Large Outbreak Linked to a Popular Burger
Lisa Berger MD
Associate Medical Officer of Health, Toronto Public Health
May 29, 2014
1
http://news.nationalpost.com/2013/08/21/at-least-12-treated-for-gastrointestinal-illness-at-cne-in-toronto/
Outline
1.
2.
3.
4.
5.
6.
Timeline of events
TPH outbreak management response
Case investigation and epidemiology
Environmental investigation
Lessons learned – what went well
Lessons learned – challenges
2
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
3
Timeline of events
Aug 21
Wed
•
•
•
•
•
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 22
Thu
•
•
•
•
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 23
Fri
•
•
•
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:
4
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 deepfrying croissant
pastry.”
Rick McGinnis, blogTO
5
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/
Timeline of events
Aug 24- • Epic Burgers and Waffles remains closed
25
• Inspections across CNE food vendors
Sat/Sun • New foodborne illness complaints to TPH slow down
Aug 26
Mon
• 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 27
Tue
•
•
•
•
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
6
Timeline of events
Aug 28
Wed
•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
7
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 deepfrying croissant
pastry.”
Rick McGinnis, blogTO
8
http://www.blogto.com/eat_drink/2013/08/how_to_have_a_heart_attack_at_the_2013_cne/
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)
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
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 10
Preliminary case definition
Confirmed case: individuals who:
• Visited the CNE on Tuesday August 20, 2013 and consumed food
or drink purchased at the CNE
AND
• 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 CNE
AND
• Subsequently became ill with diarrhea and/or vomiting, with or
without abdominal pain
11
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.
12
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.
13
Final suspect case definition
Suspect case:
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 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
14
within 10 hours.
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
10:00 to 11:59
12:00 to 13:59
14:00 to 15:59
16:00 to 17:59
18:00 to 19:59
20:00 to 21:59
22:00 to 23:59
00:00 to 01:59
02:00 to 03:59
04:00 to 05:59
06:00 to 07:59
08:00 to 09:59
10:00 to 11:59
12:00 to 13:59
14:00 to 15:59
16:00 to 17:59
18:00 to 19:59
20:00 to 21:59
22:00 to 23:59
00:00 to 01:59
02:00 to 03:59
04:00 to 05:59
06:00 to 07:59
08:00 to 09:59
10:00 to 11:59
12:00 to 13:59
14:00 to 15:59
16:00 to 17:59
18:00 to 19:59
20:00 to 21:59
22:00 to 23:59
00:00 to 01:59
02:00 to 03:59
04:00 to 05:59
06:00 to 07:59
08:00 to 09:59
10:00 to 11:59
12:00 to 13:59
14:00 to 15:59
16:00 to 17:59
18:00 to 19:59
20:00 to 21:59
22:00 to 23:59
00:00 to 01:59
02:00 to 03:59
04:00 to 05:59
06:00 to 07:59
08:00 to 09:59
10:00 to 11:59
12:00 to 13:59
14:00 to 15:59
16:00 to 17:59
18:00 to 19:59
20:00 to 21:59
22:00 to 23:59
00:00 to 01:59
02:00 to 03:59
04:00 to 05:59
06:00 to 07:59
08:00 to 09:59
10:00 to 11:59
12:00 to 13:59
14:00 to 15:59
16:00 to 17:59
18:00 to 19:59
20:00 to 21:59
22:00 to 23:59
Number of reported cases**
Epidemic curve by illness onset*
Onset time (N=100)
36
34
Confirmed
32
Probable
30
Suspect
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
16-Aug
17-Aug
18-Aug
19-Aug
* Available data as of September 24, 2013; subject to change
20-Aug
21-Aug
Time and Date of symptom onset
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.html
https://maps.google.ca/maps?ie=UTF8&q=Superior+Sausage+Co&fb=1&gl=ca&hq=superior+sausage+toronto+hours&cid=0,0,5561172707282629667&ei=0VpbUru9FMXIrQGFsIHQDw&ved=0CLIBEPwSMAs
17
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
18
Food sample testing results
Sample
Date
collected
Aug 21
Location
Batch
S. aureus
PFGE
Remarks
>200,000
Enterotoxin
+
Epic Burgers
Aug 20
A
Prepared in front of PHI
Cronut burger - ready to eat
(patty to the grill 10 mins)
Cronut burger - ready to eat
Aug 21
Epic Burgers
Aug 20
7,300
+
A
Prepared in front of PHI
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
Raw bacon
Aug 21
Superior Sau.
Aug 21
720
-
B
Raw burger patty
Aug 21
Epic Burgers
Aug 20
<100
n/a
n/a
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
Brown sugar
Aug 24
Le Dolci
-
n/a
n/a
Cronut burger - ready to eat
After PHI recommendations
Raw
Kirkland brand (Costco)
19
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
20
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
http://www.publichealthontario.ca/en/eRepository/Public_Health_Inspectors_Guide_2013.pdf22
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
23
Acknowledgements
PHOL
Dr. Vanessa Allen
TPH MOH
Dr. David McKeown
Allana Murphy
Erik Kristjanson
TPH CDC
Dr. Barbara Yaffe
Manisa Jiaravuthisan
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 Arron
TPH Communications
Rishma Govani
Kris Scheuer
24