A parasite causing bouts of "severe diarrhea" has been discovered in California amid a rapidly spreading outbreak across the United States. Health officials warn that the state's official statistics likely reflect only a small fraction of the actual number of infections.
Between one and 10 cases in California are linked to a larger statewide outbreak, according to state data, and authorities continue to monitor the spread of the virus.
However, officials say many cases of infection are never confirmed because some people recover without seeking medical care or testing, specialized laboratory testing is required to detect the parasite, and it can take about six weeks for information about confirmed cases to be released.
Most of California's cases are linked to international travel, not to a multi-state outbreak.
Nationwide, at least 2,944 people in 32 states have become ill, with Michigan hit hardest by the outbreak.
The state has recorded 1,562 cases of the virus, about 31 times the typical 50 cases a year, and at least 44 people have been hospitalized.
Investigators are investigating whether contaminated food is the cause of the outbreak, but have not yet identified the specific product, supplier, or manufacturer responsible.
Cyclospora, the parasite that causes the disease known as cyclosporiasis, is usually spread through food or water contaminated with feces.
Previous outbreaks have been linked to imported fresh produce, including raspberries, basil, peas, mesclun lettuce, and cilantro.
According to the CDC, the disease can cause severe gastrointestinal symptoms, including watery diarrhea "with frequent and sometimes sudden bowel movements.".
Other symptoms include nausea, vomiting, abdominal pain, bloating, fatigue, loss of appetite, and weight loss.
Symptoms usually begin to appear about a week after infection, although they can appear as quickly as two days or even as late as two weeks, making it difficult for investigators to determine the site of infection.
The Centers for Disease Control and Prevention (CDC) recommends treating cyclosporiasis with the antibiotic trimethoprim-sulfamethoxazole, commonly sold under the brand names Bactrim, Septra, and Cotrim, for 10 days.
While investigators continue to search for the source of the outbreak, some Taco Bell restaurants have temporarily removed fresh ingredients from their menus as a precaution.
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Some establishments, including in the greater Detroit area, have posted signs informing customers that they are temporarily unable to serve lettuce, cilantro, onions, pico de gallo, and guacamole due to a nationwide product recall while health authorities respond to an increase in cyclosporiasis cases.
Restaurants in outbreak hotspots, including Michigan and Ohio, have also removed raw lettuce, onions, cilantro-onion mix, pico de gallo, and guacamole from their menus.
However, neither the Centers for Disease Control and Prevention (CDC) nor the Food and Drug Administration (FDA) have linked the Taco Bell restaurant chain to any reported cases of illness.