11 sick: New York state investigating Cyclospora outbreak

Bethany Bump of the Times Union writes that New York state and local health departments are investigating an outbreak of cyclosporiasis in the Capital Region.

The gastrointestinal illness, which can spread through contaminated food and water, has been confirmed in 11 people so far.

Symptoms began around mid-June, and several of the patients reported eating at the Italian American Community Center in Albany, Prime Life Restaurant at the Beltrone Senior Living Community Center in Colonie, and a private buffet held at Union College in Schenectady, state health officials said.

While cyclosporiasis is endemic in some areas of the world, outbreaks in the U.S. are often associated with imported fresh produce that have been contaminated with a fecal parasite known as Cyclospora cayetanensis.

State health officials say there is no indication that the parasite was spread by poor food handling or preparation at local establishments, which are cooperating with the investigation. Instead, contamination often occurs prior to arrival at food distribution centers and restaurants, they said, and is not easily removed by standard rinsing.

Additional dining establishments may be identified as the investigation continues, they added.

Are they judging jams? Blue-ribbon panel on the prevention of foodborne Cyclospora outbreaks

When someone says a blue-ribbon panel summarized results on the prevention of foodborne Cyclospora outbreaks, I think blue-ribbons is talking about jams or Holsteins at county fairs.

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.

She was sick for weeks.

It’s the fog of outbreaks..

Like the fog my daughter played in last Sat. at the Gold Coast.

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-two years after that first Guatemalan raspberry-associated outbreak — and a year after produce-associated cyclosporiasis outbreaks that were linked to U.S.-grown produce — we have taken a major step forward in our understanding of these outbreaks and how to prevent them. After Fresh Express produce was identified in one of the 2018 outbreaks, I was asked by the company leadership to bring together the best minds’ around all aspects of produceassociated cyclosporiasis. The goal was to establish a Blue-Ribbon Panel to summarize state-of-the-art advancements regarding this public health challenge and to identify immediate steps that the produce industry and regulators can take to prevent future outbreaks. The panel was also formed to determine what immediate steps can be taken for any future outbreaks to expedite the scientific investigation to prevent further cases and inform public health officials. The Blue-Ribbon Panel comprises 11 individuals with expertise in the biology of Cyclospora; the epidemiology of cyclosporiasis, including outbreak investigation; laboratory methods for identifying C. cayetanensis in human and food samples and the environment; and produce production. In addition,16 expert consultants from academia, federal and state public health agencies (including expert observers from the FDA, CDC, U.S. Department of Agriculture, and California Department of Public Health), and industry, including producers and professional trade association science experts. The collaboration and comprehensiveness of this effort was remarkable. Many hundreds of hours of meetings and conference calls took place to determine our findings and establish our recommendations.

This document, “Interim Report: Blue-Ribbon Panel on the Prevention of Cyclospora Outbreaks in the Food Supply,” summarizes the state-of-the art practices for the prevention of C. cayetanensis contamination of produce and priorities for research that will inform us as we strive to further reduce infection risk. Also, we make recommendations on how to more quickly identify and more effectively respond to produce-associated outbreaks when they occur. We greatly appreciate all the organizations represented on the panel and the expert consultants. The report does not, however, represent the official policy or recommendations of any other private, academic, trade association or federal or state government agency. Fresh Express has committed to continuing the Blue-Ribbon Panel process for as long as it can provide critical and actionable information to prevent and control Cyclospora outbreaks in the food supply.

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‡‡‡

UK Cyclospora shit fest

TTG reports a judge sitting at Manchester county court has ordered the disclosure of all documentary evidence relating to investigations carried out by Public Health England (PHE) surrounding cyclospora — a parasite spread by food contaminated with infected human faeces.

According to The Times, many customers claimed Tui did not tell them the Riviera Maya region of Mexico was subject to a public health warning due to cyclosporiasis before they booked.

This is in spite of 359 of the 440 British cases reported between June and October 2016 “involving travel to Mexico”, it is claimed.

Others customers allege they were handed a warning letter “only after their plane landed”.

440 sickened: Tui faces legal action from 400 people over Mexico sickness

TTG reports a  judge sitting at Manchester county court has ordered the disclosure of all documentary evidence relating to investigations carried out by Public Health England (PHE) surrounding cyclospora — a parasite spread by food contaminated with infected human faeces.

According to The Times, many customers claimed Tui did not tell them the Riviera Maya region of Mexico was subject to a public health warning due to cyclosporiasis before they booked.

This is in spite of 359 of the 440 British cases reported between June and October 2016 “involving travel to Mexico”, it is claimed.

Others customers allege they were handed a warning letter “only after their plane landed”.

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.