2299 confirmed sick from Cyclospora in US from multiple outbreaks May 1-Aug. 30, 2018

Shannon M. Casillas, Carolyne Bennett and Anne Straily of the U.S. Centers for Disease Control write in Morbidity and Mortality Weekly that cyclosporiasis is an intestinal illness caused by the parasite Cyclospora cayetanensis through ingestion of fecally contaminated food or water.

Symptoms of cyclosporiasis might include watery diarrhea (most common), loss of appetite, weight loss, cramping, bloating, increased gas, nausea, and fatigue. Typically, increased numbers of cases are reported in the United States during spring and summer; since the mid-1990s, outbreaks have been identified and investigated almost every year. Past outbreaks have been associated with various types of imported fresh produce (e.g., basil, cilantro, and raspberries) (1). There are currently no validated molecular typing tools* to facilitate linking cases to each other, to food vehicles, or their sources. Therefore, cyclosporiasis outbreak investigations rely primarily on epidemiologic data.

The 2018 outbreak season is noteworthy for multiple outbreaks associated with different fresh produce items and the large number of reported cases. Two multistate outbreaks resulted in 761 laboratory-confirmed illnesses. The first outbreak, identified in June, was associated with prepackaged vegetable trays (containing broccoli, cauliflower, and carrots) sold at a convenience store chain in the Midwest; 250 laboratory-confirmed cases were reported in persons with exposures in three states (illness onset mid-May–mid-June) (2). The supplier voluntarily recalled the vegetable trays (3).

The second multistate outbreak, identified in July, was associated with salads (containing carrots, romaine, and other leafy greens) sold at a fast food chain in the Midwest; 511 laboratory-confirmed cases during May–July occurred in persons with exposures in 11 states who reported consuming salads (4). The fast food chain voluntarily stopped selling salads at approximately 3,000 stores in 14 Midwest states that received the implicated salad mix from a common processing facility (5).

The traceback investigation conducted by the Food and Drug Administration (FDA) did not identify a single source or potential point of contamination for either outbreak.

In addition to the multistate outbreaks, state public health authorities, CDC, and FDA investigated cyclosporiasis clusters associated with other types of fresh produce, including basil and cilantro. Two basil-associated clusters (eight confirmed cases each) were identified among persons in two different states who became ill during June. Investigation of one cluster, for which the state health department conducted an ingredient-specific case-control study, found consumption of basil to be significantly associated with illness. A formal analytic study was not conducted for the other cluster, but all patients reported consuming basil. Three clusters associated with Mexican-style restaurants in the Midwest have resulted in reports of 53 confirmed cases in persons who became ill during May–August. Analytic studies were conducted for two clusters; consumption of cilantro was found to be significantly associated with illness in both. Although a formal analytic study was not possible for the third cluster, all 32 identified patients reported consuming cilantro at the restaurant. FDA traceback of the basil and cilantro from these clusters is ongoing. Additional clusters associated with Mexican-style restaurants were identified in multiple states; but investigations to determine a single vehicle of infection were unsuccessful because of small case counts, limited exposure information, or because fresh produce items (including cilantro) were served as components of other dishes (e.g., in salsa).

Many cases could not be directly linked to an outbreak, in part because of the lack of validated molecular typing tools for C. cayetanensis. As of October 1, 2018, a total of 2,299 laboratory-confirmed cyclosporiasis cases† have been reported by 33 states in persons who became ill during May 1–August 30 and did not have a history of international travel during the 14 days preceding illness onset. Approximately one third of these cases were associated with either the convenience store chain outbreak or the fast food chain outbreak.

The median patient age was 49 years (range = <1–103 years) and 56% were female (1,288 of 2,285). At least 160 patients were hospitalized; no deaths have been reported.

The 2,299 domestically acquired, laboratory-confirmed cases reported in persons who became ill during May–August 2018 are markedly higher than the numbers of cases reported for the same period in 2016 (174) and 2017 (623). This increase might be due, in part, to changes in diagnostic testing practices, including increased use of gastrointestinal molecular testing panels. CDC is working with state public health partners to determine whether and to what extent changes in testing practices might have contributed to increased case detection and reporting.

Consumers should continue to enjoy fresh produce as part of a well-balanced diet. To reduce risk from most causes of foodborne illness and other contaminants, CDC recommends washing fresh fruits and vegetables with clean running water; however, washing, including use of routine chemical disinfection or sanitizing methods, is unlikely to kill C. cayetanensis. Persons with diarrheal illness that lasts >3 days or who have any other concerning symptoms should see a health care provider if they think they might have become ill from eating contaminated food.

Acknowledgments

Contributing state and local public health department personnel; Food and Drug Administration

A heavenly match: Cilantro and cyclospora

According to Food Safety Magazine, since 2014, the U.S. Food and Drug Administration (FDA) has been trying a new approach to produce sampling to assess microbial contamination in food commodities. The approach involves collecting a statistically-valid number of samples of targeted foods over a 12-18 month period, then identifying common microbial factors among them.

For fiscal year 2018, FDA had already been sampling fresh herbs, specifically basil, parsley, and cilantro, along with processed avocado and guacamole–all from both domestic and imported sources. The fresh herbs were chosen for sampling because they are eaten without having gone through any type of kill step (ie. cooking) to reduce or eliminate pathogens. Also, these items are grown low to the ground, which makes them susceptible to contamination. Initially, the sampling was to measure the prevalence of Salmonella and Shiga toxin-producing E. coli (STEC) in these herbs.

Recently, FDA added a new test to this sampling group: Cyclospora cayetanensis. The agency has a new analytical testing method for this parasite.

And my kid is really into this song; also no explanation.

Cyclospora contaminated food in the US, health alert issued

Cyclospora is one of those pathogens spread through poop and water/food tends to be the most favorable vehicle of transmission.

The Federal Safety and Inspection Service has issued a health alert over certain meat products over concern for Cyclospora.
The agency is telling people to be extra cautious with beef pork and poultry salad and wrap products out of Caito Foods LLC, in Indianapolis, Indiana.
The items with “best by” or “sell by” dates ranging from July 18th to July 23rd are under the alert. 
The problem within Caito Foods is related to the lettuce supplier, Fresh Express. The chopped romaine is being recalled.
Cyclospora infection, defined by the Centers for Disease Control, is an intestinal illness caused by a parasite. The infection can cause Cyclosporiasis.
The symptoms of Cyclosporiasis include loss of appetite, weight loss, cramping, bloating, nausea, fatigue, and other flu-like symptoms.

61 sick in 7 states from Cyclospora in new outbreak linked to McDonald’s; 3000 locations removing salads

At least 61 people in seven Midwestern States have been sickened with Cyclospora possibly linked to salads served at McDonald’s restaurants.

The U.S. Food and Drug Administration and the Centers for Disease Control and Prevention (CDC) report that two people have been hospitalized and to date, no deaths have been reported.

Ashley Nickle of The Packer reports that health authorities in Illinois and Iowa have reported 105 recent cases of cyclosporiasis and have linked some of them to McDonald’s salads.

“Out of an abundance of caution, we decided to voluntarily stop selling salads at impacted restaurants until we can switch to another lettuce blend supplier,” McDonald’s said in a statement. “We are in the process of removing existing salad blends from identified restaurants and distribution centers, which includes approximately 3,000 of our U.S. restaurants, primarily located in the Midwest.”

McDonald’s spokeswoman Terri Hickey said, “McDonald’s is committed to the highest standards of food safety and quality control. We are closely monitoring this situation and cooperating with state and federal public health authorities as they further investigate”

In June, federal agencies investigated cyclosporiasis cases that were linked to Del Monte vegetable trays. More than 225 illnesses have been reported in that outbreak. At this time, no link has been made by health authorities between the outbreak linked to McDonald’s salads and the outbreak linked to Del Monte vegetable trays, which included broccoli, cauliflower, carrots and dip.

212 sick: Multistate outbreak of cyclosporiasis linked to Del Monte Fresh produce vegetable tray

The U.S. Centers for Disease Control and Prevention (CDC) reports that Cyclospora cayetanensis is a single-celled parasite that causes an intestinal infection called cyclosporiasis.

As of July 5, 2018 (9am EDT), CDC has been notified of 212 laboratory-confirmed cases of cyclosporiasis in persons who reportedly consumed pre-packaged Del Monte Fresh Produce vegetable trays containing broccoli, cauliflower, carrots, and dill dip. The reports have come from four states.

Seven (7) of these people have been hospitalized, and no deaths have been reported.

Epidemiologic evidence indicates that pre-packaged Del Monte Fresh Produce vegetable trays containing broccoli, cauliflower, carrots, and dill dip are the likely source of these infections.

Most ill people reported eating pre-packaged Del Monte Fresh Produce vegetable trays containing broccoli, cauliflower, carrots, and dill dip.

Most ill people reported buying pre-packaged Del Monte Fresh Produce vegetable trays containing broccoli, cauliflower, carrots, and dill dip in the Midwest. Most people reported buying the trays at Kwik Trip convenience stores.

The investigation is ongoing. CDC will provide updates when more information is available.

General advice for consumers about prevention of cyclosporiasis can be found here.

On June 15, 2018, Del Monte Fresh Produce recalled 6 oz., 12 oz., and 28 oz. vegetable trays containing fresh broccoli, cauliflower, celery sticks, carrots, and dill dip. Recalled products were sold in clear, plastic clamshell containers.

Recalled products were distributed to the following stores: Kwik Trip, Kwik Star, Demond’s, Sentry, Potash, Meehan’s, Country Market, FoodMax Supermarket, and Peapod.

Salmonella in pesto triggers Irish recall

Brisbane has fabulous produce and seafood, befitting a costal sub-tropical town.

Sure, it’s way too hot for three months in the summer, but the weather is ideal the rest of the year.

A friend of mine – a food safety professional — was telling me yesterday about this snapper he got, straight of the trawler, and the pesto sauce he made to go with it.

I really try not to be Debbie/Dougie downer when people tell me their proud achievements, so I didn’t go into all the outbreaks on pesto from uncooked basil.

Usually it’s cyclospora, but the Food Safety Authority of Ireland has issued a public notification that Dunnes Stores and Spar are initiating a recall of their own brand pestos, due to the possible presence of Salmonella. Consumers who have bought the implicated batches should dispose of the product or return it to the place of purchase.

185 sick: Cyclosporiasis in Del Monte veggie trays

As of June 28, 2018 (11am EDT), the U.S Centers for Disease Control (CDC) has been notified of 185 laboratory-confirmed cases of cyclosporiasis in persons who reportedly consumed pre-packaged Del Monte Fresh Produce vegetable trays containing broccoli, cauliflower, carrots, and dill dip. The reports have come from four states.

Seven (7) of these people have been hospitalized, and no deaths have been reported.

  • Epidemiologic evidenceindicates that pre-packaged Del Monte Fresh Produce vegetable trays containing broccoli, cauliflower, carrots, and dill dip are the likely source of these infections.
    • Most ill people reported eating pre-packaged Del Monte Fresh Produce vegetable trays containing broccoli, cauliflower, carrots, and dill dip.
    • Most ill people reported buying pre-packaged Del Monte Fresh Produce vegetable trays containing broccoli, cauliflower, carrots, and dill dip in the Midwest. Most people reported buying the trays at Kwik Trip convenience stores.
    • The investigation is ongoing. CDC will provide updates when more information is available.

The median illness onset date among patients is May 31, 2018 (range: May 14 to June 9).  Ill people range in age from 13 to 79 years old, with a median age of 47. Fifty-seven percent (57%) are female and 7 people have been hospitalized. No deaths have been reported.

Illnesses that began after May 17, 2018 might not have been reported yet due to the time it takes between when a person becomes ill and when the illness is reported.

Cyclospora infections linked to vegetable trays sold at Kwik Trip stores

Rick Barrett of the Journal Sentinel reports that Wisconsin and Minnesota health officials are investigating an increase of Cyclospora infections that may be linked to Del Monte vegetable trays purchased from Kwik Trip stores.

Eleven people in Wisconsin and three in Minnesota have reported becoming ill after eating vegetables from the trays that contained broccoli, cauliflower, carrots and dill dip, according to the Wisconsin Department of Health Services.

Kwik Trip has removed the 6-ounce and 12-ounce trays from its stores and is cooperating with state officials. The trays may also have been available from other businesses, health officials said.

The produce problem: Ingredient analysis at restaurants in Cyclospora outbreaks

By Sept. 2017, the U.S. Centers for Disease Control reported that almost 1,000 people had laboratory-confirmed cases of cyclosporiasis for the year.

Another banner year for the parasite famously associated with Guatemalan raspberries in 1996.

During July 21–August 8, 2017, the Texas Department of State Health Services (DSHS) was notified of 20 cases of cyclosporiasis among persons who dined at a Mediterranean-style restaurant chain (chain A) in the Houston area. On August 10, 2017, DSHS requested assistance from CDC to support ongoing investigations by the City of Houston Health Department, Harris County Public Health, Fort Bend County Health and Human Services, and Brazoria County Health Department. The objectives of this investigation were to determine the source of the illnesses in the Houston area and to generate hypotheses about the source of the national increase in cyclosporiasis in 2017.

Chain A has four locations in the Houston area and a central kitchen where many dishes are prepared. A case-control study was performed using a menu-specific questionnaire focusing on items containing fresh produce. A confirmed case was defined as laboratory-confirmed Cyclospora infection and clinically compatible illness in a person who ate at any location of chain A during May 28–July 15, 2017. A probable case was defined as diarrhea and at least one additional sign or symptom compatible with cyclosporiasis (e.g., anorexia, abdominal cramping, bloating, myalgia, fatigue, vomiting, or low-grade fever) in a person within 2 weeks after dining at chain A during May 28–July 15, 2017. Controls were identified as either dining companions of case-patients who had no illness or patrons who dined at the same chain A location within 2 days of a case-patient visit and who had no illness. For controls identified by the latter method, contact information was obtained using commercially available databases used by local health agencies in Texas. Three controls per case-patient were recruited.

A total of 22 case-patients (16 confirmed and six probable) and 66 controls were enrolled in the study. Case-patients had a median age of 52 years (range = 29–79 years); 50% were female. Analysis compared menu items consumed by case-patients and controls, followed by ingredient-level analysis. The following ingredients were identified as being significantly associated with illness: green onions (matched odds ratio = 11.3; 95% confidence interval = 2.55–104.68), tomatoes (5.5; 1.2–51.7), red onions (4.7; 1.3–21.0), and cabbage (4.0; 1.1–15.9). When analysis was limited to the 16 confirmed case-patients and their corresponding 48 controls, only green onions remained significantly associated with illness (17.6; 2.5–775.7). Restaurant invoices from chain A were collected for all items identified during the epidemiologic investigation, but efforts to trace any food item to its source were inconclusive. Although the current study identified potential foods associated with illness in Texas, investigators were not able to identify the illness source or confirm whether the patients within the chain A subcluster had consumed a product reported by other ill persons in the United States.

Cyclosporiasis is an intestinal illness caused by the parasite Cyclospora cayetanensis. Since 2013, the United States has experienced annual increases in the incidence of cyclosporiasis incidence during the summer months, with some illnesses linked to imported produce (1–3). Molecular subtyping of Cyclospora is not currently available; therefore, identification of an ingredient associated with a particular illness subcluster might provide information about a source contributing to other cyclosporiasis illnesses. Previous U.S. outbreaks of cyclosporiasis have been linked to fresh produce, such as prepackaged salad mix, raspberries, and cilantro (3,4). Identification of a vehicle for Cyclospora is complicated by the short shelf life of fresh produce as well as the use of potential vehicles such as garnishes or mixtures with other items that could also harbor the parasite. Ingredient-level analysis within restaurant clusters and subclusters therefore remains critical in Cyclospora outbreak investigations.

Notes from the field: Cyclosporiasis cases associated with dining at a Mediterranean-style restaurant chain- Texas 2017

1.jun.18 CDC

Amelia A. Keaton, MD1,2; Noemi Borsay Hall, PhD2,3; Rebecca J. Chancey, MD2,4; Vivienne Heines, MPH3; Venessa Cantu, MPH3; Varsha Vakil, MPH5; Stephen Long, MD5; Kirstin Short, MPH5; Elya Franciscus, MPH6; Natasha Wahab, MPH6; Aisha Haynie, MD6; Laura Gieraltowski, PhD2; Anne Straily, DVM4

https://www.cdc.gov/mmwr/volumes/67/wr/mm6721a5.htm

1000 sick: As North America turns to Fall, another bumper crop of Cyclospora

CDC reports that as of September 13, 2017 they have been notified of 988 laboratory-confirmed cases of cyclosporiasis in persons who became ill in 2017. This number includes persons who reported international travel as well as persons who did not report travel. The reports have come from 40 states.

  • At least 553 (56%) of these persons did not report international travel (i.e., likely were infected in the United States) and became ill on or after May 1, 2017 (a date after which cases tend to increase each year). These 553 persons were from the following 36 states: Arizona (1), California (10), Colorado (6), Connecticut (23), Florida (68), Georgia (10), Illinois (17), Indiana (4), Iowa (14), Kansas (2), Louisiana (7), Maryland (12), Massachusetts (13), Michigan (3), Minnesota (11), Mississippi (1), Missouri (13), Montana (2), Nebraska (5), New Hampshire (4), New Jersey (19), New Mexico (1), New York (excluding NYC) (15), New York City (30), North Carolina (45), Ohio (16), Pennsylvania (2), Rhode Island (2), South Carolina (7), South Dakota (4), Tennessee (3), Texas (163), Utah (1), Virginia (7), Washington (1), West Virginia (2), and Wisconsin (9).
  • At this time, no specific vehicle of interest has been identified, and investigations to identify a potential source (or sources) of infection are ongoing. It is too early to say whether cases of Cyclosporainfection in different states are related to each other or to the same food item(s).

Previous U.S. outbreaks of cyclosporiasis have been linked to various types of imported fresh produce (e.g., basil, cilantro, mesclun lettuce, raspberries, snow peas). Consumers should continue to enjoy the health benefits of eating fresh fruits and vegetables as part of a well-balanced diet.