Increase in Locally-Acquired Cyclosporiasis Cases in Ontario Update to York Region health care providers as of July 31, 2018

Ontario is experiencing an increase in the number of infections. Forty-five locally-acquired cyclosporiasis cases have been reported in the province between April 1 and July 27, 2018, including six locally-acquired cases reported in York Region.

As a York Region health care provider, your help is needed for prompt diagnosis of infected patients. Testing for Cyclospora will support prompt treatment of patients to lessen duration of symptoms and will assist with identifying the source of illness. Diagnosis: Cyclospora infection can be diagnosed by a stool ova and parasite (O&P) examination. If patients present with cyclosporiasis-compatible symptoms between now and the end of summer, please request testing for stool parasites on the Public Health Ontario Laboratory General Test Requisition form (see link at end of notice) and specify the request is to test for Cyclospora. Treatment: First-line treatment is trimethoprim-sulfamethoxazole (TMP-SMX). What is cyclosporiasis?

Cyclosporiasis is a gastrointestinal illness caused by infection with the parasite , commonly characterized by frequent watery . Other symptoms include anorexia, fatigue, abdominal cramps, nausea, and myalgia. Left untreated, symptoms typically last six to seven weeks, vary in intensity, and may follow a relapsing course. Symptoms usually improve within two to three days of starting first-line treatment of TMP-SMX. How is Cyclospora infection acquired?

People are infected by ingesting or water contaminated with the parasite. Cyclospora is not endemic in Canada. Most reported cases in Ontario are infected when visiting an endemic country (e.g., in the Caribbean, South and Central America, South and South East Asia.) When cases occur in individuals who did not travel (as is currently occurring in Ontario), an investigation is launched to determine potential sources of Cyclospora in imported . Most cases in Ontario occur in spring and summer. Locally-acquired infections are likely due to fresh produce such as herbs or berries imported from Cyclospora-endemic countries. The infection is unlikely to spread from person to person. Contact York Region Public Health If you have questions about cyclosporiasis, please call York Region Public Health at 1-877-464-9675 ext. 73588. Additional resources and a cyclosporiasis fact sheet follow this message.

PUBLIC HEALTH 9060 Jane St Vaughan, Ontario L4K 2M9 1-877-464-9675 ext. 73588 Fax: 905-895-6066 york.ca/healthprofessionals Additional Resources on Cyclosporiasis

For the Public Health Ontario Laboratory General Test Requisition Form, visit: https://www.publichealthontario.ca/en/eRepository/General_test_fillable_requisition.pdf

For more information on cyclosporiasis testing in Ontario, visit: https://www.publichealthontario.ca/en/ServicesAndTools/LaboratoryServices/Pages/Cyclospora_Faece s.aspx.

For treatment information, visit the Cyclosporiasis – Provider Fact Sheet from the CDC at: https://www.cdc.gov/parasites/cyclosporiasis/resources/pdf/cyclosporiasis_provider.pdf

CYCLOSPORIASIS What is cyclosporiasis?

Cyclosporiasis is a gastrointestinal illness caused by infection with the parasite Cyclospora cayetanensis, and is commonly characterized by frequent watery diarrhea. People are infected by eating food or drinking water contaminated with the parasite. Cyclospora is not endemic in Canada. Most reported cases in Ontario are infected when visiting an endemic country (e.g., in the Caribbean, South and Central America, South and South East Asia). In the last several years, outbreaks of cyclosporiasis have been reported in Canada, the United States, and countries in Europe. How does cyclosporiasis spread?

Cyclospora is spread by eating foods or drinking water contaminated with the parasite. When the parasite is passed from the body, it needs time to develop in a warm, moist external environment (e.g., soil) before it can infect another person. The infection is unlikely to spread from person to person. What are the symptoms of cyclosporiasis?

Cyclosporiasis is commonly characterized by frequent watery diarrhea. Other symptoms include anorexia, fatigue, abdominal cramps, nausea, and myalgia. Some infected people may have few or no symptoms. Symptoms usually appear about one week after eating food or drinking liquids contaminated with the parasite. Left untreated, symptoms typically last six to seven weeks, vary in intensity, and may follow a relapsing course. Symptoms usually improve within two to three days of starting the appropriate antibiotic treatment. How is cyclosporiasis diagnosed and treated? Cyclosporiasis can be diagnosed through a test ordered by a health care provider. Antibiotic treatment is available for cyclosporiasis and must be prescribed by a physician. Visit a health care provider if you are experiencing symptoms similar to cyclosporiasis. How can cyclosporiasis be prevented? It can be difficult to prevent cyclosporiasis, however you can help reduce the risk through the following measures: • Before consuming produce, wash it thoroughly in safe water to help reduce the risk of contamination with Cyclospora. (Note: washing produce does not always completely eliminate the risk of cyclosporiasis.) • Consume fresh produce grown in countries where Cyclospora is not commonly found (e.g., Canada) • Cook produce imported from countries in regions where Cyclospora is found • When travelling to a country/region where Cyclospora is found: o drink water from a safe source o eat cooked produce, or produce that you can wash (using safe water) and peel yourself

July 2018 Source: Cyclosporiasis (Cyclospora), Government of Canada, https://www.canada.ca/en/public- health/services/diseases/cyclosporiasis-cyclospora.html PUBLIC HEALTH york.ca/health Date received PHOL No.

yyyy / mm / dd

General Test Requisition ALL Sections of this Form MUST be Completed

1 - Submitter 2 - Patient Information Courier Code Health No. Sex Date of Birth: yyyy / mm / dd

Medical Record No. Provide Return Address:

Name Patient’s Last Name (per OHIP card) First Name (per OHIP card) Address City & Province Postal Code Patient Address

Postal Code Patient Phone No.

Clinician Initial / Surname and OHIP / CPSO Number Submitter Lab No.

TTel: Fax: Public Health Unit Outbreak No.

cc Doctor Information Public Health Investigator Information Name: Tel: Name: Lab/Clinic Name: Fax: Health Unit: CPSO #: Address: Postal Code: Tel: Fax:

3 - Test(s) Requested (Please see descriptions on reverse) Hepatitis Serology Test: Enter test descriptions below

Reason for test (Check () only one box): Immune status Acute infection Chronic infection Indicate specific viruses (Check () all that apply):

Hepatitis A Hepatitis B Hepatitis C (testing only available for acute or chronic infection; no test for determining immunity to HCV is currently available)

4 - Specimen Type and Site Patient Setting blood / serum faeces nasopharyngeal physician office/clinic ER (not admitted) sputum urine vaginal smear inpatient (ward) inpatient (ICU) institution urethral cervix BAL other - (specify)

5 - Reason for Test Clinical Information

diagnostic immune status Date Collected: fever gastroenteritis respiratory symptoms needle stick follow-up yyyy / mm / dd STI headache / stiff neck vesicular rash prenatal chronic condition Onset Date: pregnant encephalitis / meningitis maculopapular rash immunocompromised jaundice yyyy / mm / dd post-mortem other - (specify)

other - (specify) influenza high risk - (specify) recent travel - (specify location)

For HIV, please use the HIV serology form. - For referred cultures, please use the reference bacteriology form.To re-order this test requisition contact your local Public Health Laboratory and ask for form number F-SD-SCG-1000. Current version of Public Health Laboratory requisitions are available at www.publichealthontario.ca/requisitions The personal health information is collected under the authority of the Personal Health Information Protection Act, s.36 (1)(c)(iii) for the purpose of clinical laboratory testing. If you have questions about the collection of this personal health information please contact the PHOL Manager of Customer Service at 416-235-6556 or toll free 1-877-604-4567. F-SD-SCG-1000 (08/2013)

Public Health Laboratories Tes g Menu For HIV, please use the HIV Serology form.

For historical duplex code information please access website at www.publichealthontario.ca/requisitions

Test (enter in Test Descrip on Se on 3) Test (enter in Test Descrip on Se n 3) Adenovirus (virus detection only) Mycoplasma pneumoniae - Culture Antimicrobial Susceptibility Testing - Bacteria Mycoplasma pneumoniae - PCR Antimicrobial Susceptibility Testing - Fungi, Nocardia Mumps IgG Immune Status Antimicrobial Susceptibility Testing - Mycobacteria Mumps IgG/IgM Diagnosis Arbovirus Serology Mumps Virus Detection Arthropod identification (ticks, lice, mites from human sources) Neisseria gonorrhoeae - NAAT/Culture Bacterial Culture and Sensitivity Detection Bacterial Vaginosis - Gram Stain Parainfluenza 1, 2, 3 (virus detection only) Bordetella - PCR Parvovirus B19 (Fifth Disease, Erythema Infectiosum) IgG Immune Status Cat Scratch Fever (Bacilliary angiomatosis, Bartonella) Parvovirus B19 (Fifth Disease, Erythema Infectiosum) IgG/IgM Diagnosis Chlamydia trachomatis - NAAT/Culture Q Fever Serology Chlamydophila pneumoniae - PCR Rabies Virus Antibody Screen Clostridium difficile toxin Referred Culture - Fungus Nocardia Cytomegalovirus (CMV) Culture/Early Antigen Referred Culture - TB Cytomegalovirus (CMV) IgG Immune status Respiratory Syncytial Virus (RSV) (virus detection only) Cytomegalovirus (CMV) IgG/IgM Diagnosis Rickettsia (Typhus, RMSF) Serology Dengue Virus Serology (virus detection only) Diphtheria antitoxin antibody1 Rubella (German Measles) IgG Immune Status Electron microscopy Rubella (German Measles) IgG/IgM Diagnosis Enterovirus (Coxsackie, ECHO, Polio) (virus detection only) Rubella (German Measles) Virus Detection Epstein Barr Virus (EBV) - EBV VCA IgG/EA/EBNA Serology - Bacterial (specify agent) Epstein Barr Virus (EBV) - EBV VCA IgM Serology - Mycotic (specify agent) Fungus - Superficial - Microscopy & Culture Serology - Parasitic (specify agent) Fungus - Systemic - Microscopy & Culture Stool parasites Haemorrhagic Fever Serology (Yellow Fever, Ebola, Lassa)2 Syphilis - Direct Fluorescence Hantavirus Serology Syphilis CSF (VDRL) Helicobacter pylori serology (H. pylori) Syphilis screen Virus Immune Status TB - Culture and Susceptibility (Mycobacteria culture) Hepatitis A Virus Acute Tetanus antitoxin antibody Hepatitis B Virus Immune Status TORCH (Toxoplasma, Rubella, CMV, Herpes Simplex) Diagnostic Screen Hepatitis B Virus Acute TORCH (Toxoplasma, Rubella, CMV, Herpes Simplex) IgG Screen Hepatitis B Virus Chronic Torovirus (virus detection only) Hepatitis B - HBcIgM3 - Serology Hepatitis B - HBeAb3 Urogenital mycoplasma/ureaplasma Hepatitis B - HBeAg3 Varicella - Zoster (Chicken Pox) IgG Immune Status Hepatitis B Virus DNA4 Varicella - Zoster (Chicken Pox) IgG/IgM Diagnosis Hepatitis C Virus Serology Varicella - Zoster (Chicken Pox) Virus Detection Hepatitis C Virus RNA - Genotyping4 Viral Diarrhea (virus detection only) Hepatitis C Virus RNA - Quantitative4 Virus Isolation/Detection Hepatitis D Virus (Delta Agent) West Nile Virus - Serology Virus Worm Identification Herpes Simplex Virus (HSV) IgG Immune Status Herpes Simplex Virus (HSV) Virus Detection 1. Testing is available only for the rare event of an adverse reaction to Diphtheria or the possibility of humoral immunodeficiency in the Human Herpes Virus 6 (Roseola, Exanthema Subitum) - PCR patient. This must be indicated on the test requisition in order for testing to Influenza A, B (Flu) Virus Detection be performed. Legionnaires Disease Lyme Disease - Serology 2. Contact Medical Officer of Health and Public Health Ontario Laboratory before ordering, 416.235.6556 or toll: 1.877.604.4567. Measles IgG Immune Status Measles IgG/IgM Diagnosis 3. Individual Hepatitis B virus markers may be ordered individually. Measles Virus Detection 4. The General Test Requisition is not required. Use the form F-C-HE-036, Molluscum contagiosum (Poxvirus) Virus Detection Hepatitis PCR Requisition and Information Form located at: www.publichealthontario.ca/requistions

Public Health Ontario Laboratories

Customer Service Centre tel: 416.235.6556 7:30 am - 7:00 pm, Monday to Friday toll free: 1.877.604.4567 8:00 am - 3:45 pm, Saturday fax: 416.235.6552 email: [email protected]

Emergency After-Hours Duty Officer tel: 416.605.3113 website: www.publichealthontario.ca