Raw is still risky: Say no to raw dough

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.

No more.

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.”

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.

Happy birthday Sam, no, you can’t eat the batter

My youngest kid is 8 today. He’s the funniest, cutest and most charming of any of us.

And he knows it.

He pretty much gets away with everything. Last year during the annual parent/teacher conference his teacher told us, sure, he talks all the time, he distracts other kids, but how can you discipline him? ‘He’s Sam’.

Today, this budding mite hockey player has practice, donuts with his teammates and then we’e going home for pizza and cake.

As Dani was making the cake earlier today I checked to see whether it was Duncan Hines. Although we’ve long outlawed eating cookie dough and licking the mixing bowl in our house, I still didn’t want to use the stuff that was recalled yesterday after being linked to five cases of Salmonella Agbeni.

From FDA’s website:

The FDA is investigating the manufacturing facility that made recalled Duncan Hines cake mixes.

FDA and the CDC informed Conagra Brands that a sample of Duncan Hines Classic White Cake Mix that contained Salmonella Agbeni matched the Salmonella collected from ill persons reported to the CDC. This was determined through Whole Genome Sequencing, a type of DNA analysis.

Based on this information, Conagra Brands is working with FDA to proactively conduct a voluntary recall of Duncan Hines cake mixes from the market. The FDA is conducting an inspection at the Conagra Brands-owned manufacturing facility that produced the cake mixes. The FDA is also collecting environmental and product samples.

Recommendation:

Consumers should not bake with or eat the recalled product. Additionally, consumers should not eat uncooked batter, flour, or cake mix powder.

Salmonella in low moisture foods continues to be an issue. As the Salmonella dries out it gets hardier and survives for months (or longer). Flour (if that’s the source) comes from dried wheat that’s milled and not heat treated (because it messes with the gluten. Salmonella or E. coli from wheat fields can make it to cake batter fairly easily.

Flour power: Raw is risky

When I was a kid, I had this multi-colored swim towel that stated Flower Power (right, not exactly as shown).

I should have known that if a 1960s slogan had been co-opted by towel manufacturers in the early 1970s, it was a sign of corporate greed rather than earth-tone sentiment.

For the past decade, raw flour has increasingly come under the food safety microscope.

Flour was suspect in a 2008 outbreak of Salmonella in New Zealand. In June, 2009, an outbreak of shiga-toxin producing E. coli (primarily O157:H7) in Nestle Toll House cookie dough sickened at least 77 people in 30 American states. Thirty-five people were hospitalized – from flour in the cookie dough.

Hemp seed flour sickened 15 Germans in 2010.

There was the U.S. General Mills outbreak of 2016 which sickened at least 56 people with the outbreak strain of E. coli O121 and O26, followed by a separate outbreak of E. coli O121 in Robin Hood flour in Canada in late 2016 going into 2017, that sickened at least 29.

It’s this latter outbreak that has journalist Jim Romahn’s attention.

Romahn writes the release of 759 pages of mostly e-mails indicates there was a massive effort involved in a recall of flour milled in Saskatoon that was contaminated with E. coli O121.

Twenty-two Canadians were identified as sickened by the flour, including one key case where the person consumed raw dough.

With hindsight, health officials were able to determine the first person sickened was Nov. 13, 2016. The others sickened and linked to the flour were between then and Feb. 26, 2017.

Robin Hood flour was identified as the source in March and on March 26 the Canadian Food Inspection Agency began a recall that eventually grew to scores of brand-name products across Canada and even an export shipment to Guyana.

The recall involved a number of major companies, such as Smucker Foods of Toronto and the Sobeys supermarket chain.

There were some unusual difficulties, including the challenge of contacting Mennonites who have no telephones.

The investigation and lab results eventually traced the source to flour milled at Ardent’s Saskatoon plant on Oct. 15, 16 and 17.

A high percentage of packages of flour milled on those dates turned up with E. coli O121.

But even then it’s not clear where the wheat originated.

Ardent Mills said it was probably spring wheat, but it could have also contained soft wheat, and that it probably was from the 2016 harvest, but might have had some wheat from the 2015 harvest.

That’s reflective of the amount of blending that happens both with the wheat used in milling and the flours that are blended into products for sale.

The documents were released under Access to Information at the request of a woman who spent time in a hospital in Medicine Hat, Alta.

 An Outbreak of Shiga Toxin–Producing Escherichia coli O121 Infections Associated with Flour – Canada, 2016–2017

MMWR Morb Mortal Wkly Rep 2017; 66: 705–706

Morton V, Cheng JM, Sharma D, Kearney A.

Bob’s Red Mill Natural Foods gets Salmonella, and thinks it’s important to capitalize to push BS

The press release from Bob’s reads like this:

Bob’s Red Mill Natural Foods is voluntarily recalling 2,099 cases of Organic Amaranth Flour (22 oz.), after recent testing revealed the presence of Salmonella in a single LOT of Organic Amaranth Flour (22 oz.) with a Sell By date of Nov. 26, 2015.

The recalled Organic Amaranth Flour (22 oz.) was distributed through retailers and distributors nationwide. This product and LOT was distributed in CA, FL, MI, ND, N, NY, OH, OR, TX, and WA starting June 11, 2014 and ended shipping on August 7, 2014

The recalled product is Organic Amaranth Flour (22 oz.) with a Sell By Date of 11/26/2015, LOT: 169617, which can be found on the side of the package, near the top of the panel. UPC: 0 39978 00911 1

While this product expired in November 2015, this product was found on the shelves of one retail store, and thus Bob’s Red Mill is recalling the product out of an abundance of caution.

How cautious is it to sell flour with shit three years past expiration?

E. coli: Flour fights not such a good idea

In June, 2009, an outbreak of shiga-toxin producing E. coli (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 56 people fell sick from with the outbreak strain of E. coli O121 from Dec. 2015 to Sept. 2016 were linked to raw General Mills flour.

The peer-reviewed summary of the outbreak investigation was published last week in The New England Journal of Medicine.

Abstract below:

In 2016, a multijurisdictional team investigated an outbreak of Shiga toxin–producing Escherichia coli (STEC) serogroup O121 and O26 infections linked to contaminated flour from a large domestic producer.

Methods

A case was defined as infection with an outbreak strain in which illness onset was between December 21, 2015, and September 5, 2016. To identify exposures associated with the outbreak, outbreak cases were compared with non-STEC enteric illness cases, matched according to age group, sex, and state of residence. Products suspected to be related to the outbreak were collected for STEC testing, and a common point of contamination was sought. Whole-genome sequencing was performed on isolates from clinical and food samples.

Results

A total of 56 cases were identified in 24 states. Univariable exact conditional logistic-regression models of 22 matched sets showed that infection was significantly associated with the use of one brand of flour (odds ratio, 21.04; 95% confidence interval [CI], 4.69 to 94.37) and with tasting unbaked homemade dough or batter (odds ratio, 36.02; 95% CI, 4.63 to 280.17). Laboratory testing isolated the outbreak strains from flour samples, and whole-genome sequencing revealed that the isolates from clinical and food samples were closely related to one another genetically. Trace-back investigation identified a common flour-production facility.

Conclusions

This investigation implicated raw flour as the source of an outbreak of STEC infections. Although it is a low-moisture food, raw flour can be a vehicle for foodborne pathogens.

Shiga toxin–producing E. coli infections associated with flour

N Engl J Med 2017; 377:2036-2043, November 23, 2017, DOI: 10.1056/NEJMoa1615910

Samuel J. Crowe, Ph.D., M.P.H., Lyndsay Bottichio, M.P.H., Lauren N. Shade, B.S., Brooke M. Whitney, Ph.D., Nereida Corral, M.P.H., Beth Melius, M.N., M.P.H., Katherine D. Arends, M.P.H., Danielle Donovan, M.S., Jolianne Stone, M.P.H., Krisandra Allen, M.P.H., Jessica Rosner, M.P.H., Jennifer Beal, M.P.H., Laura Whitlock, M.P.H., Anna Blackstock, Ph.D., June Wetherington, M.S., Lisa A. Newberry, Ph.D., Morgan N. Schroeder, M.P.H., Darlene Wagner, Ph.D., Eija Trees, D.V.M., Ph.D., Stelios Viazis, Ph.D., Matthew E. Wise, M.P.H., Ph.D., and Karen P. Neil, M.D., M.S.P.H.

http://www.nejm.org/doi/full/10.1056/NEJMoa1615910

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.