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Friday, July 20, 2018
Cyclosporiases parasite is the cause of 126 people eating MacDonald's salads getting sick
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CDC - Cyclosporiasis
https://www.cdc.gov/parasites/cyclosporiasis/index.html
Cyclosporiasis is an intestinal illness caused by the microscopic parasite Cyclospora cayetanensis.
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CDC - Cyclosporiasis - General Information - Cyclosporiasis FAQs
https://www.cdc.gov/parasites/cyclosporiasis/gen_info/faqs.html
May 29, 2018 - Cyclospora is spread by people ingesting something—such as food or water—Cyclospora infection - Symptoms and causes - Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/cyclospora/symptoms.../syc-2035306...
Aug 3, 2017 - Cyclospora infection (cyclosporiasis) causes watery, and sometimes explosive, diarrhea. The one-celled parasite that causes cyclospora ...McDonald's salads: More people sickened by cyclospora illness ...
https://www.cnn.com/2018/07/19/health/cyclospora-parasite-outbreak.../index.html
1 day ago - More illnesses have been reported across the United States in two separate cyclosporaoutbreaks, federal health officials said Thursday.Cyclospora illness outbreak: McDonald's salads have sickened 163 ...
https://www.washingtonpost.com/.../salads-from-mcdonalds-have-now-sickened-163-pe...
8 hours ago - Cyclospora cayetanensis is a parasite that can contaminate food and water through feces.begin quote from:
Cyclospora cayetanensis - Wikipedia
https://en.wikipedia.org/wiki/Cyclospora_cayetanensis
Cyclospora cayetanensis is a protozoan that causes disease in humans, and perhaps primates.
Species: C. cayetanensis
Family: Eimeriidae
Domain: Eukaryota
Class: Conoidasida
Cyclospora cayetanensis
| Cyclospora cayetanensis | |
|---|---|
 | |
| Cyclospora cayetanensis oocysts | |
| Scientific classification | |
| Domain: | Eukaryota |
| (unranked): | SAR |
| (unranked): | Alveolata |
| Phylum: | Apicomplexa |
| Class: | Conoidasida |
| Subclass: | Coccidiasina |
| Order: | Eucoccidiorida |
| Suborder: | Eimeriorina |
| Family: | Eimeriidae |
| Genus: | Cyclospora |
| Species: | C. cayetanensis |
| Binomial name | |
| Cyclospora cayetanensis Ortega, Gilman & Sterling, 1994 | |
Cyclospora cayetanensis is a protozoan that causes disease in humans, and perhaps primates. It has been linked in the United States to fecally contaminated
imported produce, and was virtually unknown before about 1990, but has
been on the rise since. The health risk associated with the disease is
usually confined to adult foreigners visiting regions where the species
is endemic and acquiring the infection; consequently, C. cayetanensis is a cause of "traveler's diarrhea".
This species was placed in the genus Cyclospora because of the spherical shape of its sporocysts. The species name refers to the Cayetano Heredia University in Lima, Peru, where early epidemiological and taxonomic work was done.[1]
Contents
- 1History
- 2Characterization
- 3Symptoms
- 4Risk factors
- 5Recognition
- 6Treatment
- 7Prevention
- 8Cyclospora and raspberries
- 92013 United States outbreak
- 102015 Texas outbreak
- 112016 Texas outbreak
- 122018 Midwestern Del Monte vegetable outbreak
- 132018 Midwestern McDonalds salad outbreak
- 14U.S. foodborne outbreaks of cyclosporiasis: 2000–2014
- 15References
History
The first published report of Cyclospora cayetanensis in humans appears to be by Ashford (1979), who found unidentified Isospora-like coccidia in
the feces of three individuals in Papua, New Guinea. The
photomicrographs in the paper reveal an organism morphologically
identical to that seen now. Later, Narango et al. (1989) reported what
may be the same organism from several Peruvians with chronic diarrhea
and termed the organism Cryptosporidium muris–like. Other investigators thought the unsporulated oocysts appeared more similar to cyanobacteria,
and the name "cyanobacterium-like body" or CLB became prevalent in the
literature (occasionally, authors also used the term "coccidian-like
body", or CLB). Eventually, Ortega et al. (1992) published an abstract
reporting that they had sporulated and excysted the oocysts, resulting
in placement of the parasite in the genus Cyclospora. They also created the name Cyclospora cayetanensis at this time. However, since no morphologic information was presented in the abstract, C. cayetanensis technically became a nomen nudum (a
named species without a description). Although Ortega et al. (1993)
later published additional details about this coccidian, a complete
morphologic description was not published to validate the name until
1994.[2] Thus, the correct name for this parasite is Cyclospora cayetanensis Ortega, Gilman, & Sterling, 1994, and the etymology of the nomen triviale is derived from Cayetano Heredia University in Lima, Peru. During this two-year period when C. cayetanensis was a nomen nudum, anyone wishing to publish a complete morphologic description and change the name would have been free to do so.[1]
Characterization
Cyclospora cayetanensis is an apicomplexan, cyst-forming coccidian protozoan that causes a self-limiting diarrhea. In terms of morphology, It has spherical oocysts that are between 7.5 and 10 μm in diameter that also have a 50-nm-thick
wall with an outer thread-like coat that has been called a wrinkle by
some researchers. The oocyst formula is O.2.2 because one oocyst
contains two sporocysts and each sporocyst contains two sporozoites.[3]
The only hosts for C. cayentanensis are humans. The protozoan lives out its lifecycle intracellularly within the host's epithelial cells and gastrointestinal tract.
Infection is transmitted through the fecal-oral route, and begins when a
person ingests oocysts in feces-contaminated food or water. Various
chemicals in the host's gastrointestinal tract cause the oocysts to
excyst and release sporozoites; generally, two are observed per oocyst. After these sporozoites invade the epithelial cells, they undergo merogony, a form of asexual reproduction that
results in many daughter merozoites. These daughter cells may either
infect new host cells and initiate yet another round of merogony or take
on a sexual track via gametogony:
Daughter merozoites become male macrogamonts—which form many
microgametes—and female macrogamonts. After fertilization has occurred
via male microgamete fusion with female macrogamont, the zygote matures into an oocyst and ruptures the host cell, from which point it is passed with the stool.
The oocysts that are passed are not, however, immediately infectious.
Sporulation can take from one to several weeks, meaning person-to-person
transmission is not a likely problem. This differentiates C. cayentanensis from Cryptosporidium parvum—a closely related organism that causes a similar disease—since C. parvum oocysts are immediately infectious upon release from the host.[4]
Symptoms
C. cayentanensis causes gastroenteritis,
with the extent of the illness varying based on age, condition of the
host, and size of the infectious dose. Symptoms include "watery
diarrhea, loss of appetite, weight loss, abdominal bloating and
cramping, increased flatulence, nausea, fatigue, and low-grade fever",
though this can be augmented in more severe cases by vomiting,
substantial weight loss, excessive diarrhea, and muscle aches.
Typically, patients with a persistent watery diarrhea lasting over
several days may be suspected of harboring the disease, especially if
they have traveled to a region where the protozoan is endemic. The incubation period in
the host is typically around a week, and illness can last six weeks
before self-limiting. Unless treated, illness may relapse. The more
severe forms of the disease can occur in immunocompromised patients, such as those with AIDS.[5] Human cyclosporiasis is clinically similar to cryptosporidiosis, isosporiasis, giardiasis and microsporidiosis because of the similar clinical features. Flu like syndrome with myalgias and arthralgias may
precede the onset of diarrhea. Fever is low grade and is unusual. There
is presence of moderate to severe dehydration, compensatory tachycardia,
systolic blood pressure (SBP<90 a="" and="" class="mw-redirect"
decreased="" href="https://en.wikipedia.org/wiki/Skin_turgor" mmhg=""
nbsp="" style="background: none; color: #0b0080; text-decoration-line:
none;" title="Skin turgor">skin turgor
Risk factors
Persons living or traveling in poorly developed areas in the tropics and subtropics may be at an increased risk of acquiring C. cayetanensis,
as they are identified as endemic areas. Additionally, in some regions
infections tend to be more prevalent at certain times of the year,
typically most frequently in late spring and summer. In addition, this
time of year correlates with increased import of fruits and vegetables
into the US from the more southern neighbors.[1] Consuming
food or water while visiting developing countries is a well-documented
way of developing traveler's diarrhea. Travelers are often warned
against such actions, but over 70 percent of certain produce items
consumed in the United States is imported from developing countries,
making "traveler's diarrhea" possible without international travel.[7] It
should be noted that since the oocysts are shed in the feces of
infected persons and then have to mature in the environment 2–14 days
before they can become infectious, it is unlikely for a person to get an
infection directly from an infected person, such as a restaurant worker
who did not wash their hands fully after using the toilet.[8]
Recognition
Due to its small size, intracellular habitat, and inability to properly take up many histological stains, diagnosis of C. cayetanensis can
be very difficult. Four methods have thus far been established for
positive diagnosis of the protozoan: microscopic detection in stool
samples of oocysts; recovering oocysts in intestinal fluid/small bowel
biopsy specimens; demonstration of oocyst sporulation; and amplification
by polymerase chain reaction (PCR) of C. cayetanensis DNA. Since detection is so hard, one negative result should not discount the possibility of C. cayetanensis: tests involving fresh stool samples over the next few days should also be considered.
Except for PCR amplification, once a sample with suspected oocysts has been recovered, standard tests are followed to identify C. cayetanensis. These tests include phase contrast microscopy to
check for the spherical oocysts described earlier, modified acid-fast
staining to check for variable staining (from pale to red), and autofluorescence with UV lights.
Obtaining these oocysts is usually the challenge, though recent studies
show easier methods of obtaining them. In a recent study on different
techniques used in fecal exams to identify oocysts, centrifuging a
sample of feces in a sucrose solution and then transferring a small
amount to a slide was found to be remarkably effective—both in oocysts
found and relative ease of labor—in detecting C. cayetanensis oocysts: indeed, the paper concluded the positive samples obtained were around 84%.[9]
C. cayetanensis has been confused with other protozoan infections in the past, most commonly being misidentified as Cryptosporidium parvum.
Several differences can be noted between the two, however, to ensure
proper diagnosis. These differences include: size difference—C. parvum is smaller; differing results from modified acid-fast staining—C. parvum has consistent red staining, whereas C. cayetanensis shows variable staining; and autofluorescence under UV light—C. cayetanensisexhibits this, whereas C. parvum does not.
Treatment
Most people who have healthy immune systems will recover without
treatment. If not treated, the illness may last for a few days to a
month or longer. Symptoms may seem to go away and then return one or
more times (relapse). Antidiarrheal medicine may help reduce diarrhea,
but consult with a health care provider before the medicine is taken.
People who are in poor health or who have weakened immune systems may be
at higher risk for severe or prolonged illness.[10] To date, the most effective drug for the treatment of the protozoan is a seven-day course of oral trimethoprim-sulfamethoxazole (TMP-SMX).
Effects of the drug include a significant decrease in the duration of
oocyst excretion, cessation of diarrhea, and stool samples negative for
oocysts within two to three days.[10] TMP-SMX is classified as a Category C during pregnancy, meaning potential adverse effects (such as teratogenic or
embryocidal or other) could results and should only be given if the
potential benefit significantly justifies the risk. The drug should be
avoided near-term, as high potentials exist for hyperbilirubinemia and kernicterus in
newborns. Additionally, TMP-SMX can be excreted in breast milk, which
is compatible in healthy, full-term newborns, but should be avoided in
premature, ill, stressed, or jaundiced infants.[11] No highly alternative antibiotic regimen has been discovered yet for patients who possess a sulfa-allergy.[12]
Prevention
No vaccine against this pathogen is available.[13] Since
infection occurs via fecally contaminated food and water in endemic
environments, several simple solutions have been suggested for the
prevention of C. cayetanensis infections. The simplest is to warn
travelers not to visit regions where the protozoan is endemic (in
general, tropical and subtropical regions where sanitation is poor, such
as Peru, Brazil, and Haiti), especially when the season is best for
spreading: Travelers also should be aware that treatment of water or
food with chlorine or iodine is unlikely to kill Cyclospora oocysts.[14] Additionally,
better health practices in the originating agricultural setting—such as
making sure produce watering systems are not pulling water that has
access to human feces. Additionally, using filtering systems such as a 1
micron absolute carbon filtration system will reduce the presence of Cyclospora, drastically decreasing the incidence of the spread of this parasite.[8] The odds of becoming infected with Cyclospora,
and many other foodborne pathogens, can be greatly diminished by
thoroughly washing fruits and vegetables in clean water prior to
consumption. However, it should be noted that simply washing foods does
not remove 100% of the oocysts present.[1]
Cyclospora and raspberries
A study done testing stool specimens of raspberry farm workers showed a higher incidence of Cyclospora oocysts in their specimens compared to other people in the area.[15] This could be because Cyclospora spp.
are highly resistant to disinfectants commonly used by workers for
hygiene purposes and food and water processing. This resistance is
probably heightened by higher binding affinities to certain fresh
produce. Fine, hair-like projections on raspberries help facilitate the
entrapment of the sticky oocysts to their surfaces compared to those of
other fruits, such as blackberries. Contrast between the surface of a
raspberry (left) and a blackberry (right), as viewed by scanning
electron microscopy: Note the uneven surface of the raspberry, complete
with crevices and hairs.[16]
2013 United States outbreak
At least 285 people in 11 states had been affected as of July 26, 2013.
The exact cause of the outbreak had not yet been identified according to
the U.S. Centers for Disease Control and Prevention (CDC). The majority of cases were located in the Midwest, with 138 reported cases in Iowa and 70 in Nebraska. The other states affected are: Texas, Florida, Georgia, Wisconsin, Connecticut, Illinois, Kansas, Minnesota, New Jersey, and Ohio.
As of July 29, 2013, the CDC reported 373 people in 15 states had been
affected by the outbreak. So far, 21 patients from three states had been
hospitalized, with no deaths reported. No food source had been
identified, but health officials in Iowa—the state reporting the most
cases—said they suspected imported vegetables.[17]
On July 30, 2013, the Nebraska Department of Health & Human Services and the Iowa Department of Health announced that a restaurant chain's packaged salad was the disease vector for the parasite.[18] However, the CDC and the U.S. Food and Drug Administration (FDA) are still assessing information from other states to see if the findings apply to illnesses there.[19]
In an August 1, 2013, update, the CDC reported 397 cases, while Iowa and
Texas added another 22 more. This pushed the unofficial count to over
400 cases. Additionally, Louisiana reported its first case, bringing the
total number of states affected to 16.[20]
On August 3, 2013, CNN reported that the outbreak was traced to packaged
salad served at Olive Garden and Red Lobster restaurants that was
manufactured by Taylor Farms de Mexico.
On August 15, 2013, the CDC reported nine more Cyclospora infections,
raising its case count to 548. The number of affected states remained
at 19, but the CDC said that not all cases were confirmed to be linked
to an outbreak in Iowa and Nebraska traced to a contaminated salad mix
from Mexico.[21]
On August 19, 2013, the CDC reported 10 more Cyclospora cases,
raising the unofficial count to over 600. Tennessee also reported its
first case, bringing the number of states affect to 20. The CDC still
cautions that whether cases in all of the states are related to
outbreaks in Iowa and Nebraska is not clear.[22]
As of August 27, 2013, the origin of the outbreak still remained a
mystery. The FDA said it found no food safety violations at the Taylor
Farms de Mexico salad plant in Mexico that were linked to some of the
illnesses.[23]
2015 Texas outbreak
In an FDA statement, the CDC is quoted, "there is currently (in July
2015) another ongoing outbreak of cyclosporiasis in the United States in
which both the Texas Department of State Health Services and the
Wisconsin Department of Health Services and the Wisconsin Department of
Agriculture, Trade and Consumer Protection have identified cilantro from
the Mexican state of Puebla as a suspect vehicle with respect to
separate illness clusters." Last year, Texas had 200 cases, some of
which were associated with cilantro from the Puebla region.[24]
2016 Texas outbreak
Health officials said more than a dozen cases of cyclosporiasis had been
confirmed in North Texas' four major counties and that the source was
likely contaminated food. The Texas Department of State Health Services
said Wednesday the parasite was found in Dallas, Tarrant, Collin and
Denton counties and that the origin may have been linked to a fresh
produce item.
County officials told NBC 5 there were four cases recorded in Dallas
County, three in Collin County, four in Denton County and seven in
Tarrant County. The Denton County cases and at least four of the Tarrant
County cases had recently traveled out of the country—calling into
question the point of origin.
Across the state, there were currently 66 confirmed cases of
cyclosporiasis—though the sources of infection were unconfirmed. For
most people, the symptoms were not serious. "But for those who are very
young and those who are older, or those who have a suppressed immune
system, this illness can cause major problems," said Dr. Khang Tran,
chief medical officer at The Medical Center of Plano. In recent years,
2012–2015, cyclospora outbreaks were associated with fresh cilantro
imported from Puebla, Mexico. Since the summer of 2015, the Food and
Drug Administration has instituted ban on imports from that region
between from April through August.[25]
2018 Midwestern Del Monte vegetable outbreak
Del Monte recalled packaged Del Monte Fresh Produce vegetable trays,
which contained broccoli, carrots, cauliflower, celery sticks, and dill
dip, from certain retailers, including Kwik Trip and Peapod, according
to the CDC. Residents in four states — Iowa, Michigan, Minnesota, and
Wisconsin got sick from Cyclospora.[26]
2018 Midwestern McDonalds salad outbreak
McDonald's stopped selling salads at some 3,000 locations across the country mostly in the Midwest United States due to a multistate parasite outbreak that has sickened dozens of customers caused by Cyclospora.[27]
| Year | Case Count | Incidence Rate |
|---|---|---|
| 2015 | 316 | |
| 2014* | 200 | 0.7 |
| 2013* | 351 | 1.3 |
| 2012* | 44 | 0.2 |
| 2011* | 14 | 0.1 |
| 2010 | 9 | 0.0 |
| 2009 | 10 | 0.0 |
| 2008 | 6 | 0.0 |
| 2007 | 2 | 0.0 |
| 2006 | 1 | 0.0 |
| 2005 | 1 | 0.0 |
| 2004 | 4 | 0.0 |
| 2003 | 1 | 0.0 |
| 2002 | 1 | 0.0 |
| 2001 | 0 | 0.0 |
IR=incidence rate per 100,000
* incidence rates are based on projected census data obtained from the DSHS Center for Health Statistics.
* incidence rates are based on projected census data obtained from the DSHS Center for Health Statistics.
U.S. foodborne outbreaks of cyclosporiasis: 2000–2014
Foodborne outbreaks of cyclosporiasis have been reported in the United
States since the mid-1990s and have been linked to various types of
imported fresh produce, including raspberries, basil, snow peas, mesclun
lettuce, and cilantro; no commercially frozen produce has been
implicated to date. U.S. foodborne outbreaks of cyclosporiasis that
occurred before 2000 were summarized previously, as were the major documented outbreaks in 2013 and 2014.
Foodborne outbreaks during the 15-year period of 2000–2014 are
summarized in table. The table provides information about 31 reported
foodborne outbreaks of cyclosporiasis that occurred in the United States
during 2000–2014; the total case count was 1,562. No outbreaks were
reported in 2003, 2007, or 2010. Overall, a median of two outbreaks were
reported per year, with a median of 20 cases per outbreak (range, 3 to
582 cases). Although the outbreaks occurred during 8 different months
(December through July), the peak months were May, June, and July. As
indicated in the table, a food vehicle of infection was identified for
15 of the 31 outbreaks.
Summary of U.S. foodborne outbreaks of cyclosporiasis, 2000–2014 [28]
| Year(s)* | Month(s)* | Jurisdiction(s)* | No. of cases† | Food vehicle and source, if identified‡ |
|---|---|---|---|---|
| 2000 | May | Georgia | 19 | Raspberries and/or blackberries (suspected) |
| 2000 | June | Pennsylvania | 54 | Raspberries |
| 2001 | January–February | Florida | 39 | |
| 2001 | January | New York City | 3 | |
| 2001–02 | December–January | Vermont | 22 | Raspberries (likely) |
| 2002 | April–May | Massachusetts | 8 | |
| 2002 | June | New York | 14 | |
| 2004 | February | Texas | 38 | |
| 2004 | February | Illinois | 57 | Basil (likely) |
| 2004 | May | Tennessee | 12 | |
| 2004 | May–June | Pennsylvania | 96 | Snow peas from Guatemala |
| 2005 | March–May | Florida | 582 ¶ | Basil from Peru |
| 2005 | May | South Carolina | 6 | |
| 2005 | April | Massachusetts | 58 | |
| 2005 | May | Massachusetts | 16 | |
| 2005 | June | Connecticut | 30 | Basil (suspected) |
| 2006 | June | Minnesota | 14 | |
| 2006 | June | New York | 20 | |
| 2006 | July | Georgia | 3 | |
| 2008 | March | Wisconsin | 4 | Sugar snap peas (likely) |
| 2008 | July | California | 45 ¶ | Raspberries and/or blackberries (likely) |
| 2009 | June | District of Columbia | 34 | |
| 2011 | June | Florida | 12 | |
| 2011 | July | Georgia | 100 | |
| 2012 | June–July | Texas | 16 | |
| 2013** | June | Iowa and Nebraska | 161 | Bagged salad mix from Mexico |
| 2013** | June–July | Texas | 38 | Cilantro from Mexico |
| 2013 | July | Wisconsin | 8 | Berry salad (suspected) |
| 2014 | June | Michigan | 14 | |
| 2014†† | June–July | Texas | 26 | Cilantro from Mexico |
| 2014 | July | South Carolina | 13 |
* The entries in the first three columns refer to the known or likely
year(s), month(s), and jurisdiction(s) in which the exposure(s) to Cyclospora occurred.
** For additional details, see summary information about the outbreak investigations in 2013. For the purposes of this table, the exposure month(s) and case counts are limited to those explicitly linked in the investigations to the food item specified in the last column.
† The case counts include laboratory-confirmed and probable cases of cyclosporiasis. By definition, each outbreak included at least two linked cases, at least one of which was laboratory confirmed.
‡ A food vehicle is specified only if a single ingredient or commodity was identified in an outbreak investigation.
¶ Cases that occurred in Canadian travelers to the United States were not included.
†† For additional perspective, see summary information about outbreak investigations in 2014. For the purposes of this table, the exposure months and the case count for the outbreak in Texas are limited to those explicitly linked in the investigations to the food item specified in the last column.
** For additional details, see summary information about the outbreak investigations in 2013. For the purposes of this table, the exposure month(s) and case counts are limited to those explicitly linked in the investigations to the food item specified in the last column.
† The case counts include laboratory-confirmed and probable cases of cyclosporiasis. By definition, each outbreak included at least two linked cases, at least one of which was laboratory confirmed.
‡ A food vehicle is specified only if a single ingredient or commodity was identified in an outbreak investigation.
¶ Cases that occurred in Canadian travelers to the United States were not included.
†† For additional perspective, see summary information about outbreak investigations in 2014. For the purposes of this table, the exposure months and the case count for the outbreak in Texas are limited to those explicitly linked in the investigations to the food item specified in the last column.
References
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- "Parasites-Cyclosporiasis (Cyclospora Infection). Biology". Global Health - Division of Parasitic Diseases and Malaria Notice. Retrieved March 17, 2015.
- "Symptoms of cyclosporiasis. Disease". Global Health - Division of Parasitic Diseases and Malaria Notice. Retrieved January 10, 2013.
- Tirth Raj Ghimire, Jeevan B. Sherchan. Human infection of cyclospora cayetanensis: a review on its medico-biological and epidemiological pattern in global scenario. 2006. Journal of Nepal Health Research Council.25-40
- NaTashua Davis, ed. (Fall 2002). "The McNair Journal" (PDF). University of Missouri-Columbia.
- Ortega, Ynés R.; Sanchez, Roxana (2010). "Update on Cyclospora cayetanensis, a Food-Borne and Waterborne Parasite". Clinical Microbiology Reviews. 23 (1): 218–234. doi:10.1128/CMR.00026-09. PMC 2806662
. PMID 20065331. - Riner DK, Mullin AS, Lucas SY, Cross JH, Lindquist HD (2007). "Enhanced concentration and isolation of Cyclospora cayetanensis oocysts from human fecal samples". Journal of Microbiological Methods. 71: 75–77. doi:10.1016/j.mimet.2007.06.021.
- Prevention, CDC - Centers for Disease Control and. "CDC - Cyclosporiasis - Treatment".
- Prevention, CDC - Centers for Disease Control and. "CDC - Cyclosporiasis - Resources for Health Professionals - Treatment for Cyclosporiasis".
- "Cyclospora infection Treatments and drugs". Mayo Clinic.
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- Herwaldt, Barbara L. (1 October 2000). "Cyclospora cayetanensis:A Review, Focusing on the Outbreaks of Cyclosporiasis in the 1990s". Clin Infect Dis. 31 (4): 1040–1057. doi:10.1086/314051.
- Schnirring, Lisa (July 29, 2013). "More states report Cyclospora cases; total reaches 373". CIDRAP News.
- "Stomach Bug Outbreak Linked to Salad Mix". ABC News. Retrieved 30 July2013.
- Schnirring, Lisa (July 30, 2013). "Iowa, Nebraska link Cyclospora cases to bagged salad mix". CIDRAP News.
- Lisa, Schnirring (August 1, 2013). "Iowa, Texas cases push Cyclospora count over 400". CIDRAP News.
- "NEWS SCAN: Cyclospora case count rises; Meningitis in NYC". CIDRAP News. August 14, 2013.
- "News Scan for Aug 19, 2013". CIDRAP News. Aug 19, 2013.
- "Salad plant linked to cyclospora outbreak resumes operations". CBS News. Retrieved 27 August 2013.
- "Mexican Cilantro Again Blamed for Texas Cyclospora Outbreak After Feces Found in Growing Field". NBC 5 Dallas-Fort Worth. Retrieved 27 July 2015.
- "Cyclospora Found in North Texas Counties Likely Food Borne". NBC 5 Dallas-Fort Worth. Retrieved 3 August 2016.
- "McDonald's pulls salad from thousands of locations after people are sickened by parasite". Washington Post. Retrieved 14 July 2018.
- "McDonald's pulls salad from thousands of locations after people are sickened by parasite". Washington Post. Retrieved 14 July 2018.
- "U.S. Foodborne Outbreaks of Cyclosporiasis—2000–2014". Centers for Disease Control and Prevention. Retrieved 30 June 2015.
- Türk M, Türker M, Ak M, Karaayak B, Kaya T (March 2004). "Cyclosporiasis associated with diarrhoea in an immunocompetent patient in Turkey". J. Med. Microbiol. 53 (Pt 3): 255–7. doi:10.1099/jmm.0.45531-0. PMID 14970253.
- Kimura K, Kumar Rai S, Takemasa K, et al. (September 2004). "Comparison of three microscopic techniques for diagnosis of Cyclospora cayentanensis". FEMS Microbiol. Lett. 238 (1): 263–6. doi:10.1016/j.femsle.2004.07.045. PMID 15336431.
- Mansfield LS, Gajadhar AA (December 2004). "Cyclospora cayentanensis, a food- and waterborne coccidian parasite". Vet. Parasitol. 126 (1–2): 73–90. doi:10.1016/j.vetpar.2004.09.011. PMID 15567580.
- Yu JR, Sohn WM (October 2003). "A case of human cyclosporiasis causing traveler's diarrhea after visiting Indonesia". J. Korean Med. Sci. 18 (5): 738–41. doi:10.3346/jkms.2003.18.5.738. PMC 3055112 . PMID 14555830.
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