Sheila Weatherill, Independent Investigator

Listeriosis Investigative Review
Notes for delivery at a news conference
to release the
Report of the Independent Investigator into the 2008 Listeriosis Outbreak

Ottawa, Ontario
July 21, 2009

Introduction

Good morning everybody.

Welcome and thank you for joining me. I will be outlining the results of my investigation into the 2008 listeriosis outbreak, one of the worst foodborne illness emergencies in Canadian history. Yesterday, I delivered my final report to the Minister of Agriculture and Agri-Food. I am here now to share my findings and recommendations with you and all Canadians.

Before outlining what I learned during the course of this independent review, I first want to acknowledge the individuals for whom this report was written:

• The surviving family members of the 22 people who died from listeriosis as well as the 35 others who were seriously ill from the disease.

This report is dedicated to all those affected by the tragedy. My goal in this investigation was to uncover what led to the listeriosis outbreak. What can be done to prevent this or similar outbreaks from occurring again. And to optimize our response if this type of event occurs again.

About the investigation

In order to do this, we have completed a thorough and comprehensive investigation resulting in 57 recommendations. Many people shared their experiences and perspectives. And many came forward with solutions. I consulted with respected Canadian and U.S. food safety and public health experts. This group of expert advisors provided advice throughout the investigation. I had document experts that collected and collated over 5.8 million pages of information - including research reports. I interviewed and met with people with first-hand knowledge of the events of last summer.

I talked with:

1. frontline workers in industry,
2. officials from the public health and food safety sectors,
3. representatives from Unions,
4. consumer groups,
5. equipment manufacturers,
6. middle managers and senior executives within industry, federal and provincial public service,
7. And family members of those who died.

I also heard from many Canadians who contacted the Listeriosis Investigative Review by letter, phone and email to express their positions on the issues being examined.

So, what did I learn?

First, I learned there are no easy answers. Last summer's listeriosis outbreak was a rare and complex event that defies simple explanations or simple solutions. This was a complicated issue involving multiple jurisdictions and their constitutional relationships.

It concerned both the public and private sectors. It also included the fast-changing world of science and technology. I learned that, in hindsight, it is much easier to see the sequence of events that led to the outbreak. And to identify steps that could have been taken. I heard, repeatedly, that if people had only known or recognized then what they know now, these events might have evolved differently.

Nevertheless, 22 vulnerable Canadians died as a result of the outbreak. It has taken months to unravel the numerous factors and complex chain of events that led to the tragedy. Chief among them is the fact that listeriosis is one of the most unique and deadly forms of foodborne illness. It is a disease that affects most seriously vulnerable citizens - the elderly, people with compromised immune systems, pregnant women and their newborns.

In this outbreak almost 40% of people who became ill with listeriosis died. It is also one of the most difficult illnesses to detect as it begins often like the flu and requires complicated tests to diagnose. The listeria organism is widespread in the world around us. It is so pervasive that it is impossible to totally eliminate the risk. And this is why we must take all necessary measures to manage this problem and avert another listeriosis outbreak.

Foodborne illnesses are the fastest growing class of infectious diseases in the country. While rare, listeriosis cases have doubled since 2005. And we can expect to see more outbreaks in the future unless we take concrete action to prevent them. Food supply is no longer primarily local. Food is often produced in one part of the world and widely dispersed in the market place. Although Canada is considered to have one of the best food safety systems in the world.

In fact in 2008 ranked as 5th of 17 OECD countries. This investigation found problems that need to be addressed to better protect Canadians.

Before highlighting some of the findings, I want to read you a quote from one of our expert advisors, Dr. John Carsley, a public health practitioner.

So what happened?

"In all likelihood, none of the individual elements that contributed to the outbreak was sufficient to have caused it alone, so each part of the food safety system must work together as perfectly as possible."

And what we found is that our food safety system did not work as perfectly as it needed to. There is no question that people were committed and gave it their all once they understood the extent of the emergency. Having said that, this investigation has made clear that more could have been done to prevent it from happening in the first place. More to the point, more must be done to make sure it doesn't happen again.

Key Findings

We have identified findings in 4 key areas:

1. the focus on food safety,
2. the state of readiness,
3. the sense of urgency,
4. and the communications.

First: Listeria defeated the best efforts of all those trying to prevent it from entering the food supply, including workers attempting to control it in the Maple Leaf Foods Bartor Road plant.

It also evaded the oversight systems of both Maple Leaf Foods and the federal government (CFIA). Also, while evidence of food contact surface contamination on ready-to-eat meat production lines was available before the outbreak. But these trends were not being monitored to identify a recurring problem. There was no legal obligation to report this contamination, and there was no requirement for government inspectors to request this information. Once people were ill and an outbreak in more than one province was suspected, the existing intergovernmental protocols to deal with the event were not well understood. This created confusion about who should do what and when. Policies and directives were sometimes vague, therefore open to different interpretation, and thus creating opportunity for problems. The majority of Canadians were unaware which segments of the population were at greater risk of becoming ill if exposed to Listeria monocytogenes, and what foods these vulnerable groups should avoid.

Simple, clear information about these risks and how to protect themselves was not always effectively communicated to people at increased risk for listeriosis, health professionals and the general public.

Encouragingly, a lot of the problems identified immediately following the event have since been corrected. While I welcome these improvements, and acknowledge they are a good start, this review has revealed areas that require improvements.

Recommendations

The 57 recommendations for action contained in the report underscore this point. You will find all 57 recommendations embedded in each of the chapters following the relevant key findings and we have highlighted some in the backgrounder.

Conclusion

It took the 2008 listeriosis outbreak to raise awareness that food safety cannot be taken for granted. Implementation of the recommendations I am proposing will not only protect Canada's food supply and the health of Canadians. They will strengthen industry's competitiveness in a world that wants assurance that food products are safe. By being proactive and progressive, Canada can carve out a niche as a world leader in food safety. Raising our global food safety ranking from one of the best to the very best in the world. After 6 months of studying this outbreak and determining how best to protect. I am urging all sectors to go beyond compliance and create a genuine culture of food safety. Canadians expect no less

Thank you