sylvanus thompson phd, cphi(c) associate director toronto public health
TRANSCRIPT
Investigation of a Large Foodborne Illness Outbreak in Toronto, Canada
Sylvanus Thompson PhD, CPHI(C)Associate Director
Toronto Public Health
City of Toronto
Largest City in CanadaMost multi-cultural city2.7 million people17000 Food Establishments
437,00 cases of foodborne illnesses annually $476 – 587 million
Numerous special eventsCanadian National Exhibition (CNE)
Canadian National Exhibition
Canada's largest community eventFounded in 1879 - a showcase of the
nation7th largest fair in North AmericaClose to 1.5 million visitors over its 18 day
durationStarts mid AugustEnds on Labour Day
Food Building
FBI Outbreak at the CNECall from CNE Manager at 10:30 pm-August
20Several persons reported being ill shortly
after consuming food at a specific outletTPH 24/7 On Call system
Dial 311CNE 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 analysisRTE burgers, bacon jam
Production site of major ingredient inspected and sample taken Bacon jam sample
Epi InvestigationCDC staff interviewed 257 persons
Standard Outbreak investigation questionnaire
Fluid survey data entry tool iPHISAt risk population exposure August 16 –20Kits provided for specimen collectionVictims reported
Treated onsite by EMS personnel Taken to Hospital Family physician
Food handling staff interviewed
Incubation Period
Short Incubation Period Mean 4.7 hoursMedian 4.0 hoursRange 0.5 – 22.0 hours
SymptomsWatery 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 CareResponsibility for healthcare systemChairs Outbreak Investigation Coordinating
CommitteeInform Public Health Ontario
Public Health LaboratoryTechnical support
Table 1: Age and Gender of Reported Cases, by Classification.
Confirmed Probable Suspect Total
N=88 N=43 N=13 N=144
Sex Male 49 21 4 74
Female 39 21 7 67
Unknown 0 1 2 3
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*
Confirmed Probable Suspect Total
N=88 % N=43 % N=13 % N=144 %
Cronut burger 87 99% 37 86% 10 77% 134 93%
Chicken in waffle 4 5% 3 7% 1 8% 8 6%
Beverage 3 3% 4 9% 0 0% 7 5%
Krispy kreme burger 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 Waffles.
Outbreak ManagementNews ReleaseImplicated premises closed voluntarily Section 13 Order contemplated
No health hazard identifiedEpi evidenceNo new cases
Follow-up visit to establishment where bacon jam producedTeaching schoolBakery
Modified HACCP Audit and additional sampling
Laboratory Results
Seven Food samples positive for Staph aureus4 RTE burgers with bacon jam2 bacon jamsmoked bacon
All samples, except the bacon, had same PFGE pattern and entero-toxin present
All other samples negative
Food sample testing resultsSample Date
collectedLocation Batch S. aureus Entero-
toxinPFGE Remarks
Cronut burger - ready to eat Aug 21 Epic Burgers Aug 20 >200,000 + A Prepared in front of PHI
Cronut burger - ready to eat (patty held 10 mins)
Aug 21 Epic Burgers Aug 20 7,300 + A Prepared in front of PHI
Cronut burger - ready to eat Aug 20 Epic Burgers Aug 20 >200,000 + A Collected by CNE staff
Cronut burger - ready to eat Aug 22 Client home Aug 20 Positive + A Saved by ill case
Bacon puree Aug 21 Epic Burgers Aug 20 1,000 + A Sampled from 10 litre 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 Superior Sau. Aug 21 720 - B
Raw burger patty Aug 21 Epic Burgers Aug 20 <100 n/a n/a Raw
Processed cheese Aug 21 Epic Burgers Aug 20 <100 n/a n/a
Cronut (croissant donut) Aug 21 Epic Burgers Aug 20 <100 n/a n/a Bread product only
Toppings Aug 20 Epic Burgers Aug 20 - n/a n/a Collected by CNE staff
Donut product Aug 21 Le Dolci Aug 21 <100 n/a n/a
Maple syrup Aug 24 Le Dolci - n/a n/a Kirkland brand (Costco)
Brown sugar Aug 24 Le Dolci - n/a n/a 19
Bacon Jam
Bacon jam determined as cause of illnessMedia releaseFood establishment at the CNE permitted
to re-open under specified conditionsno bacon jam from that producerre-training of all food handlersthorough cleaning and sanitization
Re-opened on August 27
Epic re-opened (pic)
Bacon Jam ProducerEstablishment voluntarily closed
Section 13 issued Environmental sampling before and after
cleaningTraining of food handlersAll samples negative for Staph aureus
More detailed interview of food handlersNasal swabs
Permitted to re-open under conditionsmodify bacon jam production process
1 of 4 food handler positive for Staphunrelated PFGE pattern
Communication
Media releases on timely basisActions being taken by TPHInvestigation into sourceLab results5 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
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=0VpbUru9FMXIrQGFsIHQDw&ved=0CLIBEPwSMAs24
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16-Aug 17-Aug 18-Aug 19-Aug 20-Aug 21-Aug
Numb
er of
repo
rted c
ases
**
Time and Date of symptom onset
Onset time (N=100)
Confirmed
Probable
Suspect
Lessons LearnedPrompt TPH responseImportance of keeping the public informed
and re-assuredDetailed sampling and analysisMulti – agency coordination and response
Resulted in quick identification of the implicated food and end outbreak!
Quick identification of the implicated food and end outbreak!
