U.S. health authorities are investigating an outbreak of cyclosporine disease linked to iceberg lettuce that has already reached 6,358 patients and 278 hospitalizations in 15 states, according to figures compiled by Food Safety News on August 7. Two people have died, both in Michigan.
The product cited by the CDC and FDA is iceberg lettuce processed by Taylor Farms at a facility in central Mexico. The company recalled the batch on July 17 and suspended production at the factory the following day.
What is cyclospora, and why does it take so long to appear?
Cyclospora is a microscopic parasite transmitted through water or food contaminated with feces. The Washington State Department of Health describes the typical symptoms as prolonged watery diarrhea, fatigue, loss of appetite, abdominal cramps, nausea, and weight loss.
Symptoms usually appear about a week after exposure, with a time frame ranging from 1 to 14 days. This delay explains why the investigation is slow: when the person gets sick, the salad has already been consumed for days and is rarely refrigerated for testing.
The numbers don't add up, and there's a reason.
Different counts are circulating because they measure different things. The snapshot of the multi-state outbreak linked to lettuce was 6,358 patients in 15 states at the beginning of August.
The total number of cyclosporiasis cases in the country is much higher. The Associated Press reported on August 6 that 47 states have recorded cases of the parasite this year, totaling more than 25,000, of which more than 12,000 are in Michigan alone. For comparison, the previous record for the United States was approximately 4,700 cases in 2019.
There is still a backlog: Food Safety News has recorded 10,468 laboratory-confirmed cases in separate outbreaks and another 12,255 awaiting investigation.
The 15 states affected by the lettuce outbreak
According to the AP, the iceberg lettuce outbreak involves Arkansas, Illinois, Indiana, Iowa, Kansas, Kentucky, Michigan, Missouri, Nebraska, New Hampshire, North Carolina, Ohio, Oklahoma, Pennsylvania, and West Virginia. Colorado and Washington are not on this list.
The Washington State Department of Health reported 67 cases of cyclosporiasis in the state between May 1 and August 14, with two hospitalizations and no deaths; seven of these cases were acquired domestically, with no history of international travel. The agency notes that the lettuce collected was not distributed to the state.
The recall: 27 states and 18 days of distribution.
Taylor Farms reports that the iceberg lettuce collected was distributed between June 29 and July 16 to 27 states, including Alabama, Arkansas, Connecticut, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Maryland, Michigan, Missouri, Mississippi, North Carolina, New Hampshire, New Jersey, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Wisconsin, and West Virginia.
Most of the volume went to food service establishments, meaning restaurants and chains, and not to supermarket shelves. In retail, the company listed Marketside brand products sold at Walmart: 12- and 24-ounce iceberg salads and 8- and 16-ounce shredded lettuce.
The initial link in the investigation was to lettuce served at Taco Bell restaurants. The Washington State Department of Health has recorded at least 1,947 cases linked to the chain's stores in nine states.
The company disputes this and cites two thousand tests.
Taylor Farms denies responsibility. In a statement, the company claims to have been operating for over 30 years, producing billions of servings of vegetables annually and being "at the forefront of advances in food safety." It says it invests over $200 million annually in this area—less than 3% of its $7 billion annual revenue, according to Food Safety News.
The company maintains that approximately 2,000 samples collected at its central Mexico facility since May have not detected the parasite and that the FDA had, as of August 20, no confirmed positive results in tests of the product. A positive result released by the agency on July 18 was retracted as a false positive within 24 hours.
The link made by the CDC and FDA is based on epidemiological and source-tracing data, not on a positive sample.
The precedent from 2013 in the same unit.
This is not the first time this factory has been the subject of an investigation. Food Safety News recalls a 2013 outbreak associated with the same Mexican facility; at the time, the FDA found evidence of vegetables being washed with recycled water and inadequate hand sanitizing facilities.
Frank Yiannas, former deputy commissioner of the FDA, criticized the repetition: "We need to rethink our approaches. The definition of insanity is doing the same thing and expecting different results."
Cuts in public health are delaying the investigation.
The investigation is hampered by a lack of personnel. Juan Luis Marquez, medical director of health departments in Michigan, told the AP that there have been "staff cuts at all levels of public health—federal, local, and state," which limits the resources available to trace cases.
Michigan is the state with the highest number of cases and where the two deaths from the outbreak occurred.
How to protect yourself at home
The Washington State Department of Health recommends washing fresh fruits and vegetables under running water, washing hands before preparing food, and, when traveling to regions where the parasite is common, consuming only cooked food and bottled water, giving preference to fruits that can be peeled or canned products.
Washing the leaf reduces the risk but does not eliminate it: Cyclospora adheres to the surface of the vegetable. Anyone with watery diarrhea that lasts for more than three days should seek medical attention and mention recent consumption of salad, because diagnosis requires a specific test that is not part of routine screening.
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