Posted: June 20th, 2009 - 9:24am
Source: CIDRAP

The US Food and Drug Administration (FDA) warned consumers today not to eat Nestle Toll House refrigerated raw cookie dough, as state and federal officials investigate 66 Escherichia coli O157:H7 illnesses, many of them children, across 28 states that they suspect are linked to the product.
The FDA, in a statement, advised consumers that cooking the dough could still present a cross-contamination risk and that they should throw away any prepackaged Nestle dough they have in their homes.
A few hours before the FDA warning, Nestle issued a voluntary recall of its Toll House refrigerated dough products. Company officials said that, though the E coli outbreak strain has not been detected in any of its products, it recalled the dough out of an abundance of caution.
The recall applies to all varieties of its Toll house refrigerated cookie, brownie, and bar dough that is packaged in rectangular packages, tubes, and tubs.
The FDA statement didn't specify the states that are reporting illnesses, but some states—including Colorado, Minnesota, Texas, and Washington—have confirmed they have sick patients and are involved in the outbreak investigation.
E coli O157:H7 outbreaks are most often associated with ground beef and, in recent years, fresh produce. The strain produces a toxin that causes diarrhea—often bloody—and abdominal cramps but typically no fever. The illness usually resolves in 5 to 10 days, but it can cause hemolytic uremic syndrome (HUS), a potentially fatal kidney condition, in 2% to 7% of patients.
The FDA said that, of the 66 illnesses reported, 25 people were hospitalized and 7 developed HUS. No fatalities have been reported.
Patients tend to be young
Officials from the Colorado Department of Public Health and Environment (CDPHE) released a statement yesterday saying five cases from three counties have been linked to the outbreak. Two patients were hospitalized, and one developed HUS. Four of the patients interviewed so far by Colorado authorities reported eating the raw cookie dough the week before they got sick.
The Minnesota Department of Health (MDH) said today in a press release that it is investigating six illnesses, all caused by E coli O157:H7 with the same genetic fingerprint that it identified during routine monitoring. The patients range from 2 to 18 years old and became ill between May 3 and Jun 11. All reported eating raw Nestle Toll House cookie dough. One patient was hospitalized, and all recovered.
Two other states have reported cases, according to media reports. Washington reported 5, and Texas reported 3.
Carlota Medus, PhD, MPH, an epidemiologist in the MDH foodborne illness unit, said in the statement that the outbreak illustrates the risk of eating any raw cookie dough. "Cookie dough, whether purchased in a tub from the store, or made at home from scratch, should not be eaten raw," she said.
Medus told CIDRAP News that the US Centers for Disease Control and Prevention (CDC) and the state of Washington were the first groups to pick up on the connection between sick patients and the exposure many of them had to the Nestle raw cookie dough. As more states became involved in the investigation, the connection to the dough became even more striking, she said.
The younger age of the patients also stood out as an unusual outbreak feature, she said. However, she added that age range nationally is a little broader and more skewed toward female patients.
Contamination source unknown
Minnesota officials said investigators haven't determined how E coli contaminated the cookie dough, but the FDA is working with Nestle to identify the source. The Minnesota Department of Agriculture is testing Nestle dough collected from stores and the homes of sick patients.
Craig Hedberg, PhD, a foodborne disease expert at the University of Minnesota, told CIDRAP News that public health officials are puzzled how E coli O157:H7 could contaminate refrigerated cookie dough.
"In looking at the ingredients, there are not any obvious sources of potential O157 contamination, but as we saw with PCA [Peanut Corporation of America], this may be difficult to rule out," he said.
Though FDA officials haven't revealed many details about their investigation, Hedberg said they will probably explore if the processing plant or plants are located near dairy or beef feedlots that could present a risk of contamination through water, dust, flies, infected workers, or cross-contamination from hands and clothes.
Nestle didn't specify in its recall notice where it makes the cookie dough products. However, the Virginia-based Danville Register Bee quoted a company spokeswoman who said Nestle makes the majority of its refrigerated cookie dough at a plant in Danville, which also makes refrigerated pasta. She said Nestle has stopped production of the dough, but not the pasta products.
Because the infectious agent and food product combination is so unusual, FDA investigators might consider the possibility of intentional contamination, Hedberg said. "Whether it were a disgruntled employee or an attack on an iconic American product, the potential needs to be considered," he said.
Hedberg said investigators are also likely to weigh other possibilities such as potentially contaminated flour, untreated groundwater entering the plant, or dust from a cattle facility that can serve as a transfer mechanism for E coli O157:H7.
Medus added that E coli O157:H7 can sometimes survive in dry environments such as flour, or perhaps there was a breakdown in pasteurizing the milk fat used to make the dough.
"There are so many possibilities; it's just too early to know," she said. "But something went really wrong, whether it was intentional or not."