29 sick: An outbreak of Shiga toxin-producing Escherichia coli O121 infections associated with flour- Canada, 2016-2017

On December 29, 2016, PulseNet Canada identified a cluster of six Escherichia coli non-O157 isolates with a matching pulsed-field gel electrophoresis (PFGE) pattern combination that was new to the PulseNet Canada database. The patients resided in three geographically distinct provinces. In January 2017, the Public Health Agency of Canada (PHAC) initiated an investigation with local, provincial, and federal partners to investigate the source of the outbreak.

A case was defined as isolation of E. coli non-O157 with the outbreak PFGE pattern or closely related by whole genome sequencing (WGS) in a Canadian resident or visitor with onset of symptoms of gastroenteritis on or after November 1, 2016. Patients’ illness onset dates ranged from November 2016 to April 2017 (Figure). As of May 23, 2017, a total of 29 cases were identified in six provinces (Alberta, British Columbia, Newfoundland and Labrador, Ontario, Quebec, and Saskatchewan). One additional case was identified in a U.S. resident who traveled to Canada during the exposure period. Patients’ ages ranged from 2–79 years (median = 23.5 years) and 50% were female. Eight patients were hospitalized, and one developed hemolytic uremic syndrome. Clinical isolates were typed as E. coli O121:H19 (one case was typed as E. coli O121:H undetermined) with Shiga toxin 2–producing genes by in silico toxin testing and had closely related PFGE patterns and WGS.

Initial investigation into the source of the outbreak did not identify any clear hypotheses; common exposures were ground beef, sausage style deli-meats, pizza, and pork, but the data did not converge on any specific products. Patients were reinterviewed by PHAC using an open-ended approach. Knowledge of a recent E. coli O121 flour-associated outbreak prompted interviewers to ask about baking and exposure to raw flour or dough (1). Patients were also asked if any food items of interest, including flour, were available for testing.

In March 2017, E. coli O121 with the outbreak PFGE pattern was isolated from an open flour sample from a patient’s home and a closed sample collected at a retail store, both of the same brand and production date. The clinical and flour isolates grouped together, with only 0–6 whole genome multilocus sequence typing allele differences. As a result of these findings, a product recall was issued. Based on possible connections to the recalled lot of flour, market sampling of flour within certain periods was initiated. The investigation led to additional recalls of flour and many secondary products (2).

As of May 23, 2017, 22 patients had been asked about flour exposure in the 7 days before illness onset; 16 (73%) reported that the implicated brand of flour was used or probably used in the home during the exposure period. Comparison data on the expected proportion with exposure to this brand of flour were not available. Eleven of these sixteen patients reported they ate or probably ate raw dough during their exposure period.

This is the first national outbreak of non-O157 Shiga toxin–producing E. coli infections identified in Canada and the first Canadian outbreak linked to flour. An open-ended interview approach and flour sampling were used to implicate flour as the source. Because of the recent emergence of E. coli outbreaks linked to flour, public health professionals should consider flour as a possible source in E. coli outbreaks and communicate the risk associated with exposure to flour, raw batter, and dough in public health messaging.

Food safety, Idaho style

The kids in Idaho are alright. Thanks to University of Idaho’s Josh Bevan and the rest of the IFT Intermountain section, I’m in Sun Valley, Idaho taking in the sites after talking some food safety stuff. I gave a talk Friday morning (slides here) on things we’ve seen on barfblog that some might consider emerging issues (kimchi, tempeh, kombucha, sous vide) and a bit on where mere mortals in the kitchen might get food safety information.

One of the things I talked about was illnesses from handling and/or eating raw flour – current with Canadian’s experiencing their second outbreak in a few months.

From CBC news (home of Hockey Night in Canada and topical food safety news):

A new, separate recall involves a batch of Rogers 10-kilogram all-purpose flour possibly contaminated with E.coli and sold at B.C. Costco stores.The recall was triggered by a Canadian Food Inspection Agency (CFIA) investigation after five people in B.C. all became infected with the same strain of E.coli.The B.C. Centre for Disease Control tested the Rogers flour purchased by one of the victims who fell ill after eating raw dough. It contained the E.coli strain O121.Rogers Foods says a direct link to its flour product has not yet been proven and that it’s working with the CFIA on investigating the situation.The company stresses that people can protect themselves by not eating raw flour or dough — the cooking process helps kill any lingering pathogens.”We must emphasize that flour is a raw agricultural product and must be thoroughly baked or cooked before eating,” Rogers Foods said in a letter to customers.

Also this week, Schaffner posed a question to a Facebook group of food safety nerds, ‘E. coli in flour: So always there and now we see it, or new problem?’

My guess, instep with lots of the responses, is it has been there in low levels resulting illnesses. But they looked sporadic with the long shelf life of the product and commingling.

Back in Idaho, I shared some of the materials that from a workshop on STEC in flour that Natalie Seymour and I organized. Karen Neil of CDC, Tim Jackson from Nestle and Scott Hood from General Mills spoke about challenges in flour food safety. The workshop focused on stuff like, there’s no kill step in the milling process, there’s literally tons of commingling and although it’s not intended to be eaten raw – sometimes it is (in cookie dough, cake mix).

And a risk factor in the 2016 Gold Medal-linked outbreak was kids handling raw tortilla and pizza dough in restaurants. There’s some other stuff known about flour – generic E. coli species have been found in flour in NZ. A survey conducted on wheat and flour milling in Australia showed no detectable Salmonella, 3.0 MPN/g of generic E. coli and 0.3 MPN/g of B. cereus recovered on average from 650 samples (from two mills).

And a 2007 US study found generic E. coli in 12.8% of commercial wheat flour samples examined.

We need better messages, better delivery and not just the same old stuff to get folks the risk information they need to make decisions.

 

Going public: about E. coli O121 in Rogers Flour: Why a 17-day difference between feds and province?

In April 2017, health-types in Canada said E.coli O121 had sickened 26 people that was linked to Robin Hood All Purpose Flour, Original.

On May 26, 2017, the Canadian Food Inspection Agency said Ardent Mills is recalling various brands of flour and flour products due to possible E. coli O121 contamination.

On May 21, 2017 the B.C. Centre for Disease Control (BCCDC) alerted British Columbians after six people in B.C. were infected with the same strain of E. coli O121 between February and April, 2017.

Now, CFIA has gotten in on the act – 17 days after BCCDC –announcing on June 7, 2017 that Rogers Foods Ltd. is recalling Rogers brand All Purpose flour from the marketplace due to possible E. coli O121 contamination.

The following product has been sold from Costco warehouse locations in British Columbia.

Brand Name: Rogers, Common Name: All Purpose Flour, Size: 10 kg, Code(s) on Product: MFD 17 JAN 19 C, UPC: 0 60179 10231 8

This recall was triggered by findings by the CFIA during its investigation into a foodborne illness outbreak. The CFIA is conducting a food safety investigation, which may lead to the recall of other products.

There have been reported illnesses that may be associated with the consumption of this product. Further lab testing is underway to confirm the link.

Handle flour like raw meat: More Canadian flour and people sickened with E. coli O121

In April 2017, health-types in Canada said E.coli O121 had sickened 26 people that was linked to Robin Hood All Purpose Flour, Original.

On May 26, 2017, the Canadian Food Inspection Agency said Ardent Mills is recalling various brands of flour and flour products due to possible E. coli O121 contamination. Consumers should not consume the recalled products described below.

This recall was triggered by findings by the CFIA during its investigation into a foodborne illness outbreak. The CFIA is conducting a food safety investigation, which may lead to the recall of other products. If other high-risk products are recalled, the CFIA will notify the public through updated Food Recall Warnings.

The CFIA is verifying that industry is removing recalled products from the marketplace.

There have been reported illnesses associated with flour; however, at this time, there have been no confirmed illnesses associated with the products identified in this Food Recall Warning.

But there have been with Roger flour in B.C.

On May 21, 2017 the B.C. Centre for Disease Control (BCCDC) alerted British Columbians after six people in BC were infected with the same strain of E. coli O121 between February and April, 2017.

A sample of flour from one of the ill people was tested by the BCCDC Public Health Laboratory and found positive for the same strain of E. coli O121 as seen in all the illnesses.

While it is unknown at this time whether the other ill people consumed the same flour, the BCCDC recommends consumers:

Dispose of Rogers all-purpose flour in a 10kg bag with the lot number MFD 17 Jan 19 C.  This flour was available to Costco customers in B.C. beginning in January 2017.

Although this outbreak is occurring at the same time as a national outbreak involving a different strain of E. coli O121 that has been linked to various flours and flour products, it is unclear whether there is a link between the two outbreaks.

The national outbreak has affected 30 people from six provinces: British Columbia (13), Saskatchewan (4), Alberta (5), Ontario (1), Quebec (1) and Newfoundland and Labrador (5). One of the 30 cases was a visitor to Canada. The illness onset dates range from November 2016 to April 2017.

These are the questions that remain about the interactions between Robin Hood, Ardent, Rogers and their flour: Do you folks all get your flour from the same place and slap your name on it like Trump slaps his name on towers? If so, where is the common processor, and why the fuck is there E. coli O121 in it? What are companies prepared to do, like offering pasteurized flour, especially so the medically vulnerable can continue to bake without fretting about flour dust?And when will the Public Health Agency of Canada move beyond boilerplate fairy tales like wash hands, and offer something meaningful to Canadians who bake?

Overpaid bureacrats, worried about their retirement savings rather than a nasty bug like E. coli O121.

Inhale the dust, assholes.

The outpouring of compassion for the victims is underwhelming.

From the E. coli O121 in low-moisture foods file: flour power edition

It’s all so confusing. There’s a cluster of E. coli O121 in Canada. Sort of a big one. 24 people ill in four provinces (British Columbia, Saskatchewan, Alberta and Newfoundland and Labrador) going back to November 2016.

These illness came on the tail end of another E. coli O121 outbreak in the U.S. linked to Gold Medal brand all purpose flour.

Today, CFIA (that’s the Canadian Food Inspection Agency for those following along at home) announces a recall of Robin Hood brand all purpose flour distributed in four provinces (Alberta, British Columbia, Manitoba, Saskatchewan) due to E. coli O121 contamination – linked to one illness.

In the new world of whole genome sequencing it would seem easy to say whether these clusters are linked – or totally different. And is the single illness CFIA reports part of the E. coli O121 cluster? Is it different?

My head hurts.

Earlier this year Natalie Seymour and I organized a workshop on STEC in flour. Karen Neil of CDC, Tim Jackson from Nestle and Scott Hood from General Mills spoke about challenges in flour food safety. The workshop focused on stuff like, there’s no kill step in the milling process, there’s literally tons of commingling and although it’s not intended to be eaten raw – sometimes it is (in cookie dough, cake mix).

And a risk factor in the 2016 Gold Medal-linked outbreak was kids handling raw tortilla and pizza dough in restaurants.

There’s some other stuff known about flour – generic E. coli species have been found in flour in NZ.

A survey conducted on wheat and flour milling in Australia showed no detectable Salmonella, 3.0 MPN/g of generic E. coli and 0.3 MPN/g of B. cereus recovered on average from 650 samples (from two mills).

And a US study found generic E. coli in 12.8% of commercial wheat flour samples examined.

So, yeah, flour.

Playing with raw dough: 63 sickened with Shiga toxin-producing Escherichia coli infections linked to flour (final update)

The U.S. Centers for Disease Control worked with public health and regulatory officials in many states and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli (STEC) infections.

gold-medal-all-purpose5lbSixty-three people infected with the outbreak strains of STEC O121 or STEC O26 were reported from 24 states. A list of the states and the number of cases in each can be found on the Case Count Map page. WGS showed that isolates from ill people were closely related genetically. This close genetic relationship means that people in this outbreak were more likely to share a common source of infection.

Illnesses started on dates ranging from December 21, 2015 to September 5, 2016. Ill people range in age from 1 year to 95, with a median age of 18. Seventy-six percent of ill people were female. Seventeen ill people were hospitalized. One person developed hemolytic uremic syndrome, a type of kidney failure, and no deaths were reported.

Epidemiologic, laboratory, and traceback evidence indicated that flour produced at a General Mills facility in Kansas City, Missouri was the likely source of this outbreak.

In interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. Twenty-eight (76%) of 37 people reported that they or someone in their household used flour in the week before they became ill. Nineteen (50%) of 38 people reported eating or tasting raw homemade dough or batter. Twenty-one (57%) of 37 people reported using Gold Medal brand flour. Three ill people, all children, reported eating or playing with raw dough at restaurants.

In an epidemiologic investigation, investigators compared the responses of ill people in this outbreak to those of people of similar age and gender reported to state health departments with other gastrointestinal illnesses. Results from this investigation indicated an association between getting sick with STEC and someone in the household using Gold Medal brand flour.

Federal, state, and local regulatory officials performed traceback investigations using package information collected from ill people’s homes and records collected from restaurants where ill people were exposed to raw dough. These initial investigations indicated that the flour used by ill people or used in the restaurants was produced during the same week in November 2015 at the General Mills facility in Kansas City, Missouri, where Gold Medal brand flour is produced.

whole-wheat_-flour_-jan_-13-768x576On May 31, 2016, General Mills recalled several sizes and varieties of Gold Medal Flour, Gold Medal Wondra Flour, and Signature Kitchens Flour due to possible E. coli contamination. The recalled flours were produced in the Kansas City facility and sold nationwide.

In June 2016, laboratory testing by FDA isolated STEC O121 in open samples of General Mills flour collected from the homes of ill people in Arizona, Colorado, and Oklahoma. WGS showed that the STEC O121 isolates from the flour samples were closely related genetically to the STEC O121 isolates from ill people. The flour collected in Oklahoma was not included in the initial General Mills recall. The other flour samples that were tested came from lots of flour included in the initial recall announced by General Mills. In July 2016, laboratory testing by General Mills and FDA isolated STEC O26 from a sample of General Mills flour. WGS showed that the STEC O26 isolated from the flour sample was closely related genetically to isolates from an ill person in the PulseNet database. The flour tested was not included in the earlier General Mills recalls. As a result of these findings, General Mills expanded its recall on July 1, 2016 and again on July 25, 2016 to include more production dates.

Although the outbreak investigation is over, illnesses are expected to continue for some time. The recalled flour and flour products have long shelf lives and may still be in people’s homes. Consumers who don’t know about the recalls could continue to eat the products and get sick. A list of the recalled products and how to identify them is available on the Advice to Consumers page.

This outbreak is a reminder that is it not safe to taste or eat raw dough or batter, whether made from recalled flour or any other flour. Flour or other ingredients used to make raw dough or batter can be contaminated with STEC and other germs that can make people sick.

More STEC found: Multistate outbreak of Shiga toxin-producing Escherichia coli infections linked to flour

On July 25, 2016, General Mills expanded its recall to include more production dates. A list of all the recalled flours and how to identify them is available on the Advice to Consumers page.

sorenne.doug.usa.today.jun.11Four more ill people have been reported from two states. The most recent illness started on June 25, 2016.

An infection with another serotype, Shiga toxin-producing Escherichia coli (STEC O26), has been added to this outbreak investigation. STEC O26 was isolated from a sample of General Mills flour (pic, left, from 2011; Sorenne did not eat the flour and awareness of cross-contamination was robust).

One person has developed hemolytic uremic syndrome, a type of kidney failure.

The U.S. Centers for Disease Control, multiple states, and the U.S. Food and Drug Administration(FDA) are investigating a multistate outbreak of Shiga toxin-producing Escherichia coli (STEC) infections.

46 people infected with the outbreak strains of STEC O121 or STEC O26 have been reported from 21 states.

Thirteen ill people have been hospitalized. One person developed hemolytic uremic syndrome, a type of kidney failure. No deaths have been reported.

Epidemiologic, laboratory, and traceback evidence indicate that flour produced at the General Mills facility in Kansas City, Missouri is a likely source of this outbreak.

Several recalls and recall expansions have been announced as a result of this investigation.

In July 2016, laboratory testing by General Mills and FDA isolated STEC O26 from a sample of General Mills flour. Whole genome sequencing (WGS) showed that the STEC O26 isolated from the flour sample was closely related genetically to isolates from an ill person. The flour tested was not included in the earlier General Mills recalls.

On July 25, 2016, General Mills further expanded its flour recall to include additional lots.

CDC recommends that consumers, restaurants, and retailers do not use, serve, or sell the recalled flours.

Do not eat raw dough or batter, whether made from recalled flour or any other flour. Flour or other ingredients used to make raw dough or batter can be contaminated with STEC and other pathogens.

Consumers should bake all items made with raw dough or batter before eating them. Do not taste raw dough or batter.

Restaurants and retailers should not serve raw dough to customers or allow children and other guests to play with raw dough.

This investigation is ongoing, and we will update the public when more information becomes available.

 

 

46 now sick: Creepy crawly General Mills E. coli O121 flour recall expands again

Amy and kids made playdoh from scratch the other day. Flour, water, salt, food coloring, and a mess.

Amy’s gluten-intolerant, but wasn’t about to use expensive gluten-free flour to make playdoh.

whole.wheat.flour.jan.13Flour dust was everywhere, and within 15 minutes Amy announced, “I’ve been glutened. Damn.”

Now image if that flour had E. coli O121 or some other Shiga-toxin producing E. coli inside.

So it’s a stretch to say, as General Mills does, that, “No illnesses have been connected with flour that has been properly baked, cooked or handled.”

Maybe. A better solution may be to use pasteurized flour.

From the PR:

Due to four new confirmed illnesses, General Mills is adding additional flour production dates to the previously announced U.S. retail flour recall that was originally announced on May 31, 2016.

The illnesses reported to health officials continue to be connected with consumers reporting that they ate or handled uncooked dough or ate uncooked batter made with raw flour.  No illnesses have been connected with flour that has been properly baked, cooked or handled.

The addition of new flour production dates is the result of General Mills conducting proactive flour testing and new information from health officials who are using new whole genome sequencing techniques to trace illnesses. E.coli (several sub-types) has been detected in a small number of General Mills flour samples and some have been linked to new patient illnesses that fell outside of the previously recalled dates.

At this time, it is unknown if we are experiencing a higher prevalence of E.coli in flour than normal, if this is an issue isolated to General Mills’ flour, or if this is an issue across the flour industry. The newer detection and genome sequencing tools are also possibly making a connection to flour that may have always existed at these levels.

“As a leader in flour production for 150 years, General Mills is committed to convening experts to work with government officials to learn more and create new protocols, if needed,” said General Mills President and Chief Operating Officer Jeff Harmening. “Most importantly, we want all the avid home bakers out there to have peace of mind and know the most important thing they can do to keep safe is to not eat uncooked flour.”

Flour is a raw ingredient that is intended to be cooked or baked.  Flour is made from wheat that is grown outdoors where bacteria are often present and the normal flour milling process does not remove these bacteria.

Previously announced recalled flour production dates ranged from November 4, 2015 through December 4, 2015. The expansion announced today includes select production dates through February 10, 2016. The new recall applies only to the specific product and date codes listed below.  

A full list of retail products included in the flour recall since May 31, 2016 can be found at www.generalmills.com/flour.

Flour power: Live Science edition

US Secretary of State for Defense Donald Rumsfeld told the defense department in 2002, ‘There are known knowns. There are things we know that we know. There are known unknowns. That is to say, there are things that we now know we don’t know.’

Sorta like E. coli O121 and flour, I guess.

Stephanie Pappas of Live Science and I chatted last week about what’s up with FDA’s recommendation that folks don’t eat raw dough and why don’t they make the same warning about produce – after Slate posted something about the recommendation being oppressive.Kraft-designs-production-method-for-shelf-stable-whole-grain-flour

Friend and colleague Jenny Scott answered it better than I did.

“We just want to provide consumers with the best information to take steps to reduce their risk,” said Jenny Scott, a senior adviser in the office of food safety at the FDA Center for Food Safety and Applied Nutrition. “The same thing happens when we have a produce outbreak.”

But the ways that people traditionally use flour did influence both the timing and the content of the recommendation. Typically, Scott told Live Science, people don’t eat raw flour in large quantities.

“Because people donꞌt think of raw flour as being a concern, that’s one of the reasons we’re making the effort to get the information out,” she said. The risk of illness from raw flour is low, she said, but then, so is the risk from raw produce.

The current flour-related outbreak is the second of two such outbreaks in the past seven years. The earlier one was a 2009 outbreak of another strain of E. coli caused by Nestlé Toll House prepackaged cookie dough, which — surprise, surprise — people were eating raw. Exhibiting a clear-eyed realism about human nature, Nestlé opted to start heat-treating all of the flour in its raw cookie dough.

Known unknowns

Food safety experts are now aware of the flour risk, but are only beginning to understand it. Outbreaks related to produce have been studied intensively for two decades, starting with a massive outbreak of infection with the parasite Cyclospora in 1996 (it eventually was traced to raspberries imported from Guatemala). By comparison, there isn’t much data on the prevalence of pathogens in flour, said Ben Chapman, a professor of food safety at North Carolina State University.

“Over 20 years, we have a pretty good understanding, or a better understanding, of fresh produce consumption, but when it comes to flour, we don’t know,” Chapman told Live Science. “It’s hard to make risk-management decisions based on unknowns.”

No one really knows how General Mills’ flour became contaminated, or if contamination is a widespread problem among other brands. E. coli can spread through animal feces, so wildlife pooping in and around fields might be the culprit. But untreated irrigation water could spread the bacteria, too, Chapman said, or there could be some sort of cross-contamination during the milling process. No one knows how long E. coli or other pathogens persist in dry foods like flour, he said (literature points to it being a long time though if Salmonella is a model; thanks Larry Beuchat, Linda Harris and others -ben).

“It’s still relatively new for us to be looking at this as a community,” he said (there is this great 2007 JFP paper by Bill Sperber that has some info on flour -ben).

As for produce, which is currently responsible for far more outbreaks than raw flour, the FDA is making strides on safety. The agency recently released a new Produce Safety rule under the FDA Food Safety Modernization Act that requires specific water quality guidelines and testing for irrigation water, rules for manure and compost use, and standards related to worker hygiene and equipment and tools. Raw sprouts, the culprit in 42 outbreaks between 1996 and 2014, get special attention under the new rule.

But with huge grain-consuming companies like Nestlé and General Mills linked to outbreaks, producers will be examining their supply chains and processing practices, Chapman said.

“It’s bad business, being linked to outbreaks,” he said.

42 now sickened from E. coli O121 linked to flour

The U.S. Centers for Disease Control reports that as of June 28, 2016, 42 people infected with the outbreak strain of Shiga-toxin producing E. coli O121 have been reported from 21 states.

wondraOn July 1, 2016, General Mills expanded its recall to include additional lots of Gold Medal Flour, Signature Kitchens Flour, and Gold Medal Wondra Flour.

STEC O121 was isolated from samples of General Mills flour collected from the homes of ill people in Arizona, Colorado, and Oklahoma.

Four more ill people have been reported from four states. The most recent illness started on June 8, 2016. One new state, Indiana, has been added to the list of states with ill people.

Illnesses started on dates ranging from December 21, 2015 to June 8, 2016. Ill people range in age from 1 year to 95, with a median age of 18. Eighty-one percent of ill people are female. Eleven ill people have been hospitalized. No one has developed hemolytic uremic syndrome, a type of kidney failure, and no deaths have been reported.

gold-medal-all-purpose5LBGuidance from the Food and Drug Administration (FDA) and CDC continues to warn that consumers should refrain from consuming any raw products made with flour. E. coli O121 is eliminated by heat through baking, frying, sautéing or boiling products made with flour. All surfaces, hands and utensils should be properly cleaned after contact with flour or dough.