investigation of a large foodborne illness outbreak in toronto, canada

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 resideNotify to Ministry of Health and Long Term Care

Responsibility 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 JamBacon 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

Num

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*

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!

Sylvanus Thompsonsthomps@toronto.ca416 338 3661