CDC reports 641 cases of Cyclospora linked to recalled salad mixes nationwide

Since the last case count update on July 9, 2020, the U.S. Centers for Disease Control reported 132 new laboratory-confirmed Cyclospora infections have been reported, including 16 from three new states: Georgia, Pennsylvania, and South Dakota.

As of  July 22, 2020, a total of 641 people with laboratory-confirmed Cyclospora infections associated with this outbreak have been reported from 11 states: Georgia (1), Illinois (198), Iowa (195), Kansas (5), Minnesota (73), Missouri (57) Nebraska (55), North Dakota (6), Pennsylvania (2), South Dakota (13) and Wisconsin (36). The ill person from Georgia purchased and ate a bagged salad product while traveling in Missouri.

Illnesses started on dates ranging from May 11, 2020 to July 5, 2020. Ill people range in age from 10 to 92 years with a median age of 59 and 52% are female. Of 636 people with available information, 37 people (6%) have been hospitalized. No deaths have been reported.

Illnesses might not yet be reported due to the time it takes between when a person becomes ill and when the illness is reported. This takes an average of 4 to 6 weeks. If the number of cases reported by CDC is different from the number reported by state or local health officials, data reported by local jurisdictions should be considered the most up to date. Any differences may be due to the timing of reporting and website updates.

This investigation is ongoing.

The CDC says that it is specifically examining salad ingredients (iceberg lettuce, carrots, red cabbage) for the purposes of its investigation. The affected products include salad mixes made by Fresh Express, Hy-Vee Inc., Little Salad Bar, Signature Farms, Marketside and Hy-Vee. The products were sold at ALDI, Giant Eagle, Hy-Vee, Jewel-Osco, ShopRite, and Walmart locations.

The products were manufactured in Streamwood, Illinois at a Fresh Express production facility.

“Cyclosporiasis is an intestinal infection caused by the Cyclospora parasite,” the CDC says. “A person may become infected after ingesting contaminated food or water. Common symptoms include severe abdominal pain, diarrhea, nausea and vomiting, body aches and fatigue. The infection is treated with antibiotics and most people respond quickly to treatment.”

Specifically, the CDC says the products with a Z178 code or lower and “Best by” date that runs through July 14, 2020 are the ones potentially affected by the contamination.

However, only Georgia, Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, Pennsylvania, South Dakota and Wisconsin have reported cases of Cyclospora related to eating the salad mix. According to the CDC, the dates of the illness range from May 11, 2020 to July 5, 2020, with 37 people hospitalized as of Friday. Patients are ages 10 to 92 years with a median age of 59 years as of Friday’s data. No related deaths have been reported. People can go 4 to 6 weeks before noticing any symptoms of Cyclospora, the CDC says.

Write down what you ate in the two weeks before you started to get sick.

Report your illness to the health department.

Assist public health investigators by answering questions about your illness.

The CDC issued its recall warnings June 19, and Giant Eagle issued a recall on its Fresh Express products on June 29.

On June 27, 2020, Fresh Express Fresh Express brand and private label brand salad products produced at its Streamwood, IL facility that contain iceberg lettuce, red cabbage, and/or carrots due to possible Cyclospora contamination.

The Public Health Agency of Canada is investigating an outbreak of Cyclospora infections occurring in three Canadian provinces. Exposure to certain Fresh Express brand salad products containing iceberg lettuce, carrots, and red cabbage, has been identified as a likely source of the outbreak.

  • Epidemiologic and traceback evidence indicates that bagged salad mix containing iceberg lettuce, carrots, and red cabbage produced by Fresh Express is a likely source of this outbreak.
  • CDC and FDA continue to investigate to determine which ingredient or ingredients in the salad mix was contaminated and whether other products are a source of illnesses.
  • CDC will provide updates when more information is available.

Raw is risky: Yes, for dogs too

There’s a subset of pet guardians who feverishly believe raw food is the only food for dogs and cats and other pets because that’s all that was available in the wild.

As Hobbes noted in 1651, nature is “solitary, poor, nasty, brutish, and short.”

Dogs too.

The Canadian Food Inspection Agency announced last week that Carnivora Fresh Frozen Patties for Dogs and Cats may be contaminated with Escherichia coli O157 (E. coli) and there is risk of cross contamination and illness after handling.

Consumers should immediately stop using any of the affected pet food products and contact the retailer where they purchased the affected product for a full refund or exchange.

As of June 12, 2020, the company has been made aware of 4 reports of illnesses in Canada – in people.

Consumers are advised to always wash hands, surfaces and utensils thoroughly with soap and water after feeding, handling or cleaning up after pets. Clean surfaces that come into contact with pet food or ill pets.

One of daughter Sorenne’s daily tasks is to give stress-reducing wet food to our neurotic cat, and she absolutely knows to wash her hands after handling the food.

Scott Weese over at the Worms and Germs blog writes that while people were presumably not eating the pet food (I wouldn’t presume that), there is the potential for cross-contamination of human food when handling raw pet food, as well as potential for exposure to pathogens through things like contact with pet food bowls and pet feces.

The main concern with raw pet food tends to be Salmonella; however, E. coli O157 is another significant concern because of the  potential severity of disease. A death was reported in a UK a couple years ago from exposure to E. coli O157 from contaminated pet food.

While most dogs and cats that eat raw diets are fine, and most owners don’t get sick, it’s clear that feeding raw diet or raw animal-based treats (e.g. pig ears) is associated with risks to the pet and any human contacts. I’d rather people not feed raw diets to their pets, particularly when the pet or household members are very young, elderly, pregnant or have compromised immune systems. If none of those risk factors are present and someone wants to feed a raw diet, I’d still rather they didn’t, but there are some things that can reduce the risks, as outlined on the Worms & Germs infosheet on raw diets available on our Resources – Pets page.

Oh, and don’t go to the company’s website for accurate information about risk and risk mitigation. They bury some good prevention recommendations in a pile of often out-of-context dialogue to try to deflect any concerns and the typical raw diet misinformation. Some other raw pet food companies are up front about the risks and prevention measures – I have a lot more confidence in companies like that.

Good on ya, Dr. Weese.

Trust but verify: Food fraud is hidden in plain sight

John Keogh of Big News Network writes that the globalization of the food chain has resulted in increased complexity and diminished transparency and trust into how and where our foods are grown, harvested, processed and by whom.

But this homily – we knew our grower so it must be safer – has no basis in factor data.

It’s like washing produce: It might make you feel better, but microbiologically, it does shit.

While the extent of global food fraud is difficult to quantify, the Canadian Food Inspection Agency (CFIA) suggests food fraud affects 10 per cent of commercially sold food. Various academic and industry sources suggest that globally, food fraud ranges from US$10 billion to $49 billion. This is likely a conservative range considering estimates of fake Australian meats alone and sold worldwide are as high as AUD$4 billion, or more than US$2.5 billion.

If you add the sales of fake wines and alcohol, adulterated honey and spices, mislabelled fish and false claims of organic products, wild-caught fish or grain-fed

As social media amplifies recurring high-profile incidents of food fraud, trust in our global food supply chains remains a concern. For the foreseeable future, much of Canada’s food fraud remains hidden in plain sight, sitting right there on our grocery store shelves.

Toxo in Canadian deer hunters eating undercooked venison from Illinois

We conducted a recent investigation in Quebec, Canada, concerning Canadian deer hunters who went to the United States to hunt deer and returned with symptoms of fever, severe headache, myalgia, and articular pain of undetermined etiology. Further investigation identified that a group of 10 hunters from Quebec attended a hunting retreat in Illinois (USA) during November 22–December 4, 2018.

Six of the 10 hunters had similar symptoms and illness onset dates. Serologic tests indicated a recent toxoplasmosis infection for all symptomatic hunters, and the risk factor identified was consumption of undercooked deer meat. Among asymptomatic hunters, 2 were already immune to toxoplasmosis, 1 was not immune, and the immune status of 1 remains unknown. Outbreaks of acute toxoplasmosis infection are rare in North America, but physicians should be aware that such outbreaks could become more common.

Acute toxoplasmosis among Canadian deer hunters associated with consumption of undercooked deer meat hunted in the U.S.

Emerging Infectious Diseases, vol. 26, no. 2

Colette Gaulin , Danielle Ramsay, Karine Thivierge, Joanne Tataryn, Ariane Courville, Catherine Martin, Patricia Cunningham, Joane Désilets, Diane Morin, and Réjean Dion

https://wwwnc.cdc.gov/eid/article/26/2/19-1218_article?deliveryName=DM17555

Twelve in Ontario, Quebec sickened in Salmonella outbreak linked to sausages

People always thought I was a bit affected when I would do the cooking for an Australian sausage sizzle and whip out my tip=sensitive digital thermometer and test every sausage.

I would say, no kid is getting sick on my watch.

Canadian health types say an outbreak of Salmonella that sickened a dozen people in Ontario and Quebec has been linked to a brand of sausage.

The Public Health Agency of Canada says the outbreak appears to be ongoing, in spite of a recall of the affected sausages.

The agency says the source of the outbreak is Filicetti brand Italian Style mild, dry, cured sausage (which is supposed to be cooked, but apparently not so much)

Ten people in Ontario and two in Quebec have become sick.

7 sick with Listeria in Canada linked to Rosemount brand cooked diced chicken: 2 dead 22 sick in US possibly related

As of August 23 2019, there have been seven confirmed cases of Listeria monocytogenes illness in three Canadian provinces: British Columbia (1), Manitoba (1) and Ontario (5) linked to cooked Rosemount brand cooked diced chicken.

The Public Health Agency of Canada notes Rosemount cooked diced chicken was supplied to institutions (including cafeterias, hospitals and nursing homes) where many of the individuals who became sick resided, or visited, before becoming ill.

Individuals became sick between November 2017 and June 2019. Six individuals have been hospitalized. Individuals who became ill are between 51 and 97 years of age. The majority of cases (86%) are female.

The collaborative outbreak investigation was initiated because of an increase of Listeria illnesses that were reported in June 2019. Through the use of a laboratory method called whole genome sequencing, two Listeria illnesses from November 2017 were identified to have the same genetic strain as the illnesses that occurred between April and June 2019. It is possible that more recent illnesses may be reported in the outbreak because of the period of time it takes between when a person becomes ill and when the illness is reported to public health officials. In national Listeria monocytogenes outbreak investigations, the reporting time period is usually between four and six weeks.

The U.S. CDC is also investigating an outbreak  of Listeria illnesses occurring in several states. The type of Listeria identified in the U.S. is closely related genetically (by whole genome sequencing) to the Listeria making people sick in Canada. Canada and U.S. public health and food safety partners are collaborating on these ongoing Listeria investigations.

CDC is not recommending that consumers avoid any particular food at this time. Restaurants and retailers are not advised to avoid serving or selling any particular food. We will update our advice if a source is identified.

Latest Outbreak Information

At A Glance

Reported Cases: 24

States: 13

Hospitalizations: 22

Deaths: 2

24 people infected with the outbreak strain of Listeria monocytogeneshave been reported from 13 states.

Of 23 ill people with information available, 22 hospitalizations have been reported.

Two deaths have been reported.

Canada: Raw frozen chicken thingies outbreaks

We’ve done extensive work on this topic dating back to 2006 (search barfblog.com), but new tools, like whole genome sequencing, mean additional outbreaks have been identified. A summary paper of recent outbreaks has just been published. Abstract below:

Frozen raw breaded chicken products (FRBCP) have been identified as a risk factor for Salmonella infection in Canada. In 2017, Canada implemented whole genome sequencing (WGS) for clinical and non-clinical Salmonella isolates, which increased understanding of the relatedness of Salmonella isolates, resulting in an increased number of Salmonella outbreak investigations. A total of 18 outbreaks and 584 laboratory-confirmed cases have been associated with FRBCP or chicken since 2017. The introduction of WGS provided the evidence needed to support a new requirement to control the risk of Salmonella in FRBCP produced for retail sale.

Outbreak of salmonella illness associated with frozen raw breaded chicken products in Canada 2015-2019

22 August 2019

Epidemiology and Infection vol. 147

  1. K. Morton(a1)A. Kearney(a2)S. Coleman (a3)M. Viswanathan (a1)K. Chau (a4)A. Orr (a5)and A. Hexemer (a1) 

DOI: https://doi.org/10.1017/S0950268819001432

https://www.cambridge.org/core/journals/epidemiology-and-infection/article/outbreaks-of-salmonella-illness-associated-with-frozen-raw-breaded-chicken-products-in-canada-20152019/9F1E5C0D2BF560E540C47BA064E7F713

7 sick in Canada: Listeria infections linked to Rosemount brand cooked diced chicken

As of August 18, 2019, there have been 7 confirmed cases of Listeria monocytogenes linked to Rosemount brand cooked diced chicken in British Columbia (1), Manitoba (1) and Ontario (5). Individuals became sick between November 2017 and June 2019. Six individuals have been hospitalized. Individuals who became ill are between 51 and 97 years of age. The majority of cases (86%) are female.

The collaborative outbreak investigation was initiated because of an increase of Listeria illnesses that were reported in June 2019. Through the use of whole genome sequencing, two Listeria illnesses from November 2017 were identified to have the same genetic strain as the illnesses that occurred between April and June 2019.

It is possible that more recent illnesses may be reported in the outbreak because of the delay between when a person becomes ill and when the illness is reported to public health officials. In national Listeria monocytogenes outbreak investigations, the case reporting delay is usually between 4 and 6 weeks.

If you have Rosemount brand cooked diced chicken meat 13mm – ½” (#16305), packdate – 01/21/2019 in your food establishment, do not eat the product or serve it to others

Secure the product and any foods made with the product in a plastic bag, throw it out and wash your hands with soapy water.

North American Cyclospora outbreaks

My aunt got sick from Cyclospora in some basil-based thingy in Florida, in 2005.

She was sick for weeks.

On June 12, 1996, Ontario’s chief medical officer, Dr. Richard Schabas, issued a public health advisory on the presumed link between consumption of California strawberries and an outbreak of diarrheal illness among some 40 people in the Metro Toronto area. The announcement followed a similar statement from the Department of Health and Human Services in Houston, Texas, who were investigating a cluster of 18 cases of Cyclospora illness among oil executives.

Dr. Schabas advised consumers to wash California berries “very carefully” before eating them, and recommended that people with compromised immune systems avoid them entirely. He also stated that Ontario strawberries, which were just beginning to be harvested, were safe for consumption. Almost immediately, people in Ontario stopped buying strawberries. Two supermarket chains took California berries off their shelves, in response to pressure from consumers. The market collapsed so thoroughly that newspapers reported truck drivers headed for Toronto with loads of berries being directed, by telephone, to other markets.

However, by June 20, 1996, discrepancies began to appear in the link between California strawberries and illness caused by the parasite, Cyclospora, even though the number of reported illnesses continued to increase across North America. Texas health officials strengthened their assertion that California strawberries were the cause of the outbreak, while scientists at the U.S. Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) said there were not yet ready to identify a food vehicle for the outbreak. On June 27, 1996, the New York City Health Department became the first in North America to publicly state that raspberries were also suspected in the outbreak of Cyclospora.

By July 18, 1996, the CDC declared that raspberries from Guatemala — which had been sprayed with pesticides mixed with water that could have been contaminated with human sewage containing Cyclospora — were the likely source of the Cyclospora outbreak, which ultimately sickened about 1,000 people across North America. Guatemalan health authorities and producers have vigorously refuted the charges. The California Strawberry Commission estimates it lost $15 million to $20 million in reduced strawberry sales.

Cyclospora cayetanensis is a recently characterised coccidian parasite; the first known cases of infection in humans were diagnosed in 1977. Before 1996, only three outbreaks of Cyclospora infection had been reported in the United States. Cyclospora is normally associated with warm, Latin American countries with poor sanitation.

One reason for the large amount of uncertainty in the 1996 Cyclospora outbreak is the lack of effective testing procedures for this organism. To date, Cyclospora oocysts have not been found on any strawberries, raspberries or other fruit, either from North America or Guatemala. That does not mean that cyclospora was absent; it means the tests are unreliable and somewhat meaningless. FDA, CDC and others are developing standardized methods for such testing and are currently evaluating their sensitivity.

The initial, and subsequent, links between Cyclospora and strawberries or raspberries were therefore based on epidemiology, a statistical association between consumption of a particular food and the onset of disease. For example, the Toronto outbreak was first identified because some 35 guests attending a May 11, 1996 wedding reception developed the same severe, intestinal illness, seven to 10 days after the wedding, and subsequently tested positive for cyclospora. Based on interviews with those stricken, health authorities in Toronto and Texas concluded that California strawberries were the most likely source. However, attempts to remember exactly what one ate two weeks earlier is an extremely difficult task; and larger foods, like strawberries, are recalled more frequently than smaller foods, like raspberries. Ontario strawberries were never implicated in the outbreak.

Once epidemiology identifies a probable link, health officials have to decide whether it makes sense to warn the public. In retrospect, the decision seems straightforward, but there are several possibilities that must be weighed at the time. If the Ontario Ministry of Health decided to warn people that eating imported strawberries might be connected to Cyclospora infection, two outcomes were possible: if it turned out that strawberries are implicated, the ministry has made a smart decision, warning people against something that could hurt them; if strawberries were not implicated, then the ministry has made a bad decision with the result that strawberry growers and sellers will lose money and people will stop eating something that is good for them. If the ministry decides not to warn people, another two outcomes are possible: if strawberries were implicated, then the ministry has made a bad decision and people may get a parasitic infection they would have avoided had they been given the information (lawsuits usually follow); if strawberries were definitely not implicated then nothing happens, the industry does not suffer and the ministry does not get in trouble for not telling people. Research is currently being undertaken to develop more rigorous, scientifically-tested guidelines for informing the public of uncertain risks.

But in Sarnia (Ontario, Canada) they got a lot of sick people who attended the Big Sisters of Sarnia-Lambton Chef’s Challenge on May 12, 2010.

Michael T. Osterholm, PhD, who has a lot of titles and once called me at 5 a.m. to tell me I was an asshole (maybe not the exact words, but the sentiment) and chair of the Holstein Blue-Ribbon Panel on the Prevention of Foodborne Cyclospora Outbreaks writes that the 1996 cyclosporiasis outbreak in the United States and Canada associated with the late spring harvest of imported Guatemalan-produced raspberries was an early warning to public health officials and the produce industry that the international sourcing of produce means that infectious agents once thought of as only causing traveler’s diarrhea could now infect at home. The public health investigation of the 1996 outbreak couldn’t identify how, when, where, or why the berries became contaminated with Cyclospora cayetanensis.

The investigation results were published in the New England Journal of Medicine in 1997. I was asked to write an editorial to accompany the investigation report.2 In my editorial, I noted the unknowns surrounding the C. cayetanensis contamination. The 1997 spring harvest of Guatemalan raspberries was allowed to be imported into both the United States and Canada—and again, a large outbreak of cyclosporiasis occurred. As in the 1996 outbreak, no source for the contamination of berries was found. Later in 1997, the Food and Drug Administration (FDA) prohibited the importation of future spring harvests of Guatemalan raspberries until a cause for the contamination could be demonstrated and corrective actions taken. While the FDA did not permit the 1998 importation of the raspberries into the United States, the berries continued to be available in Canada. Outbreaks linked to raspberries occurred in Ontario in May 1998. When the U.S. Centers for Disease Control and Prevention (CDC)-led investigative team published its 1997 outbreak findings in the Annals of Internal Medicine, 3 I was again asked to write an accompanying editorial.4 As I had done in my previous editorial, I highlighted how little we know about the factors associated with the transmission Cyclospora on produce and how to prevent it.

Unfortunately, the state of the art for preventing foodborne, produce-associated cyclosporiasis had changed little since the 1996 outbreak despite the relatively frequent occurrence of such outbreaks.

Thirty-four years after that first Guatemalan raspberry-associated outbreak — and a year after produce-associated cyclosporiasis outbreaks that were linked to U.S.-grown produce — there has been a major leap in prevention, yet the outbreaks still happen.

 Foodborne outbreaks of cyclosporiasis have been reported in the United States since the mid-1990s and have been linked to various types of imported fresh produce, including raspberries, basil, snow peas, mesclun lettuce, and cilantro; no commercially frozen produce has been implicated to date. U.S. foodborne outbreaks of cyclosporiasis that occurred before 2000 were summarized previously, as were the major documented outbreaks in 2013 and 2014. Foodborne outbreaks during the 18-year period of 2000–2017 are summarized here.

The table provides information about 39 reported foodborne outbreaks of cyclosporiasis that occurred in the United States during 2000–2017; the total case count was 1,730. No outbreaks were reported in 2003, 2007, or 2010. Overall, a median of two outbreaks were reported per year, with a median of 19 cases per outbreak (range, 3 to 582 cases). Although the outbreaks occurred during 8 different months (December through July), the peak months were May, June, and July. As indicated in the table, a food vehicle of infection was identified (or suspected) for 17 of the 39 outbreaks.

Identifying the particular food item/ingredient that caused an outbreak of cyclosporiasis can be very challenging—for example, if fresh produce was served as a garnish or topping or if several types of produce were mixed together. CDC and other agencies are working to develop and validate molecular typing methods that could distinguish among different strains of the parasite Cyclospora cayetanensis that causes cyclosporiasis. In the future, such tools could help link cases of cyclosporiasis to each other and to particular types of produce, which could help public health officials investigate and prevent cases and outbreaks of Cyclospora infection.

Table: Summary of U.S. foodborne outbreaks of cyclosporiasis, 2000–2017
Year(s)* Month(s)* Jurisdiction(s)* No. of cases† Food vehicle and source, if identified‡
2000 May Georgia 19 Raspberries and/or blackberries (suspected)
2000 June Pennsylvania 54 Raspberries
2001 January–February Florida 39
2001 January New York City 3
2001–02 December–January Vermont 22 Raspberries (likely)
2002 April–May Massachusetts 8
2002 June New York 14
2004 February Texas 38
2004 February Illinois 57 Basil (likely)
2004 May Tennessee 12
2004 May–June Pennsylvania 96 Snow peas from Guatemala ⁂
2005 March–May Florida 582 ¶ Basil from Peru
2005 May South Carolina 6
2005 April Massachusetts 58
2005 May Massachusetts 16
2005 June Connecticut 30 Basil (suspected)
2006 June Minnesota 14
2006 June New York 20
2006 July Georgia 3
2008 March Wisconsin 4 Sugar snap peas (likely) ⁂
2008 July California 45 ¶ Raspberries and/or blackberries (likely)
2009 June District of Columbia 34
2011 June Florida 12
2011 July Georgia 88**
2012 June–July Texas 16
2013†† June Iowa, Nebraska, and neighboring states 162 Bagged salad mix from Mexico
2013†† June–July Texas 38 Cilantro from Mexico
2013 July Wisconsin 8 Berry salad (suspected)
2014 June Michigan 14
2014‡‡ June–July Texas 26 Cilantro from Mexico
2014 July South Carolina 13
2015 May–July Georgia, Texas, and Wisconsin 90 Cilantro from Mexico
2016 June–July Texas 6¶¶ Carrots or green cabbage (suspected)
2017 May Florida 6 Berries (suspected)
2017 May–July Texas 38*** Scallions (i.e., green onions)
2017 June Michigan 29
2017 June Tennessee 4†††
2017 June Connecticut 3
2017 July Florida 3‡‡‡

* The entries in the first three columns refer to the known or likely year(s), month(s), and jurisdiction(s) in which the exposure(s) to Cyclospora occurred.

† The case counts include laboratory-confirmed and probable cases of cyclosporiasis. By definition, each outbreak included at least two linked cases, at least one of which was laboratory confirmed.

‡ A food vehicle is specified only if a single ingredient or commodity was identified in an outbreak investigation.

¶ Cases that occurred in Canadian travelers to the United States were not included.

** An additional 10 probable cases were associated with this outbreak but were not counted in the table: nine of these cases were in residents of states in which cyclosporiasis was not a reportable condition, and the other case was in a patient whose state of residence was unknown.

†† For additional details, see summary information about the outbreak investigations in 2013. For the purposes of this table, the exposure month(s) and case counts are limited to those explicitly linked in the investigations to the food item specified in the last column.

‡‡ For additional perspective, see summary information about outbreak investigations in 2014. For the purposes of this table, the exposure months and the case count for the outbreak in Texas are limited to those explicitly linked in the investigations to the food item specified in the last column.

¶¶ An additional nine suspected cases were identified in persons associated with this outbreak but were not counted in the table because of reporting issues (e.g., insufficient case data).

*** An additional three probable cases were identified in persons associated with this outbreak but were not counted in the table because of reporting issues (e.g., insufficient case data).

††† An additional two probable cases were identified in persons associated with this outbreak but were not counted in the table because of reporting issues (e.g., insufficient case data).

‡‡‡ One additional probable case was identified in a person associated with this outbreak but was not counted in the table because of a reporting issue.

⁂ More information to help distinguish among types of peas can be found herepdf icon.

Table: Summary of U.S. foodborne outbreaks of cyclosporiasis, 2000–2017
Year(s)* Month(s)* Jurisdiction(s)* No. of cases† Food vehicle and source, if identified‡
2000 May Georgia 19 Raspberries and/or blackberries (suspected)
2000 June Pennsylvania 54 Raspberries
2001 January–February Florida 39
2001 January New York City 3
2001–02 December–January Vermont 22 Raspberries (likely)
2002 April–May Massachusetts 8
2002 June New York 14
2004 February Texas 38
2004 February Illinois 57 Basil (likely)
2004 May Tennessee 12
2004 May–June Pennsylvania 96 Snow peas from Guatemala ⁂
2005 March–May Florida 582 ¶ Basil from Peru
2005 May South Carolina 6
2005 April Massachusetts 58
2005 May Massachusetts 16
2005 June Connecticut 30 Basil (suspected)
2006 June Minnesota 14
2006 June New York 20
2006 July Georgia 3
2008 March Wisconsin 4 Sugar snap peas (likely) ⁂
2008 July California 45 ¶ Raspberries and/or blackberries (likely)
2009 June District of Columbia 34
2011 June Florida 12
2011 July Georgia 88**
2012 June–July Texas 16
2013†† June Iowa, Nebraska, and neighboring states 162 Bagged salad mix from Mexico
2013†† June–July Texas 38 Cilantro from Mexico
2013 July Wisconsin 8 Berry salad (suspected)
2014 June Michigan 14
2014‡‡ June–July Texas 26 Cilantro from Mexico
2014 July South Carolina 13
2015 May–July Georgia, Texas, and Wisconsin 90 Cilantro from Mexico
2016 June–July Texas 6¶¶ Carrots or green cabbage (suspected)
2017 May Florida 6 Berries (suspected)
2017 May–July Texas 38*** Scallions (i.e., green onions)
2017 June Michigan 29
2017 June Tennessee 4†††
2017 June Connecticut 3
2017 July Florida 3‡‡‡

By July 18, 1996, the CDC declared that raspberries from Guatemala — which had been sprayed with pesticides mixed with water that could have been contaminated with human sewage containing Cyclospora — were the likely source of the Cyclospora outbreak, which ultimately sickened about 1,000 people across North America. Guatemalan health authorities and producers have vigorously refuted the charges. The California Strawberry Commission estimates it lost $15 million to $20 million in reduced strawberry sales.

Cyclospora cayetanensis is a recently characterised coccidian parasite; the first known cases of infection in humans were diagnosed in 1977. Before 1996, only three outbreaks of Cyclospora infection had been reported in the United States. Cyclospora is normally associated with warm, Latin American countries with poor sanitation.

One reason for the large amount of uncertainty in the 1996 Cyclospora outbreak is the lack of effective testing procedures for this organism. To date, Cyclospora oocysts have not been found on any strawberries, raspberries or other fruit, either from North America or Guatemala. That does not mean that cyclospora was absent; it means the tests are unreliable and somewhat meaningless. FDA, CDC and others are developing standardized methods for such testing and are currently evaluating their sensitivity.

The initial, and subsequent, links between Cyclospora and strawberries or raspberries were therefore based on epidemiology, a statistical association between consumption of a particular food and the onset of disease. For example, the Toronto outbreak was first identified because some 35 guests attending a May 11, 1996 wedding reception developed the same severe, intestinal illness, seven to 10 days after the wedding, and subsequently tested positive for cyclospora. Based on interviews with those stricken, health authorities in Toronto and Texas concluded that California strawberries were the most likely source. However, attempts to remember exactly what one ate two weeks earlier is an extremely difficult task; and larger foods, like strawberries, are recalled more frequently than smaller foods, like raspberries. Ontario strawberries were never implicated in the outbreak.

Once epidemiology identifies a probable link, health officials have to decide whether it makes sense to warn the public. In retrospect, the decision seems straightforward, but there are several possibilities that must be weighed at the time. If the Ontario Ministry of Health decided to warn people that eating imported strawberries might be connected to Cyclospora infection, two outcomes were possible: if it turned out that strawberries are implicated, the ministry has made a smart decision, warning people against something that could hurt them; if strawberries were not implicated, then the ministry has made a bad decision with the result that strawberry growers and sellers will lose money and people will stop eating something that is good for them. If the ministry decides not to warn people, another two outcomes are possible: if strawberries were implicated, then the ministry has made a bad decision and people may get a parasitic infection they would have avoided had they been given the information (lawsuits usually follow); if strawberries were definitely not implicated then nothing happens, the industry does not suffer and the ministry does not get in trouble for not telling people. Research is currently being undertaken to develop more rigorous, scientifically-tested guidelines for informing the public of uncertain risks.

But in Sarnia (Ontario, Canada) they got a lot of sick people who attended the Big Sisters of Sarnia-Lambton Chef’s Challenge on May 12, 2010.

Michael T. Osterholm, PhD, who has a lot of titles and once called me at 5 a.m. to tell me I was an asshole (maybe not the exact words, but the sentiment) and chair of the Holstein Blue-Ribbon Panel on the Prevention of Foodborne Cyclospora Outbreaks writes that the 1996 cyclosporiasis outbreak in the United States and Canada associated with the late spring harvest of imported Guatemalan-produced raspberries was an early warning to public health officials and the produce industry that the international sourcing of produce means that infectious agents once thought of as only causing traveler’s diarrhea could now infect at home. The public health investigation of the 1996 outbreak couldn’t identify how, when, where, or why the berries became contaminated with Cyclospora cayetanensis.

The investigation results were published in the New England Journal of Medicine in 1997. I was asked to write an editorial to accompany the investigation report.2 In my editorial, I noted the unknowns surrounding the C. cayetanensis contamination. The 1997 spring harvest of Guatemalan raspberries was allowed to be imported into both the United States and Canada—and again, a large outbreak of cyclosporiasis occurred. As in the 1996 outbreak, no source for the contamination of berries was found. Later in 1997, the Food and Drug Administration (FDA) prohibited the importation of future spring harvests of Guatemalan raspberries until a cause for the contamination could be demonstrated and corrective actions taken. While the FDA did not permit the 1998 importation of the raspberries into the United States, the berries continued to be available in Canada. Outbreaks linked to raspberries occurred in Ontario in May 1998. When the U.S. Centers for Disease Control and Prevention (CDC)-led investigative team published its 1997 outbreak findings in the Annals of Internal Medicine, 3 I was again asked to write an accompanying editorial.4 As I had done in my previous editorial, I highlighted how little we know about the factors associated with the transmission Cyclospora on produce and how to prevent it.

Unfortunately, the state of the art for preventing foodborne, produce-associated cyclosporiasis had changed little since the 1996 outbreak despite the relatively frequent occurrence of such outbreaks.

Thirty-four years after that first Guatemalan raspberry-associated outbreak — and a year after produce-associated cyclosporiasis outbreaks that were linked to U.S.-grown produce — there has been a major leap in prevention, yet the outbreaks still happen.

Foodborne outbreaks of cyclosporiasis have been reported in the United States since the mid-1990s and have been linked to various types of imported fresh produce, including raspberries, basil, snow peas, mesclun lettuce, and cilantro; no commercially frozen produce has been implicated to date. U.S. foodborne outbreaks of cyclosporiasis that occurred before 2000 were summarized previously, as were the major documented outbreaks in 2013 and 2014. Foodborne outbreaks during the 18-year period of 2000–2017 are summarized here.

The table provides information about 39 reported foodborne outbreaks of cyclosporiasis that occurred in the United States during 2000–2017; the total case count was 1,730. No outbreaks were reported in 2003, 2007, or 2010. Overall, a median of two outbreaks were reported per year, with a median of 19 cases per outbreak (range, 3 to 582 cases). Although the outbreaks occurred during 8 different months (December through July), the peak months were May, June, and July. As indicated in the table, a food vehicle of infection was identified (or suspected) for 17 of the 39 outbreaks.

Identifying the particular food item/ingredient that caused an outbreak of cyclosporiasis can be very challenging—for example, if fresh produce was served as a garnish or topping or if several types of produce were mixed together. CDC and other agencies are working to develop and validate molecular typing methods that could distinguish among different strains of the parasite Cyclospora cayetanensis that causes cyclosporiasis. In the future, such tools could help link cases of cyclosporiasis to each other and to particular types of produce, which could help public health officials investigate and prevent cases and outbreaks of Cyclospora infection.

Table: Summary of U.S. foodborne outbreaks of cyclosporiasis, 2000–2017
Year(s)* Month(s)* Jurisdiction(s)* No. of cases† Food vehicle and source, if identified‡
2000 May Georgia 19 Raspberries and/or blackberries (suspected)
2000 June Pennsylvania 54 Raspberries
2001 January–February Florida 39
2001 January New York City 3
2001–02 December–January Vermont 22 Raspberries (likely)
2002 April–May Massachusetts 8
2002 June New York 14
2004 February Texas 38
2004 February Illinois 57 Basil (likely)
2004 May Tennessee 12
2004 May–June Pennsylvania 96 Snow peas from Guatemala ⁂
2005 March–May Florida 582 ¶ Basil from Peru
2005 May South Carolina 6
2005 April Massachusetts 58
2005 May Massachusetts 16
2005 June Connecticut 30 Basil (suspected)
2006 June Minnesota 14
2006 June New York 20
2006 July Georgia 3
2008 March Wisconsin 4 Sugar snap peas (likely) ⁂
2008 July California 45 ¶ Raspberries and/or blackberries (likely)
2009 June District of Columbia 34
2011 June Florida 12
2011 July Georgia 88**
2012 June–July Texas 16
2013†† June Iowa, Nebraska, and neighboring states 162 Bagged salad mix from Mexico
2013†† June–July Texas 38 Cilantro from Mexico
2013 July Wisconsin 8 Berry salad (suspected)
2014 June Michigan 14
2014‡‡ June–July Texas 26 Cilantro from Mexico
2014 July South Carolina 13
2015 May–July Georgia, Texas, and Wisconsin 90 Cilantro from Mexico
2016 June–July Texas 6¶¶ Carrots or green cabbage (suspected)
2017 May Florida 6 Berries (suspected)
2017 May–July Texas 38*** Scallions (i.e., green onions)
2017 June Michigan 29
2017 June Tennessee 4†††
2017 June Connecticut 3
2017 July Florida 3‡‡‡

Ontario parents speak out after 2-year-old’s E. coli linked death

I seemed to have missed this, which is inexcusable, volunteer or not, medical stuff for me or not, but here it is, a month later (and if I did publish it, shows where my brain is going).

Avis Favaro of CTV News reported in early May that it all started with a romaine salad.

Kristen and Brad Bell felt a little sick after eating the salad last October.

Their two-year-old son soon started to show more severe symptoms. Cooper Bell was vomiting. He developed diarrhea. Then his mother noticed the blood in his diaper.

“I had no idea [what] was happening,” Kristen Bell told CTV News from her home in Stirling, Ont.

“I thought ‘This is not normal.'”

An emergency room doctor thought Cooper might have contracted a bacterial infection. The family’s pediatrician agreed, saying the Bells should keep their son hydrated and bring him back in the morning.

Soon after the Bells returned home, they noticed some worrying changes in Cooper’s behavior.

“He wasn’t responding to me the same as he was earlier. It wasn’t long after that, that he had a seizure in Brad’s arms,” Kristen Bell said.

Seeing their son shaking uncontrollably with his eyes closed, the Bells called an ambulance. He spent a few hours in hospital in nearby Belleville, Ont., and was then airlifted to the Children’s Hospital of Eastern Ontario in Ottawa.

Doctors at CHEO diagnosed Cooper with kidney failure brought on by E. coli. He suffered cardiac arrest and died. The Bells believe it was the romaine lettuce that made Cooper sick, although they were unable to send the lettuce for testing to confirm their belief because it had been thrown out.

There were 29 illnesses and 10 hospitalizations reported across Canada during last fall’s E. coli outbreak, according to the Public Health Agency of Canada. It was one of three outbreaks in North America over the past year all of which were linked to romaine lettuce.

Keith Warriner, a food safety expert and professor at the University of Guelph in Ontario, said in an interview that the food industry has long been slow to improve its testing practices something that could improve overall food safety, but would mean extra costs for their operations.

“The industry itself has known for many years what it needs to do, but it’s just been reluctant to do it,” he said.

The Bells agree. They’re sharing their story of grief with the hope it will help hospital workers and other parents better understand the danger of E. coli, but also because they want to see changes at the food production level.

“E. coli shouldn’t be in our food,” Brad Bell said.

“The way that we’re growing food is dangerous, and something has to change.”