MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH GUIDE TO SURVEILLANCE, REPORTING, AND CONTROL
Cyclosporiasis

Section 1
ABOUT THE DISEASE

A. Etiologic Agent

Cyclospora cayetanensis is a coccidian protozoan parasite. Humans with cyclosporiasis shed the parasite in a non-infectious form that takes from several days to two weeks in the environment to mature into its infectious form. The time required for maturation to the infectious form depends on factors such as temperature and moisture.

B. Clinical Description

This parasite infects the small intestine (bowel) and typically causes watery diarrhea. Other symptoms include nausea, vomiting, abdominal cramps, gas and bloating, fatigue, loss of appetite, and weight loss. Occasionally, infected individuals may not have any symptoms. Untreated, symptoms may last from several days to several weeks (longer in immunocompromised individuals), and weight loss can be significant (exceeding 20 pounds in some cases).

C. Vectors and Reservoirs

Humans are the only known reservoir for C. cayetanensis, although the epidemiology of human cyclosporiasis suggests the existence of animal reservoirs, possibly in birds.

D. Modes of Transmission

Current knowledge of human cyclosporiasis suggests that it is not transmitted directly from person to person. After being shed in human stool, the parasite must undergo developmental changes (taking days to weeks) before becoming infectious. Humans become infected by consuming food or water that has been contaminated by Cyclospora.

E. Incubation Period

The incubation period for cyclosporiasis is typically one week but can range from 2 days to 2 weeks.

F. Period of Communicability or Infectious Period

People may shed Cyclospora parasites from days to over one month (while actively ill). It is not known how long the parasite may be shed after symptoms have stopped.

G. Epidemiology 

Cyclosporiasis was first recognized in 1979. The parasite appears to be widely distributed throughout the world, with a predominant number of cases occurring during the warmer months. The largest documented outbreaks of cyclosporiasis in the U.S. occurred during the summers of 1996 and 1997; a majority of those cases had consumed imported raspberries that were presumed to be contaminated. 

H. Bioterrorist Potential

Cyclospora are listed by the Centers for Disease Control and Prevention (CDC) as Category B bioterrorist agents. If acquired and properly disseminated, this organism could cause serious public health challenges.

Section 2
REPORTING CRITERIA AND LABORATORY TESTING

A. What to Report to the Massachusetts Department of Public Health (MDPH)

Report a case that meets either of the following criteria:

•	Demonstration of C. cayetanensis oocysts in stool or the parasite in duodenal/jejunal aspirates or small bowel biopsies; or

•	Demonstration of C. cayetanensis DNA in stool, duodenal/jejunal aspirates, or small bowel biopsies.

Note: See Section 3C for information on how to report a case.

Note: Positive laboratory results may be reported out as preliminary with the following language “oocysts resembling Cyclospora seen.”  Confirmatory testing occurs only when a healthcare provider orders a subsequent test after receiving this result. Since preliminary results do not automatically reflex to a confirmatory test, this rarely occurs.  CDC has tested numerous specimens reported by Quest Diagnostics with preliminary results and all have confirmed as Cyclospora cayetanensis.  Therefore, CDC and MDPH are treating these preliminary Quest results as confirmed cases of cyclosporiasis.  
B. Laboratory Testing Services Available

The Massachusetts State Public Health Laboratory (MA SPHL) does not provide testing for Cyclospora from clinical or food samples.

Section 3
REPORTING RESPONSIBILITIES AND CASE INVESTIGATION

A. Purpose of Surveillance and Reporting

•	To identify transmission sources of public health concern (e.g., contaminated food or water), and to stop transmission from such sources.

•	To provide education about reducing risk of infection.

B. Laboratory and Health Care Provider Reporting Requirements

Cyclosporiasis is reportable to the local board of health (LBOH). The MDPH requests that health care providers immediately report to the LBOH in the community where the case is diagnosed, all confirmed or suspect cases of cyclosporiasis, as defined by the reporting criteria in Section 2A.

Laboratories performing examinations on any specimens derived from Massachusetts residents that yield evidence of Cyclospora infection shall report such evidence of infection directly to the MDPH within 24 hours.

C. Local Board of Health (LBOH) Reporting and Follow-Up Responsibilities

Reporting Requirements

MDPH regulations (105 CMR 300.000) stipulate that cyclosporiasis is reportable to the LBOH and that each LBOH must report any confirmed case of cyclosporiasis or suspect case of cyclosporiasis, as defined by the reporting criteria in Section 2A. Cases should be reported to the MDPH Bureau of Infectious Disease and Laboratory Sciences (BIDLS), Office of Integrated Surveillance and Informatics Services (ISIS) via MAVEN. Refer to the List of Diseases Reportable to Local Boards of Health for information on prioritization and timeliness requirements of reporting and case investigation http://www.mass.gov/eohhs/docs/dph/cdc/reporting/rprtbldiseases-lboh.pdf 
Case Investigation
It is the responsibility of the LBOH to complete all questions in each of the question packages by interviewing the case and others who may be able to provide information. Much of the information required can be obtained from the health care provider or from the medical record. 

The Center for Disease Control and Prevention (CDC) is specifically interested in food exposure information for domestically acquired cases of cyclosporiasis from May to August, using the Cyclosporiasis National Hypothesis Generating Questionnaire, (CNHGQ). 

The CNHGQ will either be emailed to you or attached to the MAVEN event. Please look at the MAVEN event notes section for additional directions from the MDPH Epidemiologist of the Day (EOD) on how to complete the CNHGQ.  If the case has recent international travel, and the travel occurred within 14 days of the symptom onset, remaining food exposure questions do not need to be completed. Please make sure to record travel dates, both on the CNHGQ and in MAVEN. Once the CNHGQ is complete, please fax it to the EOD or attach it to the MAVEN event. 

From September-April only the case investigation is needed for cases of Cyclosporiasis.
Calling the provider
If the case was hospitalized (i.e. reporting facility is a hospital), call infection control at the named hospital. A list of infection preventionists can be found in the help section of MAVEN. If the case was seen at a clinician’s office, ask to speak to a nurse working with the ordering provider. 

Calling the case or parent/guardian of the case 
Before calling the case, review the disease fact sheet by clicking on the Help Button located in MAVEN and/or review all the information in this chapter. The call may take a few minutes, so in order to maximize the chance of getting the information needed, it might be good to note the potential length of the call with your contact, and offer the opportunity to call back when it is more convenient. Asking questions about how the case or child is feeling may get the case or parent talking. If you are unable to answer a question they have, don’t hesitate to call the Division of Epidemiology and Immunization at 617-983-6800 for assistance, and call the case back with the answer later. People are often more than willing to talk about their illness, and they may be very happy to speak with someone who can answer their questions. 
Using MAVEN
Review the notes section for specific instructions from EOD on what to do for these cases during summer months of May-August.

Administrative Question Package 
Monitor your “LBOH Notification for Immediate Disease” workflow in MAVEN for any new cases of Cyclosporiasis.  Once a new event appears in this workflow, open the Administrative Question Package (QP) and under the “Local Health and Investigation” section, answer the first question “Step 1 - LBOH acknowledged” by selecting “Yes”.   The “LBOH acknowledged date” will then auto populate to the current day.  Completing this first step will move the event out of this workflow and into your “Online LBOH notified but Case Report Forms (CRF) are pending” workflow. Note the date you started your investigation by answering “Step 2 – Investigation started” as “Yes” and then note the date where shown.  Record your name, agency, and phone numbers where shown in “Step 3 - LBOH/Agency Investigator.” 

Demographic Question Package
Record all demographic and employment information.  It is particularly important to complete the Race/Ethnicity and Occupation questions.

Clinical Question Package
Complete the “Diagnosis/Clinical Information” section, providing the diagnosis date, symptom information and date of symptom onset, hospitalizations, and other medical information

Risk Exposure/Control & Prevention Question Package
Accurately record all risk questions regarding travel and consumption of any high risk foods.  As you enter data into MAVEN, additional questions will appear for you to answer regarding risk/exposure. When asking about exposure history (e.g., food, travel, activities), if possible, keep in mind that the incubation period can be long, 1-2 weeks, although it is usually about one week. 
Completing Your Investigation
1.	If you were able to finish the case investigation and follow-up is complete, mark “Step 4 – Case Report Form Completed” as “Yes” and then choose Local Board of Health (LBOH) –Ready for MDPH review for the Completed by variable. 
2.	If you have made several attempts to obtain case information but have been unsuccessful (e.g., the case or health care provider does not return your calls or respond to a letter, or the case refuses to divulge information or is too ill to be interviewed), please complete “Step 4 - Case Report Form Completed” as “No” and then choose a primary reason why the case investigation was not completed from the choices provided in the primary reason answer variable list.
3.	If you are not online for MAVEN you may submit a paper case report form. After completing the form, attach laboratory report(s) and fax or mail (in an envelope marked “Confidential”) to ISIS. The confidential fax number is (617) 983-6813. Call ISIS at (617) 983-6801 to obtain a copy of the case report form and to confirm receipt of your fax.

The mailing address is:
MDPH, Office of Integrated Surveillance and Informatics Services (ISIS)
305 South Street, 5th Floor
Jamaica Plain, MA 02130
   Fax: (617) 983-6813

Section 4
CONTROLLING FURTHER SPREAD

A. Isolation and Quarantine Requirements (105 CMR 300.200)

Symptomatic food handlers with cyclosporiasis must be excluded from work.

Note: A case of cyclosporiasis is defined by the reporting criteria in Section 2A of this chapter.

Minimum Period of Isolation of Patient 

Food handlers may return to food handling duties after diarrhea has resolved. In certain circumstances, however, food handlers may be required to produce one or two negative stool specimens before returning to food handling duties. If a case has been treated with an antimicrobial, the stool specimen shall not be collected until at least 48 hours after cessation of therapy. 

Minimum Period of Quarantine of Contacts

Contacts with diarrhea who are food handlers shall be considered the same as a case and shall be handled in the same fashion. In certain outbreak circumstances, asymptomatic contacts who are food handlers may be required to produce one or two negative stool specimens prior to returning to food handling duties. Otherwise there are no restrictions.

Note: A food handler is any person directly preparing or handling food. This can include a patient care or childcare provider. 

B. Protection of Contacts of a Case

None.

C. Managing Special Situations

Daycare and Schools

As noted in Section 1D of this chapter, current knowledge of human cyclosporiasis suggests that it is not transmitted directly from person-to-person. After being shed in stool, the parasite must undergo developmental changes (taking days to weeks) before becoming infectious. Humans become infected by consuming food or water that has been contaminated with feces containing Cyclospora.  Therefore, students, teachers, and daycare attendees without diarrhea can continue to attend their programs as long as they feel well enough to do so. 

Licensed daycare facilities must notify all parents in accordance with MDPH recommendations when any communicable disease or condition has been introduced into the program (606 CMR 7.11). However, when cases of cyclosporiasis occur in children or staff, while notifying parents/guardians of attendees can be considered, it is typically not necessary as the organism is not transmitted directly from person to person.  MDPH epidemiologists are available to help determine whether notification is recommended and sample letters are available from the Division of Epidemiology and Immunization at (617) 983-6800.

Community Residential Programs
 
Actions taken in response to a case of cyclosporiasis in a community residential program will depend on the type of program and the level of functioning of the residents.

In long-term care facilities, residents with cyclosporiasis should be maintained on standard (including enteric) precautions until their symptoms subside. Refer to the MDPH Division of Epidemiology and Immunization’s Long Term Care Infection Control Guidelines http://www.mass.gov/eohhs/gov/departments/dph/programs/id/epidemiology/providers/infection-control.html for further actions. Staff members who provide direct patient care (e.g., feed patients, give mouth or denture care, or give medications) are considered food handlers and are subject to food handler restrictions (per 105 CMR 300.200). See Section 4A for more information. In addition, staff members with cyclosporiasis who are not food handlers should also not work while symptomatic.

Reported Incidence Is Higher Than Usual/Outbreak Suspected

If the number of reported cases of cyclosporiasis in your city/town is higher than usual or if you suspect an outbreak, investigate to determine the source of infection and the mode of transmission. A common vehicle, such as water or food, should be sought, and applicable preventive or control measures should be instituted. Consult with the epidemiologist on-call at the MDPH Division of Epidemiology and Immunization at (617) 983-6800. The Division can help determine a course of action to prevent further cases and can perform surveillance for cases across town lines, which would otherwise be difficult to identify at the local level.

D. Preventive Measures

Environmental Measures

Implicated food items must be removed from consumption. Since testing for Cyclospora from implicated food items is not available at MA SPHL, testing decisions will be made in consultation with the Bureau of Environmental Health Food Protection Program (FPP), the MDPH Division of Epidemiology and Immunization, and the CDC. If testing is considered appropriate, the FPP can help coordinate pickup and testing of food samples. If a commercial product is suspected, the FPP will coordinate follow up with relevant outside agencies. The FPP can be reached at (617) 983-6712.

Note: The role of the FPP is to establish policy and to provide technical assistance with the environmental investigation, such as interpreting the Massachusetts Food Code, conducting a Hazard Analysis and Critical Control Point (HACCP) risk assessment, initiating enforcement actions, and collecting food samples.

Note: Refer to the MDPH Foodborne Illness Investigation and Control Reference Manual for comprehensive information on investigating foodborne illness complaints and outbreaks at http://www.mass.gov/eohhs/gov/departments/dph/programs/environmental-health/food-safety/foodbourne-illness/tools/foodborne-illness-investigations-and-control.html. For the most recent changes to the Massachusetts Food Code, contact the FPP at (617) 983-6712 or through the MDPH website at www.mass.gov/dph/fpp .

Personal Preventive Measures/Education

To avoid infection with Cyclospora, recommend that individuals:

•	Avoid drinking untreated water when hiking, traveling in developing countries, or visiting areas where water quality is unknown. Bringing water to a full, rolling boil is sufficient to kill Cyclospora.
•	Thoroughly wash all fresh fruits and vegetables prior to consumption

ADDITIONAL INFORMATION

The formal Centers for Disease Control and Prevention (CDC) surveillance case definition for Cyclospora is the same as the criteria outlined in Section 2A of this chapter. (CDC case definitions are used by the MDPH and the CDC to maintain uniform standards for national reporting.) When reporting to the MDPH, always use the criteria outlined in Section 2A.

Note: The most up-to-date CDC case definitions are available on the CDC website at http://wwwn.cdc.gov/nndss/conditions/cyclosporiasis/case-definition/2010/ .

REFERENCES

American Academy of Pediatrics. [Cyclospora Infections.] In: Pickering L.K., ed. Red Book: 2015 Report of the Committee on Infectious Diseases, 30th Edition. Elk Grove Village, IL, American Academy of Pediatrics; 2015: 316-317.

“Cyclospora Infection.” Centers for Disease Control and Prevention. February, 2015.
http://www.cdc.gov/parasites/cyclosporiasis/  

Heymann, D., ed. Control of Communicable Diseases Manual, 20th Edition. Washington, DC, American Public Health Association, 2015.

MDPH. Foodborne Illness Investigation and Control Reference Manual. Massachusetts Department of Public Health. 1997.
http://www.mass.gov/eohhs/docs/dph/environmental/foodsafety/ref-manual/intro-pages.pdf   
MDPH. Regulation 105 CMR 300.000: Reportable Diseases, Surveillance, and Isolation and Quarantine Requirements. MDPH, Promulgated December 6, 2013, 2005.

Soave, R. Cyclospora: An Overview. Clinical Infectious Diseases. 1996; 23: 429–37.