Notes from the Field Use of Electronic Messaging and the Media to Increase Case Finding During a Cyclospora Outbreak — Iowa, July 2013 On Friday, June 28, 2013, the Iowa Department of Public Health routinely reported two cases of a rare parasitic disease, cyclosporiasis, in its weekly electronic newsletter, the Epi Update. This newsletter’s primary audience is Iowa’s public health officials and health-care providers but includes many news reporters. By Wednesday, July 3, seven cases had been reported, resulting in a special Epi Update ”Alert” and a Health Alert Network alert to all hospitals, emergency departments, infection preventionists, public health agencies, and other health-care providers in Iowa. Both alerts included information on symptoms of cyclosporiasis and diagnosis and treatment guidelines. By July 4, most major media outlets in Iowa had reported the outbreak. A press release, updating information on this outbreak, was sent on July 8 to almost 400 individuals, almost all members of the media. That same day, IDH tweeted a message about the outbreak to the department’s 5,000 followers. By July 9, daily updates were being requested by the media. After both health- care providers and the public became aware of the outbreak, many people in Iowa were tested and diagnosed with this rare disease. Cyclospora, a recently identified coccidian parasite, causes prolonged and relapsing diarrhea and vomiting, which can last several weeks to months in healthy adults (1). It can only be identified in the laboratory using special techniques. Commonly requested tests such as bacterial cultures and microscopic examination of stool for ova and parasite cannot reliably detect this organism. It is not spread from person to person, because excreted oocysts require at least several days outside the host to become infectious. Previous outbreaks have been associated with fruits (i.e., raspberries (2)) and raw vegetables (i.e., mesclun lettuce, basil, and snow peas (3)). Almost all Iowa cases have been diagnosed by testing at the state’s public health laboratory, the State Hygienic Laboratory (SHL). An astute laboratorian at SHL first spotted possible Cyclospora oocysts by microscopic examination of fresh stool and confirmed this diagnosis using a modified acid-fast stain technique. At SHL in June, 271 stool tests for ova and parasites were requested, and none specifically requested Cyclospora testing. In contrast, during the first 11 days of July, requests for ova and parasites stool tests increased to 378, and Cyclospora testing was specifically requested on 160 specimens. Case: On June 24, a male aged 61 years presented to an Iowa emergency department with severe vomiting and diarrhea. Despite extensive testing during the patient’s 5-day hospital stay, no cause of illness was identified. After some symptomatic improvement, the patient was discharged, but within days relapsed with severe vomiting and diarrhea. On July 5, the patient’s health care provider, after reading the Epi Update “Alert”, ordered Cyclospora testing on a specimen from the patient, which was positive. The patient was treated with trimethoprim- sulfamethoxazole and symptoms resolved within days. Cyclosporiasis is unusual in that patients can have diarrhea for weeks or months, in contrast to other foodborne pathogens. Its rarity, especially in Americans with no history of foreign travel, hinders diagnosis. Public health authorities have the ability not only to identify cyclosporiasis outbreaks, but to quickly educate health professionals and the public about the symptoms of this disease and the need for specialized testing. They also can provide this special testing in a timely manner through public health laboratories, resulting in increased case detection and assisting in the diagnosis and treatment of patients suffering from this often serious and prolonged infection. Reported by Nicholas Kalas, MPH, Patricia Quinlisk, MPH, MD, Iowa Dept of Public Health. Corresponding contributor: Should this be Barbara Herwalt?<name, email, tel no>. References 1. Herwaldt BL. Cyclospora cayetanensis: a review, focusing on the outbreaks of cyclosporiasis in the 1990s. Clin Infect Dis 2000;31:1040-57. 2. Ho AY, Lopez AS, Eberhart MG, Levenson R, Finkel BS, da Silva AJ, et al. Outbreak of cyclosporiasis associated with imported raspberries, Philadelphia, Pennsylvania, 2000. Emerg Infect Dis [serial online] 2002 Aug [7/11/13];8. Available from: URL: http://wwwnc.cdc.gov/eid/article/8/8/02-0012.htm 3. Ortega, Ynes R. and Sanchez, Roxana. Update on Cyclospora cayetanensis, a Food-Borne and Waterborne Parasite. Clinical Microbiology Reviews 2010;23:218-234. Iowa Cyclospora Outbreak 2013 Talking Points 7.10.13 IDPH, CDC, the State Hygienic Laboratory and local public health agencies are investigating an outbreak caused by Cyclospora. o Cyclospora is a rare parasite. o Previous outbreaks have been associated with fresh produce (fresh fruits and vegetables) o People become infected with Cyclospora by consuming food or water contaminated with the parasite. The source of this outbreak is unknown at this time. o IDPH is working with local public health agencies to interview individuals who are ill to determine if there is a common food exposure that would indicate the source of illness. o Cluster investigations have also begun, which asks questions of both the ill person and their family and friends who are not ill, to determine what the well people did not eat. Cyclospora infection causes a watery diarrhea that lasts an average of 57 days, if untreated. o Most of the illnesses in this outbreak began in mid to late June. Many people report still being ill and some have had relapses. There is treatment (medicine) available to treat Cyclospora infection. o Specific laboratory testing (not commonly ordered) must be done to detect Cyclospora. o Specific treatment (not typically used to treat more common diarrheal illnesses) can be prescribed. If you are experiencing diarrhea, or have recently had a long bout with diarrhea, you should contact your health care provider and see if you should be tested for Cyclospora infection. o Additional symptoms of cyclosporiasis (the infection caused by Cyclospora) include: . Watery diarrhea . Fatigue (severe tiredness) . Loss of appetite . Weight loss . Bloating . Increased gas . Stomach cramps . Nausea . Vomiting . Muscle aches . Low-grade fever EPI Update for Friday, July 19, 2013 Center for Acute Disease Epidemiology (CADE) Iowa Department of Public Health (IDPH) Items for this week’s EPI Update include: Cyclospora outbreak investigation continues West Nile virus update RAGBRAI XLI study Meeting announcements and training opportunities Cyclospora outbreak investigation continues To date, almost all confirmed cases of Cyclospora in Iowa report their illness beginning on or before July 1st; therefore, healthcare providers should consider the following when determining whether Cyclospora testing is indicated: If diarrheal illness onset occurred after July 1st, illness is more likely caused by a different pathogen. The percent of ordered tests that are positive for Cyclospora is decreasing dramatically. Fresh produce (fruits and vegetables) has been implicated in previous Cyclospora outbreaks and interviews with those who have been ill indicate vegetables were probably the source of this outbreak. Illness onset dates, coupled with the shelf life of fresh produce, make it very likely the vegetable that was the source of the outbreak has already been eaten or thrown away, and will not cause anyone else to become ill. While additional confirmed cases of Cyclospora infection continue to be reported and investigated, the focus of the investigation now turns to determining the source of the contamination (at no time was an Iowa-grown fruit or vegetable suspected to be the cause of the outbreak). In Iowa, this investigation is ongoing and led by DIA. IDPH will continue to update the CDC and the FDA as the Iowa epidemiologic investigation continues. Daily case counts will continue to be posted to the IDPH web site. For continuing updates of the investigation, visit www.idph.state.ia.us/EHI/Issue.aspx?issue=Cyclospora Outbreak Investigation. West Nile virus (WNV) update Two human cases of West Nile virus have been reported in Iowa this summer, including a middle-aged (41 to 60 years of age) male from Linn County and an adult (18 to 40 years of age) female from Shelby County. Sentinel surveillance has identified one sentinel chicken as positive for West Nile virus infection in Pottawattamie County. West Nile virus is endemic in Iowa and activity usually peaks in late summer and early fall. Please continue to encourage measures to prevent mosquito bites: Insect repellant containing DEET used as directed for age Light-colored, long-sleeved shirt and long pants when outside for long periods of time when mosquitoes are most active (between dusk and dawn) Empty standing water where mosquitoes may breed For more information on West Nile virus, visit www.idph.state.ia.us/CADE/DiseaseIndex.aspx?disease=West%20Nile%20Virus RAGBRAI XLI study The 41st Register’s Annual Great Bike Ride Across Iowa (RAGBRAI) will take place July 21 through 27. An epidemiologist from IDPH will be participating and performing a study on dehydration and rehydration among RAGBRAI riders. We hope all those involved with this year’s event have a safe and enjoyable week! Meeting announcements and training opportunities Extension Training Program for Infection Prevention: October 7-11,