Cyclospora Outbreak:

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• MI announced that preliminary findings show that this Cyclospora outbreak may be linked to lettuce or salad greens, “although other food items cannot be completely ruled out [...and] no specific type of produce, grower or supplier has been identified as the source.” (NY Times, MDHHS)
  
  
• MI has 3,309 cases as of Tuesday, an increase of 669 overnight. Nearby OH reports somewhere in the 300s, but one local health department in the northwest part of the state reports 660+ confirmed cases. (Georgetown HSOC)
  
  
• NY state is next with 470 cases, more than half of which are in New York City. (Georgetown HSOC)
  
  
• CDC updated its website today to confirm 1,645 confirmed cases and that it’s “aware of more than 5,100 cases that require further analysis”. By this time last year, the U.S. had only 249 cases. Of the 1,645 patients with available information, 141 (9%) were hospitalized, and none have died. (CDC)

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Health News:

• Measles is continuing to climb in the U.S., with 62 new cases last week, more than half in Virginia. (MedPage Today)
  
  
• A U.S. citizen on an aid mission contracted Ebola bundibugyo virus and is being treated in Germany. Meanwhile, the U.S. will not allow citizens to return to the U.S. for 3 weeks after visiting the DRC. (Reuters)
  
  
• Four out of every five new Ebola patients in the DRC have no known link to existing patients, indicating that this outbreak could be 2-4x larger than the official count. (Reuters via AOL)
  
  
• NY’s famous Guggenheim Museum was one of the 31 buildings that tested positive for Legionnaires' disease amid an NYC outbreak. (AP)
  
  
• 1 in 4 adults in tick-heavy states (AR, KY, MO, TN, VA) tested positive for alpha-gal antibodies. (MMWR, CIDRAP)
  
  
• Heat waves raise hospital admissions for mental health issues. (U.S. News)
• Some good news: Oxford began the first human trial of an Ebola bundibugyo vaccine. (Reuters)
  
  
• More good news: Tick bites have peaked and are dropping quickly as the summer heats up. (YLE)

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Best Questions:

How long should we exclude an employee who tests positive for Cyclospora? 

With over 6,000 people having tested positive for Cyclospora since the end of June, it’s no surprise that our clients have started to see positive test results roll in.

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There’s no clear recommendation from the CDC or health departments on this, so, as always, ZHH uses our team’s expertise, the available clinical research, and data to create a recommendation for you that balances the science, risk, and your operational needs. 

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If an employee has tested positive for Cyclospora, first we’ll want to verify the results. Since most tests for this parasite are actually full GI panels, we’ll also want to make sure they didn’t test positive for anything else, too (That’s less common in this domestic outbreak, but more common with travel-related cases - but there’s always a risk that one big splashy outbreak like this can hide other, smaller ones). 

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Our recommendation is to require a doctor’s note that clears the employee to return to work in a foodservice setting, as well as confirming that the employee is at least 48 hours symptom free with absolutely no diarrhea or other GI symptoms in that time. We do not require that they start on antibiotics or complete a course (which can last up to 10 days), since some people won’t need treatment at all. 

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If we start to see 50 or 100 employees testing positive, we may reassess whether a doctor’s note is feasible (since many people will have sought medical attention at a local Emergency Room, and notes may not be realistic if they don’t have a primary care doctor). But for now, we think these numbers are reasonable enough that it pays to be safe rather than sorry. 

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For ZHH clients, the ZHH App puts our clinical team at your fingertips - we can verify results, review doctor’s notes, and answer any specific questions about your case. 

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Sources: ZHH, CDC

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Now that Michigan has said they suspect leafy greens in the Cyclospora outbreak, should we pull those from our menu? 

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Michigan’s state health department has been leading the charge on this massive, multistate Cyclospora outbreak, and yesterday they announced that their preliminary investigation indicates lettuce or salad greens as a possible source. It’s not a smoking gun (they’ve said other food items can’t be ruled out), but they wanted to alert the public because a disproportionate number of people they interviewed seem to have eaten lettuce or salad mix. 

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Naturally, the question we started getting yesterday afternoon was whether restaurants and food service operators should stop serving lettuce and salad greens until we have specifics. 

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Our answer to this question really depends on a lot of factors:

• If you’re in MI (or northwestern OH)
• If you have multiple employees or guests with lab-confirmed Cyclosporiasis
• How operationally challenging it would be to pull lettuce or salad greens from your menu 

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There are a few things that make this less clear-cut: 

• We don’t know anything about the type of lettuce or greens, and they haven’t named a specific supplier or grower yet.
• There may be multiple outbreaks going on across the country. 
  
  • While there has been shockingly little communication from the FDA, their website lists four separate Cyclospora investigations as ongoing, which might imply there are genetic differences or compelling reasons to list them separately (take that with a big grain of salt, though – they list a grand total of 35 cases between the four outbreaks…compare that to at least 5,000 cases reported by states). 
• Even though Michigan looks like it’s the epicenter of this outbreak, it may be an illusion. Because they did more testing and noticed an increase before other states, more people are aware of the outbreak and getting tested there. In fact, early national data show that this outbreak may have started in the Northeast back in May, per Dr. Caitlin Rivers of FOI Clinical. 
• As we covered in Friday’s Best Question, there are real brand risks to pulling items earlier than others, including the perception that you’re involved, even if that’s absolutely untrue. 

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So, to pull or not to pull? It’s worth some consideration if it’s not a huge disruption to your operations. But before you act, just know that we expect to find out more in the next few days, and it’s not so clear cut as to be a public health responsibility just yet. There are no recalls, and no states or federal agencies are asking restaurants to stop serving lettuce or salad greens just yet. 

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If you do decide to temporarily stop serving lettuce and salad mix, clear communication with guests is key (“it’s out of an abundance of caution after the MI State Health Department identified it as a possible source of the multistate outbreak,” “we have no reports of guest illness,” etc). If you keep serving lettuce, it’s worth checking whether you can easily switch to getting whole-head lettuce, removing the outer leaves, and washing it on-site. 

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Either way, we hope states and the FDA will narrow this down a bit more in the coming days and look forward to clearer guidance on specific brands, suppliers, or growers. 

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Sources: FOI Clinical, Georgetown HSOC, YLE, MDHHS

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Best Read:

It’s been weeks now of this Cyclospora outbreak growing, and we’re only just starting to pinpoint food items. That’s because it’s a nasty little parasite that’s incredibly hard to track down - it has a long incubation period, so it can be hard for people to remember the brand of salad mix they ate 1, 2, or even 3+ weeks ago. It’s also genetically harder to analyze than bacterial illnesses like E. coli or Salmonella. Big shoutout to the epidemiologists in Michigan and around the country working on this tough challenge! 

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Why it's been so hard to find what food is spreading the parasite that's sickened thousands - Washington Post (Gift Article)

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