How well did the federal government and its food safety partners respond to the outbreak?

The previous chapter outlined the chain of events that culminated in the 2008 outbreak. As illustrated in our descriptive chronology, investigating a foodborne illness outbreak is highly complex. It is necessary to

1. confirm that food is the likely source of the human illness (epidemiological investigation);
2. identify precisely which food product is the cause of the illness and determine when it was commercially produced, using brand names and production codes (food safety investigation);
3. stop its distribution, production and consumption to reduce illness and deaths (recall); and
4. make changes to prevent it from happening again (post-event investigation).

As we have described earlier in the report, the various governments do not regularly work closely together to respond to the outbreak. In this chapter, we provide our conclusions about what worked well and what could be changed to better manage a foodborne emergency.

Understanding the challenges of managing a foodborne emergency

To understand what worked and what did not, we first need to explain the key challenges in managing a foodborne outbreak. Such a crisis brings together multiple jurisdictions and two sectors of the federal government that, on a day-to-day basis are not required to work closely together: the public health and food safety sectors. At the provincial level, in most provinces, food safety is a direct responsibility of public health through environmental health inspection.

Even though both sectors focus on human health and safety, the daily work of those in the food sector is to monitor the processes keeping food safe free from harmful agents. The public health sector monitors disease occurrence to make sure those processes have worked. Staff working in these areas approach an outbreak from different perspectives; their education, training and experience are complementary.

When an outbreak is viewed through the lens of public health, the focus is primarily on identifying what is making people ill. Consequently, the sector works to quickly determine the likely cause of the illness and remove this threat as rapidly as possible.

In an outbreak, the primary function of public health in such events is 'forensic' - assisting the food safety sector in rapidly identifying the food source so it can stop its distribution and consumption. This role is an important one, especially given the long incubation period of Listeria.

The food safety sector is focused primarily on identifying the exact food product that is causing the illness so that the correct food is removed from the market. This is not always easy, given that food distribution is less often local as consumers now have access to food products from all over the world. In the 2008 outbreak, contaminated deli meats from a single plant in Ontario that produces dozens of brands and products were distributed all across the country, resulting in a national outbreak. For this reason, it was essential to match the location of the people who were ill with the distribution patterns of the food products. This made the food safety investigation both a time-consuming and complex task.

Once the suspected food source was identified, even though it was not yet confirmed, public health officials assumed it was the food safety sector's responsibility to lead and that their role was to provide support. This view ran counter to public perception that the outbreak was primarily a health matter.

During the 2008 outbreak, the differing perspectives of who should lead were evident. From our observations, while the food safety sector assumed leadership in recalling the contaminated food products, other elements of the emergency that required attention were slow to get underway (e.g. the overall coordination of all involved in managing the outbreak and communications to the public).

Nonetheless, it is important to note that, due to the long incubation period of Listeria monocytogenes, much of the damage had already been done. We verified that, by the time the outbreak was detected, most of the individuals who became ill had already been exposed to the bacteria. So, while our report proposes improvements that could lead to a quicker and more efficient response in the event of another outbreak, little could have been done at the time of the 2008 outbreak to prevent others from becoming ill.

We believe that by being proactive - for example, advising the public sooner that certain foods were suspected - governments could have averted confusion during repeated recalls of deli meats. This ultimately amounted to the recall of 191 products from Maple Leaf Foods Bartor Road plant, many of which had been on the market for months. This confusion affected public confidence in Canada's food safety system and in governments' capacity to respond to such foodborne emergencies.

To explain our conclusions we have broken down the different issues under the following headings:

• Leadership
• Emergency Management
  • Federal, provincial/territorial and local coordination
  • Federal organizations structures and operating procedures
  • Disease reporting
  • Epidemiological investigation
  • Food investigation and recall
  • Laboratorie

Leadership

The 2008 outbreak clearly demonstrated that managing this type of emergency was not only complicated but was also not well understood by those involved.

At the outset, the outbreak was not considered a severe foodborne emergency. This view led to a void in leadership in managing the crisis. It took close to three weeks before senior executives in all key organizations became fully engaged in the event. The fact that many officials were on vacation during this period has been offered as one explanation for the slow response.

This should not have posed a problem, at least in theory, since an intergovernmental agreement - the Foodborne Illness Outbreak Response Protocol (FIORP) - had been endorsed by all federal, provincial and territorial governments in 2004 to coordinate the management of a foodborne emergency. Put into place following a national foodborne outbreak in 1999, FIORP was designed to guide a multi-jurisdictional response when such an emergency arose.

However, few of those involved in the 2008 outbreak, especially senior executives, were familiar with FIORP. Even fewer acted in accordance with the multi-jurisdictional guidelines to manage such an event.

Through interviews we learned that, within the Canadian Food Inspection Agency, the Public Health Agency of Canada, Health Canada and the Ontario Ministry, few officials above the Director level (the management level charged with administering the protocol when required) were aware of FIORP`s existence when first alerted to the unfolding listeriosis crisis.

We were told that while front line and scientific staff on both the public health and food safety sides of the investigation were hard at work responding to the crisis, their superiors were not initially fully engaged.

Furthermore, no single organization took the overall role of coordinating the actions of the various parties involved. This left a vacuum in senior leadership that caused confusion and weak decision-making. Despite this, the epidemiological and food safety investigations were reasonably well done.

Key Findings:

• National foodborne outbreaks are rare in Canada. Nevertheless, agreements are in place to manage such events but they were not widely known or understood by senior leadership at the time of the 2008 outbreak.
• In Ontario, although field staff was at work, senior public health executives did not become engaged in the event until the week of August 11, three and half weeks after the investigation was initiated.
• Within the responsible federal organizations, although staff was at work, senior executives did not become engaged until the week of August 18, after the first recall.
• The public health and food safety sectors come at foodborne emergencies from different perspectives. This, coupled with the infrequent occurrence of such emergencies, compounded the challenges in managing such a crisis.

Recommendation:

1. The Public Health Agency of Canada, with the support of the Canadian Food Inspection Agency and Health Canada, should assume the leading role in coordinating the federal government's response to a national foodborne emergency.

Emergency Management

Emergency management of a foodborne illness outbreak requires clear and concise planning, including:

• the determination of roles and responsibilities
• the timing and processes for interaction; and
• exchange of information

Since national foodborne illness outbreaks of this magnitude are rare in Canada, opportunities to practice this emergency management approach are very limited. As a result, the system is not mature. We learned that both food safety and public health officials participating in the 2008 outbreak were not adequately prepared or equipped to properly manage this event. This lack of advance preparation, particularly in communicating to vulnerable groups, contributed to confusion.

Federal, provincial/territorial and local coordination

The Foodborne Illness Outbreak Response Protocol has been ratified by Deputy Ministers for all fourteen jurisdictions, although not by Ministers of Health. To complement the protocol, bilateral agreements have been signed between the federal and provincial or territorial governments to recognize the particular circumstances of each jurisdiction.

We heard that this protocol is valuable, but it is rarely needed nor fully understood by many of its signatories. We also heard that elements of the protocol are out of date.

In spite of having formal intergovernmental agreements to work collaboratively and share information in times of emergency, the events of the 2008 outbreak revealed that, at the time they were most needed, they were not fully used. Since the emergency provisions were not invoked the conference calls although helpful were informal. For example, the continuity between calls was not fully captured as minutes were not taken at any point in the management of the event. Several people with first-hand knowledge of these events reported that crucial information was circulated but not moved up the chain of command.

We heard repeatedly that the roles and responsibilities of various governments need to be clarified and better communicated. 'Lessons learned' reports prepared by all of the organizations involved in the outbreak came to similar conclusions.

The unusual characteristics of a listeriosis outbreak underscore the need for maximum collaboration.

When a listeriosis crisis emerges, it starts with just a few people from specific groups becoming ill. Since each person will develop the illness at a different rate (the incubation period varies from 3 to 70 days), each case is different. It is only when an increase in cases or unusual factors are noticed that local public health officers start investigating, as occasional cases are the norm. This is what happened in the 2008 outbreak, when two people from the same long term care home developed listeriosis a few days apart.

When the number of cases grows beyond a local health unit the provincial or territorial ministry gets involved. And when the number of cases extends beyond one province, the federal public health sector gets involved. At any point in this process when a food product is suspected, the provincial or federal organizations responsible for food safety are called in.

For example, the 2008 outbreak quickly expanded from a small number of cases in Ontario to, eventually, 57 cases across seven provinces. This complicated communications and management of the event. The lack of a clear understanding of which organization or level of government was responsible for doing what - including what organization should lead the crisis - contributed to the inconsistent management of the outbreak.

One of the goals in creating the Public Health Agency of Canada was to avoid just such situations, which Canada had learned when confronted with SARS. We are convinced that strong national leadership for foodborne emergencies is required as a national priority. We conclude that the PHAC is the organization best placed to take on this role.

Key Findings:

• The long incubation period of listeriosis, combined with the large number of individual public health units reporting isolated cases across Ontario, meant that the small increase in cases was hard to identify.
• There were strong indications as early as July 29th that a foodborne illness emergency was developing. Fifteen of Ontario's local public health units reported 24 cases of listeriosis when only 11 would normally be expected for the time period, which was confirmed in a national alert to all provincial, territorial and local health authorities across Canada.
• There is a need to pre-determine how governments will interact and to coordinate the interventions of the different organizations.
• FIORP, which is in need of updating, was not recognized as the protocol to be used during the outbreak to avoid duplication or to fill gaps and was not well recognized or understood by many federal/provincial/territorial officials.
• Based on our investigation, to maintain confidence in the food safety system, there is a need for independent review after all national foodborne emergencies, in addition to each organization's lessons learned review.

Recommendations:

4. In preparedness for national foodborne emergencies, the federal, provincial and territorial governments should:
   1. complete the revision of the Foodborne Illness Outbreak Response Protocol (FIORP) currently underway, at the earliest opportunity; and
   2. enhance FIORP, by developing and ratifying a Foodborne Illness Emergency Plan building on the experience of the Canadian Pandemic Influenza Plan, to:
      1. designate the Public Health Agency of Canada as the lead Agency taking leadership at both the national (multi-provincial/territorial) and the federal (multi-departmental) level;
      2. use a common incident command structure;
      3. define the roles and responsibilities of each of the organizations involved clearly and concisely, in plain, unambiguous language including surge capacity;
      4. increase the use and timing of health advisories and precautionary warnings, where reasonable and probable grounds exist, to advise consumers to suspend consumption of suspected foods while tests to confirm the precise source are pending, taking into account
         • suspected illnesses and deaths,
         • geographic distribution, and
         • test results of opened or unopened food samples.
      5. create a ready-to-implement crisis communications plan to ensure that all Canadians are kept informed in a timely and detailed manner (including pre-arranged media spots, pre-developed material, and the like); and
      6. share all information, including epidemiological data, needed to identify the emergency taking into account privacy and data confidentiality issues;
   3. include in FIORP periodic mock exercises to validate that the protocol and its Emergency Plan are fully understood by federal, provincial, territorial and local governments as well as by the food processing and distribution industry and is in a state of readiness.
5. The authority of the federal Minister of Health to protect the health of all Canadians under section 30.1 of the Food and Drugs Act, and subsections 4(1) and (2) of the Department of Health Act should be used in a national foodborne emergency, whenever warranted.
6. Where human deaths or serious illnesses have occurred, the Canadian Food Inspection Agency should promptly disclose the results of its investigation of the implicated plant and the corrective actions taken, to the public and food safety partners.
7. The federal government should establish an independent post-event review process made up of a pre-identified team of experts not involved in the emergency. Following all future national foodborne emergencies, this team should conduct an in-depth review and report to the government. The report should be made public.

Federal organizations' structures and operating procedures

Beyond difficulties in federal, provincial/territorial and local coordination, we observed problems specific to the three federal organizations directly involved in the 2008 outbreak. Some of these problems were identified in the lessons learned reports prepared by the Public Health Agency of Canada, the CFIA and Health Canada.

Public Health Agency of Canada
The Public Health Agency of Canada was initially pulled in to the 2008 outbreak on July 29th through the foodborne epidemiological team. On August 22nd, the team partially activated the Agency's Emergency Operations Centre to 'Increased Vigilance' (Level 2). However, we heard it did not activate all the functions called for in the Agency's emergency plan. For example, no one was assigned to undertake the advance planning required to manage the outbreak, nor was a specific communications team established. While the PHAC personnel recognized the severity of the outbreak, their resources were not fully deployed to respond in an emergency situation.

Canadian Food Inspection Agency
The CFIA recall team was first made aware of the emerging outbreak and the suspected food source on August 6th. Senior executives were advised the next day, but were not fully involved in decision-making until the week of August 18th, after the first recall took place. This means that key decision makers who could have helped with the strategic management of the crisis were not involved. In the past, the Agency used an emergency management structure that engaged all critical senior personnel and technical resources to deal with significant food inspection events. This process was not used during the 2008 outbreak since the Agency did not foresee the magnitude of the outbreak early enough. In addition, the CFIA did not activate its Incident Command Structure, which is designed to coordinate this type of situation.

Health Canada
When the CFIA receives confirmation that a particular food product is contaminated, it calls on Health Canada to evaluate the risk this food poses to the health of consumers based on the potential exposure to the bacterium and the severity of its impact. We learned that the department's team assigned to this task in the summer of 2008 was not operating on a 24/7 basis, leaving gaps in coverage during emergency response situations.

Key Finding:

• The Public Health Agency of Canada did not consider it had the federal leadership role, therefore there was a delay in identifying the outbreak as a public health emergency and it only activated its Emergency Operations Centre, which served as the coordination hub for the Agency and Health Canada, in late Augus.

Recommendation:

8. In the event of a national foodborne emergency, an incident command structure should be activated under the leadership of the Public Health Agency of Canada with the direct participation of the Canadian Food Inspection Agency and Health Canada.

Disease Reporting

Although there were gaps in reporting requirements for listeriosis, we have been advised it would not have made a difference in the 2008 outbreak, since listeriosis was already a notifiable disease in Ontario when the outbreak was first identified. There are currently 55 active diseases or conditions on the National Notifiable Diseases List¹. Including a disease on the list means that, when provincial/territorial public health authorities (local and regional report to their province/territory) are able to confirm that someone has a listed illness, they voluntarily report the case(s) to the PHAC.

Listeriosis was a nationally notifiable disease from 1990 following the 1982 outbreak of Listeria in ready-to-eat coleslaw salad. However, since there were n. significant outbreaks between 1990 and the events of 2008, it was removed from the list in 1999. At the time of the outbreak, listeriosis was not a notifiable disease in many provinces. The doubling in listeriosis cases since 2005, and the fact that it is now in the process of becoming a national notifiable disease, reflects the growing awareness that the disease is a significant health threat for vulnerable populations. The process is underway of once again identifying listeriosis as a national notifiable disease.

Epidemiological Investigation

In July, the Ontario Ministry of Health and Long-Term Care began to identify an increase in the number of listeriosis cases that were being reported by local public health units through Ontario's electronic surveillance system. With the help of one of its analysis systems² the Ontario Ministry was able to statistically validate that something unusual was occurring. Officials in the Ontario Ministry began contacting both public health units, the Public Health Agency of Canada and Health Canada to discuss these findings.

A notice was posted on the national surveillance system on July 29th to alert other jurisdictions to the increase in cases occurring in Ontario. Within a few days, the federal-provincial epidemiological team, which was communicating daily via conference calls and postings on the national surveillance system, learned of a potential link between one of the listeriosis cases and a food source. Over the next few days, there were several new cases reported with possible links to a similar food source.

By August 6th, the daily conference calls included officials from the CFIA who were brought in to investigate the source of the contaminated food. This food investigation eventually led to the confirmation of the food source and the associated food product recalls (three main and 21 secondary recalls), which are discussed in the next section in more detail.

While progress on the recall was being made, efforts to link the food source and cases of listeriosis across the country were just beginning. DNA fingerprinting of the food source enabled public health teams to refine their analyses of listeriosis cases occurring within their jurisdictions. Eventually, they were able to match the cases of illness with the consumption of contaminated products from Maple Leaf Foods.

This was a significant accomplishment and a reflection of the increasingly important role technology, such as DNA fingerprinting, plays in identifying foodborne illnesses. As recently as five years ago, foodborne diseases were not easily linked to a specific food product.

Thanks to the use of a test known as pulsed-field gel electrophoresis (PFGE), it is now possible to link human cases more quickly by comparing DNA fingerprints. Similarly, this technology can link human cases and the foods that caused the illnesses.

Food Investigation and Recall

Foodborne illness outbreaks that are traced back to a commercial production source are rare. According to US data, up to 97% of foodborne illnesses result from the handling or preparation of food once it has left the food processing plant. In such cases, investigating the food source of the illnesses is less complicated. Such investigations are led by public health officials and do not often involve the food safety sector.

However, in the remaining two to three percent of cases, a food safety investigation is required because the cause of the outbreak is not evident. Several different organizations become involved in this type of investigation. Public health teams identify the cause of the illness while the CFIA tracks down the product that is causing it. Health Canada provides an assessment of the risk associated with the contaminant, the exposure of humans and the risks to peoples' health.

In the 2008 outbreak, the CFIA was notified by Toronto Public Health that three samples of deli meats tested positive for Listeria monocytogenes. The CFIA initiated a food safety investigation to determine the exact food product, its source, production date and code. In the course of Toronto Public Health's epidemiological investigation, which involved collecting a variety of food samples, they were advised by the Toronto area long term care home staff that the likely source of the food product was Maple Leaf Foods. The company produced the larger packages of deli meats which both of the home's ill residents had eaten. The food samples initially collected by Toronto Public Health were from 'retention' samples of meals that had been served to the residents earlier in July. Long-term care homes, hospitals and other large institutions keep samples for this purpose.

The original packages containing the deli meats had long been discarded by the time the CFIA became involved in the investigation. This was understandable, as the time between the original collection of the food samples and confirmation of positive results from the lab spanned three weeks. Access to the original packages was essential to pinpoint the information required to identify the precise product and production date.

As part of the food safety investigation, the CFIA investigators had to methodically sort out the following:

• Some local public health units in Ontario did not immediately enter their listeriosis cases in the provincial surveillance system therefore when provincial authorities first checked, nothing appeared to be out of the ordinary.
• Early reports from one of the national surveillance systems did not indicate a clustering of illnesses in Ontario.
• There was contradictory information concerning the exposure of patients to Maple Leaf Foods products in the case of a hospital in Burlington, Ontario. At first, patients were reported as not having eaten meals prepared with deli meats although they, in fact, had.
• Maple Leaf Foods did not initially report the presence of Listeria at the Bartor Road plant or provide product distribution records.

As Ontario public health units undertook investigations into cases in their jurisdictions, a pattern linking Maple Leaf Foods deli meat products to ill individuals started to emerge. We were told that, as their investigations progressed, some public health officials believed that sufficient information was available to proceed with a recall of these food products.

There are differing views about when to advise the public about potential food contamination. Some advocate for a precautionary approach, based on epidemiological evidence, to protect the public from potential harm. Put simply, this means that, in the absence of absolute certainty, it is better to err on the side of caution, using reasonable and probable grounds.

There are numerous examples of food recalls by the federal government that have been undertaken without the definitive proof established by laboratory confirmation. However, in those instances, all the evidence pointed toward the same food product.

The other approach is to wait for more conclusive evidence, before alerting the public to a health threat. The practice usually followed by Health Canada, based on the recommendation of the World Health Organization and years of experience is to, wherever possible, rely on laboratory confirmation before recommending a recall of specific food products.

Laboratory confirmation is based on extensive testing and conclusive results that provide proof that a specific food product is contaminated. This is often referred to as the 'unopened packages' approach.

Health Canada has relied on this standard of proof, which provides evidence that the product was contaminated during the production stage and not cross-contaminated after leaving the plant or while being handled in consumers' kitchens.

The quality of the information is crucial to identify the correct food in order to ensure the real contaminated product is removed from the marketplace.

In the 2008 outbreak, the early findings were not converging or conclusive. Although there were indications the product originated at Maple Leaf Foods, there was no conclusive information on the specific food or its production dates. Therefore, the CFIA investigators sought unopened packages of the same product, which were eventually found and tested positive for Listeria monocytogenes.

Based on this confirmation, Maple Leaf Foods undertook a voluntary recall of two specific brands of Sure Slice Roast Beef and Corned Beef.

Following the confirmation of the source, the epidemiological investigation broadened. It quickly identified and linked other cases associated with the outbreak. As the investigation continued, two additional recalls of Maple Leaf Foods products took place, followed by 21 secondary recalls. Secondary recalls were necessary since a variety of food products (e.g. sandwiches, meat and cheese platters, pizza) were prepared using Maple Leaf Foods deli meat products that had been recalled. These products were packaged and sold by different companies under various brand names.

Following each of the 24 product recalls, it was necessary to verify that all the contaminated products had been removed from the marketplace. It was also important to ensure they were not continuing to be served in institutions especially those caring for vulnerable populations.

In total, over 29,000 verification checks post-recall were carried out over a three week period by the CFIA staff and local public health inspectors from across the country. This put a tremendous strain on all involved and disrupted their efforts in conducting their normal duties. We have learned that, while these activities were necessary, there was very little information circulating which would have helped the public health officials to better understand why they were being asked to repeatedly visit the same facilities. During these events, more information was needed on the reasons behind the successive secondary recalls.

Key Findings:

• Considering that contaminated food was being consumed for some weeks prior to the initiation of the investigation, the work performed by epidemiological and food safety teams contributed to identifying the source of the illness and removing contaminated food from the marketplace
• Although there were some problems, regular conference calls which started in Ontario and expanded to eventually include federal organizations and other provinces assisted in determining the magnitude of the foodborne emergency and advancing the investigation
• The differences in perspectives regarding the quality and strength of evidence on which to base recall decisions, including timing, support the need for advance agreement across sectors and levels of government to improve the management of future similar investigations
• Information and the supporting rationale, provided to public health officials by the CFIA that were assisting with verification checks following product recalls, was insufficient

Recommendations:

9. Health Canada, the Canadian Food Inspection Agency and the Public Health Agency of Canada should review, update and publish the criteria for proceeding with a food recall to ensure that the weight of evidence takes into account epidemiological information, including suspected illnesses and deaths, geographic distribution, and food sample test results whether packages are opened or unopened.
10. The Canadian Food Inspection Agency should encourage federally regulated meat processors to move beyond the minimum existing requirement for accessibility of distribution records to include electronic access in non-proprietary and unlocked formats to assist in potential product recalls.
11. The Canadian Food Inspection Agency should establish a formal protocol to ensure that timely and consistent information is provided to staff of the provincial/territorial or local public health organizations who are asked by the Agency to help it complete post-recall verification activities.
12. In providing information related to a given product recall to the distribution industry, including grocers, the Canadian Food Inspection Agency should use a standardized form (as suggested by the Canadian Council of Grocery Distributors).

Laboratories

The listeriosis outbreak revealed gaps in the laboratory system that contributed to delays in detecting the disease and in notifying the public.

In health emergencies, human biological samples and the follow-up test results may be circulated between private and hospital labs as well as both provincial and federal public health laboratories. This complex system of human biological laboratories was not fully networked at the time of the 2008 outbreak and not all provincial or federal laboratories were accredited to test for Listeria monocytogenes.

Furthermore, we learned that there are only a few laboratories with the capacity and certification to test food products for Listeria monocytogenes, and none of those were networked. We have also learned that many provinces did not have the capacity to test for Listeria and relied on Health Canada's National Reference Laboratory to test their food samples during investigations. As a result, opportunities may have been missed to confirm the food source of the outbreak sooner.

We heard from many interviewees that methods to collect and retain food samples as well as testing methodologies are not standardized. There is also no cross-coding³ of the human biological samples and corresponding food samples. Consequently, more time was needed to reconcile results. This could have been avoided with pre-approved processes and practices.

Another complication was that current confirmation testing for Listeria monocytogenes and the DNA fingerprinting involves a series of tests. It can take up to 14 days to complete all these tests before identifying the fingerprint of the bacteria.

Due to all of these factors, we consider that there might have been earlier opportunities to identify the link between the human infection and the food source of the outbreak.

Key Findings:

• All foodborne illness emergencies require extensive laboratory testing and analysis. Both human and food samples are required to link the disease to the contaminated food products.
• Public health labs are not formally networked and could be more effectively used during a foodborne illness emergency.
• The Public Health Agency of Canada has improved its epidemiological data collection and analysis for human illness, but improvements are still required for integrating the data collection and analysis of food samples.
• In the case of Listeria, laboratory resources are limited and the testing required is sophisticated, complex and takes considerable time to properly undertake (up to 10 to 14 days to confirm Listeria monocytogenes in food).
• Advances in laboratory testing allow for DNA fingerprinting of the Listeria monocytogenes bacteria, which is used to confirm the linkage between human illness and contaminated food products.
• While significant progress has been made, enhanced coordination of testing could further accelerate the analysis and decision-making necessary in the management of foodborne outbreaks.

Recommendations:

1. Given that laboratories across Canada are not networked, the federal, provincial and territorial governments should proceed to establish a nationally integrated network (i.e. network of networks) among the following:
   1. human disease labs (where this has not yet occurred),
   2. food labs,
   3. animal labs, and
   4. all of the above.
2. This network of federal, provincial, territorial, local, and private laboratories should be integrated to ensure:
   1. rapid tests, analysis and reporting of test results into monitoring and surveillance systems, on a priority basis; and,
   2. the identification of back-up capacity to support regional and local gaps and surge capacity needs during a national foodborne emergency.
3. Federal, provincial and territorial governments should review laboratory procedures and methodologies to develop consistent practices in testing for foodborne diseases, against predetermined benchmarks and giving priority to the following:
   1. cross-coding human samples and corresponding food samples in order to accelerate the linkage of test results;
   2. agreeing to protocols designed to accelerate the process for accrediting public (by the federal government) and private (by the provinces) laboratories for Listeria monocytogenes DNA fingerprinting;
   3. standardizing methodologies for the collection and retention of food samples, including the requirement that all Listeria monocytogenes positive food isolates be forwarded to a designated lab for DNA fingerprinting;
   4. developing and delivering the necessary training required to ensure that laboratories have built-in human resources redundancy;
   5. ensuring that positive Listeria monocytogenes isolates are held for at least six (6) months to facilitate the comparison of data and to accelerate the identification of potential outbreaks, and
   6. researching and applying novel and emerging lab technologies.
4. Federal, provincial and territorial governments and their research funding agencies should initiate and support further research into:
   1. testing for, and control of, Listeria monocytogenes;
   2. improved traceability technology and methodology; and
   3. novel and emerging laboratory technologies.

Next chapter

"From everything we heard, if there is a single issue that garnered near unanimous agreement, it is that the public was confused and did not understand what they should be doing following news of the food recalls..."

¹ Public Health Agency of Canada - National Notifiable Diseases (Table 1: Current List of Nationally Notifiable Diseases and Year the First Positive Report was Recorded) - online

² The Early Aberration Reporting System is a system that detects statistical increases in the number of cases above the norm and therefore can help public health officials detect an outbreak.

³ Cross-coding: a method of identifying human samples and corresponding food samples to make it easier to link their test results