Large Outbreak Linked to a Popular Burger Lisa Berger MD

1. Large Outbreak Linked to a Popular Burger Lisa Berger MD Associate Medical Officer of Health, Toronto Public Health May 29, 2014 http://news.nationalpost.com/2013/08/21/at-least-12-treated-for-gastrointestinal-illness-at-cne-in-toronto/

2. Outline • Timeline of events • TPH outbreak management response • Case investigation and epidemiology • Environmental investigation • Lessons learned – what went well • Lessons learned – challenges

3. How it all started • 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

4. Timeline of events 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

5. 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/

6. Timeline of events

7. Timeline of events

8. 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/

9. 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)

10. 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

11. 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

12. Final confirmed case definition • Confirmed case: • Purchased and consumed food from Epic Burger and Waffles at the CNE on August 20, 2013 • AND • Developed 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.

13. Final probable case definition • Probable case: • Either • Purchased and consumed food from Epic Burger and Waffles at the CNE between Aug 16-19, 2013 • AND • Developed 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 pain • OR • Purchased and consumed food from Epic Burger and Waffles at the CNE on August 20, 2013 • AND • Developed 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.

14. Final suspect case definition • Suspect case: • Purchased and consumed food from Epic Burger and Waffles at the CNE between Aug 16-19, 2013AND • Developed 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.

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

16. Epidemic curve by illness onset* * Available data as of September 24, 2013; subject to change

17. http://news.nationalpost.com/2013/08/22/close-to-100-complaints-of-illness-at-cne-as-cronut-burger-maker-still-shut-down/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=0CLIBEPwSMAs

18. 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

19. Food sample testing results

20. 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 close

21. 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

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

23. 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

24. Acknowledgements