Executive summary: Evaluation of food-borne enteric illness prevention, detection and response activities at the Public Health Agency

Executive summary

This report presents the findings of an evaluation of the prevention, detection and response to food-borne enteric illness activities at the Public Health Agency of Canada.

Evaluation purpose and methodology

Senior management requested this evaluation to support program planning and decision making. Evaluative information was also needed to inform the Public Health Agency’s contributions to the Government of Canada’s response on the implementation of the recommendations made by the Independent Investigator of the 2008 Listeriosis outbreak, Sheila Weatherill.

The purpose of the evaluation is to explore the current relevance and performance of the prevention, detection and response to food-borne enteric illness activities at the Public Health Agency and, as appropriate, make recommendations to improve the design and delivery of these activities. The evaluation covers activities undertaken between April 2006 and December 2011.

The evaluation does not take into consideration activities related to food security, allergens, chemicals, water-borne and zoonotic diseases, or other food-borne non-enteric illnesses.

The evaluation analyzes information from a number of sources:

  • a review of existing literature
  • a study of key internal documents, including administrative records, correspondence, performance information and communication
  • web analytics and public opinion research
  • interviews with key senior managers and program staff within the Public Health Agency, and with senior managers from other government departments
  • interviews with external experts.

Food-borne enteric illness prevention, detection and response activities

Food-borne enteric illnesses are diseases caused by the ingestion of food contaminated by bacteria, viruses, parasites and chemicals, as well as bio-toxins (poisonous substances). Nausea, vomiting, abdominal cramps and diarrhoea are frequent symptoms of a food-borne enteric illness. The most common causes of food-borne enteric illness are bacteria such as E. coli, Listeria, Campylobacter, Salmonella, and Shigella.

The Public Health Agency is just one player in the overall food safety system that works to prevent, detect and respond to food-borne enteric illness. Local authorities, provincial/territorial governments and other federal government organizations (such as the Canadian Food Inspection Agency and Health Canada) all have a role to play. The Public Health Agency’s activities in this area include national and international surveillance (e.g. antimicrobial resistance, sentinel site and enteric illness surveillance), laboratory and epidemiological investigations, as well as outbreak response coordination and communications to the public (when human illness occurs in multiple jurisdictions).

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. Within the Infectious Disease Prevention and Control Branch alone it is estimated that over $17 million is allocated each year for these types of activities.

Evaluation findings, conclusions and recommendations

The synthesis and analysis of the information gathered for this evaluation resulted in findings and conclusions about both relevance and performance, which in turn led to three recommendations (see Figure 1).

Summary of findings and conclusions

Relevance

Every year, food-borne illness affects millions of Canadians. Food safety is continually stated as a priority for the Government of Canada. There is a need for a federal public health role in food-borne enteric illness prevention, detection and response.

The Public Health Agency of Canada Act guides the Agency’s roles and responsibilities in the prevention and response to infectious disease outbreaks. The federal government has a clear public health role in coordinating and facilitating the response to multi-jurisdictional outbreaks. The guiding document for this is the Foodborne Illness Outbreak Response Protocol (FIORP).Footnote a

Certain upstream prevention activities align with the Public Health Agency role in food-borne illness. Surveillance of antimicrobial resistance and source attribution is a recognized role for the Public Health Agency, which mirrors activities undertaken by the Centers for Disease Control and Prevention in the United States.

However, this evaluation found that certain Public Health Agency upstream prevention activities, namely risk modelling and research synthesis which focus their attention on animal and food products, do not clearly align with a traditional public health mandate.

Performance

The Public Health Agency has worked with its federal food safety partners such as the Canadian Food Inspection Agency and Health Canada, as well as the provinces and territories, to improve the food safety system, especially in the area of detecting food-borne enteric illness and responding to multi-jurisdictional outbreaks.

Considerable improvements have been made following the 2008 Listeriosis outbreak. The revised FIORP and subsequent exercises have clarified roles and responsibilities during a multi-jurisdictional outbreak. Key communication tools have been developed, and more evidence is produced and used to detect and respond to food-borne enteric illness outbreaks.

However, two key challenges remain. First of all, food safety partners do not appear to be using information generated by some of the Public Health Agency’s upstream prevention activities (i.e. source attribution surveillance, risk modelling, research synthesis). Secondly, the Public Health Agency does not have one overarching epidemiological surge capacity plan in place to respond to all food-borne enteric illness outbreak scenarios.

Recommendations

Given the findings above, three key recommendations are put forward.

Strategic Planning

As previously mentioned, there are certain Public Health Agency activities that do not clearly fit within a typical public health mandate. This is apparent in some upstream prevention activities such as research synthesis and risk modelling which examine animal and food products. When the role is not as clear, there is limited use of the evidence that is produced. These upstream prevention surveillance activities do, however, have a clear public health role.

With the exception of antimicrobial resistance surveillance, the evidence generated by some upstream prevention activities does not appear to have been used by food safety partners. Other activities do fall within a public health mandate (e. g. source attribution surveillance work) but are not yet fully operational, limiting their capacity to provide fulsome national data that can be used by federal food safety partners.

These activities should be reviewed to ensure that they are meeting a need or addressing a gap. Priority setting should be done in conjunction with food safety partners, both federal and provincial/territorial.

Recommendation 1

Take a more strategic Agency-wide and interdepartmental approach to food-borne enteric illness, which includes but is not limited to:

  1. priority setting mechanisms for determining key Public Health Agency food-borne activities
  2. a shared understanding of the role of upstream prevention activities and their link to the Public Health Agency’s broader food-borne activities
  3. a mechanism for tracking ongoing food-borne enteric illness expenditures that reflects the horizontality of this program area.
 
Outbreak Response Capacity

Providing support to the provinces and territories during an outbreak is part of the Public Health Agency’s national leadership and capacity-building role. This refers to the development and sharing of epidemiological and laboratory tools, methods and best practices to assist provinces and territories in conducting their own laboratory and epidemiological investigations. This support is appreciated by the provinces and territories as well as by the federal food safety partners, however, there appears to be a gap in sharing standardized tools and techniques with provinces and territories to assist with their epidemiological investigations.

Although epidemiologists from other areas within the Public Health Agency can be deployed in the event of an outbreak, the Public Health Agency does not have an overarching surge capacity plan to manage a large food-borne enteric illness outbreak. As food-borne outbreak epidemiology uses specific tools and methods which sets it apart from epidemiological investigations in other disease areas, trained human resources need to be available in the event of an outbreak.

Recommendation 2

Address capacity issues in detecting and responding to food-borne outbreaks:

  1. maintain Public Health Agency core capacity for daily operations in detecting and responding to outbreaks
  2. develop a Public Health Agency-wide surge capacity plan to respond to large outbreaks with a particular focus on Public Health Agency and provincial/territorial epidemiological capacity
  3. continue to develop and implement capacity-building activities, including tools and methods, to assist provinces and territories in conducting their own laboratory and epidemiological investigations.
 
Exercising Plans and Protocols

Exercising of the Foodborne Illness Outbreak Response Protocol resulted in a better understanding of roles and processes during a multi-jurisdictional outbreak. The FIORP exercises were recommended in the Weatherill Report after the 2008 Listeriosis outbreak and identified in the Public Health Agency’s Listeriosis Lessons Learned Review. More bilateral exercises were carried out than planned and all exercises were designed in collaboration with the provinces and territories. The development and exercise of FIORP was also recommended by Weatherill. This has been developed and is expected to be fully exercised in February 2013.

Exercising plans and protocols helps ensure that roles and responsibilities remain clear to all involved. In addition, it provides an opportunity for all partners to develop and maintain relationships, which has been identified as a key contributing factor to the success of detection and response activities.

Recommendation 3
Continue with exercises of the Foodborne Illness Outbreak Response Protocol and the Food-borne Illness Emergency Response Plan.
 
Figure 1: Summary of findings, conclusions and recommendations
  Findings Conclusions Recommendations
Relevance Many Canadians experience food-borne enteric illness each year. There is a need for, and a federal public health role in, the prevention and detection of, and response to, food-borne enteric illness.  However, there are certain Public Health Agency activities that do not necessarily fit within a typical public health mandate. These should be reviewed to ensure that they are meeting a need or addressing a gap.
  1. Take a more strategic Agency-wide and interdepartmental approach to food-borne enteric illness, which includes but is not limited to:
    1. priority setting mechanisms for determining key Public Health Agency food-borne activities
    2. a shared understanding of the role of upstream prevention activities and their link to the Public Health Agency's broader food-borne activities
    3. a mechanism for tracking ongoing food-borne enteric illness expenditures that reflects the horizontality of this program area.
  2. Address capacity issues in detecting and responding to food-borne outbreaks:
    1. maintain Public Health Agency core capacity for daily operations in detecting and responding to outbreaks
    2. develop a Public Health Agency-wide surge capacity plan to respond to large outbreaks with a particular focus on Public Health Agency and provincial/territorial epidemiological capacity
    3. continue to develop and implement capacity-building activities, including tools and methods, to assist provinces and territories in conducting their own laboratory and epidemiological investigations.
  3. Continue with the FIORP and FI ERP exercises.
There is a federal role in preventing, detecting and responding to food-borne enteric illness.
Food safety is a Government of Canada and Public Health Agency priority.
The Public Health Agency's role is clear and understood by partners in the detection of, and response to, food-borne enteric outbreaks.
The Public Health Agency's role is clear in upstream prevention surveillance activities, such as antimicrobial resistance.
The Laboratory for Food-borne Zoonoses' activities in the area of upstream prevention do not clearly align with a typical public health role.
Performance Detection and response activities and some upstream prevention activities are well coordinated, allowing for timely information sharing. Since the 2008 Listeriosis outbreak, significant improvements have been made. Exercises have been conducted which have led to increased knowledge of roles and processes. More evidence is produced and used to detect and respond to food-borne enteric illness. However, a few challenges remain, including the absence of one overarching epidemiological surge capacity plan. As well, when the Public Health Agency's role is clear and understood, evidence is provided and used in a timely and efficient manner. When the role is not as clear, there is limited use of evidence (i.e. evident in upstream prevention activities).
Evidence on public health food safety risks is generated and used in detecting and responding to food-borne enteric illness. 
The Public Health Agency is now better prepared than before the 2008 Listeriosis outbreak to communicate to the public – key tools have been developed and tested. 
Exercising of the Foodborne Illness Outbreak Response Protocol (FIORP) resulted in a better understanding of roles and processes during a multi-jurisdictional outbreak. 
Food-borne enteric illness activities tend to be well integrated at the Public Health Agency although there is room for improvement in information sharing and coordination in managing surge capacity and some upstream prevention activities.
While there are no data-sharing agreements in place with the provinces and territories, various protocols have been developed to guide the collaboration of partners in the detection and response to food-borne enteric illness outbreaks. 
Although a considerable amount of information is generated as a result of some upstream prevention activities, little evidence is available on the use of this information.
There appears to be a gap in sharing standardized tools and techniques with the provinces and territories to conduct their own epidemiological investigations. In addition, there is no overall plan to manage epidemiological surge capacity at the Public Health Agency.
Performance data are collected but there is no overarching performance measurement strategy for food-borne enteric illness activities.
Although recent time-limited food safety funding is systematically tracked, there is no mechanism to track ongoing expenditures at the food-borne enteric illness activity level.

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