after they have been washed. Public Health Canada recommends that people cook vegetables and fruit imported from Peru, Cuba, India, Nepal, Mexico, Guatemala, Southeast Asia and Dominican Republic.

Last week, health officials in Texas also reported a major outbreak of the disease, and are continuing an investigation into fresh produce as a possible source. After a series of outbreaks linked to imported produce from Puebla Mexico in 2015, the U.S. Food and Drug Administration banned imports from the region during summer months.

Previous outbreaks of Cyclospora have been linked to pre-packaged salad mix, basil, cilantro, raspberries, blackberries, and snap-peas.

At the same time, 148 British tourists have been confirmed with Cyclospora after visiting 24 luxury hotel complexes most of which are in the Riviera Maya resort near Cancun in Mexico.

Public Health England  are now warning UK tourists to be wary of travelling to Mexico and the Foreign Office have updated their website to include a warning from health authorities about travelling to the region.

On the toilet 30X a day: UK couple’s Mexico holiday hell after contracting Cyclospora

Tony Larner of the Mirror reports a British couple’s dream Mexican holiday was left in tatters after they were struck down Cyclospora.

hanging.on.in.quiet.desperationSandra and Lee Harper splashed out £3,700 on an all-inclusive Thomson break to Riviera Maya resort, near Cancun.

But the couple, from Birmingham, were unable to leave their room for almost a week after falling ill with Cyclospora and needing the toilet up to 30 times every day.

The pair claim they complained about their illness and hygiene issues at their hotel to Thomson, but did not got a reply until after they arrived home, the Birmingham Mail reported.

UK Health officials have issued warnings about visiting the area after almost 100 Brits were struck down with the bug since the outbreak began in June.

A spokesthingy for Thomson said: “Public Health England has advised us of a number of sickness cases associated to an issue called Cyclospora in the Riviera Maya region of Mexico.”

An issue called Cyclospora?

“Hanging on in quiet desperation is the English way.”

14 sick with Cyclospora in (North) Texas

Frank Heinz of NBC DFW 5 cited health officials as saying more than a dozen cases of cyclosporiasis have been confirmed in North Texas’ four major counties and that the source is likely contaminated food.

pesto.basil.cyclosporaThe Texas Department of State Health Services said Wednesday the parasite was found in Dallas, Tarrant, Collin and Denton counties and that the origin may be linked to a fresh produce item.
County officials told NBC 5 there have been four cases recorded in Dallas County, three in Collin County, four in Denton County and seven in Tarrant County. The Denton County cases and at least four of the Tarrant County cases had recently traveled out of the country — calling into question the point of origin.

Across the state, there are currently 66 confirmed cases of cyclosporiasis — though the sources of infection haven’t been confirmed. For most people, the symptoms are serious. “But for those who are very young and those who are older, or those who have a suppressed immune system, this illness can cause major problems,” said Dr. Khang Tran, chief medical officer at The Medical Center of Plano. 

In recent years, 2012-2015, cyclospora outbreaks were associated with fresh cilantro imported from Puebla, Mexico. Since the summer of 2015, the Food and Drug Administration has instituted ban on imports from that region between from April through August.
In 2015, the DSHS said there were 316 cases of cyclosporiasis in Texas.

Cyclosporiasis Case Counts and Incidence Rates in Texas, 2001-2014

Year | Case Count | Incidence Rates

2014* | 200 | 0.7
2013* | 351 | 1.3
2012* | 44 | 0.2
2011* | 14 | 0.1
2010 | 9 | 0.0
2009 | 10 | 0.0
2008 | 6 | 0.0
2007 | 2 | 0.0
2006 | 1 | 0.0
2005 | 1 | 0.0
2004 | 4 | 0.0
2003 | 1 | 0.0
2002 | 1 | 0.0
2001 | 0 | 0.0

IR=incidence rate per 100,000 *incidence rates are bases on projected census data obtained from the DSHS Center for Health Statistics. 

Cyclospora cluster reported in UK travelers to Mexico

Outbreak News Today reports UK health officials are seeing an increase in the parasitic infection, cyclosporiasis, in travelers returning from Mexico, according to Travel Health Pro report.

love.boat.cyclosporaThe cluster has been seen since June and many of the travelers stayed in Riviera Maya, the same place where some 80 travelers contracted Cyclospora last summer.

Cyclospora has been implicated in numerous outbreaks with contaminated fruits and vegetables being the common culprits (raspberries, basil and lettuce all washed with contaminated water), especially those imported from developing nations.

All fruits and vegetables should be thoroughly washed before eating though this does not guarantee safety. Cyclospora is resistant to chlorination.

Treatment is usually successful after a course of the antibiotic Septra.

Going public (not): Leafy green cone of silence on Cyclospora in Romaine lettuce, 2013

Read this Packer story from 2013 for the convoluted hoops public health types are faced with while investigating foodborne illness outbreaks. And now the scientific report: same hoops, same dance, same unsatisfactory outcome for consumers who want to know what’s safe.

cone.of.silence.get.smartA regional, multistate investigation into a June–August 2013 cyclosporiasis outbreak was conducted in Nebraska, Iowa, and neighbouring states. Cases were confirmed on the basis of laboratory and clinical findings.

Of 227 cases in Iowa (n = 140) and Nebraska (n = 87) residents, 162 (71%) reported dining at chain A/B restaurants – 96% reported house salad consumption. A case-control study identified chain A/B house salad as the most likely vehicle. Traceback was conducted to ascertain production lot codes of bagged salad mix (iceberg and romaine lettuce, red cabbage, and carrots) served as house salad in implicated restaurants. A single production lot code of salad mix supplied by both a common producer and distributor was linked to the majority of confirmed cases in persons reporting regional chain A/B exposure.

The salad mix linked to illnesses contained imported romaine lettuce from two separate single-grower fields-of-origin and ≥1 additional field from another grower.

Regional investigation of a cyclosporiasis outbreak linked to imported romaine lettuce – Nebraska and Iowa, June–August 2013

Epidemiology and Infection / Volume 144 / Issue 09 / July 2016, pp 1807-1817Copyright © Cambridge University Press 2015  DOI: http://dx.doi.org/10.1017/S0950268815002484 (About DOI), Published online: 22 October 2015

F. Buss, M. V. Joshi, A. L. O’keefe, C. D. Allensworth, A. Garvey, K. Obbink, S. Mandernach And T. J. Safranek

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=10346466&utm_source=Issue_Alert&utm_medium=RSS&utm_campaign=HYG

are.you.mental

Parasites at retail: Not so much (cause testing don’t tell ya much)

Cyclospora and Cryptosporidium are protozoan parasites which infect humans, primarily through contaminated food and water. Cyclospora is endemic in a number of subtropical and tropical countries. Cryptosporidium infection can be found in people worldwide. Cyclospora and Cryptosporidium infections can cause mild to severe gastrointestinal (GI) symptoms including, but not limited to, diarrhea, weight loss, cramping, flatulence, nausea, fatigue and low grade fever.

basil.salmonellaCyclospora and Cryptosporidium were ranked 13th and 5th, respectively, out of 24 parasites in overall global ranking for their public health importance by a Food and Agriculture Organization of the United Nations/World Health Organization (FAO/WHO) expert committee (September 3 to 7, 2012). Produce such as fresh herbs and berries have been identified in the past as sources of Cyclospora and Cryptosporidium contamination in Canada. This survey focused on fresh herbs, berries, green onions and mushrooms.

The objective of this survey was to determine the occurrence and distribution of Cyclospora and Cryptosporidium contamination in fresh produce such as herbs, berries, mushrooms and green onions. A total of 1,590 samples were analyzed for the presence of Cyclospora and 1,788 samples were analyzed for Cryptosporidium. Samples were collected at retail from various regions across Canada between May 2011 and March 2013.

raspberryOf the samples analyzed for Cyclospora, none were positive for the parasite. Of the samples analyzed for Cryptosporidium, six samples of green onions, one sample of parsley, and one sample of mushroom were positive, however, the analytical method used to detect the parasites in the samples cannot determine if the parasite is viable and potentially infectious. It is important to note that there were no reported illnesses associated with the consumption of the products found to be positive for Cryptosporidium. Positive results are followed up by the Canadian Food Inspection Agency (CFIA). In this case, because of the perishable nature of the products and the time elapsed between sample pick up and the completion of analysis, the fresh product was no longer available on the market when the parasite was detected. As such, no direct follow up was possible. This information was used to inform CFIA’s programs and inspection activities.

The Canadian Food Inspection Agency regulates and provides oversight to the industry, works with provinces and territories, and promotes safe handling of foods throughout the food production chain. However, it is important to note that the food industry and retail sectors in Canada are ultimately responsible for the food they produce and sell, while individual consumers are responsible for the safe handling of the food they have in their possession. Moreover, general advice for the consumer on the safe handling of foods is widely available. The CFIA will continue its surveillance activities and inform stakeholders of its findings.

Cyclospora in cilantro: Again and again and again

Thomas Burke, a Kansas boy pursuing his Masters in Public Health at Emory University, with an emphasis in epidemiology, writes that Cyclospora-laden cilantro from the State of Puebla in Mexico had already sickened large parts of the U.S. in the summers of 2013 and 2014. Unfortunately, the summer of 2015 repeated the same pattern: a large, multi-state outbreak dispersed across the nation.

cilantro.slugs.powell.10The Georgia Food and Feed Rapid Response Team (GaRRT) activated in July 2015 to counter this threat to food safety. In any outbreak investigation, three of the most important pieces of evidence are place, time and the means of exposure to the suspected pathogen (the disease-causing bug). During this investigation, GaRRT members worked together through a combination of surveillance, fact-finding detective work, interstate communications and international collaboration in both public health interventions and policy changes.

Like many detective stories, the Cyclospora outbreak began with a phone call; complaints of gastrointestinal distress reached the Georgia Department of Public Health (DPH). As with any positive Cyclospora case, these complaints were reported due to Cyclospora being a reportable pathogen, or one of “the usual suspects” for severe or rare outbreaks. Cyclospora has the distinction of being the only parasite on Georgia’s list.

Epidemiologists at DPH noted the uptick in Cyclospora cases, which were clusters confined to particular localities across the state. From the epidemiologic evidence, DPH determined the connection — certain restaurants were the common denominator to those found ill with Cyclospora. It became clear at this point that the investigation would span other agencies, because of the many possible leads and evidence involved.

Though DPH is traditionally the lead agency to investigate restaurant outbreaks, the Georgia Department of Agriculture (GDA) routinely works in conjunction by tracing ingredients used in restaurants. Among GDA’s responsibilities are inspecting retail and wholesale food establishments as well as food manufacturers. Since fieldwork members represent both GDA and DPH on the GaRRT, it was easy to bring together the 2 agencies during this investigation, to share the work and combine resources.

Because of the previous 2 outbreaks of Cyclospora, the Centers for Disease Control and Prevention (CDC) asked regulatory agencies across the country to pay particular attention to the origin and distribution of cilantro in the investigation. In 2013 and 2014, cilantro from the State of Puebla, Mexico had been implicated in multi-state outbreaks of Cyclospora, making cilantro the chief suspect in the investigation.

Once the details began to crystalize, the GaRRT officially activated to coordinate federal, state and local entities pertaining to the outbreak. As the epidemiologic evidence from Georgia and Texas (among other states) was assembled, the chase to trace the cilantro started. DPH interviews with restaurant owners and staff directed investigators towards the restaurants’ wholesale suppliers who purchase, store and ship ingredients to restaurants and other food establishments. These interviews led the investigation team down the trucking route to Texas.

Teaming up with officials at the Texas Rapid Response Team, the GaRRT ascertained ports of entry for the cilantro under investigation: Hidalgo and McAllen, Texas. Thanks to this discovery, the team found the cilantro originated from the State of Puebla in Mexico, the same state that produced cilantro contaminated by Cyclospora in the summers of 2013 and 2014.

Because of continuing problems with this region, Mexican and U.S. Food & Drug Administration (FDA) authorities collaborated to address the conditions that allowed for another Cyclospora outbreak. Enhancing fresh cilantro safety was the priority during and after the outbreak. The safety mechanisms incorporated a system for risk reduction — including export controls — for cilantro from the State of Puebla.

Correspondingly, on July 27, 2015, the FDA (a member organization of the GaRRT) implemented a supportive framework of import controls to detain without physical examination shipments of fresh cilantro from Puebla from April through August, 2015. This control framework will continue to be implemented for the same time period in future years.

Shipments of fresh cilantro from other states in Mexico were cleared for importation into the U.S. during this timeframe last summer, but only if documentation demonstrated the cilantro was harvested outside of Puebla. Additionally, the FDA and Mexican public health agencies worked collaboratively to prepare a “Green List” of companies not implicated in the outbreak that are known and documented to be safe in Puebla, whose shipments of fresh cilantro were not detained.

When the outbreak concluded, Cyclospora illnesses attributed to cilantro affected 546 persons in 31 states. Georgia had the third highest case count with 26 documented illnesses. Through the GaRRT, our state also had the distinction of identifying clusters and investigating leads that ultimately helped solve questions presented by the outbreak. 

Probably cilantro: Over 700 sick from Cyclospora traced to Mexico, travelers edition

Cyclospora cayetanensis was identified in 176 returned travellers from the Riviera Maya region of Mexico between 1 June and 22 September 2015; 79 in the United Kingdom (UK) and 97 in Canada. UK cases completed a food exposure questionnaire.

love.boat.cyclosporaThis increase in reported Cyclospora cases highlights risks of gastrointestinal infections through travelling, limitations in Cyclospora surveillance and the need for improved hygiene in the production of food consumed in holiday resorts.

On 14 July 2015, Health Protection Scotland (HPS) identified an unusual increase in Cyclospora infections in travellers to Mexico. National and international partners were informed and upon further investigation, a total of 176 cases have been identified in England, Scotland, Wales and Canada. An outbreak control team managed the investigation in the United Kingdom (UK). UK patients were interviewed about travel history, food consumption, clinical symptoms and demography using a questionnaire. The majority of cases had travelled to the Riviera Maya region of Mexico.

Investigation of UK cases

Cyclospora cases were identified in primary clinical diagnostic and commercial laboratories by microscopy or molecular testing. Cases were confirmed in reference laboratories using microscopic methods (e.g. examination of a wet preparation by bright field microscopy and, if structures resembling Cyclospora were observed, viewing under UV light for autofluorescence). In addition, smears were permanently stained using modified Ziehl Neelsen and examined.

In the UK, probable cases were defined as individuals with onset of gastrointestinal (GI) symptoms or a specimen date on or after 1 June 2015, travel to Mexico in the previous 14 days and C. cayetanensis oocysts identified in stool specimens by a local diagnostic laboratory. Confirmed UK cases were probable cases confirmed microscopically by national reference laboratories. Cases without either local or national reference laboratory confirmation were excluded from this analysis. No cases associated with travel to Mexico were identified in the UK in 2015 before 1 June.

Outbreak description

Between 1 June and 22 September 2015, 79 probable or confirmed case-patients (hereafter called cases) were reported in England (n = 55), Scotland (n = 21) and Wales (n = 3). No further cases linked to Mexico have been identified in the period since that date (as at 28 October 2015). Symptom onset dates were available for 62 confirmed or probable cases and ranged from 8 June to 19 August 2015 (Figure 1). Travel information was available for 60 cases; the earliest departure date from the UK to Mexico was 22 May and the latest date of return was 30 August 2015. The median age of cases was 44 years (range: 15–66) with 46 of 79 cases 40 years and older; 43 of 79 were female. Only 43 of the 79 cases diagnosed in local laboratories were confirmed by a reference laboratory.

Cases occurred over an extended period and in people who stayed at 32 different hotels on the Riviera Maya coast of Mexico, from Cancun to Tulum. A formal epidemiological study was not therefore possible. Questionnaires were completed for 46 of 79 cases, with 43 reporting all-inclusive catering, of whom 24 (56%) reported also eating outside their hotel.

Of 44 cases with symptom details recorded, all had diarrhoea (range: 5–62 days; mean: 16 days) which was rapid onset in 30. Other symptoms included abdominal pain (n = 35), fatigue (n = 31), nausea (n = 27), vomiting (n = 24), fever (n = 19), weight loss (n = 19) and headache (n = 17). There were no hospitalisations or deaths.

Of 45 cases for whom food histories were available, 43 consumed fruit or berries, 41 consumed salad or vegetables and 35 consumed fresh herbs. Specific items mentioned by cases included fresh mint in drinks (n = 15), strawberries or raspberries (n = 9) and coriander (n = 6). Most cases ate from all-inclusive buffets which also included a number of meat and fish products, cheese and desserts. Consumption of bottled water and ice was reported by 39 and 38 cases, respectively.

cilantro.slugs.powell.10Awareness was raised among laboratories and public health professionals by circulating diagnostic aid sheets and travel advice and communicating with health authorities in Mexico, UK tour operators, the European Centre for Disease Prevention and Control, the Public Health Agency of Canada, the United States (US) Centers for Disease Control and Prevention (CDC) and European Union countries.

Discussion

Cyclospora cayetanensis is a protozoan parasite that causes treatable diarrhoea [1-3], and predominantly occurs in tropical and subtropical countries [4-6]. Cyclospora oocysts sporulate 10 days after being defecated and become infectious. Outbreaks of cyclosporiasis [3,7], have been linked to contaminated snow peas [8], basil [9], salad/herbs [10], raspberries and other berries [3,11,12], and drinking water [13,14]. Sporadic infections follow travel to endemic countries, including Mexico [15-17], and imported basil from Mexico was implicated in an outbreak in Canada [18].

An increase in cyclosporiasis has been observed in UK travellers to Mexico this summer. A similar increase has also been noted in Canada: while Canada has no routine travel surveillance, 97 cases of Cyclospora infection in travellers returning from Mexico were reported from May to August 2015; the cases reporting staying at various resorts in the same geographical area as the UK cases. The UK and Canadian cases occurred in people returning from at least 36 hotels on the Riviera Maya coast of Mexico. Drinking water was an unlikely source as several different water networks supply the resorts (some hotels have their own borehole and treatment). Geographical and temporal associations suggest that the outbreak was related to a consumed product(s) distributed throughout the region rather than hygiene deficiencies in individual hotels. A multistate outbreak of cyclosporiasis has also occurred in the US, concurrent with our investigations, in which fresh cilantro from Puebla, Mexico has been implicated as the cause of cluster-associated cases in three US states [19]. Local investigation in Mexico suggests fresh cilantro from Puebla had been distributed to hotels in the Riviera Maya region. Food safety control measures have since been implemented by the Mexican authorities to ensure the safety of cilantro from Puebla state (personal communication to Public Health England: National Focal Point for Emergency INFOSAN in Mexico and National Focal Point for IHR, Mexico, 6 October 2015).

cilantroCyclospora infections are seasonal in England and Wales (Figure 2). Where travel history is known, travel to the Indian subcontinent, Turkey, the Caribbean, Central and South America is commonly reported (Figure 3). Childhood infections are uncommon and case numbers in male and female patients are equivalent (Figure 4). Eleven laboratories detected five or more cases between 2005 and 2014, and many laboratories had no detections. Cyclospora oocysts can be detected readily by microscopy, but if screening algorithms are not followed, cases can go undetected. National External Quality Assessment for Cyclospora has improved from 23% in the mid-1990s to 86% by 2011 (personal communication: UK National External Quality Assessment Service, 18 September 2015). Limited information is available on cases in other EU Member States. The FilmArray GI Panel [20] or equivalent PCR array would facilitate faecal screening for Cyclospora infections, in part because it does not require the physician or laboratory to specifically request Cyclospora testing. Improvements are needed in hygiene control during the production and harvesting of salad and soft fruit products in countries with higher incidence [21].

 Cyclospora Infection Linked to Travel to Mexico, June to September 2015

Eurosurveillance, Volume 20, Issue 43, 29 October 2015

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=21284