Independent Listeriosis Investigative Review
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TABLE OF CONTENTS INVESTIGATor’s message ...................................iii EXECUTIVE SUMMARY .......................................vii COMPLETE SET OF RECOMMENDATIONS ......................xv 1. HOW DID WE APPROACH THIS REPORT? ..................1 » About the Listeriosis Investigative Review .......................2 » Approach ...............................................2 2. WHAT IS LISTERIOSIS? ...................................5 » Preventing . .7 3. WHO WAS AFFECTED? ....................................9 4. HOW DOES CANADA’s food safety system WORK? ... 13 » Responsibilities of the various organizations involved ............ 13 » Understanding the federal regulatory system overseeing meat processors ....................................... 17 » Understanding public health and the organizations involved ....... 24 » Detecting and investigating foodborne illness .................. 25 5. WHAT LED TO THE OUTBREAK? ......................... 29 1. Maple Leaf Foods believed its strategy to control Listeria was working – it was not ................................. 30 2. The federal meat inspection system did not identify these problems .............................. 36 3. There were gaps in the federal rules governing meat production and inspection ........................... 39 4. Once contaminated products entered the food supply, Institutions served it to vulnerable populations ................ 44 5. As contaminated food was being consumed, the public health system slowly recognized the outbreak ........ 44 6. HOW DID EVENTS ACTUALLY UNFOLD? .................. 47 i 7. HOW WELL DID THE FEDERAL GOVERNMENT AND ITS FOOD SAFETY PARTNERS RESPOND TO THE OUTBREAK? . 61 » Understanding the challenges of managing a foodborne emergency .......................... 62 » Leadership ............................................ 63 » Emergency management ................................. 64 » Federal, provincial/territorial and local coordination ........... 64 » Federal organizations’ structures and operating procedures ...... 67 » Disease reporting .................................... 68 » Epidemiological investigation ............................ 68 » Food investigation and recall ............................ 69 » Laboratories ......................................... 72 8. HOW WELL WERE COMMUNICATIONS HANDLED? ....... 75 » Communications to the public ............................. 75 » Observations and assessment ............................. 76 » Communications to physicians ............................. 81 » Public education ....................................... 82 9. WhAT PROGRESS HAS BEEN MADE SINCE THE OUTBREAK? ................................. 85 10. WhAT ELSE DID WE LEARN DURING THIS INVESTIGATION? .......................... 87 » Government of Canada food safety legislative and regulatory framework ................................. 88 » Federal organizational governance and structure ............... 88 » CFIA ................................................ 88 » Public Health Agency of Canada ............................ 91 » Multi-departmental governance of food safety ................. 92 » Multi-jurisdictional governance of food safety .................. 93 » Going forward ......................................... 94 APPENDICES a. Biographies of the Independent Investigator and the members of the Expert Advisory Group ............... 95 b. Detailed chronology ..................................101 c. Progress to date .....................................129 d. List of interviewees ...................................143 e. Glossary of terms ....................................149 f. Acronyms ..........................................155 ii A message from the Investigator When I was asked to lead the investigation into the August 2008 Listeriosis outbreak, I recognized this was not just a professional challenge but also a great responsibility . My goal, from the time I accepted this role, was to provide Canadians with answers about how and why this outbreak occurred .While examining thousands of pages of research findings, participating in hundreds of hours of interviews, and being guided by the advice of experts, I stayed committed to this objective . I felt a strong obligation to find the facts and make recommendations that will help to protect the Canadian public from future outbreaks or optimize the response if they do arise . No one deserves answers more than the families and friends of those who died as well as the individuals who became ill . I extend my deepest sympathy, and dedicate this report, to all those who were affected by this tragedy . Many people shared their experiences and perspectives to better understand the events that took place, and many came forward with proposed solutions to prevent similar foodborne emergencies . Over 100 interviews and fact-findings meetings were conducted with individuals from all sectors . I learned that, in hindsight, it is much easier to see the sequence of events that led to the outbreak and to identify steps that could or should have been taken . I heard, repeatedly, that if people had only known or recognized then what they now know, these events may have evolved differently . Despite these insights and the best efforts of everyone concerned, the fact remains: 22 lives were lost .These individuals, mostly elderly and at risk of infections, put their faith in Canada’s food safety system, expecting it to protect them .Their faith, and that of all Canadians, was shaken . For all the effort of all involved, the food safety system let them down . This is a serious matter with potentially deadly consequences for vulnerable individuals – people with compromised immune systems, the elderly, pregnant women and their newborns .Although outbreaks of listeriosis are rare, the risks of foodborne illnesses are on the rise and will only intensify in the future for reasons explained in this report .And once the bacteria causing the disease finds its way into the food chain and onto peoples’ plates, it is difficult to get under control no matter how committed and dedicated those involved in food safety may be . As we learned from this event – the worst national listeriosis outbreak in Canadian history – it is often too late to save people at greatest risk from an unnecessary illness or untimely death once food contaminated with Listeria monocytogenes iii is on the market . It is vital that we take all necessary measures to avert another listeriosis outbreak . Some point out that Canada’s food safety approach receives high marks and is considered among the best in the world .A 2008 international food safety review ranked Canadafifth among 17 member countries of the Organization for Economic Co-Operation and Development (OECD), identifying it as a superior system . It is true that, for the most part, Canadians can have confidence in Canada’s food safety system . However, this investigation found problems that need to be addressed to better protect Canadians . These problems, which apply not only to federal organizations but to industry and other governments as well, fell under four broad themes . The first was an insufficient focus on food safety among senior management in both the public and private domains . Even though there was evidence of contamination on production lines producing ready-to-eat meats months before the outbreak, these trends were not being monitored to identify the recurring presence of the bacteria .There was a lack of understanding about intergovernmental protocols to deal with such emergencies, which created confusion about who should do what and when . Government approval processes for new food additives and techniques, with a direct bearing on food safety, were not prioritized or fast- tracked . Information did not always make its way to the senior ranks of the public service and company headquarters which exacerbated these challenges .There were also cases of inadequate decision making which was apparent, for example, in implementing a new program designed to improve food safety . In addition, some policies and directives were vague leaving them open to interpretation, thus creating opportunity for problems . The second, related area of concern was the state of readiness . It appeared there was not enough advance planning and preparation on a number of fronts, which left people unprepared when the outbreak struck . Examples include the shortage of workers needed to handle surge capacity in times of emergency, summer vacation with substitutes who did not always understand their roles, the lack of exercises to sort out these issues in advance of an actual crisis, insufficient training for food inspectors charged with the new inspection procedures, and confusion over where lab samples should be sent . The third observation was the lack of a sense of urgency at the outset of the outbreak . For instance, key pieces of information and even personnel were unavailable over a given weekend delaying decisions until the start of the following work week .Another key element was the differing views on when to warn the public about the potential harm from certain foods . Once the gravity of the situation was recognized, emergency operations centres were not immediately activated, if at all . iv As well, some who might have been prominent on the national stage were not as visible as expected . The fourth area that left room for improvement was communications – to members of groups at increased risk for listeriosis, health professionals and the general public . Canadians