Outbreak of cyclosporiasis associated with imported raspberries, Philadelphia, Pennsylvania, 2000. (Research).An outbreak of cyclosporiasis occurred in attendees of a wedding reception held in Philadelphia, Pennsylvania, on June 10, 2000. In a retrospective cohort study A cohort study is a form of longitudinal study used in medicine and social science. It is one type of study design.
In medicine, it is usually undertaken to obtain evidence to try to refute the existence of a suspected association between cause and disease; failure to refute , 54 (68.4%) of the 79 interviewed guests and members of the wedding party met the case definition. The wedding cake, which had a cream filling that included raspberries, was the food item most strongly associated with illness (multivariate relative risk, 5.9; 95% confidence interval confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. , 3.6 to 10.5). Leftover cake was positive for Cyclospora DNA DNA: see nucleic acid.
or deoxyribonucleic acid
One of two types of nucleic acid (the other is RNA); a complex organic compound found in all living cells and many viruses. It is the chemical substance of genes. by polymerase chain reaction polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is analyses. Sequencing of the amplified fragments confirmed that the organism was Cyclospora cayetanensis Cyclospora cayetanensis Parasitology A Cryptosporidium-like coccidian protozoan, family Eimeriidae, which is implicated in episodic traveler's diarrhea; it infects the GI tract of immunocompetent and immunocompromised hosts–especially with AIDS. . The year 2000 was the fifth year since 1995 that outbreaks of cyclosporiasis definitely or probably associated with Guatemalan raspberries have occurred in the spring in North America North America, third largest continent (1990 est. pop. 365,000,000), c.9,400,000 sq mi (24,346,000 sq km), the northern of the two continents of the Western Hemisphere. . Additionally, this is the second documented U.S. outbreak, and the first associated with raspberries, for which Cyclospora has been detected in the epidemiologically implicated im·pli·cate
tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates
1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot.
2. food item.
On June 10, 2000, a total of 83 persons attended a catered wedding reception in Pennsylvania. Approximately 8 days later, the bride notified the local health department that she, her husband, and many guests at the reception had a gastrointestinal illness. Stool specimens from attendees were positive for oocysts of the coccidian parasite Cyclospora cayetanensis, and an epidemiologic investigation was begun by the Philadelphia Department of Public Health and the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice.
CDC - Control Data Corporation ).
Previous foodborne outbreaks of cyclosporiasis in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. have been associated with consumption of fresh raspberries, mesclun mes·clun
A mixture of young leafy greens, often including young lettuces, used as salad.
[Provençal mesclom, mesclumo, mixture, from Vulgar Latin lettuce, and basil (1-8). An important feature of the biology of Cyclospora is that oocysts excreted in feces require days to weeks outside the host to sporulate spor·u·late
To produce or release spores. and thus to become infectious. However, the minimum time required for sporulation sporulation /spor·u·la·tion/ (spor?u-la´shun) formation of spores.
The production or release of spores.
formation of spores or sporozoites. is unknown. Cyclospora oocysts must survive in the environment long enough to sporulate and infect a susceptible host, which suggests that they are very hardy.
A retrospective cohort study was conducted by administering a structured questionnaire by telephone about symptoms and event-related exposures. A case of cyclosporiasis was defined as onset of illness 1-14 days after the reception and either (a) one positive stool specimen and at least one gastrointestinal symptom (i.e., loose stools, nausea, vomiting, stomach cramps, gas/bloating, loss of appetite loss of appetite Medtalk Anorexia, see there , and unintentional weight loss) or constitutional symptom constitutional symptom
A symptom indicating that a disease or disorder is affecting the whole body. (i.e., fever, chills, muscle aches, generalized body aches, and headaches); (b) any loose stools in a 24-hour period and at least one other gastrointestinal or constitutional symptom; or (c) a total of at least three gastrointestinal symptoms.
We attempted to identify more cases of cyclosporiasis by having the Pennsylvania State Bureau of Epidemiology alert health departments throughout the state of the investigation. We also requested the catering company to contact the six groups to which they had served raspberries during the period June 2-4 that might have been from the suspected raspberry shipments.
Univariate relative risks and 95% confidence intervals (CIs) were calculated by using Epi-Info, version 6.04 (CDC). Multivariate Poisson regression In statistics, the Poisson regression model attributes to a response variable Y a Poisson distribution whose expected value depends on a predictor variable x, typically in the following way:
The local diagnostic reference laboratory examined stool specimens from five patients for Cyclospora oocysts by Kinyoun's modified acid-fast technique. CDC reevaluated specimens from three of these patients either by examining slides made by the local laboratory or by UV fluorescence microscopy Noun 1. fluorescence microscopy - light microscopy in which the specimen is irradiated at wavelengths that excite fluorochromes
microscopy - research with the use of microscopes of a stool specimen concentrated by the formalin-ethyl acetate technique. An unknown number of specimens were tested at the local diagnostic reference laboratory for Cryptosporidium parvum Cryptosporidium parvum is one of several species that cause cryptosporidiosis.
Cryptosporidium parvum is a protozoal infection which causes an acute, watery, and non-bloody diarrhoea in immunocompromised patients. ; Salmonella, Shigella shigella
Any of the rod-shaped bacteria that make up the genus Shigella, which are normal inhabitants of the human intestinal tract and can cause dysentery, or shigellosis. Shigellae are gram-negative (see gram stain), non-spore-forming, stationary bacteria. S. , and Campylobacter Campylobacter
Genus of gram-negative spiral-shaped bacteria infecting mammals. Many species, especially C. fetus, cause miscarriage in sheep and cattle. C. jejuni is a common cause of food poisoning. Sources include meats (particularly chicken) and unpasteurized milk. spp.; and Escherichia coli Escherichia coli (ĕsh'ərĭk`ēə kō`lī), common bacterium that normally inhabits the intestinal tracts of humans and animals, but can cause infection in other parts of the body, especially the urinary tract. O157:H7.
CDC and the Food and Drug Administration (FDA FDA
Food and Drug Administration
n.pr See Food and Drug Administration.
n.pr the abbreviation for the Food and Drug Administration. ) used molecular methods to examine leftover wedding cake, which the bride and groom had frozen, for Cyclospora. FDA's methods were as follows. One-gram portions of the icing from the top of the wedding cake, the raspberry filling, and the cake itself were processed for molecular analyses by using 20 mL of Tris buffer (containing 100 mM Tris-HCL, pH 8.0, 10 mM EDTA EDTA: see chelating agents. , 150 mM NaCl) and 5 mL of ethyl acetate ethyl acetate
A colorless volatile flammable liquid, CH3COOC2H5, used in perfumes, flavorings, lacquers, pharmaceuticals, and rayon and as a general solvent. . The samples were shaken vigorously, heated at 56[degrees]C, and gently agitated ag·i·tate
v. ag·i·tat·ed, ag·i·tat·ing, ag·i·tates
1. To cause to move with violence or sudden force.
2. for 30 min. The samples were centrifuged for 15 min at 4500 x g at 15[degrees]C. The organic phase, the interface, and the aqueous (upper) phase were aspirated. Next, the pellet was washed twice with 25 mL of Tris buffer and centrifuged as above. The pellet was suspended in 4 mL of Tris buffer, layered over a 4-mL Optiprep solution (Invitrogen Corporation, Carlsbad, CA), and diluted 1:1 with the Tris buffer. The samples were centrifuged for 15 min at 250 x g at 15[degrees]C. The aqueous phase aqueous phase
The water portion of a system consisting of two liquid phases, one that is primarily water and a second that is a liquid immiscible with water. , the interface, and 1.5 mL of the upper portion of the Optiprep layer were removed and saved in a 15-mL centrifuge centrifuge (sĕn`trəfyj), device using centrifugal force to separate two or more substances of different density, e.g., two liquids or a liquid and a solid. tube. The remaining pellet and Optiprep solution were discarded. All saved samples were diluted further with 2-3 mL of Tris buffer and centrifuged for 10 min at 20,000 x g.
The supernatant supernatant /su·per·na·tant/ (-na´tant) the liquid lying above a layer of precipitated insoluble material.
the liquid lying above a layer of precipitated insoluble material. from each sample was aspirated to within 1 mL of the bottom, and the pellets were suspended in this volume and transferred to a 1.5-mL microcentrifuge tube. The samples were then centrifuged for 2 min in a microcentrifuge at 14,000 x g, and the supernatant was aspirated. The final pellets were suspended in 50 [micro]L of distilled water Noun 1. distilled water - water that has been purified by distillation
H2O, water - binary compound that occurs at room temperature as a clear colorless odorless tasteless liquid; freezes into ice below 0 degrees centigrade and boils above 100 degrees centigrade; , and a 10-[micro]L volume of each sample was spotted onto Flinders Technologies of Australia (FTA FTA
Future Teachers of America ) filters (Fitzco, Inc., Maple Plain Maple Plain can refer to:
There are three basic steps in a DNA extraction, the details of which may vary depending on the type of sample and any substances that may and subsequent polymerase chain reaction (PCR PCR polymerase chain reaction.
polymerase chain reaction
Polymerase chain reaction (PCR) ) analyses as described previously (9).
CDC's methods were as follows. DNA was extracted directly from nine randomly selected 1-g portions of raspberry filling from the cake by using selected components from the FastDNA kit (BIO 101, Inc., Vista, CA). The portions were placed into tubes containing disruption beads that were included in the kit, and DNA extraction was performed as described (10).
Nested PCR amplification was performed by using primers modified from those described elsewhere (11). The restriction sites Restriction sites, or restriction recognition sites, are particular sequences of nucleotides that are recognized by restriction enzymes as sites to cut the DNA molecule. The sites are generally palindromic, (because restriction enzymes usually bind as homodimers) and a particular EcoRI and BamHI were removed from the 5' end, and bases matching the C. cayetanensis small subunit (SSU SSU Small Subunit
SSU Sonoma State University
SSU Savannah State University (Savannah, Georgia)
SSU Shawnee State University (Ohio)
SSU Salisbury State University ) rRNA coding region The coding region of a gene is the portion of DNA that is transcribed into mRNA and translated into proteins. This does not include such regions as a recognition site, initiator sequence, or termination sequence, only the region that will directly code for amino acid linkage. were added. Thus, primers CYCF1 (5'-ATTACCCAATGAAAACAGTTT-3') and CYCR2 (5'-TGCAGGAGAAGCCAAGGTAGG-3') were used for the first step of nested amplification; the preamplified fragment was nested with primers CYCF3 (5'-GCCTTCCGCGCTTCGCTGCGT-3') and CYCR4 (5'- TCGTCTTCAAACCCCCTACTG-3'). Amplification with these primers generates a 294-bp fragment from the C. cayetanensis SSUrRNA coding region.
Besides the nested PCR, a 636-bp fragment from the Cyclospora sp. SSUrRNA, flanked by primers CYCF1/ CYCR2, was amplified and sequenced to identify the parasite at the species level. This fragment contains substitutions that allow differentiation among the Cyclospora spp. for which the sequence of the SSUrRNA coding region is available in GenBank (i.e., C. cayetanensis, C. cercopitheci, C. colobi, and C. papionis). Sequencing reactions were performed on PCR products that had been purified with the StrataPrep PCR Purification Kit (Stratagene, La Jolla La Jolla (lə hoi`yə), on the Pacific Ocean, S Calif., an uninc. district within the confines of San Diego; founded 1869. The beautiful ocean beaches, in particular La Jolla shores and Black's Beach, and sea-washed caves attract visitors and , CA). Sequencing reactions, analyses, and assemblage of sequences were performed as described (12).
Environmental and Source Investigations
The reception facility was inspected, and food-handling and storage practices were observed. Information about illness in the catering staff was collected by examining the caterer's sick logs. The caterer was also asked to contact the health department if staff called in sick. Ill staff members would then be asked whether they had had a gastrointestinal illness during the 3 weeks before and after the reception.
The caterer and the distributors that supplied his company were interviewed, and shipping documents were obtained to determine the source of the raspberries used in the cake (13). In cooperation with the Guatemalan government, FDA inspected one of the farms that could have supplied the raspberries served at the wedding; this farm also could have supplied the raspberries for an event in another state in 2000 that was associated with an outbreak of cyclosporiasis.
Seventy-nine (95.2%) of the 83 attendees of the wedding reception were interviewed. Fifty-four (68.4%) of the 79 had illness that met the case definition. Five (9.3%) of the 54 case-patients had laboratory-confirmed cyclosporiasis, and 49 (90.7%) of the 54 case-patients had clinically defined cyclosporiasis. All case-patients who met part (c) of the case definition also met part (b). Therefore, parts (b) and (c) were combined to represent the clinically defined category of the case definition. The median incubation period incubation period
1. See latent period.
2. See incubative stage.
Incubation period was 7 days (range 1-9 days) (Figure 1). The symptoms associated with illness are listed in Table 1.
[FIGURE 1 OMITTED]
Several food items were significantly associated with illness in univariate analyses (Table 2). However, only the cake, which had a cream filling that included pieces of raspberries, was significantly associated with illness in multivariate analyses (relative risk 5.9; 95% CI 3.6 to 10.5). Mesclun lettuce was used as a garnish for several food items, and fresh basil was served in one food item; neither was significantly associated with illness.
We did not identify additional cases through the Pennsylvania State Bureau of Epidemiology's alert to local health departments. Moreover, the catering company contacted the six groups to which they served raspberries during June 2-4, and no additional cases were identified.
For three of the five case-patients who had laboratory-confirmed cyclosporiasis (Table 1), stool specimens were sent to CDC and reconfirmed as positive for Cyclospora oocysts. Results of stool testing for other microbes were negative.
PCR analyses conducted by both FDA and CDC confirmed the presence of Cyclospora DNA in the raspberry filling of the cake. At FDA, an FTA-based PCR identified Cyclospora DNA in the raspberry filling but not in the icing from the top of the cake or in the cake itself. At CDC, PCR amplification was possible from DNA directly extracted from four of the nine portions of the raspberry filling that were tested. All positive samples generated sequences that were identical to C. cayetanensis in the 636-bp PCR product.
Environmental and Source Investigations
None of the catering staff reported having been ill during the 3 weeks before or after the reception. However, on July 18, the local health department learned, through routine surveillance, about a caterer, who had worked during the reception, in whom gastrointestinal illness developed 8 days later; she had laboratory-confirmed cyclosporiasis. Although she could not recall her duties for the event, her usual tasks included cutting and serving wedding cake. She also identified two other staff members in whom gastrointestinal illness developed a median of 6 days after the reception; their symptoms resolved spontaneously, and no stool specimens were tested. They had not worked during the reception but had worked later that day and reported that they probably ate leftover cake.
Raspberries were the only produce used in the wedding cake. The catering company had received four shipments of fresh raspberries June 1-3. Some of the raspberries from these shipments were served fresh at events on June 3-4. The leftover raspberries were frozen for 1-4 days. Two to three pints of leftover, unwashed raspberries were thawed, crushed into pieces, and folded into the butter cream Butter cream or buttercream or mock cream is a type of icing used inside cakes, as a coating, and as decoration. In its simplest form, it is made by creaming butter with icing sugar, although other fats can be used, such as margarine. filling used in the cake. The cake was then frozen for another 4-5 days until it was thawed and eaten on June 10, the date of the wedding (Figure 2).
[FIGURE 2 OMITTED]
Local distributors A and B supplied the four shipments of raspberries received by the catering company during the period June 1-3 (Figure 3). Distributors A and B had received shipments from three other local distributors (C, D, and E) during May 30-June 3. During this period, one Guatemalan farm and one Mexican farm were the sources of the raspberries that were delivered to importers F and G that supplied distributor C, and an unknown number of U.S. farms supplied the raspberries delivered to distributors D and E (Figure 3). Which raspberries from which shipment were actually used in the cake is unknown.
[FIGURE 3 OMITTED]
The one Guatemalan farm that could have supplied the raspberries used in the cake was also one of the possible sources (and the only Guatemalan source) of raspberries served at a bridal brunch in Georgia in May 2000 that was associated with an outbreak of cyclosporiasis (14). The Guatemalan farm was the only known source in common to the events in Pennsylvania and Georgia. FDA inspected this farm and found no definitive source for contamination (J. Guzewich, pers. comm).
We investigated an outbreak of cyclosporiasis associated with a wedding reception in Philadelphia in June 2000. The epidemiologic evidence and the identification by PCR analyses of Cyclospora DNA in the food item most strongly associated with illness indicated that the outbreak was foodborne. This is the first outbreak associated with raspberries for which Cyclospora DNA has been identified in the epidemiologically implicated food item. Because of the outbreak, the Philadelphia health department subsequently made cases of Cyclospora infection reportable.
We do not know whether the outbreak involved more cases in Pennsylvania than the cluster of cases we investigated. The catering company for the wedding reception received four shipments of fresh raspberries the weekend before the cake was prepared; which raspberries from which shipment were used for the reception rather than the other six events during the period of interest at which raspberries were served is unknown. We did not identify any more cases of cyclosporiasis by contacting the other six groups. However, perhaps only one of the shipments of raspberries and only some of the raspberries in that shipment were contaminated contaminated,
v 1. made radioactive by the addition of small quantities of radioactive material.
2. made contaminated by adding infective or radiographic materials.
3. an infective surface or object. . The same Guatemalan farm was one of the possible sources of the raspberries (and the only Guatemalan source) served at the reception in Pennsylvania in June 2000 and the bridal brunch in Georgia in May 2000. The identification of only one farm in common to the two events suggests that the events were related.
The year 2000 was the fifth year since 1995 (i.e., 1995, 1996, 1997, 1998, and 2000) that outbreaks of cyclosporiasis occurred in the spring in the United States or Canada that definitely or probably were associated with Guatemalan raspberries (7). However, the recent outbreaks have been much smaller than the multistate outbreaks in 1996 and 1997 (7). After the outbreaks in 1996 and 1997 (2,3), FDA began working with the Guatemalan government and berry industry to improve farming and exporting practices for raspberries. Only farms that meet certain standards--including water, sanitation, and worker hygiene issues--have been allowed to export fresh raspberries to the United States during the "spring season" (March through August). The standards are reviewed and updated yearly. During the spring of 2000, five Guatemalan farms were allowed to export to the United States. After the outbreaks in Pennsylvania and Georgia, FDA did not allow the farm that was in common to the events to export raspberries to the United States during the spring of 2001. No U.S. outbreaks of cyclosporiasis associated with Guatemalan raspberries were identified that spring. During the spring of 2002, only three farms, which have never been implicated in outbreaks of cyclosporiasis, were allowed to export raspberries to the United States.
The cyclosporiasis outbreak in Philadelphia is the first for which raspberries that reportedly had been frozen, rather than served fresh, were implicated. The raspberries used in the wedding cake had been bought fresh but then reportedly frozen and thawed twice before they were served (Figure 2). The temperature of the freezer where the raspberries were stored is unknown. When the freezer was inspected 2 weeks after the outbreak, the temperature of the freezer was -3.3[degrees]C, which might not have been cold enough to kill Cyclospora oocysts. Although limited information is available about the effects of freezing on their survival, for Cryptosporidium parvum, another coccidian parasite, oocysts remain infectious for mice after storage at -10[degrees]C for 1 week (15). Freezing at sufficiently cold temperatures for sufficiently long periods, as during commercial freezing, should kill Cyclospora oocysts. For Cryptosporidium parvum, oocysts were not infectious for mice after storage at -15[degrees]C for 1 week (15).
This Pennsylvania outbreak is the second documented U.S. outbreak, and the first associated with raspberries, for which Cyclospora has been detected in the epidemiologically implicated food item. The first U.S. outbreak for which Cyclospora was detected in a food item occurred in 1999 in Missouri and was associated with fresh basil in a chicken pasta salad (8). Neither the raspberries in 2000 nor the basil in 1999 had been washed. Although all produce should be thoroughly washed before being eaten, other outbreaks (2,3,7) and a laboratory study (16) have shown that washing does not eliminate the risk for Cyclospora infection.
Fortunately, leftovers from both the Pennsylvania and Missouri outbreaks had been frozen and were available for testing. Contamination of the implicated food items for the 1999 outbreak was demonstrated by PCR analyses and light microscopy and for the 2000 outbreak by PCR analyses. The modes of contamination of the produce associated with outbreaks of cyclosporiasis have not yet been definitively identified for any of the outbreaks. However, molecular methods are sensitive tools that can be used to identify the organism in the vehicle and in environmental samples, which then may provide information useful for determining the mode of contamination. Molecular methods for detecting Cyclospora continue to improve (9). Continued research about the biology and epidemiology of Cyclospora is important for identifying effective measures for preventing future outbreaks.
Table 1. Information on attendees of a wedding reception associated with an outbreak of cyclosporiasis, Pennsylvania, June 2000 Case-patients Non-case attendees Variable (n=54) (a) (n=25) (b) Age, y, median (range) (c) 38.8 (18-87) Female sex, no. (%) (c) 32 (59.3) Symptoms, no. (%) Diarrhea (d) 54 (100) 1 (4.0) Nausea 43 (79.6) 1 (4.0) Stomach cramps 41 (75.9) 1 (4.0) Chills/sweats 41 (75.9) 0 Headache 36 (66.7) 0 Muscle/body aches 36 (66.7) 1 (4.0) Fever (e) 32 (59.3) 0 Vomiting 26 (48.1) 0 Dizziness 25 (46.3) 0 Rash 3 (5.6) 0 Hospitalization, no. (%) 2 (3.7) 0 Length of stay, days, 12 (10-14) 0 median (range) (a) Five of the 54 case-patients had laboratory-confirmed cyclosporiasis. (b) Two of the 25 non-case attendees reported having at least one symptom. (c) Information about age and sex was obtained from only two non-case attendees and was not included in the table. (d) Diarrhea was defined as having three or more loose stools in a 24-hour period. (e) In case-patients, the median temperature was 37.8[degrees]C (range 37.2-38.5[degrees]C). No non-case attendees were febrile. Table 2. Food items at a wedding reception that were significantly associated with cyclosporiasis in univariate analyses, Pennsylvania, June 2000 Attack rate in attendees, no. ill/no. exposed or unexposed (%) Food items (a) Exposed Unexposed RR (95% CI) Wedding cake (b) 50/53 (94.3) 4/26 (15.4) 6.1 (2.5 to 15.1) Fresh fruit (c) 36/43 (83.7) 18/36 (50.0) 1.7 (1.2 to 2.4) Arugula salad 34/41 (82.9) 20/38 (52.6) 1.6 (1.1 to 2.2) Focaccia bread 15/16 (93.8) 39/63 (61.9) 1.5 (1.2 to 1.9) Hearthbaked 23/27 (85.2) 31/52 (59.6) 1.4 (1.1 to 1.9) bread (a) Mesclun lettuce was served as a garnish on several hors d'oeuvres trays, and basil was served fresh in one food item. Neither was significantly associated with illness. (b) Food item was statistically significant in multivariate analyses (relative risk, 5.9; 95% confidence interval [CI] 3.6 to 10.5). (c) Fresh fruit included strawberries, raspberries, blueberries, and blackberries. Persons served themselves from a bowl of fresh strawberries and a bowl of fresh raspberries, blueberries, and blackberries next to the cake. The raspberries in the bowl came from a different source than the raspberries in the cake filling and were not statistically significant in multivariate analyses.
We thank Michael Arrowood, Jeff Bier bier
1. A stand on which a corpse or a coffin containing a corpse is placed before burial.
2. A coffin along with its stand: followed the bier to the cemetery. , Paul Blake Paul Blake is the current Chairman of the British Basketball League, succeeding Vince Macaulay-Razaq in 2006, as well as working as the current Managing Director of the Newcastle Eagles basketball franchise.
He attended Northumbria University in Newcastle upon Tyne. , Loretta Brown, Ronald Colucci, Paula Davis-Debella, Phil DeLisle, Michelle Dunaway, Mark Eberhard, Kris Foster, John Guzewich, Travis Hunt, George Jackson, Stephanie Johnston, John Kvenberg, Eva Nace, Jim O'Neal, James Peiffer, Sarah Pichette, Kathleen Sinninger, Luis Solorzano, Bill Tackett, Susanne Wahlquist, Davina Watson, and Kimberly Won for their help with the investigation.
(1.) Koumans EHA EHA European Hematology Association
EHA Economic History Association
EHA Emmanuel Hospital Association
EHA Education for All Handicapped Children Act of 1975
EHA Empty Homes Agency
EHA English Hockey Association
EHA Electrohydrostatic Actuator , Katz DJ, Malecki JM, Kumar S, Wahlquist SP, Arrowood MJ, et al. An outbreak of cyclosporiasis in Florida in 1995: a harbinger of multistate outbreaks in 1996 and 1997. Am J Trop Med Hyg 1998;59:235-42.
(2.) Herwaldt BL, Ackers ML, Cyclospora Working Group. An outbreak in 1996 of cyclosporiasis associated with imported raspberries. N Engl J Med 1997;336:1548-56.
(3.) Herwaldt BL, Beach MJ, Cyclospora Working Group. The return of Cyclospora in 1997: another outbreak of cyclosporiasis in North America associated with imported raspberries. Ann Intern Med 1999;130:210-20.
(4.) Centers for Disease Control and Prevention. Outbreak of cyclosporiasis--northern Virginia-Washington, D.C.-Baltimore, Maryland, metropolitan area, 1997. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morb Mortal Wkly Rep 1997;46:689-91.
(5.) Levy DA, Rullan J, Pritchett R, Gossman C, Radke V, Moore J, et al. Multicluster outbreak of foodborne cyclosporiasis associated with fresh basil [abstract no. P-3.19]. In: Program and abstracts of the International Conference on Emerging Infectious Diseases The ICEID or International Conference on Emerging Infectious Diseases is a conference for public health professionals on the subject of emerging infectious diseases. ; 1998 Mar 8-11; Atlanta (GA). 1998. p. 86.
(6.) Centers for Disease Control and Prevention. Outbreak of cyclosporiasis--Ontario, Canada, May 1998. MMWR Morb Mortal Wkly Rep 1998;47:806-9.
(7.) Herwaldt BH. Cyclospora cayetanensis: a review, focusing on the outbreaks of cyclosporiasis in the 1990s. Clin Infect Dis 2000;31:1040-57.
(8.) Lopez AS, Dodson DR, Arrowood MJ, Orlandi PA, da Silva AJ, Bier JW, et al. Outbreak of cyclosporiasis associated with basil in Missouri in 1999. Clin Infect Dis 2001;32:1010-7.
(9.) Orlandi PA, Lampel KA. Extraction-free, filter-based template preparation for the rapid and sensitive PCR detection of pathogenic parasitic protozoa. J Clin Microbiol 2000;38:2271-7.
(10.) da Silva AJ, Bornay-Llinares FJ, Moura I, Slemenda SB, Turtle JL, Pieniazek NJ. Fast and reliable extraction of protozoan protozoan (prō'təzō`ən), informal term for the unicellular heterotrophs of the kingdom Protista. Protozoans comprise a large, diverse assortment of microscopic or near-microscopic organisms that live as single cells or in simple parasite DNA from fecal specimens. Mol Diagn 1999;4:57-64.
(11.) Relman DA, Schmidt TM, Gajadhar A, Sogin M, Cross J, Yoder K, et al. Molecular phylogenetic phy·lo·ge·net·ic
1. Of or relating to phylogeny or phylogenetics.
2. Relating to or based on evolutionary development or history. analysis of Cyclospora, the human intestinal pathogen, suggests that it is closely related to Eimeria species. J Infect Dis 1996;173:440-5.
(12.) Pieniazek NJ, Bornay-Llinares FJ, Slemenda SB, da Silva AJ, Moura INS INS
1. Immigration and Naturalization Service
2. International News Service
Noun 1. INS , Arrowood MJ, et al. New Cryptosporidium cryptosporidium (krĭp'tōspərĭd`ēəm), genus of protozoans having at least four species; they are waterborne parasites that cause the disease cryptosporidiosis. genotypes in HIV-infected persons. Emerg Infect Dis 1999;5:444-9.
(13.) U.S. Food and Drug Administration. Guide to traceback of fresh fruits and vegetables implicated in epidemiological investigations. Rockville (MD): The Division of Emergency and Investigational Operations, Office of Regional Operations, Office of Regulatory Affairs The Office of Regulatory Affairs (ORA) is the part of the United States FDA that enforces the laws that govern food, drugs, medical devices, and other products that FDA regulates. , FDA; 2001. Available from: URL URL
in full Uniform Resource Locator
Address of a resource on the Internet. The resource can be any type of file stored on a server, such as a Web page, a text file, a graphics file, or an application program. : http://www.fda.gov/ora/inspect_ref/igs/epigde/ epigde.html
(14.) Murrow LB, Blake P, Kreckman L. Outbreak of cyclosporiasis in Fulton County, Georgia Fulton County is a county located in the U.S. state of Georgia. Its county seat is Atlanta6, the principal city of the Atlanta metropolitan area. As of the 2000 census, the population was 816,006. The 2006 Census Estimate placed the population at 960,009 . . Georgia Epidemiology Report January 2002;18:1-2.
(15.) Fayer R, Speer CA, Dubey JP. The general biology of Cryptosporidium. In: Fayer R, editor. Cryptosporidium and cryptosporidiosis Cryptosporidiosis Definition
Cryptosporidiosis refers to infection by the sporeforming protozoan known as Cryptosporidia. Protozoa are a group of parasites that infect the human intestine, and include the better known Giardia. . Revised edition of Cryptosporidiosis of man and animals. Boca Raton (FL): CRC (Cyclical Redundancy Checking) An error checking technique used to ensure the accuracy of transmitting digital data. The transmitted messages are divided into predetermined lengths which, used as dividends, are divided by a fixed divisor. Press; 1997. p. 1-33.
(16.) Ortega YR, Roxas CR, Gilman RH, Miller NJ, Cabrera L, Taquiri C, et al. Isolation of Cryptosporidium parvum and Cyclospora cayetanensis from vegetables collected in markets of an endemic region in Peru. Am J Trop Med Hyg 1997:57;683-6.
Alice Y. Ho is the Nurse Epidemiologist for the Philadelphia Department of Public Health, Division of Disease Control. She oversees communicable disease communicable disease
A disease that is transmitted through direct contact with an infected individual or indirectly through a vector. Also called contagious disease. surveillance and outbreak investigations in Philadelphia.
Address for correspondence: Alice Y. Ho, Philadelphia Department of Public Health, Division of Disease Control, 500 South Broad Street, 2nd floor, Philadelphia, PA 19146, USA; fax: 215-545-8362; e-mail: Alice.Ho@phila.gov
Alice Y. Ho, * Adriana S. Lopez, ([dagger]) ([double dagger]) Michael G. Eberhart, * Robert Levenson, * Bernard S. Finkel, * Alexandre J. da Silva, ([double dagger]) Jacquelin M. Roberts, ([double dagger]) Palmer A. Orlandi, ([section]) Caroline C. Johnson, * and Barbara L. Herwaldt ([double dagger])
* Philadelphia Department of Public Health, Philadelphia, Pennsylvania, USA; ([dagger]) Atlanta Research and Education Foundation, Atlanta, Georgia, USA; ([double dagger]) Centers for Disease Control and Prevention, Atlanta, Georgia, USA; and ([section]) Food and Drug Administration, Washington, DC, USA