Cyclospora Outbreak Linked to Veggie Trays

FDA is investigating an outbreak of cyclospora linked to Del Monte Vegetable Trays containing broccoli, cauliflower, carrots, and dill dip.  There have been 78 confirmed cases.

Cyclospora is a single cell parasite that causes “diarrhea, with frequent, sometimes explosive, bowel movements. Other common symptoms include loss of appetite, weight loss, stomach cramps/pain, bloating, increased gas, nausea, and fatigue. Vomiting, body aches, headache, fever, and other flu-like symptoms may be noted. Some people who are infected with Cyclospora do not have any symptoms. If not treated, the illness may last from a few days to a month or longer”.

While FDA has not identified a source or reason, Cyclospora contamination can occur when contaminated water is used to irrigate vegetables.

FDA Outbreak Investigation
https://www.fda.gov/Food/RecallsOutbreaksEmergencies/Outbreaks/ucm610982.htm
FDA Investigates Multistate Outbreak of Cyclospora illnesses linked to Del Monte Vegetable Trays
The U.S. Food and Drug Administration (FDA) along with the Centers for Disease Control and Prevention (CDC) and state and local officials have been investigating a cluster of cyclosporiasis illnesses associated with recalled Del Monte vegetable trays from Kwik Trip/Kwik Star locations in the United States.

CDC MMWR - An Increase in Strongyloidiasis Cases in LA

According to CDC's MMWR weekly report, there has been an increase in the number of cases of Strongyloidiasis in LA County, California.  While there were none in 2012, there were 14 cases in 2013 and 29 cases in 2014.

So what the heck is strongyloidiasis?  Just because you wanted to know.......

So, there you are out tending your garden (or whatever they do in LA where one has their hands in the soil), and this little parasitic worm burrows into your skin and then finds its way to your intestines where it creates a never-ending maternity ward for more parasitic worms.  Isn't that a pleasant thought.

Strongyloidiasis is a disease caused by a nematode, or a roundworm, in the genus Strongyloides. While there are a number of species of this roundworm that can infect birds, reptiles and such, Strongyloides stercoralis is the primary species that infects humans. The larvae are only about 1.5mm in length and are found in the soil. "When the larvae come in contact with skin, they are able to penetrate it and migrate through the body, eventually finding their way to the small intestine where they burrow and lay their eggs and these eggs hatch into larvae in the intestine. Most of these larvae will be excreted in the stool, but some of the larvae may molt and immediately re-infect the host either by burrowing into the intestinal wall, or by penetrating the perianal skin. This characteristic of Strongyloides is termed auto-infection. The significance of auto-infection is that unless treated for Strongyloides, persons may remain infected throughout their lifetime."
"The majority of people infected with Strongyloides are without symptoms. Those who do develop symptoms tend to have non-specific, or generalized complaints. Some people develop abdominal pain, bloating, heartburn, intermittent episodes of diarrhea and constipation, a dry cough, and rashes. Rarely people will develop arthritis, kidney problems, and heart conditions."

"In the United States, Strongyloides has classically been associated with uniformed-service veterans who returned from tropical regions such as Southeast Asia and the South Pacific during World War II. Small domestic studies have shown locations of infection in rural Appalachia. The highest rates in the United States have been documented in immigrant populations."



CDC - MMWR
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6433a8.htm?s_cid=mm6433a8_e
Increase in Reports of Strongyloides Infection — Los Angeles County, 2013–2014
Weekly
August 28, 2015 / 64(33);922-923
Curtis Croker, MPH1; Rosemary She, MD2

During the 1990s, reports of infection with the nematode (roundworm) Strongyloides stercoralis submitted to the Los Angeles County Department of Public Health (LACDPH) ranged from 40 to 50 per year, but by 2000, reports had decreased to five per year; in 2006, Strongyloides infection was removed from the LACDPH reportable disease list. Currently, it is only reported at the discretion of Los Angeles County clinicians and laboratories as an unusual disease occurrence. LACDPH currently only monitors case counts and does not investigate reported Strongyloides cases. During 2013–2014, an increase in Strongyloides cases occurred, with 43 cases reported.

MMWR - Outbreaks Associated with Drinking Water - 2011-2012

 We generally regard drinking water safe, and rightfully so.  For the amount of water that is consumed each day, there have been relatively few issues.  An MMWR article reports that in the two year period reviewed, 2011-2012, there have been 32 water related outbreaks resulting in 431 cases of illness, 102 hospitalizations, and 14 deaths.

The biggest culprit was Legionella and this was primarily related to drinking water in hospitals affecting at-risk patients.  While we hear of Legionella in air conditioning systems, such as the current issue in NY where over 100 have become ill and 12 have died (Legionella grows in the cooling water systems and then is inhaled through the water vapors), evidently Legionella is an issue in hospitals (along with other HAIs (hospital acquired infections) including Clostridium difficile, MRSA, etc).  "Legionella outbreaks are particularly challenging to prevent and control, in part because the organism lives and multiplies in building plumbing systems, which usually fall outside water utility and regulatory oversight (6,7). One Legionella outbreak occurred in a hotel that used point-of-entry water filters, which effectively dechlorinated all water entering the building, and illustrates the importance of maintaining sufficient residual disinfectant in plumbing systems."

EPA has a publication on Legionella in drinking water.

The other issue was non-community water systems.  "All five noncommunity outbreaks originated from groundwater sources. Specifically, four occurred in outdoor camp or work settings where a source spring was contaminated directly or by inflow from a stream, and the fifth occurred at a meeting facility where a well was contaminated with septic tank overflow."  In these cases, Norovirus, non-Legionella bacteria, and Giardia (a parasite) were responsible.   (You are probably wondering how you ever made it through summer camp as a kid considering the pond water where you swam and that nasty spigot you drank from....and you are also then wondering why your parents sent you there.)

Here, an elk enjoys a drink of water from a spigot used for filling water bottles at Grand Canyon National Park (photo courtesy of Nika Bucknavage).

CDC MMWR
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6431a2.htm?s_cid=mm6431a2_e
Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water — United States, 2011–2012

Weekly
August 14, 2015 / 64(31);842-848
Karlyn D. Beer, PhD1,2; Julia W. Gargano, PhD2; Virginia A. Roberts, MSPH2; Vincent R. Hill, PhD2; Laurel E. Garrison, MPH3; Preeta K. Kutty, MD3; Elizabeth D. Hilborn, DVM4; Timothy J. Wade, PhD4; Kathleen E. Fullerton, MPH2; Jonathan S. Yoder, MPH, MSW2

Advances in water management and sanitation have substantially reduced waterborne disease in the United States, although outbreaks continue to occur (1). Public health agencies in the U.S. states and territories* report information on waterborne disease outbreaks to the CDC Waterborne Disease and Outbreak Surveillance System (http://www.cdc.gov/healthywater/surveillance/index.html). For 2011–2012, 32 drinking water–associated outbreaks were reported, accounting for at least 431 cases of illness, 102 hospitalizations, and 14 deaths. Legionella was responsible for 66% of outbreaks and 26% of illnesses, and viruses and non-Legionella bacteria together accounted for 16% of outbreaks and 53% of illnesses. The two most commonly identified deficiencies† leading to drinking water–associated outbreaks were Legionella in building plumbing§ systems (66%) and untreated groundwater (13%). Continued vigilance by public health, regulatory, and industry professionals to identify and correct deficiencies associated with building plumbing systems and groundwater systems could prevent most reported outbreaks and illnesses associated with drinking water systems.

FAO Releases Top Ten Parasite List

The FAO (Food and Agricultural Organization of the United Nations) released a "Top Ten" list identifying the food-borne parasites of greatest global concern.  Fortunately, there are only four that have any importance in the US and Canada.  Most cases of parasitic infection have been isolated cases.  The fout include:

• Toxoplasma
• Cryptosporidium
• Cyclospora
• Giardia

The risk, although small, increases with consumption of produce from developing countries.  Such as the case with Cyclospora in raspberries, lettuce, and basil.  Washing in potable water is a common practice that helps to mitigate this risk.

Contaminated water and produce irrigated with contaminated water has been an issue that has contributed to Cryptosporidium and Giardia outbreaks.

According to the report "Taxoplasmosis is a recognized concern of physicians for women during pregnancy, but emphasis is placed on potential contamination from cats rather than from foodborne infection".

Trichinellosis cases are still seen, but primarily limited to undercooked game meat (bear, wild boar, and marine mammals).  Taenia, primarily Taenia solium (tapeworm associated with undercooked pork) have been seen in a few cases, primarily associated with people who have immigrated from Central and South America.

Undercooked seafood have been a source of a number of parasites (Anisakis ssp, Dipyllobothium, Echinostomidae, Nonophyetes, Opisthorchis, Clonorchis, Paragoniumus, Pseudoterranova), but there have been very few cases of each over the last 30 or 40 years.

 

Update on Cyclospora outbreak in produce

In August, CDC had reported a Cyclospora outbreak in the US that affected over 600 and indicated that it was actually two different cases, one centered in Iowa and Nebraska, and the other centered in Texas. (http://pennstatefoodsafety.blogspot.com/2013/08/as-of-august-26th-cdc-is-reporting-that.html). The CDC has updated their information regarding the second case. While the outbreak in Iowa and Nebraska was linked to contaminated bagged lettuce produced by the Mexican subsidiary of Taylor Farms, the second case is being linked to Mexican cilantro, but no company has been identified at this point. In all, there were approximately 643 illnesses in 25 states.

 

CDC Outbreak Update

Investigation of an Outbreak of Cyclosporiasis in the United States

Highlights

 

Cyclospora cayetanensis is a single-celled parasite that causes an intestinal infection called cyclosporiasis.

Cyclospora cases now over 600, Texas cases not linked to Taylor bagged salad

As of August 26th, CDC is reporting that there are 610 cases of Cyclospora infection in 22 states. While many of the illnesses in IA and NB were linked to bagged salad mix produced by Taylor Farms de Mexico, CDC indicates that a number of cases in Texas are unrelated to the cases in IA and NB, but rather originated with people eating at the same restaurant..

CDC is investigating the Texas cases as well as the cases seen in other states to see how any of them might be related and what might be the source (CDC release below).

The Taylor Farms facility in Mexico that was linked to the IA and NB cases has resumed production after undergoing an extensive FDA audit. (story and link below).


CDC News
Investigation of an Outbreak of Cyclosporiasis in the United Stateshttp://www.cdc.gov/parasites/cyclosporiasis/outbreaks/investigation-2013.html

LAST UPDATED AUGUST 26, 2013 7:00 PM EDT
Case counts are updated Mondays, Wednesdays, and Fridays
On June 28, 2013, CDC was notified of 2 laboratory-confirmed cases of Cyclospora infection in Iowa residents who had become ill in June and did not have a history of international travel during the 14 days before the onset of illness. Since that date, CDC has been collaborating with public health officials in multiple states and the U.S. Food and Drug Administration (FDA) to investigate an outbreak of cyclosporiasis.

Highlights
Read the Advice to Consumers
Read the Guidance for Laboratories
Cyclospora cayetanensis is a single-celled parasite that causes an intestinal infection called cyclosporiasis.
As of August 23, 2013 (5pm EDT), CDC has been notified of 610 ill persons with Cyclospora infection from 22 states: Arkansas, California, Connecticut, Florida, Georgia, Illinois, Iowa, Kansas, Louisiana, Minnesota, Missouri, Nebraska, New Jersey, New Hampshire, New York (including New York City), Ohio, South Dakota, Tennessee, Texas, Virginia, Wisconsin, and Wyoming.
Most of the illness onset dates have ranged from mid-June through mid-July.
Among 581 ill persons with available information, 43 (7%) have reported being hospitalized. No deaths have been reported.
Public health officials in Iowa and Nebraska performed investigations within their states and concluded that restaurant-associated cases of Cyclospora infection in their states were linked to a salad mix produced by Taylor Farms de Mexico.
On August 12, 2013, Taylor Farms de Mexico informed FDA that the company had voluntarily suspended production and shipment of any salad mix, leafy green, or salad mix components from its operations in Mexico to the United States.
On August 25, 2013, Taylor Farms de Mexico, with FDA concurrence , resumed production and shipment of salad mix, leafy greens, and salad mix components to the United States.
Currently, CDC is collaborating with the Texas Department of Health and Human Services and local public health departments to investigate cases of cyclosporiasis reported among people in Texas.
The preliminary analysis of results from an investigation into a cluster of cases that ate at a Texas restaurant does not show a connection to Taylor Farms de Mexico. This investigation is ongoing.
Although the investigation of cases continues, available evidence suggests that not all of the cases of cyclosporiasis in the various states are directly related to each other.

Cyclospora outbreak in salad linked to Mexican farm

The cyclospora outbreak has been linked to foodservice bagged salad served at Olive Garden and Red Lobster. The source of the salad was a Mexican farm. The farm, run as a subsidiary of the US produce company Taylor Farms, was said to be a state-of-the-art facility with an exception food safety record. It had been recently inspected by FDA in 2011 and they found no notable issues.

To date, over 400 individuals in 16 states have become ill from salad contaminated with cyclospora. Taylor Farms reports that none of the salad is still on the market.

 

FDA Links Bagged Salad Mix Stomach Bug In 2 States To Mexican Farm
By MARY CLARE JALONICK 08/02/13 11:16 PM ET EDT
http://www.huffingtonpost.com/2013/08/02/cyclospora-stomach-bug-mexican-farm-fda_n_3698075.html


WASHINGTON — The Food and Drug Administration says an outbreak of stomach illnesses in Iowa and Nebraska is linked to salad mix served at local Olive Garden and Red Lobster restaurants and supplied by a Mexican farm.

The outbreak of cyclospora infections has sickened more than 400 people in 16 states in all. The agency says it is still working to determine whether the salad mix is the source of illnesses in the other 14 states.

Cyclospora outbreak linked to bagged salad

The cyclospora outbreak centered in Iowa has been linked to bagged spinach. The brand has not yet been identified. At this point, there is a reported 378 cases in 15 states.

 Cyclospora is a parasite, most often seen in tropical and subtropical regions, results in watery diarrhea, stomach pain, etc (http://pennstatefoodsafety.blogspot.com/2013/07/cyclospora-outbreak-in-ia-and-ne-may-be.html ). If one had to guess, cyclospora oocysts would have contaminated the produce in the field probably from contaminated irrigation water and then it would be unlikely that washing would be sufficient to destroy the oocysts, perhaps even spreading it to more more product and thus more bags in the washing system. Although it could also be that the wash water used was contaminated. Hopefully the investigation will provide that information.

CDC has a listing of organisms and their inactivation by chlorine. (Bottom of this and http://www.cdc.gov/safewater/effectiveness-on-pathogens.html. ) As can be seen, parasites are much more resistant, especially cyclospora (listed in the footnote on the CDC table).

At this point, they have not yet released the information surrounding the brand name. This is interesting in that they know the product is no longer on the shelf. As a consumer, I would be interested in knowing that information so that I could avoid that brand, and then would also have more confidence in buying other brands. Therefore, I think delaying the release of this information, it has the potential to negatively impact sales of other brands of bagged salad.


Salad Mix Behind Food Poisoning Outbreak, Health Officials Say 
By GRANT SCHULTE and MARY CLARE JALONICK 07/30/13 08:02 PM ET EDT  http://www.huffingtonpost.com/2013/07/30/salad-mix-food-poisoning_n_3679072.html

 LINCOLN, Neb. — Health officials in Iowa and Nebraska on Tuesday identified prepackaged salad mix as the source of a severe stomach bug that sickened hundreds of people in both states, but federal authorities said it's not clear whether cyclospora outbreaks elsewhere in the U.S. are also linked to that produce.

Cyclospora is a rare parasite that causes a lengthy gastrointestinal illness, and outbreaks of the illness have been reported in 15 states. The U.S. Centers for Disease Control and Prevention said Tuesday that it's not clear whether all of the illnesses are linked to a single source. The outbreak has sickened at least 145 residents in Iowa and 78 in Nebraska.

Cyclospora outbreak In IA and NE may be due to contaminated vegetables

Approximately 100 people have become ill from Cyclospora in Iowa and Nebraska.  Fresh vegetables are considered the likely source.

Cyclospora is a single cell parasite that infects the intestinal tract when oocysts are ingested.  According to the CDC website (http://www.cdc.gov/parasites/cyclosporiasis/gen_info/faqs.html), the symptoms are watery diarrhea (sometimes  explosive), loss of appetite, weight loss, stomach pain and bloating, increased gas and nausea.  If not treated, symptoms can last several days to over a month.  Patients will often have one or more relapses.  For immunocompromised individuals, symptoms can last much longer.

 


This parasite is more common in tropical and subtropical areas, but has been involved in outbreaks in the US, primarily through contaminated produce.  The last large outbreak was in 1996, when more than 850 become ill from eating contaminated raspberries.





Officials say vegetables likely cause of cyclospora outbreak -

See more at: http://www.thepacker.com/fruit-vegetable-news/Officials-think-fresh-veggies-likely-cause-of-cyclospora-outbreak-215584211.html#sthash.tkfOmaJX.dpuf
The Packer
07/15/2013 04:42:00 PMCoral Beach   

With more than 100 people in at least two states confirmed to have infections from the cyclospora parasite, public health officials investigating the outbreak suspect the culprit is some kind of fresh vegetable.

We are pretty sure it’s not fruit but a vegetable,” said Dr. Patricia Quinlisk, head epidemiologist and medical director for the Iowa Department of Health. “We are trying to correlate what the common source might be.”

USDA's Updated Trichinella Fact Sheet

USDA recently updated its webpage on Trichinella, and this provides a nice reference on the topic.  I thought it would be good to post this as well as an op-ed column in the NY Times on Trichinella in free range pigs (2009). In the 1930s, there were hundreds of cases per year that were reported (although it was not a reportable illness in many states).  An estimate made from autopsies indicated that the level in the US population may have been as high as 12% (ref below).  In the past decade, there have only been a handful of cases, mostly related to wild game, specifically bear.  Much of this is due to industry practices and veterinary inspections. While there are some that refuted the NY Times piece based upon the lack of Trichinella cases related to free range pigs, in theory, it seems that if pigs are allowed to free range, there is potentially a higher risk of these pigs encountering this parasite (through the eating on infected rats or the feces of infected animals.)

While the mortality rate is low, symptoms of trichinosis can range from mild to severe.

“Nausea, diarrhea, vomiting, fatigue, fever, and abdominal discomfort are the first symptoms of trichinosis. Headaches, fevers, chills, cough, eye swelling, aching joints and muscle pains, itchy skin, diarrhea, or constipation follow the first symptoms. If the infection is heavy, patients may experience difficulty coordinating movements, and have heart and breathing problems. In severe cases, death can occur.  The acute phase occurs after the mature warm lays eggs in the small intestine and these eggs hatch into larvae which enter the bloodstream and travel to muscle tissue within the body, such as the diaphragm.  There they become encysted.

USDA’s review of Trichinella

A Focus on Trichinella -- Updated Version

http://fsrio.nal.usda.gov/nal_web/fsrio/fsheet.php?id=230

A primer on trichinosis from CDC

http://www.cdc.gov/ncidod/dpd/parasites/trichinosis/factsht_trichinosis.htm

A 1938 survey of trichinosis in the US

http://www.jstor.org/stable/4582479

2009 NY Times Op-Ed on free range pigs and Trichinella

http://www.nytimes.com/2009/04/10/opinion/10mcwilliams.html?_r=1&scp=1&sq=free-range%20trichinosis&st=cse