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Report of the Independent Investigator into the

VIEWS: 8 PAGES: 181

									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
 assesses how well federal organizations
                                                             Why it matters                                     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
number of persons




                                                     Surveillance System Issued                 Bartor Road Sure Slice Products
                     6         July 16: Toronto Public Health                                         Aug 19: Recall of all Maple Leaf Foods Bartor
                                         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
                                                                                                                            after its closure on Aug 20

                     3

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                                                                                                      14
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                                                                                   week of Illness onset
                                                  * Some illness onset dates have been estimated from available information

                  The greater challenge is connecting
              the illness to the consumption of a
                                                                                   ate that was contaminated . Rapid
                                                                                   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,
including consumers themselves .
                                                       Because coordinating the response
                                                    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) .
Similar functions are also performed
                                                    How events unfolded                                 a segment of the population that is
                                                                                                        the most vulnerable was exposed to its
at the provincial, and sometimes,                   With the benefit of hindsight,
                                                                                                        damaging and sometimes deadly effects .
local levels which demands close                    we have been able to understand
                                                                                                           Once people were ill, there were
working relationships and clear lines               the day-by-day, step-by-step actions
                                                                                                        many challenges in managing the
of authority and communication in                   taken as the emergency unfolded .
                                                                                                        emergency right in the middle of
a foodborne emergency .                             An abbreviated chronology, found in
                                                                                                        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)                                                                                  monocytogenes, and what foods
                                                publIc HealtH and
»   Most organizations involved in the                                                         these vulnerable groups should
                                                food safety sectors
    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
        ‘advance’ communications strategy       What else was learned                      of food as one of its top priorities .
                                                                                           (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
 In the order they appear                   6. To ensure active and transparent
                                                communications, all federally
                                                                                          inspection staff. Inspectors should
                                                                                          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
      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
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
     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.”
                                                 » DR . MICHAEL DOyLE
involved in the outbreak were complex .            REGENTS PROFESSOR OF FOOD MICROBIOLOGy AND DIRECTOR OF THE CENTER
These issues involve the constitutional            FOR FOOD SAFETy AT THE UNIVERSITy OF GEORGIA
                                                   MEMBER OF THE LISTERIOSIS INVESTIGATION ExPERT ADVISORy GROUP
relationship between the federal and
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
food processors . Finally, they involve
                                             meat products involved in the disease
                                             outbreak, and the subsequent recalls
                                                                                                       Approach
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
                                                                                                       methodology used to guide the work
Investigative Review                               and communication with their
                                                   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




          Who we interviewed                                   In total we conducted over 100 interviews and meetings representing several
                                                               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
                                                                                                          » Canadian Poultry and Egg
                                                            famIlIes and
                                                                                                            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
NUMBER OF PERSONS




                     200                                                                                  and includes the
                                                                                                                               but rarely become seriously ill .
                                                                    128          140                      57 associated           Listeriosis is the name given to any
                     150                                105                                               with the 2008
                                            96                                                                                 form of disease or invasive infection
                                85                                                                        outbreak
                     100                                                                                                       caused by Listeria monocytogenes .
                                                                                                          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 .
                                                                                                                                  The most common forms of
                    Professor Rick Holley
                                                                                                                               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
                                                                                                                    listeriosis
    » 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
      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 that Listeria 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 .

    NEXT CHAPTER

     “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
number of persons




                                                     Serveillance System Issued                Bartor Road Sure Slice Products
                     6         July 16: Toronto Public Health                                        Aug 19: Recall of all Maple Leaf Foods Bartor
                                         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
                                                                                                                            after its closure on Aug 20

                     3

                     2

                     1

                     0
                         un
                              un

                                    n
                                          n
                                                 n
                                                       ul

                                                                         l
                                                                         l
                                                                         l
                                                                      ug

                                                                        g
                                                                        g
                                                                        g
                                                                        g
                                                                      ep

                                                                        p
                                                                        p
                                                                        p
                                                                       ct
                                                                       ct
                                                                       ct
                                                                       ct
                                                                       ov

                                                                16 v
                                                                       ov
                                                            -Ju
                                                                     -Ju
                                                                     -Ju




                                                                     No
                                                                    -Au
                                                                    -Au
                                                                    -Au
                                                                    -Au
                                   -Ju
                                         -Ju
                                               -Ju




                                                                   -Se
                                                                   -Se
                                                                   -Se
                                                     6-J




                                                                  5-O

                                                                    -O
                                                                    -O
                                                                    -O
                                                                  2-N



                                                                   -N
                                                                  3-A
                     1-J
                           8-J




                                                                  7-S
                                                           13
                                                                 20
                                                                  27




                                                                 9-
                                 15
                                      22
                                            29




                                                                 12
                                                                 19
                                                                 26
                                                                 10
                                                                 17
                                                                 24
                                                                 31


                                                                14
                                                                21
                                                                28




                                                                                   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 pRoCessoR
steps and people involved at each                     »   Cooking
                                                                                                             tRanspoRtation
                                                      »   Slicing
stage starting with farmers and                       »   Preperation
                                                      »   Packaging
ranchers, followed by employees in
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
                 » Establishes and conductsfood safety
                                                                                                       inspeCtion agenCy (Cfia)
                   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
                 » Consumes foods with caution
                                                                                                       health Canada (hC)
                                                                                                       » 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
        FOOd SAFETy And QUALITy SySTEMS SPECIALIST
                                                                                                           is to ensure the safety of Canada’s food
        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
Understanding the                                       by better supporting the collective
                                                                                                              enhance Canada’s food safety system.
                                                                                                              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
                                                          The Action Plan is based on the
                                                                                                              safety system, provide more consistent
                                                                                                              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
   Under the food and drugs act,                                                                                        plant. They include the conditions
                                                            ➤ Today, it is an internationally endorsed
Health Canada sets out food safety                                                                                      needed to produce safe food.
                                                              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




                                         1
                                                                     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.




                                         2
                                                NO                      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




                                         3
                                                NO
                                                                     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,




                                         4
                                                yeS
                                                                     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
                                                                     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
of foods in which the additive may be              Post-packaging heat treatments (typically
                                                                                                     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                                                            » Irradiation: Food irradiation is
                                                   thermal processing (Beckwith, 1995).
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

health and the                                     as “a shared responsibility. While
                                                   governments enact laws, develop
                                                                                                        out consultations with Canadians to
                                                                                                        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
system.                                            both within and outside government,                  take an active role in their health13.
   Public health covers a wide range               to address health challenges.12                         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
        publiC health aleRt                           e-mail aleRt                                   occurs across large geographic areas
        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
         and food-borne illness                            CIOSC                                     tools for dnA fingerprinting of disease
         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
is agreed to by consensus with the
                                                          confirmed enteric (intestinal) disease
                                                          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
exposure to contaminated foods.
                                                                                           NEXT CHAPTER
   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
a series of modifications to federal        BELIEVED ITS PROCEDURE                     protection at the end of the nineties –
                                                                                       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
the lead-up to the event. These recent
                                            WORKING – IT WAS NOT                         Like most food processors, Maple
                                                                                       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
                                                 SuBCOMMITTEE On FOOD SAFETy, APRIL 20, 2009
occurrences as isolated incidents.
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
INSPECTION SYSTEM                                           introduced, in the spring of 2008, in
                                                            the nearly 400 federally registered
                                                                                                                 deficiencies are noteworthy because
                                                                                                                 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
                                                            streamline and integrate previous CFIA
                                                                                                                 standards against which compliance is
                                                                                                                 verified.
                                                            inspection approaches. It was first                     The gaps can be explained, in large
HOW THE SYSTEM                                              introduced as a pilot project in 2005,               measure, by the fact that the CvS was
WAS DESIGNED                                                                                                     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
                                                                food producer to ensure that the product is
                                                                                                                 and in the absence of a rigorous
quality assurance processes, the
                                                                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
                                                                industry in particular, it has been adopted by
                                                                                                                 had been more engaged, the CFIA
food processing plants to ensure
                                                                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                                                         under their CvS tasks. Had the
                                                 Road plant, inspectors were following
     identified prior to the outbreak, despite                                               CFIA inspectors reviewed these test
                                                 their CvS work plans and doing the
     daily inspections by Maple Leaf Foods’                                                  results they could have identified the
                                                 prescribed activities and their other
     quality assurance team and third party
                                                 duties (e.g. export certification) as       frequency of positive Listeria results
     auditors, as well as CFIA inspectors.
                                                 well as travelling between plants.          and brought this concern to the
                                                 For example, the day shift inspector        attention of the plant management.
                                                 had seven different plants to cover            Other potential factors contributing
   We were also told that supervision,
                                                 (including cold storage facilities          to the outbreak were the general belief
support, and oversight of inspectors
                                                 for export purposes). We heard that         that both Maple Leaf Foods’ food
were not adapted to the CvS. Further,
                                                 inspectors’ workloads left them limited     safety system and the CFIA’s inspection
it was reported that supervisors
                                                 time to accomplish their tasks in           system were reliable, and that the
received minimal training to
                                                 depth. What’s more the inspectors           Bartor Road plant needed minimal
prepare them for their additional
                                                 may have missed early warning signs         oversight since it had historically not
responsibilities.
                                                 due largely to the nature of their tasks,   presented cause for concern.
   In addition, we heard that a
                                                 insufficient training and understanding        The issues identified during the
‘curiosity’ factor was not always present
                                                 of the new procedures and the               two post-outbreak reviews conducted
in inspectors – understanding the
                                                 supervision they received.                  by the Maple Leaf Foods panel of
difference between what is needed and
                                                    In addition, the inspectors were not     independent experts and the CFIA’s
what is important. Inspectors were
                                                 scheduled to visit the plant between        In-depth Review Audit Team pointed to
not expressly encouraged to use their
                                                 operating shifts when sanitation was        deficiencies in the inspection system.
judgment, based on their education
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
    due to their responsibilities at
                                          8. The Canadian Food Inspection
                                             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
    hours of operation, and necessary
                                             and training specific to each
                                             function they perform. This
                                                                                    PRODUCTION AND
    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
                                                 conclusions are suggestive of design           specifications and instructions
   the use of bacteriophages, food additives
   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
          contamination, or                         5
                                                        The testing requirements (e.g. number of tests)
                                                                                                                manner.
       » 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
4. ONCE CONTAMINATED                           practices aimed at vulnerable
                                               populations, including those most
                                                                                     prevent and control infectious and
                                                                                     chronic diseases, and injuries, and
PRODUCTS ENTERED                               vulnerable to listeriosis (such       promote health.6
THE FOOD SUPPLY,                               as the practices set out in the
                                               British Columbia Guideline for
                                                                                        nevertheless, as a growing number of
                                                                                     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.
POPULATIONS                                    and territories.)                        As it became increasingly clear that
                                                                                     this was likely a foodborne emergency7
Another, quite reasonable assumption
at the time of the outbreak was the
                                           5. AS CONTAMINATED                        and people were treated, the public

general belief that ‘ready-to-eat’         FOOD WAS BEING                            health sector gradually responded but
                                                                                     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
preparation or precaution.
                                           HEALTH SYSTEM SLOWLY                      the reasons for the gradual response
                                                                                     are more evident.
  While true for the most part, in         RECOGNIZED THE                               First, listeriosis is both less common
the case of vulnerable populations,
contamination with Listeria
                                           OUTBREAK                                  than other foodborne illnesses and
                                                                                     more difficult to diagnose, so it was not
monocytogenes can have serious             In recent years, Canada, and indeed
                                                                                     immediately obvious that an outbreak
consequences. Of the 57 eventual           the world, has been confronted with
                                                                                     was emerging. When isolated cases
confirmed cases of listeriosis during      wave after wave of health crises.
                                                                                     of listeriosis are detected, they are
this outbreak, 54 of the individuals       From SARS and West nile virus, to
                                                                                     generally dealt with at the local level.
who became ill were elderly people in      mad cow disease, the listeriosis
                                                                                     This is normal, and a small number
hospitals and long-term care homes.        outbreak and the H1n1 virus, we have
                                                                                     of cases does not immediately trigger
The operators of these facilities served   been reminded of the threats such
                                                                                     suspicion or provoke an emergency
the ready-to-eat food products –           infections pose to our health. Canadian
                                                                                     response. There are routinely five to
working from the assumption, based on      governments, industry, and citizens
                                                                                     six such cases reported each month in
years of experience, that the products     have strived to protect themselves from
                                                                                     Ontario. It was only when clusters of
were nutritious, easy to chew and safe     these threats.
                                                                                     listeriosis cases became apparent in
– without taking extra precautions or         The Public Health Agency of Canada
                                                                                     different communities across Ontario
avoiding serving them to vulnerable        was created in 2004 in response to
                                                                                     that there was increased action at
populations.                               SARS and the growing recognition
                                                                                     the provincial and, eventually, the
                                           that we need to better anticipate and
                                                                                     national level.
                                           plan for health emergencies and be
RECOMMENDATION
                                           better coordinated in our responses
21. Organizations providing housing
                                           when they arise. The Agency has a         6
                                                                                         Public Health Agency of Canada, About the
    and/or food services to seniors
                                           mandate to prepare for and respond to         Agency: Who We Are; What We Do, online
    and other vulnerable groups,                                                         http://www.phac-aspc.gc.ca/about_apropos/
                                           public health emergencies, strengthen
    including long-term care                                                             index-eng.php
                                           Canada’s capacity to protect and          7
                                                                                         A foodborne emergency occurs when
    homes and hospitals, should be
                                           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 1st 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

CHALLENGES OF MAN-                          source so it can stop its distribution
                                            and consumption . This role is an
                                                                                                   was to provide support . This view ran
                                                                                                   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
                                                  FROM OUR INTERVIEWS
provincial level, in most provinces,


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
       not widely known or understood                       MANAGEMENT                                    nor fully understood by many of
                                                                                                          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
      CHIEF PUBLIC HEALTH OFFICER OF CANADA, TO THE STANDING COMMITTEE ON HEALTH, OCTOBER 2004
                                                                                                            management of the outbreak .
                                                                                                               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 and year 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;
more conclusive evidence, before                                                                          ➤ Food safety/public health response needs
                                                           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            investigation
    important to collect unopened packages of that
                                                         information on packaged foods should be             » The differences in perspectives
    food—ideally from the same lot.
                                                         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)
    records to include electronic                                                                 same (2 to 4 days)
                                               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
    potential product recalls.              b. Detection: indicates whether or not the
                                                                                                  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
                                                       canada are not networked, the                    Suggestion
  Dr Mansell Griffith
                                                       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
                                                       b. food labs,                                    access to patients’ health records.”
     IN THE FOOD SCIENCE DEPARTMENT
     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,
other provinces, and Maple Leaf                            OBSERVATIONS AND                                           After the first few days of coverage,
                                                                                                                   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
to the public against the key objectives      The overall approach to                                   dramatically after September 6th,
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,
                                                             APPEARING BEFORE THE AGRICULTURE SUBCOMMITTEE ON FOOD SAFETy, APRIL 22, 2009
fragmentation and reactive nature
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




                                                                                                                                                                                                Intensity of communications effort (national)
                                                                                                                                              Sep 8: Federal election call
                     7
number of persons




                     6
                               Aug 17: Recall of Maple Leaf Foods Bartor Road                                                                 Government of Canada
                                                           Sure Slice products                                                                public communications
                     5



                     4



                     3
                                                                                                                                              Sept 17: Maple Leaf Foods Bartor Road
                                                                                                                                              plant re-open after its closure on Aug 20
                     2



                     1



                     0
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                                                                                                                                                                                    9-
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                                                                                                                                                                                          16
                                                                                  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.”
                                              » A SUGGESTION By A FAMILy AFFECTED By THE OUTBREAK
        consumers;
      » 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
    organizations .
                                              audiences as quickly as possible.
                                                   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%) .
     » Their preferred sources of
                                              PUBLIC EDUCATION                            awareness of listeriosis, contributed to
                                                                                          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

Food Safety Legislative                             these limitations . The government
                                                    acknowledged this recommendation .
                                                                                                     disclose any threat to food safety
                                                                                                     as covered by recommendations
and Regulatory                                      In 2004, the government introduced               6 and 20).
Framework                                           a modification of the earlier bill that

Several pieces of key federal
                                                    focussed only on inspector powers and        Federal organizational
legislation in place to govern food
                                                    a series of prohibitions and licensing
                                                    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
                                                 PRESIDENT OF THE AGRICULTURE CHAPTER OF THE PUBLIC SERVICE ALLIANCE OF CANADA
rationale for the introduction of an
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
    food Inspection agency,
                                               the board should be specifically
                                               directed to advise the minister
                                                                                                    lines of business
    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
                                               of its rules and enabling                            in designing appropriate and timely
         at a minimum, the federal
                                               legislation.                                         regulatory interventions to meet the
    government should consider the
                                                                                                    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 .

Safety and Recall                               recall should report directly to
                                                the office of the president of the
                                                                                         We repeatedly heard that the Centre
                                                                                      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
multi-jurisdictional management of          Going forward                                57. following its receipt and review
                                                                                             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
the Montreal General Hospital, he worked for the Department
                                                                    Walter F. Schlech III, MD
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
                                                                         office; another resident was hospitalized . The
» wednesday, july 16
                                                                         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 a L. 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
                                                                               additional information from MLF Bartor Rd .
pHac sItuatIon report update
  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
                                                                             products .
» frIday, august 29
                                                                       [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
                                                                                the CFIA, PHAC and HC respond to questions .
pHac sItuatIon report update
 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


                                                                        [212] PHAC posts an updated fact sheet on its website
pHac sItuatIon report update
                                                                              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 .
                                                                      bc     ab   sk   mb   on   qc   nb   bc   ab   on   qc    nb
           This sampling program continues on a daily basis .
                                                                      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 .
                                                                      [267] MLF begins distributing foods manufactured
» frIday, october 10                                                        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
                                                             » dr. 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

 Meetings by Organization                                          »   tom graham, National Inspection Manager FSEP/
                                                                       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                                               » dr. 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




156

								
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