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Letters Widespread Foodborne Cyclosporiasis Outbreaks Present Major Challenges Letters Widespread Foodborne Cyclosporiasis trace-backs of raspberry shipments related to more than 25 of the events have indicated Outbreaks Present Major Challenges that the raspberries responsible were imported from Guatemala between early To the Editor: The organism now named May and mid-June 1996. Cyclospora cayetanensis was first recognized On June 17, 1996, CDC began hosting as a cause of human illness in 1977. For thrice-weekly conference calls to ensure several years, as its taxonomy was deliber- close coordination among CDC, the U.S. Food ated, it was referred to as “cyanobacterium-, and Drug Administration (FDA), and the or coccidia-like bodies” (CLBs), or considered many state and local health agencies to be blue-green algae. In 1993, C. investigating these widespread outbreaks cayetanensis was reported to be a protozoan and cases. The conference calls provided parasite, a coccidian member of the family coordination in tracking and discussing this Eimeriidae. To be infectious, the spherical, multifocal problem. In addition, on July 17, chlorine-resistant oocyst (8µm to 10µm) 1996, in Atlanta, CDC and FDA held a 1-day found in the feces of infected persons must work-shop entitled “cyclospora - 1996,” sporulate in the environment, a process which was attended by more than 80 persons that, depending on conditions, takes at least representing CDC, FDA, the U.S. Depart- several days. Upon examination by ultravio- ment of Agriculture, 16 states, one province, let microscopy, Cyclospora oocysts autofluo- five cities, five universities, the Council of resce and upon staining, they are variably State and Territorial Epidemiologists, the acid-fast. The incubation period between Association of State and Territorial Public infection and onset of symptoms averages Health Laboratory Directors, the Pan approximately 1 week. Cyclospora infects the American Health Organization, and the small intestine and usually causes watery government of Canada. The participants in diarrhea, with frequent stools. It can also the investigations of Cyclospora shared the cause loss of appetite, weight loss, stomach knowledge gained through their individual cramps, nausea, vomiting, fatigue, increased investigations of this multistate, multicountry flatus, and low-grade fever. The duration of outbreak. The goals of the workshop were to symptoms is often several weeks, and begin to formulate effective prevention remitting courses spanning 1 to 2 months, strategies for Cyclospora infection, to dis- with several relapses, have been reported. cuss the strength of the evidence implicating Cyclosporiasis is effectively treated with Guatemalan raspberries, and to formulate trimethoprim/sulfamethoxazole; however, research needs. The workshop allowed for therapy for patients who are sulfa-intolerant discussions about the epidemiologic and has not been identified. trace-back studies conducted and specula- Before 1996, only three outbreaks of tion about where and how the raspberries Cyclospora infection had been reported in became contaminated. Representatives from the United States. However, between May 1 Texas, South Carolina, New York City, and mid-July 1996 almost 1,000 laboratory- Florida, and New Jersey presented data from confirmed cases were reported to the Centers their respective case-control and cohort for Disease Control and Prevention (CDC). A studies; CDC representatives provided an few hospitalizations (<20) were reported, but overview of the outbreaks and focused on no Cyclospora-related deaths were confirmed. multiple, specific trace-backs from more These infections occurred in at least 15 than 20 of the event-related outbreaks. FDA states and Canadian provinces and the representatives discussed their roles and District of Columbia. Investigations of regulatory authority in foodborne investiga- approximately 50 event-related outbreaks of tions. diarrheal illness due to C. cayetanensis, as The workshop also addressed the array of well as case-control studies of sporadic, scientific challenges concerning C. laboratory-confirmed cases by several states, cayetanensis, such as clinical diagnostic now clearly implicate consumption of fresh techniques, protocols for detection of the raspberries. Complete, high confidence level organism on produce, and the basic biology of Emerging Infectious Diseases354 Vol. 2, No. 4—October-December 1996 Letters this protozoon. We do not know the infectious exporter associations were most helpful in dose, the proportion of infected persons who the investigations and need to remain have diarrhea, the proportion of diarrheal involved if we are to better understand what illness caused in various settings by occurred in May and June of this year. Cyclospora, the existence of animal reser- Throughout the workshop, a wider issue voirs, or the viability of the organism in than the current situation with Cyclospora different environmental conditions. It can be was discussed: the management of the transmitted by water and food, and its emerging problem of widespread multistate transmission is seasonal (late spring/early and international foodborne outbreaks of summer), at least where it has been studied both infectious and toxic nature. Such (primarily temperate, seasonal climates). outbreaks are increasing and can be expected The poor sensitivity and specificity of to worsen as the world moves toward a global current methods for diagnosis and detection food economy. What contaminates a particu- of Cyclospora were discussed. A photomicro- lar food item on a farm, in a herd or crop, at a graphic demonstration convinced the partici- processing shed, or from a handler, can now pants that currently the foremost require- cause widely distributed outbreaks, conti- ment for accurate clinical diagnosis is a nents away, in a day. More coordination is skilled microscopist. The status of poly- needed on several fronts in the management merase chain reaction technologies for of such outbreaks: 1) the development of a detection and diagnosis of Cyclospora was structured process for integration and presented and discussed, including the coordination of epidemiologic studies; 2) inhibitory aspects of berry juices and the more aggressive laboratory diagnostic train- difficulty in oocyst recoveries from spiked ing related to poorly recognized or under- berry samples. Participants stated the need stood emerging infections; 3) better coordi- for a bank of Cyclospora organisms and their nation of press releases related to multistate DNA (molecular libraries) from different outbreaks; 4) better understanding and locations and outbreaks. Currently, we may clarification of the legal roles and responsi- not be able to take full advantage of such bilities of federal, state, and local agencies; epidemiologically well-documented speci- 5) and earlier involvement of industrial mens; however, the technologies and tools partners at all levels, including growing/ will continue to advance, and these speci- processing, exporting/importing, transport- mens need to be centrally banked now, to be ing, and wholesale/retail sales. Because made available when the tools are up to the these types of outbreaks are likely to become task. An animal model needs to be developed, international this aspect must be addressed or at least explored. The uses for such a in considering appropriate approaches. model include providing material (oocysts The Cyclospora outbreaks of May and and other life-cycle stages) for reagent June 1996 underlined that without the development (monoclonal antibodies) to ability to culture and grow the organisms, allow studies of the organisms, the disease, without a supply of the organism to develop immune responses, and potential environ- expedient assays, without an established mental transmission. Such a model will coordinating body to expedite agreed-upon facilitate the development of prevention and means for dissemination of information, we, treatment strategies. as public health officials, are called upon to Ongoing investigations into how the provide guidance without the benefit of all raspberries were contaminated were dis- the appropriate knowledge. The workshop cussed. The lack of sensitive and reproduc- engendered interchange and discussion on ible detection assays for Cyclospora, which critical issues concerning what is known and does not replicate outside the human host, unknown about Cyclospora and the out- remains the major stumbling block in breaks of cyclosporiasis during May and providing proof of contamination of sus- June 1996. The workshop also provided a pected transmission vehicles. Studies were forum in which it became apparent that too preliminary for conclusions. Both the public health officials must launch a government of Guatemala and the producer/ committed effort to develop an established, Vol. 2, No. 4—October-December 1996 355 Emerging Infectious Diseases Letters coordinating system among agencies at all by 1) characteristic morphology and size levels and deal with the threat of wide- (8µm to 10µm), 2) positive staining with spread, multistate/international foodborne Kinyoun’s acid-fast stain, 3) positive outbreaks caused by infectious or toxic autofluorescence under ultraviolet light, and agents. 4) sporulation of oocysts with formation of sporocysts after a 10-day incubation. All Daniel G. Colley these are diagnostic features of C. Centers for Disease Control and Prevention, cayetanensis (8) and to our knowledge are not Atlanta, Georgia, USA described for any known poultry coccidia. On the basis of these
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