BISMARCK — The North Dakota Department of Health reported six cases of cyclospora infection, also known as cyclosporiasis, Sunday, June 28.

The department also reported that Walmart's store brand Marketside classic iceberg lettuce has been implicated in a multistate outbreak of cyclospora infection, according to the Centers for Disease Control and Prevention.

With cases of cyclospora infection traced to Walmart's lettuce, the product was recalled and added to the list of impacted bagged salad mixes. Bags of garden salad sold at Aldi and HyVee had previously been linked to cyclospora infections across Minnesota and North Dakota. Store-brand garden salad sold at Jewel-Osco, a grocery chain in Illinois, Indiana and Iowa, has also been implicated in the outbreak.

Trace-back procedures have indicated that Fresh Express salad mixes containing iceberg lettuce, red cabbage and carrots are a likely source of the outbreak.

While initial traceback did not indicate infected products were sold at restaurants or grocery stores in North Dakota, further investigation proved otherwise, Julie Wagendorf, director of the Division of Food and Lodging for the North Dakota Department of Health, told Forum News Service on June 23.

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“The cases in North Dakota are part of a larger outbreak occurring among Midwestern states,” Department of Health epidemiologist Laura Cronquist said via news release. “All six individuals consumed Marketside brand salad. The NDDoH continues to work with the Centers for Disease Control and Prevention, the Food and Drug Administration and other public health agencies in this ongoing investigation.”

Nationwide, the CDC had verified 206 cases of cyclospora infection and 23 hospitalizations across Minnesota, North Dakota, Illinois, Iowa, Kansas, Missouri, Nebraska and Wisconsin. None of the cases from North Dakota have been hospitalized.

The Minnesota Department of Health reported 13 cases of cyclospora infection on June 20, though updated figures from the CDC indicate there are between 16 and 35 cases in the state.

Cyclospora infection is marked by nausea, watery diarrhea, loss of appetite, weight loss, tiredness, abdominal cramping and body aches, the North Dakota Department of Health said. Symptoms typically present themselves one week after consuming contaminated food but can manifest two to 14 days after consumption.

Those who have purchased salad mixes from Aldi, HyVee, Jewel-Osco and Walmart should throw them away, the CDC advised.