1. Sylvanus Thompson PhD, CPHI(C) Associate Director Toronto Public Health

2. City of Toronto Largest City in Canada Most multi-cultural city 2.7 million people 17000 Food Establishments 437,00 cases of foodborne illnesses annually $476 – 587 million Numerous special events Canadian National Exhibition (CNE)

4. Canadian National Exhibition Canada's largest community event Founded in 1879 - a showcase of the nation 7th largest fair in North America Close to 1.5 million visitors over its 18 day duration Starts mid August Ends on Labour Day

6. Food Building

8. FBI Outbreak at the CNE Call from CNE Manager at 10:30 pm-August 20 Several persons reported being ill shortly after consuming food at a specific outlet TPH 24/7 On Call system Dial 311 CNE advised to ensure premise is kept closed Secure any left over food product Control of Communicable Disease Manager informed

9. 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 analysis RTE burgers, bacon jam Production site of major ingredient inspected and sample taken Bacon jam sample

10. Epi Investigation CDC staff interviewed 257 persons Standard Outbreak investigation questionnaire Fluid survey data entry tool iPHIS At risk population exposure August 16 –20 Kits provided for specimen collection Victims reported Treated onsite by EMS personnel Taken to Hospital Family physician Food handling staff interviewed

11. Incubation Period Short Incubation Period Mean 4.7 hours Median 4.0 hours Range 0.5 – 22.0 hours

12. Symptoms Watery diarrhea (83%) Vomiting (81%) Nausea (76%) Abdominal pain (74%) Loss of appetite (62%) Headache (43%) Chills (42%) Bloody diarrhea (6%)

13. Inter- Agency Collaboration Liaise with other affected health units based on where cases reside Notify to Ministry of Health and Long Term Care Responsibility for healthcare system Chairs Outbreak Investigation Coordinating Committee Inform Public Health Ontario Public Health Laboratory Technical support

14. Table 1: Age and Gender of Reported Cases, by Classification. ConfirmedProbableSuspectTotal N=88N=43N=13N=144 Sex Male4921474 Female3921767 Unknown0123 Age* Mean32.032.930.132.4 (years)Median28.529.031.229.5 Range0 to 690 to 680 to 52 *Age was unavailable for one confirmed and two probable cases.

15. Table 5: Frequency of foods consumed from implicated premises by classification* ConfirmedProbableSuspectTotal N=88%N=43%N=13%N=144% Cronut burger8799%3786%1077%13493% Chicken in waffle45%37%18%86% Beverage33%49%00%75% Krispy kreme burger33%37%215%86% Fries22%1 00%32% "Other" burger11%12%215%43% Not specified11%12%00%21% *Cases could report eating more than one item at Epic Burger and Waffles.

17. Outbreak Management News Release Implicated premises closed voluntarily Section 13 Order contemplated No health hazard identified Epi evidence No new cases Follow-up visit to establishment where bacon jam produced Teaching school Bakery Modified HACCP Audit and additional sampling

18. Laboratory Results Seven Food samples positive for Staph aureus 4 RTE burgers with bacon jam 2 bacon jam smoked bacon All samples, except the bacon, had same PFGE pattern and entero-toxin present All other samples negative

19. Food sample testing results SampleDate collected LocationBatch S. aureus Entero- toxin PFGERemarks Cronut burger - ready to eatAug 21Epic BurgersAug 20>200,000+APrepared in front of PHI Cronut burger - ready to eat (patty held 10 mins) Aug 21Epic BurgersAug 207,300+APrepared in front of PHI Cronut burger - ready to eatAug 20Epic BurgersAug 20>200,000+ACollected by CNE staff Cronut burger - ready to eatAug 22Client homeAug 20Positive+ASaved by ill case Bacon pureeAug 21Epic BurgersAug 201,000+ASampled from 10 litre bucket Bacon pureeAug 21Le DolciAug 21100+A Bacon pureeAug 23Le Dolci n/a- After PHI consultation Raw baconAug 21Superior Sau.Aug 21720-B Raw burger pattyAug 21Epic BurgersAug 20<100n/a Raw Processed cheeseAug 21Epic BurgersAug 20<100n/a Cronut (croissant donut)Aug 21Epic BurgersAug 20<100n/a Bread product only ToppingsAug 20Epic BurgersAug 20-n/a Collected by CNE staff Donut productAug 21Le DolciAug 21<100n/a Maple syrupAug 24Le Dolci -n/a Kirkland brand (Costco) Brown sugarAug 24Le Dolci -n/a 19

20. Bacon Jam Bacon jam determined as cause of illness Media release Food establishment at the CNE permitted to re- open under specified conditions no bacon jam from that producer re-training of all food handlers thorough cleaning and sanitization Re-opened on August 27

21. Epic re-opened (pic)

22. Bacon Jam Producer Establishment voluntarily closed Section 13 issued Environmental sampling before and after cleaning Training of food handlers All samples negative for Staph aureus More detailed interview of food handlers Nasal swabs Permitted to re-open under conditions modify bacon jam production process 1 of 4 food handler positive for Staph unrelated PFGE pattern

23. Communication Media releases on timely basis Actions being taken by TPH Investigation into source Lab results 5 media advisories 4 press conferences 190 media calls

24. 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 24

26. Lessons Learned Prompt TPH response Importance of keeping the public informed and re- assured Detailed sampling and analysis Multi – agency coordination and response Resulted in quick identification of the implicated food and end outbreak!

27. Quick identification of the implicated food and end outbreak!

28. Sylvanus Thompson sthomps@toronto.ca 416 338 3661 sthomps@toronto.ca