Public health officials are urging North Carolina residents to learn the symptoms of cyclosporiasis as cases of the intestinal illness continue to climb across the state and nation.

North Carolina has reported 867 cases since May, including two confirmed cases in Dare County and one in Currituck County, according to state county-level data. The Martin-Tyrrell-Washington District Health Department issued a public notice Aug. 4 advising residents about the increase and offering steps to reduce their risk.

Albemarle Regional Health, which serves much of northeastern North Carolina, has not issued a public notice related to this issue.

As of 8 a.m. Aug. 4, the North Carolina Department of Health and Human Services had recorded 149 newly reported cases since its July 28 update. Thirty-three people had been hospitalized. Wake County accounted for 494 cases—about 57% of the statewide total.

The state typically identifies about 150 cases in an entire year. Health officials say the current increase in North Carolina does not appear to be associated with a separate multistate outbreak involving iceberg lettuce served at a national restaurant chain.

Here are five things physicians and public health officials want patients to know, according to the American Medical Association.

1. Know how cyclosporiasis spreads

Cyclosporiasis is a gastrointestinal illness caused by Cyclospora, a microscopic parasite. People become infected when they consume food or water contaminated with fecal matter containing the parasite.

Fresh produce—including lettuce, fruit, cilantro, parsley and other herbs—has been associated with previous outbreaks.

The illness is not considered contagious through ordinary direct contact. After Cyclospora is passed in stool, it must generally remain in the environment for days or weeks before it becomes infectious. That makes direct person-to-person transmission unlikely.

Humans are the only known hosts for the parasite. Recovering from cyclosporiasis does not create lasting immunity, so a person can become infected more than once.

Federal officials are separately investigating a nine-state outbreak linked to iceberg lettuce from Taylor Farms de Mexico. As of the Centers for Disease Control and Prevention’s July 24 case update, that outbreak included 1,947 cases and at least 98 hospitalizations. The CDC subsequently reported two cyclosporiasis-related deaths involving Michigan residents with underlying health conditions.

The recalled lettuce was distributed to restaurants, retailers and food-service customers. It included certain Marketside-brand iceberg salad and shredded lettuce products sold at Walmart.

2. Recognize the symptoms

Symptoms typically begin about seven days after exposure, although they can appear as soon as two days or more than two weeks later.

Watery diarrhea is the most common symptom. Others can include:

• Loss of appetite
• Weight loss
• Stomach cramps
• Bloating and increased gas
• Nausea
• Fatigue
• Vomiting
• Body aches
• Headache
• Low-grade fever

Some infected people do not develop symptoms.

Without treatment, cyclosporiasis may last anywhere from a few days to a month or longer. Symptoms can appear to improve and then return. Fatigue may persist even after diarrhea and other gastrointestinal symptoms have stopped.

Although many otherwise healthy people recover, prolonged diarrhea can lead to dehydration. People with weakened immune systems may experience more severe or longer-lasting illness.

3. Seek medical care and ask about specific testing

People experiencing persistent watery diarrhea or other possible symptoms should contact a physician or another health professional.

Patients should rest and drink plenty of water or beverages containing electrolytes. Medical care is especially important for people who cannot keep fluids down, have severe or worsening symptoms, show signs of dehydration or have weakened immune systems.

Signs of serious dehydration can include:

• Very little urination
• Dry mouth
• Dizziness or fainting
• Confusion
• Unusual weakness or sleepiness

Patients may need to ask specifically about testing for Cyclospora. Many routine stool tests and gastrointestinal PCR panels do not automatically screen for the parasite.

Diagnosis can also be difficult because an infected person may not shed enough of the parasite in every stool sample for it to be detected. A health professional may request several samples collected on different days.

The preferred treatment is the prescription antibiotic trimethoprim-sulfamethoxazole, commonly called TMP-SMX. People who are pregnant, breastfeeding or allergic to sulfa drugs should discuss treatment options with their health professional.

4. Follow recall information closely

Taylor Farms de Mexico recalled all iceberg lettuce sourced from central Mexico on July 17 because of potential Cyclospora contamination. Consumers should not eat any lettuce covered by the recall.

Recalled products should be thrown away or returned to the place of purchase. Anyone who cannot determine the source of potentially affected iceberg lettuce should consider discarding it.

Refrigerators, containers, utensils, cutting boards and other surfaces that may have touched recalled lettuce should be carefully cleaned and sanitized.

The federal lettuce outbreak should not be confused with the wider increase in North Carolina. NCDHHS says the state’s increase does not currently appear to be connected to the outbreak involving Taco Bell restaurants.

A source for the broader North Carolina increase has not been identified. However, recent patients reported eating parsley and cilantro more often than would be expected based on population surveys, according to state health officials.

5. Practice safe produce handling

Washing fruits and vegetables cannot guarantee that Cyclospora will be removed, but proper food handling can reduce the risk of infection.

The Martin-Tyrrell-Washington District Health Department recommends:

• Rinsing produce before peeling it so dirt and germs are not transferred from the outer surface to the inside by a knife.
• Gently rubbing produce while holding it under plain running water. Soap is not necessary.
• Drying produce with a clean cloth or paper towel.
• Removing the outermost leaves of lettuce and cabbage.
• Washing hands for at least 20 seconds with warm water and soap before preparing or eating food.
• Washing hands after preparing fresh produce, using the bathroom or changing a diaper.

The CDC also advises consumers to wash produce even when it is labeled “pre-washed,” scrub firm fruits and vegetables with a clean produce brush, and remove bruised or damaged areas.

Cooking can kill the parasite. When practical, produce can be cooked to an internal temperature of at least 158 degrees Fahrenheit, or 70 degrees Celsius. Washing alone cannot guarantee removal of Cyclospora.

NCDHHS updates its cytosporiasis case dashboard weekly. Consumers can also monitor the CDC outbreak investigation, the FDA recall notice and FoodSafety.gov for updated guidance.