Molly O'Shea, M.D. 0:00
I think we are really underestimating the number of cases that are are happening in the community.

Austin Littrell 0:12
Welcome to Off the Chart, a business of medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, Medical Economics senior editor Richard Payerton sat down with Dr. Molly O'Shea, a pediatrician who's owned an independent practice in Michigan for more than 30 years, and who served as a spokesperson for the American Academy of Pediatrics and Americans for Healthy Communities. If you followed the news at all over the past few weeks, you've heard about cyclospora, and depending where you practice, you might have already seen it in your own exam rooms. Michigan has been hit particularly hard by this outbreak. In an average year, the state usually records about 50 cases of cyclosporiosis, but this year it's already counted 1000s, putting Dr. O'Shea's practice at the center of what officials now describe as the largest cyclospora outbreak on record in the United States today, Dr. O'Shea walks through what cyclosporiosis actually looks like in the exam room and how to separate it from the other summer illnesses that present the same way. What to order and how to have that conversation with your lab, and why she tells families to wait three or four days before coming in at all. She also walks through the treatment questions the patients are likely to bring in from the internet, the federal surveillance changes that took effect last July, and what a two-week incubation period does to your ability to take a useful history. With all of that said, Dr. O'Shea, thank you for joining us. Let's get into the episode.

Richard Payerchin 1:36
I'm Richard Payerchin, reporting for Medical Economics. With me today is Dr. Molly O'Shea, a pediatrician and entrepreneur who has served as a spokesperson for the American Academy of Pediatrics and Americans for Healthy Communities. Dr. O'Shea, thank you for joining us today.

Speaker 1 1:53
I'm very happy to be here. We'll

Richard Payerchin 1:55
start begin at the beginning, so to speak. What is cyclosporiosis?

Speaker 1 2:00
Yes, well, it's a parasitic infection that occurs in people of all ages. It knows no distinctions. It's commonly caused by eating fresh vegetables or fruits that are contaminated with the ova or parasite itself. It's not spread from person to person. It's actually contracted just by eating the food, and then the parasite goes into our intestinal tract and replicates there. We then poop it out. You know, as a pediatrician, I'll just call it like it is. We poop it out. It gets into our water supply or into our sanitation system, and then it may then get a life of its own again in another place. So we don't actually spread it from person to person. It's thought to have gotten onto the fruits and vegetables we're eating through irrigation systems or through the processing of equip the equipment processing of the fruits and vegetables that we're consuming. I'm in Michigan, so we're like ground zero for this parasitic infection. We have the most cases in the nation, so we're definitely well aware of the symptoms it's presenting. I do think a lot of people have forgone eating fruits and vegetables right now because of this risk, but actually there are things that we can do to make our fruits and vegetables safer to eat, and we can still enjoy the abundance of the fresh produce that's available right now in the beautiful summer harvest that we're beginning to see. I think if we if we do bring the fruits and vegetables home to our own house to eat them. There are things that we can do in the way in which we wash and prepare our food that can really dramatically reduce our risk. So if you have lettuce or other kinds of you know leafy vegetables like that, taking that outer coating off and throwing it away, and then washing it really well for a minute or more. Actually rubbing it. Same for fruits that have a peel that you don't peel off, but that you would eat. Doing that same thing. There are some fruits like raspberries or leafy vegetables like cilantro that have teeny little hairs that may kind of attract and hold that parasite to them that make it harder to get rid of, and there may be some benefit in those cases to doing a one part vinegar, three parts water solution, and agitating them in that, rinsing them off afterwards, and that may also reduce your risk. So I don't know that we need to totally forego all good things in the summer, just you know, and cooking any vegetable or fruit up to about 157 degrees. But who measures it, right? But cooking them to a point will also kill the parasite and its and the ova. So there are ways to still enjoy our produce. I really want to encourage people to still eat fruits and vegetables in the summertime because they are abundant and delicious and healthy and important. But there are ways to do it safely.

Richard Payerchin 5:11
I was wondering what your thoughts may be about this. There has been, I think, some encouragement for people to buy local. At least that way, you know where you're sourcing things from even before you get to all those different stages of kind of cleaning and food preparation that you had mentioned.

Speaker 1 5:26
I think that's true. I mean, I think you really need to think about buying local. Of course, is great anytime. The food will have been on the vine longer. It will have grown to a riper point before being picked and then brought to market, so you are going to be getting the nutrients at their fullest anyway. So buying local plus you're supporting people in your own community. There are lots of reasons to buy local, but if depending on what buying local means, you still don't know necessarily what their irrigation system is, and so it may or may not be that much safer. Buying local also doesn't necessarily mean you know exactly how that produce was prepared from a get to market standpoint. What sort of machinery they're using necessarily to get it to market. So I think there are a little bit more due diligence to do than just assuming that because it's local, it's automatically safer.

Richard Payerchin 6:26
For physicians who haven't seen a case before, what does cyclosporiaisis look like in the office, and how do you distinguish it from some of those other illnesses or diseases?

Speaker 1 6:36
It can be very very tricky because, like many other parasitic gastrointestinal issues; it causes bloating, it causes explosive diarrhea and cramping, and many Giardia will do that as well, and other common summer parasites will do that. Enteroviruses, which will also cause GI distress in the summer. Don't cause as much explosive diarrhea, and they are less apt to be as like long duration. So these this will last six weeks without treatment. I think it can be tricky. We actually will tell families not to even bother coming in until about three days, four days into symptoms, because other norovirus, you know, other kinds of conditions that can result in GI distress often are relatively short-lived. You get better relatively quickly and have symptom improvement. So rather than have everybody come in on day one of diarrhea, we're saying come in on day three, day four, if your symptoms aren't beginning to abate, and if at that point you're still having seven, eight, you know, or more times a day of explosive diarrhea, we do want to hear from you and come on in. Let's take a look, and we'll talk about the different types of testing that are available. Either we'll do three ONPs three days apart with a specific type of ONP test that we'll look for the cyclist for a parasite. Can't just order a traditional ONP, or we'll do the PCR test looking for it.

Richard Payerchin 8:20
From some of the information I had seen, there was a claim that cyclospora isn't caught on routine stool testing. Usually,

Speaker 1 8:27
it's not right.

Richard Payerchin 8:28
Okay, what what do you want physicians to know about that?

Speaker 1 8:32
Right, I think you have to speak to your lab. So each lab may handle ONP assessments differently, and understanding what you need to order in order to ensure that cyclospora parasite is looked for and detected requires a special stain in order to detect it, and it will not be looked for if it's not asked for in in most lab settings. So our lab sent us different containers to send off for it. So now we send a traditional ONP and a cyclosporine ONP if we're doing the three days in a row, and if we're doing a PCR, then we're only looking for cyclosporine in that case. You're not doing a PCR for other things, but we'll do a PCR for cyclospora

Richard Payerchin 9:21
because it may have an incubation period of up to two weeks, how would you advise physicians approach that in their questioning with patients, particularly when people are busy in the summer? You may not exactly remember where you were and what you were eating two weeks ago.

Speaker 1 9:37
That makes it super difficult for the epidemiologists of the world. You know, the ones who have to be the detectives and figure out, you know, where what started this outbreak, you know, what are the what's the origin of it. I'm so glad that is not my job. You know, I get to just decide whether or not I'm going to do the test because, frankly, every parent has. Is is constantly wondering, you know, where do they get this cold? You know, where do they get this, you know, little rash on their cheek? Let alone where do they get cyclosporum from? So doing that backwards detective work when the incubation period is both could be as far back as that or as short as you know a week ago. There's an abundant variety of both types of foods, locations, all the things, and when you could have just one person in the family develop symptoms, even though everybody in the family ate similar things, also points to the fact that it takes a Relatively high kind of dose of the of the parasite in order to become infected, and and so you that's you you might not get infected if you had like a like three raspberries you know that had it on it, but but if you were that kid who ate an entire, you know, pint of raspberries? Well, you might be in trouble. So, or if you're the person who eats salad at every meal, it might be a big deal. So that makes it tricky too. And people might believe that if more than one person in the family became symptomatic, that it passed from one person to another. When of course we understand it doesn't. So there are all kinds of misunderstandings in the in the community, and you really, I tell parents don't try to play the where did I get it game. It's it is just not worth your time. Instead, play the how do I get rid of it game, and let's figure out what it is and and manage what we have.

Richard Payerchin 11:43
As I understand it, this can be treated with relatively inexpensive antibiotics. Can you talk about the best treatment regimen?

Speaker 1 11:51
Yeah. So once diagnosed, you know, with a positive test, either PCR or or ovum parasite positive test, it's it is a simple treatment. It's bactrim, which is sulfomethoxazole trimethoprim. I can almost not say it, and you take it for about a week, and that's usually enough to do the do the job. Some, if you've had symptoms for a long time, you might need a somewhat longer course of treatment, but usually it's about a week-long treatment. There's some debate about whether or not, if someone has been symptomatic for a long time, you may have false negative findings on ONP because of the small shedding after over time. So, you know, you get this replication. You poop it all out. It's now, you know, living its its full and complete life outside of you. But your intestines have become so inflamed and irritated by the experience of harboring this parasite that they continue to to be inflamed and having these symptoms. So you may not have enough of the parasitic, the parasite or the ova left to gain a positive test. So the question is, you know, when do you decide to treat based on symptoms? You know, long duration of symptoms and all that, and that's a very individualized decision for each of us in our in our clinical settings, but but it is simple to treat. Assuming you don't have a sulfa allergy, you can take bactrim and be okay. I haven't yet had a patient with a bactrim or sulfa allergy that I've had to treat, and I would have to look up what the alternative is. I'm not sure.

Richard Payerchin 13:40
Can you talk about the need for either hospitalization or specialist referral? Is that very common? Does it tend not to be needed? Is that maybe only in isolated instances, or does it have to happen a lot?

Speaker 1 13:52
Well, I think we're I think we are really underestimating the number of cases that are are happening in the community. We're underdiagnosing it because some people may have milder symptoms, or they are just not being considered as that's the cause by their primary care provider for whatever reason. So, although Michigan has a huge number relative to the number we usually have, I still think we're way undercounting the number of cases that are actually occurring in the community, and and yet the hospitalization rate is yes, there absolutely there are hospitalizations, and the people who are getting hospitalized are quite sick, and they tend to have some underlying health issues that make them more susceptible to having severe illness, no matter what they get. And yes, you absolutely have to be concerned about dehydration and other complications, especially of underlying GI issues. Or if you have kidney issues or cardio, pulmonary issues, because it really puts a stress on your whole system if you are having that much diarrhea.

Keith A. Reynolds 15:20
Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven, real-world tactics you can plug into your practice today. Whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at kreynolds at mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute.

Richard Payerchin 16:11
There has been some online discussion about use of ivermectin as a supposed treatment. If patients ask about that, what should physicians say?

Speaker 1 16:20
The best answer is that the most high-quality evidence we have is that bactrim is by far the best treatment for cyclospora. As far as prevention goes, the best prevention is good washing of your fruits and vegetables prior to consuming them or cooking them. That the use of ivermectin as a strategy for reducing risk or treatment has not been studied well enough to to place it in the treatment or prevention category.

Richard Payerchin 17:04
Have you come across any kind of online or social media claims about other either preventives or treatments that may be suspect?

Speaker 1 17:13
Some people have talked about doing cleanses, you know, or other kind of intestinal cleanouts as strategies to to rid their body of parasites, just as they've tried other things to rid their body of you know yeast overgrowth, other things, and again those are they're anything that that sort that's what your body's already trying to do. Okay, so so just to kind of put it full circle in in having the amount of diarrhea that you have with this with this specific parasite. Your body's trying to do that. It's trying to like poop that thing out there, like flush it out as as much as possible, and after six weeks or so, it does work. You will get rid of it without any additional treatment. It's a long six weeks, and you feel lousy, and you're intermittently bloated, and you have diarrhea, and you have a poor appetite, and you know all of these things during this time, so it's not as though you absolutely are required to take an antibiotic in order to recover from this parasite, assuming that you are an otherwise healthy, well person. Typically, so I. there is no data to show whether or not accelerating that process by using something else to kind of flush your system does that speed it up and make it five and a half weeks? I don't know, but I think that your body is already undergoing such tremendous Stress through the amount of diarrhea that this parasite causes, and the kind of collateral stress of that process, both on your electrolytes, on your fluid balance, etc. that adding additional stress by doing a cleanse that kind of pulls out more stuff seems like an unnecessary additional risk.

Richard Payerchin 19:29
What what advice would you give to other physicians who maybe encounter patients who are at times understandably worried about a health trend or a concern, but really not very likely to have it themselves. I

Speaker 1 19:42
think that one of the one of the joys and opportunities that we have as primary care providers is building that relationship with the families we serve and collaborate with, and if we've had the opportunity to do that, and if they. Families have been with us for a while. They look to us not to order a test, but to answer their question and to give them guidance. So when they do hear something on the news that sounds alarming and concerning, and then especially then if they develop a symptom of that condition which alarms and concerns them, what they are looking for from us is not usually very very rarely in my experience of 30 plus years. Very rarely are they looking for us to knee jerk order the test. My experience is that they're looking for us to listen, to really hear what they have to say, what their symptoms really are, what their worries are about them, and then for us to empathize with that, you know, kind of absolutely acknowledge it, and then if we feel that it isn't time. This isn't the right answer. This test isn't what we're looking to do right now. Explain why, and then explain a plan of what the next steps would be. Like here's what we'll do for the next two days, the next 12 minutes, the next three weeks, whatever, and here is where that test fits in this plan, and that sort of reassurance that I'm not dismissing you, I have a plan, and here's what the plan looks like, and this is why the reasoning is what gives them a sense of calm and confidence in the next 12 minutes or three days or two weeks. So when they are looking for that on day one or poop two, you know, then they can feel comfortable waiting until day three, and then if they still have diarrhea on day three, believe me, I want to do the test as much as they do, and we're both eager to get it done at that point,

Richard Payerchin 22:00
because as I understand it, federal reporting mandates for cyclospora were dropped in July 2025, even though most states still require it. What does that gap mean in practice for physicians trying to track or report a suspected case?

Speaker 1 22:19
Well, because states still require it, I do think that we, at the state level, can get those alarm bells from our our state public health officials, which is very valuable. I think, though, at the federal level, there has been that is one of several areas where dismantling of oversight has occurred that have hobbled the national response to outbreaks like this and have resulted in a very disjointed approach at responding to them. So even though we might, in one state, be able to forge ahead with great guidance and approach and very structured information that's being cascaded out, because other states who haven't yet been made as aware of it are only learning of it by by news stories. It does delay that surveillance happening really at the grassroots level in in ways that in the before that surveillance was kind of dismantled would have been happening everywhere, and there would have been kind of the the warning Will Robinson sort of messaging going out nationally to say here are the signs and symptoms, here's what you should be looking for, you know don't forget to send this special kind of OMP rather than just your standard one, if patients are coming in, whether you were in Alaska or whether you were in Michigan, and and that, in addition to the fact that there has been have been other changes, you know, there the number of scientists available to really look at parasitic infections has been reduced dramatically at the CDC, and so that part of it has also changed significantly. We're really kind of, you know, running a three-legged race with one leg. You know, we're just not able to keep up with what is happening, and you know we see this in in many infectious diseases right now. We're at the highest rate of measles infection we've seen since 1991, It's it we're seeing it happening in in many spheres.

Richard Payerchin 24:55
Michigan has gotten a lot of attention, but this is not necessarily. Something that is isolated just to Michigan or just to the Midwest, it can turn up in other other states and regions. Is that right? It is

Speaker 1 25:06
going to be happening everywhere, but because I think we had a robust and early recognition of it, and our state health department is robust, it resulted in a statewide messaging and very coordinated approach to getting everybody on board, so we all began looking for it in ways that then allowed for diagnoses, and I feel that because of the lack of national coordination in that way, federal coordination in that way. That's why at the beginning, when I said I think we have many, many more cases that just aren't being identified at this point, because you know, it just people aren't looking, aren't going ahead and and sending the test off. It isn't that people aren't pooping like crazy, that they're not sending the test off.

Richard Payerchin 26:05
Is there a policy recommendation you would make that could be enacted fast enough to make a difference in this outbreak?

Speaker 1 26:13
Yes, I think that if there were someone at HHS who stood up and made a proclamation that we are in the midst of an outbreak. Here is what we all need to be doing. We're going to coordinate an effort. We're going to put people to kind of not only monitor it but also to like organize kind of what the what the information is that everybody's going to be getting and cascading out. We're going to be gathering information and doing the work that the CDC traditionally has done as a detective to really get to the bottom of it. They just don't have the manpower anymore to do it in the way they've done before because of the cuts they've been cut. You know they have the 20% of the workforce for this sort of work that they've had in the past. So I think that policy change would be to you know what we need an emergency response team. Let's get them in here right now and let's work on this. We need that, and the priority just isn't there. The priority isn't about managing infectious disease. That's the the the the assumptions have changed. The assumption is infectious disease is a part of life. It's just how nature works, and you know, as opposed to no infectious disease is something that we have the opportunity to influence, and we have the opportunity, depending on the disease, to prevent. And instead of making that front and center, instead it's been sort of like ah, you know. And so when it happens, there isn't this interest in having a full-on approach to put it and put it in check.

Richard Payerchin 28:07
What did I not ask about that you would like our audience to know?

Speaker 1 28:11
I think there are a couple things. One is that care has gotten increasingly fragmented for a lot of reasons, and I think for families who, especially in pediatrics, where half of our kids have Medicaid as their insurance, and as Medicaid has been in peril because of the shifts at the federal level, it's been harder and harder for families, and and also as the Affordable Care Act and other kinds of changes that have been done at the federal level have made insurance less and less affordable, frankly, and harder and harder for people to access. Many people are only coming for care at their primary care office, either not at all when they need a form completed, or when they've already been to an urgent care twice, and something hasn't been figured out. So, for something like cyclospora infection, where it isn't clear right away what's going on? You know, a kid may have, or an adult for that matter, may have profuse diarrhea for a while, and not be so sick they need hospitalization. But they're not feeling well, and they're debilitated. You know, it's difficult to go to work. They can't go to school, or if they can't go to school or daycare, if their parent can't go to work, you know there are all these, you know, kind of cascading things that occur, and if your insurance is either such a high deductible that seeking care is kind of cost prohibitive, or you don't have insurance anymore because you couldn't afford it in the first. Place or you used to have Medicaid, but now you don't. It's going to be even harder for us to manage families with these now increasing numbers of infectious diseases that we're seeing with the cutbacks in federal interest, frankly, in surveillance of these of these diseases and trying to prevent these conditions. Period. We see a real shift in interest in prevention, and I know that there's a lot of talk about the idea of wellness and prevention and and all of that coming from HHS. But if you look at the brass tacks of the strategies that we currently have in our arsenal for disease prevention, including vaccines, that has been really rolled back. You know the interest in promoting and encouraging and providing, and the interest in even giving people access or providing people the ability to have access to healthcare, which you would need if you wanted to maximize wellness and health outcomes, has also been dialed back dramatically. So we will see more and more of these kinds of not only because we have fewer people surveilling for things like cyclospora outbreaks, but we will see more and more of these kinds of infectious outbreaks, because of our structural, systematic approaches to wellness in this country, that are not really about wellness at all, and are ultimately going to fail this us as a as a society.

Austin Littrell 32:13
Once again, that was a conversation between medical economics senior editor Richard Payerton and Dr. Molly O'Shea, a pediatrician in independent practice in Michigan, and a spokesperson for the American Academy of Pediatrics and Americans for Healthy Communities. For more information on the outbreak, the investigation is still moving, and you can find current case counts from the CDC and the FDA's recall notice linked in the show notes below. But with all that said, my name is Austin Latrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories, and solutions for your practice. You can find us by searching "Off the Chart" wherever you get your podcasts. And if you'd like the best stories that Medical Economics and Physicians Practice publish, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and PhysiciansPractice.com. Off the chart, a business and medicine podcast is executive produced by Chris Masolini and Keith Reynolds, and produced by Austin Latrell. Medical Economics and Physicians Practice are both members of the MJH Life Sciences family. Thank you.

Transcribed by https://otter.ai