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US health authorities have expanded their investigation into a multistate outbreak of cyclosporiasis after new infections were identified in four additional states. The outbreak has been linked to shredded iceberg lettuce imported from central Mexico and supplied by Taylor Farms. Officials from the US Food and Drug Administration and the Centers for Disease Control and Prevention are continuing efforts to determine the full extent of the outbreak and trace all affected products. According to the FDA, confirmed outbreak-related cases have now been reported in nine states including Illinois, Indiana, Kansas, Kentucky, Michigan, Ohio, Oklahoma, Pennsylvania and West Virginia. Health officials said nearly 2,000 people have become infected with the cyclospora parasite after being exposed to food served at Taco Bell restaurants. So far, at least 98 people have required hospital treatment, although no deaths have been reported. The investigation remains active as authorities work to identify additional cases that may be connected to the contaminated lettuce. Oklahoma’s health department said it is cooperating with federal officials to determine whether more illnesses reported in the state are linked to the outbreak. Cyclosporiasis cases have been recorded in at least 41 states across the country this year. However, investigators say not every infection is connected to the current outbreak. Health officials are still examining which cases are directly linked to shredded iceberg lettuce supplied by Taylor Farms and served at Taco Bell locations. Several states have already completed preliminary reviews and found no evidence connecting their reported cases to the nationwide outbreak. Health departments in Nebraska, Rhode Island, New Mexico and Maryland said investigations have not identified a link between local infections and the recalled lettuce. Officials stressed that cyclospora infections can result from exposure to a variety of contaminated fresh produce, making each case important to investigate separately. In New Hampshire, health authorities confirmed nine infections associated with recalled Taylor Farms lettuce that had been served in the cafeteria at Cheshire Medical Center. Officials are continuing to investigate whether additional illnesses reported in the area are related to the same source. Oregon health officials also reported two infections believed to be connected to the ongoing outbreak. Both individuals had recently traveled to states included in the nationwide recall and were believed to have consumed pre-shredded lettuce associated with the investigation. North Carolina has also seen an increase in cyclosporiasis cases this year, but state health officials said the available evidence does not suggest those infections are related to the Taco Bell outbreak. Instead, investigators found that patients had commonly consumed fresh herbs such as parsley and cilantro along with lettuce, indicating different sources of exposure may be responsible. Michigan remains the state reporting the highest number of suspected infections. State officials said more than 8,000 probable cases of the intestinal illness have now been identified, with hundreds of additional cases reported within a single day. Investigators continue to monitor the situation closely as new reports are received. The outbreak prompted Taylor Farms to announce a voluntary recall of iceberg lettuce sourced from central Mexico on July 17. The recall covers products sold in grocery stores, supplied to restaurants and distributed to food service businesses across the United States. Federal health officials continue to advise consumers, restaurants and retailers not to use or serve any products included in the recall until the investigation is complete. An industry source familiar with the matter said Taylor Farms has temporarily suspended operations at the processing facility in central Mexico that US health authorities have linked to the outbreak. Officials hope the closure, combined with the product recall and continued public health monitoring, will help prevent additional infections while investigators work to identify the exact source of the contamination.