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Foodborne Illness Outbreaks

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Restaurants in Texas, Wisconsin and Georgia Link in 26 State Cyclospora Outbreak

Cilantro from Mexico a suspected source.

As of July 30, 2015, the CDC had been notified of 358 ill persons with confirmed Cyclospora infection from 26 states in 2015.

Most (199; 56%) ill persons experienced onset of illness on or after May 1, 2015 and did not report international travel prior to symptom onset.

Clusters of illness linked to restaurants or events have been identified in Texas, Wisconsin, and Georgia. Cluster investigations are ongoing in Texas and Georgia.

Cluster investigations in Wisconsin and Texas have preliminarily identified cilantro as a suspect vehicle. Investigations are ongoing to identify specific food item(s) linked to the cases that are not part of the identified clusters.

Previous U.S. outbreaks of cyclosporiasis have been linked to imported fresh produce, including cilantro from the Puebla region of Mexico. Read the related FDA Import Alert issued July 27, 2015.

Screen-shot-2010-10-30-at-10_13_31-PMWhat 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 each year in the United States. The first outbreak in North America occurred in 1990 from contaminated water. Since then, several outbreaks of cyclosporiasis 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 travelers to those areas have become infected as well.

Where does Cyclospora come from?

Cyclospora is spread by people ingesting water or food contaminated with infected stool. For example, exposure to contaminated water among farm workers may have been the original source 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 infection to people.

What are the typical symptoms of Cyclospora infection?

Cyclospora infects the small intestine (bowel) and usually causes watery diarrhea, bloating, increased gas, stomach cramps, loss of appetite, nausea, low-grade fever, and fatigue. In some cases, vomiting, explosive diarrhea, muscle aches, and substantial weight loss can occur. Some people who are infected with Cyclospora do not have any symptoms. The time between becoming infected and becoming ill is usually about one week. If not treated, the illness may last from a few days up to six weeks. Symptoms also may recur one or more times (relapse). 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 health care provider will ask you to submit stool specimens to see if you are infected. 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-sulfamethoxazole, also known as Bactrim, Septra, or Cotrim. People who 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.

Washington Salmonella Outbreak Linked to Pork expands to 90 Cases

Federal disease investigation team to join state and local health officials next week

The outbreak of Salmonella infections that may be linked to pork products has grown to 90 cases in several counties around the state. The ongoing outbreak is under investigation by state, local, and federal public health agencies.

With the increase in cases, state health officials have asked the federal Centers for Disease Control and Prevention (CDC) to send a special team to help with the investigation. This team of “disease detectives” will arrive in Washington next week.

Disease investigators are searching for possible exposure sources from farm to table. An apparent link to pork consumption or contamination from raw pork is the strongest lead, though no specific source has yet been found. The likely source of exposure for some of the ill people appears to have been whole roasted pigs, cooked and served at private events.

All of the people who’ve been sickened have been infected with the same strain of Salmonella bacteria. Salmonellosis, the illness caused by infection with Salmonella, can cause severe and even bloody diarrhea, fever, chills, abdominal discomfort, and vomiting. Serious bloodstream infections may also occur.

The cases, many of which are in King County, appear to have been caused by the same rare strain of Salmonella bacteria, health officials said. The outbreak is linked to Salmonella I, 4, 5, 12:i:-, a germ that has been emerging nationally but has never before been seen in Washington state.

Salmonella: Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Salmonella outbreaks. The Salmonella lawyers of Marler Clark have represented thousands of victims of Salmonella and other foodborne illness outbreaks and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation. Our Salmonella lawyers have litigated Salmonella cases stemming from outbreaks traced to a variety of foods, such as cantaloupe, tomatoes, ground turkey, salami, sprouts, cereal, peanut butter, and food served in restaurants. The law firm has brought Salmonella lawsuits against such companies as Cargill, ConAgra, Peanut Corporation of America, Sheetz, Taco Bell, Subway and Wal-Mart.

If you or a family member became ill with a Salmonella infection, including Reactive Arthritis or Irritable bowel syndrome (IBS), after consuming food and you’re interested in pursuing a legal claim, contact the Marler Clark Salmonella attorneys for a free case evaluation.

Boise Co-op Salmonella Outbreak Information Update: 300 Sickened

The Central District Health Department (CDHD) investigated a Salmonella outbreak associated with the Boise Co-op deli – specifically food purchased from the deli after June 1, 2015.

As of the end of July, approximately 300 cases of Salmonella were associated with the outbreak. Test results showed Salmonella growth in raw turkey, tomatoes and onion.

Salmonella is a bacteria that can cause diarrheal illness in humans. They are microscopic living creatures that pass from the feces of people or animals to other people or other animals. There are many different kinds of Salmonella bacteria.

Salmonella serotype Typhimurium and Salmonella serotype Enteritidis are the most common in the United States.

Salmonella: Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Salmonella outbreaks. The Salmonella lawyers of Marler Clark have represented thousands of victims of Salmonella and other foodborne illness outbreaks and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation. Our Salmonella lawyers have litigated Salmonella cases stemming from outbreaks traced to a variety of foods, such as cantaloupe, tomatoes, ground turkey, salami, sprouts, cereal, peanut butter, and food served in restaurants. The law firm has brought Salmonella lawsuits against such companies as Cargill, ConAgra, Peanut Corporation of America, Sheetz, Taco Bell, Subway and Wal-Mart.

If you or a family member became ill with a Salmonella infection, including Reactive Arthritis or Irritable bowel syndrome (IBS), after consuming food and you’re interested in pursuing a legal claim, contact the Marler Clark Salmonella attorneys for a free case evaluation.

CDC Weighs in in Deadly Ohio Botulism Outbreak

Outbreak
On April 21, 2015, the Fairfield Medical Center (FMC) and Fairfield Department of Health contacted the Ohio Department of Health (ODH) about a patient suspected of having botulism in Fairfield County, Ohio. Botulism is a severe, potentially fatal neuroparalytic illness.* A single case is a public health emergency, because it can signal an outbreak (1). Within 2 hours of health department notification, four more patients with similar clinical features arrived at FMC’s emergency department. Later that afternoon, one patient died of respiratory failure shortly after arriving at the emergency department. All affected persons had eaten at the same widely attended church potluck meal on April 19. CDC’s Strategic National Stockpile sent 50 doses of botulinum antitoxin to Ohio. FMC, the Fairfield Department of Health, ODH, and CDC rapidly responded to confirm the diagnosis, identify and treat additional patients, and determine the source.A confirmed case of botulism was defined as clinically compatible illness in a person who ate food from the potluck meal and had 1) laboratory-confirmed botulism or 2) two or more signs of botulism or one sign and two or more symptoms† of botulism. A probable case was a compatible illness that did not meet the confirmed case definition in a person who ate food from the potluck meal.

Among 77 persons who consumed potluck food, 25 (33%) met the confirmed case definition, and four (5%) met the probable case definition. The median age of patients was 64 years (range = 9–87 years); 17 (59%) were female. Among 26 (90%) patients who reported onset dates, illness began a median of 2 days after the potluck (range = 1–6 days).

Twenty-seven of the 29 patients initially went to FMC. Twenty-two (76%) patients were transferred from FMC to six hospitals in the Columbus metropolitan area approximately 30 miles away; these transfers required substantial and rapid coordination. Twenty-five (86%) patients received botulinum antitoxin, and 11 (38%) required endotracheal intubation and mechanical ventilation; no other patients died. Within 1 week of the first patient’s arrival at the emergency department, 16 patients (55%) had been discharged. Among 19 cases that were laboratory-confirmed, serum and stool specimens were positive for botulinum neurotoxin type A or Clostridium botulinum type A.

Interviews were conducted with 75 of 77 persons who ate any of the 52 potluck foods. Consumption of any potato salad (homemade or commercial) yielded the highest association with probable or confirmed case status (risk ratio [RR] = 13.9; 95% confidence interval [CI] = 4.6–41.8), followed by homemade potato salad (RR = 9.1; CI = 3.9–21.2). Of 12 food specimens collected from the church dumpster, six were positive for botulinum neurotoxin type A; five contained potato salad and one contained macaroni and cheese that might have been contaminated after being discarded.

The attendee who prepared the potato salad with home-canned potatoes reported using a boiling water canner, which does not kill C. botulinum spores, rather than a pressure canner, which does eliminate spores (2). In addition, the potatoes were not heated after removal from the can, a step that can inactivate botulinum toxin. The combined evidence implicated potato salad prepared with improperly home-canned potatoes, a known vehicle for botulism (3).

This was the largest botulism outbreak in the United States in nearly 40 years (Table). Early recognition of the outbreak by an astute clinician and a rapid, coordinated response likely reduced illness severity and facilitated early hospital discharge. This outbreak response illustrates the benefits of coordination among responders during botulism outbreaks. Close adherence to established home-canning guidelines can prevent botulism and enable safe sharing of home-canned produce (2).

Acknowledgments

Fairfield Medical Center, Lancaster, Ohio; Fairfield Department of Health, Lancaster, Ohio; Ohio Department of Health (ODH) Bureau of Infectious Diseases, Columbus, Ohio; ODH Bureau of Public Health Laboratory, Reynoldsburg, Ohio; ODH Office of Preparedness, Columbus, Ohio; Franklin County Public Health, Columbus, Ohio; Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; Strategic National Stockpile, Office of Public Health Preparedness and Response, CDC; Office of Regulatory Affairs, CDC.
1Ohio Department of Health; 2Epidemic Intelligence Service, CDC; 3Division of Foodborne, Waterborne, and Infectious Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 4Fairfield Department of Health; 5Fairfield Medical Center. Corresponding author: Carolyn L. McCarty, wmw8@cdc.gov, 614-728-6941.

References

Sobel J. Botulism. Clin Infect Dis 2005;41:1167–73.
National Center for Home Food Preservation, US Department of Agriculture. USDA complete guide to home canning, 2009 revision. Washington, DC: US Department of Agriculture; 2009. Available at http://nchfp.uga.edu/publications/publications_usda.htmlExternal Web Site Icon.
Sobel J, Tucker N, Sulka A, McLaughlin J, Maslanka S. Foodborne botulism in the United States, 1990–2000. Emerg Infect Dis 2004;10:1606–11.

Texas Cyclospora Cases Hit 212 Linked to Mexican Cilantro

Texas Department of Health reports a recent surge in reports of illnesses due to the parasite Cyclospora has prompted DSHS to investigate the infections in hopes of determining a common source. DSHS has received reports of 212 Cyclosporiasis cases from around Texas this year. Past outbreaks have been associated with cilantro from the Puebla area of Mexico. While the investigation into the current outbreak is ongoing, DSHS has identified imported cilantro as a possible source of some infections.

Cyclosporiasis is an intestinal illness caused by consuming food or water contaminated with the Cyclospora parasite. The major symptom is watery diarrhea lasting a few days to a few months. Additional symptoms may include loss of appetite, fatigue, weight loss, abdominal cramps, bloating, increased gas, nausea, vomiting and a low fever. People who think they may have a Cyclospora infection should contact their health care provider.

DSHS recommends thoroughly washing fresh produce, but that may not entirely eliminate the risk because Cyclospora can be difficult to wash off. Cooking will kill the parasite.

Last year, Texas had 200 cases, some of which were associated with cilantro from the Puebla region in Mexico.

Kenosha Salmonella Outbreak Over After 70 Sickened

The final case count for the Salmonella outbreak in Kenosha County, WI, in May was 70 people.

The illnesses, first reported to the Kenosha County Division of Health (KCDOH) on May 14, were eventually linked to pork carnitas sold at Supermercado Los Corrales during Mother’s Day weekend (May 8-10, 2015).

A public health nurse conducted case investigations on the reports and detected that at least 10 people were ill with similar complaints after eating food purchased from one food establishment. The chief complaints reported included diarrhea, nausea, vomiting, headache, abdominal cramping and fever.

The meat and food preparation area of Supermercado Los Corrales was temporarily closed during the investigation on May 18 and reopened June 4.

In early July, Health Officer Cynthia Johnson presented a case study of the outbreak to the Kenosha County Human Services Committee meeting.

Some of the investigation’s majors strengths, Johnson said, were the early identification of illnesses, the department’s Incident Command System, and collaboration with the Wisconsin Division of Public Health Communicable Disease team, the Kenosha Unified School District staff, local and regional media, and the Kenosha County government.

She also identified two areas for improvement. The efficiency of entering data into the Wisconsin Electronic Disease Surveillance System should be improved, and the Kenosha County phone system should be reviewed for effective utilization during an event.

Tarheel Q Salmonella Outbreak Over After 280 Sick and 1 Death

tarheelThe Salmonella outbreak connected with the Tarheel Q restaurant in Lexington, NC, has been deemed over with at least 280 people sickened, according to a July 28 case count. One person died.

The designation was announced after two incubation periods (six days for most Salmonella cases) had passed without new illnesses since the restaurant reopened. Local health departments will no longer accept additional reports of illness.

The 280 cases were distributed across 21 North Carolina counties and 6 states. Of the North Carolina cases, 77 percent were residents of Davidson County and Davie County.

Laboratory testing indicated that the BBQ sample and a sample from a patient who became ill during the beginning of the outbreak were both positive for Salmonella species. The serogroup was Typhimurium, and both samples had the same PFGE pattern (DNA fingerprint). Three additional patients had a different PFGE pattern.

Fifty-eight percent of those sickened were male, 42 percent were between the ages of 20 and 49, and 9 percent had been hospitalized. Most cases had illness onset dates between June 16 and June 21.

Salmonella: Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Salmonella outbreaks. The Salmonella lawyers of Marler Clark have represented thousands of victims of Salmonella and other foodborne illness outbreaks and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation. Our Salmonella lawyers have litigated Salmonella cases stemming from outbreaks traced to a variety of foods, such as cantaloupe, tomatoes, ground turkey, salami, sprouts, cereal, peanut butter, and food served in restaurants. The law firm has brought Salmonella lawsuits against such companies as Cargill, ConAgra, Peanut Corporation of America, Sheetz, Taco Bell, Subway and Wal-Mart.

If you or a family member became ill with a Salmonella infection, including Reactive Arthritis or Irritable bowel syndrome (IBS), after consuming food and you’re interested in pursuing a legal claim, contact the Marler Clark Salmonella attorneys for a free case evaluation.

Washington Whole Roasted Pigs Link in Salmonella Outbreak

5315336-golden-whole-roasted-pig-on-a-spit-spit-roasting-is-a-traditional-luau-method-of-cooking-a-whole-pigState health officials are working with state and local partners to investigate several cases and clusters of Salmonella infections that appear to be linked to eating pork. The ongoing investigation of at least 61 cases in eight counties around the state includes food served at a variety of events.

Disease investigators continue to explore several sources from farm to table, and are focused on an apparent link to pork consumption or contamination from raw pork. Salmonellosis, the illness caused by infection with Salmonella, can cause severe and even bloody diarrhea, fever, chills, abdominal discomfort, and vomiting. Serious bloodstream infections may also occur.

Cases include residents of King, Snohomish, Mason, Thurston, Pierce, Grays Harbor, Yakima, and Clark counties. Five of the cases were hospitalized; no deaths have been reported. All were infected with the same strain of Salmonella bacteria. The disease investigation shows a potential exposure source for several cases was whole roasted pigs, cooked and served at private events. The source of contamination remains under investigation by state and local health officials and federal partners.

Barber Foods Salmonella Stuffed Chicken Entrees Sicken Nine

map-07-28-2015-newCDC, several states, and the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS) are investigating an outbreak of Salmonella Enteritidis infections linked to raw, frozen, stuffed chicken entrees produced by Barber Foods.

Nine people infected with a strain of Salmonella Enteritidis have been reported from four states: Illinois (1), Minnesota (6), Oklahoma (1), and Wisconsin (1). Three of these ill people have been hospitalized. No deaths have been reported.

CDC’s National Antimicrobial Resistance Monitoring System (NARMS) laboratory conducted antibiotic resistance testing on clinical isolates collected from four ill people infected with the outbreak strain.

All four (100%) isolates tested were resistant to ampicillin and tetracycline.

Antibiotic resistance may be associated with increased risk of hospitalization, development of a bloodstream infection, or treatment failure in patients.

Barber Foods issued an expanded recall of approximately 1.7 million pounds of frozen, raw stuffed chicken products that may be contaminated with Salmonella Enteritidis on July 12, 2015. This recall expanded the initial Barber Foods recall of chicken Kiev on July 2, 2015.

Products were sold under many different brand names, including Barber Foods, Meijer, and Sysco.

Products subject to recall bear the establishment number “P-276” on the packaging.

Products were shipped to retail locations nationwide and Canada.

A list of recalled products is available.

Photos of recalled product labels are available.

On July 13, 2015, Omaha Steaks issued a recall of stuffed chicken breast entrees that may be contaminated with Salmonella.

Products were manufactured by Barber Foods and sold under the Omaha Steaks label.

Products subject to recall bear the establishment number “P-4230A” on the packaging.

A list of recalled products is available and includes chicken cordon bleu, chicken Kiev, and chicken with broccoli and cheese.

Consumers should check their freezers for recalled frozen chicken products and should not eat them. Retailers should not sell them and restaurants should not serve them.

Salmonella: Marler Clark, The Food Safety Law Firm, is the nation’s leading law firm representing victims of Salmonella outbreaks. The Salmonella lawyers of Marler Clark have represented thousands of victims of Salmonella and other foodborne illness outbreaks and have recovered over $600 million for clients. Marler Clark is the only law firm in the nation with a practice focused exclusively on foodborne illness litigation. Our Salmonella lawyers have litigated Salmonella cases stemming from outbreaks traced to a variety of foods, such as cantaloupe, tomatoes, ground turkey, salami, sprouts, cereal, peanut butter, and food served in restaurants. The law firm has brought Salmonella lawsuits against such companies as Cargill, ConAgra, Peanut Corporation of America, Sheetz, Taco Bell, Subway and Wal-Mart.

If you or a family member became ill with a Salmonella infection, including Reactive Arthritis or Irritable bowel syndrome (IBS), after consuming food and you’re interested in pursuing a legal claim, contact the Marler Clark Salmonella attorneys for a free case evaluation.

Human Feces Tainted Cilantro from Mexico Sickens Hundreds in US

FDA Investigators found:

  • Human feces and toilet paper found in growing fields and around facilities; Inadequately maintained and supplied toilet and hand washing facilities (no soap, no toilet paper, no running water, no paper towels) or a complete lack of toilet and hand washing facilities;
  • Food-contact surfaces (such as plastic crates used to transport cilantro or tables where cilantro was cut and bundled) visibly dirty and not washed;
  • Water used for purposes such as washing cilantro vulnerable to contamination from sewage/septic systems;
  • In addition, at one such firm, water in a holding tank used to provide water to employees to wash their hands at the bathrooms was found to be positive for Cyclospora cayetanensis.

cilantroThe Centers for Disease Control and Prevention (CDC) and state public health officials have identified annually recurring outbreaks (in 2012, 2013, and 2014) of cyclosporiasis in the United States, which have been associated with fresh cilantro from the state of Puebla, Mexico. There is currently (in July 2015) another ongoing outbreak of cyclosporiasis in the United States in which both the Texas Department of State Health Services and the Wisconsin Department of Health Services and the Wisconsin Department of Agriculture, Trade and Consumer Protection have identified cilantro from the Mexican state of Puebla as a suspect vehicle with respect to separate illness clusters.

Texas DSHS has received reports of 205 Cyclosporiasis cases from around Texas this year, prompting an investigation into the infections in hopes of determining a common source. People who have a diarrheal illness lasting more than a few days or diarrhea accompanied by a severe loss of appetite or severe fatigue should contact their health care provider.

Past outbreaks have been associated with cilantro from the Puebla area of Mexico. While the investigation into the current outbreak is ongoing, imported cilantro has been identified as a possible source of some infections. The U.S. Food and Drug Administration recently issued an import alert detaining cilantro from that area coming into the U.S.

DSHS recommends thoroughly washing fresh produce, but that may not entirely eliminate the risk because Cyclospora can be difficult to wash off. Cooking will kill the parasite.

Cyclospora cayetanensis is a human-specific protozoan parasite that causes a prolonged and severe diarrheal illness known as cyclosporiasis. In order to become infectious, the organism requires a period outside of its host. Illnesses are known to be seasonal and the parasite is not known to be endemic to the United States. Cyclosporiasis occurs in many countries, but it seems to be most common in tropical and subtropical regions. People become infected with C. cayetanensis by ingesting sporulated oocysts, which are the infective form of the parasite. This most commonly occurs when food or water contaminated with feces is consumed. An infected person sheds unsporulated (immature, non-infective) C. cayetanenis oocysts in the feces.

Based on epidemiological evidence collected by affected domestic states, the CDC and traceback evaluations conducted by FDA, cilantro from the state of Puebla, Mexico was implicated as the vehicle for some of the U.S. cyclosporiasis infections in 2013 and 2014. In addition, after cyclosporiasis illnesses from the 2013 outbreak were linked to cilantro from Puebla, FDA reviewed a cluster of cyclosporiasis illnesses from 2012 in which the state of Texas had previously identified cilantro as one of multiple possible suspect vehicles and determined that cilantro from the state of Puebla, MX was supplied to the point of service implicated in that outbreak. While this means that cilantro from the state of Puebla, MX was one potential source of the 2012 outbreak, this was not confirmed by epidemiological means. The Texas Department of State Health Services has also identified cilantro from the state of Puebla as a suspect vehicle in an ongoing outbreak (as of May 2015). Additionally, in the 2015 outbreak Wisconsin officials have identified cilantro from the state of Puebla, MX as a suspect vehicle for a cluster of illnesses associated with a single restaurant. The source(s) of the 2015 outbreak(s) are still under investigation.

FDA believes it is extremely unlikely that these outbreaks of cyclosporiasis are due to isolated contamination events because of their recurring nature, both in the timing with which they occur (typically April August each year) and the repeated association of illnesses with cilantro from the state of Puebla. No single supplier (including retail outlets or distribution centers), packing date, shipping date, or lot code can explain all the illnesses. FDA believes the source of C. cayetanensis contamination is likely attributable to a broader source of contamination. Sources of contamination may include fecal contamination of growing areas, irrigation of fields with water contaminated with sewage, cleaning or cooling produce with contaminated water, and/or poor hygienic practices of workers that harvest and process the produce, and lack of adequate cleaning and sanitizing of equipment that comes in contact with the product.

FDA and the Mexican regulatory authorities for farms, packing houses and processors in Mexico, Servicio Nacional de Sanidad, Inocuida y Calidad Agroalimentaria (SENASICA) and the Comisin Federal para la Proteccion contra Riesgos Sanitarios (COFEPRIS), investigated farms and packing houses in Mexico, including in the state of Puebla, to ascertain the conditions and practices that may have resulted in the contamination of cilantro. From 2013 to 2015, FDA, SENASICA, and COFEPRIS inspected 11 farms and packing houses that produce cilantro in the state of Puebla, 5 of them linked to the US C. cayetanensis illnesses, and observed objectionable conditions at 8 of them, including all five of the firms linked through traceback to the U.S. illnesses. Conditions observed at multiple such firms in the state of Puebla included human feces and toilet paper found in growing fields and around facilities; inadequately maintained and supplied toilet and hand washing facilities (no soap, no toilet paper, no running water, no paper towels) or a complete lack of toilet and hand washing facilities; food-contact surfaces (such as plastic crates used to transport cilantro or tables where cilantro was cut and bundled) visibly dirty and not washed; and water used for purposes such as washing cilantro vulnerable to contamination from sewage/septic systems. In addition, at one such firm, water in a holding tank used to provide water to employees to wash their hands at the bathrooms was found to be positive for C. cayetanensis. Based on those joint investigations, FDA considers that the most likely routes of contamination of fresh cilantro are contact with the parasite shed from the intestinal tract of humans affecting the growing fields, harvesting, processing or packing activities or contamination with the parasite through contaminated irrigation water, contaminated crop protectant sprays, or contaminated wash waters.

The outbreak investigations repeatedly associating cilantro from the state of Puebla, MX with U.S. cyclosporiasis illnesses, and the repeatedly observed insanitary conditions providing likely routes of contamination for C. cayetanensis at multiple firms producing cilantro in the state of Puebla, MX, lead FDA to conclude that cilantro imported from the state of Puebla, Mexico appears to be adulterated under Section 402(a)(4) of the Act because it appears to have been prepared, packed, or held under insanitary conditions whereby it may have been rendered injurious to health. It is therefore subject to refusal of admission under Section 801(a)(3) of the Act. In addition, the cilantro appears to have been manufactured, processed, or packed under insanitary conditions within the meaning of Section 801(a)(1) of the Act. The seasonality of the previous C. cayetanensis outbreaks warrants detaining cilantro from the state of Puebla, Mexico during April 1 through August 31 of every year.