2. Investigation of a Salmonella Thompson Outbreak at a Local London Restaurant

3. Overview Background Information The investigation process:  Information gathering: Case interviews, premise follow-up/ investigation, team meetings and food samples. Collaboration with partner agencies Risk Assessment: decisions made Lessons Learned

4. Background Information MLHU Outbreak response team: PHN (Joanne Dow), Outbreak lead PHI (Carrie Warring) and District PHI (Randy Walker); managers David Pavletic and Tristan Squire-Smith. IDCOutbreak LeadDistrict PHIOther PHI’sManagersDirectors/MOH

5. Background Information S. Thompson common sources: beef, bread, chicken, cilantro, eggs, lettuce, peanuts, pet treats, potato salad, roast beef, salmon, tomatoes (PHO, 2014). Middlesex-London investigated a sub-cluster of 19 outbreak confirmed cases 15 cases reported eating at the same restaurant in London Two cases from Oxford also ate at same restaurant

6. National and Provincial Public Health Agency of Canada (PHAC) created the OICC on July 2 nd 2014 National cases (75, expect 14) Public Health Ontario ON-OICC initiated on August 12, 2014 Ontario cases (51, expect 9) As of August 16 th, 2014 OICC- Outbreak investigation coordinating committee

7. Timeline

8. Case Interviews Joanne Dow Single interviewer Provides “memo” regarding suspect exposures Collaborates with Outbreak Lead Information sharing with Public Health Ontario (PHO)

12. Local Restaurant Located downtown London, Ontario No special events during incubation (Victoria Park) Very popular: high volume of customers Mediterranean food items: Shawarma, Falafel, Salads etc

13. Investigation 2 Cases reported on July 16 th 2014 Then, 7 Cases reported on Friday July 25 th (5 pending). Only 2 cases report the Shawarma food premise PHO/PHAC shift focus to grocery store food items (national/provincial outbreak) Recalls: paprika and pepper for Salmonella

14. Investigation 5 suspect food premises (2 cases for the Shawarma restaurant) PHI’s asked to complete investigations at all implicated premises In addition: document ingredients used (spices), product source (name, supplier, lot codes etc) Changes to recipes, ingredients or suppliers HACCP audits Staff illness / other complaints

15. Food Samples July 31 st 2014 Red Cabbage Oregano Parsley S. Thompson ½ Shawarma ½ Mala Salad Aug. 1 (7 exposures )

16. Parsley? CFIA follow up: Perishable food item (fresh product) Typically not cooked Common ingredient High turnover Difficult to trace Distribution (national/ provincial ?) Increase in cases?

17. Outbreak Team Meeting Management Outbreak Lead IDC PHN District PHI/ PHI’s Food Chart created to distinguish ingredients Chicken most common Submit 2 chicken samples

18. Food Samples Obtained food samples (raw chicken and marinated raw chicken) Then 2 chicken suppliers discovered (CFIA, OMAFRA) Determined frequency of delivery Information provided to PHO, OMAFRA and CFIA (also investigating parsley) Raw chicken samples submitted: one from each supplier Results?

19. Salmonella Detected

20. Update Salmonella detected in: chopped parsley, oregano, raw chicken and marinated raw chicken. E.coli found in Hummus Not detected in raw chicken samples submitted from each supplier Parsley S. Thompson only Investigation focused on parsley, cross contamination, hand washing, product discarded (put on hold), and cleaning/ sanitizing

21. Partner Agencies Public Health Agency of Canada Public Health Ontario The Canadian Food Inspection Agency Ontario Ministry of Agriculture, Food and Rural Affairs Public Health Lab

22. Risk Assessments Premise closure? Media disclosure? Food premise cooperation, frequency of district inspector visiting premise, lag in time, ill food handlers(?)

23. Lessons Learned Team work: Sharing ideas and open discussion Collaboration of IDC PHN and Outbreak Lead Information sharing with partner agencies Document EVERYTHING

24. Thank You!

25. References Public Health Agency of Canada (2014). National Enteric Surveillance Program: Weekly report. Week 2014-33. Aug. 10-16, 2014. Public Health Ontario (2014). Ontario Investigation Summary: Salmonella Thompson. Updated Oct. 1, 2015 Public Health Ontario (2014). Ontario Salmonellosis Investigation Tool: Appendix 2 Source attribution of the common Salmonella serovars. Aug. 2014

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