Final Report

Report of the Independent Investigator into the 2008 Listeriosis Outbreak

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Table of Contents

Investigator's message

Executive summary

List of all recommendations

1. How did we approach this report?

• About the Listeriosis Investigative Review
• Approach

2. What is listeriosis?

• Preventing listeriosis

3. Who was affected?

4. How does Canada's food safety system work?

• Responsibilities of the various organizations involved
• Understanding the federal regulatory system overseeing meat processors
• Understanding public health and the organizations involved
• Detecting and investigating foodborne illness

5. What led to the outbreak?

• #1 - Maple Leaf Foods believed its strategy to control Listeria was working - it was not
• #2 - The federal meat inspection system did not identify these problems
• #3 - There were gaps in the federal rules governing meat production and inspection
• #4 - Once contaminated products entered the food supply, Institutions served it to vulnerable populations
• #5 - As contaminated food was being consumed, the public health system slowly recognized the outbreak

6. How did events actually unfold?

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

• Understanding the challenges of managing a foodborne emergency
• Leadership
• Emergency management
  • Federal, provincial/territorial and local coordination
  • Federal organizations' structures and operating procedures
  • Disease reporting
  • Epidemiological investigation
  • Food investigation and recall
  • Laboratories

8. How well were communications handled?

• Communications to the public
• Observations and assessment
• Communications to physicians
• Public education

9. What progress has been made since the outbreak?

10. What else did we learn during this investigation?

• Government of Canada food safety legislative and regulatory framework
• Federal organizational governance and structure
• CFIA
• Public Health Agency of Canada
• Multi-departmental governance of food safety
• Multi-jurisdictional governance of food safety
• Going forward

11. Appendices

1. Biographies of the Independent Investigator and the members of the Expert Advisory Group
2. Detailed chronology
3. Progress to date
4. List of interviewees
5. Glossary of terms
6. Acronyms

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Email: info@agr.gc.ca

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