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13/07/18: Cyclospora parasite cases in Illinois, Iowa, Michigan, Minnesota and Wisconsin

cyclosporaoutbreak_406x250The Illinois Department of Public Health (IDPH) has received confirmation of approximately 90 cases of cyclosporiasis, an intestinal illness caused by the microscopic Cyclospora parasite. Cases have been reported in counties across Illinois with people becoming ill starting in mid-May. The initial investigation indicates a link to consumption of McDonald’s salads produced for McDonald’s restaurants. Approximately one-fourth of Illinois cases reported eating salads from McDonald’s in the days before they became ill. The Iowa Department of Health has noted a similar increase in cases.

“Although a link has been made to salads sold in McDonald’s restaurants in some Illinois cases, public health officials continue to investigate other sources,” said IDPH Director Nirav D. Shah, M.D., J.D. “If you ate a salad from McDonald’s since mid-May and developed diarrhea and fatigue, contact a health care provider about testing and treatment.”

The Iowa Department of Public Health (IDPH) is investigating an increase in Cyclospora infections that appear to be connected to consumption of McDonald’s salads. The Illinois Department of Public Health has noted a similar increase in cases associated with the product.

“This summer there have been several clusters of Cyclospora illness associated with various foods that are commercially available. This week IDPH has identified 15 Iowans who ate McDonald’s salads in late June to early July prior to getting ill,” said Dr Patricia Quinlisk. “Anyone who ate these salads since the middle of June and who developed diarrhoea, especially watery diarrhoea and fatigue, should see their health care provider and get tested for Cyclospora to ensure an accurate diagnosis and appropriate treatment.”

On June 15, the CDC announced a Cyclospora outbreak linked to Del Monte 6oz and 12oz vegetable trays containing cauliflower, carrots, and dill dip. As of July 5, 212 people are ill in Iowa, Michigan, Minnesota, Wisconsin (CDC map). Seven people have been hospitalized, no deaths have been reported. Onset dates range from May 14 to June 13. The veggie trays include broccoli, cauliflower, carrots, celery, and dill dip.

Del Monte has recalled all vegetable trays from retail locations. Consumers are advised to dispose of trays with expiration dates of June 27, 2018, or earlier.

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

Recalled products have a “Best If Enjoyed By” date of June 17, 2018.

What is Cyclospora?

Cyclospora is a parasite composed of one cell, too small to be seen without a microscope. The organism was previously thought to be a blue-green alga or a large form of Cryptosporidium. Cyclospora cayetanensis is the only species of this organism found in humans. The first known human cases of illness caused by cyclospora infection (that is, cyclosporiasis) were first discovered in 1977. An increase in the number of cases being reported began in the mid-1980s, in part due to the availability of better diagnostic techniques. Over 15,000 cases are estimated to occur in the United States each year. The first recorded Cyclospora outbreak in North America occurred in 1990 and was linked to contaminated water. Since then, several cyclosporiasis outbreaks have been reported in the U.S. and Canada, many associated with eating fresh fruits or vegetables. In some developing countries, cyclosporiasis is common among the population and travellers to those areas have become infected as well. See, www.outbreakdatabase.com for past outbreaks related to Cyclospora cayetanensis.

Where does Cyclospora come from?

Cyclospora is spread when people ingest water or food contaminated with infected stool. For example, exposure to contaminated water among farm workers may have been the original source of the parasite in raspberry-associated outbreaks in North America.

Cyclospora needs time (one to several weeks) after being passed in a bowel movement to become infectious. Therefore, it is unlikely that Cyclospora is passed directly from one person to another. It is not known whether or not animals can be infected and pass the infection to people.

What are the typical symptoms of Cyclospora infection?

Cyclospora infects the small intestine (bowel) and usually causes watery diarrhoea, bloating, increased gas, stomach cramps, and loss of appetite, nausea, low-grade fever, and fatigue. In some cases, vomiting, explosive diarrhoea, muscle aches, and substantial weight loss can occur. Some people who are infected with Cyclospora do not have any symptoms. Symptoms generally appear about a week after infection. If not treated, the illness may last from a few days up to six weeks. Symptoms may also recur one or more times. In addition, people who have previously been infected with Cyclospora can become infected again.

What are the serious and long-term risks of Cyclospora infection?

Cyclospora has been associated with a variety of chronic complications such as Guillain-Barre syndrome, reactive arthritis or Reiter’s syndrome, biliary disease, and acalculous cholecystitis. Since Cyclospora infections tend to respond to the appropriate treatment, complications are more likely to occur in individuals who are not treated or not treated promptly. Extraintestinal infection also appears to occur more commonly in individuals with a compromised immune system.

How is Cyclospora infection detected?

Your healthcare provider may ask you to submit a stool specimen for analysis. Because testing for Cyclospora infection can be difficult, you may be asked to submit several stool specimens over several days. Identification of this parasite in stool requires special laboratory tests that are not routinely done. Therefore, your health care provider should specifically request testing for Cyclospora if it is suspected. Your health care provider might have your stool checked for other organisms that can cause similar symptoms.

How is Cyclospora infection treated?

The recommended treatment for infection with cyclospora is a combination of two antibiotics, trimethoprim-sulfamate diarrhoea, also known as Bactrim, Septra, or Cotrim.diarrhoeawho have diarrhea should rest and drink plenty of fluids. No alternative drugs have been identified yet for people with Cyclospora infection who are unable to take sulfa drugs. Some experimental studies, however, have suggested that ciprofloxacin or nitazoxanide may be effective, although to a lesser degree than trimethoprim-sulfamethoxazole. See your health care provider to discuss alternative treatment options.

How can Cyclospora infection be prevented?

Avoiding water or food that may be contaminated is advisable when traveling. Drinking bottled or boiled water and avoiding fresh ready-to-eat produce should help to reduce the risk of infection in regions with high rates of infection. Improving sanitary conditions in developing regions with poor environmental and economic conditions is likely to help to reduce exposure.

Washing fresh fruits and vegetables at home may help to remove some of the organisms, but Cyclospora may remain on produce even after washing.

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