Lessons Learned: Public Health Agency of Canada's Response to the 2008 Listeriosis Outbreak

December 2008

The information in this report was obtained by the Centre for Excellence in Evaluation and Program Design (CEEPD) through a review of relevant material and a series of interviews. This report does not draw exhaustive or definitive conclusions on fact on all the activities leading up to or taken by various individuals or entities during the Listeriosis outbreak. Rather, the observations set out in this report are meant to give a general overview to PHAC senior management of what worked well in this particular event and what needs further refinement for the Agency to be better prepared for future outbreaks.

Table of Contents

1. Executive Summary
2. Purpose and Methods
3. Background and Context
   • 3.1. Facts on Foodborne Illness
   • 3.2. Listeria / Listeriosis
   • 3.3. General Mandates of Federal Organizations
   • 3.4. Foodborne Illness Outbreak Response
4. Findings and Recommendations
   • 4.1. What Worked Well
   • 4.2. What Needs to be Improved
   • 4.3. Recommendation #1: Revisit The FIORP
   • 4.3.1. Recommendation #1.1: Revisit The FIORP – Integrate Current Work on Information Sharing Agreements
   • 4.3.2. Recommendation #1.2: Revisit The FIORP – Modernize Communications Guidelines
   • 4.3.3. Recommendation #1.3: Revisit The FIORP – Develop a Standard Approach to Reviewing Outbreaks
   • 4.4. Recommendation #2: Create a Central Repository of Agreements
   • 4.5. Recommendation #3: Clarify, Communicate and Practise Event Management Roles, Responsibilities and Mechanisms
   • 4.6. Recommendation #4: Enhance CFEZID Capacity
5. Next Steps
6. List Of Acronyms
7. Chronology of Federal Actions Taken for the Listeriosis Outbreak

1. Executive Summary

The Listeriosis outbreak in the summer/fall of 2008 linked to ready-to-eat meats produced at a Maple Leaf plant in Ontario was a significant public health event. There were 20 deaths across five provinces where Listeriosis was the underlying or contributing cause of death and the outbreak generated high media and public interest. The collective efforts of local and regional health authorities, provincial and territorial governments and federal officials detected and contained the outbreak.

Gaining a high-level understanding of what worked well and what requires improvement was the purpose of this Lessons Learned Report for the Public Health Agency of Canada (PHAC). Information was gathered by reviewing key documents and interviewing federal staff involved in the outbreak as well as some key provincial/territorial stakeholders such as members of the Council of Chief Medical Officers of Health.

PHAC demonstrated a strong federal leadership role during the Listeriosis outbreak.

• The Outbreak Management Division in the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases coordinated the national epidemiological investigation.
• The National Microbiology Laboratory led the laboratory arm of the national outbreak investigation, coordinating and analyzing all laboratory data including results generated elsewhere, and providing analyses and interpretation of genetic “fingerprints”.
• The Agency's considerable investment in information technology infrastructure, namely the Canadian Network for Public Health Information, was invaluable for sharing information among local, provincial/territorial and federal organizations.
• The Emergency Operations Centre helped to facilitate extensive communication and coordination between federal, provincial/territorial and local public health officials, as well as with the Minister's Office and Central Agencies which were intensely involved.
• The Communications Directorate led the national public health communications response with a variety of communications products for the general public, at-risk populations, and health practitioners.

However, there are always lessons to be learned, especially following extremely high profile events. Two threads and a number of key questions weave through the lessons learned from PHAC's response to the Listeriosis outbreak:

• The importance of advanced planning - in a complex, high profile, national outbreak situation, are key PHAC staff aware of roles and responsibilities? Are there appropriate linkages between outbreak response protocols and emergency response policies, plans and procedures? Are PHAC staff aware of and trained in the protocols? Have PHAC staff practised implementing protocols as a result of simulation exercises?
• The need for more formalized approaches in determining, declaring, discussing, documenting, and debriefing outbreak and other event responses.

Four broad actions are recommended for improving PHAC's management of foodborne outbreaks, as follows.

1. Revisit the Foodborne Illness Outbreak Response Protocol (FIORP) to Guide a Multi-jurisdictional Response
   • 1.1: Integrate Current Work on Information Sharing Agreements
   • 1.2: Modernize Communications Guidelines
   • 1.3: Develop a Standard Approach to Reviewing Outbreaks
2. Create a Central Repository of Agreements
3. Clarify, Communicate and Practise Event Management Roles, Responsibilities and Mechanisms
   • 3.1: Approve and Implement the Health Portfolio Emergency Response Policy and Plan
   • 3.2: Orient and Train on the Emergency Response Policy and Plan
   • 3.3: Practise Implementing the Emergency Response Policy and Plan with Foodborne Examples
   • 3.4: Improve Systems for Event Communications
4. Enhance Capacity in the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases (Ongoing, Surge, and Succession)

The visual below captures the themes underlying the recommendations stemming from the lessons learned exercise. PHAC will be better prepared for future high profile, significant, national outbreaks of foodborne illness by implementing the recommendations above which will serve to clarify roles, responsibilities, and relationships as well as provide PHAC staff with training and practice in outbreak and emergency response. As a standard practice, PHAC should regularly assess its response performance and put mechanisms in place to ensure lessons learned are implemented.

Figure 1

If national leadership in foodborne illness is a priority for the Agency, then immediate steps should be taken to develop, implement and oversee an action plan to address the findings and recommendations in this report. PHAC senior management should regularly monitor progress on implementation of these lessons learned.

2. Purpose and Methods

This report examines the Public Health Agency of Canada's (PHAC) response to the 2008 Listeriosis outbreak to gain a high-level understanding of what worked well and what requires improvement. PHAC management and staff will use the report for planning and decision-making purposes to address areas requiring improvement in preparation for future outbreaks of foodborne illness.

The project was conducted by the Centre for Excellence in Evaluation and Program Design, a group internal to PHAC but not involved in the program areas that responded to the outbreak. A project Steering Committee oversaw the development and implementation of the lessons learned exercise. The methodology had two main components:

• Review of key documents including Memoranda of Understanding, protocols, agreements and after action reports; and
• Interviews from mid-October to mid-November 2008 with staff from PHAC, the Canadian Food Inspection Agency (CFIA), Health Canada (HC), Ontario Ministry of Health and Long Term Care and British Columbia Ministry of Health, as well as group discussions with some members of the Council of Chief Medical Officers of Health and the Pan-Canadian Public Health Network Council.

CFIA and HC also conducted similar lessons learned exercises. Although each organization had separate Terms of Reference and produced independent reports, the three organizations coordinated their efforts in data collection through joint interviews where possible.

3. Background and Context

The 2008 Listeriosis outbreak was identified following three weeks of higher than expected case reports of Listeriosis in Ontario. Eventually seven provinces were implicated in the outbreak. The Public Health Agency of Canada (PHAC) became involved when it was apparent that cases were occurring in more than one province. The source of illness was linked to ready-to-eat meats produced at a Maple Leaf plant in Ontario.  Of the 56 confirmed cases (75% of which were in Ontario) and 2 probable cases, there were 20 deaths where Listeriosis was the underlying or contributing cause of death (across five provinces; 75% of total deaths occurred in Ontario).

3.1 Facts on Foodborne Illness

Foodborne illness refers to diseases acquired through eating food or drinking liquids that have been contaminated with bacteria, parasites or viruses. Foodborne illnesses are relatively common. PHAC estimates that there are 11 million cases of foodborne illness each year in Canada.^{Footnote 1} However, many cases of foodborne illness go unreported because the illness is self-limiting and does not require medical consultation. Symptoms often include stomach cramps, nausea, vomiting, diarrhea and fever. Many of these illnesses are sporadic cases, but some become part of an outbreak. People often refer to foodborne illness as “food poisoning”.

An outbreak occurs when there is an unexpected increase of disease occurring within a specific population at a given time and place. Each outbreak occurrence is unique. The number of cases in an outbreak will vary according to the infectious agent, size and type of population exposed, population immunity, and time and place of occurrence. Therefore, the status of an outbreak is relative to the usual frequency of the disease in the same area, among the same population, at the same season of the year.^{Footnote 2}

Preventing foodborne illnesses is a major public health challenge. Several factors are altering the epidemiology of foodborne diseases and increasing the complexity of managing foodborne illness outbreaks including: the emergence of new and uncommon pathogens; changes in agricultural practices; increased globalization of the food industry; new methods of food processing, especially mass production and ready-to-eat products; and, changes in consumer behaviour and susceptibility. To underscore the complexity of the outbreak scenario, Table 1 highlights the factors that distinguish the new outbreak scenario from the traditional scenario.^{Footnote 3}

In the traditional scenario, diseases are clustered in time and space, usually occurring as a result of common mistakes in food handling in restaurants or in the home. A classic local outbreak might follow a catered meal at a reception, a pot-luck supper, or eating a meal at a restaurant. An outbreak is recognized when a group of ill people with a common exposure are identified by a local public health unit. However, outbreaks are increasingly more widespread, affecting persons in many different places, and spread out over several weeks. Long shelf lives, wider distribution of ready-to-eat foods, and increased travel and trade opportunities, all contribute to this new scenario in which contracting and spreading a foodborne illness can occur locally, regionally, nationally and internationally. Advances in laboratory surveillance have significantly enhanced the ability to identify outbreaks occurring over wide geographical areas and/or time period.

3.2 Listeria / Listeriosis

The foodborne illness involved in the outbreak that is the focus of this report is Listeriosis. Listeriosis is a serious infection caused by eating foods contaminated with a bacterium, Listeria monocytogenes, commonly known as Listeria. Listeria is widespread in the environment in soil, vegetation, water, sewage and in the feces of animals and humans, including healthy human adults. Plants and vegetables can become contaminated with Listeria from the soil, water and manure-based fertilizers. Farm animals that appear healthy may also carry Listeria and contaminate foods such as meats and dairy products. Listeria is of great concern in the food industry and among public health officials due to its ability to grow on foods stored at refrigerator temperatures and at relatively high salt levels.

Listeriosis occurs infrequently. Under normal circumstances, two or three cases are reported weekly in Canada. It is a serious disease for pregnant women, infants, the elderly and individuals with a weakened immune system. Listeria is more likely to cause death than other bacteria that cause food poisoning. In fact, 20 to 30 percent of foodborne Listeriosis infections in high-risk individuals may be fatal.^{Footnote 5}   Healthy adults and children occasionally get infected with Listeria, but rarely become seriously ill.

Listeria has a long incubation period of up to 70 days. Symptoms can occur within 2 to 30 days and up to 70 days after eating food contaminated with Listeria. This long incubation period makes Listeriosis outbreaks a particular challenge to investigate as people often cannot recall what they ate over such an extended time frame. Symptoms of milder forms of Listeriosis can include constipation, cramps, diarrhea, headache, persistent fever, vomiting and mild “flu-like” symptoms (e.g., chills, fatigue, muscle and joint pain).  In serious cases, the disease can spread to the nervous system causing headache, stiff neck, confusion, loss of balance, convulsions, or spontaneous abortion.

Listeriosis has been associated with the consumption of a range of food products, including milk, meat products, soft cheese or shellfish. The bacteria can be found in cold cuts/deli-meats/pâté, undercooked hot dogs or chicken, smoked fish and unpasteurized (raw) dairy products, or raw vegetables. Foods such as hot dogs, cold cuts or deli-meats can be contaminated after processing.

3.3 General Mandates of Federal Organizations

Multi-jurisdictional outbreaks of foodborne illness such as Listeriosis involve health professionals, local health authorities, provincial and territorial ministries of health, as well as PHAC and its federal partners: the Canadian Food Inspection Agency (CFIA) and Health Canada (HC). All levels share responsibilities and work closely together to help identify and respond to an outbreak.

The mandates of the Ministers responsible for the three federal organizations involved in an outbreak, namely the Minister of Health for HC and PHAC, and the Minister of Agriculture and Agri-Food for CFIA, can be found, in part, in the particular statutes establishing these entities. Each Minister administers various laws and programs to carry out his/her mandate, through his/her respective department or agencies.

The Minster of Health has a broad mandate, under the Department of Health Act, to protect the people of Canada against the risks of health and the spread of diseases. The Minister's duties, functions and powers in relation to health include the investigation and research into public health, including the monitoring of diseases. Both HC and PHAC can exercise various duties, functions and powers, on behalf of the Minister. The preamble in the Public Health Agency of Canada Act recognizes that the creation of PHAC and the appointment of the Chief Public Health Officer of Canada contributes to federal efforts to identify and reduce public health risk factors and supports national readiness for public health threats.

PHAC works in collaboration with various partners to lead federal efforts and to mobilize pan-Canadian action in preventing disease and injury, and to promote and protect public health in Canada and around the world. PHAC anticipates, prepares for, responds to, and recovers from threats to public health by conducting surveillance, research, and investigations, and reports on diseases and injuries, as well as other preventable health risks and their determinants.

PHAC responds to public health emergencies and disease outbreaks of national concern, including foodborne illnesses, in collaboration with provinces and territories and other federal partners. In an outbreak situation, PHAC conducts national public health surveillance and may provide assistance to provincial authorities through applied epidemiological studies. PHAC's laboratories provide reference services for strain differentiation as well as national laboratory-based surveillance and dissemination of information. PHAC's National Microbiology Laboratory (NML) maintains national databases of clinical isolates for all bacterial foodborne diseases, and operates the Listeriosis Reference Service (LRS) jointly with HC. The Agency also supports provincial and territorial investigations of public health events providing disease/issue-specific technical expertise and guidance, deploying epidemiological and laboratory personnel to assist with field investigations where additional assistance is required. In outbreaks of significant national interest, or outbreaks that involve more than one jurisdiction, PHAC is guided by an established protocol with the provinces/territories, HC and CFIA, namely the Foodborne Illness Outbreak Response Protocol (FIORP) to Guide a Multi-jurisdictional Response.^{Footnote 6} If an outbreak extends beyond Canadian borders, PHAC works with international partners, such as the World Health Organization and the Centers for Disease Control and Prevention in the United States.

HC plays an important role in the protection of the health and safety of Canadians. HC's role includes the regulation of various foods and provision of related safety information.^{Footnote 7} HC develops regulations for food standards and the nutritional quality of foods. CFIA and PHAC have an interest in HC's roles and responsibilities for setting standards and policies related to food safety. HC regulates and, to some extent, approves food products.

HC develops food safety standards and policies to help minimize the risk of foodborne illnesses. As a founding member of the Canadian Partners for Consumer Food Safety Education, HC participates in public awareness campaigns about safe food practices. In collaboration with CFIA, HC has developed a Policy on Listeria monocytogenes in Ready-to-Eat Foods which includes guidance on inspection and compliance action. HC's Food Directorate operates the LRS jointly with PHAC's NML.

Food surveillance is conducted by HC while the human surveillance component is conducted by PHAC.  A major focus of the LRS is providing a national database of all isolates (clinical, environmental and food) for use as a resource for outbreak investigations, surveillance, and other microbiological investigations. The molecular typing database of human, food and environmental isolates is housed at PHAC's NML.

CFIA inspects Canada's food supply to verify that it complies with food safety standards and policies established by HC. CFIA establishes policies for food (such as meat, fish, eggs, dairy products, fruit and vegetables, along with processed and packaged foods) in order to facilitate inter-provincial and international trade.

CFIA contributes to the investigation and control of foodborne illness outbreaks through the enforcement of comprehensive food safety legislation and regulations, through extensive inspections and testing at food production plants across the country and through its food safety investigation and recall activities. When CFIA learns of a potential food safety issue, a food safety investigation is launched. These investigations can be triggered by various sources including consumer and industry complaints, inspections, audits, laboratory results or referrals from other organizations. As a result of the investigations by CFIA, if the Minister of Agriculture and Agri-Food believes on reasonable grounds that the food poses a risk, he/she may order any person selling, marketing or distributing the food to recall it or order it sent to a place designated by the Minister. However, before an order is issued, industry may voluntarily recall its product from the marketplace where a health risk and/or a violation is confirmed. In recall activities, CFIA works in collaboration with HC as well as with industry and other regulatory agencies.

3.4 Foodborne Illness Outbreak Response

The process of detecting an outbreak generally starts when a person falls ill and sees a physician or presents at a hospital emergency room. If the physician suspects a foodborne illness, she/he may confirm the diagnosis by sending a sample of blood, stool, cerebral spinal fluid or amniotic fluid to a laboratory. Positive laboratory results are reported through the local public health unit to the provincial Ministry of Health. The laboratory may also decide to send an isolate of Listeria monocytogenes bacteria from the human sample to a provincial laboratory or to PHAC's NML to determine the genetic “fingerprint” of the bacteria. Pulsed field gel electrophoresis (PFGE) results help to determine if there are links between the cases of illness and a food source. Genetic “fingerprinting” refers to a technique for determining the likelihood that genetic material has a common source. When two or more Listeria monocytogenes bacteria have matching genetic “fingerprints”, this suggests the bacteria may have a common source and the resulting cases of Listeriosis could be part of the same outbreak. Further epidemiological investigation to look for common exposure must be conducted to be able to fully interpret the significance of finding a common genetic “fingerprint”.

Laboratories post results on PulseNet, a virtual electronic network. PHAC's NML in Winnipeg plays the leadership role in coordinating PulseNet Canada. PulseNet allows microbiologists to track and share genetic “fingerprints” for comparison. It ties together public health and laboratories of all provinces, plus some federal laboratories, by linking their computers and databases. PulseNet participants perform standardized molecular sub-typing (“fingerprinting”) of foodborne disease-causing bacteria by PFGE. PFGE can be used to distinguish strains of organisms such as Listeria at the DNA level. DNA “fingerprints,” or patterns, are submitted electronically to PulseNet. This allows for detection of foodborne disease case clusters by PFGE and rapid comparison of the patterns; allows for real-time communication among federal, provincial and local health departments; and, facilitates the early detection of outbreaks as well as accurate transmission of information to the public. Laboratories can compare their results to those posted on the PulseNet national database to find matches and identify outbreaks.

Foodborne outbreaks may come to the attention of public health officials through various sources, including: identification at the community-level by clinicians, the public, or individuals; identification by local, provincial/territorial or federal laboratories; or, identification through routine surveillance activities by local, provincial/territorial or federal epidemiologists with the recognition of unusual rates of an illness or a number of people falling ill after eating at the same place or eating the same food, as for example, in a nursing home.

To keep the public health community in Canada informed, local, provincial/territorial and federal public health officials can issue Public Health Alerts about foodborne illness outbreaks (and other diseases including Respiratory and Zoonotic) through the Canadian Integrated Outbreak Surveillance Centre (CIOSC).

CIOSC is a component of the Canadian Network for Public Health Information (CNPHI). CNPHI is a collection of secure web-based public health applications developed by PHAC. CNPHI includes tools for sharing information in real time across Canada among local, provincial/territorial health departments as well as PHAC and affiliated organizations involved in public health surveillance and/or outbreak response. Public Health Alerts are used for receiving, posting and distributing information concerning confirmed or suspected outbreaks or other public health events under investigation. CNPHI tools assist in determining the existence/extent of an outbreak through the recognition of related cases across jurisdictions and then bring an outbreak to the attention of public health authorities to help promote a timely response. PulseNet (mentioned above) also uses CNPHI as its communication platform for sharing information amongst federal and provincial/territorial laboratories and epidemiologists.

An outbreak investigation is initiated to determine the source of an outbreak and to implement available control measures aimed at reducing public health impact and preventing further spread of disease. Investigations involving food product contamination involve local and provincial public health officials and laboratories, HC, PHAC, and CFIA. Epidemiological investigation involves verification of the existence of an outbreak and the development of a case definition followed by case findings. This requires the population at risk to be defined and cases identified through retrospective review of suspect cases, or prospective enhanced surveillance.  Data are analyzed in terms of time, person and place in order to generate a hypothesis explaining the exposure that caused the outbreak. Further analytic studies which make statistical comparisons between the exposures of ill and well people are often conducted to support or refute the hypothesis. In suspected foodborne outbreaks, recovery of the agent from the food and from the ill person for laboratory testing provides data to support the implication of a food vehicle.

The implementation of prevention and control measures, which target the outbreak source, contaminated vehicles of infection transmission, and susceptible humans, may be considered at all stages of the investigation although definitive measures usually require knowledge of the source and other factors responsible for the outbreak. Decisions are based on an understanding of the disease agent, probable sources, and modes of transmission. Food testing can result in targeted recalls. The incidence and severity of the disease will determine the urgency of implementing certain control measures. Interventions may include warnings about suspect foods, food recalls, establishment closures and public messaging to reinforce key food handling and hygiene practices.

4. Findings and Recommendations

4.1. What Worked Well

The public health response to the 2008 Listeriosis outbreak unfolded much as any other outbreak but was complicated by the long incubation period of Listeriosis. A detailed chronology of federal actions taken during the Listeriosis outbreak is provided in the last section of this report.

The detection, investigation, containment and coordination of the 2008 Listeriosis outbreak which spanned multiple provinces involved the collective efforts of local public health authorities, provincial and territorial governments, and federal officials (PHAC, HC, and CFIA). Considerable commitment and effort was displayed by PHAC staff to respond to the event. Most aspects of PHAC's response were viewed positively by key informants.

With the identification of a national distribution of cases in mid-August, PHAC's Outbreak Management Division in CFEZID assumed a leadership role in coordinating the national epidemiological investigation. Specifically, the Outbreak Management Division was involved in:

• Organizing and chairing conference calls with PHAC colleagues in NML, provincial/territorial partners, CFIA, and HC to review new findings, discuss investigative approaches and findings;
• Developing and disseminating standardized data gathering instruments for P/T data collection;
• Establishment of a national database, updating data regularly, analyzing the data and producing regular reports;
• One-on-one consultations with P/T epidemiologists, CFIA and HC; and
• Communication with the U.S. Centers for Disease Control and Prevention.

PHAC's NML played a key role by leading the laboratory arm of the national outbreak investigation, coordinating and analyzing all laboratory data (i.e., tests that were performed at NML as well as the results of all tests performed elsewhere) and providing the analyses and interpretation of genetic “fingerprints” to CFEZID. NML provided laboratory services and kept the provincial and federal laboratories apprised throughout the outbreak. During the outbreak, NML reduced lab testing times to four days. Genetic “fingerprinting” and serotyping together for routine, non-urgent samples can take up to 14 days, not including the time it takes to collect samples and send it to a federal laboratory. NML routinely shared all information through PulseNet and the CNPHI communication application for laboratories that NML operates.  PulseNet is used through a formal agreement between PHAC and the provinces/territories.

Specifically, NML was involved in:

• Analyzing all genetic “fingerprints” generated by all laboratories during the outbreak investigation, providing interpretation guidance to, and collaborating with, CFEZID;
• Testing human isolates of Listeria monocytogenes received from provincial laboratories for matching genetic “fingerprints”;
• Providing analysis of the genetic “fingerprints” and posting the information through PulseNet to alert the laboratory community of a possible outbreak;
• Notifying laboratories across Canada that genetic “fingerprinting” showed a clustering of cases with a similar strain in more than one province. NML also notified PHAC's CFEZID that British Columbia and Alberta had Listeria monocytogenes isolates that matched the outbreak strain in Ontario;
• Supporting HC in the testing of isolates of Listeria monocytogenes from food samples to determine a match to the outbreak “fingerprint”;
• Testing isolates sent by CFIA from the food processing environment to determine if they matched the outbreak “fingerprint”; and
• Hosting teleconferences with the Canadian Public Health Laboratory Network (CPHLN) to discuss issues such as laboratory practices for Listeria monocytogenes and convening an expert committee to discuss laboratory testing guidelines.

PHAC's overall management of its role in the outbreak was generally deemed positive by key informants. There was also general agreement that working relationships with federal partners were good and that daily calls between federal, provincial/territorial and local public health officials supported coordination and information sharing among the partners, as well as with the Minister's Office and Central Agencies, which were highly involved. As well, PHAC communicated extensively with the media, the public and practitioners.

Not all outbreaks of foodborne illness are “solved”. In this case, PHAC played a significant role in detecting and containing the Listeriosis outbreak. Epidemiologists coordinated the epidemiological investigation; microbiologists conducted the necessary laboratory tests; PHAC's information technology infrastructure assisted in the exchange of technical data (e.g., CNPHI, PulseNet); F/P/T networks coordinated by PHAC staff assisted with the information flow amongst P/T partners (e.g., Council of Chief Medical Officers of Health (CCMOH), network of F/P/T epidemiologists); and the Emergency Operations Centre (EOC) supported communication and coordination during the outbreak.

4.2 What Needs to Be Improved

PHAC demonstrated a strong federal leadership role during the Listeriosis outbreak.  However, there is room for improvement.  The remainder of the report focuses on these areas for improvement.

Two threads and a number of key questions weave through the lessons learned from PHAC's response to the Listeriosis outbreak: the importance of advanced planning, and the need for more formalized approaches to outbreak and other event responses. Below are some examples.

•  Before an event
  • Are agreements and protocols in place that clearly delineate and explain roles, responsibilities and procedures? In a complex, high profile, national outbreak situation, are key PHAC staff at all levels aware of their roles and responsibilities? Are there appropriate linkages between outbreak response protocols and emergency response policies, plans and procedures? Are key PHAC staff aware of and trained in the protocols? Have PHAC staff practised implementing established protocols?
• During an event
  • In a high pressure environment, in addition to responding and reacting, PHAC needs to systematically build in mechanisms that allow PHAC adequate time, with the right people involved, to anticipate and ‘scenario' plan (e.g., what could happen next? what surge capacity can we draw on?).
• After an event
  • What are the policy and practice implications of the event?  What needs to be done now to ensure better preparedness in the future?

Formality
PHAC has good working relationships with a wide variety of stakeholders. This is very positive. However, in some respects these may be too informal. A relatively informal approach may work during small/routine outbreaks but it does not guarantee a shared understanding of roles, responsibilities and procedures during a complex, high profile, national outbreak. There is too much room for assumption, misinterpretation, and/or miscommunication.

Virtually across the board, PHAC could benefit from adopting a more formal approach to determining, declaring, discussing, documenting, and debriefing on significant events. For instance, on the epidemiological side, it is critical to formally declare that PHAC is taking leadership of an Outbreak Investigation Coordination Committee. Similarly, PHAC should always formally declare activation of the Emergency Operations Centre, explain why it is being activated at a particular level, and remind stakeholders about its purpose as well as the response structure and its accompanying roles and responsibilities. Key stakeholders need to be aware, even if it is a relatively small-scale event.

These two threads, the need for concerted advanced planning and more formalization of procedures and processes, run through the three broad areas covered in the remainder of the report:

• Clarity of roles and responsibilities (specifically in foodborne illness outbreak management, and more generally in event management via the EOC);
• Systems/tools; and
• Capacity.

4.3 Recommendation #1: Revisit the FIORP

What is the FIORP?

The Foodborne Illness Outbreak Response Protocol (FIORP) to Guide a Multi-jurisdictional Response sets out general principles and procedures for foodborne illness outbreaks in Canada. It covers foodborne illness outbreaks associated with microbiological or chemical hazards. The FIORP covers the technical roles and responsibilities of federal, provincial/territorial, regional and local authorities involved in an outbreak. It provides guidance for key response activities including: the exchange of information relevant to the investigation, the disclosure of third party information, the coordination of response activities and the conduct of post outbreak reviews. It also includes guidelines for communication with the public. The FIORP has apparently been used as a model for the development of some provincial protocols as well.

The initial version of the FIORP was developed in 1999 by HC and CFIA with agreement from the provinces and territories to use it as a reference document. The FIORP was subsequently revised with a view to obtaining national endorsement to reflect the important contribution of the FIORP to national emergency preparedness. In 2004, the revised FIORP was endorsed by the Federal/Provincial/Territorial Committee on Food Safety Policy, the CCMOH, and the F/P/T Deputy Ministers of Health. In addition to these collective endorsements, approval of the FIORP by individual provinces and territories has never been sought.

Clarity of Roles and Responsibilities during the Listeriosis Outbreak

The FIORP was designed to be “flexible” and to reflect a “principled, spirit of cooperation” guidance document. The protocol sets out very high level technical roles and responsibilities. As a result, there is very little specificity on exactly what is entailed in the overall coordination and management of a national outbreak and which organization, or part thereof, is responsible for which aspects of coordinating and managing an outbreak.

Among PHAC, HC and CFIA key informants, roles and responsibilities of federal partners were seen as relatively clear during the Listeriosis outbreak, with the exception of which federal department acts as the communications lead for particular aspects of an outbreak. Again, among the federal partners, there was agreement that PHAC, HC and CFIA generally worked well together.

On the other hand, P/T partners, the media and the public were not particularly clear on the specific division of federal roles and responsibilities and the inter-relationships amongst PHAC, HC and CFIA.

There is agreement among PHAC technical staff that the FIORP works well during routine situations. However, the FIORP does not provide sufficient clarity on roles and responsibilities during a significant national situation.

As mentioned previously, the management of foodborne illness outbreaks has become increasingly complex due to: new methods of food processing, especially mass production and ready-to-eat products; increased globalization of the food industry; the emergence of new and uncommon pathogens; changes in agricultural practices; and, changes in consumer behaviour and susceptibility. Accompanying this emergence of new outbreak scenarios, is the complex nature of jurisdictional roles and responsibilities, as well as the number of parties involved. The FIORP does not provide a sufficient level of detail to clarify roles and responsibilities.

Other Issues with the FIORP

There are a number of other issues which warrant attention within the FIORP:

• The protocol does not reflect advancements in tools such as CNPHI and PulseNet.
• FIORP does not reflect the role of PHAC's NML in leading the laboratory side of outbreak response by coordinating, collecting and analyzing laboratory data nationwide and providing results interpretation and recommendations to partners.
• The FIORP does not reflect the considerable dialogue that has occurred in the past several years in preparation for government-to-government information sharing agreements.
• The FIORP does not incorporate recent work done in crisis and risk communications nor does it address the Chief Public Health Officer's (CPHO's) mandate to speak directly to Canadians on matters of public health.
• The FIORP does not acknowledge agreements reached since its drafting (e.g. such as the Listeriosis Reference Service or the F/P/T MOU on Information Sharing During a Public Health Emergency).
• The FIORP is posted on the HC web site but the document itself does not indicate who is the overall custodian or “keeper” of the FIORP, or whether a process exists for regular review and update (PHAC's Outbreak Management Division in CFEZID maintains the contact list for the FIORP).

The FIORP predates the establishment of PHAC. Prior to the establishment of PHAC, foodborne illness responsibilities resided with HC. The FIORP has not been fully updated since the creation of PHAC; consequently, some of the FIORP reflects outdated organizational structures.  For instance, the List of Acronyms states that PHAC's National Microbiology Laboratory is part of HC. Similarly, the FIORP has not been updated since PHAC's Infectious Disease and Emergency Preparedness (IDEP) Branch reorganized in 2007. The FIORP provides the first point of contact at the federal level as the Centre for Infectious Disease Prevention and Control at PHAC ─ this Centre no longer exists, and in Annex 2, the PHAC staff person for providing the overall FIORP contact listing is no longer employed by PHAC.

Level of Awareness of the FIORP

While the technical level used the FIORP to guide their response to the Listeriosis outbreak, it is apparent that there is limited awareness of the FIORP among senior management, emergency preparedness and communications staff, as well as other key staff within PHAC.  

There is a need for better orientation and training on the protocol of key PHAC staff (e.g., senior management, staff in emergency preparedness, communications, and corporate secretariat, etc.). Over the longer-term, PHAC should explore opportunities for joint orientation and training regarding other response protocols such as the Zoonotic Illness Outbreak Response Protocol (ZIORP) and the Respiratory Illness Outbreak Response Protocol (RIORP). There is also a definite need to raise awareness about the linkages between outbreak response protocols and the protocols and procedures associated with the EOC for occasions when the EOC is activated to deal with an outbreak. Therefore, linkages to PHAC's all-staff training in Emergency Preparedness and Response should also be considered.

Recommendation

Due to the reasons explained above, in addition to issues elaborated upon in the next three sections of the report, PHAC should work with partners to revisit the FIORP. It will be an important opportunity for all partners to critically assess recent experience with Listeriosis and other foodborne illness in order to develop a refreshed FIORP that can adequately and clearly guide multi-jurisdictional response to the many routine outbreaks that occur locally, provincially and nationally each year, in addition to complex, large-scale, and/or high profile outbreaks that cut across the country and beyond our borders. A revised FIORP is a necessary foundation upon which to build ongoing training as well as regular practice exercises.

The FIORP should be reviewed routinely to ensure that it continues to align with emerging policy developments such as the National Strategy for Safe Food. The National Strategy covers the entire food continuum, encompassing domestic and imported food, and addresses not only the biological and chemical safety of food but also its nutritional safety. Its vision and guiding principles are intended to provide guidance to food safety related initiatives generally.

Learning from the Experience of Other Jurisdictions

In revisiting the FIORP, best practices from other jurisdictions may offer insights that can be applied to the Canadian situation. Attention should be paid to governance structures and the stakeholders involved as well as programs, processes, products and guidelines that facilitate good foodborne illness outbreak response. One model to explore is the Council to Improve Foodborne Outbreak Responses (CIFOR) in the United States.^{Footnote 8} CIFOR is a multi-disciplinary working group convened in 2006 to increase collaboration across the United States to reduce the burden of foodborne illness. Current CIFOR initiatives include:

• Consensus guidelines for foodborne disease outbreak detection and response;
• Guidelines for multi-jurisdictional outbreaks;
• Outbreak training;
• Epidemiological/laboratory reporting; and
• Cluster definitions to identify key factors for successful investigations.

4.3.1 Recommendation #1.1: Revisit the FIORP – Integrate Current Work on Information Sharing Agreements

Several issues arose during the Listeriosis outbreak around information exchange and the sharing of technical data. These issues are highlighted below.

Information Exchange

During an Outbreak
During the management of an outbreak, at the operational level, there is a strong connection between PHAC's Outbreak Management Division in Guelph and the informal network of P/T epidemiologists. This technical group works together routinely on outbreak investigations using the FIORP as their guide. During an outbreak, there are regular conference calls amongst the group and a great deal of one-on-one communication between PHAC and the epidemiologists in the P/Ts dealing with an outbreak. Similarly, the sharing of laboratory information occurs via the CPHLN.

At the most senior level within PHAC, there is a connection between the CPHO and P/T Medical Officers of Health via the CCMOH. This group conveys technical information but also addresses important strategic and policy issues. PHAC convened two teleconferences with the CCMOH during the Listeriosis outbreak (August 26 and September 4). CCMOH felt they could have been engaged by PHAC earlier and that the approach to teleconference calls should have been better coordinated.

There are several challenges to address regarding how these groups share information during an outbreak:

• There are different relationships within P/Ts between the Chief Medical Officer of Health and the Deputy or Assistant Deputy Minister of Health. Communication with CCMOH or a Medical Officer of Health does not necessarily constitute communication with the DM or ADM.
• There is no clear Director General-level connection between PHAC and P/T counterparts in the area of foodborne illness. During the Listeriosis outbreak, this might have been helpful with Ontario where the outbreak was first identified and where the bulk of cases existed. The FIORP contact list, for instance, does not list PHAC's DG of CFEZID or any contacts in the Centre for Emergency Preparedness and Response (CEPR), including the DG.
• There is some disconnection in both PHAC and some P/Ts between the working and senior levels (despite many meetings, etc.). There is no clear mechanism to ensure that pertinent information gets pushed up from the working level or trickles down from the senior level.

This information exchange is relatively informal and is not explicitly addressed in the FIORP (i.e., there is no guidance about timing and/or frequency of these interactions nor are there clear expectations for briefing up or down within an organization).

Advanced Planning In addition to these mechanisms that are critical for information sharing during an outbreak, there are formal F/P/T groups that are conceptually linked to issues of foodborne illness. Within the Public Health Network (PHN) structure, four of the six Expert Groups have some bearing on outbreaks of foodborne illness (see Diagram 1): Communicable Disease Control and its National Enteric Foodborne and Waterborne Disease Working Group as well as the Communications Working Group of the Pandemic Information Committee; Canadian Public Health Laboratories and its Water and Food Safety Subcommittee; Surveillance and Information and its Information Sharing Agreement Task Group; and Emergency Preparedness and Response. Also, reporting directly to the PHN Council is the Communications Task Group on Pandemic. While the initial work of this Group focused on antivirals prophylaxis, the work and role of the group could be expanded to other F/P/T communications issues.

PHAC should review the Terms of Reference, status and work plans of the various F/P/T mechanisms and clarify how they connect to each other on issues of foodborne illness. For instance, it appears that the Terms of Reference for the National Enteric Foodborne and Waterborne Disease Working Group remain in draft form and that the Working Group has met just once (in 2007).

The lack of clarity in inter-relationships amongst PHN structures did not necessarily impact on PHAC's response to the Listeriosis outbreak; however, existing F/P/T mechanisms may be able to assist in future planning (e.g., consultation on and clarification of roles and responsibilities, expert advice on technical issues, development and implementation of training programs and practice exercises, etc.).

There may even be roles for specific PHN mechanisms during an outbreak. For instance, PHAC Communications staff were able to use the PHN Communications Task Group on Pandemic as a way to connect with senior-level P/T communications counterparts regularly throughout the Listeriosis outbreak. According to PHAC communications staff, this information system was invaluable during the outbreak.

Diagram 1: Illustrates the formal structures of the Public Health Network

Data Sharing

Data Sharing Between PHAC and P/T Epidemiologists
PHAC is dependent upon timely and accurate data from the P/Ts to carry out a national-level epidemiological investigation. Initially, during the Listeriosis outbreak, Ontario only provided aggregate level data to PHAC and was not willing to provide full individual level data which impacted PHAC's ability to investigate. Ontario began sharing case level information only after PHAC epidemiologists re-iterated that this was a national investigation and thus national level reports must be produced.

The Role of P/Ts to Communicate to the Public about Cases in their Jurisdiction
There was concern in the media about the timeliness and accuracy of numbers reported by PHAC. At the outset, Ontario released outbreak numbers at different times than PHAC and the media independently uncovered and reported cases and deaths. Also, the way deaths were defined and counted by Ontario changed during the course of the outbreak. This led to the number of reported deaths changing significantly from one day to the next. As a result, this change required considerable explanation to internal and external stakeholders.

There is a need for clearer protocols for communicating information on P/T cases (and deaths) during a national outbreak situation, i.e., ensuring the P/Ts comment on cases in their own jurisdiction before PHAC presents the national picture.

Pressure for Details on Individual Cases
When an outbreak is limited to only one province or territory, that jurisdiction leads the epidemiological investigation. PHAC does not receive individual level data. When an outbreak spans more than one province or territory, P/T epidemiologists share individual level data with PHAC to aid in the national epidemiological investigation. PHAC epidemiologists use that data for analytical purposes only.

During the Listeriosis outbreak, there was intense pressure for detailed information. PHAC epidemiologists, and to a lesser extent lab scientists, report that they felt pressure from PHAC senior management and Central Agencies to seek information on individual cases from P/T colleagues and to share information for purposes other than for which it was intended. This pertained to the outbreak related to Maple Leaf ready-to-eat meats, as well as other outbreaks happening at the same time. Also, PHAC epidemiologists and lab scientists felt they were being required to impose on their professional relationships with P/T colleagues to seek and share information that was strictly within P/T jurisdiction. PHAC senior management, corporate secretariat, NML, and the Outbreak Management Division should continue dialogue on this issue.

Conclusions and Recommendation

Arrangements for sharing laboratory information are formal and specific via the PulseNet Memorandum of Understanding. In contrast, arrangements for sharing epidemiological information tend to be “organic” in the sense that PHAC staff are working with people they know (and trust) versus strictly following a formal protocol or procedure around data sharing. There are weaknesses to informal networks. When an organization restructures or someone is on holidays or changes positions, the network disappears. There is a need for clearer protocols on the level of information that can be shared for various purposes in different situations.

These information sharing issues may not be unique to foodborne illness. There is a great deal of work currently underway within PHAC regarding broader government-to-government information sharing agreements consistent with Chapter 5 of the May 2008 Auditor General's Report on the Surveillance of Infectious Disease. It is critical to ensure that issues related to foodborne illness, including those mentioned above, are factored into these agreements between PHAC and each P/T (e.g., case definitions, level of information, as well as the timing of analysis, confirmation and public release of information). Then, details from F/P/T information sharing agreements must be integrated into the FIORP or, FIORP should directly point to the F/P/T information sharing agreements for guidance in various situations to ensure there are no inconsistencies.

If national leadership in foodborne illness is a priority for the Agency, then immediate steps should be taken to develop, implement and oversee an action plan to address the findings and recommendations in this report. PHAC senior management should regularly monitor progress on implementation of these lessons learned.

2. Purpose and Methods

This report examines the Public Health Agency of Canada's (PHAC) response to the 2008 Listeriosis outbreak to gain a high-level understanding of what worked well and what requires improvement. PHAC management and staff will use the report for planning and decision-making purposes to address areas requiring improvement in preparation for future outbreaks of foodborne illness.

The project was conducted by the Centre for Excellence in Evaluation and Program Design, a group internal to PHAC but not involved in the program areas that responded to the outbreak. A project Steering Committee oversaw the development and implementation of the lessons learned exercise. The methodology had two main components:

• Review of key documents including Memoranda of Understanding, protocols, agreements and after action reports; and
• Interviews from mid-October to mid-November 2008 with staff from PHAC, the Canadian Food Inspection Agency (CFIA), Health Canada (HC), Ontario Ministry of Health and Long Term Care and British Columbia Ministry of Health, as well as group discussions with some members of the Council of Chief Medical Officers of Health and the Pan-Canadian Public Health Network Council.

CFIA and HC also conducted similar lessons learned exercises. Although each organization had separate Terms of Reference and produced independent reports, the three organizations coordinated their efforts in data collection through joint interviews where possible.

3. Background and Context

The 2008 Listeriosis outbreak was identified following three weeks of higher than expected case reports of Listeriosis in Ontario. Eventually seven provinces were implicated in the outbreak. The Public Health Agency of Canada (PHAC) became involved when it was apparent that cases were occurring in more than one province. The source of illness was linked to ready-to-eat meats produced at a Maple Leaf plant in Ontario.  Of the 56 confirmed cases (75% of which were in Ontario) and 2 probable cases, there were 20 deaths where Listeriosis was the underlying or contributing cause of death (across five provinces; 75% of total deaths occurred in Ontario).

3.1 Facts on Foodborne Illness

Foodborne illness refers to diseases acquired through eating food or drinking liquids that have been contaminated with bacteria, parasites or viruses. Foodborne illnesses are relatively common. PHAC estimates that there are 11 million cases of foodborne illness each year in Canada.^{Footnote 1} However, many cases of foodborne illness go unreported because the illness is self-limiting and does not require medical consultation. Symptoms often include stomach cramps, nausea, vomiting, diarrhea and fever. Many of these illnesses are sporadic cases, but some become part of an outbreak. People often refer to foodborne illness as “food poisoning”.

An outbreak occurs when there is an unexpected increase of disease occurring within a specific population at a given time and place. Each outbreak occurrence is unique. The number of cases in an outbreak will vary according to the infectious agent, size and type of population exposed, population immunity, and time and place of occurrence. Therefore, the status of an outbreak is relative to the usual frequency of the disease in the same area, among the same population, at the same season of the year.^{Footnote 2}

Preventing foodborne illnesses is a major public health challenge. Several factors are altering the epidemiology of foodborne diseases and increasing the complexity of managing foodborne illness outbreaks including: the emergence of new and uncommon pathogens; changes in agricultural practices; increased globalization of the food industry; new methods of food processing, especially mass production and ready-to-eat products; and, changes in consumer behaviour and susceptibility. To underscore the complexity of the outbreak scenario, Table 1 highlights the factors that distinguish the new outbreak scenario from the traditional scenario.^{Footnote 3}

4.3.2. Recommendation #1.2: Revisit the FIORP – Modernize Communications Guidelines

Perceptions of What Happened

The Listeriosis outbreak generated a very high level of media interest. A review of print and television media between August 18 and October 1, 2008 revealed themes that are of relevance to PHAC. Details on PHAC's actual communication response are outlined in the next section of this report.

Timelines for Investigation and Notification of the Public Several articles between August 18 and Sept 13 were predominated by a perception that it took more than a month for the public to be informed of the possible contamination of meat; some articles cite a time lag of seven weeks. Within these articles there are references to possible causes for delay, including the process of determining the occurrence of an outbreak, the time required for investigation and the transmission of outbreak information between the local, provincial and federal agencies. On a related issue, a few articles also made reference to the need for more public information about the number of cases, where they were occurring and the number of deaths.

Availability of Information
A few articles in late August referred to the difficulty the public had in getting information about Listeriosis and the outbreak. Criticism included comments to the effect that information was “buried” on federal government websites. Several articles made reference to the perceived lack of timeliness in the provision of information to high risk members of the public such as seniors, pregnant women and people with compromised immune systems and other chronic conditions, as well as to doctors charged with their care.

Clarity of Roles and Responsibilities of Government
Several articles expressed concern about the need for clarity regarding who within government has the lead responsibility during an outbreak. Linked to this were media reports on the perceived lack of visibility of the CPHO of Canada.

Food Safety
In addition to these themes of relevance to PHAC, there was an overriding theme in much of the media concerning public safety and communication regarding the overall safety of the food testing and monitoring system, plus the issue of private versus public sector roles in detecting, communicating and managing contaminated food. These issues are outside of the mandate of PHAC.

What Worked Well

Notwithstanding the criticisms identified above, PHAC was involved in providing many communications products during the outbreak. In terms of direct interactions with the media:

• The Acting Director of the Outbreak Management Division of the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases gave five media interviews on August 20 with updates on the epidemiological status of the outbreak.
• The Director General of the Centre for Food-borne, Environmental and Zoonotic Infectious Diseases gave two interviews on August 22 with an explanation of Listeriosis and an update on the outbreak.
• The CPHO participated in three media interviews:
  • CTV National interview on August 27 to discuss advice for parents (back to school - lunch bags);
  • Canada AM interview on August 28 on the issue of food safety; and
  • The Toronto Star interview on August 30 in response to criticism that PHAC took too long to inform Canadians.
• Media briefings were held daily from August 23 to September 5 (joint efforts - CFIA, PHAC and HC).
• NML led a detailed technical briefing for the media on September 4 including a video and a visit to the lab.
• PHAC Communications responded to approximately 150-160 media requests.

In addition, PHAC staff participated in 14 Ministerial briefings that included preparation for media briefings.

PHAC provided an array of communications products including:

• Three fact sheets directed to at-risk populations (pregnant women, seniors, and people with compromised immune systems), posted to the PHAC website and distributed directly to 38 organizations serving these groups (beginning September 2), who in turn distributed to their own networks (for example, the Canadian AIDS Treatment Information Exchange includes 200 organizations and a tuberculosis listserve reaches over 500 physicians and nurses);
• Public notices, purchased in 123 daily and weekly newspapers across Canada between August 29 and September 1, 2008;
• An online video message by the CPHO using YouTube which garnered over 1000 views between August 28 and November 19, 2008; and
• Eleven bilingual web pages featuring general facts about Listeriosis and updates on the outbreak for the public, for the media, and for health professionals that saw over 43,000 visitors^{Footnote 9} between August 20 and November 2, 2008.

Despite the criticism in the media, there was a general sense among key informants that the PHAC communications response was good, given the scope of the products. An important part of this success was the good working relationship between the communications teams at PHAC, HC and CFIA.

With that said, there are areas for improvement.

What Can Be Improved

Federal communications staff reflecting on the Listeriosis outbreak response identified a number of areas that could have been handled differently.

Timing
Risk and crisis communications activities focused on communicating deeper public health messages to population groups at greater risk from the outbreak (such as seniors and pregnant women) instead of solely conveying technical information about the outbreak (such as the number of cases of illness) via the media. Some PHAC key informants indicated that such activities could have been started a little earlier, although it is unclear how much sooner would have actually been possible.

PHAC did produce public health messages relevant to specific target groups(e.g., health professionals and vulnerable populations) beginning September 2 but there was a strong sense from the CCMOH that this needed to be faster and should have been an early action taken by PHAC. An ad-hoc committee including representatives from the CCMOH, HC, and PHAC, with coordinating support from PHAC, is currently analyzing existing Listeria-related material and will make recommendations on generic messaging for practitioners and the general public.

There is a need for agreement amongst federal partners on ways to reduce the time required to approve joint communications products. A draft protocol is currently being discussed by Directors General of Communications at PHAC, HC and CFIA.

Spokespeople
More clarity is required regarding which federal department acts as the communications lead for particular aspects of a foodborne illness outbreak.

Within PHAC, there is a need for clearer protocols for identifying lead spokespeople and their alternates. For a variety of different outbreak scenarios, consideration must be given to the appropriate level of spokesperson (CPHO, ADM, DG) and type of spokesperson expertise (e.g., physician or technical specialist).  All spokespeople and their alternates must receive adequate media training and regular refreshers.

Relationships amongst Federal Communications Teams
While the communications teams at HC, PHAC and CFIA reported working very well together during the Listeriosis outbreak, communication was limited to e-mails and telephone calls. Gains may be realized by creating opportunities for face-to-face strategic discussions of the federal communications directors to build a shared understanding of the delineation of roles and responsibilities in various circumstances.

PHAC Surge Capacity
The PHAC Communications Directorate in general, and especially the media relations and crisis communications teams, needs to have a better plan in place to deal with surge capacity (weekend coverage, on-call practices, vacation schedules, well-briefed alternates/back-ups, etc.).

Technical staff at both the NML and the Outbreak Management Division, were required to provide frequent information updates for senior management, Ministerial and Central Agency staff, as well as the media. The intensity of pressure for information was high and timelines were often extremely short. PHAC should provide additional communications and policy support to technical areas in these types of high profile events to ensure that the technical experts can focus on their investigative work. By bringing together the technical experts with policy and communications advisors, the Agency will be able to better serve the Minister, public health officials, the media, and the public.

Conclusions and Recommendation

The FIORP, the protocol which guides the multi-jurisdictional response during an outbreak of foodborne illness, includes an Annex entitled “Communication with the Public – Guidelines”. There are several issues related to these guidelines.

• Most PHAC communications staff were not aware of the FIORP communications guidelines.
• The FIORP communications guidelines do not provide sufficient clarity on roles and responsibilities.
• The FIORP communications guidelines, originally developed in 1999, do not reflect recent work on crisis communications guidelines^{Footnote 10}> (which include templates, checklists and other tools that could be tailored to the foodborne illness context) and on the joint PHAC/HC Strategic Risk Communications Framework. CFIA and P/Ts may have also done similar work on crisis and risk communications that could be applicable.

Therefore, it is recommended that PHAC work with its partners to modernize the communications guidelines in the FIORP based on new approaches to risk and crisis communications as well as recent experience with significant outbreaks of national concern. The guidelines must clearly delineate roles, responsibilities and procedures during a high profile, significant, national outbreak.

Work has been done in communications in the area of pandemic preparedness. Communications planning for other types of potential outbreaks must build on the pandemic infrastructure for reasons of both efficiency and consistency. For example, there is a draft F/P/T Operational Plan developed by the Communications Working Group of the Pandemic Information Committee of the Communicable Disease Control Expert Group of the PHN. The purpose of the plan is to provide operational guidance in aligning the communications activities of federal and P/T partners during a response to an influenza pandemic or other public health emergency to ensure a coordinated communications response. This group is composed of communications officials from the Ministry of Health in every P/T with responsibility for infectious disease or emergency communications.

Once the guidelines are revised, it is also recommended that key PHAC staff be oriented and trained on the FIORP communications guidelines. Finally, PHAC staff should practise implementing communications responses to high profile national outbreaks of foodborne illness. Federally, this could be via inter-departmental exercises building on the existing pandemic influenza response infrastructure which already involves HC, but would need to integrate CFIA.  Similarly, building on F/P/T pandemic infrastructure, the PHN Communications Task Group on Pandemic might be an appropriate vehicle for coordinating F/P/T exercises. These exercises could also offer the opportunity to draft generic content which could be adapted to the particulars of a specific future outbreak situation.

4.3.3 Recommendation #1.3:   Revisit the FIORP – Develop A Standard Approach to Reviewing Outbreaks

There are a variety of mechanisms, with varying degrees of formality, for assessing response efforts.

Within PHAC, debriefing sessions amongst staff are routinely carried out following significant events. These exercises are sometimes referred to as “hotwashes”, “post-mortems” or “first impressions reports”. In the field of emergency response, “after-action reports” are common. There is currently no standardized approach within PHAC for conducting, disseminating or following up on these types of assessments.

Three internal debriefs on the Listeriosis outbreak were conducted within specific PHAC operational areas: Communications Directorate; NML; and the Outbreak Management Division of CFEZID. The notes from the Communications Directorate post mortem were made available to the project team for this lessons learned exercise; the project team did not receive notes from the NML or CFEZID debriefs. These debriefs involved the staff for those particular operational areas. PHAC staff outside each of these operational areas were not necessarily aware that debriefs had taken place. One key informant, who was intensely involved in the outbreak, expressed frustration that there had not been an opportunity to be involved in the Communications debrief.

The CEPR facilitated a broader hotwash on September 11 which included staff from across the Agency who had been involved in the Listeriosis outbreak.  The lessons learned project team attended the hotwash as observers and used their notes from the session as one input to this exercise. At the time of writing the final lessons learned report, the project team had reviewed a draft version of the hotwash report but it had not yet been finalized or approved.

In addition, reflections on the success and shortcomings of response efforts are sometimes addressed as part of regular interdepartmental and/or multi-jurisdictional meetings. For instance, the CCMOH have discussed their perceptions of the multi-jurisdictional Listeriosis response efforts. Similarly, the Federal Food Safety Senior Managers at HC, PHAC, CFIA, and Agriculture and Agri-Food Canada have discussed the federal response to the Listeriosis outbreak.

The FIORP contains a section on post outbreak reviews for: assessing collaborative response efforts and the usefulness of the FIORP in guiding the response efforts; as well as, confirmation of the cause and an action plan for prevention of the recurrence of a similar outbreak. The section in the FIORP on post outbreak reviews does not describe when and how reviews are to be carried out. In addition, there are no clear processes for: review and approvals, dissemination, or follow-up on action. There is no repository of post outbreak reports, and there is no mechanism for ongoing synthesis of findings and recommendations for the purpose of integrating them into practice.

As part of revisiting the FIORP, it is therefore recommended that a standard approach be developed for reviewing multi-jurisdictional response efforts. The approach should outline the criteria for determining when, how and who conducts a review. Three types of issues need to be addressed in a post outbreak review:

• Technical/scientific issues related to the outbreak;
• Event management processes; and
• Broader policy and practice implications.

In addition to participating in a review and revision of the FIORP post-outbreak review process, PHAC's CEPR should review its current approach to after-action reporting for events managed via the EOC.

4.4 Recommendation #2: Create a Central Repository of Agreements

There are myriad agreements, MOUs, protocols and procedures involving PHAC that in some way or another are relevant to the FIORP and the management of an outbreak (see Diagram 2). Some of the documents relate to the Health Portfolio; others involve multiple jurisdictions.

Diagram 2: Illustrates the myriad agreements associated with addressing an outbreak

There are a number of issues:

• Some of these documents were difficult to find, especially final signed versions.
• It is very difficult to understand the various inter-relationships amongst these documents. Most do not name or point to the related documents or protocols. What does a change in one agreement mean for another agreement?
• It is also difficult to discern if there are any conflicting objectives or undertakings in the various agreements. It is critical to ensure that no agreement is inconsistent with another.

Given the importance of the various documents, access to the most recent versions (and their accompanying contact lists) is paramount. It is similarly critical to have the ability to understand the linkages amongst the various agreements and reflect this in updates to PHAC orientation and training materials.

It is therefore recommended that PHAC develop and maintain a searchable, web-based repository of formal agreements and their accompanying contact lists.

With such a repository, a PHAC “custodian” should ensure:

• Contact lists are updated: Presumably some key stakeholders are listed in multiple contact lists; efficiencies could be gained by coordinating the process of updating and maintaining contact lists when key Agency personnel change positions.
• PHAC organizational changes are reflected in agreements with other parties (i.e., recent restructuring in IDEP Branch).

Work is currently underway in the Corporate Administration, Facilities and Security Directorate to develop a PHAC corporate administrative policy suite. It is possible that there are some conceptual and/or technological connections that can be made between these two repositories.

4.5. Recommendation #3: Clarify, Communicate and Practise Event Management Roles, Responsibilities and Mechanisms

The Listeriosis outbreak was the first time the Health Portfolio Operations Centre (HPOC) was used to support the management of a foodborne illness outbreak. There is strong agreement among key informants from PHAC that the HPOC, which includes the EOC, provided good support during the Listeriosis outbreak. It should be noted that there is some concern about use of the term “emergency” as this may lead to confusion – there is a difference between managing an emergency and an outbreak such as Listeriosis.

The activation of the EOC provided an opportunity for PHAC to manage the growing demand for information and address the needs of all stakeholders including internal PHAC staff, Ministerial and Central Agency staff, other federal government departments, P/T partners, the media and the public.

Formalizing all Aspects of Event Management

However, it is clear that a more formal approach in implementing the EOC is systematically required. A few examples follow:

• Activation of the EOC: Not all stakeholders were aware of when and why the EOC was activated by PHAC's ADM of the IDEP Branch. Some interviewees, even within PHAC, had a different perception of the purpose and level of activation of the EOC (full activation vs. for the purposes of managing the communications and information demands). It is unclear what criteria are used for determining a specific level of activation. In this outbreak, the EOC was activated to Level 2 (increased vigilance) to support PHAC activities including programmatic coordination and communications/information flow. It is important that the activation of the EOC be formally declared at the outset and the level and rationale be immediately communicated to key stakeholders.
• Response structure: A multitude of players are involved in managing an outbreak (see Diagram 3). 
  • At the outset of any event supported by the EOC, the response structure should be formally declared with names assigned to each role within the structure. Roles should be carefully reviewed with key staff. This should be standard procedure regardless of the size or type of event being managed.
  • Some key functions within the formal response structure (sometimes known as the Incident Command Structure or ICS for short) were not implemented (i.e., Advanced Planning Group). For any event (planned or emergency), the Event Manager should always identify a Lead for the Advanced Planning Group. The Lead for the Advanced Planning Group can then, in discussion with the Event Manager, examine the need for, and composition of, the Advanced Planning Group.
  • During the Listeriosis outbreak, there was a transition in staff assuming the Event Manager role. This caused some confusion. If there is a change in roles within the response structure, this should be formally communicated and explained to key stakeholders to avoid confusion.
• De-activation of the EOC: It is unclear if the de-activation of the EOC was formally declared and communicated to key stakeholders involved in the event. Again, as with activation, de-activation of the EOC should be formally communicated to key stakeholders.

On the topic of the response structure, CEPR should work to clearly articulate the roles and composition of:

• Executive Group (especially important in multiple event situation);
• Event Manager versus the Operational/Technical Chief and their inter-relationship; and
• Executive Liaison.

CEPR, the Communications Directorate, and other key PHAC areas should also work with the Agency Regional Offices to clarify the Regional role (including surge response) during significant national events such as the Listeriosis outbreak. What is the role of the Regional Communications Advisors, the Regional Emergency Preparedness and Response Coordinators, Regional Directors, and the Regional Director General as contacts for provincial/local public health officials, Regional Offices of other federal departments, and community-based organizations (e.g., for distributing risk communications information)?

CEPR should also work with HC, CFIA, and IDEP's Policy Integration, Planning, Reporting and International Directorate to clarify the scope of their involvement with the EOC in various future scenarios.

The existing F/P/T secretariat function should be formally integrated into the response structure to ensure continuity in the communication and coordination with key P/T partners.  In the Listeriosis case, the EOC was the initial contact with CCMOH rather than the CCMOH secretariat from PHAC's Strategic Policy Directorate.  This created some challenges.

Below are some of the issues raised by the CCMOH.

Meetings:

• Confirm MOH attendance in advance to ensure all participants are aware of who is participating on calls;
• Coordinate daily schedule of meetings; and
• Record and distribute notes from all calls (list of participants, discussion, action items, decisions, be clear on who is to follow-up, review notes/actions from previous call at next call).

Information flow between meetings:

• Ensure e-mail is coordinated well (label subjects appropriately, be clear on purpose of communication and what is expected of the Medical Officer of Health and specify what information is for internal use versus external distribution);
• Indicate draft versus final on all documents (during the Listeriosis outbreak, guidelines went to Medical Officers of Health with tracked changes which caused confusion); and
• Address the need for a central location/repository of key, final information products.

The relevant secretariats should take responsibility for the logistics of calls and manage the flow of information to these P/T groups during an event to address the issues above. As a result, these secretariats must consider 24/7 coverage. It is not clear what the role of the F/P/T secretariat would be in managing information flow between CCMOH, for instance, and HC and CFIA during an event.

Diagram 3: Illustrates the various groups involved in the response structure

Information Flow: Protocols and IM/IT Systems

Internal
During key informant interviews, PHAC technical staff reported multiple requests for similar information from different people (e.g., communications, corporate secretariat, etc.) in-person, by phone, and via e-mail. In situations with extensive information flow and demand for timely information, there may be a need for protocols. Given the recent experience with Listeriosis as a high-profile event with intense media and Central Agency interest, PHAC should reflect on how information/documents are handled, managed and tracked in future events.

During the event, PHAC staff relied heavily on Lotus Notes e-mail. There were a number of challenges with relying on e-mail:

• When the EOC is activated, all PHAC staff are to “c.c.” the PHAC EOC e-mail account; however, not everyone remembered to do so consistently;
• Discussions were difficult to track (impossible to sort by subject); and
• Corporate archiving is difficult.

PHAC should explore options in addition to and/or beyond Lotus Notes to manage communication flow during an event. CEPR currently uses E-Team, an incident management system. Also, CNPHI, contains a secure web-based event management system called DynaEvent that provides electronic incident command system management including news board, discussion forums and documents management. In addition to secure web-based tools for Pan-Canadian Alerting, Surveillance and Collaboration, CNPHI includes an outbreak summary management tool for enteric diseases that can be used to report summary information of an outbreak within and across jurisdictions.

Reflecting on the Listeriosis event, CEPR should review the schedules and interconnection of daily meetings and calls that typically take place during an event.  Daily timing of calls during the Listeriosis outbreak was very tight:

• 8:15 – PHAC/CFIA call
• 9:00 – PMO/PCO/CFIA/PHAC call to discuss activities for day
• 10:00 – CFIA/PHAC Communications call to debrief and set action list for day
• 10:30 – F/P/T Communications call with P/Ts and Agency Regional Communications Advisors to debrief from earlier calls, identify and coordinate federal activities and P/T activities for the day, and to discuss outreach occurring in P/Ts
• 13:00 – Epidemiologist call with P/Ts to discuss numbers
• 14:00 – Call with PMO/PCO to confirm numbers and rollout
• 15:00 – Frequent time of dry run of press conference
• 16:00 – Frequent time of press conference, time to post updated numbers online.

In reviewing the schedule of daily calls during an event, CEPR should:

• Be clear on the purpose and topic of the various calls and therefore who should, and should not, be on which calls; and
• Ensure there is a formal mechanism in place to record and communicate the discussions and decisions.

Conclusions and Recommendation

In order to address these issues, there are four main areas for immediate action: 

• The need to move forward promptly on consultations, approval and implementation of the Health Portfolio Emergency Response Policy and Plan (already underway) incorporating lessons learned from the Listeriosis outbreak and other recent events;
• Orient and train PHAC staff on the Response Policy and Plan (including senior management);
• Practice implementation of the Policy and Plan using a foodborne example; and
• Improve systems and protocols for event communications with internal and external stakeholders.

4.6. Recommendation #4: Enhance CFEZID Capacity

During the outbreak, CFEZID staff showed commitment and dedication in meeting the growing demands of the epidemiological investigation, coordination with P/Ts, in addition to communication with PHAC, HC, and CFIA personnel, as well as Ministerial and Central Agency staff.

CFEZID's Outbreak Management Division is a small team of epidemiologists located in Guelph.

The Division is involved in approximately 50 outbreaks per year:^{Footnote 11}

• 30% involve international partners (typically U.S.A./Canada);
• 40% involve more than one province;
• 20% involve only one province; and
• 10% involve a local health region.

For the international and multi-provincial outbreaks, the Division leads and coordinates the gathering, analysis and dissemination of epidemiological information. For provincial and local investigations, Divisional staff are asked by the province to provide expertise. Also, when a federal field epidemiologist is deployed to assist in a provincial or local investigation, epidemiologists in the Outbreak Management Division act as the content supervisor.

In addition to outbreak investigations, the Division provides training at the local, provincial, national and international level. The Division is also involved in emergency response planning, such as preparations for the 2010 Olympics.

During the period of their involvement in the Listeriosis outbreak, the Division was involved in 20 other outbreaks.^{Footnote 12} In addition to providing technical expertise for the outbreak investigation, epidemiologists also contributed to briefing and media material during the Listeriosis event, including:

• Providing information for daily web updates and situation reports;
• Briefing senior management and corporate secretariat on latest developments;
• Participation in several of the briefing calls each day;
• Reviewing media lines and messages;
• Writing briefing notes; and
• Responding to media inquires, including giving interviews during the early stage of the outbreak.

If national leadership in foodborne illness is a priority for the Agency, then proactive investments should be made in: more permanent capacity within CFEZID; additional surge capacity to sustain work during an outbreak; and longer-term capacity as a result of appropriate succession planning.

Ongoing

Given the small size of the team in the Outbreak Management Division, the current complement of epidemiological staff should be analyzed to determine if it is sufficient to carry out its projected future workload.

In addition to examining the outbreak epidemiological capacity, there is a need to enhance the non-technical capacity in CFEZID especially in the areas of policy and communications. First, CFEZID would benefit from policy and planning analyst support within the Director General's Office. Second, given that technical experts are often required to play policy and communication support roles, it will be important to afford additional training and support to the Outbreak Management Division in order for them to better apply a policy and communications lens to their work to meet briefing requirements and to respond to media requests. This may include crisis and risk communications training, exposure to policy shops in the National Capital Region, coaching/mentorships, etc.

In addition to policy and communications support, the Outbreak Management Division could benefit from an injection of support from other corporate services. This includes: media training; support for improving records management and preparation for responding to Access to Information and Privacy requests; and IM/IT support for the development of a database to assist in the follow-up on foodborne requests. Some foodborne and waterborne outbreaks result in litigation. The Outbreak Management Division is asked to provide evidence and occasionally to testify in legal proceedings, which requires a great deal of time and preparation. The Division benefits from advice from legal counsel in these situations but they feel they could benefit from additional, more general support from legal services.

Epidemiologists in PHAC's Outbreak Management Division serve as the secretariat for an informal network of epidemiologists from P/Ts. There are regular quarterly teleconferences and an annual face-to-face meeting for which PHAC covers the expenses. This secretariat role should be formalized and resourced with an appropriate level of staff support. In addition, it is recommended that Terms of Reference be developed for the network of P/T epidemiologists.   

Surge and Sustainability during an Outbreak

Given the small team within the Outbreak Management Team that must respond to outbreaks, it would be beneficial to analyze opportunities to address surge requirements through existing resources within PHAC (e.g., other CFEZID divisions or the Laboratory for Foodborne Zoonosis in Guelph, as well as the PHAC Regional Office in Toronto, etc.).

Improvements can be made by ensuring increased policy and communication capacity is provided (ideally on-site) to the Outbreak Management Division during an outbreak to deal with the increased demand for briefing notes or the response to web mail information requests, etc.  

On the technical side, outbreak investigation is a specialized area of epidemiology. Surge epidemiologists must have solid skills and experience in outbreak investigation. As an organization, PHAC must have sufficient epidemiological capacity Agency-wide to allow for reassignment of staff for outbreak investigation while at the same time be able to maintain routine business.

Existing PHAC programs for preparing and training other types of epidemiologists to assist in significant outbreak situations should be more fully utilized, namely the Epidemiology Emergency Response Team (Epi-ERT) and the Canadian Field Epidemiology Program's (CFEP) Epi-AID.

PHAC's Epi-ERT, managed through CFEZID's Outbreak Management Division, is a potential source of epidemiology surge capacity. Epi-ERT's roster is comprised of epidemiologists from within IDEP who can be called upon to provide surge capacity during public health events. Individuals on the roster have received additional training in outbreaks, and some are graduates of CFEP. These individuals can support the Agency in a number of ways including providing assistance and surge capacity to a Division or Centre experiencing an urgent situation; providing assistance in the Emergency Operations Centre; as well as providing field support within Canada under the mandate of the Agency in the event of a major crisis.

Epi-AID, which is a component of the CFEP managed by PHAC's Office of Public Health Practice, is another potential source of epidemiology surge capacity. Epi-AID offers short-term epidemiological assistance by deploying field epidemiologists to work on field investigations, upon request. Field epidemiologists can assist with the following: outbreak investigation and control; cluster investigation and control; environmental risk assessment; surveillance activities, field epidemiology studies (descriptive epidemiology, needs assessments, vaccine effectiveness, case control studies, cohort studies); and teaching and training in outbreak investigation. Any Canadian region, province, territory or federal group investigating a public health issue may request field epidemiology assistance.

Although two CFEP field epidemiologists stationed with the Outbreak Management Division were very involved with the outbreak, neither the Epi-AID nor the Epi-ERT roster were called upon during the Listeriosis outbreak. These could have provided additional epidemiological capacity.

Limited capacity within the Outbreak Management Division has impeded the on-going development and maintenance of Epi-ERT. The last training session provided was in 2007 and the roster requires updating. Thought should be given to where to locate and how best to resource, manage and develop Epi-ERT to its full capacity. Specific consideration should be given to expanding the roster to include epidemiologists from other areas within PHAC beyond IDEP, with training support provided by the Office of Public Health Practice.

Succession

PHAC's Canadian Field Epidemiology Program builds public health capacity by providing specialized training for health professionals in the practice of applied epidemiology. PHAC continues to invest in the 30 year history of the Canadian Field Epidemiology Program. This is positive: the two Field Epidemiologists on site in Guelph during the Listeriosis outbreak were an asset.

However, there is a need for long-term succession planning in anticipation of inevitable staff departures and the possibility of increasing workloads due to changing trends in foodborne illness. This includes the need for management development/succession planning in this key technical skill area.

The Canadian Public Health Service (CPHS)^{Footnote 13} will be a potential source of qualified public health personnel, including outbreak epidemiologists, for work on both routine and periodic public health-related events. The emphasis of the CPHS is on building public health capacity by recruiting and hiring qualified staff, and providing these staff with ongoing field experience and training. These Public Health Officers (PHOs) will be permanently deployed to locations (mostly with provincial, territorial, or local health authorities) across the country where there is an ongoing requirement for assistance or support in a public health activity. These positions will supplement an organization's overall capacity to meet routine requirements. This includes the enhancing of routine surveillance and epidemiological work, being available and prepared to deal with broader public health issues and, outbreak or pandemic duties as these needs emerge.

5. Next Steps

The project Steering Committee should prepare a Management Response to this report and the Infectious Disease and Emergency Preparedness (IDEP) Assistant Deputy Minister (ADM) should be responsible for developing, implementing and overseeing an Action Plan to address findings and recommendations.

PHAC's Chief Audit Executive should monitor implementation of the Action Plan and report back to senior management on an ongoing basis.

6. List of Acronyms

ADM

Assistant Deputy Minister

ARC

Area Recall Coordinator (CFIA)

BC

British Columbia

CCMOH

Council of Chief Medical Officers of Health

CEPR

Centre for Emergency Preparedness and Response, IDEP (PHAC)

CFEZID

Centre for Food-borne, Environmental, Zoonotic Infectious Diseases, IDEP (PHAC)

CFIA

Canadian Food Inspection Agency

CIFOR

Council to Improve Foodborne Outbreak Response (USA)

CIOSC

Canadian Integrated Outbreak Surveillance Centre

CMOH

Chief Medical Officer of Health (P/T's)

CNPHI

Canadian Network for Public Health Intelligence

CPHLN

Canadian Public Health Lab Network

CPHO

Chief Public Health Officer (for Canada)

CVS

Compliance Verification System (CFIA)

DG

Director General

DGO

Director General's Office

DM

Deputy Minister

EOC

Emergency Operations Centre

FIORP

Foodborne Illness Outbreak Response Protocol

F/P/T

Federal/Provincial/Territorial

HC

Health Canada

HCBMH

Health Canada Bureau of Microbial Hazards

HIV/AIDS

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

HPOC

Health Portfolio Operations Centre

HR

Human Resources

ICS

Incident Command Structure

IDEP

Infectious Disease and Emergency Preparedness Branch (PHAC)

IM/IT

Information Management/Information Technology

LRS

Listeriosis Reference Service (jointly operated by Health Canada and PHAC)

MOHLTC

Ministry of Health and Long Term Care (Ontario)

MOU

Memorandum of Understanding

NML

National Microbiology Laboratory (PHAC)

OFSR

Office of Food Safety and Recall (CFIA)

PHAC

Public Health Agency of Canada

PHN

Public Health Network (Pan-Canadian Council)

PIPRID

Policy Integration, Planning, Reporting and International Directorate, IDEP (PHAC)

PFGE

Pulsed Field Gel Electrophoresis

PCO

Privy Council Office

PMO

Prime Minister's Office

P/T

Provincial/Territorial

TB

Tuberculosis

TPH

Toronto Public Health

7. Chronology of Federal Actions Taken for the Listeriosis Outbreak

Thursday, July 10

The Public Health Agency of Canada's (PHAC) National Microbiology Laboratory (NML) in Winnipeg, as part of routine practice, receives several human isolates of Listeria monocytogenes (L. mono) from the Ontario Ministry of Health and Long-Term Care (MOHLTC) for genetic fingerprinting.^{Footnote 14}

Friday, July 18

PHAC's NML in Winnipeg finds that two isolates from Ontario's MOHLTC have matching genetic fingerprints. Results are reported to Ontario's MOHLTC by NML. The genetic fingerprints are placed on PulseNet, a shared national database for laboratories. The database allows the bacteria's genetic fingerprints to be compared and shared rapidly across Canada.

The NML continues to receive routine isolates of L. mono from provincial public health laboratories throughout July.

Thursday, July 24

Health Canada's Bureau of Microbial Hazards (HCBMH) in Ottawa, receives eleven routine food samples from Toronto Public Health (TPH).

Tuesday, July 29

The Ontario MOHLTC notifies PHAC's Centre for Foodborne, Environmental and Zoonosis Infectious Disease (CFEZID) of an increased number of listeriosis cases. Ontario issues an alert to public health units across Canada via the Canadian Network for Public Health Intelligence (CNPHI).^{Footnote 15}  PHAC's NML provides analysis of the genetic fingerprints of 20 cases of listeriosis from the previous three months across Canada, and posts the information through PulseNet. At this point, no other information is known and the local public health unit investigations continue throughout Ontario.

Wednesday, July 30

PHAC's CFEZID, the Ontario MOHLTC and Ontario public health units participate in a teleconference on technical issues. At this time, there is no clustering of listeriosis cases containing the same genetic fingerprint.

Ontario's local public health units are, nevertheless, asked to send isolates from human L. mono cases to NML via their provincial laboratories for further genetic fingerprint testing. Ontario remains the lead, with support from federal departments and agencies.

From July 30 to August 5, PHAC's NML continues testing additional human isolates, which are routinely sent, of L. mono received from the provincial laboratories during this time period. HCBMH is also receiving and analyzing food samples and isolates during this time.

Tuesday, August 5

PHAC's CFEZID contacts the Ontario MOHLTC regarding the samples and is informed that listeriosis cases continue to be reported and no suspect food source is yet identified.

HCBMH notifies TPH that three of the eleven food samples received July 24 were positive for L. mono. This was done within the standard timelines (7-10 days) for the isolation of listeria from foods.

Wednesday, August 6

TPH informs the Canadian Food Inspection Agency's (CFIA) Toronto Regional Office of two listeriosis illnesses reported at a Toronto Leisureworld nursing home.   TPH also informs the CFIA of three positive L. mono results reported on August 5, indicating the presence of L. mono in lunch meats served at the Leisureworld facility.   The positive samples were of unidentified deli meat from sandwiches served at the nursing home earlier in July and collected by TPH during the week of July 21st.

Thursday, August 7

Following notification from the CFIA's Toronto Regional Office, the CFIA's Office of Food Safety and Recall (OFSR) initiates a food safety investigation to determine if a food safety-related hazard exists. The CFIA's OFSR requests information from TPH and from HCBMH regarding sample collection practices and testing methodology for the positive samples collected by TPH.

HCBMH informs the CFIA that the samples received from TPH were from previously-opened products retained and handled by nursing home staff as part of the facility's own internal practices. Because the samples were not collected in a scientifically-controlled environment, they could not be considered aseptic – the possibility of cross-contamination from other food, surfaces, instruments, etc. at the time of sample collection could not be ruled out.  L.mono-positive samples of unopened product would be required for a health risk assessment and product action.

In working to locate unopened samples, the CFIA receives confirmation from TPH that Maple Leaf meats were used in the sandwiches that tested positive for L. mono made at the Toronto Leisureworld facility. The CFIA collects and reviews records from the Toronto Leisureworld's supplier, Sysco Canada, to identify the specific Maple Leaf products served at the facility.

Friday, August 8

The CFIA's Toronto Regional Office determines that the meat from the sampled sandwiches originated at Maple Leaf Est. 97B (Toronto) based on records obtained from the supplier Sysco, Canada. 

The CFIA meat hygiene program inspector responsible for daily inspections at Establishment 97B requests information from Maple Leaf plant officials to further confirm the identity of the specific positive product. CFIA field staff begin the search for deli meats with the same product code and production date as the samples that tested positive for L. mono. The purpose of this sampling was to establish a positive link between Maple Leaf product and the L. mono strain found in the Toronto Leisureworld product and to rule out the possibility of cross-contamination at the nursing home.

The CFIA's Toronto Regional Office contacts Maple Leaf to obtain product distribution records in order to identify additional search locations for product, however, the CFIA is unsuccessful as the Maple Leaf's sales office had closed for the weekend. The CFIA requests that Maple Leaf continue tracing product purchase orders with the instruction to contact the CFIA's Ontario Area Recall Coordinator (ARC) if the product is found. The CFIA's Greater Toronto Area Laboratory was on standby for product testing over the weekend; however, the ARC was not contacted by Maple Leaf.

Monday, August 11

The CFIA receives the product distribution records from Maple Leaf requested August 8. The three largest product distributors are contacted immediately, however, none of the distributors have samples of the Maple Leaf product codes under investigation in their possession.   CFIA's Ontario ARC team broadens the search by contacting other facilities in the Leisureworld chain to determine if they have the product under investigation on hand.

Tuesday, August 12

CFIA Ontario ARC staff locates an unopened package of Maple Leaf product, with a best before date that would place it as a possible product of interest at a Mississauga Leisureworld facility. A sample of this product is collected by CFIA's Toronto Regional Office staff for testing to determine if the product contained L. mono and could be linked to the production at Maple Leaf's Est. 97B, thus ruling out the possibility of cross-contamination at the Mississauga Leisureworld facility.

The CFIA is notified by the Halton Region Health Department of two additional listeriosis illnesses in hospitalized patients at Joseph Brant Memorial Hospital in Burlington and of test results on two samples of Maple Leaf deli meats served at the hospital that tested positive for L. mono. However, it is reported by the Halton Region Health Department that the two patients had not consumed deli meats in the hospital and samples collected by Halton Region Health Department did not contain critical information linking to the product codes under investigation. Since there is no scientific link established between the cases at the Toronto Leisureworld and Joseph Brant Memorial Hospital, the CFIA initiates a separate food safety investigation.

Wednesday, August 13

CFIA food specialists continue to review production and distribution records at Est. 97B to identify the specific kind of product (e.g., product codes, best before dates, etc.) that tested positive for L. mono from the Toronto Leisureworld facility and Joseph Brant Memorial Hospital. Based on common distribution information and product codes, the CFIA team identifies a possible link between the five L.mono-positive samples of deli meats (three from the Toronto Leisureworld and two from Joseph Brant Memorial Hospital): the products may all have originated from production lines 8 and 9 in Maple Leaf's Est. 97B.

CFIA's OFSR initiates a teleconference with PHAC, Health Canada, the MOHLTC and Ontario public health units to review laboratory and epidemiological information collected to date. Call participants are notified by MOHLTC that additional listeriosis cases had been reported by public health units in Simcoe, Peterborough and Etobicoke. Investigations by those public health units identified Maple Leaf brand products as a possible source of the illnesses.

PHAC's CFEZID and CFIA are informed by the Health Canada lab that five food samples from open packages collected by public health officials (re-testing the three Toronto Leisureworld samples received July 24 and testing the additional two from the hospital received August 1) are the same strain as found in human isolates identified by PulseNet Canada. The isolates from the human cases reported from Joseph Brant Memorial Hospital also matched this strain.

The information presented in this teleconference (i.e. the fact that these were tests on open samples and lack of evidence of patients' exposure to contaminated product) was insufficient to prove that the product was contaminated at the source of production. A definitive scientific link between a specific Maple Leaf product and the listeriosis illnesses could not be made based on scientific evidence at that time.

Epidemiological information provided to PHAC at this time by the various parties involved in the investigation did not clearly identify a linkage between reported illnesses and Maple Leaf products. It was the consensus of all teleconference participants that further hazard and exposure information was required before HC or CFIA could initiate a risk assessment leading to a recall. No public notification or recall was deemed appropriate by any of the attending groups.

PHAC's NML notifies laboratories across Canada via PulseNet that genetic fingerprinting shows a clustering of cases with a similar strain in more than one province. PHAC's CFEZID is informed by PHAC's NML that BC and Alberta had L. mono isolates that match the outbreak strain in Ontario. In response to this information, PHAC CFEZID contacted BC and Alberta to ask for epidemiological information on these matching cases. The case reported by Alberta was determined to be a Saskatchewan resident.

A large-scale sampling plan to cover all Sure Slice brand products (with best before dates of August 1 to September 30) produced on the two suspect Maple Leaf production lines is developed. This plan is forwarded to Toronto Regional Office (ARC) for distribution to CFIA, MOHLTC and public health units. The sampling is conducted by the CFIA with assistance from public health units across Ontario over the following two days.

Thursday, August 14

CFIA regional staff and Ontario public health units collect samples of Maple Leaf Sure Slice products from locations across Ontario over the next two days and submit them to the CFIA's Greater Toronto Area laboratory for testing.

Conference calls led by the CFIA continue with PHAC, Health Canada, MOHLTC and public health units to share information. Progress on the execution of the sampling plan to collect samples of Sure Slice products to submit to the CFIA's Greater Toronto Area Laboratory is discussed by the CFIA. No public notification or recall was deemed appropriate by any of the attending groups.

PHAC CEFIZD follows up with Saskatchewan regarding their case. A public health alert is drafted and a questionnaire put together to facilitate the standardization of inter-provincial data collection.

Friday, August 15

PHAC takes the lead coordinating role in the epidemiological investigation for the Listeriosis outbreak, as per the Foodborne Illness Outbreak Response Protocol, since it had become apparent that the illnesses are distributed nationally. This involves the standardization of data collection, centralization of data to enable national reporting and analysis to identify linkages between cases in different provinces. PHAC sends a Public Health Alert to request that all public health units use a standardized questionnaire to obtain information on cases infected with the outbreak strain of L. mono.

CFIA and Ontario public health units continue to collect samples of Sure Slice products and submit them to the CFIA's Greater Toronto Area Laboratory for L. mono testing.

Conference calls led by the CFIA continue with PHAC, Health Canada, MOHLTC and public health units to share information. No public notification or recall was deemed appropriate by any of the attending groups.

Saturday, August 16

At 5pm,the CFIA's Greater Toronto Area Laboratory confirms a positive result for L. mono in a sample from an unopened package of Maple Leaf Sure Slice Roast Beef collected August 12 at the Mississauga Leisureworld facility and produced in Establishment 97B. The CFIA's technical risk assessors immediately undertake an assessment of the information to determine the risk posed by the product.  The assessment determines that Sure Slice Roast Beef and Corned Beef (the latter having been produced on the same production line at 97B immediately following the Roast Beef) meet the criteria set by Health Canada for a ‘Health Risk I' concern (i.e., there is a reasonable probability that the use of, or exposure to, a violative product will cause serious adverse consequences or death).

The CFIA prepares a health hazard alert to the public and provides information to Maple Leaf to initiate a voluntary recall of two specific product codes of Sure Slice Roast Beef and Corned Beef products.

Sunday, August 17

At 2am, a health hazard alert is issued by CFIA advising the public not to consume or serve specific Maple Leaf Sure Slice Roast Beef and Corned Beef products.

Maple Leaf Foods issues a press release to announce the voluntary recall of specific Roast and Corned Beef products sold under the Sure Slice name.

Monday, August 18

Epidemiological data from the British Columbia case identifies a potential link to the cases in Ontario.

Conference calls led by the CFIA continue with PHAC, Health Canada, MOHLTC and public health units to share information on the recall of Maple Leaf product. PHAC chairs the epidemiological data portion of the call.

Tuesday, August 19

Conference calls initiated by the CFIA continue with PHAC, Health Canada, MOHLTC and public health units to share information. PHAC chairs the epidemiological investigation portion of the call.

At 11am, the CFIA's Greater Toronto Area Laboratory reports two more positive results on samples of Maple Leaf products produced on line 9 at Est. 97B. These samples were among the  samples collected August 14-15 by CFIA and various Ontario public health units. The positive results were of Maple Leaf product (Sure Slice) not included in the August 17 recall (different best before dates than the products recalled on August 17). A health risk assessment for all Maple Leaf Sure Slice meats produced on lines 8 and 9 in Est. 97B is immediately requested from Health Canada (with support from PHAC) by the CFIA technical risk assessors. The assessment is completed later that day. The assessment determines that Sure Slice products produced in Establishment 97b meet the criteria set by Health Canada for a precautionary ‘Health Risk I' concern.

At 6pm,Maple Leaf agrees to voluntarily recall all products produced on the affected lines at the plant. CFIA and Maple Leaf work together to identify all 23 products and codes (Sure Slice brand and other products) that were manufactured on the two production lines.

The health risk assessment is done by Health Canada, with support from PHAC that evening. The assessment determines that Sure Slice products produced in Establishment 97B meet the criteria set by Health Canada for a precautionary ‘Health Risk I' concern.

The CFIA's OFSR provides the risk assessment information to Maple Leaf.

The CFIA's OFSR issues a health hazard alert advising the public not to serve or consume any of the 23 products produced on lines 8 and 9 at Est. 97B. While the health hazard alert indicates that these positive samples were collected as part of an ongoing investigation, it was noted that no link between the recalled products and reported illnesses had been established by PHAC's NML and that the investigation into the source of the listeriosis cases was ongoing. A PHAC contact to whom enquiries about the epidemiological investigation should be directed was listed in the press release.

Wednesday, August 20

Maple Leaf issues a press release to announce the recall notice/advisory for the 23 products. The CFIA meat inspection program requires that Maple Leaf implement a hold and test protocol whereby no meat product produced at Est. 97B is made available to the consumer before test results are negative for L. mono. Maple Leaf suspends all production at Est. 97B.

With the assistance of the Ontario public health units, CFIA officials begin recall effectiveness checks to verify the recalled products' removal from the marketplace. Hospitals, nursing homes and independent grocery stores are subjected to an enhanced verification process (100% verification coverage), while chain stores are subject to recall effectiveness checks at a normal rate of verification.^{Footnote 16}

The CFIA begins receiving media inquiries regarding the recalls. Between August 20 and August 30, the CFIA's OFSR responds to over 200 such requests from television networks, radio stations and local and national newspapers.

PHAC issues a statement from the Chief Public Health Officer informing Canadians about the public health investigation.

HCBMH receives three isolates for genetic fingerprinting from the CFIA regional office in Greater Toronto area.

Conference calls initiated by the CFIA continue with PHAC, Health Canada, MOHLTC and public health units to share information. PHAC chairs the epidemiological investigation portion of the call.

Thursday, August 21

PHAC requests all provinces and territories to review all cases of listeriosis from August 1, 2008.

The CFIA issues a notice to news outlets to ensure media are reporting the recalled product codes correctly, following reports that the media were omitting salient details of the affected products.

CFIA and Health Canada laboratories continue to test recalled products and results show a large number of samples that are positive. Level and contaminations and genetic fingerprinting were not available at this point.

Maple Leaf continues its efforts at Est. 97B to determine the cause of the contamination.

The CFIA designs a sampling plan, in consultation with Health Canada, for products produced on other lines at Est. 97B.

Friday, August 22

PHAC activates its Emergency Operations Centre to Level 2 (Increased Vigilance).

PHAC, Health Canada and CFIA hold a joint press conference in Ottawa to alert the public about the food safety investigation and to answer questions from the media.

Health Canada conducts a health risk assessment on products (beyond the Sure Slice products assessed on August 19) produced on lines 8 and 9, which were recalled by Maple Leaf on August 20. The assessment determines these products meet the criteria set by Health Canada for a ‘Health Risk II' concern (i.e., the use of, or exposure to, violative product may cause adverse health consequences or the probability of serious adverse health consequence is remote).

CFIA and Royal Touch Foods issue a health hazard alert warning the public not to serve or consume Shopsy's deli-fresh Classic Reuben sandwich because the product contained Maple Leaf Corned Beef that may be contaminated with L. mono.

Daily conference calls led by the CFIA continue with PHAC, Health Canada, MOHLTC and Ontario public health units to share information. PHAC chairs the epidemiological investigation portion of the call.

Saturday, August 23

Based on additional information received from Est. 97B, Health Canada upgrades the health risk assessment issued on August 22 (regarding products produced on lines 8 and 9 beyond the Sure Slice products assessed on August 19) from a ‘Health Risk II' to a ‘Health Risk I' concern.

The Minister of Agriculture and Agri-Food holds a press conference in Ottawa announcing that genetic testing, completed by the Health Canada food laboratory, of recalled Maple Leaf products show that two out of three samples test positive for the same outbreak strain of L. mono. The third sample is a close match to the outbreak strain, but with a slight variance. Results are shared with PHAC's NML to compare genetic fingerprints from the human samples being tested.

Maple Leaf holds a press conference to respond to the determination by PHAC that the outbreak is linked to Est. 97B. The company announces that it has decided to voluntarily expand its recall to include all products produced in that facility, while emphasizing that there is no evidence of contamination beyond production lines 8 and 9.

PHAC's NML receives 15 isolates of L. mono (received in two shipments) obtained from unopened meat samples from the CFIA laboratory for genetic fingerprinting. These were sent to PHAC's NML instead of HCBMH due to capacity issues and as per the Memorandum of Understanding between PHAC's NML and HCBMH.

The CFIA requests a health risk assessment from Health Canada on the entire production of Maple Leaf Est. 97B. The CFIA notifies Maple Leaf that this assessment is being initiated as part of ongoing communication between the two parties that day.

Sunday, August 24

Health Canada responds to the request for a health risk assessment, indicating that all products produced in Establishment 97B meet the criteria for a ‘Health Risk I' concern.

The CFIA issues an expanded health hazard alert warning the public not to serve or consume any meat products produced at Est. 97B because these products may be contaminated with L. mono.

Maple Leaf issues a second press release regarding the voluntary recall for all Est. 97B products and lists the affected products on its corporate website.
The Minister of Health holds a news conference in which technical spokespeople from the CFIA, PHAC and Health Canada respond to questions regarding the outbreak and recall.

CFIA identifies that some Est. 97B product had been shipped to another Maple Leaf facility in Laval, Québec, through an inter-facility transfer of work-in-progress process. The CFIA OFSR initiates a secondary food safety investigation at that facility, Est. 271B.

Monday, August 25

The CFIA and Lucerne Foods issue a health hazard alert warning the public not to serve or consume certain Safeway brand and Take Away Café brand sandwiches because these products contained one of the previously-recalled Maple Leaf products that may be contaminated with L. mono. This alert is one of more than 20 secondary recalls of products associated with the recalls of Est. 97B products issued by the CFIA August 25 – September 5 (Appendix One).

The CFIA continues to conduct recall effectiveness checks to determine that all recalled product was successfully removed from the marketplace. Approximately 29,000 checks were conducted from August 20 to September 14.

MOHLTC changes its reporting methodology to include all deaths among the listeriosis cases linked to the outbreak from those that had listeriosis as the underlying cause of death. Twelve deaths (eleven in Ontario and one in BC) from the L. mono outbreak are now being publicly reported by PHAC.

The Minister of Agriculture and Agri-Food Canada hosts a news conference to discuss the outbreak. Technical spokespeople from the CFIA, PHAC and Health Canada respond to questions.

PHAC assumes responsibility for hosting a teleconference for all provincial/territorial public health and environmental health officials and federal food safety partners (Health Canada and CFIA) to discuss the epidemiologic and environmental investigation. PHAC prepares and distributes to provinces, territories and key partners a brief epidemiologic report.

A final conference call led by the CFIA includes Health Canada, MOHLTC and Ontario public health units to share information.

A news conference is held in which technical spokespeople from the CFIA, PHAC and Health Canada respond to questions regarding the outbreak and recall.

Tuesday, August 26

Investigation of listeriosis cases by public health officials continues, but changes to the number of confirmed cases are related to laboratory test results for suspect cases. The number of confirmed listeriosis cases with the outbreak strain is listed as 29, with 15 deaths. 

PHAC prepares and distributes to provinces, territories and key partners an updated brief epidemiologic report.

The Minister of Agriculture and Agri-Food Canada hosts a news conference to discuss the outbreak. Technical spokespeople from the CFIA, PHAC and Health Canada respond to questions.

PHAC hosts a teleconference with Council of Chief Medical Officers of Health and the CFIA to discuss the epidemiological investigation and further public health actions, including testing guidelines for listeriosis.

CFIA requests a health risk assessment from Health Canada for products processed by other food processing establishments either using recalled Maple Leaf meat or meat products produced using the same equipment as that used in Maple Leaf Est. 97B. Over the following days, CFIA and Health Canada work to clarify the types of products to be assessed.

From August 26 to 31, PHAC's NML reports to CFIA's OFSR that 42 of the 44 recalled isolates (from samples collected by CFIA and Ontario's public health units on August 14 & 15) submitted between August 23 and 27 have the outbreak pattern.
PHAC's NML reports the results of 1 of 15 CFIA closed food L. mono isolates submitted to NML on August 23. The L. mono isolate matches the genetic fingerprint of the product from Maple Leaf's Est. 97B.

PHAC's NML continues to receive and perform genetic fingerprinting on all suspect cases. NML continues to report results to provinces and territories.

Daily conference calls hosted by PHAC with P/T colleagues, Health Canada and CFIA to share information continue.

Wednesday, August 27

No change to the number of confirmed cases or deaths.

Secondary recalls are continuing to occur to capture wider distribution of the recalled meats from Maple Leaf. The secondary recalls are of processed meat product utilizing meat (i.e. a pre-packaged sandwich) produced at Maple Leaf Est. 97B. (See Appendix One).
From August 27 to September 18, Health Canada continues to receive and analyze food and environmental samples for L. mono.

The Minister of Agriculture and Agri-Food Canada hosts a news conference to discuss the outbreak. Technical spokespeople from the CFIA, PHAC and Health Canada respond to questions.

CPHO participates in CTV National interview.

The Health Canada Listeria ‘It's Your Health' document, was slightly modified and re-posted.

PHAC's NML reports the results of the remaining 14 of 15 closed food L mono isolates submitted to NML on August 23. The L. mono matches the genetic fingerprint of the recalled product from Maple Leaf's Establishment 97B.

PHAC's NML receives an additional 29 isolates of L. mono obtained from closed meat samples from the CFIA laboratory for genetic fingerprinting.

Daily conference calls hosted by PHAC with P/T colleagues, Health Canada and CFIA to share information continue.

Thursday, August 28

No change to the number of confirmed cases or deaths.

Health Canada conducts a health risk assessment indicating that products processed by other establishments that contain recalled Maple Leaf meat meet the criteria for a ‘Health Risk I' concern.

The Minister of Agriculture and Agri-Food Canada hosts a news conference to discuss the outbreak. Technical spokespeople from the CFIA, PHAC and Health Canada respond to questions.

CPHO video posted to PHAC website and YouTube.

CPHO grants Canada AM interview.

Secondary recalls of product produced utilizing meat product from Maple Leaf Est. 97B continue.

The CFIA, Health Canada and PHAC discuss Maple Leaf's environmental investigation, employee issues and food product testing associated with Est. 97B.
Maple Leaf submits a corrective action plan to mitigate deficiencies identified by the CFIA investigation team to the CFIA for review and approval.

PHAC's NML holds a teleconference with the Canadian Public Health Laboratory Network (CPHLN), which includes P/T representatives, to discuss issues such as laboratory practices for L. mono. NML convenes an expert committee to discuss L. mono laboratory testing guidelines.

Daily conference call hosted by PHAC with P/T colleagues, Health Canada and the CFIA to share information.

Friday, August 29

No change to the number of confirmed cases or deaths.

PHAC's NML has a teleconference with provincial and territorial Chief Medical Officers of Health to finalize the L. mono clinical laboratory testing guidelines and to discuss recommendations for testing at-risk populations and the general public. The results of this discussion are distributed amongst the clinical community. The L. mono laboratory testing guidelines are posted on the PHAC website on the evening of August 29.

The Minister of Agriculture and Agri-Food Canada hosts a news conference to discuss the outbreak. Technical spokespeople from the CFIA, PHAC and Health Canada respond to questions.

Public health notices are placed in 123 Canadian daily newspapers between Aug 29-Sept 1.

Secondary recalls are continuing to occur to capture wider distribution of the recalled meats from Est. 97B.

PHAC prepares an updated brief epidemiologic report and distributes it to provinces, territories and key partners.

Daily conference calls hosted by PHAC with P/T colleagues, Health Canada and CFIA to share information continue.

Saturday, August 30

The number of confirmed listeriosis cases is listed as 31, with 16 deaths associated with the outbreak strain.

The Minister of Agriculture and Agri-Food Canada hosts a news conference to discuss the outbreak. Technical spokespeople from the CFIA, PHAC and Health Canada respond to questions.

CPHO grants an interview with the Toronto Star.

Fact sheet: Listeriosis – Protecting Your Pregnancy posted on PHAC website and distributed to Agency distribution lists and to national organizations such as the Society of Obstetricians and Gynaecologists and Canadian Paediatric Society, who distributed it to their distribution lists.

PHAC's NML reports the results of 4 of 29 isolates of L. mono from unopened food samples submitted to NML by the CFIA on August 27. All match the outbreak fingerprint.

Sunday, August 31

The number of confirmed listeriosis cases is listed as 33, with 17 deaths associated with the outbreak strain.

PHAC's NML reports the results of the remaining 25 of 29 CFIA closed food L. mono isolates submitted to NML on August 27. Twenty three isolates match the outbreak fingerprint, and two are a different species of Listeria (with a different genetic fingerprint).

The Minister of Agriculture and Agri-Food Canada hosts a news conference to discuss the outbreak. Technical spokespeople from the CFIA, PHAC and Health Canada respond to questions.

Monday, September 1

The number of confirmed listeriosis cases is listed as 38, with 19 deaths associated with the outbreak strain.

PHAC prepares and distributes to provinces, territories and key partners an updated brief epidemiologic report.

The Minister of Agriculture and Agri-Food Canada hosts a news conference to discuss the outbreak. Technical spokespeople from the CFIA, PHAC and Health Canada respond to questions.

Tuesday, September 2

No change to the number of confirmed cases or deaths.

Daily conference calls hosted by PHAC with P/T colleagues, Health Canada and CFIA to share information continue.

The Minister of Agriculture and Agri-Food Canada holds a press conference to discuss the listeriosis outbreak and investigation. The Chief Public Health Officer and senior HC and CFIA staff participate in the press conference to provide updates and answer questions.

Wednesday, September 3

No change to the number of confirmed cases or deaths.

Teleconference with Health Canada, CFIA, and PHAC's NML to discuss Maple Leaf's environmental investigation at Est. 97B.

Teleconference between the CFIA's laboratory and PHAC's NML to discuss laboratory results.

Daily conference calls hosted by PHAC with P/T colleagues, Health Canada and CFIA to share information continue.

In a live press conference, the Prime Minister calls for an independent inquiry into the listeriosis outbreak.

The Minister of Agriculture and Agri-Food Canada holds a press conference to discuss the listeriosis outbreak and investigation. The Chief Public Health Officer and senior HC and CFIA staff participate in the press conference to provide updates and answer questions.

Thursday, September 4

No change to the number of confirmed cases or deaths.

Teleconference with Council of Chief Medical Officers of Health and the Chief Public Health Officer. They discuss policy issues, consumer recommendations and public health advice.

PHAC's NML hosts a technical briefing for the media.

Daily conference calls hosted by PHAC with P/T colleagues, Health Canada and CFIA to share information continue.

PHAC hosts a technical briefing on the surveillance systems used to detect and track listeria and other foodborne pathogens.

The Minister of Agriculture and Agri-Food Canada hosts a news conference to discuss the outbreak. Technical spokespeople from the CFIA, PHAC and Health Canada respond to questions.

Fact sheet: Listeriosis– Protecting the Health of Senior Citizens posted on PHAC website and distributed to senior organizations and home care associations and was distributed at the Seniors Aging Conference being held in Montreal.

Friday, September 5

No change to the number of confirmed cases or deaths.

Daily conference calls hosted by PHAC with P/T colleagues, Health Canada and CFIA to share information continue.

The CFIA issues an advisory to operators of federally-registered establishments processing ready-to-eat meats to ensure meat slicers are completely dismantled and cleaned, collect environmental samples to test for the presence of listeria, and to review cleaning and disinfecting procedures with the CFIA inspector to ensure proper sanitation of the slicers. The advisory also instructed operators to inform the CFIA Inspector of all details of the required activities and of test results.   Associated CVS tasks (for sanitation of meat slicing equipment) are issued to CFIA inspectors on September 9, 2008.

The Minister of Agriculture and Agri-Food Canada hosts a news conference to discuss the outbreak. Technical spokespeople from the CFIA, PHAC and Health Canada respond to questions.

Saturday, September 6

No change to the number of confirmed cases or deaths.

Daily conference calls hosted by PHAC with P/T colleagues, Health Canada and CFIA to share information.

The Minister of Agriculture and Agri-Food Canada hosts a news conference to discuss the outbreak. Technical spokespeople from the CFIA, PHAC and Health Canada respond to questions.

Prime Minister Harper announces an investigation into the L. mono outbreak.

Sunday, September 7

No change to the number of confirmed cases or deaths.

Daily conference calls hosted by PHAC with P/T colleagues, Health Canada and CFIA to share information.

Monday, September 8

No change to the number of confirmed cases or deaths.

PHAC's Emergency Operations Centre is de-activated to Level 1 (Normal Readiness)

Teleconferences with P/Ts to discuss the epidemiology of the outbreak are reduced from daily to every other day.

PHAC prepares and distributes to provinces, territories and key partners an updated brief epidemiologic report.

Fact Sheet: Listeriosis – Protecting Those with Weakened Immune Systems - was distributed by PHAC to TB and HIV/AIDS distribution lists.

In anticipation of the resumption of production at Establishment 97B, the CFIA begins week-long on-site review to assess the facility's suitability for resumption of operations. Four corrective action requests are identified by the CFIA inspectors and are subsequently addressed by Maple Leaf.

PHAC's NML receives 8 isolates of L mono obtained from the food processing environment at Est. 97B. (The genetic fingerprinting results of these isolates are reported to CFIA on September 18. 7 of 8 match the outbreak strain.) 

Tuesday, September 16

Maple Leaf provides the CFIA's Ontario Area Office with a summary of its proposed action plan in anticipation of the restarting of operations at Est. 97B. The Maple Leaf document includes the results of the company-led investigation to identify the cause of the listeria contamination. The Maple Leaf Foods investigation into the source of the contamination is inconclusive; however, it provides five likely sources, including the cooked meat slicers.   

Wednesday, September 17

In correspondence from the CFIA's Executive Director for Ontario, Maple Leaf receives CFIA's approval to restart operations at Est. 97B.

A detailed directive from the CFIA's Area Program Manager is provided to the CFIA's inspector in charge of Est. 97B with the sampling plans and conditions for the re-start of operations. 

Following multiple revisions and consultation with Health Canada on start-up requirements, the CFIA approved Maple Leaf's corrective action plan and Est. 97B resumed production on September 17.

CFIA daily inspection presence continues in the facility.

Wednesday, October 8

Maple Leaf notifies the CFIA that four end product samples from Est. 97B had tested positive for L.mono. None of the affected product had been released for sale. Increased L. mono testing continues in the facility.

Health Canada issues a precautionary “Health Risk I” assessment for product manufactured the week prior to the positive results. The CFIA issues a Class I recall to the distribution level to ensure the product is not made available to consumers. A subsequent health risk assessment conducted by Health Canada determined that the product posed no health risk.

Friday, October 17

A health risk assessment conducted by Health Canada determined that the products manufactured on Line 7 at Est. 97B following start-up of the plant in September (September 19 to October 7, 2008) are suspect, and, if distributed to the consumer, they would be considered to represent a Health Risk I situation.

Monday, October 20

CFIA announces that Est. 97B products with satisfactory L. mono test results could be released for distribution. Test and hold protocols continue at Est. 97B as does enhanced inspection presence.

Appendix Two – PHAC Listeriosis Epidemiological Curve