Subcommittee on Food Safety Committee on May 27th, 2009

[Dr. David Williams]

No, not since the letter and our response back to them. In Ontario, we've been consumed with issues around H1N1, so that may be a reason there. But we haven't received any formal correspondence as a follow-up to our letter back.

[Malcolm Allen, NDP, Welland, ON]

I don't know whether you can comment on this. It may be difficult or I may just be putting you on the spot.

From the jurisdictional perspective of understanding--and I know you understand your office and its responsibilities--are you able to describe for us the potential similarities or differences between your office as the chief medical officer of health for the province of Ontario and the office of the chief medical officer for Canada? Are you aware of the differences or are you able to describe those to us in any way?

[Dr. David Williams]

Overall, I haven't had the opportunity, because the Public Health Agency of Canada is relatively new and the legislation, roles, and responsibilities are ones that we're interested to understand well from the chief public health officer of Canada.

While we have been involved and we look at our public health legislation--it's been there for a long time and modified under the Ontario Health Protection and Promotion Act, which lays out the roles and responsibilities of my role as a chief medical officer of health in an acting capacity and that of local medical officers of health--we have that shared dynamic, the one between the chief public health officer and how his or her authority works with the other agencies.

In Ontario, when there is a public health crisis or situation, the chief medical officer of health has leadership in that and, through our emergency response systems, can then work with the other ministries to coordinate a province-wide response when necessary. There's a way to layer up on that with leadership, because when it's public health leadership, it's the public health concern that is paramount, first of all, on a precautionary basis. We assume the same may occur at the federal level, but I am personally not sure how that works regarding the structures at the federal level, how the chief public health officer of Canada has authority and jurisdiction to lead that process with other federal agencies and ministries. I'm hoping that through this I might be better informed on that matter as they go through their review process.

[Malcolm Allen, NDP, Welland, ON]

When it comes to jurisdictional pieces, I realize we have to deal with legislation, and it may have been more difficult for you to answer.

I think there is a short answer to this. In your role, do you feel you have a great deal of autonomy to act in the public's interest when it comes to their health when we deal with crises, or do you have a sense that you're limited in any particular way?

[Dr. David Williams]

The uniqueness of Ontario is that we have 36 autonomous public health units. A medical officer of health such as Dr. David McKeown has the full legal authority to look after his own jurisdiction and has responsibilities and legal rights to carry that out. As a chief medical officer myself, I don't have my own separate staff who do inspections and carry that out; I work through the local medical officers.

The challenge we faced with this outbreak was that normally when there is an outbreak, it usually starts at a local level, where a health unit takes the lead, and we help and assist them. In this case, we had a province-wide outbreak with no local outbreaks. That's a new challenge and reality that we have to face in the days of advanced laboratory testing. It was a new paradigm shift for us.

Therefore, I suggested in my report the establishment of an Ontario outbreak coordinating committee, where the chief medical officer of health can meet with the other medical officers of health and key people to carry out a concerted coordinated activity. We can't afford to gather round and talk about consensus where we all agree to do something, when we need to move more expeditiously for the protection of the public. So we're looking at that type of forum that would work in these very unique situations that I think we'll face more of in the future.

[Malcolm Allen, NDP, Welland, ON]

I understand that when it comes to public health, consensus building isn't necessarily the model we want to look at.

I'm interested in your use of words, because I was going to raise the issue about what one sees in science, what's called the precautionary principle, with which not everybody is familiar. I'll ask Dr. McKeown to look at that.

You talked about it earlier and I thought you were leading to a precautionary principle, where one doesn't wait until we absolutely know it's either bean sprouts, tomatoes, or red peppers. We talked about the public issue rather than worrying about individual producers or suppliers of a product to make sure that we actually get that absolutely right. It doesn't mean to say we stop looking to find out what the product is that's contaminated.

So perhaps, Dr. McKeown, you could enlighten us about that. Should we be using that as a more frequent model, or is it something we should be ignoring?

[Dr. David McKeown]

As a local medical officer of health, I feel my primary responsibility is to protect the health of the public. And if I'm trying to make a decision about health protection in the face of some uncertainty, which is a very common situation, I will try to err on the side of health protection. You could describe that as a precautionary principle, of taking action without having absolute certainty. The principle, I think, is the same.

[Malcolm Allen, NDP, Welland, ON]

I raise that because when CFIA was here, they raised that very issue about bean sprouts and peppers versus tomatoes, not being certain as to which one it was, and mislabelling it. I felt they suggested in their testimony that until they got it right and could identify the product, we should not scare people into not eating a product that might be contaminated when it could turn out not to be contaminated. In my view, this affects public health rather than the bottom line of a particular company.

So is that what we should be doing, protecting the company? Or should we be protecting the public's health?

[The Chair, Conservative, Larry Miller]

Mr. Allen, the answer will have to be very brief. Mr. Easter and I were talking here, and you were over your time.

But go ahead, Mr. Williams. It's a good question.

[Dr. David Williams]

The issue is an important one. In our public health legislation, when we have reasonable and probable grounds that a hazard may exist, it allows our medical officers to act. That means, then, that one has to have some evidence to move--you can't just go about and be casual--but one has the ability to say that you should take steps to curtail, as soon as you can, the exposure of the public, or a portion thereof, to a presumed hazard until you investigate that one adequately.

So waiting until one has evidence beyond doubt, which may be useful for litigation purposes, is often too late to protect the public. The public expect, first, to be warned to take precautions. Then we can do the investigation to satisfy, when it requires, further litigious-type activity, if it were to take place.

So Dr. McKeown's answer would be correct: medical officers can close facilities, stop the sale or use of materials, or hold on to it in order to stop, in their minds, a potential hazard, if there are some reasonable grounds that the public would be exposed to a hazard, even if it's not fully known yet, because you need to take that time to investigate that.

It is important to understand the difference between that and waiting until you have all the evidence before you can carry out the action accordingly. The public's protection is paramount.

At that stage, I think that's the difference. When you have an outbreak that switches from being the industrial aspect to being the public's protection first and foremost, that other side can be looked after. But one needs to still coordinate with those so that there is some sense of coordination and communication. You don't do it in isolation as you're carrying out your investigation.

[The Chair, Conservative, Larry Miller]

Thank you.

Mr. Shipley, for seven minutes.

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

Thank you, Mr. Chair.

Thank you to our guests for coming.

This is an interesting and actually very beneficial process that we're going through. In terms of helping to determine all this, I think maybe some of the objectives are different from one side of the table to the other.

Quite honestly, I have the greatest of respect for Maple Leaf Foods. Mr. McCain made a presentation here. This came from his plant, this happened in his equipment, and there is a responsibility that he has accepted. I said it before and I'll keep saying it: I think all of us, quite honestly, at all levels could learn a lot about how to handle a crisis situation from the way he did it. I think he and his company have led by example in terms of accepting responsibility.

From this perspective, when we brought in this subcommittee, it wasn't just about listeriosis; it was about food safety also. I just want to make it clear what it's really about--namely, what happened? What did we learn from it? How do we move ahead? We still recognize, certainly, the sympathy that goes to those who were ill, and particularly to those families who were affected by losses.

I appreciate having the chief medical officer of health's report on the management of the 2008 listeriosis outbreak in Ontario. I want to just go back to the start, going back to June and July.

It says in here that on July 25--and this may involve Dr. McKeown also--“Public Health Division detects an increase in reported cases of listeriosis through monitoring iPHIS data.”

Was this just in Toronto?

[Dr. David Williams]

No, it wasn't just in Toronto.

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

Just in Ontario, then?

[Dr. David Williams]

In Ontario.

When we collect the data, we normally have about 40 cases a year of listeriosis. There are different amounts each month, ranging from two or three up to about five or six cases a month. The system then, with our team of people such as Ms. Badiani, does the recording. They look at the epidemiologists who watch that. They have that early aberration detection system that says, if there are slight blips in the numbers, whether it's significant or not.

As of the time we had that, there was no large number in any one health unit in Ontario, but we were starting to have a small increase in our background numbers. Sometimes we have that; it may not be important, but we want to make sure we check every one to see if there's something happening behind that.

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

With the 40 cases a year, is that the average number of people affected by listeria each year?

[Dr. David Williams]

Yes, we average about 40 a year. Those numbers go up and down a little bit, but that's the average number per year that we've experienced over the last three to four years.

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

What made this an epidemic or an issue, then? When you have that 40 a year, are there never any deaths that come from that?

[Dr. David Williams]

There are some deaths. It wasn't deaths that drove us to look at the numbers; it was the number of cases, first of all. As we look at those significant cases, we see if there are any unusual patterns. And right off the bat, the one thing that became obvious was that the cases were all in long-term care facilities. We immediately thought that was unusual and asked if there was something to that or not. As we investigated further and the numbers kept coming in, that pattern continued to grow.

Then they asked the health units, as they often do, to go back out to the system to those reported cases and go from passive surveillance to enhanced surveillance. They put out an enhanced surveillance directive that asked those health units to go back and check their data to see if there was a case in a nursing home. They asked if they could check to make sure there weren't other people in that home who were sick at that time, to see if they missed some cases or something. And they started doing some further investigation out there, asking if they did or did not have an outbreak in that place.

So it evokes a lot of activity to test the hypotheses or theories that are generated in that.

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

When I look through the chronology a little bit here, it would appear that on August 4 there had been samples set, there had been tests sent, and lab tests had been done. There had been opened packages of cold meats. There was a concern that it might even come to investigate exposure to two or three meat products as well as mushrooms and cheese. And then we got back to a concern that it was in cold meats.

I think what you're saying is that it's obviously a complex issue to track. I think we've heard that time and time again, that in fact it may take up to a number of days or weeks to be able to pinpoint it.

It was my understanding that when it was all resolved, this was in a sandwich that had not just meat in it, but lettuce, bread, and maybe condiments that were attached. Can listeriosis be in any of those things?

[Dr. David Williams]

There are a number of questions there.

One aspect is that as you're going through the food-borne outbreak and you're trying to follow it, one has a method of generating certain hypotheses as to what is the source of it, and one looks for evidence. One of the things we always try to do is make sure we don't focus too quickly. You look at other possibilities just in case, so you're not eliminating other possibilities.

Most of the time when they were serving these products, it's not clear whether they were serving them in sandwiches or not, or in what format in the homes, because you're asking people to recollect what they ate three to four weeks ago. And with elderly people in homes, their recall isn't good. Most of us would have trouble remembering what we ate two days ago. So there is that challenge that we don't have that same local outbreak.

The aspect is whether we question other things such as fresh-cut vegetables. Those were looked at as well. So we asked what the common thing was that would give the same bacteria in the fingerprinting. It was something that was in a nursing home here, one 300 kilometres over there, and another one 400 kilometres over there.

With the laboratory test that was evolving up through the fingerprinting and the PFGE typing, there was a debate on what the types were and how specific that typing was. Much like DNA used in early courtroom cases, it is like saying that if it is this one PFGE type, and if I have it and Dr. McKeown has it 300 kilometres away, what's the chance of that occurring by happenstance? Or is it so specific that it would be unlikely? There must be some common event that we experienced that connects it. We just have to look for it. That was what was evolving at that time.

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

Am I out of time?

[The Vice-Chair, Liberal, Wayne Easter]

You are out. We'll get you in the next round.

Dr. Bennett.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Thanks very much. Thank you for coming.

I have a concern with the reasonable and probable grounds issue. It sounds like the CFIA does have the power to act on reasonable and probable grounds but in this situation did not. They were waiting for the lab tests to come back. I have a concern that it shouldn't be a culture thing. Public health officers choose to operate on reasonable and probable grounds in order to protect the interests of the public, but CFIA for some reason decided not to do that until they got the lab tests back. That surely should be determined long before an outbreak. I had thought that this was written down in FIORP, in the Foodborne Illness Outbreak Response Protocol, that one would have rules about this, not just feelings or culture about this.

I am concerned, having heard the testimony from Lynn Wilcott, who said that during routine food recalls, when there are no illnesses involved, a good working relationship, good communication, with CFIA is possible, but where things seem to go off the rails, he said, is during recalls where there are illnesses involved or potential for illnesses, or potential adverse publicity, or even prior to recall when we as a province are doing an illness outbreak investigation. He said that in examples like that CFIA becomes very reluctant to share information openly and freely.

I wondered if you had any other experience in terms of the reluctance of CFIA to operate on reasonable and probable grounds, and why they waited to get the lab tests back if indeed there is a protocol and they have the power to act when there is the potential for trouble.

[Dr. David Williams]

First, the protocol, as it was developed, is a protocol. It was known from the outset that it's not binding. Therefore, that was one of our struggles. If we're going to have a protocol and we all sign on to it, we should agree that it has to apply to all the partners involved. It was meant to be a guidance document, and we've heard at times that others didn't have to follow all the steps they didn't want to.