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 generally do not understand which level of government, let alone what organization has specific jurisdictional responsibility for public health or food safety . What they do know is that they want someone to explain to them, simply and clearly, what is happening and what they should be doing to protect themselves . Subsequent polling, along with the personal anecdotes of family members and others who shared their views during this investigation, indicated that communications about the outbreak did not provide the information they needed .There was near unanimous agreement that Canadians were confused following news of the food recalls . There is no question this was a complex undertaking and everyone involved was under great pressure to deal with the foodborne emergency while responding to public concerns . I discovered how hard people worked and recognize how dedicated all those involved were in finding the source of the illness, linking the bacteria DNA fingerprints between humans and foods, removing contaminated food products from the market, communicating and managing the event . Encouragingly, actions are underway to correct problems that were identified immediately following the event . I urge those with a role in food safety to continue to examine their policies, programs and practices and to look for long-term solutions to the remaining challenges . For, while the measures taken to date are a good start, this investigation has concluded that many areas require ongoing improvements . Until the system is remedied,events like those of the summer of 2008 remain a real risk .That is why I am recommending changes that span all sectors – from food processors to regulators to public health professionals and individual consumers .As this report explains, ultimately, all Canadians need to take ownership of food safety because we are collectively responsible for ensuring the security of the foods we eat . I am calling for swift and significant action in key areas that are critical to food safety – the culture of food processing companies, the design of food processing equipment,the rules and requirements for food safety set out by the federal government as well as governments’ capacity to manage national foodborne emergencies .This includes governance considerations and relationships among all levels of government involved . Equally important, I am calling on the Government of Canada to establish food safety as one of its top priorities and to report back to Canadians on the steps it
v has taken to improve Canada’s food inspection and food safety emergency response systems . As much as there is a legal obligation to uphold the laws and regulations governing food safety in this country, there is a moral duty of care to consumers – especially the most vulnerable . Safeguarding Canadians must be at the centre of the consciousness and collective actions of all those involved in food safety . It is my hope that, this time, the recommendations being offered will be acted upon .This is not the first report on food safety produced in this country that has called for fundamental change . From past food safety auditsby the Auditor General of Canada to the “Farm to Fork” Haines report following the Ontario Meat Regulatory and Inspection Review a decade later, there have been repeated calls for action . It is in the best interest of all Canadians that these recommendations be implemented .Action in these areas will not only protect Canada’s food supply and the health of older Canadians and members of other vulnerable groups . It will also contribute to industry’s competitiveness in a world that wants assurance that food products are safe . By being proactive, Canada can raise its global food safety ranking from superior to the best in the world . If we have good standards and regulations, good adherence to the rules and good oversight, it will be a win-win for public health and safety, national economic and employment growth, and the food industry . It took the 2008 listeriosis outbreak to raise awareness that food safety cannot be taken for granted .We cannot wait for another foodborne emergency to occur and more lives to be lost before we act .While there will be costs in implementing some of these recommendations, the costs of inaction – whether measured by the damage to individual Canadians’ lives, lost revenues and reputation for industry, or Canada’s global competitiveness in an increasingly food safety conscious world – are far greater . The lessons learned from this outbreak provide an opportunity for Canada to show leadership . I call on all sectors to step up and meet this challenge . Canadians expect no less .
vi Executive Summary
This report represents the culmination of the work undertaken by the Independent Listeriosis Investigative Review, which was set up to examine the factors that contributed to the 2008 listeriosis outbreak .This tragic event resulted in serious illness for 57 vulnerable individuals and eventually cost the lives of 221 Canadians .
The Independent Investigator was appointed in January 2009 to explorehow and why the outbreak happened, and to make recommendations about what can be done to prevent a similar incident in the future .This work has been driven by a determination to find answers to these questions for surviving family and friends, and others directly affected by the event . To understand the process that led to this report,
1 The number of cases reported changed over time as results were confirmed, a process that took time .
vii Dr. John Carsley Equally noteworthy, almost 80% of “In all likelihood, none of the individual elements that contributed to the outbreak was sufficient to those who developed listeriosis lived have caused it alone, so each part of the food safety system must work together as perfectly in a long term care home or were as possible.” admitted to a hospital that had served »» DR . John Carsley contaminated deli-meats from large Medical Health Officer for the Vancouver Coastal Health Authority in British Columbia Member of the Listeriosis Investigation Expert Advisory Group packages produced specifically for institutions . please see the introduction which Parliamentarians (and government The risks of foodborne illness are describes the steps taken in this review officials), to food industry workers also greater than ever before . Large and how best to read the full report . and family members – they highlight scale farming and food processing, The work of this Investigation has been our key findings and refer to key along with the impacts of globalization complemented by the important work recommendations of interest to which provide consumers with access of the House of Commons Agriculture all Canadians .To guide readers, to foods from around the world, all Subcommittee on Food Safety which bracketed numbers correspond to the contribute to increased opportunities has also examined many aspects of recommendations found in the section for contamination .These same trends this critical matter . entitled ‘List of all recommendations’ make it harder to trace the source of This report describes the chain of as well as embedded throughout the a foodborne illness than in the past, events which led to the recall of 191 full report . when outbreaks were usually linked to meat products produced by Maple Leaf local food sources . Foods Bartor Road plant .The report Why it matters assesses how well federal organizations A complex disease and their food safety partners Foodborne illness outbreaks like responded to the event . It notes best that of 2008 do not happen often Listeriosis, itself, can be hard to practices from other jurisdictions in Canada .There has, however, detect .The first symptoms of the which have been incorporated into been a steady increase in listeriosis illness appear between three to 70 the recommendations . cases in recent years . Since 2005, days after contaminated food is eaten Most importantly, the report the number of cases of listeriosis and, even then, are initially difficult to focuses on areas which require urgent reported annually in Canada has distinguish from the flu . It is often only attention, providing recommendations doubled .Among those at greatest when people become seriously ill that for concrete action .The Investigation risk of contracting the illness are lab tests are conducted; a positive calls on governments and industry older people – one of the fastest result confirming that an individual to take swift and appropriate steps growing segments of Canada’s has the disease . Unlike TV dramas, in to make sure a tragedy such as this population . Some 40% of those which scientific testing produces nearly doesn’t happen again . who became ill during the 2008 instantaneous results, it takes several Since these main points, like listeriosis outbreak died of the disease . days before bacteria DNA fingerprints the complete report, must answer The average age of people who had results are available . the questions of a wide variety of listeriosis listed as the underlying or audiences – from scientists and health contributing cause of death was 76 . professionals, to journalists and
viii Infections with the Outbreak Strain of Listeria monocytogenes by Symptom Onset Date or Estimated date*
10 Aug 12: Confirmation of illness outside of Aug 15: Ontario Ministry asks that Illness with Ontario by Public Health Agency of Canada Long-term care homes be alerted Patient Recovery 9 Death Resulting from Illness 8
7 Jul 29: Alert on National Aug 17: Recall of Maple Leaf Foods Surveillance System Issued Bartor Road Sure Slice Products 6 July 16: Toronto Public Health Aug 19: Recall of all Maple Leaf Foods Bartor ersons
P investigates 2 cases Road Products from lines 8 & 9
5 Aug 24: Recall of all products from Maple Leaf Foods Bartor Road
4 Maple Leaf Foods Bartor Road plant re-opens
N umber of after its closure on Aug 20 3
2
1
0
1-Jun 8-Jun 6-Jul 13-Jul 20-Jul 27-Jul 3-Aug 7-Sep 5-Oct 2-Nov 15-Jun 22-Jun 29-Jun 10-Aug 17-Aug 24-Aug 31-Aug 14-Sep 21-Sep 28-Sep 12-Oct 19-Oct 26-Oct 9 -Nov 16 -Nov Week of Illness Onset * Some illness onset dates have been estimated from available information
The greater challenge is connecting ate that was contaminated . Rapid the illness to the consumption of a testing, analyses and reporting of test How Canada’s food specific food, a process which can results are critical to public health and safety system works take several weeks . Multiple tests are food safety investigators in a national A foodborne emergency is complex needed, often involving specialized labs, foodborne emergency in order to because of the multiple sectors involved which may require inter-governmental identify the exact illness and the food and the way Canada’s health and food cooperation . Not all communities can source causing it . In light of the growing safety systems work .There are many do the necessary testing to confirm frequency of foodborne illnesses, this is different steps and people involved that listeriosis is what is making people equally crucial to all Canadians . ill and, if so, the particular food they
Executive Summary ix Key dates of the outbreak
➤➤ February to July (2008) – sporadic positive ➤➤ July 18 – Maple Leaf Foods first identified ➤➤ August 7 – THE CFIA initiates a food safety Listeria test results at Bartor Road plant as possible source of contaminated food investigation products ➤➤ June 3 – earliest known human illness ➤➤ August 12 – DNA fingerprinting matches linked to the listeriosis outbreak ➤➤ July 22 – 11 food samples from Toronto cases from several provinces long-term care home sent for testing ➤➤ June 17 – first death linked to ➤➤ August 13 – Maple Leaf Foods advises listeriosis from contaminated ➤➤ July 29 – more than double the normal distributors to hold certain products Maple Leaf Foods product number of listeriosis cases (24 vs. 11 ➤➤ August 16 – THE CFIA confirms Listeria expected) reported by almost half of ➤➤ July 10 – first 2 listeriosis cases in monocytogenes in Maple Leaf Foods Ontario public health units the outbreak identified through DNA products (Sure Slice) fingerprinting ➤➤ August 4 – food samples from long-term care home test positive for Listeria monocytogenes ateach stage in the food supply chain, Because coordinating the response including consumers themselves . to large national outbreaks of What the Overseeing the activities of all these foodborne disease is unusually Investigation Found groups are three levels of government, complex, the federal, provincial In retrospect, it is easy to see the mix each with varying responsibilities for and territorial governments have a of variables that created the conditions public health and food safety . Federal, joint protocol, the Foodborne Illness enabling listeriosis to take hold provincial and territorial governments Outbreak Response Protocol, which (Chapter 5) . Listeria defeated the best and local entities administer their identifies their individual roles and efforts of all those trying to prevent it respective laws and regulations, using responsibilities in investigating from entering the food supply, including their own systems and procedures . and overseeing a national health workers attempting to control it in the Responsibility for food safety within emergency . It was put in place Maple Leaf Foods Bartor Road plant . the federal government is shared as a result of a previous national It also evaded the oversight systems among Health Canada, the Canadian foodborne emergency . of both Maple Leaf Foods and the Food Inspection Agency (CFIA) and the federal government (CFIA) .As a result, Public Health Agency of Canada (PHAC) . How events unfolded a segment of the population that is Similar functions are also performed the most vulnerable was exposed to its With the benefit of hindsight, at the provincial, and sometimes, damaging and sometimes deadly effects . we have been able to understand local levels which demands close Once people were ill, there were the day-by-day, step-by-step actions working relationships and clear lines many challenges in managing the taken as the emergency unfolded . of authority and communication in emergency right in the middle of An abbreviated chronology, found in a foodborne emergency . summer . It brought together multiple Chapter 6, “How did events actually jurisdictions and two sectors of the unfold”, as well as a fully detailed one, federal government that, on a day-to-day available in Appendix B, have been basis are not required to work closely prepared to guide readers . together: the public health and food
x safety sectors .When viewed through procedures standard in the not required to, nor did they the lens of public health, the focus is industry .The plant’s management volunteer, information concerning primarily on identifying what is making thought Listeria was under control . the repeated occurrences of people ill . But when viewed through the (Chap . 5, Rec . 5, 15 a to d) Listeria in the plant to the CFIA lens of the food safety sector, the focus »»Maple Leaf Foods did not conduct Inspectors . (Chap . 5, Rec . 6) is primarily on identifying the exact food the trend analysis required product that is causing the illness so under its Listeria control policy . Canadian Food that the correct food is removed from the The recurring positive results were Inspection Agency market .This, coupled with the infrequent not known nor were the positive »»A new federal inspection approach, occurrence of such emergencies, results verified to determine the the Compliance Verification compounded the challenges in managing presence/absence of Listeria System (CVS), was put into this event (Chapters 7 and 8) . monocytogenes .At the same effect in the spring of 2008, After in-depth analysis, and expert time, the company was producing at the same time Maple Leaf advice from five food safety and public larger packages of deli-meat Foods’ environmental testing was health authorities, the Investigation found products for sale to institutions, identifying Listeria at the Bartor weaknesses in fourcritical parts of the including hospitals and long-term Road plant . (Chap .5, Rec . 10) food safety system which are summarized care homes .They had created »»Although the CVS is regarded below . Our analysis has also identified a recipe that used less sodium, as a sound system and has additional improvements, which can which was attractive to the broad support, it needs critical be found throughout the various institutional market as many of its improvements related to its design, recommendations . clients benefited from reduced- planning, and implementation . sodium diets .This combination of (Chap .5, Rec . 10) circumstances exposed vulnerable »»The CFIA inspectors had no 1. The focus on populations to risk . (Chap . 5, Rec . obligation to request or examine food safety among 15 e, 21) the company’s Listeria testing senior management »»Maple Leaf Foods staff notified results under their CVS tasks . in both the public their superiors of the repeated (Chap .5, Rec . 20) and private domains. presence of Listeria beyond the »»In the lead-up to the outbreak Bartor Road plant into the Head the number, capacity and training Our key findings are: Office . However, this information of inspectors assigned to Maple did not reach the office of the Leaf Foods Bartor Road plant Maple Leaf Foods Chief Executive Officer because appear to have been stressed due »»Maple Leaf Foods’ Bartor Road it was thought that the plant’s to their responsibilities at other plant was aware that it had interventions had controlled the plants, the complexity of the Bartor occurrences of Listeria in the plant problem . (Chap . 5, Rec . 1) Road plant including its size and in 2007 and 2008, and tried to »»Employees in the Maple Leaf hours of operation, and necessary correct the problem with sanitation Foods Bartor Road plant were adjustments required by the
Executive Summary xi implementation of the CVS . Health Canada 2. The state of (Chap .5, Rec . 7) »»The Health Canada Listeria readiness of »»Due to the lack of detailed monocytogenes policy (currently the various information and differing views under review) does not provide governments. heard, the Investigation was not adequate direction on expected able to determine the current outcomes leaving room for Our key findings are: level of resources as well as the interpretation by industry .The resources needed to conduct lack of integration with the CFIA Multi-jurisdictional the CVS activities effectively . policies creates gaps and overlaps . Emergency Response For the same reason, we were also (Chap .5, Rec . 11) »»The 2008 outbreak first emerged unable to come to a conclusion »»In approving food additives and in Ontario and was therefore under concerning the adequacy of the technologies, Health Canada has provincial leadership . program design, implementation not been taking into account »»At the outset, the outbreak was plan, training and supervision of food safety considerations when not considered a severe foodborne inspectors, as well as oversight assigning priorities or fast-tracking emergency .This led to a void and performance monitoring . for approval these substances and in leadership in managing the (Chap .5, Rec . 7) processes . (Chap .5, Rec . 12) crisis . It took close to three weeks »»The latest CFIA Listeria controls before senior executives in all key do not distinguish between Multi-jurisdictional organizations became fully engaged foods at much lower risk of Emergency Response in the event . (Chap . 7, Rec . 24 b .i) harbouring Listeria (e .g . dried National foodborne outbreaks are »»The protocol (FIORP), which is sausages) and those that are rare in Canada . Nevertheless, the in need of updating, was not much higher risk (e .g . hot-dogs) . Foodborne Illness Outbreak Response recognized as the protocol to Furthermore, they do not establish Protocol (FIORP) and complementary be used . The lack of a clear ‘test and hold’ product controls . agreements are in place to manage understanding about which (Chap .5, Rec . 15 d) such events but they were not widely organization or level of government »»There is a need for increased known or understood by senior was responsible for doing what coordination and improved leadership at the time of the 2008 – including which organization communication about food outbreak . (Chap .5, Rec . 24) should lead the response to processing equipment among the the crisis – contributed to the manufacturer, the food processor, inconsistent management of the and the CFIA regarding design outbreak . Few of those involved specifications and the validation in the 2008 outbreak, especially of sanitation procedures . (Chap .5, senior executives, were familiar Rec . 14) with the FIORP . (Chap . 7, Rec . 24) »»Since national foodborne illness outbreaks of this magnitude are rare in Canada, opportunities to practice this emergency
xii management approach are very 3. The sense of recall the food product . Some limited . (Chap . 7, Rec . 24 c) urgency at the advocate specific laboratory »»Public health labs are not formally outset of the confirmation to ensure the correct networked and could be more outbreak. product is removed from the effectively used during a foodborne market . Others advocate for a illness emergency . (Chap . 7, Our key findings are: precautionary approach, based Rec . 33) on epidemiological evidence, to »»The Public Health Agency of Maple Leaf Foods protect the public from potential Canada is making headway in »»Maple Leaf Foods did not initially harm . (Chap . 7, Rec . 24 b-iv, 29) epidemiological data collection and report the presence of Listeria at analysis in cases of human illness the Bartor Road plant or provide (e .g . H1N1), but improvements are product distribution records . (Chap . 4. National still required in integrating the data 5, Rec . 6) communications collection, and analysis, of food with the public samples (e g. . listeriosis) . (Chap . 7, Public Health Rec . 35 c) Agency of Canada Our key findings are: »»Enhanced coordination of various »»The Public Health Agency of Canada »»Canadians were seeking testing (e .g . cross-coding of did not consider it had the federal reassurance from governments that human and food samples linked leadership role, therefore there was public health was being protected . to the same patient) could a delay in identifying the outbreak »»Information about the outbreak did further accelerate the analysis as a public health emergency . not provide the public with what and decision-making necessary (Chap . 7, Rec . 24 b-i) they needed; it was sometimes in the management of foodborne inconsistent given the many emergencies . (Chap . 7, Rec . 35 a) Health Canada jurisdictions involved, sometimes »»Based on our investigation, to »»Health Canada’s Health Risk hard to find and sometimes maintain confidence in the food Assessment team was not operating difficult to understand . (Chap . 8, safety system, there is a need on a 24/7 basis during the summer Rec . 26, 40) for independent review after all of 2008, leaving gaps in coverage »»The majority of Canadians were national foodborne emergencies, during the response to the unaware which segments of the in addition to each organization’s emergency . (Chap . 9, Appendix C) population were at greater risk of lessons learned review . (Chap . 7, becoming ill if exposed to Listeria rec . 27) Public Health and monocytogenes, and what foods »»Most organizations involved in the Food Safety Sectors these vulnerable groups should response to the 2008 outbreak avoid (e .g . pointing to the need for »»There are differing views on the had very limited pre-planned surge precautionary labelling) . (Chap . 8, quality of evidence needed to capacity . (Chap . 7, Rec . 24 b-iii Rec . 42) . advise the public about potential and 34 b) food contamination and/or to
Executive Summary xiii »»There was an absence of an of food as one of its top priorities . ‘advance’ communications strategy What else was learned (Chap . 10, Rec . 56) and related implementation plan, The Investigation came across other Everyone involved in the events that should have included ready- matters of capacity, governance and leading to, and in managing the made information products and structure affecting the response to response to, the 2008 listeriosis the use of traditional and new the outbreak and meriting further outbreak should view the lessons media vehicles . (Chap . 8, Rec . 41) examination . Progress has been made learned from this tragic event and »»Federal communications to the since the 2008 outbreak on a number the recommendations as imposing an public were slow off the mark, of fronts however, thereis room for obligation to pursue innovation and and were not sustained for a ongoing improvement in the federal improvement . sufficient period of time . In food safety and legislative framework . The Independent Investigator invites addition, there was no designated Readers are strongly encouraged to all to read the full report . communications coordinator, review Chapter 10 (Rec . 43, 44, 52) which resulted in a fragmented to gain a better understanding of the approach and seemingly additional recommendations . inconsistent messaging . (Chap . 8, Rec . 37) »»Having the Minister responsible for Actions, not words Agriculture and Agri-food and the Many of the issues – and even some CFIA serve as the lead ministerial of the recommendations generated by spokesperson, was considered this Investigation – have been raised by some to be a ‘conflict of in previous reports on food safety in interest’even though the minister Canada . Recommendations are only has a legitimate role in relation words on paper until they are acted on . to the food industry . It appeared As foodborne illnesses are now the to limit government’s capacity to largest class of emerging infectious communicate health information diseases in the country, and listeriosis sought by the public .The perceived is a serious disease with deadly lack of federal public health consequences for vulnerable groups, leadership during the outbreak governments cannot afford to ignore attracted many comments . these findings . (Chap . 8) That is why the Investigation »»The greatest challenges for recommends that, in setting its agenda physicians in educating patients for the fall of 2009, the Government of about minimizing risks of Canada should be mindful that food foodborne illness are lack of safety requires increased attention . patient-friendly materials (77%), Although Canada is viewed as a leader lack of knowledge about the in food safety practices and systems, outbreak (69%), and lack of time the Government should clearly and (69%) . (Chap . 8) emphatically commit to the safety
xiv List of all recommendations
xv 6. To ensure active and transparent inspection staff. Inspectors should In the order they appear communications, all federally regularly receive a mandatory throughout the report registered meat processors should program on current trends in disclose any threat to food safety science and technology in the Chapter 5 – What led occurring in their premises to the processing of food, including to the outbreak Canadian Food Inspection Agency compliance and verification Chapter 5 – To enhance food safety inspectors in a timely manner. processes. awareness of meat processors Meat processors should not wait 9. The Canadian Food Inspection including but not limited to for requests for information from Agency should equip its inspectors federally registered ones: the CFIA inspectors and should, with modern technology (e.g. 1. The CEO and senior management in the interests of food safety, e-note pad) to increase their of all meat processors should ensure that inspectors have all efficiency. accept oversight responsibility for information they require. 10. The Canadian Food Inspection ensuring that food safety is fully Chapter 5 – To consolidate the Agency should amend its meat embedded in every level of their Canadian Food Inspection Agency’s inspection system (CVS) to ensure: business. inspection responsiveness a. the appropriate human 2. The CEO and senior management 7. To accurately determine the resources are available of all meat processors should demand on its inspection to respond to workload ensure effective design and resources and the number requirements; actively promote all aspects of of required inspectors, the b. comprehensive training food safety consistent with their Canadian Food Inspection based on required Food Safety Plan. Agency should retain third-party competencies and skills; 3. Food safety plans should be experts to conduct a resources c. timely delivery of on- regularly updated to ensure audit. The experts should also going training; on-going attention to pathogen recommend required changes and d. supervision of inspection control. implementation strategies. The staff structured to encourage 4. All meat processors should ensure audit should include analysis as enterprise and accountability. that new and existing equipment to how many plants an inspector Chapter 5 – To improve the is and remains appropriate for the should be responsible for and the Listeria Policy intended use. appropriateness of rotation of 11. Health Canada should complete 5. Sanitation methods should be inspectors. the revision of its 2004 Listeria validated and implemented by 8. The Canadian Food Inspection Policy, by no later than March meat processors in consultation Agency should ensure that 2010, and ensure that: with the equipment manufacturer, inspectors receive timely a. the Policy outlines clearly and with a particular focus on the education and training specific concisely the expected results intended use and the products to each function which they for all identified food products being processed on each piece of perform. This should be based on where Listeria is a potential equipment. an assessment of the additional threat to human health, training required to address gaps consistent with international in the knowledge and abilities of standards;
xvi b. risk categories of ready-to-eat 14. In addition, manufacturers of food to-eat meat products, in addition product are retained, although processing equipment should to the current environmental and they should be more clearly accept responsibility for the product testing: defined; foreseeable impact of the design a. to ensure that any required c. post-processing measures that and operation of their equipment testing is a verification step control Listeria monocytogenes on food safety. The design and to confirm the effectiveness of are considered when operation of, and recommended the company’s Listeria control determining product risk sanitation methods for all food program and not a control categories; and, processing equipment should: program in itself; d. it focuses only on the safety a. enable thorough cleaning and b. by differentiating the testing of foods (i.e. should be a food disinfection; requirements to reflect the risk safety standard) and not on b. allow for efficient and complete associated with each product providing risk management disassembly and reassembly (i.e. more testing for high risk direction to the food industry or when required; products and less for low risk ones); the Canadian Food Inspection c. eliminate to the fullest extent c. by requiring the testing of non- Agency. possible all areas likely to food contact surfaces in the Chapter 5 – To provide more harbour pathogens, including processing environment; responsive solutions to improve Listeria monocytogenes; d. by establishing ‘hold and test’ food safety d. wherever possible, use material product control requirements 12. Health Canada should review that is scientifically validated following positive test results its approval processes and fast to limit pathogen growth or for Listeria on food contact track, where appropriate, new food survival; and surfaces as follows: additives and technologies that e. be peer-reviewed (applicable i. several tests for Listeria on have the potential to contribute only for the recommended food contact surfaces should to food safety giving particular sanitation methods). be conducted immediately on attention to those that have Chapter 5 – To enhance the and around the area where been scientifically validated in effectiveness and timeliness of the positive results were found to other jurisdictions (provinces or Canadian Food Inspection Agency’s food determine: countries). safety requirements »»if there is persistent Chapter 5 – To improve sanitation of 15. The Canadian Food Inspection contamination, or food processing equipment Agency, in conjunction with and »»if the previous positives 13. Manufacturers of food processing in conformity to the proposed have already been dealt equipment should ensure that their revisions to Health Canada’s with using standard specifications and instructions Listeria Policy, should strengthen sanitation procedures; to users specifically emphasize its February 2009 Listeria controls ii. if the follow-up tests are the necessity to control the found in the Meat Hygiene Manual positive, then testing for risk of pathogens, including of Procedures to focus on control Listeria monocytogenes must Listeria monocytogenes. measures for Listeria in ready- occur in products from the
List of all recommendations xvii production line of concern1. 18. The Canadian Food Inspection Chapter 5 – To improve surveillance During this testing phase, all Agency should update its 22. The federal, provincial and products produced on that Food Safety Enhancement territorial governments should line and day (i.e. between Program Manual to require food continue to use and support two complete sanitation processors to include all standard surveillance and monitoring shifts) should be withheld operating procedures and good systems, such as Canadian from the marketplace until manufacturing practices in their Integrated Outbreak Surveillance the results are known; food safety plan. Centre (CIOSC), and consider the by further e. by further defining 19. The Canadian Food Inspection development of next generation expectations of trend analysis Agency should ensure that systems (e.g. Panorama). to identify weaknesses in the the Meat Hygiene Manual of company’s control programs Procedures is updated whenever Chapter 7 – How well did the (including its HACCP plan) by there is a significant change to the federal government and determining if a pattern of practices imposed on industry. its food safety partners contamination is emerging. 20. The Canadian Food Inspection respond to the outbreak 16. The Canadian Food Inspection Agency should formally Chapter 7 – To improve national Agency should revise its monitoring communicate its expectation that foodborne emergency leadership programs (M-200 and M-205 registered meat processors will 23. The Public Health Agency of plans), by tailoring the sampling bring all information with potential Canada, with the support of frequencies to each plant consequences for food safety to the Canadian Food Inspection based on risk factors including the attention of their assigned Agency and Health Canada, compliance history, product risks inspector in a timely manner. should assume the leading and target market (i.e. higher Chapter 5 – To protect vulnerable role in coordinating the federal sampling frequency in some populations government’s response to a plants, lower in others.) 21. Organizations providing housing national foodborne emergency. 17. The Canadian Food Inspection and/or food services to seniors Chapter 7 - To improve national Agency should review and update and other vulnerable groups, foodborne emergency preparedness existing food safety programs, including long-term care homes 24. In preparedness for national regulations and directives to and hospitals, should be foodborne emergencies, the best reflect current food safety encouraged to adopt food safety federal, provincial and territorial practices. practices aimed at vulnerable governments should: populations, including those most a. complete the revision of the vulnerable to listeriosis (such Foodborne Illness Outbreak as the practices set out in the Response Protocol (FIORP) British Columbia Guideline for currently underway, at the
1 The testing requirements (e.g. number of Food Services or in guidelines earliest opportunity; and tests) should be based on an authoritative issued by the other provinces and b. enhance the FIORP, by source such as the International Commission territories.) developing and ratifying a on Microbiological Specifications for Food and should be consistent with the Health Canada’s Foodborne Illness Emergency Listeria Policy. Plan building on the experience
xviii of the Canadian Pandemic pre-arranged media spots, event review process made up of Influenza Plan, to: pre-developed material, and a pre-identified team of experts i. designate the Public the like); and not involved in the emergency . Health Agency of Canada vi. share all information, Following all future national as the lead Agency taking including epidemiological foodborne emergencies, this team leadership at both the data, needed to identify should conduct an in-depth review national (multi-provincial/ the emergency taking into and report to the government .The territorial) and the federal account privacy and data report should be made public . (multi-departmental); confidentiality issues; Chapter 7 – To better manage ii. use a common incident vii. include in the FIORP periodic national foodborne emergencies command structure; mock exercises to validate 28. In the event of a national define the iii. define the roles and that the protocol and its foodborne emergency, an incident responsibilities of each of Emergency Plan are fully command structure should be the organizations involved understood by federal, activated under the leadership of clearly and concisely, in plain, provincial, territorial and the Public Health Agency of Canada unambiguous language, local governments as well as with the direct participation of the including surge capacity; by the food processing and Canadian Food Inspection Agency iv. increase the use and timing distribution industry and is in and Health Canada . of health advisories and a state of readiness. Chapter 7 – To clarify the ‘weight precautionary warnings, 25. The authority of the federal Minister of evidence’ needed to recall food where reasonable and of Health to protect the health of products probable grounds exist, to all Canadians under section 30 1. 29. Health Canada, the Canadian Food advise consumers to suspend of the Food and Drugs Act, and Inspection Agency and the Public consumption of suspected subsections 4(1) and (2) of the Health Agency of Canada should foods while tests to confirm Department of Health Act should review, update and publish the the precise source are be used in a national foodborne criteria for proceeding with a food pending, taking into account emergency, whenever warranted . recall to ensure that the weight »»suspected illnesses and 26. Where human deaths or serious of evidence takes into account deaths, illnesses have occurred, the epidemiological information, »»geographic distribution, and Canadian Food Inspection Agency including suspected illnesses and »»test results of opened or should promptly disclose the deaths, geographic distribution, unopened food samples. results of its investigation of the and food sample test results v. create a ready-to-implement implicated plant and the corrective whether packages are opened crisis communications plan to actions taken, to the public and or unopened . ensure that all Canadians are food safety partners . 30. The Canadian Food Inspection kept informed in a timely and 27. The federal government should Agency should encourage federally detailed manner (including establish an independent post- regulated meat processors to move
List of all recommendations xix beyond the minimum existing 34. This network of federal, provincial, positive food isolates be requirement for accessibility territorial, local and private forwarded to a designated lab of distribution records to laboratories should be integrated for DNA fingerprinting; include electronic access in non- to ensure: d . developing and delivering the proprietary and unlocked formats a . rapid tests, analysis and necessary training required to assist in potential product reporting of test results into to ensure that laboratories recalls . monitoring and surveillance have built-in human resources 31. The Canadian Food Inspection systems, on a priority basis; redundancy; Agency should establish a formal and, e . ensuring that positive Listeria protocol to ensure that timely b . the identification of back-up monocytogenes isolates are and consistent information is capacity to support regional held for at least six (6) months provided to staff of the provincial/ and local gaps and surge to facilitate the comparison territorial or local public health capacity needs during a of data and to accelerate organizations who are asked by national foodborne emergency . the identification of potential the Agency to help it complete 35. Federal, provincial and territorial outbreaks, and post-recall verification activities . governments should review f . researching and applying novel 32. In providing information related laboratory procedures and and emerging lab technologies . to a given product recall to the methodologies to develop 36. Federal, provincial and territorial distribution industry, including consistent practices in testing governments and their research grocers, the Canadian Food for foodborne diseases, against funding agencies should initiate Inspection Agency should use a predetermined benchmarks and and support further research into: standardized form (as suggested giving priority to the following: a . testing for, and control of, by the Canadian Council of Grocery a . cross-coding human samples Listeria monocytogenes; Distributors) . and corresponding food b . improved traceability Chapter 7 – To enhance the samples in order to accelerate technology and methodology; responsiveness of laboratories to the linkage of test results; and national foodborne emergencies b . agreeing to protocols designed c . novel and emerging laboratory 33. Given that laboratories across to accelerate the process technologies . Canada are not networked, the for accrediting public (by federal, provincial and territorial the federal government) and Chapter 8 – How well were governments should proceed to private (by the provinces) communications handled establish a nationally integrated laboratories for Listeria Chapter 8 – To enhance network (i.e. network of networks) monocytogenes DNA communications during a national among the following: fingerprinting; foodborne emergency a . human disease labs (where this c . standardizing methodologies 37. The Public Health Agency of has not yet occurred), for the collection and Canada should assume the food labs, b . food labs, retention of food samples, lead role (non-ministerial) in c . animal labs, and including the requirement that communicating to the public for a d . all of the above . all Listeria monocytogenes national foodborne emergency .
xx 38. The Canadian Food Inspection These would include simulation Chapter 10 – What else Agency and the Public Health training, contingency planning to did we learn during this Agency of Canada should enhance ensure availability of key resources investigation? their public profile to increase and ready access to outside Chapter 10 – To modernize the federal awareness of their mandates. suppliers. The measures should also regulatory framework on food safety 39. The principles of risk include the preparation of certain 43. To simplify and modernize federal communications should drive the communications material in legislation and regulations which federal communications strategy advance, such as basic information significantly affect food safety, the and activities. Therefore, the Health on listeriosis and other foodborne Government of Canada should Canada/Public Health Agency of illnesses for at-risk populations and mandate a lead agency to conduct Canada Risk Communications health providers. a comprehensive review and Framework should be implemented It would also include the recommend improvements in a and become the principal reference development of a communications timely manner, taking into account point and standard for federal strategy, based on solid marketing the amendments or additions government communication to the research and analysis, and a required to enforce, where public on foodborne emergencies, related implementation plan. applicable, the recommendations such as listeriosis. The strategy should identify the included in this report (e.g. the 40. Communications staff should target audiences, their information requirement to disclose any threat be aware of developing trends in requirements, and how and by to food safety as covered by communication and ensure the whom they are best reached. recommendations 6 and 20). capability exists to use the best Chapter 8 – To increase consumer Chapter 10 – To enhance the vehicles available to reach key awareness governance of food safety in Canada audiences as quickly as possible. 42. To protect vulnerable populations, 44. As soon as possible, the Canadian A ‘one-stop’ website capability including the immuno- Food Inspection Agency, supported should be developed in order to compromised, older people and by independent experts, should provide easier public access to pregnant women, Health Canada initiate a comprehensive review of crucial information. Accountability should promote consumer a. its organizational structure; for its maintenance should be education into the risks associated b. the current delegation of clearly identified. with Listeria. This could include responsibility and lines of 41. A series of communication targeted measures, such as accountability within the measures that will contribute precautionary labelling. This should Agency; and to an acceptable level of be accomplished in collaboration c. its decision-making processes. preparedness should be with the Public Health Agency of 45. Concurrent with the review, the identified and put into place. Canada and in conjunction with federal government should consider provincial and territorial health replacing the current requirement partners. for an Advisory Board with a Board of Management which, subject to powers to be retained by the
List of all recommendations xxi Minister including all decisions Chapter 10 – To enhance 53. Concurrent with the review, related to policy, legislative, proactiveness of the Canadian Food the federal government regulatory and emergency matters, Inspection Agency should consider permanently should oversee the organization 49. The three main lines of business assigning day-to-day operational and operational management of of the Canadian Food Inspection management responsibilities of the Agency, and advise the Minister Agency, food safety, animal the PHAC to an associate deputy on policy matters. health, and plant health should head (i.e. a Chief Operating At a minimum, the federal be assisted by permanent expert Officer equivalent to a second- government should consider the advisory committees to guide their in-command) to allow the Chief immediate appointment of the evolution. Public Health Officer to focus Advisory Board established under Chapter 10 – To ensure prompt on his executive duties and subsection 10 (1) of the Canadian response to food safety situations responsibilities as the lead health Food Inspection Agency Act. The 50. The Office of Food Safety and professional of the Government Board should be specifically directed Recall should report directly to of Canada in relation to public to advise the Minister on issues the office of the President of the health and to ensure continuity relevant to the vision, accountability, Canadian Food Inspection Agency. of management. mandate, and public perception of 51. The Canadian Food Inspection At a minimum the day-to- the Agency and risk management. Agency should ensure that the day operational management 46. The federal government should Office of Food Safety and Recall responsibilities of the Chief endorse the need for continuity has dedicated resources to Public Health Officer of the Public and vision at the Canadian Food undertake all the CFIA activities Health Agency of Canada during Inspection Agency by making concerning recalls. The Office of a national foodborne emergency, efforts to ensure, wherever Food Safety and Recall should should be temporarily assigned practical, that the 5-year mandate be identified as the CFIA’s to an acting deputy head for given to the President under primary point of contact with the PHAC until the end of the section 5 of the Canadian Food Health Canada during a national emergency. Inspection Agency Act is fulfilled. foodborne emergency. Chapter 10 – To improve how 47. As a regulatory agency, the Chapter 10 – To enhance the federal federal organizations collaborate Canadian Food Inspection Agency governance of public health on food safety should create a formal and 52. As soon as possible, the Public 54. The Clerk of the Privy Council transparent consultation strategy Health Agency of Canada, should appoint an independent which will define its required supported by independent experts, expert to chair a special engagement with stakeholders. should initiate a comprehensive committee of the deputy ministers 48. To ensure timely and consistent review of its structure and responsible for Health Canada, enforcement practices across operational procedures with the Public Health Agency of the country, the Canadian Food the objective of ensuring a Canada, and the Canadian Food Inspection Agency should review more responsive and flexible Inspection Agency. The chair the interpretation and application organization to support national should report to the Clerk directly. of its rules and enabling readiness for public health threats. This committee should provide legislation. recommendations to improve
xxii the ways the organizations work The committee should be together in their roles in food composed of officials from the safety . It should also oversee the Health and Agriculture Ministries development of our proposal to across Canada, the Canadian Food simplify and modernize federal Inspection Agency, and the Public legislation and regulations . Health Agency of Canada . The first tasks of this committee Chapter 10 – To demonstrate the should be to reduce overlaps Government of Canada’s commitment and address gaps among to food safety the organizations, improve 56. In setting its agenda for the fall communication and the sharing of of 2009, the government should be information, resolve existing issues mindful that due to globalization preventing harmonization of roles, and increased Canada-wide and provide a report on these production and distribution of matters within six months . food, food safety will require Chapter 10 – To improve how the increased attention .Although federal, provincial and territorial Canada is already a leader in food organizations collaborate on food safety safety practices and systems, the 55. Considering the serious government should clearly and implications of foodborne illnesses, emphatically commit to the safety governments should create a of food as one of its top priorities . distinct federal, provincial and 57. Following its receipt and review territorial committee reporting of this report, the government regularly to the federal Minister of should commit to reporting back Health .The Minister should share to Canadians, within two years, the progress of this committee on the implementation of the with his provincial and territorial recommendations contained in this ministerial counterparts regularly . report together with an assessment This committee should enable of their impact on improving national preparedness for Canada’s food inspection and food foodborne outbreaks . One of its safety emergency response systems . first tasks should be to develop and implement programs alerting vulnerable populations to the risks of listeriosis and identifying recommended sanitation and prevention practices .
List of all recommendations xxiii
CHAPTER 1 How did we approach this report?
How did we approach this report? The summer of 2008 will be remembered by many Canadians for the listeriosis outbreak that made national and international headlines – an event that, ultimately, claimed 22 Canadians’ lives and touched many more .
Hundreds of news stories and website blogs as well as ‘lessons learned’ reports have been written about the outbreak . Yet, despite the thousands of words used to describe these events, many questions remained unanswered – particularly for survivors and family members of those who died . This report is an attempt to fill that gap .
1 Dr. Michael Doyle Before reviewing this document to find out who did what and when, “The responsibility for food safety is not restricted to one person or one entity. There is a network it is helpful to recognize that the issues of people and organizations responsible.” involved in the outbreak were complex . »» DR . Michael Doyle Regents Professor of Food Microbiology and Director of the Center These issues involve the constitutional for Food Safety at the University of Georgia relationship between the federal and Member of the Listeriosis Investigation Expert Advisory Group provincial governments in public health and food safety .They involve The Independent Investigator’s This report represents the results the mandates and legal relationships mandate was to review the August 2008 of this Investigation . among three federal organizations, listeriosis outbreak, focusing on all the their provincial counterparts and meat products involved in the disease Approach food processors . Finally, they involve outbreak, and the subsequent recalls the complex world of science and of foods, originally produced at the The Investigation needed to be both technology . Maple Leaf Foods’ Bartor Road plant . methodical and systematic to ensure This report examines the way Specifically, the Investigation was set it explored the factors that played a these relationships played out during up to: role in the 2008 listeriosis outbreak the 2008 listeriosis outbreak and »»Examine the events, circumstances to contribute to future policy decisions the response of the various parties and factors that contributed to the and/or to improve industry practices . involved . It also focuses on ways in listeriosis outbreak; which government, industry and others »»Review the efficiency and Expert advice with a role in food safety can work effectiveness of the response During the investigative process, better in the future to reduce the risk of the federal organizations, in advice was received from a group of that the tragic events of the summer conjunction with their food safety expert advisors made up of respected of 2008 will be repeated . system partners, in terms of Canadian and US food safety and prevention, recall of contaminated public health authorities .The group About the Listeriosis products, and collaboration was consulted on the approach and and communication with their methodology used to guide the work Investigative Review food safety system partners and of the Independent Investigator . At the height of the nation-wide recall consumers; The experts reviewed and commented of contaminated ready-to-eat meat and, on this report during its development . products, on September 3, 2008, »»Make recommendations, based In addition to scientists, external the Prime Minister announced an on lessons learned from that event specialists from the medical, public independent investigation into the and from other countries in terms health, food safety, long-term care, events surrounding the 2008 listeriosis of best practices, as to what can legal, communications and governance outbreak . On January 20, 2009, be done to enhance both the fields provided advice throughout the Sheila Weatherill was appointed by prevention of a similar outbreak process to assist the progress of the the Governor in Council to lead the occurrence in the future and the Investigation . Independent Listeriosis Investigative removal of contaminated products Review . from the food supply .
2 Comprehensive review Forensic investigators and technology relevant information .This material To the extent possible, the investigative experts collected and analyzed in excess established the key facts and assisted team considered all viewpoints and of 5 8. million pages of information the Independent Investigator in implemented necessary measures to be received in both paper and electronic formulating questions for interviews . fair and balanced . Considerable effort forms, including emails .They scanned Much more than a paper exercise, was made to ensure this was both a and processed this information into a the Independent Investigator also comprehensive and inclusive process . database used to search and target conducted more than 100 interviews
In total we conducted over 100 interviews and meetings representing several Who we interviewed hundred hours . We also received over 5 million pages of information .
Federal Organizations »» Ministers (Agriculture and Agri-Food Canada and former Minister of Health) »» Auditor General of Canada Health Sector Professionals »» Staff from Prime Minister’s Office »» Deputy Ministers of Health and »» Ministers’ Chiefs of Staff and Advisors Chief Medical Officers of Provinces »» Deputy Ministers (AAFC, HC, PHAC, CFIA, PCO) & Territories »» Former CFIA Presidents »» Canadian Medical Association »» Staff from CFIA, PHAC, HC and PCO »» Local Medical Health Units (Toronto, »» Unions Peel, Hastings and Prince Edward County) Experts »» Ontario Agency of Health Promotion and Protection »» Governance »» Urban Public Health Network »» Public health »» Long term care homes »» Food safety »» Laboratory »» Long term care Food Processing Industry »» Maple Leaf Foods Inc . Consumers »» Canadian Meat Council »» Canadian Council of Grocery »» Consumers Council of Canada Distributors »» Union des consommateurs »» Food Processors of Canada »» Option consommateurs Families and »» Canadian Poultry and Egg Processors Council the Canadian Public »» Further Poultry Processors AAFC Agriculture and Agri-Food Canada CFIA Canadian Food Inspection Agency Association of Canada PHAC Public Health Agency of Canada »» Innovotech HC Health Canada PCO Privy Council Office »» GS1 Canada »» FORMAX Inc .
Chapter 1 – How did we approach this report? 3 with a broad cross-section of Key best practices or alternative nature of the subject matter, some individuals having first-hand knowledge approaches to food safety are referred of the information contained in this of the events .These included workers to throughout the report . report may appear technical to people on the plant floor, executives, frontline This work has been complemented unfamiliar with the terminology used, public health and food safety workers, by the important work of the House of especially scientific, medical and legal . researchers and scientists, managers, Commons Agriculture Subcommittee Translating the full range of information deputy ministers and Ministers from on Food Safety which has also gathered through this Investigation in the federal and provincial governments, examined many aspects of this critical a clear and straightforward way that all representatives from consumer and matter .We also heard from many of Canadians can understand has been industry associations and unions, and the witnesses who appeared before an overarching goal in preparing this family members of those who died and the Subcommittee, and we have document . whose lives were personally touched taken account of what we heard from In order to follow the report’s by the tragedy . them and on occasion what they have findings, it has been structured to The Independent Investigator said during the public hearings of the provide answers to the key questions appreciates the significant cooperation Subcommittee . many Canadians have about the 2008 received from those affected by the listeriosis outbreak and what can be listeriosis outbreak, both directly and Listening to Canadians done to prevent a similar incident indirectly . Everyone who was asked to The Independent Investigator also in the future . Our aim has been to participate agreed to be interviewed . reached out and listened to Canadians lay out the information in a way that The Investigator received open and to consider their views and concerns . chronologically and logically explains forthcoming information and advice . Many interested Canadians contacted the chain of events which culminated It was clear that people wanted her to express their positions on the in the outbreak, follow-up by the to provide information to be part issues being examined .The Investigator actions in the aftermath of the event, of the solution . received hundreds of emails from as well as the areas that continue to A number of roundtables with food private citizens . Many more visited require attention and action . safety experts – drawn from industry, the website to learn about the The Independent Investigator is consumer groups, academia and Investigation . From the time of its confident that this report will assist government – were convened to learn launch on January 23, 2009, the in answering Canadians’ questions more about the latest technologies and Listeriosis Investigative Review web about what happened during the 2008 industry practices . Information sessions site averaged approximately 300 listeriosis outbreak, how it could have were also held with food processors, visits per week . happened, and what should be done to equipment manufacturers, grocers and This level of interest reinforced a make sure it never happens again . others with valuable insights into food further consideration in preparing this safety to learn of their experiences and document: the need to make it both to seek their counsel . understandable and accessible to a NEXT CHAPTER As valuable as the lessons learned wide array of interested readers – from from the events of 2008 are, as part people affected by the outbreak to “Before the summer of 2008, most of the Investigation we examined and Parliamentarians . Canadians had probably never heard obtained advice from experts into There are many potential audiences of listeriosis…” the experiences of other jurisdictions . for this report . Given the complex
4 CHAPTER 2 What is listeriosis?
What is listeriosis? Before the summer of 2008, most Canadians had probably never heard of listeriosis .That’s not surprising, since the disease is far less common than other forms of foodborne illness such as Salmonella, E. Coli or the Norwalk virus . There are more than 250 different foodborne illnesses that can be caused by a variety of bacteria, as well as viruses, parasites and toxins .According to the Public Health Agency of Canada, there are as many as 11 to 13 million cases of food-related illness in Canada annually . Of these, listeriosis cases are in the low hundreds .
5 Reported Cases* of Listeriosis in Canada, 2003-2008 without getting ill, because our immune
300 * Number of systems are strong enough to fight off 239 cases in 2008 is infection . Healthy adults and children 250 preliminary and is occasionally get infected with Listeria, subject to change 200 and includes the but rarely become seriously ill . 128 140 57 associated Listeriosis is the name given to any 150 105 96 with the 2008 form of disease or invasive infection 85 outbreak 100 caused by Listeria monocytogenes . NUMBER OF PERSONS Source: Public It primarily affects older people, 50 Health Agency of adults with compromised immune Canada 0 systems and in, about one-third of 2003 2004 2005 2006 2007 2008 cases, pregnant women and their YEAR newborns . People in these groups are While listeriosis may be rare, it is a that appear healthy can carry Listeria at higher risk of disease because their very serious form of foodborne illness . and contaminate food such as weakened immune systems make them It accounts for only a fraction of all meats and dairy products . Plants more susceptible . reported foodborne illnesses each and vegetables can also become One unusual characteristic of Listeria year but is responsible for about contaminated with Listeria from infection, mild or invasive, compared one-quarter of all deaths resulting the soil, water and manure-based to other foodborne illnesses is that from them . fertilizers . the time between consumption of a Nearly all cases of listeriosis are Listeria can be present in an contaminated food and the onset of thought to be foodborne .The illness assortment of foods we routinely eat, illness is much longer . It ranges from results from eating food contaminated including prepared meats such as three to 70 days, with a median of with a bacterium called Listeria cold cuts and hot dogs, soft cheeses three weeks . In contrast, Salmonella monocytogenes . and fresh fruit and vegetables . infection occurs within 12‑72 hours Listeria organisms are widespread Unpasteurized (raw) milk and foods after eating a contaminated food . in the world around us, including in made from unpasteurized milk may The early symptoms of listeriosis soil, water and vegetation .Animals also contain Listeria . can easily be initially mistaken for the and humans can carry the bacterium Most of us can consume products flu . However, the illness soon becomes without knowing it . Even farm animals containing Listeria monocytogenes severe enough to send the person to a physician or hospital . Professor Rick Holley The most common forms of listeriosis are: The organism [Listeria] … will grow very, very slowly at refrigerator temperatures, so four degrees »»Sepsis (bloodstream infection) [Celsius] is not a problem. And it will get to very, very high numbers over a period of 59 days, which – patients have high fever and is the shelf life of a cooked, cured meat product in a vacuum package. It does not need oxygen. And appear very ill . Infection of the it will also grow at body temperature, and we know that because it kills people.” heart valves can occur and other
»» Professor Rick Holley, organs can also become infected Professor of Microbial ecology of food spoilage and food safety, University of Manitoba Member of the CFIA’s Academic Advisory Panel
6 Dr. Walter Schlech Listeriosis outbreaks1 are rare, although “Listeriosis implies a disease state and means an invasive infection with Listeria monocytogenes Canada has experienced a number over not just colonization of the gastro-intestinal tract by the organism. In fact the risk-assessment the years . literature suggests that most people probably ingest the bug around ten times a year without being infected by it.” Preventing »» DR .Walter Schlech Professor of Medicine in the Dalhousie University Faculty of Medicine, member of the Division of Infectious Diseases, involved in Listeria research since 1980 listeriosis Member of the Listeriosis Investigation Expert Advisory Group Listeria organisms are so widespread that it is difficult, if not impossible, to »»Infection of the central nervous is generally not diagnosed until keep them out of the foods we eat . system (usually meningitis) – the laboratory reports that Listeria Listeria is more resistant than most symptoms can include high fever, monocytogenes has been cultured from bacteria to sanitation measures and intense headache, neck stiffness, blood, cerebrospinal fluid or amniotic treatments used to control foodborne altered consciousness and fluid .The treatment for listeriosis is pathogens, which are micro-organisms convulsions antibiotics, usually given intravenously . that can cause disease . It is very hard »»Miscarriage, still birth or premature Despite treatment, up to 20-30% of to remove the bacterium once it has delivery of a newborn .The infected cases end in death . attached itself to solid surfaces where pregnant woman may have only a In Canada, the number of people who it continues to flourish . Unlike most mild flu-like illness herself . If a baby become seriously ill with listeriosis has pathogens, Listeria can survive and is infected by its mother at the been increasing steadily, from 85 cases grow – even in vacuum-packed products time of birth, it can develop blood in 2003 to an estimated 239 cases in stream infection or meningitis 2008 . Most cases have been isolated 1 An outbreak is defined as occurring when two Because the disease does not ones and not associated with outbreaks . or more people experience similar illness after have specific symptoms, listeriosis consuming food from a common source .
Listeriosis outbreaks in Canada
There have been other listeriosis outbreaks in Canadian history. ➤➤ In 2002, an earlier listeriosis outbreak in Quebec involved 17 cases and was also associated with cheese. ➤➤ In the summer of 2008, coincidentally, there was an unrelated outbreak of listeriosis linked to cheese which occurred in Quebec. ➤➤ In 1981, a significant listeriosis outbreak in Nova Scotia resulted in There were 38 confirmed cases associated with this outbreak and 41 cases and 18 deaths. In this incident, the contamination was traced two deaths. Twenty-six of the cases were women, 13 of whom were to coleslaw. Cabbages grown on a farm where Listeria-contaminated pregnant. Three of the pregnant women lost their babies at birth sheep manure was used as a fertilizer were found to be the source of or soon after and five gave birth prematurely. the outbreak. At the time, it was the largest outbreak of its kind in the world and the first time thatListeria monocytogenes was proven to cause foodborne illness in humans.
Chapter 2 – What is listeriosis? 7 SUGGESTED PRECAUTIONS FOR HIGH-RISK INDIVIDUALS or in foods kept in cold storage . In fact, studies have shown Listeria can be Foods to Avoid: Safer alternatives: found in home refrigerators . Given that it is so pervasive in our Hot dogs, especially straight from the package Hot dogs reheated until steaming hot everyday lives, totally eliminating the without further heating. The fluid within hot dog risk of Listeria infection is not possible . packages may contain more Listeria than the Therefore, it is essential to reduce and hot dogs. manage the risks that contaminated Avoid spreading fluid from packages onto other food will be eaten .This is precisely foods, cutting boards, utensils, dishes and food what government regulations and food preparation surfaces. Wash hands after handling processing companies’ food safety hot dogs. policies and practices are designed to do .These regulatory and manufacturing Non-dried deli-meats Dried and salted deli-meats such as salami approaches to making food safe and pepperoni, as they generally do not from Listeria contamination will be support the growth of Listeria. In addition, described elsewhere in this report . risk can be reduced by reheating deli-meats There are also important steps that until steaming hot. we can take as individuals to prevent Soft and semi-soft cheeses such as feta, Brie, Pasteurized milk and milk products including illness . For listeriosis, special measures Camembert and blue-veined cheese if they are cheeses made from pasteurized milk are required to protect people who made from unpasteurized milk are most vulnerable, such as pregnant women, the elderly and those with Refrigerated pâté and meat spreads Canned or shelf-stable pâté and meat spreads compromised immune systems . For instance, luncheon meats, deli-meats Refrigerated smoked seafood and fish Cooked refrigerated smoked seafood and fish. Canned or shelf-stable smoked seafood and fish. and hot dogs should not be eaten by people in these groups unless they Raw or undercooked meat, poultry and fish Thoroughly cooked meat, poultry and fish are steaming hot while certain foods, such as unpasteurized soft cheeses, refrigerated pâtés, meat spread or Source: Health Canada - http://www .hc-sc .gc .ca/hl-vs/iyh-vsv/food-aliment/listeria-eng .php#mi smoked seafood, should be avoided altogether .
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“By the end of the 2008 outbreak, listeriosis was confirmed in 57 people and was reported as the underlying or contributing cause of death for 22 of these individuals…”
8 CHAPTER 3 Who was affected by the 2008 outbreak?
Who was affected by the 2008 outbreak?
By the end of the 2008 outbreak, listeriosis was confirmed in 57 people and was reported as the underlying or contributing cause of death for 22 of these individuals .Though the majority were in Ontario, illnesses occurred in seven provinces .
9 Infections with the Outbreak Strain of Listeria monocytogenes by Symptom Onset Date or Estimated date*
10 Aug 12: Confirmation of illness outside of Aug 15: Ontario Ministry asks that Illness with Ontario by Public Health Agency of Canada Long-term care homes be alerted Patient Recovery 9 Death Resulting from Illness 8
7 Jul 29: Alert on National Aug 17: Recall of Maple Leaf Foods Serveillance System Issued Bartor Road Sure Slice Products 6 July 16: Toronto Public Health Aug 19: Recall of all Maple Leaf Foods Bartor ersons
P investigates 2 cases Road Products from lines 8 & 9
5 Aug 24: Recall of all products from Maple Leaf Foods Bartor Road
4 Maple Leaf Foods Bartor Road plant re-opens
N umber of after its closure on Aug 20 3
2
1
0
1-Jun 8-Jun 6-Jul 13-Jul 20-Jul 27-Jul 3-Aug 7-Sep 5-Oct 2-Nov 15-Jun 22-Jun 29-Jun 10-Aug 17-Aug 24-Aug 31-Aug 14-Sep 21-Sep 28-Sep 12-Oct 19-Oct 26-Oct 9 -Nov 16 -Nov Week of Illness Onset * Some illness onset dates have been estimated from available information
Figure 1 – Confirmed cases of listeriosis by week of illness onset, Canada 2008 Source: Public Based on data from Health Agency of Canada
These numbers do not adequately fell ill .Whatever their age or personal for the very institutions where these describe the human impact of this circumstances, listeriosis took a vulnerable people were most likely outbreak, which affected mostly frail, terrible toll on their lives and those to be found . elderly individuals living in long- of their families . Forty percent of those The 2008 outbreak analysis term care homes . Several people affected in this outbreak died of this shows that almost 80% of those hospitalized because of other diseases, serious illness . who developed listeriosis lived such as cancer that weakened their Some of the Listeria monocytogenes- in a long-term care home or was immune systems that left them contaminated products that caused the admitted to a hospital that had susceptible to Listeria infection, also outbreak were specifically packaged served deli-meats taken from large
10 Suggestion packages contaminated with Listeria Development of listeriosis after the monocytogenes . three main food recalls took place is “Health care institutions should place signs The following graphs and tables not surprising, given the long incubation outside the doors of immune-compromised show some of the key characteristics period and the possible delay of up individuals indicating that they should not of the listeriosis outbreak .The cases to 70 days for illness to develop after be served ready-to-eat meats or food from included in the provincial and national eating contaminated food . In addition, outside the facility.” analyses are those that meet the some people consumed previously »» A suggestion by a family affected by the outbreak national outbreak case definition frozen deli-meat packages they had of a ‘confirmed’1 case of listeriosis . not thrown away when the recalls The Public Health Agency of Canada were made public .They, unfortunately, some point during their incubation (PHAC) defines a case as “a person in consumed contaminated product when period . Of these confirmed cases, the population or study group identified they defrosted their reserve (Listeria four out of five indicated they had as having a particular disease ”. 2 monocytogenes survives freezing) . eaten deli‑meats, two reported not Case definitions are established Most of the affected people were eating any deli‑meats (but were in an for surveillance purposes by PHAC in very old, again unsurprising because institution before becoming ill) and no collaboration with heads of public so many were residents of long-term consumption information was available health of the provinces and territories . care homes .According to an analysis3 for the remaining 10 cases .The pattern Figure 1, which is called an of the 56 confirmed cases, the average of illness in the 2008 listeriosis epidemiological curve, shows that the age was 74 and 68% of those who outbreak reflects the distribution of majority of persons became ill in July became ill were female .The youngest contaminated deli‑meats primarily and August 2008 . In retrospect, the first person affected was aged 29 and the to institutions where it was served person who developed listeriosis as part eldest was 98 .The average age of to vulnerable individuals . of the outbreak became ill on June 3rd people who died and had listeriosis Another quite reasonable assumption and the last person developed illness listed as the underlying or contributing by the public, at the time of the on November 22nd . cause of death was 76 years . outbreak, was the general belief that No pregnant women were identified ‘ready-to-eat’ meats such as cold cuts among confirmed cases . are safe to eat without the need for Among 56 confirmed cases in additional preparation .The operators November 2008, 44 individuals (79%) of hospitals and long-term care homes 1 Confirmed cases: Isolation of Listeria monocytogenes from a normally sterile had been in long-term care homes, served the ready-to-eat food products – site, including fetal gastrointestinal hospitalized or had made frequent working from the assumption, based on contents, with the following PFGE pattern out-patient visits to a hospital at years of experience, that the products (Scientifically referred as LMACI .0040, LMAAI .0001/ .0003 or LMACI .0001, were nutritious, easy to chew and safe - LMAAI .0001); Symptom onset (date of 3 Multi-provincial outbreak of listeriosis – brief without taking extra precautions . isolation of asymptomatic) on or after June 1, epidemiological update, 30 November 2008, People in these high-risk groups 2008; and, visitor to or resident of Canada . Public Health Agency of Canada . Unpublished 2 http://dsol-smed .phac-aspc .gc .ca/dsol- report produced before the last confirmed case need protection from potentially smed/ndis/glossa_e .html was reported . contaminated foods – something that
Chapter 3 – Who was affected by the 2008 outbreak? 11 did not happen in the case of all the Canadians who, in 2008, learned first- hand the serious and frequently fatal consequences of exposure to Listeria monocytogenes .
NEXT CHAPTER
The federal, provincial, territorial and municipal governments (and/or Regional Health Boards) have shared responsibility for food safety as a result of the division of powers in Canada’s Constitution…”
12 CHAPTER 4 How does Canada’s food safety system work?
How does Canada’s food safety system work? Responsibilities of the various organizations involved The federal, provincial, territorial and municipal governments (and/or Regional Health Boards) have shared responsibility for food safety as a result of the division of powers in Canada’s Constitution. The food processing sector also has its own legal obligations related to the production and sale of safe foods. And all of us as consumers have a role to play. Some of these responsibilities are unique while others are shared. To help understand why the 2008 listeriosis outbreak was so complex and difficult to address, it is helpful to have a clearer sense of who does what.
13 Consumer grocery stores. Whatever their role, all Food-borne diseases While this report focuses on food of those engaged in the food supply processors and governments, as chain have a responsibility to ensure Food-borne diseases pose a considerable consumers we have to be mindful that they take all necessary measures threat to human health and the economy that we also have a role to play. Food to ensure the foods Canadians eat are of individuals, families and nations. Their safety depends as much on our own safe. control requires a concerted effort on individual actions as those of others. Food processors take various the part of the three principal partners, Many people will be surprised ingredients, including vegetables, flour, namely governments, the food industry and to learn that foodborne illnesses eggs and meat, and transform these consumers. are usually the result of the things raw materials into a variety of new food http://www.who.int/mediacentre/ individual consumers do – or do not do products that generally have a long factsheets/fs124/en/index.html – once purchased food is taken home shelf life. from the store. Research indicates that Meat processors represent the the vast majority of foodborne illnesses largest sector of Canada’s food Canadians. It is also one of Canada’s (up to 97%) are because of the way processing industry, accounting for leading manufacturing sectors with people store or prepare food. Keeping 10% of Canada’s agri-food shipments annual sales of over $20 billion. our families safe from harmful bacteria and employing more than 63,000 also depends on making sure we do simple things like clean, separate, cook Food Distribution Chain and chill1 our foods. That said it is important to emphasize that consumer practices TRANSPORTATION were not a contributing factor in the RANCH 2008 listeriosis outbreak.
RAW MATERIAL
TRANSPORTATION Food processing industry Food processors provide a critical Slaughterhouse link in the food supply chain, which TRANSPORTATION begins at the farm gate and ends at your plate. There are many different Food p rocessor steps and people involved at each »»Cooking »»Slicing TRANSPORTATION stage starting with farmers and »»Preperation ranchers, followed by employees in »»Packaging slaughter facilities and food processing Warehouse/Distributor plants, as well as those working in the transportation, distribution and Retail Institution warehousing sectors, restaurants and »»Grocery stores »»Hospitals »»Confectionaries »»Long Term Care Units »»Vending Machines »»Schools »»Etc... »»Restaurants 1 Canadian Partnership for Consumer Food »»Etc... Safety Education, www.befoodsafe.ca Consumer
14 Who is responsible for food safety in Canada? ACHIEVING FOOD SAFETY FEDERAL GOVERNMENT Industry Canadian Food Inspection Agency (CFIA) »» Establishes and conductsfood safety programs in accordance with regulatory »» Enforces all federal laws and requirements and industry practices regulations dealing with food »» Verifies effectiveness of food safety »» Ensures industry compliance with systems and ensures safe production food safety regulations through and distribution of food inspection/compliance verification of food producers Consumer »» Investigates food responsible for »» Clean, Washes hands foodborne illness outbreaks with with soap food safety partners »» Handles, prepares and cooks food »» Initiates food recalls (with industry) safely Health Canada (HC) »» Consumes foods with caution »» Sets food safety standards/policies »» Makes health risk assessment decisions re foods on market »» Communicates to public on food safety issues Local Public Health/ Regional Public Health Provincial / Territorial Public Health Agency Authorities Governments of Canada (PHAC) »» Inspect food establishments »» Regulate food processing »» Acts as first point of contact for federal »» Educate regarding food safety practices within their jurisdiction government for human health impact »» Report confirmed cases of foodborne »» Implement food safety programs of foodborne outbreaks illnesses to province/territory »» Lead outbreak investigations within »» Conducts public health surveillance »» Investigate foodborne illness outbreaks; their jurisdiction »» Leads epidemiological investigations collect food samples; send samples »» Communicate food safetymessages when investigation is in morethan one to labs to public province »» Conduct analyses of findings
Some meat processors make Local and/or regional Regardless of the organizational products that are called ‘ready-to-eat,’ authorities set-up, local and regional authorities which simply means that generally you The organization of food safety at the contribute to food safety by inspecting do not have to do anything else to the local or regional level varies significantly local food processors, and food service food before eating it, except maybe across provinces and territories in and food retail establishments that thawing or warming. Ready-to-eat meat Canada. There are regional health are not federally registered. Some products include: deli meat, pepperoni, authorities in Western Canada and the health authorities provide food handler bacon bits, liver pâté and dry salami. Atlantic provinces, local public health training and information to increase units in Ontario, and health and social awareness among consumers of safe service regions and municipalities in food handling, preparation, storage, Quebec. and serving methods. Local/regional
Chapter 4 – How does Canada’s food safety system work? 15 Ron Usborne safety standards are not met or when “We need better coordination and cooperation in food safety activities amongst the various health risks are identified. When public jurisdictions… safety is threatened, it conducts food Discussions should continue with the federal, provincial and territorial committee in developing an investigations and product recalls. outcome based meat safety system with recognition of provincial program like Ontario’s HACCP In carrying out this role and in fulfilling Advantage program. And, last, food safety is a journey. It is not a destination.” its responsibility for all federal food
»» Ron Usborne inspection activities, CFIA’s objective Member of the CFIA’s Academic Advisory Panel is to ensure the safety of Canada’s food Food Safety and Quality Systems Specialist Appearing before the Agriculture Sub-Committee on Food Safety, April 29, 2009 supply. The Public Health Agency of Canada plays an active role once an illness public health authorities also conduct organisation, Agriculture and Agri-Foods caused by food is detected in humans. surveillance of foodborne illnesses and Canada, supports food safety policies PHAC supports action in preventing report confirmed cases to provincial through food quality research. injury and disease across the country, ministries of health. Finally, local/ Health Canada establishes policies including diseases transmitted by regional public health officials carry and standards for the safety and food or animals (foodborne and out epidemiological investigations, nutritional quality of food sold in zoonotic2) and to promote national if a foodborne illness outbreak is Canada. Food policy decisions are and international public health. suspected or confirmed. based on assessments of risks In a foodborne illness outbreak, associated with products or processes PHAC conducts national public health Provincial and territorial from a public health perspective. In surveillance and may provide assistance governments some situations, when an unacceptable to provincial authorities by contributing Provincial and territorial governments risk is identified, the product or process to epidemiological studies. PHAC’s set food safety standards for plants may be prohibited. Health Canada laboratories provide reference services3 licensed in their jurisdiction and enact is also responsible for assessing the to identify and differentiate the various and enforce food safety laws that apply effectiveness of the CFIA’s food safety types of micro-organisms involved in to food produced and distributed activities. the illness as well as systems to assist within their jurisdiction. They also The Canadian Food Inspection surveillance and sharing of information. have the authority to investigate and Agency’s main role is to enforce the PHAC maintains national databases for take action to control human illness food safety and nutritional quality all foodborne diseases, and operates the outbreaks, including foodborne illness standards set out by Health Canada Listeriosis Reference Service, jointly with outbreaks, within their borders. for domestic and imported products. Health Canada.”4 The Agency delivers inspection Federal government programs in food safety and quality, Responsibility for food safety within and plant and animal health across 2 The umbrella term describing diseases that can be passed to humans from animals. the federal government is assigned Canada, including food processing 3 Laboratory reference services provide the primarily to three organizations: Health plants. It also ensures that all food national expert advice on a particular Canada, the Canadian Food Inspection products meet federal packaging and scientific issue. 4 Lessons Learned: Public Health Agency Agency (CFIA) and the Public Health labelling requirements. The Agency of Canada’s Response to the 2008 Agency of Canada (PHAC). A fourth takes enforcement action when food Listeriosis Outbreak
16 health and consumer product safety enhance Canada’s food safety system. Understanding the by better supporting the collective The proposed changes to the Food and federal regulatory responsibilities of government, industry Drugs Act would help streamline the food system overseeing and consumers for product safety.6 safety system, provide more consistent The Action Plan is based on the regulatory tools across all food sectors meat processors understanding that modernizing our food and better enable the Government of safety system demands an integrated Canada to fulfill its food safety mandate. Canada’s 2007 Food approach, new and better information on and Consumer Safety food risks in the Canadian marketplace, Action Plan and the full involvement of industry and In December 2007, Prime Minister Canadians in responding to potential Harper announced “Canada’s Food hazards. and Consumer Safety Action Plan.”5 The Action Plan includes both The Plan is designed to strengthen food, legislative amendments to the Food and Drugs Act to replace outdated statutes and expanded program measures to 5 Health Canada, Strengthening and Modernizing Canada’s Safety for Food, Health and Consumer Products: A Discussion Paper on Canada’s Food 6 Public Health Law & Policy in Canada, Second and Safety Action Plan, (10 January 2008), online Edition, Bailey, Caulfield, Ries, Chapter 12, http://www.healthycanadians.ca/pr-rp/dpaper- Foodborne Illness and Public Health (Ronald L. papier_e.html#a Doering), Ottawa, p. 492.
Framework for Canada’s Food and Consumer Safety Action Plan
Objective Protecting the health and safety of Canadians
Oversight where risks are greatest Strategy over the life cycle of a product
1. Corporate Responsibility PRINCIPLES 2. Empowered Consumers 3. Enabling Government
Active Targeted rapid ACTION PLAN Prevention oversight response
Inter-Agency co-operation
Chapter 4 – How does Canada’s food safety system work? 17 Brief History
The Government of Canada has a long history Governance changes were introduced following quality standards and risk-based inspection had of regulating the food industry with some the Nielsen Task Force report in 1985. While some not been fully achieved. federal laws dating back over 100 years. Prior regulations governing food safety/inspection were In 1995, the Office of Food Inspection Systems to 1997 five federal department were involved amended, a priority was placed on clarifying roles was established to review and recommend the in delivering the federal food safety mandate. and responsibilities and increasing co-operation potential improvements to the federal component Health Canada had overall responsibility for and co-ordination of the federal food inspection of the Canadian food inspection system, including health, safety and nutritional aspects of food. and emergency response activities. The purpose possible changes to the organizational structure. Agriculture and Agri-Food Canada and Fisheries was to introduce more uniformity in the delivery and Oceans Canada regulated and inspected the of inspection services and address provincial and In 1997 the Canadian Food Inspection Agency agri-food and fisheries sectors. Industry Canada industry concerns for uniform national standards (CFIA) was created by combining the food was responsible for the general food labelling as well as public concerns about food safety. safety and inspection programs of three federal provisions (applied to all pre-packaged food) and departments: Agriculture and Agri-Food Canada, In 1994 a Report to Parliament by the Auditor Revenue Canada-Customs played a significant Health Canada, and Fisheries and Oceans. The General reported on the limited progress made by supporting role by notifying federal departments Agency’s creation was to address a long history the government. The government had begun the of shipments and enforcing import regulations at of needed reforms to the federal food safety/ planned reforms but attempts to facilitate a more ports of entry. inspection system. uniform and consistent approach to safety and
Overview of sold or imported for sale in Canada. exporting to other countries, as well legislative framework Under the Meat Inspection Act, the as for companies importing food to be All meat processing companies that CFIA establishes the quality, packaging sold in Canada. The CFIA is the federal distribute and sell their products and labelling standards for companies organization responsible for verifying in more than one province and/or selling in more than one province or that all the rules and requirements are in other countries are governed by rules and requirements set out by Hazard Analysis and Critical Control Point (HACCP) the Government of Canada7. The rules cover food safety, quality, ingredients, ➤➤ HACCP was developed in the late 1960s at conditions (e.g.: design of the packaging and labelling. These rules the request of the US National Aeronautics machines, cleaning and sanitation, and requirements are found in several and Space Administration (NASA) to the building, employee cleanliness federal laws, mainly the Food and reduce the likelihood of foodborne illness and training, transportation, recall Drugs Act and the Meat Inspection Act. while travelling in space. procedures, etc) of the food processing plant. They include the conditions Under the Food and Drugs Act, ➤➤ Today, it is an internationally endorsed needed to produce safe food. Health Canada sets out food safety food safety approach to assessing standards, including the types of and controlling the hazards and risks »»HACCP Plan: a document detailing ingredients, that apply to all food associated with any food operation. all the control points of hazard (i.e.: dangers) that are critical from a food ➤➤ HACCP systems have 2 parts: safety perspective and specific to the 7 Food processors that sell locally or within »»Prerequisite Programs: steps or processes and plant for which the plan a province are governed by the rules of procedures to control the operational is developed. that particular jurisdiction.
18 Compliance Verification System (CVS) consumers’ health and ensure fair trade ➤➤ CFIA designed the CVS by consolidating ➤➤ The CVS was piloted in 2006 and 2007 in practices in the food trade. all the inspection requirements that over a 100 processing plants across the Food processors that want to market previously existed in different meat country before being implemented, in April their food inter-provincially and/ inspection programs. 2008, in all federally registered meat, or internationally must implement, poultry and storage plants. ➤➤ The CVS sets out the procedures to be at minimum, HACCP plans in order to used by CFIA inspectors to verify the ➤➤ The CVS consists of a series of verification export their products. Each individual design and implementation of a plant’s tasks to be completed by the inspector, plant’s food safety plan must cover all food safety plan and how the plan is based on procedures to be followed when aspects of food safety including safety being kept up to date. conducting verifications. standards in the building where the ➤➤ One the key goals of the CVS is to food is produced, the land surrounding improve the efficiency and consistency it as well as the equipment used in food of inspections. preparation and packaging. The plan also outlines safety procedures for people working at the facility and respected by companies under both safety plan, which includes a key their movements within the plant. laws. component called the “Hazard Analysis Microbiologists employed by each The way the federal government and Critical Control Point” (HACCP) plan. food processor do all the swabbing fulfills these duties has changed in The HAACP plan for each plant must of equipment and scientific testing recent years. be endorsed by CFIA. This systematic to detect bacteria according to the preventive approach (see box) to food standards laid out in the plant’s food Federal rules safety is now considered the universal safety plan. Food processors also have and requirements standard. quality assurance officers who do The CFIA Meat inspection regulations HACCP has been approved by the internal verifications such as making flow from the Meat Inspection Act. Codex Alimentarius Commission, the sure that temperature controls are The regulations require meat processing global body established by the Food precise, charts are kept up to date, companies that sell products in more and Agriculture Organization8 of the and so on. There are a minimum of than one province or to other countries United Nations and the World Health three people per quality assurance to be federally registered and licensed. Organization. The Commission oversees team: one person undertakes the Licensed operators, such as Maple Leaf food standards, guidelines and codes activity; a second person monitors Foods, must establish safety measures of practice under the Joint Food and the activity; and, a third person and controls at every step of the food Agriculture Organization / World verifies the activity. production process in order to comply Health Organization Food Standards with the regulations. Programme, which aims to protect
Food Processors
Food processors are required by 8 Codex Alimentarius Commission, online http:// regulations to develop their own food www.codexalimentarius.net/web/index_en.jsp
Chapter 4 – How does Canada’s food safety system work? 19 Voluntary vs. Mandatory Food Recall a two-year period, in addition to their Voluntary Recall Mandatory Recall daily inspections. ➤➤ In Canada and in all other countries, food ➤➤ In exceptional cases, upon the Aside from its inspection powers processing companies have the legal recommendation of CFIA, the Minister of the CFIA, under the authority of the obligation to ensure that the products that Agriculture and Agri-Food has the power Food and Drugs Act and the Canadian they offer for sale on the marketplace are under the Canadian Food Inspection Food Inspection Agency Act, can safe and fit for human consumption. Agency Act to order a “Mandatory” recall: remove products from the market ➤➤ If a product on the marketplace is found »»It is used when a company is unwilling when a suspected contaminated food to be contaminated, the vast majority or unable to recall its contaminated poses a risk to public health and of companies “voluntarily” recall their product or when the company can not safety. Such intervention can take product and physically remove or have it be found (e.g.:bankrupty) or identified; place whether the product has been removed from the marketplace. produced in a federally registered or »»A mandatory recall is significantly more provincially (territorially) licensed plant, ➤➤ In these cases, CFIA with the support of challenging as it takes additional time HC ensures that the actions taken by the to locate and remove the product from or imported for sale into Canada. The company are appropriate in order to deal the market (product and distribution CFIA has broad powers to investigate, with the risk to the health of the public. information is not available since the search, seize and hold food products company is not cooperating); that violate the Food and Drugs Act. »»Note: In some cases, provincal/ An inspector can enter any food territorial governments can undertake »»CFIA staff is required to remove the processing facility or vehicle and open the roles described above for products product from the market in addition to any package that is suspected of sold in their jurisdiction. its regular recall duties. containing a contaminated product.9 The Canadian Food Inspection Canadian Food at registered federal meat plants Agency warns the public when a Inspection Agency each day. These inspections activities, specific food has been identified In addition to industry’s in-house include daily and monthly tasks, and as a risk to human health and can food safety plans and controls, are based on known risks associated order a company to recall particular the CFIA conducts inspections at with food processing and the facility. products. Recalls are almost always food processing plants to ensure With the introduction of the CVS done voluntarily by the responsible food processors respect federal (see box), CFIA inspectors are to audit food processor. In the past 12 years laws and regulations. the plant’s key control systems within since the CFIA was created, the Agency These inspections include an has conducted several thousand assessment of the plant’s HACCP investigations that concluded in an plans which must be endorsed by CFIA. Suggestion average of 235 primary recalls per year With the introduction in April 2008 of in recent years. Of all the recalls since the Compliance Verification System “Health care institutions should follow the 1997, only seven were mandatory. (CVS), CFIA inspectors are required to federal Policy on Listeria, in particular the conduct specific inspection activities recommendations regarding ready-to-eat meats and vulnerable populations.” 9 Public Health Law & Policy in Canada, Second »» A suggestion by a family affected by the Edition, Bailey, Caulfield, Ries, Chapter 12, outbreak Foodborne Illness and Public Health (Ronald L. Doering), Ottawa, p. 489.
20 Listeria Policy In 2004, Health Canada, Decision tree to identify food in collaboration with the CFIA, additives and processing aids updated and implemented the federal Listeria policy10. The current policy is based on the principles of HACCP Substance must me used in accordance Substance excluded and an approach that assesses the with Food and Drugs YES from definition of food risks of contaminated foods to human Act and Food and additive? health. It includes a combination of Drug Regulations inspection, environmental sampling and end product testing. 1NO The 2004 Policy focuses on ready-to-eat foods which have been linked to outbreaks of listeriosis Use of substance and those that support growth Food Additive YES affects characteristic(s) of Listeria monocytogenes with a of the food? greater than 10‑day refrigerated shelf-life. It recognizes that the risk of contamination by Listeria 2NO monocytogenes can be reduced, but that Listeria cannot always be eradicated from finished products or Substance becomes the food processing plant environment. Processing Aid NO part of the food? The 2004 Policy guides food processors on food safety standards and risk management approaches to controlling Listeria monocytogenes, 3YES including effective sanitation programs
NO YES to address Listeria monocytogenes in Negligible residues the environment of their plant. of substance in food In addition, the Policy sets out in accordance with food processors’ responsibility policy? with respect to the development 4 of sampling approaches and the use 10 The ‘Policy on Listeria monocytogenes in ready-to-eat foods’ replaced the 1994 Field Compliance Guide.
Chapter 4 – How does Canada’s food safety system work? 21 of microbiological testing to verify that results in no or negligible residues Post-processing their control measures, eg. sanitation, of the substance or its by-products bacteria ‘kill steps’ are working as intended. in or on the finished food. While some processes are used during the stage when food is being Food additives Additives that can processed, others are used in the and technologies inhibit Listeria growth period before or during packaging. In Canada, the Food and Drugs Act Additives such as sodium diacetate and These activities are clustered under governs the use of all substances in sodium lactate have been approved the general category of post-processing food processing and manufacture. for use in the United States for close bacteria ‘kill steps’ such as: Under the Act, the Food and Drug to a decade to inhibit Listeria growth. »»Heat and UHP (ultra high Regulations permit the use of additives The two chemicals have been used pressure): These procedures which can be used to preserve food singly or in combination by American to kill Listeria include heating, or to control harmful bacteria. The food processing companies. They steam, submersion in hot water, regulatory definition of food additive are also used in other jurisdictions, radiant oven heat, high pressure includes ‘any substance the use of including the UK, the EU, Australia processing, consumer reheating; which results, or may reasonably and New Zealand, and have proven »»Post-processing, post- be expected to result, in it or its safe and effective in controlling the pasteurization or post-lethality by-products becoming a part of or alternatives: These are physical affecting the characteristics of a Post-Pasteurization treatments such as chemical food.11 Regulations can include a list antimicrobials: biological: lactic Post-packaging heat treatments (typically of foods in which the additive may be acid bacteria, bacteriocins/ referred to as post-pasteurization) have used and their level of use, as well bacteriophages that can destroy long been used for whole muscle products as a requirement that the additive be the bacteria; that are unavoidably handled after initial declared on the label of a prepackaged thermal processing (Beckwith, 1995). »»Irradiation: Food irradiation is food. a safe method to decontaminate There are other substances foods for human consumption, used during food processing and proliferation of Listeria bacteria. although it is controversial with manufacture that do not meet the These additives are endorsed consumers. It has been proven definition of food additive, which by industry associations including to be the single most effective are commonly referred to as food the Canadian Meat Council and methods of eradicating bacteria, ‘processing aids.’ These include the American Meat Institute and and it does not alter appearance, chemicals and treatments, such international bodies such as the taste or texture of foods. Despite as some antimicrobial substances, Codex Alimentarius as successful its many advantages, this antifoaming agents, filtration and ways to inhibit Listeria growth. Both proven technique is unlikely to fining agents. Use of processing chemicals were approved by Health be adopted by food processors aids does not affect the natural Canada in the fall of 2008 on an without a major consumer characteristics of the food and interim basis but new regulations education program. have yet to be finalized.
11 From HC Website: http://www.hc-sc.gc.ca/ fn-an/pubs/policy_fa-pa-eng.php
22 Public Health Core Functions in Canada
The following six activities are generally ➤➤ Health Protection: Actions to ensure safe ➤➤ Health Promotion: Public policies and considered to be the “core public health water, food and air, including the control programs (e.g., community-based, functions” in Canada: of infectious diseases, protecting the advocacy, active public participation etc) population from environmental threats to improve the prospects of safe behavior ➤➤ Health Surveillance: On-going, systematic and providing advice to food and drug and healthy lifestyles and address the collection, analysis and sharing of high regulators. broader determinants of health. quality health data, in a timely manner, in order to forecast and respond to new and ➤➤ Disease and Injury Prevention: Policies ➤➤ Emergency Preparedness and Response: emerging health challenges and programs to promote safe and healthy Planning and preparation to help protect lifestyles to reduce illness and prevent the population from both natural and man- ➤➤ Population Health Assessment: injuries. Includes investigating disease and made disasters to reduce or prevent serious Understanding the health status of preventive measures to reduce the illness, fatalities and social disruption. communities or populations and the factors risk of infectious diseases and outbreaks. that foster good health or that may cause ill-health.
Emerging technologies and the United States, as well as cases have declined there by as Bio-sensors: These highly sophisticated in the European Union, the United much as 40% since the late 1990’s, devices can detect minute changes to Kingdom, Australia and New Zealand when these new sanitizing procedures reveal the presence and concentration use sanitizers to control Listeria in their were encouraged in the aftermath of contaminants in food. Because manufacturing processes. of a serious listeriosis outbreak in bio-sensors can reveal even very small The meat industry uses four main that country. This approach has had amounts of contamination, they hold types of sanitizers: hot water, chlorine, the greatest impact in reducing the promise for enhancing food safety in iodophors and quaternary ammonia. number of pathogens in ready-to-eat the future. However, these technologies Sanitizers approved for use in meat poultry and red meat products. are still in the developmental phase production facilities combine both and are not yet in use in the food products and sanitation techniques Design of food processing industry. to eradicate Listeria bacteria that are processing equipment harmful to humans. All food processing plants are Sanitizers used Several of these sanitizers comprised of numerous pieces to control Listeria (quaternary ammonium and idophors) of equipment. The design of this The Listeria bacteria have the ability are most effective when combined equipment can facilitate, or complicate, to form bio-films – microorganisms with post-processing steam and heat the sanitation measures needed to that adhere to surfaces – that are treatments. produce safe foods. resistant to conventional industrial The introduction of sanitizers has Specific direction on sanitation cleaning methods. Recognizing this, a made a noticeable difference in the and other maintenance guidance that number of meat processing industries incidence of Listeria contamination in affect food safety is provided through in North America, including Canada ready-to-eat foods in the US. Listeriosis directives issued periodically by CFIA.
Chapter 4 – How does Canada’s food safety system work? 23 PulseNet Canada What is surveillance?
➤➤ PulseNet was initially developed Centers ➤➤ PulseNet contains information on The ongoing, systematic collection, for Disease Control and Prevention foodborne illness and their causes, used analysis and sharing of high quality (CDC) in Atlanta, United States and in helping identify outbreaks in real time health data, in a timely matter, in order to currently operates virtually worldwide once the necessary data is inputted forecast and respond to new and emerging health challenges ➤➤ PulseNet Canada set up in 2000 ➤➤ PulseNet can track cases of E. coli, is a national electronic network, Salmonella, Shigella and Listeria coordinated by PHAC, that provides a monocytogenes rapid communications platform and links public health laboratories from all provinces and Health Canada
Food processing equipment, including from leading public health experts who and Canadian Forces veterans. It also slicers that can affect the safety of called for clear federal leadership on provides funding to provincial and food, is part of each plant’s food safety public health matters and improved territorial health systems. A further plan approved by government. collaboration within and between function of Health Canada and the jurisdictions. Public Health Agency of Canada is Understanding public The PHAC describes public health to conduct scientific research, carry as “a shared responsibility. While out consultations with Canadians to health and the governments enact laws, develop determine how to best meet their organizations involved policies and provide resources to long-term health needs, communicate Public health involves much more than fund public health activities, it takes information about disease prevention hospitals and doctors – what most the combined efforts of a variety of to protect Canadians from avoidable Canadians think of as the health care organizations, sectors, and people, risks and encourage Canadians to 13 system. both within and outside government, take an active role in their health . 12 Public health covers a wide range to address health challenges. The sharing of these responsibilities of disciplines. Unlike the health care In the event of foodborne illnesses, is laid out in Canada’s Constitution. system which treats each patient provincial or territorial officials individually, public health practitioners generally have the mandate to are concerned with the health of the investigate human illness outbreaks entire population. that occur within their own borders. The Public Health Agency of Canada The federal government delivers was established in 2004 in response health care services to First Nations to growing concerns about the capacity and Inuit populations, as well as war of Canada’s public health system to 13 Drawn from HC website http://www.hc-sc. anticipate and respond effectively 12 Public Health Agency of Canada, Report on the gc.ca/ahc-asc/index-eng.php and ‘The to public health threats, including State of Public Health in Canada 2008, What Government of Canada’s role in health” foodborne illnesses. The Agency’s we mean by public health, online http://www. http://www.hc-sc.gc.ca/hcs-sss/pubs/ phac-aspc.gc.ca/publicat/2008/cpho-aspc/ system-regime/2002-fed-comp-indicat/2002- creation followed recommendations cpho-aspc02-eng.php health-sante4-eng.php
24 Detecting and investigating foodborne illness Canadian Integrated Outbreak Surveillance Centre – CIOSC Surveillance of Objective: Outbreak Surveillance (Early Detection of Outbreak) foodborne illness The routine monitoring of important PUBLIC HEALTH ALERT »»Public health alerts are posted to CIOSC by Provincial / Territorial or Federal conditions and diseases, including Public Health Officials foodborne illness, carried out by public »»Alerts CIOSC to inform users* of confirmed / suspected outbreaks or health, is called surveillance. This is provide additional information to on-going outbreaks / investigations one of the six core functions of public health. The purpose of surveillance Canadian Integrated Outbreak Surveillance Centre – CIOSC in foodborne illnesses is to prevent the spread of infection to susceptible CIOSC Enteric Alert Site »»Early alert system people. Surveillance is carried out »»National secure environment by all three levels of government. »»Real time information sharing of public health intelligence Most cases of foodborne illness between users* »»Receives public health alerts are not part of recognized outbreaks but occur as individual or ‘sporadic’ Effect of Public Health Alert in CIOSC cases. However, some may be part of »»Informs all users* of possible / confirmed outbreaks »»Once outbreak identified, public health alerts spur appropriate unrecognized outbreaks. As the 2008 public health officials and food safety partners (e.g. CFIA, etc.) listeriosis outbreak demonstrates, to initiate outbreak investigation detecting large outbreaks can be a challenge especially where illness occurs across large geographic areas PUBLIC HEALTH ALERT E-MAIL ALERT CIOSC allows registered Goes to all users* at and local jurisdictions may see only one users* to see nation-wide same time as public health alert goes to or two cases. That is where laboratory communicable disease tools for DNA fingerprinting of disease and food-borne illness CIOSC activity which may be organisms (described later) are valuable * Users: Local, Regional, Provincial / Territorial and similar to local / regional National Public Health Stakeholders (e.g., public in making connections between cases occurrences health officials including affiliated organizations, such as CFIA) and in linking them to a specific food or other source. Certain diseases have been made “notifiable”, meaning that when they are diagnosed they must be reported to public health authorities. Surveillance
Chapter 4 – How does Canada’s food safety system work? 25 Epidemiological investigation Dr. Horacio Arruda
An epidemiological investigation aims to identify This type of investigation is commonly used “Epidemiological information is to a public common links between illnesses in the general to identify the source of communicable and health physician what CAT scans are to population in order to determine the source foodborne illnesses. In the latter case, the other physicians.” of the illness and the means of exposure and investigation searches for the specific food »» Dr. Horacio Arruda Director of Health Protection, Ministry transmission. which is the causal agent. of Health and Social Services of Quebec of a notifiable foodborne illness usually monitor notifiable illnesses vary from Another national initiative, the begins with a report to local public province to province. Many systems Canadian Integrated Outbreak health by a physician who has made monitor illnesses and identify spikes Surveillance Centre (CIOSC)16 plays a the diagnosis or by the laboratory in the number of cases. If the number key role in detecting disease outbreaks that detected a positive lab specimen. increases, provincial/territorial by receiving, posting and distributing The patient information is recorded public health officials may alert all electronic alerts about respiratory in an electronic surveillance system local and regional health units, as or enteric diseases to public health which is uploaded into a provincial well as those in other jurisdictions, practitioners across Canada and information system. If the disease to enhance surveillance which may related organizations like CFIA. This is nationally notifiable, information lead to preventative measures. encourages others to look for similar is also transferred to the Public Health The Public Health Agency of Canada cases that might be connected. CIOSC Agency of Canada. has several national surveillance alerts may be initiated at any level of In 2008, listeriosis was a notifiable systems in place for foodborne illness. the public health system and are not disease in most but not all Canadian The National Enteric Surveillance restricted to notifiable diseases. provinces. However, it was not Program15 is designed to provide nationally notifiable14. The list of timely analysis and reporting of lab- Investigating notifiable diseases at the federal level confirmed enteric (intestinal) disease is agreed to by consensus with the cases in Canada. Their National foodborne illness provinces and territories, as they must Microbiology Lab coordinates PulseNet When an apparent cluster of cases supply the reports. Since the 2008 Canada, an electronic laboratory is detected, public health officials outbreak, the process to add listeriosis network that identifies clusters of first determine whether the cases to the list of notifiable diseases has foodborne pathogens including Listeria represent a real increase above the been undertaken by all jurisdictions. monocytogenes based on their DNA expected number of cases and whether Public health officials monitor fingerprints. PulseNet allows DNA they really might be related. Once an the illness reports they receive to fingerprints to be compared in real outbreak is strongly suspected, an look for increased numbers of cases time so that foodborne illness from investigation begins. or clusters that could indicate an a common source can be identified. Typical steps in an investigation emerging problem. The systems that include: 15 national Surveillance Enteric Program »»search for more cases among people includes C-EnterNet as a pilot initiative who might have been exposed 14 national Notifiable Diseases – to obtain more complete information on http://dsol-smed.phac-aspc.gc.ca/dsol- enteric disease by conducting surveillance smed/ndis/list_e.html in selected sentinel sites 16 CIOSC is operated by PHAC
26 Foodborne Illness Outbreak Response Protocol (FIORP)
FIORP is a joint protocol to guide multi- and territories. In 2002, as part of a special Once that work was completed by an FPT Working jurisdictional responses when a foodborne illness session on Emergency Preparedness, the Federal/ Group, in 2004, the updated FIORP was endorsed emergency arises. The roles and responsibilities Provincial/Territorial (FPT) Committee on Food by the FPT Committee on Food Safety Policy, the of all governments charged with investigating and Safety Policy recognized the protocol as a key Council of Chief Medical Officers of Health and managing such an outbreak are outlined. document to outline procedures for national Federal, Provincial and Territorial Deputy Ministers emergency preparedness and agreed to work of Health. It was first developed in 1999 by Health Canada together to amend it to reflect the perspectives of and CFIA, in consultation with the provinces public health officials from across the country.
»»‘case definition’ developed to The epidemiological investigation provincial or territorial government describe typical cases often provides enough evidence to requests assistance or once an illness »»description of the outbreak - establish the source of the outbreak extends beyond a single province or who is affected, graph of cases and how it is being spread. This allows territory. over time etc. appropriate control measures to be When commercial food products »»additional sampling as needed taken. In other circumstances additional are implicated, provincial Ministries to determine the organism laboratory studies (for example to link of Agriculture and/or the CFIA also responsible human illness and the implicated foods) become involved to conduct a detailed »»interviews to identify potential are needed to provide the evidence food safety investigation to identify foods that might be implicated needed for action. the food responsible for causing the »»formal epidemiological When outbreaks of foodborne illness illness. This usually includes working investigation to measure the occur, epidemiological investigations closely with the manufacturer to obtain association between the illness and are handled by the local/regional distribution records and additional food the suspected source of food public health departments, a province samples for testing, and conducting »»investigation into the implicated or territory or the federal government, a comprehensive inspection of the food – its ingredients, preparation depending on the scope of the manufacturing facility. and microbiological culture of illness or the capacity to manage the Provinces and territories also have leftover ingredients or the food investigation. The Public Health Agency the authority to investigate food safety itself (if available) of Canada becomes involved when issues and provide notification to the
Recall Decision Epidemiological Food Safety Implementation Surveillance Making/Risk Follow-up Investigation Investigation and Recall Assessment Effectiveness
Determining and Responding to a Foodborne Illness Outbreak (From Lessons Learned: The Canadian Food Inspection Agency’s Recall Response to the 2008 Listeriosis Outbreak, p8)
Chapter 4 – How does Canada’s food safety system work? 27 public concerning food safety and Foodborne Illness Outbreak Response conduct recalls within their boundaries Protocol to Guide a Multi-Jurisdictional if the plant if provincially registered. For Response (FIORP). This protocol has instance, the Ontario Ministry of Health been ratified in 2004 by Deputy and Long-Term Care can issue a food Ministers for all fourteen jurisdictions. recall of unfit food under the Ontario Aside from this national-level Health Protection and Promotion Act. protocol involving federal, provincial At the federal level food safety and territorial governments, a number investigations are the responsibility of of provinces and territories – British CFIA, and carried out in collaboration Columbia, Alberta, Saskatchewan, with Health Canada. Each year, the Northwest Territories, Ontario and the CFIA conducts approximately Quebec – have specific agreements 3000 food safety investigations. with the federal government relating These investigations can be triggered to food safety. by various sources including consumer and industry complaints, inspections, audits, laboratory results or referral from other organizations. As a result of these investigations, approximately 235 primary food recalls are initiated each year to remove products from the market, in most cases before products are consumed. Key CFIA staff, including those from the national Office of Food Safety and Recall, Area Recall Coordinators and laboratory services, are involved in such food safety investigations. Health Canada’s role is to conduct, at the request of CFIA, an assessment of the health risks from human NEXT CHAPTER exposure to contaminated foods. Coordination of the response to “With the advantage of hindsight, it was large national outbreaks of foodborne possible to see the factors that created disease is unusually complex because the conditions that allowed listeriosis to there are many organizations involved take hold. Coincidences and decisions, at three levels of government. The roles which were not thoroughly thought through and responsibilities of all governments or executed, contributed to the 2008 charged with investigating a foodborne outbreak…” illness outbreak are outlined in the
28 CHAPTER 5 What led to the outbreak?
What led to the outbreak? With the advantage of hindsight, it is easy to see the mix of variables that created the conditions enabling listeriosis to take hold. Among the many variables, is simply the fact that the disease involves a virulent bug that is very difficult to pinpoint and even harder to keep in check. Beyond that, a number of coincidences as well as specific decisions, which were not thoroughly thought through or executed, may have contributed to the 2008 outbreak. Whatever the explanation, the reality is Listeria defeated the best efforts of all those trying to prevent it from entering the food supply, including workers attempting to control it in the Maple Leaf Bartor Road plant. It also evaded the oversight systems of both Maple Leaf Foods and the federal government (CFIA). As a result, a segment of the population that is the most vulnerable was exposed to its damaging and sometimes deadly effects.
29 Then, there is the fact that the and operating on different timetables plant in that it routinely met all the food business has undergone a made things even more complicated. regulatory requirements under the transformation in recent years, due in These challenges were intensified by federal Meat Inspection Act and got great part to new technologies and the time of year that the events took satisfactory marks for complying globalization. The way food is raised, place – the summer vacation period. with the government’s inspection processed, transported and distributed Senior management in several key and testing tasks. When Canadian to consumers now means that food organizations were on vacation, which Food Inspection Agency’s inspectors produced in one part of the country is may have contributed to delays in identified any compliance problems, available within days in communities decision making in some situations. the plant addressed them. Bartor big and small all across the country. In the end, the lost time made Road’s management maintained the This ready access to a wide variety little difference because most of the necessary required records, ensured of foods, especially ready-to-eat contaminated food was on the market that staff training took place, and made products that are a growing staple in and eaten before people in the food sure its quality assurance program was many Canadians’ busy lives, is a bonus safety and public health sectors were completed. for both consumers and industry. even aware of the outbreak’s existence. Much of the credit for Maple Leaf However, each step in the modern food We identified weaknesses in four Foods’ good reputation rested with chain increases the chance of food critical parts of the food safety system the firm’s in-house safety plan. The contamination. It also makes tracing that, collectively, led to the Listeria company had introduced its own food the source of a foodborne illness when outbreak. safety procedures - which includes an outbreak occurs far more difficult a comprehensive HACCP1 plan, than in the past. 1. MAPLE LEAF FOODS an additional layer of food safety These conditions were affected by protection at the end of the nineties – a series of modifications to federal BELIEVED ITS PROCEDURE years earlier than was required by the food safety policies and programs that TO CONTROL LISTERIA WAS regulations. had been introduced by the CFIA in WORKING – IT WAS NOT Like most food processors, Maple the lead-up to the event. These recent Leaf Foods` food safety approach laid changes contributed to additional Like all firms operating food processing out a hazard monitoring and control complication and confusion when plants regulated by the federal program. As a general rule, these plans it was finally obvious that a major government, Maple Leaf Foods was are effective. Over 400 meat processing listeriosis outbreak was underway. required to maintain a hygienic companies across the country Many of the new initiatives were not operating environment in order to produce tons of food products daily well understood or only partially control bacteria. without incident. implemented, at the very time that At the outset of the 2008 listeriosis clear communications, cooperation outbreak, Maple Leaf Foods was and coordinated action were required viewed as a good company using the 1 The “Hazard Analysis and Critical Control latest food safety control systems. Point” (HACCP) places the responsibility on the on the part of multiple players. food producer to ensure that the product is In addition, the fact that food safety It viewed itself then, and continues safe to be consumed. Proposed by the Codex and public health is shared among to view itself now, as a leader in the Alimentarius Commission for the food industry industry. The Bartor Road plant was in general, and meat, poultry, and seafood three levels of government, using industry in particular, it has been adopted by different systems and procedures considered by many to be a compliant some 150 countries.
30 Incidence of food contamination The food safety plan of Maple Leaf Health Canada’s Listeria Policy which Foods covered all expected aspects, recommends environmental testing. ➤➤ There are few episodes of foodborne including safety standards in the In fact, like many of Canada’s ready- illness, particularly listeriosis, despite building where the food is produced, to-eat meat processing plants, Bartor millions of meals a day of food the land surrounding it, as well as the Road actually went beyond the Policy products being packaged and shipped equipment used in food preparation and requirements in that the company across Canada and around the world. and packaging. The plan outlined safety had an extensive environmental testing ➤➤ The CFIA does approximately 3000 procedures for people working at the program of its own. food investigations annually. In an facility and their movements within the Doing more than was required did average year, this results in 235 plant. It also identified who is in charge not guarantee the company was trouble primary recalls. of various aspects of the company’s free. As early as summer and fall of ➤➤ Occurrences of contaminated food operations and the corresponding levels 2007, the company’s environmental reaching consumers and causing of responsibility and accountability. testing program showed positive foodborne illness outbreaks account Maple Leaf Foods was confident Listeria environmental test results from for only 5 to 6 cases per year. that its monitoring and control production lines 7 and 8 in the plant, programs would find any problems if every two to three weeks, at various they arose and, for the most part, they locations on those lines. testing were also identified during the did. The company had a good track This pattern carried on into 2008. week of June 23rd. record in preventing contamination For example, in the first week of In each instance, the plant staff in its products. Listeria did surface February, the plant’s environmental took action to destroy the bug. They periodically. When test results from test results showed an increase in the employed a ‘search and destroy’ environmental testing2 identified the number of positive Listeria results from approach - the recognized standard presence of Listeria, plant employees line 7. The problem also occurred procedure - sanitizing all the surfaces took corrective actions such as in March and April when increased where the bacteria could grow on increased sanitation. numbers of positive Listeria test results production lines and throughout At that time, while environmental showed up on line 8, every two to three the building. Every time employees testing for Listeria was not a weeks. During the week of May 19th, intervened, the follow-up test results requirement set out in the CFIA more positive test results appeared on were negative, at least for awhile. This regulations, the company was following the plant’s lines 7 and 8. led to the assumption that the problem With the benefit of hindsight, we now had been solved, creating a false sense 2 Environmental testing: a group of tests used know that this problem persisted over of security. to determine if food contact and non-contact several months before the June 3rd What was missing was the big picture surfaces, such as a slicer, equipment, refrigeration units or ceilings (over production onset of the first case of human illness – recognizing the repeated pattern lines) are Listeria free. Testing is conducted linked to contaminated Maple Leaf of presence of Listeria on the same using a sterile cotton swab or a sponge wiped Foods deli meat products. Positive production lines several weeks after on a selected portion of each pre-determined surface. The swab/sponge is also known as results for Listeria from environmental the problem was presumed to have a sample, and is then tested to see if any been fixed. Although data were being bacteria can be found.
Chapter 5 – What led to the outbreak? 31 Michael McCain collected to note such instances, they were not being analyzed by the plant “It was a failure to analyze test data that we weren’t even obligated to collect – a failure on our part or company headquarters to detect to analyze that data and look for root-cause analysis, investigate and follow-up on individual trends, trends over time. Had such analyses to look for patterns so that we could find the bacteria that we couldn’t see inside these facilities, and been conducted, the re-emergence of end up with a different result. Listeria on a regular basis would have It was more a failure to analyze those findings for a root cause, and a failure of those protocols, become obvious much sooner. than it was a failure of inspection, per se.”
Bartor Road staff treated these »» Michael McCain, President and CEO Maple Leaf Foods Inc. Appearing before the Agriculture occurrences as isolated incidents. SubCommittee on Food Safety, April 20, 2009 Since the positive results were never looked at together, no one identified more frequently found bacteria such as completely apart, thoroughly sanitize the recurring pattern and Listeria Salmonella and E. coli. and then reassemble would have continued to thrive in the plant. We were told that during this period, required shutting down the plant for Because the original source of the Maple Leaf Foods was responding to three days. We also heard that it could bacteria was not recognized and a demand for large packages of deli take considerably less time. treated, the underlying cause of the meats. This market included hotels, contamination was not addressed until restaurants, and institutions, such as POST OUTBREAK REVIEW after the outbreak. long-term care homes and hospitals. Following the outbreak, both Maple Looking back, it becomes more There was a demand for these products Leaf Foods and the Canadian Food apparent why these warning signs in institutions, as they must offer Inspection Agency completed detailed were missed. choices to their residents/patients, and reviews to determine the cause of The new federal food safety deli meat is a popular choice. To meet the Listeria contamination within the procedures, including HACCP, had only this increased demand, the company Bartor Road plant. been mandatory since 2005. Bartor was operating the plant for long hours, Maple Leaf Foods convened a panel Road was one of the first in the country running double shifts. of international food safety experts in to adopt this approach in 1999, Between midnight and the morning late August 2008 to investigate the making it a flagship plant for Maple shift, when the production lines were source of the Listeria bacteria. The Leaf Foods. closed down, sanitation was being Expert Panel identified deficiencies in Although these procedures are performed. the company’s physical, operational, now recommended by the World A further factor is the time required sanitation, environmental, and contact- Health Organization for food safety, to disassemble the meat slicers and point testing. The experts concluded they were and are still relatively new. other production line equipment for that the most probable cause of Both employees’ understanding, and a thorough cleaning and verification. the outbreak was contamination of the actual implementation of this While there was daily sanitation of all deli meat products by commercial approach, was still maturing in the surfaces coming into contact with food, meat slicers used on production spring and summer of 2008. We were a complete cleaning of the entire plant lines 8 and 9 in the plant. The Panel told Listeria was not top of mind for only took place on the weekends and determined that the meat slicers many people working in Bartor Road. not every piece of equipment was fully had meat residue deep inside the At the time, employees were likely dismantled. For example, we heard slicing mechanisms, which provided a more inclined to look for and eliminate that to take the meat slicing machines breeding ground where Listeria could
32 Dr. Bruce Tompkin FOOD SAFETY PRACTICES “Ironically, Listeria is sometimes described as a bug of clean plants because some believe that AT MAPLE LEAF FOODS intense sanitizing kills off the bacteria’s natural predators. This belief, however, has not been Something else that has since been demonstrated to be true and contributes to ineffective Listeria control procedures.” confirmed by Maple Leaf Foods and the »» Dr. Bruce Tompkin, Member of the US National Advisory Committee on Microbiological Criteria for Foods for 10 years and the International Commission Microbiological Specifications for CFIA is that knowledge of the presence Foods for 20 years, Member of the Listeriosis Investigation Expert Advisory Group of Listeria, and their actions to control it, were not disclosed by Maple Leaf grow. Several pieces of equipment, on additional factors that contributed Foods to the CFIA inspection staff including cutters and slicers, were to the contamination. The In-depth (not a regulatory requirement). eventually replaced. Review found that the Maple Leaf Foods The CFIA inspectors did not ask We were informed by the instructions for equipment maintenance specifically for this information and manufacturer that two of the slicers were insufficient. It noted potential plant employees did not volunteer it. were relocated to the Saskatoon cross-contamination as employees Maple Leaf Foods employees notified Maple Leaf Foods plant in late fall moved from one room to another. The their superiors beyond Bartor Road into 2008. This information was confirmed Review also cited structural damage the Head Office, but this information by the CFIA. Before going back to and maintenance issues in rooms where did not reach the office of the Chief production the slicers were completely ready-to-eat meats were handled. As Executive Officer. disassembled, fully sanitized, rebuilt, well, it highlighted several biological, Equally noteworthy the company and verified by the manufacturer for chemical, and physical risks that were had invested in a specific Listeria their new intended use. The slicers are not incorporated into the company’s environmental testing program currently in use to slice “casing” type food safety plan. (environmental results data software, products.3 Extra sanitation measures While there is not conclusive evidence compilation reports, remedial action have been implemented by the operator, that it played any role, it appears that plans), but this was not effectively in addition to having enhanced construction work that took place at the implemented. Staff at the plant level did environmental testing conducted on Bartor Road plant a few months earlier, not look at the overall testing results the equipment both on food contact in the spring of 2008, could have added to identify patterns that might indicate surfaces and non-food ones. to these problems. The construction emerging problems. Further, we were The CFIA also conducted an In- may have exposed the plant to moisture told that corporate quality assurance depth Review using its food safety and could have also allowed Listeria officials did not conduct sporadic spot experts in early September 2008 that to enter the facility, making sanitation checks or undertake trend analyses. corroborated many of the findings of the control more difficult. Listeria thrives in Both Maple Leaf Foods and the Expert Panel. This review shed new light moist conditions. CFIA have since acknowledged that, Taken together, these challenges and if the company had conducted deficiencies meant that opportunities meaningful trend analyses of its test 3 “Casing” type products are various food to prevent Listeria contamination of results and shared these findings with products which are cooked in an envelop (casing) before being sliced (such as mock products at the Maple Leaf plant were the CFIA inspectors, the source of chicken, bologna, pepperoni, salami, and missed. the contamination could have been summer sausage).
Chapter 5 – What led to the outbreak? 33 Michael McCain identified sooner and the sale of unsafe foods may have been prevented. “We [Industry] are the ones who make food. Government should set the rules and provide oversight There was another factor at play that to ensure the rules are being complied with. But, ultimately, safe food depends on the food company, fostered the conditions for Listeria and we have a very material obligation to deliver.” to flourish. As referred to earlier, »» Michael McCain, President and CEO Maple Leaf Foods Inc. Appearing before the Agriculture SubCommittee on Food Safety, April 20, 2009 Maple Leaf Foods was producing larger packages of its ready-to-eat meat products for sale to institutions, food safety procedures to reflect the possibility that vulnerable people could including hospitals and long-term care higher risks associated with lower become ill. facilities whose clientele are at higher sodium levels and larger packages. Maple Leaf Foods has acknowledged risk of infection. It is generally accepted that the a failure in the ‘total food safety The company had created a recipe concept of zero risk is not achievable system’ inside its plants. It has since that uses less sodium, which was in the food processing business, but recognized these problems and has attractive to the institutional market control measures need to be in place increased its environmental testing as many of its clients benefited from to eliminate risks to the greatest program (hold and test). It has also reduced-sodium diets. However, extent possible. introduced new measures to hold all reduced sodium levels in deli meats Although there were no regulatory products until test results indicate that are known to increase the risk for requirements to put products on they are Listeria free. bacteria growth, including Listeria. hold awaiting confirmation that they As well, the company is looking into Hospitals and long-term care homes were Listeria monocytogenes free, other measures to reduce risk including first approached Maple Leaf Foods the company still had an obligation additives, post-packaging high pressure through one of its distributors about to produce safe foods for the treatment and other technologies that producing larger packages of this marketplace. An environmental ‘hold can control Listeria growth. And it is low-sodium product, to serve to their and test’ approach, as recommended considering potential changes to its patients and residents. The company by some experts, could have further product packaging. seized the opportunity to meet the reduced the risks, but was not in place As Maple Leaf Foods has publicly needs of this new market (we were at Bartor Road in the months leading acknowledged, for the hundreds of told from 20 cases a week to 2,000 to the event. consumers who were affected by the to 3,000 cases a week). Since it In the end, contaminated food left contaminated products in 2008, this considered that its practices were Bartor Road. And once contaminated awareness comes late. ‘state-of-the-art’, it did not adapt its packages left the plant, there was a KEY FINDINGS Dr. Brian Evans »»Two comprehensive reviews of the Maple Leaf Foods Bartor Road “In hindsight, it was determined that the company was doing environmental testing. There was plant completed post-outbreak by information being kept at the plant that was not provided at that time to the inspector. We must Maple Leaf Foods International achieve a collective commitment and culture that supports the timely and transparent sharing of Expert Panel and the CFIA’s In- all information, even in the absence of regulatory obligation, to maximize food safety outcomes.” depth Review Audit Team revealed »» Dr. Brian Evans Executive Vice-President, CFIA numerous deficiencies that contributed to the outbreak.
34 »»The food safety focus in Maple Leaf »»Maple Leaf Foods did not conduct »»The corporate approach to food Foods Bartor Road plant, which the trend analysis required under safety needs to evolve from one has since changed, did not place its Listeria control policy. Without of compliance to one of individual a priority on controlling Listeria this analysis, the recurring positive commitment – from the Chief monocytogenes. results were not known nor were Executive Officer to the company »»Maple Leaf Foods’ Bartor Road the positive results verified to janitor. plant was aware that it had determine the presence/absence »»The mandatory Hazard Analysis and occurrences of Listeria in the of Listeria monocytogenes. This Critical Control Point (HACCP) plan plant in 2007 and 2008, and shortcoming, coupled with the is a sound food safety approach for tried to correct the problem with significant demand for these deli meat processing. sanitation procedures standard in meat products from institutions the industry. As a result, the plant’s including hospitals and long-term Recommendations to meat management thought Listeria was care facilities, exposed a vulnerable processors including, but under control. population to unnecessary risk. not limited to, federally »»Employees in the plant were not »»In response to a market registered ones: required nor did they volunteer opportunity, Maple Leaf Foods 1. The CEO and senior management information concerning the produced and sold larger packages of all meat processors should repeated occurrences of Listeria in of its deli meat products, targeted accept oversight responsibility for the plant to the CFIA Inspectors. specifically to institutions such as ensuring that food safety is fully »»Maple Leaf Foods staff notified long-term care homes serving high- embedded in every level of their their superiors of the repeated risk individuals, using a low-sodium business. presence of Listeria beyond Bartor recipe that increased the potential 2. The CEO and senior management Road into the Head Office. However, for Listeria to grow. of all meat processors should this information did not reach the »»Maple Leaf Foods has recognized ensure effective design and office of the Chief Executive Officer the shortcomings of its past actively promote all aspects of because it was thought that the practices in controlling Listeria food safety consistent with their plant’s interventions had controlled and has since taken measures to Food Safety Plan. the problem. reduce the risk of reoccurrence. 3. Food safety plans should be regularly updated to ensure on-going attention to pathogen control. According to experts, environmental testing When such additional tests are being conducted 4. All meat processors should ensure programs should include a step by step experts recommend that products from that that new and existing equipment approach to drill further if environmental specific production line be put on hold until results identify the presence of Listeria. In such these further results are obtained. is and remains appropriate for the situations, further testing is in order to identify intended use. if a plant is dealing with Listeria monocytogenes. If they were to be positive then the food 5. Sanitation methods should be products put on hold should be destroyed. validated and implemented by meat processors in consultation
Chapter 5 – What led to the outbreak? 35 Dr. Randy Huffman which involved approximately 120 “The idea of a ‘food safety culture’ is that every person in the organization should understand their plants, including Maple Leaf Foods on role in producing safe food and the challenge is in the communication of that message.” Bartor Road. »» Dr. Randy Huffman With the introduction of the CVS Chief Food Safety Officer, Maple Leaf Foods June 2, 2009 (which we heard is a more thorough approach), the CFIA inspectors are with the equipment manufacturer, firms comply with federal laws and required to conduct a complete audit with a particular focus on the regulations. The inspections comprise of a plant’s key control systems once intended use and the products an assessment of the company’s within a 24-month period, in addition being processed on each piece of compliance with its regulatory to enhanced daily inspections. equipment. requirements which include its HACCP4 Prior to this new meat inspection 6. To ensure active and transparent plan. The CFIA inspectors are required system, audits were scheduled to be communications, all federally to conduct their inspection activities conducted every three months, but they registered meat processors at registered federal meat plants each did not take place at Maple Leaf Foods should disclose any threat to day. These duties include tasks to be Bartor Road plant at the prescribed food safety occurring in their completed daily, monthly, or annually, frequency in 2005, 2006, or 2007. premises to the CFIA inspectors based on varying levels of risk. In a No audit took place in 2008, and they in a timely manner. Meat food processing ready-to-eat plant, were only conducted three times over processors should not wait for such as Maple Leaf Foods on Bartor this three-year period. requests for information from Road, tasks like verifying the plant’s We heard that the new inspection the CFIA inspectors and should, sanitation program are conducted approach is considered a major in the interests of food safety, monthly. improvement and sufficient to protect ensure that inspectors have all Coincidental to the events that led public safety. But we were told of gaps information they require. to the 2008 outbreak, a new federal in its design and implementation as meat inspection system (Compliance well as in the on-going management 2. THE FEDERAL MEAT Verification System (CVS)) was and delivery of the CVS. These introduced, in the spring of 2008, in deficiencies are noteworthy because INSPECTION SYSTEM the nearly 400 federally registered inspection requirements can only be as DID NOT IDENTIFY meat processing plants across the strong as the regulatory policies and THESE PROBLEMS country. The CVS was implemented to standards against which compliance is streamline and integrate previous CFIA verified. inspection approaches. It was first The gaps can be explained, in large HOW THE SYSTEM introduced as a pilot project in 2005, WAS DESIGNED measure, by the fact that the CVS was developed and implemented without In addition to industry’s food 4 The “Hazard Analysis and Critical Control establishing a detailed business case safety controls and in-house Point (HACCP) places the responsibility on the and in the absence of a rigorous quality assurance processes, the food producer to ensure that the product is safe to be consumed. Proposed by the Codex senior management decision-making Canadian Food Inspection Agency Alimentarius Commission for the food industry process. If senior management conducts inspections at registered in general, and meat, poultry, and seafood had been more engaged, the CFIA food processing plants to ensure industry in particular, it has been adopted by some 150 countries. executives might have recognized
36 Something we heard during our interviews that the new inspection system was being implemented without a detailed It will always be a scenario where we have to improve the CVS … what is nice about it is the flexibility assessment of the resources available … the only challenge we have is to make sure everybody is trained. to take on these new tasks, relative to those needed to apply the new These disparities included the policy required to fully implement it, inspection approach. Senior executives requirement to monitor the plant’s was not undertaken by the CVS might also have recognized that the pathogen practices, including Listeria development team. Although training Manual of Procedures for the meat controls. The CVS, as developed, did for the implementation of the CVS was inspection program needed updating. not include a clear task for inspectors developed, it was not fully delivered. Furthermore, the decision to to verify a company’s Listeria There was no formal assessment of the proceed directly from the pilot to full environmental controls. We also need for change management support. implementation was made with limited learned that the CVS was designed to It was also revealed that, since the CVS evaluation of the pilot’s strengths take into account the particularities of combined previously implemented food and weaknesses and without detailed each plant’s safety provisions contained safety approaches, in-depth validation costing and adequate determination in its HACCP plan, but this appears to and evaluation steps were not deemed of resources implications, including have been lost in implementation. necessary. the need for supervision and training. As another example, the CVS required We heard varying views on the level We were told that an evaluation of the inspectors to take on different and and adequacy of resourcing available to CVS pilot was prepared but was not expanded roles, especially in the area deliver this system. discussed throughout the CFIA hierarchy. of inspecting the plants’ food safety A number of sources said that the We heard that, because these controls. This change required an lack of staff was a major constraint as essential steps were not taken, gaps evaluation of the tasks being assigned was the pressure of time. The system’s between the Meat Hygiene Manual of and the competencies of the people design did not take account of the Procedures – the regulatory framework who would be carrying them out. number of inspectors or the time – and the CVS were never identified and, We learned that an assessment available to conduct the CVS tasks therefore, not resolved. of competencies needed to deliver because of their other duties, nor did the CVS, as well as the resources it take into account travel time from plant to plant. Inspectors assigned Comparing Sectors to Bartor Road were also responsible for several different plants in their The CFIA’s Quality Management Program This approach is based on research indicating district, necessitating travel between governing fish processing facilities requires that, when full inspections are conducted at these companies daily. Without full frequent audits of plants. intervals of eight months or more, operating consideration of all these factors, it standards tend to slip. was not possible to adequately assess A full review of a company’s operations is the resource levels required to properly undertaken every six months and more often conduct the full range of activities if needed. assigned to inspectors.
Chapter 5 – What led to the outbreak? 37 HOW IT WORKED its test results to the CFIA. Equally The in-depth reviews of the Bartor Road IN PRACTICE notable, the CFIA inspectors had no plant identified a variety of structural At the time that Listeria problems obligation to request or examine the deficiencies that required correction. were starting to surface at the Bartor company’s Listeria testing results Many of these problems were not Road plant, inspectors were following under their CVS tasks. Had the identified prior to the outbreak, despite their CVS work plans and doing the CFIA inspectors reviewed these test daily inspections by Maple Leaf Foods’ prescribed activities and their other results they could have identified the quality assurance team and third party frequency of positive Listeria results auditors, as well as CFIA inspectors. duties (e.g. export certification) as well as travelling between plants. and brought this concern to the For example, the day shift inspector attention of the plant management. Other potential factors contributing We were also told that supervision, had seven different plants to cover to the outbreak were the general belief support, and oversight of inspectors (including cold storage facilities that both Maple Leaf Foods’ food were not adapted to the CVS. Further, for export purposes). We heard that safety system and the CFIA’s inspection it was reported that supervisors inspectors’ workloads left them limited system were reliable, and that the received minimal training to time to accomplish their tasks in Bartor Road plant needed minimal prepare them for their additional depth. What’s more the inspectors oversight since it had historically not responsibilities. may have missed early warning signs presented cause for concern. In addition, we heard that a due largely to the nature of their tasks, The issues identified during the ‘curiosity’ factor was not always present insufficient training and understanding two post-outbreak reviews conducted in inspectors – understanding the of the new procedures and the by the Maple Leaf Foods panel of difference between what is needed and supervision they received. independent experts and the CFIA’s what is important. Inspectors were In addition, the inspectors were not In-depth Review Audit Team pointed to not expressly encouraged to use their scheduled to visit the plant between deficiencies in the inspection system. judgment, based on their education operating shifts when sanitation was and experience, or to follow up if taking place to observe whether the something struck them as unusual. plant’s sanitation team completely KEY FINDINGS Some inspectors welcomed the CVS dismantled the equipment or to »»The new federal inspection given that their workloads did not witness the company’s quality system (CVS) was put into permit meat inspection tasks to be assurance officers taking environmental effect in the spring of 2008 at completed thoroughly. They indicated samples. In the case of Bartor Road, the same time that Maple Leaf there was not enough time to take on these activities often occurred in the Foods’ environmental testing was extra food safety inspection duties middle of the night, as the company identifying Listeria at the Bartor outside of their required tasks. Others was operating two shifts. This schedule Road plant. welcomed the very prescriptive nature reduced the potential that inspectors »»Insufficient consideration was of the CVS as they only had to follow would pick up on possible problems. given to the effect that the CVS the instructions they were given. More significantly, the Bartor would have on the ability of the Road plant’s HACCP plan required inspectors to perform their tasks. environmental Listeria testing but the »»Although the CVS is regarded company was not obliged to report as a sound system and has
38 broad support, it needs critical supervision of inspectors, as well with modern technology improvements related to its design, as oversight and performance (e.g. e-note pad) to increase planning and implementation. monitoring. their efficiency. »»Training necessary to implement 10. The Canadian Food Inspection the new CVS system was developed Recommendations Agency should amend its meat but not fully delivered and lacked 7. To accurately determine the inspection system (CVS) to ensure: change management support. demand on its inspection a. the appropriate human »»The lack of its adaptation to resources and the number resources are available the specific risks of each plant of required inspectors, the to respond to workload weakened the implementation of Canadian Food Inspection requirements; the CVS. Agency should retain third-party b. comprehensive training »»Under the CVS, the CFIA inspectors experts to conduct a resources based on required were not required to fully examine audit. The experts should also competencies and skills; key food safety controls (e.g. recommend required changes and c. timely delivery of ongoing sanitation program) or to verify implementation strategies. The training; and how the company was reviewing its audit should include analysis as d. supervision of inspection environmental testing results. to how many plants an inspector staff structured to encourage »»In the lead-up to the outbreak, should be responsible for and the enterprise and accountability. the number, capacity and training appropriateness of rotation of of inspectors assigned to Bartor inspectors. 3. THERE WERE GAPS Road appear to have been stressed 8. The Canadian Food Inspection due to their responsibilities at Agency should ensure that IN THE FEDERAL RULES other plants, the complexity of inspectors receive timely education GOVERNING MEAT Bartor Road including its size and and training specific to each PRODUCTION AND hours of operation, and necessary function they perform. This adjustments required by the education should be based on INSPECTION implementation of the CVS. an assessment of the additional Maple Leaf Foods has stated that it »»Due to the lack of detailed training required to address gaps was meeting all federal legislative and information and differing views in the knowledge and abilities of regulatory obligations at the time of the heard, we were unable to determine inspection staff. Inspectors should outbreak. Even so, there were gaps in the current level of resources regularly receive a mandatory the regulatory framework that allowed as well as the resources needed program on current trends in this outbreak to happen. to conduct the CVS activities science and technology in the As noted previously, the federal food effectively. For the same reason, processing of food, including safety framework is the responsibility of we were also unable to come compliance and verification Health Canada and the Canadian Food to a conclusion concerning the processes. Inspection Agency. The two organizations adequacy of the program design 9. The Canadian Food Inspection have interdependent roles: Health implementation plan, training and Agency should equip its inspectors Canada is responsible for the Listeria
Chapter 5 – What led to the outbreak? 39 monocytogenes Policy; which is In the case of Maple Leaf Foods this Recommendation complemented by the CFIA Meat Policy was followed and even exceeded, 11. Health Canada should complete Hygiene Manual of Procedures, at the time Listeria was detected at the the revision of its 2004 Listeria which includes the CFIA testing Bartor Road plant. However, the Policy Policy, by no later than March program (i.e. equivalent to its internal measures were insufficient to address 2010, and ensure that: instructions to inspectors). the underlying source of contamination a. the Policy outlines clearly and (e.g. the slicing equipment where the concisely the expected results bacterium was harboured). for all identified food products HEALTH CANADA The Policy offers no concrete advice where Listeria is a potential on how industry should prevent threat to human health, Listeria monocytogenes Listeria contamination or how to consistent with international Policy meet the standards it sets, including standards; When Health Canada’s Listeria environmental testing requirements. b. risk categories of ready-to-eat monocytogenes Policy was first There is also no recognition that product are retained, although published in 2004, it put Canada at “harbourage sites,” such as slicers, they should be more clearly the forefront of food safety policy. make it harder to identify and find defined; However, we learned that, even though Listeria. c. post-processing measures that it is only a few years old, it has not kept The Policy references “trend analysis” control Listeria monocytogenes pace with rapid advances in science, but does not describe what is meant are considered when knowledge and technologies. by the term nor does it offer advice determining product risk The Policy sets the standards on what outcomes or results are to be categories; and, for the acceptable level of Listeria achieved by such analyses. d. it focuses only on the safety monocytogenes in ready-to-eat of foods (i.e. should be a food products and provides guidance KEY FINDINGs safety standard) and not on to food processors and the CFIA »»The current Health Canada Listeria providing risk management inspectors about managing the risks monocytogenes Policy does not direction to the food industry of Listeria. If the bacterium is found provide adequate direction on or the Canadian Food on a company’s equipment, the Policy expected outcomes leaving room Inspection Agency. indicates that the contaminated area for interpretation by industry. is to be cleaned and to be retested. »»The lack of integration between Food additives If these results come back negative, Health Canada and CFIA policies and technologies the company can continue to produce created gaps and overlap that led As indicated in the previous chapter, and ship its food products. to confusion. Health Canada is also responsible for the approval of additives for use in foods to control or destroy pathogens. Something we heard during our interviews In addition, it approves many other The Policy should have stipulated what the outcomes of controlling Listeria should be – ensuring substances and chemicals used during the bacterium is monitored and that all possible measures are taken to control and prevent it from food processing and manufacture contaminating food products. including food enzymes (e.g.: used in
40 cheese production), colouring agents, Recommendation The American Meat Institute has gelling agents, and fining agents. 12. Health Canada should review its developed stringent specifications We learned that some food additives approval processes and fast track, for the design of slicers and other and technologies, which had been where appropriate, new food equipment, which it identifies as approved in other countries and could additives and technologies that “10 principles of sanitary design.” have reduced the risks associated have the potential to contribute The Institute confirms that equipment with Listeria, had been waiting for to food safety giving particular sanitary design and operation are Health Canada approval for several attention to those that have critical to the control of Listeria years. We were told that a backlog had been scientifically validated in contamination in ready-to-eat meat and built up and that each new product other jurisdictions (provinces or poultry processing plants. The American brought forward for approval was being countries). Meat Institute believes that the sanitary considered on a ‘first come, first served’ design of equipment can be achieved basis. Even if these products had been DESIGN OF FOOD “through a non-competitive and approved, Maple Leaf Foods would not PROCESSING EQUIPMENT cooperative effort between customers have been obligated to include them in Food processing plants use a vast and suppliers.” However, their their recipes or processes. array of tools and equipment on their specifications do not address peer-level production lines, including slicers and review of the design, operation and KEY FINDING conveyors. This equipment, particularly recommended sanitation methods for »»In approving food additives and in ready-to-eat plants, needs to be food processing equipment. technologies, Health Canada has frequently cleaned and sanitized to not been taking into account produce safe foods. For this reason, KEY FINDING food safety considerations when its design must accommodate hygiene »»Increased coordination and assigning priorities for approval of considerations. improved communication about these substances and processes. Maple Leaf Foods’ International food processing equipment is Expert Panel concluded that the needed among the manufacturer, most likely origin (root source) of the the food processor and the CFIA contamination of deli meat products regarding design specifications was deep inside a commercial meat and the validation of sanitation slicer. The company has reported procedures. that to disassemble the meat slicing machines, thoroughly sanitize and then Recommendations Suggestion reassemble them, necessitated shutting 13. Manufacturers of food processing down the plant for three days. Their equipment should ensure that their “The government should consider allowing specifications and instructions the use of bacteriophages, food additives conclusions are suggestive of design to kill Listeria, for ready-to-eat meats.” problems, which made regular cleaning to users specifically emphasize of the commercial slicers both difficult the necessity to control the risk »» A suggestion by a family affected by the outbreak and costly for the food processor. of pathogens, including Listeria monocytogenes.
Chapter 5 – What led to the outbreak? 41 Jim Laws products identified by the standards in “Listeria control is about good plant hygiene and good manufacturing practices. But it is also about the Health Canada Policy. equipment and building design.” In 2005, the CFIA updated its testing
»» Jim Laws, CEO, Canadian Meat Council program, eliminating the obligation of inspectors to conduct environmental monitoring for Listeria on food contact 14. In addition, manufacturers of food monocytogenes. The manual, which surfaces in plants. This was done, at least processing equipment should is complemented by directives and in part, to better align and maintain accept responsibility for the guidelines, is the main document equivalency with newly instituted foreseeable impact of the design guiding the CFIA inspectors and requirements from the US Department of and operation of their equipment operators of meat processing plants Agriculture. Canadian food processors on food safety. The design and for the production of safe food. need to match US requirements in order operation of, and recommended The manual is not reviewed on a to continue exporting their products to sanitation methods for all food routine basis and at the time of the this important market. processing equipment should: outbreak, was out-of date. Aside from a. enable thorough cleaning and being out of date, it is prescriptive KEY FINDINGS disinfection; in its approach. In an effort to be »»The latest CFIA Listeria directive b. allow for efficient and complete complete, the manual provides very does not distinguish between disassembly and reassembly generic information in most cases so foods at much lower risk of when required; food processors do not have a clear harbouring Listeria (e.g. dried and c. eliminate to the fullest extent indication of what outcomes they frozen meats) and those that are possible all areas likely to should be working toward or how to much higher risk (e.g. deli meats, harbour pathogens, including control Listeria monocytogenes. In fact, hot-dogs, soft cheeses). Listeria monocytogenes; although plants were expected to control »»Out-of-date manuals and policies d. wherever possible, use material pathogens, the manual offered no contributed to a weakened that is scientifically validated practical information on how to sample government oversight. to limit pathogen growth or and test, what to test or which bacteria survival; and should be tested. The lack of precise Recommendations e. be peer-reviewed (applicable detail in the instructions left too much 15. The Canadian Food Inspection only for the recommended room for interpretation, allowing almost Agency, in conjunction with and sanitation methods). any action to meet the written rule in conformity to the proposed without achieving the outcome sought. revisions to Health Canada’s THE CFIA’S MEAT HYGIENE The Health Canada Listeria Listeria Policy, should strengthen MANUAL OF PROCEDURES monocytogenes Policy is complemented its February 2009 Listeria controls The federal Meat Inspection Act by the CFIA testing program, which is found in the Meat Hygiene Manual provides the authority for the Meat equivalent to the internal instructions of Procedures to focus on control Hygiene Manual of Procedures to inspectors. The testing program measures for Listeria in ready- (which is equivalent to a regulation). sets out the operational requirements to-eat meat products, in addition The manual requires food processors for inspectors to monitor the safety of to the current environmental and to control pathogens such as Listeria product testing:
42 Comparison of Canada vs. US Listeria Rules (select) each plant based on risk factors Listeriosis outbreaks in the United States from such as sodium lactate, that are proven to including compliance history, 1998 to 2002 resulted in 100 illnesses and 21 reduce the risks of foodborne illnesses. product risks and target market deaths. In response, the U.S. Drug Administration (i.e. higher sampling frequency in (USDA) changed its rules governing Listeria Health Canada’s policy, although amended in some plants, lower in others.) monocytogenes to include approval for additives, 2004, did not include these improvements. 17. The Canadian Food Inspection Agency should review and update a. to ensure that any required ii. if the follow-up tests are existing food safety programs, testing is a verification step to positive, then testing for regulations and directives to confirm the effectiveness of Listeria monocytogenes must best reflect current food safety the company’s Listeria control occur in products from the practices. program and not a control production line of concern5. 18. The Canadian Food Inspection program in itself; During this testing phase, all Agency should update its b. by differentiating the testing products produced on that Food Safety Enhancement requirements to reflect the risk line and day (i.e. between two Program Manual to require food associated with each product (i.e. complete sanitation shifts) processors to include all standard more testing for high-risk products should be withheld from the operating procedures and good and less for low-risk ones); marketplace until the results manufacturing practices in their c. by requiring the testing of non- are known; food safety plan. food contact surfaces in the e. by further defining expectations 19. The Canadian Food Inspection processing environment; of trend analysis to identify Agency should ensure that d. by establishing ‘hold and test’ weaknesses in the company’s the Meat Hygiene Manual of product control requirements control programs (including its Procedures is updated whenever following positive test results for HACCP plan) by determining if there is a significant change to Listeria on food contact surfaces a pattern of contamination is the practices imposed on industry. as follows: emerging. 20. The Canadian Food Inspection i. several tests for Listeria on 16. The Canadian Food Inspection Agency should formally food contact surfaces should Agency should revise its communicate its expectation be conducted immediately on monitoring programs (M-200 that registered meat processors and around the area where and M-205 plans), by tailoring will bring all information with positive results were found to the sampling frequencies to potential consequences for food determine: safety to the attention of their »»if there is persistent assigned inspector in a timely manner. contamination, or 5 The testing requirements (e.g. number of tests) »»if the previous positives should be based on an authoritative source have already been dealt such as the International Commission on Microbiological Specifications for Food and with using standard should be consistent with the Health Canada’s sanitation procedures; Listeria Policy.
Chapter 5 – What led to the outbreak? 43 practices aimed at vulnerable prevent and control infectious and 4. ONCE CONTAMINATED populations, including those most chronic diseases, and injuries, and PRODUCTS ENTERED vulnerable to listeriosis (such promote health.6 THE FOOD SUPPLY, as the practices set out in the Nevertheless, as a growing number of British Columbia Guideline for people started to get seriously ill in the INSTITUTIONS SERVED Food Services or in guidelines summer of 2008, weaknesses in the IT TO VULNERABLE issued by the other provinces system became apparent. and territories.) As it became increasingly clear that POPULATIONS this was likely a foodborne emergency7 Another, quite reasonable assumption 5. AS CONTAMINATED and people were treated, the public at the time of the outbreak was the health sector gradually responded but general belief that ‘ready-to-eat’ FOOD WAS BEING there were delays in mobilizing a full meats, such as deli meats, are safe CONSUMED, THE PUBLIC response. With the benefit of hindsight, to eat without the need for additional HEALTH SYSTEM SLOWLY the reasons for the gradual response preparation or precaution. are more evident. While true for the most part, in RECOGNIZED THE First, listeriosis is both less common the case of vulnerable populations, OUTBREAK than other foodborne illnesses and contamination with Listeria more difficult to diagnose, so it was not In recent years, Canada, and indeed monocytogenes can have serious immediately obvious that an outbreak the world, has been confronted with consequences. Of the 57 eventual was emerging. When isolated cases wave after wave of health crises. confirmed cases of listeriosis during of listeriosis are detected, they are From SARS and West Nile virus, to this outbreak, 54 of the individuals generally dealt with at the local level. mad cow disease, the listeriosis who became ill were elderly people in This is normal, and a small number outbreak and the H1N1 virus, we have hospitals and long-term care homes. of cases does not immediately trigger been reminded of the threats such The operators of these facilities served suspicion or provoke an emergency infections pose to our health. Canadian the ready-to-eat food products – response. There are routinely five to governments, industry, and citizens working from the assumption, based on six such cases reported each month in have strived to protect themselves from years of experience, that the products Ontario. It was only when clusters of these threats. were nutritious, easy to chew and safe listeriosis cases became apparent in The Public Health Agency of Canada – without taking extra precautions or different communities across Ontario was created in 2004 in response to avoiding serving them to vulnerable that there was increased action at SARS and the growing recognition populations. the provincial and, eventually, the that we need to better anticipate and national level. Recommendation plan for health emergencies and be better coordinated in our responses 21. Organizations providing housing when they arise. The Agency has a 6 and/or food services to seniors Public Health Agency of Canada, About the mandate to prepare for and respond to Agency: Who We Are; What We Do, online and other vulnerable groups, public health emergencies, strengthen http://www.phac-aspc.gc.ca/about_apropos/ including long-term care index-eng.php Canada’s capacity to protect and 7 homes and hospitals, should be A foodborne emergency occurs when improve the health of Canadians, people are becoming ill from a common encouraged to adopt food safety contaminated food source.
44 Ontario’s iPHIS and EARS Ontario had instituted new disease ➤➤ In 2005, Ontario developed and put into ➤➤ The Public Health Division (of Ontario’s detection and prevention measures place a web-based system: integrated Ministry of Health and Long-Term Care) in its public health system. The Public Health Information System (iPHIS). monitors and analyzes the iPHIS data daily improvements included iPHIS – supported by a program called Early ➤➤ All 36 public health units in Ontario are (integrated Public Health Information Aberration Reporting System (EARS). legally obligated to enter case information System), a web-based system used on all notifiable diseases (including ➤➤ EARS detects statistical increases in the by all public health units to report listeriosis) into iPHIS. number of cases above the norm and infectious, communicable and therefore can help Public Health Division foodborne diseases, and EARS officials detect an outbreak. (Early Aberration Reporting System), which detects increases in cases to The next challenge faced by the A further factor is that, traditionally, identify an outbreak when the number public health sector was determining foodborne illness outbreaks were traced exceeds the norm. which food was causing the illness and to locally produced and distributed We were told that the new system was establishing the source of this food. food products. This is less and less the better than what existed before but that Most foodborne illnesses are caused by case in today’s world of globalization it was not as effective as public health contamination of food while it is being and large scale food production. So officials believed at the time. iPHIS and handled or prepared. in the first few days, the public health EARS were not yet fully developed nor With this understanding, Toronto inspectors did not immediately suspect completely implemented, particularly Public Health inspectors used a a nationally distributed food product. for monitoring foodborne illness. Public standard investigative approach in health units were required to upload investigating the initial listeriosis cases. HOW THE PUBLIC HEALTH notifiable disease data into iPHIS but This included determining the likelihood SURVEILLANCE SYSTEM we heard that local resources were of food handling contamination at the WORKED IN PRACTICE not readily available to input all the institution and through testing of food, There is a patchwork of disease information on a timely basis. a determination of how the pathogen reporting and recording procedures Delays in entering local data, coupled found its way into the kitchen. In this used across the country. The approach with incomplete records, held up the instance, with two illnesses from the varies from one jurisdiction to the epidemiological investigation at the same Toronto area long-term care home, next. For example, in British Columbia provincial level. These investigations are and with no other illnesses yet linked, physicians were not required to report vital to assess the risks to the general the public health inspectors’ focus was listeriosis cases. These differences do population or to identify specific groups primarily on the possibility of cross- not matter when an illness is confined at increased risk. contamination resulting from the way to one province but, as soon as it jumps Also problematic, the early warning food was handled in the kitchen, and borders, these variations matter. system was not as helpful as intended secondarily on where the food might An additional factor was that Ontario because local public health units only have been manufactured. had recently changed its surveillance had access to the data of their district system. In the aftermath of SARS, but could not access the data of the
Chapter 5 – What led to the outbreak? 45 other 35 Ontario public health units Health requested that they enter and therefore could not see the spread listeriosis cases into the system on of disease across the province. At the an urgent basis. time of the outbreak, the data was only »»In the 2008 outbreak, the Ontario available to some sections within the surveillance systems helped detect Ontario Ministry, and the information the Ontario-wide outbreak; without received was not complete. these systems, the outbreak While the reasons are numerous and, would have been detected later in retrospect, understandable, the fact – possibly after more vulnerable remains that the data on the listeriosis people became ill. cases that began to appear in July of »»The approach to gathering food 2008 was not entered immediately into samples by local public health iPHIS by many local public health units. staff at the long-term care home As a result, the Ontario Ministry did not was geared towards identifying have all the information it needed to a local source for the outbreak assess the ‘bigger picture’. Without all (e.g. cross contamination in the necessary facts at hand, officials the kitchen); this delayed did not fully understand the level of identification of the commercial contamination in the food supply and food source. thus were unable to issue early health advisories to institutions caring for Recommendation vulnerable populations or the general 22. The federal, provincial and public until the outbreak was well territorial governments should advanced. continue to use and support surveillance and monitoring KEY FINDINGS systems, such as the Canadian »»The pattern of isolated cases Integrated Outbreak Surveillance occurring in different public Centre (CIOSC), and consider the health units across Ontario, over a development of next generation number of weeks, meant that the systems (e.g. Panorama). small increase in cases was hard to identify. »»Early in the outbreak, there were NEXT CHAPTER delays in some local public health units to enter case information “The chain of events that led to the initial into Ontario’s surveillance identification of the outbreak and the system; this improved over the eventual recall of contaminated meats course of the outbreak when the produced by Maple Leaf Foods is not easily Ontario Chief Medical Officer of or succinctly explained…”
46 CHAPTER 6 How did events actually unfold?
How did events actually unfold? The chain of events that led to the initial identification of the outbreak and the eventual recall of contaminated meats produced by Maple Leaf Foods is not easily or succinctly explained.
A foodborne emergency is complex because of the multiple sectors involved and the way Canada’s health and food safety systems work.
Three levels of government have different roles to play in such incidents. Within the federal government alone, there are three different organizations, each with unique mandates and functions.
47 In addition, both the health and food of this outbreak became ill in the first the 2008 listeriosis outbreak, explaining safety systems are science based and week of June. Therefore, contaminated the decisions and actions of government. depend on sophisticated methodologies Maple Leaf Foods products were on the A detailed chronology listing all of the and technologies. market and being consumed before events can be found in Appendix B. Taken together, the reasons why it took that time. several weeks to confirm the source of The problem was not picked up by the the outbreak and to stop the distribution surveillance systems designed to identify of contaminated food became clearer. foodborne outbreaks until later, due in In hindsight, we recognize that the first part to the long incubation period. This person who developed listeriosis as part chapter highlights the key milestones in
WHAT HAPPENED HOW IT HAPPENED July 2008 »»First 2 listeriosis cases (later identified We now know that the pivotal factors concerning this event began to unfold as part of the outbreak through DNA around Thursday July 10th, when the Public Health Agency of Canada’s fingerprinting) National Microbiology Lab1– the national reference laboratory for human biological testing – received two Listeria specimens for DNA fingerprinting of the pathogen. These samples were taken from the first two Ontario patients diagnosed with listeriosis by their treating physicians; both would later be associated with the outbreak. We know these patients were from Ontario but the specimens did not have detailed information that would identify them when they reached the reference lab. »»Two cases of listeriosis diagnosed in 2 A few days later, two residents of a Toronto area long-term care home residents of the same Toronto area long- became seriously ill. Based on lab results, the attending physicians term care home diagnosed listeriosis. The original blood tests in these two cases were done by a private laboratory which didn’t retain or forward the samples for further testing. This made it impossible later in the investigation to confirm the strain of Listeria that affected these two individuals. Nonetheless, their treating physician reported to Toronto Public Health, his concern that there were two cases of listeriosis involving residents living in the same home.
Wednesday, July 16th »»Toronto Public Health inspectors began With this information, Toronto Public Health investigated the Toronto area investigating two cases of listeriosis in the long-term care home where the two residents lived, to try to find the cause Toronto area long-term care home of their illness. Public health inspectors conducted their investigation considering a potential food handling problem in the kitchen.
1 National Microbiology Laboratory in Winnipeg
48 WHAT HAPPENED HOW IT HAPPENED Friday, July 18th »»Match confirmed on DNA fingerprinting PHAC’s National Microbiology Lab confirmed that the two human listeriosis from first two human samples samples received from Ontario on July 10th had matching DNA fingerprints, which meant the two cases were linked. MONday, July 21st »»Toronto Public Health inspectors picked Toronto Public Health went back to the Toronto area long-term care home up food samples from a Toronto area long- to collect 11 food products (e.g. sandwiches and cheeses) from samples term care home. of meals previously prepared and served at the home (Institutions such as long- term care homes are not required to keep such samples under provincial regulations). When the samples were collected, the name of the food supplier and product identification information such as ‘best before’ dates were not available or recorded. Tuesday, July 22nd »»No cases appear on Ontario’s surveillance The Ontario Ministry checked its surveillance system to see if an unusual system number of listeriosis cases had been reported from long-term care homes. As not all of the data had been loaded into the surveillance system, the answer came back ‘no’. »»11 food samples received by The Ontario Ministry received 11 food samples from Toronto Public Health Ontario Ministry from the investigation launched July 16th. Wednesday, July 23rd »»11 food samples now sent to Reference The Ontario Ministry sent the 11 food samples to Health Canada’s National Laboratory in Ottawa as routine samples Reference Lab in Ottawa, the national reference laboratory for food testing. These food samples were identified as ‘routine’ with the main symptom noted as ‘fever’ rather than indicating a death linked to a food safety investigation. »»Long-term care home operator withdraws Toronto area long-term care operator stopped serving, at all of their high risk food products facilities, all foods that could potentially pose a Listeria health risk to its residents, including cold cuts, cheeses and ice cream. Friday, July 25th »»Increased cases now detected on the The Ontario Ministry began to detect an increase in the number of cases of provincial surveillance system listeriosis, which were now reported on the provincial surveillance system.
Chapter 6 – How did events actually unfold? 49 WHAT HAPPENED HOW IT HAPPENED FEDERAL MONITORING OF THE EVENT BEGINS Tuesday, July 29th »»Ontario notifies Public Health Agency The Ontario Ministry concluded that a cluster of illnesses was emerging, of Canada that clusters of cases are although it had limited information on the precise food product that was emerging in the province the source of the disease. »»Alert posted on the federal With this pattern detected, the Ministry notified its federal counterpart, the surveillance system Public Health Agency of Canada (PHAC), and posted an alert on the national surveillance system. This alert was accessible to all provinces and territories, Health Canada, and the CFIA. Wednesday, July 30th »»Conference call with Ontario and the Following the national surveillance system alert, a conference call was Public Health Agency of Canada to initiated by the Ontario Ministry that included 15 of Ontario’s 36 public discuss reporting and routing of lab health units, PHAC, and Health Canada. It was decided that, for all existing samples cases or new cases identified, each local health unit would submit human »»Enhanced surveillance alert issued to all samples to the PHAC’s National Microbiology Lab and food samples to Ontario public health units by Ontario Health Canada’s National Reference Lab via the Ontario Ministry public Ministry health laboratory. These samples would be collected by the Ontario Ministry and forwarded to the federal labs. It was also agreed that the Ministry would issue an Enhanced Surveillance Directive to all Ontario public health units, requesting additional and timely reporting of listeriosis cases through the provincial surveillance system as well as providing the information regarding where the human and food samples were to be sent. Monday, August 4th »»Three of 11 food samples from the The results of the 11 food samples collected from the Toronto area long- Toronto area long-term care home test term care home on July 21st and tested by Health Canada’s National positive for Listeria monocytogenes Reference Lab were emailed to the Ontario Ministry. Three of the 11 food samples were positive for Listeria monocytogenes. Since the samples came from a Toronto institution, the Ontario Ministry informed it of the results.
50 WHAT HAPPENED HOW IT HAPPENED FEDERAL INVOLVEMENT IN THE EVENT BEGINS Wednesday, August 6th »»Toronto area long-term care home The Toronto area long-term care home management suspected that its two suspects Maple Leaf Foods products to residents had contracted listeriosis from eating sandwiches made with deli be the source of listeriosis meats produced at the Maple Leaf Foods Bartor Road plant. The staff shared this information with the Ontario Ministry of Health and Long-term Care.. »»Help requested from CFIA Toronto Public Health requested the Canadian Food Inspection Agency’s assistance. Thursday, August 7th »»CFIA initiates a food safety investigation The CFIA initiated a food safety investigation on the extent and source of the potential food hazard. It received confirmation from Toronto Public Health that Maple Leaf Foods deli meats used in sandwiches taken from the long- term care home tested positive for Listeria monocytogenes. Friday, August 8th »»CFIA conducts document review but no The CFIA conducted a document review at Maple Leaf Foods Bartor irregularities are reported Road plant to determine if the facility was following its food safety plan. No anomalies were noted or reported. »»CFIA requests deli meats distribution Late in the day, the CFIA requested distribution records for deli meats. records Maple Leaf Foods’ Sales Office, which keeps these records, was closed for the weekend. Monday, August 11th »»Distribution records received from Maple The CFIA received product distribution records from Maple Leaf Foods that Leaf Foods included product codes and ‘best before’ dates for products that were used at the Toronto long term care home in July. These Sure Slice brand products were mainly sold to institutions, such as hospitals, long term care homes, prisons, restaurants and hotels.
Chapter 6 – How did events actually unfold? 51 WHAT HAPPENED HOW IT HAPPENED »»Search begins for unopened food Maple Leaf Foods’ three largest distributors were contacted, but they had no packages to verify the source remaining products matching the specific codes and dates in their inventory. The CFIA broadened its search of suspected products to include other long- term care homes in an attempt to locate any unopened-packages2 of the product in their inventory. HOW GOVERNMENTS RESPONDED Tuesday, August 12th »»DNA fingerprint matches cases from The PHAC’s National Microbiology Lab confirmed that DNA fingerprinting several provinces patterns on human cases from Ontario matched cases from other provinces, »»This was the first indication that a including Newfoundland & Labrador and Quebec. national outbreak might be developing Concurrently, Quebec was beginning to deal with another listeriosis outbreak (of a different DNA fingerprint), this time traced to cheese, which resulted in 38 illnesses and two deaths (plus 3 babies who died at birth or shortly after). »»Halton long-term care homes advised Based on the available information, the Halton Region Health Department to discontinue serving deli meats to issued a precautionary advisory to long-term care homes in its region. residents It notified them that Maple Leaf Foods deli meat products were potentially contaminated and recommended they suspend serving these products to their residents. »»Unopened package of suspected meat Meanwhile, the CFIA located an unopened package of the suspected Maple located and sent for testing to confirm Leaf Foods meat for testing. The package came from another long-term care source home affiliated with the home where the early listeriosis cases were first observed. These unopened food packages were sent to the CFIA’s Toronto lab for testing. The CFIA continued to look for samples in long-term care homes and among other clients.
2 Meat from unopened packages was sought to provide conclusive evidence that these products were the source of the listeriosis outbreak, which is standard recall procedure.
52 WHAT HAPPENED HOW IT HAPPENED »»Two cases appeared in a Burlington The CFIA was also notified by the Halton Region Health Department of two hospital but were not initially connected additional listeriosis cases at a hospital in Burlington. However, there was to Maple Leaf Food products conflicting information initially about these cases. The CFIA was told that two (were later linked) samples of Maple Leaf Foods deli meats served at the hospital had tested positive for Listeria monocytogenes, but it was first reported that the two patients had not consumed the suspected deli meats. Later, it was confirmed that the two patients did, in fact, eat the contaminated meat while in the hospital. Testing confirmed that their illnesses were linked to the outbreak. »»A possible link is found between cases at As was the case with the Toronto area long-term term home, food samples the Burlington hospital and the long-term taken from the Burlington hospital did not include product code information. care home Since product test results from the two institutions could not be linked initially, a separate food safety investigation was initiated by the CFIA. In the course of this new investigation, the CFIA was informed by one of Maple Leaf Foods’ distributors of a possible connection between the two institutions. The distributor had delivered deli meats to the Burlington hospital with the same suspected codes as those being investigated at the Toronto area long- term care home. Wednesday, August 13th »»Maple Leaf Foods advises its distributors Maple Leaf Foods sent a letter to its distributors informing them that the to hold certain Sure Slice products Canadian Food Inspection Agency was investigating illnesses that could be related to its products. It advised distributors to place on hold any remaining inventory of Sure Slice Roast Beef, Corned Beef and Black Forest Ham. »»The CFIA initiates a conference call to The CFIA organized a teleconference involving the Public Health Agency exchange information of Canada, Health Canada, the Ontario Ministry of Health and Long-Term Care and Ontario public health units to update and exchange information. It was learned that listeriosis cases had now been identified in Simcoe, Peterborough and Etobicoke. It was also discussed that Maple Leaf Foods products could be the possible source of the outbreak.
Chapter 6 – How did events actually unfold? 53 WHAT HAPPENED HOW IT HAPPENED »»Ontario public health units conduct a Ontario Public health units agreed to support the CFIA by undertaking a food sampling blitz large scale sampling ‘blitz’ to cover all Sure Slice brand products with ‘best before’ dates from August 1 to September 30, 2008 of products that were likely to be still in the marketplace produced on two suspected production lines at Maple Leaf Foods Bartor Road plant. »»Decision made that more information The conference call concluded that more precise information regarding needed prior to recall human health hazard and exposure was needed before the CFIA, in collaboration with Health Canada, could initiate a food recall. It was believed that the Sure Slice deli meats had only been distributed to large institutions, so it was not necessary to notify the general public. These products were not thought to be sold to retailers. »»The Public Health Agency of Canada At the same time, the PHAC’s National Microbiology Lab notified labs across notifies labs country-wide of cases in Canada that DNA fingerprinting showed a clustering of human cases of multiple provinces listeriosis with a similar strain in more than one province. »»The CFIA identifies a possible link By now, the CFIA had identified a possible link among five positive food between Bartor Road plant and positive samples – three from the Toronto area long-term care home and two from food samples the Burlington hospital. The CFIA’s review of production and distribution records at Maple Leaf Foods Bartor Road plant indicated the suspected products might all have originated on production lines 8 and 9. Thursday, August 14th »»Confirmation that st1 listeriosis death The first death linked to the consumption of contaminated Maple Leaf in mid-June linked to consumption of Foods deli meat products was confirmed as having occurred on deli meats June 17, 2008. »»Toronto Public Health advises all Toronto Public Health inspectors started contacting all institutions within institutions to stop serving Sure Slice their jurisdiction to advise them not to use Maple Leaf Foods Sure Slice products brand products (as per Maple Leaf Foods’ advisory to its distributors the previous day).
54 WHAT HAPPENED HOW IT HAPPENED Friday, August 15th »»The Public Health Agency of Canada The PHAC assumed the coordinating role for the epidemiological assumes coordinating role in the investigation of the outbreak since cases of listeriosis were now being epidemiological investigation identified nationally. This was done according to the Foodborne Illness Outbreak Response Protocol (FIORP). »»Public Health Agency of Canada issues The PHAC issued an alert to all public health authorities across Canada alert to all public health authorities about the Ontario outbreak and requested they collect information on in Canada the consumption of deli meats for cases matching the DNA fingerprint associated with the outbreak. »»Ontario institutions advised to stop In turn, the Ontario Ministry instructed all public health units to contact all serving Sure Slice products hospitals, nursing homes, long-term care homes and seniors’ residences in the province and recommend they stop using Maple Leaf Foods Sure Slice brand products (as per Maple Leaf Foods’ advisory of August 13th ). Saturday, August 16th »»The CFIA confirms Listeria monocytogenes The CFIA confirmed a positive test result for Listeria monocytogenes from in unopened Sure Slice package an unopened Sure Slice package, collected on August 12th, which had been produced at Maple Leaf Foods Bartor Road plant. The CFIA’s assessment determined that Sure Slice Roast Beef and Corned Beef met the criteria for the highest level of risk for health which requires recalling the product to protect the public. The CFIA contacted Maple Leaf Foods to inform the company of this result and to advise it that the Agency was preparing to issue a “Health Hazard Alert” for the two specific product codes of Sure Slice products. Sunday, August 17th »»Public warned not to eat 2 Sure Slice At 2 a.m., the CFIA issued a “Health Hazard Alert” warning the public not products to consume or serve Sure Slice Roast Beef and Corned Beef. The Alert also stated that the CFIA had not yet been able to link the DNA fingerprints between the human listeriosis cases and the recalled Maple Leaf Foods products. »»1st recall of Maple Leaf Foods brand At 3:30 a.m., Maple Leaf Foods announced it was voluntarily recalling two products Sure Slice brand products sold in 1 kilogram packages.
Chapter 6 – How did events actually unfold? 55 WHAT HAPPENED HOW IT HAPPENED Tuesday, August 19th »»2nd recall of Maple Leaf Foods brand The CFIA issued a second ‘Health Hazard Alert’ warning the public not to products consume or serve 23 additional deli meat products from lines 8 and 9 of Maple Leaf Foods Bartor Road plant. This new ‘Health Hazard Alert’ was based on the first results from the sampling blitz conducted in Ontario. The CFIA initiated another teleconference with the Public Health Agency of Canada, Health Canada, the Ontario Ministry and Ontario public health units, during which the PHAC continued to coordinate the epidemiological portion of the discussion. »»Toronto Public Health alerts physicians Toronto Public Health sent a surveillance alert to physicians and institutions and institutions about the outbreak. Wednesday, August 20th »»Maple Leaf Foods suspends all Maple Leaf Foods suspended all production at its Bartor Road plant and production at its Bartor Road plant announced that it was voluntarily recalling the 23 other deli meat products originating from the plant. »»Verification to ensure removal of The CFIA also initiated verification checks, with the assistance of various contaminated products public health teams across the country, to ensure recalled products had been removed from the market with special emphasis on institutions (hospitals, long-term care homes and day cares). »»Products from Bartor Road held until The CFIA ordered Maple Leaf Foods to implement a hold and test protocol. Listeria test results are negative This meant that no meat product produced at Maple Leaf Foods Bartor Road would be made available to consumers before test results for Listeria monocytogenes were found to be negative. Thursday, August 21st »»18 products test positive – The CFIA Labs confirmed the 18 Sure Slice products tested following the already on recall lists Ontario sampling blitz were positive and already on the recall lists. Friday, August 22nd »»Public Health Agency of Canada activates The PHAC partially activated its Emergency Operations Center to “Increased its Emergency Operations Center Vigilance’ (Level 2) »»1st federal press conference Senior executives from the PHAC, the CFIA, and Health Canada held a joint press conference to inform the public of the food safety investigation.
56 WHAT HAPPENED HOW IT HAPPENED »»1st of 21 secondary food recalls The day also marked the first of a series of secondary recalls – 21 in total. Secondary recalls were required since a variety of foods (e.g. sandwiches, meat and cheese platters, and pizza) were prepared using Maple Leaf Foods deli meats that had been recalled. The new products were sold by different companies under various brand names. Saturday, August 23rd »»LINK CONFIRMED BETWEEN HUMAN The test results from the unopened package confirmed the link between ILLNESS AND CONTAMINATED DELI the listeriosis outbreak and contaminated products from Maple Leaf Foods MEATS Bartor Road plant »»3rd recall of Maple Leaf Foods The Minister of Agriculture and Agri-Foods, assisted by senior executives brand products of the PHAC, the CFIA, and Health Canada, held a press conference to »»2nd Federal press conference confirming announce that the DNA fingerprints of the strain of Listeria monocytogenes the link between listeriosis and Maple found in humans and in the Maple Leaf Foods products were linked. Leaf Food products This would be the first in a series of fifteen consecutive daily federal media briefings by a Minister. A press release was also issued with the same information. »»Maple Leaf Foods CEO takes The Maple Leaf Foods’ CEO broadcast a national network television message responsibility for the outbreak taking responsibility for the outbreak following the determination that Maple »»Voluntary recall of all products from Leaf Foods’ Bartor Road plant was the source of the contaminated food that Bartor Road caused listeriosis. Maple Leaf Foods also indicated that, as a precaution, it was voluntarily expanding its product recall to include all 191 items produced at the Bartor Road plant. They took a zero risk approach by recalling all products from the marketplace, as they had no means to assure that the contamination at the plant could not have been more dispersed, including products which best before dates had expired but that could have been stored in freezers. The CFIA requested a health risk assessment from Health Canada on all products from the Bartor Road plant and notified Maple Leaf Foods that the assessment had been initiated.
Chapter 6 – How did events actually unfold? 57 WHAT HAPPENED HOW IT HAPPENED Sunday, August 24th »»Health Hazard Alert’ for all products The CFIA issued an expanded ‘Health Hazard Alert’ to cover all products produced at Maple Leaf Foods at Bartor Road. Maple Leaf Foods issued a press release confirming its previous day’s TV announcement that “[Maple Leaf Foods] voluntarily expanded its recall of products manufactured at its Bartor Road plant in Toronto, as a precautionary measure.” »»Federal Minister of Health holds press The federal Minister of Health held a news conference, assisted by senior conference executives of the PHAC, the CFIA and Health Canada to respond to questions regarding the listeriosis outbreak and food recall. Monday, August 25th »»News conference led by Minister of The Minister of Agriculture and Agri-food Canada resumed the federal lead Agriculture and Agri-food; continued daily on the file, holding a news conference assisted by senior executives of the for 13 days PHAC, the CFIA and Health Canada to respond to media questions. From this point forward until the federal election call on September 8th, the federal government held a 4 p.m. daily news conference, led by the Minister of Agriculture and Agri-food Canada, assisted by senior executives from the PHAC, the CFIA and Health Canada, as work continued to identify all illness cases linked to the outbreak as well as all the necessary secondary food recalls. Friday, September 5th »»All federally-regulated ready-to-eat The CFIA issued an advisory on slicers to all federally registered meat plants advised of new rules on establishments processing ready-to-eat meats. Companies were directed to slicer sanitation ensure that meat slicers were completely dismantled and cleaned, that they collected environmental samples to test for Listeria, and to review cleaning and disinfecting procedures with their CFIA inspector to ensure proper sanitation of the slicers. This change led to further Listeria contamination investigations and some product recalls from various food processors later in the fall.
58 WHAT HAPPENED HOW IT HAPPENED »»Maple Leaf Foods announces results of The Maple Leaf Foods’ CEO updated the public on the results of the Bartor its panel of International Food Safety Road plant investigation by its panel of International Food Safety Experts, Experts review indicating that the most likely source of Listeria monocytogenes was »»Slicing machines most likely source of contamination in the slicing machines. food contamination Saturday, September 6th »»Last federal news conference before The Minister of Agriculture and Agri-food Canada held the last of fifteen election call news conferences, assisted by senior executives from the PHAC, the CFIA and Health Canada. Monday, September 8th »»The PHAC back to ‘Normal Readiness’ The PHAC’s Emergency Operations Centre was de-activated to ‘Normal Readiness’ (Level 1). Wednesday, September 17th »»Bartor Road operations resumed Maple Leaf Foods received the CFIA’s approval to restart its operations at the Maple Leaf Foods Bartor Road plant. The company’s operations had been suspended on August 20th. The conditions set by the CFIA to resume production required that all products be tested for Listeria monocytogenes prior to being distributed to market.
NEXT CHAPTER
“The previous chapter outlined the chain of events that culminated in the 2008 outbreak. As illustrated in our descriptive chronology, investigating a foodborne illness outbreak is highly complex…”
Chapter 6 – How did events actually unfold? 59
CHAPTER 7 How well did the federal government and its food safety partners respond to the outbreak?
How well did the federal government and its food safety partners respond to the outbreak? The previous chapter outlined the chain of events that culminated in the 2008 outbreak .As illustrated in our descriptive chronology, investigating a foodborne illness outbreak is highly complex . It is necessary to
61 1 . confirm that food is the likely food safety is a direct responsibility of The food safety sector is focused source of the human illness public health through environmental primarily on identifying the exact food (epidemiological investigation); health inspection . product that is causing the illness so 2 . identify precisely which food Even though both sectors focus on that the correct food is removed from product is the cause of the human health and safety, the daily work the market .This is not always easy, illness and determine when it was of those in the food sector is to monitor given that food distribution is less often commercially produced, using the processes keeping food safe free local as consumers now have access to brand names and production from harmful agents .The public health food products from all over the world . codes (food safety investigation); sector monitors disease occurrence In the 2008 outbreak, contaminated 3 . stop its distribution, production to make sure those processes have deli meats from a single plant in and consumption to reduce illness worked . Staffs working in these areas Ontario that produces dozens of and deaths (recall); and approach an outbreak from different brands and products were distributed 4 . make changes to prevent it from perspectives; their education, training all across the country, resulting in a happening again (post-event and experience are complementary . national outbreak . For this reason, investigation) . When an outbreak is viewed through it was essential to match the location As we have described earlier in the the lens of public health, the focus is of the people who were ill with the report, the various governments do primarily on identifying what is making distribution patterns of the food not regularly work closely together people ill . Consequently, the sector products .This made the food safety to respond to the outbreak . In this works to quickly determine the likely investigation both a time-consuming chapter, we provide our conclusions cause of the illness and remove this and complex task . about what worked well and what threat as rapidly as possible . Once the suspected food source could be changed to better manage In an outbreak, the primary function was identified, even though it was not a foodborne emergency . of public health in such events is yet confirmed, public health officials ‘forensic’ – assisting the food safety assumed it was the food safety sector’s UNDERSTANDING THE sector in rapidly identifying the food responsibility to lead and that their role source so it can stop its distribution was to provide support .This view ran CHALLENGES OF MAN- and consumption .This role is an counter to public perception that the AGING A FOODBORNE important one, especially given the outbreak was primarily a health matter . EMERGENCY long incubation period of Listeria. During the 2008 outbreak, the differing perspectives of who To understand what worked and what did not, we first need to explain the key challenges in managing a foodborne Dr. Brian Evans outbreak . Such a crisis brings together “I think consumers’ confidence is shaken. We have an obligation to do everything humanly possible multiple jurisdictions and two sectors to restore, to the extent that we can restore, public confidence. We have to earn it every day. Every of the federal government that, on day we’ve got to go out and re-earn that and we have to be able to communicate a lot better with the a day-to-day basis are not required public than we have.” to work closely together: the public »» DR . Brian Evans health and food safety sectors .At the Executive Vice-President, CFIA provincial level, in most provinces, From our interviews
62 should lead were evident . From our To explain our conclusions we have been offered as one explanation for the observations, while the food safety broken down the different issues under slow response . sector assumed leadership in recalling the following headings: This should not have posed a the contaminated food products, other »»Leadership problem, at least in theory, since elements of the emergency that required »»Emergency Management an intergovernmental agreement attention were slow to get underway »»Federal, provincial/territorial – the Foodborne Illness Outbreak (e .g . the overall coordination of all and local coordination Response Protocol (FIORP) – had involved in managing the outbreak and »»Federal organizations structures been endorsed by all federal, provincial communications to the public) . and operating procedures and territorial governments in 2004 Nonetheless, it is important to note »»Disease reporting to coordinate the management of a that, due to the long incubation period »»Epidemiological investigation foodborne emergency . Put into place of Listeria monocytogenes, much of the following a national foodborne outbreak »»Food investigation and recall damage had already been done .We in 1999, FIORP was designed to guide a »»Laboratories verified that, by the time the outbreak multi-jurisdictional response when such was detected, most of the individuals an emergency arose . who became ill had already been LEADERSHIP However, few of those involved in exposed to the bacteria . So, while our The 2008 outbreak clearly the 2008 outbreak, especially senior report proposes improvements that demonstrated that managing this type executives, were familiar with FIORP . could lead to a quicker and more of emergency was not only complicated Even fewer acted in accordance with efficient response in the event of but was also not well understood by the multi-jurisdictional guidelines to another outbreak, little could have been those involved . manage such an event . done at the time of the 2008 outbreak At the outset, the outbreak was Through interviews we learned that, to prevent others from becoming ill . not considered a severe foodborne within the Canadian Food Inspection We believe that by being proactive - emergency .This view led to a void Agency, the Public Health Agency for example, advising the public sooner in leadership in managing the of Canada, Health Canada and the that certain foods were suspected crisis . It took close to three weeks Ontario Ministry, few officials above – governments could have averted before senior executives in all key the Director level (the management confusion during repeated recalls of deli organizations became fully engaged in level charged with administering the meats .This ultimately amounted to the the event .The fact that many officials protocol when required) were aware of recall of 191 products from Maple Leaf were on vacation during this period has FIORP’s existence when first alerted to Foods Bartor Road plant, many of which the unfolding listeriosis crisis . had been on the market for months . Listeriosis We were told that while front This confusion affected public line and scientific staff on both the confidence in Canada’s food safety Prior to 2005, there were less than one public health and food safety sides system and in governments’ capacity hundred cases of listeriosis reported in of the investigation were hard at work to respond to such foodborne Canada annually. However, since 2005 responding to the crisis, their superiors emergencies . this number has more than doubled. were not initially fully engaged .
Chapter 7 – How well did the federal government and its food safety partners respond to the outbreak? 63 Dr. Brian Evans manage this event . This lack of “It is one thing to have protocols in place but if everyone doesn’t act in accordance with them or advance preparation, particularly in they’re not aware of their roles, they are not effective protocols.” communicating to vulnerable groups, »» DR . Brian Evans, Executive Vice-President, CFIA contributed to confusion . From our interviews Federal, provincial/ Furthermore, no single organization emergencies, compounded the territorial and local took the overall role of coordinating challenges in managing such a crisis . coordination the actions of the various parties The Foodborne Illness Outbreak involved .This left a vacuum in senior Recommendation Response Protocol has been ratified leadership that caused confusion 23. The Public Health Agency by Deputy Ministers for all fourteen and weak decision-making . Despite of Canada, with the support jurisdictions, although not by Ministers this, the epidemiological and food of the Canadian Food Inspection of Health .To complement the protocol, safety investigations were reasonably Agency and Health Canada, bilateral agreements have been signed well done . should assume the leading between the federal and provincial or role in coordinating the federal territorial governments to recognize KEY FINDINGS government’s response to a the particular circumstances of each »»National foodborne outbreaks national foodborne emergency. jurisdiction . are rare in Canada . Nevertheless, We heard that this protocol is agreements are in place to EMERGENCY valuable, but it is rarely needed manage such events but they were nor fully understood by many of not widely known or understood MANAGEMENT its signatories .We also heard that by senior leadership at the time of Emergency management of a foodborne elements of the protocol are out the 2008 outbreak . illness outbreak requires clear and of date . »»In Ontario, although field staff concise planning, including: In spite of having formal was at work, senior public health »»the determination of roles and intergovernmental agreements to work executives did not become engaged responsibilities collaboratively and share information in the event until the week of »»the timing and processes for in times of emergency, the events of August 11, three and half weeks interaction; and the 2008 outbreak revealed that, at the after the investigation was initiated . »»exchange of information time they were most needed, they were »»Within the responsible federal Since national foodborne illness not fully used . Since the emergency organizations, although staff was outbreaks of this magnitude are provisions were not invoked the at work, senior executives did not rare in Canada, opportunities to conference calls although helpful were become engaged until the week of practice this emergency management informal . For example, the continuity August 18, after the first recall . approach are very limited . As a result, between calls was not fully captured as »»The public health and food safety the system is not mature .We learned minutes were not taken at any point in sectors come at foodborne that both food safety and public the management of the event . Several emergencies from different health officials participating in the people with first-hand knowledge of perspectives .This, coupled with 2008 outbreak were not adequately these events reported that crucial the infrequent occurrence of such prepared or equipped to properly
64 Dr. David Butler-Jones of a clear understanding of which “The “Public Health Agency of Canada” was formed in large part in response to the report of organization or level of government was Dr. David Naylor, “Learning from SARS.” In particular, Dr. Naylor discussed the need for fulfilling responsible for doing what – including the four Cs n collaboration, communication, cooperation and clarity n which I think is a pretty what organization should lead the good description of what this new Agency and myself should strive for.” crisis – contributed to the inconsistent »» DR . David Butler-Jones management of the outbreak . Chief Public Health Officer of Canada, to the Standing Committee on Health, October 2004 One of the goals in creating the Public Health Agency of Canada was information was circulated but not investigating, as occasional cases are to avoid just such situations, which moved up the chain of command . the norm .This is what happened in Canada had learned when confronted We heard repeatedly that the the 2008 outbreak, when two people with SARS .We are convinced that strong roles and responsibilities of various from the same long term care home national leadership for foodborne governments need to be clarified developed listeriosis a few days apart . emergencies is required as a national and better communicated .‘Lessons When the number of cases grows priority .We conclude that the PHAC is learned’ reports prepared by all of the beyond a local health unit the provincial the organization best placed to take organizations involved in the outbreak or territorial ministry gets involved .And on this role . came to similar conclusions . when the number of cases extends The unusual characteristics of a beyond one province, the federal public KEY FINDINGS listeriosis outbreak underscore the need health sector gets involved .At any point »»The long incubation period of for maximum collaboration . in this process when a food product listeriosis, combined with the large When a listeriosis crisis emerges, is suspected, the provincial or federal number of individual public health it starts with just a few people from organizations responsible for food safety units reporting isolated cases specific groups becoming ill . Since are called in . across Ontario, meant that the each person will develop the illness at For example, the 2008 outbreak small increase in cases was hard a different rate (the incubation period quickly expanded from a small number to identify . varies from 3 to 70 days), each case is of cases in Ontario to, eventually, »»There were strong indications as different . It is only when an increase in 57 cases across seven provinces . early as July 29th that a foodborne cases or unusual factors are noticed This complicated communications and illness emergency was developing . that local public health officers start management of the event .The lack Fifteen of Ontario’s local public health units reported 24 cases Dr. David Williams of listeriosis when only 11 would normally be expected for the time “We have different organizations involved, so if we can just get it better coordinated and clearer period, which was confirmed in lines of authority and responsibility, so that at an outbreak or a suspicion of outbreak, the public’s a national alert to all provincial, protection is paramount.” territorial and local health »» DR . David Williams authorities across Canada . Acting Chief Medical Officer of Ontario From our interviews
Chapter 7 – How well did the federal government and its food safety partners respond to the outbreak? 65 »»There is a need to pre-determine national (multi-provincial/ vi. share all information, how governments will interact and territorial) and the federal including epidemiological to coordinate the interventions of (multi-departmental) level; data, needed to identify the different organizations . ii. use a common incident the emergency taking into »»FIORP, which is in need of command structure; account privacy and data updating, was not recognized as iii. define the roles and confidentiality issues; the protocol to be used during responsibilities of each of c. include in FIORP periodic mock the outbreak to avoid duplication the organizations involved exercises to validate that the or to fill gaps and was not well clearly and concisely, in protocol and its Emergency recognized or understood by many plain, unambiguous language Plan are fully understood by federal/provincial/territorial including surge capacity; federal, provincial, territorial officials . iv. increase the use and timing and local governments as well »»Based on our investigation, to of health advisories and as by the food processing and maintain confidence in the food precautionary warnings, distribution industry and is safety system, there is a need where reasonable and in a state of readiness. for independent review after all probable grounds exist, to 25. The authority of the federal national foodborne emergencies, advise consumers to suspend Minister of Health to protect the in addition to each organization’s consumption of suspected health of all Canadians under lessons learned review . foods while tests to confirm section 30.1 of the Food and the precise source are Drugs Act, and subsections Recommendations pending, taking into account 4(1) and (2) of the Department 24. In preparedness for national »»suspected illnesses of Health Act should be used in foodborne emergencies, the and deaths, a national foodborne emergency, federal, provincial and territorial »»geographic distribution, and whenever warranted. governments should: »»test results of opened or 26. Where human deaths or serious a. complete the revision of the unopened food samples. illnesses have occurred, the Foodborne Illness Outbreak v. create a ready-to-implement Canadian Food Inspection Agency Response Protocol (FIORP) crisis communications plan should promptly disclose the currently underway, at the to ensure that all Canadians results of its investigation of earliest opportunity; and are kept informed in a the implicated plant and the b. enhance FIORP, by developing timely and detailed manner corrective actions taken, to the and ratifying a Foodborne (including pre-arranged public and food safety partners. Illness Emergency Plan building media spots, pre-developed 27. The federal government should on the experience of the material, and the like); and establish an independent post- Canadian Pandemic Influenza event review process made up of Plan, to: Something we heard during our interviews i. designate the Public Health Agency of Canada The federal organizations have initiated discussions to improve FIORP, and some of the as the lead Agency taking enhancements considered have been exercised during the health emergency of H1N1. leadership at both the
66 Ronald L. Doering Command Structure, which is designed “No function is more important than the management of these high profile cases. to coordinate this type of situation . No activity is so central to the credibility of the CFIA.” »» Ronald L . Doering Health Canada Former President of the Canadian Food Inspection Agency When the CFIA receives confirmation that a particular food product is a pre-identified team of experts Agency’s emergency plan . For example, contaminated, it calls on Health Canada not involved in the emergency. no one was assigned to undertake the to evaluate the risk this food poses to Following all future national advance planning required to manage the health of consumers based on the foodborne emergencies, this team the outbreak, nor was a specific potential exposure to the bacterium and should conduct an in-depth review communications team established . the severity of its impact .We learned and report to the government. While the PHAC personnel recognized that the department’s team assigned to The report should be made public. the severity of the outbreak, their this task in the summer of 2008 was not resources were not fully deployed to operating on a 24/7 basis, leaving gaps Federal organizations’ respond in an emergency situation . in coverage during emergency response structures and operating situations . procedures Canadian Food Beyond difficulties in federal, provincial/ Inspection Agency KEY FINDING territorial and local coordination, we The CFIA recall team was first made »»The Public Health Agency of Canada observed problems specific to the three aware of the emerging outbreak and did not consider it had the federal federal organizations directly involved the suspected food source on August leadership role, therefore there was in the 2008 outbreak . Some of these 6th . Senior executives were advised the a delay in identifying the outbreak problems were identified in the lessons next day, but were not fully involved as a public health emergency and learned reports prepared by the Public in decision-making until the week of it only activated its Emergency Health Agency of Canada, the CFIA and August 18th, after the first recall took Operations Centre, which served as Health Canada . place .This means that key decision the coordination hub for the Agency makers who could have helped with and Health Canada, in late August Public Health Agency the strategic management of the crisis of Canada were not involved . In the past, the Recommendation The Public Health Agency of Canada Agency used an emergency management 28. In the event of a national was initially pulled in to the 2008 structure that engaged all critical senior foodborne emergency, an outbreak on July 29th through the personnel and technical resources to incident command structure foodborne epidemiological team . On deal with significant food inspection should be activated under the August 22nd, the team partially activated events .This process was not used during leadership of the Public Health the Agency’s Emergency Operations the 2008 outbreak since the Agency Agency of Canada with the direct Centre to ‘Increased Vigilance’ (Level 2) . did not foresee the magnitude of the participation of the Canadian However, we heard it did not activate outbreak early enough . In addition, Food Inspection Agency and all the functions called for in the the CFIA did not activate its Incident Health Canada.
Chapter 7 – How well did the federal government and its food safety partners respond to the outbreak? 67 Disease Reporting of once again identifying listeriosis as who were brought in to investigate the Although there were gaps in reporting a national notifiable disease . source of the contaminated food .This requirements for listeriosis, we have food investigation eventually led to the been advised it would not have made a Epidemiological confirmation of the food source and difference in the 2008 outbreak, since Investigation the associated food product recalls listeriosis was already a notifiable In July, the Ontario Ministry of Health (three main and 21 secondary recalls), disease in Ontario when the outbreak and Long-Term Care began to identify which are discussed in the next section was first identified .There are currently an increase in the number of listeriosis in more detail . 55 active diseases or conditions on cases that were being reported by local While progress on the recall was the National Notifiable Diseases List1 . public health units through Ontario’s being made, efforts to link the food Including a disease on the list means electronic surveillance system .With source and cases of listeriosis across that, when provincial/territorial public the help of one of its analysis systems2 the country were just beginning . health authorities (local and regional the Ontario Ministry was able to DNA fingerprinting of the food source report to their province/territory) are statistically validate that something enabled public health teams to refine able to confirm that someone has a unusual was occurring . Officials in the their analyses of listeriosis cases listed illness, they voluntarily report the Ontario Ministry began contacting both occurring within their jurisdictions . case(s) to the PHAC . public health units, the Public Health Eventually, they were able to match the Listeriosis was a nationally notifiable Agency of Canada and Health Canada cases of illness with the consumption disease from 1990 following the 1982 to discuss these findings . of contaminated products from Maple outbreak of Listeria in ready-to-eat A notice was posted on the national Leaf Foods . coleslaw salad . However, since there surveillance system on July 29th to This was a significant were no significant outbreaks between alert other jurisdictions to the increase accomplishment and a reflection of the 1990 and the events of 2008, it was in cases occurring in Ontario .Within increasingly important role technology, removed from the list in 1999 .At the a few days, the federal-provincial such as DNA fingerprinting, plays in time of the outbreak, listeriosis was not epidemiological team, which was identifying foodborne illnesses .As a notifiable disease in many provinces . communicating daily via conference recently as five years ago, foodborne The doubling in listeriosis cases since calls and postings on the national diseases were not easily linked to a 2005, and the fact that it is now in surveillance system, learned of a specific food product . the process of becoming a national potential link between one of the Thanks to the use of a test known notifiable disease, reflects the growing listeriosis cases and a food source . as pulsed-field gel electrophoresis awareness that the disease is a Over the next few days, there were (PFGE), it is now possible to link human significant health threat for vulnerable several new cases reported with cases more quickly by comparing DNA populations .The process is underway possible links to a similar food source . fingerprints . Similarly, this technology By August 6th, the daily conference can link human cases and the foods calls included officials from the CFIA that caused the illnesses .
1 Public Health Agency of Canada - National Notifiable Diseases (1: Current List of 2 The Early Aberration Reporting System is a Nationally Notifiable Diseases andY ear the system that detects statistical increases in First Positive Report was Recorded) – online: the number of cases above the norm and http://dsol-smed phac-aspc. .gc .ca/dsol- therefore can help public health officials smed/ndis/list_e .html#tab1 detect an outbreak .
68 Food Investigation Toronto area long term care home did not indicate a clustering of and Recall staff that the likely source of the food illnesses in Ontario . Foodborne illness outbreaks that are product was Maple Leaf Foods .The »»There was contradictory information traced back to a commercial production company produced the larger packages concerning the exposure of patients source are rare .According to US data, of deli meats which both of the home’s to Maple Leaf Foods products in up to 97% of foodborne illnesses result ill residents had eaten .The food the case of a hospital in Burlington, from the handling or preparation of samples initially collected by Toronto Ontario .At first, patients were food once it has left the food processing Public Health were from ‘retention’ reported as not having eaten meals plant . In such cases, investigating the samples of meals that had been served prepared with deli meats although food source of the illnesses is less to the residents earlier in July . Long- they, in fact, had . complicated . Such investigations are term care homes, hospitals and other »»Maple Leaf Foods did not initially led by public health officials and do not large institutions keep samples for this report the presence of Listeria at often involve the food safety sector . purpose . the Bartor Road plant or provide However, in the remaining two to The original packages containing product distribution records . three percent of cases, a food safety the deli meats had long been As Ontario public health units investigation is required because the discarded by the time the CFIA undertook investigations into cases cause of the outbreak is not evident . became involved in the investigation . in their jurisdictions, a pattern linking Several different organizations become This was understandable, as the time Maple Leaf Foods deli meat products involved in this type of investigation . between the original collection of the to ill individuals started to emerge . Public health teams identify the cause food samples and confirmation of We were told that, as their investigations of the illness while the CFIA tracks down positive results from the lab spanned progressed, some public health officials the product that is causing it . Health three weeks .Access to the original believed that sufficient information was Canada provides an assessment of the packages was essential to pinpoint available to proceed with a recall of risk associated with the contaminant, the information required to identify the these food products . the exposure of humans and the risks to precise product and production date . There are differing views about when peoples’ health . As part of the food safety to advise the public about potential In the 2008 outbreak, the CFIA was investigation, the CFIA investigators had food contamination . Some advocate notified by Toronto Public Health that to methodically sort out the following: for a precautionary approach, based on three samples of deli meats tested »»Some local public health units epidemiological evidence, to protect positive for Listeria monocytogenes .The in Ontario did not immediately the public from potential harm . Put CFIA initiated a food safety investigation enter their listeriosis cases simply, this means that, in the absence to determine the exact food product, in the provincial surveillance of absolute certainty, it is better to err its source, production date and code . system therefore when provincial on the side of caution, using reasonable In the course of Toronto Public Health’s authorities first checked, nothing and probable grounds . epidemiological investigation, which appeared to be out of the ordinary . There are numerous examples of involved collecting a variety of food »»Early reports from one of the food recalls by the federal government samples, they were advised by the national surveillance systems that have been undertaken without
Chapter 7 – How well did the federal government and its food safety partners respond to the outbreak? 69 Salmonella Saint Paul Outbreak, 2008 the definitive proof established by laboratory confirmation . However, ➤➤ At least 1400 persons infected with What Was Learned? in those instances, all the evidence Salmonella ➤➤ Improved safety standards needed for pointed toward the same food product . ➤➤ Initial investigation incorrectly identified fresh produce The other approach is to wait for tomatoes as source of contamination; ➤➤ Food safety/public health response needs more conclusive evidence, before jalapeno peppers were true source. alerting the public to a health to improve outbreak investigation methods ➤ threat .The practice usually followed ➤ Premature national public health warnings – more accurate not to consume tomatoes. by Health Canada, based on the ➤➤ Public health communication to media recommendation of the World Health ➤➤ Recall of peppers was delayed which and public needs to be responsive, clear, Organization and years of experience is allowed peppers to remain a threat to and accurate (better to be a little slower to, wherever possible, rely on laboratory public health. but accurate). confirmation before recommending a ➤➤ Undermined consumer confidence in safety recall of specific food products . of fresh produce and food safety system. Laboratory confirmation is based on extensive testing and conclusive results that provide proof that a specific food contaminated during the production product is removed from the product is contaminated .This is often stage and not cross-contaminated marketplace . referred to as the ‘unopened packages’ after leaving the plant or while being In the 2008 outbreak, the early approach . handled in consumers’ kitchens . findings were not converging or Health Canada has relied on this The quality of the information is conclusive .Although there were standard of proof, which provides crucial to identify the correct food in indications the product originated evidence that the product was order to ensure the real contaminated at Maple Leaf Foods, there was no conclusive information on the specific Salmonella Peanut Butter Recall 2008-09 food or its production dates .Therefore, the CFIA investigators sought unopened ➤➤ One of the largest recalls in American What Was Learned? packages of the same product, which history were eventually found and tested ➤ ➤ Responsible collaboration between positive for Listeria monocytogenes . ➤➤ Salmonella-tainted peanut butter from one government and producers is essential – Based on this confirmation, Maple Georgia company distributed throughout companies must notify government when Leaf Foods undertook a voluntary recall U.S pathogens identified in their food products of two specific brands of Sure Slice ➤➤ Approximately 700 people ill (1 in 4 ➤➤ Retailers must know their suppliers so that Roast Beef and Corned Beef . hospitalized); 9 deaths; almost 400 contaminated products can be pulled off Following the confirmation of products recalled (and growing) market quickly, with accuracy the source, the epidemiological ➤➤ Company shipped contaminated products ➤➤ Congress learns of corporate failure to investigation broadened . It quickly after knowing tests for Salmonella were distribute safe food: pledges to make identified and linked other cases positive; difficulty in identifying product major changes to protect nation’s food associated with the outbreak . distribution (traceability) supply As the investigation continued, two additional recalls of Maple Leaf Foods
70 Sampling Procedures and Information federal organizations and other World Health Organization Samples should be accompanied by product provinces assisted in determining information such as the circumstances in the magnitude of the foodborne If a packaged food item is suspected of being which samples were collected, the names of emergency and advancing the the cause of a foodborne illness, it is particularly the suppliers and distributors, and coding important to collect unopened packages of that investigation information on packaged foods should be food—ideally from the same lot. »»The differences in perspectives recorded. This facilitates the determination of regarding the quality and strength This can help to establish the stage of the distribution channels of the product. of evidence on which to base production when the food was contaminated Source: Foodborne Disease Outbreak: recall decisions, including timing, before the package is handled or opened and Guidelines for Investigation and Control. 2008 support the need for advance its contents are used in meal preparation. agreement across sectors and levels of government to improve products took place, followed by 21 in conducting their normal duties .We the management of future similar secondary recalls . Secondary recalls have learned that, while these activities investigations were necessary since a variety of food were necessary, there was very little »»Information and the supporting products (e .g . sandwiches, meat and information circulating which would rationale, provided to public health cheese platters, pizza) were prepared have helped the public health officials officials by the CFIA that were using Maple Leaf Foods deli meat to better understand why they were assisting with verification checks products that had been recalled .These being asked to repeatedly visit the same following product recalls, was products were packaged and sold by facilities . During these events, more insufficient different companies under various information was needed on the reasons brand names . behind the successive secondary recalls . Recommendations Following each of the 24 product 29. Health Canada, the Canadian Food recalls, it was necessary to verify that all KEY FINDINGS Inspection Agency and the Public the contaminated products had been »»Considering that contaminated Health Agency of Canada should removed from the marketplace . It was food was being consumed for some review, update and publish the also important to ensure they were not weeks prior to the initiation of the criteria for proceeding with a food continuing to be served in institutions investigation, the work performed recall to ensure that the weight especially those caring for vulnerable by epidemiological and food safety of evidence takes into account populations . teams contributed to identifying the epidemiological information, In total, over 29,000 verification source of the illness and removing including suspected illnesses and checks post-recall were carried out contaminated food from the deaths, geographic distribution, over a three week period by the marketplace and food sample test results CFIA staff and local public health »»Although there were some whether packages are opened inspectors from across the country . problems, regular conference or unopened. This put a tremendous strain on all calls which started in Ontario and 30. The Canadian Food Inspection involved and disrupted their efforts expanded to eventually include Agency should encourage
Chapter 7 – How well did the federal government and its food safety partners respond to the outbreak? 71 Testing for Listeria federally regulated meat processors to move beyond the The following tests are used to find out if a d. Serotyping: a follow-up test to compare minimum existing requirement food is contaminated with Listeria: different strains (e.g.: from 2 different for accessibility of distribution packages of food) to see if they are the a. ‘Quick test’: indicates if one (or more) same (2 to 4 days) records to include electronic of the six Listeria types is present (3 to access in non-proprietary and 4 days) e. DNA ‘fingerprinting’: another follow-up unlocked formats to assist in test to determine the strain of Listeria b. Detection: indicates whether or not the potential product recalls. monocytogenes. Not as good as bacteria is present – there are tests 31. The Canadian Food Inspection fingerprinting on people – but a good way for Listeria species and for Listeria Agency should establish a formal to match Listeria monocytogenes from 2 monocytogenes (7 to 10 days) protocol to ensure that timely different food or human samples (4 to 6 and consistent information c. Counts: used to complement the days; if urgent 3 days) is provided to staff of the detection test to indicate the quantity of provincial/territorial or local bacteria present (4 days) public health organizations who are asked by the Agency to help it complete post-recall laboratories was not fully networked at There is also no cross-coding3 of verification activities. the time of the 2008 outbreak and not the human biological samples 32. In providing information related all provincial or federal laboratories and corresponding food samples . to a given product recall to the were accredited to test for Listeria Consequently, more time was needed to distribution industry, including monocytogenes . reconcile results .This could have been grocers, the Canadian Food Furthermore, we learned that there are avoided with pre-approved processes Inspection Agency should use a only a few laboratories with the capacity and practices . standardized form (as suggested and certification to test food products Another complication was that by the Canadian Council of for Listeria monocytogenes, and none current confirmation testing for Grocery Distributors). of those were networked .We have also Listeria monocytogenes and the DNA learned that many provinces did not fingerprinting involves a series of tests . Laboratories have the capacity to test for Listeria It can take up to 14 days to complete The listeriosis outbreak revealed and relied on Health Canada’s National all these tests before identifying the gaps in the laboratory system that Reference Laboratory to test their food fingerprint of the bacteria . contributed to delays in detecting the samples during investigations .As a result, Due to all of these factors, we disease and in notifying the public . opportunities may have been missed to consider that there might have been In health emergencies, human confirm the food source of the outbreak earlier opportunities to identify the link biological samples and the follow- sooner . between the human infection and the up test results may be circulated We heard from many interviewees food source of the outbreak . between private and hospital labs as that methods to collect and retain well as both provincial and federal food samples as well as testing public health laboratories .This methodologies are not standardized . 3 Cross-coding: a method of identifying human complex system of human biological samples and corresponding food samples to make it easier to link their test results
72 Dr Frank Plummer human illness, but improvements 34. This network of federal, “What we can do to make that better is are still required for integrating the provincial, territorial, local, decentralize to the provinces, which we’ve data collection and analysis of food and private laboratories should already started to do. … That will take a bit samples . be integrated to ensure: of time off the time it takes to detect cases »»In the case of Listeria, laboratory a. rapid tests, analysis and – a few days, three or four maybe – but it resources are limited and the reporting of test results into will improve the system.” testing required is sophisticated, monitoring and surveillance »» Dr Frank Plummer complex and takes considerable systems, on a priority basis; Scientific Director General, National Microbiology Laboratory time to properly undertake (up to and, Public Health Agency of Canada 10 to 14 days to confirm Listeria b. the identification of back-up monocytogenes in food) . capacity to support regional KEY FINDINGS »»Advances in laboratory testing and local gaps and surge »»All foodborne illness emergencies allow for DNA fingerprinting of the capacity needs during a require extensive laboratory testing Listeria monocytogenes bacteria, national foodborne emergency. and analysis . Both human and food which is used to confirm the 35. Federal, provincial and territorial samples are required to link the linkage between human illness and governments should review disease to the contaminated food contaminated food products . laboratory procedures and products . »»While significant progress has been methodologies to develop »»Public health labs are not formally made, enhanced coordination of consistent practices in testing networked and could be more testing could further accelerate for foodborne diseases, against effectively used during a foodborne the analysis and decision-making predetermined benchmarks and illness emergency . necessary in the management of giving priority to the following: »»The Public Health Agency of Canada foodborne outbreaks . a. cross-coding human samples ihas improved its epidemiological and corresponding food data collection and analysis for Recommendations 33. Given that laboratories across Suggestion Dr Mansell Griffith Canada are not networked, the federal, provincial and territorial “Research is needed to develop rapid, governments should proceed to “Laboratory testing needs to be inexpensive and easy-to-use methods to establish a nationally integrated improved so there is either centralized or detect Listeria in the environment and network (i.e. network of networks) standardized testing for foodborne bacteria in food that can be completed within a among the following: to avoid confusion over lab results. In working day.” a. human disease labs (where this addition, all health care institutions and »» Dr Mansell Griffith has not yet occurred), emergency personnel should have computer Chair of Dairy Microbiology access to patients’ health records.” in the Food Science Department food labs,b. at the University of Guelph c. animal labs, and »» A suggestion by a family Member of the Listeriosis Investigation affected by the outbreak Expert Advisory Group d. all of the above.
Chapter 7 – How well did the federal government and its food safety partners respond to the outbreak? 73 samples in order to accelerate 36. Federal, provincial and territorial the linkage of test results; governments and their research b. agreeing to protocols designed funding agencies should initiate to accelerate the process and support further research into: for accrediting public (by a. testing for, and control of, the federal government) and Listeria monocytogenes; private (by the provinces) b. improved traceability technology laboratories for Listeria and methodology; and monocytogenes DNA c. novel and emerging laboratory fingerprinting; technologies. c. standardizing methodologies for the collection and retention of food samples, including the requirement that all Listeria monocytogenes positive food isolates be forwarded to a designated lab for DNA fingerprinting; d. developing and delivering the necessary training required to ensure that laboratories have built-in human resources redundancy; e. ensuring that positive Listeria monocytogenes isolates are held for at least six (6) months to facilitate the comparison of data and to accelerate the identification of potential outbreaks, and f. researching and applying novel and emerging lab technologies. NEXT CHAPTER
“From everything we heard, if there is a single issue that garnered near unanimous agreement, it is that the public was confused and did not understand what they should be doing following news of the food recalls…”
74 CHAPTER 8 How well were communications handled?
Communications to the public From everything we heard, if there is a single issue that garnered near unanimous agreement, it is that the public was confused and did not understand what they should be doing following news of the food recalls .This is not surprising, considering the complexity of the issues involved in the outbreak and the many organizations providing varying levels of information at different points in the event .
75 Something we heard during our interviews: its food safety inspection practices There is lack of clarity on who is responsible to communicate with vulnerable populations on food became the subject of critical media safety issues. reporting . Indeed, the tone changed rapidly and dramatically . The Ontario and federal governments, After the first few days of coverage, other provinces, and Maple Leaf OBSERVATIONS AND news stories routinely reported Foods were each making formal news ASSESSMENT concerns from worried consumers and announcements with different rates If measured by the level of activity, criticisms from prominent health and of frequency . Many others voiced hours worked and sheer number food experts . The public discourse their opinions about the outbreak of information products generated shifted from an emphasis on the and the way it was being handled in by communications staff at the specifics of the threat to Canadians’ media reports . Over the course of Canadian Food Inspection Agency, health to questions about the Canadian several weeks, official government the Public Health Agency of Canada, food system and whether it was an spokespersons, public health and food and Health Canada, it would seem (inhibiting) or a (contributing) factor to safety experts, politicians, unions, and that communications to the public the outbreak . consumer groups were interviewed were effective . However, we heard that Other factors helped shape the frequently . The very fact that there were more needs to be done to better meet nature of the coverage and influenced so many different organizations making Canadians’ information needs during a the debate . Ongoing discussions so many statements contributed foodborne emergency . between the CFIA and its unions (the to Canadians’ misunderstanding Initial media reports on the listeriosis Public Service Alliance of Canada and anxiety . outbreak focussed on the facts, closely and the Professional Institute of the Canadians generally do not reflecting the statements and key Public Service of Canada) meant that understand which level of government, messages issued by the Canadian issues at the labour relations forum, let alone what organization, has Food Inspection Agency, the Public especially related to staffing levels specific jurisdictional responsibility for Health Agency of Canada and provincial and jobs duties, became newsworthy . public health or food safety . What they spokespersons . Coverage provided Media focused on these issues through do know is that they want someone basic information about health risks, the prism of the performance of food to explain to them, simply and clearly, as well as how health authorities were inspection before and during the what is happening and what they managing the outbreak .As time went outbreak . should be doing to protect themselves . on, however, the federal response to Similarly, the fact that the outbreak Subsequent public opinion polling, the emergency and, more generally, occurred during the period leading up along with the personal anecdotes of family members and others who Dr. K. Wilson shared their views with us during this investigation, indicated that “The outbreak crossed over two areas – food safety and public health – and had political repercussions, communications about the outbreak given the presence of the federal election.” did not provide the information »» DR . K .Wilson they needed . Canada Research Chair, Public Health Policy University of Ottawa appearing before the Agriculture SubCommittee on Food Safety June 10, 2009
76 Communications Risk Strategy to a federal general election, and then during the campaign itself, played a The 2006 Strategic Risk Communications Framework and Handbook adopted by Health Canada and role in how the outbreak was covered by the PHAC defines risk communications as “any exchange of information concerning the existence, the media . nature, risk, form, severity or acceptability of health or environmental risks”. While these contextual factors can Ultimately, effective risk communications by government should influence decisions and behaviours. have an impact on media coverage In a period of health emergency, its key purposes are twofold: and public attitudes about an issue ➤➤ First, it should allay concerns of the public; and, as serious as a listeriosis outbreak, examining the actual communications ➤➤ Second, it should provide timely and accurate guidance on steps members of the public should activities of the federal government take to protect themselves and mitigate the risks associated with the illness. during this period is important to determine if there are changes that could be made that would lead to more This was due not to a major or government was also late in using effective communications to the public . systemic failure of the communications communication vehicles well- We measured the effectiveness of the function, but rather to a series of suited to reaching specific, at-risk federal government in communicating substantive factors . populations . Activity dropped off th to the public against the key objectives The overall approach to dramatically after September 6 , and the federal approach to risk communicating the outbreak targeted when the election was called (not communications in an emergency primarily food safety . As such, it was not an uncommon practice during situation, described in the 2006 oriented enough toward informing the election campaigns), even though Strategic Risk Communications public of a potential hazard, but instead demand for information by the Framework and Handbook . focused on gathering scientific evidence public was still high . The Government of Canada’s efforts to confirm the foodborne illness and its »»Fragmentation: More than one were partially successful in achieving source before going public about it . source had to be accessed in the objectives of risk communications . Overall, the shortcomings in order to get the complete story . While communications staff communicating to the public the In addition, greater emphasis demonstrated commitment, federal relevant information related to the on food safety and technical communications efforts during the health emergency fall into three information about the outbreak, outbreak did not consistently meet main categories: rather than on its public health the level of performance the situation »»Timing: The federal communication dimensions, resulted in an demanded . This diminished the efforts began at a late stage of unbalanced communications effort . government’s ability to inform and the outbreak, after the first recall »»Reactive: The federal government’s reassure an anxious public . In fact, – later than the efforts of other communication efforts became the performance itself became part parties involved . Against this it focused on ‘damage control’ of the story, thereby further impairing must be remembered that the to answer allegations of the effectiveness of the government’s 2008 outbreak first emerged in mismanagement of the inspection communication efforts . Ontario and was therefore under services . Keeping to the usual provincial leadership .The federal approach for risk communication
Chapter 8 – How well were communications handled? 77 Dr. David Butler-Jones was difficult .This diminished the ability of the government to ‘Our public communications were important. But it’s clear that much needs to be improved. It was effectively address Canadians’ found that the agency should approve its advance planning and formalize … its communication concerns . protocols. We must also work on clarifying our roles and responsibilities in outbreaks, for the public as well as our partners. … Chronology of the The human health aspects of it [foodborne emergency]--the understanding and making sure of the advice to the system and the process on human health--are for the public health agencies. It’s my outbreak and federal responsibility and accountability to do that. That’s what we did at that time. One of the lessons public communications learned is that there’s an expectation of more visibility of the CPHO.’ »» DR . David Butler-Jones Factors compounding the timing, Chief Public Health Officer of Canada, fragmentation and reactive nature appearing before the Agriculture SubCommittee on Food Safety, April 22, 2009 of the federal government’s communication efforts were: public were not well understood the public health dimension »»The lack of a single lead by the general population . Even of communications activities . organization and management media representatives were not We heard that consideration of the federal government’s certain as to which government had been given to reassessing communications efforts to the officials should be contacted to the choice of ministerial public .With different parties obtain information . The fact that spokesperson, depending on in charge of various segments, provincial governments were also changing circumstances . However, communications activities were very active - and appropriately we also heard that the best not always well coordinated or so – on the communications practice in communications is to optimized .The Foodborne Illness front added to the feeling of maintain a single spokesperson Outbreak Response Protocol1 confusion .This was particularly throughout an event .The Minister was inadequate in this regard . true since, initially at least, federal of Agriculture and Agri-food From an audience point of view, information provided on the was prepared and available to having to obtain information from status of the outbreak was not comment on both the food safety three different federal government easily reconciled with information and public health dimensions sources imposed a burden on an provided by provincial authorities; of the issue, and was assisted already-confused public .The roles »»While the public expects in by senior officials in both fields . and responsibilities of the federal an emergency that the lead But the public view was that the organizations involved in managing spokesperson will be a minister, government did not put enough the public health emergency an ‘elected’ official, the choice emphasis on advising Canadians and in communicating to the of the appropriate ministerial about what they needed to do to lead was a matter of debate . protect themselves; The government’s decision to »»The view among some, especially 1 FIORP is a joint federal, provincial and territorial protocol to guide multi-jurisdictional have the Minister responsible in the public health community, responses when a foodborne emergency for the CFIA act as lead, while that the Chief Public Health Officer arises .The roles and responsibilities of all it made sense initially given of Canada was not visible enough governments charged with investigating and managing such an outbreak are outlined in that the event was considered during the outbreak; and, the protocol . a food safety issue, limited
78 Chronology of the outbreak and federal public communications Infections with the Outbreak Strain of Listeria monocytogenes by Symptom Onset Date or Estimated date* 10 Aug 23: First federal ministerial news conference Aug 24: Recall of all products from Maple Leaf Foods Bartor Road 9 Aug 19: Recall of all Maple Leaf Foods Bartor Road products from lines 8 & 9 Sep 6: Last federal ministerial news conference 8 Sep 8: Federal election call
7 ational) N ersons
6 ffort ( Aug 17: Recall of Maple Leaf Foods Bartor Road Government of Canada Sure Slice products public communications 5 umber of P N
4 ommunications E
3 Sept 17: Maple Leaf Foods Bartor Road
plant re-open after its closure on Aug 20 Intensity of C 2
1
0 *** 1-Jun 8-Jun 6-Jul 13-Jul 20-Jul 27-Jul 3-Aug 7-Sep 5-Oct 2-Nov 15-Jun 22-Jun 29-Jun 10-Aug 17-Aug 24-Aug 31-Aug 14-Sep 21-Sep 28-Sep 12-Oct 19-Oct 26-Oct 9 -Nov 16 -Nov Week beginning of Illness Onset * Some illness onset dates have been estimated from available information August 22 to September 6: Peak of national communications Approximate representation of occurances of cases phase which concurrent with the timing of the recalls
»»The lack of preparedness applying the recently-adopted 2006 about the outbreak was difficult (e .g . unavailability of basic Risk Communications Framework) . to locate and understand . The communications material early on content of messages to the public for the most at-risk populations, KEY FINDINGS could have been improved by: no pre-existing arrangements Our findings are based on six »»better integrating the food safety with external suppliers for dimensions of the federal government’s and public health dimensions of key communications support, communications efforts: the outbreak; insufficient simulation-type training, »»Content: We heard from consumer »»getting their advice on the and inexperience with regard to organizations that information
Chapter 8 – How well were communications handled? 79 Suggestion content as well as asking for their assistance in rapidly “Appropriate authorities should increase communications to the general public during a foodborne disseminating information to disease outbreak using television, radio and other news sources.” consumers; »» A suggestion by a family affected by the outbreak »»Using more ‘plain’ language and everyday examples; and, improved the federal government’s the public perception of the »»ensuring consistent and communications to the public event .The CFIA was aware of and during the listeriosis outbreak supported Maple Leaf Foods’ harmonized definitions and »»Relationship with media: Since approach to communications . methods of calculating the the effectiveness of public Meanwhile, Canadians were number of cases among communications is enhanced seeking reassurance from organizations and between by a collaborative relationship government that public health governments . with media that can maximize was being protected . »»Timeliness: Federal the impact of communications, Having the Minister communications to the public were a strategy to establish and responsible for Agriculture and slow off the mark, and were not maintain such relationships should Agri-food and the CFIA serve as sustained for a sufficient period be developed and implemented . the lead ministerial spokesperson, of time During a public health emergency, was considered by some to be a »»Roles and responsibilities: The the media play two roles: a) ‘conflict of interest’ even though duties of federal agencies and to report, in an independent the minister has a legitimate role departments involved in managing manner, any related news it in relation to the food industry . the health emergency and in deems relevant, and; b) to relay It appeared to limit government’s communicating to the public important public health messages capacity to communicate health should be well understood by from the government regarding information sought by the public . both the general population and the emergency . The government The perceived lack of federal the media before an emergency should also make all possible public health leadership in the occurs .This would require efforts to ensure that its public event attracted many comments . efforts to better position these health messages are accurately »»Leadership and coordination: organizations (i e. ., clarifying and effectively communicated . Communications teams from mandate and functions; describing »»Spokespersons: Maple Leaf Foods the different federal agencies roles, activities and key practices took the lead in communicating to understood the importance before, during and after an Canadians about the cause of the of cooperation and they outbreak) . outbreak, assuming responsibility demonstrated a willingness to »»Communications strategy: for it and, in the process, shaping work together . However, the An advance communications strategy and related implementation plan, including Something we heard during our interviews: ready-made information products There was a general intent of the senior management at Maple Leaf Foods and the CFIA to cooperate and the use of traditional and fully on communications and to share to the extent possible, a common communication strategy. new media vehicles, would have
80 absence of a designated point and standard for federal research and analysis, and a communications coordinator government communication to the related implementation plan. resulted in a fragmented approach public on foodborne emergencies, The strategy should identify and seemingly inconsistent such as listeriosis. the target audiences, their messaging . This was compounded 40. Communications staff should be information requirements, and by the fact that the public, the aware of developing trends in how and by whom they are media, and even provincial and communication and ensure the best reached. territorial partners were not clear capability exists to use the best about the division of roles and vehicles available to reach key COMMUNICATIONS TO responsibilities among federal audiences as quickly as possible. organizations . A “one-stop” website PHYSICIANS »»Preparedness: Lack of appropriate capability should be developed The Canadian Medical Association advance planning resulted in in order to provide easier public (CMA) maintains an e-panel made up sometimes onerous adjustments access to crucial information. of 950 physician members of CMA who that delayed and impaired effective Accountability for its maintenance have agreed to respond to regular brief communications . should be clearly identified. electronic questionnaires about 41. A series of communication a variety of topical issues . Recommendations: measures that will contribute In April 2009, following discussions 37. The Public Health Agency of to an acceptable level of between the CMA and our team, an Canada should assume the preparedness should be identified e-panel survey2 on listeriosis asked lead role (non-ministerial) in and put into place. about the use of health alert advisories, communicating to the public for These would include information needed to diagnose and a national foodborne emergency. simulation training, contingency treat listeriosis cases, and preferred 38. The Canadian Food Inspection planning to ensure availability sources of information and methods Agency and the Public Health of key resources and ready of communication during a national Agency of Canada should enhance access to outside suppliers. disease outbreak .The survey was a their public profile to increase The measures should also combination of open- and closed- awareness of their mandates. include the preparation of ended questions . 39. The principles of risk certain communications material communications should drive the in advance, such as basic federal communications strategy information on listeriosis and and activities. Therefore, the other foodborne illnesses for Health Canada/Public Health at-risk populations and health 2 The survey was conducted in April 2009, Agency of Canada Strategic Risk providers. seven to eight months after the outbreak Communications Framework It would also include the occurred . According to the CMA, a 23% response rate is acceptable for e-panel surveys . should be implemented and development of a communications The e-panel includes physicians who use become the principal reference strategy, based on solid marketing electronic communication methods, thus their preferences are representative of this cohort .
Chapter 8 – How well were communications handled? 81 Key survey results: »»To more effectively diagnose and reduce disease and premature death . »»60% of the physicians surveyed treat suspected listeriosis cases, They do so by identifying and reducing remembered receiving a health physicians report they need health threats . Directly related to this alert on listeriosis (from some situation-specific clinical practice role, another key activity of public source), and of those, almost guidelines (96%), information health is educating people about how everyone (94%) judged it useful . on lab testing (90%), clinical to protect themselves from illness »»Responses to the open-ended case definitions (89%), screening and injury, and prevent the spread of questions highlighted the need questionnaires (86%) and websites diseases . for alerts to be concise and from tailored to physicians (86%) . With some exceptions, public one source, a centralized web site education efforts to raise awareness for physician information such as KEY FINDINGS about listeriosis were minimal when the guidelines and screening tools, »»Physicians value ‘just in time’ crisis struck . The majority of Canadians and notification of physicians information from credible source were unaware of those at greatest risk before the media . – outbreak (and local situation) of becoming ill if exposed to Listeria »»Physicians’ greatest challenges update, guidelines, patient monocytogenes, what foods these in educating patients about materials, etc . individuals should avoid, or proper food minimizing risks of foodborne »»They look first to local/provincial preparation and handling measures or illness are lack of patient friendly public health for information about the unique characteristics of Listeria . materials (77%), lack of knowledge an outbreak Overall, the scarcity of educational regarding the outbreak (69%), materials, coupled with the lack of and lack of time (69%) . PUBLIC EDUCATION awareness of listeriosis, contributed to »»Their preferred sources of public confusion about what individuals information during a foodborne Before the 2008 outbreak and the could and should do to protect outbreak are the local public widespread media coverage of the themselves during the 2008 outbreak . health unit (79%) and the foodborne disease outbreak, even The fact that there were nearly provincial or territorial department well informed Canadians were likely two and a half million visits to the of health (78%) or the provincial unaware of listeriosis . Given that older CFIA’s website between August 17 and or territorial Chief Medical Officer Canadians – one of the fastest growing September 14, and, that telephone of Health (75%) .The next most segments of the population – are the calls from consumers to the CFIA frequent sources would be Google most susceptible to the disease and climbed from an average of 75 calls (70%), the Centers for Disease that there are things individuals can per day to more than 1,400 daily Control and Prevention in Atlanta, do to protect themselves, there is a following the food recalls is a clear USA (62%) and the Public Health strong argument for public education indication of the public’s urgent Agency of Canada (57%) . programs to raise awareness about need for information about the »»Their preferred methods for the disease and its transmission . outbreak and how to avoid eating receiving information during a Information geared to members of contaminated foods . national disease outbreak are high-risk groups or those who care for Health Canada and the Public Health email alert (100%), web site them is especially important . Agency of Canada provided general (92%), fax alert (69%) and One of the primary functions of information about listeriosis on their mail (57%) . public health officials is to prevent and web sites . However, a telephone
82 Suggestion Recommendation: “There should be warning labels on food 42. To protect vulnerable packaging for high risk groups and more populations, including the public education funded by governments immuno-compromised, older regarding the prevention of foodborne people and pregnant women, illness among vulnerable populations.” Health Canada should promote »» A suggestion by a family affected by the consumer education into the outbreak risks associated with Listeria. This could include targeted hotline and other interactive measures, such as precautionary communications vehicles were not labelling. This should be available, so it is not possible to accomplished in collaboration compare the level of public interest in with the Public Health Agency of receiving information about the disease . Canada and in conjunction with Another example of targeted public provincial and territorial health education is labelling . We have heard partners. support for warning labels, which could be targeted to vulnerable populations to help educate and prevent the use of food products that could pose a risk to their health . We also heard other views from industry and institutional associations of the risk of over utilization of such labelling causing the public to become indifferent to their intent .
Precautionary Labelling NEXT CHAPTER
Some countries use warning labels that indicate are safe, those that require caution and those “Following the 2008 outbreak, each of the allergens or ingredients which may pose risks to that should be avoided by certain populations. key federal organizations (Health Canada, health for at risk populations. A variation of the ‘heart check’ approach to the Public Health Agency of Canada and identify foods that are safer for certain at-risk the Canadian Food Inspection Agency) In the U.K., a ‘traffic light warning’ system populations, the program provides information involved in the event prepared ‘lessons utilizes green, yellow and red colour coding on to consumers at the point of purchase. learned’ reports. …” product packages to identify which products
Chapter 8 – How well were communications handled? 83
CHAPTER 9 What progress has been made since the outbreak?
What progress has been made since the outbreak? Following the 2008 outbreak, each of the key federal organizations (Health Canada, the Public Health Agency of Canada and the Canadian Food Inspection Agency) involved in the event prepared ‘lessons learned’ reports .The objective of these reports was to assess the respective organizations’ performances in the outbreak, to identify any weaknesses, and to develop action plans to address these shortcomings .
85 Carol Swan account of their progress to date “The events of last summer exposed vulnerabilities in collective surveillance and in a national since the outbreak, as shared with us . protective network. We recognize that our work to improve is never done – that continuous The progress is presented using the improvement is key to food safety. Through the review process, we determined where immediate following four broad categories: improvements could be made and we have made them.” »»Policies »» Carol Swan, President, CFIA »»Surveillance and Laboratories appearing before the Agriculture Subcommittee on Food Safety, April 20, 2009 »»Foodborne Emergency Preparedness and Response At the provincial level, Ontario minimum, to respond more effectively »»Food Safety and British Columbia’s Chief Medical and efficiently when they occur . Officers of Health undertook similar Federal organizations involved in the NEXT CHAPTER exercises, reporting on their provinces’ outbreak were awaiting the report from management of the outbreak . the House of Commons Subcommittee “During the course of this investigation, On the industry side, Maple Leaf on Food Safety, which was tabled in we came across a number of issues which, Foods also conducted a post-outbreak June 2009, as well as this review by while not the focus of this review, have review in order to learn from the the Independent Investigator before raised important points that merit closer event .The company contracted finalizing improvements to their examination. …” an international panel of experts operations . comprising leading North American In the interim, some of the experts in Listeria control to review its recommendations generated by the operations at the Bartor Roadplant .The early post-outbreak reviews have panel was charged with identifying the already been acted on; in other cases, probable causal factors that resulted improvements are in progress . in Maple Leaf Foods inability to control Health Canada, the Public Health Listeria inside the plant and that Agency of Canada, the Canadian Food consequently led to the outbreak . Inspection Agency, and Maple Leaf Taken together, these post-outbreak Foods have all developed plans that reviews provide valuable lessons for identify the work in progress to meet the federal government, along with the recommendations set out in their its food safety partners and the food lessons learned reports . processors, about how to prevent Attached as Appendix C, provides foodborne illness outbreaks, or at a an overview of each organization’s
Michael McCain
“I think there are lessons learned that all stakeholders, from the regulator to Maple Leaf Foods and other industry participants, can capture from this tragedy and improve in the future.”
»» Michael McCain President and CEO, Maple Leaf Foods INC . Appearing before the Agriculture Subcommittee on Food Safety, April 20, 2009
86 CHAPTER 10 What else did we learn during this investigation?
What else did we learn during this investigation? During the course of this investigation, we came across a number of issues which, while not the focus of this review, have raised important points that merit closer examination .
Many of the things we heard and many of the issues we have considered have to do with the mandates of governments in ensuring Canada’s food safety . As others have said before us, Canada’s food safety requires the active, informed, and committed participation of all food safety partners . Current governance is not as sophisticated as this very important domain requires . Furthermore, many of the structures and the tools currently in place are outdated .
87 In a further effort to reform and entry for certain commodities . The bill conduct a comprehensive review modernize the food safety system in passed first reading but never made it and recommend improvements Canada, we offer the following guidance further on the House calendar due to in a timely manner, taking to the Government of Canada on an election . into account the amendments additional matters, which should be The Auditor General’s 2000 Report to or additions required to acted upon . Parliament noted constraints in federal enforce, where applicable, the food legislation and recommended recommendations included in this Government of Canada that the government address report (e.g. the requirement to these limitations .The government disclose any threat to food safety Food Safety Legislative acknowledged this recommendation . as covered by recommendations and Regulatory In 2004, the government introduced 6 and 20). Framework a modification of the earlier bill that focussed only on inspector powers and Federal organizational Several pieces of key federal a series of prohibitions and licensing legislation in place to govern food provisions . The bill, like the 1999 draft governance and structure safety and quality were enacted by legislation C-80, did not proceed . Through interviews with senior Parliament many decades ago (e .g . the A third attempt to update selected executives from various levels of current Food and Drugs Act was first federal food safety legislation was government, industry, and other enacted in 1951) . These are widely introduced in the spring of 2008, stakeholders, as well as the recognized to be out of date and in but it also died on the order paper documentation review, we identified need of substantial consolidation and when the election was called in governance and structural problems . modernization . September 2008 . These recommendations are After the CFIA was created in A fourth attempt is currently being relevant to the overall performance 1997, a bill was drafted to deal with considered, although the scope of and effectiveness of the federal legislative shortcomings known at that the proposed changes is modest organizations that were involved in the time . In 1999, Bill C-80, the Canada in relation to earlier proposed 2008 outbreak and their relationships Food Safety and Inspection Act, was amendments . We heard that the latest with provincial and territorial partners tabled in the House of Commons . proposed legislative changes are under in carrying out their food safety The proposed bill would have allowed discussion . mandates and responsibilities . for the enhancement of inspectors’ powers, the implementation of Recommendation: Canadian Food electronic commerce, inspection of all 43. To simplify and modernize federal Inspection Agency food products at points of entry, the legislation and regulations which licensing of all food importers, and significantly affect food safety, Governance, structure, the designation of specific points of the Government of Canada and accountability should mandate a lead agency to The Canadian Food Inspection Agency Something we heard during our interviews was created, in part, to contribute to consumer protection and to create a Science changes quickly, regulations do not. more uniform and consistent approach to safety and quality standards as
88 well as a risk-based inspection system . meaningful collaboration . There is little plant’s unique characteristics .This is These expectations have not been information available publicly on overall an example of the organization not fully met . program performance, expectations, and putting appropriate emphasis on a key Several attempts were initiated to costs beyond the high-level measures component of its regulatory mandate . update federal food safety laws and found in the CFIA’s Departmental With respect to accountability to introduce risk-based approaches to Performance Report . Developing to Parliament and Canadians, the the CFIA inspection activities . However, clearer lines of authority by introducting Canadian Food Inspection Agency has while Bills were presented, they were organizational direction, responsibility, tabled, in lieu of its legislated five-year not adopted because events including and accountability measures could Corporate Business Plan (2008-2013), elections and major crises, such as improve the Agency’s performance a one-year operational plan taken mad cow and avian influenza outbreaks, and enhance collaboration within and entirely from its annual Report on Plan disrupted the CFIA’s renewal agenda to outside the organization . and Priorities document (Estimates, update laws and programs . Also noteworthy is the frequent Part III) . This submission falls short Furthermore, by establishing the turnover of the person appointed as of the five-year plan required by the Agency, the government sought a President (Chief Executive Officer) of legislation . As well, the absence of a greater degree of collaboration the CFIA . The Canadian Food Inspection consultative process with the Agency’s and consultation among federal Agency Act authorizes the appointment partners and stakeholders, and a lack of organizations and with other levels of of a President for a renewable five-year consensus on a shared long-term vision government . This collaboration has not term . Since the Agency’s creation in on its primary areas of focus for the next yet happened to the degree anticipated . 1997, no president has stayed for a five-year business cycle, has isolated As noted in previous chapters, there full five years . Five different presidents the CFIA . were problems with collaboration and have been appointed in the past 12 The oversight and decision-making there was confusion about the roles and years . This level of change at the most associated with the CFIA’s resources responsibilities of various organizations senior position of the organization does allocation, regulatory program delivery, during the initial stages of the food not promote continuity of executive and personnel management appears to safety investigation . management or advance the renewal lack the rigour warranted by a regulatory In addition, the Canadian Food agenda . agency of this nature . The previous Inspection Agency is limited by the The introduction of the new federal example of the Agency’s Corporate fact that it is organized, structured, meat inspection system (Compliance Business Plan for 2008-13 is another and managed as a traditional federal Verification System) lacked adequate demonstration of functioning more department . Its objectives would planning and consultation and was like a department in the conduct of its be better achieved if it had greater not approved by the Agency’s Executive business . flexibility to focus on its primary Committee . While the Canadian Food Inspection regulatory mandate of inspection As previously described, the CVS Agency Act includes a provision for a (compliance) and enforcement . The has shortcomings, including the fact Minister’s Advisory Board to provide current model has not resulted in clear that inspectors’ tasks have not been advice on any matter within the lines of authority, accountability, or adjusted to take into account each responsibilities of the Agency, Board
Chapter 10 – What else did we learn during this investigation? 89 Bob Kingston members have not been appointed since 2002 . “If you look after animal and plant health and food safety in Canada – your goods will be highly These factors represent, within the marketable in other countries.” context of our investigative review, the »» Bob Kingston rationale for the introduction of an President of the Agriculture Chapter of the Public Service Alliance of Canada enhanced model of governance for the CFIA . Advisory Board established under subsection 10 (1) of the Canadian Broad mandate Recommendations: Food Inspection Agency Act. that covers three 44. As soon as possible, the Canadian The Board should be specifically lines of business Food Inspection Agency, directed to advise the Minister supported by independent on issues relevant to the vision, The Canadian Food Inspection Agency experts, should initiate a accountability, mandate, and has a broad mandate that covers the comprehensive review of public perception of the Agency administration and/or enforcement a. its organizational structure; and risk management. of thirteen laws, which regulate b. the current delegation of 46. The federal government should more than thirty-five sectors of the responsibility and lines of endorse the need for continuity economy . These sectors are commonly accountability within the and vision at the Canadian Food categorized under three lines of Agency; and Inspection Agency by making business: food safety, animal health, c. its decision-making processes. efforts to ensure, wherever and plant health . 45. Concurrent with the review, practical, that the 5-year The inherent complexities of such the federal government mandate given to the President breadth and the constant pressures of should consider replacing the under section 5 of the Canadian emerging issues, including numerous current requirement for an Food Inspection Agency Act is crises management interventions Advisory Board with a Board of fulfilled. in those sectors, limit the Executive Management which, subject to 47. As a regulatory agency, the Committee’s ability to be anticipatory powers to be retained by the Canadian Food Inspection and proactive . Minister including all decisions Agency should create a formal In our view, the CFIA could benefit related to policy, legislative, and transparent consultation from the ongoing advice of experts regulatory and emergency strategy to define its required in the field to stay current with the matters, should oversee the engagement with stakeholders. numerous elements that should be organization and operational 48. To ensure consistent and timely guiding the organization’s future .These management of the Canadian enforcement practices across experts could help each management Food Inspection Agency, and the country, the Canadian Food team focus on current, and anticipate advise the Minister on policy Inspection Agency should review future, changes affecting each line matters. the interpretation and application of business . They could also assist in designing appropriate and timely At a minimum, the federal of its rules and enabling regulatory interventions to meet the government should consider the legislation. needs of consumers and industry . immediate appointment of the In saying this, we acknowledge the
90 advice being provided by the CFIA’s changes in the organization over the to public health threats, including Scientific Advisory Committee and Audit years have resulted in the removal of foodborne illnesses . Committee (which includes external some key functions that reduce its The PHAC’s creation followed members) . effectiveness in times of emergency . recommendations from leading public During the 2008 outbreak, recall health experts who called for clear Recommendation: activities were managed within this federal leadership on public health 49. The three main lines of business single part of the organization, with matters and improved collaboration of the Canadian Food Inspection very limited engagement of senior within and between jurisdictions . Agency, food safety, animal executives . Nevertheless, the recall We heard continued support for health, and plant health should activities associated with the outbreak the PHAC to play this role . be assisted by permanent expert were appropriate and all standard As was said of the CFIA, we heard advisory committees to guide operating procedures were followed . that the PHAC’s structure too closely their evolution. resembles that of a federal department . Recommendations: As a result, it may be hampered in its Office of Food 50. The Office of Food Safety and ability to fulfil its mandate . Recall should report directly to We repeatedly heard that the Centre Safety and Recall the office of the President of the for Foodborne, Environmental, and A further concern raised during the Canadian Food Inspection Agency. Zoonotic Infectious Diseases team is investigative review is the structural 51. The Canadian Food Inspection under-resourced and not optimally situation of the Office of Food Safety Agency should ensure that the organized to face growing emergency and Recall within CFIA .The Office was Office of Food Safety and Recall situations . Because of globalization, established as a stand-alone operation has dedicated resources to the incidence of foodborne illnesses is following a major foodborne emergency undertake all the CFIA activities increasing . Foodborne illness is now in 1999 due to pre-packaged luncheon concerning recalls. The Office of the largest class of emerging infectious meats . The incident involved 800 Food Safety and Recall should be diseases in Canada . And, at that, there Canadians, mainly children, who identified as the CFIA’s primary is a growing consensus that the actual became ill after eating tainted foods . point of contact with Health rate of foodborne diseases maybe be The mandate of the Office is Canada during a food emergency. 300 to 350 times more frequent than to coordinate food emergency the number of reported cases suggests 1. investigations and execute recall Public Health The PHAC does not appear to have activities (including identifying the Agency of Canada adequately adjusted its focus to be source of food contamination), as The Public Health Agency of Canada ready to respond to this new reality . well as supporting Health Canada in was established in 2004 in response conducting health risk assessments . to growing concerns about the capacity The Office has critical responsibilities of Canada’s public health system to 1 Public Health Law & Policy in Canada, Second that do not easily fit within any anticipate and respond effectively Edition, Bailey, Caulfield, Ries, Chapter 12, particular part of the CFIA . Repeated Foodborne Illness and Public Health (Ronald L . Doering), p . 483-4 .
Chapter 10 – What else did we learn during this investigation? 91 As well, we heard that more attention Recommendations: Multi-departmental should be given to the management 52. As soon as possible, the Public governance of food safety needs of this organization as it is Health Agency of Canada, Responsibility for food safety within the primarily an operational entity . supported by independent federal government is shared to various Its main concerns should be to experts, should initiate a degrees among the Canadian Food »»develop the capacity and the comprehensive review of its Inspection Agency, Health Canada, and capability to rapidly and efficiently structure and operational the Public Health Agency of Canada . respond to the broad spectrum procedures with the objective of While some would propose that a of health emergency situations ensuring a more responsive and single organization should assume that fall within the mandate of the flexible organization to support responsibility for all these functions, federal government; national readiness for public we recognize that it would be too »»adjust the assignment of resources health threats. complex and inefficient to address the to pre-determined priorities; 53. Concurrent with the review, current gaps and conflicts by such a »»identify the surge capacity needs the federal government major structural change . to support various emergencies should consider permanently However, we believe that there in infectious, communicable, and assigning day-to-day operational is an urgent need to put in place a foodborne diseases; management responsibilities coordinating body, which should focus »»continuously create better of the Public Health Agency of on implementing actions to address networks among various Canada to an associate deputy the recommendations presented in components of the federal- head (i.e. a Chief Operating this report . It could also examine provincial/territorial-local Officer equivalent to a second- the opportunity to institute a joint operational response systems in-command) to allow the Chief Scientific Committee on Food Safety . needed to manage public health in Public Health Officer to focus Consideration could be given to a Canada; and on his executive duties and more permanent structure to develop »»address technology support gaps responsibilities as the lead health an overall approach to federal food to enable this dispersed network of professional of the Government safety policies and programs with a public health officials to respond of Canada in relation to public more cohesive and forward looking quickly to health emergencies . health and to ensure continuity agenda than is currently in place, such We heard that the PHAC was of management. as existed between 1988 and 1994 – expected to be more advanced in At a minimum the day-to- the Interdepartmental Committee of its development after five years, day operational management Food Regulations . especially in the area of national responsibilities of the Chief With the creation of PHAC and health emergency leadership and Public Health Officer of the introduction of a third federal entity management . However, we have also PHAC during a national foodborne with key responsibilities for food safety heard that recent progress has been emergency, should be temporarily in 2005, the need for joint action is noted with respect to the way the assigned to an acting deputy greater than ever and demands a pre- current H1N1 health crisis has been head for the PHAC until the end determined coordinating structure to handled . of the emergency. instil rigour, focus, and timely direction .
92 Dr. David Williams Recommendation: 54. The Clerk of the Privy Council “It was not clear to the partners which responsibilities rested with the Public Health Agency of should appoint an independent Canada and the Chief Public Health Officer, and which ones with the Chief Medical Officer of Health expert to chair a special in Ontario. It was also not clear whether the lead federal agency was PHAC or the CFIA, or to what committee of the deputy ministers extent local medical officers of health or the Chief Medical Officer of Health in Ontario could act alone to protect public health.” responsible for Health Canada, »» DR . David Williams the Public Health Agency of Chief Medical Officer of Health’s Report Canada, and the Canadian Food on the management of the 2008 Listeriosis Outbreak in Ontario Inspection Agency. The chair should report to the Clerk directly. This committee should provide provincial powers set out in the ensure that terminology was uniform recommendations to improve Constitution Act, 18672 . and consistent . the ways the organizations work Food safety is important to all These efforts have evolved and together in their roles in food consumers and, therefore, important increased over the past two decades, safety. It should also oversee the to all levels of government . Canadians yet many of the problems remain development of our proposal to expect governments to collaborate and unresolved .This was noted in the simplify and modernize federal ensure that the food supply is safe, 2004 Auditor General of Canada legislation and regulations. wherever they eat or purchase their Report on the Food Safety System, The first tasks of this food, and care little about jurisdictional which highlighted the complexity committee should be to reduce matters . and challenges faced by all levels of overlaps and address gaps among Nonetheless, improving the way government in effectively managing such the organizations, improve governments address food safety is a a demanding sector . communication and the sharing cumbersome undertaking, given the There is a Federal-Provincial/ of information, resolve existing multiple jurisdictions and complex Territorial Food Safety Committee, issues preventing harmonization issues involved . Moving forward in an currently composed of, and chaired of roles, and provide a report on efficient and proactive manner remains by, Assistant Deputy Ministers from these matters within six months. a challenge for all . Health and Agriculture Ministries across Despite these difficulties, since the Canada . Its purpose is to present all Multi-jurisdictional mid-1980s, a series of coordinated government perspectives on food safety governance of food safety efforts among the various jurisdictions as new issues emerge . At the national level, food safety is has led to the development of Although this committee released a the joint responsibility of the federal, preliminary components of a national draft report in September 2008 entitled provincial and territorial, and local integrated food safety system . ‘National Strategy for Safe Food’ . governments . This joint responsibility For example, in 1989 there was work However, the report addresses only has its roots in the federal and to review regulations and statutes to some of the weaknesses that became apparent in the 2008 outbreak . More 2 Online: http://laws justice. .gc .ca/en/const/1 . concerted and focused efforts are html
Chapter 10 – What else did we learn during this investigation? 93 needed to address current gaps in the 57. Following its receipt and review multi-jurisdictional management of Going forward of this report, the government foodborne emergencies . Furthermore, In the November 2008 Speech for the should commit to reporting back this report does not appear to have Throne and subsequent budget, the to Canadians, within two years, been endorsed by Ministers . Government of Canada committed to on the implementation of the In recent years, the work of the “keeping Canadians safe by putting in recommendations contained Food Safety Committee on has not place new rules for food safety ”. in this report together with had the same level of support as in The 2008 outbreak has underscored an assessment of their impact the past when Deputy Ministers led the importance of a safe and nutritious on improving Canada’s food these files on behalf of their respective food supply to the social and economic inspection and food safety governments . well being of all Canadians . In addition, emergency response systems. given the increase in foodborne Recommendation: emergencies around the world, it is 55. Considering the serious important for all Canadians as well implications of foodborne as for Canada’s reputation as a major illnesses, governments should world class supplier of safe and high create a distinct federal, quality food, to continue to instil public provincial and territorial confidence in Canada’s food production committee reporting regularly and distribution chain . to the federal Minister of Health. Canada is well positioned to The Minister should share the succeed as it addresses the various progress of this committee with recommendations outlined in this report . his provincial and territorial However, in light of the findings of this ministerial counterparts regularly. investigation, and in order to play a This committee should global leadership role, the following is enable national preparedness for recommended . foodborne outbreaks. One of its first tasks should be to develop Recommendations: and implement programs alerting 56. In setting its agenda for the fall vulnerable populations to the of 2009, the government should be risks of listeriosis and identifying mindful that due to globalization recommended sanitation and and increased Canada-wide prevention practices. production and distribution of The committee should be food, food safety will require composed of officials from the increased attention. Although Health and Agriculture Ministries Canada is already a leader in food across Canada, the Canadian Food safety practices and systems, the Inspection Agency, and the Public government should clearly and Health Agency of Canada. emphatically commit to the safety of food as one of its top priorities.
94 Appendix A Biographies
95 Independent Investigator Sheila Weatherill, C.M., B. Sc.N. Ms .Weatherill earned her B .Sc . in Nursing and the Association of Canadian Academic Health Organizations post‑graduate Diploma in Public Health from the and the Edmonton YMCA . University of Alberta . Ms .Weatherill was named one of Canada’s 100 Most She has occupied a number of positions in the Powerful Women by the Women’s Executive Network in 2003, administration and delivery of health services prior to 2004, 2005 and 2006 and admitted to its Hall of Fame becoming President and CEO of Capital Health (Edmonton, in 2007 . Alberta) from 1996 to 2006 . Capital Health is one of In July 2006, Ms .Weatherill was appointed a Member of Canada’s largest integrated, academic health systems, the Order of Canada . In November 2006, she was appointed providing health services to over one million residents in a member of the Prime Minister’s Advisory Committee on the Edmonton and area and complex tertiary/quaternary services Public Service, and in May 2008, she received the degree to two million people across central and northern Alberta and of Doctor of Laws honoris causa from the University of northern and western Canada . Lethbridge . Her most recent initiatives include the development of the Mazankowski Alberta Heart Institute, Western Canada’s first heart institute; the Edmonton Clinic, a new patient-centred approach to ambulatory care, education and research; and netCARE, Alberta’s first electronic health record . Ms .Weatherill is active in community and professional organizations . She is currently Vice-Chair of EPCOR’s board of directors as well as serving on the board of directors for Shaw Communications . She is an Associate Member of the Faculty of Nursing at the University of Alberta . Ms .Weatherill has previously served on the boards of the Conference Board of Canada, the Canadian Institute for Health Information,
96 Expert Advisory Group John Carsley MD CM MSc CCFP FCFP FRCPC Dr . John Carsley is a Medical Health Officer for the Medicine, as associate professor in the department of Vancouver Coastal Health Authority in British Columbia, Family Medicine and the department of Epidemiology and medical consultant to the Infant, Child & Youth Program Biostatistics and Occupational health, at Université de in Vancouver, and School Medical Officer for BC School Montréal, and, since moving to Vancouver, for the community District 39 . medicine post-graduate education program at the University A Community Medicine Specialist, Dr . Carsley is a graduate of British Columbia . He is a Fellow of the Royal College of Yale University and the McGill University Faculty of Medicine, of Physicians and Surgeons of Canada and the College where he received his medical degree and a Master’s degree of Family Physicians of Canada . in Epidemiology and Biostatistics .After completing residency training in both family medicine and community medicine at Walter F. Schlech III, MD the Montreal General Hospital, he worked for the Department of Community Health of the Montreal General Hospital (le Dr . Schlech is a graduate of Williams College (BA, Poli Sci) Département de santé communautaire de l’Hôpital générale and Cornell University Medical College (MD) . He is certified de Montréal) and the Public Health Department (la Direction in Internal Medicine and Infectious Diseases and currently de santé publique) of the Montreal Health and Social Services Professor of Medicine in the Dalhousie University Faculty of Agency (l’Agence de la santé et des services sociaux de Medicine and a member of the Division of Infectious Diseases . Montréal) . He has been involved in listeria research since 1980 when In his twenty-five years in this urban public health setting, as an Epidemic Intelligence Officer at CDC, Atlanta, his team he worked in primary care organization, immunization helped investigate the Maritime listeriosis outbreak in 1981, programming and evaluation, communicable disease the largest at the time, and established for the first time that prevention and control, and environmental health, spending listeriosis was a foodborne disease . He has subsequently the last ten years in Montreal as head of the health protection carried out work in both the pathogenesis and epidemiology sector . He has been involved in the investigation of, and of foodborne listeriosis . He organized the XIIth International response to, many significant outbreaks of communicable Symposium on Problems of Listeriosis (ISOPOL) which disease at the local, regional and national levels and has occurred in Halifax in 1998 . served on a wide variety of regional, provincial and national As a clinical researcher, his other interests include research expert committees on communicable disease prevention in a wide variety of infectious diseases including HIV .He is a and public health program development, practice and policy . past president of the Canadian Infectious Diseases Society, As well, Dr . Carsley has had a long career as a public a past member of the National Advisory Committee on AIDS health teacher, both in McGill University’s Faculty of in Canada and CDC Atlanta’s Advisory Committee on HIV, STD,
Appendix A – Biographies 97 and Tuberculosis . He is a principal investigator of the Canada- Scientific Advisory Committee for Dairy Farmers of Canada . Africa Prevention Trials (CAPT) Network with partnerships He is Chair of the International Advisory Board of the EU 6th in Uganda, South Africa, and Kenya . Dr Schlech is also Framework Project entitled “Biotracer” . He was the recipient Governor for the Atlantic Provinces of the American College of the International Association of Food Protection Maurice of Physicians and a member of its International Advisory Weber Laboratorian of the Year for 2002 and served on the Committee . Ontario Meat Inspection Review, Expert Scientific Advisory Committee in 2004 . In 2006 he was appointed Visiting Dr Mansel W. Griffiths Professor at Jinan University, China . Dr Griffiths was born and raised in Swansea, S .Wales . He took his BSc degree in Applied Biology at North East London R. Bruce Tompkin Polytechnic and his PhD was obtained from Leicester Bruce received his Ph .D . in microbiology from Ohio State University where he studied the biochemistry of thermophilic University in 1963 and started as a research microbiologist microorganisms under the supervision of Sir Hans Kornberg . with Swift & Company in 1964 . He became Chief Dr Griffiths was appointed to the staff of the Hannah Microbiologist in 1966 and retained that position until Research Institute, Ayr, Scotland in 1974 and, in 1980, 1993 when he was promoted to Vice President Product he was appointed head of the Dairy Microbiology Safety for ConAgra Refrigerated Foods . He and his colleagues group . In 1990 Dr Griffiths was appointed Chair in Dairy investigated how to control pathogens in a wide variety of Microbiology in the Food Science Department at the foods and food processing environments, new processing University of Guelph . Dr Griffiths’ position is funded jointly technologies, the use of additives to improve food safety and by the Dairy Farmers of Ontario and the Natural Science the role of sodium nitrite in controlling Clostridium botulinum . and Engineering Research Council of Canada (NSERC) . From 1987 until his retirement approximately 70% of his Dr Griffiths is Program Chair for the M .Sc . in Food Safety time was devoted to managing Listeria in ready-to-eat food and Quality Assurance being offered at Guelph and is the operations . During that time the company grew to include Director of the Canadian Research Institute for Food Safety . over 200 packaging lines for ready-to-eat meat and poultry His current research interests include rapid detection products in more than 25 plants .A significant portion of his of foodborne pathogens; factors controlling growth and time involved sharing best practices with others in industry, survival of microorganisms in foods; and beneficial uses of government and academia . He has contributed more than microorganisms . Dr Griffiths has authored more than 250 175 publications, presentations and 30 book chapters . peer-reviewed articles and appears on ISI HighlyCited com. . Bruce was a member of the US National Advisory Dr Griffiths is an Editor of Applied and Environmental Committee on Microbiological Criteria for Foods for Microbiology; an Associate Scientific Editor of the Journal of 10 years and the International Commission Microbiological Food Science, a member of the Executive Editorial Board of Specifications for Foods for 20 years, serving as a consultant Journal of the Science of Food and Agriculture, and serves on to the Commission for an additional 7 years . He helped the editorial boards of Food Research International, Journal define the principles of HACCP, the concept of a food safety of Food Protection, International Journal of Food Microbiology objective, the role of microbiological testing in food safety and Foodborne Pathogens and Disease . He is a member of management systems and the significance of harborage sites the International Dairy Federation working group on milk- as a source of Salmonella and Listeria in food operations . He borne pathogens and is chair of the Canada IDF Coordinating retired from ConAgra in 2002 and continues to promote food Committee on Food Safety . He also serves on the Expert safety through participation on committees and other means .
98 Michael P. Doyle Dr . Michael P . Doyle is a Regents Professor of Food Microbiology and Director of the Center for Food Safety at the University of Georgia . He is an active researcher in the area of food safety and security and works closely with the food industry, government agencies, and consumer groups on issues related to the microbiological safety of foods . Dr . Doyle is a graduate of the University of Wisconsin-Madison where he received his B .S . degree in Bacteriology, and M .S . and Ph .D . degrees in Food Microbiology . He serves on food safety committees of many scientific organizations and has served as a scientific advisor to many groups, including the World Health Organization, the Institute of Medicine, the National Academy of Science-National Research Council, the International Life Sciences Institute-North America, the Food and Drug Administration, the U .S . Department of Agriculture, the U .S . Department of Defense, and the U .S . Environmental Protection Agency . He has more than 350 scientific publications and has given more than 700 invited presentations at national and international scientific meetings . In addition, he has received several research awards from academic and national scientific organizations, is a Fellow of the American Academy of Microbiology, the International Association for Food Protection and the Institute of Food Technologists, and is a member of the National Academies Institute of Medicine .
Appendix A – Biographies 99
Appendix B Chronology of the listeriosis outbreak
Chronology of the listeriosis outbreak The following chronology has been prepared based on the detailed review of information available to the investigative team from both testimony and documents .
The investigation identified key documents and testimony which have been used to validate each entry . Certain entries were drawn, and relied upon, from the chronologies prepared in the lessons learned reports of the Federal (CFIA/HC/PHAC) and Provincial (MOHLTC) departments and agencies involved with these events .
101 ACRONYMS PRE-OUTBREAK AAFC Agriculture and Agri-Food Canada »» Week of March 25, 2007 CEO Chief Executive Officer [1] Increase in positive Listeria test results, on line CFEZID Centre for Foodborne, Environmental, Zoonotic 7 from the MLF plant’s environmental monitoring and Infectious Disease (PHAC) program . CFIA Canadian Food Inspection Agency CIOSC Canadian Integrated Outbreak Surveillance »» Week of July 22 Centre [2] Increase in positive Listeria test results, on line CMOH Chief Medical Officer of Health 8 from the MLF plant’s environmental monitoring program . CPHO Chief Public Health Officer CVS Compliance Verification System »» Week of August 12 FIORP Foodborne Illness Outbreak Response Protocol [3] Increase in positive Listeria test results, on line P/T Provincial/Territorial 8 from the MLF plant’s environmental monitoring HACCP Hazard Analysis Critical Control Point program . HC Health Canada LRS Listeriosis Reference Service (HC) »» Week of November 18 HRA Health Risk Assessment [4] Increase in positive Listeria test results, iPHIS Integrated Public Health Information System on lines 7 & 8 from the MLF plant’s MLF Maple Leaf Foods environmentalmonitoring program . MOHLTC Ministry of Health and Long-Term Care (Ontario) »» Friday, February 1, 2008 NML National Microbiology Laboratory (PHAC) [5] Earliest production date of a sample that tested positive for L. monocytogenes of a product OFSR Office of Food Safety and Recalls (CFIA) produced on line 7 at MLF Bartor Rd of MLF OMAFRA Ontario Ministry of Agriculture and Food and based on CFIA’s post recall sampling . Rural Affairs PHAC Public Health Agency of Canada »» Week of February 4 PFGE Pulsed Field Gel Electrophoresis [6] Increase in the positive Listeria test results, on PHU Public Health Unit line 7 from MLF plant’s environmental monitoring RTE Ready-to-eat program . TPH Toronto Public Health US United States »» Wednesday, April 2 [7] MLF completes a Positive Recovery Corrective Action Report (CAR) for Bartor Rd in response to the positive Listeria environmental program results .
102 EMERGENCE OF OUTBREAK »» Thursday April 10 »» Tuesday, June 3 [8] MLF completes a Positive Recovery Corrective [13] Earliest known onset of human illness related to Action Report (CAR) for Bartor Rd in response to the listeriosis outbreak positive Listeria environmental program results . »» Thursday, June 12 »» Wednesday, April 16 [14] Slicing dates of product from MLF that tested [9] MLF completes a Positive Recovery Corrective positive that was collected and analyzed during the Action Report (CAR) for Bartor Rd in response to week of August 12 the positive Listeria environmental program results . »» Tuesday, June 17 »» Week of May 19 [15] First death linked to listeriosis from contaminated [10] Increase in the positive Listeria test results, on line MLF products (diagnosed on June 10 and 7 & 8 from MLF plant’s environmental monitoring confirmed August 14) . program . »» Friday, June 20 »» Wednesday, May 14 [16] Slicing dates of product from MLF that tested [11] MLF completes a Positive Recovery Corrective positive that was collected and analyzed during the Action Report (CAR) for Bartor Rd in response to the week of August 12 . positive Listeria environmental program results . »» Week of June 23 »» Thursday, May 27 [17] Increase in the positive Listeria test results, [12] MLF completes a Positive Recovery Corrective from line 8 & 9 of the MLF plant’s environmental Action Report (CAR) for Bartor Rd in response to the monitoring program . positive Listeria environmental program results . »» Tuesday, June 24 [18] MLF completes a Positive Recovery Corrective Action Report (CAR) for Bartor Rd in response to the positive Listeria environmental program results . [ID#141910] [Food Safety Investigation]
Appendix B – Chronology of the listeriosis outbreak 103 »» Wednesday, June 25 »» Saturday, July 5 [19] Slicing dates of product from MLF that tested [26] Slicing dates of product from MLF that tested positive that was collected and analyzed during positive that was collected and analyzed during the week of August 12 . the week of August 12 .
»» Thursday, June 26 »» Monday, July 7 [20] Slicing dates of product from MLF that tested [27] Slicing dates of product from MLF that tested positive that was collected and analyzed during positive that was collected and analyzed during the week of August 12 . the week of August 12 .
»» Friday, June 27 »» Tuesday, July 8 [21] Slicing dates of product from MLF that tested [28] Slicing dates of product from MLF that tested positive that was collected and analyzed during positive that was collected and analyzed during the week of August 12 . the week of August 12 .
»» Saturday, June 28 »» Wednesday, July 9 [22] Slicing dates of product from MLF that tested [29] Slicing dates of product from MLF that tested positive that was collected and analyzed during positive that was collected and analyzed during the week of August 12 . the week of August 12 .
»» Monday, June 30 »» Thursday, July 10 [23] Slicing dates of product from MLF that tested [30] As part of routine sampling, NML receives several positive that was collected and analyzed during human isolates of L. monocytogenes from the the week of August 12 . Ontario MOHLTC for DNA fingerprinting .
»» Thursday, July 3 »» Saturday, July 12 [24] Slicing dates of product from MLF that tested [31] Slicing dates of product from MLF that tested positive that was collected and analyzed during positive that was collected and analyzed during the week of August 12 . the week of August 12 .
[25] MLF completes a Positive Recovery Corrective »» Monday, July 14 Action Report (CAR) for Bartor Rd in response to the [32] Slicing dates of product from MLF that tested positive Listeria environmental program results . positive that was collected and analyzed during the week of August 12 .
104 »» Tuesday, July 15 [40] The MOHLTC’s Toronto Service Area Office receives [33] Slicing dates of product from MLF that tested a call from a Toronto long-term care facility on the positive that was collected and analyzed during the evening of July 21st .The facility reports that it has week of August 12 . two cases of listeriosis . One resident had died and the death is being investigated by the coroner’s »» Wednesday, July 16 office; another resident was hospitalized .The Toronto Service Area Office forwards this information [34] TPH begins investigating two cases of listeriosis to MOHLTC . in the same long-term care facility in Toronto . 11 food samples are collected and sent to TPH Labs . »» Tuesday, July 22 Samples were collected from prepared meals (retention samples) but were not linked to a [41] MOHLTC analyzes surveillance information from manufacturer or production date . iPHIS and finds no listeriosis illnesses reported from long term care facilities . [35] Slicing dates of product from MLF that tested positive that was collected and analyzed during [42] MOHLTC makes contact with TPH to follow up on the week of August 12 . reported cases of listeriosis in the long term care facility . »» Friday, July 18 [43] MOHLTC (Lab) receives eleven food samples [36] As part of routine sampling, NML testing identifies collected for testing by TPH from investigation two human listeriosis samples received from launched July 16 . MOHLTC that have matching DNA fingerprints . [44] Slicing dates of product from MLF that tested [37] Slicing dates of product from MLF that tested positive that was collected and analyzed during the positive that was collected and analyzed during week of August 12 . the week of August 12 . »» Wednesday, July 23 »» Monday, July 21 [45] MOHLTC (Lab) forwards eleven food samples [38] Slicing dates of product from MLF that tested received on July 22 to the LRS . positive that was collected and analyzed during the week of August 12 . »» Thursday, July 24 [39] MLF completes a Positive Recovery Corrective [46] LRS receives the eleven food samples sent Action Report (CAR) for Bartor Rd in response to by MOHLTC . the positive Listeria environmental program results .
Appendix B – Chronology of the listeriosis outbreak 105 »» Friday, July 25 »» Wednesday, July 30 [47] MOHLTC program staff detects an increase in the [54] MOHLTC initiates conference call with PHAC, HC number of cases of listeriosis from iPHIS data . and 15 Ontario PHUs .Actions taken include: 1) MOHLTC asks public health units to ensure Listeria [48] LRS begins analyzing the eleven samples . isolates are forwarded to MOHLTC (Lab) who will then submit human isolates to the NML and food [49] Slicing dates of product from MLF that tested isolates to LRS; 2) LRS continues to receive and positive that was collected and analyzed during the analyze food samples and isolates; and 3) MOHLTC week of August 12 . issues an Enhanced Surveillance Directive to all PHUs, requesting additional and timely reporting »» Monday, July 28 of listeriosis cases through iPHIS and that Listeria [50] MOHLTC (Lab) reviews all cases of listeriosis from isolates be sent to the MOHLTC (Lab) . January 1 to July 28, 2008 . MOHLTC staff contacts MOHLTC (Lab) and confirms 6 listeriosis cases [55] NML informs MOHLTC that the results from the first (more than expected for July) . MOHLTC continues available PFGE data for Ontario Listeria isolates investigating listeriosis cases (from July 25) . collected prior to July 31st does not suggest a common source outbreak (clustering) as only 2 of [51] Slicing dates of product from MLF that tested the 13 human Listeria isolates have the same DNA positive that was collected and analyzed during the fingerprint . week of August 12 . [56] Slicing dates of product from MLF that tested [52] Halton Region Health Department sampled meats positive that was collected and analyzed during the from unopened boxes that were used at the week of August 12 . Burlington Hospital (ham, roast beef and turkey) and forwarded them to the Hamilton Public Health »» Thursday, July 31 Lab for testing . [57] MOHLTC continues to field calls from PHUs and assist with case management . »» Tuesday, July 29 [53] MOHLTC notifies CFEZID of an increase in the [58] MOHLTC forwards questionnaire and food sampling number of listeriosis cases reported by Ontario information sheets for use in prioritizing cases e .g . health units .An alert, through CIOSC, is issued to cold cuts, to PHUs to assist with epidemiological all provincial, territorial and local health authorities investigation for the listeriosis cases . MOHLTC also across Canada regarding the increase in listeriosis advises PHUs to collect food samples, providing cases .This represents the first knowledge nationally guidance on how to do this . of the growing problem in Ontario . [59] LRS takes note of the 3 positive results in the sampling from the 11 food samples that were received on July 24 .
106 »» Friday, August 1 »» Wednesday, August 6 [60] MOHLTC continues to analyze iPHIS data and [66] TPH informs CFIA of the 3 positive food samples out case files, and identifies 16 cases of listeriosis of the 11 samples collected (see August 4) . for the month of July .The norm for listeriosis cases in July is 5 . »» Thursday, August 7 [67] OFSR initiates a food safety investigation to [61] LRS continues to receive samples from Ontario, determine the extent and source of the potential including samples from Halton Region Health food hazard . OFSR requests information from TPH Department . and from LRS regarding sample collection practices and testing methodology for the positive samples »» Saturday, August 2 collected by TPH . [62] LRS receives the samples for testing from Halton Region Health Department . (See August 11 for [68] MLF informed by one of their distributors (Sysco) positive results) . of an investigation in sliced meat production was underway by TPH . MLF contacted TPH to offer »» Monday, August 4 assistance .They were advised that no assistance [63] LRS informs to MOHLTC via email that 3 of the was needed . 11 food samples collected July 21 from the Toronto long term care facility have tested positive [69] OFSR received confirmation from TPH that MLF for Listeria .The three positive results come meats were used in the sandwiches that tested from retention samples from foods prepared on positive for L. monocytogenes made at the Toronto July 13 and July 19 . long term care facility .
»» Tuesday, August 5 [70] HC provides additional information to CFIA on the samples received from TPH including that samples [64] LRS confirms to MOHLTC via fax that 3 of the were from previously-opened products retained 11 food samples collected July 21 from the and handled by nursing home staff as part of their Toronto long term care facility have tested daily retention protocols and therefore could not be positive for Listeria . considered aseptic and therefore relied upon as the basis for a HRA and product action . [65] PHAC receives an update from MOHLTC indicating that 16 cases of listeriosis have been confirmed in »» Friday, August 8 Ontario during July 2008 . [71] CFIA conducts a document review at MLF Bartor Rd to determine if the facility was following its food safety plan . No anomalies were noted .
Appendix B – Chronology of the listeriosis outbreak 107 [72] CFIA requests distribution records from MLF but is [78] MOHLTC (Lab) reports that two additional food unable to obtain any because the MLF Sales Office samples, submitted by the Halton Region Health was closed; MLF later informs the CFIA that the Department (the Burlington Hospital), test positive required information had already been provided for Listeria . separately to TPH on August 6, 2008 . »» Tuesday, August 12 [73] MLF provides CFIA with specific product information [79] NML confirms that DNA fingerprinting patterns (name, product code, best before dates) for MLF on human cases from Ontario match patterns product supplied to the Toronto long term care identified in cases from other provinces, including facility . Newfoundland & Labrador and Quebec .This represents the first suspicion that a national [74] CFIA confirms that positive product from the Toronto outbreak might be developing . long term care facility originated at MLF Bartor Rd based on matching product information from a MLF [80] Halton Region Health Department issues an distributor and MLF . advisory to its long-term care facilities .
[75] CFIA collects and reviews records from a MLF [81] OFSR informed by MOHLTC that there may be distributor to identify the specific MLF Products additional cases in 3 other PHUs in Ontario served at the facility . (Peterborough, Simcoe, Etobicoke) .
»» Week of August 11 [82] CFIA locates and collects an unopened-package [76] Increase in the positive Listeria test results, of suspected MLF product for testing from another from line 7 & 8 of the MLF plant’s environmental long term care facility affiliated to the Toronto long monitoring program . term care facility that had the initial listeriosis cases .These unopened food samples are forwarded »» Monday, August 11 to the lab for testing . CFIA continues to search [77] OFSR receives product distribution records from for samples in nursing homes and other clients MLF with product codes and best before dates of food distributors . that were used to prepare meals at the Toronto long term care facility in July .Three largest [83] OFSR is notified by Halton Regional Health distributors are immediately contacted but have Department of 2 additional listeriosis cases at no suspected product left in their possession . CFIA the Burlington Hospital .Also 2 samples of MLF broadens search of suspect product to include deli meats served at the hospital tested positive other long term care facilities affiliated with the for L. monocytogenes . However it is reported Toronto long term care facility that had the initial that the two patients had not consumed the deli listeriosis cases to determine whether they have any meats and the samples did not contain product unopened-package product on hand . code information . Since no scientific link can be established between the Toronto long term care
108 facility and the Burlington Hospital cases, CFIA [88] NML also notifies labs across Canada that DNA initiates a separate food safety investigation . fingerprinting shows a clustering of human cases CFIA informs MLF that an investigation has with a similar strain in more than one province . been launched . [89] Teleconference concluded that further hazard and [84] A MLF distributor informs OFSR based on an exposure information was required before HC could internal records review, suspect product associated initiate a risk assessment and/or CFIA could initiate with two lot codes, were provided to the Burlington a recall procedure . No public notification or recall Hospital during the time that listeriosis illnesses was deemed appropriate by any of the attending were reported . groups as the “Sure Slice” products were not sold to the general public and are not able to confirm [85] CFIA informs MLF that an investigation has been a definitive link between the illnesses and specific launched . product . Further investigation is still required .
»» Wednesday, August 13 [90] After a review of production and distribution records [86] MLF sends a letter to distributors informing them at MLF Bartor Rd, OFSR identified a possible link they are being investigated by the CFIA, and to between the 5 positive samples – the products may place on hold any remaining inventory of “Sure all have originated from production lines 8 & 9 at Slice” Roast Beef, Corned Beef and Black Forest the MLF Bartor Rd . Ham .These “Sure Slice” brand products were sold only to institutions (hospitals, long term [91] PHAC learns that 5 samples of meat from open care facilities, restaurants, hotels, prisons) packages collected from institutions by local public health officials tested positive for outbreak strain of [87] CFIA initiates a teleconference with PHAC, L.monocytogenes . HC, MOHLTC and Ontario PHUs to review epidemiological information collected to date . Call [92] Slicing dates of product from MLF that tested participants are notified by MOHLTC that additional positive that was collected and analyzed during listeriosis cases had been reported to PHUs in the week of August 12 . Simcoe, Peterborough and Etobicoke . Investigations by those PHUs identified MLF brand as a possible [93] MOHLTC makes a verbal request to PHUs reporting source of the illness . Participants agreed to a listeriosis cases to immediately start collecting large scale sampling plan to cover all “Sure Slice” closed samples of “Sure Slice” cold cuts and to brand products (with best before dates of August submit them to the CFIA laboratory for analysis . 1 to September 30) produced on two suspect MLF PHUs respond immediately . Bartor Rd production lines .This plan was agreed to by MOHLTC and initiated by PHUs .
Appendix B – Chronology of the listeriosis outbreak 109 [94] Federal officials confirm there is a match in the L. [99] PHAC follows up with the Saskatchewan Ministry monocytogenes strain in the product samples as of Health regarding their cases in that province . well as the human samples identified in Ontario . A public health alert is drafted and a questionnaire DNA fingerprinting between the human cases and put together to facilitate the standardization of the food samples is still being conducted to find a inter-provincial data collection . definitive link . [100] MOHLTC holds a teleconference with affected PHUs [95] The LRS reports to MOHLTC regarding the PFGE to advise them of the laboratory results received results from food specimens collected as part of and the ongoing listeriosis outbreak investigation . the epidemiological investigation . It indicates that PHAC asks MOHLTC to send its hypothesis- PFGE patterns taken from open food samples from generating questionnaire to other provinces . the Toronto long-term care home have matched PFGE patterns in two human cases, one from [101] Halton Hills PHU notifies care homes not to Toronto and one from Halton Regional Health consume cold cuts . Department . Both cases had been hospitalized at a Burlington Hospital prior to the onset of [102] CFIA regional staff in collaboration with MOHLTC symptoms . Six other human cases have closely and Ontario PHUs collect samples of MLF “Sure related PFGE patterns . Slice” products from locations across Ontario over the next two days and submit them to the CFIA’s [96] It was also reported that a further 17 cases Greater Toronto Area laboratory for analysis over of Listeriosis were reported in July that were not the weekend . clinically linked to the illnesses at Toronto long term care facility or at the Burlington Hospital, [103] Conference calls led by CFIA continue with PHAC, but the two of these illnesses that were PFGE typed HC, MOHLTC and PHUs to share information and matched the PFGE patterns of the original food update regarding the investigation at MLF Bartor samples taken from the Toronto long term care Rd . Progress on the execution of the sampling facility . plan to collect samples of “Sure Slice” products is discussed by CFIA . No public notification or »» Thursday, August 14 recall was deemed appropriate by any of the [97] June 17, 2008 death confirmed as being linked attending groups . to the MLF listeriosis outbreak . »» Friday, August 15 [98] TPH asks its inspectors to contact all of their [104] PHAC takes the lead coordinating role in the institutions to advise them to refrain from using epidemiological investigation for the listeriosis MLF products, as per MLF’s advisory to its outbreak, as per FIORP, since it had become customers/distributors on August 13 . apparent that the illnesses are distributed nationally .
110 [105] Conference calls lead by the CFIA continue with »» Sunday, August 17 PHAC, HC, MOHLTC and Ontario PHUs to continue [111] At 2AM, CFIA issues a Health Hazard Alert warning investigating the cause of the outbreak . the public not to consume “Sure Slice” Roast Beef and “Sure Slice” Corned Beef . CFIA states that no [106] PHAC issues an alert to all Public Health authorities confirmed cases of listeriosis have been associated in Canada to provide an update on the Ontario with the consumption of the recalled products .This investigation and requests that health units collect is the first primary recall of MLF brand products .A information on consumption of RTE meats for cases primary recall indicates a recall of a product sold that match the DNA fingerprint associated with the under the MLF name or one of its subsidiaries . outbreak . [112] At 3:30AM, MLF announces that it is voluntarily [107] MOHLTC instructs all PHUs to contact all hospitals, recalling two “Sure Slice” brand products sold in 1 nursing homes, long-term care facilities and kg packages . retirement homes in Ontario and instruct them to hold suspect product . (Notes no distribution lists [113] CMOH sends a notice alerting all Medical Officers are available at this time) of Health to the hazard and asks that their staff ensure that all products listed in the recall have [108] CFIA continues to investigate the food sources been removed from their respective long-term care and related information from the Burlington homes and hospitals . Hospital .They request and receive menu and deli meat information . »» Monday, August 18 »» Saturday, August 16 [114] Epidemiological data from British Columbia identifies a potential link to the outbreak in Ontario . [109] CFIA confirms aL. monocytogenes positive test result from an unopened package (see August 12) [115] Conference calls led by CFIA continue with PHAC, in a product produced at MLF Bartor Rd .The risk HC, MOHLTC and PHUs to share information on assessment determines that “Sure Slice” Roast MLF recall . PHAC chairs the epidemiological data Beef and Corned Beef meet the criteria for a portion of the call . “Health Risk I” [116] MOHLTC issues a notice to food-recall contacts, [110] CFIA contacts MLF to inform them the positive directors of inspection and Medical Officers of samples and that a Health Hazard Alert is being Health in all PHUs .This notice provides updates prepared for 2 specific product code of “Sure Slice” on the CFIA Health Hazard Alert and requests products . assistance from PHUs to check the effectiveness of the food product recall at hospitals and other health care facilities .
Appendix B – Chronology of the listeriosis outbreak 111 [117] PHAC holds an inter-provincial teleconference . [123] PHAC updates its alert to provincial, territorial CFIA and MOHLTC are invited . CFIA advises that it and local health authorities and requests that may request assistance from PHUs to determine all provinces and territories review all cases of the presence of suspected products at local listeriosis from August 1, 2008 . food establishments . CFIA also reports that it is monitoring the effectiveness of the recall in [124] At 10:25PM, HC advises CFIA that all “Sure Slice” premises such as restaurants and deli counters . meat products in distribution present a risk to the public . HC indicates that PHAC has been consulting »» Tuesday, August 19 and is in agreement with this assessment . [118] CFIA issues a Health Hazard Alert advising public not to consume or serve 23 other RTE deli meat [125] A HRA is done by HC .The assessment determines products originating from MLF Bartor Rd .This is the that “Sure Slice” products produced at MLF Bartor second primary recall of MLF brand products . Rd met the criteria set by HC for a precautionary ‘Health Risk I” concern . [119] MLF was made aware by CFIA that two more tests on products produced at different times on the »» Wednesday, August 20 same lines had come back positive . MLF sends [126] CFIA initiates verification checks to ensure recalled a letter to its customers informing them of its products have been removed at hospitals, long-term expanded recall to include all products produced care homes and day cares . on lines 8 and 9 from June 2nd . [127] MLF suspends all production at MLF Bartor Rd [120] TPH surveillance alert sent to physicians and and announces that it is voluntarily recalling 23 facilities . products .
[121] Conference calls initiated by the CFIA continue with [128] CFIA requires that MLF implement a hold and test PHAC, HC, MOHLTC and PHUs to share information . protocol whereby no meat product produced at MLF PHAC chairs the epidemiological data portion of Bartor Rd is made available to the consumer before the call . test results are negative for L. monocytogenes .
[122] At 11am, CFIA reports two more positive results on [129] PHAC issues statement informing Canadians about MLF products from line 9 at MLF Bartor Rd collected the public health investigation . August 14 and 15 . Results were from product not included in August 17 recall . CFIA technical risk [130] MOHLTC issues a listeriosis notice press release . assessors request, from HC, a HRA for all “Sure Slice” meats from lines 8 & 9 in MLF Bartor Rd .Assessment [131] CMOH advises the public, especially those at determines that “Sure Slice” products produced high risk for listeriosis, such as the elderly, in MLF Bartor Rd meet the criteria set by HC for a pregnant women and those with weak immune precautionary “Health Risk I” concern . systems, to make sure they avoid consuming the implicated products .
112 [132] CFIA inspectors sampled product from some lines [140] Conference calls led by CFIA continue with PHAC, prior to the end of the production run and took HC, MOHLTC and PHUs to share information on environmental swab samples of food contact MLF recall . PHAC chairs the epidemiological data surfaces in the plant (Note: All of the CFIA sampling portion of the call . results were negative ). [141] Enhanced effectiveness checks are requested by [133] Conference calls led by CFIA continue with PHAC, CFIA officials .This includes 100% verification of HC, MOHLTC and PHUs to share information on removal of recalled product, with the assistance MLF recall . PHAC chairs the epidemiological data of local PHUs, at hospitals, nursing homes and portion of the call . independent grocery stores . Chain stores are checked via a normal verification process . »» Thursday, August 21 [134] CFIA receives lab results that indicate 18 “Sure »» Friday, August 22 Slice” product samples collected in Ontario have [142] PHAC, HC and CFIA hold a joint press conference tested positive for Listeria .All samples testing in Ottawa to alert public about the food safety positive for Listeria are on the current recall lists . investigation and to answer questions from the media . (Attendees are senior executives of their [135] CFIA issues an update to the previous day’s warning departments .) to clarify best before dates on the 23 previously recalled products . [143] CFIA and Royal Touch Foods issue a Health Hazard Alert regarding seven products sold under the [136] TPH sends out a second surveillance alert sent to Shopsy’s brand that contain MLF deli meats physicians and facilities . that may be contaminated This is the first of the secondary recalls of MLF deli meats . (Secondary [137] CMOH holds a press conference to update the recall refers to recall of a product prepared by media on the outbreak . another company which contains Maple Leaf products as an ingredient .) [138] PHAC requests all provinces and territories to review all cases of listeriosis from August 1, 2008 . [144] PHAC activates its Emergency Operations Centre to Level 2 (Increased Vigilance) . [139] MOHLTC holds provincial teleconference with Ontario PHUs to provide updates on the outbreak . [145] HC conducts a HRA, indicating that the additional An update on the epidemiological investigation is products produced on lines 8 and 9 at MLF Bartor provided and made available on the Public Health Rd (i .e ., products recalled by MLF on August 19 Ontario Portal . other than “Sure Slice” products) constitute a ‘Health Risk II’ .
Appendix B – Chronology of the listeriosis outbreak 113 »» Saturday, August 23 [150] HC upgrades the HRA done on August 22, from “Health Risk II” to “Health Risk I” based on PHAC Situation Report Update additional information from MLF Bartor Rd . 21 Confirmed Cases [151] Conference calls led by CFIA continue with PHAC, BC AB SK MB ON QC NB BC AB ON QC NB HC, MOHLTC and PHUs to share information on 3 1 16 1 MLF recall . PHAC chairs the epidemiological data portion of the call . [146] Minister of AAFC holds a press conference assisted by senior executives of PHAC, CFIA and HC (the first »» Sunday, August 24 of a series of fifteen held by a Cabinet Minister) to announce that two out of three samples of recalled PHAC Situation Report Update products test positive for the same outbreak strain 22 Confirmed Cases of L. monocytogenes. The third sample is a slight variant . Results are shared with PHAC to compare BC AB SK MB ON QC NB BC AB ON QC NB with human samples . 3 1 17 1
[147] At 9:30PM, joint PHAC/CFIA news release indicates [152] CFIA issues an expanded Health Hazard Alert to a confirmed link between the listeriosis outbreak cover all products produced at MLF Bartor Rd back strain and MLF Bartor Rd products . Lab results to January 1st, 2008 .This is the third primary recall establish the link between products recalled by of MLF brand products . MLF Bartor Rd and the outbreak of listeriosis in four provinces .To date, 21 cases of listeriosis are [153] MLF issues a press release confirming their confirmed, and the same strain has been detected voluntarily recall and expands it to include all 191 in four people who have died .A further 30 cases items produced at MLF Bartor Rd as a precaution . remain under investigation . MLF emphasizes that there is no evidence of contamination beyond lines 8 and 9 . [148] MLF CEO broadcasts a message to take responsibility following the determination that MLF [154] Minister of Health holds a press conference Bartor Rd is the source of the outbreak . MLF also assisted by senior executives from PHAC, CFIA and indicates that they will voluntarily expand their HC (the second of a series of fifteen by a Cabinet recall to include all 191 items produced at MLF Minister) to respond to questions regarding Bartor Rd as a precaution .This is part of the third outbreak and recall . primary recall of MLF brand products . [155] HC conducts an HRA that determines and [149] CFIA requests a HRA from HC on the entire concludes that all products produced in MLF Bartor production of MLF Bartor Rd and notifies MLF that Rd meet the criteria for a “Health Risk I” concern . assessment is being initiated as part of ongoing communication between the two parties .
114 [156] CFIA identifies that some MLF Bartor Rd product [162] A final conference call led by the CFIA with HC, had been shipped to another MLF facility in Quebec PHAC, MOHLTC and PHUs to share information . (Est . 271B) and initiates a secondary food safety investigation at that facility . [163] CFIA continues with recall effectiveness checks to determine that all recalled product was removed [157] Conference calls led by CFIA continue with PHAC, from the marketplace .Approximately 29,000 HC, MOHLTC and PHUs to share information on checks were conducted between August 20th MLF recall . PHAC chairs the epidemiological data and September 14th . portion of the call . [164] The CFIA receives a HRA from HC on MLF product »» Monday, August 25 produced at MLF Bartor Rd .
PHAC Situation Report Update [165] MLF establishes an expert technical review panel to conduct a comprehensive investigation of 26 Confirmed Cases 6 Deaths food safety at MLF Bartor Rd with a mandate BC AB SK MB ON QC NB BC AB ON QC NB to determine root cause and likely source of 4 1 20 1 6 contamination and to prepare for re-opening . Panel consisted of MLF people and three external experts [158] Minister of AAFC, holds a press conference in which in Listeria . technical spokespeople from the CFIA, PHAC and HC respond to questions . »» Tuesday, August 26
[159] CFIA and Lucerne Foods issue a Health Hazard PHAC Situation Report Update Alert regarding 27 products sold under the Safeway and TakeAwayCafe brands that may contain 29 Confirmed Cases 6 Deaths contaminated MLF deli meats .This is the second BC AB SK MB ON QC NB BC AB ON QC NB secondary recall of MLF brand products . 4 1 22 2 6
[160] MOHLTC changes its reporting methodology to [166] CFIA issues two separate Health Hazard Alerts include all deaths among the listeriosis cases regarding products that may contain contaminated linked to the outbreak that had listeriosis as the MLF deli meats: underlying cause of death . CFIA and Metro Ontario Inc issue an alert regarding [161] PHAC hosts teleconference for: all provincial/ 3 products sold under the Fresh 2 Go brand . territorial public health; environmental health officials; and federal food safety partners to CFIA and Atlantic Prepared Foods Limited issue an discuss the investigation . alert regarding 11 products sold under the Irving,
Appendix B – Chronology of the listeriosis outbreak 115 Sub Delicious and Needs . »» Wednesday, August 27
This is the third secondary recall of MLF brand PHAC Situation Report Update products . 29 Confirmed Cases 5 Deaths [167] Minister of AAFC, holds a press conference in which BC AB SK MB ON QC NB BC AB ON QC NB technical spokespeople from the CFIA, PHAC and HC 4 1 22 2 5 respond to questions . [173] CFIA issues two separate Health Hazard Alerts [168] Minister of Health was interviewed by reporters regarding products that may contain contaminated at an event in Denver, Colorado regarding the MLF deli meats: listeriosis outbreak . CFIA and Costco Wholesale Canada issue an alert [169] TPH makes a verbal request to the CFIA to send regarding two products sold under the Kirkland a Toronto health inspector to accompany the CFIA Signature brands . audit team at the MLF facility (MLF Bartor Rd) . CFIA and Sobeys Inc . issue an alert regarding six [170] PHAC hosts a teleconference with the CMOH and products sold in Sobeys’ Foodland and IGA stores . the CFIA to discuss the investigation and further public health actions, including testing guidelines This is the fourth secondary recall of MLF brand for listeriosis . products .
[171] Daily conference calls hosted by PHAC with [174] CPHO issues his first public statement on P/T colleagues, HC and CFIA continue . the outbreak .
[172] CFIA requests a HRA from HC for products [175] TPH makes a formal request to CFIA to send a processed by other food processing establishments Toronto health inspector to accompany CFIA audit either using recalled MLF meat or meat products team at MLF Bartor Rd .TPH is provided with a copy produced using the same equipment as that used of MLF’ action plan outlining steps necessary for the in MLF Bartor Rd . Over the following days, CFIA re-opening of the facility . and HC work to clarify the types of product to be assessed . [176] Minister of AAFC, holds a press conference in which technical spokespeople from the CFIA, PHAC and HC respond to questions .
[177] CPHO participates in CTV National interview .
116 [178] The HC Listeria ‘Its Your Health’ document was CFIA and Loblaw Companies Limited issue an alert slightly modified and re-posted . regarding 13 products sold at various Loblaws’ stores in Ontario and Quebec . [179] Daily conference calls hosted by PHAC with P/T colleagues, HC and CFIA continue . CFIA and Sobeys Inc issue an alert regarding 33 products sold at various Sobeys’ stores across [180] PHAC hosts a teleconference with TPH and MOHLTC Canada . to discuss whether food handlers could have played a role in advancing the outbreak . This is the fifth secondary recall of MLF brand products . »» Thursday, August 28 [182] Minister of AAFC, holds a press conference in which PHAC Situation Report Update technical spokespeople from the CFIA, PHAC and HC respond to questions . 29 Confirmed Cases 8 Deaths BC AB SK MB ON QC NB BC AB ON QC NB [183] CPHO grants Canada AM interview and video posted 4 1 22 2 8 to PHAC website and YouTube .
[181] CFIA issues five separate Health Hazard Alerts [184] HC conducts and issues a HRA indicating that and one expanded Health Hazard Alert regarding products processed by other establishments that products that may contain contaminated MLF deli contain recalled MLF meat meet the criteria for meats: a “Health Risk I” concern .
CFIA and Sobeys Inc . has expanded their alert from [185] CFIA, HC and PHAC discuss MLF’s environmental August 27 to include two additional products . investigation, employee issues and food product testing associated with MLF Bartor Rd . CFIA and White House Meats Inc . issue an alert regarding one product sold at White House Meats [186] MLF submits, to CFIA, a corrective action plan deli counters . to mitigate deficiencies identified by the CFIA investigation team for review and approval . CFIA and Delta Country Market issue an alert regarding three products sold at their deli counters . [187] Daily conference calls hosted by PHAC with P/T colleagues, HC and CFIA continue . CFIA and Glen Fine Foods issue an alert regarding one product sold through vending machines in Ontario .
Appendix B – Chronology of the listeriosis outbreak 117 »» Friday August 29 to September 1 CFIA and Co-op Atlantic issue an alert regarding [188] PHAC issues public health notices daily to seven products sold at Co-op Atlantic stores . 123 newspapers across the country . This is the sixth secondary recall of MLF brand »» Friday, August 29 products . [190] Minister of AAFC, holds a press conference to PHAC Situation Report Update discuss the outbreak .Technical spokespeople from 29 Confirmed Cases 9 Deaths the CFIA, PHAC and HC respond to questions . BC AB SK MB ON QC NB BC AB ON QC NB 4 1 22 2 1 8 [191] The CFIA hosts a teleconference with PHAC, HC and PHUs and provides an update on the outbreak . [189] CFIA issues five separate Health Hazard Alerts and one updated Health Hazard Alert regarding [192] NML has a teleconference with P/T and CMOH to products that may contain contaminated MLF deli finalize the cytogenes clinical laboratory testing meats: guidelines and to discuss recommendations for testing at-risk populations and the general public . CFIA and Metro-Richelieu Inc issue an alert The results of this discussion are distributed regarding three products sold in certain Metro, amongst the community .The L. monocytogenes Richelieu, Ami and Gem stores in Quebec . laboratory testing guidelines are posted on the PHAC website on the evening of August 29 . CFIA and Sobeys Inc issue an updated alert to clarify distribution information regarding the 33 [193] PHAC prepares and distributes to provinces, products from the August 28 alert . territories and key partners an updated Brief Epidemiologic Report . CFIA and Metro Ontario Inc . issues an alert regarding one product sold at some A&P, Dominion, [194] Daily conference calls hosted by PHAC Loeb and The Barn Stores in Ontario . with P/T colleagues, HC and CFIA to share information continue . CFIA and Canada Safeway Limited issue an alert regarding five products sold at Safeway stores in Western Canada and Ontario .
CFIA and Country Traditions Frozen Foods issue an alert regarding three products sold at Country Traditions, Taste of Country and Country Farm Supply stores in Ontario .
118 »» Saturday, August 30 [200] Minister of AAFC, holds a press conference to discuss the outbreak .Technical spokespeople from PHAC Situation Report Update the CFIA, PHAC and HC respond to questions . 29 Confirmed Cases 9 Deaths »» Monday, September 1 BC AB SK MB ON QC NB BC AB ON QC NB 4 1 22 2 1 8 PHAC Situation Report Update [195] PHAC posts an updated fact sheet on its website 38 Confirmed Cases 12 Deaths advising pregnant women how to protect BC AB SK MB ON QC NB BC AB ON QC NB themselves from listeriosis . PHAC also distributes 4 2 1 29 2 1 1 10 this fact sheet to health care providers . [201] Minister of AAFC, holds a press conference to [196] CFIA and King Bean Wholesalers issue a Health discuss the outbreak .Technical spokespeople from Hazard Alert regarding four products under the King the CFIA, PHAC and HC respond to questions . Bean brand that may contain contaminated MLF deli meats .This is the seventh secondary recall [202] PHAC prepares and distributes to provinces, of MLF brand products . territories and key partners an updated Brief Epidemiologic Report . [197] Minister of AAFC, holds a press conference to discuss the outbreak .Technical spokespeople from »» Tuesday, September 2 the CFIA, PHAC and HC respond to questions . PHAC Situation Report Update [198] CPHO grants an interview with the Toronto Star 38 Confirmed Cases 12 Deaths (which occurs on September 1) . BC AB SK MB ON QC NB BC AB ON QC NB [199] CFIA inspections staff and Meat Program specialists 4 2 1 29 2 1 1 10 visit MLF Bartor Rd to initiate an in-depth review if the plant’s standard operating procedures . [203] Minister of AAFC, holds a press conference to discuss the listeriosis outbreak and investigation . »» Sunday, August 31 CPHO and senior HC and CFIA staff participates in the press conference to provide updates and answer questions . PHAC Situation Report Update 33 Confirmed Cases 11 Deaths [204] Daily conference calls hosted by PHAC with BC AB SK MB ON QC NB BC AB ON QC NB P/T colleagues, HC and CFIA to share information 4 2 1 22 2 1 1 9 continue .
Appendix B – Chronology of the listeriosis outbreak 119 [205] TPH joins the CFIA in-depth review team at MLF »» Thursday, September 4 Bartor Rd . PHAC Situation Report Update [206] Conference call between CFIA and HC, to discuss 38 Confirmed Cases 13 Deaths the sampling proposals from MLF . BC AB SK MB ON QC NB BC AB ON QC NB »» Wednesday, September 3 4 2 1 29 2 1 1 11
PHAC Situation Report Update [212] PHAC posts an updated fact sheet on its website advising seniors how to protect themselves from 38 Confirmed Cases 13 Deaths listeriosis . PHAC also distributes this fact sheet to BC AB SK MB ON QC NB BC AB ON QC NB senior organizations and health care providers . 4 2 1 29 2 1 1 11 [213] Minister of AAFC, holds a press conference to [207] Prime Minister calls for an independent inquiry into discuss the outbreak .Technical spokespeople from the outbreak . the CFIA, PHAC and HC respond to questions .
[208] The Ontario CMOH posts clinical guidelines for [214] CFIA issues a Health Hazard Alert regarding one L.monocytogenes to health care providers on the product sold at a Canex Retail Supermarket in MOHLTC website . Newfoundland and Labrador .This is the eighth and final secondary recall of MLF brand products . [209] Minister of AAFC, holds a press conference to discuss the listeriosis outbreak and investigation . [215] PHAC hosts a technical briefing with media on CPHO and senior HC and CFIA staff participates the surveillance systems used to detect and track in the press conference to provide updates and Listeria and other foodborne pathogens . answer questions . [216] Teleconference with the CMOH and the CPHO .They [210] Daily conference calls hosted by PHAC with P/T discuss policy issues, consumer recommendations colleagues, HC and CFIA to share information and public health advice . continue . [217] Daily conference calls hosted by PHAC with P/T [211] Conference call between CFIA and HC, to discuss colleagues, HC and CFIA to share information the sampling proposals from MLF . continue .
120 »» Friday, September 5 TPH shares its findings from the inspections of the MLF Bartor Rd PHAC Situation Report Update [223] MLF announced that the Expert technical review 38 Confirmed Cases 13 Deaths panel concluded that the most likely source of BC AB SK MB ON QC NB BC AB ON QC NB Listeria contamination was deep inside the slicing 4 2 1 29 2 1 1 11 machines on lines 8 and 9 . Other environmental factors may also have contributed to the Listeria [218] Prime Minister’s office announces Prime Minister contamination . will meet with the Governor General to ask her to dissolve Parliament for an election call . [224] Expert technical review panel also recommended initiatives to improve the physical and operational [219] CFIA issues an advisory to federally registered systems and processes that contribute to food establishments processing RTE meats to ensure safety . MLF begins work immediately on these meat slicers are completely dismantled and initiatives . cleaned, collect environmental samples to test for Listeria, and to review cleaning and disinfecting [225] MLF indicated that CFIA has provided an interim procedures with the CFIA inspector to ensure proper assessment which concurs with many of the findings sanitation of the slicers . of the expert technical review panel .
[220] Minister of AAFC, holds a press conference to [226] Company submits 7 day start-up plan to CFIA . discuss the outbreak .Technical spokespeople from the CFIA, PHAC and HC respond to questions . [227] HC provides a sampling plan established to sample all of the recalled product from August 17, 19 and [221] Daily conference calls hosted by PHAC with P/T 24 .Theses minimum sampling requirements are sent colleagues, HC and CFIA to share information to CFIA, and then forwarded to Maple Leaf Foods . continue . »» Saturday, September 6 [222] MOHLTC holds a provincial teleconference with the PHUs to provide updates on the outbreak . PHAC Situation Report Update 38 Confirmed Cases 13 Deaths MOHLTC shares the results of food sample testing received from the CFIA . 116 sample results were BC AB SK MB ON QC NB BC AB ON QC NB received, 68 samples tested positive and 48 4 2 1 29 2 1 1 11 negative .
Appendix B – Chronology of the listeriosis outbreak 121 [228] The Minister of AAFC, holds a press conference [235] Anticipation of the resumption of production at assisted by senior executives of PHAC, CFIA and MLF Bartor Road, the CFIA begins an in-depth HC (the last of a series of fifteen) to respond to review to assess the establishment’s suitability for questions . resumption of operations . Four corrective action requests are identified by the CFIA inspection team . [229] Prime Minister announces an investigation into the L. monocytogenes outbreak . [236] CFIA meets with MLF to discuss disposal plan .
»» Monday, September 8 »» Tuesday, September 9
PHAC Situation Report Update PHAC Situation Report Update 38 Confirmed Cases 13 Deaths 38 Confirmed Cases 14 Deaths BC AB SK MB ON QC NB BC AB ON QC NB BC AB SK MB ON QC NB BC AB ON QC NB 4 2 1 29 2 1 1 11 4 2 1 29 2 1 1 12
[230] Federal Election called . [237] CFIA HQ distributes a memorandum regarding Task 1401 (Meat Slicing Equipment Sanitation) to CFIA [231] PHAC posts an updated fact sheet on its website field staff for immediate implementation .This CVS advising those with weakened immune systems task was created to direct a survey targeted at about how to protect themselves from listeriosis . all federally registered RTE meat establishments PHAC also distributes this fact sheet to TB and required a verification activity to evaluate and HIV/AIDS distribution lists . the effectiveness of an operator’s HACCP system, focusing on sanitation in post-cook area . [232] PHAC’s Emergency Operations Centre is de- activated to Level 1 (Normal Readiness) [238] The CFIA issues a new compliance verification task procedure as a follow-up to the September [233] Teleconferences with P/Ts to discuss the 5th advisory to federally inspected plants that epidemiology of the outbreak are reduced from addresses: daily to every other day . 1 . review of written sanitation program [234] PHAC prepares and distributes to provinces, territories and key partners an updated Brief 2 . on-site review of the sanitation operations and Epidemiologic Report . 3 . on-site review of pre-operational sanitation .
122 »» Wednesday, September 10 »» Friday, September 12
PHAC Situation Report Update PHAC Situation Report Update 42 Confirmed Cases 15 Deaths 45 Confirmed Cases 16 Deaths BC AB SK MB ON QC NB BC AB ON QC NB BC AB SK MB ON QC NB BC AB ON QC NB 4 2 1 33 2 1 1 13 4 2 1 1 35 2 1 1 14
[239] OMAFRA forwards the CFIA advisory on cleaning and [243] MOHLTC holds a provincial teleconference with all sanitation to all provincially licensed plants . PHUs to update them on the listeriosis outbreak .
[240] MOHLTC hosts a provincial teleconference and [244] MOHLTC introduces and discusses institutional advises PHUs about TPH’s visits to the plant questionnaire . MOHLTC circulates an institutional and informs them that a CFIA audit team is also questionnaire to all health units with outbreak- present at the plant . related cases that resided in a long-term care home, retirement home and/or hospital requesting [241] Daily conference calls hosted by PHAC feedback .The questionnaire is designed to solicit with P/T colleagues, HC and CFIA to share more comprehensive information on the outbreak . information continue . [245] PHAC prepares and distributes to provinces, »» Thursday, September 11 territories and key partners an updated Brief Epidemiologic Report . PHAC Situation Report Update 44 Confirmed Cases 16 Deaths »» Monday, September 15 BC AB SK MB ON QC NB BC AB ON QC NB [246] CFIA Headquarters distributes new directives to field staff re: Audit approach for RTE plants: 4 2 1 1 34 2 1 1 14 1 . Current Issue Task 1402 (Premises Sanitation) [242] CFIA informs MOHLTC that the effectiveness
checks with respect to MLF in Ontario have been For all federally registered RTE meat completed . establishments to evaluate the effectiveness of an operator’s HACCP system focusing on sanitation in post-cook area .
2 . Current Issue Task 1403 (Sampling Program Survey)
Appendix B – Chronology of the listeriosis outbreak 123 A one-time CVS inspection and sampling task [249] MLF receives CFIA’s approval to restart operations used to survey establishments in order to at the MLF Bartor Rd which were suspended on gather information regarding operator biological August 20th . pathogen controls . [250] MLF resumed limited production under the 3 .The CVS inspection and sampling Tasks 3106 following conditions: and 3107 (Risk-based Sampling in US-eligible Establishments) Test and hold protocols to be in place for the first six weeks of operation . [247] Daily conference calls hosted by PHAC with P/T colleagues, HC and CFIA to share information Re-testing and corrective action, if required, of all continue . previously positive food contact surfaces .
»» Tuesday, September 16 Submission in advance of Listeria sampling schedules to the CFIA responsible inspector . PHAC Situation Report Update Environmental sites to be predetermined with CFIA 47 Confirmed Cases 16 Deaths input and production schedules to be supplied . BC AB SK MB ON QC NB BC AB ON QC NB Explicit directives from the CFIA on environmental 4 2 1 1 36 2 1 1 1 14 Listeria sampling to be followed .
[248] MLF provides the CFIA’s Ontario Area Office with a All lab results for Listeria sampling, including summary of its proposed action plan in anticipation immediate notification of positive results, must be of the restarting of operations at MLF Bartor Rd .The provided to the CFIA . MLF document includes the results of the company- led investigation to identify the cause of the Listeria The release of all RTE products would require prior contamination . CFIA approval .
MLF BARTOR RD PLANT RE-OPENS »» Thursday, September 18
»» Wednesday, September 17 PHAC Situation Report Update 47 Confirmed Cases 17 Deaths PHAC Situation Report Update BC AB SK MB ON QC NB BC AB ON QC NB 47 Confirmed Cases 17 Deaths 4 2 1 1 36 2 1 1 1 14 1 BC AB SK MB ON QC NB BC AB ON QC NB 4 2 1 1 36 2 1 1 1 14 1
124 »» Friday, September 19 »» Thursday, September 25
PHAC Situation Report Update PHAC Situation Report Update 48 Confirmed Cases 18 Deaths 48 Confirmed Cases 18 Deaths BC AB SK MB ON QC NB BC AB ON QC NB BC AB SK MB ON QC NB BC AB ON QC NB 5 2 1 1 36 2 1 2 1 14 1 5 2 1 1 36 2 1 2 1 14 1
[251] PHAC prepares and distributes to provinces, »» Friday, September 26 territories and key partners an updated Brief Epidemiologic Report . PHAC Situation Report Update 49 Confirmed Cases 19 Deaths »» Tuesday, September 23 BC AB SK MB ON QC NB BC AB ON QC NB 5 2 1 1 36 3 1 2 1 14 1 1 PHAC Situation Report Update 48 Confirmed Cases 18 Deaths »» Monday, September 29 BC AB SK MB ON QC NB BC AB ON QC NB 5 2 1 1 36 2 1 2 1 14 1 PHAC Situation Report Update 49 Confirmed Cases 19 Deaths »» Wednesday, September 24 BC AB SK MB ON QC NB BC AB ON QC NB 5 2 1 1 36 3 1 2 1 14 1 1 PHAC Situation Report Update 48 Confirmed Cases 18 Deaths »» Thursday, October 2 BC AB SK MB ON QC NB BC AB ON QC NB 5 2 1 1 36 2 1 2 1 14 1 PHAC Situation Report Update 53 Confirmed Cases 20 Deaths [252] First set of CFIA environmental swabs negative . This sampling program continues on a daily basis . BC AB SK MB ON QC NB BC AB ON QC NB 5 2 1 1 40 3 1 2 1 15 1 1
[253] Letter to company for product release for production dates of September 19 to 23 only .
Appendix B – Chronology of the listeriosis outbreak 125 »» Friday, October 3 »» Friday, October 17 [254] PHAC prepares and distributes to provinces, [260] CFIA approves the release of product produced territories and key partners an updated Brief between September 19 to 25 at the MLF Bartor Rd, Epidemiologic Report . except for product produced on line 7 .
»» Tuesday, October 7 [261] Information posted on CFIA’s website regarding [255] Positive test on food contact surface found for a the re-opening of MLF Bartor Rd . sample taken October 1 (list spp) . Further testing required of environmental sample to determine [262] A HRA conducted by HC determined that the subspecies (i e. . if L. monocytogenes) . Much products manufactured on Line 7 at MLF Bartor communication regarding positive result . 4 products Rd between September 19 and October 7 are from line 7 and 8 test positive for L. monocytogenes suspect, and if distributed to the consumer, from products from September 29 and 30 . would be considered a “Health Risk I” situation .
»» Wednesday, October 8 »» Sunday, October 19 [256] MLF and CFIA announce that four end product [263] Advice on Food Safety posted by CPHO . samples have tested positive for L. monocytogenes. None of the affected product had been released for »» Monday, October 20 sale . Increased L. monocytogenes testing continues [264] CFIA announced that MLF Bartor Rd products with in the facility . satisfactory L. monocytogenes test results could be released for distribution .Test and hold protocols [257] HC issues a precautionary “Health Risk I” continue at MLF Bartor Rd as does enhanced assessment for product manufactured the week inspection presence . prior to the positive results . CFIA issues a Class 1 recall to distributors to ensure the product is not »» Tuesday, October 21 made available to consumers .A subsequent HRA [265] Product starts to be shipped to customers, with conducted by HC determined that the product exception of Line 7 production . posed no health risk . »» Wednesday, October 22 [258] MLF submits plan to sample detained product over [266] MLF considers the crisis over . the next 2 week period for legal purposes .
»» Friday, October 10 [267] MLF begins distributing foods manufactured at its MLF Bartor Rd for public consumption . [259] Memorandum regarding current issue Task 1404 Operator Environmental and Product testing for Listeria distributed to CFIA field staff .
126 »» Friday, November 14 [268] MOHLTC discontinues Enhanced Surveillance Directive for L. monocytogenes . that was distributed to PHUs .
»» Monday, December 8 [269] Ontario’s CMOH declares the listeriosis outbreak over in Ontario .
»» Wednesday, December 17 [270] Disposal of 100% of the recalled product complete . 1 .3 million kg of product was properly disposed of under supervision of CFIA and Ontario Ministry of Environment .
»» Thursday, December 18 [271] Three class action suits were settled for up to $27 million, subject to court approval .
»» January 1, 2009 [272] The latest expiry date found on the recalled products .
»» April 17, 2009
PHAC Situation Report Update 57 Confirmed Cases 22 Deaths BC AB SK MB ON QC NB BC AB ON QC NB 5 2 2 1 41 5 1 2 1 16 2 1
Appendix B – Chronology of the listeriosis outbreak 127
Appendix C Progress to date as reported by the organizations
129 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT Policies Public Health Following the 2008 outbreak, listeriosis Agency of has been included in the new set of Canada diseases to be reported to PHAC . All provinces and territories have agreed to implement notification as soon as possible .They are at different stages of implementation since making adjustments to reporting and notification systems takes time . Once all jurisdictions have completed the necessary steps, all future listeriosis cases in Canada will be reported to the Canadian Notifiable Diseases Surveillance System, most likely before the end of 2009 . Health Canada In September 2008, Health Canada, See recommendation 12 under the provisions of the Food and Drugs Act, issued Interim Market Authorizations to allow the use of sodium acetate and sodium diacetate for meat, poultry, and fish products to help slow the growth of Listeria . In March 2009, Health Canada published the Regulatory Modernization Strategy for Food and Nutrition, which articulates its role in food safety and nutrition, and outlines a vision and plan to modernize the regulatory system . The plan will be completed in summer 2009 .
130 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT Health Canada has taken a number of steps to further standardize the Health Risk Assessment request process . It has »»revised its Standard Operating Procedures from 24 hours to an 8-hour turnaround time for anticipated Health Risk 1 requests (the most severe risk which could lead to widespread human impact or death); »»increased capacity and training; »»established a central logging and tracking system; »»identified a single point of contact for microbiology, nutrition and chemical safety issues; and, »»made arrangements to ensure response 24/7 in emergency situations . Health Canada’s 2004 Listeria See recommendation 11 policy is undergoing revision to be finalized by March 2010 to reflect the latest knowledge and scientific advances in the field . Controls and inspection practices, use of additives and technologies that can inhibit the growth of Listeria, and the needs of vulnerable populations are being considered .
Appendix C - Progress to date as reported by the organizations 131 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT Surveillance and Laboratories
Surveillance Public Health The Public Health Agency of Agency of Canada has acted to improve the Canada capacity of PulseNet by training and certifying personnel in a number of provincial and federal laboratories across Canada . Since the outbreak, the PHAC’s See recommendation 35 National Microbiology Laboratory has trained and certified one laboratory person in the province of Alberta and two in Ontario . Four additional CFIA laboratory personnel have also been certified . NML has increased its own number of certified laboratory personnel from three to seven . PHAC is also working on the See recommendation 22 development of another surveillance instrument tool – Panorama .
132 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT
Laboratories Health Canada Health Canada is working to increase surge capacity in its lab testing functions, like the Listeria Reference Centre .This means ensuring that there are enough people to meet demand in urgent situations . It is enhancing its laboratory capacity by increasing training and cross-training of laboratory technicians . Already, three individuals are in the process of being certified for Pulsed-Field Gel Electrophoresis (PFGE) testing, and the current E. coli technician has been cross-trained to test for Listeria . Public Health The PHAC’s National Microbiology Agency of Laboratory has taken action to improve Canada its own laboratory capacity . In addition to increasing the Lab’s number of certified personnel in Listeria genetic fingerprinting, NML has doubled its PFGE equipment in the PulseNet Canada Lab and has formalized back-up PFGE units . Canadian Food Investments have been made in new Inspection equipment for the CFIA’s laboratories Agency to expand their testing capacity .
Appendix C - Progress to date as reported by the organizations 133 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT Health Canada’s 2004 Listeria See recommendation 11 policy is undergoing revision to be finalized by March 2010 to reflect the latest knowledge and scientific advances in the field . Controls and inspection practices, use of additives and technologies that can inhibit the growth of Listeria, and the needs of vulnerable populations are being considered . Surveillance and Laboratories
Surveillance Public Health The Public Health Agency of Canada Agency of has acted to improve the capacity of Canada PulseNet by training and certifying personnel in a number of provincial and federal laboratories across Canada . Since the outbreak, the PHAC’s See recommendation 35 National Microbiology Laboratory has trained and certified one laboratory person in the province of Alberta and two in Ontario . Four additional CFIA laboratory personnel have also been certified . NML has increased its own number of certified laboratory personnel from three to seven . PHAC is also working on the See recommendation 22 development of another surveillance instrument tool – Panorama .
134 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT
Laboratories Health Canada Health Canada is working to increase CFIA has improved its communications See recommendation 35 surge capacity in its lab testing with HC and PHAC laboratories and functions, like the Listeria Reference introducing a screening method for Centre .This means ensuring that there Listeria monocytogenes in meat which are enough people to meet demand allows for the reporting of negative in urgent situations . It is enhancing results in only five days . its laboratory capacity by increasing training and cross-training of laboratory technicians . Already, three individuals are in the process of being certified for Pulsed-Field Gel Electrophoresis (PFGE) testing, and the current E. coli technician has been cross-trained to test for Listeria. Public Health The PHAC’s National Microbiology Agency of Laboratory has taken action to improve Canada its own laboratory capacity . In addition to increasing the Lab’s number of certified personnel in Listeria genetic fingerprinting, NML has doubled its PFGE equipment in the PulseNet Canada Lab and has formalized back- up PFGE units . Canadian Food Investments have been made in new Inspection equipment for the CFIA’s laboratories Agency to expand their testing capacity .
Appendix C - Progress to date as reported by the organizations 135 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT The CFIA, with HC and the PHAC, have See recommendation 35 developed a standard template for use by F/P/T food safety partners . The template includes all the required information for sampling . CFIA has also developed training material for inspectors on sampling . The CFIA has improved its See recommendation 36 communications with HC and the PHAC laboratories and introducing a screening method for Listeria monocytogenes in meat which allows for the reporting of negative results in only five days . In conjunction with the Standards Council of Canada (SCC) a forum has been established to promptly share CFIA requirements with private accredited labs through information bulletins . Foodborne Emergency Preparedness and Response
Among federal organizations The PHAC, HC and the CFIA are critically Consistent communication among the See recommendation 24 assessing the Foodborne Illness CFIA, the PHAC and HC is taking place Outbreak Response Protocol (FIORP) through regular senior management in light of the recent event, to present meetings between Assistant Deputy a proposal to their provincial and Ministers in each organization . territorial counterparts . Health Canada Health Canada has set up a single point of contact for the rapid flow of information among partners and has increased Health Canada’s email capacity for key operational personnel .
136 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT Health Canada continues to work Health Canada has enhanced risk with the Council of Chief Medical communications to the public through Officers of Health to develop key wider distribution of communications health advice on listeriosis for at products to stakeholders that can risk groups and caregivers . assist with disseminating information to at-risk populations . Public Health The PHAC has made progress in See recommendation 28 Agency of clarifying the scope of Health Canada’s Canada and the CFIA’s involvement in the Agency’s Emergency Operations Centre during outbreaks . The PHAC’s Centre for Emergency See recommendation 24 Preparedness and Response is improving clarity regarding the purpose of calls, who should be attending them, and how to communicate discussions and decisions .Templates and standard operating procedures have been developed . Canadian Food The CFIA is updating its Food The criteria and process for identifying See recommendation 28 Inspection Emergency Response Manual with and managing high-profile incidents Agency respect to roles and responsibilities has been reviewed and revamped . and has enhanced decision-making for The CFIA will now use its emergency non-routine cases . response structure to manage high- profile issues, including significant food safety incidents . The Office of Emergency Management has provided incident command system training for staff involved in food safety incidents, with ongoing sessions planned .
Appendix C - Progress to date as reported by the organizations 137 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT
Among food safety partners Canadian Food The CFIA is working to increase See recommendation 38 Inspection provincial/territorial awareness of Agency its roles and responsibilities when responding to foodborne illness outbreaks . For instance, The CFIA is part of the Ontario Multi-Agency Foodborne Outbreak/Food Recall Working Group, established to improve multi-jurisdictional coordination and response to health hazards and foodborne outbreaks .
Food Safety Canadian Food The Meat Hygiene Manual of Procedures See recommendations Inspection and the Compliance Verification System 16 to 20 Agency (CVS) have been updated to reflect that in September 2008: »»an industry advisory notification was issued for the proper cleaning and sanitation of slicing equipment; and »»inspection procedures were strengthened and inspection tasks were added: »»review company records of finished product and environmental test results on a daily basis; »»review cleaning and sanitation programs to control bacteria and other foodborne diseases; »»analyze trends in positive environmental test results; and »»increase the frequency of on-site inspections .
138 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT As of April 2009, the section of the See recommendation 15 Meat Hygiene Manual of Procedures on Listeria was updated: »»Meat processors must implement food contact surface testing programs in accordance with the prescribed requirements; »»Meat processors must perform trend analysis on their test results; »» Plant operators must notify the CFIA immediately of any Listeria positive food contact surface area test results; As of April 2009, the CFIA had implemented a food contact surface testing plan in meat processing plants . The CFIA has requested from its Academic Advisory Panel to provide advice on emerging and changing risks in the food production system . The CFIA has begun the process of evaluating meat inspection programs for imports for the control of Listeria monocytogenes in ready-to-eat meat products .
Appendix C - Progress to date as reported by the organizations 139 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT Maple Leaf Maple Leaf Foods has implemented See recommendations Foods all of the requirements under the 1 to 6 CFIA’s Corrective Action Plan as well as the Agency’s new policies . In several instances, the company has activated measures that go beyond the minimum requirements in an effort to prevent a reoccurrence of the events of the summer of 2008 . Maple Leaf Foods has improved food See recommendations safety in all of its ready-to-eat plants 1 to 6 by taking four essential steps . It has »»developed comprehensive Enhanced Food Safety Protocols; »»improved daily sanitization procedures, such as machinery disassembly and deep cleaning of slicing equipment; »»implemented a more rigorous environmental testing regimen; »»required that all employees entering their plants wear shrouds, masks, aprons and sleeves; »»improved the physical infrastructure of buildings; »»created the position of Chief Food Safety Officer; »»established a Maple Leaf Foods Food Safety Council comprising leading international experts in food safety, microbiology, and public health; and »»increased collaboration with government and industry to improve food safety across the industry .
140 IN PROGRESS COMPLETED RECOMMENDATIONS OF THIS REPORT The company’s Food Safety First See recommendations 2 program – probably the most important part of its post-outbreak food safety enhancement – consists of a four-part cycle: 1) Interpret; 2) Remediate; 3) Act; and 4) Audit Canadian The Canadian Meat Council is leading See recommendations 3 Meat Council the Industry Listeria Working Group which is working on the development of a best practices document that reflects revisions of the CFIA’s Listeria control measures for ready-to-eat meat products .
Appendix C - Progress to date as reported by the organizations 141
Appendix D List of Interviewees
143 »»Johanne Bray, Manager of Policy and National List of Meetings Representational Activities »»Minister Gerry Ritz, Federal Minister for Agriculture Meetings by Individual: »»Morris Rosenberg, Deputy Minister Health Canada »»Dr. Merv Baker, Canadian Meat Council »»Yvan Roy, Counsel to the Clerk of the Pricy Council, PCO »»Yaprak Baltacioglu, Former Deputy Minister, AAFC »»Ron Sapsford, Deputy Minister, Health & Long-Term Care, »»Jane Billings, Sr .ADM, PHAC & Ontario Nancy Porteous, Dir . Eval ., Centre for Excellence and »»Ian Shugart, Deputy Minister, Environment Canada Program Design »»Anne Marie Smart, Assistant Secretary to the Cabinet, »»Dr. David Butler-Jones, Chief Public Health Officer, PHAC Communications and Consultations, PCO »»Robert Clarke, Former ADM, PHAC (Retired) »»Carole Swan, President, CFIA »»David Cutler, CEO, Leisure World »»Suzanne Vinet, Assoc . Deputy Minister, Transport »»Ronald Doering, Gowling Consultants, (formerly Assoc . DM Health Canada) Former President of CFIA »»Dr. David Williams, A/Chief Medical Officer of Health, »»Barbara Drew, CEO/Exec, Dir, CMA & Ontario Dr. Briane Scharfstein, Assoc . Sec . Gen, Prof .Affairs »»Dr. Brian Evans, Executive Vice President, CFIA Presentations by Organization: »»Dr. Jeff Farber, Director of Microbial Hazards, »»Tour of Maple Leaf Plant Health Canada »»CFIA Presentation re Cognos Based Fish Program »»Ian Green, Formerly Deputy Minister for Health Canada Management Information System (currently retired) »»CFIA Presentation re Compliance and Enforcement »»François Guimont, Deputy Receiver General of Canada »»CFIA Presentation re HACCP/CVS (formerly Pres . CFIA) »»CFIA Presentation re Recall »»Dr. Rick Holley, CFIA Advisory Member »»Visit to CFIA’s Emergency Operations Centre »»Randy Huffman, Maple Leaf Foods »»Health Canada Presentation re Modernization of »»Nick Jennery, Canadian Council of Grocery Distributors Food and Drug Act »»Bob Kingston, PSAC Agriculture Union President & »»Health Canada Presentation re Regulatory Systems Jim Thompson, Communications Advisor, PSAC Union for Additives »»Michael McCain, President, Maple Leaf Foods »»PHAC Presentation re FIORP »»Marie-Lucie Morin, National Security Advisor to the PM »»Visit to PHAC’s Emergency Operations Centre and Assoc . Secretary, PCO »»Formax Meat Slicing Equipment »»Dr. Frank Plummer, Scientific Director General & »»Dave Brown, Vice-President, Sales Dr. Céline Nadon, PHAC Microbilogy Lab »»Bob Carson, Legal Counsel »»Cameron Prince, VP Operations, CFIA »»Bill Dickover, Vice-President Customer Services »»The Professional Institute of the Public Service of »»Meetings with Family Members Canada (PIPSC) »»Gary Corbett, President »»Geoffrey Grenville-Wood, Legal Counsel »»Isabelle Roy, Legal Counsel
144 »»D r. Joel Kettner, Chief Public Health Officer and Chief Roundtables Medical Officer of Health, Manitoba »»Alex MacKenzie, Executive Director of Surveillance and Advisory Group of Experts Environmental Health, Alberta Health and Wellness »»Dr. John Carsley »»Scott MacLean, Executive Director of Health Protection »»Dr. Michael Doyle Programs, New-Brunswick »»Dr. Mansel Griffiths »»Dr. Duff Montgomerie, Deputy Minister of Health »»Dr. Walter Schlech Promotion and Protection, Nova Scotia »»Dr. Bruce Tompkin »»Ryan Neale, Environmental Health Officer, Prince Edward Island CFIA Advisory Panel Roundtable Discussion »»Joanna Plater, Executive Director, Manitoba Health and »»Dr. Rick Holley, Canadian Poultry & Healthy Living Egg Processors Council »»Dr. Mark Raizenne, Director General, Centre for Food- »»Carole Swan, President, Canadian Food Borne and Environmental and Zoonotic Infectious Inspection Agency Diseases, Public Health Agency of Canada »»Ron Sapsford, Deputy Minister, Health and Long-Term Consumer Groups Roundtable Discussion Care, Ontario »»Bruce Cran, Consumers Association of Canada »»Dr. Richard Schabas, Medical Officer of Health, Ontario »»François Décary-Gilardeau, Option Consommateurs »»Dr. Robert Strang, Chief Public Health Officer and Chief »»Lucienne Lemire, Consumers Council of Canada Medical Officer of Health, Nova Scotia »»Dr. Faith Stratton, Chief Medical Officer of Health, Federal, Provincial, Territorial Newfoundland Roundtablewith Deputy Ministers of Health »»Arlene Wilgosh, Deputy Minister of Health, Manitoba and Chief Medical Officers »»Dr. David Williams, Chief Medical Officer of Health, »»Dr. Horacio Arruda, Director Public Health Protection, Ontario Québec »»Meena Ballantyne, Assistant Deputy Minister, Health Food Processing Groups Products and Food Branch, Health Canada Roundtable Discussion »»Dr. David Butler-Jones, Chief Public Health Officer, »»Robert De Valk, Further Poultry Processors of Canada Public Health Agency of Canada »»Robin Hoel, Canadian Poultry and Egg Processors Council »»Lauren Donnelly, Assistant Deputy Minister Health »»Chris Kyte, Food Processors of Canada Prevention, Saskatchewan »»Jim Laws, Canadian Meat Council »»Dr. Kami Kandola, A/Chief Medical Officer of Health, Northwest Territories »»Don Keats, Deputy Minister of Health and Community Services, Newfoundland »»Dr. Perry Kendall, Provincial Health Officer, BC
Appendix D – List of Interviewees 145 Urban Public Health Network Canadian Food Inspection Agency (CFIA) »»Dr. David Allison, Medical Officer of Health, Eastern »»Paul Mayers, Associate Vice President, Programs, CFIA Health, St . John’s »»Brian Evans, Executive Vice President, CFIA »»Dr. Tania Diener, Medical Health Officer, Regina »»Cameron Prince, Vice President, Operations, CFIA Qu’appelle Health Region »»Dr. Martine Dubuc, Vice President, Science, CFIA »»Dr. Maurice Hennink, Deputy Medical Health Officer, »»Mario Zalac, Food Processing Specialist Inspector, CFIA Regina Qu’appelle Health Region »»David Engel, Food Processing (FSEP) Supervisor, CFIA »»Dr. Patricia Hudson, A/Director, Montérégie »»Dan Schlegel, Food Processing Inspector, CFIA Public Health »»Dave Gagnon, FSEP/HACCP Area Coordinator, CFIA »»Dr. James Lu, Medical Health Officer, Vancouver Coastal »»Alex Radoja, Inspection Program Officer, CFIA Health »»Carlo Pernarella, Food Processing Specialist »»Dr. Judy MacDonald, Deputy Medical Officer of Health Inspector, CFIA Alberta »»Laurel Herwig, Director, Programs Communications, CFIA »»Dr. David McKeown, Medical Officer of Health, Toronto »»Catherine Airth, Accociate Vice-President, Public Health Operations, CFIA »»Dr. Terry-Nan Tannenbaum, Public Health, Montreal »»Vance McEachern, Executive Director, Operations »»Dr. Gaynor Watson-Creed, Medical Officer of Health, Strategy and Delivery, CFIA Capital District Health Authority »»Richard Arsenault, Director, Meat Programs »»Dr. Babara Yaffe, Associate Medical Officer of Health, Division, CFIA Toronto Public Health »»Judy Strazds, Inspection Manager, CFIA »»Bill Teeter, Executive Director, Ontario Operations, CFIA »»Urszula Sierpinska, Food Specialist, CFIA List of Investigative »»Don Irons, Food Processing Supervisor, CFIA »»Tom Graham, National Inspection Manager FSEP/ Meetings by Organization HACCP, CFIA
Ministers and Deputy Ministers and Staff Health Canada »»The Honourable Gerry Ritz, Minister and Yaprak »»Dr. Jeff Farber, Director, Bureau of Microbial Hazards, Baltacioglu, Deputy Minister, Agriculture and Agri-Food Health Canada Canada »»Hélène Couture, Chief Evaluations Division, Health »»The Honourable Tony Clement (formerly Minister of Canada Health) & Morris Rosenberg, Deputy Minister, Health »»Dr. Franco Pagotto, Research Scientist, Health Canada Canada »»Meena Ballantyne, Assistant Deputy Minister, Health »»Carole Swan, President, Canadian Food Inspection Products and Food Branch, Health Canada Agency »»Alan Sakach, Media Officer PMO (formerly Director of Communications for Minister Ritz)
146 Prime Minister’s Office (PMO) Urban and Provincial Health Specialists »»Jenni Byrne, Director, Issues Management, PMO »»Dr. Dean Middleton, Ontario Agency for Health Protection and Promotion Privy Council Office »»Dr. Barbara Yaffe, Toronto Public Health »»Daniel Jean, Deputy Secretary to the Cabinet, »»Dr. Horacio Arruda, Québec Public Health Operations PCO »»D r. David Williams, Ontario Public Health »»Anne-Marie Smart, Assistant Secretary to the Cabinet, »»David Cutler Communications and Consultations . PCO Family Members of Deceased Public Health Agency of Canada (PHAC) »»Dr. David Butler-Jones, Chief Public Health Officer, PHAC »»Dr. Frank Plummer, Scientific Director General, National Microbiology Laboratory, PHAC »»Dr. Andrea Ellis, Section Manager, Outbreak Response & Issues Management, PHAC »»Diane MacDonald, Epidemiologist, Outbreak Management Division, PHAC »»Sarah Lawley, Director Corporate Communications, PHAC »»Mark Raizenne, Director General, Centre for Food-Borne Environment and Zoonotic Infectious Diseases, PHAC »»Robert Clarke, Retired from position of ADM, Infectious Disease and Emergency Preparedness, PHAC
Maple Leaf Foods Inc. »»Ivy Balancia, Maple Leaf Foods »»Juan Alvarez, Maple Leaf Foods »»Ron Judge, Maple Leaf Foods »»Larry Mendes, Maple Leaf Foods »»Dr. Randall Huffman, Maple Leaf Foods »»Steve Dowbiggin, Maple Leaf Foods
Appendix D – List of Interviewees 147
Appendix E Glossary
149 Agriculture Sub-Committee on Food Safety Best Practices: The House of Commons has permanent (‘Standing’) all-party There is no universally accepted definition but there is broad committees that examine relevant legislation, the activities agreement that best practices share common characteristics . and expenditures of a department or agency and the They are innovative, make a difference, have a lasting effect effectiveness of its policies and programs . Subcommittees and have the potential to be replicated . are sometimes set up by the main committee to focus on specific issues . C-EnterNet: On February 12, 2009 the Standing Committee on A comprehensive, multi-partner surveillance system enteric Agriculture and Agri-Food established a Sub-Committee (gastrointestinal) disease on Food Safety to study the food safety system in Canada including the events and factors that lead the listeriosis Case outbreak of 2008 .The Sub-Committee produced a report A person in the population or study group identified as having entitled Beyond the Listeriosis Crisis: Strengthening the a particular disease . Food Safety System, which was tabled in the House of Commons on June 18, 2009 Case Definition: The method used by public health professionals to define At-Risk Population who is included as a case in an outbreak investigation, Individuals belonging to a specific group who share (e .g . a person considered directly affected by a disease) . common characteristics, such as age, gender, that are A case definition defines a case in terms of time, person more susceptible to illness or likely to develop a medical and place . condition .Also referred to as ‘vulnerable’ groups . Compliance Verification System (CVS): Audit: The CVS provides a uniform approach to food safety An in-depth review of an establishment to ensure proper inspection . Its purpose is to verify that federally regulated procedures are being followed . In the case of the food food-based establishments are complying with federal Meat processing industry, CFIA carries out an audit to verify whether Inspection Regulations .The system includes verification tasks national health standards are being met . An audit requires and detailed procedures for CFIA inspectors to follow when inspectors to go through all areas of a plant and evaluate the conducting verifications . Inspections activities include daily entire establishment in one session .This differs from a daily and monthly tasks, and are based on known risks associated inspection that covers all points an audit does, but cyclically with food processing and the facility . over an extended period of time . Communicable Disease: Best Before Date: An illness caused by a specific infectious agent or its toxic Labelling on food items that signifies the last recommended products that is spread from an infected person, animal or date the product should be consumed as shown on the label . reservoir to a susceptible host, either directly or indirectly Best before dates assist traceability by identifying when the through an intermediary such as a plant or animal host, product was manufactured . sector or the inanimate environment .
150 CODEX: Epidemiology: The short form for Codex Alimentarius Commission, a body The study of the incidence and prevalence of illness in large established by the United Nations Food and Agriculture populations to discover how often diseases occur in certain Organization in partnership with the World Health Organization . groups and why . The information is used to plan approaches It was set up to protect the health of consumers and to to prevent diseases or to manage them in cases of outbreaks, ensure fair practices for international trade in food products . such as infectious and foodborne disease epidemics . CODEX includes internationally recognized standards, codes of practice and guidelines for industry to follow to export Establishment (Est.) 97-B: their products . The Maple Leaf Foods plant at 150 Bartor Rd .Toronto, Ontario – referred to in this report as Bartor Road – where Listeria Cross-coding: contamination in deli-meats resulted in the 2008 listeriosis A method of identifying human samples and corresponding outbreak . food samples to make it easier to link their test results Food Safety: Deputy Head: The overall safety and nutritional quality of food sold in The highest ranking public servant in a federal department or Canada . Policies, standards and activities relating to food agency (usually referred to as a Deputy Minister) who manages safety are the statutory responsibility of the Minister of Health . the organization on a day-to-day basis and reports to the Minister . In some federal agencies, the position is also called Food Supply Chain / Distribution System: President or Commissioner . The path that foods take as they move from food producers to consumers . Early Aberration Reporting System (EARS): An electronic surveillance system used in Ontario to monitor Foodborne Illness: health trends based on disease information provided by local Foodborne illness occurs when a person consumes food public health units . The system makes it easier to identify contaminated with bacteria, viruses, parasites or toxins . statistical increases in infectious and foodborne illnesses and to identify clusters of a disease . Foodborne Illness Outbreak Response Protocol (FIORP): Environmental Sampling: An intergovernmental agreement involving the federal, A testing method for example by swabbing used in the food provincial and territorial governments that outlines the roles processing industry to identify microorganisms on surfaces and responsibilities of all regulatory parties involved in a that could come into contact with food in order to control foodborne illness outbreak in Canada harmful bacteria that may be a threat to human health .
Appendix E – Glossary 151 Forensic investigator: Lead Agency: An individual with specialized training and expertise In an outbreak the lead is the agency that has responsibility (e .g legal, scientific, accounting, engineering) who reviews for the overall management of the emergency documentation to confirm facts or to identify factors that explain why or how an event unfolded, including the cause Listeria: or causes of a problem The umbrella term to describe six strains of bacteria referred to as Listeria species (or Listeria spp .) Of these, only one Hazard Analysis and Critical Control Point strain, Listeria monocytogenes is known to cause illness in (HACCP): humans (listeriosis) . An internationally recognized approach to food safety that became mandatory in Canada in 2005 . HACCP is a core Listeriosis: element of food processing plants’ food safety program A serious, potentially fatal, infection caused by eating food designed to assess and control hazards and risks associated contaminated with the bacteria Listeria Monocytogenes . with food production . It occurs primarily in newborn infants, elderly patients, and patients who have compromised immune systems . High Risk Foods (for Listeria): Products most susceptible to listeria contamination, such Lot Code: as deli-meats, unpasteurized (raw) milk, soft cheeses, pâté, A number printed on a product or its packaging that meat spreads, and smoked seafood and fish . signifies the day and year it was manufactured as well as the establishment where it was manufactured . Incubation period: The time between exposure to a bacterial or viral infection Mandatory Recall: and the onset of symptoms or other signs of a disease . It can When a product is deemed to pose a threat to human health take between three to 70 days before people become ill with or safety, Section 19 of the Canadian Food Inspection Act give listeriosis . the Minister of Agriculture and Agri-food the authority to order that it be removed from the marketplace . Mandatory recalls (Food safety) Inspection: are used when a company is unwilling or unable to recall its The activities carried out by a food inspector fulfilling contaminated product or when the company cannot be found daily or monthly tasks under the CFIA’s Compliance (e .g . bankruptcy) or identified . Verification System . Manual of Procedures for the Meat Integrated Public Information System (iPHIS): Inspection Program: Ontario’s automated client health record and reporting Contains information and instructions to inspectors about database used by public health officials . It supports public policies on the importation, exportation and interprovincial health interventions, tracking, follow-ups, case management trade of meat products, as well as policies concerning the and reporting, immunization tracking, communicable disease preparation of meat products in establishments licensed case management and population health surveillance under the 1990 Meat Inspection Act and Regulations . components .
152 Memorandum of Undersanding (MOU): Pathogen: A document describing a bi-lateral or multi-lateral agreement The term used to describe bacteria, viruses or fungi among parties that indicates an intended action . It is most that are the agents or producers of a disease . commonly used in cases where there is not an existing legal obligation or in situations where one is not legally enforceable . Post-Processing Treatments: Measures taken after products have been processed and Microbe/Microbial: packaged to kill contaminants before the products are A microorganism that causes a disease . distributed .
Multi-departmental: Precautionary Approach: Refers to the relationship among departments or agencies The principle that there is a duty to take action to protect the within government . public or the environment, even in the absence of scientific certainty, to avoid severe or irreversible harm . Multi-jurisdictional: Refers to the relationship among different levels of government (e .g . federal-provincial, federal-provincial-local) Product Code: A series of numbers and/or letters that signify specific product Notifiable Disease: information primarily for the use of the manufacturer to assist A disease deemed of sufficient importance to public health in tracing products and for quality assurance . to require that its occurence be reported to public health officials . The reporting of notifiable diseases is mandated Public Safety: by the province and territories; notifiable diseases may Preventive or remedial action to protect the public from events vary from province to province . Reporting by the provinces that otherwise would pose significant danger, injury, harm or and territories to the federal level is voluntary; however, damage resulting from natural disasters or man-made crises agreement is reached by consensus of the Advisory Committee on Epidemiology, which comprises representatives from all Public Health: provinces and territories . (PHAC) The efforts of a society to keep its population healthy and safe by promoting good health, as well as preventing illness, injury Outbreak: and premature death . A sudden increase of disease greater than would otherwise be expected in a particular time and place . Public Health Surveillance: The ongoing, systematic collection, analysis and interpretation Panorama: of data essential to the planning, implementation and Next generation information management solution to better evaluation of public health practice, closely integrated with manage public health outbreaks in a coordinated manner . the timely dissemination of these data to those responsible for prevention and control (PHAC) .
Appendix E – Glossary 153 Pulsed-Field Gel Electrophoresis (PFGE): Voluntary Recall: Scientific method used to identify genes at the DNA A product recall initiated and carried out by a company level commonly referred to as molecular sub-typing that manufactured the product without being ordered to or “fingerprinting ”. by government .
PulseNet: Warning (Food Safety): A national network of public health and food regulatory A public warning alerts consumers they may have purchased agency laboratories coordinated in Canada by PHAC’s or otherwise obtained a product that presents a serious National Microbiology Laboratory locacted in Winnipeg . hazard to health and advises them not to consume it . PulseNet participants perform standardized DNA fingerprinting to distinguish foodborne disease- Weight of Evidence: causing bacteria . Evidence has different weight in inducing belief or action with respect to facts or circumstances . Evidence that is indefinite, Ready-to-eat: vague, or improbable will be given less weight than evidence Term used to describe food that requires no preparation that is direct and unrefuted . before consumption . Zoonotic: Recall (Food Safety): The umbrella term describing diseases that can be passed to A requested return of an entire production run of a product humans from animals . usually to preserve the health and well-being of the consumer and to limit liabilities .
Risk Communications: Term used to describe the communication approach and practices in situations where there is a high level of public concern or anxiety such as a health emergency
Standard Operating Procedure: A routine course of action; a normal practice .
Traceability: The ability to trace and follow food, feed, food-producing animals or substances through all stages of production and distribution .Tags, tattoos, brands, best-before dates, billing and shipping invoices, and paper-based logbooks are examples of traceability tools used by industry and government .
154 Appendix F Acronyms
155 ACRONYMS AAFC Agriculture and Agri-Food Canada CEO Chief Executive Officer CFEZID Centre for Foodborne, Environmental, Zoonotic and Infectious Disease (PHAC) CFIA Canadian Food Inspection Agency CIOSC Canadian Integrated Outbreak Surveillance Centre CMOH Chief Medical Officer of Health CPHO Chief Public Health Officer CVS Compliance Verification System FIORP Foodborne Illness Outbreak Response Protocol P/T Provincial/Territorial HACCP Hazard Analysis Critical Control Point HC Health Canada LRS Listeriosis Reference Service (HC) HRA Health Risk Assessment iPHIS Integrated Public Health Information System MLF Maple Leaf Foods MOHLTC Ministry of Health and Long-Term Care (Ontario) NML National Microbiology Laboratory (PHAC) OFSR Office of Food Safety and Recalls (CFIA) OMAFRA Ontario Ministry of Agriculture and Food and Rural Affairs PHAC Public Health Agency of Canada PFGE Pulsed Field Gel Electrophoresis PHU Public Health Unit RTE Ready-to-eat TPH Toronto Public Health US United States
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