As of August 1, 2013, CDC has been notified of 400 cases of Cyclospora infection from the following 17 health departments: Iowa, Texas, Nebraska, Florida, Wisconsin, New York City, Georgia, Illinois, Arkansas, Kansas, Louisiana, Missouri, Connecticut, Minnesota, New Jersey, New York, and Ohio.

Most of the illness onset dates have ranged from mid-June through early July.

At least 22 persons reportedly have been hospitalized in five states.

As of August 3, 2013, the FDA traceback investigation has confirmed that the salad mix identified by Iowa and Nebraska as being linked to the outbreak of cyclosporiasis in those states was supplied to restaurants in those states by Taylor Farms de Mexico, S. de R.L. de C.V., a processor of foodservice salads. The FDA traceback investigation found that illness clusters at restaurants were traced to a common supplier, Taylor Farms de Mexico, S. de R.L. de C.V. The restaurants in Iowa and Nebraska include Olive Garden and Red Lobster, both of which are owned by Darden Restaurants.

FDA’s investigation has not implicated consumer packages sold in grocery stores.

Taylor Farms de Mexico, S. de R.L. de C.V. has been cooperating with all FDA requests during the investigation. The FDA and the firm will be conducting an environmental assessment of the firm’s processing facility in Mexico, to try to learn the probable cause of the outbreak and identify preventive controls to put in place to try and prevent a recurrence. The most recent inspection, in 2011, of the processing facility of Taylor Farms de Mexico, S. de R.L. de C.V. conducted by FDA found no notable issues. Additionally, as a result of the current investigation FDA is increasing its surveillance efforts on green leafy products exported to the U.S. from Mexico.

Mexican food regulatory authorities, the Federal Commission for Protection against Sanitary Risks (COFEPRIS) and the National Agro-Alimentary Health, Safety and Quality Service (SENASICA), are also collaborating with FDA in the investigation of this outbreak.

The Iowa Department of Inspections and Appeals (DIA) and the Nebraska Department of Health and Human Services have announced that they believe the contaminated salad is no longer in the food supply in those states. The last date that someone reportedly became ill with cycloporiasis in Iowa was on July 1, and in Nebraska on July 2. The typical shelf life for a salad mix is up to 14 days.

It is not yet clear whether the cases reported from other states are all part of the same outbreak. The investigation of increased cases of cyclosporiasis in other states continues.

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 travelers 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 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, and 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. 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 health care provider may ask you to submit 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-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.