Large Outbreak Linked to a Popular Burger

Lisa Berger MDAssociate Medical Officer of Health, Toronto Public HealthMay 29, 2014

http://news.nationalpost.com/2013/08/21/at-least-12-treated-for-gastrointestinal-illness-at-cne-in-toronto/

1

Outline

1. Timeline of events

2. TPH outbreak management response

3. Case investigation and epidemiology

4. Environmental investigation

5. Lessons learned – what went well

6. Lessons learned – challenges

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How it all started

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August 20, 2013

Tuesday

12 people present to the EMS booth at the CNE with severe vomiting, diarrhea and abdominal pain allegedly

after eating at one premise. The premise closes voluntarily. CNE’s assistant GM contacts TPH’s Healthy Environments (HE) and Communicable Disease Control

(CDC) managers

Timeline of events

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Aug 21Wed

• Inspection of Epic Burgers and Waffles and Le Dolci, food samples• TPH invokes IMS to manage the investigation• MOHLTC/PHO informed• Press conference• High media coverage probably prompted case reporting

Aug 22Thu

• 98 reports; at a glance15/17 ate the cronut (no epi avail.)• Discussions about TPH response if Epic chose to reopen• PHUs agree to centralize all case investigations to TPH• CNE’s private lab: “endotoxin A, E” in the burger and/or bacon puree

Aug 23Fri

• 147 reports; 36/46 confirmed cases ate cronut, no other common items• Early epidemiology analysis with Fluid Survey• Early results from PHOL confirms S. aureus enterotoxin in cronut

burger• Press conference reporting S. aureus food poisoning from cronut

burger

Link to news conferences:http://www.citynews.ca/2013/08/21/34-people-fell-ill-at-cne-toronto-public-health/http://www.citynews.ca/2013/08/23/outbreak-of-food-borne-illness-at-cne-linked-to-cronut-burger/#related-content-preview

The cronut burger: “‘the star’ of the CNE 2013”

“Marrying a trendy snack pastry with the reliable beef patty… A food fad that began in New York City, the cronut is a donut made by shaping and deep-frying croissant pastry.”

Rick McGinnis, blogTO

http://news.nationalpost.com/2013/08/21/at-least-12-treated-for-gastrointestinal-illness-at-cne-in-toronto/http://www.blogto.com/eat_drink/2013/08/how_to_have_a_heart_attack_at_the_2013_cne/

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Timeline of events

Aug 24-25Sat/Sun

• Epic Burgers and Waffles remains closed• Inspections across CNE food vendors• New foodborne illness complaints to TPH slow down

Aug 26Mon

• Confirmed case definition includes Epic Burgers and Waffles• 211 reports; 54 confirmed, 39 suspect cases• PHOL tests: bacon puree at Epic and Le Dolci had

enterotoxin+ S. aureus • Le Dolci closed on Mondays

Aug 27Tue

• 233 reports; 83 confirmed, 29 suspect cases• Epic Burgers and Waffles reopens after cleaning, staff training• Le Dolci re-inspection with environmental samples• Media scrum reporting bacon jam from Le Dolci as

contaminated

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Timeline of events

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Aug 28Wed

•Joint OMAF/TPH inspection of Superior Sausage•TPH disbands IMS

Aug 30 •PHOL results show same strain of S. aureus at Epic and Le Dolci

Sep 4 •Le Dolci food handlers swabbed

Sep 5 •Le Dolci reopens after cleaning, staff training

The rise and fall of the cronut burger

“Marrying a trendy snack pastry with the reliable beef patty… A food fad that began in New York City, the cronut is a donut made by shaping and deep-frying croissant pastry.”

Rick McGinnis, blogTO

http://www.blogto.com/eat_drink/2013/08/how_to_have_a_heart_attack_at_the_2013_cne/8

Case definitions

• Initially broad, included consumption of any food from the CNE and subsequent illness (diarrhea and/or vomiting)• Confirmed cases August 20• Suspect cases August 16-19

• Final case definitions by level of evidence supporting inclusion in outbreak• Food from Epic Burgers and Waffles• Symptoms consistent with S. aureus intoxication• Consumption and onset times consistent with IP• Date of consumption and illness (August 20, 16-19)

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Case definitions

• Initially broad, included consumption of any food from the CNE and subsequent illness (diarrhea and/or vomiting)• Confirmed cases August 20• Suspect cases August 16-19

• Final case definitions by level of evidence supporting inclusion in outbreak

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Confirmed Probable Suspect

Food from Epic Burger and Waffles X X X X

Symptoms of S. aureus intoxication X X X X

Consumption and onset times consistent with IP X X

Date of consumption and illness (August 20 vs 16-19) 20 16-19 20 16-19

Preliminary case definition

Confirmed case: individuals who:• Visited the CNE on Tuesday August 20, 2013 and consumed food

or drink purchased at the CNEAND

• Subsequently became ill with diarrhea and/or vomiting, with or without abdominal pain

Suspect case: individuals who:• Visited the CNE between August 16-19, 2013 and consumed food

or drink purchased at the CNEAND

• Subsequently became ill with diarrhea and/or vomiting, with or without abdominal pain

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Final confirmed case definition

Confirmed case: Purchased and consumed food from Epic Burger and Waffles at the CNE on August 20, 2013

ANDDeveloped symptoms consistent with Staphylococcus aureus (S. aureus) intoxication within 10 hours of food consumption, and reported the occurrence of diarrhea and/or vomiting, with or without abdominal pain.

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Final probable case definition

Probable case: EitherPurchased and consumed food from Epic Burger and Waffles at the CNE between Aug 16-19, 2013

ANDDeveloped symptoms consistent with S.aureus intoxication within 10 hours of food consumption, and reported the occurrence of diarrhea and/or vomiting, with or without abdominal painOR Purchased and consumed food from Epic Burger and Waffles at the CNE on August 20, 2013

ANDDeveloped symptoms consistent with S.aureus intoxication more than 10 hours but less than 24 hours after consuming the food, or if the symptom onset time or time of food consumption are missing/unknown*, and reported the occurrence of diarrhea and/or vomiting, with or without abdominal pain.

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Final suspect case definition

Suspect case:Purchased and consumed food from Epic Burger and Waffles at the CNE between Aug 16-19, 2013ANDDeveloped symptoms consistent with S.aureus intoxication more than 10 hours but less than 24 hours after consuming the food, or if the symptom onset time or time of food consumption are missing/unknown*, and reported the occurrence of diarrhea and/or vomiting, with or without abdominal pain.

*If cases had a symptom onset date but no time available, and the time of consumption was such that the maximum time on that day would have been within the 10 hour window, these cases are considered to be within 10 hours. E.g. if a case ate at 8:00pm and had symptoms on the same date, even if there is no time reported we will consider it within 10 hours.

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Case information

• 257 reports investigated• 144 cases, 0-82 yrs• Toronto residents 56.3%• Residents from 12 other health units

Confirmed Probable Suspect Total

Cases 88 (61%) 43 (30%) 13 (9%) 144 (100%)

Male sex* 49 (56%) 21 (49%) 4 (31%) 74 (51%)

Median age 28.5 years 29.0 years 31.2 years 29.5 years

Ate cronut 87 (99%) 37 (86%) 10 (77%) 134 (93%)

Mean incubation^ 4.0 hours 5.7 hours 17.6 hours 4.7 hours*Where sex known^Where incubation period could be calculated 15

Epidemic curve by illness onset*

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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

* Available data as of September 24, 2013; subject to change 16

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.htmlhttps://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=0CLIBEPwSMAs

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Environmental investigation

Food establishments

•Epic Burgers and Waffles – Aug 21

• Voluntary closure Aug 21-Aug 26

• Temperature abuse, inadequate cold holding

•Le Dolci – Aug 21

• Voluntary closure Aug 26-Sept 4

• Temperature abuse

• Environmental swabs of equipment, handles etc. (20) all negative

• Food handler swabs 1/5 positive for S. aureus, non-outbreak PFGE

•Superior Sausage – Aug 28 (OMAF/TPH)

• No infraction identified

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Food sample testing results

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Sample Date collected

Location Batch S. aureus Entero-toxin

PFGE 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 to the grill 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 recommendations

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

Lessons learned – what went well

• Cooperation with CNE (and vendors)• CNE had private food inspection contractor

• TPH Healthy Environments office onsite

• Early invocation of IMS at TPH• Best practice is real application

• Centralized investigation to one HU• PHOL consultation and support• Speedy environmental investigation

• Food testing was the only way to isolate pathogen

• Discussions about reasons to close/not close20

Lessons learned – challenges

• Media demands• Jurisdictional differences – thresholds for food

testing in public health and OMAF• Managing intense early ramp up phase

• Staffing and coordination of staffing

• Variable staff familiarity with IMS• Consistency between case interviews

21

22http://www.publichealthontario.ca/en/eRepository/Public_Health_Inspectors_Guide_2013.pdf

Final thoughts

• Relatively manageable point-source outbreak• No person-to-person transmission – prompt control

measures stopped further illness• Rapid environmental sampling was critical

• Key advantage was having helpful and supportive fair organizers

• Early decision to use IMS was a good one• For managing this outbreak• For the organization – opportunity to practice, refine

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Acknowledgements

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PHOL TPH MOH TPH CDC

Dr. Vanessa Allen Dr. David McKeown Dr. Barbara Yaffe

Allana Murphy Manisa Jiaravuthisan

Erik Kristjanson TPH Healthy Environments Anne Arthur

Sylvanus Thompson Debra Hayden

PHO Dr. Kit Young Hoon Faron Kolbe

Stephen Moore Jim Chan Effie Gournis

Dr. Jin Hee Kim Tom Marjanovich

Fred Taylor TPH Strategic Support

MOHLTC Phil Jackson

Clint Shingler Jenn Veenboer

Nina ArronTPH Communications

Rishma Govani

Kris Scheuer