AGRI Committee Report

Background

A. Foodborne Illness and Listeriosis

Consumption of food and beverages contaminated with microorganisms such as bacteria, parasites and viruses can produce illness and in some cases death. Mild cases of foodborne illness are not uncommon; PHAC estimates that there are as many as 13 million cases yearly in this country. Fortunately, the vast majority of these illnesses are not serious enough to cause the sufferer to seek medical attention. In other instances, individuals may report to a doctor who may choose to treat the patient for their symptoms and the cause of the illness may not be pursued. In a small portion of all foodborne illnesses, the disease will be serious enough to seek medical attention, and the cause of the illness will be determined. Generally, the symptoms of foodborne illness, often referred to as food poisoning, include nausea, vomiting, diarrhea, stomach cramps and fever. Overall, children and adults who are in good health do not succumb to serious illness from contaminated food. Vulnerable populations, which include infants and very young children, pregnant women, the elderly and individuals with compromised health, may suffer serious illness from these pathogens. The determination of the source of foodborne illness is a challenge, as it requires recollection of all food and beverages consumed over several days or weeks.

Listeriosis is caused by ingestion of the bacterium Listeria monocytogenes, herein referred to as listeria. Listeria is widespread in the environment in soil and water, which can then contaminate vegetation and animals. Contaminated plants and animals in turn can infect humans. The resultant infected human and animal waste keeps the cycle going. Like other sources of foodborne illness, listeria does not produce disease in all individuals who consume contaminated food and drink. Many people will experience no ill effects, while others will suffer only mild symptoms that may not even be enough to alert them to the fact that they have been infected with anything. However, for those vulnerable populations listed above, listeria can produce serious illness. In addition to the general symptoms already mentioned, listeria can spread to the nervous system causing headache, stiff neck, confusion, loss of balance and convulsions. For pregnant women, the infection can result in an infected newborn, or worse, spontaneous abortion or still birth. Listeria is more likely to cause death than other foodborne bacteria. Approximately 20 to 30% of cases in high risk individuals can be fatal.

Most commonly, listeriosis is associated with consumption of contaminated milk, milk products and ready-to-eat foods. While listeria can be eliminated from milk and milk products by pasteurization, raw milk and its products, particularly soft cheeses, pose an increased risk. Ready-to-eat and processed foods pose an increased risk because of the number of manipulations involved in preparing the products. Each step involved introduces another possibility for contamination. For those foods that are cooked prior to consumption, listeria and other bacteria present are destroyed. Listeria is unique among foodborne bacteria in that its growth is not inhibited by refrigeration or high salt concentration. Listeriosis is even more difficult to investigate than other foodborne pathogens, in terms of determining the source of the infection, because symptoms may not appear for as much as 70 days after consumption of the contaminated product. On average, however, illness appears around 30 days after ingesting the microorganism. Determining what foods and beverages were consumed a month or two earlier can be very challenging.

B. The Outbreak

In summer 2008, Canada experienced an outbreak of listeriosis that required the recall of several Maple Leaf products. By the time all of the statistics were in, 57 cases had been confirmed, causing or contributing to 22 deaths.

In Canada, cases of listeriosis are routinely reported a few times weekly. An outbreak will not be suspected until more cases than would normally be expected are reported. In June and early July 2008, Ontario’s Ministry of Health and Long-term Care (MOHLC) indicated that it had detected a small increase in the number of listeriosis cases[1] through its Early Aberration Reporting System (EARS), which analyzes routine surveillance from the integrated Public Health Information System (iPHIS), but no pattern or link was determined until the end of July after more cases had been identified. While Ontario retained the lead, the next few weeks involved collaboration between Toronto Public Health, MOHLC, PHAC and Health Canada to analyze food and human samples, perform genetic fingerprinting to establish a link between specific food samples and human cases, as well as determine the food source of the outbreak. On 29 July, MOHLC issued a report through the Canadian Integrated Outbreak Surveillance Centre (CIOSC) (described under Managing Emergencies, National Foodborne Illness Surveillance System), which would have alerted all public health partners, including CFIA, to the increased incidence of listeriosis. On 30 July it held a teleconference to which upwards of 100 participants were invited although no roll-call was taken. Testimony was contradictory as to whether CFIA was invited. The Subcommittee acknowledges a dispute between Ontario public health officials and CFIA officials as to whether CFIA was made aware of the listeriosis issue on 29 July or 6 August. It is clear, however, that on 6 August, CFIA was notified of a public health investigation into two listeriosis cases in a nursing home in Toronto. CFIA then launched an investigation to confirm the affected batches of food. On 8 August, CFIA contacted Maple Leaf Foods to ask the company whether it had the ability to trace certain products.

PHAC took the lead coordinating role in the public health investigation on 15 August when it became apparent that the cases were distributed nationally. After CFIA obtained positive results for L. monocytogenes in unopened Maple Leaf product on 16 August, Maple Leaf Foods was contacted with the information, and it initiated a voluntary recall immediately. Ultimately, the list of recalled products grew until 5 September. Determination of the source of contamination within the Maple Leaf Foods plant was found to be deep within a slicing machine and required its complete disassembly for sanitization. By the beginning of September, 31 cases of listeriosis linked to the outbreak had been confirmed, and 16 deaths were attributed to listeria. This number continued to grow over the next few months to 57 confirmed cases and 22 deaths, as a testament to the potentially long incubation period for listeria.

What the Subcommittee Heard about the Outbreak

A. Overview of Federal Departments’ and Agencies’ Roles during the Outbreak and Actions in Response to It

The Subcommittee first invited Maple Leaf Foods to testify about the listeriosis outbreak. It heard from them as well as other industry witnesses that they consider the standards and regulations enforced by CFIA to be a ‘floor’, and that industry strives to go beyond these minimum requirements in their production of food in order to maintain a high level of quality and safety. The President of the company, Mr. Michael McCain, described how his company carried out frequent environmental tests within the plant, testing that was not required by CFIA. He testified that Maple Leaf Foods was collecting, at the time of the tragedy, over 3,000 samples per year in their environmental monitoring program. Whenever listeria or other contamination was detected they would sanitize until they got a negative result. Despite the diligent sampling and testing, listeria growth went undetected, since the bacteria were able to colonize deep within a slicer in an area considered to be inaccessible. The Subcommittee was told that no amount of inspection would have changed the outcome. Members also heard that what Maple Leaf Foods environmental testing did not involve at the time, but what they have since implemented, is the application of a sophisticated investigative and pattern recognition science to analyze test results to better determine the root cause. In the words of Michael McCain:

But if you want to go to the exact cause of this outbreak, it was not about a lack of inspection. It was not about a lack of product testing or a lack of inspectors. It was about a failure to analyze test data that we weren’t even obligated to collect.[2]

The Subcommittee was told by several witnesses that since the outbreak, there has been implementation of a new policy, effective 1 April 2009. CFIA indicated that the new measures largely address those concerns raised by Mr. McCain above. The new policy will be discussed in greater detail in a later section.

Mr McCain was praised by members for his conduct throughout the crisis, as well as since. Several members commented that Mr. McCain was the face of the listeriosis crisis and questioned whether the federal government was sufficiently visible during the outbreak. Others questioned Mr. McCain and other industry witnesses as to whether CFIA’s inspections were to blame for the contamination.

The Subcommittee heard conflicting testimony with respect to CFIA inspection reports for the Maple Leaf Food plant that were altered after the outbreak. Mr. Bob Kingston, president of the Agriculture Union, felt that altering the report so long after the fact is not normal. CFIA officials agreed that inspection reports had been altered but claimed this was done in order to clarify the records in anticipation of the in depth investigation.[3] Testimony from Mr. Don Irons, a food processing supervisor at CFIA, confirmed that although not common, this is done periodically when there is an in-depth audit.

Some industry witnesses agreed that more frequent inspections would not have changed the outcome, although Mr. Bob Kingston, president of the union representing food inspectors, noted that more visual inspections of the premises and equipment is often useful in identifying symptoms and situations favourable to the development of food safety hazards. Witnesses emphasized that the decontamination of the source equipment required complete disassembly of a machine that was not meant to be disassembled. However, the Subcommittee heard from Mr. Nelson Vessey, a former CFIA auditor, that an effective equipment auditing program might have detected the problem.

CFIA told the Subcommittee that its role in the outbreak began once it was made aware of the listeriosis cases on 6 August, and it launched a food safety investigation beginning on 7 August. David Williams, Chief Medical Officer of Health, MOHLC, and David McKeown, Medical Officer of Health, Toronto Public Health, testified, however, that CFIA had been made aware of the increased cases of listeriosis on 29 July, when Ontario issued reports through CIOSC. Once CFIA’s food safety investigation determined that meat from sampled sandwiches originated from Maple Leaf Foods, CFIA contacted the company on 8 August to enquire about its records and product traceability capacity. The CFIA then searched for unopened products, as positive results had been obtained from opened product only at this point; introducing the possibility that contamination had happened subsequent to opening. On 12 August CFIA located unopened product and sent it for testing. This came back on 16 August, positive for L. monocytogenes, and CFIA informed Maple Leaf Foods of the result, prompting the company to immediately initiate a voluntary recall process.

Dr. Williams and Dr. McKeown disagreed with CFIA’s position that unopened product was required before a conclusive statement could be made about the source of contamination. They pointed out to Subcommittee members that it would be very unlikely that different opened packages of meat could subsequently become contaminated with the same type of bacteria. They suggested that the process could have been shortened by several days if CFIA had not pursued the locating, sampling and analyzing of unopened packages. However, CFIA officials emphasized that unopened product was necessary to confirm the recall order.

Health Canada has had a policy on L. monocytogenes in ready-to-eat foods since 1994; it was updated in 2004. The policy sets out guidance for the safe manufacturing of ready-to-eat foods as well as controls to address risks related to listeria. With respect to Health Canada’s role in the 2008 listeriosis outbreak, its first involvement was in late July when the department received a routine request to test food samples for the presence of listeria. A national Listeriosis Reference Service (LRS) was created in 2001 and is a joint venture between Health Canada’s Bureau of Microbial Hazards and PHAC’s National Microbiology Laboratory (NML). The LRS analyzes food and clinical samples. Laboratories within Health Canada analyze foods samples while NML focuses on clinical human isolates. Throughout the outbreak, Health Canada laboratories carried out genetic typing as necessary, over 200 samples in all.

The Subcommittee heard that addition of a relatively simple and inexpensive compound to ready-to-eat meat products could inhibit the growth of listeria. It heard that, had Maple Leaf Foods been able to add either sodium acetate or sodium diacetate to their ready-to-eat products, the growth of listeria in those products might have been avoided. These additives have been approved in the United States for five years, and the Subcommittee was told by the Canadian Meat Council that there has not been a recall of ready-to-eat meat due to listeria-related illness since that time.[4] These food additives were not approved by Health Canada at the time of the tragedy, although Schneider Foods had requested approval as early as 2002.[5] Members were told by Health Canada officials that these substances received approval in September 2008.

PHAC began to receive clinical samples for routine analysis on 10 July from MOHLC and throughout the remainder of the month from provincial public health laboratories. Some members expressed concerns over the time that elapsed between samples being sent for analysis and the results being communicated. Dr. Frank Plummer, Director of PHAC’s NML, explained that these procedures, particularly genetic fingerprinting, can take as much as 14 days for non-urgent samples. In a letter to Dr. David Williams, the heads of CFIA, PHAC and Health Canada suggested that MOHLC should not have sent samples to the Ottawa lab, but rather to a CFIA lab in Scarborough. Dr. Williams replied that, at the time of sampling, there was no indication that an outbreak was underway; that in fact, at that time they were routine samples and as such would be expected to go to the LRS in Ottawa. Federal officials confirmed that samples were sent to the correct laboratory. The Subcommittee was told that MOHLC requested distribution records from CFIA of the implicated food products, but did not receive them.

PHAC continued to conduct analyses and communicate with public health authorities on results and possible sources. Only after connecting the listeriosis cases in other provinces to the outbreak in Ontario did PHAC take the lead in coordinating the national investigation and response; this was not until 15 August. As lead coordinator, PHAC standardized data collection and centralized data to enable national reporting and analysis for identification of linkages between cases. It sent a public health alert requesting that all public health units use a standardized questionnaire to obtain information on the listeria cases, and the Chief Public Health Officer issued a statement to inform Canadians about the ongoing public health investigation.

The Subcommittee was told that in addition to daily press conferences or technical briefings, PHAC also issued traditional media notices and advisories and wrote to senior organizations and professional organizations; as well, it developed guidelines. PHAC stated that they felt that they were trying to be very visible in their role in the outbreak as well as in the collaboration with the other federal partners. The Subcommittee was told that throughout the crisis, Health Canada, PHAC and CFIA, along with Toronto Public Health, held daily teleconferences. The Minister of Agriculture and Agri-Food was also actively involved in the teleconferences.

B. The Independent Inquiry — A Review of Federal Actions During the Outbreak

On 20 January 2009, the Prime Minister announced the appointment of Sheila Weatherill as Independent Investigator into the listeriosis outbreak. Ms. Weatherill indicated that her mandate was:

to examine the events, circumstances and factors that contributed to the outbreak; review the efficiency and the effectiveness of the response of the federal organizations in conjunction with their food safety system partners in terms of prevention, recall of contaminated products, and collaboration and communication, including communication with consumers; and make recommendations based on lessons learned from that event and from other countries’ best practices to prevent a similar outbreak in the future and remove contaminated products from the food supply.[6]

The timeline set out by Ms. Weatherill includes fact gathering and analysis between January and the end of April, followed by in-depth probing until June, and finally report writing.

The Subcommittee heard about the six terms of reference set out for the investigation. In addition to the three set out above in the mandate, the investigation is not to assign or suggest criminal or civil liability to anyone or any organization and is to use procedures for the expedient and proper conduct of an investigation, including reviewing relevant documents and consulting as appropriate. The report is to be completed and submitted to the Minister of Agriculture and Agri-food, in both official languages, by 20 July 2009.

The five guiding principles for carrying out the investigation were enumerated by Ms. Weatherill as: “access to the most accurate and complete information available; independence from all parties, both inside and outside government; systematic investigative techniques; external expert advice; and consideration of all legitimate viewpoints to ensure that the approach is fair, collaborative and constructive.”[7]

The investigation, with an estimated cost of $2.7 million, is being conducted with dedicated staff, as well as others on an as-needed basis. The Subcommittee was told that staff included those with expertise in discovery and document retrieval, in order to ensure that all required documentation and testimony would be obtained. Full-time staff for the investigation includes professionals from three expert firms and six federal public servants from Environment Canada, the Public Health Agency of Canada, the Canadian Food Inspection Agency and Agriculture and Agri-food Canada. On an as-needed basis, the investigation has access to five expert advisors and seven consultant researchers.

Ms. Weatherill indicated in her testimony to the Subcommittee that she has had complete cooperation from all those from whom she has requested input, both documentation and interviews. She indicated that her role is restricted to examining the federal government’s involvement only during the outbreak and she clarified that she had no input into the terms of reference for the investigation. Some members expressed concern that she had not interviewed the Minister of Agriculture and Agri-food at the time of her appearance. Another concern expressed was that the inquiry is not sufficiently arm’s length from the Minister of Agriculture and Agri-food, since it will report directly to him. Ms. Weatherill stated that there had been “no attempt to influence or limit the investigation in any way, from any source”[8] and expressed confidence in the manner in which the investigation and reporting was to be conducted. She assured members that she would be interviewing the Minister and gathering all data required, emphasized that “the evidence trail is being followed wherever it leads” and expressed confidence that the report would be submitted on time. In fact, the Subcommittee learned that the Minister met personally with Ms. Weatherill on 4 May for two hours.

The Minister of Agriculture and Agri-food indicated during his appearance at Subcommittee that he would be meeting with Ms. Weatherill in the coming days. He expressed confidence in her ability to conduct a thorough and comprehensive investigation and described her as extraordinarily qualified. The Minister confirmed that the report will be made public and he pledged that “the recommendations that come forward through the lessons-learned reports and through the report that Ms. Weatherill will table will be followed up on and will be implemented.”[9]

Recommendation 1:

The Subcommittee recommends that the government call for a fully transparent and independent public inquiry, with all the powers provided under the Inquiries Act, into the actions of the federal government, its agencies and departments in relation to the events leading up to, during, and subsequent to the listeriosis crisis of the summer 2008.