CDC is investigating an outbreak of the parasite Cyclospora. There have been 358 confirmed cases in 26 states so far in 2015. Symptoms of cyclospora infection or cyclosporiasis last for an average of 7 days, but can range from 2 days to longer than 2 weeks after ingestion of sporulated oocysts (the infective form of the parasite). Symptoms of cyclosporiasis include: watery diarrhea (most common), loss of appetite, weight loss, cramping, bloating, increased gas, nausea, and fatigue.
Cilantro has been identified as a potential source. FDA has issued an import alert for cilantro imported from Puebla, Mexico. A potential scenario is that the cilantro becomes contaminated from contaminated water used for irrigation or washing, or from contaminated workers handling the fresh product. The fresh cilantro is then added to flavor items such as fresh salsa and consumed, so there are no processing steps that would eliminate the parasite.
CDC Outbreak Investigation
Cyclosporiasis Outbreak Investigations — United States, 2015
Last Updated July 31, 2015 1:00 PM EDT
UPDATES WILL BE PROVIDED WHEN MORE INFORMATION IS AVAILABLE
CDC and federal, state, and local public health partners are investigating an increase in reported cases of Cyclospora infection.
Read the related statement from the U.S. Food and Drug Administration
Read the Advice to Consumers
Cyclospora cayetanensis is a single-celled parasite that causes an intestinal infection called cyclosporiasis.
As of July 30, 2015 (11am EDT), 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.
Consumers should continue to enjoy the health benefits of eating fresh fruits and vegetables as part of a well-balanced diet.
Consumers and retailers should always follow safe produce handling recommendations.
More information about Cyclospora can be found on CDC's Cyclospora pages.
Progression of the Outbreak Investigation
INITIAL ANNOUNCEMENT expanded
July 31, 2015
As of July 30, 2015 (11am EDT), a total of 358 ill persons with confirmed Cyclospora infection were reported to CDC in 2015. Most (199; 56%) ill persons reported onset of illness on or after May 1, 2015 and no international travel. 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.
FDA Import Alert
Import Alert 24-23
(Note: This import alert represents the Agency's current guidance to FDA field personnel regarding the manufacturer(s) and/or products(s) at issue. It does not create or confer any rights for or on any person, and does not operate to bind FDA or the public).
Import Alert # 24-23
Published Date: 07/28/2015
Import Alert Name:
"DETENTION WITHOUT PHYSICAL EXAMINATION OF FRESH CILANTRO FROM THE
STATE OF PUEBLA, MEXICO" - Seasonal (April 1 � August 30)
Reason for Alert:
NOTE: Revision to this Import Alert dated July 28, 2015 updates the guidance section to provide clarification to SENASICA and COFEPRIS� processes. Changes are noted and bracketed by three asterisks (***).
The 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.
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 Comisi�n 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.
Districts may detain without physical examination shipments of fresh cilantro from ***Puebla,*** Mexico offered for entry from April 1 through August 31 of every year, unless the cilantro is offered for entry from a firm listed on the Green List of this import alert.
This alert covers fresh cilantro, whether it is intact or has been cut or chopped (i.e., �fresh cut�). Cutting and chopping cilantro increases the opportunity for contamination and the chance of cross-contamination over an even larger volume of product. However, multi-ingredient processed foods that contain cilantro as an ingredient are not covered under this alert and neither is cilantro that has been processed in other ways besides being cut or chopped (e.g., dried).
Since the article is subject to Refusal of Admission per Section 801(a)(1) of the Act, FDA considers submission of analytical results indicating the absence of C. cayetanensis to be insufficient to overcome the appearance the product has been prepared, packed, or held under insanitary conditions. In addition, the appearance of a violation per Section 801(a)(1) of the Act precludes reconditioning under Section 801(b) of the Act.
To facilitate entry review of shipments from firms not located in the state of Puebla, Mexico, importers must provide documentation (i.e., invoices, bills of lading) declaring the source farm(s). FDA has found that firms producing cilantro in the state of Puebla often do business under multiple names, addresses, and registration numbers, and some firms declaring their suppliers to be located outside of the state of Puebla have in fact been sourcing cilantro, at least in part, from the state of Puebla. Therefore, if the required documents are not provided at the time of entry, this may cause a delay in review of the entry and FDA may request documentation on the location of the farms where the cilantro was sourced. If you find that you are unable to provide source farm documentation, FDA may detain your product as appearing to be sourced from Puebla.
Requests for Removal of Individual Firm or Shipments from Detention Without Physical Examination Under This Import Alert:
Mexican firms from the state of Puebla that are not listed on the Green List of this import alert wishing to ship product during April 1 through August 31 must provide information to FDA to adequately demonstrate that they have in place appropriate measures to overcome the appearance of the violation, so that the Agency will have confidence that future entries will be in compliance.*** Verification of these practices may occur through inspection and certification of farms by SENASICA for recognition in their System for Reduction of Risk from Contamination (SRRC) program and inspection and listing by COFEPRIS of processing facilities complying with Good Production Practices.*** Alternately, for firms not participating in the SRRC who petition the FDA directly, FDA (either solely or in partnership with the relevant Mexican regulatory authority) may conduct a limited number of on-site inspections of the growing/processing areas to audit the validity of the information submitted to FDA. FDA, however, encourages firms growing, harvesting, packing, and holding cilantro to participate in the SENASICA�s SRRC program. ***FDA, however, encourages firms growing, harvesting and holding cilantro to participate in the SENASICA�s SRRC program and firms packing cilantro to obtain approval of COFEPRIS for compliance with Good Production Practices***
Findings of insanitary conditions at firms producing commodities other than cilantro may lead the FDA to add the firm to other existing import alerts.
Mexican firms who want to request removal from detention without physical examination by inclusion on the Green List of the Alert, should forward information supporting their request for addition on to the Green List to FDA at the following address:
Food and Drug Administration
Division of Import Operations
Import Operation and Maintenance Branch
12420 Parklawn Drive, ELEM-3100Rockville, MD 20857
Or be sent via email: Importalerts2@fda.hhs.gov
Requests for removal from detention without physical examination will be reviewed by the subject matter experts within the Division of Import Operation (DIO) and referred to the Office of Compliance, Division of Enforcement, CFSAN for additional subject matter expert evaluation within CFSAN.
For questions or issues involving import operations, contact the Division of Import Operations, ORA, at (301) 796-0356.
For additional guidance on removal from detention without physical examination, refer to FDAs Regulatory Procedures Manual, Chapter 9, Section 9-6, "Detention Without Physical Examination (DWPE)."
PRODUCT DESCRIPTION: Cilantro
PROBLEM: Cyclospora cayetanensis, Insanitary Conditions
The article is subject to refusal of admission pursuant to Section 801(a)(1) of the Act in that it appears to have been manufactured, processed, or packed under insanitary conditions. [ADULTERATION, Section 402(a)(4)]
OASIS Charge Code: MFR INSAN
The article is subject to refusal of admission pursuant to Section 801(a)(3) in that it appears to have been prepared, packed, or held under insanitary conditions whereby it may have been rendered injurious to health [Adulteration, Section 402(a)(4)].
OASIS Charge Code: INSANITARY