Flour power: NEJM paper on 2016 outbreak

A couple of weeks ago Duncan Hines brand cake mixes were recalled because of Salmonella. Maybe it was the flour. Flour comes from dried wheat that’s milled and not heat treated (because it messes with the gluten). As the Salmonella dries out it gets hardier and survives for months (or longer).

In 2016 pathogenic E. coli (both O121 and O26 serogroups) was the culprit in another raw flour outbreak. The good folks involved with that investigation (Crowe and colleagues) published their findings this week in the New England Journal of Medicine.

The outbreak began in December 2015 and lasted through to September 2016. Fifty-six cases in 22 states were identified.

The biggest takeaway for me was this (such a great explanation of how an investigation works):

Open-ended telephone interviews then were conducted with 10 patients, all of whom stated that they baked frequently or regularly consumed home-baked foods. Five of the patients recalled baking during the week before illness onset, and 3 others reported thatthey might have baked during that period. Of the 5 case patients who remembered baking, 4 reported eating or tasting homemade batter or dough, 3 of whom used brand A flour. The fourth used either brand A or another brand. Two of the patients (a resident of Colorado and a resident of Washington) still had the bags of brand A flour that they had used in the week before illness onset.

Shortly thereafter, state investigators identified 3 ill children who had been exposed to raw flour at restaurants in Maryland, Virginia, and Texas. Restaurant staff had given them raw dough to play with while they waited for their food to be served.

Folks in the media or the hockey arena often ask how these outbreaks get solved. This is how – lots of interviewing, hypothesis generating and then a case-case or case-control analysis. It’s part detective work, part statistics and all science. Sometimes the interviews are messy but this one shows what happens when it works.

Trace-back investigation of the two bags of brand A flour collected from patients in Colorado andWashington revealed that the flour from Colorado was unbleached all-purpose flour manufactured on November 14, 2015, and the flour from Washington was bleached all-purpose flour manufactured on November 15, 2015. The two bags were produced in the same facility. The flour that was used in the raw dough given to the children exposed in the Maryland, Virginia, and Texas restaurants also was from this facility, as was flour from three additional bags collected from case patients residing in Arizona, Califor- nia, and Oklahoma.

Raw is risky: Longtime North Dakota lawmaker dies after eating raw oysters in New Orleans

The New Orleans Advocate reports that former longtime Mandan Republican state Rep. Rae Ann Kelsch has died.

Alex Kelsch says his mother died early Tuesday morning at a New Orleans hospital from a bacterial infection caused by eating raw oysters at a restaurant there. She was 58.

Kelsch died after becoming infected with Vibrio vulnificus, which is linked to oysters, according to the Bismarck Tribune.

Kelsch was first elected to the North Dakota House in 1990 and served 22 years, including as the chairwoman of the Education Committee.

She was defeated in the 2012 primary, after it came to light she didn’t file state income tax returns for seven years.

Kelsch’s husband, Thomas, a lawyer, said at the time that he was to blame for the tax problems. The couple said the tax bill was eventually paid.

Raw pet food and human illness

My buddy Scott Weese, whom I haven’t played hockey with for about 15 years (but we won the faculty tournament in 2005, so I figured that was a good time to retire and move to Kansas; I’m the goalie, he’s third from left, back row) writes on his WormsAndGermsBlog that human health risks from raw pet food (either from exposure to pathogens in the food or in the feces of pets eating the food) are known to exist but they’re not well characterized. We know that dogs fed raw meat-based diets clearly have increased risk of shedding various pathogens, particularly Salmonella and multidrug resistant E. coli. We know this results in some degree of disease risk in animals and in humans, but the scope of the problem is poorly understood. A recent report from Public Health England provides some more information about the risks associated with feeding raw pet food.

The report is about four people who were infected with E coli O157, a particularly nasty strain of E. coli that can cause serious disease in people.

One person developed hemolytic uremic syndrome (HUS), a particularly severe consequence of infection, and died.

The four cases involved the same strain of E. coli O157. Three individuals had been exposed to dogs fed a raw meat diet. Tripe was the specific ingredient that was implicated.

Samples of raw pet food were collected for testing. All samples from one raw pet food producer were positive for STEC (shiga toxigenic E. coli, the group to which E. coli O157 belongs). A positive test was also obtained from the freezer of one of the affected individuals, and from one sample of raw tripe. It strain isolated from the tripe was a different from the outbreak strain but supported the notion that tripe might have been the cause. It’s not surprising that they couldn’t isolate the outbreak strain from the food, given the lag from the time of exposure of people to the time of sampling of pet food. Contamination is probably sporadic, with different strains contaminating different batches.

Feeding raw meat-based diets is popular, but associated with risks to pets and people (have we said that enough times yet?). My preference is for it not to be done, but I’m realistic enough to know that people are going to do it anyway. So, I focus on two things:

Who should definitely NOT feed raw meat to their pets?

Households where pets or people are at increased risk of severe disease, including those where young, old, pregnant or immunocompromised individuals (human or animal) are present.

If raw meat is to be fed, how can the risk be reduced?

We have a fact sheet on the Worms & Germs Resources – Pets page about how to reduce the risk. In response to this outbreak, Public Health England produced some similar recommendations on handling raw pet food and preventing infections.

Good on ya Scott.

Now, work on driving to the net.

Jeni’s Ice Cream uses raw milk?

According to the Charlotte Business Journal, Jeni’s Ice Cream is coming to North Carolina and bringing their fun flavors and tasty desserts. And raw milk?

Jeni’s Splendid Ice Creams is scooping up its signature gourmet ice cream and frozen yogurt in South End.

That roughly 1,000-square-foot boutique ice cream shop is located in the Design Center complex. It marks the brand’s first N.C. scoop shop — and 35th overall.

That spot just fit for the brand, says founder Jeni Britton Bauer.

Jeni’s sets itself apart with how its ice cream is prepared.

That means using raw milk, avoiding stabilizers and emulsifiers and using the best ingredients. For example, whiskey is distilled in the U.S., and the brand uses Fair Trade Chocolate and local ingredients when possible, such as fresh fruit or mint from the farmers market.

I tweeted at the @jenisicecreams handle looking for clarification. Have yet to hear what they mean by raw milk. I read it as unpasteurized milk goes into their ice cream. Other folks on Twitter have pointed out that it might just be marketing speak. Like ‘Hey, we make ice cream out of raw milk, well milk that starts raw, and then gets pasteurized.’

I don’t want to get into the raw milk choice debate here. You can check out Food Safety Talk 53: Raw Milk Hampsterdam for my thoughts on that.

Thanks to Dr. Tara Smith (@aetiology) on sleuthing this passage from the Jeni’s website where they talk about raw milk,

Dairy is the foundation of everything we do, so we use the best we can find. Smith’s, the 110-year-old dairy in Orrville, Ohio, has been sourcing raw cream and grass-grazed milk and pasteurizing it for us for the past couple of years. They work with small family farms within 200 miles of our kitchen.

Back to the Biz Journal article:

“Our ice creams really are fundamentally different from others,” she says.

If they make it with raw milk, yeah. And would be doing so illegally in NC. If they are talking about raw milk that becomes pasteurized before they get it, or they pasteurize it, then they are like pretty much every other ice cream processor in the U.S.

Update: Jeni’s (@jenisicecreams) tweeted back to me with this info:

 

Father of Tennessee E. coli victim ‘Nutritionist recommended raw milk’

James Zenker never imagined his young son would battle for his life at just two-years-old.

“It’s affected his kidneys; they shut down,” Zenker said. “It affected his intestines; he couldn’t digest any of his food and its affected his brain — he has a substantial brain injury.”

His son William got E. coli after drinking raw milk linked to French Broad Farm. Zenker said a nutritionist recommended the raw milk to help William fight allergies.

“He’s not able to speak and not able to do the same activities as before he was ill,” Zenker said.

The vast majority of nutritionists, dieticians and physicians I encounter – and it’s frequent with my brain status and trips to emergency – know shit about microbial food safety.

The odd ones do, and they are food safety heros.

But when hospitals continue to serve raw sprouts to immunocompromised people, when they won’t be sold at WalMart in the U.S., I gotta question their food safety credibility.

To reiterate, I stared the Food Safety Network (the original FSN) over 25 years ago as an incoming graduate student in 1993 in the wake of the Jack-in-the-Box outbreak, combining my science and journalism learnings, and because a constant refrain I observed was, I never knew foodborne illness could be so serious.

That’s why I continue to do it as a form of community service (I haven’t been paid since 2016).

Of the 15 children sick with E. coli in Tennessee that has now been linked to consumption of raw milk and contact with ruminants from French Broad Farm, William is the last one left in the hospital. His father said East Tennessee Children’s Hospital saved his son’s life.

The Knox County Health Department said an investigation concluded that the outbreak was caused by two separate sources, the exposure to farm animals and exposure to raw milk.

“While it is rare, it appears we had two sets of children sickened by two different strains of E. coli O157 at the same time. The epidemiological evidence overwhelmingly supported the two-source theory: consumption of raw milk and some type of contact, most likely indirect, with ruminant animals,” said KCHD Director Dr. Martha Buchanan.

William has had several blood transfusions during his recovery and still needs more. His home church Temple Baptist in Powell (no relation – dp) hosted a replacement drive Tuesday for William and the community.

“It’s so encouraging to see people take time out of their busy day and donate from their own life to help Will and others affected by E. coli,” Zenker said.

If you would like more information about future blood drives click here: 
Blood drives scheduled to help children infected with E. coli.

Night soil: Kenyans feeding on Sukuma wiki grown in raw sewage

While some city residents have become farmers either by design or default depending on the residential area one resides in, cheap is proving to be life threatening as farmers are now using raw sewage for farming. This means much of the vegetables especially sukuma wiki (kales) on sale in Nairobi are highly contaminated and pose a serious health risk to consumers.

A visit to the sewage collection point in Njiru, Nairobi by Linda Shiundu of TUKO.co.ke revealed the effluence deposited there is always tapped and used for farming by farmers living. The farmers who wished to remain anonymous said instead of waiting for the rains, they would rather take advantage of the 75,000 liters of untreated sewage disposed daily to water their crops. They do so by digging trenches from the deposit site channeling the semi solid human waste into their farms which they use to water the crops and as manure. They mainly grow vegetables like sukuma wiki, spinach and other crops like bananas. Sewage deposited at the sewage collection point around Njiru area is always trapped by farmers living around the collection center and use for planting. The vegetables later on find their way into the market and in to the plates and stomachs of many unsuspecting residents. The vegetables later on find their way into the market.

Despite the health risks posed by the exposed raw sewage including, diarrhea, abdominal pain, vomiting and even death, open food kiosks are also run next to the disposal site. The kiosks are normally flooded with drivers who bring in the hundreds of lorries daily to deposit the sewage.

Raw is risky: NZ raw milk warning as Campylobacter cases rise

Nelson Marlborough Health said in the last four weeks, 24 cases had been notified to the Medical Officer of Health, compared to a range of 6-16 cases in the same period over the previous five years.

A number of known risk factors for campylobacteriosis had been identified in the people affected. These were: drinking raw (unpasteurised) milk or untreated water, and contact with animals and/or nappies.

Nelson Marlborough Medical Officer of Health Dr Stephen Bridgman advised people against drinking raw milk and said it was risky for anyone to consume, but young children and babies, older people, pregnant women and people with a weakened immune system were especially at risk of severe illness.

The public health service was working with the Ministry for Primary Industries, the Ministry of Health and the Institute of Environmental Science and Research to identify the reasons for the increase.

A single source cause was yet to be found and investigations were ongoing.

Raw is risky: ‘Not aware this was remotely possible’ Father of toddlers critically sickened by E. coli linked to raw milk in Tenn.

I started the Food Safety Network (the original FSN) as an incoming graduate student in 1993 in the wake of the Jack-in-the-Box outbreak, combining my science and journalism learnings, and because a constant refrain I observed was, I never knew foodborne illness could be so serious.

That’s why I continue to do it as a form of community service (I haven’t been paid since 2016).

There are now at least 15 children sick with E. coli in Tennessee that has now been linked to consumption of raw milk from French Broad Farm.

According to Kristi L Nelson of Knox News, Jordan and Stephanie Schiding wanted to give their children every health advantage.

That’s the reason the Schidings, two months ago, signed up for a local cow-share program after they read about the health benefits of unpasteurized milk.

Instead, 18-month-old Genevieve and 3-year-old Anthony contracted an illness caused by E. coli bacteria and ended up with kidney failure in the pediatric intensive care unit at East Tennessee Children’s Hospital — two of 12 local children hospitalized with E. coli since the end of May.

Knox County Health Department staff told the Schidings the E. coli infection was likely linked to the consumption of raw milk from French Broad Farm. On Thursday, the health department lifted its directive that requested French Broad Farm temporarily cease operations. But health department Director Dr. Martha Buchanan reiterated that consuming raw milk is always risky and health officials recommend the public consume only pasteurized milk and dairy products.

Jordan Schiding said he and his wife knew there was “potential” for food poisoning from unpasteurized milk, which both adults drank with seemingly no serious effects, but “we were definitely not aware that anything like this was remotely possible.”

The Schiding children seem to have turned a corner, he said, with Anthony discharged Friday afternoon and Genevieve still hospitalized but out of intensive care.

But what started as a supposed stomach bug May 31 turned into a terrifying experience that traumatized both the children and their parents, who had to watch them suffer.

Schiding said the family brought Genevieve to the emergency room at Children’s Hospital May 31 after she became seriously dehydrated with diarrhea and vomiting. As she was being admitted, Anthony also began vomiting.

The hospital rehydrated the children and discharged them a few hours later. Schiding believes they were among the first children related to the current cluster of E. coli cases to come to Children’s Hospital.

Two days later, after both children continued to get sicker, the Schidings brought them back to the hospital. This time, hospital staff took a stool sample from Genevieve, which tested positive for E. coli, and then from Anthony, who also tested positive. Both children were admitted, and Knox County Health Department contacted the couple the next day, he said.

The Schidings knew little about E. coli; certain strains produce a toxin, Shiga, that can cause a chain of reactions in the body — hemolytic uremic syndrome — resulting in clots in the small blood vessels in the kidneys that cause kidney failure. The very young, the very old and people whose immune systems are already compromised are more susceptible to HUS.

Four children admitted to Children’s so far have had HUS, including Genevieve and Anthony. Though Anthony wasn’t quite as sick as his sister, both had surgery to implant central lines so they could get fluids, dialysis and blood transfusions, Schiding said. Anthony had three days of dialysis, Genevieve seven.

In addition, Anthony’s central lines became infected with staph, Schiding said, but the antibiotics typically prescribed to treat staph are too hard on the kidneys to give a child with HUS, so doctors had to use a less common medication, which has seemed to work.

“Obviously, we were freaked out a little bit,” Schiding said. “It seemed like he had started turning the corner” until he spiked a fever of 104.9 and tested positive for staph.

Schiding said his family no longer will consume raw milk.

Raw is risky: Netherlands study finds STEC and Campylobacter in dairy goats and dairy sheep, shows importance of pasteurization

Researchers with the Dutch National Institute for Public Health and the Environment (RIVM) and the Dutch Food and Consumer Product Safety Authority (NVWA) shows that two types of bacteria that can cause diarrhea in humans ( STEC and Campylobacter) are common in dairy goat farms and dairy sheep farms, according to a RIVM press release (computer translated).

According to Outbreak News Today, in the animal study, 181 dairy goat farms and 24 dairy sheep farms were examined. STEC (Shiga-toxin-producing E. coli) and Campylobacter was found on most. STEC appeared on virtually all the farms studied. Campylobacter has been demonstrated in one out of three goat farms (33 percent) and almost all sheep farms (96 percent). These bacteria have found much less among cattle farmers and family members.

Listeria was less common, at about 9 percent of the goat and about 17 percent of the sheep farms. The bacteria was not found in the people studied. People run the risk of becoming infected with the listeria bacteria by eating raw milk soft cheese. The study also looked at Salmonella and ESBL-producing bacteria. These were not very common on the farms surveyed.

The results show that pasteurization of milk and hygiene after visiting a dairy goat farm or dairy sheep farm is important to prevent disease.

The bacteria found are in the intestines of the animals and thus enter the manure. A small amount of manure can contaminate raw milk or raw milk cheese. Contamination can be prevented by drinking only pasteurized milk or using it in other foods. In addition, people at a farm can become infected if they have contact with the animals or their environment. Visitors can reduce the risk of illness by washing their hands after contact with the animals or their environment.

In unrelated but related news, Brandon Macz of the Monroe Monitor reports that St. John Creamery in Monroe, Washington, announced on Thursday it is voluntarily recalling raw goat milk that may be contaminated with Escherichia coli (E.coli) bacteria.

A June 14 news release states the recall was initiated after “the presence of toxin-producing E.coli in retail raw goal milk dated 6/17” was discovered during routine sampling by the Washington State Department of Agriculture.

Included in the recall are half-gallon and one-pint containers of raw goat milk marked best by June 17-21.

Raw is risky: Oysters suspected as jury awards couple $6.7 million in Tampa food poisoning

Jonathan Capriel of Tampa Bay reports a jury awarded a couple $6.7 million after they got sick from eating seafood at a Tampa restaurant. The verdict came in May, years after the husband’s illness led to a rare disorder that causes paralysis and nerve damage.

Angel Martinez and his wife Maria Elena Martinez had eaten 10 times earlier at Lobster Haven, 12807 W Hillsborough Ave., when they sat down Dec. 21, 2013, for their usual — two three-pound lobsters and a dozen Bluepoint oysters, according to court records.

The couple declined to comment for this story, as did Lobster Haven owner Daniel Hall.

Attorneys for the couple said the illness was likely caused by the oysters.

“You take a risk when eating raw oysters,” said Brandon Cathey, who represented the Martinezes. “It might get you sick, but you don’t expect it to cause lifelong nerve damage.”

A few hours after the meal, the couple experienced vomiting and diarrhea, according to court records.

Maria Elena Martinez recovered in a few days, but three weeks later, her husband had to be taken by ambulance to Pasco Regional Medical Center after he collapsed on the floor at his home, according to court records.

Doctors transferred him to Tampa General Hospital, where he spent seven days in the intensive care unit, according to court records. He was paralyzed from the waist down for several months and had to learn how to walk again, according to court records.

Martinez’s foodborne illness developed into Guillain-Barre Syndrome, a rare disorder that causes the immune system to attack one’s own body.

He has recovered from the most severe symptoms of the illness but will likely feel long term effects, said his attorney Brent Steinberg.

Lobster Haven admitted it served the couple seafood that poisoned them but denied that it caused Guillain-Barre Syndrome, blaming instead a lamb that Mr. Martinez slaughtered and ate days later.

Lobster Haven’s insurance company offered to settle the case for $20,000 in 2016, Cathey said, but by then Martinez’s medical bills had reached more than $325,000, according to court records.

The restaurant had liability insurance up to $1 million and the Martinez’ likely would have settled for that amount, Cathey said.

“Now this restaurant may go out of business,” he said, “because of the way his insurance company handled this.”