Food Protection Trends - March/April 2020 - 98

containing the meals could be delivered to a house porch or
condo/workplace reception area and potentially remain there
for an extended period of time. As of May 2016, the delivery
area covered five public health authorities in the Greater
Toronto Area (York, Peel, Halton, Durham and Toronto).
None of the outbreak cases used the home/workplace
delivery option.
Toronto Public Health inspected the base kitchen, as
well as the two locations where cases had picked up their
meals. Location A was inspected on July 26. Refrigerator
temperatures and temperature logs were within acceptable
limits; no control food samples were collected. Location
B was inspected on July 26; refrigerator temperatures and
temperature logs were within acceptable limits. Three
control food samples from the July 25 batch (poultry, beef,
and pork meals) were taken and sent for laboratory testing.
Inspection of the base kitchen on July 27 revealed that the
designated handwashing sink lacked running hot water and
paper towels; employees were using the dishwashing sink or
washroom sink to wash their hands, or using gloves without
proper hand hygiene. Employees were also observed to be
putting hot prepared meals in the refrigerator for overnight
storage, without first cooling them properly. An inspection
"conditional pass" was therefore issued. There were no
prepared meals or raw ingredients remaining from the July
11 batch, but control samples from the latest batch of poultry
and pork meals were taken and sent for laboratory testing
on July 27. The base kitchen was re-inspected on July 29;
because the handwashing sink had been repaired and the
incorrect use of disposable gloves had ceased, an inspection
"pass" was issued.
On August 2 and 3, an HACCP audit focusing on production of the poultry meal was conducted. The audit revealed
inadequate cooling and cold-holding of ready-to-eat meals
at the base kitchen. Under provincial food premises regulations (7), potentially hazardous foods cannot be maintained
or stored at temperatures above 4 degrees Celsius or below
60 degrees Celsius for more than two hours. The public
health inspector observed that after cooking the poultry at
340 degrees Celsius for 40 minutes, the poultry was cooled
using a fan in front of the cooling rack for 30 minutes. Meals
intended for staff delivery to pickup locations were then
placed into insulated bags without ice packs (up to 50 meals
per bag) before being placed in the refrigerator. The refrigerator at the base kitchen was also of inadequate size to sufficiently cool the volume of prepared meals produced in one
batch. Internal temperatures after refrigeration for more than
eight hours ranged between 8 and 12 degrees Celsius for the
poultry meals. Similarly, internal temperatures of the beef,
pork and vegetarian meals prepared concurrently with the
poultry meal ranged between 7 and 15 degrees Celsius. As a
result of the audit findings, the operator voluntarily discarded
all 1,484 meals scheduled to be delivered on August 4 and
closed the food premise pending process revisions.

Food Protection Trends March/April

On August 16, Toronto Public Health was informed that
the online meal subscription service tested the production
of a sample batch and were not successful at reducing the
internal temperature of the meals to below 4 degrees Celsius
in the recommended time frame; they therefore decided
to halt all production. A follow-up inspection was not
conducted, as the base kitchen was permanently closed and
their refrigerators were removed from the pickup locations.
Laboratory findings
All six confirmed cases and one probable case tested positive for Salmonella Typhimurium, PFGE pattern STXAI.0193
and STBNI.0753. Because of the time delay between the
suspected exposure and reporting to public health (7-12
days), neither prepared meals nor raw ingredients from the
suspected batch were available for laboratory testing at the
time of the investigation. None of the control food samples
submitted for testing were positive for Salmonella. However,
the control samples taken from both the base kitchen and
pickup location B showed evidence of inadequate cooling
and cold-holding; total coliforms and total Gram-negative
counts were elevated in all nine samples, and the Bacillus
cereus count was elevated in four of nine samples.
DISCUSSION
Although Salmonella Typhimurium is a common serotype among salmonellosis cases in Ontario (12) and the
pathogen was not isolated from the implicated food item,
the epidemiologic evidence and findings of the food safety
investigation strongly support the conclusion that the
outbreak was associated with this online meal subscription
service. The weight of evidence (11) points toward a
common source for the outbreak: all seven outbreakassociated cases shared matching PFGE patterns, and all
six confirmed cases reported eating the poultry dish during
their incubation period. Results from the inspection of the
food production facility, HACCP audit, and laboratory
testing of other prepared meals at the base kitchen and at
the centralized pickup points revealed significant food safety
issues, specifically time and temperature abuse, as the root
cause of the outbreak. The last symptom onset date among
confirmed cases was July 18, and no further cases were
reported to Toronto Public Health after August 4.
The outbreak investigation had several limitations. The
investigation focused exclusively on cases confirmed through
laboratory testing. Cases who did not have illness diagnosed
through a health care provider would not have been reported
to Toronto Public Health. Case-finding among potentiallyexposed customers was not conducted, because the online
meal subscription service did not keep a record of what meals
were purchased or picked up by its subscribers and because
of the self-limiting nature of the infection. The delay of 7 to
12 days between the suspected exposure and Salmonella case
reporting to public health resulted in the suspect meals being

Food Protection Trends - March/April 2020

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