02 Feb

An outbreak of cyclosporiasis in 1996 associated with consumption of fresh berries

consumption of fresh berries

PATIENTS AND METHODS

The index Ontario cluster was investigated by the North York Public Health Department, Toronto, Ontario. Ini­tially, cases were ascertained and an environmental inspec­tion of the implicated venue was conducted. Thereafter, a retrospective cohort study examined food and water consump­tion by attendees. For this first cluster, a case was defined as having three or more unexplained loose or watery bowel move­ments/day for three consecutive days, or a stool specimen posi­tive for cyclospora oocysts.

Further case finding and cluster identification: Laborato­ries do not routinely look for cyclospora oocysts in stools sub­mitted for ‘ova and parasite’ testing. To facilitate the diagnosis of cases and to enhance surveillance, the Ontario Ministry of Health, Toronto, Ontario requested that laboratories in Ontario report when cyclospora oocysts were identified in stool speci­mens and that public health units interview all laboratory- confirmed cases with a structured questionnaire. The sporadic case questionnaire gathered information about demographics, travel history outside Ontario and North America, and con­sumption of strawberries, raspberries, blackberries, blueber­ries and other fresh produce during the two weeks before the onset of symptoms.

A sporadic case was defined as a person with a stool speci­men positive for cyclospora oocysts during May 1 through July 30, 1996 who did not travel overnight outside North America in the four weeks before illness and who was not associated with a cluster. Clinical cases associated with clusters were defined in a similar manner as for the index cluster. Clus­ters were defined as two or more cases associated with a com­mon event, with at least one case being laboratory-confirmed by a reference laboratory (Ontario Provincial Laboratory, To­ronto, Ontario or CDC). The local public health unit(s) per­formed cluster investigations. Provincial and territorial epidemiologists across Canada were notified about the inves­tigations in Ontario and the United States. Traceback investigations: The Canadian Food Inspection Agency, Ottawa, Ontario, Health Canada and the public health inspectors of the specific health units carried out traceback in­vestigations with assistance from the Ontario Ministry of Health. Only imported berries were available for sale in Ontario when the initial events occurred. Airway bill numbers of im­ported berries likely served at the implicated events were pro­vided to the CDC and United States Food and Drug Administration (FDA) to trace the sources of the berries to the exporters and farms that contributed to specific shipments. Traceback activities in Canada were coordinated with the ex­tensive activities in the United States. A well documented traceback of produce was considered one that confirmed ver­bally and in writing (eg, through copies of invoices) all steps from consumers back to farms.
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