Section 2: Evaluation of food-borne enteric illness prevention, detection and response activities at the Public Health Agency – Background

2. Background and Context

2.1 Food-borne enteric illnesses are caused by a variety of pathogens

Food-borne illnesses are diseases caused by the ingestion of food contaminated by bacteria, viruses, parasites and chemicals, as well as bio-toxins (poisonous substances). Food is a vehicle in which many pathogens (disease-causing microorganisms) can be transferred to people.

A food-borne enteric illness affects the stomach or intestinal tract. Nausea, vomiting, abdominal cramps and diarrhoea are frequent symptoms. Food-borne pathogens can also cause systemic and invasive infectious diseases. In the 2008 Listeriosis outbreak, Listeria monocytogenes caused the death of Canadians. The most common causes of food-borne enteric illness are bacteria such as E. coli, Listeria, Campylobacter, Salmonella, and Shigella.

Some pathogens, such as prions, are transmitted to humans through food but affect organs other than the digestive tract. They generate non-enteric food-borne illnesses which are not covered in this evaluation.^{Footnote 1}

2.2 Food safety involves many players

There are many players addressing food safety in Canada.^{Footnote A} At the local and regional level, staff investigate human illnesses that occur within their geographic boundaries, investigate food establishments, and report food-borne pathogens and human illness cases to provincial and territorial officials.

The provinces and territories inspect and licence some provincial food premises including production facilities, processing and distribution plants, retail stores and restaurants. These activities are carried out by local public health units who also conduct surveillance, and epidemiological and food safety investigations. The provinces and territories lead these activities when outbreaks cross more than one health unit in addition to conducting provincial/territorial surveillance. In most provinces, provincial laboratories test food and clinical samples within their jurisdiction (please note that none of the territories have laboratories).^{Footnote 2Footnote 3}

On the federal scene, partners working with the Public Health Agency include:^{Footnote 4Footnote 5}

• Health Canada, which establishes policies, sets standards and provides advice and information on the safety of food. In the event of an outbreak, they conduct health risk assessments.^{Footnote 6}
• The Canadian Food Inspection Agency, which conducts ongoing monitoring and inspection of food products. In the event of an outbreak, they conduct food safety investigations, including product recalls.^{Footnote 7}
• Agriculture and Agri-Food Canada, which supports activities that extend from the farmer to the consumer through all phases of food production, processing and marketing of food products.^{Footnote 8}

2.3 The Public Health Agency conducts many activities to prevent, detect and respond to food-borne enteric illness

These activities are included in the Public Health Agency’s 2011-12 Program Activity Architecture under:

• 1.1 – Science and Technology for Public Health
• 1.2.1.3 – Surveillance of Infectious Disease
• 1.3.1.1 – Public Health Workforce
• 1.3.1.2 – Public Health Tools
• 1.3.2.2 – Emergency Preparedness
• 1.5.3.5 – Food-borne, Environmental and Zoonotic Diseases
• 1.6.2.2 – Health Emergency Response Team
• 2.1.1.2 – Communications Services.

Upstream prevention

The activities conducted by the Public Health Agency in the area of prevention are called upstream prevention activities (also called active prevention or primary prevention). These activities are carried out by the Laboratory for Food-borne Zoonoses and the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, with support from the National Microbiology Laboratory.

These activities include the coordination of surveillance systems designed to provide data and trends on source attribution (C-EnterNet) and antimicrobial resistance (Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS)). Refer to Appendix F for more information on these surveillance systems. Although these surveillance systems do detect illnesses as part of their data collection, their purpose is not to respond to food-borne enteric illness outbreaks. Their focus is to collect and analyze data to determine trends, identify sources of illnesses and then influence policy. The United States Centers for Disease Control and Prevention also carries out similar activities through its FoodNet and National Antimicrobial Resistance Monitoring System programs (see Appendix A for more information on the United States’ public health role in preventing, detecting and responding to food-borne enteric illness outbreaks).

In addition to these surveillance activities, the Public Health Agency also conducts upstream prevention activities that look at the farm-to-fork continuum to better understand the cause of illnesses. Carried out by the Laboratory for Food-borne Zoonoses, some of these activities include:

• risk modelling to predict the points in the food safety system where interventions would reduce risks to public health
• research synthesis to analyze the scientific literature on food safety risks to determine the best scientific evidence
• outbreak reports to identify pathogen and food commodity combinations that affect human health, through historical data on food-borne illness outbreaks and food recalls.

Note that the Public Health Agency was allocated funding through the Food and Consumer Safety Action Plan under the Active Prevention category, which also substantiates the categorization of these activities under upstream prevention as opposed to detection or response.

The Public Health Agency researches the sources of food-borne enteric illness. In terms of secondary prevention activities, these are essentially communication and education activities to the public and, in the food safety system, those activities are conducted locally. Federally, these secondary prevention activities are carried out by Health Canada and the Canadian Food Inspection Agency (see sections 3.1.2 and 3.1.3 for more information).

Detection

The Public Health Agency collaborates with the provinces and territories to identify enteric diseases that have occurred. At the federal level, the Public Health Agency coordinates laboratory (i.e. the National Microbiology Laboratory) and epidemiological national surveillance (i.e. the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases) through the National Enteric Surveillance Program and PulseNet Canada. Through these systems, illnesses are monitored and clusters of illnesses are identified (see Appendix F for further information on these surveillance systems).

In addition to these surveillance systems, the Public Health Agency also relies on the National Notifiable Diseases Surveillance System. This system receives data that covers 59 diseases, including enteric diseases, which are collected on a mandatory basis by local health units, forwarded to provincial and territorial health authorities and collated by the Surveillance and Risk Assessment Division of the Centre for Communicable Diseases and Infection Control. Data is used for trend analysis from the immediate to the long term.^{Footnote 9}

The National Microbiology Laboratory assists provinces and territories in identifying the pathogens that are causing illnesses. These services range from diagnostic to DNA fingerprinting to whole genome sequencing. With the Laboratory for Food-borne Zoonoses, the National Microbiology Laboratory develops new laboratory methods and tools, which are then shared with federal, provincial and territorial public health laboratories.^{Footnote 10Footnote 11Footnote 12}

Response

The Public Health Agency also leads national food-borne illness outbreak response activities. Once a cluster of illnesses is identified in more than one province or territory, or in Canada and another country or countries, the Outbreak Management Division of the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases, through the Foodborne Illness Outbreak Response Protocol (FIORP), leads an assessment call with its federal, provincial and territorial partners. If the partners agree that a response is needed, the Outbreak Management Division will generally assume lead of the Outbreak Investigation Coordinating Committee. In some cases, the province or territory with the majority of cases and with an active investigation underway, may be elected to lead the Outbreak Investigation Coordinating Committee. Through this mechanism, the lead of the Outbreak Investigation Coordinating Committee coordinates information sharing and investigation activities, including laboratory (i.e. National Microbiology Laboratory), epidemiological investigations (i.e. Outbreak Management Division in collaboration with the provinces and territories with human cases), communications to the public (Communications Directorate), as well as food safety investigations (i.e. Canadian Food Inspection Agency).

In addition to activities related to outbreak management response, other groups within the Public Health Agency conduct activities that are essential to responding to food-borne enteric illness outbreaks (the Office of Public Health Practice, the Centre for Emergency Preparedness and Response and the Communications Directorate).

Activities carried out by the Office of Public Health Practice include the following.

• Surge capacity planning if/when the Public Health Agency requires additional resources to respond to food-borne outbreaks.
• Developing training/capacity building programs to provide provinces and territories with capacity through programs such as the Canadian Field Epidemiology Program, which include food-borne illness specific modules and placements.
• Data sharing and data standardization for surveillance activities.
• Developing and coordinating surveillance platforms which explore the feasibility of a pan-Canadian surveillance platform, which includes an outbreak management module.

The activities carried out by the Centre for Emergency Preparedness and Response, within the Emergency Management and Corporate Affairs Branch, include the following.

• Escalating the activation of the Emergency Operations Centre, as per the Food-borne Illness Emergency Response Plan, to ensure that food-borne illness emergency response activities are coordinated within a scalable Incident Management System.
• Ongoing monitoring of publically available information to immediately identify outbreaks around the world through the Global Public Health Intelligence Network.
• Functioning as the International Health Regulations National Focus Point for Canada, which includes coordinating Canada’s communications with the World Health Organization in the event of a potential public health emergency of international concern.
• Coordinating the development and delivery of outbreak preparedness and response exercises with the Outbreak Management Division of the Centre for Food-borne, Environmental Zoonotics Infectious Diseases.

The Communications Directorate coordinates federal food safety communication activities, develops risk communications material and leads communications in collaboration with provinces and territories to the public during a multi-jurisdictional outbreak.^{Footnote 13,Footnote 14,Footnote 15}

2.4 The Public Health Agency makes investments to prevent, detect and respond to food-borne enteric illness

Profile of financial resources

Resources for food-borne enteric illness activities come from different sources. The two current program authorities were developed in conjunction with Health Canada and the Canadian Food Inspection Agency following high visibility food recalls and food-borne enteric illness outbreaks.

• Food and Consumer Safety Action Plan (2008-09 to 2012-13 and anticipated to be ongoing) — $26 million. In response to a growing number of product recalls and concerns about food safety, the Government of Canada launched this initiative to modernize and strengthen Canada’s safety systems for food, health and consumer products. The Public Health Agency received 69 per cent of this funding to enhance surveillance and to conduct molecular typing and systems modelling while the remaining 31 per cent went to other Public Health Agency consumer safety activities.

• Government Response and Action Plan to the 2008 Listeriosis Outbreak (2009-10 to 2011-12) — $17.7 million over three years. In response to the recommendations made by the Independent Investigator of the outbreak, Sheila Weatherill, the Public Health Agency, the Canadian Food Inspection Agency and Health Canada received funding to respond to some of the Independent Investigator’s 57 recommendations. The Public Health Agency received funding to enhance surveillance and early detection (75 per cent), and to improve response to food-borne enteric illness outbreaks in Canada (25 per cent).

Ongoing funding for food-borne enteric illness activities comes from previous program authorities, such as the Food Safety and Nutrition Quality program, as well as the Pan-Canadian Public Health System.

Due to the integrated nature of the work involved, it is difficult to determine the total amount that is allocated and spent to prevent, detect and respond to food-borne enteric illness in the Public Health Agency. These activities would be closely conducted in conjunction with other activities, such as infectious disease or emergency response as a whole. For example, enteric illness activities conducted by the National Microbiology Laboratory fall within the Bacteriology and Enteric Diseases Division which examines both food and water-borne enteric illness.

In 2010, the Infectious Disease Prevention and Control Branch estimated the financial resources dedicated to preventing, detecting and responding to food-borne illnesses within the Branch (note that this would exclude activities conducted by Communications and the Centre for Emergency Preparedness and Response). As previously mentioned, these activities are conducted through two laboratories (National Microbiology Laboratory and the Laboratory for Food-borne Zoonoses) as well as the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases. The Branch estimated that approximately $17.2 million (salary and operations and maintenance only) of its 2010-11 total budget ($124 million) was dedicated to these activities (approximately 14 per cent of Branch funding). Of that $17.2 million, it was estimated that about 56 per cent went to upstream prevention activities, 29 per cent to detection activities and 15 per cent to response activities. There are no grants and contribution monies for these sets of activities.

Profile of human resources

It is difficult to determine the number of staff positions for food-borne enteric illness activities across the Public Health Agency due to the number of Centres and Laboratories that work in this area, and the number of areas that are covered under the Program Activity Architecture. As has been mentioned previously, many staff who work on food-borne enteric illness activities also work on a number of other unrelated activities. Work in this area may also vary dependent on current events (e.g. if a multi-jurisdictional food-borne enteric illness outbreak occurs). Taking that into account, it is estimated that in 2010-11, about 32 full-time equivalents worked on food-borne illness in the National Microbiology Laboratory, 72 full-time equivalents in the Laboratory for Food-borne Zoonoses, and 27 full-time equivalents in the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases. Positions range from administrative assistants to scientists to policy analysts. As with financial expenditures, it is difficult to determine how many full-time employees are assigned to food-borne enteric illness in other program areas, such as Communications and the Centre for Emergency Preparedness and Response. These positions are embedded within other activities, such as infectious disease or emergency response as a whole.