CDC, public health and regulatory officials in 11 states, and the U.S. Food and Drug Administration investigated a multistate outbreak of Cyclospora infections.

As of September 27, 2019, a total of 241 people with laboratory-confirmed Cyclospora infections associated with this outbreak were reported from 11 states:  Connecticut (1), Florida (62), Georgia (2), Iowa (2), Massachusetts (1), Minnesota (33), New York (131), Ohio (3), Rhode Island (1), South Carolina (1), and Wisconsin (4).  Exposures were reported in 5 states (Florida, Minnesota, New York, Ohio, and Wisconsin).

Illnesses started on dates ranging from June 10, 2019 to July 26, 2019. Ill people ranged in age from 15 to 98 years with a median age of 49 and 70% were female. Six (2%) people were hospitalized. No deaths attributed to Cyclospora were reported in this outbreak.

Epidemiologic evidence and product distribution information indicated that fresh basil exported by Siga Logistics de RL de CV of Morelos, Mexico, was a likely source of this outbreak.

In interviews, ill people answered questions about the foods they ate and other exposures in the 2 weeks before they became ill. An illness cluster is defined as two or more people who do not live in the same household who report eating at the same restaurant location, attending a common event, or shopping at the same location of a grocery store in the week before becoming ill. Investigating illness clusters provides critical clues about the source of an outbreak. If several unrelated ill people ate or shopped at the same location of a restaurant or store within several days of each other, it suggests that the contaminated food item was served or sold there. In this fresh basil-associated cluster, there were several situations in which people reported eating at the same restaurants.

The FDA and regulatory officials in several states collected records to determine the source of the fresh basil that ill people ate in the five affected states. Product distribution information indicated that the fresh basil that made people sick was exported by Siga Logistics de RL de CV of Morelos, Mexico.

As of August 28, 2019, 1,696 laboratory-confirmed cases of cyclosporiasis were reported to CDC by 33 states, District of Columbia and New York City in people who became ill since May 1, 2019 and who had no history of international travel during the 14-day period before illness onset.

The median illness onset date was June 29, 2019 (range: May 1–August 13, 2019).

At least 92 people were hospitalized; no deaths were reported.

At this time, multiple clusters of cases associated with different restaurants or events are being investigated by state public health authorities, CDC, and FDA.

One multistate outbreak of Cyclospora infections has been linked to fresh basil imported from Siga Logistics de RL de CV of Morelos, Mexico . It is unknown at this time if other reported cases of Cyclospora infection in the United States this season are linked to fresh basil. This investigation is ongoing.

Two hundred and five people with laboratory-confirmed Cyclospora infections and who reported eating fresh basil have been reported from 11 states; exposures occurred at restaurants in 5 states (Florida, Minnesota, New York, Ohio, and Wisconsin).

Illnesses started on dates ranging from June 10, 2019 to July 18, 2019.

Five people have been hospitalized. No deaths attributed to Cyclospora have been reported in this outbreak.

Epidemiologic evidence and early product distribution information indicate that fresh basil from Siga Logistics de RL de CV of Morelos, Mexico is a likely source of this outbreak.

CDC, public health and regulatory officials in multiple states, and the U.S. Food and Drug Administration (FDA) investigated a multistate outbreak of Cyclospora cayetanensis infections.

As of September 11, 2018, CDC was notified of 511 laboratory-confirmed cases of Cyclospora infections in people from 15 states and New York City who reported consuming a variety of salads from McDonald’s restaurants in the Midwest.

Twenty-four (24) people were hospitalized. No deaths were reported.

Epidemiologic and traceback evidence indicated that salads purchased from McDonald’s restaurants were one likely source of this outbreak.

On July 13, 2018, McDonald’s voluntarily stopped selling salads at over 3,000 locations in 14 states. The company has since reportedExternal that it has replaced the supplier of salad mix in those states.

On July 26, 2018, the FDA completed final analysis of an unused package of romaine lettuce and carrot mix distributed to McDonald’s by the Fresh Express processor in Streamwood, IL. The analysis confirmed the presence of Cyclospora in that sample.

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.

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, 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.