Appendix C: Evaluation of food-borne enteric illness prevention, detection and response activities at the Public Health Agency – 2008 Listeriosis outbreak

Appendix C: Progress from Listeriosis 2008 outbreak

Context: What Happened in Listeriosis 2008 Outbreak?

In August 2008, a national outbreak of Listeriosis led to the largest recall of contaminated food products in recent Canadian history. In total, 57 cases of Listeriosis were confirmed and 23 deaths linked to the outbreak. Following the 2008 outbreak, a review of Canada’s food safety system’s response to the outbreak was conducted by each of the federal partners and by Sheila Weatherill, an independent investigator appointed by the Prime Minister. The Report of the Independent Investigator (also known as the Weatherill Report) was released in July 2009. The report identified a number of systemic gaps in the Canadian food safety system and contained a total of 57 recommendations. The Public Health Agency was identified as the lead for 10 recommendations and co-lead or implicated in the response for an additional nine recommendations. As outlined in the Weatherill Report, 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 complex. Multiple sectors and three levels of government play different roles with distinct mandates in a food-borne outbreak.Footnote 102

In September of 2009, the Government of Canada committed $75 million over three years to address the recommendations identified in the Weatherill Report. The Public Health Agency of Canada received $17.7 million for activities carried out by the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, National Microbiology Laboratory, Communications, Office of Public Health Practice, and Centre for Emergency Preparedness and Response. The activities included:

Project Title Lead Program Area 3-year Funding Allocation
National public health surveillance tools and platforms (Panorama) OPHP $4.5M
Strengthen laboratory diagnostic and networking tools NML $2.9M
Modernize and exercise the Foodborne Illness Outbreak Response Protocol (FIORP) CFEZID $2.8M
Create Incident Command (IC) for food-borne illness outbreaks (the Food-borne Illness Emergency Response Plan) CEPR, CFEZID $2.7M
Pilot test a surge capacity model OPHP $3.3M
Develop and implement multifaceted risk communications plan Communi-cations $1.5M
Source: Public Health Agency

The evaluation looked at progress made by the Public Health Agency in addressing the recommendations.

Roles and responsibilities

There is better clarity of roles and responsibilities. The FIORP, Canada’s guiding document to respond to food-borne illness outbreaks, was revised following extensive consultations with federal, provincial and territorial partners in June of 2010. It was endorsed by federal, provincial and territorial Deputy Ministers of Health and Agriculture, the Council of Chief Medical Officers of Health and the Public Health Network.

The revised FIORP includes the following key changes:

  • identifies the Public Health Agency of Canada as the lead in coordination of multi-jurisdictional outbreaks
  • includes provisions for data sharing, including epidemiological data to facilitate the identification of outbreaks while respecting privacy and confidentiality
  • includes guidelines for improved coordination of federal, provincial and territorial communication responsibilities and an appendix that discusses communicating with the public and with those at greater risk
  • clarifies the newly developed role of the FIORP Duty Officer.

The FIORP exercises have resulted in a better understanding of the roles and processes during a multi-jurisdictional outbreak. Thirteen bilateral FIORP training exercises have taken place with all provinces and territories. To best meet the training needs of each province and territory, working groups were established to identify specific training objectives. Various scenarios were developed and tested in collaboration with and according to the needs of the provinces and territories. There were participants from areas involved in a multi-jurisdictional food-borne illness outbreak investigation. The agenda included presentations from federal, provincial and territorial partners, an overview of the FIORP and mock outbreak scenario exercises at a local, provincial and national level.

The exercises incorporated a number of key issues including: outbreak investigation tools; laboratory processes and test analysis; the role of the Outbreak Investigation Coordinating Committee; communicating with the public; and the food recall process. Participants were asked to complete a pre and post-exercise form to assess changes in knowledge. Results of the evaluation demonstrated increases in participants’ confidence related to their knowledge of many FIORP processes. It was suggested that the training exercises be repeated every two to five years to address changes in personnel and processes. As well, according to key informant interviews, an unexpected outcome of the FIORP exercises was that the provinces and territories gained knowledge of their own roles and responsibilities within their own jurisdictions, as several did not have good knowledge of provincial/territorial protocols prior to the FIORP exercises.

As of November 2011, the Outbreak Investigation Coordinating Committee has been activated four times since the FIORP revisions. According to key informants, roles and responsibilities are clearer which has facilitated earlier discussion on the identification of potential outbreaks through the assessment calls. As well, duty officers are given full information so that they can brief their own senior management. Post-outbreak reviews have been conducted when Coordinating Committee members agree a “hot wash” is needed to follow-up on lessons learned. As of November 2011, four post-outbreak reviews have been conducted under the revised FIORP.

In addition to the FIORP revisions, the Food-borne Illness Emergency Response Plan (FI ERP) has been developed and approved. The plan was developed by the Centre for Emergency Preparedness and Response in collaboration with the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, Health Canada and the Canadian Food Inspection Agency. Presently, it is a Health Portfolio plan. The Incident Management Structure within the FI ERP demonstrates how federal and provincial partners will be connected to the management structure that would be implemented in the event of a food-borne illness emergency response. The scale of the activation will be tailored to the specific hazard. The Public Health Agency plans to lead an exercise of the emergency response plan with all partners by the end of the 2012-13 fiscal year.

Surveillance platform

The Weatherill Report recommended that an assessment of the pan-Canadian health surveillance program, Panorama, be undertaken. The Public Health Agency received funding to develop and assess an outbreak management module within Panorama. The Office of Public Health Practice determined that this public health case management system does not meet the Public Health Agency’s business requirements for managing multi-jurisdictional food-borne outbreaks. Key informants confirmed that the Public Health Agency will not continue to pursue this project. Rather, the current focus will be to ensure that the Agency can collect and analyze data from multiple systems being used across jurisdictions in addition to providing leadership in the areas of data standards.

Panorama development experienced many delays and a few jurisdictions have been considering alternative systems. One key informant explained:

While Panorama was certainly developed in its initial vision as a one stop type of solution for case and outbreak management…we’ve realized now that it will never be the one stop solution for all jurisdictions. Not all P/Ts are adopting the system, and may actually be using other systems for specific functionality, such as outbreak.  Within the Public Health Agency and within our unit, we are still trying to wrap up that analysis of the system and produce a report that will give a definitive answer for the Agency to consider in terms of the direct adoption and deployment of Panorama or whether the effort and focus should be more on developing standards and interoperability type of approaches.

Public Health Reserve Pilot Project

The Office of Public Health Practice received funding to develop and pilot a surge capacity model. The model looked at establishing a national roster of epidemiologists to be deployed to provinces and territories during an outbreak.

By the end of the 2011-12 fiscal year, the Public Health Agency established a coordination office to develop project plan and undertake business analysis. This work includes the development of potential administrative frameworks including policies, procedures and processes to recruit, retain and operationalize pilot reservists. A range of national public health professionals with skills in epidemiology were identified as pilot reservists and a portal designed to support and access the pilot roster at all times and under any circumstance. The pilot project developed and delivered competency based training to pilot reservists and Public Health Agency staff.

The pilot project experienced challenges in confirming administrative issues, such as legal and human resources requirements, given that the reserve will be composed of individuals that are not Public Health Agency employees. The project still needs to determine how best to integrate the concept into a Public Health Agency wide coordinated approach to surge capacity. Notwithstanding these challenges, the pilot project will result in options for a Public Health Reserve by the end of the 2011-12 fiscal year.

While information and project progress were communicated to program areas on a regular basis, some key informants noted that the project may have benefitted from better consultations within the Public Health Agency.

Laboratories surge capacity

The National Microbiology Laboratory, through PulseNet Canada, has ensured surge capacity by increasing the number of laboratories and staff trained to perform DNA fingerprinting tests and analysis. As of 2011 there was an increase in the number of laboratories and staff certified to conduct testing and analysis of E. coli O157, Salmonella, Shigella and Listeria across the country. Specifically, there are more laboratories and laboratory staff certified to work with Listeria monocytogenes than prior to the 2008 Listeriosis outbreak, allowing for more certified resources to be leveraged in an outbreak. PulseNet member certification and method standardization is an ongoing activity.

Development of a curriculum and web-based training course for laboratory staff by the National Microbiology Laboratory’s PulseNet Canada will serve as a training and certification program to new and existing member laboratories and is one of the key capacity building activities undertaken by the Public Health Agency to support provincial laboratories. The training will include components on DNA fingerprinting protocols including testing, computer-based analyses, data sharing and the interpretation of results. The web-based training will enable more personnel in the laboratories to become certified. The online training program will reduce the need for on-site training and will also facilitate resource allocation. The official website is planned to be launched by March 31, 2012.

Next-generation laboratory method development

The National Microbiology Laboratory staff applied genome sequencing in response to the 2008 Listeriosis outbreak and this work was highlighted as the first known application of whole genome sequencing to support a public health crisis caused by a bacterial pathogen. Whole genome sequencing is an emerging laboratory tool used to study outbreak-associated pathogens. It is a detailed typing platform capable of providing the entire genetic blueprint of a pathogen with the capacity to distinguish strains to a precise level.

The National Microbiology Laboratory received funding to sequence Listeria genomes. Laboratory staff developed expertise and was able to sequence more Listeria genomes than originally planned. In addition, the National Microbiology Laboratory staff was successful in assisting the United States Centers for Disease Control and Prevention in the response to the cholera outbreak in Haiti in 2010 by analyzing genome data. According to key informant, part of the role of a national laboratory is to consider innovations in laboratory technology like genomics, evaluate them, standardize them and then offer them to the provinces. In discussing the importance of new laboratory technology, one key informant noted:

These new methods offer the ability to actually understand these organisms that are causing disease and actually trace them to their origins and track them to what diseases they are causing. Instead of just getting a sprinkling of information on these organisms, we are getting the full blueprint. Presenting the work internationally demonstrates that n ew technology does have a place within public health labs. It could be business as usual from here to eternity with the existing tool sets that we have or we could be slightly innovative and creative and move on to these other technologies that may turn out to be cheaper than what we are doing now.

Communications

Progress has been made in preparation for communicating to the public during an outbreak. Key tools have been developed. The Public Health Agency developed a comprehensive risk communications strategy that includes approaches that can be adapted to various outbreak scenarios. It includes approaches for media relations, online communications, marketing and stakeholder outreach that can each be tailored to meet the needs of audiences in a given outbreak. Marketing concepts and messages have been tested to help ensure they are effective when used. In addition, a tool to assess the effectiveness of these communications approaches is being finalized so that learning can continue and approaches can be improved following an outbreak.

In addition, roles and responsibilities in communicating to the public have been clarified. The Public Health Agency collaborated with the Canadian Food Inspection Agency and Health Canada in developing a federal Food Safety Communications Protocol. The protocol clarifies various scenarios related to roles and responsibilities in communicating to the public. Certain areas, however, remain unclear. Some informants noted that the role of the Public Health Agency in communicating prevention messages to the public is an area of concern. Currently, this is an area led by Health Canada and the Canadian Food Inspection Agency. Given its mandate to prevent illnesses, in the context of food safety communications, the Public Health Agency appears to play a different role than it is used to.

Data-sharing agreements

Although the initial funding allocation for the Public Health Agency did include an amount to address the data-sharing agreement gap identified in the Weatherill Report, the Office of Public Health Practice decided to reallocate funding to Panorama. This decision was made that given that the Multilateral Information Sharing Agreement (MLISA) initiative would not be able to achieve its outcomes within the three-year funding period. The MLISA initiative still progresses given that this work also aims to address gaps identified in previous reports, including the 2008 Auditor General Report on Surveillance of Infectious Disease.

The Multilateral Information Sharing Agreement initiative aims to develop data-sharing agreements across infectious disease areas. It is not solely focused on enteric illnesses. While the work is progressing, challenges of limited resources and unclear data requirements have been identified by key informants as obstacles to developing data-sharing agreements. The importance of having formalized data sharing was acknowledged by key informants but some were unsure of its feasibility.

One of the gaps identified by the initiative to date has been that program areas do not clearly communicate to stakeholders the intent behind collecting data, and what the data will be used for. It was noted that among the enteric illnesses program areas the criteria established about the type and use of information collected from provincial and territorial partners is very clear and well understood.

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