Subcommittee on Food Safety Committee on May 27th, 2009

[The Chair, Conservative, Larry Miller]

I call our meeting to order.

I know Mr. David McKeown from Toronto Public Health was here a minute ago, and I'm sure he'll be right back.

Welcome to Ms. Allen, Ms. Badiani, and Mr. Williams from Ontario Ministry of Health and Long-Term Care.

We'll open our presentations. Each organization or individual will have 10 minutes or less.

Mr. Williams, are you starting out?

[Dr. David Williams, Chief Medical Officer of Health, Ontario Ministry of Health and Long-Term Care]

I believe so.

[The Chair, Conservative, Larry Miller]

Okay, then, you have 10 minutes or less, please.

[Dr. David Williams]

I'll start off with some general comments and my introductory part.

Good afternoon, and thank you for the opportunity to address this committee on the management of the 2008 listeriosis outbreak in Ontario.

Today l'd like to talk about my report on the outbreak, released publicly on April 17, 2009, basically on what we did right, on what we could do better, and the lessons learned for the future. Copies of the report, in both official languages, I have heard, have been provided to the members.

As you know, the outbreak that began last summer was first detected in Ontario and eventually spread to seven provinces across Canada. By the time the outbreak was declared over, 57 confirmed cases were reported across Canada and 22 people died. Ontario suffered the brunt of the outbreak. Sixteen people died, most of them elderly and either living in a long-term care home or hospitalized. Ultimately, our goal is to strengthen the public health system to protect Ontarians from food-borne illnesses that cause such suffering.

Any time there's an outbreak affecting so many people in so many communities, it's important to engage in a thoughtful analysis of the way we respond to and manage these situations. That's why I established a provincial listeriosis outbreak review committee. The report I released in April, of which you have copies, outlined the committee's key findings and my recommendations to help us improve how we respond in future.

Ontario's priority has been to build on existing resources to create a more coordinated, better-resourced, and more responsive food-borne outbreak surveillance and response system. Since this outbreak affected so many Canadians, I shared the report's recommendations with our federal, provincial, and territorial partners so that others might benefit from Ontario's analysis.

Let me now turn to my report's findings and recommendations.

First of all, detecting the outbreak.... The Integrated Public Health Information System, or iPHIS, as some people say, is a web-based system into which all public health units enter case information on all reportable diseases. It was put in place after SARS and it continues to prove its worth. Ministry staff analyze data from iPHIS every day with the help of another system called EARS, the early aberration reporting system. EARS detects and raises flags when there are statistically significant increases in the number of cases above a given norm. Thanks to iPHIS and EARS, the small number of listeriosis cases at the outset were linked together and allowed us to detect the outbreak before many people fell ill.

Although the iPHIS system works well, there is sometimes a lag between when a public health unit is aware of a case and when the data on the case is entered into the system. My report therefore recommends that public health units be vigilant about providing timely, comprehensive data to ensure the full effectiveness of the surveillance system. At the time, we need to make sure that local health units as well as the ministry have the necessary skilled staff and resources to investigate and respond to signs of possible outbreaks.

Confirming the outbreak. The symptoms of listeriosis are not specific. Vomiting, nausea, severe headaches, and fever can be symptoms of many other illnesses. Also, historically, only a relatively small number of people fall ill with listeriosis. That's why lab testing is essential to help identify and confirm an outbreak. For the 2008 outbreak, molecular typing, or what is often referred to as fingerprinting, was conducted through a complex test called the pulsed-field gel electrophoresis, or PFGE, for short, for this presentation. It was PFGE testing that confirmed that the listeriosis cases across the country were in fact linked, and that the source of the contamination was packaged luncheon meat from the Maple Leaf Foods plant in Toronto. This molecular typing was done in federal laboratories, at the National Microbiology Laboratory in Winnipeg, and at the Listeria Reference Laboratory in Ottawa.

The federal government should consider the need for greater regional capacity for this testing as molecular typing moves from being a research tool into a more standardized use. I also recommend in my report that the Ontario Agency for Health Protection and Promotion develop a plan to increase the Ontario Public Health Laboratories' capacity to conduct a wider range of tests, to monitor strains of bacteria and other organisms that pose a threat to public health, and to educate public health units about optimal and quality sampling techniques. Because time is crucial during an outbreak, the Ontario Agency for Health Protection and Promotion should also assess the potential to improve testing timelines.

Managing the outbreak. Today, foods are processed and packaged in a few large plants, then shipped across the country, and even abroad, either to be sold as a packaged product or made into other products. For example, the two lines that were contaminated at the Maple Leaf Foods plant made products that were shipped across Canada and marketed under more than 200 different brand names or labels, and that's not unusual in the industry.

In that light, when food-borne outbreaks occur, more and more of them will be cross-jurisdictional, with a national or even international perspective. To ensure a better response to such outbreaks, roles and responsibilities need to be clarified among local, provincial, and federal agencies.

In a provincial outbreak, I recommend that the chief medical officer of health should establish an outbreak coordinating committee to provide information and advice in managing the outbreak. The committee should include all lead provincial and federal food inspection, regulation, and public health agencies, including labs. Despite the differing mandates of these agencies, the committee's overarching priority needs to be to protect the public's health.

In the case of a national or international outbreak, I recommend that the federal chief public health officer establish a similar committee on the national level with participation by the chief medical officers of health of the provinces and territories. The role of the federal chief public health officer would allow for the integration of information so as to inform decision-making by the provincial and territorial chief medical officers of health.

Communications. There is no doubt that effective, timely communication is essential in managing an outbreak and in maintaining public confidence. Effective communications in a cross-jurisdictional outbreak can be challenging. Frankly, during the listeria outbreak, there was a lack of effective communications among some of the partner agencies, and this created a sense of lack of coordination.

Communications to the public were not well coordinated. Each level of government provided communication within their own jurisdictions. There was no clear public spokesperson for the outbreak or food recall. Once Maple Leaf Foods announced a voluntary recall of its products, the media turned to the company for information. In my view, it would have been more appropriate to have a government spokesperson take the lead to ensure that appropriate public health messages were communicated to the public.

This was a national outbreak, but it was not clear whether the federal chief public health officer had a mandate for leadership at the federal level in this cross-jurisdictional outbreak. I therefore recommend that in a province-wide outbreak, the provincial chief medical officer of health should be the official media spokesperson. In a national outbreak, on the other hand, the spokesperson should be the federal chief public health officer.

My report also recommends that all agencies involved in managing the outbreak should adopt the 24-hour information cycle that is an integral part of our emergency response plans. This would encourage a coordinated sharing of information among partner agencies and clear, more timely communication to the public.

Overall, I was pleased that the public health system in Ontario worked well during this outbreak, but there are indeed ways we could improve in the future. I want to emphasize that this review was not merely an academic exercise. Our mandate is protecting people's lives, and we take that responsibility very seriously. We recognize that we must continue to do our utmost to strengthen and enhance Ontario's public health system.

Thank you. I'm prepared to answer your questions.

[The Chair, Conservative, Larry Miller]

Thank you very much.

We'll now move to Mr. McKeown. Thanks very much for being here. Ten minutes or less, please.

[Dr. David McKeown, Medical Officer of Health, Toronto Public Health]

Thank you very much, Mr. Chairman, for the opportunity to join you here today.

My name is David McKeown and I'm the medical officer of health for the city of Toronto. For context, Toronto Public Health—the organization that I lead—provides public health services to the 2.6 million people in the city. Our responsibilities include surveillance for food-borne illness, delivering local food safety programs, and of course, responding to outbreaks. We're the largest organization of our type at the local level in Canada.

In April of this year, I issued two reports on food-borne illness and on food safety in Toronto. In these reports, I made a number of recommendations for improving food safety. Those recommendations were adopted by the Toronto Board of Health and they have been sent to the organizations and governments to whom they are directed. I have copies of the reports here for you today that I hope you will find helpful.

In my time here today, I'd like to talk about the issues and recommendations that I raised in these reports, which pertain to the food safety role of the federal government and its agencies. But first, let me very briefly outline the burden of food-borne illness in Toronto, which I think is broadly representative—

[Bev Shipley, Conservative, Lambton—Kent—Middlesex, ON]

Could we have your presentation?

[Dr. David McKeown]

I can provide a copy.

[The Chair, Conservative, Larry Miller]

It would have to be in both languages. Otherwise, it would have to go to the clerk and be distributed later.

[Dr. David McKeown]

I'm happy to provide a copy. I didn't provide translated copies.

[Bev Shipley, Conservative, Lambton—Kent—Middlesex, ON]

Okay. Thank you very much.

[The Chair, Conservative, Larry Miller]

Go ahead, Mr. McKeown.

[Dr. David McKeown]

Thank you very much.

Food-borne illnesses, of course, are legally reportable in Canada, but most, as you know, go unreported, either because they're not brought to medical attention or because the diagnosis is not confirmed by laboratory testing. In my reports, we estimated the true burden of food-borne illness in Toronto using methods developed by the Public Health Agency of Canada to fill in the missing unreported cases, and the results indicate that Toronto residents experience over 400,000 cases per year, or to put it another way, about one in six Torontonians gets a food-borne illness each year.

Now, although most of these illnesses are mild, they nonetheless are responsible for direct and indirect cost to the health care system and the economy, which we estimated to be in the range of about $500 million annually just within our city.

The food safety system in Canada is designed to prevent and respond to this large burden of illness, and it's a system that has important roles for governments and government agencies at all three levels of government, as well as for food producers, manufacturers, distributors, and retailers. Food safety is regulated at virtually every stage, from grow it to throw it.

Now, although the food safety system has many strengths, there are also some opportunities for improvement. I'd like to focus briefly on three areas that are within federal jurisdiction.

The first concerns transparency. Since about 2001 in Toronto, we've had a program of public disclosure of food safety performance. The results of all public health inspections of the 16,000 food premises in Toronto are available to the public at the door of the food premise when you walk in, they're available on a searchable public website, and they're available by telephone for those who don't use the Internet.

This program, which is called DineSafe, has promoted public awareness of food safety and provided a very strong incentive for food service operators to maintain good food safety practices and to quickly address any deficiencies that are identified during inspections. The DineSafe website, in fact, is one of the most frequently visited websites of the City of Toronto, and I would invite you to take a look at it. Based on our experience in our city, I would recommend that all federally regulated food facilities be subject to the same degree of public disclosure as those in Toronto.

The second area I'd like to speak to is food notification and recalls. The Canadian Food Inspection Agency is the national lead for notifying the public of potentially hazardous food products and for recalling products from sale. The decision to notify the public and recall a product is an important food safety intervention that can prevent illness and can even save lives. Timeliness is critical, as a hazardous product may still be leaving store shelves or being consumed in homes and restaurants as the outbreak investigation is proceeding.

Now, in our experience with several large-scale multi-jurisdictional outbreaks over the past several years, the Canadian Food Inspection Agency has generally waited for conclusive evidence that a specific product is responsible for documented human illness before taking action. Two examples come to mind. In a large salmonella outbreak in 2005, epidemiologic evidence pointed to bean sprouts produced at a Toronto facility as the probable source. In my assessment at the time, there was sufficient evidence to take action to protect the public. The CFIA, at that time, was not prepared to notify, so I closed the plant since it was within my jurisdiction to do so.

The second example concerns the 2008 listeriosis outbreak, in which at one point in the process the manufacturer notified customers not to use certain implicated products, and Ontario public health officials, at the provincial level, issued their own notification to consumers. Both actions were taken several days before the CFIA confirmed that the products had caused human illness based on finding matching strains of listeria from ill individuals and from unopened packages of food. In my view, in general, during the investigation of a food-borne outbreak, public health officials should have a bias toward health protection and should take action whenever there are reasonable and probable grounds to believe that a food product poses a health hazard. This is the standard that is included in Ontario public health legislation.

Finally, I think there are some practical steps that can be taken to improve inter-agency cooperation in the case of a large multi-jurisdictional outbreak. Existing protocols, such as the Foodborne Illness Outbreak Response Protocol, or FIORP, should be updated, and there should be substantial training in the protocol for all parties who may have to collaborate during an outbreak. During the 2008 listeriosis outbreak, it did not appear to me and my colleagues that the protocol was being used to guide the investigation and response, and some participants were apparently unaware of its status or its existence. It would be very useful to conduct simulation exercises, such as are used to prepare for other large emergencies—influenza pandemic comes to mind—to give responding agencies from all orders of government more experience in working effectively together during a large outbreak.

Thank you very much for your attention and for the opportunity to raise these issues with the committee.

[The Chair, Conservative, Larry Miller]

Thank you very much, both of you, for being brief.

We'll turn to our questioning. Mr. Easter, seven minutes.

[Wayne Easter, Liberal, Malpeque, PE]

Thank you, folks, for coming.

Certainly, Dr. Williams, when you tabled this report, it got quite a reaction from Ottawa very quickly, with press conferences being called and accusations going back and forth.

I might as well tell you in the beginning that we have some concerns, on this side of the committee anyway, that the concern of the government at the time over the political fallout may have caused some delays, and I use the word “may”. We're not saying it did, but it may have caused some delays, and neither the minister nor CFIA is willing to accept responsibility. I find it remarkably strange that the head of a meat processing plant, Michael McCain, seems to have had to accept all the responsibility, when I believe governments are responsible for food safety in this country.

The other critical area that we should inform you of as well is that when CFIA was before this committee, president Swan said that they are not responsible for food safety, industry is. I personally don't accept that, but that's what was said.

On page 8 of your remarks, you do say, “...it would have been more appropriate to have a government spokesperson take the lead to ensure that appropriate public health messages were communicated to the public”. I can tell you that we agree with that recommendation. There needs to be an independent public voice out there.

My question, though, relates to the evidence when we were trying to find the chronology of events. CFIA claims that the first they were notified was on August 6, and there seems to be some discrepancy about that. In fact, in the letter reacting to the report, this is what the president of CFIA; the chief public health officer, Dr. Butler-Jones; and the Deputy Minister of Health had to say, and I want your response to this. I'll quote it to you. They do talk about reports, conclusion, and coordination agreeing with that.

They go on to say, and I quote:

The need for better coordination also extends to laboratory testing - a critical element of the outbreak response. Since the CFIA was not advised of sampling on July 21st, opportunities were missed that may have reduced the timeframe for confirming the source of contamination. For example, samples taken by Toronto Public Health were sent to Health Canada's Listeria Reference Service (LRS) laboratory in Ottawa for testing, rather than to the CFIA regional laboratory in Scarborough.

Then they go on to say:

Based on the initial advisement received on August 6 from Toronto Public Health, the CFIA acted swiftly to launch a food safety investigation...

In discussions we've had with your people, you folks claim that CFIA should have known on July 29. Can you respond to that?

[Dr. David Williams]

Thank you.

Speaking through the chair, we did respond to the letter, with my response on the 29th back to the group. There are two points to make.

First of all, when Toronto Public Health was investigating two cases in a nursing home in Toronto, there was no outbreak at the time. Health units are continually doing investigations and submitting food samples. They do that through proper channels, and they did so in this case too. To say that if they had been doing it correctly in the midst of an outbreak they would have submitted it to a regional lab.... There was no outbreak at that time, on July 21. They were doing their normal sampling.

Our lab itself will get 20 to 100 samples a day. There are processes that go through us; there's all sorts of food sampling being done and going on to the labs accordingly. The correct place to send it was to Health Canada's lab, which is the Listeria Reference Laboratory. That would not be out of order, and it was not inappropriate for them to send it there.

One would wonder, if it went to that lab and there were cases detected...we talk about laboratory surveillance. If there were indications of increased numbers of cases that are of concern at the laboratory level, especially from one federal authority, you would assume there would be some networking or discussion to alert the other side if there was something in their mind that was remiss or of concern. That's with that level. I don't how that worked or should work.

On the aspect of when they're notified, part of our process in the past in working in conjunction with the Foodborne Illness Outbreak Response Protocol has been that we notify our partners in a fairly prompt time. On July 29, we put out a kiosk report—the kiosk report is how we are proactive in notifying our public health partners both in the province and across the country—to our federal counterparts, including the Public Health Agency of Canada, Health Canada, and the Canadian Food Inspection Agency, who monitor these reports and are alerted that we are undertaking an investigation. It gives the context of it, so that our other partners—and, we now hear, some American counterparts—can look at it and assess or ascertain whether they need to be aware of it or ask us any further questions to clarify it. So we had done our part to alert the wider sector on July 29.

As for the comment about whether someone was on a teleconference or not on the 30th, when we call for a teleconference and there are anywhere from 40 to 100 people on, we can't do the full roll call to know whether someone is at it or has walked away from the microphone. So in that sense of “report”, we checked the records and couldn't document whether this person was on during that teleconference or not, but we had already notified everybody of the fact that we were undertaking this investigation on July 29 through the kiosk system.

[The Chair, Conservative, Larry Miller]

You time has expired, Mr. Easter.

Mr. Bellavance, you have seven minutes.

[André Bellavance, Bloc, Richmond—Arthabaska, QC]

Thank you very much.

Mr. Williams, I would like to congratulate you on the exhaustive report you've prepared since the crisis. It's the report on the management of the listeriosis outbreak that is the most exhaustive. It also contains specific points that are very useful to the committee.

However, I would like to go back to certain remarks you made in the media after the report was tabled. You said that this tragedy would not be the last. In an article in the April 18 issue of Le Soleil, you are reported as saying:

In view of increasingly large-scale food processing methods, it is likely that outbreaks of diseases originating from food will occur increasingly often.

You've no doubt seen the reports of the Canadian Food Inspection Agency and Health Canada and the measures the government and even Maple Leaf Foods decided to put in place after the crisis occurred. Do you still maintain that we should expect crises of this kind to occur increasingly often? If so, why?

[Dr. David Williams]

Thank you for that question.

I think the point I emphasized at that press conference is that in the new reality of our food services, where we're having more products than ever before from ever larger organizations of international scope—products that are often made offshore and over which we have very little control—and a wider population with importation coming in, it behooves us to look at how we can survey that even more effectively and appropriately, or we will be left with further outbreaks, such as we experienced with listeriosis.

So the first issue or problem is the extent and breadth of the change in the food retailing market that we're experiencing in Canada as part of the global community.

The second aspect that listeriosis did bring out is that we have an ever-increasing vulnerable population. The success of our medical health care system is that we have an ever-aging population, and a very mobile and active octogenarian and nonagenarian group that is out there moving around. We have more people who are living long term from having survived either cancer or a transplant by taking medications for the long term that are immuno-suppressive. So unlike healthy people, who could have listeriosis and normally just pass it off and not become ill, this ever-growing group in the population is there and very susceptible.

I believe it's our responsibility to put in place the surveillance methods that can provide quick alerts to protect this group from the consequences of food-borne illnesses—as Dr. McKeown has alluded to in his talk—which are quite prevalent out there.

This means that if we don't improve our surveillance systems and our laboratory surveillance systems as well, and our coordination at all levels—because it is becoming a more complicated global issue—we will face these issues even more in the future, because they will not go away. The organisms are ubiquitous in our environment; they can enter easily into our food chain. And especially when products are coming from afar, we may not be as well versed on what's in those products, and what we have to cautious about, and the preparation systems.

So our surveillance, coordination, and communication have to be much improved in the future for this.

[André Bellavance, Bloc, Richmond—Arthabaska, QC]

Your report contains the most information on the deficiencies in Canada's food safety system. Obviously you focus on the unfortunate event that occurred at the Maple Leaf plant, but I think that's symptomatic of all the other issues that fortunately don't necessary cause the deaths of 22 persons or make a number of people sick.

You emphasize in particular that the Canadian Food Inspection Agency was the only intermediary between Maple Leaf Foods and public health officials. Toronto's public health officials were unable to take part in the investigation, even though they had asked to participate. You had to make a special request to involve the audit team. Ontario inspectors did not have access to the plant. In fact, they did have access, but only three weeks after the Canadian Food Inspection Agency had established that Maple Leaf Foods was the manufacturer of the product that had produced positive results.

I get the impression there were some obstacles in your path when you tried to do your job. At the same time, the Canadian Food Inspection Agency wrote you a letter blaming you for not sending the tests to the right place. You talked about coordination, but the protocol that was followed during the crisis likely did not work well.

[Dr. David Williams]

That's one of my concerns in my recommendations in the report. We should be seeking ever better levels to bring our key stakeholders and the key partners together--local, provincial, and federal--to respond quickly, with timeliness, effectively, and efficiently. That's correct.

I think the listeriosis outbreak is one that went very well and very quickly. From that, it's a good one to evaluate the system, because you can look at the system blockages that are there, and we can analyze and ask how we can improve the system. That was the main purpose of the report: that we'll do our part at the Ontario level, but we do need to have strong coordination with our other federal, provincial, and territorial partners as well if we're going to carry out a consistent response.

On the issues you're raising that did come up, in fact, I was caught by surprise that there was some difficulty for the Toronto inspectors to gain access to the facility. As I understand it, they did the proper thing and informed that they were coming over as a matter of courtesy, because we tried to take the high road and to work in a cooperative and coordinated way. I only learned after a day or so that there was some need for some letter and a request, and I wasn't sure why that was required. Perhaps Dr. McKeown could answer some of that further. But that was not under our fiat or protocol.

While that's not binding, there is a recommendation for a committee where, if an inspection is required, all inspectors are invited in to work together. That includes federal inspectors. In our case in Ontario, our Ministry of Agriculture, Food and Rural Affairs inspectors and our local public health unit inspectors are not to be in competition but to work as a team to quickly gather the information you need to inform each sector and to inform each other on a rapid coordinated response.

That is one of my main concerns from the recommendation. What kind of forum can we have? I recommended a coordinating committee, an outbreak one at the local level, the provincial level, and the federal level. That would require the key heads of each one to be there to be forthcoming with information, to solve those problems, and to encourage a level of coordination and communication. Because in these cases, much as we've seen with water and in the past with blood-borne infections, the public expects a higher level of performance. Jurisdictional issues should not be a factor. The public's protection is paramount, and we need to be striving towards that.

[The Chair, Conservative, Larry Miller]

Thank you, Mr. Williams.

Mr. Allen, seven minutes.

[Malcolm Allen, NDP, Welland, ON]

Thank you, Mr. Chair.

Thanks to all of you for coming.

If I could, Dr. Williams, I will continue on in that vein. There's the sense of the public's perception about its protection versus a jurisdictional dispute between one or the other...or not a dispute, because maybe that's a harsh word. But there is a sense that one jurisdiction is here and one jurisdiction is there, like a couple of ships with their lights out passing in the dark. They don't necessarily see one another, nor do they communicate effectively sometimes.

After you wrote your report, as we all know, we've seen the reply that came from the federal departments, from CFIA and the Public Health Agency of Canada. After that particular letter was sent to you, have either CFIA or Public Health made any communications or overtures to you or to your department in any way other than that letter?

[Dr. David Williams]

Prior to the letter, we did have a meeting with some officials, facilitated by our Ontario Ministry of Agriculture, Food and Rural Affairs. We talked on a high level about going forward with more coordination. That was prior to receiving the letter. Prior to the letter, I also had a phone conversation with CFIA officials on just some general questions they wanted to ask.

Again, the sense of this was that we need to be looking at how we can work better together and cooperate and coordinate better. It was more a setting of the stage for that. We said that's certainly what we're interested in, and we asked what we can establish that would move us into what I would say is the new phase and the more enhanced level of food-borne illness surveillance outbreak management and coordination.

[Malcolm Allen, NDP, Welland, ON]

But post-letter, have you received any other communications from them about going forward with the things you talked about?