Day 25: Monday, June 1, 2020 (n=14)

An OICC call is held with investigative partners. The epi summary you prepared was distributed prior to the call (Module 2 – Epi summary). There are a total of fourteen confirmed cases under investigation (BC=3, AB=3, ON=7, QC=1). Hypothesis-generation interviews have identified spinach, blueberries, almonds, walnuts, sesame seeds, chia seeds and flax seeds to be of interest for further investigation.

The following information is shared on the call:

Provincial updates:

• British Columbia (n=3)
  • The newest case, BC-11, is a 26 year-old female with an onset date of May 6, 2020. Based on the initial interview by the local public health authority, the case reports consuming a vegetarian diet that is high in fruit consumption with the exception of a blueberry allergy. This case rarely eats at restaurants aside from consuming salads at a local sandwich shop, and primarily buys food at the local farmer’s market. The local public health authority has followed up with the sandwich shop to gather menu information. Only two salads are on the menu and none of them include spinach, berries, nuts or seeds. British Columbia notes that they can share the menu information with PHAC.
• Alberta (n=3)
  • AB-10 is a 53 year-old female with an onset date of May 4, 2020. Based on her interview with the local health authority, this case reported “No” to vegetarianism; however, emphasized a diet high in fresh fruits, vegetables, and whole grains. She indicated consumption of seeds, particularly flax, hemp, and chia, which she uses in baking. Each morning she has a peanut butter and banana sandwich.
  • AB-12 is a 20 year-old female who is currently attending a local college. Based on initial interview data, this case reports eating healthy foods most of the time, and frequently prepares smoothies for quick and easy meals.
• Ontario (n=7)
  • ON-14 is a 45 year-old male who reports being a manager at a bulk food shop, and since he purchases a lot of his own store’s products there is high likelihood that he consumed all nuts and seeds inquired about by the local health authority.
• Quebec (n=1)
  • Quebec notes their case (QC-13) was challenging to contact and declined to be interviewed. This case is lost to follow up.

National Microbiology Laboratory (NML) Update:

• NML notes that they checked for any US matches to this Salmonella Newport cluster and that they found no matches. The Canadian cases are not genetically related to the cases in the United States by whole genome sequencing (WGS).

Food Safety Update:

• The Canadian Food Inspection Agency (CFIA) has conducted traceback investigations for the baby spinach consumed by the three Ontario cases and one BC case. The spinach eaten by the Ontario cases can be traced back to two distributors. Both distributors obtain spinach from a hydroponic greenhouse located in the province and only distribute product within Ontario. This greenhouse provides product to only these two distributors. As the spinach is not distributed outside of Ontario and the other cases are not reporting travel to Ontario, it is unlikely that the spinach is the source of the outbreak. Traceback conducted into the spinach consumed by the British Columbia case found that the particular store they purchased spinach from sources their produce from a farm that only distributes produce in Western Canada, so no further traceback was conducted. Because of the lack of commonalties between the spinach the sources consumed, spinach has been ruled out as a likely source of these illnesses.

Next steps:

• CFIA would like to initiate traceback on more products including the nuts and seeds; however, more product details would be required.
• The OICC members agree that the next step should be to refine the hypotheses and gather more detailed information on the types of nuts and seeds, as well as brand and purchase locations where possible, from cases. Additional product details on blueberries should also be collected.
• Provinces agree to share available exposure information for their newest cases with PHAC from the initial case interviews completed by local public health authorities. Provinces also agree to contact local public health authorities for case contact information for the new cases, so the Public Health Agency of Canada (PHAC) can continue the re-interviewing process. They also agree for a focused questionnaire to be used to re-interview the new cases, as well to re-interview certain cases again (e.g., recent cases, cases that were cooperative and/or had a good recall). The focused questionnaire will emphasize data collection on the food items of interest: nuts, seeds, and blueberries. During re-interviews, PHAC will continue to ask cases for purchase record information where possible. PHAC will draft the focused questionnaire and circulate it to provincial epidemiologists for review as soon as possible.

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