Cyclosporiasis outbreak exposes a weakened US public health system

During the height of the summer outbreak of cyclosporiasis, Dea Lancaster set aside her usual duties as nurse coordinator at Michigan's Washtenaw County Health Department ​to call patients, asking about their symptoms and tracing the contaminated food they ate.

The stress of handling one of ‌the largest ​U.S. foodborne illness outbreaks in decades gave her an eye twitch as she called dozens of patients a day while commiserating with overwhelmed colleagues and cracking dark jokes to cope. “It was a lot of exhaustion, phone calls and clicking of the keys,” said Lancaster, 44. “It was being busy at work and starving but taking food histories and being terrified of eating what they were eating. It was not a good time.”

The outbreak may represent a new — and risky — normal: a public-health system some experts say has been weakened by decades of underfunding, particularly ‌for food safety, and further hollowed out by Trump administration cuts, leaving the country less able to detect and contain outbreaks. Cyclosporiasis is a parasitic disease that causes explosive diarrhea, abdominal pain and fatigue but is rarely fatal. “What you're seeing this summer demonstrates the vulnerabilities in the system and what happens when they're put under stress," said Barbara Kowalcyk, a food safety expert at George Washington University.

"We used to have one hand tied behind our back and now we have both," Kowalcyk said. CONTAMINATED LETTUCE

On July 16, the U.S. Food and Drug Administration and U.S. Centers for Disease Control and Prevention linked an outbreak that the agencies now say has sickened over 11,000 people in 20 states to shredded iceberg lettuce served at Taco Bell restaurants. Two people died. The next day, the agencies ‌confirmed the lettuce came from the Mexico operations of U.S. produce company Taylor Farms. Taylor Farms issued a recall the same day.

Michigan public health officials said the government announcement came far too late. By then, Washtenaw County was swamped with cases. State officials have said lettuce is once again safe to eat, but the cyclosporiasis surge has raised questions about how ‌well the U.S. is equipped to respond to the next outbreak. As Michigan scrambled to contain the outbreak, some health workers dropped their usual duties. A nurse stopped giving vaccinations and some restaurant inspectors paused health inspections to call hundreds of sick patients.

In late June, weeks before the U.S. government outbreak announcement, Michigan health officials alerted the FDA and CDC about an unusually high number of cyclosporiasis cases. On July 4, as residents set up barbecues and picnics for the Independence Day holiday, Michigan advised residents to avoid lettuce and a handful of other fruits and vegetables. The state's chief medical executive said the move likely prevented more infections. But in the weeks before the federal announcement, the illness spread rapidly across Michigan and the country. Washtenaw County, which logged a handful of cases per day in late June, was recording 80 cases a day by mid-July.

The FDA defended its response, saying it quickly conducted its analysis tracing the contaminated ⁠food. "It wasn’t until the ​states received necessary information from suppliers on July 13 that the FDA could use that information to ⁠determine which commodity was the likely vehicle," an FDA spokesperson said.

Taylor Farms has said it quickly recalled the affected lettuce and hired independent experts to review its food-safety protocols. Taco Bell has said it voluntarily removed Taylor Farms lettuce from its restaurants. STATE TOOK ON MORE WORK: HEALTH EXECUTIVE

Dr. Natasha Bagdasarian, Michigan's chief medical executive, said the state undertook work typically handled by the federal government, such as tracing contaminated produce and issuing food safety guidance. "The state health ⁠department was taking on far more responsibility than is normally the case," she said. “I don’t think that this is sustainable. We simply don’t have the staffing; we don’t have the bandwidth."

A CDC spokesperson said the agency held weekly calls with states and met daily with the FDA and state health officials to share information and coordinate the response. “CDC has made this response a priority, providing direct support and conducting outreach with ​states at least four times each week," the spokesperson said.

In Washtenaw County, the caseload climbed into late July. Soon, the county had to reassign staff from its 108-person health department. Many of them were still exhausted after a recent measles outbreak.

As many as eight county health staff were assigned daily to conduct time-consuming interviews with patients, questioning them ⁠about what food they ate, when they ate it and where they got it. Gathering that information was difficult, as it takes one week on average for cyclosporiasis symptoms to appear. The county health department also took calls from baffled health providers seeking guidance on how to treat the cyclosporiasis patients filling doctors’ offices, urgent care centers and hospitals.

“I have never talked to so many people who have pooped their pants in adulthood,” said Adrienne Walling, a specialist in sexually transmitted ⁠disease prevention ​at the Washtenaw County Health Department. “It was overwhelming.” Walling set aside her usual work to assist with the outbreak response. A colleague stopped performing blood draws and giving vaccinations at the department’s family health clinic to call cyclosporiasis patients.

‘I THOUGHT I WAS GOING TO DIE’ In neighboring Ingham County, the surge was similarly overwhelming.

By late August, the county, home to about 290,000 people, had recorded 915 cases, though new cases had fallen to about three or four a day from 20 to 30 cases a day during the outbreak's peak. Ingham's five communicable disease nurses struggled to manage the crush of case investigations, bringing in other county health workers. They included restaurant inspectors with little prior experience in disease investigations who had to be trained on the fly.

Some Michigan labs ⁠ran out of cyclosporiasis tests, while others were so overwhelmed by the surge in samples that they were still working through backlogs in late August. While health department employees made hundreds of calls, patients continued to fall ill.

“It was so scary. I literally thought I was going to die on more than one occasion. It’s been a nightmare,” said ⁠Kellye O’Hara, a 62-year-old retiree in Muskegon, Michigan, who became ill with cyclosporiasis in July and took more ⁠than a month to recover. She was hospitalized for six days during her infection, which she said caused excruciating pain, fevers, countless trips to the bathroom and intense fatigue.

“It feels like you have pins passing through your colon,” she said. O'Hara and hundreds of other cyclosporiasis patients are suing Taco Bell and Taylor Farms.

The companies did not immediately respond to requests for comment on the lawsuit. Bill Marler, a lawyer specializing in foodborne illness who is representing O'Hara and the other patients, said the scale of the outbreak is unlike anything he has seen.

“Had we had ‌more boots on the ground doing investigations and interviewing people, my ‌view is that this outbreak would have been caught earlier," he said. "We would have gotten product pulled off the market.”