Ep 216 Cyclospora: Explosive Diarrhea Everywhere

You’ve seen the headlines: a food-borne parasite is infecting people across the US, leaving them chained to the toilet sometimes for weeks on end, as they are ravaged by wave after wave of gastrointestinal upset. What the heck is cyclosporiasis and where did it come from? How scared should we be of our raspberries or lettuce or cilantro? To dish out the answers as fast we could, we put together this fact-filled episode about the biology of Cyclospora cayetanensis, how this parasite makes you sick, when we first learned about it (more recently than you might think), and what we know about this current outbreak (or outbreaks). We also probe how recent changes to foodborne pathogen surveillance on a national scale are contributing to the challenges in understanding the scope and origin of outbreaks such as this. You don’t want to miss this one! Support this podcast by shopping our latest sponsor deals and promotions at this link: https://bit.ly/3WwtIAu See omnystudio.com/listener https://omnystudio.com/listener for privacy information.

• 0:01Speaker 00

  This is Exactly Right.

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• 2:29Speaker 04

  Hi, I'm Erin Welsh.

• 2:31Speaker 05

  And I'm Erin Allmann Updike.

• 2:32Speaker 04

  And this is This Podcast Will Kill You.

• 2:35Speaker 05

  We're coming to you with a very rapid-fire episode.

• 2:39Speaker 04

  Rapid-fire episode on Cyclospora because it's been in the news, you've seen it in the news, many of you have asked us about it, and we had not yet covered it. So, yeah, we wanted to kind of like put some stuff together really quickly to get information out to you about what this thing is, where it came from, and what's going on with the current outbreak, a little bit of that. We will note that we are recording this on Sunday, July 12th, and so this will come out, you know, in a week and a few days, and things, the numbers will probably have shifted by then, maybe we'll know.

• 3:17Speaker 05

  100%. They will be different.

• 3:19Speaker 04

  They will be different. We might know more about like what foods are linked to this outbreak potentially.

• 3:26Speaker 05

  I doubt it, but maybe.

• 3:27Speaker 04

  But, you know, we will be giving you some information that is sort of evergreen in terms of what this parasite is and why. It's a foodborne illness that we have been looking out for, for a number of years, and then stopped looking out for, kind of.

• 3:42Speaker 05

  Kind of.

• 3:43Speaker 04

  Yeah, we'll get to all of that.

• 3:44Speaker 05

  Yeah. But first, it's quarantine time.

• 3:49Speaker 04

  It is. You know, we're still gonna do one even for this. I think we ended up, we landed on "This Stinks."

• 3:57Speaker 05

  "This Stinks."

• 3:58Speaker 04

  "This Stinks."

• 4:01Speaker 05

  It's so accurate on so many levels, Erin.

• 4:04Speaker 04

  Yep, it really stinks. And it's basically like, honestly, it's water plus your favorite electrolytes.

• 4:11Speaker 05

  Non-branded, non-propertory. I want everyone to know, you probably don't actually need electrolytes in your life unless you are actually having profuse watery diarrhea or working out way more than most of us actually work out.

• 4:25Speaker 04

  We do not support supplements and branded supplements, so.

• 4:30Speaker 05

  But you know, it's quarantine time.

• 4:32Speaker 04

  Quarantine time.

• 4:36Speaker 04

  We'll post the full recipe, not that you need one for this, honestly, on our website and on our social media. Make sure you're following us there if you're not already. On our website, there's all sorts of things. I don't think we'd really need to get into it for this rapid-fire episode. I think people want the information, so let's take a break and begin.

• 5:20Speaker 05

  So, the disorder, the disease we're talking about today is known as cyclosporiosis. It's caused by a parasite called Cyclospora cayatenensis. I think I'm saying that right. There are a number of other species of this pathogen that infect snakes and insectivorous animals, some that infect monkeys, but it's only this one species that seems to be important for humans and which infects only humans, as far as we know. It's a type of parasite called an Apicomplexan.

• 5:52Speaker 04

  Okay.

• 5:53Speaker 05

  Which, I know that we've talked about parasites in this phylum before, but I don't know that we've actually said that word, but it's the same group that includes malaria parasites, toxoplasmosis, Cryptosporidium, which we have not done yet.

• 6:10Speaker 04

  Nope.

• 6:10Speaker 05

  And of course, there are lots of other protozoan parasite friends that we've covered on this podcast, like Shoggoes Disease, Girardia, et cetera. Those are just sort of slightly different vibes, right?

• 6:20Speaker 04

  Yeah.

• 6:21Speaker 05

  So, we get exposed to the infectious stage of this parasite from either food or water in our mouths that has been contaminated with old poop.

• 6:35Speaker 04

  Tell me about "old."

• 6:37Speaker 05

  We'll get there, Erin.

• 6:38Speaker 04

  Okay.

• 6:38Speaker 05

  But I wanted you to ask that because it's an important part, okay? Old poop, not just any poop.

• 6:45Speaker 04

  You set me up.

• 6:46Speaker 05

  I did.

• 6:48Speaker 05

  So, the infectious stage of this parasite, these are single-celled parasites, by the way, like, okay, and the infectious stage are these teeny-tiny little balls, little spherical balls, and by teeny-tiny, I mean they're like 8 to 10 microns. They're very small. You cannot see them with your eyes.

• 7:04Speaker 04

  Okay.

• 7:05Speaker 05

  And these balls are filled with these two bunches of bananas, like these little critters that are shaped like bananas. We eat these little, little tiny balls filled with four bananas total, okay?

• 7:20Speaker 04

  Okay.

• 7:21Speaker 05

  Once these banana-filled balls pass through our stomach and get to our small intestine, they punch their way out of the ball, and these bananas, these sporozoites, invade the cells that line our small intestine.

• 7:35Speaker 04

  Okay, question real quick. So, within the ball, once it lands safely, these bunches of four bananas, that's still one individual, like, is that still one individual thing, or is it multiple?

• 7:45Speaker 05

  It's four sporozoites.

• 7:47Speaker 04

  Okay.

• 7:48Speaker 05

  Yeah, in each one of these balls.

• 7:50Speaker 04

  How interesting.

• 7:52Speaker 05

  I know. It gets better, Erin, okay? This is a really interesting parasite.

• 7:55Speaker 04

  Yeah.

• 7:56Speaker 05

  Once they are inside the cells, so these are intracellular parasites, they're invading the cells inside our small intestine, and there they start to reproduce asexually. So, they're making a bunch more of these banana-shaped critters. They now have a different name, again, why? Because they're different. And then, at some point, some of these bananas that are invading our cells, replicating, and then going out to invade more and more of the cells in our small intestine. At some point, some will differentiate into a form that actually undergoes sexual reproduction.

• 8:35Speaker 04

  What proportion?

• 8:36Speaker 05

  Oh, I have no idea, Erin. It doesn't matter.

• 8:39Speaker 04

  Not a clue.

• 8:40Speaker 05

  Yeah. But some of them do. And so they form these basically like micro and macro gametes. And then they fertilize each other to form a zygote, the same way that we think of a zygote in humans, except completely different because it's a single cell parasite. And then these zygotes become oocysts. These are what will pop out of our small intestine cells, travel the rest of the way through our guts and be pooped out in an explosive fashion.

• 9:10Speaker 04

  Yeah.

• 9:11Speaker 05

  And then these balls, these oocysts, have to live in the environment for at least a week before they grow those banana things inside of them and actually become infectious. That's why I said old poop.

• 9:29Speaker 04

  Yeah. Okay. So just so I understand, so what happens is you consume these little, these little banana, banana filled balls.

• 9:37Speaker 05

  Yep.

• 9:37Speaker 04

  Those then invade, once they're safely in your gut, they invade your cells. There, they replicate asexually until a certain point.

• 9:47Speaker 05

  Point.

• 9:48Speaker 04

  They begin to rep, some will differentiate so that they can undergo sexual reproduction.

• 9:54Speaker 05

  Correct.

• 9:54Speaker 04

  And then those, the offspring produced by those are the ones that make it into the, the environment for, to then mature and infect other, potentially other people.

• 10:04Speaker 05

  Nailed it.

• 10:05Speaker 04

  You've pooped out these parasites.

• 10:07Speaker 05

  You've pooped them out.

• 10:08Speaker 04

  They then will, in the environment, in water? Like what, what's the environment?

• 10:15Speaker 05

  Wherever, wherever they land. These are incredibly hardy parasites. So the oocysts, which take a week to become infectious, but during that week and after, once they are what they call sporulated and infectious, they, I tried to get a number on exactly how long they can live, and I could not find that in the literature. Maybe I was not looking at the right terms. But I can assume, based on the studies that I did read, that it's a long time that they're able to persist in the environment. They also can withstand freezing to a certain degree. Freezing is not guaranteed to kill them. They also withstand most of the disinfection techniques that we use, including chlorination.

• 10:59Speaker 05

  So the only way to actually rid them of, let's say, our water sources, if, you know, poop is contaminating water sources, is with physical filtration to literally remove them, get them stuck on a filter, or with like UV filtration.

• 11:14Speaker 04

  What about like boiling?

• 11:15Speaker 05

  Boiling will do it, yes. So heat does kill them. Same thing with cooking your foods, if your foods, and food can get contaminated, both because the soil can be contaminated, if you're using reclaimed water or, you know, unfiltered water to irrigate your crops, then they can get contaminated that way. And apparently, they're quite sticky, the oocysts. And so they really glom on to, let's say, the tiny bumps and hairs covering a raspberry.

• 11:42Speaker 04

  raspberries, yep.

• 11:44Speaker 05

  And so.

• 11:45Speaker 04

  Yeah, raspberries are, are culprits.

• 11:48Speaker 05

  Often.

• 11:49Speaker 04

  Speaking of timeline, from ingestion of these parasites to symptoms, to the diarrhea, how long is that taking? And then how long does it take for symptoms to resolve? How do some, yeah, all the rest of that stuff?

• 12:04Speaker 05

  So glad you asked. That's the next thing I have written, Erin. So the incubation period, usually it's about a week, but it could be as short as two days. It could be as long as two weeks. But on average, it's a week, which for a foodborne infection is a very long time.

• 12:20Speaker 04

  Super long time.

• 12:21Speaker 05

  And we'll talk about the importance of that when we try it, when we talk about like tracing what was the source of this outbreak, right?

• 12:27Speaker 04

  Right.

• 12:28Speaker 05

  It's also very possible and very, probably more common than we know, that people have asymptomatic infections.

• 12:35Speaker 04

  Okay.

• 12:36Speaker 05

  So they're not getting sick at all, does not mean that they're not infecting others because they can still be excreting oocysts in their stool. And again, we do not have great numbers on like, how often are we having asymptomatic versus symptomatic infections? The symptoms themselves, so after that week, in the literature, never so often have I seen the words explosive, foul smelling diarrhea.

• 13:02Speaker 04

  Not even with C. diff or nor?

• 13:05Speaker 05

  I, I don't remember seeing specifically the words explosive quite as often as I do with this parasite in particular.

• 13:13Speaker 04

  Okay.

• 13:14Speaker 05

  We can get a little bit more into the symptoms. It's a very watery diarrhea, hence the explosiveness. We talked in our poop episode about how our anal canal has sensors to detect between a poop and a fart, and they're really not good at detecting liquid. So when we have like very watery stools.

• 13:31Speaker 04

  This is when trusting a fart is.

• 13:34Speaker 05

  Not the way to go.

• 13:35Speaker 04

  Can go the wrong way.

• 13:36Speaker 05

  Yep. We also see a lot of abdominal cramping, bloating, people can have nausea or like a headache. Not often do we see vomiting, but sometimes people might have vomiting. And sometimes people might have a fever, but it's not super common that you get a fever with this particular parasite. But it can last for quite a long time. So we can see like weight loss because of how just like yucky people are feeling and that they're not really eating, their appetite is down. And when I say can go on for a long time, I mean, this can go on for weeks to a month to six weeks if it's untreated.

• 14:14Speaker 04

  Whoa.

• 14:15Speaker 05

  Yes. So it's usually at least two weeks of illness and like five to 15 explosive liquidy stools a day.

• 14:24Speaker 05

  Not minor. That can go on for at least two weeks if it's untreated, but often it's lasting longer than two weeks, right? Like a month, five, six weeks.

• 14:35Speaker 04

  Uh, I have two questions about numbers.

• 14:37Speaker 05

  Give it to me.

• 14:38Speaker 04

  How much, how many parasites does it take to get sick? And then how much are you pooping out during this process?

• 14:46Speaker 05

  I love that you asked me this question. I don't know. The only thing I saw in the literature of how many parasites does it take is that we think, I wish I had written the exact quote, but it was like, we think that it's quite low.

• 14:59Speaker 04

  Yeah.

• 15:00Speaker 05

  So we don't really know, but it's probably just a handful of these individual oocysts, right? Each one has four sporozoites that are causing infection, then they're replicating asexually before doing the sexual reproduction thing. So I couldn't find a specific infectious dose. And similarly, I don't have an exact number on how many oocysts are you pooping out. But what makes this really challenging is that it's not a lot. This is not cholera where, or norovirus where you're releasing, you know, thousands, tens of thousands.

• 15:31Speaker 04

  Yep.

• 15:32Speaker 05

  It is low numbers of these oocysts and it can be sporadic. So you might, even though you're having diarrhea continuously, you might not be releasing oocysts in every stool. And it's in part because of this, it's not every single parasite that's getting excreted, right? Like it's only the oocysts that they're producing.

• 15:52Speaker 04

  That's kind of, I mean, that's so rude, right?

• 15:55Speaker 05

  I know.

• 15:56Speaker 04

  Just save the, save the oocysts, save the diarrhea for the oocysts.

• 16:00Speaker 05

  Nope. They're like, no, no, no, we're just going to keep it continuous, keep it, keep it moving. And so that can make it really hard to diagnose because if you're looking in the stool for these oocysts, they might be in very low numbers and they might not be there on one day. And so you might have to look for multiple days in a row. They're also hard to detect on, like typical stool studies don't actually look for them. And they don't stain the same way that other parasites do, which means you actually have to use like special stains to find them. They're easier to detect with PCR based methods. And so I, I did check, they are on our like GI pathogen panel that I order when someone has unexplained diarrhea that I don't know if I need to treat or not. It is on ours, but again, even though PCR helps because you're increasing the number,

• 16:45Speaker 05

  like the amount of DNA in the sample, it makes it easier to detect. If you only have a couple of oocysts there, you still might not pick it up.

• 16:52Speaker 04

  You might not pick it up. That's interesting.

• 16:56Speaker 05

  It's really interesting.

• 16:58Speaker 04

  And so how does it resolve?

• 17:02Speaker 05

  I mean, either with time, though some people can have a kind of relapsing, remitting course. So we do see that some people, you know, recover and then weeks later might have more symptoms or the symptoms are just like really, really prolonged. We also see, especially in people who are immunocompromised, so whether they are on immunosuppressive medications or maybe have uncontrolled HIV, the disease can spread outside of just the intestine and cause disease elsewhere, like say the biliary system, that's the gall, bladder and liver. Or we sometimes see these kind of post-infectious inflammatory type syndromes that we see after other foodborne illnesses like Salmonella or Campylobacter.

• 17:44Speaker 04

  Right.

• 17:44Speaker 05

  And these are things like inflammation in the eye, joint pain and inflammation, bladder inflammation. And so it's kind of an interesting component that like, we don't really have a handle on, and it doesn't happen all that often, but it certainly can happen where you have this prolonged extra intestinal illness as a result of like inflammatory response to this parasite.

• 18:05Speaker 05

  The good news is that it is treatable. And we use actually an antibiotic.

• 18:10Speaker 04

  Yeah.

• 18:11Speaker 05

  Even though it's not a bacteria. I double checked the mechanism of action of the main antibiotic that we use, which is trimethoprine sulfamethoxazole, or bacrim or septra in the US.

• 18:20Speaker 04

  I'm so glad that you pronounce that because I just wrote like whatever the initials are that it's abbreviated at. I was like, Erin's gonna, Erin's gonna handle this.

• 18:29Speaker 05

  The mechanism of it is that it's a folate blocker. It blocks the synthesis of folate. And so like all organisms need folate and most single celled organisms, including bacteria and many parasites, make their own folate. And we don't, we get it from our diet. And so by blocking the synthesis of folate, they can, this particular antibiotic can also work against some parasites, though not all.

• 18:51Speaker 04

  So that's very cool.

• 18:53Speaker 05

  I know. I re-looked it up and I was like, I love learning things like this that I knew once before. So it is treatable if you can detect it. So really, a lot of times it's diagnosis. That is one of the biggest challenges. The good news too, is that even though it's hard to detect and it can last for such a long time, it usually is a self limited illness in that the mortality rate is very low. I do not have an exact number, but for example, in the US, in the last few years, there have been only a small handful, like single digit number of deaths associated with cyclospora. Globally, it probably contributes much more than we realize to mortality rates, however.

• 19:36Speaker 05

  Because this is a parasite that is endemic in a lot of tropical and subtropical regions in the world where diarrheal illnesses kill children under age five. It's the leading cause of death.

• 19:47Speaker 04

  Yeah.

• 19:47Speaker 05

  So the dehydration that can accompany any kind of diarrheal illness is something to take very seriously, especially in small kids and the elderly. So I don't want to say that this is like not an important illness. It definitely is. And we're probably underestimating it overall.

• 20:02Speaker 04

  Oh, absolutely.

• 20:03Speaker 05

  Yeah.

• 20:03Speaker 04

  I mean, for sure. And, and I'm sure that you'll get into some of the reasons for that in like the current and what's going on. And, and, and also I think that, yeah, there's, there's a lot more when it comes to like the shape of outbreaks.

• 20:18Speaker 05

  Yes.

• 20:19Speaker 04

  Associated with cyclospora.

• 20:20Speaker 05

  Yeah. It's really, it's really interesting. And like what, who is getting the most sick? Like here in the US, it's mostly adults, whereas in other parts of the world, it's mostly children and not super young children, but like, you know, children aged two to five, 10, 12. And so that kind of gives us ideas as to like how endemic this parasite really is. How much is it just something that we live with versus something that is only there occasionally?

• 20:46Speaker 04

  Yeah.

• 20:47Speaker 05

  It's also interesting.

• 20:48Speaker 04

  It is. I have a question about symptoms, duration, you know, all these things. So diarrhea can be caused by a lot of different things.

• 20:56Speaker 05

  Yeah.

• 20:56Speaker 04

  And it can resolve on its own quite, you know, sooner rather than later. At what point with an illness like this, with cyclospora, should someone, and I know this is not a medical advice podcast, but like, at what point is going to the doctor for a diagnosis, like something that like, you know, that's, that's a good idea?

• 21:14Speaker 05

  Yeah. That's such a, such a good question, Erin. There's not like a, a perfect answer to it. It so much depends on how severe your symptoms are. I would say probably on average, like two to three days of severe diarrhea that's not going away or getting better.

• 21:31Speaker 04

  Okay. Like not being able to keep anything down.

• 21:33Speaker 05

  Not being able to keep things down. It's going to differ if you're having a lot of fevers or if you're super, super sick. But I would say probably two to three days is the point at which we know it's probably not noro, it's probably not something, it might be something that we need to treat is really the question.

• 21:47Speaker 04

  Yeah. Okay.

• 21:49Speaker 05

  And it is hard because this isn't necessarily something that's always tested for or picked up on, on the first try.

• 21:54Speaker 04

  Yeah. Well, and I imagine too, it's different for, you know, different people of like, if it's you're a small child or if you're, you know, elderly, then it could be more severe more quickly. And so.

• 22:04Speaker 05

  Exactly. Exactly.

• 22:05Speaker 04

  Okay. Okay. Cool.

• 22:07Speaker 05

  Trying to think if there's anything else I wanted to make sure that you knew. I feel like there's a lot more, but Erin, can you tell me where the heck this thing came from?

• 22:15Speaker 04

  Let's give it a go.

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• 24:11Speaker 08

  Oh my God, Lexi, we have a new podcast. It's called Don't Lie To Me.

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• 25:30Speaker 04

  If this current outbreak is the first time that cyclospora has been on your radar, first of all, count yourself lucky because as you just shared, Erin, it is not something that anyone wants to deal with. And second, it's totally understandable if you had never heard of this parasite before, because it was not actually that long ago that researchers first identified cyclospora as infecting humans, as a parasite capable of infecting humans.

• 25:56Speaker 05

  I was shocked, Erin. I couldn't avoid some of the numbers because they're just so recent and in every single paper, but like.

• 26:04Speaker 04

  So recent.

• 26:05Speaker 05

  What?

• 26:06Speaker 04

  I know. 1979.

• 26:08Speaker 05

  That's like, that's so recent.

• 26:10Speaker 04

  It's so recent. So what happened that year in 1979, R. W. Ashford, who was a British parasitologist, who was in the Department of Pathology at the University of Papua New Guinea, he reported that he had come across three cases of what appeared to be a new species of Coccidien in routine stool samples from two patients over the years of 1977 and 1978. Two of the three at least had been experiencing diarrhea and general malaise, like flu like symptoms for some time, about a week or two. And the infection over time began, it's like seemed to resolve on its own. And at the time of finding these parasites, he was like, well, it's possible that this parasite

• 26:52Speaker 04

  is causing diarrhea, but it's not conclusive by any means, given that, you know, one patient was also co-infected with Giardia and the other could have had diarrhea from something else of, you know, just something they ate, virus, whatever. And he also had difficulty, yeah, categorizing it. Like it looked like a Coccidien parasite, but he wasn't sure about the genus. And so the parasite remained unnamed and unclassified in that initial report.

• 27:18Speaker 05

  Wow.

• 27:19Speaker 04

  And owing in part to this sort of unclassification, as well as just the relative obscurity of a three case case report, you know, in, from like a journal of tropical medicine or whatever.

• 27:31Speaker 05

  Right.

• 27:31Speaker 04

  It's a pretty niche area of study. His initial paper mostly went unnoticed until sporadic reports over the next decade, the 1980s, of a Coccidien parasite infecting humans. And that show, these, these reports showed that this is, might not be one off infections. These cases might be indications of a more widespread disease or a widespread parasite. And the researchers who worked on these cases throughout the 1980s, they also struggled with what this parasite was. Like some thought, you know, it kind of looks like fungal spores in certain settings. So it'd be like fungal like. Others felt that it resembled blue green algae. And so they called it cyanobacterium like body or CLB.

• 28:15Speaker 04

  There were like a few papers from the 80s that show that. And it didn't get its final name, Cyclospora caetanensis, until 1994. And caetanensis comes from the Peruvian university where the research had been carried out. But it was by Ortega et al. They'd conducted studies on the parasite and been like, okay, this is, this is what it is.

• 28:36Speaker 05

  This is what it is.

• 28:36Speaker 04

  Yeah.

• 28:36Speaker 05

  And they named it. 94.

• 28:39Speaker 04

  94 is when it got its final name. It's surprisingly recent. But the genus also was a little bit of a surprise, too, because, as you mentioned, Cyclospora, this genus had been around since 1881. And all members up to this point of this genus Cyclospora infected only non-human animals. Like you said, you know, voles or reptiles or whatever.

• 29:04Speaker 05

  Right.

• 29:04Speaker 04

  So does that mean that Cyclospora jumped into humans recently? I mean, probably not. It's probably just, I think, I mean, this is what people have suggested in the literature. It's probably just that it had been masquerading as other pathogens. And given that the course of disease is mostly self-limited, resolves on its own, given that it is also difficult to detect, seems to be difficult to detect. It was probably just lurking and causing periodic outbreaks or sporadic cases. And or just sort of like endemic. And, you know, in the places where Cyclospora is endemic, it tends to be most common, as you said, in children. And in these children, it tends to be more mild and asymptomatic.

• 29:49Speaker 04

  And it also might provide some protection later in life.

• 29:52Speaker 05

  Right.

• 29:52Speaker 04

  Meaning that an outbreak, like you might not see outbreaks take shape this, the way that they do in countries where this parasite is not endemic.

• 30:01Speaker 05

  Yes, which is super interesting that like usually people who live in non-endemic areas and then travel to somewhere endemic get way sicker.

• 30:09Speaker 04

  Way sicker, yeah.

• 30:10Speaker 05

  From this parasite than people who who live there.

• 30:12Speaker 04

  Yeah, exactly. And as far as I read, and it sounds like as far as you read, too, there's no currently known animal reservoir for Cyclospora. There could be one. It could be, you know, we just haven't found it yet.

• 30:24Speaker 05

  Yeah.

• 30:24Speaker 04

  But it seems to be like, pretty hearty, pretty, pretty chill on its own in the environment, you know, just hanging out in contaminated soil and water.

• 30:32Speaker 05

  Right.

• 30:33Speaker 04

  And another thing that points towards a longer history of Cyclospora in humans is just how far ranging these case reports in the 1980s and 1990s were. So you see case reports of travelers, a lot of, a lot of travel-associated illness. People returning from Haiti, from Peru, from Mexico, from Nepal. Also, studies showing that residents of Nepal and Peru were infected with Cyclospora. And also patients who had AIDS, these made up the bulk of these early reports. So it's kind of, it was like all over the place.

• 31:07Speaker 05

  Right.

• 31:08Speaker 04

  And in addition to showing that this is a pretty geographically widespread parasite, these also indicated that the parasite can cause a range of infections from asymptomatic to symptomatic. It can impact both immunocompetent and immunocompromised individuals. In a pretty relatively short period of time, a decade and a half or so, by the mid 90s, scientists had a pretty good handle on the distribution of the parasite. The clinical picture, treatment, like studies had identified TMP SMZ as an effective therapy. And they also had some clues as to its transmission. Contaminated water seemed very viable as a source of infection. And there were some early hints that contaminated food could also lead to illness.

• 31:54Speaker 04

  In 1996, those hints about foodborne illness turned into shouting from the rooftops when the first major outbreak occurred in North America. And so this resulted in at least 1,465 cases of Cyclosporiasis reported by 20 different US states, the District of Columbia, and two Canadian provinces over at least a month, likely an underestimate of true totals.

• 32:21Speaker 05

  For sure.

• 32:22Speaker 04

  And very widespread from a geographic sense. The outbreak was ultimately linked to raspberries from Guatemala. And crucial to the epidemiological tracing were several dozen events, like gatherings, where raspberries were served. And so with those clusters, those really helped to narrow down the exposure and like the specific exposure. So they were like, oh, here's, you know, at this banquet, there was a raspberry dessert. And this person had raspberries there and this person didn't, which is so interesting.

• 32:54Speaker 05

  It's so interesting, Erin. All of this, like, contact tracing and, and, and like questionnaires and trying to identify the source is so, so interesting.

• 33:05Speaker 04

  Yep.

• 33:06Speaker 05

  And so hard.

• 33:08Speaker 04

  It's very hard. It's very hard, especially with the week, the week from, you know, who remembers what they ate a week ago?

• 33:16Speaker 05

  I can't barely remember what I ate two days ago. Okay? A week? I literally have no clue. Not, not a clue.

• 33:24Speaker 04

  I do, I remember, but only because I was traveling back from Wyoming. So I remember where we stopped to eat and stuff. And what we had for camp breakfast.

• 33:32Speaker 05

  I can't even think where I was a week ago, Erin.

• 33:36Speaker 04

  But yeah, it's hard. Like, this is why, I mean, foodborne, foodborne outbreaks can be very difficult to get a handle on. And it turned out that with, with continued study, the raspberries were actually being exported during a time of year that Cyclospora is more prevalent. So it tends to be seasonal and endemic countries. And while the precise method of contamination, like how did these raspberries get contaminated in the first place, it was never figured out. Researchers narrowed it down to a handful of farms. And they suggested that it was likely from contaminated water. So maybe either irrigation, maybe fertilizers or pesticides were diluted with contaminated water and then sprayed over the crops.

• 34:17Speaker 04

  And this would help to explain the sheer number of raspberries that had been contaminated. But again, it doesn't take that many oocysts to cause infection.

• 34:27Speaker 05

  Right.

• 34:27Speaker 04

  So. Why raspberries? We touched on this a bit, but raspberries have been one of the things implicated in this current outbreak, also cilantro and lettuce. We'll get there in a bit. But raspberries are difficult to scrub clean. You can't just run them under the water and expect the Cyclospora, the oocysts to just pop off. All those nooks and crannies, it's hard.

• 34:53Speaker 05

  Teeny tiny hairs, just grabbing on.

• 34:56Speaker 04

  Yeah, raspberries are often, are often the culprits in these. And the 1996 epidemic, it acted as somewhat of a wake-up call and certainly a warning bell. More Cyclospora outbreaks were on the way. And they would only get worse unless we did something about it. 1997 and 1998 both saw outbreaks in North America associated, again with raspberries and other berries. There was a cruise ship that had over 200 people report infections. There was a wedding in 2000 in Philadelphia that sickened 83 attendees, again linked, though not definitively to raspberries. Poor raspberries.

• 35:35Speaker 05

  Poor raspberries.

• 35:36Speaker 04

  And they're, they're not the only culprit by any means. There have been outbreaks linked to basil, snow peas, cilantro, green onions, and salad mix. And in fact, a large outbreak in 2019 involving over 2,400 cases across North America was associated with fresh basil. The lesson from all of these outbreaks is pretty clear. And it was summed up nicely in the last few sentences of the New England Journal of Medicine article detailing the situation in the 1996 outbreak. Quote, "In summary, Cyclospora has now been established to be a foodborne pathogen. This outbreak is a reminder that our supply of fresh produce has become increasingly

• 36:19Speaker 04

  international and underscores the need to identify and investigate foodborne outbreaks promptly, to consider that a local cluster of cases could be part of a widespread outbreak, and to pursue investigations to the source of the implicated vehicle. For imported vehicles, international collaboration is critical to the success of the investigation and to the identification of appropriate measures of prevention and control." End quote. Vehicle meaning food, which food item.

• 36:50Speaker 04

  An incredibly clear, level-headed, and well-reasoned response.

• 36:54Speaker 05

  Uh huh.

• 36:54Speaker 04

  Who could argue with that?

• 36:56Speaker 05

  Not me.

• 36:57Speaker 04

  Not me.

• 37:00Speaker 05

  But.

• 37:00Speaker 04

  But, da, da, da.

• 37:03Speaker 04

  So following the outbreaks in 1996 and 1997, the Guatemalan government has cooperated with the FDA and the berry industry to institute policies to reduce contamination of Cyclospora, to help identify the source of these outbreaks. And other countries where contaminated food was traced have also followed suit, which is great and no doubt has reduced exposures to foodborne pathogens and parasites. But of course, no policy is perfect. And so it is crucial to have a well-functioning, well-funded surveillance system in place in this country to gather data and report any foodborne parasites or pathogens that pop up. Seems pretty obvious.

• 37:44Speaker 05

  Seems pretty obvious.

• 37:45Speaker 04

  Who wouldn't want that?

• 37:46Speaker 05

  I want it.

• 37:47Speaker 04

  I want it, too. And we did have something like that. Technically, we still do, but it is kind of a shell of its former self. Let me tell you about FoodNet.

• 37:57Speaker 05

  Yes.

• 37:58Speaker 04

  Cyclospora was not the only foodborne infection popping up in the 1990s in North America. E. coli O. 157 was the real baddie, having sickened over 700 people and killed four children in 1992 and 1993. And in response to this, I mean, it was a horrifying outbreak, a lot of fear. Listen to our E. coli episode, I think we talked about it.

• 38:19Speaker 05

  It's like mostly what we talk about.

• 38:20Speaker 04

  Okay, okay. But the USDA was like, okay, we gotta start testing some meat and produce and we gotta implement a certain inspection system. Like, we have to have some kind of system for this. But of course, in order to justify the continued funding of such a system, there needed to be a way to measure its efficacy. Did infections go down? Did exposure go down? Thus, FoodNet was born. So in 1995, the Food Safety and Inspection Service of the USDA linked up with the CDC to create the Foodborne Diseases Active Surveillance Network, FoodNet, which was intended to monitor the incidence of certain foodborne pathogens across the

• 39:02Speaker 04

  country to get a sense of where infections were happening and estimate how many infections there were total. FoodNet started out small, collaborating with just a handful of state and local health departments, covering, you know, at the very beginning, 14.3 million total, and then screening for just a few pathogens. But over the years, FoodNet proved how valuable of a surveillance tool it was, and more and more areas were included in the surveillance and the overall surveillance network. The data collected by FoodNet also went far beyond, is this pathogen present or not? Is there an outbreak or not? It was used to assess things like how food prep at long-term care facilities could improve,

• 39:45Speaker 04

  the long-term effects of antibiotic-resistant Salmonella infections, how informed physicians are about certain types of E. coli infections, and eventually, online tools were launched, which then allowed users access to a huge array of data on foodborne illness. I mean, it was awesome.

• 40:05Speaker 05

  Yeah, like, really, the amount of work and the fact that it was all an active surveillance network.

• 40:11Speaker 04

  Active surveillance.

• 40:12Speaker 05

  Not just passive surveillance.

• 40:14Speaker 04

  Yes.

• 40:15Speaker 05

  Is massive.

• 40:16Speaker 04

  Yep.

• 40:17Speaker 05

  Was massive.

• 40:18Speaker 04

  Was massive, yeah. By 2024, FoodNet's surveillance area had expanded to cover 16% of the US population, about 54 million people, and eight different infections and outcomes were required to be tracked. So, Campylobacter, Cyclospora, Listeria, Salmonella, Shigella, Shiga toxin-producing E. coli, Vibrio, Yersinia, and Hemolytic Erymia Syndrome, which is caused by Shiga toxin-producing E. coli. I mean, great.

• 40:52Speaker 05

  Great.

• 40:52Speaker 04

  Like, what a valuable and fantastic public health tool. Essential, you could say.

• 40:58Speaker 05

  You could say.

• 40:59Speaker 04

  On July 1, 2025, the CDC announced that FoodNet was cutting back on the number of pathogens it monitored. Reporting became optional for all but two. So now, the only required reporting was for Salmonella and Shiga-producing E. coli, Shiga toxin-producing E. coli. Cyclospora is, of course, one of the ones on the optional list. Why make reporting optional? Funding was the reason given. It's, I'm sure, I mean, funding is a smokescreen for this, we don't value this. And so now, with Cyclospora' cases rapidly rising,

• 41:41Speaker 04

  and with no clear picture as to which food or foods are responsible, the American public is paying the cost, right? So if the government is saving how much money, like, one minute of the military budget for a day or something?

• 41:54Speaker 05

  One of the papers that I read actually said that the FoodNet budget, like, to fund all of the local sites where they were working, as well as the, like, central staff, was $7 million? And I don't, it was only one paper that I read, but really? Are you serious? Is that it?

• 42:13Speaker 04

  I mean, and it's, it's the kind of thing where you expect something like this to grow and grow and grow over the years, to have the number of pathogens that you're screening for grow as you have increased technology capabilities of doing this and increased desire to, if you have the tools, why not use them to make the world a better place, to help the general public, to...

• 42:33Speaker 05

  To make America healthy or something?

• 42:35Speaker 04

  Implement, I guess. And so, yes, under the guise of cutting budget, FoodNet has now been diminished. When what was once a trusted governmental public health institution like the CDC makes a policy change that reduces protections for its citizens, how can we interpret that any other way than shifting the cost and the consequences onto us, onto the general public? I mean, do you remember what Trump said during the pandemic in 2020?

• 43:06Speaker 05

  No.

• 43:07Speaker 04

  So, on June 15, or sometime in June 2020, he said, "If we stop testing right now, we'd have very few cases, if any." Is that the same strategy that we're using with Cyclospora?

• 43:20Speaker 05

  If we just don't test for it, then it's not there? Then we don't have it? That's not how the world works.

• 43:26Speaker 04

  I mean, yeah, it's shocking, but that doesn't actually prevent disease from spreading.

• 43:31Speaker 05

  No.

• 43:32Speaker 04

  Who, you know, who knew? Many people knew, everyone knew. So, many states in this current outbreak are still individually monitoring Cyclospora, like Michigan, which seems to be the epicenter of this current outbreak, and has now launched, you know, like, an interface where you can actually see cases and the number of cases.

• 43:52Speaker 05

  Their website is incredible. Way to go, Michigan.

• 43:55Speaker 04

  Beautiful, yeah. But other states, such as Colorado, have suggested that without FoodNet's support, they may have to cut back on disease surveillance as well. I don't know if that has extended to Cyclospora and this current outbreak, but I know that without, with the loss of this federal monitoring system, we are not going to have, and we do not have, this outbreak shows it, as good ability to get a sense of the scope of an epidemic like this. We are scrambling in the dark without this former cornerstone of public health, and it makes it much more difficult to halt its spread, to gather information that we need. And the general public is trying to make up for this federal failure by crowdsourcing

• 44:37Speaker 04

  information on, like, threads and other social media platforms, seeing if they can piece together anecdotes to identify, like, a particular fruit or veggie, or a farm linked to the cases, like, oh, I got sick and I had these raspberries, and this is on the label, and this is the date, and whatever. Maybe that's where the answer will eventually come from. You know, people can do amazing things when they work together.

• 44:57Speaker 05

  Yeah, we love it.

• 44:58Speaker 04

  We do. And at the same time, I don't want a future where public health is solely conducted on social media without any peer review. Like, that is not what we should have. What I want is a future where public health is prioritized and valued and respected and funded. One of the longstanding challenges in championing public health is that the money saved by public health programs like FoodNet, it's not always easy to calculate or visualize to see it as money saved. But the cost of cutting public health is very, very clear. We're seeing it right now. And so with that, Erin, I'll turn it over to you to tell me what's happening with this current outbreak.

• 45:41Speaker 05

  I would love to.

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• 46:28Speaker 08

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• 48:50Speaker 05

  I'm going to take a step back and give us a broader picture of where cyclospora fits in because it is probably something that most people never heard of until this year, despite the fact that we have had outbreaks in the past. And globally, I said already, this is a much more prevalent pathogen even than I realized. In some areas where it is endemic, like in parts of Latin America and in Southeast Asia, prevalences can range from 10 to 40% in some populations, meaning that that parasite is just around. It's just around. It's infecting people. Some of them show symptoms and some of them don't. So

• 49:31Speaker 05

  far, in places like the US and Europe, it has not been considered endemic. However, there's a lot of questions as to whether or not it really is because, like you said, Erin, in the past, a lot of times outbreaks have been associated with produce that has been imported. But in the last few years, there have been well documented cases of outbreaks associated with produce grown here in the US.

• 49:56Speaker 04

  Yeah. Or I think that there was an outbreak in Germany associated with salad mix that had been grown in France. And so they're like, okay, now it's in Europe potentially.

• 50:05Speaker 05

  Well, in Italy, ever since 2015, there were like 12% of environmental samples that were testing positive for cyclospora and prevalence in some studies in humans was up to 27%. So it's certainly around. We maybe just haven't been paying that much attention to it. But cases in the US have certainly been on the rise since at least 2016. So despite the fact that FoodNet, we can just say, has crumbled at this point, cyclospora is still a nationally notifiable disease, which means that there is a system here in the US called the National Notifiable Disease Surveillance System. It's like the longest acronym. But it is still the case that when hospitals and clinics pick up

• 50:50Speaker 05

  on cyclospora, they have to report that to the CDC. This is a passive surveillance system.

• 50:57Speaker 04

  Yeah.

• 50:58Speaker 05

  It's great that we have it. It is not the same thing as actively looking for cases of foodborne illness, the way that FoodNet did.

• 51:08Speaker 04

  Nope.

• 51:09Speaker 05

  So even though FoodNet only covered, what did you say, 16% of the US?

• 51:13Speaker 04

  Something like that.

• 51:14Speaker 05

  It was actively looking for and identifying, hey, these cases might actually represent a larger outbreak than what we're realizing. And that is what we have lost here.

• 51:23Speaker 04

  Yep. Passive surveillance is not a substitute for active surveillance.

• 51:27Speaker 05

  No, it's not. And I think that it's really easy to just, well, at least on the CDC's website, what they have said is like, don't worry, we're still surveilling for these things. And we're not in the same way, period. We are not. So all of the data that I have right now is from the National Notifiable Disease Surveillance System, so the NNDSS. And they only have updated it as of July 4, which is annoying because they were supposed to update it yesterday because that's the end of the week.

• 51:56Speaker 04

  Yeah.

• 51:57Speaker 05

  But as of July 4, according to the NNDSS, there were 1,838 cases so far in 2026.

• 52:06Speaker 04

  Okay. As of July 4.

• 52:08Speaker 05

  As of July 4.

• 52:09Speaker 04

  Yeah.

• 52:10Speaker 05

  And, and this is just that had been reported to the CDC. There's always a delay between when something has been, I shouldn't even say reported to the CDC. These have just been reported to this surveillance system. The CDC then has to like confirm whether or not that case is a confirmed case. By this same point in 2025, we can compare, there were just over 1,000 cases. So we're looking at over 800 more cases as of July 4 compared to 2025. But if we look at the beautiful state of Michigan, who is doing a phenomenal job

• 52:45Speaker 04

  Truly.

• 52:46Speaker 05

  of keeping the public informed and of updating what their case numbers are, they have reported as of July 9, 1,562 cases just in Michigan alone.

• 52:57Speaker 04

  Yeah.

• 52:58Speaker 05

  44 hospitalizations, and several hundred of those cases happened just in the last week. So from July 5 to July 11.

• 53:07Speaker 04

  Right.

• 53:08Speaker 05

  Ohio has also reported a number of cases and the Ohio State Department of Health is not updating it on a regular basis, but the Toledo Lucas County has a really great active tracker. So way to go, Toledo County.

• 53:19Speaker 04

  Nice Toledo, yeah.

• 53:21Speaker 05

  They have reported 412 cases in Lucas County and 661 in Northwest Ohio. And that's compared to like Ohio as a state, which so far only reported 177 as of July 8.

• 53:32Speaker 04

  It's such a mess.

• 53:34Speaker 05

  It's a mess.

• 53:35Speaker 04

  Yeah.

• 53:36Speaker 05

  It's a mess and we are in the middle of it. We are not at the end of it. We are not at the beginning. We are smack in the middle of this. New York City, New York State has reported just under 400 cases. Again, I couldn't get info from their exact website. It's all from news reports. North Carolina, 200, Illinois, 161. And that's just the cases that seem to maybe be associated with these outbreaks. Here's the thing, we do not know if this is one outbreak, if this is one multi-state outbreak, if this is many, many outbreaks.

• 54:11Speaker 04

  Yeah.

• 54:12Speaker 05

  Cases are reported every single year, especially from May through August, which is cyclospora season. So we've had cases in like over 31 states, but that's not unusual. What's unusual is the sheer number that have happened in the last less than one month, essentially.

• 54:29Speaker 04

  Record breaking.

• 54:30Speaker 05

  Yes, yes.

• 54:31Speaker 04

  Getting there, yeah.

• 54:33Speaker 05

  It's getting there. It's getting there. If we look at overall numbers, like say, yearly numbers, they have been increasing since 2016, per the National Notifiable Disease Surveillance. Before 2016, it was usually just a couple of hundred cases a year, except for years when we had larger outbreaks. But every year since 2017, there have been over 2,000 cases. In 2025, there was 3,900 cases. 2024, there was 4,200 cases. But again, even, even knowing that, at this point last year, we had seen well under the number of cases that we're seeing right now. And if you look at the actual state level

• 55:15Speaker 05

  data, like this is July 12, there's probably close to 3,000 cases that have actually been reported to states. And the CDC is just really lagging on updating that data overall because their numbers on their official website say like 800.

• 55:28Speaker 04

  Ah.

• 55:30Speaker 05

  So it's not just the loss of FoodNet. It is also the massive reductions in force that we have seen at the FDA, the USDA, and the CDC that have all had major effects on our ability, not just to identify and trace back the sources of these outbreaks, but also communicate with the public. A lot of the people that got laid off were in charge of this public facing communication.

• 55:55Speaker 04

  Yep.

• 55:56Speaker 05

  And then the question of what is causing this particular outbreak, or however many outbreaks are going on right now? We don't know. Historically, Erin, you mentioned a lot of the common culprits, raspberries and other berries, things that you tend to maybe not wash that thoroughly or that are really difficult to completely wash. Same thing with pre-washed bagged salad mixes and like fresh herbs, things like basil, cilantro, parsley, all of those have been implicated in the past. From what I could tell, there's absolutely nothing that has been identified at this point. We do not know, period. Despite that, Taco Bell in Michigan is like not serving any fresh lettuce or onion or anything like that. And I'm like,

• 56:35Speaker 04

  I saw that. I saw that.

• 56:36Speaker 05

  Way to go Taco Bell, be proactive. But places like Michigan have put together some really great resources on how people can try and protect themselves. Cooking your food does inactivate this parasite. So anytime that fruits and vegetables can be cooked, they're going to be safer than if you're eating them raw. Things that you're not going to cook or cannot cook for whatever reason, washing them in a solution with vinegar, like completely submerging them and swishing them around and soaking them, they say maybe helps a little bit more than just a quick rinse.

• 57:08Speaker 04

  Hmm.

• 57:09Speaker 05

  There's not like great data to support any of that because again, none of the things that we typically use for disinfection, even like chlorine, are actually effective in killing this. So all of that is, the goal is washing it away, not killing or inactivating the parasite. Even freezing doesn't completely kill it because we have seen outbreaks associated with frozen raspberries in the past.

• 57:28Speaker 04

  Yeah.

• 57:29Speaker 05

  So yeah, I don't have a, there's not a perfect answer here. Authorities are recommending that if people, especially in areas where there have been a lot of cases reported so far, so Ohio, Michigan, New York, Illinois, also North Carolina, if people are having more than two to three days of diarrhea, it's recommended that they go get tested, in part so they can get treatment and in part so that we can get a better handle on what's actually going on.

• 57:54Speaker 04

  Yep.

• 57:55Speaker 05

  And how large this outbreak really is.

• 57:56Speaker 04

  Yeah.

• 57:57Speaker 05

  That's what I got, Erin. It's a bit of a mess. And if we do not invest in public health infrastructure, which is the same refrain that we say every single time.

• 58:04Speaker 04

  All the time.

• 58:05Speaker 05

  Then we are going to continue to see outbreaks like this. Outbreaks happen no matter what, but our ability to get a handle on them and to be able to identify what factors led to this outbreak and then get them under control is severely hampered when we fail to adequately fund public health.

• 58:22Speaker 04

  Yep.

• 58:23Speaker 05

  Especially to staff our agencies with knowledgeable people who know what the heck they're doing.

• 58:28Speaker 04

  Right. Yep. I mean, and it's like, it is, it is not satisfying.

• 58:34Speaker 05

  No.

• 58:35Speaker 04

  Or pleasant in any way to say, I told you so, in a situation like this. It's, it is really frustrating and it is, is tiring. It exhausts, it's exhausting. Like we, no one wants to have to say, I told you so, when it comes to matters of defunding public health.

• 58:52Speaker 05

  No.

• 58:53Speaker 04

  But this, in many ways, our lack of ability to understand the, the scope and the source of this outbreak is very much associated with the cuts in funding to FoodNet, to CDC, to other governmental institutions that you mentioned. No one wants to say, I told you so. But guess what? People,

• 59:15Speaker 05

  I told you so.

• 59:16Speaker 04

  People told us so.

• 59:19Speaker 05

  Yep, Erin, that's cyclospora thus far. Keep refreshing your news feeds because there will be more.

• 59:25Speaker 04

  There will be more. Sources for this. So I have a bunch of different papers on cyclospora. There was a paper, I think if you would like to read about the 1996 outbreak, an outbreak in 1996 of cyclosporiosis associated with imported raspberries by Herwalt et al. And then there are a few reviews in there. But if you would like to read about the Food Net, there's a paper from 2015 that talks about Food Net and it's called, it's by Hanal. Yeah, Foodborne Diseases Active Surveillance Network. So, check it out.

• 1:00:03Speaker 05

  My favorite paper for just an overview of cyclospora in general was from Lancet Infectious Disease 2019, and it was called Human Cyclosporiosis. That one's a great overview. There was another one from Veterinary Parasitology in 2004 called Cyclospora Caetanensis, A Food and Waterborne Coccidiid Parasite. A bunch of other reviews just of the parasite itself. I have a number that details some of the previous outbreaks, as well as some of the data on surveillance prior to the last few years. So there was like an MMWR that was from 2019 that looked at surveillance in the US from 2011 to 2015. I'll have links to the National Notifiable Disease Surveillance Systems. You can get updates every week on

• 1:00:44Speaker 05

  that. That data is not finalized by any means, but it's at least a sense of like where things are going, as well, of course, as the Michigan Department of Health and the Toledo one. If I find others, I'll try and post them as well, too, just so that people know where they can find more up-to-date information. The CDC seems to be updating every two weeks. I'm not really sure how often they're updating, but you can find the list of sources from all of our episodes on our website, thispodcastwillkillyou.com.

• 1:01:09Speaker 04

  You can. Thank you to Blubmobile for providing the music for this episode and all of our episodes.

• 1:01:15Speaker 05

  Thank you to Leanna and Tom and Mark and Pete and Jessica, especially for getting this episode out on such a short timeline.

• 1:01:21Speaker 04

  Yes, thank you all so much.

• 1:01:23Speaker 05

  Sorry for making more work for you, but we really appreciate it.

• 1:01:26Speaker 04

  Thank you, thank you. And a big thank you to you listeners. Let us know what other questions you have about cyclospora. We're curious. Yeah.

• 1:01:35Speaker 05

  We have questions, too.

• 1:01:36Speaker 04

  Yeah, you do.

• 1:01:37Speaker 05

  And as always, a shout out to our patrons. Thank you so much for your support over on Patreon. It means a lot.

• 1:01:41Speaker 04

  It really does. It really does. Well, until next time, wash your hands.

• 1:01:45Speaker 05

  You filthy animals.

• 1:02:14Speaker 12

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• 1:02:51Speaker 07

  Lisa, tell them about our new show.

• 1:02:54Speaker 08

  We have a new podcast. It's called Don't Lie to Me.

• 1:02:56Speaker 07

  I'm Lexi Iwanu. We're two best friends, 22 years apart, but so close at heart.

• 1:03:02Speaker 08

  And I'm Lisi DiGiulio, the old one, which means we have wildly different references, occasionally different opinions, and at this point in my 50s, I've lived it all.

• 1:03:10Speaker 07

  Now in my 30s, being the founder of new shoes, good taste is my business.

• 1:03:15Speaker 08

  Listen on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.