My mother used to make and lot of cakes and brownies with her groovy 1960s hand mixer and I always got to lick the beaters.
And it’s not just the raw eggs, it’s the raw flour.
In June, 2009, an outbreak of shiga-toxin producing E. coli (STEC, primarily O157:H7) in Nestle Toll House cookie dough sickened at least 77 people in 30 American states. Thirty-five people were hospitalized – from cookie dough.
The researchers could not conclusively implicate flour as the E. coli source, but it remains the prime suspect. They pointed out that a single purchase of contaminated flour might have been used to manufacture multiple lots and varieties of dough over a period of time as suggested by the use-by dates on the contaminated product.
The study authors concluded that “foods containing raw flour should be considered as possible vehicles of infection of future outbreaks of STEC.”
So it wasn’t much of a surprise when 63 people fell sick from the outbreak strain of E. coli O121 from Dec. 2015 to Sept. 2016 linked to raw General Mills flour.
There have been about a dozen other flour-related outbreaks. STEC means people – and kids – get quite sick.
Flour is a raw commodity, crops the flour is derived from could be exposed to anything, and testing is so much better than it used to be.
There are some brands of pasteurized flour out there, but people seem to have gotten used to flour as a cheap source of play-dough-like stuff for kids and something to throw at people.
The U.S. Centres for Disease Control says, nope.
This is not a Christmas conspiracy (although I prefer Solstice Season): it’s CDC providing information, like they are supposed to.
People can, and will, do what they want.
As Maggie Fox of NBC reports, “Do not taste or eat any raw dough or batter, whether for cookies, tortillas, pizza, biscuits, pancakes, or crafts made with raw flour, such as homemade play dough or holiday ornaments,” the CDC advises.
“Do not let children play with or eat raw dough, including dough for crafts.”
Handling food, including flour, requires care and hygiene.
“Keep raw foods such as flour or eggs separate from ready-to eat-foods. Because flour is a powder, it can spread easily,” the CDC notes. “Follow label directions to refrigerate products containing raw dough or eggs until they are cooked. Clean up thoroughly after handling flour, eggs, or raw dough.”
Turtles were inexpensive, popular, and low maintenance, with an array of groovy pre-molded plastic housing designs to choose from. Invariably they would escape, only to be found days later behind the couch along with the skeleton of the class bunny my younger sister brought home from kindergarten one weekend.
But eventually, replacement turtles became harder to come by. Reports started surfacing that people with pet turtles were getting sick. In 1975, the U.S. Food and Drug Administration (FDA) banned commercial distribution of turtles less than 4 inches in length, and it has been estimated that the FDA ban prevents some 100,000 cases of salmonellosis among children each year.
Maybe I picked up my turtle, rolled around on the carpet with it, pet it a bit, and then stuck my finger in my mouth. Maybe in my emotionally vacant adolescence I kissed my turtle. Who can remember?
The U.S. Centers for Disease Control reports today that in June 2017, PulseNet, the national molecular subtyping network for foodborne disease surveillance, identified 17 Salmonella Agbeni clinical isolates with indistinguishable XbaI enzyme pattern (outbreak strain) by pulsed-field gel electrophoresis. The same Salmonella Agbeni XbaI pattern was isolated from a turtle in 2015; in a 2016 investigation involving the same outbreak strain, 63% of patients reported contact with turtles (CDC, unpublished data, 2016). Despite prohibition of sale of small turtles (shell length less <4 inches) in the United States since 1975 (1), illness outbreaks associated with turtle contact continue to occur. Ill persons in previous Salmonella Poona and Salmonella Pomona outbreaks linked to turtles were geographically concentrated in the Southwest region of the United States (2,3). Turtle production is known to be higher in the Southeast region of the country (2). An outbreak investigation by CDC and health departments was initiated to identify the source of the 2017 illness outbreak.
A case was defined as isolation of Salmonella Agbeni with the outbreak strain from an ill patient during April–December 2017. State and local health officials interviewed patients to ascertain turtle exposure information, including details about the species of turtle and purchasing information. Purchase locations reported by patients were contacted for traceback information. Whole genome sequencing (WGS), using high quality single nucleotide polymorphism (hqSNP) analysis, was performed by CDC on clinical isolates from the 2017 outbreak, the 2016 illness cluster, and the turtle isolate from 2015 to characterize genetic relatedness.
Seventy-six cases were identified in 19 states in 2017; two thirds (67%) of patients resided in East Coast states (Connecticut, Delaware, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, Rhode Island, and Virginia).* Patient ages ranged from <1–100 years (median = 21 years). Among 63 (83%) patients with information on hospitalization, 30 (48%) were hospitalized; no deaths were reported. Fifty-nine (78%) patients provided exposure information, including 23 (39%) who reported contact with turtles; among these, 14 (61%) specified small turtles. Among 12 patients who reported how the turtles were obtained, six purchased them from a street or roadside vendor, three purchased them from a retail store, two purchased them at festivals, and one reported receiving them as a gift. The traceback investigation did not identify a common turtle farm that supplied purchase locations. WGS hqSNP analysis indicated that the 2017 and 2016 clinical isolates and the 2015 turtle isolate were closely related, differing by 0–18 SNPs.
This salmonellosis outbreak was linked to contact with small turtles and was associated with a higher frequency of hospitalization (48%) than multistate foodborne pathogen outbreaks (27%) as well as recent Salmonella outbreaks linked to turtles (28%–33%) (2–4). The geographic distribution of patients differed from that of previous outbreaks, suggesting the need to better understand the breeding of turtles and distribution of turtle sales in the United States. WGS hqSNP analysis was used to link historic illnesses and turtle isolates to isolates from 2017 patients, supporting the hypothesis that turtles were the likely source of this outbreak. This outbreak indicates further need to educate consumers and retail store staff members regarding the ban on sale of small turtles and to educate consumers to prevent transmission of Salmonella from pets to humans.
Notes from the Field: An Outbreak of Salmonella Agbeni Infections Linked to Turtle Exposure — United States, 2017
Lia Koski, MPH1,2; Lauren Stevenson, MHS1,3; Jasmine Huffman1; Amy Robbins, MPH4; Julia Latash, MPH5,6; Enoma Omoregie, PhD5; Kelly Kline, MPH7; Megin Nichols, DVM1 (View author affiliations)
Gambino-Shirley K, Stevenson L, Concepción-Acevedo J, et al. Flea market finds and global exports: four multistate outbreaks of human Salmonellainfections linked to small turtles, United States—2015. Zoonoses Public Health 2018;65:560–8. CrossRefPubMed
Basler C, Bottichio L, Higa J, Prado B, Wong M, Bosch S. Multistate outbreak of human SalmonellaPoona infections associated with pet turtle exposure—United States, 2014. MMWR Morb Mortal Wkly Rep 2015;64:804. CrossRefPubMed
Longtime friend of the barfblog.com, Michéle Samarya-Timm, health educator at the Somerset County Department of Health (that’s in New Jersey, represent) writes:
Baking pumpkin pies with Aunt Kay’s secret recipe. Watching Miracle on 34th Street. Preparing the dining room with the good china. Diffusing political conversations at the dinner table.
Some traditions give a sense of warmth, connection, and continuity, and regularly define a family’s holiday. Unfortunately, there is now a need to add an additional tradition to the season – actively checking for foodborne outbreaks and recalls to prevent folks from getting sick.
Last week, on Tuesday, November 20th at 2pm, (two days before Thanksgiving), the CDC posted a media statement with advice to consumers, restaurants, and retailers:
“CDC is advising that U.S. consumers not eat any romaine lettuce, and retailers and restaurants not serve or sell any, until we learn more about the outbreak.”
The need to release such a notice, right before a major holiday is an unpropitious scenario. It was also very concerning in its specificity to consumers, retailers and restaurants:
“Wash and sanitize drawers or shelves in refrigerators where romaine was stored.”
Such an alert is most effective if it reaches the intended audiences. Folks at my holiday table did not hear about the outbreak. Neither did many local health departments.
Issuing media releases is one way for public health agencies to reach large groups of people. However, distracted by holiday preparations, travel, shopping, family, football and bad weather this advisory was only partially disseminated to the public. A person had to be following news outlets or social media to receive timely notice. I heard about the recall from the woman next to me while I was getting a haircut – not from the CDC or FDA, or any other federal or state agency.
It’s disturbing. The CDC could have sent this info directly to local health departments, or notify them that a news release was issued. This was not the first time as a local public health official that I received delayed – or no – official communication about a national foodborne issue.
Local public health professionals rely on communications systems established by federal and state oversight agencies. Most commonly, if a verified or suspect foodborne contamination or outbreak has occurred, the Centers for Disease Control and Prevention (CDC), the U.S. Department of Agriculture, or the U.S. Food and Drug Administration (FDA) will ascertain the appropriateness of information release. If this information is deemed credible, notification is forwarded individually or en masse to state departments of health. The states, in turn, push this information down to local regulators. Each step in the process contains elements that may delay the rapid dissemination of outbreak information. The ability and willingness of all stakeholders to quickly and readily share incident particulars with fellow responding agencies can enhance effectiveness and amplify response efforts.
Electronically sending this advisory directly to the nearly 3,000 local health departments in the US would provide the opportunity for hundreds of health inspectors, health educators, epidemiologists and other to reach the hospitals, food banks, schools, mom and pop establishments and local residents who may not have otherwise received the alert. This was a missed opportunity, and hopefully one that didn’t cause additional cases of illness.
As I’ve written before, coordinated communication strategies within and between public health agencies is less robust than it should be. As a result, state and local public health officials may hear about foodborne disease issues first from other sources, such as the media, word of mouth, public complaints, or the food industry.
We need to learn how to communicate better with each other. Local public health shouldn’t have to keep an eye on the news media, Twitter or Facebook for information pertinent to protecting the people in our jurisdictions. A multitude of electronic portals exist for purposes of interagency communication, CDC, FDA, and the public health system should collectively define how pertinent information – such as this romaine advisory – rapidly and routinely gets to the grass roots public health workforce. Continuously improving interagency coordination and communication is a goal that is fundamental to increasing the effectiveness of this nation’s food safety systems. I’m putting this out there, because I’m willing to help with the solution. That way, in future years, I can spend my holidays perfecting Aunt Kay’s pie recipe.
This holiday, I’m thankful for public health influencers and amplifiers – like barfblog.com – that act as outbreak aggregators, and push out info to local public health types like me.
Some background information and recommendations on this topic can be found in: Getting the message across: an analysis of foodborne outbreak communications between federal, state, and local health agencies https://calhoun.nps.edu/handle/10945/49379
The U.S. Centers for Disease Control reports on November 28, 2017, the manager of restaurant A in Tennessee reported receiving 18 complaints from patrons with gastrointestinal illness who had dined there on Thanksgiving Day, November 23, 2017. Tennessee Department of Health officials conducted an investigation to confirm the outbreak, assess exposures, and recommend measures to prevent continued spread.
On November 23, one patron vomited in a private dining room, and an employee immediately used disinfectant spray labeled as effective against norovirus* to clean the vomitus. After handwashing, the employee served family-style platters of food and cut pecan pie. For the November 23 Thanksgiving Day, restaurant A served 676 patrons a limited menu from 11 a.m. to 8 p.m. The manager provided contact information, seating times, and seating locations for 114 patrons with reservations. All patrons with contact information were telephoned, and a questionnaire was used to assess illness and exposures for anyone living in the household who ate at restaurant A on November 23. Stool specimens were requested from ill patrons. Among the 676 patrons, 137 (20%) were enrolled in a case-control study.
A probable case was defined as diarrhea (three or more loose stools in 24 hours) or vomiting within 72 hours of eating at restaurant A on November 23; probable cases with norovirus RNA detected in a stool specimen by real-time reverse transcription–polymerase-chain reaction (RT-PCR) were considered confirmed. On November 30, environmental swabs for norovirus testing were collected in the restaurant. Patient and environmental samples were tested by real-time RT-PCR and sequenced at the Tennessee State Public Health Laboratory.
Thirty-six (26%) case-patients (two confirmed and 34 probable) and 101 (74%) controls were enrolled in the case-control study. Illness onsets occurred during November 23–25, with 17 of 35 (49%) cases occurring on November 24. The mean incubation period was 31 hours (range = 2.5–54.5 hours), and the mean illness duration was 3 days (range = 0–6 days). Only one case-patient sought medical care. Diarrhea was reported by 33 (94%) case-patients, fatigue by 29 (83%), nausea and abdominal cramps by 28 (80%), vomiting by 24 (69%), and fever by six (17%).
Among menu items, only pecan pie was significantly associated with illness (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.1–5.8); however, it was eaten by only 16 (47%) of 34 case-patients. The vomiting event occurred around noon; patrons seated during 11 a.m.–1 p.m. were significantly more likely to become ill than were patrons seated during other times (OR = 6.0; 95% CI = 2.6–15.3). No significant differences between dining locations (i.e., private dining room versus general seating) were identified (OR = 1.4; 95% CI = 0.4–4.3). Logistic regression was used to evaluate the effects of eating pecan pie, seating time, and seating location; only seating time during 11 a.m.–1 p.m. remained statistically significant (OR = 6.0; 95% CI = 2.2–16.5).
Stool specimens from two case-patients identified Norovirus GII.P16-GII.4 Sydney. Norovirus GII was identified in one environmental swab collected from the underside of a table leg adjacent to the vomitus.
A point-source norovirus outbreak occurred after an infected patron vomited in a restaurant. Transmission near the vomiting event likely occurred by aerosol or fomite. Norovirus spread throughout the restaurant could have occurred by aerosol, person-to-person, fomite, or foodborne routes. Inadequate employee handwashing likely facilitated foodborne transmission through servings of pecan pie.
In hospital settings, CDC and the Tennessee Department of Health recommend contact precautions (e.g., gloves and gowns) when personnel have contact with vomitus (1). Similarly, the Food and Drug Administration’s 2017 Food Code recommends restaurants have a written plan detailing when and how employees should use personal protective equipment for cleaning vomitus (2). Reinforcing the need for proper handwashing and performing thorough environmental cleaning with appropriate personal protective equipment in food service establishments can prevent or mitigate future outbreaks.
Teresa Vantrease, Jana Tolleson, Tiffany Rugless, Lee Wood, Anita Bryant-Winton, Heather Mendez, Jeannette Dill, Alan Pugh, Jason Pepper, Katie Nixon, Marcy McMillian, Jane Yackley; FoodCORE Interview Team; staff members from restaurant A.
1Epidemic Intelligence Service, CDC; 2Division of Scientific Education and Professional Development, CDC; 3Communicable and Environmental Diseases and Emergency Preparedness, Tennessee Department of Health; 4Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.
All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. William Schaffner reports personal fees from Pfizer, Merck, Dynavax, Seqirus, SutroVax, and Shionogi, outside the submitted work. No other potential conflicts of interest were disclosed.
* Active ingredients = n-Alkyl dimethyl benzyl ammonium chlorides and n-Alkyl dimethyl ethylbenzyl ammonium chlorides.
CDC continues to investigate a multistate outbreak of E. coli O157 infections linked to romaine lettuce. We understand this outbreak is of concern to many Americans – especially with so many gathering for meals this Thanksgiving week. CDC’s disease detectives are working with federal regulatory partners to investigate and determine the source of contamination as quickly as possible. We will continue to provide more information as it becomes available. The good news is we were able to detect and identify the outbreak quickly through our disease surveillance system, which can prevent further illness.
However, until we know more, it’s crucial that Americans continue to follow the guidance that CDC issued. There are no exceptions – all romaine lettuce must be discarded, regardless of brand, type, or if it is in a mixture. We also continue to urge people to follow our tips to help prevent E. coli illness. In addition, we remind clinicians that antibiotics are not recommended for patients in whom E. coli O157 is suspected until diagnostic testing rules out this infection.
The U.S. Centers for Disease Control (CDC) and public health and regulatory officials in several states are investigating a multistate outbreak of multidrug-resistant Salmonella infections linked to raw chicken products. The U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS) is monitoring the outbreak.
Always handle raw chicken carefully and cook it thoroughly to prevent food poisoning. This outbreak is a reminder that raw chicken can have germs that spread around food preparation areas and make you sick.
CDC is not advising that consumers avoid eating properly cooked chicken, or that retailers stop selling raw chicken products.
CDC advises consumers to follow these steps to help prevent Salmonella infection from raw chicken:
Wash your hands. Salmonella infections can spread from one person to another if hands have Salmonella germs on them. Wash hands before and after preparing or eating food, after contact with animals, and after using the restroom or changing diapers.
Don’t spread germs from raw chicken around food preparation areas. Washing raw poultry before cooking is not recommended. Germs in raw chicken can spread to other foods and kitchen surfaces. Thoroughly wash hands, counters, cutting boards, and utensils with warm, soapy water after they touch raw chicken. Use a separate cutting board for raw chicken and other raw meats if possible.
CDC does not recommend feeding raw diets to pets. Germs like Salmonella in raw pet food can make your pets sick. Your family also can get sick by handling the raw food or by taking care of your pet.
CDC will update the advice to consumers and retailers if more information comes available, such as a supplier or type of raw chicken product linked to illness.
Symptoms of Salmonella Infection
Most people infected with Salmonella develop diarrhea, fever, and stomach cramps 12 to 72 hours after being exposed to the bacteria.
The illness usually lasts 4 to 7 days, and most people recover without treatment.
In some people, the diarrhea may be so severe that the patient needs to be hospitalized. Salmonella infection may spread from the intestines to the bloodstream and then to other places in the body.
In rare cases, Salmonella infection can cause death unless the person is treated promptly with antibiotics.
Children younger than 5 years of age, adults older than 65 years of age, and people with weakened immune systems are more likely to have severe illness.
What you do at home is your own business, but when cooking for 120 children, risk management is a little different.
For example, the U.S. Food and Drug Administration, along with the Centers for Disease Control and Prevention (CDC) and state and local partners, investigated a multi-state outbreak of Salmonella Enteritidis illnesses linked to shell eggs.
As of October 25, 2018, there were 44 illnesses associated with shell eggs from Gravel Ridge Farms, in Cullman Alabama. The CDC has announced that this outbreak appears to be over.
The FDA advises consumers not to eat recalled shell eggs produced by Gravel Ridge Farms. Consumers who have purchased these products should discard the eggs or return them to the store for a refund. For a complete list of stores, visit the recall notice.
Consumers should always practice safe food handling and preparation measures. Wash hands, utensils, and surfaces with hot, soapy water before and after handling raw eggs and raw egg-containing foods. Dishes containing eggs should be cooked to 160° F. For recipes that call for eggs that are raw or undercooked when the dish is use either eggs that have been treated to destroy Salmonella, by pasteurization or another approved method, or pasteurized egg products.
On September 5, 2018, the FDA and Alabama Department of Agriculture and Industry began an inspection at Gravel Ridge Farms and collected environmental and egg samples for laboratory testing. The results were used to confirm that Salmonella Enteritidis isolates collected from environmental and egg samples taken at the farm were genetically related to isolates obtained from ill persons.
As a result of the outbreak, Gravel Ridge Farms voluntarily recalled cage-free, large eggs and removed the eggs from the shelves at grocery stores, restaurants, and other retail locations.
Twenty-six of 32 (81%) people interviewed reported eating restaurant dishes made with eggs. These restaurants reported using shell eggs in the dishes eaten by ill people.
The whole restaurant dishes-made-with-raw-eggs-thing, such as mayo and aioli is problematic. My 9-year-old knows to ask how the aioli is made if she gets fish, and the server always comes back and says, chef makes it only with raw eggs, and she knows enough to say no.
But we are the poop family (it’s on the front door).
I had a couple of thermometers in my back pack but were not necessary.
In December 2017, the Colorado Department of Public Health and Environment reported two human Salmonella Enteritidis infections in persons with exposure to pet guinea pigs. The guinea pigs had been purchased from two separate pet stores, belonging to a single chain, and supplied by a common distributor located in California. Clinical isolates were indistinguishable by pulsed-field gel electrophoresis (PFGE), suggesting the infections were related. This PFGE pattern was previously seen in a 2010 multistate outbreak linked to contact with pet guinea pigs (1). An investigation was initiated to determine the number of patients affected and to identify the source of human illnesses.
A case was defined as Salmonella Enteritidis infection with a clinical isolate having an identical PFGE pattern to those from the Colorado isolates and closely related to a guinea pig isolate by whole genome sequencing (WGS), and with onset of clinical signs on or after January 1, 2015. State health departments were asked to review recent Salmonella Enteritidis illness records for patient exposure to guinea pigs. In addition, the U.S. Department of Agriculture’s National Veterinary Services Laboratories was queried for isolates from guinea pigs that matched the outbreak strain. All isolates underwent WGS using high-quality single nucleotide polymorphism (SNP) analysis. An isolate from the 2010 outbreak was sequenced for comparison. Guinea pig purchase invoices were used to trace guinea pigs with an epidemiologic link to human illness back to the distributor of origin.
Nine cases in humans were identified from eight states, including two cases in Colorado and one each in Iowa, Indiana, Massachusetts, Michigan, New York, Vermont, and Virginia. Five of eight patients reported exposure to guinea pigs. Onset dates ranged from July 15, 2015, to December 15, 2017. The median patient age was 12 years (range = 1–70 years). Five patients were female. One patient was hospitalized, and no deaths were reported. Six isolates submitted to veterinary diagnostic laboratories from ill guinea pigs and one isolate from a patient’s guinea pig were sequenced and found to be closely related to the outbreak strain. Including the 2010 isolate tested for comparison, all isolates were within 38 SNPs by WGS.
Traceback information was available for four guinea pigs purchased from two large pet store chains (Figure). The two distributors supplying guinea pigs to pet stores during this outbreak received guinea pigs from multiple wholesalers; however, a single common wholesaler was mentioned by both. This wholesaler also supplied guinea pigs that were associated with cases during the 2010 outbreak.
Following the 2010 outbreak, recommendations including environmental testing were made to the wholesaler regarding Salmonella prevention; however, the actions were not implemented. Failure to implement recommended prevention measures might have contributed to recurrence of the outbreak. To enhance compliance with recommendations made in this outbreak, CDC developed a document containing prevention measures aimed at reducing the prevalence of Salmonella in guinea pig colonies intended for use in the pet industry. Content was also posted on the CDC website to increase consumer awareness of risk for Salmonella infection linked to pet guinea pigs. Recommendations to pet owners during this outbreak focused on proper hand hygiene. Recommendations to distributors and wholesalers included routine monitoring of guinea pigs for Salmonella through diagnostic testing, recordkeeping to aid in traceback, and evaluating husbandry and environmental sanitation practices of guinea pig breeders to reduce the prevalence of Salmonella and other zoonotic diseases of concern to the pet industry (2).
1Epidemic Intelligence Service, CDC; 2Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 3Colorado Department of Public Health and Environment; 4Vermont Department of Health; 5National Veterinary Services Laboratories, U.S. Department of Agriculture, Ames, Iowa; 6CAITTA, Inc., Herndon, Virginia.
Bartholomew ML, Heffernan RT, Wright JG, et al. Multistate outbreak of Salmonella entericaserotype enteritidis infection associated with pet guinea pigs. Vector Borne Zoonotic Dis 2014;14:414–21. CrossRefPubMed
CDC. Multistate outbreak of Salmonella Enteritidis infections linked to pet guinea pigs.
The U.S. Centers for Disease Control (CDC), public health and regulatory officials in several states, and the U.S. Department of Agriculture’s Food Safety and Inspection Service are investigating a multistate outbreak of Salmonella Newport infections linked to ground beef produced by JBS Tolleson, Inc.
Recalled beef products were produced and packaged from July 26, 2018, to September 7, 2018 and were shipped to retailers nationwide under many brand names.
Products are labeled with the establishment number “EST. 267.” This is usually found inside the USDA mark of inspect
Sixty-three more ill people from 14 states were added to this investigation since the last update on October 4, 2018. Six more states reported ill people: Hawaii, Kansas, New Mexico, Oklahoma, Texas, and Washington.
As of October 23, 2018, 120 people infected with the outbreak strain of Salmonella Newport have been reported from 22 states.
Join CDC expert, Dr. Vincent Hill for a Facebook Live handwashing demonstration on October 15 at 11:00 AM EDT in observance of Global Handwashing Day. Global Handwashing Day is an occasion to support a global and local culture of handwashing with soap, and promote handwashing with soap as an easy and affordable way to prevent disease in communities around the world.