Cyclospora: Back to the future

During the summers of 2015 and 2016, the United Kingdom experienced large outbreaks of cyclosporiasis in travellers returning from Mexico. As the source of the outbreaks was not identified, there is the potential for a similar outbreak to occur in 2017; indeed 78 cases had already been reported as at 27 July 2017. Early communication and international collaboration is essential to provide a better understanding of the source and extent of this recurring situation.

Cyclosporiasis in travellers returning to the United Kingdom from Mexico in Summer 2017: Lessons from the recent past to inform the future

Eurosurveillance, vol. 22, issue 32, 10 August 2017, DFP Marques, CL Alexander, RM Chalmers, R Elson, J Freedman, G Hawkins, J Lo, G Robinson, K Russell, A Smith-Palmer, H Kirkbride, DOI: http://dx.doi.org/10.2807/1560-7917.ES.2017.22.32.30592

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=22854

Food fraud: Mexican alcohol edition

To my four Canadian daughters: Pay attention.

Tourists to all-inclusive resorts in Mexico suspect they were given tainted alcohol.

Raquel Rutledge of the Milwaukee Journal Sentinel writes the scene at the swim-up bar at the Mexican resort where Abbey Conner was pulled listless from the pool in January was full of young tourists last month when an attorney hired by Conner’s family showed up.

It wasn’t surprising. It was a typical scene at an all-inclusive five-star resort where foreigners from both sides of the equator flock to escape their cold winters.

But as he watched, the attorney noticed something disturbing.

“They serve alcoholic drinks with alcohol of bad quality and in great amounts, mixing different types of drinks,” he wrote in his native Spanish.

That single paragraph, buried near the end of a four-page report summarizing how 20-year-old Conner drowned within a couple hours of arriving at the Iberostar Hotel & Resorts’ Paraiso del Mar, offers a possible lead in the investigation into her death.

And it could shed light on the circumstances surrounding numerous reports from others who have told the Milwaukee Journal Sentinel they experienced sickness, blackouts and injuries after drinking at Iberostar and other resorts around Cancun and Playa del Carmen in recent months.

A Pewaukee family traveled to an all-inclusive resort in Playa del Carmen in January. Their two college kids wound up unconscious, face down in the pool within two hours. Twenty-year-old Abbey died.

They told the Journal Sentinel they believe they were drugged or the alcohol may have been tainted. They questioned how they could fall into a stupor so quickly. And whether they had been targeted.

Toxoplasma at high levels in pigs from tropical Mexico

Background: Toxoplasmosis is caused by the protozoon Toxoplasma gondii, which is one of the most widespread parasites that infect animals and humans worldwide. One of the main routes of infection for humans is through the consumption of infected meat containing bradyzoites in tissue cysts. Pork is one of the foremost meat types associated with outbreaks of acute toxoplasmosis in humans (photo, right, from http://www.mexicocooks.typepad.com).

pig-mexicoMaterials and Methods: Sixty blood samples were collected from finished pigs at slaughter and their sera was evaluated by an indirect-IgG ELISA. Matched muscle samples were obtained from the tongue and loin. Whole blood and tissue samples were evaluated to search for T. gondii DNA using a nested-polymerase chain reaction.

Results: Seroprevalence of T. gondii was 96.6% (58/60) of sampled pigs. Meanwhile, T. gondii DNA was present in 23.21% of tongue tissue samples (13/56), 7% of loin tissues (4/57), and 0% in blood samples (0/44), respectively. Two pigs were serologically indeterminate.

Conclusion: This is the first report of the presence of T. gondii DNA in tissue samples obtained from finalized pigs. Results from the present study suggest a high exposure to T. gondii in pigs intended for human consumption from the tropical region of Mexico. Thus, the consumption of some undercooked pork meat meals typical from the southern region of Mexico could represent a significant risk for acquiring infection for the human population.

Presence of Toxoplasma gondii in pork intended for human consumption in tropical southern of Mexico

Foodborne Pathogens and Disease. September 2016, ahead of print. doi:10.1089/fpd.2016.2165.

IB Hernández-Cortazar, KY Acosta-Viana, E Guzmán-Marin, A Ortega-Pacheco, JF de Jesus Torres-Acosta, M Jimenez-Coello

http://online.liebertpub.com/doi/abs/10.1089/fpd.2016.2165

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.”

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.

Final tally: 907 sick, 6 dead from Salmonella linked to imported cucumbers

According to the U.S. Centers for Disease Control, this outbreak appears to be over. However, Salmonella remains an important cause of human illness in the United States.

cucumber.facialA total of 907 people infected with the outbreak strains of Salmonella Poona were reported from 40 states.

A total of 204 ill people were hospitalized, and six deaths were reported from Arizona (1), California (3), Oklahoma (1), and Texas (1). Salmonella infection was not considered to be a contributing factor in two of the three deaths in California.

Epidemiologic, laboratory, and traceback investigations identified cucumbers imported from Mexico and distributed by Andrew & Williamson Fresh Produce as the likely source of the infections in this outbreak.

Two recalls of cucumbers that may be contaminated with Salmonella were announced in September 2015 as a result of this investigation: Andrew & Williamson Fresh Produce and Custom Produce Sales.

Investigation of illnesses that were reported after the peak of the outbreak in August and September 2015 did not identify an additional food linked to illness. The source of contamination for the cucumbers distributed by Andrew & Williamson Fresh Produce has not been identified.

Among people for whom information was available, illnesses started on dates ranging from July 3, 2015 to February 29, 2016. Ill people ranged in age from less than 1 year to 99, with a median age of 18. Forty-nine percent of ill people were children younger than 18 years. Fifty-six percent of ill people were female. Among 720 people with available information, 204 (28%) were hospitalized. Six deaths were reported.

salm.cucumber.sep.15WGS showed that isolates from ill people were closely related genetically. These results also included isolates from people who became ill in October, November and January after the outbreak’s peak. This close genetic relationship means that people in this outbreak were more likely to share a common source of infection, such as a contaminated food.

Several state health and agriculture departments collected and tested cucumbers from retail locations and isolated the outbreak strains of Salmonella Poona. Information indicated that these cucumbers were distributed by Andrew & Williamson Fresh Produce. Additionally, testing of cucumbers collected from the Andrew & Williamson Fresh Produce facility isolated the outbreak strains of Salmonella Poona.

WGS of Salmonella Poona isolates from ill people and from contaminated cucumbers distributed by Andrew & Williamson Fresh Produce showed that the strains were closely related genetically. This close genetic relationship provided additional evidence that ill people in this outbreak became ill from consuming cucumbers distributed by Andrew & Williamson.

$550,000 in meth seized in strawberry load

Brisbane has fabulous produce, befitting the sub-tropical climate.

pick-your-own-strawberriesStrawberries were going for $0.50 a pint this week, and excellent quality.

Officers with the U.S. Customs and Border Protection’s Office of Field Operations at the Pharr International Bridge seized an estimated $550,000 worth of alleged methamphetamine hidden a commercial load of fresh strawberries.

On Feb. 27, CBP officers at the Pharr International Bridge cargo facility encountered a 39-year-old man from Reynosa, Mexico, driving a tractor/trailer carrying a commercial shipment of fresh strawberries, according to a Customs and Border Protection news release.

After referring the truck for secondary inspection, officers discovered and seized two packages of alleged methamphetamine weighing about 28 pounds and seized the Freightliner tractor as well, the release said.

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

4 dead, 732 sick from Salmonella Poona linked to imported cucumbers

As of October 5, 2015, 732 people infected with the outbreak strains of Salmonella Poona have been reported from 35 states. The number of ill people reported from each state is as follows: Alabama (1), Alaska (14), Arizona (114), Arkansas (11), California (192), Colorado (18), Hawaii (1), Idaho (24), Illinois (9), Indiana (3), Iowa (6), Kansas (2), Kentucky (1), Louisiana (5), Maryland (1), Minnesota (37), Missouri (11), Montana (14), Nebraska (6), Nevada (14), New Mexico (31), New York (6), North Dakota (6), Ohio (2), Oklahoma (12), Oregon (20), Pennsylvania (2), South Carolina (9), South Dakota (3), Texas (34), Utah (53), Virginia (1), Washington (22), Wisconsin (40), and Wyoming (7).

cucumberAmong people for whom information is available, illnesses started on dates ranging from July 3, 2015 to September 25, 2015. Ill people range in age from less than 1 year to 99, with a median age of 17. Fifty percent of ill people are children younger than 18 years. Fifty-five percent of ill people are female. Among 536 people with available information, 150 (28%) report being hospitalized. Four deaths have been reported from Arizona (1), California (1), Oklahoma (1), and Texas (1).

Illnesses that occurred after September 8, 2015 might not be reported yet. A series of events occurs between the time a person is infected and the time public health officials can determine that the person is part of an outbreak. This means that there will be a delay between when a person gets sick and confirmation that he or she is part of an outbreak. This takes an average of 2 to 4 weeks.