Appendix D: Evaluation of food-borne enteric illness prevention, detection and response activities at the Public Health Agency – Evaluation matrices

Acute and enteric food-borne illnesses are under-diagnosed and under-reported. According to the study, Canada Communicable Disease Report: Burden of acute gastrointestinal illness in Canada, 1997-2007 the rate of under-reporting for infectious gastrointestinal illness in Ontario found that for each reported case of enteric illness, an estimated 313 cases of illness occurred in the community. The study also reported that according to Canadian surveys of self-reported acute gastrointestinal illnesses there are about 11 million cases of food-borne illnesses every year.

In 2009, the National Enteric Surveillance Program recorded a total of 14,262 cases of enteric-associated infections. For the last 10 years incidence of laboratory confirmed cases of Salmonella, Shigella and Verotoxigenic E. coli have shown a decreasing trend compared to baseline data. However, Salmonella Enteridis and enteric viruses have increased, as result of the adaption of the pathogen.

In 2009 there were 344 food-borne enteric illness outbreaks with a provincial or multi-jurisdictional distribution reported to the National Enteric Surveillance Program, involving 847 ill persons. The most common organisms related to these outbreaks were Norovirus (90 percent), Salmonella (5.5 percent) and E. coli (1.4 percent).

Global burden of food-borne illness is unknown. The extent of the cost is largely unknown. In the per capita cost of acute gastrointestinal illnesses was estimated at $115, or $3.7 billion annually in healthcare and societal costs. A few people infected with enteric pathogens may develop longer term health problems, such as chronic arthritis.

Resistance to antibiotics is a significant issue for bacterial pathogens in the food chain. The use of antibiotics in human and food animals can promote bacteria with resistance genes which can contribute to a risk of infection after eating or handling infected food.

Consumer demands are contributing to food-borne illnesses. The demand for convenience is a key factor in determining food choices among consumers.  Several published articles have identified that the increased consumption of convenient ready-to-eat foods has been responsible for multiple outbreaks as processed foods involve multiple stages of handling which increase the chances of contamination.

Global food supply chains and cost pressures have resulted in worldwide sourcing of food products and ingredients. Many food trading countries have weak regulatory systems and are not equipped to respond to food safety issues.

Migration and travel trends have contributed to the speed of transmission of food-borne enteric illness and outbreaks. The reach to most destinations is less than the incubation period of most infectious diseases. Globalization contributes to worldwide sourcing of food products. The Infectious Disease Prevention and Control Strategic Plan 2011-2016 and published article note that food products are among the most exchanged commodities and not all food trading countries have appropriate levels of regulation to protect the consumer.

Food production has become more industrialized with a single food processing establishment distributing products to millions of consumers, which increase the likelihood of having a food-borne illness that is international in scope.  According to published articles, changes in livestock farming including slaughtering practices play an important role in the transfer of pathogens. 

Adaptation and evolution of food-borne pathogens has been demonstrated in changing trends in food-borne outbreaks. According to published articles food-borne outbreaks have shifted from animal origin foods to fresh foods such as produce, dry food and ingredients. New threats continue to be identified because enteric pathogens are adaptable and able to evolve and respond to environmental challenges. Despite improvements in production, processing and monitoring along the food-chain, pathogens have not been successfully contained.

The FIORP and the Federal Food Safety Communications Protocol define and clarify the Public Health Agency’s leadership role in communicating to the public during a multi-jurisdictional outbreak. In an evaluation report from the Canadian Food Inspection Agency, all key informants who were interviewed  agreed that the Public Health Agency’s role in detecting and responding to food-borne outbreaks is clear and well understood.

The Public Health Agency’s role in detecting and responding to food-borne enteric illness outbreaks is well defined in key documents such as Memoranda of Understanding and program authorities. Through the funding of activities, the Public Health Agency was given the authority to conduct surveillance, develop laboratory technology, lead protocol and emergency plan development and conduct epidemiological investigations, which confirm that these are recognized federal public health roles.

Some of the key roles of the Public Health Agency, according to the Public Health Agency of Canada Act, are to foster collaboration and coordination in the field of public health and to promote cooperation and consultation with the provinces and territories. The funding authorities for the Listeriosis and Food andConsumer Safety Action Plan confirm the Public Health Agency’s role in some capacity building activities — FIORP exercises, the PulseNet Canada training program and outbreak response tools. These activities have all been undertaken to assist provinces and territories in improving their outbreak response capacity.Provinces and territories need and appreciate capacity building but the Public Health Agency’s role is not clearly mandated.

The other upstream prevention activities the Public Health Agency carries out are conducted by the Laboratory for Food-borne Zoonoses. This laboratory focuses its work on food hazards, which entail the analysis of animals, food products and water samples. It does not look at human clinical samples. The work conducted by the Laboratory for Food-borne Zoonoses, in conjunction with other Public Health Agency partners, is referred to as veterinary public health or the interaction of human, environment and animal health.

There are not many key documents that confirm the role of the Public Health Agency in these upstream prevention activities. The Memorandum of Understanding between Health Canada, the Public Health Agency and the Canadian Food Inspection Agency does mention the risk assessment activities conducted by the Public Health Agency. The Food and Consumer Safety Action Plan funding also gave the Public Health Agency the authority to conduct risk modelling activities.

Overall, federal partners and internal key informants expressed confusion over the activities conducted by the Laboratory for Food-borne Zoonoses. They questioned whether certain activities such as laboratory testing and risk modelling should be carried out by Health Canada or the Canadian Food Inspection Agency given their respective mandates.

There appears to be duplication in these areas:

• The Canadian Food Inspection Agency and Health Canada, for their own monitoring activities, collect food and animal product samples. The Public Health Agency also collects these types of samples for the purpose of its active surveillance systems (CIPARS and C-EnterNet). As recommended in the C-EnterNet Evaluation, activities may be better integrated to avoid duplication of data collection. The Public Health Agency has looked into integration of CIPARS and C-EnterNet sampling and, where feasible, resources now address the requirements of both surveillance systems. However, there does not appear to be much progress in integrating other government departments’ sampling activities.
• Risk modelling activities look at the areas in the food continuum where health risks are greater. In addition to the Public Health Agency, every other federal food safety partner conducts activities in this area. For instance:
  • Health Canada conducts health risk assessments as part of its mandate to determine the risks associated with product consumption
  • Agriculture and Agri-Food Canada conducts food safety research to determine routes of product contamination
  • The Canadian Food Inspection Agency conducts risk profiling and prioritization activities to prioritize food safety risks and determine food hazards along the food continuum.

The 2010 Speech from the Throne emphasized the Government of Canada’s commitment to strengthening Canada's food safety system. The Listeriosis outbreak was an important catalyst for improving Canada’s food safety capacity. Food safety and Listeriosis were specifically mentioned in Budget 2011, which described food safety as fundamental to the health and daily life of Canadian families. Budget 2011 also noted the magnitude of the Government of Canada’s investments in food safety since the Listeriosis outbreak, totaling $175 million to date.

The Public Health Agency’s corporate documents have continually highlighted its efforts to respond to food-borne illness. There is clear recognition that effective prevention, detection and response to food-borne illness requires the collective efforts of numerous partners within the Public Health Agency as well as other federal departments and provincial and territorial governments.

The evaluation found that the Public Health Agency have a strong coordination role in monitoring potential food-borne enteric illness outbreaks. Through ongoing formal and informal communications between federal departments and provincial laboratories, the Public Health Agency coordinates a number of key activities outlined below:

Outbreak management: The Outbreak Management Division works closely with the Canadian Food Inspection Agency, Health Canada, provinces/territories and international partners to coordinate the public health response to a multi-jurisdictional food-borne enteric illness outbreak.  In 2010the Division took action in 41 food-borne illness notifications and led four Outbreak Investigation Coordinating Committees under the revised FIORP.

Epidemiological and laboratory monitoring and investigations: The National Microbiology Laboratory activities through PulseNet Canada are closely coordinated with the Outbreak Management Division. Through weekly meeting with the Outbreak Management Division, PulseNet Canada provides detailed updates on any clusters detected, reported infections caused by similar strains and other laboratory issues that came up during the week. The National Enteric Surveillance Program’s weekly report is a joint collaborative effort between the National Microbiology Laboratory and the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases.  These two complementary laboratory surveillance systems share information and assess the laboratory evidence during multi-jurisdictional epidemiologic investigations.

Laboratory detection and response: PulseNet database managers provide analysis for all uploads and identify clusters of outbreaks. At any given time there are approximately 70 to 100 active clusters posted to the discussion board. According to key informant interviews, all member laboratories routinely check their data and post whether or not there are provincial matches to be identified as clusters. Requests to provincial member laboratories for DNA fingerprinting on specific organisms will be initiated in specific situations, such as a food recall or an outbreak investigation. The number of personnel certified to perform laboratory tests and analysis of results across the country has increased. In 2010, 100 per cent of Listeria cases were tested; 88 per cent of E. coli O157:H7; and 48 per cent of Salmonella cases. Testing and sharing with PulseNet Canada has increased since 2006-07.

Coordination of laboratories through the Network of Networks Initiative: A business case for the creation of an integrated laboratory and response network is expected to be completed by June 2012.

Coordination of communication activities: The Canadian Food Inspection Agency, Health Canada and the Public Health Agency collaborate to ensure that the three departments have consistent messages on food safety. The Federal Food Safety Communications Protocol has been tested twice: once in November 2010, and again in February 2011. Key informants have pointed to the almost daily communications as helping collaboration among partners. There is also collaboration with provinces and territories through the Public Health Network Communications Working Group. International collaboration takes place with the Global Health Security Initiative Communication Group.

Coordination of detection and response activities with international partners: There are both formal and informal coordination mechanisms at the international level with the United States Centers for Disease Control and Prevention. PulseNet Canada has a formal link including a Memorandum of Understanding with the United States and their PulseNet database to monitor laboratory surveillance for emerging bacterial pathogens. In addition to collaboration through PulseNet, there is direct collaboration with the United States on epidemiological investigations. The Outbreak Management Division also collaborates with international partners on travel issue investigations, where Canadians travelling abroad become ill. This collaboration is often in the form of information sharing; including the sending and receiving of International Health Regulations notifications.

Coordination of source attribution surveillance: There is good coordination of activities between C-EnterNet and its partners. Each sentinel site has a Steering Committee for information sharing and validation. Sentinel sites have built strong partnerships with the local public health unit, private laboratories, water and agri-food sectors, as well as the provincial and federal institutions responsible for public health, food and water safety.

Coordination of antimicrobial resistance surveillance: CIPARS coordinates the national surveillance of antimicrobial resistance in bacteria from humans, animals and food. The Public Health Agency has successfully maintained effective communications and coordination between partners on the issue of antimicrobial resistance in enteric pathogens. Its activities are well understood and recognized at the national and international level.

Some of the detection and response activities are well integrated within the Public Health Agency. The Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, the National Microbiology Laboratory and Communications Directorate have integrated activities, especially in detecting and responding to food-borne enteric illness outbreaks.  All groups communicate on a regular basis to prepare for potential multi-jurisdictional outbreaks. Key informants were satisfied with the current level of collaboration.

The Outbreak Management Division and the International Health Regulations Coordination Unit have integrated their activities. The Public Health Agency is the "national focal point" for Canada's communications with the World Health Organization in the event of a disease outbreak or an international public health emergency.  The World Health Organization communicated its satisfaction with the prompt and thorough Canadian response during the Germany E. coli outbreak.

Surge capacity and surveillance platform activities do not appear to be well integrated. According to key informants, there does not appear to be a strong integration between the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases and the Office of Public Health Practice, in the areas of the Public Health Reserve pilot project and the outbreak management module of Panorama.

There is limited evidence of the integration of the Laboratory for Food-borne Zoonoses activities with the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases and the National Microbiology Laboratory, with the exception of C-EnterNet, CIPARS and the development of some laboratory methodologies. According to key informants, other activities conducted by the Laboratory for Food-borne Zoonoses do not appear to be linked to detection and response activities.

There is no evidence of a food-specific Public Health Agency-wide strategic plan, nor a priority-setting mechanism for food-borne illness activities.

National enteric surveillance activities: Improvements have been made in the detection of, and response to, food-borne illness. Weekly National Enteric Surveillance Program reports produced jointly by the National Microbiology Laboratory and the Centre for Food-borne, Environmental Zoonotic Infectious Diseases provide the Public Health Agency and the National Enteric Surveillance Program’s provincial and territorial partners with the first triggers that a significant food-borne illness trend is emerging, and therefore allow for a more timely response.^{Footnote 103} The percentage of cases analyzed and shared with PulseNet Canada has increased from under 5,000 cases in 2006-07 to more than 6,000 in 2010. During this time there also has been an increase in the identification of clusters. This evidence has led to more efficient response to food-borne outbreaks.

Laboratory activities: The National Microbiology Laboratory applied genome sequencing in response to the 2008 Listeriosis outbreak. Using the genome data and analysis that was developed during the original Listeria project, the National Microbiology Laboratory has now sequenced 29 additional Listeria genomes, in collaboration with the Canadian Public Health Laboratory Network, Health Canada and the Canadian Food Inspection Agency. The Laboratory for Food-borne Zoonoses has used whole genome sequencing on Salmonella to enhance accuracy and speed in identifying bacteria. Scientists have sequenced 24 Salmonella genomes and are currently sequencing an additional 39 Salmonella strains.

The work in genomics has led to collaboration between staff at the National Microbiology Laboratory and the US Centers for Disease Control and Prevention on the cholera outbreak in Haiti.

Antimicrobial resistance surveillance activities: Evidence from the CIPARS has made one key change to food safety. The Public Health Agency tracked the emergence of a specific antimicrobial resistance in chicken meat and in human cases of Salmonella Heidelberg. The antimicrobial, ceftiofur, is considered to be of very critical importance in human medicine as it is used in the treatment of serious bacterial infections. Through presentations and publications, this finding facilitated the voluntary ban of extra label use of cetifofur in Quebec hatcheries. While the action was temporary, it resulted in the reduction of ceftiofur resistant Salmonella in both chicken meat and in humans. The findings were also used by the Veterinary Drugs Directorate at Health Canada to modify veterinary drug labels. The US Food and Drug Administration imposed a new rule banning extra-label use of ceftiofur in US hatcheries. Internationally, the Advisory Group on Integrated Surveillance of Antimicrobial Resistance uses the experience of the Canadian Integrated Program for Antimicrobial Resistance Surveillance to promote the adoption of a similar model by member countries.

Source attribution surveillance activities: Attribution data are useful in shaping targeted prevention and control activities, but its current use is limited to the local level because C-EnterNet is only partially implemented. The C-EnterNet evaluation confirmed that there had been no work on source attribution prior to the sentinel site and the resulting research is noted internationally. According to the evaluation, the information produced by the C-EnterNet program is well received by most recipients and appears to be used by researchers and by those in service and program delivery.^{Footnote 104}

The Canadian Food Inspection Agency, Health Canada and the Public Health Agency of Canada collaborated to develop the federal Food Safety Communications Protocol. The annex to the Federal Food Safety Communications Protocol, Food-borne Incident Federal Risk Management Scenarios, outlines seven scenarios representing a sample of situations related to potential food-borne illness, with the communications actions being based on the FIORP.

Progress has been made in preparing communications during a food-borne enteric illness outbreak. Key tools, such as public notice templates, online content and key messages for spokespeople, have been developed. This falls in line with the needs of Canadians. In 2010, Canadians were asked to indicate their main source of information during a food-borne enteric illness outbreak. Nearly three-quarters of Canadians (74 per cent) cited traditional media (newspapers, radio and television) as their primary source of information. Key informants have expressed that roles and responsibilities for communications are much clearer since the Foodborne Illness Outbreak Response Protocol was revised and the Federal Food Safety Communications Protocol was developed and tested.

According to public opinion research, one in six Canadians (16 per cent) listed information from websites as their main source of information.^{Footnote 105} The Public Health Agency’s website provides food-borne enteric illness outbreak information to the public. Measuring from December 1, 2010 to December 1, 2011, Canadians appear to be using the website as a source of information on food-borne enteric illness:

• Out of more than 31,000 Public Health Agency of Canada web pages, the Food Safety homepage ranks high in popularity (#64 in English and # 179 in French).
• In total, there were 63,049 visits to the Food Safety section, with 95,999 pageviews (the number of pageviews refers to each time a web page was accessed).

As reported in the Interdepartmental Interfaces Evaluation by the Canadian Food Inspection Agency and by key informants, the provinces and territories look to the federal government to provide them with tools to facilitate an outbreak response. The Public Health Agency works to build capacity in the following areas:

Capacity building for outbreak management guidance and tools - According to key informants, the FIORP has provided clarity on roles and responsibilities and has assisted provinces and territories in understanding multi-jurisdictional outbreak response. Training exercises for the FIORP have helped to build relationships. The Public Health Agency has expanded the capacity of the web-based Outbreak Summary Reporting System, which was developed with extensive provincial and territorial input. The system allows standardized dissemination of the results of disease outbreak investigations.

Capacity building for epidemiological investigations - The provinces and territories require additional guidance so that managing and responding to multi-jurisdictional food-borne enteric illness outbreaks is consistent.^{Footnote 106} The Outbreak Management Division and the Office of Public Health Practice both develop and offer training to provincial and territorial epidemiologists, students, and international stakeholders. Although there are numerous training opportunities offered, there appears to be a gap in providing the provinces and territories with standardized tools and techniques to lead their own epidemiological investigations.

Capacity building for public health laboratories - With the development of new technologies to help improve the detection of food-borne enteric illness, additional laboratory capacity building (i.e. people, equipment and training) will be required on an ongoing basis. Time-limited funding received to address the 2008 Listeriosis outbreak helped develop public health genomics expertise and the PulseNet Canada training program. However, these are not permanent resources.

PulseNet Canada has been working to improve the capacity of provincial laboratories to perform DNA fingerprinting tests and analysis. As a result, there has been an increase in the number of laboratories and personnel certified to conduct testing and analysis of E. coli O157, Salmonella, Shigella and Listeria across the country. Additional improvements are required to improve the capacity of provincial and territorial laboratories. While data are now shared more easily during food-borne illness occurrences, not all provincial laboratories have the capacity to implement the new testing methods developed by the National Microbiology Laboratory.

The need for regular training on the DNA fingerprinting technique and on the interpretation of results will be addressed in part by a web-based training program being developed by PulseNet Canada. This training will enable more personnel in the laboratories to become certified. A comprehensive and fully interactive online training program is expected to be launched by March 31, 2012. It is intended to reduce the need for on-site training and ensure that training needs are met in the most efficient manner.

• The Public Health Agency has a Human Resources Skills Survey which assesses the number of potential epidemiologists at the Public Health Agency. This roster has been used on a variety of occasions, including during the H1N1 response in 2009, as it identifies individuals who have self-reported epidemiologic skills and knowledge. As of October 2011, there were approximately 100 people on the list. But there may be individuals on the list who are no longer with the Public Health Agency for a variety of reasons, such as retirement and maternity leave. The list will also contain the names of those who are not currently epidemiologists but policy analysts, or who work in the veterinary medicine or medical groups within the Public Health Agency.
• The Canadian Field Epidemiology Program and the Canadian Public Health Service are other options that can be used by the provinces or territories in an outbreak. The programs provide training in epidemiological investigations.
• Through time-limited Listeriosis funding, the feasibility of a public health reserve of provincial or territorial epidemiologists is currently being examined as another option that provinces and territories could use in the event of a food-borne outbreak.

The Public Health Agency’s Outbreak Management Division validated the FIORP in each of the 13 provinces and territories through a series of bilateral training exercises. Between January 17, 2011 and April 6, 2011, 13 bilateral training exercises were held across Canada and were attended by over 640 participants, including Medical Officers of Health, program managers and directors, public health inspectors/environmental health officers, veterinarians, food safety specialists, epidemiologists, public health nurses, communications staff, microbiologists and laboratory technologists.

Based on a pre- and post-exercise evaluation form to measure the knowledge participants gained through the exercises, the results showed a significant increase in knowledge following the training exercises. In addition, the Canadian Food Inspection Agency’s Evaluation of Changes to Inter-Departmental Interfaces found that the training exercises were “highly beneficial to raising awareness about the FIORP, and individual and collective partner roles and responsibilities”.^{Footnote 107} This was reinforced by external and internal key informants who found the exercises very useful.

The Auditor General’s Report on Surveillance of Infectious Disease, tabled in 2008, identified gaps in the area of information sharing, both among federal, provincial and territorial partners and internationally. One of the report’s key recommendations is to improve surveillance information-sharing by ensuring that the Public Health Agency establishes “data-sharing agreements to ensure that it receives timely, complete, and accurate surveillance information from all provinces and territories”.^{Footnote 108}

The Public Health Agency is leading a Multilateral Information Sharing Agreement initiative through a federal, provincial and territorial task group under the Public Health Network. As a federal, provincial and territorial initiative, the Public Health Agency and Health Canada recently agreed that the Multilateral Information Sharing Agreement initiative will be a joint initiative presenting a common approach to addressing shared public health responsibilities.

While the work on the Multilateral Information Sharing Agreement initiative is progressing, it is experiencing a few challenges. Key informants noted that food-borne illness program areas established clear criteria about the type and use of information they are collecting from their provincial and territorial partners which contribute to the effective flow of data. In the absence of formal data-sharing agreements, multiple protocols and Memoranda of Understanding have been signed. Although these accords were described by some interviewees as successful alternatives, there is no overarching framework for timely information sharing that establishes an obligation to share information.

In addition to Memoranda of Understanding, the Foodborne Illness Outbreak Response Protocol does include a section on the sharing and centralization of information during an outbreak.

The Public Health Agency does not have one overarching performance measurement strategy to assess the performance of its food-borne enteric illness activities. There are, however, a few separate mechanisms through which food-borne activities are measured and monitored, at an initiative level and at a program level.

Initiative-level performance measurement activities- Through the funding received under the Food and Consumer Safety Action Plan, the Public Health Agency identified performance indicators in the action plan’s interdepartmental Results-based Management and Accountability Framework. The activities undertaken by each of the funded government departments are contained in internal annual reports detailing their progress.

An interdepartmental performance measurement framework was developed for the Government Response and Action Plan to the 2008 Listeriosis outbreak. Through the Federal Food Safety Progress Reports, the Public Health Agency has provided data detailing progress of the funded activities. These reports are publicly available.

In addition to the interdepartmental reports, the Public Health Agency has created internal ‘performance stories’ reports to inform management of the key achievements of the Listeriosis-funded activities. Individual ‘performance stories’ have been produced for the majority of the funded activities.

Program area-level performance measurement activities – Data from for some food-borne illness activities is collected on an ongoing basis:

• National Microbiology Laboratory — Enterics Program: Through the Canadian Public Health Laboratory Network, the Enterics Program produces annual reports on the performance of their activities. The reports are peer reviewed and include a vast amount of data.
• Centre for Food-borne, Environmental and Zoonotics Infectious Disease: The Centre produced an annual report outlining activities and outputs. In addition, the Outbreak Management Division within the Centre also produced an annual report, detailing some of their specific key achievements.

Time limited funding received to address the 2008 Listeriosis outbreak and the Food and Consumer Safety Action Plan were tracked at the activity level.

Core funding makes up a substantial base for all activities in the Public Health Agency. When examining the combination of time-limited and ongoing funding, around half of all dollars spent on food-borne enteric illness is dedicated to upstream prevention. Some of these activities are not clearly aligned with the Public Health Agency’s role nor is there a clear demonstration of how this information is being used within the Public Health Agency or by the federal food safety partners.

Concerning the funding for upstream prevention, key informants stated that CIPARS accounts for about half of all spending in the Laboratory for Food-borne Zoonoses, which is supported by funding sources such as the Food and Consumer Safety Action Plan.  The surveillance system falls within the Public Health Agency’s role and is used as a source of evidence by federal food safety partners.  Key informants mentioned that C-EnterNet also accounts for a substantial proportion of funding received and, although not fully functional, is a source of information that potentially could be used to improve the food safety system.

Without a systematic tracking system for ongoing funding, it is difficult to make any concrete assessments of efficiencies in the Public Health Agency’s overall spending in prevention, detection and response activities relating to food-borne enteric illness.