Investigation of a Large Foodborne Illness Outbreak in
Investigation of a Large Foodborne Illness Outbreak in Toronto, Canada Sylvanus Thompson Ph. D, CPHI(C) Associate Director Toronto Public Health
City of Toronto Largest City in Canada Most multi-cultural city 2. 7 million people 17000 Food Establishments 437, 00 cases of foodborne illnesses annually $476 – 587 million Numerous special events Canadian National Exhibition (CNE)
Canadian National Exhibition Canada's largest community event Founded in 1879 - a showcase of the nation 7 th largest fair in North America Close to 1. 5 million visitors over its 18 day duration Starts mid August Ends on Labour Day
Food Building
FBI Outbreak at the CNE �Call from CNE Manager at 10: 30 pm-August 20 �Several persons reported being ill shortly after consuming food at a specific outlet �TPH 24/7 On Call system �Dial 311 �CNE advised to ensure premise is kept closed �Secure any left over food product �Control of Communicable Disease Manager informed
FBI Outbreak Investigation �Outbreak included in news � PHI and CDC staff onsite by 8: 30 am �Modified HACCP Audit and inspection �Food and environmental samples collected for lab analysis �RTE burgers, bacon jam �Production site of major ingredient inspected and sample taken �Bacon jam sample
Epi Investigation CDC staff interviewed 257 persons Standard Outbreak investigation questionnaire Fluid survey data entry tool i. PHIS At risk population exposure August 16 – 20 Kits provided for specimen collection Victims reported Treated onsite by EMS personnel Taken to Hospital Family physician Food handling staff interviewed
Incubation Period Short Incubation Period Mean 4. 7 hours Median 4. 0 hours Range 0. 5 – 22. 0 hours
Symptoms Watery diarrhea (83%) Vomiting (81%) Nausea (76%) Abdominal pain (74%) Loss of appetite (62%) Headache (43%) Chills (42%) Bloody diarrhea (6%)
Inter- Agency Collaboration �Liaise with other affected health units based on where cases reside �Notify to Ministry of Health and Long Term Care �Responsibility for healthcare system �Chairs Outbreak Investigation Coordinating Committee �Inform Public Health Ontario �Public Health Laboratory �Technical support
Table 1: Age and Gender of Reported Cases, by Classification. Confirmed N=88 Sex Probable Suspect N=43 N=13 Total N=144 Male 49 21 4 74 Female 39 21 7 67 0 1 2 3 Unknown Age* Mean 32. 0 32. 9 30. 1 32. 4 (years) Median 28. 5 29. 0 31. 2 29. 5 Range 0 to 69 0 to 68 0 to 52 *Age was unavailable for one confirmed and two probable cases.
Table 5: Frequency of foods consumed from implicated premises by classification* Cronut burger Confirmed Probable Suspect N=4 N=1 N=88 % 3 % 87 99% 37 86% 10 77% Total N=14 4 % 134 93% Chicken in waffle 4 5% 3 7% 1 8% 8 6% Beverage Krispy kreme burger 3 3% 4 9% 0 0% 7 5% 3 3% 3 7% 2 15% 8 6% Fries 2 2% 1 2% 0 0% 3 2% "Other" burger 1 1% 1 2% 2 15% 4 3% Not specified 1 1% 1 2% 0 0% 2 1% *Cases could report eating more than one item at Epic Burger and
Outbreak Management News Release Implicated premises closed voluntarily Section 13 Order contemplated No health hazard identified Epi evidence No new cases Follow-up visit to establishment where bacon jam produced Teaching school Bakery Modified HACCP Audit and additional sampling
Laboratory Results Seven Food samples positive for Staph aureus 4 RTE burgers with bacon jam 2 bacon jam smoked bacon All samples, except the bacon, had same PFGE pattern and entero-toxin present All other samples negative
Food sample testing results Sample Date Location Batch S. aureus Entero- PFGE Remarks collected toxin Cronut burger - ready to Aug 21 Epic Aug 20 >200, 000 + A Prepared in front of PHI eat Burgers Cronut burger - ready to Aug 21 Epic Aug 20 7, 300 + A Prepared in front of PHI eat (patty held 10 mins) Burgers Cronut burger - ready to Aug 20 Epic Aug 20 >200, 000 + A Collected by CNE staff eat Burgers Cronut burger - ready to Aug 22 Client home Aug 20 Positive + A Saved by ill case eat Bacon puree Aug 21 Epic Aug 20 1, 000 + A Sampled from 10 litre Burgers bucket Bacon puree Aug 21 Le Dolci Aug 21 100 + A Bacon puree Aug 23 Le Dolci n/a - n/a After PHI consultation Raw bacon Aug 21 720 - B Raw burger patty Aug 21 Aug 20 <100 n/a Raw Processed cheese Aug 21 Aug 20 <100 n/a Cronut (croissant donut) Aug 21 Aug 20 <100 n/a Bread product only Toppings Aug 20 Superior Sau. Epic Burgers Aug 20 - n/a Collected by CNE staff 19
Bacon Jam Bacon jam determined as cause of illness Media release Food establishment at the CNE permitted to reopen under specified conditions no bacon jam from that producer re-training of all food handlers thorough cleaning and sanitization Re-opened on August 27
Epic re-opened (pic)
Bacon Jam Producer Establishment voluntarily closed Section 13 issued Environmental sampling before and after cleaning Training of food handlers All samples negative for Staph aureus More detailed interview of food handlers Nasal swabs Permitted to re-open under conditions modify bacon jam production process 1 of 4 food handler positive for Staph unrelated PFGE pattern
Communication Media releases on timely basis Actions being taken by TPH Investigation into source Lab results 5 media advisories 4 press conferences 190 media calls
http: //news. nationalpost. com/2013/08/22/close-to-100 -complaints-of-illness-at-cne-as-cronut-burger-maker-still-shut-down/ http: //www. thestar. com/news/gta/2013/08/27/le_dolci_fun_foodie_studio_linked_to_cronut_burger_illnesses. html 24 https: //maps. google. ca/maps? ie=UTF-8&q=Superior+Sausage+Co&fb=1&gl=ca&hq=superior+sausage+toronto+hours&cid=0, 0, 5561172707282629667&ei=0 Vpb. Uru 9 FMXIr. QGFs. IHQDw&ved=0 CLIBEPw. SMAs
Lessons Learned Prompt TPH response Importance of keeping the public informed and reassured Detailed sampling and analysis Multi – agency coordination and response Resulted in quick identification of the implicated food and end outbreak!
Quick identification of the implicated food and end outbreak!
Sylvanus Thompson sthomps@toronto. ca 416 338 3661
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