IAFP年会：雀巢专家重提09年冷冻曲奇细菌爆发事件

食品伙伴网报道：据美国食品安全新闻网编辑对国际食品保护协会（IAFP）年会的关注，近日雀巢公司食品安全专家Tim Jackson在会上就HACCP体系在2009年6月份的该公司所生产的冷冻曲奇甜品大肠杆菌爆发事件中所具有的优势与劣势做了报告，并与与会者分享了该公司专有的一些研究数据。
 

    对于2009年6月雀巢公司相关产品所引起的细菌爆发及召回事件，食品伙伴网做了相关报道：

2009-06-30 15:25美国FDA宣布从雀巢冷冻甜品中检出大肠杆菌
2009-06-24 08:15雀巢甜点疑受污染 可能已导致66起大肠杆菌病例
2009-06-22 08:49雀巢在美召回疑感染大肠杆菌冷冻曲奇饼
2009-06-22 08:17雀巢公司在美召回疑染病菌冷冻甜品

    通过对该事件的分析，可以帮助我们更好的理解HACCP体系，以及S510法案或者HR2749法案在通往食品安全的路上是如何发挥其影响的。

    很显然，雀巢公司在生产冷冻曲奇时，已实施并遵守了HACCP体系。因此也完全符合S150法案，那么原因就出在面粉上面，而面粉由面粉厂供应，并且危险性分析应该在面粉厂进行，但面粉厂不会对这些面粉热处理，因为他们不认为这具有显著性危险。事实上，雀巢公司对3.2万份面粉样本进行检测，只发现了一份由大肠杆菌所污染，可见被大肠杆菌O157:H7污染的的风险是多么小。而这次爆发也显示了对于未加工的食品来说，是缺乏真正的危险控制点（CCPs）。这清楚地表明，HACCP体系并不能确保食品的安全。 HACCP是危害分析，而危害分析永远不会结束，因为原料的状态在加工过程中不断的变化。

    本报道由食品伙伴网编译整理，仅供食品行业相关人士参考，详细内容以国外原文报道为准。

    原文地址：http://www.foodsafetynews.com/2010/08/letter-from-the-editor-iafp/

    原文报道：

Letter From The Editor: IAFP

by Dan Flynn | Aug 08, 2010
The publisher wanted one of us to attend last week's meetings of the International Association for Food Protection at the Anaheim Convention Center near Disneyland.  I decided to go myself and "take one for the team," hoping this was a group that has a couple of meetings in the morning and then adjourns for pool time.

Given my hopes, I did not choose wisely.   IAFP is about as serious about its symposia, roundtables, technical sessions, and poster presentations as any organization I've ever encountered.

They had multiple sessions going all day with start times beginning at 8:30 a.m. and not ending until those that began at 4:30 p.m. were over.   Numerous newsmakers in multiple rooms present a real dilemma for a reporter.  As I told the publisher later, it was a little bit like trying to drink out of a fire hose.

From the sessions I did attend, there was one star of the IAFP that's worth talking about.   News is not, as an old journalism professor once told me, when a dog bites a man.  News is when a man bites a dog.

In that spirit, Tim Jackson, the safety guru for Nestle USA, was a star of the IAFP for making news by doing something we do not usually see.  

We do not usually see a company whose product was responsible for an outbreak pretty much baring all about the experience in front of an audience of regulators from all levels of government.

Jackson was just six months into his USA assignment from Nestle S.A. in Switzerland when he found himself on a conference call late on June 17, 2009 with officials from the federal Centers for Disease Control and Prevention (CDC) in Atlanta and the U.S. Food and Drug Administration (FDA) in Washington D.C.

They told him they believed raw cookie dough manufactured by Nestle in Danville, VA was responsible for a multi-state outbreak of E. coli O157:H7 that as of the moment had led to infections in 63 people.  Some were critically ill, and would touch death's door.

Before there was any "recovery" of one of its raw cookie dough products with a test positive for E. coli, or anything else like a date or product type that would help narrow the scope, Jackson said Nestle had a decision to make.

"Everything we had on the market was potentially at risk," Jackson said.  He brought together the company's crisis management team and opted to recall its entire cookie dough line-up.  It was the largest recall in scope in the history of Nestle USA, a company that still managed $10.4 billion in sales last year.

Twenty-four hours later, FDA inspectors arrived at the Danville plant to launch the investigation that would go on for months.  Jackson says, the plant continued cookie dough production just so FDA could watch how it made.

All that dough was discarded along with the recalled product.  When FDA had seen enough, the plant was shut down and taken apart as Nestle tried to solve the mystery of how a bacterium that typically originates in the hind gut of a cow ended up in raw cookie dough.

The investigators looked at just about everything.  Raw materials, air and water, the plant and equipment, the possibility of some outside event like a failure of the municipal water system, cross contamination, and employees were among the items investigated.

Most of these were dead-ends.  Nestle and FDA both investigated possible "disgruntled employees" and concluded there was not any evidence of that.  Some employees do live in rural areas with access to cattle, but environmental controls for coming and going were sufficient.

Nestle did not subject employees to testing because that would probably be too invasive from a legal standpoint, and there was no indication any employee was a problem.

Because different strains of E. coli were found in cookie dough at the plant and then after in January 2010 after it went back into production (none of these were ever shipped), Nestle opted to switch to using only "heat treated" flour.

In a panel specifically on flour, Jackson shared Nestlé's proprietary research on testing flour for E. coli O157:H7.   It has long been known that flour can harbor bacteria like Salmonella and E. coli.

But since almost all flour is cooked in some form before it's consumed that has not been a problem.  The common practice of eating raw cookie dough and the now growing trend of eating raw frozen pizza has both the industry and its regulators concerned.

Jackson disclosed that Nestle had to sample more than 32,000 samples of flour before coming up with one positive test for E. coli.   Still, as the investigation continued and the repeat presence of E. coli was found in cookie dough in January, Nestle USA opted to go with "heat-treated" flour.

While flour is tops on the suspect list, Jackson says Nestle cannot say it found the "root cause."

Nestle figures the recall and investigation has cost the company more than $30 million, with ongoing research and litigation still ahead.  For Nestle, Jackson said, it was good news that its cookie dough sales quickly resumed their place in the market once the product was returned to the shelf in new packaging and colors.

As it took apart is plant, equipment, ingredients, transportation system, and other elements, Nestle searched for the "root cause" using a system that diagrams like boning a fish. 

When Jackson was through with his second presentation of the conference, I don't think anyone could think of a bone he'd missed.

Discuss：
Harry Hamil
08/08/2010
6:10AM Thanks for the info, Dan. This is exactly the kind of news that I look for in Food Safety News.

Do you know of a way to get a copy of Tim Jackson’s entire presentation?

Harry Hamil
08/08/2010
9:34AM This report of what happened in the Nestle cookie dough outbreak highlights key strengths and weaknesses of the application of HACCP to raw food. An analysis of what happened will help us better understand HACCP and part of the likely impact of an S 510/HR 2749 industrial-size-only approach to food safety.

The industrial nature of the processing made it possible for there to be a very thorough investigation of what happened. Despite that, there was no “smoking gun.”

Though not explicitly stated, it is clear that Nestle had a HACCP plan in force at the time the cookie dough was produced. Thus, it was already in full compliance with S 510. In other words, had S 510 been full in force at the time of this outbreak, it would NOT have changed anything that happened. As the article stated, "since almost all flour is cooked in some form before it's consumed that has not been a problem. The common practice of eating raw cookie dough and the now growing trend of eating raw frozen pizza has both the industry and its regulators concerned." Thus, IF the flour contained the contaminant, there is little reason to believe that S 510 would have caused the flour to have been heat treated by its producer. And the FDA certainly would NOT have required it.

Why? Because the Hazard Analysis at the flour mill would have, almost certainly, arrived at the same conclusion that Nestle did. The flour mill would NOT have heat treated the flour because it didn't recognize the hazard as being significant. The fact that it took Nestle 32,000 samples to find a single case of contamination with E. coli O157:H7 shows how small the risk was.

This outbreak shows the lack of true critical control points (CCPs) with raw foods.

Once a hazard is recognized, this shows that a CCP or a prerequisite program must be created to eliminate or reduce it. In this case, the heat treatment of the flour appears to have eliminated the hazard.

Nestle's estimate of the cost ("$30,000,000 with ongoing research and litigation still ahead") shows clearly the high financial cost of true HACCP...and it failures

This clearly shows that HACCP does NOT guarantee safe food. HACCP is only as good as its hazard analysis and Hazard Analysis is never finished because the state of the raw materials is constantly in flux and/or processes changed.

A final point to highlight is that Nestle appears to have handled itself admirably during the outbreak and its aftermath. I know that I have learned a lot from its sharing this valuable information at the IAFP.

In turn, the Nestle cookie dough outbreak clearly shows the following about a post S 510/HR 2749 world:

1) Major food-borne illness outbreaks will continue to occur even for the limited number of foods covered by S 510/HR 2749. There is very little chance that S 510/HR 2749 would have made any difference; Nestle's raw cookie dough would have still made people sick.
2) S 510/HR 2849 is not the "silver bullet" that some of its supporters tout it to be.
3) The FDA’s having mandatory recall would have made NO difference There is nothing to show that FDA would have instituted a mandatory recall in this cases had it had that authority because it did NOT have the information to support such an action. Despite that fact, Nestle not only instituted a recall, it shut its plant down until it was convinced that it had handled the problem.
4) Though this clearly involved a global supply chain, the existing powers of the FDA and CDC were all that was needed.

In summary, had S 510 or HR 2749 been fully in force, there is no reason to believe that either would have made any difference in this case. The outbreak and number of cases would have been the same.