What we really know about the huge Cyclospora outbreak in the United States – and what we don’t know

Together, the two states account for more than 4,000 cases of cyclosporiasis, making it one of the worst years for infections. So far, 31 states have reported cases, with some noting higher numbers than usual.

The source of the outbreak remains unknown. Cyclospora tends to spread more in summer and has been found on “a variety of fresh produce, both fruits and vegetables,” Hedberg said.

In its HAN today, the CDC is reporting only 1,645 confirmed cases, including 141 people requiring hospitalization. The agency noted that an additional 5,100 cases need to be confirmed. More than 400 cases in Michigan, Ohio, West Virginia and Kentucky yesterday may represent a single cluster, the CDC said, meaning the infections could be linked to a common source.

The challenge of monitoring cyclosporosis

When public health experts investigate foodborne illnesses, such as those caused by Salmonella, Listeria or Escherichia coli O157, a laboratory can create a culture, grow the bacteria and subtype it using whole genome sequencing, Hedberg explained. The CDC can then trace the pathogen through a laboratory surveillance system known as PulseNet.

“If there is an outbreak of E coli O157 or Salmonella in multiple states, many of them will be recognized by CDC surveillance through PulseNet,” Hedberg said. “If the CDC recognizes that there is an outbreak in multiple states, they will coordinate investigations with all states that have cases.”

But Cyclospora, he says, “is a little different.”

“Cyclospora is not an organism that we have the ability to grow in the laboratory,” Hedberg said. “The subtyping that we might see to identify cases related to each other is not readily available.”

The CDC relies on partial genotyping to link cases of cyclosporosis because “the genome of the parasite is much more complicated,” Gwen Biggerstaff, MPH, deputy director of the CDC’s Division of Foodborne, Waterborne, and Environmental Diseases, said at a press briefing today.

There is often a lag in reporting between the state and the CDC, which can complicate investigations.

“As we have seen with this Cyclospora outbreak, in many cases these increases will be recognized at the state level before the data is compiled nationally to allow our federal officials to have a clear picture of what is happening,” Hedberg said.

Changes at the CDC and response to the outbreak

Last year, the CDC’s Active Foodborne Illness Surveillance Network (FoodNet) reduced the number of pathogens it tracked to two, Salmonella and Shiga toxin-producing E coli (STEC). It is now optional for participating states to report illnesses caused by Campylobacter, Cyclospora, Listeria, Shigella, Vibrio and Yersinia via FoodNet. The network covers 10 locations, in which approximately 16% of the U.S. population lives.

Some have speculated that this change at the federal level is contributing to the severity of the outbreak. But FoodNet has never been used to detect new foodborne illnesses.

“FoodNet really has no role to play in systematically identifying nationally notifiable disease outbreaks,” Hedberg said. “It’s really about helping to monitor trends in the occurrence of these diseases over time so that we can see from year to year whether diseases are increasing or decreasing – so that we can have better estimates of the disease burden associated with these pathogens.”

Cyclospora is a reportable disease to the CDC. When a foodborne illness outbreak occurs, the CDC’s Food and Waterborne Illness Group typically investigates. “They’re really, really good,” Osterholm said.

However, because Cyclospora is a parasite, another CDC unit is studying it.

“This outbreak is being handled by the parasitic disease branch with people who are really inexperienced in this type of outbreak investigation,” Osterholm added.

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