Food Protection Trends - March/April 2020 - 96

On July 26, 2016, a Toronto Public Health investigator
identified four cases of salmonellosis (including two household members), with the same online meal subscription
service reported as a common exposure. The cause of three
of these cases was subtyped as Salmonella Typhimurium on
July 28, 2016, the same day that a fifth case of salmonellosis
with exposure to the same online meal subscription service
was identified.
The objectives of this outbreak report are to describe
a community outbreak of disease caused by Salmonella
Typhimurium involving an online meal subscription service
in Toronto, Canada and to increase awareness among food
safety professionals about consumers' exposure to this
increasingly popular business model.
MATERIALS AND METHODS
Case finding and data collection
Laboratory-confirmed cases of salmonellosis are routinely
reported to Toronto Public Health under the Province of
Ontario's Health Protection and Promotion Act (7). Case
information, including exposure histories, is obtained through
telephone interviews, using a standardized provincial investigation tool for salmonellosis cases (13). Components of the
questionnaire include symptoms and onset, hospitalization
and complications, behavioral and social risk factors, a threeday food history including names of visited food premises,
and involvement in high-risk settings such as child care centers.
Data are entered into Ontario's Integrated Public Health
Information System (iPHIS). Toronto Public Health and the
provincial public health agency, Public Health Ontario, queried
iPHIS to identify any additional cases of S. Typhimurium
infection in Toronto and neighboring health authorities
served by the online meal subscription service. Descriptive
analyses were conducted using Microsoft Excel 2010.
Laboratory testing
Clinical diagnostic laboratories in Ontario forward isolates
of Salmonella to the Public Health Ontario (PHO) Laboratory
for serotyping and provincial enteric illness surveillance purposes. Clinical isolates of Salmonella were serotyped according to recognized laboratory serotyping slide agglutination
protocols (5, 8). Pulsed-field gel electrophoresis (PFGE) was
also performed according to standardized PulseNet Canada
protocols (1) for clinical isolates of Salmonella Typhimurium
for surveillance purposes and to support the investigation.
The PFGE pattern designations were provided by the National
Microbiology Laboratory in Winnipeg in order to identify
isolates that were considered to be genetically related.
Food samples submitted to PHO Laboratory for analysis
were tested according to the food type and reason for testing,
as submitted by the health unit. Testing for control samples
included analysis for indicator organisms in order to perform a
microbiological assessment of the ready-to-eat food samples as
well as testing for bacterial pathogens (14).

96

Food Protection Trends March/April

Outbreak case definitions
*	 Confirmed case: Toronto resident with laboratoryconfirmed Salmonella Typhimurium, PFGE patterns
STXAI.0193 and STBNI.0753, with onset of symptoms
on or after July 1st, 2016, who consumed food from the
online meal subscription service on or after July 1st,
2016.
*	 Probable case: Toronto resident with laboratory-confirmed Salmonella Typhimurium, PFGE patterns STXAI.0193 and STBNI.0753, reported to Toronto Public
Health on or after July 1st, 2016, but where exposures
could not be ascertained.
Reported salmonellosis cases who had traveled outside
Canada for the entire duration of the incubation period
(3 days prior to onset of symptoms) were excluded.
Food safety investigation
Toronto Public Health conducted food safety inspections
of the commercial food premises identified by the outbreak
cases through the food history questionnaire, including the
online meal subscription service and pickup locations. The
public health inspector also conducted a Hazard Analysis
Critical Control Point (HACCP) audit, following the meal
preparation process for the implicated meal type at their
base kitchen from meat delivery through steps of handling,
preparation, cooking, cooling, cold holding, storage and
delivery. Samples of uneaten food from the online meal
subscription service and control food samples from the base
kitchen and centralized pickup locations were submitted for
laboratory testing.
RESULTS
Descriptive epidemiology
A total of six confirmed cases and one probable case were
reported to Toronto Public Health between July 18 and
August 4, 2016. Stool specimen collection dates ranged
from July 13 to 29, 2016. The epidemic curve (Fig. 1) was
consistent with a point-source outbreak. Six of the seven
cases (86%) were male. Cases' median age was 28 years
(range: 1-55 years). All of the cases were identified as
Toronto residents.
Among the confirmed cases, the most common signs
and symptoms were diarrhea (6/6, 100%), fever (4/6, 67%),
and abdominal pain (4/6, 67%). Two of the confirmed
cases and the probable case were reported to have had
bloody diarrhea. Three of the confirmed cases (50%) also
experienced vomiting. Mean duration of symptoms was
7.6 days (range 6-10 days). Three of the seven (43%)
outbreak cases sought care at a hospital emergency
department, while the remainder (57%) went to an
outpatient clinic. None of the cases were hospitalized,
and there were no deaths.



Food Protection Trends - March/April 2020

Table of Contents for the Digital Edition of Food Protection Trends - March/April 2020

Food Safety Knowledge and Practice in Low-income Families in the United States: An Exploratory Study
Outbreak of Disease Caused by Salmonella Typhimurium Associated with an Online Meal Subscription Service in Toronto, Canada, 2016
Microbiological Contamination in Restaurants and Food Hygiene Practices among Migrant Food Handlers in Samut Sakhon Province, Thailand
Predictors of Safe Food Handling among Canadian Seniors Living at Home
Beyond the Bio Chip Manuel
PDG Highlight Student PDG
Industry Products
Coming Events
Food Protection Trends - March/April 2020 - Cover1
Food Protection Trends - March/April 2020 - Cover2
Food Protection Trends - March/April 2020 - 73
Food Protection Trends - March/April 2020 - 74
Food Protection Trends - March/April 2020 - 75
Food Protection Trends - March/April 2020 - 76
Food Protection Trends - March/April 2020 - 77
Food Protection Trends - March/April 2020 - 78
Food Protection Trends - March/April 2020 - 79
Food Protection Trends - March/April 2020 - Food Safety Knowledge and Practice in Low-income Families in the United States: An Exploratory Study
Food Protection Trends - March/April 2020 - 81
Food Protection Trends - March/April 2020 - 82
Food Protection Trends - March/April 2020 - 83
Food Protection Trends - March/April 2020 - 84
Food Protection Trends - March/April 2020 - 85
Food Protection Trends - March/April 2020 - 86
Food Protection Trends - March/April 2020 - 87
Food Protection Trends - March/April 2020 - 88
Food Protection Trends - March/April 2020 - 89
Food Protection Trends - March/April 2020 - 90
Food Protection Trends - March/April 2020 - 91
Food Protection Trends - March/April 2020 - 92
Food Protection Trends - March/April 2020 - 93
Food Protection Trends - March/April 2020 - 94
Food Protection Trends - March/April 2020 - Outbreak of Disease Caused by Salmonella Typhimurium Associated with an Online Meal Subscription Service in Toronto, Canada, 2016
Food Protection Trends - March/April 2020 - 96
Food Protection Trends - March/April 2020 - 97
Food Protection Trends - March/April 2020 - 98
Food Protection Trends - March/April 2020 - 99
Food Protection Trends - March/April 2020 - 100
Food Protection Trends - March/April 2020 - Microbiological Contamination in Restaurants and Food Hygiene Practices among Migrant Food Handlers in Samut Sakhon Province, Thailand
Food Protection Trends - March/April 2020 - 102
Food Protection Trends - March/April 2020 - 103
Food Protection Trends - March/April 2020 - 104
Food Protection Trends - March/April 2020 - 105
Food Protection Trends - March/April 2020 - 106
Food Protection Trends - March/April 2020 - 107
Food Protection Trends - March/April 2020 - 108
Food Protection Trends - March/April 2020 - 109
Food Protection Trends - March/April 2020 - 110
Food Protection Trends - March/April 2020 - Predictors of Safe Food Handling among Canadian Seniors Living at Home
Food Protection Trends - March/April 2020 - 112
Food Protection Trends - March/April 2020 - 113
Food Protection Trends - March/April 2020 - 114
Food Protection Trends - March/April 2020 - 115
Food Protection Trends - March/April 2020 - 116
Food Protection Trends - March/April 2020 - 117
Food Protection Trends - March/April 2020 - 118
Food Protection Trends - March/April 2020 - 119
Food Protection Trends - March/April 2020 - 120
Food Protection Trends - March/April 2020 - 121
Food Protection Trends - March/April 2020 - Beyond the Bio Chip Manuel
Food Protection Trends - March/April 2020 - 123
Food Protection Trends - March/April 2020 - 124
Food Protection Trends - March/April 2020 - PDG Highlight Student PDG
Food Protection Trends - March/April 2020 - 126
Food Protection Trends - March/April 2020 - 127
Food Protection Trends - March/April 2020 - 128
Food Protection Trends - March/April 2020 - 129
Food Protection Trends - March/April 2020 - Industry Products
Food Protection Trends - March/April 2020 - 131
Food Protection Trends - March/April 2020 - Coming Events
Food Protection Trends - March/April 2020 - Cover3
Food Protection Trends - March/April 2020 - Cover4
https://www.nxtbook.com/nxtbooks/trilix/fpt_20240304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20240102
https://www.nxtbook.com/nxtbooks/trilix/fpt_20231112
https://www.nxtbook.com/nxtbooks/trilix/fpt_20230910
https://www.nxtbook.com/nxtbooks/trilix/fpt_20230708
https://www.nxtbook.com/nxtbooks/trilix/fpt_20230506
https://www.nxtbook.com/nxtbooks/trilix/fpt_20230304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20230102
https://www.nxtbook.com/nxtbooks/trilix/fpt_20221112
https://www.nxtbook.com/nxtbooks/trilix/fpt_20220910
https://www.nxtbook.com/nxtbooks/trilix/fpt_20220708
https://www.nxtbook.com/nxtbooks/trilix/fpt_20220506
https://www.nxtbook.com/nxtbooks/trilix/fpt_20220304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20220102
https://www.nxtbook.com/nxtbooks/trilix/fpt_20211112
https://www.nxtbook.com/nxtbooks/trilix/fpt_20210910
https://www.nxtbook.com/nxtbooks/trilix/fpt_20210708
https://www.nxtbook.com/nxtbooks/trilix/fpt_20210506
https://www.nxtbook.com/nxtbooks/trilix/fpt_20210304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20210102
https://www.nxtbook.com/nxtbooks/trilix/fpt_20201112
https://www.nxtbook.com/nxtbooks/trilix/fpt_20200910
https://www.nxtbook.com/nxtbooks/trilix/fpt_20200708
https://www.nxtbook.com/nxtbooks/trilix/fpt_20200506
https://www.nxtbook.com/nxtbooks/trilix/fpt_20200304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20200102
https://www.nxtbook.com/nxtbooks/trilix/fpt_20191112
https://www.nxtbook.com/nxtbooks/trilix/fpt_20190910
https://www.nxtbook.com/nxtbooks/trilix/fpt_20190708
https://www.nxtbook.com/nxtbooks/trilix/fpt_20190506
https://www.nxtbook.com/nxtbooks/trilix/fpt_20190304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20190102
https://www.nxtbook.com/nxtbooks/trilix/fpt_20181112
https://www.nxtbook.com/nxtbooks/trilix/fpt_20180910
https://www.nxtbook.com/nxtbooks/trilix/fpt_20180708
https://www.nxtbook.com/nxtbooks/trilix/fpt_20180506
https://www.nxtbook.com/nxtbooks/trilix/fpt_20180304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20180102
https://www.nxtbook.com/nxtbooks/trilix/fpt_20171112
https://www.nxtbook.com/nxtbooks/trilix/fpt_20170910
https://www.nxtbook.com/nxtbooks/trilix/fpt_20170708
https://www.nxtbook.com/nxtbooks/trilix/fpt_20170506
https://www.nxtbook.com/nxtbooks/trilix/fpt_20170304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20170102
https://www.nxtbook.com/nxtbooks/trilix/fpt_20161112
https://www.nxtbook.com/nxtbooks/trilix/fpt_20160910
https://www.nxtbook.com/nxtbooks/trilix/fpt_20160708
https://www.nxtbook.com/nxtbooks/trilix/fpt_20160506
https://www.nxtbook.com/nxtbooks/trilix/fpt_20160304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20160102
https://www.nxtbook.com/nxtbooks/trilix/fpt_20151112
https://www.nxtbook.com/nxtbooks/trilix/fpt_20150910
https://www.nxtbook.com/nxtbooks/trilix/fpt_20150708
https://www.nxtbook.com/nxtbooks/trilix/fpt_20150506
https://www.nxtbook.com/nxtbooks/trilix/fpt_20150304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20150102
https://www.nxtbook.com/nxtbooks/trilix/fpt_20141112
https://www.nxtbook.com/nxtbooks/trilix/fpt_20140910
https://www.nxtbook.com/nxtbooks/trilix/fpt_20140708
https://www.nxtbook.com/nxtbooks/trilix/fpt_20140506
https://www.nxtbook.com/nxtbooks/trilix/fpt_20140304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20140102
https://www.nxtbook.com/nxtbooks/trilix/fpt_20131112
https://www.nxtbook.com/nxtbooks/trilix/fpt_20130910
https://www.nxtbook.com/nxtbooks/trilix/fpt_20130708
https://www.nxtbook.com/nxtbooks/trilix/fpt_20130506
https://www.nxtbook.com/nxtbooks/trilix/fpt_20130304
https://www.nxtbook.com/nxtbooks/trilix/fpt_20130102
https://www.nxtbook.com/nxtbooks/trilix/fpt_201212
https://www.nxtbook.com/nxtbooks/trilix/fpt_201211
https://www.nxtbook.com/nxtbooks/trilix/fpt_201210
https://www.nxtbook.com/nxtbooks/trilix/fpt_201209
https://www.nxtbook.com/nxtbooks/trilix/fpt_201208
https://www.nxtbook.com/nxtbooks/trilix/fpt_201207
https://www.nxtbook.com/nxtbooks/trilix/fpt_201206
https://www.nxtbook.com/nxtbooks/trilix/fpt_201205
https://www.nxtbook.com/nxtbooks/trilix/fpt_201204
https://www.nxtbook.com/nxtbooks/trilix/fpt_201203
https://www.nxtbook.com/nxtbooks/trilix/fpt_201202
https://www.nxtbook.com/nxtbooks/trilix/fpt_201201
https://www.nxtbook.com/nxtbooks/trilix/fpt_201112
https://www.nxtbook.com/nxtbooks/trilix/fpt_201111
https://www.nxtbook.com/nxtbooks/trilix/fpt_201110
https://www.nxtbook.com/nxtbooks/trilix/fpt_201109
https://www.nxtbook.com/nxtbooks/trilix/fpt_201108
https://www.nxtbook.com/nxtbooks/trilix/fpt_201107
https://www.nxtbook.com/nxtbooks/trilix/fpt_201106
https://www.nxtbook.com/nxtbooks/trilix/fpt_201105
https://www.nxtbook.com/nxtbooks/trilix/fpt_201104
https://www.nxtbook.com/nxtbooks/trilix/fpt_201103
https://www.nxtbook.com/nxtbooks/trilix/fpt_201102
https://www.nxtbook.com/nxtbooks/trilix/fpt_201101
https://www.nxtbook.com/nxtbooks/trilix/fpt_201012
https://www.nxtbook.com/nxtbooks/trilix/fpt_201011
https://www.nxtbook.com/nxtbooks/trilix/fpt_201010
https://www.nxtbook.com/nxtbooks/trilix/fpt_201009
https://www.nxtbook.com/nxtbooks/trilix/fpt_201008
https://www.nxtbook.com/nxtbooks/trilix/fpt_201007
https://www.nxtbook.com/nxtbooks/trilix/fpt_201006
https://www.nxtbook.com/nxtbooks/trilix/fpt_201005
https://www.nxtbook.com/nxtbooks/trilix/fpt_201004
https://www.nxtbook.com/nxtbooks/trilix/fpt_201003
https://www.nxtbook.com/nxtbooks/trilix/fpt_201002
https://www.nxtbook.com/nxtbooks/trilix/fpt_201001
https://www.nxtbook.com/nxtbooks/trilix/fpt_200912
https://www.nxtbook.com/nxtbooks/trilix/fpt_200911
https://www.nxtbook.com/nxtbooks/trilix/fpt_200910
https://www.nxtbook.com/nxtbooks/trilix/fpt_200909
https://www.nxtbook.com/nxtbooks/trilix/fpt_200908
https://www.nxtbook.com/nxtbooks/trilix/fpt_200907
https://www.nxtbook.com/nxtbooks/trilix/fpt_200906
https://www.nxtbook.com/nxtbooks/trilix/fpt_200905
https://www.nxtbook.com/nxtbooks/trilix/fpt_200904
https://www.nxtbook.com/nxtbooks/trilix/fpt_200903
https://www.nxtbook.com/nxtbooks/trilix/fpt_200902
https://www.nxtbook.com/nxtbooks/trilix/fpt_200901
https://www.nxtbook.com/nxtbooks/trilix/fpt_200812
https://www.nxtbook.com/nxtbooks/trilix/fpt_200811
https://www.nxtbook.com/nxtbooks/trilix/fpt_200810
https://www.nxtbook.com/nxtbooks/trilix/fpt_200809
https://www.nxtbook.com/nxtbooks/trilix/fpt_200808
https://www.nxtbook.com/nxtbooks/trilix/fpt_200807
https://www.nxtbookmedia.com