The Lone Star State put out the warning on Monday — those microscopic parasites are back.

During June and July, the Texas Department of State Health Services saw a spike in the intestinal illness caused by consuming food or water contaminated with Cyclospora parasites, upping the year-to-date number of cases to 68. There were 148 cases of cyclosporiasis illness in 2016.

The 2016 case count was an improvement on the previous three years. Texas reported 351 cyclosporiasis in 2013; 200 in 2014; and 316 in 2015.

In response to the recent uptick, the Texas Department of State Health Services is asking healthcare providers to test for the Cyclospora parasite if any patient reports having diarrheal illness lasting more than a few days or diarrhea accompanied by severe anorexia or fatigue.

A cyclosporiasis diagnosis requires three stool samples for “Ova and Parasite” testing.

“Rapid reporting to public health, enabling prompt investigation to identify possible common exposures, is essential to preventing additional cases of cyclosporiasis,” according to the department. “Usually, cyclosporiasis symptoms begin in 2 to 14 days after ingestion of the Cyclospora oocysts in contaminated food and water. Profuse diarrhea can last for weeks to months, and may relapse. Anorexia, fatigue, weight loss, abdominal cramps, bloating, increased gas, nausea, vomiting and low-grade fever are among the additional symptoms.”

Texas has yet to determine a common exposure source for this year’s increased cases. However, a statement from Health Services said past outbreaks have been associated with consumption of imported fresh produce, including fresh cilantro, pre-packaged salad mixes, raspberries, basil, snow peas and mesclun lettuce. The state recommends washing fresh produce, but warns that Cyclospora can be difficult to remove. Cooking kills the parasite.

The parasite infection is not generally transmitted from person-to-person.

In 2016, the U.S. Food and Drug Administration said reductions in cyclosporiasis illnesses in Texas and as many as two dozen other states was because Mexican cilantro imports to the United States were getting more careful scrutiny. FDA has been focused on fresh cilantro from the Puebla region of Mexico for at least the past four years. In 2013-2015, FDA found farms and packing houses in the Puebla region with “objectionable conditions” that could contaminate produce with “human fecal pathogens.” After that, imported cilantro from the region was subject to an Import Alert and “detained” at U.S. borders without physical inspection.

FDA then came up with a so-called “Green List” of 10 Puebla region growers who agreed to good production practices in order to get their imports cleared. The project was developed in cooperation with Mexico’s National Agro-Alimentary Health, Safety, and Quality Service and the Federal Commission for Protection from Sanitary Risks. FDA is hoping the reduction in cyclosporiasis cases experienced in 2016 holds up in 2017.

The federal Centers for Disease Control and Prevention repots that people who travel or live in tropical or subtropical areas of the world are at greater risk of consuming parasites.

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