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November 23, 1994, Vol 272, No. 20 >
ARTICLE | November 23, 1994

An Outbreak of Cryptosporidiosis From Fresh-Pressed Apple Cider FREE

Peter S. Millard, MD; Kathleen F. Gensheimer, MD, MPH; David G. Addiss, MD, MPH; Daniel M. Sosin, MD, MPH; Geoffrey A. Beckett, PA-C, MPH; Agnes Houck-Jankoski, RN; Arlene Hudson, MS
[+] Author Affiliations

Reprint requests to Division of Disease Control, Maine Bureau of Health, 157 Capitol St, Augusta, ME 04333 (Dr Gensheimer).


JAMA. 1994;272(20):1592-1596. doi:10.1001/jama.1994.03520200048034
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References

Background.  —Recent waterborne outbreaks have established Cryptosporidium as an emerging enteric pathogen, but foodborne transmission has rarely been reported. In October 1993, an outbreak of cryptosporidiosis occurred among students and staff attending a 1-day school agricultural fair in central Maine.

Design.  —Environmental/laboratory investigation and cohort study.

Participants.  —Attendees of the fair and their household members.

Main Outcome Measures.  —Clinical or laboratory-confirmed cryptosporidiosis. Clinical cryptosporidiosis was defined as 3 days of either diarrhea (three loose stools in a 24-hour period) or vomiting.

Results.  —Surveys were completed for 611 (81%) of the estimated 759 fair attendees. Among attendees who completed the survey, there were 160 (26%) primary cases. Cryptosporidium oocysts were detected in the stools of 50 (89%) of 56 primary and secondary case patients tested. The median incubation period was 6 days (range, 10 hours to 13 days); the median duration of illness was 6 days (range, 1 to 16 days). Eighty-four percent of primary case patients had diarrhea and 82% had vomiting. Persons drinking apple cider that was hand pressed in the afternoon were at increased risk for cryptosporidiosis (154 [54%] of 284 exposed vs six [2%] of 292 unexposed; relative risk, 26; 95% confidence interval, 12 to 59). Cryptosporidium oocysts were detected in the apple cider, on the cider press, and in the stool specimen of a calf on the farm that supplied the apples. The secondary household transmission rate was 15% (53/353).

Conclusions.  —This is the first large cryptosporidiosis outbreak in which foodborne transmission has been documented. It underscores the need for agricultural producers to take measures to avoid contamination of foodstuffs with infectious agents common to the farm environment.(JAMA. 1994;272:1592-1596)

REFERENCES

1 +
Ungar BLP.  Cryptosporidiosis in humans (Homo sapiens).  In: Dubey JP, Speer CA, Fayer R, eds. Cryptosporidiosis of Man and Animals . Boca Raton, Fla: CRC Press; 1990;.
2 +
Institute of Medicine. Emerging Infections: Microbial Threats to Health in the United States . Washington, DC: National Academy Press; 1992;.
3 +
Jokipii L, Jokipii AMM.  Timing of symptoms and oocyst excretion in human cryptosporidiosis. N Engl J Med . 1986;;315:1643-1647.
4 +
Lengerich EJ, Addiss DG, Marx JJ, Ungar BLP, Juranek DD.  Increased exposure to cryptosporidia among dairy farmers in Wisconsin. J Infect Dis . 1993;;167:1252-1255.
5 +
Miron D, Kenes J, Dagan R.  Calves as a source of an outbreak of cryptosporidiosis among young children in an agricultural closed community. Pediatr Infect Dis J . 1991;;10:438-441.
6 +
Tangerman RH, Gordon S, Wiesner P, Kreckman L.  An outbreak of cryptosporidiosis in a day-care center in Georgia. Am J Epidemiol . 1991;;133: 471-476.
7 +
Alpert G, Bell LM, Kirkpatrick CE, Budnick LD, Campos JM, Friedman HM, Plotkin SA.  Outbreak of cryptosporidiosis in a day care center. Pediatrics . 1986;;77:152-157.
8 +
Egger M, Mausezahl D, Odermatt P, Marti H-P, Tanner M.  Symptoms and transmission of intestinal cryptosporidiosis. Arch Dis Child . 1990;;65:445-447.
9 +
Koch KL, Phillips DJ, Aber RC, Current WL.  Cryptosporidiosis in hospital personnel: evidence for person-to-person transmission. Ann Intern Med . 1985;;102:593-596.
10 +
Addiss DG, Stewart JM, Finton RJ, et al.  Giardia lamblia and Cryptosporidium infections in child day-care centers in Fulton County, Georgia. Pediatr Infect Dis J . 1991;;10:907-911.
11 +
D'Antonio RG, Winn RE, Taylor JO.  A waterborne outbreak of cryptosporidiosis in normal hosts. Ann Intern Med . 1985;;103:886-888.
12 +
Hayes EB, Matte TD, O'Brien TR, et al.  Large community outbreak of cryptosporidiosis due to contamination of a filtered public water supply. N Engl J Med . 1989;;320:1372-1376.
13 +
Leland D, McAnulty J, Keene W, Stevens G.  A cryptosporidiosis outbreak in a filtered-water supply. J Am Water Works Assoc . (June) 1993;:34-42.
14 +
Centers for Disease Control and Prevention.  Surveillance for waterborne disease outbreaks— United States, 1991-1992. MMWR Morb Mortal Wkly Rep . 1994;;42( (SS-5) ):1-22.
15 +
MacKenzie WR, Hoxie NJ, Proctor ME, et al.  Massive waterborne outbreak of Cryptosporidium infection associated with a filtered public water supply, Milwaukee, Wisconsin, March and April, 1993. N Engl J Med . 1994;;331:161-167.
16 +
Freidank H, Kist M.  Cryptosporidia in immunocompetent patients with gastroenteritis. Eur J Clin Microbiol . 1987;;6:56-59.
17 +
Casemore DP.  Epidemiological aspects of human cryptosporidiosis. Epidemiol Infect . 1990;;104:1-28.
18 +
Shield J, Baumer JH, Dawson JA, Wilkinson PJ.  Cryptosporidiosis—an educational experience. J Infect . 1990;;21:297-301.
19 +
Romanova TV, Shkarin VV, Khazenson LB.  Group morbidity with cryptosporidiosis in infants. Med Parazitol . 1992;;3:50-52.
20 +
Smith JL.  Cryptosporidium and Giardia as agents of foodborne disease. J Food Protection . 1993;;56:451-461.
21 +
Greenland S, Robins JM.  Estimation of a common effect parameter from sparse follow-up data. Biometrics . 1985;;41:55-61.
22 +
SAS Institute. SAS Release 6.03 . Cary, NC: SAS Institute Inc; 1990;.
23 +
Current WL, Garcia LS.  Cryptosporidiosis. Clin Microbiol Rev . 1991;;4:325-358.
24 +
Miller RA, Bronsdon MA, Morton WR.  Experimental cryptosporidiosis in a primate model. J Infect Dis . 1990;;161:312-315.
25 +
Casemore DP.  Foodborne illness. Lancet . 1990;; 336:1427-1432.
26 +
Public Health Laboratory Study Group.  Cryptosporidiosis in England and Wales: prevalence and clinical and epidemiological features. BMJ . 1990;; 300:774-777.
27 +
Casemore DP.  Is human cryptosporidiosis a zoonotic infection? Lancet . 1993;;342:312.
28 +
Newman RD, Zu S-X, Wuhib T, Lima AAM, Guerrant RL, Sears CL.  Household epidemiology of Cryptosporidium parvum infection in an urban community in northeast Brazil. Ann Intern Med . 1994;;120:500-505.
29 +
Stehr-Green JK, McCaig L, Remsen HM, Rains CS, Fox M, Juranek DD.  Shedding of oocysts in immunocompetent individuals infected with Cryptosporidium. Am J Trop Med Hyg . 1987;;36:338-342.
30 +
Combee CL, Collinge ML, Britt EM.  Cryptosporidiosis in a hospital-associated day care center. Pediatr Infect Dis J . 1986;;5:528-532.
31 +
Centers for Disease Control and Prevention.  Salmonella typhimurium outbreak traced to a commercial apple cider—New Jersey. MMWR Morb Mortal Wkly Rep . 1975;;24:87-88.
32 +
Besser RE, Lett SM, Weber JT, et al.  An outbreak of diarrhea and hemolytic uremic syndrome from Escherichia coli O157:H7 in fresh-pressed apple cider. JAMA . 1993;;269:2217-2220.
33 +
Campbell I, Tzipori S, Hutchison G, Angus KW.  Effect of disinfectants on survival of Cryptosporidium oocysts. Vet Rec . 1982;;111:414-415.
34 +
Anderson BC.  Moist heat inactivation of Cryptosporidium sp. Am J Public Health . 1985;;75:1433-1434.
35 +
Massachusetts Cider Guild. Manual for Massachusetts Cider Producers . Amherst: University of Massachusetts Cooperative Extension; 1993;.

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1 +
Ungar BLP.  Cryptosporidiosis in humans (Homo sapiens).  In: Dubey JP, Speer CA, Fayer R, eds. Cryptosporidiosis of Man and Animals . Boca Raton, Fla: CRC Press; 1990;.
2 +
Institute of Medicine. Emerging Infections: Microbial Threats to Health in the United States . Washington, DC: National Academy Press; 1992;.
3 +
Jokipii L, Jokipii AMM.  Timing of symptoms and oocyst excretion in human cryptosporidiosis. N Engl J Med . 1986;;315:1643-1647.
4 +
Lengerich EJ, Addiss DG, Marx JJ, Ungar BLP, Juranek DD.  Increased exposure to cryptosporidia among dairy farmers in Wisconsin. J Infect Dis . 1993;;167:1252-1255.
5 +
Miron D, Kenes J, Dagan R.  Calves as a source of an outbreak of cryptosporidiosis among young children in an agricultural closed community. Pediatr Infect Dis J . 1991;;10:438-441.
6 +
Tangerman RH, Gordon S, Wiesner P, Kreckman L.  An outbreak of cryptosporidiosis in a day-care center in Georgia. Am J Epidemiol . 1991;;133: 471-476.
7 +
Alpert G, Bell LM, Kirkpatrick CE, Budnick LD, Campos JM, Friedman HM, Plotkin SA.  Outbreak of cryptosporidiosis in a day care center. Pediatrics . 1986;;77:152-157.
8 +
Egger M, Mausezahl D, Odermatt P, Marti H-P, Tanner M.  Symptoms and transmission of intestinal cryptosporidiosis. Arch Dis Child . 1990;;65:445-447.
9 +
Koch KL, Phillips DJ, Aber RC, Current WL.  Cryptosporidiosis in hospital personnel: evidence for person-to-person transmission. Ann Intern Med . 1985;;102:593-596.
10 +
Addiss DG, Stewart JM, Finton RJ, et al.  Giardia lamblia and Cryptosporidium infections in child day-care centers in Fulton County, Georgia. Pediatr Infect Dis J . 1991;;10:907-911.
11 +
D'Antonio RG, Winn RE, Taylor JO.  A waterborne outbreak of cryptosporidiosis in normal hosts. Ann Intern Med . 1985;;103:886-888.
12 +
Hayes EB, Matte TD, O'Brien TR, et al.  Large community outbreak of cryptosporidiosis due to contamination of a filtered public water supply. N Engl J Med . 1989;;320:1372-1376.
13 +
Leland D, McAnulty J, Keene W, Stevens G.  A cryptosporidiosis outbreak in a filtered-water supply. J Am Water Works Assoc . (June) 1993;:34-42.
14 +
Centers for Disease Control and Prevention.  Surveillance for waterborne disease outbreaks— United States, 1991-1992. MMWR Morb Mortal Wkly Rep . 1994;;42( (SS-5) ):1-22.
15 +
MacKenzie WR, Hoxie NJ, Proctor ME, et al.  Massive waterborne outbreak of Cryptosporidium infection associated with a filtered public water supply, Milwaukee, Wisconsin, March and April, 1993. N Engl J Med . 1994;;331:161-167.
16 +
Freidank H, Kist M.  Cryptosporidia in immunocompetent patients with gastroenteritis. Eur J Clin Microbiol . 1987;;6:56-59.
17 +
Casemore DP.  Epidemiological aspects of human cryptosporidiosis. Epidemiol Infect . 1990;;104:1-28.
18 +
Shield J, Baumer JH, Dawson JA, Wilkinson PJ.  Cryptosporidiosis—an educational experience. J Infect . 1990;;21:297-301.
19 +
Romanova TV, Shkarin VV, Khazenson LB.  Group morbidity with cryptosporidiosis in infants. Med Parazitol . 1992;;3:50-52.
20 +
Smith JL.  Cryptosporidium and Giardia as agents of foodborne disease. J Food Protection . 1993;;56:451-461.
21 +
Greenland S, Robins JM.  Estimation of a common effect parameter from sparse follow-up data. Biometrics . 1985;;41:55-61.
22 +
SAS Institute. SAS Release 6.03 . Cary, NC: SAS Institute Inc; 1990;.
23 +
Current WL, Garcia LS.  Cryptosporidiosis. Clin Microbiol Rev . 1991;;4:325-358.
24 +
Miller RA, Bronsdon MA, Morton WR.  Experimental cryptosporidiosis in a primate model. J Infect Dis . 1990;;161:312-315.
25 +
Casemore DP.  Foodborne illness. Lancet . 1990;; 336:1427-1432.
26 +
Public Health Laboratory Study Group.  Cryptosporidiosis in England and Wales: prevalence and clinical and epidemiological features. BMJ . 1990;; 300:774-777.
27 +
Casemore DP.  Is human cryptosporidiosis a zoonotic infection? Lancet . 1993;;342:312.
28 +
Newman RD, Zu S-X, Wuhib T, Lima AAM, Guerrant RL, Sears CL.  Household epidemiology of Cryptosporidium parvum infection in an urban community in northeast Brazil. Ann Intern Med . 1994;;120:500-505.
29 +
Stehr-Green JK, McCaig L, Remsen HM, Rains CS, Fox M, Juranek DD.  Shedding of oocysts in immunocompetent individuals infected with Cryptosporidium. Am J Trop Med Hyg . 1987;;36:338-342.
30 +
Combee CL, Collinge ML, Britt EM.  Cryptosporidiosis in a hospital-associated day care center. Pediatr Infect Dis J . 1986;;5:528-532.
31 +
Centers for Disease Control and Prevention.  Salmonella typhimurium outbreak traced to a commercial apple cider—New Jersey. MMWR Morb Mortal Wkly Rep . 1975;;24:87-88.
32 +
Besser RE, Lett SM, Weber JT, et al.  An outbreak of diarrhea and hemolytic uremic syndrome from Escherichia coli O157:H7 in fresh-pressed apple cider. JAMA . 1993;;269:2217-2220.
33 +
Campbell I, Tzipori S, Hutchison G, Angus KW.  Effect of disinfectants on survival of Cryptosporidium oocysts. Vet Rec . 1982;;111:414-415.
34 +
Anderson BC.  Moist heat inactivation of Cryptosporidium sp. Am J Public Health . 1985;;75:1433-1434.
35 +
Massachusetts Cider Guild. Manual for Massachusetts Cider Producers . Amherst: University of Massachusetts Cooperative Extension; 1993;.

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