As of October 24, 2023, 41 jurisdictions, including 40 states and New York City, have reported a total of 2,272 laboratory-confirmed cases of cyclosporiasis. 

These individuals had not traveled outside of the United States during the 14 days before they got sick. This is an increase of 315 cases since the last update on August 31, 2023.

Sick people ranged in age from 2 to 96 years, with a median age of 51, and 57% were female. The median illness onset date was June 24, 2023 (range: April 1 to August 31). Of 2,242 people with information available, 186 have been hospitalized. Zero deaths have been reported.

Food Safety News reports:

The International Fresh Produce Association (IFPA), formerly the United Fresh and Produce Marketing Association, has distributed a report on Cyclospora cayetanensis in produce.

This report is released and published by the National Advisory Committee on Microbiological Criteria for Foods (NACMCF).  The USDA empowers this committee, and it is not otherwise associated with IFPA otherwise.

The committee worked for two years to prepare the report, which is based on expert interviews and data collected from expert sources,  published literature, reports, and other sources. The report has been published and can be read in full on the USDA website.  

Cyclospora is a microscopic parasite that causes Cyclosoriosis, an intestinal illness. People can become infected with Cyclosporine by consuming food or water, including fresh produce, contaminated with the parasite. Living or traveling in areas where cyclosporiasis is endemic increases the risk of infection.

The IFPA report answers 18 questions the U.S. Food and Drug Administration put forth. The FDA had sought  “information on the factors that can contribute to C. cayetanensis contamination of domestically grown and imported produce and recommendations for developing an effective prevention and management strategy.”

In response to the FDA’s questions, the IFPA report makes these four recommendations:

1. To facilitate future research, e.g., validation of surrogates, studies on environmental persistence and attachment, and identification and validation of control strategies, the committee urges the development of a practical method to propagate C. cayetanensis oocysts in laboratory settings.

2. Because of the limited availability of C. cayetanensis oocysts, research with surrogates — and specifically with the close relative Eimeria — can be informative for identifying control strategies and learning about persistence in the production environment.

3. Method development for detecting C. cayetanensis in food and environmental samples should include the evaluation of multiple genetic targets representing different genome regions. Modifications to current molecular methods for detecting C. cayetanensis should be thoroughly validated for impacts on specificity before using modified methods on food or environmental samples. Conversely, detection methods should be robust, reproducible, and tolerant of minor modifications in the methodologies, e.g., brand of equipment or reagents, minor deviations in PCR conditions, etc., without sacrificing specificity or sensitivity.

4. Given that the hypothesized likeliest source of the parasite in the food production environment (individuals with a history of recent travel to areas where infections with C.cayetanensis are common or other exposures to the parasite), preventative measures should center around clear sanitation guidelines, ensuring on-site capacity for implementing sanitation protocols (i.e., readily accessible hand washing stations with soap, etc.) and periodic training of the employees.

“Cyclospora spp. are protozoan parasites in the phylum Apicomplexan that can parasitize different species of mammals with remarkable host-specificity. Cyclospora has a complex life cycle and can only multiply within the infected hosts. Among the Cyclospora species, only Cyclospora cayetanensis is known to infect humans; all other species are associated with infections in other animals,” according to the IFPA report.  

In releasing the report, IFPA said there were “four major takeaways” for the produce industry, including:

  • Based on the research from the committee, the current testing procedures in place do not adequately differentiate between the species of Cyclospora that causes illness in humans and others, referencing reports indicating 90 percent false-positive rates of methodologies underlying some standard tests. To manage this parasite and the risks associated with it, there must be a reliable and replicable testing procedure to identify Cyclospora in environmental samples and foods.  
  • The pathogen C. cayetanesis appears to be resistant to common chemical interventions, and it is recommended that antimicrobials or chemicals should be evaluated.  This is an area of potential innovation for the industry.  
  • The report also highlights the need for a risk-based (rather than hazard-based) approach to managing this parasite. 
  • Cyclospora is only carried by humans, and individuals with a recent history of travel to areas where Cyclospora is highly prevalent are likely the primary source of contamination with the parasite along the entire production-processing-food service/retail continuum.  Therefore, it is essential to ensure that workers are well-trained in inappropriate hygienic practices and that necessary equipment and infrastructure are on-site to manage any contamination of farm water sources. This includes well-managed toilet facilities, gloves, aprons, etc, are all available.  Public health aspects of managing Cyclospora cannot be overlooked. 

“Humans are the only known reservoir for Cyclospora cayetanensis and an essential host for the lifecycle of this protozoan parasite, but there is so much that we still do not understand about the organism,” said Natalie Dyenson, IFPA chief food safety officer. 

“The produce industry, through organizations like the Center for Produce Safety, has been funding research over the past six years, but to fill these knowledge gaps, public health agencies must engage and provide federal funding to support these efforts. Treating this organism as a public health concern by early identification and treatment of human cases in communities where the parasite is endemic to disrupt the life cycle of the parasite is already being used effectively in countries outside of the U.S. where Cyclospora is endemic.”  

IFPA’s  Dr. Max Teplitski said much is unknown about Cyclospora because we don’t have reliable means to identify it in our food system. 

“The produce industry is committed to being the best partner with our regulatory bodies to use the science available to us to improve our ability to keep our consumers safe,” Teplitski added. “As an industry, we’re committed to following the best available science to guide decisions and strategies to ensure that produce is as safe as possible.” 

No specific food items have been identified as the source of most of these illnesses. State and local public health officials are interviewing people with cyclosporiasis to find out what foods they ate before getting sick.

As of July 11, 2023, a total of 581 laboratory-confirmed cases of cyclosporiasis in people who had not traveled outside the United States during the 14 days before they got sick have been reported from 32 jurisdictions, including 31 states and New York City. This is an increase of 371 cases since the last update on June 22, 2023.

Sick people range in age from 3 to 96 years, with a median age of 49, and 61% are female. The median illness onset date is May 28, 2023 (range: April 1 to July 2).  Of 569 people with information available, 55 have been hospitalized. Zero deaths have been reported.

The total number of laboratory-confirmed cases reported since April 1, 2023, includes 20 cases in Georgia and Alabama linked to an outbreak associated with raw imported broccoli.  Although FDA and state and local partners conducted traceback investigations, there was not enough information to identify a specific type or producer of the broccoli.

  • The broccoli outbreak appears to be over. There is no indication at this time that broccoli continues to be a source of illness for other cyclosporiasis cases being reported in the United States.

Multiple potential clusters of cases are being investigated by state and local public health authorities, CDC, and FDA. No specific food(s) have yet been identified as the cause of these clusters, and investigations to identify a potential source (or sources) are ongoing.

This is an update on the number of cyclosporiasis illnesses acquired in the United States with onset on or after April 1, 2023. Cases continue to be reported.

Arizona

Colorado

Nebraska

Texas

Minnesota

Alabama

Tennessee

Georgia

South Carolina

Virginia

Maryland

New Jersey

Ney York

Connecticut 

No specific food items have been identified as the source of most of these illnesses. State and local public health officials are interviewing people with cyclosporiasis to find out what foods they ate before getting sick.

As of June 6, 2023, a total of 97 laboratory-confirmed cases of cyclosporiasis in people who had not traveled outside the United States during the 14-days before they got sick have been reported from 14 states and New York City.

Sick people range in age from 16 to 92 years, with a median age of 48, and 71% are female. The median illness onset date is April 27, 2023 (range: April 1 to May 25). Of 96 people with information available, 16 have been hospitalized. No deaths have been reported.

Unknown

The Georgia Department of Public Health Northwest Health District is investigating reports of Cyclospora infection in Northwest Georgia.

In the U.S., people can get sick with cyclosporiasis by eating fresh produce that was grown outside the U.S. and contaminated with Cyclospora.  Cyclosporiasis causes an illness that can result in prolonged gastrointestinal (gut) distress, including watery diarrhea with frequent, sometimes explosive, bowel movements that can last for weeks. In severe cases, Cyclospora infection can require hospitalization.

If you have had diarrhea, stomach cramps, bloating, or other gastrointestinal symptoms lasting longer than several days, public health officials urge you to talk to your healthcare provider. If not treated, cyclosporiasis can last a month or longer.  Symptoms may subside or go away and then return several times. Your healthcare provider can order testing to confirm the illness and may treat you with antibiotics.

A Cyclospora infection can be mild or very serious. You are most at risk for a serious infection if you have a compromised (weakened) immune system, for instance, you are living with HIV/AIDS or cancer or taking immunosuppressive medications.

Cyclosporiasis is not contagious. There is no evidence it spreads from person to person. The public health officials say their investigation is ongoing and the number of cases is expected to increase.

The Centers for Disease Control and Prevention (CDC), along with health departments in 14 states and the Food and Drug Administration (FDA), investigated a national outbreak of Cyclospora in the summer of 2020. 

As of September 23, 2020, a total of 701 lab-confirmed cases were found to be associated with this outbreak from 14 states (GA (1), IL (211), IA (206), KS (5), MA (1), MI (4), MN (86), MO (57), NE (55), ND (6), OH (7), PA (2), SD (13), WI (47). Exposures were reported in 13 states (IL, IA, KS, MA, MI, MN, MO, NE, ND, OH, PA, SD, WI). Cases reported illness from May 11, 2020 to July 24, 2020. Five percent were hospitalized, and no deaths were reported. Cases ranged from 11 to 92 years of age (median of 57). Fifty-one percent of cases were female.[1]

In Canada, as of November 4, 2020, 370 confirmed cases of Cyclospora illness were reported in the following provinces and territories: British Columbia (1), Ontario (255), Quebec (105), New Brunswick (1), Newfoundland and Labrador (6), and Nunavut (2). Individuals became sick between mid-May and late August 2020. Ten individuals were hospitalized. No deaths were reported. Individuals who became ill are between 0 and 83 years of age. The illnesses are distributed equally among men (50%) and women (50%).[2]

Epidemiological and traceback evidence indicated that bagged salad mix containing iceberg lettuce, carrots and red cabbage by Fresh Express was the likely source of this outbreak. Further traceback efforts by the FDA led to the investigation of a farm in southern Florida. The FDA detected Cyclospora in a regional water management canal (C-23), located west of Port St. Lucie, Florida. However, the FDA has been unable to determine if this Cyclospora was a genetic match to cases associated with the outbreak. Nevertheless, the presence of Cyclospora in a canal that had previously supplied irrigation water in the region, and specifically to a farm identified in the traceback, was suspicious and requires the need for further investigation and response from the FDA and it’s investigating partners.

               Fresh Express recalled salad products produced at its Streamwood, Illinois facility on June 27, 2020. The Fresh Express recall included only those salads products containing the ingredients iceberg lettuce, red cabbage and/or carrots AND displaying the Product Code Z178, or a lower number. Recalled products were distributed to select retail stores – including ALDI, Giant Eagle, Hy-Vee, Jewel-Osco, ShopRite, and Walmart – between June 6 and June 26 in various states. The recalled retail store brands were ALDI Little Salad Bar, Giant Eagle, Hy-Vee, Jewel-Osco Signature Farms, ShopRite Wholesome Pantry, and Walmart Marketside. The “Best by” date on the recalled products ran through July 14, 2020. As of September 23, 2020, the outbreak was considered over.[3]

[1]           CDC. (2020, September 24). CDC – Outbreak of Cyclospora Infections Linked to Bagged Salad Mix. https://www.cdc.gov/parasites/cyclosporiasis/outbreaks/2020/index.html

[2]           Public Health Agency of Canada (2020, November 4). Public Health Notice: Outbreak of Cyclospora infections linked to salad products and fresh herbs – Final Update. https://www.canada.ca/en/public-health/services/public-health-notices/2020/outbreak-cyclospora-infections-salad-products.html

[3]           FDA. (2020, September 25). Outbreak Investigation of Cyclospora: Bagged Salads (June 2020). Outbreak Investigation of Cyclospora: Bagged Salads (June 2020) | FDA; FDA. (2020, June 29). Fresh Express Issues a Precautionary Recall of Products Containing Iceberg, Red Cabbage and Carrots Produced at its Streamwood, IL Facility Due to a Potential Cyclospora Risk. Fresh Express Issues a Precautionary Recall of Products Containing Iceberg, Red Cabbage and Carrots Produced at its Streamwood, IL Facility Due to a Potential Cyclospora Risk | FDA

Cyclosporiasis illnesses are reported year-round in the United States. However, during the spring and summer months there is often an increase in cyclosporiasis acquired in the United States (i.e., “domestically acquired”). The exact timing and duration of these seasonal increases in domestically acquired cyclosporiasis can vary, but reports tend to increase starting in May. In previous years the reported number of cases peaked between June and July, although activity can last as late as September. The overall health impact (e.g., number of infections or hospitalizations) and the number of identified clusters of cases (i.e., cases that can be linked to a common exposure) also vary from season to season. Previous U.S. outbreaks of cyclosporiasis have been linked to various types of fresh produce, including basil, cilantro, mesclun lettuce, raspberries, and snow peas.

At a Glance

  • Illnesses: 1,060
  • Hospitalizations: 69
  • Deaths: 0
  • States reporting cases: 33

CDC, along with state and federal health and regulatory officials, monitor cases of cyclosporiasis in the United States in the spring and summer months to detect outbreaks linked to a common food source. However, many cases of cyclosporiasis cannot be directly linked to an outbreak, in part because of the lack of validated laboratory “fingerprinting” methods needed to link cases of Cyclospora infection. Officials use questionnaires to interview sick people to determine what they ate in the 14-day period before illness onset. If a commonality is found, CDC and partners work quickly to determine if a contaminated food product is still available in stores or in peoples’ homes and issue advisories.

Latest Information

  • The number of reported cases of domestically acquired cyclosporiasis illnesses has increased by 260 cases since the last update on August 25, 2022. Cases continue to be reported.
  • As of September 28, 2022, 1,060 laboratory-confirmed cases of cyclosporiasis in people who had no history of international travel during the 14-day period before illness onset have been reported to CDC by 34 jurisdictions, including 33 states and New York City, since May 1, 2022.
    • The median illness onset date is June 30, 2022 (range: May 1, 2022–August 28, 2022).
    • At least 69 people have been hospitalized; 0 deaths have been reported.

Cyclospora in the United States at a glance

            •          Illnesses: 800

            •          Hospitalizations: 52

            •          Deaths: 0

            •          States reporting cases: 30

Cyclosporiasis illnesses are reported year-round in the United States. However, during the spring and summer months there is often an increase in cyclosporiasis acquired in the United States (i.e., “domestically acquired”). The exact timing and duration of these seasonal increases in domestically acquired cyclosporiasis can vary, but reports tend to increase starting in May. In previous years the reported number of cases peaked between June and July, although activity can last as late as September. The overall health impact (e.g., number of infections or hospitalizations) and the number of identified clusters of cases (i.e., cases that can be linked to a common exposure) also vary from season to season. Previous U.S. outbreaks of cyclosporiasis have been linked to various types of fresh produce, including basil, cilantro, mesclun lettuce, raspberries, and snow peas. 

CDC, along with state and federal health and regulatory officials, monitor cases of cyclosporiasis in the United States in the spring and summer months to detect outbreaks linked to a common food source. However, many cases of cyclosporiasis cannot be directly linked to an outbreak, in part because of the lack of validated laboratory “fingerprinting” methods needed to link cases of Cyclospora infection. Officials use questionnaires to interview sick people to determine what they ate in the 14-day period before illness onset. If a commonality is found, CDC and partners work quickly to determine if a contaminated food product is still available in stores or in peoples’ homes and issue advisories.

Latest Information

            •          The number of reported cases of domestically acquired cyclosporiasis illnesses has increased by 323 cases since the last update on June 30, 2022. Cases continue to be reported.

            •          As of July 26, 2022, 384 laboratory-confirmed cases of cyclosporiasis in people who had no history of international travel during the 14-day period before illness onset have been reported to CDC by 23 jurisdictions, including 22 states and New York City, since May 1, 2022. The median illness onset date is June 20, 2022 (range: May 3, 2022–July 18, 2022). At least 30 people have been hospitalized; 0 deaths have been reported.

CDC, along with state and federal health and regulatory officials, monitor cases of cyclosporiasis in the United States in the spring and summer months to detect outbreaks linked to a common food source. However, many cases of cyclosporiasis cannot be directly linked to an outbreak, in part because of the lack of validated laboratory “fingerprinting” methods needed to link cases of Cyclospora infection. Officials use questionnaires to interview sick people to determine what they ate in the 14-day period before illness onset. If a commonality is found, CDC and partners work quickly to determine if a contaminated food product is still available in stores or in peoples’ homes and issue advisories.

Cyclosporiasis illnesses are reported year-round in the United States. However, during the spring and summer months there is often an increase in cyclosporiasis acquired in the United States (i.e., “domestically acquired”). The exact timing and duration of these seasonal increases in domestically acquired cyclosporiasis can vary, but reports tend to increase starting in May. In previous years the reported number of cases peaked between June and July, although activity can last as late as September. The overall health impact (e.g., number of infections or hospitalizations) and the number of identified clusters of cases (i.e., cases that can be linked to a common exposure) also vary from season to season. Previous U.S. outbreaks of cyclosporiasis have been linked to various types of fresh produce, including basil, cilantro, mesclun lettuce, raspberries, and snow peas.

At a Glance

            •          Illnesses: 61

            •          Hospitalizations: 6

            •          Deaths: 0

            •          States reporting cases: 13

Cyclosporiasis illnesses are reported year-round in the United States. However, during the spring and summer months there is often an increase in cyclosporiasis acquired in the United States (i.e., “domestically acquired”). The exact timing and duration of these seasonal increases in domestically acquired cyclosporiasis can vary, but reports tend to increase starting in May. In previous years the reported number of cases peaked between June and July, although activity can last as late as September. The overall health impact (e.g., number of infections or hospitalizations) and the number of identified clusters of cases (i.e., cases that can be linked to a common exposure) also vary from season to season. Previous U.S. outbreaks of cyclosporiasis have been linked to various types of fresh produce, including basil, cilantro, mesclun lettuce, raspberries, and snow peas. 

CDC, along with state and federal health and regulatory officials, monitor cases of cyclosporiasis in the United States in the spring and summer months to detect outbreaks linked to a common food source. However, many cases of cyclosporiasis cannot be directly linked to an outbreak, in part because of the lack of validated laboratory “fingerprinting” methods needed to link cases of Cyclospora infection. Officials use questionnaires to interview sick people to determine what they ate in the 14-day period before illness onset. If a commonality is found, CDC and partners work quickly to determine if a contaminated food product is still available in stores or in peoples’ homes and issue advisories.

Latest Information

            •          This is the first monthly report on the number of domestically acquired cyclosporiasis illnesses with onset on or after May 1, 2022. Cases continue to be reported.

            •          As of June 28, 2022, 61 laboratory-confirmed cases of cyclosporiasis in people who had no history of international travel during the 14-day period before illness onset have been reported to CDC by 13 states since May 1, 2022.

            ◦           The median illness onset date is May 31, 2022 (range: May 3–June 20, 2022).

            ◦           At least 6 people have been hospitalized; no deaths have been reported.