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.

More proof: Same E. coli O121 found in flour in sick consumer’s home

On June 10, 2016, U.S. Food and Drug Administration whole genome sequencing on E. coli O121 isolates recovered from an open sample of General Mills flour belonging to one of the consumers who was sickened was found to be closely genetically related the clinical isolates from human illnesses. The flour came from a lot that General Mills has recalled.

flour.e.coli.O121To date, 38 people infected with the outbreak strain of E. coli O121 have been reported from 20 states. Illnesses started on dates ranging from December 21, 2015 to May 3, 2016. Ten ill people have been hospitalized. In its investigation, CDC learned that some people who got sick had eaten or handled raw dough.

FDA’s traceback investigation determined that the raw dough eaten or handled by ill people or used in restaurant locations was made using General Mills flour that was produced in the same week in November 2015 at the General Mills facility in Kansas City, Missouri. Epidemiology and traceback evidence available at this time indicate that General Mills flour manufactured at this facility is the likely source of the outbreak.

On May 31, 2016, following a conference call among FDA, CDC and the firm, General Mills conducted a voluntary recall of flour products produced between November 14, 2015 and December 4, 2015. Recalled products are sold in stores nationwide or may be in consumers’ pantries and are sold under three brand names: Gold Medal flour, Signature Kitchens flour and Gold Medal Wondra flour. The varieties include unbleached, all-purpose, and self-rising flours.

General Mills also sells bulk flour to customers who use it to make other products. General Mills has contacted these customers directly to inform them of the recall. FDA is working with General Mills to ensure that the customers have been notified, and to evaluate the recall for effectiveness.

Flour has a long shelf life, and bags of flour may be kept in peoples’ homes for a long time. Consumers unaware of the recall could continue to eat these recalled flours and potentially get sick. If consumers have any of these recalled flours in their homes, they should throw them away.

(this is bad)

kids.cookie.doughPeople usually get sick from STEC O121 2-8 days (average of 3-4 days) after swallowing the bacteria. Most people develop diarrhea (often bloody) and abdominal cramps. Most people recover within a week.

Some illnesses last longer and can be more severe, resulting in a type of kidney failure called hemolytic uremic syndrome (HUS). HUS can occur in people of any age, but is most common in young children under 5 years, older adults, and people with weakened immune systems.

Restaurants and retailers should throw away any recalled General Mills flour. Some ill people reported handling raw dough at restaurants prior to eating their meal. Restaurants that allow their customers to handle raw dough should evaluate whether this practice is appropriate.

Restaurants and retailers should be aware that flour may be a source of pathogens and should control the potential for cross-contamination of food processing equipment and the food processing environment. They should follow the steps below:

Wash and sanitize display cases and refrigerators where potentially contaminated products were stored.

Wash and sanitize cutting boards, surfaces, and utensils used to prepare, serve, or store potentially contaminated products.

Wash hands with hot water and soap following the cleaning and sanitation process.

Retailers, restaurants, and other food service operators who have processed and packaged any potentially contaminated products need to be concerned about cross contamination of cutting surfaces and utensils through contact with the potentially contaminated products.

Regular frequent cleaning and sanitizing of food contact surfaces and utensils used in food preparation may help to minimize the likelihood of cross-contamination.

(this is bad)

kid-cookie3What Do Consumers Need To Do?

The recalled General Mills products have a long shelf-life, and they may be in peoples’ homes. Consumers unaware of the recall could continue to eat these products and potentially get sick.

If consumers have these products in their homes, they should throw it away. As a precaution, flour no longer stored in its original packaging should be discarded if it could be covered by this recall, and the containers used to store this flour should be thoroughly washed and sanitized.

Three people who became ill reported handling raw dough at restaurants prior to eating their meal. As a precaution, consumers, especially children, should not handle raw dough at home or at restaurant locations.

FDA warns against eating raw dough products made with any brand of flour or baking mix before cooking. Consumers should always practice safe food handling and preparation measures when handling flour. The FDA recommends following these safe food-handling practices to stay healthy:

Do not eat or play with any raw cookie dough or any other raw dough product made with flour that is intended to be cooked or baked.

Follow package directions on baking mixes and other flour-containing products for proper cooking temperatures and for specified times.

Wash hands, work surfaces, and utensils thoroughly after contact with raw dough products containing flour.

Keep raw foods separate from other foods while preparing them to prevent any contamination that might be present from spreading.

E. coli O121 in flour: One bite of cookie dough left Spokane teen fighting for life

Alyssa Donovan of KXLY reports that Sydney Rypien was a healthy Spokane teenager and a three-sport athlete. Then she took a bite of raw cookie dough and ended up in the hospital soon afterward fighting for her life.

Sydney Rypien.e.coli.O121Rypien, 17, was baking cookies back in February when she took a bite of raw cookie dough.

“They say it’s just one bite. Just one tiny bite,” Rypien said.

A week after she ate the dough the teen had such bad cramps she could hardly stand.

“They ran a couple tests and within a day they knew it was E. coli,” she said.

She spent a week at Sacred Heart Medical Center where doctors told her if it weren’t for her athletic build this illness likely would’ve killed her.

“I was shedding like stomach lining, yeah it was bad. I lost a lot of weight in a week that was an unhealthy amount of weight to lose,” Rypien said.

Instead she is slowly recovering but it could be months before she fully recovers.

“I still don’t feel normal,” Rypien said.

This week Rypien learned how she contracted the deadly strain of E. coli. Health officials have tied Rypien’s E. coli and more than 30 others nationwide to General Mills flour. Today, 10 million pounds of flour have been pulled from the shelves. Rypien says a handful of the people sickened were young girls right around her age.

Missing more than 3 months of school the high school junior is still catching up.

“I’m doing fine and my teachers are really understanding so they are giving me a little leeway with that too and I’m doing my work. I’m cramming it out as much as I can,” she said.

Outside the classroom everyday tasks are harder now than they’ve ever been.

“Everything that was easy for me to do like volleyball or sports or activities or going out and hanging out with friends or visiting grandparents or family, it’s harder to do, my energy is just drained,” she said.

The effects of the illness could last up to a year but she’s grateful the recall will stop others from feeling the pain she is still dealing with.

“This is by far the worst pain I have been in in my entire life.”

Rypien says as she has recovered she’s had to be very careful about what she eats. She plans to continue eating healthier so that she never has to feel anything like that excruciating pain again. She also hopes this helps educate people that E. coli is not your typical foodborne illness. Its more dangerous, more painful and the effects can be long term.

CDC confirms it: Multistate outbreak of Shiga toxin-producing Escherichia coli O121 infections linked to flour

CDC is collaborating with public health and regulatory officials in multiple states and the U.S. Food and Drug Administration (FDA) to investigate a multistate outbreak of Shiga toxin-producing Escherichia coli O121 (STEC O121) infections.

flour.e.coli.O121Public health investigators are using the PulseNet system to identify illnesses that may be part of this outbreak. PulseNet, coordinated by CDC, is the national subtyping network of public health and food regulatory agency laboratories. PulseNet performs DNA fingerprinting on STEC bacteria isolated from ill people by using techniques called pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). CDC PulseNet manages a national database of these DNA fingerprints to identify possible outbreaks.

Thirty-eight people infected with the outbreak strain of STEC O121 have been reported from 20 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 are closely related genetically. This close genetic relationship means that people in this outbreak are more likely to share a common source of infection.

Illnesses started on dates ranging from December 21, 2015 to May 3, 2016. Ill people range in age from 1 year to 95, with a median age of 18. Seventy-eight percent of ill people are female. Ten ill people have been hospitalized. No one has developed hemolytic uremic syndrome, a type of kidney failure, and no deaths have been reported.

Collaborative investigative efforts of state, local, and federal health and regulatory officials indicate that flour produced at General Mills’ Kansas City, Missouri facility is a likely source of this outbreak. This investigation is ongoing.

In interviews, ill people answered questions about the foods they ate and other exposures in the week before they became ill. Sixteen (76%) of 21 people reported that they or someone in their household used flour in the week before they became ill. Nine (41%) of 22 people reported eating or tasting raw homemade dough or batter. Twelve (55%) of 22 people reported using Gold Medal brand flour. Three ill people reported eating or playing with raw dough at restaurants.

e.coli.o121.epiIn 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 illnesses. Preliminary results of this investigation indicate an association between STEC O121 infection and someone in the household using Gold Medal brand flour to make something to eat.

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

On 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 during a time frame identified by traceback and sold nationwide. CDC recommends that consumers, restaurants, and retailers do not use, serve, or sell the recalled flours.

We will update the public when more information becomes available. CDC and state and local public health partners are continuing laboratory surveillance through PulseNet to identify additional ill people and to interview those people about foods they ate before they got sick.

 

Blame the consumer, flour edition: 38 sick with E. coli O121 linked to General Mills

Amy was cooking some gluten-free pie shit the other night and she asked me what the temp should be – we have conversations like that in our family – and I said I’m not too concerned about the interior fruit filling, but make sure the pastry exterior hits 165F.

sifting_flour-chris_marchantThat was because of past outbreaks.

And now this.

General Mills is recalling about 10 million pounds of flour after an E. coli outbreak associated with flour sickened 38 people in 20 states.

Mike Hughlett of the Star Tribune reports the Golden Valley-based packaged food giant on Tuesday announced the voluntary recall of some lots of its signature Gold Medal flour, along with flour sold under the Wondra and Signature Kitchens brands. Signature Kitchens is a store brand sold at several major U.S. grocery chains including Safeway, Albertson’s, Jewel, Vons and Acme.

The federal Centers for Disease Control (CDC) said Tuesday there have been 10 hospitalizations associated with the outbreak, but no deaths have been reported.

The CDC has not yet released names of states affected by the recall, but the Minnesota Department of Health confirmed that three of the 38 people sickened lived in the Twin Cities area. All three — two adults and a child — have since recovered, and none were hospitalized, said Doug Schultz, a health department spokesman.

State and federal health authorities have been investigating an outbreak of E. coli O121 from Dec. 21 to May 3, General Mills said in a statement. The Minnesota health department said the Minnesota cases occurred in January and March.

The Centers for Disease Control found that about half of the 38 sickened people reported making homemade food with flour before becoming ill. Some reported using a General Mills brand of flour. Some also might have consumed raw dough or batter.

General Mills said it has not found E. coli O121 in any of its products or at its flour facilities, nor has it received any illness reports directly from consumers. The flour involved in the recall was mostly produced at General Mills’ Kansas City plant.

But Liz Nordlie, president of General Mills Baking division, did say, Consumers are reminded to not consume any raw products made with flour. Flour is an ingredient that comes from milling wheat, something grown outdoors that carries with it risks of bacteria which are rendered harmless by baking, frying or boiling. Consumers are reminded to wash their hands, work surfaces, and utensils thoroughly after contact with raw dough products or flour, and to never eat raw dough or batter.

“As a leading provider of flour for 150 years, we felt it was important to not only recall the product and replace it for consumers if there was any doubt, but also to take this opportunity to remind our consumers how to safely handle flour.”